Introduction
Background
Since its discovery in Wuhan China, coronavirus disease-19 (COVID-19) has spread rapidly across the world in a few months (Oud et al. Reference Oud, Winter, Vermeulen-Smit, Bodden, Nauta, Stone, Van Den Heuvel, Taher, De Graaf, Kendall, Engels and Stikkelbroek2019). Having been declared a global pandemic in January 2020, Canada has not been spared (Brown et al. Reference Brown, Sellwood, Beecham, Slade, Andiappan, Landau, Johnson and Smith2011). As it has progressed, the pandemic leaves in its wake a significant death toll, worsening economic indices, and increased global disease burden (Gautam & Sharma, Reference Gautam and Sharma2020). This trail of devastation has caused governments to take unprecedented actions to curb the spread of this novel disease, including partial shutdown of the economy, physical distancing, and quarantine (Abba-Aji et al. Reference Abba-Aji, Li, Hrabok, Shalaby, Gusnowski, Vuong, Surood, Nkire, Li, Greenshaw and Agyapong2020; Nwachukwu et al. Reference Nwachukwu, Nkire, Shalaby, Hrabok, Vuong, Gusnowski, Surood, Urichuk, Greenshaw and Agyapong2020). These measures coupled with the direct effects of the illness itself have disturbed the natural rhythm and structure of individuals’ lives, which in turn has had an adverse impact on mental health and well-being (Wang et al. Reference Wang, Pan, Wan, Tan, Xu, Ho and Ho2020).
Quarantine and self-isolation are well-established means for managing highly contagious disease outbreaks in an epidemic (Taha et al. Reference Taha, Matheson, Cronin and Anisman2014). The two terms, although used interchangeably, have different meanings. Self-isolation is the sequestration of individuals who have been diagnosed with a contagious disease from those who are not sick (Brooks et al. Reference Brooks, Webster, Smith, Woodland, Wessely, Greenberg and Rubin2020, Manuell & Cukor, Reference Manuell and Cukor2010), while quarantine is the separation and limitation of movement of individuals who have potentially been exposed to a contagious disease to see whether they become unwell, thereby reducing the risk of infection to others (Williams & Potts, Reference Williams and Pott2010; Taha et al. Reference Taha, Matheson, Cronin and Anisman2014). These well-intentioned methods of managing a pandemic produce unintended consequences. Prior research indicates that both measures may increase anxiety, stress and depression (Nkire et al. Reference Nkire, Mrklas, Hrabook, Gusnowski, Vuong, Surood, Abba-Aji, Urichuck, Greenshaw and Agyapomg2021), increase suicidal risk (Barbisch et al. Reference Barbisch, Koenig and Shih2015), escalate boredom, increase fears of infecting family particularly among those with young children, limit supplies of essential goods, affect family finances, induce frustration and anger and litigation (Miles, Reference Miles2015; Brooks et al. Reference Brooks, Webster, Smith, Woodland, Wessely, Greenberg and Rubin2020), and in some circumstances, result in the stigmatization of affected individuals. As well, by putting cohabiting individuals (eg. partners, roommates and families) in unusually close proximity for a long time in a mostly closed unit, it may expose or worsen existing tensions in relationships. While for single individuals, it may reduce access to previous supports, which may in turn increase their stress.
Stress levels, anxiety, and depression are usually elevated during crises (Wang et al. Reference Wang, Pan, Wan, Tan, Xu, Ho and Ho2020). As work places have closed and individuals have become limited to their family units or households, intimate partner relationships became an important source of coping with stress posed by the pandemic. Relationships have a bidirectional association with mental health such that a good relationship bodes well for good mental health, while severe mental illness may pose a strain on relationships. Some researchers have observed that relationships on the whole predict better mental health outcomes (Braithwaite & Holt-Lunstad, Reference Braithwaithe and Holt-Lunstad2017). They also note that the quality of the relationship plays a role in ensuring good mental health. They further posit that established committed relationships are associated with greater benefit to mental health (Braithwaithe & Holt-Lunstad, Reference Braithwaithe and Holt-Lunstad2017). A contentious or troubled relationship is associated with more mental health problems in mothers and children (Dush & Amato, Reference Dush and Amato2005; Hannighofer et al. Reference Hannighofer, Foran, Hahlweg and Zimmermann2017). To further highlight the importance of the quality of relationship on mental health, prior studies have shown that single people have better mental health outcomes than those who are in an unhappy union (Holt-Lunstad et al. Reference Holt-Lunstad, Birmingham and Jones2008). Some authors show that levels of anxiety and depression are considerably higher in single mothers than in married mothers (Crosier et al. Reference Crosier, Butterworth and Rodgers2007; Rousou et al. Reference Rousou, Kouta, Middleton and Karanikola2019), and the Millennium Cohort Study demonstrates that mothers in unstable families (separated or divorced) have worse mental health outcomes than those in stable family units (Baldridge, Reference Balbridge2011). Individuals who are in unstable relationships show higher levels of depression and anxiety than those in stable relationships (Cairney et al. Reference Cairney, Boyle, Offord and Racine2003; Hannighofer et al. Reference Hannighofer, Foran, Hahlweg and Zimmermann2017), which supports the view that positive interaction with partners or a spouse reduces the risk of depression and anxiety (Santini et al. Reference Santini, Koyanagi, Tyrovolas and Haro2015). Research indicates that marital status differences in mental health are greatest when the comparison group is the divorced or widowed and smaller or nonsignificant in comparison to the never married, suggesting a more nuanced effect of marriage on mental health outcomes such as anxiety and depression (Cairney & Krause, Reference Cairney and Krause2005; Williams & Carlson, 2012).
