Front. Psychiatry Frontiers in Psychiatry Front. Psychiatry 1664-0640 Frontiers Media S.A. 10.3389/fpsyt.2022.860683 Psychiatry Original Research Psychological Distress, Fear and Coping Strategies During the Second and Third Waves of the COVID-19 Pandemic in Southern Germany Elsayed Mohamed 1 * Schönfeldt-Lecuona Carlos 1 2 † Welte Xenia Anna 1 Dardeer Khaled Tarek 3 Kamal Manar Ahmed 4 Abdelnaby Ramy 5 Rudek Markus A. 6 Riedel Evelyne 7 Denkinger Michael 2 8 Gahr Maximilian 1 Connemann Bernhard J. 1 Alif Sheikh M. 9 Banik Biswajit 10 Cross Wendy 10 Rahman Muhammad Aziz 10 11 * † 1Department of Psychiatry and Psychotherapy III, University of Ulm, Ulm, Germany 2Geriatric Center Ulm (GZU), Ulm, Germany 3Faculty of Medicine, Cairo University, Cairo, Egypt 4Faculty of Medicine, Benha University, Benha, Egypt 5Department of Neurology, RWTH Aachen University, Aachen, Germany 6Division of Nephrology, University of Heidelberg, Heidelberg, Germany 7Center of Psychiatry (ZfP), Biberach, Germany 8Agaplesion Bethesda Clinic, Geriatric Research Unit Ulm University, Ulm, Germany 9School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia 10School of Health, Federation University Australia, Berwick, VIC, Australia 11Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia

Edited by: Mohammadreza Shalbafan, Iran University of Medical Sciences, Iran

Reviewed by: Nabi Nazari, Lorestan University, Iran; Abdorreza Naser Moghadasi, Tehran University of Medical Sciences, Iran

 *Correspondence: Mohamed Elsayed mohamed.elsayed@mein.gmx Muhammad Aziz Rahman ma.rahman@federation.edu.au; aziz.rahman@y7mail.com

This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry

†These authors have contributed equally to this work

 25 04 2022 2022 13 860683 23 01 2022 22 03 2022 Copyright © 2022 Elsayed, Schönfeldt-Lecuona, Welte, Dardeer, Kamal, Abdelnaby, Rudek, Riedel, Denkinger, Gahr, Connemann, Alif, Banik, Cross and Rahman. 2022 Elsayed, Schönfeldt-Lecuona, Welte, Dardeer, Kamal, Abdelnaby, Rudek, Riedel, Denkinger, Gahr, Connemann, Alif, Banik, Cross and Rahman

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

 Background

The COVID-19 pandemic has imposed enormous psychological discomfort and fear across the globe, including Germany.

 Objectives

To assess the levels of COVID-19 associated psychological distress and fear amongst Southern German population, and to identify their coping strategies.

 Methods

A cross-sectional survey using an online questionnaire was conducted in healthcare and community settings in the region of Ulm, Southern Germany. Assessment inventories were the Kessler Psychological Distress Scale (K-10), the Brief Resilient Coping Scale (BRCS), and the Fear of COVID-19 Scale (FCV-19S), which were valid and reliable tools.

 Results

A total of 474 Individuals participated in the study. The mean age was 33.6 years, and 327 (69%) were females. Most participants (n = 381, 80.4%) had high levels of psychological distress, whereas only 5.1% had high levels of fear, and two-thirds of participants showed higher levels of coping. Moderate to very high levels of psychological distress were associated with being female, living alone, distress due to employment changes, experiencing financial impact, having multiple co-morbidities, being a smoker, increased alcohol use over the previous 6 months, contact with COVID-19 cases and healthcare providers for COVID-19-related stress. Individuals who were ≥60 years, lived with non-family members, had co-morbidities and visited a healthcare provider had higher levels of fear. Higher levels of education and income showed better coping amongst participants.

 Conclusion

Psychological distress was very high during the COVID-19 pandemic in Germany and associated with low levels of coping. This study identified vulnerable groups of people, who should be given priorities for addressing their health and wellbeing in future crisis periods.

 COVID-19 psychological distress fear cross-sectional survey coping mental health Germany Introduction

The coronavirus disease (COVID-19) has spread into 222 countries and territories worldwide and the World Health Organization (WHO) declared a global public health emergency on 30 January 2020 (1). As of 23 November 2021, Germany reported more than five million confirmed cases and almost 100,000 deaths from COVID-19 (2). This led to enact public health measures by the Government such as physical distancing, canceling large gatherings, imposing travel restrictions and lockdown in large cities, ensuring obligatory quarantine for positive cases, primary close contacts, along with closing of educational institutions. The lockdown also resulted in the closure of many small businesses, and the unemployment rate increased to 4.1% in summer 2020 compared to 3.1% just before the pandemic (3). Ongoing restrictions also impacted on the physical and mental health of the population, especially older adults with multiple comorbidities (4). Ongoing social isolation and uncertainty of further COVID-19 pandemic waves could potentially trigger long-term mental disorders (5).

Furthermore, Unemployment and social isolation were associated with risky behaviors such as increased tobacco and alcohol consumption (6). Lockdown measures and social distancing restrictions caused a shift to telehealth facilities (7). Previous studies showed that healthcare workers engaged in the diagnosis and management of COVID-19 patients were more prone to psychological distress and various mental disorders, such as depression, anxiety, anger, fear of spreading the infection to their relatives, friends, or colleagues (8, 9).

Studies from several countries around the world including Germany found that the pandemic caused higher psychological distress, anxiety, and depression amongst a large proportion of community members (10–16). Studies also showed that depression, stress, and anxiety during the pandemic triggered sleep disorders and increased consumption of tobacco and alcohol (17). However, with increased vaccination rates and easing of restrictions, impacts may change during the current pandemic waves. Although there are previously published studies that assessed anxiety, fear and distress amongst community members and healthcare workers in Germany during the COVID-19 pandemic, the existing evidence lacks a full understanding of the impacts of the pandemic on mental health and coping strategies amongst the public in Germany and identification of the relevant predictors. Therefore, this study aimed to assess the levels of psychological distress, fear of the COVID-19 disease, and coping strategies among a wide range of population in Germany; it also aimed to identify critical factors associated with those outcomes. The population subgroups who were at higher risk of developing poor mental health outcomes would be identified in this study, which would enable the policymakers to optimize psychosocial interventions targeted to those vulnerable groups of population and guide resource planning to avoid long-term mental health impacts.

