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\begin{document}

\title{Prevalence and predictors of psychological response during immediate
covid-19 pandemia}



\author[1]{Neslihan Cansel}%
\author[1]{İlknur Ucuz}%
\author[2]{Ahmet Kadir  Arslan}%
\author[2]{Burcu Kayhan Tetik}%
\author[3]{Cemil Colak}%
\author[4]{Şahide Nur İpek  Melez}%
\author[5]{RAZİYE GÜMÜŞTAKIM}%
\author[6]{Sinem  Ceylan }%
\author[7]{Güzin Zeren  Öztürk}%
\author[8]{Yasemin Kılıç Öztürk }%
\author[9]{Dursun  Çadırcı}%
\affil[1]{Inonu University School of Medicine}%
\affil[2]{Inonu University}%
\affil[3]{Inonu Universitesi Tip fakultesi}%
\affil[4]{Affiliation not available}%
\affil[5]{Kahramanmaras Sutcu Imam University - Avsar Campus}%
\affil[6]{Ankara Medipol University}%
\affil[7]{Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi}%
\affil[8]{Izmir Tepecik Training and Research Hospital}%
\affil[9]{Harran University}%


\vspace{-1em}



  
  \date{May 20, 2024}


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\selectlanguage{english}
\begin{abstract}
Purpose: COVID-19 pandemic has created a serious psychological impact
worldwide since it has been declared. This study aims to investigate the
level of psychological impacts of COVID-19 pandemic on Turkish
population and to determine related factors. Methods: The study was
carried out by using an online questionnaire using the virtual snowball
sampling method. The sociodemographic data were collected on the
following subjects: Participants' experience on any signs of infection
within the last month, the history of COVID-19
contact-treatment-quarantine, level of compliance with precautionary
measures, the sources of information and level of knowledge about the
pandemic process and their belief levels on the knowledge they acquire.
Besides, questions that take place in the depression, anxiety, stress
scale (DASS-21), and impact of events scale (IESR) were asked. Results:
Of the 3549 participants, anxiety was found in 15.8\%, depression in
22.6\%, stress in 12.9\%, and psychological trauma in 20.29\%. Female
gender, young age, higher education level, being single, high monthly
income, presence of psychiatric illness, a high number of people living
together, having any signs of infection, and contact history with
COVID-19 infected person or contaminated object are identified as risk
factors that may increase psychological impact. Compliance with the
rules was found to reduce the risk of psychological response.
Conclusions: During the pandemic, reducing the spread of the virus and
knowing the risk factors in protecting the mental health of individuals
will be guided in determining the measures to be followed and the
policies to be followed.%
\end{abstract}%



\sloppy




\textbf{What's known}

1. The covid-19 pandemic caused various problems related to viral
infection, including the risk of death.

2. In addition, it caused different levels of psychological effects in
individuals.

\textbf{What's new}

1. Risk factors causing psychological response such as sociodemographic
variables, data on areas of concern, the level of compliance with
precautionary measures, the participants' information source, the
presence of physical symptoms, were determined in detail within the same
study.

2. Female gender, young age, higher education level, being single, high
monthly income, presence of psychiatric illness, a high number of people
living together, having any signs of infection, and contact history with
COVID-19 infected person are identified as risk factors that may
increase psychological impact.

3. Compliance with the rules was found to reduce the risk of
psychological response.

\textbf{1 INTRODUCTION}

COVID-19 emerged as pneumonia of unknown etiology in a group of patients
with a connection to the Huanan South China Seafood Market in Wuhan,
China, in late 2019, and soon spread across the
world.\textsuperscript{1} Being much more widespread than Severe Acute
Respiratory Disorder Syndrome (SARS) in 2002, and Middle East
Respiratory Syndrome (MERS) in 2012,\textsuperscript{2} COVID 19, which
is considered as the most common viral epidemic of our time, has spread
to more than 200 countries worldwide and has affected thousands of
people since its inception. The number of reported cases increases every
day and at the time of writing this study (03.06.2020), throughout the
world the number of confirmed cases has reached the number of 6.194.533
and 376.320 people died.\textsuperscript{3}

The outbreak not only increased the risk of death from a viral infection
but also caused people to experience unbearable psychological
pressures.\textsuperscript{4} Before the declaration of any confirmed
cases in Turkey, images and videos which were spread via social media
and TV news have created a panic in Turkey as well as all over the
world. These images and videos displayed examples of abrupt falling and
deaths of people in the middle of the street, patients' agony in
quarantine, and experiences of confluence during strife with the
prohibitions and restrictions, and the suffering of people who could not
see the funerals of their relatives.

