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Food insecurity and mental health of women during COVID-19: Evidence from a developing country

Background This study examines the association between food insecurity and mental health of women during the COVID-19 pandemic in a resource poor setting. Materials and methods Data were collected at two time-points (wave 1 and 2) from 2402 women, one per household, participating in a larger study during extended COVID-19 lockdown in the rural areas of the southwest region of Bangladesh. The primary outcome of the analyses is the association between food insecurity, measured using the Food Insecurity Experience Scale (FIES), and stress level, measured using the Perceived Stress Scale (PSS), for women during the lockdown. General awareness about COVID-19 and attitude towards prescribed preventive measures were also measured since COVID-19 health concerns could exacerbate food insecurity. Results An individual-level evaluation of the effect of wave 2 FIES score on PSS score showed that worsening of the food security status increasing the stress level of the participants (95% CI: 1.61; 2.13; p-value: <0.001). Additionally, a significant negative association was observed between the PSS score and change in food security status between the two waves (Coefficient: -1.15, 95% CI: -1.30; -0.99, p-value: <0.001), indicating that deterioration in food security status over the pandemic period increasing the stress level. At the village level, the results showed a similar pattern. General awareness around ways coronavirus spreads was high, yet there were misperceptions at a higher level. Maintaining hand hygiene, wearing face masks outside the home, and going outside only when necessary were widely practised. Fewer respondents could maintain a 1.5-metre distance from others in the outside and maintained cough and sneeze etiquette. Conclusion The results indicate a higher stress level, a potential contributor to poor mental health, as food insecurity deteriorated. Policy initiatives in ameliorating immediate food insecurity during crises, improving long-term wellbeing, and expanding the reach of mental health support are warranted.

Experts call for early planning, research, and supportive measures to tackle the impact of COVID-19 on mental health, particularly due to the isolation it may cause [26]. Previous studies show that prolonged isolation may result in several psychological problems, including acute stress, post-traumatic stress symptom, psychological distress, depressive symptoms, stress, and emotional disturbance, and can have a lasting psychological impact [27]. In varying degrees, a lockdown was widely adopted to curb the spread of coronavirus. Millions living in developing countries found themselves trading-off between keeping safe from the virus and poverty and hunger [28]. Apart from the high human cost, the COVID-19 pandemic has led to a global economic crisis, to a large extent due to lockdown and disruption of economic activities that ensued and massive public health and social safety cost. Experts predict income loss and food insecurity in countries where poverty is widespread and are reliant on the informal sector [29]. Bangladesh, where this study was conducted, had an extended lockdown from 26 March to 30 May 2020 [30]. It was estimated that about 52% of the Bangladeshi population was at the risk of becoming poor, and about five million people may have been driven into poverty due to the pandemic [31]. The economic disruption caused by COVID-19 and the lockdown that followed was likely to impact Bangladesh's food security scenario, with 31% of its population either moderately or severely food insecure even before the pandemic [32]. Consequently, with the rise of poverty and food insecurity, the health effects, particularly on women and children, such as anemia [33] and prevalence of thinness among women of reproductive age, malnutrition [34,35], stunting and wasting of children [33] may potentially follow suit. There has been ample evidence on the influence of food insecurity on the mental health of individuals. In a study that included data from 149 countries, Jones (2017) found that food insecurity has a dose-response relationship with poor mental health status regardless of socioeconomic and demographic characteristics coming from 11 regions, indicating that the relationship holds across cultural contexts [36]. Food insecure individuals were found to have higher odds of experiencing adverse psychosocial conditions such as sadness, worry, stress, anger, and lower odds of experiencing positive psychosocial conditions such as enjoyment, feeling well-rested, being treated with respect. In another study that included data from 147 countries, Frongillo et al. (2019) found that prevalence of food insecurity was strongly negatively associated with subjective wellbeing, measured using daily experience index, with variation in magnitude among developed and developing countries likely due to other relevant factors [37]. Thus, food insecurity can potentially have adverse effects not only on an individual's physical health but also on mental health [21,38,39].