 Materials and Methods Study Design and Setting

A cross-sectional study was conducted according to The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement Checklist (18). This study was a part of a large study involving 17 countries and was led by the last author (10). Participants were informed about the study using social media and received the link of the questionnaire through social media or by emails. In addition, Quick Response (QR) codes were used on professional posters in outpatient clinics to inform patients about the study and invite participation. Data were collected from healthcare settings, including General Practices, hospitals, allied health professionals, and community settings, using a structured self-administered online questionnaire (10, 13, 14, 19).

 Study Population

Adult participants who were ≥18 years old with the capacity to respond to an online questionnaire in German language were included in three main groups: (a) patients who attended a healthcare setting, either for face-to-face or telehealth consultation in the last 4 weeks irrespective of respiratory/COVID-19 symptoms, (b) healthcare workers (full time, part-time or casual) who have been in contact with patients in the last 4 weeks in a healthcare setting (doctor, nurses, allied health professionals, technicians, patient service attendants, receptionists, etc.) irrespective of caring for respiratory/COVID-19 patients, and (c) community members who did not consult any healthcare provider in the last 4 weeks.

 Data Collection

An online link to the web-based questionnaire was developed using Google forms to collect data from February to April 2021 during the second and third waves of the COVID-19 pandemic. According to Robert Koch Institute, the second German wave began in October 2020 (https://www.shorturl.at/shortener.php), while the third wave started in March 2021 (https://www.shorturl.at/loqHP). Initially, there was a screening question related to age to confirm eligibility; subsequently data were collected on: (a) socio-demographics as age, gender, location of residence, marital status, living conditions (alone or with families), the highest level of education, country of birth; (b) profession as a primary occupation, the impact of COVID-19 on occupation, identification as a frontline healthcare worker; (c) self-reported comorbidities as hypertension, cardiovascular diseases, chronic respiratory diseases, diabetes, cancer; (d) behavioral risk factors as current smoking, alcohol intake; (e) health service utilization (in the last 4 weeks) as consultation with a healthcare provider for any symptom, admission to the hospital including reasons for admission; (f) exposure and contact history of COVID-19, test and diagnosis of COVID-19, close contact, isolation and quarantine status; (g) psychological impact measured by the Kessler Depression Scale (K-10) (20), and fear measured by the Fear of COVID-19 Scale (FCV) (21); (h) coping strategies measured by the Brief Resilient Coping Scale (BRCS) (22); and (j) access to mental health resources (in the last four weeks) (see Appendix 1).

 Study Tools Kessler Psychological Distress Scale (K10)

The K10 scale is a 10-item self-rated questionnaire that measures distress based on depressive and anxiety symptoms. Each item has five possible answers (none of the time = 1, a little of the time = 2, some of the time = 3, most of the time = 4, all of the time = 5) allowing for a total score of 50. A score of 10–15 is likely to be well, 16–29 is medium risk for anxiety or depression and 30–50 is high risk for anxiety or depressive symptoms (20). Cronbach's alpha for this tool was 0.902, which was satisfactory.

 Fear of COVID-19 Scale (FCV-19S)

The FCV-19S is a seven-item scale that assesses fear of COVID-19 among the general population. Each item has five possible answers (strongly disagree = 1 disagree = 2 neutral = 3 agree = 4 strongly agree = 5) allowing for a maximum score of 35, a score of 7-22 is considered low fear and 23–35 is considered high fear of COVID-19 (21). Cronbach's alpha for this tool was 0.82, which was satisfactory.

 Brief Resilient Coping Scale (BRCS)

The BRCS is a 4-item scale that measures a psychological well-being construct: resilience. Each item is a 5-point response (does not describe me at all = 1, does not describe me = 2, neutral = 3, describes me = 4, describes me very well = 5). The maximum possible score is 20, and it is categorized into low resilience (score 4–13), medium resilience (score 14–16) and high resilience (Score 17–20) (22). Cronbach's alpha for this tool was 0.758, which was satisfactory.

 Sample Size Calculation

All participants fulfilling the inclusion criteria were invited to participate. Considering Germany's population of 84 million according to World Population Prospects (23), the prevalence of lifetime mental health issues amongst Germans was 31.1% (24), at 95% confidence intervals, margin of error (5%), and 80% power, the required sample size was 329. The sample size was calculated using Open Epi Info software version 7.2. Convenient sampling was used to recruit the study participants by following snowball sampling.

 Ethics

Ethical approval was obtained from the Research Ethical Committee (REC) of the Ulm University (Ethical Approval Number 448/20 – FSt/Sta).

 Statistical Analysis

International Business Machines Corporation (IBM) Statistical Package for the Social Sciences (SPSS) statistics software version 25 was used for data analysis. Descriptive analyses were conducted and followed by inferential analyses. Continuous variables were presented as mean ± standard deviation (SD), while categorical variables were presented as numbers and percentages. Internal consistency of the instruments was calculated using Cronbach's alpha. The study outcomes were categorized into binary variables as follows: K-10 score was categorized into low (score 10–15) and moderate to very high (score 16–50), FCV-19S score was categorized into low (score 7–21) and high (score 22–35) and BRCS score was defined into low (score 4–13) and medium to high (score 14–20) resilient copers. Univariate and multivariate logistic regression (adjusted for age, gender, born in Germany, living status, employment status, level of education) were performed to explore the association between population characteristics and the study's outcomes. Odds ratios (ORs), adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs) were obtained. Firth logistic regression with penalized maximum likelihood was used for fear of COVID-19 outcome as the number of events was relatively low for the number of adjusted variables. To measure the association between distress, fear and coping, partial rank correlation was conducted on the overall score as a continuous variable for each scale. This was done after controlling for potential confounding factors (age, gender, born in Germany, living status, employment status and level of education). P values less than 0.05 were considered statistically significant.

 Results Population Characteristics

A total of 474 people participated in the study. The mean age of the participants was 33.6 (13.3) years, and 327 (69%) were females. Most of them were born in Germany (89.9%, n=426), and around half lived with family members (48.5%, n = 230). Two-thirds (62.4%, n = 296) of the participants had a source of income during the pandemic, and only 2.1% (n = 10) had their jobs affected by the pandemic. Half of the participants (57%, n = 270) reported change in the employment situation, and half of them (49.4%, n = 196) had higher perceived distress due to that change. About half participants (47.3%, n = 224) self-identified as essential service workers and 54.6% (n = 259) reported being healthcare workers. Only 7.4% (n = 35) participants reported having psychiatric or mental health issues, although a quarter of the participants (24.1%, n = 114) perceived their mental health status as poor to fair. Table 1 shows the characteristics of included participants, and Tables 2–4 shows multivariate analyses of psychological distress, fear, and coping.

