VOL 10 No.1 2022 rev.2.indd


12 International Journal of Integrated Health Sciences (IIJHS) 

Introduction

The novel coronavirus 2019 (COVID-19) 
is one of the global infections currently a 
pandemic in 215 countries globally, including 
Indonesia. Indonesia is currently ranked 
first as the country with the most COVID-19 
cases in ASEAN, with more than 41 thousand 
total cases and a mortality of 5.5%.1 As of 
February 2022, the number of positive cases 
of COVID-19 in Indonesia reached more than 
5,1 million positive cases and more than 146 
thousand mortality cases while Bali reached 
more than 146 thousand positive cases with a 
mortality of more than 4200 people.2

Depression, Anxiety, and Stress due to Changes in Employment Status 
during COVID-19 Pandemic: A Study in Badung Districts, Bali Indonesia

               Abstract

 Objective:  To determine the relationship between depression, anxiety, 
and stress with the employment status of people in Bali during Covid-19 
pandemic.

 
 Methods: This study was a cross-sectional analytical study conducted in 

Bali, Indonesia, in 2021. The instrument used was DASS-21 questionnaire, 
which was distributed to a total sample size of 96 people. The relationship 
between variables were analyzed with a p-value of <0.05 as the cut-off for 
a significant relationship.

 
 Results: Depression symptoms had a significant relationship with gender 

(p=0.024) while anxiety symptoms had a significant association with the 
employment status during the pandemic (p=0.027). Similarly, stress 
symptoms also had a significant relationship with gender (p=0.007) and 
employment status during COVID-19 pandemic (p=0.007).

 
 Conclusion: There is a relationship between depression, anxiety, 

and stress due to changes in employment status during the COVID-19 
pandemic in Badung Districts, Bali.

 Keywords: Anxiety, depression, COVID-19, employment status, stress
 

Received:
September 19, 2021

Accepted:
February 23, 2022

Correspondence: 
Ni Ketut Sri Diniari; 
Department of Psychiatry, Faculty of Medicine, Udayana 
University/Sanglah General Hospital Denpasar, Bali, 
Indonesia
e-mail: sridiniari@ymail.com

Original Article

Made Violin Weda Yani,1 Made Sindy Astri Pratiwi,1 Agus Indra Yudhistira Diva Putra,1
Ni Ketut Sri Diniari2

1Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia
2Department of Psychiatry, Faculty of Medicine, Udayana University/Sanglah General Hospital Denpasar, 
Bali, Indonesia

pISSN: 2302-1381; 
eISSN: 2338-4506; 
http://doi.org/10.15850/
ijihs.v10n1.2541
IJIHS. 2022;10(1):12–19

The COVID-19 pandemic has also had an 
impact on Indonesia’s economic conditions, 
according to data from the International 
Labor Organization (ILO), which states that 
quarantine during the pandemic caused 2.7 
billion workers or the equivalent of 81% 
of the world’s workforce, to experience 
income imbalances.3 This condition triggers 
an estimate of an increase in the number 
of open unemployment in 2020, which will 
reach 9.35 million workers.4 Bali is a province 
in Indonesia that is highly dependent on 
tourism conditions. The COVID-19 pandemic 
has certainly caused instability in the tourism 
sector’s growth due to a decrease in tourists 
visiting Bali. Seventy-five thousand workers 
have been temporarily fired and laid off, which 
led to an increase in Bali’s unemployment rate 
by 5.63%.5

This situation will undoubtedly impact 
health conditions such as depression, anxiety, 
and stress due to decreased income. All 



International Journal of Integrated Health Sciences (IIJHS) 13

individuals from various groups can feel stress 
conditions, ranging from school-age students 
who feel stress due to the distance learning 
system, productive age who experience stress 
due to employment termination, to older 
people who experience anxiety and depression 
due to limited time to socialize.6 However, 
there is no descriptive or analytical data that 
assess the level of depression, anxiety, and 
stress in people in Bali and their relationship 
to work status during the pandemic COVID-19 
in Bali, Indonesia. Therefore, this study 
aims to determine the relationship between 
depression, anxiety, and stress conditions with 
the work status of people in Badung Districts 
Bali during the Covid-19 pandemic. 

