Content uploaded by Patricio Trujillo
Author content
All content in this area was uploaded by Patricio Trujillo on Mar 14, 2023
Content may be subject to copyright.
RESEARCH ARTICLE
Determinants of self-reported health status
during COVID-19 lockdown among surveyed
Ecuadorian population: A cross sectional
study
Iva
´n Dueñas-Espı
´nID
1
*, Constanza Jacques-Aviño
´
2,3
, Vero
´nica Egas-Reyes
4
,
Sara Larrea
5
, Ana Lucı
´a Torres-Castillo
1
, Patricio Trujillo
1
, Andre
´s Peralta
1
1Instituto de Salud Pu
´blica, Facultad de Medicina, Pontificia Universidad Cato
´lica del Ecuador, Quito,
Ecuador, 2Fundacio
´Institut Universitari per a la Recerca a l’Atencio
´Primària de Salut Jordi Gol i Gurina
(IDIAPJGol), Barcelona, Spain, 3Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès,
Barcelona, Spain, 4Facultad de Psicologı
´a Pontificia Universidad Cato
´lica del Ecuador, Quito, Ecuador,
5Independent Consultant, Quito, Ecuador
*aaperalta@puce.edu.ec
Abstract
Objective
To examine the associations of sociodemographic, socioeconomic, and behavioral factors
with depression, anxiety, and self-reported health status during the COVID-19 lockdown in
Ecuador. We also assessed the differences in these associations between women and
men.
Design, setting, and participants
We conducted a cross-sectional survey between July to October 2020 to adults who were
living in Ecuador between March to October 2020. All data were collected through an online
survey. We ran descriptive and bivariate analyses and fitted sex-stratified multivariate logis-
tic regression models to assess the association between explanatory variables and self-
reported health status.
Results
1801 women and 1123 men completed the survey. Their median (IQR) age was 34 (27–44)
years, most participants had a university education (84%) and a full-time public or private
job (63%); 16% of participants had poor health self-perception. Poor self-perceived health
was associated with being female, having solely public healthcare system access, perceiv-
ing housing conditions as inadequate, living with cohabitants requiring care, perceiving diffi-
culties in coping with work or managing household chores, COVID-19 infection, chronic
disease, and depression symptoms were significantly and independently associated with
poor self-reported health status. For women, self-employment, having solely public health-
care system access, perceiving housing conditions as inadequate, having cohabitants
requiring care, having very high difficulties to cope with household chores, having COVID-
19, and having a chronic disease increased the likelihood of having poor self-reported health
PLOS ONE
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 1 / 20
a1111111111
a1111111111
a1111111111
a1111111111
a1111111111
OPEN ACCESS
Citation: Dueñas-Espı
´n I, Jacques-Aviño
´C, Egas-
Reyes V, Larrea S, Torres-Castillo AL, Trujillo P, et
al. (2023) Determinants of self-reported health
status during COVID-19 lockdown among
surveyed Ecuadorian population: A cross sectional
study. PLoS ONE 18(3): e0275698. https://doi.org/
10.1371/journal.pone.0275698
Editor: Hadi Ghasemi, Shahid Beheshti University
of Medical Sciences, School of Dentistry, ISLAMIC
REPUBLIC OF IRAN
Received: September 21, 2022
Accepted: February 21, 2023
Published: March 8, 2023
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author
responses alongside final, published articles. The
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0275698
Copyright: ©2023 Dueñas-Espı
´n et al. This is an
open access article distributed under the terms of
the Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
status. For men, poor or inadequate housing, presence of any chronic disease, and depres-
sion increased the likelihood of having poor self-reported health status.
Conclusion
Being female, having solely public healthcare system access, perceiving housing conditions
as inadequate, living with cohabitants requiring care, perceiving difficulties in coping with
work or managing household chores, COVID-19 infection, chronic disease, and depression
symptoms were significantly and independently associated with poor self-reported health
status in Ecuadorian population.
Introduction
Globally, lockdown’s impact on physical and mental health during the COVID-19 pandemic
has been well-documented [1–6]. In several countries worldwide, lockdowns cause a high inci-
dence of anxiety, depression, post-traumatic stress disorder, psychological distress, and other
types of stress in the general population [7–9]. These conditions seem to affect women, chil-
dren, adolescents, the elderly, and populations experiencing socioeconomic deprivation [7–
10]. However, few studies have examined the specific impact of lockdown measures in the con-
text of rampant social and economic inequalities and weak states with low emergency response
capacities.
Specifically, in the Latin American and Caribbean regions, accentuated impacts from lock-
down and the COVID-19 pandemic have generated several undesired effects such as the for-
mation of COVID-19 hotspots exacerbated by weak social protection structures, fragmented
health systems, and deep inequalities [11]. Although the region’s development process was fac-
ing serious structural limitations before the pandemic, it is expected that COVID-19 will cause
a worse recession in the region, with subsequent contraction of regional gross domestic prod-
uct (GDP) [12].
Similar to other Latin American countries, Ecuador was severely affected by the COVID-19
pandemic [13]. In 2020, the country reached the second highest rate of confirmed cases in
South America [10] and the ninth place worldwide in the number of deaths per million people
[14]. In April 2020, Ecuador’s case called global attention to disturbing images of corpses piling
up in the streets of Guayaquil [15]. In the same year, 24% of the urban population and 49% of
the rural population lived under the poverty line [16]. Moreover, only approximately 30% of
the economically active population had an adequate job, that is, employed persons who, during
a reference week, received labor income equal to or greater than the minimum wage and
worked equal to or greater than 40 hours a week, regardless of the desire and availability to
work additional hours [17]. Fewer than 60% of rural households had access to the Internet,
and fewer than 20% owned a computer [18].
Despite the precarious economic situation of most of the population, the measures taken by
the Ecuadorian government to prevent COVID-19’s spread were mainly restrictive interven-
tions, such as social distancing policies and mandatory lockdowns enforced by the police and
military forces [13]. The Ecuadorian government’s response to the global emergency was also
characterized by poor epidemiological surveillance, lack of access to the public health system,
corruption scandals, null community participation, and insufficient social support [19,20]. In
June 2021, the Ecuadorian government implemented a plan for massive vaccinations.
Thus, for more than a year, people living in Ecuador had to cope with the fear of contract-
ing COVID-19, compounded by movement and rights restrictions, an education system that
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 2 / 20
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing interests exist.
was only allowed to operate online, a collapsed health system unable to provide care for both
COVID-19 and other health conditions, and an economic recession [21]. Moreover, despite
some social protection measures, such as food kits adopted by local governments, NGOs,
churches, and civil society organizations, many basic needs went unfulfilled owing to lock-
down restrictions, such as access to medicines for chronic patients [22]. Several fields of public
health and social care were neglected by Ecuadorian authorities, leading to a profound worsen-
ing of health across all social classes, and the management of social risks, exacerbated by the
pandemic, fell to families, particularly women. In this sense, the impact has been especially sig-
nificant for women, children, teenagers, and people with disabilities [23].
These limited economic and social aid policies have resulted in significant reductions in the
coverage of health supplies and medications for chronic patients, maternal health, and sexual
and reproductive health as well as unequal vaccine access [24]. In this context, a few studies
conducted in Ecuador reported an increased prevalence of psychological distress symptoms
[25]. Some studies and anecdotal data point to an increase in many factors that are determi-
nants of poor mental health during a health emergency, such as the burden of unpaid domestic
labor for women, gender-based violence [13,19], child abuse [26], lack of access to medicine
for prior chronic diseases, poor housing conditions, and overcrowding [27].
After a brief revision from literature in Medline, we found several papers studying the social
impact from the COVID-19 lockdown in Ecuadorian population. Regarding its impact on life-
styles, one study [28] found that teachers were not ready for the sudden shift to emergency
remote teaching. Another study [29] found that stress was associated with poorer diet quality.
Therefore, the confinement affected various areas of the lives of citizens.
Regarding the impact of lockdown on mental health of Ecuadorian population, one study
[30] found that burnout has a mediating effect between job motivation and turnover intention,
and that female and male workers’ burnout and turnover intentions levels are different when
intrinsic motivation is present. Otherwise, a multicenter study [31] showed that the higher per-
ception of stress, the less self-care activities are adopted, and in turn the lower the beneficial
effects on well-being.
Regarding knowledge, attitudes and practices towards COVID-19, a paper [32] found that
participants reported high levels of adoption of preventive practices; importantly, unemployed
individuals, househusbands/housewives, or manual laborers, as well as those with an elemen-
tary school education, have lower levels of knowledge about COVID-19.
In the mental health area, a paper [33] found that cognitive emotion regulation strategies
on anxiety and depression was moderated by the sex of participants and the time of assess-
ment. Moreover, a study [34] found that age was significantly correlated with all the psycho-
logical variables; importantly, females presented higher levels of stress, especially those who
have home care responsibilities.
Thus, despite that several papers have been published, it is not clear how the determinants
of self-reported and mental health affected the general population during lockdown; and, spe-
cifically, how the lockdown circumstances affected to men and women differentially.