Baseline demographic characteristics of the participants (N = 474).

Characteristic No. %
Age 474
Mean (± SD) 33.6 ± 13.32
Age groups 474
18–29 232 48.9
30–59 220 46.4
>60 22 4.6
Gender 474
Female 327 69.0
Born in Germany 474
Yes 426 89.9
Living status 474
Live with family members 230 48.5
Live with non-family members 145 30.6
Live alone 99 20.9
Highest educational/vocational qualification 474
Secondary/Higher Secondary/Grade 7 to 12 188 39.7
Certificate/Diploma/Trade qualifications 83 17.5
Bachelor/Masters/PhD 203 42.8
Current employment condition 474
Unemployed/Housewife/Homemaker/Home duties (No source of income) 168 35.4
Jobs affected by COVID-19 (lost job/working hours reduced/afraid of job loss) 10 2.1
Have an income source (employed/Government benefits) 296 62.4
Perceived distress due to change of employment status 397
A little to none 201 50.6
Moderate to a great deal 196 49.4
Improved working situation due to change of employment status 406
A little to none 352 86.7
Moderate to a great deal 54 13.3
Self-identification as frontline or essential service worker 474
Yes 224 47.3
Self-identification as a healthcare worker 474
Yes, doctor 64 13.5
Yes, nurse 18 3.8
Yes, another healthcare worker 177 37.3
COVID-19 impacted the financial situation 474
Yes, impacted positively 43 9.1
Yes, impacted negatively 67 14.1
Affected by the change in a financial situation 474
Not at all 198 41.8
Unsure 53 11.2
Somewhat 130 27.4
A great extent 39 8.2
Co-morbidities 474
Psychiatric/Mental health problem 35 7.4
Other co-morbidities* 102 21.5
Co-morbidities 474
Single co-morbidity 98 20.7
Multiple co-morbidities 43 9.1
Perceived status of own mental health 474
Good to Excellent 360 75.9
Poor to Fair 114 24.1
Smoking 474
Ever smoker (Daily/Nondaily/Ex) 59 12.4
Increased smoking over the last 6 months 59
Yes 24 41.7
Current alcohol drinking (last 4 weeks) 474
Yes 200 42.2
Increased alcohol drinking over the last 6 months 200
Yes 46 23
Contact with known/suspected case of COVID-19 474
Unsure 51 10.8
Yes, I had indirect contact 78 16.5
Yes, provided direct care 105 22.2
Experience related to COVID-19 pandemic 474
No known exposure to COVID-19 334 70.5
Treated in hospital / Ordered to quarantine/ Tested positive / Lived with someone who had COVID-19 123 25.9
Traveled overseas and had to quarantine 17 3.6
Self-identification as a patient (visited a healthcare provider in the last 6 months) 474
Yes 224 47.3
If yes, which type of healthcare did you use? (Multiple responses) 268
Visit a primary care physician or health care professional 184 68.7
Telehealth consultation (online or by phone) with a general practitioner, specialist, or health professional 10 3.7
I was tested for COVID-19 at a special test site 42 15.7
Hospital emergency room 8 3.0
I was in a hospital for other reasons 24 9.0
Healthcare service used to overcome COVID-19 related stress in the last 6 months 474
Yes 25 5.3
If yes, which type of healthcare did you receive? (Multiple responses) 61
Consulted a primary care physician 26 42.6
Consulted a psychologist 17 27.9
Consulted a psychiatrist 4 6.6
Used specialty mental health services (hospital, community mental health services, inpatient mental health services) 2 3.3
Used mental health resources (pamphlets, brochures, leaflets, and books provided by mental health staff and distributed at hospital) 3 4.9
Mental health resources used and available through media (methods and techniques of psychological support provided by psychologists through online media, television news, or various online and social networking platforms) 5 8.2
Mental health support services used (including mental health program) 4 6.6

Data are presented as the mean and standard deviation (SD) or number (n) and percentage (%).

COVID-19, Coronavirus Disease 19; K-10, Kessler Depression Scale; FCV, Fear of Coronavirus-19 Scale; BRCS, Brief Resilient Coping Scale.

Cardiac diseases/ Stroke/ Hypertension/ Hyperlipidaemia/ Diabetes/ Cancer/ Chronic respiratory illness.

Factors associated with high psychological distress among the study population (based on K10 scoring).