Methods

This study is an analytical study with a cross-
sectional design carried out during June-
August 2020 to determine the relationship 
between individual characteristics and levels 
of depression, anxiety, and stress in Bali 
Province. This research started from proposal 
preparation, research implementation, 
data collection, and analysis to prepare a 
research report that lasted four months. The 
population in this study were all residents 
who live in Badung district, Bali Province. 
Badung was chosen as the sampling location 
because Badung district is the 3rd with the 
highest number of confirmed positive cases 
in Bali, representing the population.2 There 
are many tourism-based economic sectors 
in Badung. Badung district had become the 
center of tourism activities in Bali, with a 
portion reaching 60% of the total tourists in 
Bali. In reviewing this, most of the businesses 
in Badung certainly ran in the tourism 
sector. As many as 85% of its citizens made a 
living by working in the tourism sector, and 
only 15% work in other sectors. It is quite 
representative to show changes in economic 
status and chances of being stressed. Based 
on calculations using the analytical research 
formula with the cross-sectional method, the 
minimum subject was obtained 48 people, 

and in this study, 96 people were obtained as 
samples. 

The method of selecting samples in this 
study uses simple random sampling. According 
to the inclusion criteria, all subjects previously 
determined are Bali province residents with 
the latest education, junior high school/
equivalent, have reading and writing skills, and 
are willing to become research respondents 
by signing informed consent will immediately 
become research subjects. The data collected 
in this study were divided into independent 
and dependent variables. The independent 
variables are work status during the pandemic, 
and the dependent variable is depression score, 
anxiety, and stress. The sample collection was 
carried out by google form. The questionnaire 
questions use questions from the Depression 
Anxiety Stress Scale-21 (DASS-21), consisting 
of 21 questions. The results of filling out the 
participant questionnaire will be calculated 
based on the scoring according to Table 1. 

All data collected will be analyzed 
univariate and bivariate using data analysis 
software. Data on numerical variables such 
as age and scores for depression, anxiety, 
and stress will be tested for normality 
first with the Kolmogorov-Smirnov test. 
Univariate data analysis is used to see the 
distribution description of each dependent 
and independent variable. Bivariate analysis 
of categorical data used the chi-square test. 
Bivariate analysis of numerical variable data 
with unpaired categorical uses the Mann-
Whitney Test and Kruskal Wallis because the 
data is not normally distributed. A significant 
value states that there is a relationship between 
the dependent and independent variables if 
the p-value is obtained <0.05. Ethical approval 
for this study has been granted by the Health 
Research Ethical Committee, Faculty of 
Medicine, Udayana University, with 1836/
UN14.2.2.VII.14/LT/2020.

Results 

The characteristics of the research respondents 
in this study are in Table 2. It was found that 

Table 1 Final Score Classification from DASS-21
Classification Depression Score Anxiety Score Stress Score

Normal 0–9 0–7 0–14
Mild 10–13 8–9 15–18
Moderate 14–20 10–14 19–25
Severe 21–27 15–19 26–33
Extremely Severe >27 >19 >33

Made Violin Weda Yani, Made Sindy Astri Pratiwi,  et al



14 International Journal of Integrated Health Sciences (IIJHS) 

Table 2 Characteristics of Research Respondents

Characteristic
Sample (n=96)

Frequency (n) Percentage (%)
Respondent’s age

Mean ± sd 38.41±11.96
Median (year) 41
Minimum- maximum (year) 18-64

Sex
Male 53 55.2
Female 43 44.8

Marital status
Not married 25 26
Married 71 74

Living status 
Main family 43 44.8
Big family 53 55.2

Latest education
Junior high school (jhs) 3 3.1
Senior high school (shs) 66 68.8
Diploma 9 9.4
Bachelor 18 18.8

Job before pandemic
Civil servant 5 5.2
Private employees 53 55.2
Farmer 3 3.1
Seller 11 11.5
Others 24 25.0

Job after pandemic
Sent home for a while 24 25
Dismissal 5 5.2
Work from home 56 58.3
Still working 11 11.5

Chronic disease
Nothing 90 93.8

Diabetes 1 1.0
Hypertension 2 2.1
Asthma 3 3.1

Smoking status
Yes 16 16.7
Never 74 77.1
Yes before 6 6.3

Depression
Yes 3 3.1
No 93 96.9

Anxiety
Yes 8 8.3
No 88 91.7

Stress
Yes 5 5.2
No 91 94.8

Depression, Anxiety, and Stress due to Changes in Employment Status during COVID-19 Pandemic: 
A Study in Badung Districts, Bali Indonesia



International Journal of Integrated Health Sciences (IIJHS) 15

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Made Violin Weda Yani, Made Sindy Astri Pratiwi,  et al



16 International Journal of Integrated Health Sciences (IIJHS) 

Table 4 The Relationship between Respondents’ characteristics and Depression, Anxiety 
   and Stress based on the DASS-21 Score

