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Mental Health, Health-related Quality of Life and Behaviors among Outpatients during the COVID-19 Pandemic: A Multiple Hospitals and Health Centers Study in Vietnam

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BackgroundGlobally, the coronavirus disease (COVID-19) pandemic has been placing unprecedented challenges and burdens on various aspects of life, such as economics, culture, politics, education, and healthcare. The uncertainty of COVID-19 increases concerns and fear in the communities, especially i

n those with symptoms like COVID-19 (S-LikeCV19). Additionally, many countries have implemented preventive measures (e.g., lockdown, home confinement, social distancing), leading to considerable changes in peoples’ lives, such as working and learning from home, unemployment, lack of physical connect

ion, and food insecurity. Besides, it is reported that people with underlying health conditions (UHC) and infected with COVID-19 have a higher risk of serious symptoms and complications. Therefore, COVID-19-related factors (e.g., fear, lockdown, S-LikeCV19) and UHC may influence peoples’ psychologic

al health and health behaviors, further lowering their health-related quality of life (HRQoL). Furthermore, people who need health services encountered many challenges during the pandemic, such as difficulties in accessibility, examination and treatment delays, and concerns about COVID-19 infection.

From a public health perspective, it is crucial to understand the impacts of COVID-19-related factors and explore protective factors that can improve lifestyles, psychological health, and HRQoL in outpatients. In addition, due to unavailable specific treatments, non-pharmaceutical interventions (e.g

., adherence to preventive measures, health knowledge improvement, healthy lifestyles) are highly recommended to mitigate the consequences of the COVID-19 pandemic.Therefore, this study was conducted on outpatients during the initial stage of the COVID-19 pandemic for the following purposes:(1) To e

xplore the impacts of UHC, S-LikeCV19, and lockdown on anxiety and depressive symptoms; and examine the modification effects of health behaviors (e.g., eating behaviors, physical activity, smoking, drinking) and preventive behaviors.(2) To explore impacts of UHC, S-LikeCV19, lockdown, and fear of CO

VID-19 (F-CV19) on HRQoL; and examine the modification effects of health literacy, eHealth literacy (eHEALS), digital healthy diet literacy (DDL).(3) To explore impacts of UHC, S-LikeCV19, lockdown, and fear of COVID-19 (F-CV19) on changes in eating behaviors and physical activity; and examine the m

odification effects of eHEALS, DDL.MethodsA cross-sectional study was conducted from 14th February to 31st May 2020 in 18 hospitals and health centers in Vietnam. Data were obtained from 8291 outpatients, including socio-demographic characteristics, UHC, S-LikeCV19, F-CV19, health-related behaviors

(smoking, drinking, eating behaviors, and physical activity), preventive behaviors, eHEALS, DDL, depression (measured by 9-item Patient Health Questionnaire), anxiety (measured by 7-item Generalized Anxiety Disorders), and HRQoL (measured by 36-item Short Form Survey). In addition, multiple linear a

nd logistic regression; and interaction models were performed to explore potential associations.ResultsThe prevalence of anxiety and depression was 12.5% and 22.3%, respectively. Patients with UHC had 3.44 times higher anxiety likelihood and 2.71 times higher depression likelihood, while patients wi

th S-LikeCV19 had 3.31 times higher anxiety likelihood and 3.15 times higher depression likelihood than their counterparts. Similarly, patients under lockdown were 2.39 and 2.89 times more likely to have anxiety and depression than those without lockdown, respectively. Interaction models indicated h

igh compliance with preventive behaviors, unchanged/more physical activity, and unchanged/healthier eating behaviors significantly attenuated the associations of UHC, S-LikeCV19, and lockdown with anxiety and depressive symptoms. In addition, unchanged/more alcohol drinking significantly attenuated

the association between UHC and anxiety. Furthermore, the association between S-LikeCV19 and depression was attenuated by higher health literacy scores in outpatients during the pandemic.This study showed that only fear of COVID-19 was negatively associated with HRQoL (B, -0.79; 95% CI, -0.88 to -0.

70; p < 0.001). Interaction models suggested that the inverse association between F-CV19 and HRQoL was mitigated by higher eHEALS scores or higher DDL scores.Patients with UHC, or with S-LikeCV19, or under lockdown had 54%, 52%, and 62% lower likelihoods of unchanged/healthier eating behaviors, and

21%, 58%, and 22% lower likelihoods of unchanged/more physical activity. Interaction models indicated that the association between lockdown and eating behaviors was significantly attenuated by higher DDL scores. Meanwhile, the association between lockdown and physical activity was significantly miti

gated by higher eHEALS scores. There was no statistically significant interaction of UHC and S-LikeCV19 with DDL and eHEALS on changes in health behavior outcomes.Conclusions:During the pandemic, patients under lockdown period, or with UHC, or S-LikeCV19 were more likely to have anxiety and depressi

ve symptoms; and less likely to have unchanged/healthier eating behaviors and unchanged/more physical activity. In addition, patients with higher F-CV19 were more likely to have poorer HRQoL.High adherence to preventive behaviors, physical activity, and healthy eating behaviors could mitigate the ne

gative impacts of UHC, S-LikeCV19, and lockdown on anxiety and depression. In addition, higher health literacy could mitigate the impact of S-LikeCV19 on depression during the pandemic. Besides, alcohol drinking was found to lower the impact of UHC on anxiety.Moreover, better eHEALS and DDL could mi

tigate the adverse impacts of F-CV19 on HRQoL. Higher eHEALS could help to alleviate the impact of lockdown on physical activity, while higher DDL could mitigate the impact of lockdown on eating behaviors.Our findings provide timely and reliable evidence for appropriate strategies to enhance healthy

lifestyles, preventive behaviors, eHEALS, and DDL, thereby preventing outpatients from psychological disorders and improving their HRQoL during the pandemic.