The impact of relationships and relationship status on anxiety and depression during a pandemic, such as COVID-19, is less studied, and most of the studies in this area involve Asian cohorts. The predominance of studies comprising primarily Asians or set in Asian countries may limit generalizability to other countries and races; hence, the need for a study set in, and comprised of samples from, a different jurisdiction. The evidence varies for studies published to date. Hawryluck et al. (Reference Hawryluck, Gold, Robinson, Pogorski, Galea and Styra2004) found no relationship between marital status and psychological outcomes in quarantine during a crisis, and Wang et al. (Reference Wang, Pan, Wan, Tan, Xu, Ho and Ho2020), in examining the psychological responses during the initial phases of the COVID-19 pandemic in China, found that marital status did not significantly impact depression and anxiety scores. However, Tan and colleagues (Reference Tan, Hao, McIntyre, Jiang, Jiang, Zhang, Zhao, Zou, Hu, Luo, Zhang, Lai, Ho, Tran, Ho and Tam2020) in their study of the immediate mental health status of the Chinese workforce during the COVID-19 pandemic found that respondents who were divorced, separated, or widowed had higher impact of event, stress, anxiety, and depression scores than individuals who were single; and the married group had lower scores. This study differs from others in that it examined mental health issues in subjects returning to work in a pandemic. The added strain of returning to work in a pandemic and the attendant stress of finding appropriate childcare may have affected responses; while this was not explicitly explored in the study, it does deserve further examination.
The present study examines the impact of relationship status on reports of stress, anxiety, and depression during the COVID-19 pandemic in a Canadian cohort. It aims to add to the literature in this area, which to the best of our knowledge is limited. Most of the literature in this area arises from Asia and may therefore not be generalizable to Canadian subjects; this in turn limits the evidence available for channelling appropriate resources and treatments to those who might need it. Findings may help to provide individuals in at-risk relationship status group with additional mental health supports/services during this and future pandemics.
Method
A cross-sectional survey was used to explore mean differences in perceived stress, anxiety, and depression symptom scores according to the relationship status of Text4Hope subscribers.
Recruitment
The study recruitment procedures and sample size estimations have been described in the published study protocol (Agyapong et al. Reference Agyapong2020). An online survey link was sent to subscribers to the Text4Hope program, a daily supportive text message service, launched by Alberta Health Services on March 23, 2020 to help Albertans cope with the mental health effects of the COVID-19 pandemic. In addition to demographic information, we assessed clinical characteristics using validated scales for self-reported symptoms, including the Perceived Stress Scale (PSS), the Generalized Anxiety Disorder 7-item (GAD-7) scale, and the Patient Health Questionnaire-9 (PHQ-9). The PSS is a validated 10-item questionnaire used to assess the self-reported level of stress in the previous 1 month by assessing thoughts and feelings. Each item on the scale is scored between 0 (never) to 5 (very often). Higher scores on the scale indicates higher levels of stress (Cohen et al. Reference Cohen, Kamarck and Mermelstein1983). The GAD-7 is a validated 7-item questionnaire used to assess the self-reported levels of anxiety in respondents in the 2 weeks prior to assessment (Spitzer et al. Reference Spitzer, Kroenke, Williams and Lowe2006). It is based on DSM-IV-TR symptoms of anxiety. Each item on the scale is scored between 0 (not at all) and 4 (nearly every day).