Characteristics Low distress High distress Unadjusted analysis Adjusted analysis*
n % n % p ORs 95% CIs p AORs 95% CIs
Age groups 93 381
18–29 23 9.9 209 90.1 Ref Ref
30–59 58 26.4 162 73.6 <0.001 0.31 0.18 0.52 0.029 0.41 0.18 0.91
>60 12 54.5 10 45.5 <0.001 0.09 0.04 0.24 0.000 0.10 0.03 0.33
Gender 93 381
Male 51 34.7 96 65.3 Ref Ref
Female 42 12.8 285 87.2 <0.001 3.61 2.26 5.76 0.000 4.04 2.41 6.77
Born in the same country of residence 93 381
No 7 14.6 41 85.4 Ref Ref
Yes 86 20.2 340 79.8 0.357 1.48 0.64 3.42 0.055 0.41 0.16 1.02
Living status 93 381
Live with family members 63 27.4 167 72.6 Ref Ref
Live with non-family members 16 11.0 129 89.0 <0.001 3.04 1.68 5.51 0.530 1.32 0.55 3.17
Live alone 14 14.1 85 85.9 0.011 2.29 1.21 4.32 0.041 2.05 1.03 4.01
Highest educational/vocational qualification 93 381
Secondary/Higher Secondary/Grade 7 to 12 21 11.2 167 88.8 Ref Ref
Certificate/Diploma/Trade qualifications 23 27.7 60 72.3 0.001 0.33 0.17 0.64 0.094 0.49 0.21 1.13
Bachelor/Masters/PhD 49 24.1 154 75.9 0.001 0.40 0.23 0.69 0.317 0.68 0.32 1.44
Current employment condition 93 381
Unemployed/Housewife/Home maker/Home duties (No source of income) 22 13.1 146 86.9 Ref Ref
Jobs affected by COVID-19 (lost job/working hours reduced/afraid of job loss) 1 10.0 9 90.0 0.778 1.36 0.16 11.23 0.272 3.56 0.37 34.23
Have an income source (employed/Government benefits) 70 23.6 226 76.4 0.007 0.49 0.29 0.82 0.522 1.27 0.61 2.63
Perceived distress due to change of employment status 68 329
A little to none 47 23.4 154 76.6 Ref Ref
Moderate to a great deal 21 10.7 175 89.3 0.001 2.54 1.45 4.44 0.001 2.85 1.54 5.27
Improved working situation due to change of employment status 72 334
A little to none 65 18.5 287 81.5 Ref Ref
Moderate to a great deal 7 13.0 47 87.0 0.327 1.52 0.66 3.52 0.735 1.17 0.48 2.85
Self-identification as a frontline or essential service worker 93 381
No 44 17.6 206 82.4 Ref Ref
Yes 49 21.9 175 78.1 0.243 0.76 0.48 1.20 0.656 1.15 0.63 2.08
Self-identification as a healthcare worker 93 381
No 37 17.2 178 82.8 Ref Ref
Yes, doctor 16 25.0 48 75.0 0.166 0.62 0.32 1.22 0.199 1.80 0.73 4.42
Yes, nurse 2 11.1 16 88.9 0.51 1.66 0.37 7.54 0.385 2.08 0.40 10.79
Yes, other healthcare worker 38 21.5 139 78.5 0.287 0.76 0.46 1.26 0.538 0.82 0.43 1.55
COVID-19 impacted financial situation 93 381
No impact 80 22.0 284 78.0 Ref Ref
Yes, impacted positively 6 14.0 37 86.0 0.228 1.74 0.71 4.26 0.286 1.74 0.63 4.78
Yes, impacted negatively 7 10.4 60 89.6 0.035 2.41 1.06 5.49 0.006 3.61 1.45 9.00
Affected by the change in financial situation 79 341
Not at all 55 27.8 143 72.2 Ref Ref
Unsure 6 11.3 47 88.7 0.017 3.01 1.22 7.45 0.046 2.78 1.02 7.61
Somewhat 16 12.3 114 87.7 0.001 2.74 1.49 5.04 0.001 3.34 1.67 6.68
A great extent 2 5.1 37 94.9 0.008 7.12 1.66 30.35 0.009 7.51 1.66 33.94
Co-morbidities 93 381
No 66 19.6 271 80.4 Ref Ref
Psychiatric/Mental health problem 3 8.6 32 91.4 0.123 2.60 0.77 8.74 0.095 2.97 0.83 10.64
Other co-morbidities* 24 23.5 78 76.5 0.388 0.79 0.47 1.35 0.622 0.86 0.48 1.56
Co-morbidities 93 381
No 64 19.2 269 80.8 Ref Ref
Single co-morbidity 24 24.5 74 75.5 0.256 0.73 0.43 1.25 0.400 0.77 0.42 1.42
Multiple co-morbidities 5 11.6 38 88.4 0.232 1.81 0.68 4.78 0.042 3.12 1.04 9.33
Perceived status of own mental health 93 381
Good to Excellent 93 25.8 267 74.2 Ref
Poor to Fair 0 0.0 114 100.0 0.002 80.04 4.93 1,300.40 No. is too low to estimate
Smoking 93 381
Never smoker 88 21.2 327 78.8 Ref Ref
Ever smoker (Daily/Nondaily/ Ex) 5 8.5 54 91.5 0.027 2.91 1.13 7.49 0.007 4.13 1.48 11.58
Increased smoking over the last 6 months 5 54
No 5 14.3 30 85.7 Ref
Yes 0 0.0 24 100.0 0.14 8.83 0.46 167.70 0.112 6.69 0.70 886.78
Current alcohol drinking (last 4 weeks) 93 381
No 51 18.6 223 81.4 Ref Ref
Yes 42 21.0 158 79.0 0.518 0.86 0.55 1.36 0.958 1.10 0.61 1.70
Increased alcohol drinking over the last 6 months 42 158
No 39 25.3 115 74.7 Ref Ref
Yes 3 6.5 43 93.5 0.011 4.86 1.43 16.55 0.019 4.77 1.29 17.61
Contact with known/suspected case of COVID-19 93 381
No 58 24.2 182 75.8 Ref
Unsure 10 19.6 41 80.4 0.486 1.31 0.62 2.77 0.542 1.30 0.56 3.02
Yes, had indirect contact 10 12.8 68 87.2 0.037 2.17 1.05 4.48 0.043 2.26 1.03 4.98
Yes, provided direct care 15 14.3 90 85.7 0.041 1.91 1.03 3.56 0.017 2.33 1.17 4.68
Experience related to COVID-19 pandemic 93 381
No known exposure to COVID-19 80 24.0 254 76.0 Ref Ref
Treated in hospital / Ordered to quarantine/ Tested positive / Lived with someone who had Covid-19 11 8.9 112 91.1 0.001 3.21 1.64 6.26 0.009 2.59 1.26 5.30
Traveled overseas and had to quarantine 2 11.8 15 88.2 0.260 2.36 0.53 10.55 0.428 1.89 0.39 9.06
Self-identification as a patient (visited a healthcare provider in the last 6 months) 93 381
No 54 21.6 196 78.4 Ref Ref
Yes 39 17.4 185 82.6 0.252 1.31 0.83 2.07 0.271 1.34 0.80 2.26
Level of fear of COVID-19 (FCV- 19S categories) 93 381
Low (score 7–21) 91 20.2 359 79.8 Ref Ref
High (score 22–35) 2 8.3 22 91.7 0.170 2.79 0.64 12.08 0.142 3.26 0.67 15.74
Level of coping (BRCS categories) 93 381
Low resilient coping (score 4– 13) 24 15.2 134 84.8 Ref Ref
Medium to high resilient coping (score 14–20) 69 21.8 247 78.2 0.087 0.64 0.39 1.07 0.097 0.61 0.34 1.09
Healthcare services used to overcome COVID-19 related stress in the last 6 months 93 381
No 93 20.7 356 79.3 Ref Ref
Yes 0 0.0 25 100.0 0.004 13.37 1.84 1,702.70 0.006 13.58 1.77 1,752.73

Data are presented as number (n) and percentage (%). P ≤ 0.05 were considered statistically significant.