A strong positive association was previously found between income and experience of food insecurity and common mental disorders among women in low and middle-income countries [2]. The variation of magnitude by which sex alters the association between food insecurity and mental health status is unclear, with literature demonstrating poorer mental health status among women than men or no effect [36]. However, the rationale for conducting this study with women has been driven by evidence that shows Bangladeshi women have low nutritional status and poorer mental health than men, particularly in rural areas [40, 41] and women's pivotal role in managing household food shortage in developing countries including Bangladesh [42][43][44].
As the COVID-19 pandemic set in, information has been abundant, often not evidencebased and spurious, misleading people to adopt harmful practices and trivialise the risks of the disease [45,46]. Knowledge and attitude have profound significance in influencing compliance to healthful practice, such as maintaining hand hygiene in developing countries [47][48][49]. Additionally, a lack of knowledge about a specific physical condition or disease can harbour misconceptions and stigma about the disease and hinder help-seeking. Lack of awareness at the community level impede social acceptance, fuel stigma, induce fear in individuals, deter disease disclosure, and care seeking [50,51]. Paradoxically, knowing about a disease and its potential after effects could induce paralysing fear and denial to such an extent that it could interfere with the reception of health messages, hinder care seeking and care provisions, and encourage people to disregard the existence of the disease altogether [52][53][54]. Understanding knowledge and attitude, including stigma, is critical in assessing and testing likely patients and maintaining the practice of COVID-19 preventive measures. In Bangladesh, women, particularly in rural areas, lack access to authentic health information [55,56] due to their limited access to information in general [57] and lower access to technology [58]. Women are predominantly caregivers for children and elderly family members at home. Thus, exploring women's knowledge and attitude regarding COVID-19 can provide important insight into infection prevention and containment in women, children and the elderly in rural Bangladesh.
Mental stress may occur due to emotional or physical stressors [59]. There are various ways stress and its impact have been conceptualised and studied from epidemiological, psychological, and biological perspectives, employing different methodologies [59][60][61]. Despite these differences, there is substantial evidence that mental stress, through various pathways, can affect individuals mental and physical health, and thus, overall wellbeing [59,60,62]. Our study is based on the evidence on food insecurity during economic crises, health crises such as epidemics and COVID-19 pandemic, and the evidence on mental health outcomes related to food insecurity. Economic crises and shocks may lead to food insecurity due to supply shortage, food price volatility, and income loss, compromising people's purchasing power [63][64][65][66][67]. Health crises can also lead to food insecurity as observed during and after previous epidemics such as HIV/AIDS, ebola influenza, scurvy and cassava virus [8,15,17,19,22,25,[68][69][70]. The economic corollaries of COVID-19 have had a significant adverse effect on food security scenario [13,14,18,20,23,24] particularly in the developing countries [9-12, 16, 18, 21, 28]. Given the influence of food insecurity on mental health [2,36,37,71], it is critical to examine the association between food insecurity and women's mental health in the context of COVID-19 in Bangladesh where food insecurity is common, and women have poor mental health outcomes. In this study, we present evidence from rural areas of Bangladesh, where we examined the association between food insecurity and women's mental health, that is, their perceived stress level, during COVID-19. Taking food insecurity as a potential stressor during the lockdown, we hypothesise that more food insecure women will experience a higher stress level. We also measured awareness about coronavirus among women and their compliance with the health directives, and their association with food security and mental health.

Study design and sample
This study is part of a larger study to understand the health and wellbeing during COVID-19. A total of 9,847 rural households (response rate 78%), chosen at random from a panel of households interviewed during the pre-COVID-19 period, were surveyed (wave 1) in the southwest region of Bangladesh, 260 km from the national capital Dhaka. The data were collected between 14 April and 3 May 2020, three weeks after a lockdown was imposed. These households have very similar characteristics and are representative of rural household surveys by the Bangladesh Bureau of Statistics [72]. A subsample of households with female respondents was re-surveyed (wave 2) following three to four weeks the first survey to understand their mental health and monitor any changes in food security status as the lockdown continued. A total of 2402 women (response rate about 95%) from the same number of households were surveyed in wave 2. Surveys were conducted over the phone in compliance with COVID-19 preventive measures. Non-participation was due to not receiving the calls. Enumerators hold at least a bachelor degree and previously collected similar data in the study area. Additional training was provided on telephone interviewing. Oral consent was obtained before the interview as obtaining written consent was not feasible due to COVID-19 health directives imposed by the government during the lockdown. Calls were scheduled at times that were nominated as most convenient by the participants. Reporting of evidence has been guided by the STROBE statement [73].