Self-reported health status is an indicator of people’s health, the use of health services, and
mortality [35]. Moreover, scientific evidence supports the idea that self-reported health differs
according to social class and job insecurity [36], with important differences by sex and gender
[37]. It is therefore relevant to analyze confinement’s effects on self-perceived health, particu-
larly because of its potential to explain and interpret inequities as explanatory factors of health
in the lockdown context, as has been shown by other studies in the region [1].
Therefore, and to examine the association between self-reported health status and its associ-
ated factors during Ecuador’s COVID-19 lockdown, we conducted a cross-sectional survey of
between July and to October 2020 to adults who were living in Ecuador between March to
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 3 / 20
October 2020. As a secondary objective, we aimed to assess the differences in these associations
between women and men.
Materials and methods
Design, population, and sample
This was a cross-sectional study based on an online survey (see S1 File). Participants were
recruited through online platforms and social media using convenience and snowball sam-
pling. Participants were aged 18 years or older and lived in Ecuador between March and Octo-
ber 2020.
Survey and measurements
We conducted a cross-sectional survey of between July and to October 2020 to adults who
were living in Ecuador between March to October 2020. The survey was created by a group of
experts including psychologists, statisticians, and epidemiologists, and was previously applied
in different countries as part of a wider study carried out by a group of researchers from the
Institut Universitari d’Atenció Primària IDIAPJGol (Spain), FIOCRUZ Brasilia, Brazil, from
the School of Public Health of the University of Chile, and from the Instituto National Public
Health Mexico, School of Public Health of Mexico. Data were collected using the Survey Mon-
key1platform hosted by IDIAPJGol. The survey questions were worded according to the cul-
tural and language particularities of Ecuador.
Dependent variable
The dependent variable was self-reported health status, with five response options on a Likert
scale, which was then dichotomized into good self-perceived health (very good and good) and
poor self-perceived health (fair, poor, and very poor), which has been used for similar purposes
in other studies [1,27,35].
Independent variables
We employed the following independent variables in the survey: participants’ demographics
(sex, age, and location); socioeconomic status (education level, employment status, access to
health services), living conditions (housing area, total number of cohabitants, number of
cohabitants who require care, age of cohabitants, and perception of the type of housing’s ade-
quacy for lockdown, suffering violence (during the lockdown), difficulties in coping with work
or managing household chores, health-oriented behaviors (physical activity during lockdown
as well as alcohol, cigarette, illicit drugs, and sugary drinks consumption); COVID-19 related
experiences and perceptions (having had COVID-19, degree of concern of being infected with
SARS-CoV-2), having chronic diseases, and general health status (prior chronic illnesses, use
of medicines).
Anxiety was measured using the Generalized Anxiety Disorder Scale (GAD-7) [38] and was
categorized as normal, mild, moderate, and severe, and depression was assessed using the
Patient Health Questionnaire (PHQ-9) [39] and was categorized as none/minimal, mild, mod-
erate, and moderately severe.
Statistical analyses and sample considerations
Assuming an alpha risk of 5% and a beta risk of 20%, it was necessary to recruit at least 1235
individuals to estimate with a confidence level of 95% and a precision of +/- 1.5 percentage
units; a population percentage having fair or poor general health will predictably be around
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 4 / 20
7% [40]. The necessary replacement percentage was predicted to be 10%. We employed the
GRANMO sample calculator version 7.12 [41].
Descriptive statistics were performed using percentages for categorical variables and medi-
ans and interquartile ranges (IQR) for discrete and non-normally distributed variables. We
tested normality by checking the histograms. We performed Chi
2
to compare differences in
proportions of explanatory variables across the two categories of health self-perception and the
U-Mann-Whitney test to assess differences in discrete or non-normally distributed explana-
tory variables across health self-perception categories. We then estimated the crude and
adjusted odds ratios (aOR) of regular or poor self-perception of health status for each explana-
tory variable and its categories.
We then fitted multivariate logistic regression models to evaluate the independent associa-
tion between each explanatory variable (age, sex, education level, educational level, employ-
ment status, access to health services, social security, perception of the type of housing’s
adequacy for lockdown, housing area, number of cohabitants who require care, physical activ-
ity during lockdown, alcohol consumption, degree of concern of being infected with SARS--
CoV-2, difficulties in coping with the job or taking care of household chores, healthy or
socially-active activities during lockdown, violence or abuse during lockdown, diseases, symp-
toms and medications, anxiety, depression, and use of antidepressants), and health status self-
perception. First, we built a saturated model that included all individual covariates. Then,
based on the researchers’ criteria, we eliminated covariates with Wald test p-value>0.25 from
the model [42], and 95% confidence intervals (95%CI) of the aOR and their corresponding p-
values were calculated. Once the parsimonious model was obtained, we compared both models
and chose the “final” model, according to its level of significance from the likelihood ratio test.
Considering that the percentage of missing data was <23%, we employed a complete case anal-
ysis to estimate statistical associations (for further details see S1 Table).
Analyses were stratified by sex; respondents who had a non-binary gender identity or did
not identify with other categories were excluded from the analysis, because the group was too
small (n = 4). Sex was tested as an effect modifier and a confounder.
To test for potential effect modification, we performed several secondary analyses to assess
the sensitivity of our estimates with our assumptions regarding biases as well as to test for
model misspecifications. We ran the final model excluding (i) high- and low-educated sub-
jects, (ii) those with chronic diseases, (iii) those with severe anxiety, and (iv) those with severe
depression.
Statistically significant differences were considered when the p-value was <0.05; all analyses
were performed using Stata 16.1 (Statistical Software Stata:Release 16.1 College Station,TX:
StataCorp LP).
Ethics approval
This study was approved by the Research Ethics Committee on Human Beings (CEISH) of the
Ministry of Public Health of Ecuador (code number MSP-CGDES-2020-0129-O) with the
authorization to obtain an online informed consent before the start of the survey. Minors were
not included in the study.
Results
Descriptive results
We analyzed the information of 2924 people. The participant characteristics are presented in
Table 1. Their median (IQR) age was 34 (27–44) years, and most patients were female (68%).
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 5 / 20
Table 1. Description of the sample.
Variable
a
Whole sample n = 2924
Age in years of life, median (IQR) 34 (27 to 44)
Female, n % 1801 (68)
Education level
Educational level lower than university education,n % 408 (16)
University educational level or higher,n % 2191 (84)
Employment status
Public or private full job,n (%) 1601 (63)
Self-employment,n (%) 315 (13)
Unpaid work,retired or student,n (%) 612 (24)
Access to health services
Social security
b
,n (%) 1517 (61)
Private health insurance,n (%) 598 (24)
Public health services user,n (%) 375 (15)
Perception of the adequacy of the type of housing to lockdown
Moderately to well adequate,n (%) 2204 (86)
Little or not adequate,n (%) 348 (14)
Housing area
<50 m
2
,n (%) 243 (10)
50 to 80 m
2
,n (%) 488 (19)
80 to 100 m
2
,n (%) 557 (22)
100 to 120 m
2
,n (%) 477 (19)
�120 m
2
,n (%) 779 (31)
Number of cohabitants, median (IQR) 4 (2 to 5)
Number of cohabitants who require care, median (IQR) 2 (1 to 3)
Number of cohabitants <18 years old, median (IQR) 2 (1 to 3)
Physical activity during lockdown
Not performing,n (%) 366 (16)
Increased performing,n (%) 588 (25)
The same performing than before lockdown,n (%) 492 (21)
Reduced performing,n (%) 871 (38)
Alcohol consumption
Increase of alcohol consumption during lockdown,n (%) 111 (5)
Any alcohol consumption during lockdown,n (%) 825 (36)
Any cigarette consumption during lockdown, n (%) 229 (10)
Any illicit drugs consumption during lockdown, n (%) 83 (4)
Any consumption of sugary drinks, n (%) 1593 (67)
Concerns arising from the pandemic: degree of concern of being infected with
SARS-CoV-2
Not worried,n (%) 69 (3)
A little worried,n (%) 295 (13)
Moderately worried,n (%) 781 (33)
Quite worried,n (%) 654 (28)
Very worried,n (%) 533 (23)
Very high difficulties to cope with the job or take care of household chores, n (%) 109 (5)
New health activities during lockdown, n (%) 1187 (51)
Suffer any type of violence or abuse during lockdown, n (%) 316 (14)
Diseases, symptoms, and medications
(Continued)
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 6 / 20
Regarding sociodemographic characteristics, most participants had a university education
(84%) and had a full-time public or private job (63%).
Sixteen percent of the participants had regular or poor health self-perception status. In the
whole sample, the prevalence of severe anxiety was 17% and severe depression was 7%; never-
theless, 76% had any anxiety level and 69% had any depression level (Table 1). When compar-
ing between both sex categories (Table 2), moderate to severe anxiety levels (10 to �15 points
of the GAD-7 questionnaire) were reported in 38% of the women and 29% of the men; and,
moderate to severe depression levels (10 to �20 points of the PHQ9 questionnaire) were
reported in 35% of the women and 26% of the men.