ORs, Odds Ratio; AOR, Adjusted Odds Ratio; CI, Confidence Interval; Ref, Reference category; COVID-19, Coronavirus Disease 19; K-10, Kessler Depression Scale; FCV, Fear of Coronavirus-19 Scale; BRCS, Brief Resilient Coping Scale.

Adjusted for Age, Gender, born in Germany, living status, employment status and level of education.

Bold indicated statistical significance.

 Psychological Distress

After adjusting for potential confounders, multivariate analyses showed that being a female, living alone, those with distress due to employment change, worsened financial situation, having multiple co-morbidities, smoking, increased alcohol consumption over the last 6 months, contact with COVID-19 case whether direct or indirect, direct experience of COVID-19 and healthcare use to overcome pandemic stress in the last 6 months were associated with moderate to very high levels of psychological distress (Table 2).

 Fear of COVID-19

Multivariate logistic regression showed that being over 60, living with non-family members, those having a diploma or a trade qualification, those with single or multiple comorbidities, perceived mental health status as poor to fair, direct experience of COVID-19, visiting a health care provider in the past 6 months and using healthcare service to overcome pandemic related stress in the last 6 months were associated with higher levels of fear of COVID-19 (Table 3).

Factors associated with high levels of fear of COVID-19 among the study population (based on FCV-19S scoring).

Characteristics Low levels of fear High levels of fear Unadjusted analyses Adjusted analysis
n % n % p ORs 95% CIs p AORs 95% CIs
Age groups 450 24
18–29 223 96.1 9 3.9 Ref Ref
30–59 209 95.0 11 5.0 0.564 1.30 0.53 3.21 0.091 3.40 0.84 17.49
> ≥60 18 81.8 4 18.2 0.009 5.51 1.54 19.65 0.002 13.93 2.66 84.21
Gender 450 24
Male 144 98.0 3 2.0 Ref Ref
Female 306 93.6 21 6.4 0.057 3.29 0.97 11.22 0.057 2.74 0.97 10.44
Born in the same country of residence 450 24
No 47 97.9 1 2.1 Ref Ref
Yes 403 94.6 23 5.4 0.340 2.68 0.35 20.32 0.651 1.46 0.34 13.62
Living status 450 24
Live with family members 221 96.1 9 3.9 Ref Ref
Live with non-family members 136 93.8 9 6.2 0.316 1.63 0.63 4.20 0.041 4.12 1.06 17.39
Live alone 93 93.9 6.1 3.9 0.395 1.58 0.55 4.58 0.164 2.19 0.71 6.35
Highest educational/vocational qualification 450 24
Secondary/Higher Secondary/Grade 7 to 12 178 94.7 10 5.3 Ref Ref
Certificate/Diploma/Trade qualifications 77 92.8 6 7.2 0.540 1.39 0.49 3.95 0.034 7.75 1.19 40.49
Bachelor/Masters/PhD 195 96.1 8 3.9 0.517 0.73 0.28 1.89 0.756 1.21 0.37 4.08
Current employment condition 450 24
Unemployed/Housewife/Home maker/Home duties (No source of income) 161 9.8 7 5.1 Ref Ref
Jobs affected by COVID-19 (lost job/working hours reduced/afraid of job loss) 8 80.0 2 20.0 0.047 5.75 1.03 32.25 0.978 0.98 0.29 3.23
Have an income source (employed/Government benefits) 281 94.9 15 5.1 0.661 1.23 0.49 3.07 0.451 0.65 0.21 2.01
Perceived distress due to change of employment status 375 22
A little to none 189 94.0 12 6.0 Ref Ref
Moderate to a great deal 186 94.9 10 5.1 0.706 0.85 0.36 2.01 0.616 0.79 0.31 1.96
Improved working situation due to change of employment status 384 22
A little to none 332 94.3 20 5.7 Ref Ref
Moderate to a great deal 52 96.3 2 3.7 0.553 0.64 0.15 2.81 0.932 1.06 0.21 3.64
Self-identification as a frontline or essential service worker 450 24
No 237 94.8 13 5.2 Ref Ref
Yes 213 95.1 11 4.9 0.886 0.94 0.41 2.15 0.982 1.01 0.37 2.93
Self-identification as a healthcare worker 450 24
No 201 93.5 14 6.5 Ref Ref
Yes, doctor 63 98.4 1 1.6 0.157 0.23 0.03 1.77 0.345 0.42 0.04 2.41
Yes, nurse 15 83.3 3 16.7 0.126 2.87 0.74 11.11 0.453 1.87 0.34 9.02
Yes, other healthcare worker 171 96.6 6 3.4 0.169 0.50 0.19 1.34 0.121 0.41 0.13 1.27
COVID-19 impacted financial situation 450 24
No impact 349 95.9 15 4.1 Ref Ref
Yes, impacted positively 40 93.0 3 7.0 0.395 1.75 0.48 6.29 0.184 2.48 0.61 7.85
Yes, impacted negatively 61 91.0 6 9.0 0.099 2.29 0.86 6.13 0.163 2.30 0.70 6.66
Affected by the change in financial situation 450 24
Not at all 188 94.9 10 5.1 Ref Ref
Unsure 51 96.2 2 3.8 0.700 0.74 0.16 3.47 0.940 0.94 0.16 3.76
Somewhat 124 95.4 6 4.6 0.858 0.91 0.32 2.57 0.896 0.93 0.31 2.63
A great extent 36 92.3 3 7.7 0.511 1.57 0.41 5.98 0.340 1.94 0.46 6.64
Co-morbidities 450 24
No 320 95.0 17 5.0 Ref Ref
Psychiatric/Mental health problem 33 94.3 2 5.7 0.864 1.14 0.25 5.16 0.429 1.84 0.34 6.72
Other co-morbidities* 97 95.1 5 4.9 0.954 0.97 0.35 2.70 0.590 1.33 0.44 3.55
Co-morbidities 450 24
No 326 97.9 7 2.1 Ref Ref
Single co-morbidity 89 90.8 9 9.2 0.003 4.71 1.71 13.00 0.001 5.76 2.01 17.44
Multiple co-morbidities 35 81.4 8 18.6 <0.001 10.65 3.64 31.12 <0.001 9.48 2.89 32.19
Perceived status of own mental health 450 24
Good to Excellent 350 97.2 10 2.8 Ref Ref
Poor to Fair 100 87.7 14 12.3 <0.001 4.90 2.11 11.37 <0.001 5.83 2.41 15.02
Smoking 450 24
Never smoker 392 94.5 23 5.5 Ref Ref
Ever smoker (Daily/Nondaily/ Ex) 58 98.3 1 1.7 0.235 0.29 0.04 2.22 0.167 0.35 0.04 1.46
Increased smoking over the last 6 months 58 1
No 35 100.0 0 0.0 Ref Ref
Yes 23 95.8 1 4.2 0.361 4.53 0.18 116.04 0.334 3.48 0.27 276.80
Current alcohol drinking (last 4 weeks) 450 24
No 258 94.2 16 5.8 Ref Ref
Yes 192 96.0 8 4.0 0.370 0.67 0.28 1.60 0.377 0.68 0.27 1.59
Increased alcohol drinking over the last 6 months 192 8
No 147 95.5 7 4.5 Ref Ref
Yes 45 97.8 1 2.2 0.481 0.47 0.06 3.90 0.928 0.92 0.10 4.72
Contact with known/suspected case of COVID-19 450 24
No 230 95.8 10 4.2 Ref Ref
Unsure 50 98.0 1 2.0 0.464 0.46 0.06 3.68 0.942 0.94 0.10 4.36
Yes, had indirect contact 70 89.7 8 10.3 0.050 2.63 1.00 6.92 0.057 2.64 0.97 7.07
Yes, provided direct care 100 95.2 5 4.8 0.803 1.15 0.38 3.45 0.513 1.47 0.44 4.46
Experience related to COVID-19 pandemic 450 24
No known exposure to COVID-19 322 96.4 12 3.6 Ref Ref
Treated in hospital / Ordered to quarantine/ Tested positive / Lived with someone who had Covid 112 91.1 11 8.9 0.025 2.64 1.13 6.14 0.021 3.09 1.19 8.12
Traveled overseas and had to quarantine 16 94.1 1 5.9 0.630 1.68 0.21 13.71 0.149 4.95 0.49 26.65
Self-identification as a patient (visited a healthcare provider in the last 6 months) 450 24
No 244 97.6 6 2.4 Ref Ref
Yes 206 92.0 18 8.0 0.008 3.55 1.39 9.12 0.024 2.81 1.14 7.77
Level of psychological distress (K10 categories) 450 24
Low (score 10–15) 91 97.8 2 2.2 Ref
Moderate to Very High (score 16–50) 359 94.2 22 5.8 0.170 2.79 0.64 12.08 0.162 2.61 0.71 14.59
Level of coping (BRCS categories) 450 24
Low resilient coping (score 4–13) 147 93.0 11 7.0 Ref
Medium to high resilient coping (score 14–20) 303 95.9 13 4.1 0.187 0.57 0.25 1.31 0.190 0.56 0.23 1.35
Healthcare services used to overcome COVID-19 related stress in the last 6 months 450 24
No 433 96.4 16 3.6 Ref
Yes 17 68.0 8 32.0 <0.001 12.74 4.79 33.84 <0.001 15.26 4.88 48.84