Outcome variables
We examined two important and immediate concerns mentioned frequently during the pandemic: food insecurity as a proxy for the financial stress of the poor people and mental health. By observing households during the lockdown, we measured the potential association between food insecurity and the mental health outcome, i.e. stress level among women. Food insecurity was measured using the Food Insecurity Experience Scale (FIES) in wave 1 and 2 surveys [74]. The mental health data were collected during wave 2 using the Perceived Stress Scale (PSS) and adapted to use in Bangladesh [75]. In addition to food insecurity and mental health, we measured knowledge level on COVID-19 (16 items), attitude level to COVID-19 (10 items), and income loss experienced due to COVID-19.
PSS scale was chosen based on previous study findings and applicability in the context of Bangladesh. However, the previously validated versions were validated and used in special populations, predominantly in urban areas [76,77]. FIES was previously used to conduct a multi-country study [78]. PSS and FIES scales were adapted for this study considering the cultural and linguistic aspects of stress and food insecurity experiences. The adaptation process was completed in three steps. Firstly, the first author (TR) translated the original PSS scale in Bengali. The translated version was then shared with the co-authors (MGH and AI). The first stage of translation was finalised after discussion among the authors. FIES was translated in Bengali following the same steps. Being born and raised in the study region, AI provided critical guidance at this stage about the perception of stress and food insecurity in study locations.
At the second step, AI shared the PSS and FIES with research collaborators based in the study locations. The group of researcher collaborators included both women and men from the communities participating in this study. This group considered each question of PSS and FIES carefully as to what they might mean to the study participants given their sociodemographic characteristics. The group suggested some changes in wording. In the third step, TR prepared second drafts of the questionnaire, incorporating changes suggested in the previous step. Subsequently, the translated scales were finalised upon discussion among all authors. Pilot testing was not feasible due to lockdown and the time-critical nature of the study. However, the community members' involvement in the scale adaptation process helped prepare the scales for the study context, taking into account the cultural perceptions and verbal expressions of stress and food insecurity.
The knowledge and attitude questions were developed by the first author (TR) consulting the World Health Organization (WHO) [79,80], Médecins Sans Frontières (MSF) [81], and the government of Bangladesh [82] online resources, including daily updates and reports and manuals. The questions were finalised and approved after repeated discussion among all authors. Moreover, the authors have experience working in social development and health with rural communities across Bangladesh and thus have relevant insight into knowledge and attitudes around health issues.

Statistical analysis
We examined the knowledge level based on True-False (0-1) dichotomous responses. The attitude level was analysed by dichotomising participants' responses to Yes-No (0-1). Scores on these for each participant were calculated by summing up scores for all items of two scales separately. Food security scores were measured on dichotomous responses, Yes-No (0-1), and by summing up scores on all items to obtain a total score. A change in food security status between wave 1 and wave 2 was measured by subtracting the wave 2 value from wave 1. A negative change in values was defined as food security conditions worsened over two surveys; a positive change indicates an improvement, and a zero-score is defined as no change. A 10-item PSS was used to measure mental health status. Each item was measured on a 5-point scale between 0 and 4. Thus, the total score lay between 0 and 40. The higher the score, the more the level of perceived stress. To capture the mental health status, we asked respondents PSS items about the time frame of "in the last 7 days".
Participant characteristics were summarised using descriptive statistics. Frequency and percentages were used for dichotomous variables. Mean and standard deviation or median and interquartile range were used for continuous variables, based on the distribution of the data. A descriptive analysis, from both the individual and village level, knowledge and attitude level and PSS scores were also performed using similar descriptive statistics.
