Psychological distress during the first phase of the COVID-19 pandemic in Ecuador: Cross-sectional study

RESEARCH ARTICLE Psychological distress during the first phase of the COVID-19 pandemic in Ecuador: Cross-sectional study Juan Go ´mez-SalgadoID 1,2 *, Ingrid Adanaque-Bravo 3 , Mo ´nica Ortega-Moreno 4 *, Regina Allande-Cusso ´ID 5 , Cristian Arturo Arias-Ulloa 2 , Carlos Ruiz-FrutosID 1,2 1Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, Huelva, Spain, 2Safety and Health Postgraduate Programme, Universidad Espı ´ritu Santo, Guayaquil, Ecuador, 3Faculty of Engineering in Mechanics and Production Sciences, Escuela Superior Polite ´cnica del Litoral, Guayaquil, Ecuador, 4Department of Economy, Faculty of Labour Sciences, University of Huelva, Huelva, Spain, 5Department of Nursing, University of Seville, Seville, Spain *[email protected] (JGS); [email protected] (MOM) Abstract Background The effects of the COVID 19 pandemic on the mental health of citizens from Asia, Europe, or North America begin to be known, but there are fewer publications on its effects in Latin American countries. In this study, its impact in Ecuador is described, with data collected during the first phase of the pandemic. The objective of this study was to analyse the level of psychological distress in the population of Ecuador during the first phase of the COVID-19 pandemic. Methods and findings Cross-sectional observational study. The questionnaires were collected through an online self-developed questionnaire, between April 2 and May 17, 2020, using the non-probabilistic sampling methodology: snowball method. The variables considered were sociodemographic variables, physical symptoms, health status, COVID-19 contact history, preventive measures, and the General Health Questionnaire (GHQ-12). The percentage with high psychological distress (PD) (GHQ-12 �3) has been somewhat lower than that found in Europe, being women, young people, people with higher level of education, living without a partner, not living with children or children under 16 years of age, and with worse perception of health the groups with the highest PD. Differences have been observed with European studies regarding common symptoms, preventive measures to avoid contagion, percentage of infected relatives, or diagnostic tests performed. Conclusions The use of the same research instrument, validated in Europe and adapted to Ecuador, has facilitated the comparison of the found results and differences, which can be explained by PLOS ONE PLOS ONE | https://doi.org/10.1371/journal.pone.0257661 September 22, 2021 1 / 16 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Go ´mez-Salgado J, Adanaque-Bravo I, Ortega-Moreno M, Allande-Cusso ´R, Arias-Ulloa CA, Ruiz-Frutos C (2021) Psychological distress during the first phase of the COVID-19 pandemic in Ecuador: Cross-sectional study. PLoS ONE 16(9): e0257661. https://doi.org/10.1371/journal. pone.0257661 Editor: Sanjay Kumar Singh Patel, Konkuk University, REPUBLIC OF KOREA Received: August 5, 2021 Accepted: September 8, 2021 Published: September 22, 2021 Copyright: ©2021 Go ´mez-Salgado et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. socio-economic or cultural variables, the health system, level of information, or by preventive measures put in place to prevent the pandemic. Introduction The SARS-CoV-2 virus disease (COVID-19) has caused a global health crisis with dramatic consequences. On 31 December 2019, the Wuhan Municipal Health Commission in China notified the World Health Organization (WHO) 27 cases of pneumonia of unknown origin [1]. On 30 January 2020, the WHO declared an international public health emergency following the COVID-19 outbreak that began in Wuhan, China. By that time, 83 cases had been identified in 18 different countries outside China [2,3]. Following the increase in spread to more than 118,000 cases in 114 countries and 4291 deaths, on 11 March 2020, the WHO reported the pandemic status of the situation [4]. In Ecuador, the first confirmed case was reported on 29 February 2020 [5], and on 11 March, the Ministry of Health declared the State of Health Emergency in the National Health System (Agreement No. 00126–2020). Subsequently, restrictive measures were established on 16 March to prevent the spread of the virus, when the President of the