On March 11, 2020, the COVID-19 pandemic was officially declared by the World Health Organization (WHO). Although the pandemic has had an unprecedented impact on our everyday lives, it is difficult to say that it was unexpected. Virologists and public health bodies have frequently warned of the global threat that pandemics pose,Reference Cox, Tamblyn and Tam1–3 and there have been serious warnings regarding the potential for a pandemic including the SARS (2003), MERS (2012), and the West African Ebola (2013-2016) virus outbreaks.Reference Naguib, Ellström and Järhult4 The COVID-19 pandemic has highlighted a need for governments to prepare for future pandemics at a population level.Reference Chaudhry, Dranitsaris and Mubashir5 However, preparedness behaviors, defined as steps undertaken by individuals to develop appropriate responses to disaster events, can also increase survival3, Reference Braunack-Mayer, Street and Rogers6 and reduce the mental health impact of disasters.Reference Clay, Goetschius and Papas7 The COVID-19 pandemic provides an opportunity for researchers to examine factors which influence perceived preparedness during distinct phases of the pandemic. Therefore, the current multi-study paper investigated how individual differences (gender, age, perceived socioeconomic and health status) impact self-reported levels of preparedness and mental health outcomes (anxiety, depression, stress symptoms) during the first period of lockdown in the UK, and again 2 years later.
Emergency preparation and positive responses to disaster warnings are frequently linked to better outcomes.Reference Das8, Reference Ronan, Alisic and Towers9 Heeding evacuation warnings, stockpiling essential supplies, and undertaking appropriate training can enhance survival.Reference Egbelakin, Poshdar and Walsh10, Reference Feinberg and Willer11 However, a high percentage of people do not take emergency warnings seriously and fail to prepare.Reference Feinberg and Willer11, Reference Codreanu, Celenza and Jacobs12 Others may on take warnings but are prevented from doing so due to financial constraints that act as a barrier to individuals from engaging in preparedness behaviors.Reference Leach13 Further, individuals are less likely to engage in preparedness behaviors if they are unable to comprehend the scope of the potential disaster,Reference Greene, Perry and Lindell14 lack sufficient time prepare,Reference Leach13 or are unsure about how to prepare.Reference Kruger, Chen and Heifeld15 The UK’s geographical location may mean that the public are less able to understand the threat posed by COVID-19 as the populace has been exposed to fewer natural disasters than other world regions.Reference Ritchie, Rosado and Roser16 Recent pandemics, such as the H1N1 influenza virus in 2009-2010, have not caused great disruption, and the last major pandemic in the UK (Spanish flu, 1918-1919) is not in living memory. Therefore, the current study examined perceived preparedness seen in the UK population in response to the COVID-19 pandemic.
Demographics and Preparedness
Within the disaster research literature, there are calls to incorporate gender analysis to ensure that appropriate action can be undertaken to promote gender and health equality effectively.Reference Wenham, Smith and Morgan17 Previous research has indicated that women are more likely to be engaged in preparednessReference Mulilis18 and follow evacuation adviceReference Thompson, Garfin and Holman19 compared to men. However, social norms relating to gender identity could be important. In Serbia, men reported greater confidence in their preparedness, but interviewers found women demonstrated higher levels of caring, both in their own household and to flood victims.Reference Cvetković, Roder and Öcal20 It has been suggested that hegemonic masculinity can be a barrier to males undertaking preparedness behaviors with negative traits,Reference Zara, Parkinson and Duncan21 such as risk-taking associated with masculinity, putting mental and physical health at risk. Given the changing gender roles within the UK population,Reference Kan and Laurie22 the current study examined the influence of gender on perceived preparedness.
Alongside gender, age has demonstrated mixed relationships with preparedness. Some studies find that preparedness increases with age,Reference Mishra and Suar23 which may be partly due to some younger people (aged 14 to 17 years) perceiving a sense of invincibility, and increased engagement in risky behaviors.Reference Wickman, Anderson and Smith Greenberg24 However, other research finds that older people (aged 65 years and over) are less likely to engage in preparedness behaviors,Reference Chan, Yue and Lee25 which may be due to an optimistic bias, whereby older people who have survived previous disasters are less likely to prepare. Conversely, some disaster research finds that age is unrelated to preparedness.Reference Najafi, Ardalan and Akbarisari26, Reference Appleby-Arnold, Brockdorff and Jakovljev27 These mixed findings require further investigation as to whether age is a determinant of preparedness.
