Emotional Stress

The COVID-19 pandemic prompted academics and several research institutes to conduct studies to better understand the virus’s effects from various angles. A global research and technology provider launched an international COVID-19-related project involving 20 countries, including Lebanon. The project aimed initially at understanding people’s emotions, fears, behaviors, and perspectives on the pandemic in different countries. More specifically, this global project was supposed to cover the aspects of functioning most affected by the pandemic, such as lifestyle changes (isolation, following guidelines, etc.), economic threats (losing jobs, not earning money due to lockdown), and emotional stress (especially health worries).
The data collection was carried out through an online survey using iCode [25 , 26 (link)] smart test. This test illustrates how hesitant people are to express their views and is a simpler alternative to Implicit Association Testing (IAT), where IAT is commonly used in psychology [27 (link)]. More specifically, iCode uses reaction time testing to measure people’s responses to questions by recording the speed and the rhythm with which the screen is touched. Reported opinions with a relatively quick reaction time are expected to reflect actual behavior [28 (link)].
The questionnaire was created and validated with the help of eight experts from the fields of psychology, sociology, marketing, and economics. It was a collaborative effort involving experts from the United States, Poland, Singapore, Hong Kong, Portugal, and Switzerland.
The questionnaire was distributed in Lebanon in three languages (Arabic, English, and French) and a sample of 988 Lebanese respondents was collected between May 3 and May 31 of 2020. Prior to filling the survey, all participants provided written informed consent online. Due to the pandemic’s rapidly changing context and to minimize the virus’s spread, we used an online convenience sampling approach. This sampling technique has been widely used in many COVID-19-related studies [16 (link), 29 (link)–31 (link)]. A link for the survey with a description, was distributed via social media platforms, including WhatsApp, Instagram, Facebook, and LinkedIn. The link was also sent by email to all current and past students (alumni), faculty and staff of the Lebanese American university (LAU). The data collection was approved by the LAU Institutional Review Board.
A series of statements were provided to respondents and their task was to agree with the sentence that appears on the screen. As shown in Fig 1, three possible answers were available: "YES", "HARD to TELL" and "NO". Simultaneously, the explicit and implicit responses were recorded, where implicit responses are reflected by reaction speed.
Before each statement, a control screen (Advanced Button) was introduced to ensure that the measured response time (RT) is not biased by the mouse’s position. More specifically, it forces the mouse position to maintain both yes and no responses at the same distance.
A calibration phase, which consisted of three parts, preceded the test part: (i) Scale familiarization. The purpose of this section was to familiarize respondents with the scale of responses and the position of the buttons on the screen; (ii) familiarization with the purpose of the task and motor warm-up. A series of statements explaining the purpose of the task were described. Participants were informed that opinions and certitude were measured by the test. Twelve such screens were presented in the main part of the test, introducing participants to the task; (iii) Increasing the engagement of participants in the task. A validation box appears twice to ensure that respondents pay attention to the presented statements, asking them to indicate what statement was shown on the previous screen. If the answer was incorrect, a message will show up asking for more careful work ("Please work carefully").

The survey included questions about the impact of the COVID-19 outbreak on their wellbeing as well as the requirements for dealing with the pandemic. Each multiple-choice question allowed participants to choose only one item. This measure of emotional and behavioral change was reported by parents who were asked about their children’s emotional and behavioral changes (e.g., emotional reactions to stress, emotional self-regulation system’s stability and emotional and behavioral problems related to ASD or DD) during the COVID-19 pandemic lockdown. Specifically, a scale of 1 = “improved,” 2 = “no change,” and 3 = “worse” was used. Demographic variables, family socioeconomic variables, and family treatment history variables were used as control variables in this study. The demographic variables included the age of the children, their gender, and the number of children in the household, and having comorbidities or not. The age was the age at the time of the survey. The comorbidities referred to neurodevelopment disorders, including intellectual disabilities (ID) and attention deficit and hyperactivity disorder (ADHD) in this study. Information on family sociodemographic and medical history was gathered. The income of families was divided into three categories: below average, average, and above average. According to the data distribution, the below average group had an annual income of less than $12,327 (RMB80,000), the average group had an annual income between $12,327 (RMB80,001) and $23,112 (RMB150,000), and the above average group had an annual income greater than $23,112 (RMB150,000).