To measure the effect of food security status (measured via FIES score during wave 2) on participant's stress level (measured via PSS score during wave 2), a univariable linear regression model was used. Two separate univariable linear regression models were used to measure the effect of knowledge and attitude level on COVID-19 (measured during wave 2) on PSS score. The effect of wave 2 food security status on participants' knowledge and attitude level of participants were also measured using two univariable linear regression models. In addition, three mixed-effects linear regression modellings were used to assess the relationship between wave 2 FIES scores and knowledge level, attitude level, and PSS score. Each model included individual family and village level random effects to address the correlation of the outcomes. The models were also adjusted for the age, level of education, monthly income and the respective scores of the participants. Finally, to measure the effect of change in food security status (measured via subtracting the wave 2 FIES score from wave 1 FIES score) on the PSS, knowledge and attitude scales, three separate univariable linear regression models were used. All the regression models were conducted using both the individual and village level data using robust standard error. Another three mixed-effects linear regression modelling was used to assess the relationship between changes in FIES scores and knowledge level, attitude status, and PSS score. Each model included individual family and village level random effects to address the correlation of the outcomes. The models were also adjusted for the age, level of education, monthly income and respective scores of the participants. All statistical analyses were conducted using Stata 14.0 version, and p-value <0.05 was considered as a statistically significant level.

Ethics approval
Ethics approval was obtained from the Monash University Human Research Ethics Committee (Project ID: 24746).

Result
A total of 2402 female responders across 357 villages were included as participants of the study. The average age of the participants was 38 years (SD ± 8 years), and among them, 993 (42%) participants were above 40 years of age. The median number of family members was 4 (3)(4)(5). The majority of the household heads were day labourer, 789 (33%) and small businessmen 564 (24%) followed by farming on own land 413 (17%), farming on other people's land 246 (10%), private job 107 (4%), Government job 77 (3%) and others 206 (9%). The median formal education year of the participants was 8 (8-10) years. About 91% of participants (2096 out of 2,402) can read at least, wherein 1896 (88%) participants mentioned that they could read and write. The median monthly income was $82.15 ($67.65-$115.99) (Based on the rate at OANDA on 15/01/2021). During wave 1 majority of the participants, 1604 (67%) had a FIES score of 2 (Moderately food insecurity), followed by 418 (17%) with the score 1 (Mildly food insecurity), 197 (8%) with the score of 3 (Severe food insecurity), and 183 (8%) with the score of 0 (No food insecurity). On the other hand, during wave 2, 1336 (56%) participants had a FIES score of 2, the number and rate for scores 0, 1, and 3 were 507 (21%), 380 (16%), and 179 (7%) respectively. Also, 829 (35%) participants reported that their food security status worsens (a negative change in FIES score from wave 1 to wave 2) over the pandemic period. Fig 1 shows the difference in various food security status between the two waves, and a significant difference in the proportions of participants was observed in the food secure, mildly insecure, and moderately insecure groups. S1 Table described (Table 1). Importantly, in the statements of "The person who is affected should be blamed or ostracised" (KLC-19:8), and "Whoever comes to this country from abroad spreads this virus" (KLC-19:11) 79% and 88% of participants respectively mentioned these two as true statements. However, 59% and 65% of participants disagreed with the following two statements: "If anyone dies due to coronavirus, he/she cannot be buried in this village" (KLC-19:6), and "If you sin, you get coronavirus" (KLC-19:9). Forty-five per cent of the participants agreed with the statement that "Anyone who gets affected by corona will die" (KLC-19:2), while 56% agreed that "If anyone in the para (community) gets affected, all other people in the para will also get affected" (KLC-19:4). About half of the participants believe that "This virus is a curse" (KLC-19:10). A similar   -19). In wave 2, almost all the participants (99%) mentioned that they washed their hands more often (ALC-19:4), and 90% of participants reported using a mask when they went outside (ALC-19:7) ( Table 2). More than 95% of participants mentioned that they felt anxious to go outside (ALC-19:2), and when someone came to their house (ALC-19:3). About 86% of the participants mentioned that they got anxious while interacting with friends and relatives (ALC-19:1). About 81% of participants mentioned that they did not go outside except for necessary works (ALC-19:5), wherein only 47% mentioned that they kept at least a 1.5-metre distance from others when outside (ALC-19:6). Additionally, only 43% of participants mentioned that they did not hug or handshake with anyone (ALC-19:9) and 33% mentioned that they used tissue or handkerchief to cough or sneeze (ALC-19:8).