Lower socioeconomic status (SES), often measured using household income, has been identified as a barrier to preparedness behaviors.Reference Eisenman, Glik and Maranon28, Reference Kohn, Eaton and Feroz29 During the influenza A (H1N1) pandemic, higher household income and homeownership were positively associated with more knowledge about the H1N1 pandemic.Reference Lin, Savoia and Agboola30 A further study revealed that lower SES is related to more difficultly accessing information about the H1N1 pandemic, due to factors such as reduced internet access.Reference Lin, Jung and McCloud31 However, other research suggests that subjective perceptions of SES are more closely aligned with well-being outcomes,Reference Zhao, Huang and Mendoza32 and engaging in pro-environmental behaviorsReference Zhong, Niu and Li33 compared to objective indicators of SES alone. Therefore, the current study assessed the influence of subjective SES on people’s perceived preparedness.
Another important factor in emergency preparedness is a person’s perceived health status, with vulnerable populations requiring additional support.Reference Nick, Savoia and Elqura34 Although it may be more prudent for people with a long-term health condition to undertake more preparedness behaviors, there is limited research into whether this influences their perceived preparedness. One American study reported that people with a disability were more likely to be prepared for emergencies.Reference Eisenman, Wold and Fielding35 A UK-based study found that people with disabilities made few attempts at emergency preparedness and tended to adopt a fatalistic approach.Reference Finkelstein and Finkelstein36 More research is needed as to whether subjective health status is related to preparedness.
Preparedness and Mental Health
As well as enhancing survival, emergency preparedness before a disaster has been shown to have a positive benefit on mental health.Reference Clay, Goetschius and Papas7, Reference Sherman, Gershon and Riley37, Reference Welton-Mitchell, James and Khanal38 For example, having extra stockpiles of food and household supplies can reduce the anxiety and fear associated with an impending disaster.Reference Columbus, Brust and Arroliga39 One Chinese study revealed that participants with perceived greater knowledge about COVID-19 also reported higher well-being.Reference Yang and Ma40 One suggestion is that more knowledge could help people feel more in control. Therefore, this paper examined whether perceived preparedness prior to the March 2020 lockdown would lead to better mental health during the lockdown period, and again 2 years later.
It is important to assess factors determining levels of preparedness and resulting mental health outcomes at various stages during the COVID-19 pandemic in the UK population to develop an understanding of people’s responses to pandemic situations. The current 2-part study had 2 aims: (1) to examine the extent to which demographic variables (gender, age, subjective SES, subjective health status) predict levels of preparedness during the COVID-19 pandemic; and (2) to assess relationships between perceived preparedness and mental health outcomes (anxiety, depression, subjective distress). Study 1 investigated these aims during the first UK lockdown, and Study 2 2 years into the pandemic, to identify predictors of preparedness and relationships with common mental health outcomes. For both studies, it was expected that demographic variables would predict perceived preparedness, and higher levels of preparedness would be associated with better mental health outcomes.
Study 1
Methods
Participants
Five hundred and seventy people initially responded to an online survey (see Supplementary Information for questions) regarding psychological responses to COVID-19. Of these participants, 161 did not complete the survey or meet the inclusion criteria, leaving a final sample of 409 participants (71.9% completion rate). Key sample characteristics are presented in Table 1.
Table 1. Sample characteristics of Study 1 and Study 2
Materials
Demographics. Participants provided brief demographic information including their gender, age, relationship status, and country of residence. Participants also indicated whether they experienced symptoms of COVID-19 and/or had hospital treatment for symptoms since March 16, 2020.
COVID-19 preparedness. A single item asked participants to rate their level of COVID-19 preparedness on a 5-point scale from 0 (not at all prepared) to 4 (extremely prepared). Higher scores infer greater perceived preparedness prior to the COVID-19 outbreak in the UK. Participants also identified the number of preparedness activities undertaken from a selection of 6, such as “reviewed information about COVID-19 on websites” or had “bought equipment, such as hand wash or a face mask.” Participants scored 1 for a yes response to each item with a maximum score of 6. A higher score indicated a higher level of prepping behaviors.
