INTRODUCTION

The first case of confirmed COVID-19 was detected in Victoria, Australia, on January 25, 2020,1 and then subsequently found in other Australian states among returned travelers. The international borders were closed to all noncitizens and nonresidents in March 2020 to reduce the number of infections coming in from overseas.2 However, as local transmission increased, a number of measures were put in place to reduce opportunities for infection. Those measures included increased access to COVID-19 screening, social distancing, working from home, restriction of visitors to home gatherings, closure of educational facilities (schools, TAFE, and universities), introduction of remote learning, and restrictions to visitors to health services and aged care residences.3 At that stage, the wearing of face masks was not compulsory. In June 2020, a second wave of infections affected Victoria, spreading rapidly, with a peak of 687 infections/cases being reported in 1 day. Another period of lockdown was commenced and mandatory mask wearing was introduced, along with nightly curfews and the restriction of movement to a 5 km radius, which remained until November 22, 2020. While COVID transmission in regional Victoria occurred at lower levels than in Melbourne and some restrictions were lifted earlier, there were several outbreaks and cases (n = 610) in the Barwon South West region of Victoria. Those outbreaks mostly occurred around workplaces, such as abattoirs and aged care, and were linked to the movement of people from infected metropolitan to regional areas.4

Rural or regional areas are resource-stretched with specialists, doctors, nurses, and mental health worker shortages commonplace.5 Globally, there have been examples where regional villages have managed to reduce COVID-19 spread by proactively undertaking community screenings, enforcing social isolation, communicating actively with their communities, and reducing contagion through restrictions.6 In response to the COVID-19 outbreak in Victoria, some regional health services focused their services to prepare and manage potential outbreaks and concentrate heavily on prevention, detection, screening, community communication, and clinical management of suspected cases. That involved redeployment of staff to areas, such as drive-through screening clinics and respiratory assessment clinics (RACs), which included the likely contact with active COVID-19 cases. Such modified service delivery from hospital settings, along with the ongoing fear of coronavirus spread in communities, might increase stress levels for patients with health conditions that put them at higher risk for COVID-19.

Australian government pandemic restrictions have resulted in social, economic, and health consequences, affecting both health-seeking behaviors of Australians and the manner of interactions with health care workers.7, 8 A recent report in The Lancet highlighted the adverse effects of the pandemic, both on people with diagnosed mental illness and the general population's mental health being exacerbated by fear, self-isolation, and stigma.9 In response to the growing global pandemic and potential COVID-19 spread across Victoria, COVID-19 screening clinics were established at Hamilton Base Hospital (300 km west of Melbourne) and South West Health Care, 256 km south west of Melbourne, to enable community members with respiratory symptoms or concerns of contact to be swabbed.10, 11 Both Hamilton and South West Health Care catchments extend to the South Australian border with some of the region's working population commuting or transporting goods and livestock into South Australia.

Frontline health care workers were redeployed and rostered to assess attendees clinically and collect swabs if they met the latest and ever-changing testing criteria. Attendees were then instructed to self-isolate at home until the results were returned, usually within 48 hours; however, initially this was up to 168 hours (7 days).11 Pathology swabs had to be sent to Melbourne (300 km away) for analysis and then returned to the health service, resulting in delays of return of results to attendees.

Frontline health care workers reported stress due to the risk of transmission from confirmed, suspected, or asymptomatic cases, working with new and frequently shifting testing criteria, and the continual wearing of personal protective equipment (PPE).12, 13 Health care workers also reported anxiousness when returning home and possibly exposing their families to the risk of COVID-19. Higher rates of infection were reported among health care workers globally, particularly in staff undertaking testing.14

Focusing on the psychological impact of current and future outbreaks was important, as evidence from previous epidemics suggests that not only short-term but also long-term impacts could occur.15, 16 Improving our approach to community screening, whether through drive-through or community clinics, was important for both the current COVID-19 pandemic and for future operation. In this study, we aimed to assess the extent of psychological distress, fear of COVID-19, and coping strategies among attendees at 2 COVID119 screening clinics in regional/rural Victoria, Australia.

MATERIALS AND METHODS Study design and settings

This was a cross-sectional study. Two COVID-19 clinics, one a drive-through and the other an RAC, were selected as study sites. Those sites are approximately 100 km apart by road with one based in a predominantly agricultural setting and the other with a larger population, in manufacturing, agriculture, meatworks, and tourism. Both sites are more than 250 km away from metropolitan Melbourne. The study was conducted during January to February 2021 and included clinic attendees from July 2020 to February 2021 inclusive.