The PHQ-9 is a 9-item validated instrument used to diagnose and measure the severity of depression in general medical and mental health settings (Kroenke et al. Reference Kroenke, Spitzer and Williams2001); it is the major depression module of the full PHQ. Each of the nine items on the questionnaire is scored between 0 (not at all) and 3 (nearly every day). It may be used to plan and monitor treatment of depression.
Sample size estimation
Based on a provincial population estimate of approximately 4.3 million, the necessary sample size to generate prevalence estimates was 4157, assuming a 99% confidence level and 2% error. Previous research employing similar methodology in Alberta generated a 20% response rate (Agyapong et al. Reference Agyapong, Mrklas, Juhas, Omeje, Ohinmaa, Dursun and Greenshaw2016). Therefore, we aimed to extract and analyze data after obtaining a minimum recruited sample of 20 785 Text4Hope subscribers.
Data analysis
Data analysis was undertaken using the IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows, version 26 (Fortuna et al. Reference Fortuna, Storm, Naslund, Chow, Aschbrenner, Lohman and Bartels2018). One-way analysis of variance (ANOVA) with two-tailed significance (p < 0.05) was performed to assess the statistical differences between relationship status and corresponding mean scores on the PSS, the GAD-7, and the PHQ-9. For variables which did not violate the assumptions of homogeneity of variance in the mean scores on the ANOVA test, we performed a Tukey’s post hoc test to determine if there were statistically significant differences in the mean scores of the various clinical measures between the different relationship status groupings. For variables which violated the homogeneity of variance assumption, we determined if there were statistically significant differences for the mean scores for the various clinical measures between the different relationship status groupings using the Welch F test and a Games-Howell post hoc test (as these tests do not require groups to have equal standard deviations).
Results
Of the 44·992 subscribers who joined Text4Hope in the first 6 weeks, 8267 responded to the online survey invitation, yielding a 19.4% response rate. Of the 8267 respondents, 5799 (70.1%) identified as either married, cohabiting, or partnered, 618 (7.5%) identified as either separated or divorced, 136 (1.6%) identified as widowed, 1541 (18.6%) identified as single, 95 (1.1%) identified as “other,” and 78 (0.9%) did not identify their relationship status.
The other demographic characteristics of the respondents are as shown in Table 1.
Table 1. Distribution of demographic characteristics of respondents by relationship status
As demonstrated in Table 1, the majority of respondents were female, (n = 7104, 86.9%), were Caucasians (n = 6684, 82.0%), had post-secondary education (n = 6947, 85.0%), were employed (n = 5982, 73.2%), were married, cohabiting, or partnered (n = 5799, 70.1%), and owned their own home (n = 5277, 65.7%). The mean scores for all the respondents were 20.79 (s.d. = 6.83, n = 7589) on the PSS, 9.68 (s.d. = 5.87, n = 6944) on the GAD-7 scale, and 9.43 (s.d. = 6.29, n = 7082) on the PHQ-9 scale.
Table 2 presents the means and standard deviations for the PSS, GAD-7, and PHQ-9 in relation to the various relationship status groups.
Table 2. Mean scores on the GAD-7 scale, PHQ-9 scale, and PSS by relationship status
GAD-7, Generalized Anxiety Disorder 7 scale; PHQ, Patient Health Questionnaire; PSS, Perceived Stress Scale.
Table 2 shows that the mean scores on the PSS, GAD-7, and PHQ-9 were highest among those who were single and lowest among those who were widowed. Respondents who were either married, cohabiting, or partnered and those who were either separated or divorced had similar mean scores on the PSS and GAD-7. However, respondents who were either separated or divorced had a higher mean score on the PHQ-9 than respondents who were either married, cohabiting, or partnered.
Table 3 represents the results of the one-way ANOVA comparing the sums of squares between and within relationship status groups for the PSS, GAD-7, and PHQ-9.
Table 3. One way ANOVA comparing sums of squares between and within groups
GAD-7, Generalized Anxiety Disorder 7 scale; PHQ, Patient Health Questionnaire; PSS, Perceived Stress Scale; DF, degree of freedom.
* p < 0.05.