Variable Depression Score
P 

value
Anxiety 

Score P value
Stress 
Score P value

Gender
Male
Female

0.55±1.13
1.63±3.25

0.024* 1.47±2.82
2.19±3.40

0.077 1.55±3.21
3.07±4.67

0.007*

Age
<39 years old
≥ 39 years old

1.15±2.25
0.95±2.48

0.220 1.88±3.27
1.73±3.00

0.569 1.83±3.01
2.52±4.56

0.883

Marital status
Not married yet
Married

0.76±1.02
1.13±2.70

0.602 1.68±2.96
1.83±3.16

0.772 1.76±3.20
2.39±4.23

0.985

Living status 
Main family
Big family

1.23±3.03
0.87±1.69

0.906 1.74±3.17
1.83±3.07

0.451 1.84±3.33
2.55±4.45

0.818

Level of education
Moderate education
High education

1.02±0.16
1.07±0.38

0.422 1.15±0.53
1.11±0.42

0.774 1.07±0.26
1.00±0.01

0.227

Work status before the 
pandemic

Government employees 
private 
Employee
Farmer
Seller
Others

0.80±1.30

0.70±1.53
1.67±2.88
2.91±5.54
0.88±1.29

0.885

1.60±3.57

1.67±3.02
1.00±1.73
3.00±4.42
1.88±2.67

0.507

1.60±1.81

2.32±4.49
3.00±5.19
3.36±5.42
1.54±1.71

0.791

Work status during the 
pandemic 

Sent home for a while
Work from home
Dismissal
Still working

1.38±2.24
0.73±1.94
0.40±0.54
2.09±4.36

0.112
1.17±1.52
1.45±2.84
8.60±4.82
1.82±2.75

0.027*
1.96±3.22
1.34±2.77
11.8±6.79
3.00±3.89

0.007**

Chronic disease
Nothing
Hypertension
Asthma

1.08±2.45
0.50±0.70
0.33±0.57

0.855
1.83±3.17
2.00±2.82
1.00±1.73

0.833
2.27±4.09
2.50±0.70
1.67±2.08

0.519

Smoking status
Never
Stop>6 months
Active

0.96±2.36
2.17±3.86
0.94±1.76

0.491
1.78±3.21
2.17±2.13
1.69±2.98

0.471
2.24±4.07
4.50±5.54
1.31±2.60

0.151

Depression, Anxiety, and Stress due to Changes in Employment Status during COVID-19 Pandemic: 
A Study in Badung Districts, Bali Indonesia



International Journal of Integrated Health Sciences (IIJHS) 17

the age of the patients was 13-64 years old, 
with an average age value of 36.46 years. 
The study’s Respondents were dominated 
by male gender (55.2%) with marital status, 
married (74%). Based on the residence 
characteristics, it was found that 55.2% of 
the respondents lived with their big family. 
Most of the research respondents had the 
latest education level at the senior high school 
level/equivalent (68.8%). The work status of 
respondents before the COVID-19 pandemic 
was dominated by private employees (55.2%), 
while the work status of respondents during 
the pandemic was dominated by work from 
home (58.3%). Most of the respondents in this 
study did not have a history of chronic disease 
(93.8%) and had no smoking habits (77.1%). 
Based on the DASS-21 interpretation, it was 
found that three people (2.9%) had depressive 
symptoms, nine people (8.6%) had anxiety, 
and 5 (4.8%) had stress.

Table 3 presents a cross tabulation between 
data on characteristics and work status with 
depression, anxiety, and stress conditions 
during the covid-19 pandemic. Most of the 
respondents have mild depression and stress 
levels and have mild to moderate levels of 
anxiety.

The bivariate test between individual 
characteristic variables with depression, 
anxiety and stress score is presented in 
table 4. This study indicates that depression 
symptoms significantly correlate with 
gender (p=0.024). Anxiety symptoms have 
a significant relationship with work status 
during the pandemic (p=0.027) and stress 
symptoms had a significant relationship with 
gender (p=0.007) and work status during the 
pandemic (p=0.007).

Discussion

The COVID-19 pandemic caused most 
countries to implement social restrictions to 
control the virus’s spread, including Indonesia. 
These social restrictions affect various aspects 
of life, such as economic conditions and 
education, and cause psychological impacts 
such as depression, anxiety, and stress.7 This 
study indicates that people in Bali who have 
depression, anxiety, and stress symptoms are 
below 50%. It was found that people with 
depression, anxiety, and stress were 2.9%, 
8.6%, 4.8%. These results are in line with 
Gonzales et al., which showed that out of 2530 
study respondents, symptoms of depression, 
anxiety, and stress during the COVID-19 
pandemic were experienced by less than 50% 

of respondents 34.19%; 21.34%; 28.14%.8 
Elbay et al.  study with 442 participants 
showed opposite results, there were more 
than 50% of respondents who experienced 
symptoms of depression (64.7%) and anxiety 
(51.6%), but respondents who experienced 
stress were below 50%. (41.2%).9