Perceived stress scale (PSS). Table 3 shows that nearly 40% of participants mentioned that they could solve their problem (PSS: 4), things were going as they wanted (PSS: 5), and they knew that they had control over everything (PSS: 8). On the other hand, about 15% of Table 2

PLOS ONE
Food security and women's mental health in Bangladesh during  participants mentioned that in the last seven days, they often thought that they did not have control (PSS:2) and got angry about things they could not control (PSS: 9). Sixteen per cent of participants mentioned that in the last seven days, they often got angry (PSS: 1), 27% mentioned they often got panicked (PSS: 3), and 24% thought that their problem was getting out of control (PSS: 10). When participants were asked how often they thought that they could keep up with everything, only 27% mentioned that they could do so often (PSS: 6), while they could manage their irritated feeling, only 23% answered that they could do it frequently (PSS:7). At the individual level, when evaluating the effect of wave 2 FIES score on PSS, KLC-19, and ALC-19, PSS score showed a significant increase of 1.87 (95% CI: 1.61; 2.13; p-value: 0.000) for each unit increase of wave 2 FIES score, indicating that worsening the level of food security status increasing the stress level of the participants ( Table 4). The effect of KLC-19 and ALC-19 scores on PSS score were statistically non-significant. While measuring the effect of wave 2 FIES score on KLC-19 and ALC-19 score, a statistically significant effect was observed between wave 2 FIES score and KLC-19 (Coefficient: -0.03; 95% CI: -0.04; -0.02; pvalue: <0.001), indicating that worsening of food security status was negatively associated with the knowledge level of the participants on COVID-19. Findings from the village level analyses were also almost similar to the individual level (Table 4).
When performing a mixed effect linear regression model, a significant positive association was observed between the PSS score and change in food security status (Coefficient: 1.80, 95% CI: -1.42; -0.98, p-value: <0.001). On the other hand, the effect of change in food security status over KLC-19 was significant (Coefficient: -0.46, 95% CI: -0.62; -0.29, p-value < 0.001) but non-significant for the ALC-19 score (Coefficient: -0.03, 95% CI: -0.14; 0.07, p-value: 0.495). A detailed description of the mixed effect model results has been described in S2 Table. Effect of the change in FIES score (from wave 1 to wave 2) on KLC-19, ALC-19 and PSS scores at the individual and village level. At the individual level, a significant negative association was observed between the PSS score and change in food security status (Coefficient: -1.15, 95% CI: -1.30; -0.99, p-value: <0.001), indicating that worsening the food security status over the pandemic period increasing the stress level of the participants. The effect of the change in FIES score on KLC-19 and ALC-19 were non-significant ( Table 5). The analysis results at the village level were also similar to the individual level analysis (Table 5).
When performing a mixed effect linear regression model, a significant negative association was observed between the PSS score and change in food security status (Coefficient: -1.20, 95%

Discussion
In this research, we measured the association between food security and mental health i.e. level of perceived stress of women in the rural areas of Bangladesh. Studies that previously investigated mental health in relation to food security in rural areas of Bangladesh focused on depression and food and nutrition status [83] and depression and anxiety symptoms of women and their families in relation to food insecurity and intimate partner violence [84]. The level of perceived stress increases with a negative change in food security status over four weeks between surveys during COVID-19 lockdown in Bangladesh. The findings indicate that stress levels may deteriorate with exacerbating food insecurity due to COVID-19 lockdown and restrictions, which may affect mental health. The general awareness around who could contract coronavirus, how it spreads, and a vaccine not being available to prevent infection seemed high among the participants (Table 1). This may be due to public awareness efforts by both government and non-government organisations, and potentially the use of electronic and social media at the household and community levels. There were still misperceptions at a high level. Half of the respondents were against the burial of a person who died of coronavirus. Also, perceptions about people infected with the virus, overseas returnees, or travellers' role in spreading the virus, and the perceived consequences of infection demonstrate misconceptions. While this is true that the absence of proper measures for containment, such as quarantining patients and isolating others who came into contact with an infected person, can spread the virus, our findings indicate that infected individuals may experience stigma in the community. Stigmatisation may work in two ways: on the one hand, stigmatising others who are infected (e.g. blaming/ostracising, unwilling to consider for matrimony), and fearing stigmatisation on self or family (e.g. fearing less prospect regarding matrimony and employment). On the other hand, stigma can potentially contribute to health inequalities by obstructing social support, resources, and health care, including care for stress, psychological and behavioural problems, and perpetuating poor health outcomes [53,54]. A statistically significant negative association between deteriorating food security status and knowledge level was found, which may suggest health related knowledge lost relevance when household food insecurity became even more concerning. Therefore, there is a need for more public awareness about coronavirus, preventive measures, and consequences of infections based on scientific evidence, along with initiatives to combat food insecurity. We found a positive attitude towards maintaining hand hygiene (99%), wearing face masks outside the home (90%), and going outside only when it was necessary (81%), with a significantly high proportion of respondents practising these to keep themselves safe from the infection (Table 2). However, these responses are to be interpreted with caution as they are selfreported and might have social desirability bias. On the contrary, fewer respondents were able to maintain a 1.5-metre distance from others on the outside (43%) and maintained cough and sneeze etiquette (33%). This, on the one hand, suggests a possible low level of compliance around and lack of awareness of the importance of these critical preventive measures; on the other hand, indicate the challenges people may have been facing in complying with some of the measures in a densely populated, resources poor setting like Bangladesh [85].
