The role of financial stress, food insecurity, and COVID-19-related illness concerns shaping mental health in five South Asian countries during the pandemic (2020–2022): A secondary analysis of the online COVID-19 Trends and Impact Survey (CTIS) data

The COVID-19 pandemic has substantially impacted mental health worldwide, yet little attention has been given to its acute and long-term effects on mental health in low- and middle-income countries (LMICs). This study investigates how a triad of pandemic-related worries—financial stress, food insecurity, and COVID-19-related illness concerns—are associated with depression and anxiety across five South Asian LMICs: Bangladesh, India, Nepal, Pakistan, and Sri Lanka. Using data from the COVID-19 Trends and Impact Survey (CTIS), we analyzed responses from over 3.6 million participants collected between June 27, 2020 and June 25, 2022. We employed survey-weighted logistic regression models based on the complete cases (N = 1,062,786), adjusting for demographics and calendar time. Due to a substantial change in the survey design on May 20, 2021, our analysis was divided into two distinct periods: Period 1 (pre-change) and Period 2 (post-change). Our main findings reveal that all three types of pandemic-related worries were significantly associated with increased levels of depression and anxiety across the studied countries. In Period 1, a random-effects meta-analysis showed financial stress had the highest pooled adjusted odds ratio (OR) for depression at 2.41 (95% confidence interval, CI: [2.26, 2.58]), followed by COVID-19-related illness concerns at 1.58 (95% CI: [1.43, 1.75]), and food insecurity at 1.52 (95% CI: [1.40, 1.67]). In Period 2, the pooled adjusted OR for depression increased to 2.74 (95% CI: [2.38, 3.12]) for financial stress, while food insecurity showed a notable rise to 2.42 (95% CI: [2.23, 2.62]). Heterogeneity across countries was substantial (I2 ranged from 60.33% to 86.68%), except for the association between food insecurity and depression in Period 2. Country-specific analyses further confirmed these results. Additionally, calendar time, vaccination status, gender, education, and rural-urban residential status modified these associations. These results underscore the need for targeted interventions to address socioeconomic stressors and improve mental health resilience in LMICs.