Table 3 demonstrates that there were statistically significant differences between and within relationship status groups for scores on the PSS (F = 30.46, p < 0.01), GAD-7 (F = 9.86, p < 0.01), and PHQ-9 (F = 45.94, p < 0.01). The Levene statistic test of homogeneity of variances suggested no violation of the assumption of equality of means for the GAD-7 (p > 0.05), and thus, a Tukey’s post hoc test was conducted to determine statistically significant differences in the mean scores between the different relationship status groups as presented in Table 4. However, the Levene statistic test of homogeneity of variances suggested there was a violation of the assumption of equality of means for the PSS and PHQ-9 (p < 0.05). Consequently, a Welch F test and a Games-Howell post hoc test were carried out to determine statistically significant differences in the mean scores on the two scales between the different relationship status groups. The Welsh F tests were statistically significant in each case, which confirms that the differences between the groups in terms of their mean PSS and PHQ-9 scores were statistically significant. Results of the Games-Howell post hoc test is presented in Table 5.
Table 4. Tukey HSD post hoc multiple comparison
GAD-7, Generalized Anxiety Disorder-7 item scale.
* p < 0.05.
Table 5. Games-Howell post hoc multiple comparison
PHQ, Patient Health Questionnaire; PSS, Perceived Stress Scale.
* The mean difference is significant at the 0.05 level.
Table 4 suggests that respondents who identified as either married, cohabiting, or partnered had significantly higher mean scores on the GAD-7 compared to respondents who identified as widowed (mean difference = 2.23, 95% CI = 0.73–3.72, and p < 0.01) but not respondents who identified as separated or divorced or other (p > 0.05). On the other hand, respondents who were either married, cohabiting, or partnered were significantly more likely to have a lower mean score on the GAD-7 compared to respondents who were single (mean difference = 0.77, 95% CI = −1.27–−0.26, p < 0.01). Table 4 also suggests that respondents who were single had a significantly higher mean score on the GAD-7 compared to respondents who were either separated or divorced (mean difference = 1.07, 95% CI = 0.25–1.89, p < 0.01) and respondents who were widowed (mean difference = 2.99, 95% CI = 1.45–4.54, p < 0.01). Finally, respondents who were either separated or divorced had a significantly higher mean score on the GAD-7 compared to respondents who were widowed (mean difference = 1.92, 95% CI = 0.3–3.55, p < 0.01).
Table 5 shows that respondents who identified as either married, cohabiting, or partnered had significantly lower mean scores on the PHQ-9 compared to respondents who identified as separated or divorced (mean difference = −1.52, 95% CI = −2.33–−0.7, p < 0.01) and respondents who identified as single (mean difference = −2.47, 95% CI = −3.02–−1.91, p < 0.01), but not respondents who identified as either widowed or other (p > 0.05). On the other hand, respondents who were single had significantly higher mean scores on the PHQ-9 compared to respondents who were separated or divorced (mean difference = 0.95, 95% CI = 0.03–1.88, p = 0.04) and those who were widowed (mean difference = 3.40, 95% CI = 1.76–5.03, p < 0.01). Finally, respondents who identified as separated or divorced had a significantly higher mean score on the PHQ-9 compared to respondents who were widowed (mean difference = 2.44, 95% CI = 0.70–4.18, p < 0.01).
Table 5 also shows that respondents who identified as either married, cohabiting, or partnered had significantly higher mean scores on the PSS compared to respondents who identified as widowed (mean difference = 2.94, 95% CI = 0.8–4.19, p < 0.01) and a significantly lower mean score than respondents who identified single (mean difference = −1.99, 95% CI = −2.57–−1.43, p < 0.01), but not respondents who identified as either widowed or other (p > 0.05). On the other hand, respondents who were single had significantly higher mean scores on the PSS compared to respondents who were separated or divorced (mean difference = 1.46, 95% CI = 0.50–2.42, p < 0.01) and those who were widowed (mean difference = 4.49, 95% CI = 2.74–6.24, p < 0.01). Finally, respondents who identified as separated or divorced had a significantly higher mean score on the PSS compared to respondents who were widowed (mean difference =3.03, 95% CI = 1.17–4.89, p < 0.01).
Discussion
This is the first study in Canada to specifically examine the impact of relationship status on measures of self-reported stress, anxiety, and depression during the COVID-19 pandemic. The majority of the participants in this study were Caucasian (n = 6684, 82%), female (n = 7104, 86.9%), aged between 26 and 60 years (n = 6357, 79.2%), with post-secondary school education (n = 6947, 85.0%), employed (n = 5982, 73.2%), and living in their own home (n = 5277, 65.7%). These figures (see Table 1) suggest a degree of socioeconomic stability within the sample, prior to COVID-19 pandemic onset.
