At present, our healthy world has been badly suffering from a bio-attack, Coronavirus pandemic [1,2,3]. Since February 2020, one by one all countries except a few have implemented home quarantine policies to protect the people from SARS-CoV-2 infection. Staying at home is enjoyable during holidays but now billions of people are stuck at home to keep themselves safe since the COVID-19 pandemic boosts up around the world. Undergoing long-term home quarantine, there is a high possibility to experience mental illness or other health problems [4,5,6]. Most recent studies show that cisgender as well as transgender individuals are being stressed due to the SARS-CoV-2 outbreak. People living in developing countries are at high risk of getting extreme levels of stress that might influence their interpersonal sensitivity [2].

Therefore, most of the persons would be more sensitive especially for communicating with others than before. In the literature, some researchers found that cisgender and transgender living in a developing country is mainly stressed due to financial obstacles during the COVID-19 crisis [7,8]. The recent mental health research shows that cisgender people are experienced stressed (moderate-severe levels) in China and the high possibility of growing similar mental stress in the other regions [1,6]. However, a significant number of cisgender and transgender people had to accept home quarantine due to the Covid-19 pandemic in the developing countries. Many of them have lost jobs or day-to-day working opportunities that spike up financial crises and they become depressed [2,6,8]. Currently, the fatality rate caused by 2019-nCoV in Bangladesh is higher than other badly affected countries like Iran, Italy, France, and the USA.

So, day by day, the situation is getting worse due to a lack of proper medicine and vaccines. Therefore, people are now more scared and stressed by 2019-nCoV pandemic news, especially new infected cases and death news in the media. Bangladeshi media confirmed that some people were committed suicide because of mental stress during the COVID-19 lockdown in Bangladesh [2,3]. Furthermore, the media also disclosed that many people living in COVID-19 emergency locations escaped during mid-night to other safe areas but unfortunately, a large number of them were infected by 2019-nCoV during this journey [2].

All the participants from this country are living in the area where the 2019-nCoV was badly spread out and some of them were infected by the Coronavirus.

Survey duration: The current study investigated the depression, anxiety, and stress level of Bangladeshi individuals during ongoing lockdown (from May to July). The total number of infected cases at the beginning of the study was 11,719 and 232,194 was at the end of the study period (Wikipedia).

Survey instrument: Before conducting the survey, the current study used the back translation method to translate the questionnaire including the DASS21 scale from English into Bangla language. Furthermore, the Bangla translated questionnaire by academic experts to measure its reliability was tested.

Then, the Bangla translated version (DASS21 Bangla translated version included in the appendix part) was used for collecting the feedback from all the participants, which was available on the online platform during the survey period.

Data collection techniques: The online survey has been distributed through ‘Google Doc’, and other social media. Additionally, the postal service was administrated to collect data from transgender people.

Ethical consent: Participation in the study was fully voluntary. The online survey process was anonymously performed and the final online survey included a cover letter/consent form that informed all participants about the main objective of the research. Before conducting the survey, this research was evaluated by the ethics committee of the University of Information Technology and Sciences and then the current study received ethical approval (#60-211).

Measurements: The present study assessed Depression Anxiety and Stress Scale-21 (DASS21), a mental illness standard survey scale to measure distress, anxiety, and stress, using a range ‘0-3’ [9]. DASS21 comprises three dimensions (Depression Anxiety and Stress) with seven items for each and three different outcome-range: 0-28+ for distress, 0-20+ for anxiety, and 0-34+ for stress [9].

The participants rated their depression, anxiety, and stress levels by using the DASS21 mental illness scale.

According to the statistical outcomes, approximately 62 (5%) transgender people responded to our survey were highly stressed compared to cisgender-female (n=379; 33%) and cisgender-male (n=721; 62%) individuals during the COVID-19 pandemic in the country. Following the cut-off scores of stress level in DASS21, 684 (59%) and 257 (22%) of the participants had normal levels and severe to extremely severe mental stress respectively. As seen in Table 1, it was found that cisgender participants had a lower level of stress in comparison to transgender individuals (β= -5.50, p=0.000, 95% CI -3.74 to -7.26).

Table-2: OLS Regression results by age and education.

Note: *p<0.05, **p<0.01, ***p<0.001

Dep: Depression; Anx: Anxiety; Str: Stress; Fre: Frequency

School dropout: An individual who attended elementary school but left education without obtaining a basic credential level (in/after a primary level or in/before higher secondary level).

Considered the current study outcomes (Table 2), the age and education levels of the participants had no direct impact on changing stress level (age: β= -0.56, p=0.267, 95% CI 0.43 to -1.54; education: β= -0.50, p=0.143, 95% CI 0.17 to -1.16). As seen in the Statistical distribution in Table 3, it was also found that the participants (54%; n=628) were unsure, whether they were infected by ‘2019-nCoV’ or not.