The study utilized location-targeted Facebook advertisements to promote the study and to invite potential target participants. In addition, the study partnered with an organization that has already been offering HIV testing, prevention, and treatment services to key populations in the country. Responses were gathered through the virtual assistant and were encrypted and automatically transported to a database in real-time. At the end of data collection, the database was anonymized by assigning a unique identifier code for each client.
The socio-demographic characteristics of the participants were collected through the virtual assistant. The feasibility of delivering HIVST kits to the target key populations in a community setting was assessed based on the following parameters: the number of HIVST kits distributed (HIVST uptake), the HIV reactivity rate, and the linkage to further testing. In addition, information on the participant’s HIV testing experience (never/ever tested for HIV) and preference on the type of sources of HIVST information was also surveyed.
Furthermore, the acceptability of the HIVST kit was the main outcome of the study. It was measured using a 10-item System Usability Scale (SUS), a standard tool that allows users to assess the usability of a given product or service [17 –19 ]. Briefly, it is comprised of ten validated statements, which cover five positive aspects and five negative aspects of a particular tool, system, or kit. The final score is out of 100, wherein each respondent answered every question on a Likert scale from Strongly Disagree to Strongly Agree. Moreover, a SUS score of less than 50 was considered “Not Acceptable” and would imply that the HIVST kit will have usability issues. SUS scores between 50 to 70 were classified as “Marginal,” whereas a SUS score of greater than 70 was categorized as “Acceptable,” with varying degrees of usability [18 ]. The SUS tool was only offered to non-reactive clients through the virtual assistant. Reactive clients were excluded due to possible high emotional stress from the result of using the HIVST kit, which may affect their response to the survey.
Moreover, counselors assigned to each client discussed evidence-based preventive strategies such as using PrEP to non-reactive clients to decrease their risk of acquiring HIV and other sexually transmitted infections. Furthermore, counselors prioritized linkage to confirmatory testing for the reactive clients and emphasized the importance of early initiation of treatment. The reactive clients were referred to “acXess by LoveYourself,” the ambulatory service created by the TLY team to overcome the mobility restrictions caused by the announcement of enhanced community quarantine lockdowns to control the spread of COVID-19. The research team excluded the reactive group from answering the survey to prioritize confirmatory testing and treatment referral. In addition, the research team contacted the participants who received invalid results and were given instructions to visit the nearest HIV facility for immediate retesting. Lastly, the research team sent notifications via the virtual assistant to those who did not disclose their HIVST result to remind them to report their test result.

Study design and setting
This study is a retrospective survey of American women who completed an electronic survey form in October of 2022. The study design was approved by the Sterling Institutional Review Board (approval no. 10225). The survey instrument was developed in consultation with experts in abortion counseling and researchers who have published in the field of abortion’s association with emotional and mental health effects. The survey included five statements regarding pressures to abort and 10 statements regarding outcome variables, collectively shown in Table 1, along with the abbreviation for each pressure stated in this report. Respondents indicated their responses using a slider on a visual analog scale displayed on their own electronic devices. While no numbers were shown to the respondents when they slid their markers, their responses on the visual analog scale were automatically converted to the appropriate percentage in a range from 0 to 100.
In brief, respondents rated the level of pressure, if any, they experienced from their male partner, their family, other persons, financial pressures, and other circumstances. To further our analyses, we also constructed the average score (AvgPr) and the maximum score (MaxPr) each woman reported across each of these five scales. The outcome scales rated each respondent’s level of experience of positive emotions, negative emotions, disruption of normal life, desire for help to cope, intrusive thoughts, frequent feelings of loss, their assessment of abortion’s impact on their mental health, and whether completing the survey increased feelings of stress.
Population
The surveyed population was drawn from 28 million Cint panelists in the United States [15 ]. Cint panelists are persons who voluntarily complete surveys using their own electronic devices in exchange for small rewards. Our selection criteria required Cint to obtain 1,000 completed surveys from females who are residents of the United States who were 41 to 45 years of age, inclusive, at a cost of three dollars per completed survey. This narrow age range was chosen to eliminate the confounding effects of age while capturing the experience of women who have completed the majority of their reproductive lives.