Subjective socioeconomic status. The MacArthur Scale of Subjective Socioeconomic StatusReference Adler and Stewart41 was used to measure participants’ subjective SES. Participants rate on a scale of 0-100 where they would position themselves in UK society. A high score of 100 reflects people who are best off, with the highest amount of schooling and respected jobs, and 0 represents those who are the worst off, with no education or job, or jobs that no one wants or respects.
Subjective health status. A visual analogue scale, taken from the EuroQol 5D (EQ-5DReference Rabin and Charro42), measured participants’ subjective perceptions of health. Participants indicated on a scale from 0 (worst) to 100 (best) how they considered their health to be, with higher scores reflecting greater perceived health status.
Anxiety. The Generalized Anxiety Disorder-7 (GAD-7Reference Spitzer, Kroenke and Williams43) is a 7-item measure of anxiety symptoms. Participants rate, on a scale from 0 (not at all) to 3 (nearly every day), how bothered they have been by the items over the previous 2 weeks. Problems include “Feeling nervous, anxious or on edge.” Higher scores are indicative of increased anxiety. The GAD-7 has demonstrated good psychometric properties,Reference Spitzer, Kroenke and Williams43 which was reflected in this study (α = .94).
Depression. The Patient Health Questionnaire (PHQ-9Reference Kroenke, Spitzer and Williams44) is a 9-item measure of depressive symptoms rated on a scale from 0 (not at all) to 3 (nearly every day). Participants rate how bothered they have been by the problems described over the last 2 weeks. Items include “Little interest or pleasure in doing things.” Higher scores are reflective of greater depressive symptoms. The PHQ-9 is a reliable and valid measure of depressive symptoms,Reference Kroenke, Spitzer and Williams44 and was demonstrated in this study (α = .91).
Stress symptoms. The Impact of Events Scale-Revised (IES-RReference Weiss, Wilson and Tang45) lists 22 difficulties people may experience after a stressful life event, on a scale of 0 (not at all) to 4 (extremely). The scale was adapted to focus on negative symptoms attributed to COVID-19 within the past 7 days. Example items include “I tried not to think about it.” Higher scores indicate greater stress symptoms. The IES-R has sound psychometric properties, which was reflected in this study (α = .90).
Procedure
Data collection took place from May 5 to June 12, 2020, during the first UK national lockdown which started on March 23, 2020. During this lockdown period, education establishments, places of worship, and non-essential shops and businesses were closed. Strict social distancing restrictions were in place and legally enforced. To comply with social distancing requirements at the time, participants were recruited via snowball sampling, online social media posts, and paid Facebook advertisements targeted at UK users to reach a larger demographic. Participants were eligible for the study if they were over the age of 18, located in the UK, and fluent in English. Prior to starting the questionnaire, participants were given the opportunity to read information regarding the study aims and requirements. Participants were made aware of their rights to confidentiality and withdrawal, voluntary participation, and secure storage of data. After providing informed consent, participants completed the survey questionnaires and were presented with a debriefing sheet at the end of the questionnaire with details of support services. The study received institutional ethics approval from the Science Ethics Review Panel (SCIENCE 0015) and was conducted in accordance with the Declaration of Helsinki.
Data analysis
Statistical analyses were conducted using the IBM-Statistical Package for the Social Sciences (IBM-SPSS) Version 29. First, correlation analyses were performed to examine relationships between key demographic, preparedness, and mental health outcomes. Next, multiple regression was conducted to examine whether demographic variables predicted COVID-19 level of preparedness.
Results
Preparedness activities
Participant preparedness data is summarized in Table 1. On average, participants undertook 2 different preparedness activities (M = 2.27, SD = 1.36; range 1-6) prior to the UK lockdown. The most preferable preparedness activities were reviewing information about COVID-19 on websites (74.6%) and buying additional food and household supplies (57.9%). Over a third of participants (36.4%) felt they were “somewhat prepared” for the pandemic. Self-reported levels of preparedness prior to the pandemic were significantly and positive correlated with the number of preparedness activities undertaken [r(407) = .45, p < .001].
Demographics, Preparedness, and Mental Health Outcomes
Correlation analysis was conducted to establish relationships between demographic, mental health, and self-reported COVID-19 preparedness variables (see Table 2). Higher levels of perceived preparedness were associated with lower levels of anxiety, depression, and stress symptoms. Subjective SES was the only demographic variable associated with perceived preparedness, demonstrating a weak positive relationship.
