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Around this time last year we surveyed how the first MCO was affecting the mental health of Malaysians. A year in, how has people’s sense of well-being changed?
By Aziff Azuddin, Ziad Razak & Nelleita Omar4 March 2021
Since the pandemic began last year, the lives of many Malaysians have been upended. For thousands, COVID-19 wreaked direct havoc via bodily infection. For millions of others, the pandemic took a toll on their overall mental and physical health.
Last year, we set out to investigate how the pandemic and the first MCO affected the mental health of Malaysians. We found that over half of our respondents experienced negative mental health. How has the situation changed now, almost a year later? We replicated last year’s study and expanded the scope to include questions on physical health and financial well-being.
In this Part 1 of the research series, we present findings on how the year-long pandemic has affected the overall mental and physical well-being of Malaysians. Part 2 will present findings on the impact of living conditions and work-from-home arrangements while Part 3 will present findings on financial well-being.
The study was conducted via an online survey distributed using a snowball sampling method between 4 February to 14 February 2021. The survey was available in Malay, English and Mandarin.
Given that a snowball sampling method was used, responses to this study do not represent a nationally stratified sample. Hence, we advise readers to interpret the results with this limitation in mind. Similar to our previous study last year, the DASS-21 questionnaire was used to measure mental well-being, specifically the presence and severity of depression, anxiety, and stress.
Developed by researchers at the University of New South Wales in Australia, the DASS-21 questionnaire (a shortened version of the original 42-question list) measures mental well-being based on individuals’ self-assessment of their mental state:
Depression is ascertained via self-reported levels of general dissatisfaction, hopelessness, and lack of interest. Anxiety is ascertained via self-reported levels of reactions to physical situations and the general experience of anxiety. Stress is ascertained via self-reported levels of difficulty in relaxing, agitation, impatience, and over-reactiveness.
*DASS-21 questionnaire table used in our study: https://forms.gle/cTryAn9sx6gvh63U8
The DASS-21 questionnaire does not diagnose depression, anxiety, or stress as a medical condition. While the DASS-21 evaluations can be used by non-psychologists for research such as this study, clinical decisions based on the scores can only be made by experienced clinicians alongside extensive clinical examination.
The scores from the DASS-21 questionnaire can be classified into levels of severity ranging from normal, mild, moderate, severe, to extremely severe (see Figure 1 below).
Figure 1: DASS-21 Scale
936 responses were collected during the study period of which 2 were rejected due to duplication, leaving a sample of 934 responses.
52% of the respondents were female, representing a good gender balance. 50% of respondents were under 35 years of age. Ethnically, 76% were Malay/Bumiputera. Geographically, 74% of respondents came from Central states, which skews this study’s findings more towards urban dwellers.
Figure 2: Respondent Demographics
IMPORTANT NOTE: The responses of the DASS-21 questionnaire measures the intensity of general feelings of depression, anxiety, or stress as reported by respondents. This study is not medically diagnostic. Any clinical diagnosis of mental health or mental illness needs to be done by a qualified professional.
We begin by looking at overall mental well-being levels as reported by respondents via the DASS-21 questionnaire. As shown in Figure 3, depression and anxiety levels are clearly higher overall than stress levels.
58% of respondents reported experiencing levels of depression with 26% reporting severe and extremely severe levels of depression. 56% of respondents reported experiencing levels of anxiety with 31% reporting severe and extremely severe anxiety – the highest among severely felt emotions. Stress appears to have the lowest scores comparatively. 42% of respondents reported experiencing levels of stress with 19% reporting severe and extremely severe stress.
Figure 3: Overall Depression, Anxiety and Stress Scores
A side-by-side comparison with our study last year shows that respondents’ scores representing depression, anxiety and stress are higher this year (Figure 4 below). 58% of respondents reported levels of depression in this year’s study compared to 48% of respondents last year. 56% of respondents reported levels of anxiety this year compared to 45% of respondents last year, while 42% of respondents reported levels of stress this year against 34% of respondents last year. ‘Severe’ and ‘extremely severe’ levels of depression, anxiety and stress as reported by respondents this year also show a marked increase compared to last year.
Figure 4: DASS-21 Score Comparison, 2021 vs. 2020
The above comparison does need to be read with caution as the sample composition between last year and this year is slightly different, as is typical with the snowball sampling method*. While this is not strictly a longitudinal study, the comparison between both years’ well-being scores does indicate a high likelihood of worsened mental well-being overall among the general population within the last year.
Note: Total number of respondents of last year’s study is 1,084 vs. 934 respondents this year. This year’s study sample had a smaller female base at 52% vs. 66% last year and a smaller Malay/Bumiputera demographic (76% compared to last year’s 81%).