Study population

Participants, ≥18 years of age, capable of responding to an online questionnaire in English, and residing in rural/regional settings of Western Victoria, were invited to participate. The study participants included patients (attendees), who presented at the study screening sites, irrespective of test results for COVID-19 from July 2020 to February 2021. Participants who partially completed the questionnaire were excluded. In addition, participants who took <1 minute to complete the survey were excluded from the analyses to avoid information bias.

Sampling

All participants fulfilling the inclusion criteria were invited to participate. Sample size was calculated using OpenEpi. Considering a total population of 120,718 (covering the study hospital's catchment areas of Warrnambool and the South-West region),17 assuming 50% prevalence of stress among Australians, 95% confidence intervals (CIs), and 80% power, the estimated minimum sample size was 383 at each site. Therefore, we aimed for a total of 766 participants as our total sample size.

Data collection

The 2 selected COVID-19 screening clinics operated independently of each other by the respective health services. Nevertheless, the services operated in a similar manner. Attendees who presented at the clinics for screening were treated as “patients” and their personal contact details were recorded by a health care worker during the screening process. Attendee details, including phone numbers, were saved and stored in the TrakCare® Electronic Medical Record System (InterSystems Corp, Cambridge, MA) at the relevant health service. Health information teams at both study sites extracted the mobile phone numbers securely from TrakCare®, which generated a list of deidentified mobile numbers (no names or other information) that was passed on securely to the research team.

An SMS was sent to all extracted mobile phone numbers with a short message inviting them to participate in the study. Invitations to complete the survey were generic, not specifically addressed to any individual, and were sent from Western District Health Service. The SMS included a QR code and the link to the online survey. Since the screening clinics were operating during the data collection period, eligible attendees at both clinics were also invited to participate with the study information included on the screening clinics handout. If anyone was interested in participating in the study, they were advised to hold their mobile phone over the QR code, which directed them to the survey on their phones immediately. The online survey was also advertised on flyers posted at the screening clinics.

The web-based survey was developed using the Qualtrics (Provo, UT) surveying platform by Federation University Australia. The first screen contained a Plain Language Information Statement (PLIS) and Consent Form. Only the participants who provided consent and agreed to participate in the study could move to the next screen containing the self-administered survey.

Study tool

A structured survey based on previously published studies by the first author (MAR) was used and adapted for this cohort.18, 19 Following the initial screening questions to confirm eligibility, the survey included questions on sociodemographics, self-reported comorbidities, behavioral risk factors, exposure and contact history of COVID-19, psychological distress (Kessler K-10),20 fear of COVID-19 (FCV-19S),21 and coping strategies (Brief Resilient Coping Scale – BRCS).22 Access to mental health resources and specific support pertaining to COVID-19 from the Victorian Department of Health and Human Services was also provided. Psychometric properties of the English version of those 3 tools were examined recently during the COVID-19 pandemic period, which demonstrated significant reliability for use among migrants and nonmigrants in Australia.23

Data analyses

Data were analyzed using SPSS v.25 (IBM Corp., Armonk, NY) and STATA v.12 (StataCorp LLC, College Station, TX). At first, study variables were analyzed for descriptive information. In addition to calculating proportions for categorical variables, mean and standard deviations were calculated for continuous variables. Based on the scoring from the K-10 scale, we categorized participants into low to moderate (score 10-21) and high to very high (score 22-50) psychological distress. BRCS scores were categorized into low (score 4-13) and medium to high (score 14-20) for resilient coping. Chi-square tests were used to compare responses according to age groups, gender, exposure history, comorbidities, and so on, for each study outcome (psychological distress, fear of COVID-19, and coping). We determined association through the P value of < .05 and strength of association was determined by binary logistic regression, which provided odds ratio (OR) and 95% CI. We considered sociodemographic variables (age, gender, living status, born in Australia, education, and employment) as potential confounders, which were adjusted during multivariate analyses, and we reported adjusted OR (AOR) with 95% CI.

Ethics

We obtained approval from the Human Research Ethics Committee at both Federation University Australia and South West Healthcare. All the responses were anonymous; therefore, no information which could identify any individual was collected. The PLIS included contact information for BeyondBlue, Lifeline, and Victorian government mental health resources on COVID-19.

RESULTS

A total of 10,599 people, who went through screening at both sites during the study period and had their mobile numbers listed, received the invitations to participate in this study. Among them, a total of 702 people (7%) participated. About two-thirds of the participants (452, 64%) had their tests undertaken at South West Healthcare at Warrnambool and the remainder (250, 36%) at Western District Health Service in Hamilton.

