COVID-19 is caused by SARS-CoV-2, which is easily transmitted through droplets and can survive for some time on surfaces. Because the virus spreads quickly, maintaining physical distance, individual hygiene, and wearing a mask are essential for prevention.1 Many countries imposed lockdowns that prevented people from entering and leaving countries and limited residents’ activities, reducing the incidence of COVID-19.2,3 Mass contact tracing also effectively reduced the spread.4,5 Unfortunately, some countries still have difficulties in combating this disease, including Indonesia.6,7
In Indonesia, physical distancing started in the middle of March 2020, about 2 weeks from the announcement of the first case in Jakarta, followed by large-scale social restrictions at the end of March 2020 that included the closing of schools and offices, restrictions on religious activities, and bans on activities in public places.8 This situation was very likely to be stressful for some individuals; fear and anxiety about an illness can be overwhelming. Changes in activity patterns and withdrawal of physical activity led to some confusion, including among mothers.9,10 In the population of mothers, increased responsibilities included teaching the children, performing household chores, and engaging in work tasks. The reduced outdoor activities in children forced mothers to spend more time with their children.11 In this scenario, conflict is inevitable because these interactions are intense and endless. In China, the first country to lockdown, the divorce rate increased, and domestic violence was reported more frequently.12–14 Even worse, decreased income, increased consumption, and rising prices for staple foods contributed to the burden.15 Taken together, all these factors might affect mental health status.16
Reaction to stressful situations is affected by demographic background. During this pandemic, people worry about personal and family health which might changes in sleeping or eating patterns, worse chronic health problems, or excessive intake of alcohol, tobacco, medications, and supplements.17 Information about medications and supplements as COVID-19 therapies or preventions (“anti-COVID”) are widely circulated, which leads to self-medication practice.18,19 Before pandemic, self-medication practice has been common in Indonesia,20 including consumption of natural products in Indonesian mother21 and over the counter (OTC) drugs in Indonesian pregnant women.22
In 2013, it was reported that the prevalence of mental health disorders, including emotional and mood disorders in Indonesia, was 6% or 14 million people. Unfortunately, only 10% had access to health facilities,23 with suicide mortality rate was 3.4 of 100,000 population.24 During the COVID-19 pandemic, it was reported that females more likely to experience medium to high anxiety, as well as working respondents (male and female) compared to housewives.25 While during non-pandemic, it was reported that working mothers had better health, less depressive symptoms, and higher self-esteem compared to housewives.26,27
Taken together, with the amount of pressure endured by mothers with school-age children, mental disorders are likely to occur, as well as increasing consumption of “anti-COVID” medications and supplementations. Therefore, this study aimed to explore the mental health of mothers with school-age children, in working mothers and housewives, during the COVID-19 pandemic. Its relationship with the consumption of “anti-COVID” medications and supplements was further investigated.
Materials and Methods
Study Design and Data Collection
This cross-sectional study regarding the association between consumption of “anti-COVID” medications, vitamin and mineral supplementation, herbs or natural product supplementation and the mental health status of Indonesian mothers with school-age children during the COVID-19 pandemic was conducted in July–December 2020. The study protocol has been approved by the Health Research Ethics Committee, Faculty of Medicine Universitas Airlangga (No. 180/EC/KEPK/FKUA/2020). All methods were conducted in accordance with the Declaration of Helsinki. Respondents were provided with an explanation of the objectives and consents of the questionnaire, which included a clause of publicity on the anonymous responses, at the beginning of the survey. Moreover, respondents were required to click BEGIN button as a sign of consent before they proceeded to start the survey.
The primary data were collected from the online questionnaire (www.surveyplanet.com) distributed by trained surveyors face-to-face and through social media such as WhatsApp, Facebook, and emails using a convenience sampling method. The online questionnaire was set to prevent multiple submissions from one device. Moreover, to reach wider respondents, specially-trained research staff recruited respondents in several cities of Indonesia, and guided the respondent to access the online questionnaire, and the respondent further completed and submitted the questionnaire independently. This study followed the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines.28
Respondents were Indonesian mothers with school-age children (elementary-high school students), older than 18 years old, and domiciled in Indonesia during the COVID-19 pandemic. We excluded those who were not Indonesian women, without school-age children, younger than 18 years old, or domiciled outside Indonesia during the COVID-19 pandemic. The required minimum sample size was 383 respondents, calculated using a sample size calculator (www.surveymonkey.com) with 5% margin of error, 95% confidence level, and unknown population number (filled with 100,000). Furthermore, to explore their feelings and medications/supplements consumption behavior, eighteen respondents were contacted and in-depth interviews were performed by RL by phone. The selection was based on the respondent’s DASS score and their “anti-COVID” drugs and supplements consumption behavior.
A set of questionnaires of three sections was distributed to measure respondents’ medications or supplementation and their mental health. The sections consisted of the basic demographic information, consumption of “anti-COVID” medications and supplements, and measurement of mental health using the Depression, Anxiety, and Stress Scales 21 (DASS-21). Two native Indonesians translated DASS-21.29 The Indonesian version of the DASS-21 was evaluated by two experts, a psychiatrist and social science expert, to determine its suitability for being adapted into local conditions. Likewise, a section of medications and supplements behavior was developed by a pharmacologist and evaluated by two experts, a pharmacologist and a medical doctor. Furthermore, the questionnaire was tested in 20 Indonesian mothers with school-age children to assure their understanding. After completing the form, respondents were asked to evaluate their understanding of the questions, including the wording and the format.
Respondents were divided into two groups based on their activities, housewives or working mothers. Medications and supplements consumption behaviors were measured using nominal or ordinal scales. The respondents’ locations were derived from the survey record. The answers to the DASS-21 were calculated according to the guidelines. Total scores were obtained and divided into five groups for each category (depression, anxiety, and stress): normal, mild, moderate, severe, and extremely severe. Data were managed in Microsoft Excel, analyzed using SPSS 25.0 (IBM, Chicago, IL), and graphs were drawn using GraphPad Prism 5.0. Descriptive statistical analyses were performed, and response rates were calculated as percentages on every item related to categorical variables. The differences of sociodemographic factors between two groups were calculated using chi-square test. The Mann–Whitney U and Kruskal–Wallis H-test were used to measure the sociodemographic factors influencing the respondents’ “anti-COVID” consumption behavior and mental health status, whilst the association between “anti-COVID” consumption and mental health status was measured using Fisher’s Exact Test. Significance was defined as a p-value <0.05. The reliability measurement on the survey data showed a Cronbach Alpha value 0.786 for depression, 0.727 for anxiety, and 0.811 for stress with nonnormality data distribution.
Characteristics of Respondents
Nine hundred nineteen respondents visit the informed consent page, 610 complete questionnaires were received and valid for use in the final analysis; the completion rate was 66.38%. Two hundred twenty respondents self-described as housewives (36%), and 390 respondents self-described as working mothers (64%). As recorded by the survey online tools, most of the respondents were located on Java Island,…