Determinants of health self-perception
When comparing the characteristics between those participants with excellent/good vs. regu-
lar/poor health self-perception, there was a lower percentage of participants with a perception
that the type of housing’s adequacy for lockdown was poor or inadequate (12% vs. 24%,
p<0.01), a lower percentage of participants with perception of greater difficulties in coping
with work or taking care of household chores (3% vs. 14%, p<0.001), a lower percentage of
participants with a history of COVID-19 (9% vs. 21%, p<0.001), and a lower percentage of
participants with chronic diseases (28% vs. 70%, p<0.001). Anxiety and depression symptoms
were less frequent among participants with good self-perception (Table 3).
The multivariate analyses (Table 4) showed that being female (aOR = 1.5, 95% CI:1.1 to
2.2), having solely public healthcare system access (aOR = 1.9, 95% CI: 1.2 to 2.9), perceiving
Table 1. (Continued)
Variable
a
Whole sample n = 2924
Have or had COVID-19 266 (11)
Presence of any chronic disease 789 (34)
Anxiety symptoms as measured by GAD-7 questionnaire
No anxiety (<5 points),n (%) 539 (23)
Mild anxiety (5 to <10 points),n (%) 801 (35)
Moderate anxiety (10 to <15 points),n (%) 579 (25)
Severe anxiety (�15 points),n (%) 384 (17)
Any anxiety level (�5 points),n (%) 1740 (76)
Depression symptoms as measured by PHQ9 questionnaire
No depression (<5 points),n (%) 708 (31)
Mild depression (5 to <10 points),n (%) 700 (30)
Moderate depression (10 to <15 points),n (%) 473 (21)
Moderately severe depression (15 to <20 points),n (%) 256 (11)
Severe depression (�20 points),n (%) 161 (7)
Any depression level (�5 points),n (%) 1590 (69)
Any use of antidepressants, n (%) 225 (10)
Poor or regular health self-perception 386 (16)
IQR = Interquartile range
GAD-7 = Generalized Anxiety Disorder Scale
PHQ9 = Patient Health Questionnaire
a
= There were missing data (<23%) in some variables. For further details, see S1 Table.
b
= It corresponds to the beneficiaries of the Ecuadorian Institute of Social Security (IESS, for its acronym in
Spanish), the social security of the armed forces (ISSFA, for its acronym in Spanish) and the social security of the
police (ISSPOL, for its acronym in Spanish). acronym in Spanish)
https://doi.org/10.1371/journal.pone.0275698.t001
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 7 / 20
Table 2. Sociodemographic characteristics, social impact variables and mental health scale of participants by sex in Ecuador during lockdown (n = 2655).
Variable Women n = 1801 Men n = 854 p-value
Age in years of life, median (IQR) 33 (26 to 42) 37 (29 to 49) 0.001
Education level
Educational level lower than university education,n % 280 (17) 119 (15) 0.332
University educational level or higher,n % 1415 (83) 675 (85)
Employment status
Public or private full job,n (%) 1005 (61) 522 (67) <0.001
Self-employment,n (%) 192 (12) 110 (14)
Unpaid work,retired or student,n (%) 449 (27) 143 (19)
Access to health services
Social security,n (%) 979 (60) 482 (63) 0.561
Private health insurance,n (%) 396 (24) 176 (23)
Public health services user,n (%) 246 (15) 111 (14)
Perception of the adequacy of the type of housing to lockdown
Moderately to well adequate,n (%) 1439 (86) 679 (87) 0.786
Little or not adequate,n (%) 226 (14) 103 (13)
Housing area
<50 m
2
,n (%) 144 (9) 85 (11) 0.005
50 to 80 m
2
,n (%) 341 (17) 130 (17)
80 to 100 m
2
,n (%) 384 (23) 152 (20)
100 to 120 m
2
,n (%) 312 (19) 147 (19)
�120 m
2
,n (%) 476 (29) 265 (34)
Number of cohabitants, median (IQR) 4 (3 to 5) 4 (2 to 4) 0.012
Number of cohabitants who require care, median (IQR) 2 (1 to 3) 1 (1 to 3) <0.001
Number of cohabitants <18 years old, median (IQR) 2 (1 to 3) 2 (1 to 3) 0.776
Physical activity during lockdown
Not performing,n (%) 275 (18) 78 (11) <0.001
Increased performing,n (%) 401 (27) 164 (23)
The same performing than before lockdown,n (%) 311 (21) 156 (22)
Reduced performing,n (%) 522 (35) 315 (44)
Alcohol consumption
Increase of alcohol consumption during lockdown,n (%) 401 (27) 164 (23) 0.071
Any alcohol consumption during lockdown,n (%) 462 (31) 325 (45) <0.001
Any cigarette consumption during lockdown, n (%) 115 (8) 103 (14) <0.001
Any illicit drugs consumption during lockdown, n (%) 47 (3) 36 (5) 0.025
Any consumption of sugary drinks, n (%) 1012 (67) 514 (72) 0.041
Concerns arising from the pandemic: degree of concern of being infected with SARS-CoV-2
Not worried,n (%) 35 (2) 32 (5) 0.003
A little worried,n (%) 190 (13) 94 (13)
Moderately worried,n (%) 493 (32) 252 (35)
Quite worried,n (%) 425 (28) 202 (28)
Very worried,n (%) 376 (25) 136 (19)
Very high difficulties to cope with the job or take care of household chores, n (%) 90 (6) 14 (2) <0.001
New health activities during lockdown, n (%) 779 (52) 353 (49) 0.336
Suffer any type of violence or abuse during lockdown, n (%) 212 (14) 97 (14) 0.826
Diseases, symptoms, and medications
Have or had COVID-19 172 (11) 83 (11) 0.746
Presence of any chronic disease 512 (33) 240 (34) 0.873
(Continued)
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 8 / 20
housing as inadequate to cope with lockdown (aOR = 2.2, 95% CI:1.4 to 3.4). Furthermore,
perceiving very high difficulties in coping with work or managing household chores was asso-
ciated with poor health self-perception (aOR = 2.7, 95% CI:1.5 to 5.0). The odds of poor self-
reported health status were as high as the increase in the number of cohabitants who required
care (aOR = 1.2, 95% CI:1.1 1.3). Furthermore, having had a diagnosis of COVID-19 or having
had COVID-19 symptoms (aOR = 3.1, 95%CI:2.0–4.7), and suffering from chronic diseases
(aOR = 6.9, 95% CI:4.9 to 9.7), having severe depression (aOR 5.9, 95%CI:3.1–11.2), were
independently associated with poor health self-perception; specifically, there was a “dose-
response” association between increasing depression severity and regular or poor self-percep-
tion of health; specifically, there was a 60% (65% CI:59%–83%, p-for-trend <0.001) increase in
the odds of poor self-reported health status for each change to a higher depressive category.
After sensitivity analyses (S2 Table), we found similar estimates when running the final
(parsimonious) model when excluding (i) high- and low-educated subjects, (ii) those with
chronic diseases, (iii) those with severe anxiety, and (iv) those with severe depression.
Differences between women and men
When comparing the variables between women and men (Table 2), we found that, women
had significantly greater percentages of: (i) unpaid work, being retired, or being a student
(27% in women vs. 19% in men, p <0.001), (ii) being extremely worried about being infected
with SARS-CoV-2 (25% vs. 19%, p<0.001), (iii) extreme difficulty in coping with work or
managing household chores (6% vs. 2%, p <0.001), (iv) severe anxiety (19% vs. 12%, p
<0.001), (v) severe depression (8% vs. 5%, p <0.001); and (vi) poor or regular health self-per-
ception (17% vs. 12%, p <0.001).
When we stratified the multivariate analyses of health self-perception by sex, we found dif-
ferences in the determinants between men and women (see S3 Table). Specifically, for
women, and considering the full-time job category as the reference, self-employment was
Table 2. (Continued)
Variable Women n = 1801 Men n = 854 p-value
Anxiety symptoms as measured by GAD-7 questionnaire
No anxiety (<5 points),n (%) 297 (20) 217 (30) <0.001
Mild anxiety (5 to <10 points),n (%) 513 (34) 244 (34)
Moderate to severe anxiety (10 to �15 points),n (%) 686 (38) 250 (29)
Any anxiety level (�5 points),n (%) 1181 (79) 489 (69) <0.001
Depression symptoms as measured by PHQ9 questionnaire
No depression (<5 points),n (%) 401 (27) 271 (38) <0.001
Mild depression (5 to <10 points),n (%) 454 (30) 213 (30)
Moderate to severe depression (10 to �20 points),n (%) 638 (35) 226 (26)
Any depression level (�5 points),n (%) 1092 (73) 439 (62) <0.001
Any use of antidepressants, n (%) 155 (10) 65 (9) 0.370
Poor or regular health self-perception 284 (17) 91 (12) 0.001
IQR = Interquartile range
GAD-7 = Generalized Anxiety Disorder Scale
PHQ9 = Patient Health Questionnaire
a
= There were missing data (<23%) in some variables. For further details, see S1 Table.
b
= It corresponds to the beneficiaries of the Ecuadorian Institute of Social Security (IESS, for its acronym in Spanish), the social security of the armed forces (ISSFA, for
its acronym in Spanish) and the social security of the police (ISSPOL, for its acronym in Spanish). acronym in Spanish)
https://doi.org/10.1371/journal.pone.0275698.t002
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 9 / 20
Table 3. Differences in characteristics across health self-perception categories.