Republic decreed the state of emergency (Executive Decree 1017), lasting 60 days [6]. The Committee on Emergency Operations (COE, for its acronym in Spanish) of the National Risk and Emergency Management Service, monitored compliance with quarantine and the set of measures that suspended the exercise of the right to freedom of movement, freedom of association and assembly, closure of the territory at the air, sea, and land level, implementing curfew, suspension of face-to-face working hours, and suspension of face-to-face classes in all levels nationwide. The state of emergency was renewed for 30 more days (Decree 1052), then for 60 (Decree 1074), and finally another 30 days (Decree 1126) [6], ending the state of alarm on September 13, 2020. The basic preventive measures proposed by the Emergency Operations Committee to prevent SARSCoV-2 contagion were to keep a 2 metre-distance, cover mouth when sneezing, and to wash hands constantly [7]. The Ecuadorian National Emergency Operations Committee, together with the Decentralised Autonomous Governments (GAD, for its acronym in Spanish), coordinated the implementation of measures to prevent the spread of the virus and established protocols for economic reactivation [8]. In compliance with WHO’s recommendation to act against a variant of SARS CoV-2, which resulted in increased cases due to agglomerations, a new state of emergency was declared on 21 December, 2020 (Decree 1217) [6]. Cases had been reported in Ecuador and Brazil by February 2020, and also in early March in Chile, Colombia, and Peru [9]. In May, an increase in the number of confirmed infected cases and deaths in Brazil, Peru, Chile, Colombia, Argentina, Bolivia, Uruguay, and Paraguay [10] was evident. In September, the Latin American and Caribbean countries that had reported a higher number of confirmed cases and deaths per million inhabitants were Brazil, Peru, and Chile [9]. As of March 26, 2021, Ecuador officially reported 318,656 confirmed cases and 16,582 deaths, with 141,191 vaccine doses administered. Worldwide, Brazil was in third place at the contagion level and second in deaths, followed by Colombia (11 th in contagions and deaths), Argentina (12 th in contagions and deaths), Peru (18 th in contagions and 14 th in deaths), Chile (25 th in contagions and 21 st in deaths), and Ecuador (47 th in contagions and 24 th in deaths) [11,12]. The mental health effects of previous or current SARS-Cov-2 pandemics [13,14] are known, with healthcare workers being the best studied group due to the dangers arising from PLOS ONE Psychological distress and COVID-19 in Ecuador PLOS ONE | https://doi.org/10.1371/journal.pone.0257661 September 22, 2021 2 / 16 proximity to infected people and having to manage situations of stress and uncertainty [15]. Healthcare workers are at increased risk of developing the disease [16] and spreading it [17] due to their proximity while treating infected people. Early mental effects of the pandemic [18], with high levels of anxiety and depression [19–21], insomnia [15], emotional disorders [22], or post-traumatic stress disorder [23] have been found. Studies in Latin America have found that 66% of respondents had had a deceased family member, friend, or acquaintance, with mental health effects affecting their degree of care, understanding, decision-making, and overall well-being [24,25]. The vulnerable groups identified are women, young people, self-employed workers, and people with previous psychological processes with treatments that had been interrupted due to the pandemic [26]. The hypothesis is that the current pandemic generates effects on mental health, but with the need for studies to corroborate it [27], as has been found in studies conducted at the international level [28]. The objective of the study was to analyse the level of psychological distress in the population of Ecuador during the first phase of the COVID-19 pandemic, identifying the possible association with sociodemographic variables, presence of physical symptoms, and contact history in order to be able to establish preventive measures and find out whether the results differ from those found in other geographical areas. Materials and methods Design type and sample Cross-sectional observational study. This investigation followed the STROBE guidelines. The total