Following the announcement of the first coronavirus case on March 11th,
2020, urgent measures were taken in order to prevent an outbreak by the
authorities in Turkey. Entries and exits to the country have been
forbidden and quarantine obligation has been introduced for the citizens
who come from abroad. Schools, including universities, were closed,
flexible working opportunities were provided in many public
institutions, and a social distance rule was established to minimize
contamination. People over the age of 65 and under 20 have been imposed
a curfew and in many provinces, the public has been made to comply with
this regulation on weekends. Also, public meetings were postponed,
intercity travel was stopped, and new rules have been introduced for
public transportation, markets, shopping malls, etc. The minister of
health shared the current information about the coronavirus cases with
the community every day and gave information about the precautionary
measures. However, despite all these precautions, thousands of people
were infected and many of our citizens died.

Many factors such as persistence of the epidemic in the world, the lack
of current treatment, and the uncertainty of the duration of the
measures taken brought forward the risk of being affected
psychologically. As a matter of fact, recent studies have shown that
struggling with this uncertainty as well as the physical effect of the
disease, economic-educational losses, etc. due to social isolation, may
decrease the communication among people and increase the rates of
depression and anxiety over time .\textsuperscript{4-7} Naturally, in an
extraordinary situation like a pandemic, acute psychological exposure
may be a foregone conclusion, but continuing the process may cause
permanent psychological and biological effects. Therefore, while
evaluating the pandemic, the detection of psychological problems, and
related factors that may develop; it is important to determine the
target audience, to take the necessary precautions, and to direct the
aid. In the light of this information, in this study, it is aimed to
determine the level of psychological impact and the factors that may be
related to the COVID-19 outbreak in Turkish society where precautionary
measures are still being implemented in the 6th week of the pandemic in
the country.

\textbf{2 METHODS}

\textbf{2.1 Participants and Study Protocol}

This study is a cross-sectional study and has been approved by the
ethics committee. This study was conducted 6 weeks after the first
COVID-19 case was officially announced. The individuals who were planned
to participate in the study were determined by a virtual snowball
sampling method and invited to participate in the web survey online.
Data acquisition was stopped when the targeted sample size was reached
within 5 consecutive days. A questionnaire consisting of 7 sub-units was
sent to the participants. Section 1 of the questionnaire included
sociodemographic features, section 2 included questions on the presence
of symptoms for any infectious disease, contact with COVID-19,
treatment, quarantine history, section 3 included questions on
compliance with the measures taken (these questions were inspired by the
14 rules determined by the official authorities in our country), section
4 included questions on the source from which information about COVID-19
was acquired; level of knowledge, belief in the information received,
health services and measures sufficiency level, level of belief in life
chances. Section 5 included questions on anxiety associated with
possible health and sociological losses of the pandemic. The 6th section
consisted of DASS-21 related questions and section 7 consists of
questions related to IES-R. DASS and IESR were used in previous pandemic
studies.\textsuperscript{8,9} Data for individuals 18 and older who
agree to participate voluntarily are included. Data of individuals with
a history of bipolar disorder and/or psychotic disorder were not
evaluated during the analysis phase.

\textbf{2.2 Data Collection Tools}

\textbf{Depression Anxiety Stress-21 Scale (DASS-21)}

In the study, DASS-21 was used to evaluate the current mental impact.
DASS-21 is a short-form version of the original 42-item questionnaire
designed as self-report.\textsuperscript{10} Its validity and
reliability in Turkish were done by Sar\selectlanguage{polish}ı\selectlanguage{ngerman}çam in
2018.\textsuperscript{11}The scale consists of depression, anxiety, and
stress subfields. In the depression subscale, 0-4 points are normal, 5-6
points are mild, 7-10 points are moderate, 11-13 points are severe, and
\selectlanguage{english}[?]14 points are extremely severe. 0-3 points are normal in the anxiety
subscale; 4-5 points mild, 6-7 points moderate, 8-9 points severe, \selectlanguage{english}[?]10
points extremely severe anxiety; in the stress subscale, 0-7 points are
normal, 7-8 mild, 10-12 moderate, 13-16 severe, and \selectlanguage{english}[?] 17 express
extremely severe stress.