Variable Good or excellent health self-perception
(n = 2111)
Regular or poor health self-perception
(n = 386)
p-value
Age in years of life, median (IQR) 35 (27 to 45) 34 (27 to 43) 0.502
Female, n % 1350 (67) 284 (76) 0.001
Education level
University educational level or higher,n % 1775 (86) 303 (80) 0.007
Employment status
Public or private full job,n (%) 1296 (64) 232 (64) 0.006
Self-employment,n (%) 271 (13) 29 (8)
Unpaid work,retired or student,n (%) 460 (23) 100 (28)
Access to health services
Social security
a
,n (%) 1218 (61) 221 (62) <0.001
Private health insurance,n (%) 499 (25) 61 (17)
Public health services user,n (%) 273 (14) 77 (22)
Perception of the adequacy of the type of housing to lockdown
Moderately to well adequate,n (%) 1860 (88) 293 (76) <0.001
Little or not adequate,n (%) 249 (12) 92 (24)
Housing area
<50 m2,n (%) 181 (9) 56 (15) <0.001
50 to 80 m2,n (%) 394 (19) 84 (22)
80 to 100 m2,n (%) 445 (21) 98 (26)
100 to 120 m2,n (%) 406 (19) 57 (15)
�120 m2,n (%) 674 (32) 87 (23)
Number of cohabitants, median (IQR) 4 (2 to 5) 4 (3 to 5) 0.039
Number of cohabitants who require care, median (IQR) 2 (1 to 3) 2 (1 to 3) <0.001
Number of cohabitants <18 years old, median (IQR) 2 (1 to 3) 2 (1 to 3) <0.084
Physical activity during lockdown
Not performing,n (%) 274 (14) 87 (25) <0.001
Increased performing,n (%) 521 (27) 67 (19)
The same performing than before lockdown,n (%) 433 (22) 57 (16)
Reduced performing,n (%) 730 (37) 136 (39)
Alcohol consumption
Increase of alcohol consumption during lockdown,n (%) 88 (5) 22 (6) 0.136
Any alcohol consumption during lockdown,n (%) 724 (37) 98 (28) 0.002
Any cigarette consumption during lockdown, n (%) 193 (10) 36 (10) 0.734
Any illicit drugs consumption during lockdown, n (%) 68 (3) 15 (4) 0.427
Any consumption of sugary drinks, n (%) 1338 (68) 246 (71) 0.369
Concerns arising from the pandemic: degree of concern of being
infected with SARS-CoV-2
Not worried,n (%) 60 (3) 9 (3) <0.001
A little worried,n (%) 250 (13) 45 (13)
Moderately worried,n (%) 703 (36) 75 (21)
Quite worried,n (%) 533 (27) 118 (34)
Very worried,n (%) 425 (22) 103 (29)
Very high difficulties to cope with the job or take care of household
chores, n (%)
57 (3) 50 (14) <0.001
New healthy or socially active activities during lockdown, n (%) 1039 (53) 143 (41)
Suffer any type of violence or abuse during lockdown, n (%) 224 (12) 80 (23) <0.001
Diseases, symptoms, and medications
(Continued)
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 10 / 20
significantly associated with a poorer self-reported health status (aOR = 0.6, 95%CI:0.2 to 0.8);
moreover, there were 30% higher odds of poor self-reported health status per each extra
cohabitant who required care (aOR = 1.3, 95% CI:1.1 to 1.5). Those having or having had
COVID-19 had 330% higher odds of regular or poor self-reported health status (aOR = 4.3,
95% CI:2.6 to 7.1) when compared with their counterparts; and those reporting any chronic
disease had a greater likelihood of having poor self-reported health status (aOR = 8.1, 95%
CI:5.3 to 12.1). We did not find such strong associations in men. For men, by contrast, we
found that those perceiving housing’s adequacy for lockdown as poor or inadequate had
greater odds of regular or poor self-reported status than women (aOR = 3.2, 95% CI:1.4 to
7.1), and depression was much more associated with regular or poor self-reported health status
than for women (aOR = 1.70, 95% CI:1.32 to 2.22).
Discussion
Our main findings were that the determinants of regular or poor self-reported health status
among Ecuadorian-surveyed adult persons were: (i) being female by comparison with being
male, (ii) perceiving housing conditions as inadequate for coping with the lockdown, (iii) liv-
ing with people who require care, (v) perceiving extreme difficulties in coping with both work
exigencies or managing household chores, (vi) a history of COVID-19 infection, (vii) presence
of chronic diseases, and (viii) depressive symptoms. Similar to other studies, the complex
Ecuadorian context during lockdown [10,13–16,18] helps explain the accentuated impact of
such factors on the self-reported health status of the Ecuadorian population.
Table 3. (Continued)
Variable Good or excellent health self-perception
(n = 2111)
Regular or poor health self-perception
(n = 386)
p-value
Have or had COVID-19 185 (9) 79 (21) <0.001
Presence of any chronic disease 551 (28) 237 (70) <0.001
Anxiety symptoms as measured by GAD questionnaire, median (IQR) 7 (4 to 12) 13 (8 to 17) <0.001
No anxiety (<5 points),n (%) 504 (26) 32 (9) <0.001
Mild anxiety (5 to <10 points),n (%) 727 (37) 73 (21)
Moderate anxiety (10 to <15 points),n (%) 464 (24) 112 (33)
Severe anxiety (�15 points),n (%) 255 (13) 125 (37)
Any anxiety level (�5 points),n (%) 1429 (73) 903 (89) <0.001
Depression symptoms as measured by PHQ9 questionnaire, median
(IQR)
7 (3 to 11) 13 (8 to 18) <0.001
No depression (<5 points),n (%) 662 (34) 43 (13) <0.001
Mild depression (5 to <10 points),n (%) 625 (32) 74 (22)
Moderate depression (10 to <15 points),n (%) 385 (20) 87 (26)
Moderately severe depression (15 to <20 points),n (%) 180 (9) 74 (22)
Severe depression (�20 points),n (%) 94 (5) 63 (18)
Any depression level (�5 points),n (%) 1284 (66) 298 (88) <0.001
Any use of antidepressants, n (%) 157 (8) 65 (19) <0.001
IQR = Interquartile range
GAD-7 = Generalized Anxiety Disorder Scale
PHQ9 = Patient Health Questionnaire
a
= It corresponds to the beneficiaries of the Ecuadorian Institute of Social Security (IESS, for its acronym in Spanish), the social security of the armed forces (ISSFA, for
its acronym in Spanish) and the social security of the police (ISSPOL, for its acronym in Spanish). acronym in Spanish)
https://doi.org/10.1371/journal.pone.0275698.t003
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 11 / 20
Table 4. Crude and adjusted odds ratios of regular or bad health self-perception.
Variable Crude p-value Saturated p-value Parsimonious p-value
Female (male is the ref.) 1.5 (1.2 to 2.0) 0.001 1.7 (1.1 to 2.5) 0.013 1.5 (1.1 to 2.2) 0.023
Education level
University educational level or higher (lower than university education is the ref.) 0.7 (0.5 to 0.9) 0.007 0.8 (0.5 to 1.3) 0.351 - -
Employment status
Public or private full job (ref.) 1 - 1 - 1 -
Self-employment 0.6 (0.4 to 0.9) 0.013 0.4 (0.2 to 0.8) 0.008 0.5 (0.3 to 0.8) 0.011
Unpaid work,retired or student 1.2 (0.9 to 1.6) 0.139 0.9 (0.6 to 1.4) 0.574 0.8 (0.5 to 1.2) 0.359
Access to health services
Social security
a
(ref.) 1 - 1 - 1 -
Private health insurance 0.7 (0.5 to 0.9) 0.010 0.7 (0.4 to 1.1) 0.134 0.7 (0.5 to 1.1) 0.162
Public health services user 1.6 (1.2 to 2.1) 0.003 1.8 (11 to 2.9) 0.022 1.9 (1.2 to 2.9) 0.009
Perception of the adequacy of the type of housing to lockdown
Little or not adequate (Moderately to well adequate is ref.) 2.4 (1.8 to 3.1) <0.001 2.1 (1.3 to 3.3) 0.003 2.2 (1.4 to 3.4) <0.001
Housing area
<50 m2 (ref) 1 - 1 - - -
50 to 80 m2 0.7 (0.5 to 1.0) 0.056 0.6 (0.3 to 1.3) 0.215 - -
80 to 100 m2 0.7 (0.5 to 1.0) 0.073 0.7 (0.4 to 1.5) 0.363 - -
100 to 120 m2 0.5 (0.3 to 0.7) <0.001 0.6 (0.3 to 1.2) 0.174 - -
�120 m2 0.4 (0.2 to 0.4) <0.001 0.5 (0.3 to 1.1) 0.096 - -
Number of cohabitants who require care (per each increase in one cohabitant) 1.3 (1.2 to 1.4) <0.001 1.2 (1.1 to 1.4) 0.002 1.2 (1.1 to 1.3) 0.004
Physical activity during lockdown
Increased performing (any increase or no performing is ref.) 0.7 (0.5 to 0.9) 0.004 0.9 (0.6 to 1.5) 0.793 - -
Alcohol consumption
Increase of alcohol consumption during lockdown,n (%) 1.4 (0.9 to 2.3) 0.138 1.3 (0.6 to 2.6) 0.525 - -
Concerns arising from the pandemic: degree of concern of being infected with
SARS-CoV-2
Nothing worried (ref) 1 - 1 - 1 -
A little worried 1.2 (0.6 to 2.6) 0.642 0.6 (0.2 to 1.7) 0.331 - -
Moderately worried,n (%) 0.7 (0.3 to 1.5) 0.367 0.8 (0.3 to 2.3) 0.697 - -
Quite worried,n (%) 1.5 (0.7 to 3.1) 0.295 1.2 (0.4 to 3.4) 0.680 - -
Very worried,n (%) 1.7 (0.8 to 3.4) 0.200 0.8 (0.3 to 2.3) 0.680 - -
Very high difficulties to cope with the job or take care of household chores (not having
is the ref.)