number of questionnaires analysed was 3640, collected between 2 April and 17 May, 2020. The inclusion criteria were: being 18 years of age or older, residing in Ecuador during the pandemic, and accepting the informed consent. Questionnaires were received from the 24 provinces of Ecuador. A strict selection criterion was adopted, eliminating all questionnaires with a response rate of less than 99% (857 questionnaires out of 4497 received). Instruments This study is integrated into a research coordinated from Spain which is carried out in a total of 16 countries, Latin American, European, African, and Asian, at different stages of adaptation and implementation, and using a similar methodology, except for the differences generated with the adaptation to each country or the dates of data collection. The original questionnaire has been validated for the Spanish population, adapting questions from previous studies [29] and reviewing literature on publications from previous epidemics [15]. To facilitate its validation and to not delay its process over time, because of the need to collect data on the effects at the onset of the pandemic, previously validated instruments were included. The draft questionnaire was analysed by a panel of experts consisting of psychologists, occupational physicians and nurses, epidemiologists, and public health experts. A pilot test was conducted involving 57 people from different professions, educational levels, sex, age, and geographic areas, and no understandability problems or relevant incidents were identified, with a Cronbach’s alpha coefficient of 0.86. Subsequently, the questionnaire was culturally adapted to the Ecuadorian population, modifying the questions that had difficulty of being understood by the citizens of the country. The questionnaire includes sociodemographic data: sex, age, cohabiting people, level of studies, employment status, having children or not, pets, or a disability. Psychological adjustment was measured using a widely used tool to assess mental health and psychological well-being: the Goldberg’s General Health questionnaire (GHQ-12) [30]. PLOS ONE Psychological distress and COVID-19 in Ecuador PLOS ONE | https://doi.org/10.1371/journal.pone.0257661 September 22, 2021 3 / 16 This questionnaire consists of 12 items with four answer options. The first two are assigned a score of 0 points and the last two are assigned a score of 1 point, with a total score ranging from 0 to 12. The set cut-off point for the general population was 3, considering psychological distress for those with scores greater than or equal to 3. Data were also collected on perceived symptoms over the last 14 days: cough, headache, rhinitis, fever, myalgia, dizziness, sore throat, chills, diarrhoea, or shortness of breath. This was provided by the World Health Organization on the most common physical symptoms associated with COVID-19. The subjects were questioned about whether they had a chronic illness or if they were taking medication at the time of answering the questionnaire; similarly, if they had been hospitalised or had required medical care in the last 14 days. They were also asked about contact history in the last 14 days, including three items: possible contact (more than 15 min less than two metres away); casual contact with confirmed infected persons; or contact with people or materials suspected of being infected, as well as the existence of an infected family member or co-worker diagnosed by diagnostic testing. Self-perceived health status was measured with five response levels, from lousy to optimal, grouping them for the final analysis into two categories, being this a well-known good indicator for predicting mortality [31]. Preventive measures were assessed through questions with five answer choices, categorised from never to always, regarding how often the following behaviours were identified: covering mouth with elbow when coughing or sneezing; avoiding sharing utensils (e.g. fork) during meals; washing hands with soap and water; washing hands with hydroalcoholic solution; washing hands immediately after coughing, touching the nose, or sneezing; washing hands after touching potentially contaminated objects; wearing a mask regardless of the presence of symptoms; leaving at least a metre and a half distance between others. Procedure