Table 2. Descriptive and correlational data for key Study 1 variables
Notes. Min. = minimum value; Max. = maximum value. Gender was dichotomized with a higher value corresponding to “female.” * p < .05, ** p < .01, *** p < .001.
Multiple regression analysis was used to examine demographic predictors of COVID-19 preparedness levels. The overall regression model was not significant [F (4, 405) = 2.30, p = .074], and only accounted for 1% of the variance in preparedness (Adj. R 2 = .01). Gender (p = .427), age (p = .077), subjective SES (p = .168), and subjective health status (p = .171) were non-significant predictors of perceived preparedness.
Discussion
Study 1 revealed that demographic factors were unrelated to levels of perceived preparedness prior to the COVID-19 outbreak. This suggests that other factors may better explain preparedness than demographic characteristicsReference Najafi, Ardalan and Akbarisari26 in the context of COVID-19. However, in the bivariate analysis, higher levels of perceived preparedness were associated with lower levels of anxiety, depression, stress symptoms, and higher SES. These findings are consistent with the potentially ameliorative effects of preparedness on mental health outcomes,Reference Clay, Goetschius and Papas7, Reference Sherman, Gershon and Riley37, Reference Welton-Mitchell, James and Khanal38 and of higher SES related to greater preparedness.Reference Lin, Savoia and Agboola30
Study 2
Method
Participants
One-hundred and fourteen people responded to an online survey regarding psychological responses to COVID-19. Of these participants, 27 participants were excluded due to incomplete data or not meeting the inclusion criteria. Therefore, the survey completion rate was 76.3%, with the final sample consisting of 87 participants (see Table 1 for sample characteristics).
Materials
The same questionnaires described in Study 1 were administered in Study 2. The GAD-7 (α = .94), PHQ-9 (α = .89), and IES-R (α = .90) demonstrated similar internal reliability to Study 1. Furthermore, participants recorded whether their mental health had improved, deteriorated, or remained the same during the pandemic, and whether they experienced long-term illness due to contracting COVID-19. Participants self-reported their perceived preparedness before COVID-19, their current perceptions, and whether they felt more prepared to deal with future pandemics (see Supplementary Information for questions).
Procedure and Data Analysis
Data collection took place from March 7 to July 5, 2022, approximately 2 years from the initial lockdown. All procedures and data analysis were the same as described in Study 1.
Results
Preparedness activities
Preparedness data for participants is summarized in Table 1. On average, participants undertook 3 different preparedness activities (M = 3.33, SD = 1.30; range 1-6) 2 years after the UK lockdown. The most preferable preparedness activities were buying additional equipment such as handwash or face masks (92.0%), reviewing information about COVID-19 on websites (86.2%), and buying additional food and household supplies (72.4%). A fifth of participants (40.2%) felt they were “not prepared” for the pandemic. Significant positive correlations were observed between the number of preparedness activities undertaken and levels of preparedness prior to the pandemic [r(85) = .22, p = .037], current preparedness [r(85) = .33, p = .002], and future preparedness [r(85) = .34, p = .001].
Demographics, Preparedness, and Mental Health Outcomes
Table 3 presents descriptive statistics and correlations between key study variables. Higher levels of perceived preparedness prior to COVID-19, and current preparedness levels, were all associated with lower levels of anxiety, depression, and stress symptoms. Depressive symptoms were negatively and weakly associated with future preparedness. Subjective SES was the only demographic variable associated with all 3 perceived preparedness variables, demonstrating positive relationships with preparedness. Subjective health status was positively associated with current and future perceived preparedness levels. All preparedness levels were strongly and positively associated with one another.
Table 3. Descriptive and correlational data for key Study 2 variables
Notes. Min. = minimum value; Max. = maximum value. Gender was dichotomized with a higher value corresponding to “female.” * p < .05, ** p < .01, *** p < .001.
Three multiple regression analyses were conducted to examine demographic predictors of (1) perceived preparedness levels before the pandemic, (2) current preparedness, and (3) future preparedness. Findings (shown in Table 4) indicated that the regression model with current preparedness as the criterion explained the most variance (13%) of all 3 models. SES was a robust positive predictor of preparedness levels in all three models.