\textbf{Impact Scale of Events (IESR)}

The scale which was originally named as Impact of Event Scale-Revised
(IES-R)\textsuperscript{12} was used to measure the psychological trauma
caused by the COVID-19 outbreak in the study. The Turkish validity and
reliability of this scale, which is widely used in daily clinical
practice and studies to evaluate the severity of post-traumatic stress,
was made by Corapc\selectlanguage{polish}ı\selectlanguage{english}o\selectlanguage{polish}ğ\selectlanguage{english}lu et al in 2016.\textsuperscript{13} There are 22
questions divided into 3 subgroups (intrusive, avoidance, hyperarousal)
on the scale where the severity of symptoms in the last 7 days is scored
between 0-4. For the total IESR score, 0-23 is normal, 24-32 mild, 33-36
moderate, and [?]37 indicate severe psychological impact.

\textbf{2.3 Statistical Analysis}

The quantitative data used in the study were summarized as arithmetic
mean \selectlanguage{ngerman}± standard deviation and qualitative data as numbers (percent). As
the four dependent variables in the study, DASS-21 anxiety, depression
and stress subfields, and IES-R total scores were selected, and the
related data were converted into binary categorical data according to
the following criteria. A cut-off of the IES-R total score \selectlanguage{english}[?]33 was used
to reflect moderate-to-severe impact.\textsuperscript{14} Similarly,
individuals with a score of 7 and above in the depression subscale, 6
and above in the anxiety subscale, 10 or above in the stress subscale
cut-off points were used to determine the moderate and above
psychological influence reflected on DASS-21.\textsuperscript{8} Since
the number of dependent variables is four, four different binary
logistic regression models were applied to the data set. Before applying
the related models, variable selection algorithms based on each
dependent variable were applied to the data, and independent variables
considered to have no contribution to modeling were removed from the
data set. As a variable selection method, LASSO (Least absolute
shrinkage and selection operator)\textsuperscript{15} logistic
regression technique was applied. The goodness of fit and coefficients
of the created models were evaluated by Hosmer-Lemeshow (p\textgreater{}
0.05) and Omnibus (p \textless{}0.05) tests, respectively. In logistic
regression models, significance level for model coefficients was
determined as p \textless{}0.05. In the analysis, ``BKSY: Information
Discovery Process Software'' developed by Inonu University Faculty of
Medicine Department of Biostatistics and Medical Informatics was used
for the data analysis.\textsuperscript{16}

\textbf{3 RESULTS}

\textbf{3.1 The Relationship between Sociodemographic Variables and
Psychological Response}

The data obtained from 3549 people were included in the research. The
average age of the participants was 38.8 +- 10.9 years, 1389 (39.1\%)
were male and 2160 (60.9\%) were female. The average age for women was
37.8 (+- 11.1) years and the average age for men was 40.3 +- 10.7 years.
When DASS-21 scores of 3549 participants were evaluated; 200 (5.6\%)
individuals were extremely severe, 124 (3.5\%) severe, 479 (13.5\%)
moderate, 416 (11.7\%) mild, 2330 (65.7\%) normal levels for depression
subspace. For the anxiety subfield, 187 (5.3\%) people were extremely
severe, 127 (3.6\%) people were severe, 246 (6.9\%) were moderate, 385
(10.8\%) were mild, and 2604 (73.4\%) were normal. For the stress
subfield 69 (1.9\%) individuals were extremely severe, severe for 160
(4.5\%) people, moderate for 220 (6.2\%) people, mild for 279 (7.9\%),
and normal range for 2821 (79.5\%). When IESR scores were evaluated; 552
(15.6\%) people were in the severe range, 168 (4.7\%) people were in the
moderate range, 662 (18.7\%) were mild and 2167 (61.1\%) were in the
normal range. The prevalence values for the moderate to extremely
severe, while DASS-21 was 10.51\% for anxiety, 16.99\% for depression,
and 10.71\% for stress, the prevalence value for the for the moderate to
extremely severe was 20.29\% for IES-R.