In addition to the DASS-21 questionnaire, we also asked respondents how they themselves perceived their mental well-being compared to last year. A significant proportion, 43%, reported no change in their mental well-being but an almost similar proportion, 42%, felt that their mental state had worsened. Only 15% stated that their mental well-being had improved over the past year.
Figure 5: Respondent Self-Perception of Mental Well-being Compared to Last Year
Respondents’ own impressions of how their mental health has changed over the past year correlate very closely to their DASS-21 scores. As shown in Figure 6 below, the incidence and severity of self-reported levels of depression, anxiety and stress are much higher for respondents who felt worse in their mental well-being compared to those who felt better or no change in their mental state within the last year.
Figure 6: Overall Mental Well-being and Relationship with DASS-21 Scores
An interesting point to note is the level of depression, anxiety and stress experienced by those who felt ‘better’ or ‘no change’ in their mental well-being compared to last year. 39% of these respondents feel some level of depression, 39-47% feel some level of anxiety and 22-23% feel some level of stress. This indicates that feeling comparatively ‘better’ mentally does not necessarily mean escaping varying levels of depression, anxiety or stress. A longitudinal study would be necessary to determine whether these are effects from the global pandemic or a base level of mental well-being for Malaysians overall.
Significant demographic differences in mental health effects were clearly seen. One significant difference is gender; more women than men reported experiencing levels of negative mental health. The second major demographic difference is age. Those from younger age groups i.e. ages 18-34 reported worse mental well-being compared to those in older age groups.
Figure 7 shows the gender differences in reported levels of depression, anxiety and stress. Women reported experiencing significantly worse mental well-being than men across the board.
Figure 7: Differences in Mental Well-being According to Gender
More women, 64%, reported experiencing levels of depression compared to 52% of men. In terms of severity, 32% of women reported severe or extremely severe depression compared to 20% of men.
Similarly for anxiety, 61% of women respondents reported experiencing levels of anxiety compared to 50% of their male counterparts. In terms of severity, 37% of women self-reported severe and extremely severe anxiety, compared to 24% of men.
For stress, 50% of women self-reported levels of stress compared to 34% of men. In terms of severity, 22% of women reported experiencing severe and extremely severe stress compared to 15% of men.
There were also gender differences in respondents’ self-assessment of their mental state this year vs. last year. As shown in Figure 8 below, 45% of women reported experiencing worse mental well-being compared to 39% of men. However, slightly more women, 17%, reported better mental well-being compared to men, at 13%.
Figure 8: Differences in Respondent Self-Perception of Mental Well-being Compared to Last Year, by Gender
Younger age groups self-reported significantly higher levels of negative emotions compared to older age groups. As seen in Figure 9a, a whopping 70% to 72% respondents under the age of 35 reported signs of depression compared to 28% to 49% of those in age groups 35 years and above. In terms of severity, age groups under 35 years old reported two to three times more severe or extremely severe depression compared to those aged 35 years and above. The generational difference is quite stark; a worrying 40% of respondents in the 18-24 age group reported severe and extremely severe levels of depression compared to a much lower 9% amongst respondents aged 55 and above.
Figure 9a: Differences in Reported Depression Levels by Age Group
Figure 9b shows similar differences for anxiety, where 66% to 70% of respondents under 35 self-reported levels of anxiety compared to 34% to 48% of those in older age groups. In terms of severity, again, respondents under 35 reported an alarming 40% to 49% of severe or extremely severe anxiety, two to four times higher than those aged 35 and above.
Figure 9b: Differences in Reported Anxiety Levels by Age Group
The pattern continues with regard to stress, with 56 to 61% of those under 35 self-reporting levels of stress, approximately two to three times the stress levels of older age groups. In terms of severity, again, respondents under 35 reported 25% to 31% of severe or extremely severe stress, compared to 8% to 13% amongst those aged 35 and above.
Figure 9c: Differences in Reported Stress Levels by Age Group
The age difference is also clearly seen in respondents’ self-assessment of their mental state this year vs. last year. 51% to 55% of respondents below 35 reported worse mental well-being compared to 22% to 37% of those aged 35 and above. Older age groups particularly those aged 45 years and above appear to be coping comparatively well, with 73% to 78% reporting no change or better mental well-being over the last year.
Figure 10: Differences in Respondent Self-Perception of Mental Well-being Compared to Last Year, by Age
We asked study respondents to name 3 major factors affecting their current mental state. Across all respondents, irrespective of how their mental well-being changed in the last year, one factor was selected much more than others: thoughts about the future (see Figure 11 below). In fact, uncertainty about the future appears to affect those who reported worse mental well-being more than those who reported no change or better mental well-being.