The majority of individuals in the cohort identified as married, cohabiting, or partnered (n = 5799, 70.1%). This is comparable to the findings of Wang et al. (Wang et al. Reference Wang, Pan, Wan, Tan, Xu, Ho and Ho2020) who surveyed the general public in mainland China in the early weeks of the COVID-19 pandemic and found that 76.4% of their participants reported being married. We found a consistent trend of higher mean scores on the PSS, GAD-7, and PHQ-9 in responders who identified as single compared to those who were married, cohabiting, or partnered, or indeed in any other relationship category. This suggests that being in a relationship of some sort mitigates the risk of developing symptoms of anxiety, depression, or stress during the COVID-19 pandemic. This is not surprising as having someone around helps to provide a means of socializing particularly with the restrictions in socializing put in place at some points during the pandemic. Individuals who identified as separated or divorced also reported higher mean scores across measures compared to those who were married, partnered, or cohabiting, although this difference was more distinct for PHQ-9 than GAD-7 or PSS. Individuals who were widowed consistently reported low levels of anxiety and depression compared to other groups; this was not in alignment with the finding of Tan et al. (Reference Tan, Hao, McIntyre, Jiang, Jiang, Zhang, Zhao, Zou, Hu, Luo, Zhang, Lai, Ho, Tran, Ho and Tam2020). It is possible that having been through the loss of a partner and its attendant grief, these individuals may have developed the resilience to help them cope with the pandemic.
Social isolation and loneliness have been identified as major adverse consequences of the COVID-19 pandemic (Menon et al. Reference Menon, Andersen, Quilty and Woodward2015). Other studies have reported that when people are isolated or lonely, they become significantly more vulnerable to anxiety, depression, deliberate self-harm, and suicide (Elovainio et al. Reference Elovainio, Hakulinen, Pulkki-Raback, Virtanen, Josefsson, Jokela, Vahtera and Kivimaki2017; Matthews et al. Reference Matthews, Danese, Caspi, Fisher, Goldman-Mellor, Kepa, Moffitt, Odgers and Arseneault2019; Nkire et al. Reference Nkire, Mrklas, Hrabook, Gusnowski, Vuong, Surood, Abba-Aji, Urichuck, Greenshaw and Agyapomg2021). Single individuals are certainly more likely to feel the effects of loneliness and isolation more than the married (Matthews et al. Reference Matthews, Danese, Caspi, Fisher, Goldman-Mellor, Kepa, Moffitt, Odgers and Arseneault2019), and this may explain the consistently higher levels of stress, anxiety, and depression among the single compared to other subgroups within this cohort. Available evidence suggests that measures aimed at reducing loneliness and promoting connectedness can be protective against emotional problems, deliberate self-harm, and completed suicide (Stack, Reference Stack1988; O’Connor & Kirtley, Reference O’Connor and Kirtley2018). While this study did not specifically ask respondents about loneliness, we hypothesize that single individuals were more likely to be lonely and socially isolated in quarantine and self-isolation, and future studies may explore this hypothesis. As such, results from the present study suggests a need for early interventions that are targeted at people who are single, with a view to preventing or mitigating mental health consequences of the COVID-19 pandemic or future crisis situations.
Wang et al. in their study of a Chinese cohort demonstrated that 75.2% of respondents reported experiencing some worry about the prospects of a family member becoming infected with the COVID-19 virus (Wang et al. Reference Wang, Pan, Wan, Tan, Xu, Ho and Ho2020). This same study found that increased levels of concern that a family member would become infected was significantly associated with depression, anxiety, and stress (DAS) subscale scores (B = 0.50, 95% CI = 0.04–0.96); the present study showed that respondents who are married, cohabiting, or partnered had higher mean anxiety scores compared to widowed. This finding may be a reflection of the concerns about infecting a partner. It merits further exploration.