Mean age (±SD) of the participants was 49 (±15.8) years and the majority (386, 55%) were aged between 30 and 59 years. More than two-thirds were female (481, 69%), the majority (615, 88%) were born in Australia, and 302 participants (43%) identified themselves as frontline or essential service workers (such as health care workers, police, supermarket workers, ambulance, farmer, veterinarian, child protection, meat factory workers, taxi driver, petrol station attendants, teacher, and kerbside collection worker). About two-thirds (456, 65%) reported that COVID-19 did not have any impact on their financial situation and 16 participants (2%) reported losing their job due to the COVID-19 pandemic. A quarter of attendees (178, 25%) reported having multiple comorbidities and 121 (17%) reported having psychiatric/mental health issues. A quarter of the participants (175, 25%) reported smoking occasionally and 51 (7%) smoked at least monthly. Since July 2020, 46% (n = 19) of those who reported smoking daily (n = 41) increased smoking. More than two-thirds (486, 69%) reported current alcohol drinking, 21% (n = 101) reported consuming stronger alcohol, and 20% (n = 97) reported increased alcohol drinking since July 2020. Study participants had an average of 2 tests, 289 (41%) participants reported more than 1 test, and only 7 participants (1%) reported positive test results for COVID-19 (Table 1).

TABLE 1. Characteristics of the study population Characteristics Total, n (%) Total study participants 702 Age (in years) 702 Mean (±SD) 49 (15.8) Range 18-87 Age groups 702 18-29 years 102 (14.5) 30-59 years 386 (55.0) ≥60 years 214 (30.5) Gender 702 Male 215 (30.6) Female 481 (68.5) Others 1 (0.1) Prefer not to say 5 (0.7) Born in Australia 702 Yes 615 (87.6) No 87 (12.4) Living status 702 Live alone 108 (15.4) Live with family members (partner and/or children) 518 (73.9) Live with others (shared accommodation/others) 75 (10.7) Completed level of education 700 Grade 1-12 144 (20.6) Trade/Certificate/Diploma 228 (32.6) Bachelor and above 328 (46.9) Self-identification as a frontline or essential service worker 702 Yes 302 (43.0) No 400 (57.0) COVID-19 impacted financial situation 701 No impact 456 (65.0) Positively 90 (12.8) Negatively 155 (22.1) Number of comorbidities 697 No 376 (53.9) Single comorbidity 143 (20.5) Multiple comorbidities 178 (25.4) Specific comorbidities 697 No 376 (53.9) Psychiatric/mental health issues 121 (17.4) Other comorbiditiesa 200 (28.7) Smoking 702 Never smokers 14 (2.0) Ex-smokers 462 (65.8) Current smokers (daily/weekly/monthly/occasionally) 226 (32.2) Increased smoking since July 2020 (among daily smokers) 51 Yes 19 (37.3) No 32 (62.7) Current alcohol drinking 700 Yes 486 (69.4) No 214 (30.6) Frequency of alcohol drinking 486 Everyday 38 (7.8) More than 5 times a week 43 (8.8) 2-4 times a week 154 (31.7) Once a week 67 (13.8) Only on weekends 65 (13.4) On special occasions 119 (24.5) Stronger alcohol drinking 486 Yes 101 (20.8) No 385 (79.2) Increased alcohol drinking since July 2020 486 Yes 97 (20.0) No 389 (80.0) Provided care to a family member/patient with known/suspected case of COVID-19 702 Yes 59 (8.4) No 643 (91.6) Identification as a patient/health care service use since July 2020 702 Yes 284 (40.5) No 418 (59.5) Health care service use to overcome COVID-19-related stress since July 2020 702 Yes 47 (6.7) No 655 (93.3) Test sites 702 Hamilton Base Hospital, Drive through 236 (33.6) Hamilton Base Hospital, Accident and Emergency 14 (2.0) South West Healthcare, Respiratory Clinic 93 (13.2) South West Healthcare, Drive/Walk through 359 (51.1) Number of tests done 539 Mean (±SD) 2 (1.3) Mode 1 Range 0-10 a(Stroke/hypertension/hyperlipidemia/diabetes/cancer/chronic respiratory illness). Psychological distress