Data were collected through an online questionnaire, the Qualtrics storage and surveys platform1. In this way, the confinement measures established during the pandemic did not interfere with the data collection process. For sampling, the non-probabilistic sampling methodology was used: snowball methods, the same methodology chosen to carry out the study in Europe on Living, Working and COVID-19 by Eurofound [32]. Universities and scientific societies were involved in the process of disseminating information, as well as social media and the press. The questionnaires were collected in the first phase of the pandemic, between 2 April and 17 May 2020, with the health alert being decreed in Ecuador thirteen days before the start of the study (Fig 1). Data analysis After cleaning-up the database, frequencies, mean, and standard deviation were determined based on the type of variable. The normality study of data distribution was carried out using the Kolmogorov-Smirnov test, obtaining a value of p>0.20. Therefore, the chi-squared association test and the Student’s T test were implemented for independent samples, which made it possible to contrast whether there was existence or not of a relationship between the different variables (sociodemographic, physical symptoms, self-perceived health status, history of contact with people infected with SARS-CoV2 virus or contaminated material, and preventive measures taken) with respect to the presence or not of psychological distress. The binary logistic regression analysis identified among the studied variables those that played a more relevant role, and a model was built to determine whether psychological distress was present. The selection of variables was carried on forward, considering the likelihood ratio PLOS ONE Psychological distress and COVID-19 in Ecuador PLOS ONE | https://doi.org/10.1371/journal.pone.0257661 September 22, 2021 4 / 16 statistic. Odd Ratios (OR) were estimated, and confidence intervals were provided for this association measure. In addition, different goodness-of-fit measures were used: HosmerLemeshow test, percentage of correctly classified values, sensitivity, and specificity. All analyses were carried out with the SPSS 26.0 statistical software (IBM, Armonk, NY, USA). Ethical principles The ethical principles set out in the Declaration of Helsinki have been followed. The participants’ permission was obtained through an informed consent in which they expressed their voluntary desire to participate in the study. At the beginning of the online survey, subjects had to indicate that they were of legal age and that they participated voluntarily in the study in order to access the content of the study. The data was recorded anonymously and treated confidentially. The study has been authorised in Ecuador by the Research Ethics Committee of the San Gregorio de Portoviejo University (USGP-DI-049-2021), and, in Spain, by the Research Ethics Committee of Huelva, belonging to the Regional Ministry of Health of Andalusia, Spain (PI 036/20). Results Sociodemographic data The sample analysed, amounting to a total of 3640 subjects, is slightly higher for the female sex (54.92%), with an age at which the percentage at 30 years or less was of 52.81%, and a marital status in which 61.43% had no partner. As regards the educational level, 74.15% had upper secondary education or lower, and 25.85% had university studies or higher. In relation to their occupation, 45.07% were public employees, 39.84% worked in a private company, and 15.09% were self-employed. In the sample, the percentage of those who didn’t have children was lower (45.4%). A majority claimed to have a pet (58.27%), and only 2.36% had some kind of disability (Table 1). Psychological distress in the sample As can be seen, in Table 2, 62.72% of the sample has psychological distress (PD), with a cut-off point of GHQ �3. The overall score on the 12 items is M = 4.41 (SD = 3.49). Fig 1. Study phases. https://doi.org/10.1371/journal.pone.0257661.g001 PLOS ONE Psychological distress and COVID-19 in Ecuador PLOS ONE | https://doi.org/10.1371/journal.pone.0257661 September 22, 2021 5 / 16 The three items with the highest rating (M>2.5) have been items 5: Have you felt constantly overwhelmed and stressed? M = 2.66 (SD = 0.94); item 7: Have you been able to develop