Increasing age was associated with high depression (p = 0.021, OR =
0.985) and stress (p = 0.015, OR = 0.981) scores, but had no effect on
anxiety and IES-R (p\textgreater{} 0.05). Being a woman generated more
risk for anxiety, depression, stress and trauma. According to the level
of education, being a university graduate reduces the risk of anxiety by
2.22 times (p = 0.026, OR = 0.451) and the risk of depression
approximately 2.02 (p = 0.04, OR = 0.495) times compared to primary
school graduates. Being secondary and high school graduate did not make
any difference compared to being a primary school graduate
(p\textgreater{} 0.05).

Being married reduced the risk of developing stress 1.739 times compared
to being single (p = 0.002, OR = 0.575). Unemployment, according to
other occupational categories; the existence of health insurance did not
affect the DASS-21 and IES-R scores according compared to its absence
(p\textgreater{} 0.05 for all subdomains). Having income above the
minimum wage significantly contributed to the development of stress. The
most risky group for the development of stress was those with the income
level of 10,000 TL and above (p = 0.003, OR = 2.029). As the number of
people living at home increased, the risk of developing stress
increased. The fact that the number of people living at home was 5 and
above posed a high risk for stress (p = 0.003, OR = 2.476). The presence
of individuals over 65 years old at home did not cause any psychological
response (p = 0.247, OR = 0.807). The presence of psychiatric illness in
the individual was significantly associated with high DASS-21 and IES-R
scores.

Having a history of psychiatric illness increased the risk of developing
anxiety 2.5 times (p \textless{}0.001, OR = 2.426), increased the risk
of developing depression 2.3 times (p\textless{}0.001; OR = 2.297),
increased the risk of developing stress 2.2 times (p\textless{}0.001, OR
= 2.224). It was observed that it increased the risk of developing
trauma approximately 2 times (p\textless{}0.001, OR = 2.034). The
presence of chronic illness in the family and smoking did not have any
effect on the development of depression, anxiety, and trauma
(p\textgreater{} 0.05 for all areas). Data related to the relationship
between sociodemographic variables and DASS-21 and IES-R are given in
Table 1.

\textbf{3.2 The Relationship between Participants' History of Contact
and Treatment with COVID-19 within the Last Month and Their
Psychological Response Levels}

538 (15.2\%) of the participants had a history of meeting with someone
diagnosed with COVID-19 and 159 (4.5\%) had a history of contact with an
individual with suspected COVID-19 or contaminated materials. 206
(5.8\%) of the individuals were tested for COVID-19 in the last month,
80 (2.3\%) were quarantined, and 30 (0.8\%) were treated. 1637 (46.1\%)
people stated that they did not know about their contact history with an
individual/object contaminated with COVID-19. The presence of a history
of contact with a COVID-19 had a 2.3-times increase in the risk of
anxiety (p \textless{}0.001, OR = 2.297), and 1.43 times enhancing
effect in the risk of depression (p = 0.029, OR = 1.428). Having a
contact history with contact with an individual with suspected COVID-19
or infected materials, increased the risk for depression 2 times (p
\textless{}0.004, OR = 2.005), 1.84 times for stress (p = 0.028, OR =
1.838) and 1.77 times (p = 0.013, OR = 1.773) had an enhancing effect
for IES-R. The test history for COVID-19 had a 1.62 times protective
effect on trauma formation (p = 0.035, OR = 0.617). Although quarantine
status had a protective effect on anxiety and stress, it had 2.35 times
risk-reducing effects for anxiety and 2.99 times for stress (p = 0.027,
OR = 0.424, p = 0.016, OR = 0.334, respectively). Treatment with
COVID-19 did not affect psychological impact. Data related to the
participants' history of contact and treatment with COVID-19 within the
last month and their psychological response levels are shown in Table 2.