5.6 (3.7 to 8.3) <0.001 2.6 (1.4 to 5.0) 0.004 2.7 (1.5 to 5.0) 0.002
New healthy or socially active activities during lockdown (not having is the ref.) 0.6 (0.5 to 0.8) <0.001 0.7 (0.5 to 1.1) 0.109 - -
Suffer any type of violence or abuse during lockdown (not having is the ref.) 2.22 (1.7 to
3.0)
<0.001 1.29 (0.8 to
2.0)
0.247 - -
Diseases, symptoms, and medications
Have or had COVID-19 (not having is the ref.) 2.7 (2.0 to 3.6) <0.001 3.1 (2.0 to 4.9) <0.001 3.1 (2.0 to 4.7) <0.001
Presence of any chronic disease (not having is the ref.) 6.1 (4.7 to 7.8) <0.001 6.9 (4.8 to
10.0)
<0.001 6.9 (4.9 to 9.7) <0.001
Anxiety symptoms as measured by GAD-7 questionnaire
No anxiety (<5 points) (ref.) 1 - 1 - - -
Mild anxiety (5 to <10 points) 1.6 (1.0 to 2.4) 0.037 1.1 (0.6 to 2.1) 0.723 - -
Moderate anxiety (10 to <15 points) 3.8 (2.5 to 5.7) <0.001 1.2 (0.6 to 2.5) 0.545 - -
Severe anxiety (�15 points) 7.7 (5.1 to
11.7)
<0.001 1.2 (0.6 to 2.7) 0.631 - -
Depression symptoms as measured by PHQ-9 questionnaire, median (IQR)
No depression (<5 points) (ref.) 1 - 1 - 1 -
(Continued)
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 12 / 20
The factors associated with self-reported health differed by sex/gender. Specifically, women
had a greater negative impact on their self-reported health when they received only public
health services, had inadequate housing for lockdown, an increasing number of cohabitants
who required care in the family, extreme perceived difficulties coping with work or managing
household chores, having COVID-19, the presence of chronic disease, and increasing depres-
sive symptoms. In men, the determinants were inadequate housing type, presence of chronic
disease, and increasing depressive symptoms. Interestingly, in women, COVID-19’s effect and
the presence of chronic diseases were more accentuated than in men as in other studies have
been found [43]; while in men, the housing inadequacy and increasing depressive symptoms
were more accentuated than in women, as was found in other contexts such as Spain [27]. We
could not demonstrate a significant interaction or effect modification by sex/gender on the
association between the associated factors and self-reported health.
Furthermore, the percentage of poor or regular health self-perception was 16%, which was
greater among women (17%) than among men (12%). The prevalence of poor self-reported
health status (16%) is greater than that found in other contexts during lockdown [40]. A com-
parison between our data and the results of an occupational health survey conducted among
workers in Quito and Guayaquil before the pandemic, where the authors found a prevalence
of 11% for self-perceived poor health status [36], suggests that the lockdown has significantly
worsened the levels of self-perceived health in Ecuador. This is possibly because of the weak-
ened social protection system, reflected on the lack of social support policies during this pan-
demic phase. Given that safe and adequate housing is essential to protect people from
environmental conditions, create social ties, and establish life projects, housing deprivation
and the lack of an adequate urban environment have significant health consequences for both
sexes [44].
These findings highlight the impact of gender inequality on the burden of care and domes-
tic work, and its negative effect on women’s health. As other researchers have shown [7,8],
being a woman was a risk factor for increased mental distress during lockdown. Furthermore,
our findings add data on unpaid care and domestic work as one of the mechanisms through
which lockdowns affect women’s health in particular ways [45]. Men did not feel this impact,
which is probably related to the assignment of traditional gender roles, in which men are usu-
ally not responsible for care and domestic work.
Although it is true female had a poorer perception of self-reported health; both, men and
women suffered a significant impact on their health, especially in the area of mental health.
Table 4. (Continued)
Variable Crude p-value Saturated p-value Parsimonious p-value
Mild depression (5 to <10 points) 1.8 (1.2 to 2.7) 0.003 1.1 (0.6 to 2.1) 0.666 1.4 (0.9 to 2.3) 0.162
Moderate depression (10 to <15 points) 3.5 (2.4 to 5.1) <0.001 2.5 (1.3 to 4.6) 0.005 3.2 (2.0 to 5.3<0.001
Moderately severe depression (15 to <20 points) 6.3 (4.2 to 9.5) <0.001 2.7 (1.3 to 5.5) 0.008 3.8 (2.2 to 6.7) <0.001
Severe depression (�20 points) 10.3 (6.6 to
16.0)
<0.001 4.3 (1.8 to
10.0)
0.001 5.9 (3.1 to
11.2)
<0.001
p-for-trend 1.6 (1.39 to
1.8)
<0.001
Any use of antidepressants (not using is the ref.) 2.6 (1.9 to 3.6) <0.001 1.3 (0.8 to 2.2) 0.270 - -
GAD-7 = Generalized Anxiety Disorder Scale
PHQ9 = Patient Health Questionnaire
a
= It corresponds to the beneficiaries of the Ecuadorian Institute of Social Security (IESS, for its acronym in Spanish), the social security of the armed forces (ISSFA, for
its acronym in Spanish) and the social security of the police (ISSPOL, for its acronym in Spanish). acronym in Spanish)
https://doi.org/10.1371/journal.pone.0275698.t004
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 13 / 20
The fact that we found a worse self-perceived health in women compared to men is coincident
with the results obtained from previous studies [46,47].
Although mortality from COVID-19 has been consistently higher in men [48], scientific lit-
erature shows that women tend to have worse living conditions and use health services more
frequently; they also have a greater number of disease diagnoses. A possible explanation is that
women have historically suffered the greatest burden of social inequalities and have assumed
more home responsibilities, which, compounded by the added responsibilities during confine-
ment [49], has entailed a greater stress load. In addition, our findings corroborate that women
have a greater burden of caring for dependent people, a fact explained by the assignment of
traditional gender roles that persist in patriarchal systems, such as the Ecuadorian society. At
the same time, these results show the poorness of the social protection system to deal with care
as a social risk managed by family ties and networks, instead of public services. Both forms of
response were eliminated during lockdown, so that care fell to women from nuclear families.
Importantly, women suffer more from the lack of proper access to tele-education for their
children, given the cultural tendency to assign women as those responsible for educating chil-
dren, despite their having to cope with everyday duties such as productive work. The regional
difficulties in educating children could explain the even more important health effect of caring
for household children. Specifically, in Latin America and the Caribbean, schools have been
closed for an average of 37 weeks since March 2020. In Ecuador, it has been 40 weeks. In addi-
tion, only 39% of primary school students can read a simple text [50], and only 37% of house-
holds have Internet access, which means that six out of ten children cannot study through
digital platforms. The situation is more serious for children in rural areas, where only 16% of
households have this service [51].
Males were affected too; as in other studies’ findings, there is poorer self-reported health in
men when inadequate housing conditions are perceived [52,53], and when there are depres-
sive symptomatology [54]. These findings could be explained by: First, the fact that men are
more prone to discomfort because of housing conditions, which is in turn related to gender
roles and its impact on self-reported health. In traditional patriarchal systems, men are seen as
the primary family breadwinners, and not being able to meet a desired standard could affect
men’s health more than women’s. Second, according to previous studies [54], potential expla-
nations of the accentuation of poor self-reported health by depression are related with the fact
that the presence of symptoms of depression have been associated with the occurrence of
severe sexual functioning disorders; and third, the intensity of other fears, not measured in
this survey, could be correlated with depressive and sexual disorders.
As a result of overcrowding, couples experience financial and family stressors, with an
increase in the number of conflicts during sustained social isolation and physical proximity,
particularly among young and newly-formed intimate relationships. Moreover, with housing
insecurity and housing conditions [55] inadequate to tackle the lockdown, a poor self-rated
health status is expected. In that sense, we corroborated that living in poor housing conditions
and having low income and/or poor labor conditions–the social determinants of health–affect
more vulnerable populations [27,56].