This study has several strengths and limitations. The use of anonymous online surveys ensures an element of blinding and mitigated the risk of bias on the part of a potential assessor or bias on the part of the respondent; it also ensured anonymity of the individuals completing the survey. On the downside, the nature and quality of relationships in the different subgroups was not explored; as well, the survey did not clarify whether people who identified as single had other close and reliable social networks such as supportive roommate situations which could well impact their coping abilities and sense of distress. The use of a self-report survey poses a limitation in the actual definition of illness, as assessment by trained mental health clinicians administering the survey may yield potentially differing results. Generalization is limited by the study sample being based primarily in Alberta Canada, and the respondents are individuals who are specifically enrolling into a service to receive anxiety and stress support. Furthermore, we were unable to measure respondents’ pre-COVID-19 baseline scores for stress, anxiety, and depression. The relatively low response rate may open the study to nonresponse bias. However, the study sample was greater than the projected sample size of 4157 needed to accurately estimate prevalence rates of mental health conditions in an Alberta population with a 99% confidence and a 2% margin of error. The use of an anonymous recruitment process also meant that we were unable to compare how responders differed from nonresponders both clinically and demographically although our representative sample suggest the two groups would have similar characteristics. In addition, while a one-way ANOVA allowed for comparison of the stress, anxiety, and depression levels between all the relationship groups as a strength, it did not take into account potential confounding factors such as sex, age, ethnicity, employment, and education status, which is a limitation. The impact of these confounding factors could be assessed using regression models, although such models would also have the limitation of not allowing for a comparison of the stress, anxiety, and depression between all relationship status categories. Notwithstanding these limitations, the findings from this study shed light on the effects of relationship status on reports of stress, anxiety, and depression in the early stages of the COVID-19 pandemic. The nature of recruitment into this study allowed for increased respondent diversity and generalizability as well as affording us the opportunity to investigate some demographic predictors. The findings are in alignment with existing literature from other geographical areas.
Results from this study suggests that being single and separated or divorced are risk factors for more severe outcome stress, anxiety, and depression scores specifically during the COVID-19 pandemic. Services aimed at providing mental health supports during pandemics should consider allocating more resources to supporting these particular groups of people. For example, supportive text messages are independent of geographic location, are free to the end users, do not require expensive data plans, and can reach thousands of people simultaneously (Agyapong et al. Reference Agyapong, Farren and McLoughlin2011, Reference Agyapong, Mrklas, Juhas, Omeje, Ohinmaa, Dursun and Greenshaw2016). Previous research has reported that daily supportive text messages are effective in reducing depressive symptoms as well as supporting individuals with problem drinking (Agyapong et al. Reference Agyapong, Ahern, McLoughlin and Farren2012, Reference Agyapong, McLoughlin and Farren2013a, Reference Agyapong, Mrklas, Suen, Rose, Jahn, Gladue, Kozak, Leslie, Dursun, Ohinmaa and Greenshaw2015, Reference Agyapong, Juhás, Ohinmaa, Omeje, Mrklas, Suen, Dursun and Greenshaw2017, Reference Agyapong, Juhas, Mrklas, Hrabok, Omeje, Gladue, Kozak, Leslie, Chue and Greenshaw2018; Hartnett et al. Reference Hartnett, Murphy, Kehoe, Agyapong, McLoughlin and Farren2017; O’Reilly et al. Reference O’Reilly, Hagerty, O’Donnell, Farrell, Hartnett, Murphy, Kehoe, Agyapong, McLoughlin and Farren2019). High user satisfaction has also been reported (Agyapong et al. Reference Agyapong, McLoughlin and Farren2013a, Reference Agyapong, Mrklas, Juhas, Omeje, Ohinmaa, Dursun and Greenshaw2016). Therefore, innovative and cost-effective interventions such as the Text4Hope program (Agyapong Reference Agyapong2020; Agyapong et al. Reference Agyapong2020) could be useful particularly to a single and separated or divorced individual who seem to be most impacted psychologically during the COVID-19 pandemic.
Acknowledgments
Support for the project was received from Alberta Health Services and the University of Alberta.
Financial Support
This study was supported by grants from the Mental Health Foundation, the Calgary Health Trust, the University Hospital Foundation, the Alberta Children’s Hospital Foundation, the Royal Alexandra Hospital Foundation, and the Alberta Cancer Foundation.
Conflict of interest
Authors have no conflicts of interest to disclose.
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
Ethical approval for the research was obtained through the University of Alberta Health Research Ethics Board (Pro00086163). Participant consent was implied by submission of subscribers’ survey responses.
Authors contribution
VIOA conceived and designed the study, including the Text4Hope program, and performed data analysis and jointly drafted the initial manuscript with NN and IN. RS, MH, AG, WV, and SS participated in study design. AG, WV, and SS participated in data collection. AJG critically reviewed the manuscript and contributed to the final draft of the manuscript. All authors reviewed and approved the final draft of the manuscript.
Role of the Funder/Sponsor
The funder had no role in the design and conduct of the study; collection, management, analysis, the interpretation of the data; preparation, review or approval of the manuscript; or the decision to submit the results for publication.
Open access