By the current-chronic disease status, 55.30% (n=643) of the participants had the chronic disease (rounded up including type 2, 3, and 4) while the rest of them (44.70%; n=519) were reported as the negative status of chronic disease.

Furthermore, results were depicted that the participants with chronic disease had more stress than healthy individuals (Type 2: β=2.36, p=0.006, 95% CI 0.84 to 4.09; Type 3: β=2.99, p=0.002, 95% CI 0.70 to 4.88; Type 4: β=3.78, p=0.000, 95% CI 0.92 to 5.33), which was also found positive in the previous study [6].

By daily exercise status (Table 4), Bangladeshi cisgender and transgender individuals who exercised one or more hours regularly stated that they had mostly normal mental condition than those who exercised zero-hour daily (β= -3.46, p=0.000, 95% CI -2.04 to -4.98). In this study, it was found that around 59% (n=687) of the participants were confirmed with no exercise status.

Table-4: OLS Regression results by exercise and employment status.

Note: *p<0.05, **p<0.01, ***p<0.001

Dep: Depression; Anx: Anxiety; Str: Stress; Fre: Frequency

By the working situation (Table 4), most of the participants (51%; n=597) had stopped/lost/unemployed working status due to the COVID-19 pandemic. They experienced high levels of stress compared to individuals working at office (31%; n=362) and from home (17%; n=203) (β= -2.93, p=0.000, 95% CI -1.81 to -3.09).

One of the studies ’ relevant facts is that age and education levels haven’t any significant impact on mental stress during an external or uncontrollable environmental pandemic but the other major differences in stress levels are denoted and significant by infected status, financial constraints, and exercise. However, the social changes such as long term restrictions on moving out and limited access to outside dramatically have reduced the income or day-to-day working opportunity mostly for transgender people than cisgender individuals in the country.

Therefore, the home quarantine procedure was like a prison life for all. This rising issue had vastly developed mental illness among cisgender as well as transgender people and reasonably they experienced high levels of stress. According to the results distributed in Table 2, similar to previous research, the current study found that mental illness might not be developed surprisingly because of any change in age or education level [1,6]. In contrast, doing daily exercise less or more significantly reduces mental stress (Table 4), which is found relevant to other recent mental health studies [1,5,6].

The study results also showed that individuals who stopped working during the lockdown were more stressed than individuals working from home (online desk) or having other working sources for income. This evidence is also supported by other research statistics in the literature [6]. In the literature, many scholars showed that having less income or working opportunities increases mental distress.

However, the current or long-term chronic disease is significantly correlated with the increasing stress level among cisgender and transgender individuals whether male or female. For example, long term sleep disturbance or insomnia reduces work abilities and mental fitness [11].

The regression distribution of the study shows that participants with chronic disease such as Loss of sexual desire, body pain or disorder related problems such as migraine, headaches, chest pain, and rapid heartbeat, Insomnia/sleeping disorder had experienced a high level of stress than attendants having common chronic diseases like Blood sugar/Diabetes, frequent colds/seasonal flu. Other recent investigations also mentioned the same positive correlation between chronic disease and mental stress among people [6].

Therefore, high levels of stress would negatively influence the health and work efficiency as well as the regular life activities of many individuals during or after the COVID-19 pandemic. So, this study recommends adopting daily exercise and positive thinking techniques to reduce mental stress and start a healthy life again. Lastly, the current research also suggests that transgender individuals may need more financial support than cisgender people to reduce their long term mental distress, which would truly increase their life satisfaction.

In the literature, this study would help to increase knowledge on the mental stress condition of cisgender and transgender due to virus fear and financial constraints in the developing country during the COVID-19 pandemic.

Amitab Bhattacharjee: Conceptualization, Investigation, Resources, Methodology, Formal Analysis, Visualization, Writing- Original, Review, and Editing.

Asghar Afshar Jahanshahi: Visualization, Writing- Review, and Editing.

Mashiur Rahman Bhuiyan: Investigation (data collection and developing database)

Sakera Sultana: Investigation (data collection), Writing-Review, and Editing.

The authors are grateful to the medical staff at BSMMU Hospital and Dhaka medical college and hospital (DMCH). The authors are also thankful to Professor Dr. A. N. M. Shareef, at the University of Information Technology and Sciences (UITS), Rupa Bhattacharjee at National University, and Dr. Satabdi Datta at Square Hospital, in Bangladesh.

Table A: The Depression Anxiety and Stress Scale-21(DASS21) in English.

Table B: The Depression Anxiety and Stress Scale-21(DASS21) in Bangla.