In addition, we found that 38% of women and 29% of men reported moderate to severe
anxiety, and moderate to severe depression levels were reported in 35% of women and 26% of
men. We corroborated that there were gender differences in depression and anxiety, as well as
differences in the quantity of (subclinical) depressive symptoms [19]. Prior studies found that
the levels of such mental health problems were much lower than our findings. Specifically, in
one study in Spain [27], 31% of women and 18% of men reported moderate to severe anxiety,
and moderate to severe depression levels were reported in 29% of women and 17% of men. It
is possible that specific contexts determine reactions to the lockdown. We believe that the
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 14 / 20
Ecuadorian population felt a profound health impact owing to the poor and uncoordinated
pandemic response from national and local authorities.
Moreover, the frequency of anxiety and depression levels was greater in females than in
males in the study population. However, the association between depression symptoms and
regular-to-poor health self-perception was stronger in men than in women. It is coincident
with a study [54] that found that the fear of contracting the COVID-19 infection, the fear of
the health condition of loved ones, depressed mood, and exposition to media reports worsened
their mental health. Furthermore, another study found that psychosocial factors explained the
highest proportion of the variance in anxiety symptoms, being even higher in men than in
women. Also, we found that depression and adverse housing conditions were more associated
to a poorer self-perceived health in men than in women, maybe explained by previous findings
that depressive symptomatology has a greater impact on men’s health when compared to
women in terms of suicide attempts [57]. While suicide attempt rates are similar between men
and women, males have an almost threefold higher risk of dying by suicide than females [58].
This higher mortality among men could be explained by various factors, including the use of
more lethal means (firearms and hanging methods), whereas drug intoxication is more fre-
quent in women. Young men may be less predisposed to help-seeking behaviors as an attempt
to exhibit masculine behaviors, and their tendency to adopt avoidance strategies may make it
more difficult for them to cope with emotional and behavioral problems [49]. In that regard,
specific pandemic and lockdown policies should use a gender approach to identify those at
risk and intervene [27].
Regarding protective variables, perceived social support was independently associated with
lower anxiety while intimate partner violence was further associated with higher anxiety symp-
toms and this pattern was consistent in men and women.
Serious questioning of the Ecuadorian Public Health System and its manner of operating
was a serious pandemic effect. Some participants reported being part of or knowing someone
who was close to the health system. The lack of response to emergencies (which involved life
or death in many cases), lack of basic information regarding COVID-19, serious difficulties in
communicating basic information to the population, and lack of psychological support spaces
for front-line professionals were the most common problems. Through proposals from civil
society and academia the population gained access to spaces for psychological support and cri-
sis intervention [59]. The evidence on the lockdown’s gendered impact on self-perceived
health found here is a strong indicator of how deep-rooted patriarchal gender beliefs affect the
health of the Ecuadorian population. Even though we have found only one study in Ecuador
on teleworking’s impact on people’s lives, especially women, there are clear impacts from
increases in teleworker numbers in the sectors where it was implemented, in the codification
of work schedules and conciliation with family life, as well as significant specific effects on
unions and teleworking health and safety [20].
The pandemic’s impact is also unknown in areas related to the additional burdens and
impacts resulting from teleworking on women, who often bear the bulk of household care
work; protection of labor rights and workers in legislative frameworks; and judgments or con-
stitutional revisions relating to teleworking laws. Specifically, in a study it was found that 76%
of the women surveyed indicate an increase in workload, and 56% dedicate themselves to their
children’s schoolwork [20]. Furthermore, women who spent long hours on housework and
childcare were more likely to report increased levels of psychological distress, and women
were more likely than men to reduce working hours and adapt employment schedules because
of increased unpaid care time [60]. In that regard, our results can be used to better justify for-
mulating regulations that guarantee a maximum of eight daily working hours [20]. Continued
gender inequality in divisions of unpaid care work during lockdown may put women at a
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 15 / 20
greater risk of psychological distress, which is a consequence of gender biases in divisions of
labor and their impact on psychological health [60]. Teleworking also raised questions about
the use of the physical household spaces, which in many cases implied no temporal limits
between hours of outside and inside home labor. In these cases, women mostly assume these
new daily dynamics, resulting in extreme fatigue, anxiety, and sadness.
The COVID-19 prevalence was around 11%, which is similar to published (and non-pub-
lished) reports of the pandemic’s evolution in Ecuador during the surveyed months [61]. It is
important to enhance this finding because it helps understanding of this population’s context
during the specific survey period.
This study has several limitations. The survey was only available online and was mainly
completed by highly educated respondents, and it may have excluded people without digital
access. As it happened with many studies during lockdown, an electronic survey had to be
applied to obtain information in that setting. The advantage of this approach was that relevant
information could be obtained in a time were performing research had many challenges. The
disadvantage was that access to the survey could be limited to some populations (higher socio-
economic status, younger age, etc.). Thus, we speculate that the associations and inequalities
would be even greater if it included more vulnerable people. Non-representative responses are
a handicap of online surveys, since they do not capture the responses of those who lack access
and/or Internet skills (e.g., the elderly, those with lower education, or those in remote loca-
tions). In addition, we had more responses from women than from men. This requires strate-
gies to ensure greater male participation. However, as the analyses were stratified by sex, the
main results were compared with those of the reference group. We plan to conduct another
survey and a qualitative study several months after this first survey. This will be carried out
using the same method, as it is being applied in other Latin American countries and Spain, to
compare the results in different populations.
Conclusions
Being female, having only access to the public healthcare system, having a perception of inade-
quate housing, living with cohabitants who require care, perceiving very high difficulties in
coping with work or managing household chores, having or having had COVID-19, the pres-
ence of chronic diseases, and depressive symptoms are associated with a poorer self-reported
health status in Ecuadorian population. Conversely, self-employment and having private
health insurance were significantly and independently associated with better self-reported
health status. For women, self-employment, having solely public healthcare system access, per-
ceiving housing conditions as inadequate, having cohabitants requiring care, having very high
difficulties to cope with household chores, having COVID-19, and having a chronic disease
increased the likelihood of having poor self-reported health status. For men, poor or inade-
quate housing, presence of any chronic disease, and depression increased the likelihood of hav-
ing poor self-reported health status.
Supporting information
S1 Data.
(CSV)
S1 File. Spanish version of the survey.
(DOCX)
S1 Table. Description of the sample and missing values per each variable.
(DOCX)
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 16 / 20
S2 Table. Adjusted odds ratios of regular or bad health self-perception excluding: (i) high
and low educated subjects, (ii) those with chronic diseases, (iii) those with severe anxiety,
and (iv) those with severe depression.
(DOCX)
S3 Table. Adjusted odds ratios of regular or bad health self-perception stratified by sex
according to the parsimonious logistic regression model of Table 3 of the main text.
(DOCX)
Acknowledgments
We thank the project members for their input and the Instituto de Salud Pública from Pontifi-
cia Universidad Católica del Ecuador for their contributions. We also thank Anna Moleras,
who prepared the database, and the study participants.
Author Contributions
Conceptualization: Iva
´n Dueñas-Espı
´n, Constanza Jacques-Aviño
´, Andre
´s Peralta.
Data curation: Iva
´n Dueñas-Espı
´n, Constanza Jacques-Aviño
´, Andre
´s Peralta.
Formal analysis: Iva
´n Dueñas-Espı
´n.
Investigation: Iva
´n Dueñas-Espı
´n, Constanza Jacques-Aviño
´, Vero
´nica Egas-Reyes, Sara Lar-
rea, Ana Lucı
´a Torres-Castillo, Patricio Trujillo, Andre
´s Peralta.
Methodology: Iva
´n Dueñas-Espı
´n, Andre
´s Peralta.
Validation: Iva
´n Dueñas-Espı
´n, Sara Larrea, Andre
´s Peralta.
Writing – original draft: Iva
´n Dueñas-Espı
´n, Constanza Jacques-Aviño
´, Sara Larrea, Andre
´s
Peralta.
Writing – review & editing: Iva
´n Dueñas-Espı
´n, Constanza Jacques-Aviño
´, Vero
´nica Egas-
Reyes, Sara Larrea, Ana Lucı
´a Torres-Castillo, Patricio Trujillo, Andre
´s Peralta.
References
1. Lo
´pez-Contreras N, Lo
´pez-Jime
´nez T, Horna-Campos OJ, Mazzeie M, Anigstein MS, Jacques-Aviño
´
C. Impacto del confinamiento por la COVID-19 en la salud autopercibida en Chile segu
´n ge
´nero. Gac
Sanit. 2022;(In press).