Table 4. Study 2 demographic predictors of perceived preparedness before COVID-19, current preparedness, and future preparedness
Notes. B = unstandardized beta coefficient; SE (B) = standard error of unstandardized beta coefficient; β = standardized beta coefficient. Gender was dichotomized with a higher value corresponding to “female.” * p < .05, ** p < .01, *** p < .001.
Discussion
Study 2 indicated that subjective SES was a robust predictor of perceived preparedness both before, during, and subsequent pandemics. This finding extends previous literatureReference Lin, Savoia and Agboola30 which has not always considered temporal aspects of preparedness in relation to SES. Study 2 also extended the findings of Study 1 by determining that prior and current preparedness are related to better mental health.
General Discussion
The current study examined perceived preparedness in a sample of the UK public in response to the COVID-19 pandemic during the first national lockdown (Study 1) and 2 years afterwards (Study 2). Across both studies, participants engaged in at least 1 preparedness activity in the lead up to the lockdown period, with 2 to 3 activities on average being undertaken. The COVID-19 pandemic posed a challenge to the UK public. As a nation who rarely face disasters, emergency preparedness is not central to public daily life compared to more disaster-prone countries.Reference Ritchie, Rosado and Roser16 Considering the major impact that COVID-19 had on the lives of people living in the UK, it is surprising that, on average, most people only undertook 2 to 3 emergency preparedness activities. Lack of preparedness experience for an emergency has been shown to negatively influence the number of preparedness behaviors undertaken,Reference Greene, Perry and Lindell14 and the novelty of the pandemic may have meant people simply did not know how to prepare.Reference Kruger, Chen and Heifeld15 However, it is useful to note that all participants in the sample did undertake at least 2 preparedness activity prior to the March 2020 lockdown and appeared to engage in similar behaviors 2 years into the pandemic.
Demographics and Preparedness
The results of the current study found no gender differences in perceived preparedness. Previous research had suggested that established gender norms can influence engagement with preparedness with hegemonic masculinity reduce preparedness in malesReference Zara, Parkinson and Duncan21 and the burden of emergency preparations falling more heavily on women.Reference Mulilis18–Reference Cvetković, Roder and Öcal20 However, the absence of gender differences in perceived COVID-19 preparedness suggested that preparing for the pandemic in the UK was equally shared between males and females. Greater gender equality with women having better social and economic freedom, and males taking on more household responsibility, could explain the lack of gender difference in perceived preparedness during various stages of the pandemic in the UK.
The current findings also imply that age was not a significant determinant of preparedness. This contrasts with results that demonstrate older people are moreReference Mishra and Suar23 or less likelyReference Chan, Yue and Lee25 to prepare due to their previous experiences of disasters. However, the results observed are like other research that has assessed preparedness in countries like the UK which experience few natural hazards.Reference Najafi, Ardalan and Akbarisari26, Reference Appleby-Arnold, Brockdorff and Jakovljev27 The results may therefore be explained by the low prevalence of natural disasters in the UK, and the relative unpreparedness of the population compared to countries more accustomed to national emergencies.Reference Ritchie, Rosado and Roser16 Further, older individuals in the study are unlikely to have faced a major pandemic of the same magnitude as the COVID-19 pandemic, and so previous experiences may have had a limited influence on their preparedness levels. Finally, it could be argued that due to the increased mortality in older people who become ill with COVID-19, preparedness behaviors should have been higher in this group.Reference Mahase46 Moving forward, it would be interesting to examine whether the optimism biasReference Chan, Yue and Lee25 or a more fatalist approachReference Finkelstein and Finkelstein36 are related to more preparedness behaviors in older people.
The current study also explored the influence of subjective SES on preparedness. The results revealed that those with lower perceived SES also had low perceived preparedness. One explanation is that those with higher SES have the time and money to engage in preparedness behaviors. Further, it is suggested that higher SES may mean that people have access to more information about potential disasters and emergency preparedness.Reference Lin, Savoia and Agboola30, Reference Lin, Jung and McCloud31
Therefore, those with lower SES may need additional support when preparing for additional waves of the COVID-19 pandemic or during future public health emergencies. Future research should explore whether enhancing access to additional information and resources to low SES households can increase emergency preparedness.