\textbf{3.3 The Relationship between the Presence of Physical Symptoms
within the Last Month and Psychological Response Levels}

When the participants were questioned whether they had experienced any /
several of the symptoms of fever, cough, sore throat, shortness of
breath, chest pain, headache, runny nose, muscle pain, diarrhea, nausea
in the past 1 month; 302 (8.5\%) for fever, 880 (24.8\%) for cough, 1248
(35.2\%) for sore throat, 390 (11\%) for shortness of breath, 404
(11.4\%) for chest pain, 1953 (55\% )for headache, 1057 (29.8\%) for
rhinorrhea, 1300 (36.6\%) for myalgia, 602 (17\%) for diarrhea, 558
(15.7\%) for nausea answered positive (i.e., presence). The three most
common symptoms were headache, myalgia, and sore throat, respectively.

In the analysis made, different symptoms caused different levels of
psychological response. The presence of fever in the last 1 month had an
enhancing effect on the development of anxiety (p \textless{}0.001, OR =
2.193) and stress (p = 0.013, OR = 1.572). Sore throat was associated
with high anxiety and IES-R (p = 0.049, OR 1.282, p = 0.016, OR = 1.431,
respectively). Chest pain had an effect on increasing the risk for
anxiety (p \textless{}0.001, OR = 2.269) and trauma (p = 0.049, OR =
1.34). Shortness of breath had an increasing effect on the risk of
experiencing anxiety (p \textless{}0.001, OR = 2.286) and depression (p
= 0.016, OR = 1.431). Headache, rhinorrhea, diarrhea, cough did not pose
a risk in psychological response. Nausea increased the risk of
developing anxiety and stress by 1.37 and 1.489 times, respectively,
compared to those who did not have nausea (p = 0.028, OR = 1.37; p =
0.007, OR = 1.489). The relationship between the presence of physical
symptoms and psychological responses in the last 1 month is given in
Table 3.

\textbf{3.4 The Relationship between Participants' Source of
Information, Level of Belief in Knowledge and Their Level of
Psychological Response on COVID-19 Pandemic}

1797 (50.6\%) participants stated that they received information about
COVID-19 most frequently from TV/radio. When the participants are
evaluated in terms of knowledge level, source, and belief level from
which the information is obtained; these variables had no effect on
psychological response (p\textgreater{} 0.05 for all areas). The
presence of chronic illness in the family and smoking did not have any
effect on the development of depression, anxiety, and trauma
(p\textgreater{} 0.05 for all areas). The belief in finding the measures
efficiently reduced the risk of depression by 1.386 times (p=0.041,
OR=0.721). In addition, compared to those who did not have the idea of
finding a high chance of survival, it had a reducing effect on
depression 1.68 times (p=0.003, OR=0.594). The relationship between the
sources of information, its level, belief in knowledge, and
psychological response is given in Table 4.

\textbf{3.5 The Relationship between the Level of Compliance with
Precautionary Measures and Psychological Response Levels}

The number of people who comply with precautionary measures; 3357
(94.6\%) for hand washing with soap, 3447 (97.1\%) for closing the mouth
and nose during coughing or sneezing,3190 (89.9\%) for canceling
international travel plans , paying attention to social distance, 3059
(86.2\%) for wearing a mask while going out with or without symptoms ,
3362 (94.7\%) for ventilation of the environment frequently, 2449 (69\%)
for cleaning the frequently used surfaces with water and detergent, 1976
(55.7\%) for separating personal belongings, 2401 (67.7\%) for washing
clothes at high temperature 2275 (64.1\%) for at least 8 hours of sleep,
2052 (57.8\%) for at least 2 liters of fluid per day and balanced
nutrition was and the curfew was 2980 (84\%).

While frequent ventilation in the environment had a reducing effect on
the anxiety level of approximately 1,577 times (p=0.047, OR=0.634),
separating personal items and doing regular sports decreased the risk of
depression (p \textless{}0.001, OR=0.626) by 1.59 times. Sleeping at
least 8 hours a day, at least 2 liters of water consumption and balanced
nutrition had a risk-reducing effect in all areas (p \textless{}0.05).
Compliance with the curfew reduced the risk of trauma by 1.34 times
(p=0.01, OR=0.745). The relationship between the compliance level of the
participants and the psychological response is given in Table 5.