your normal daily activities? M = 2.62 (SD = 0.92); and item 2: Have your worries made you lose a lot of sleep? M = 2.57 (SD = 1.00). In contrast, items with a lower rating (M<2 or less than 2) have been items 11: Have you thought that you are a worthless person? M = 1.39 (SD = 0.78); item 10: Have you lost confidence in yourself? M = 1.74 (SD = 0.92); and item 4: Have you felt capable of making decisions? M = 1.99 (SD = 0.78) (Table 2). Sociodemographic data and psychological distress Women report a higher percentage of psychological distress (69.1%) than men (55.0%), p < .001, OR = 0.546, 95% CI = (0.477, 0.626). People without a partner have higher PD (64.1%) than those who have a partner (60.5%), p = .026, OR = 1.169, 95% CI = (1.019, 1.341). Those with university studies show a higher percentage of PD (64.2%) than those with a lower level of studies (58.3%), p <.001, OR = 0.779, 95% CI = (0.679, 0.907). Not having children is associated with a higher percentage of PD, 65.0% vs. 59.9%, p <.001, OR = 0.804, 95% CI = (0.702, 0.920) (Table 1). Table 1. Association between sociodemographic variables and psychological distress during the pandemic. GHQ N (%) Yes No χ 2 p Odds Ratio (Confidence Interval at the 95 level) (N = 3640) (N = 2283) (N = 1357) Sex .546 Male 1641 (45.1) 55.0 45.0 76.822 <.001 (.477, .626) Female 1999 (54.9) 69.1 30.9 Age�1.119 30 years old or younger 1900 (52.8) 64.1 35.9 2.650 .104 (.977, 1.281) Older than 30 1698 (47.2) 61.4 38.6 Marital status 1.169 Without a partner 2236 (61.4) 64.1 35.9 4.947 .026 (1.019, 1.341) With a partner 1404 (38.6) 60.5 39.5 Level of studies .779 Upper secondary school or lower 941 (25.9) 58.3 41.7 10.401 .001 (.679, .907) University or higher 2699 (74.1) 64.2 35.8 You are�� Self-employed 326 (15.1) 61.0 39.0 5.760 .056 Public worker 974 (45.1) 65.3 34.7 Private-company worker 861 (39.8) 60.0 40.0 Children .804 Yes 1652 (45.4) 59.9 40.1 10.087 .001 (.702, .920) No 1988 (54.6) 65.0 35.0 Pet 1.011 Yes 2121 (58.3) 62.6 37.4 0.025 .874 (.882, 1.159) No 1519 (41.7) 62.9 37.1 Disability .907 Yes 86 (2.4) 60.5 39.5 0.191 .662 (.586, 1.405) No 3554 (97.6) 62.8 37.2 �Grouped variable from the median value. https://doi.org/10.1371/journal.pone.0257661.t001 PLOS ONE Psychological distress and COVID-19 in Ecuador PLOS ONE | https://doi.org/10.1371/journal.pone.0257661 September 22, 2021 6 / 16 There are no statistically significant differences in PD regarding age, type of employment (public, private, or self-employed), having a pet, or having a disability (Table 1). Physical symptoms, health-related variables and psychological distress Among the most common symptoms in the 14 days prior to the participation in the study (Table 3) the ones with a higher percentage of cases are headache (40.80%), coryza (24.12%), and sore throat (22.83%). In contrast, less frequent symptoms have been fever (>38˚C for at least 1 day) 4.42%, chills (4.48%), and breathing difficulty (4.78%). The set of symptoms, with an M = 1.59 (SD = 1.86), is associated with the level of PD, M = 1.86 (SD = 1.96) for those with PD versus M = 1.14 (SD = 1.56) for those without PD, p <.001. There is a statistically significant difference between having any of the studied symptoms or not and presenting PD, as can be seen in Table 3. The symptoms with a higher percentage that are found among those with PD are: dizziness 79.6%, OR = 2.52, 95% CI = (1.947, 3.274); breathing difficulty 76.4%, OR = 1.98, 95% CI = (1.390, 2.837); diarrhoea 75.5%, OR = 1.96, 95% CI = (1.536, 2.491); fever 75.2%, OR = 1.84, 95% CI = (1.281, 2.652); myalgia 74.8%, OR = 1.99, 95% CI = (1.654, 2.394); and sore throat 73.5%, OR = 1.89, 95% CI = (1.591, 2.242) (Table 3). The number of symptoms, with a rating of M = 1.59 (SD = 1.86), is different for those with high PD, M = 1.86 (SD = 1.96) and those with low PD, M = 1.14 (SD = 1.56), p <.001. 83.49% of participants stated an optimal self-perceived health, relating it to the level of PD. Thus, among those with optimal health, 59.8% had PD, a percentage that increases to 77.5% among those who had mediocre or lousy health, p <.001, OR = 0.431, 95% CI = (.351, .529). 19.12% were taking medications, who also had a higher percentage of people with PD, 67.8%, than those who did not take medication, 61.5%, p.002, OR = 1.32, 95% CI = (1.106, 1.571). 