The results of the current study suggest that those with perceived better health are more likely to engage in preparedness behaviors. This finding appears to be counterintuitive, as vulnerable populations require additional support during emergenciesReference Nick, Savoia and Elqura34 and so are likely to require additional preparations prior to lockdown. One explanation is that poor physical health could lead to reduced access to activities such as undertaking additional shopping trips for stockpiling. Although previous research has sometimes found that those with a disability are more likely to be prepared for emergencies,Reference Eisenman, Wold and Fielding35 other studies have found that people with disabilities can take a more fatalistic approach and so make few attempts to prepare for an emergency.Reference Finkelstein and Finkelstein36 The current study did not explore the practical and psychological barriers that may have stopped people from undertaking emergency preparedness behaviors, which could be addressed in future research.
Mental Health and Preparedness
The present study examined relationships between COVID-19 preparedness and mental health status at distinct stages of the pandemic. Some consistent findings emerged in that perceived preparedness was largely associated with lower anxiety, depression, and stress symptoms, revealing a potentially beneficial impact on mental health during a major public health emergency. Emergency preparedness has been linked to better mental healthReference Clay, Goetschius and Papas7, Reference Columbus, Brust and Arroliga39 and the results of the current study support these prior findings, as participants with greater perceived preparedness had lower anxiety and depression during lockdown. Research has indicated that people who are well-informed about COVID-19 report greater well-being as it may help people feel more in control.Reference Yang and Ma40 These results mirror findings that suggest that developing an emergency preparedness plan can help reduce the risk of adverse psychological outcomes.Reference Sherman, Gershon and Riley37, Reference Welton-Mitchell, James and Khanal38 Therefore, the results of current study indicate clear mental health advantages of engaging in preparedness behaviors prior to emergency situations occurring. Given the better mental health outcomes associated with preparedness, individuals should be encouraged to proactively prepare for emergencies.
Limitations
While these studies provided some insight into preparedness behaviors and outcomes, it is not without limitation. Participants were based in the UK, and so the results may not be generalizable to people in other geographic locations. No data were collected as to whether participants were based in rural or urban areas. Rural and urban communities face different disaster risks, present with divergent attitudes towards preparedness, and varying access to preparedness equipment.Reference Chai, Han and Han47 The research was cross-sectional, and so it was not possible to determine causality between variables. Due to possible fatigue engaging with COVID-19 research,Reference Patel, Webster and Greenberg48 the sample size for Study 2 was not comparable with that of Study 1. Considering the non-responses rates for both studies, it is possible that those who were more psychologically impacted by COVID-19 were not represented in the research.Reference Hendra and Hill49 However, other research finds no relationship between response rate and response bias. Additionally, the lack of repeated measures data means it was not possible to fully assess the extent to which individuals’ perceptions of preparedness and mental health in Study 1 had changed 2 years post-lockdown. Although common mental health outcomes were assessed, research also suggests that emergency situations can induce substance-related misuse.Reference Alexander and Ward50 During the COVID-19 lockdowns in the UK, more than 1 in 6 adults increased their alcohol consumption, which has been associated with worse mental health.Reference Jacob, Smith and Armstrong51 Future research into the impact of emergency situations on mental health should also consider if there have been increases in substance-related misuse.
Conclusion
The current study suggests that encouraging preparedness behaviors can have a positive impact on mental health during subsequent emergencies. Therefore, encouraging the public to engage with preparedness behaviors may not only have practical benefits but also help to protect mental well-being during a disaster. Demographic factors such as age and gender were not associated with the level of preparedness. As preparing for emergencies appears to have a beneficial effect on mental health during an emergency, more research is needed to examine how preparedness behaviors can be promoted.
Data availability statement
Data for the study are available upon request from the first author.
Acknowledgments
Ryan Sparkes and Calvin Robinson.
Author contribution
SJR: Conceptualization, methodology, data collection, writing—original draft. MB: Methodology, formal analysis, writing—original draft; writing—review and editing. NF: Data collection. CC: Methodology. CL: Conceptualization, data collection, writing—review and editing.
Funding statement
The study received internal funding from the University of Central Lancashire.
Competing interests
The authors declare none.
Ethical standard
Ethical approval for this study was granted by the Science Ethics Review Panel (SCIENCE 0015) at the University of Central Lancashire.
Open access