\textbf{3.6 The Relationship between Data on Areas of Concern and
Psychological Response Levels}

While 236 (6.6\%) of the individuals stated that they did not have
anxiety and the pandemic was exaggerated, the remaining 3313
participants (93.4\%) stated that they experienced more or less anxiety.
Participants were most concerned about the health of their families and
relatives (82.4\%). Considering the distribution of concerns according
to age groups, 63.46\% (n=331) of the people between the ages of 18-25
were experiencing academic anxiety mostly. While 60.4\% (n=539) of the
people between the ages of 26-35 were worried about the other people,
the object of the anxiety of the individuals of 36 years old and above
was based on the health of their families and relatives. The group with
the most common economic anxiety was those with monthly income between
2500-5000 TL (n=463, 46.3\%). 536 (54.5\%) of 983 people with chronic
diseases were worried about taking the medications that they should use
regularly.

The anxiety of one's health had an enhancing effect by 1.56 times (p
\textless{}0.001, OR= 1.565) for anxiety and 1.49 times for trauma
(p\textless{}0.001, OR=1.49). Anxiety for the health of relatives
increased the stress level by about 1.99 times (p= 0.01, OR=1.992).
Experiencing economic anxiety had a 1.25 times increasing effect on
trauma formation (p=0.042, OR=1.254). While experiencing academic
anxiety only had 1.30 times increasing effect on the risk of depression
(p = 0.028, OR = 1.305), the anxiety that treatment of the disease could
not be found and safety anxiety was a risk-increasing factor in all
areas of psychological response (p\textless{}0.001). Experiencing
anxiety while taking medications that should be used regularly increased
1.75 times the risk of anxiety (p=0.02, OR=1.755) had an enhancing
effect. Experiencing fear of going to health controls had an enhancing
effect by 1.39 times (p=0.003, OR=1.39) for depression, 1.363 times (p =
0.025, OR = 1.363) for stress and 1.269 times (p=0.031, OR=1.269) for
trauma. The relationship between the areas of concern and the level of
psychological response is given in Table 6.

\textbf{4 DISCUSSION}

This study provides important data regarding the impact of the pandemic
in Turkey. First of all, it was detected that the society was
significantly affected by the pandemic. Among the participants in the
study; based on moderate and above psychological effects, anxiety was
found in 15.8\%, depression in 22.6\%, stress in 12.9\%, and trauma in
20.29\%. In a study by the American Psychiatric Association, it was
stated that the COVID-19 epidemic caused anxiety in 50\% of the society
and more than one-third felt that their mental health was seriously
affected.\textsuperscript{17} In the study conducted by Wang et al in
the normal population in the second week of the pandemic, it was
observed that 53.8\% of the participants had a psychological response,
16.5\% with depression, 28.8\% with anxiety, and 8.1\% with high
stress.\textsuperscript{8} Although the data obtained were close to the
rates determined in China, they differed in terms of low IES-R rates.
This result is probably related to the reduction of the acute effect of
the pandemic in the community since the study was performed at the 6th
week of the epidemic. On the other hand, the fact that Turkey was not
one of the first countries experiencing the outbreak, and had time to
establish certain infrastructure related to the outbreak may be
associated with lower trauma scores. However, since there is no previous
study in our country, such a comparison is not possible to be made.

Epidemiological studies on epidemics or disasters have shown that
sociodemographic variables are associated with different levels of
psychological response. Women,\textsuperscript{18-20} young
people,\textsuperscript{21} people with higher
education,\textsuperscript{22} health
workers,\textsuperscript{23}students,\textsuperscript{24} those with low
economic income,\textsuperscript{25} people with or without a history of
any disease\textsuperscript{26} and smokers\textsuperscript{27} are
emphasized in the literature for having higher rates of psychological
response.

In our study, in accordance with the literature, young age, being
single, an excessive number of people living together, presence of
psychiatric disease history, and female gender were identified as higher
risk conditions in terms of high psychological responce. However,
contrary to the literature, high education levels significantly reduced
the risk of anxiety and depression, while smoking, lack of health
insurance, or low level of economic income were not associated with
psychological exposure. This result may be due to the effects of
cultural and/or religious differences among communities on human
behavior and perceptions.