Data are presented as number (n) and percentage (%). P-values ≤ of 0.05 were considered statistically significant.

ORs, Odds Ratio; AOR, Adjusted Odds Ratio; CI, Confidence Interval; Ref, Reference category; COVID-19, Coronavirus Disease 19; K-10, Kessler Depression Scale; FCV, Fear of Coronavirus-19 Scale; BRCS, Brief Resilient Coping Scale.

Adjusted for Age, Gender, born in Germany, living status, employment status and level of education.

Bold indicated statistical significance.

 Coping Strategies

Multivariate analyses revealed that having an income source and being a healthcare worker were associated with higher levels of coping. Conversely, higher levels of education, distress due to change in employment, worsened financial situation due to the pandemic, and perceived status of mental health as poor to fair were the factors that predicted lower levels of coping amongst the study participants (Table 4).

Factors associated with coping among the study population (based on BRCS scoring).

Characteristics Low levels of coping High levels of coping Unadjusted analysis Adjusted analysis
n % n % p ORs 95% CIs p AORs 95% CIs
Age groups 158 316
18–29 81 34.9 151 65.1 Ref Ref
30–59 71 32.3 149 67.7 0.553 1.13 0.76 1.66 0.830 0.94 0.52 1.69
>60 6 27.3 16 72.7 0.472 1.43 0.54 3.80 0.687 1.25 0.43 3.66
Gender 158 316
Male 45 30.6 102 69.4 Ref Ref
Female 113 34.6 214 65.4 0.400 0.84 0.55 1.27 0.547 0.87 0.56 1.36
Born in the same country of residence 158 316
No 18 37.5 30 62.5 Ref Ref
Yes 140 32.9 286 67.1 0.519 1.23 0.66 2.28 0.788 1.09 0.57 2.11
Living status 158 316
Live with family members 69 30.0 161 70.0 Ref Ref
Live with non-family members 48 33.1 97 66.9 0.528 0.87 0.55 1.35 0.753 1.11 0.59 2.06
Live alone 41 41.4 58 58.6 0.045 0.61 0.37 0.99 0.063 0.61 0.36 1.03
Highest educational/vocational qualification 158 316
Secondary/Higher Secondary/Grade 7 to 12 61 32.4 127 67.6 Ref Ref
Certificate/Diploma/Trade qualifications 33 39.8 50 60.2 0.245 0.73 0.43 1.24 0.013 0.43 0.22 0.83
Bachelor/Masters/PhD 64 31.5 139 68.5 0.846 1.04 0.68 1.60 0.034 0.53 0.29 0.95
Current employment condition 158 316
Unemployed/Housewife/Home maker/Home duties (No source of income) 73 43.5 95 56.5 Ref Ref
Jobs affected by COVID-19 (lost job/working hours reduced/afraid of job loss) 4 40.0 6 60.0 0.831 1.15 0.31 4.24 0.525 1.56 0.40 6.08
Have an income source (employed/Government benefits) 81 27.4 215 72.6 <0.001 2.04 1.37 3.04 <0.001 3.33 1.90 5.87
Perceived distress due to change of employment status 116 236
A little to none 53 26.4 148 73.6 Ref Ref
Moderate to a great deal 81 41.3 115 58.7 0.002 0.51 0.33 0.78 0.003 0.51 0.33 0.80
Improved working situation due to change of employment status 140 266
A little to none 116 33.0 236 67.0 Ref Ref
Moderate to a great deal 24 44.4 30 55.6 0.1 0.61 0.34 1.10 0.189 0.67 0.36 1.22
Self-identification as a frontline or essential service worker 158 316
No 97 38.8 153 61.2 Ref Ref
Yes 61 27.2 163 72.8 0.008 1.69 1.15 2.50 0.370 1.26 0.76 2.08
Self-identification as a healthcare worker 158 316
No 90 41.9 125 58.1 Ref Ref
Yes, doctor 24 37.5 40 62.5 0.534 1.20 0.68 2.13 0.482 0.76 0.36 1.63
Yes, nurse 5 27.8 13 72.2 0.249 1.87 0.64 5.44 0.534 1.45 0.45 4.64
Yes, other healthcare worker 39 22.0 138 78.0 <0.001 2.55 1.63 3.98 0.016 1.91 1.13 3.24
COVID-19 impacted financial situation 158 316
No impact 114 31.3 250 68.7 Ref Ref
Yes, impacted positively 14 32.6 29 67.4 0.869 0.95 0.48 1.86 0.669 0.86 0.43 1.73
Yes, impacted negatively 30 44.8 37 55.2 0.033 0.56 0.33 0.96 0.023 0.51 0.29 0.91
Affected by the change in financial situation 145 275
Not at all 61 30.8 137 69.2 Ref Ref
Unsure 23 43.4 30 56.6 0.087 0.58 0.31 1.08 0.091 0.57 0.29 1.10