6.10% had received medical care over the past 14 days, associated with developing PD; thus, among those who had received medical care in the last 14 days, 71.2% had PD versus 62.2% Table 2. Psychological distress: General health questionnaire GHQ-12. TOTAL (N = 3640) Item M (SD) 1. Have you been able to properly concentrate on what you were doing? 2.44 (0.76) 2. Have your worries made you lose a lot of sleep? 2.57 (1.00) 3. Have you felt you are developing a relevant role in life? 2.00 (0.88) 4. Have you felt capable of making decisions? 1.99 (0.78) 5. Have you felt constantly overwhelmed and stressed? 2.66 (0.94) 6. Have you felt unable to overcome your difficulties? 2.18 (0.96) 7. Have you been able to develop your normal daily activities? 2.62 (0.92) 8. Have you been able to properly face your difficulties? 2.23 (0.75) 9. Have you felt unhappy or depressed? 2.36 (0.98) 10. Have you lost confidence in yourself? 1.74 (0.92) 11. Have you thought that you are a worthless person? 1.39 (0.78) 12. Do you feel reasonably happy given the circumstances? 2.13 (0.79) GHQ-12 (Score on a scale of 12) 4.41 (3.49) Cut-off point �3 N (%) Yes 2283 (62.72) No 1357 (37.28) Cronbach’s α= 0.815. https://doi.org/10.1371/journal.pone.0257661.t002 PLOS ONE Psychological distress and COVID-19 in Ecuador PLOS ONE | https://doi.org/10.1371/journal.pone.0257661 September 22, 2021 7 / 16 Table 3. Association between physical symptoms, current health status, history of contacts, and psychological distress during the pandemic. GHQ N (%) Yes No χ 2 p Odds Ratio (Confidence Interval = 95) (N = 2283) (N = 1357) PHYSICAL SYMPTOMS Fever Yes 161 (4.4) 75.2 24.8 11.141 .001 1.843 No 3479 (95.6) 62.1 37.9 (1.281, 2.652) Cough Yes 623 (17.1) 70.5 29.5 19.287 <.001 1.518 No 3017 (82.9) 61.1 38.9 (1.259, 1.830) Myalgia Yes 1485 (40.8) 72.7 27.3 107.436 <.001 2.110 No 2155 (59.2) 55.8 44.2 (1.830, 2.433) Muscle pain Yes 709 (19.5) 74.8 25.2 54.529 <.001 1.990 No 2931 (80.5) 59.8 40.2 (1.654, 2.394) Dizziness Yes 378 (10.4) 79.6 20.4 51.583 <.001 2.525 No 3262 (89.6) 60.8 39.2 (1.947, 3.274) Diarrhoea Yes 388 (10.7) 75.5 24.5 30.411 <.001 1.956 No 3252 (89.3) 61.2 38.8 (1.536, 2.491) Sore throat Yes 831 (22.8) 73.5 26.5 53.778 <.001 1.889 No 2809 (77.2) 59.5 40.5 (1.591, 2.242) Rhinitis Yes 878 (24.1) 69.7 30.3 24.138 <.001 1.502 No 2762 (75.9) 60.5 39.5 (1.276, 1.768) Chills Yes 163 (4.5) 71.8 28.2 5.990 .014 1.539 No 3477 (95.5) 62.3 37.7 (1.087, 2.180) Shortness of breath Yes 174 (4.8) 76.4 23.6 14.705 <.001 1.986 No 3466 (95.2) 62.0 38.0 (1.390, 2.837) CURRENT HEALTH STATUS Self-perceived health .431 Optimal 3039 (83.5) 59.8 40.2 67.596 <.001 Mediocre or lousy 601 (16.5) 77.5 22.5 (.351, .529) Chronic illness 1.177 Yes 560 (15.4) 65.9 34.1 2.850 .091 No 3080 (84.6) 62.1 37.9 (.974, 1.422) Currently taking medication 1.318 Yes 696 (19.1) 67.8 32.2 9.559 .002 No 2944 (80.9) 61.5 38.5 (1.106, 1.571) Admitted to hosp. Last 14 days 1.340 Yes 26 (0.7) 69.2 30.8 .475 .491 No 3614 (99.3) 62.7 37.3 (.581, 3.090) (Continued) PLOS ONE Psychological distress and COVID-19 in Ecuador PLOS ONE | https://doi.org/10.1371/journal.pone.0257661 September 22, 2021 8 / 16 who had not received it, p.007, OR = 1.50, 95% CI = (1.114, 2.025). 15.38% had a chronic disease, and 0.71% had required hospitalisation in that time period, without having found a statistically significant association between these two variables and developing PD (Table 3). Contact history and psychological distress 37.1% of the sample knew they had had contact with an infected person for more than 15 minutes and/or within less than 2 metres distance or did not know if they had, compared to 62.9% who claimed to not have been in such contact. The percentage with PD among those who had been in contact, or did not know, was greater (68.6%) than among those who had not (59.2%), p<,001, OR = 1.50, 95 CI = (1.305, 1.734) (Table 3). The percentage of those who had had casual contact with an infected person or did not know if they had (35.9%) was lower than those who claimed to not have been in such contact (64.1%), with higher percentage of PD among those who had had contact (68.6%) than those who had not (59.5%), p <.001, OR = 1.48, 95% CI = 1.289, 1.716). The percentage of those who had had any contact with a person or material suspected of being infected, or did not know if they had, (43.8%) was lower than those who claimed they had not been in such situation (56.4%), with the highest percentage of PD among those who had had contact, p <.001, OR = 1.41, 95% CI = (1.227, 1.613). Similarly, the percentage of those who had had contact with an infected family member or did not know if they had (24.3%) was lower than those who had not (75.7%), p <.001, OR = 1.35, 95% CI = (1.152, 1.589) (Table 3). 