Food insecurity was found to be associated with loss of income as the pandemic hit and the lockdown set in; consequently, the concern over managing household finance outweighs concern over health [86]. It is assuring that only a fifth of the respondents could not follow the 'stay at home'. Women's caregiving responsibilities at home and an additional burden of care during the pandemic may have played a part in this instance [87]. On the contrary, with widespread loss of livelihood, health becomes less of a priority for some and may make it harder for them to stay home with no or very limited income and increasing food insecurity [28]. Thus, this is not to imply a lack of concern for health as worries about visiting crowded places, having visitors in their house, and interacting with relatives and friends are also there [86].
This study makes an important contribution to the study of women's mental health in relation to food security in rural, resource-poor settings in the context of the COVID-19 pandemic (Tables 4 and 5). Evidence on mental health problems is scarce in Bangladesh, and such problems are often not considered serious health problems. Due to the stigma attached to mental health problems, the extent of the problem is often underreported [41]. Women are more vulnerable than men to have mental health problems in both urban and rural settings [41]. In our sample, the majority of the participants reported moderate to high perceived stress. The genderbased inequities in Bangladesh result in women having lower access to resources, lower decisionmaking power, and disparities in legal, economic, and political institutions that put women in a uniquely vulnerable position in time of crises [88]. These factors are likely to negatively impact the mental health of women in rural settings where gender norms are expected to be more rigid, and recognition of mental health needs and access to mental health care is low [41].
We detected a negative correlation between change in food security status and PSS score, which means that worsening the food security status was associated with a higher perceived stress level (Fig 1). These findings give strength to the evidence that mental health problems are prevalent among socially disadvantaged people, especially women in Bangladesh, regardless of family size [40]. Food insecurity was found to be associated with anxiety and depression among women in rural areas of Africa [89]. Evidence of food insecurity affecting the mental wellbeing of women is also available in the context of other developing countries [90,91]. Food insecurity was found to be linked with a higher risk of mental illness in both women (18.4%) [95% CI 16.7-20.1] and men (13.5%) [95% CI 11.9-15.2], which may be even high because of social isolation [71]. Jones (2017) found that individuals who experienced mild, moderate and severe food insecurity have higher odds of stress, 1.8, 2.6 and 3.5 respectively, in reference to food security across different world regions [36]. A review conducted on the evidence of psychological effects of quarantine from ten countries found that longer (i.e. >10 days) duration of quarantine and inadequate supplies can lead to poorer mental health outcomes [27]. While this study's participants were not in quarantine, they experienced an extended period of lockdown which may result in prolonged isolation and feeling of uncertainty.
Climatic conditions such as cyclones or floods, which frequently happen in Bangladesh, are important factors to consider for examining the food security of households [92]. This study sample was drawn from a region in Bangladesh which experienced clyclone 'Amphan' just after the first wave of survey [93]. However, the wave 2 survey was conducted about three weeks after the cyclone. While the livelihood, food security and mental health situation could be affected by the disaster we believe that the results reported in the paper are not significantly affected by cyclone 'Amphan'. There are several reasons. First, people in this region frequently face natural disasters and are very much adaptive to changes caused by cyclones [94]. Second, only limited number of the sample we surveyed during wave 2 was directly affected by this cyclone. Still, there are reasons to expect that the mental health of women is affected by the cyclone. To the extent cyclone, Amphan had a lasting effect, our results would be subject to bias, and one should interpret the results with caution. Note also that our results are not affected by any political and social unrest since it was relatively a peaceful time in Bangladesh politics.