Somewhat 37 28.5 93 71.5 0.650 1.12 0.69 1.82 0.843 1.05 0.63 1.75
A great extent 24 61.5 15 38.5 <0.001 0.28 0.14 0.57 <0.001 0.23 0.11 0.47
Co-morbidities 158 316
No 111 32.9 226 67.1 Ref Ref
Psychiatric/Mental health problem 17 48.6 18 51.4 0.067 0.52 0.26 1.05 0.061 0.49 0.24 1.03
Other co-morbidities* 30 29.4 72 70.6 0.504 1.18 0.73 1.91 0.954 0.99 0.60 1.63
Co-morbidities 158 316
No 102 30.6 231 69.4 Ref Ref
Single co-morbidity 38 38.8 60 61.2 0.131 0.70 0.44 1.11 0.110 0.66 0.40 1.10
Multiple co-morbidities 18 41.9 25 58.1 0.140 0.61 0.32 1.17 0.144 0.59 0.29 1.20
Perceived status of own mental health 158 316
Good to Excellent 87 24.2 273 75.8 Ref Ref
Poor to Fair 71 62.3 43 37.7 <0.001 0.19 0.12 0.30 <0.001 0.20 0.13 0.33
Smoking 158 316
Never smoker 133 32.0 282 68.0 Ref Ref
Ever smoker (Daily/Nondaily/ Ex) 25 42.4 34 57.6 0.117 0.64 0.37 1.12 0.110 0.62 0.34 1.12
Increased smoking over the last 6 months 25 34
No 16 45.7 19 54.3 Ref Ref
Yes 9 37.5 15 62.5 0.531 1.40 0.49 4.05 0.349 1.99 0.47 8.38
Current alcohol drinking (last 4 weeks) 158 316
No 89 32.5 185 67.5 Ref Ref
Yes 69 34.5 131 65.5 0.645 0.91 0.62 1.34 0.375 0.83 0.55 1.25
Increased alcohol drinking over the last 6 months 69 131
No 52 33.8 102 66.2 Ref Ref
Yes 17 37.0 29 63.0 0.690 0.87 0.44 1.73 0.423 0.74 0.35 1.55
Contact with known/suspected case of COVID-19 158 316
No 85 35.4 155 64.6 Ref Ref
Unsure 24 47.1 27 52.9 0.121 0.62 0.34 1.14 0.153 0.64 0.34 1.18
Yes, had indirect contact 19 24.4 59 75.6 0.072 1.70 0.95 3.04 0.077 1.70 0.95 3.06
Yes, provided direct care 30 28.6 75 71.4 0.215 1.37 0.83 2.26 0.290 1.32 0.79 2.20
Experience related to COVID-19 pandemic 158 316
No known exposure to COVID- 19 116 34.7 218 65.3 Ref Ref
Treated in hospital / Ordered to quarantine/ Tested positive / Lived with someone who had Covid-19 38 30.9 85 69.1 0.442 1.19 0.76 1.86 0.378 1.23 0.78 1.93
Traveled overseas and had to quarantine 4 23.5 13 76.5 0.348 1.73 0.55 5.42 0.278 1.92 0.59 6.20
Self-identification as a patient (visited a healthcare provider in the last 6 months) 158 316
No 79 31.6 171 68.4 Ref Ref
Yes 79 35.3 145 64.7 0.398 0.85 0.58 1.24 0.446 0.86 0.58 1.27
Level of fear of COVID-19 (FCV- 19S categories) 158 316
Low (score 7–21) 147 32.7 303 67.3 Ref Ref
High (score 22–35) 11 45.8 13 54.2 0.187 0.57 0.25 1.31 0.201 0.55 0.22 1.38
Level of distress K-10 Score categories) 158 316
Low (score 10–15) 24 25.8 69 74.2 Ref Ref
Moderate to Very High (score 16–50) 134 35.2 247 64.8 0.087 0.64 0.39 1.07 0.130 0.64 0.36 1.14
Healthcare services used to overcome COVID-19 related stress in the last 6 months 158 316
No 146 32.5 303 67.5 Ref Ref
Yes 12 48.0 13 52.0 0.115 0.52 0.23 1.17 0.184 0.55 0.23 1.33

Data are presented as number (n) and percentage (%). P ≤ of 0.05 were considered statistically significant.

ORs, Odds Ratio; AOR, Adjusted Odds Ratio; CI, Confidence Interval; Ref, Reference category; COVID-19, Coronavirus Disease 19; K-10, Kessler Depression Scale; FCV, Fear of Coronavirus-19 Scale; BRCS, Brief Resilient Coping Scale.

Adjusted for Age, Gender, Born in Germany, living status, employment status and level of education.

Bold indicated statistical significance.

 Association Between Psychological Distress, Coping and Fear of COVID-19

The K-10 distress score correlated significantly with the FCV-19S score (spearman's r = 0.331, p < 0.001), the BRCS score showed an inverse relationship with the distress and fear scores (spearman's r = −0.276 and – 0.173, p < 0.001). People with higher distress had higher levels of fear of COVID-19 and lower coping. On the other hand, people with better coping had lower distress and fear of COVID-19 (Table 5).