While studies in the literature have shown that societies use the
internet and social media as a general information source and the posts
here play a role in psychological influence.\textsuperscript{6,28} In
our study, it was seen that most of the participants use
television/radio as a source of information and this fact is not related
to psychological influence. Although Turkish society has high levels of
internet usage, the fact that the main source of information is
expressed as TV/radio may be due to the low belief in the news on the
internet. On the other hand, the feeling of trust towards TV may be
resulted from the fact of authorized institutions' regular and effective
TV use during the pandemic. As a matter of fact, the high degree of
satisfaction and belief in the information obtained supports this
relationship.

Another conclusion drawn from our study is; although very few of the
participants were diagnosed with COVID-19, contrary to the
literature,\textsuperscript{29} interestingly, it has been found that
being treated for COVID-19 infection is not related to psychological
affect. Moreover, being quarantined and having a test reduced the level
of psychological response.

On the other hand, although there was no diagnosis of COVID-19, the
presence of symptoms suggestive of any infection, and a history of
contact with an individual or object infected with COVID-19 were also
factors that increased the risk of psychological response in
individuals. This result seems to be a reflection of the anxiety
developed in accordance with the nature of ``uncertainty''. In the
literature, ``uncertainty'' is accepted as causing a series of
cognitive, emotional, and behavioral damage in the process of time. It
is also considered as a ``basic component of all anxiety disorders''
which reduces problem-solving ability.\textsuperscript{30} Accordingly,
taking precautions such as regular sharing of information that will
eliminate this uncertainty during the days of pandemic intensification,
dissemination of diagnostic tests can contribute positively to the
mental health of the society.

According to previous studies, despite social differences, there is a
relationship between compliance with the measures taken and
psychological impact.\textsuperscript{23} In the study of Wang et al.,
compliance with precautionary measures has been shown to reduce the
psychological response.\textsuperscript{8} In our study which is
consistent with the literature, it was found that the majority of the
participants to be complying with the measures taken although Turkish
society has been facing such a pandemic for the first time in its
history. It has been also remarkable that people's adaptation with the
rules to have a positive effect on psychological response. It is an
expected result for a society in which people state that they pay more
attention to the health of their relatives rather than their own and
that they do not feel psychologically uncomfortable. In addition, it has
been observed that regular exercise, a balanced diet, and attention to
sleep patterns are protective factors in psychological response.
However, it was found that most of the participants complied with these
measures at a lower rate. Therefore, raising awareness of the society
for these measures which are effective in psychological and biological
empowerment seems to provide significant benefits in combating
pandemics.

When the areas where the participants are concerned are evaluated,
similar to previous pandemic studies,\textsuperscript{31} the first 3
places respectively were the health of family and relatives, anxiety to
infect others, and going to health controls. However, it was seen that
the characteristics of the individuals during the pandemic caused
anxiety about different issues. For example, academic anxiety was the
primary concern among young people aged 18-25. The individuals with the
most economic concerns were those with a monthly income of 2500-5000 TL
and university graduates. A remarkable result here was that people's
anxiety about taking medications that they had to take constantly
increased their stress levels by 75.5\%. Biologically at risk of further
damage than COVID-19\textsuperscript{32} this anxiety of the people is
an important situation in terms of disruption of the treatments and
subsequent serious health problems. Unfortunately, our study on why
people bear this concern has not been able to provide a clear
explanation. However, in our opinion, presenting information that has
not been confirmed about whether or not some drugs can be taken in the
media seems to cause more confusion and anxiety. Therefore, preventing
information pollution about COVID-19 and making necessary explanations
to these people at risk, will contribute to the reduction of anxiety
levels, and it seems to contribute positively to the lives of these
people with physical illness.

\textbf{Limitations and Conclusion}

Although this study has reached a relatively high sample size from
different strata of the society, inviting participants to the study in
an electronic environment has prevented those who do not have this
opportunity and those who do not read or speak Turkish. Therefore, the
results may not reflect the general population. In addition, due to the
cross-sectional type of research, its place in the determination of
psychological effects in the long term is limited. This indicates that
follow-up studies are needed to determine the long-term effects of the
pandemic.

Despite all these limitations, our study provides important data in
terms of determining the changes in the mental health of society and
related factors. These outcomes can guide in determining and directing
the measures to be taken now and in the future.

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