This study shows a significant relationship 
between depression, anxiety, and stress scores 
with gender and work status, but no significant 
relationship exists between the respondents’ 
marital status. These results are similar to 
research by Elbay et al., that state symptoms 
of depression, anxiety, and stress have a 
significant relationship with age (p <0.001), 
gender (p=0.025), and job position (p= 
0.001).9 The study showed that being married 
and having children was associated with lower 
DASS-21, while unmarried and younger had 
higher DASS-21. Also, respondents who live 
with their spouses and children have lower 
scores than those who live alone. Regression 
analysis shows that female gender, unmarried 
status, and a history of psychiatric disorders 
are independent predictors for mental health 
deterioration.9 Lai et al. also showed similar 
results that DASS-21 is significantly related 
to gender. Female respondents have a greater 
risk of having a risk of psychiatric disorders 
during the COVID-19 outbreak in China.10

The difference in stress response 
between males and females is caused by 
the hypothalamic-pituitary-adrenal (HPA) 
axis and the sympathetic nervous system, 
which provides negative feedback when 
an individual experiences stress. The 
sympathetic nervous system regulates heart 
rate and blood pressure, while HPA regulates 
the hormone cortisol regulation. The response 
of the sympathetic nervous system and HPA 
in men is higher than in women to influence 
the individual’s attitude in responding to 
stressors. There are sex hormones in females 
that affect the sympathetic response and 
HPA. There is a decrease in negative feedback 
on the hormone cortisol to the brain, which 
causes women to have a higher tendency to 
experience stress.11,12 

This study indicates that individuals laid off 
have more symptoms of depression, anxiety, 
and stress. This result is in line with Volaco 
et al.  research that individuals with relatively 
low economic conditions have a greater 
chance of experiencing stress, which causes an 
increase in stress hormones such as cortisol 
and catecholamines glucagon and growth 
hormone.13 Another study evaluating 108 men 
and 94 women showed that low economic 

Made Violin Weda Yani, Made Sindy Astri Pratiwi,  et al



18 International Journal of Integrated Health Sciences (IIJHS) 

income individuals experience increased 
blood pressure and cortisol output during 
the workday, allowing activation of biological 
pathways related to stress mechanisms.14 
Worse, several reported suicide-related 
cases to stress due to COVID-19 are based on 
job loss, sudden extreme poverty, economic 
crisis, hunger, and inability to cope with 
social problems. Traumatic situations must be 
immediately handled through counseling and 
counseling to the community appropriately. 
A study in Bangladesh found that lockdown 
policies caused mental stress due to COVID-19 
without ensuring the community’s basic 
needs.15

Several individual characteristics associated 
with depression, anxiety, and stress were also 
explored in this study. This study found that 
individuals who act as students are very few 
who experience symptoms of depression, 
anxiety, or stress. This result is contrary to 
research by Livana et al., which shows that 
most students experience stress during the 
COVID-19 pandemic, which is caused by 
learning tasks (70.29%), the boredom of the 
online learning system (55.8%), and not able 
to meet peers (40.2%).16 The cause of stress is 
reinforced by a study that states that academic 
stress has a significant relationship with the 
workload.17 This condition shows that the 
COVID-19 pandemic has a negative effect on 
students’ educational process and mental 
health growth.8

This study found that depression, anxiety, 
and stress symptoms were more common in 
individuals living with big families. Cao et al. 

show a similar result that living with parents 
was a factor preventing student anxiety during 
the pandemic (OR = 0.752, 95% CI = 0.596-
0.950).18 Multivariate analysis in the study of 
Gonzales et al. (2020) also showed that there 
was a significant relationship between stress 
scores on DASS-21 and residence status (p 
<0.05).8 Individuals who live alone have greater 
stress symptoms than individuals who live 
in the same house with 2-4 family members. 
This condition shows that the COVID-19 
pandemic has increased communication 
relationships and the closeness of individuals 
with their families so that stress symptoms 
are decreasing more.8

This study concluded that depression 
symptoms have a significant relationship with 
gender; anxiety has a significant relationship 
with work status during the pandemic. In 
contrast, stress has a significant relationship 
with gender and work status during the 
pandemic.  This study has limitations in forming 
a cross-sectional study with a relatively small 
sample size compared to the total population. 
Therefore, it is suggested that future research 
use a longitudinal study design to analyze 
the long-term impact of the COVID-19 
pandemic on an individual’s psychological 
state to conclude the main and accompanying 
factors that trigger psychological symptoms 
in individuals. Second, this study only took 
a sample from Bali province, so large-scale 
survey with various respondents was still 
needed to expand and generalize the research 
results.

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of 2019 novel coronavirus infection disease 
(COVID-19): A Chinese perspective. J Med Virol. 
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3. International Labour Organization. Covid-19 
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A Study in Badung Districts, Bali Indonesia



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