9.2% had had a diagnostic test, with no statistically significant association between having PD and having been performed the diagnostic test (Table 3). Table 3. (Continued) GHQ N (%) Yes No χ 2 p Odds Ratio (Confidence Interval = 95) (N = 2283) (N = 1357) Medical care last 14 days 1.502 Yes 222 (6.1) 71.2 28.8 7.222 .007 No 3418 (93.9) 62.2 37.8 (1.114, 2.025) CONTACT HISTORY Contact >15’ <2m with infected person 1.504 Yes, or doesn’t know 1351 (37.1) 68.6 31.4 31.941 <.001 No 2289 (62.9) 59.2 40.8 (1.305, 1.734) Casual contact with infected person 1.487 Yes, or doesn’t know 1307 (35.9) 68.6 31.4 29.685 <.001 No 2333 (64.1) 59.5 40.5 (1.289, 1.716) Contact with person or material suspected of being infected 1.407 Yes, or doesn’t know 1596 (43.8) 67.2 32.8 24.051 <.001 No 2044 (56.4) 59.2 40.8 (1.227, 1.613) Infected family member 1.353 Yes, or doesn’t know 886 (24.3) 67.9 32.1 13.678 <.001 (1.152, 1.589) No 2754 (75.7) 61.0 39.0 Has been performed diagnostic test .886 Yes 336 (9.2) 60.1 39.9 1.071 .301 (.704, 1.114) No 3304 (90.8) 63.0 37.0 https://doi.org/10.1371/journal.pone.0257661.t003 PLOS ONE Psychological distress and COVID-19 in Ecuador PLOS ONE | https://doi.org/10.1371/journal.pone.0257661 September 22, 2021 9 / 16 34. Go ´mez-Salgado J, Andre ´s-Villas M, Domı ´nguez-Salas S, Dı ´az-Milane ´s D, Ruiz-Frutos C. Related Health Factors of Psychological Distress During the COVID-19 Pandemic in Spain. Int J Environ Res Public Health. 2020; 17(11):3947. https://doi.org/10.3390/ijerph17113947 PMID: 32498401 35. Bermejo-Martins E, Luis EO, Sarrionandia A, Martı ´nez M, Garce ´s MS, Oliveros EY, et al. Different Responses to Stress, Health Practices, and Self-Care during COVID-19 Lockdown: A Stratified Analysis. Int J Environ Res Public Health. 2021 Feb 25; 18(5):2253. https://doi.org/10.3390/ijerph18052253 PMID: 33668717 36. Bank World. ‘The coronavirus is not gender-blind, nor should we be’, blog, 12 April. 2020. Available on: https://www.worldbank.org/en/topic/gender/brief/gender-and-covid-19-coronavirus (accessed on 12 Jan 2021). 37. Ruiz-Frutos C, Ortega-Moreno M, Allande-Cusso ´R, Domı ´nguez-Salas S, Dias A, Go ´mez-Salgado J. Health-related factors of psychological distress during the COVID-19 pandemic among non-health workers in Spain. Saf Sci. 2021; 133:104996. https://doi.org/10.1016/j.ssci.2020.104996 PMID: 32952305 38. Alcover CM, Rodrı ´guez F, Pastor Y, Thomas H, Rey M, Del Barrio JL. Group Membership and Social and Personal Identities as Psychosocial Coping Resources to Psychological Consequences of the COVID-19 Confinement. Int J Environ Res Public Health. 2020 Oct 12; 17(20):7413. https://doi.org/10. 3390/ijerph17207413 PMID: 33053738 39. del Pino S, Go ´mez-Salgado J, Domı ´nguez-Go ´mez JA, Ruiz-Frutos C. People of african descent of the americas, racial discrimination, and quality of the health services. Sustainability 2020, 12, 6930; https:// doi.org/10.3390/su12176930 40. Thakur V, Jain A. COVID 2019-suicides: A global psychological pandemic. Brain, Behavior, and Immunity. Volume 88. 2020. https://doi.org/10.1016/j.bbi.2020.04.062 PMID: 32335196 41. Patel S.K.S., Lee JK. & Kalia V.C. Deploying Biomolecules as Anti-COVID-19 Agents. Indian J Microbiol 60, 263–268 (2020). https://doi.org/10.1007/s12088-020-00893-4 PMID: 32647390 42. Rishi P., Thakur K., Vij S. et al. Diet, Gut Microbiota and COVID-19. Indian J Microbiol 60, 420–429 (2020). https://doi.org/10.1007/s12088-020-00908-0 PMID: 33012868 43. Go ´mez-Salgado J, Allande-Cusso ´R, Domı ´nguez-Salas S, Garcı ´a-Iglesias JJ, Coronado-Vazquez V, Ruiz-Frutos C. Design of Fear and Anxiety of COVID-19 Assessment Tool in Spanish Adult Population. Go ´mez-Salgado, J. Brain Sci. 2021, 11, 328. https://doi.org/10.3390/brainsci11030328 PLOS ONE Psychological distress and COVID-19 in Ecuador PLOS ONE | https://doi.org/10.1371/journal.pone.0257661 September 22, 2021 16 / 16