2. Gloster AT, Lamnisos D, Lubenko J, Presti G, Squatrito V, Constantinou M, et al. Impact of COVID-19
pandemic on mental health: An international study. PLoS One. 2020; 15(12 December):1–20. https://
doi.org/10.1371/journal.pone.0244809 PMID: 33382859
3. Moore S, Public BMC, Moore ES, Lambert J, Grey E, Gillison F, et al. Life in lockdown: a longitudinal
study investigating the impact of the UK COVID - 19 lockdown measures on lifestyle behaviours and
mental health. BMC Public Health [Internet]. 2022;1–15. Available from: https://doi.org/10.1186/
s12889-022-13888-1
4. O’Connor RC, Wetherall K, Cleare S, McClelland H, Melson AJ, Niedzwiedz CL, et al. Mental health
and well-being during the COVID-19 pandemic: Longitudinal analyses of adults in the UK COVID-19
Mental Health & Wellbeing study. Br J Psychiatry. 2021; 218(6):326–33.
5. Wechsler TF, Schmidmeier M, Biehl S, Gerczuk J, Maria F, Cerda G. Individual changes in stress,
depression, anxiety, pathological worry, posttraumatic stress, and health anxiety from before to during
the COVID - 19 pandemic in adults from Southeastern Germany. BMC Psychiatry [Internet]. 2022;1–
20. Available from: https://doi.org/10.1186/s12888-022-04148-y
6. Holmes EA O’Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, et al. Multidisciplinary research
priorities for the COVID-19 pandemic: a call for action for mental health science. The Lancet Psychiatry.
2020; 7(6):547–60. https://doi.org/10.1016/S2215-0366(20)30168-1 PMID: 32304649
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 17 / 20
7. Xiong J, Lipsitz O, Nasri F, Lui LMW, Gill H, Phan L, et al. Impact of COVID-19 pandemic on mental
health in the general population: A systematic review. J Affect Disord [Internet]. 2020; 277(June):55–
64. Available from: https://doi.org/10.1016/j.jad.2020.08.001
8. Panchal U, Salazar de Pablo G, Franco M, Moreno C, Parellada M, Arango C, et al. The impact of
COVID-19 lockdown on child and adolescent mental health: systematic review. Eur Child Adolesc Psy-
chiatry [Internet]. 2021;(0123456789). Available from: https://doi.org/10.1007/s00787-021-01856-w
9. Colucci E, Nadeau S, Higgins J, Kehayia E, Poldma T, Saj A, et al. COVID-19 lockdowns’ effects on the
quality of life, perceived health and well-being of healthy elderly individuals: A longitudinal comparison
of pre-lockdown and lockdown states of well-being. Arch Gerontol Geriatr [Internet]. 2022; 99(October
2021):104606. Available from: https://doi.org/10.1016/j.archger.2021.104606
10. Hallo A, Rojas A, Hallo C. Perspective from Ecuador, the Second Country with More Confirmed Cases
of Coronavirus Disease 2019 in South America: A Review. Cureus. 2020; 12(3):10–5. https://doi.org/
10.7759/cureus.7452 PMID: 32351831
11. Unidas Naciones. El impacto del COVID-19 en Ame
´rica Latina y el Caribe. Of Nac Unidas para la
Coord Asuntos Humanit -OCHA [Internet]. 2020;1–29. Available from: https://reliefweb.int/report/world/
informe-el-impacto-del-covid-19-en-am-rica-latina-y-el-caribe-julio-2020%0Ahttps://peru.un.org/sites/
default/files/2020-07/SG%20Policy%20brief%20COVID%20LAC%20%28Spanish%29_10%20July_0.
pdf
12. CEPAL CE para AL e C. CEPALSTAT. Bases de Datos y Publicaciones Estadı
´sticas [Internet].
CEPAL. Organizacion de las Naciones Unidas. ONU. 2022 [cited 2022 Aug 16]. p. 1. Available from:
https://statistics.cepal.org/portal/cepalstat/index.html?lang=es
13. Torres I, Lo
´pez-Cevallos D. In the name of COVID-19: Legitimizing the exclusion of community partici-
pation in Ecuador’s health policy. Health Promot Int. 2021; 36(5):1324–33. https://doi.org/10.1093/
heapro/daaa139 PMID: 33471084
14. Roser M, Ritchie H, Ortiz-Ospina E, Hassell J. Excess mortality during the Coronavirus pandemic
(COVID-19)—Our World in Data [Internet]. OurWorldInData.org. 2020 [cited 2022 Mar 8]. Available
from: https://ourworldindata.org/excess-mortality-covid
15. Chauca R. Covid-19 in ecuador: Political fragility and vulnerability of public health. Hist Ciencias, Saude
—Manguinhos. 2021; 28(2):587–91.
16. INEC. Encuesta Nacional de Empleo, Desempleo y Subempleo (ENEMDU), junio 2021 Encuesta.
Boletı
´n Te
´cnico N˚ 09-2021-ENEMDU. 2021;
17. Instituto Nacional de Estadı
´sticas y Censos INEC. Estadı
´sticas Laborales–Abril 2022 [Internet]. 2022
[cited 2022 Jun 17]. Available from: https://www.ecuadorencifras.gob.ec/estadisticas-laborales-abril-
2022/
18. Encuesta Nacional Multipropo
´sito de Hogares, 2020 (Seguimiento al Plan Nacional de Desarrollo).
2021;
19. Salk RH, Hyde JS, Abramson LY. Gender differences in depression in representative national samples:
Meta-analyses of diagnoses and symptoms. Psychol Bull. 2017; 143(8):783–822. https://doi.org/10.
1037/bul0000102 PMID: 28447828
20. Trujillo GO, Ventura AT, Bolaños SB. Teletrabajo y pandemia en ecuador. 2021.
21. King K, Samaniego P, Carranza C. Facing covid-19 in Ecuador: a blueprint for monetary policy and
food sovereignty. Rev la re
´gulation. 2021;(29):1–13.
22. Barone MTU, Villarroel D, de Luca PV, Harnik SB, Lima BL de S, Wieselberg RJP, et al. COVID-19
impact on people with diabetes in South and Central America (SACA region). Diabetes Res Clin Pract.
2020; 166(2020). https://doi.org/10.1016/j.diabres.2020.108301 PMID: 32623036
23. Organizacio
´n para la Cooperacio
´n y Desarrollo Econo
´mico [OCDE]. Impacto social del COVID-19 en
Ecuador: desafı
´os y respuestas [Social impact of COVID-19 in Ecuador: challenges and responses].
Mak Dev Happen [Internet]. 2020; 4:2–21. Available from: file:///E:/Downloads/Impacto-social-COVID-
19-Ecuador.pdf
24. Sua
´rez-Rodrı
´guez GL, Salazar-Loor J, Rivas-Condo J, Rodrı
´guez-Morales AJ, Navarro J-C, Ramı
´rez-
Iglesias JR. Routine Immunization Programs for Children during the COVID-19 Pandemic in Ecuador,
2020—Hidden Effects, Predictable Consequences. Vaccines. 2022; 10(6):857. https://doi.org/10.3390/
vaccines10060857 PMID: 35746465
25. Tusev A, Tonon L, Capella M. Efectos Iniciales en la Salud Mental por la Pandemia de Covid-19 en
algunas Provincias de Ecuador. Investigatio [Internet]. 2020; 15(15):11–24. Available from: https://
revistas.uees.edu.ec/index.php/IRR/article/view/471/447%0Ahttps://revistas.uees.edu.ec/index.php/
IRR/article/view/471
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 18 / 20
26. Honda C, Yoshioka-Maeda K, Iwasaki-Motegi R. Child abuse andneglect prevention by public health
nurses during the COVID-19 pandemic in Japan. J Adv Nurs. 2020; 76(11):2792–3. https://doi.org/10.
1111/jan.14526 PMID: 32820816
27. Jacques-AvinõC, Lo
´pez-Jime
´nez T, Medina-Perucha L, De Bont J, Goncąlves AQ, Duarte-Salles T,
et al. Gender-based approach on the social impact and mental health in Spain during COVID-19 lock-
down: A cross-sectional study. BMJ Open. 2020; 10(11):1–10. https://doi.org/10.1136/bmjopen-2020-
044617 PMID: 33234664
28. Estrella F. Ecuadorian university English teachers’ reflections on emergency remote teaching during
the COVID-19 pandemic. Int J Educ Res Open. 2022; 3(January).