Unsurprisingly, financial situation is another top 3 factor for respondents of all levels of well-being. Perhaps more interestingly, the country’s economic and political direction was selected as a top 3 factor by those who reported no change or worse mental well-being. Malaysia’s economic and political instability could be manifested in the country’s mental health levels, though further study would be needed in order to draw a clearer conclusion.
Figure 11: Top 3 Contributing Factors of Mental Well-being
In tandem with mental well-being, we also looked at how the physical well-being of Malaysians changed over the past year. 49% of the respondents stated that there has been no change, while 32% reported their physical well-being worsening over the past year. Only 19% reported their physical state improving.
Out of the 32% who self-reported their physical well-being worsening over the year, the most frequent choice selected as a top 3 contributing factor was the amount of unhealthy food and beverages consumed (65%). Other top 3 factors selected, in decreasing order, are the amount of cigarettes smoked (55%), the amount of sleep (54%), the frequency of physical exercise (52%) and the quality of sleep (51%).
Figure 12: Respondent Self-Perception of Physical Well-being Compared to Last Year
Figure 13 illustrates a positive relationship between respondents’ mental and physical well-being. Respondents who reported better mental well-being also reported better physical well-being (61%) and vice versa – many respondents who reported worsened mental well-being also reported worsened physical well-being (59%).
Figure 13: Relationship Pattern between Respondents’ Physical and Mental Well-being
To better understand the different ways in which the physical health of Malaysians has changed, we also asked respondents to state changes in key lifestyle behaviours. Sleep and frequency of physical activity appear to have worsened the most.
Figure 14: Changes in Health and Lifestyle Behaviours
Note: ‘Amount of cigarettes smoked’ were indicated only by respondents who reported as smokers. Self-reported smokers comprise only 13% of the total sample.
Lifestyle behaviours correlate closely with respondents’ DASS-21 scores. Taking quality of sleep as one example (Figure 15 below), we can see that depression, anxiety and stress scores are significantly higher in both occurrence and severity for respondents that report worse levels of sleep quality compared to respondents who report no change or better sleep quality. Similar patterns in DASS-21 scores are seen across all the lifestyle behaviours outlined above.
Figure 15: Relationship between Quality of Sleep and Mental Well-being
This study reveals the troubling though not unexpected finding that overall well-being has suffered over the last year of living with a global pandemic. Though not a strictly representative sample, our study does point to a high possibility that mental and physical states have worsened overall over the past year, with a concerning proportion of people reporting severe and extremely severe levels of depression, anxiety or stress. This impact is not equally felt: women and age groups under 35 in particular are disproportionately affected and need special support.
Uncertainty about the future appeared to be the top contributing factor to mental well-being, and although this may progressively improve for some in the course of this year, certain demographics may be facing much more uncertainty than others, such as those graduating from secondary school or university, or those whose jobs are being replaced by pandemic-driven digitalisation.
The connection between mental health and physical health is also clear, one that needs much more policy recognition and attention. The consistent patterns seen between DASS-21 scores with lifestyle behaviours is particularly noteworthy: negative trends in sleep, physical activity and food quality have a tremendous impact on respondents’ mental states (and perhaps also vice versa).
Currently, most of the conversation concerning the pandemic revolves around the just-launched vaccination program and restarting the economy. However, how do we respond and support those who have been, and may likely continue to be, badly affected both mentally and physically by the wider repercussions of the pandemic?
More targeted access to mental health support and facilities is important, especially for groups identified to be more vulnerable than others, i.e. younger age groups, and women. Grassroots movements to increase awareness and encourage help-seeking behaviours among these vulnerable groups should be encouraged and where needed, funded.
Outreach programmes should also encourage preventative health behaviours by making clear the link between mental and physical well-being. This could extend to educating communities on the importance of sleep, nutrition, and exercise, and ways to improve them. While all these initiatives take place, it is important to continue bridging available mental well-being support resources to those who feel overwhelmed by uncertainty about their futures.
In Part 2 of our study, we focus on the impact of living conditions and work-from-home arrangements during the pandemic, while Part 3 will present our findings on how the COVID-19 pandemic has impacted the financial and employment situations of many.
If you are experiencing emotional or mental health difficulties, get support and help on these hotlines: Mercy Malaysia and the Ministry of Health Crisis Preparedness and Response Centre’s psychosocial support hotline at 03-29359935. Ministry of Women and Family Development’s Talian Kasih hotline at 15999 or WhatsApp 019-2615999.