The mean score (±SD) for psychological distress on the K10 tool was 17 (±7), with 1 in 5 participants (156, 22%) experiencing high to very high levels of psychological distress (score 22-50) in the previous 4 weeks (Table 2). High to very high psychological distress was associated with those who had a single comorbidity (AOR 3.70, 95% CI: 2.25-6.08) or multiple comorbidities (AOR 5.74, 95% CI: 3.38-9.74), who had psychiatric/mental health issues (AOR 10.4, 95% CI: 6.25-17.2) or other comorbidities (AOR 1.84, 95% CI: 1.08-3.14), daily smokers who had increased their smoking (AOR 5.71, 95% CI: 1.04-31.4), and those who increased alcohol drinking (AOR 2.03, 95% CI: 1.21-3.40) since July 2020, who identified themselves as patients/visited health care services since July 2020 (AOR 1.91, 95% CI: 1.30-2.79), who had higher levels of fear of COVID-19 (AOR 3.26, 95% CI: 1.93-5.53), and who used health care service to overcome COVID-19-related stress since July 2020 (AOR 4.79, 95% CI: 2.56-8.99). On the other hand, low to moderate psychological distress was associated with being >30 years old (Table 3).

TABLE 2. Level of psychological distress among the study participants Anxiety and Depression Checklist (K10) (last 4 weeks) Total, n (%) About how often did you feel tired out for no good reason? 702 None 213 (30.3) A little 184 (26.2) Sometime 209 (29.8) Most of the time 72 (10.3) All the time 24 (3.4) About how often did you feel nervous? 702 None 266 (37.9) A little 208 (29.6) Sometime 179 (25.5) Most of the time 43 (6.1) All the time 6 (0.9) About how often did you feel so nervous that nothing could calm you down? 702 None 532 (75.8) A little 113 (16.1) Sometime 48 (6.8) Most of the time 6 (0.9) All the time 3 (0.4) About how often did you feel hopeless? 702 None 472 (67.2) A little 127 (18.1) Sometime 74 (10.5) Most of the time 24 (3.4) All the time 5 (0.7) About how often did you feel restless or fidgety? 702 None 331 (47.2) A little 200 (28.5) Sometime 122 (17.4) Most of the time 38 (5.4) All the time 11 (1.6) About how often did you feel so restless you could not sit still? 702 None 483 (68.8) A little 149 (21.2) Sometime 57 (8.1) Most of the time 9 (1.3) All the time 4 (0.6) About how often did you feel so depressed? 702 None 381 (54.3) A little 184 (26.2) Sometime 94 (13.4) Most of the time 37 (5.3) All the time 6 (0.9) About how often did you feel that everything was an effort? 702 None 275 (39.2) A little 248 (35.3) Sometime 100 (14.2) Most of the time 62 (8.8) All the time 17 (2.4) About how often did you feel so sad that nothing could cheer you up? 702 None 502 (71.5) A little 126 (17.9) Sometime 55 (7.8) Most of the time 17 (2.4) All the time 2 (0.3) About how often did you feel worthless? 702 None 498 (70.9) A little 113 (16.1) Sometime 60 (8.5) Most of the time 24 (3.4) All the time 7 (1.0) K10 score (total) 702 Mean (±SD) 17.1 (7.1) Range 10-46 Level of psychological distress (K10 categories) 702 Low (score 10-15) 366 (52.1) Moderate (score 16-21) 180 (25.6) High (score 22-29) 100 (14.2) Very high (score 30-50) 56 (8.0) TABLE 3. Factors associated with psychological distress among the study population (based on K10 score) High to very high (score 22+), n (%) Low to moderate (score 10-21), n (%) Unadjusted analyses Adjusted analyses Characteristics P OR 95% CIs P AOR 95% CIs Total study participants 156 546     Age groups 156 546     18-29 years 41 (26.3) 61 (11.2)   1   1 30-59 years 81 (51.9) 305 (55.9) .000 0.40 0.25-0.63 .018 0.51 0.30-0.89 ≥60 years 34 (21.8) 180 (33.0) .000 0.28 0.16-0.48 .001 0.33 0.17-0.62 Gender 153 543     Male 38 (24.8) 177 (32.6)   1   1 Female 115 (75.2) 366 (67.4) .067 1.46 0.97-2.20 .445 1.18 0.77-1.82 Living status 155 546     Live alone 32 (20.6) 76 (13.9) .042 1.61 1.01-2.54 .794 1.10 0.54-2.25 Live with family members (partner and/or children) 95 (61.3) 423 (77.5) .000 0.46 0.31-0.67 .109 0.60 0.32-1.12 Live with others (shared accommodation/others) 28 (18.1) 47 (8.6) .001 2.34 1.41-3.89 NA NA NA Born in Australia 156 546     No 18