29. Abril-Ulloa V, Santos SPL dos, Morejo
´n-Tera
´n YA, Carpio-Arias TV, Espinoza-Fajardo AC, Vinueza-
Veloz MF. Stress and Diet Quality Among Ecuadorian Adults During the COVID-19 Pandemic. A
Cross-Sectional Study. Front Nutr. 2022; 9(July):1–7. https://doi.org/10.3389/fnut.2022.924076 PMID:
35873440
30. Paredes-Aguirre MI, Barriga Medina HR, Campoverde Aguirre RE, Melo Vargas ER, Armijos Yambay
MB. Job Motivation, Burnout and Turnover Intention during the COVID-19 Pandemic: Are There Differ-
ences between Female and Male Workers? Healthc. 2022; 10(9). https://doi.org/10.3390/
healthcare10091662 PMID: 36141274
31. Luis E, Bermejo-Martins E, Martinez M, Sarrionandia A, Cortes C, Oliveros EY, et al. Relationship
between self-care activities, stress and well-being during COVID-19 lockdown: A cross-cultural media-
tion model. BMJ Open. 2021; 11(12). https://doi.org/10.1136/bmjopen-2020-048469 PMID: 34911708
32. Bates BR, Moncayo AL, Costales JA, Herrera-Cespedes CA, Grijalva MJ. Knowledge, Attitudes, and
Practices Towards COVID-19 Among Ecuadorians During the Outbreak: An Online Cross-Sectional
Survey. J Community Health [Internet]. 2020; 45(6):1158–67. Available from: https://doi.org/10.1007/
s10900-020-00916-7 PMID: 32915380
33. Rodas JA, Jara-Rizzo MF, Greene CM, Moreta-Herrera R, Oleas D. Cognitive emotion regulation strat-
egies and psychological distress during lockdown due to COVID-19. Int J Psychol. 2022; 57(3):315–24.
https://doi.org/10.1002/ijop.12818 PMID: 34747019
34. Hidalgo-Andrade P, Hermosa-Bosano C, Paz C. Teachers’ mental health and self-reported coping
strategies during the covid-19 pandemic in ecuador: A mixed-methods study. Psychol Res Behav
Manag. 2021; 14(July):933–44. https://doi.org/10.2147/PRBM.S314844 PMID: 34239334
35. McGee DL, Liao Y, Cao G, Cooper RS. Self-reported health status and mortality in a multiethnic us
cohort. Am J Epidemiol. 1999; 149(1):41–6. https://doi.org/10.1093/oxfordjournals.aje.a009725 PMID:
9883792
36. Borrell C, Muntaner C, Benach J, Artazcoz L. Social class and self-reported health status among men
and women: What is the role of work organisation, household material standards and household labour?
Soc Sci Med. 2004; 58(10):1869–87. https://doi.org/10.1016/S0277-9536(03)00408-8 PMID:
15020005
37. Klein SL, Morgan R. The impact of sex and gender on immunotherapy outcomes. Biol Sex Differ. 2020;
11(1):1–13.
38. Spitzer RL, Kroenke K, Williams JBW, Lo
¨we B. A brief measure for assessing generalized anxiety disor-
der: The GAD-7. Arch Intern Med [Internet]. 2006 May 22 [cited 2018 Apr 24]; 166(10):1092–7. Avail-
able from: http://archinte.jamanetwork.com/article.aspx?doi=https://doi.org/10.1001/archinte.166.10.
1092 PMID: 16717171
39. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure. J
Gen Intern Med. 2001; 16(9):606–13. https://doi.org/10.1046/j.1525-1497.2001.016009606.x PMID:
11556941
40. Fountoulakis KN, Apostolidou MK, Atsiova MB, Filippidou AK, Florou AK, Gousiou DS, et al. Self-
reported changes in anxiety, depression and suicidality during the COVID-19 lockdown in Greece. J
Affect Disord [Internet]. 2021; 279(October 2020):624–9. Available from: https://doi.org/10.1016/j.jad.
2020.10.061
41. Marrugat J, Vila J, Pavesi M, Sanz F. [Estimation of the sample size in clinical and epidemiological
investigations]. Med Clin (Barc) [Internet]. 1998 Sep 12; 111(7):267–76. Available from: http://www.
ncbi.nlm.nih.gov/pubmed/9789243
42. Frank E Harrell. Regression Modeling Strategies. Springer, editor. Vol. 45. 2003. 170–170 p.
43. Oginni OA, Oloniniyi IO, Ibigbami O, Ugo V, Amiola A, Ogunbajo A, et al. Depressive and anxiety symp-
toms and COVID-19-related factors among men and women in Nigeria. PLoS One [Internet]. 2021; 16
(8 August 2021):1–18. Available from: https://doi.org/10.1371/journal.pone.0256690 PMID: 34437601
44. Peralta A, Espinel-Flores V, Gotsens M, Pe
´rez G, Benach J, Marı
´-Dell’Olmo M. Developing a depriva-
tion index to study geographical health inequalities in ecuador. Rev Saude Publica. 2019; 53:1–14.
https://doi.org/10.11606/s1518-8787.2019053001410 PMID: 31800910
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 19 / 20
45. Amparo Armas, Jackeline Contreras, Alison Va
´sconez. La Economı
´a del cuidado, el trabajo no remu-
nerado y remunerado en Ecuador [Internet]. 2009. 78 p. Available from: http://biblioteca.
igualdadgenero.gob.ec/cgi-bin/koha/opac-detail.pl?biblionumber=6781&shelfbrowse_itemnumber=
6572
46. Czymara CS, Langenkamp A, Cano T. Cause for concerns: gender inequality in experiencing the
COVID-19 lockdown in Germany. Eur Soc [Internet]. 2021; 23(S1): S68–81. Available from: https://doi.
org/10.1080/14616696.2020.1808692
47. Dang HAH, Viet Nguyen C. Gender inequality during the COVID-19 pandemic: Income, expenditure,
savings, and job loss. World Dev [Internet]. 2021; 140:105296. Available from: https://doi.org/10.1016/j.
worlddev.2020.105296 PMID: 34548740
48. Bienvenu LA, Noonan J, Wang X, Peter K. Higher mortality of COVID-19 in males: Sex differences in
immune response and cardiovascular comorbidities. Cardiovasc Res. 2020; 116(14):2197–206. https://
doi.org/10.1093/cvr/cvaa284 PMID: 33063089
49. More
´P. Care work and the coronavirus crisis: The invisible labour that sustains life. Rev Esp Sociol.
2020; 29(3):737–45.
50. United Nations Children’s Fund—UNICEF-. Ame
´rica Latina & El Caribe. 2022. p. 0–2.
51. COVID-19: Co
´mo asegurar el aprendizaje de los niños sin acceso a Internet | UNICEF Ecuador [Inter-
net]. [cited 2022 Jun 29]. Available from: https://www.unicef.org/ecuador/historias/covid-19-co
´mo-
asegurar-el-aprendizaje-de-los-niños-sin-acceso-internet
52. Åberg Yngwe M, Fritzell J, Lundberg O, Diderichsen F, Burstro
¨m B. Exploring relative deprivation: Is
social comparison a mechanism in the relation between income and health? Soc Sci Med. 2003; 57
(8):1463–73. https://doi.org/10.1016/s0277-9536(02)00541-5 PMID: 12927476
53. Monica Åberg Yngwe Naoki Kondo, Sara Ha
¨gg Ichiro Kawachi. Relative deprivation and mortality–a
longitudinal study in a Swedish population of 4,7 million, 1990–2006. BMC Public Heal. 2012; 12
(664):1–7.
54. Szuster E, Pawlikowska-Gorzelańczyk A, Kostrzewska P, Mandera-Grygierzec A, Rusiecka A, Bierni-
kiewicz M, et al. Mental and Sexual Health of Men in Times of COVID-19 Lockdown. Int J Environ Res
Public Health. 2022; 19(22). https://doi.org/10.3390/ijerph192215327 PMID: 36430046
55. Housing Shaw M. and public health. Annu Rev Public Health. 2004; 25:397–418.
56. Marı
´-Dell’Olmo M, Novoa AM, Camprubı
´L, Peralta A, Va
´squez-Vera H, Bosch J, et al. Housing Policies
and Health Inequalities. Int J Heal Serv. 2017; 47(2):207–32. https://doi.org/10.1177/
0020731416684292 PMID: 28030990
57. Wilhelm Am KA. Men and depression. Aust Fam Physician. 2009; 38(3):102–5. PMID: 19283248
58. Miranda-Mendizabal A, Castellvı
´P, Pare
´s-Badell O, Alayo I, Almenara J, Alonso I, et al. Gender differ-
ences in suicidal behavior in adolescents and young adults: systematic review and meta-analysis of lon-
gitudinal studies. Int J Public Health. 2019; 64(2):265–83. https://doi.org/10.1007/s00038-018-1196-1
PMID: 30635683
59. Egas Reyes V, Torres Castillo AL, Hidalgo Jime
´nez N, Andrade Zapata S, Salao Sterckx E. Salud men-
tal, virtualidad y pandemia: Experiencias de Psico Escucha PUCE. Mundos Plur—RevLatinoam Polı
´ti-
cas y Accio
´n Pu´blica. 2020; 7(2):55–74.
60. Xue B, McMunn A. Gender differences in unpaid care work and psychological distress in the UK Covid-
19 lockdown. PLoS One [Internet]. 2021; 16(3 March):1–15. Available from: https://doi.org/10.1371/
journal.pone.0247959 PMID: 33662014
61. MSP. Actualizacio
´n de casos de coronavirus en Ecuador–Ministerio de Salud Pu
´blica [Internet]. Minis-
terio De Salud Publica. 2020 [cited 2022 Mar 21]. p. 1. Available from: https://www.salud.gob.ec/
actualizacion-de-casos-de-coronavirus-en-ecuador/
PLOS ONE
Determinants of self-reported health status during COVID-19 lockdown in Ecuador
PLOS ONE | https://doi.org/10.1371/journal.pone.0275698 March 8, 2023 20 / 20