This evidence needs to be interpreted in the context of prolonged lockdown in resourcepoor settings. We collected the PSS data when Bangladesh had been in lockdown for more than six weeks. While lockdown can help prevent the spread of disease, it can impose a significant financial burden on individuals. In Bangladesh, millions experienced income loss due to massive disruption in economic activities [95]. People in developing countries, particularly the poor, appeared to have been bearing the manifold burden of COVID-19 at the health and economic front, including poverty and food insecurity [28], which can lead to common mental illness [2]. Mental health impacts overall health and wellbeing to a great extent. To a varying degree, acute and chronic stress can impact the immune system [62]. Therefore, a higher risk of an elevated stress level due to food insecurity and potential exacerbation of stress due to social isolation may make women more vulnerable to the coronavirus and other health problems.
Currently, there is limited mental health service in magnitude and reach [41]. There are some NGO initiatives of providing tele-counselling during the COVID-19 pandemic [96]. However, such services that incur a cost might not be suitable for poorer groups who do not have enough resources to buy food, even if they felt the need to seek help. From a public health point of view, it is critical to have evidence on the COVID-19 pandemic's effect on the mental health for the most vulnerable groups so that necessary support services can be developed, relevant policies can be formulated, and resources can be allocated towards mental health care. Thus, there is an urgent need for immediate support to ameliorate food insecurity and for more research to generate evidence highlighting the need of the marginalised women living in rural areas of Bangladesh to inform and support policymakers with necessary insights. Some interventions demonstrated promising results in improving the psychological wellbeing of women in similar settings [97,98]. Similar interventions could be tried in the post-COVID-19 period in Bangladesh to develop potential strategies for mental health care.

Strength and limitation
Our study contributes new evidence on change in food security status and mental health of women living in rural areas using FIES and PSS at two time-points during the COVID-19 lockdown by measuring the implication of change in food security on stress levels. As the sample households share similar characteristics and are thus, representative of rural households in Bangladesh, the results can be generalisable to the rural household in other parts of the country. Our findings can offer insight into the mental health status of women in similar low income, resource-poor settings. Our study is not free of limitations. Due to the pandemic, we do not have any counterfactuals; thus, we are unable to examine any causal relationship. Although we found a statistically significant effect of change in food security on stress levels, we were unable to adjust for some potential confounders such as the burden of household chores during the lockdown, children's education and domestic violence due to unavailability of data. These factors might have contributed to the higher stress level. Collecting this information over the phone was not feasible due to sensitive nature of the information, which might contribute to the deterioration of the situation. We also had to limit the survey time over the phone, in an attempt of not to take too much of the participants' time, and hence could not collect many related valuable data despite our best efforts. Therefore, the presence of other stressors, as indicated by Frongillo et al. (2019), needs to be considered while interpreting this evidence [37]. This is the first study that used PSS solely with women in the context of rural Bangladesh. Thus, there is scope for further research for scale refinement. However, our findings did not differ significantly from existing literature on Bangladesh, though very limited [40,41]. This study seeks to contribute to addressing this critical evidence gap.

Conclusion
Household food insecurity during crises may put women living in rural areas under stress. Addressing food insecurity is critical in ensuring the physical health of the people and their mental health. Collaborative actions are warranted from the relevant government and nongovernment agencies to initiate public policy dialogue around ensuring food security for the poor during crises such as the COVID-19 pandemic and in the long-term. Distribution of food during crises targeting food insecure, poor households needs urgent consideration. At the same time, NGOs and policymakers should consider interventions providing psychological counselling to support rural women's mental health. They are often neglected and become more vulnerable at times of such crises. Given that food, insecurity is common in Bangladesh and women's critical role in managing household food shortage, community-based awareness-raising activities on the significance of mental health in overall wellbeing, the importance of help-seeking, and available support services could be beneficial.