Association between psychological distress, coping and fear of COVID-19 using spearman's partial rank correlation.

Variables Distress Fear of COVID Coping
Distress 1 0.331* −0.276*
Fear of COVID 1 −0.173*
Coping 1

Controlling for Age, Gender, born in Germany, living status, employment status and level of education.

Significant at p < 0.001 level.

 Discussion

Moderate to very high levels of psychological distress were associated with being a female, living alone, suffering employment change or worsening the financial situation, and poor mental health, smoking and alcohol consumption. Higher levels of fear of COVID-19 were markable in people of ≥60 years, or those with comorbidities or poor mental health. Having an income source and being a healthcare worker was associated with higher levels of coping.

During the COVID-19 pandemic, the course of psychological disturbances which were associated with psychological distress, fear, and coping strategies among the community members including healthcare workers across the world were well-studied (25). Our study can be seen as a supplement to a global cross-sectional study involving 17 countries (10). The same online instruments were used like the prior global study led by the last author (MAR), but the current study adapted German language. In this study, more females participated than males, which was in line with other similar German studies (16, 26–28) in the first wave of the pandemic, and also supports an Australian (10), Egyptian (15), Bangladeshi (14), Malaysian (13), and global study (10). A possible explanation might be that women were more inclined to share their experiences by participating in the study or women were more impacted due to the pandemic, lockdown or financially that prompted them to participate in the study. The mean age (33.6 years) showed that the study participants of this study were younger than those who were included in similar German studies (16, 26, 27).

For the issue of psychological distress in this study, there were more participants with moderate to very high distress, which was in line with the results of previous studies conducted in Germany (27), Australia (10), Malaysia (13), Bangladesh (14), Hong Kong (19) and globally (10), as well as other studies (28–31). Furthermore, similar to this study, previous studies (10, 13, 14, 27) also reported that females and younger respondents had higher psychological distress compared to the reference group. A previous study showed that women seemed to be more impacted by the pandemic in terms of wellbeing than men (32). According to the findings of this study, the common factors associated with moderate to very high levels of psychological distress were being females, those with change in the employment status, and worsening the financial situation, which was supported by earlier evidence (10, 13, 14). Similarly, Hetkamp and Schweda (33) found that respondents reported reduced sleep quality and moderate generalized anxiety and psychological burdens. A possible explanation could be that participants might experience crucial interference with their everyday lives, which was likely to increase psychological distress while the accessibility of conventional mental health care was limited (25). It could also be assumed that uncertainties about the novel coronavirus, its progression, and variable nature of pandemic, and availability and access to the varied range of evidence also could contribute to the report of various country-wise reports of moderate to a high level of psychological stress. There was also a higher correlation between potential contact with COVID-19 cases, whether direct or indirect, experience with the pandemic, and healthcare use to overcome pandemic stress.

Regarding the issue of fear in this study, there were more participants with low fear, which supports studies conducted in Bangladesh (14), Australia (10), Malaysia (13), and globally (10). That indicated habituation to the threatening situation of the pandemic. However, generalized anxiety could remain elevated over time due to the ongoing nature of pandemic (33). Similarly, a largescale German study among 3,500 randomly selected participants reported mental health (anxiety, depression) impact shortly after the lockdown came into effect (34). This study identified the factors associated with higher fear of COVID-19, which were similar as reported in the earlier studies: being female, and middle-aged, or over 60 (10, 13, 14). Being born in the same country of residence, and having at least a trade/certificate/diploma or bachelor degree were associated with higher levels of fear in this study, which were similar to the study conducted in Bangladesh (14).

Regarding the issue of coping in this study, there were more participants with high levels of coping, which is supported by the previous Malaysian (13) and the global study (10). High resilience coping could be explained by the long period of pandemic in Germany. Having an income source and being a healthcare worker were associated with higher levels of coping, findings of which were different compared to the previous studies (10, 13, 14). Finally, results showed that the COVID-19 pandemic and subsequent lockdown measures in early 2020 might slow the spread of the virus. However, those restrictions forced a sudden and dramatic change to the daily routines of community people, although not all individuals were impacted in the similar way. Some situational factors such as occupation, family status, financial and health impact, personality traits could influence individuals' experience during the ongoing COVID crisis in Germany (35).

This study had few limitations. The participants were included from the Ulm region in Southern Germany, which limits the generalizability across the whole German territory. Furthermore, it wasn't possible to exclude more responses from distressed individuals than non-distressed individuals, potentially resulting in selection bias. Finally, the study findings were limited to individuals who could access to online platforms in order to participate; therefore, there was limited generalizability due to the focus to internet-literate people. However, due to the lockdown measures applied during data collection, an online survey was the only available option to perform this study. One of the most crucial points in our study was collecting the targeted sample size during the pandemic lockdown period. Lastly, this study was the only German study that assessed the factors associated with psychological distress, fear, and coping strategies during the second and third waves of the COVID-19 pandemic. The data collection period coincided with the transition between the second and third waves in Germany, therefore, it was also not unlikely to have increased prevalence of psychological distress amongst the participants who participated in this study.

 Conclusions

This study identified levels of psychological distress, fear and coping amongst the community members during the COVID-19 pandemic in the Ulm region in Southern Germany. In addition, several factors and risk groups that were associated with those outcomes, were identified. The identified higher risk groups should be prioritized for receiving mental health support from the relevant healthcare providers such as family physicians and psychiatrists, and automated follow-up reminders could be sent through text messages which would prevent further deterioration of mental health conditions.

 Data Availability Statement

The original contributions generated for this study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author/s.

 Ethics Statement

The studies involving human participants were reviewed and approved by the Research Ethical Committee (REC) of the Ulm University (Ethical Approval Number 448/20 – FSt/Sta). The patients/participants provided their written informed consent to participate in this study.

 Author Contributions

ME had substantial contribution to the conception or design of the study, data collection, and scientific writing of the manuscript. CS-L contributed to the conception and revised the manuscript critically. XW coordinated data collection. KD performed the statistical analysis. MK took part in scientific writing. ER, RA, MD, MG, and BC revised the manuscript critically for important intellectual content. SA, BB, and WC provided critical feedback on the narrative structure and methods and results. MAR conceptualized the study, coordinated data collection, provided critical feedback, and revised the manuscript. All authors contributed to the article and approved the submitted version.

 Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

 Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

We would like to acknowledge the support of the study participants, who donated their valuable time to respond to our survey.

 Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2022.860683/full#supplementary-material

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