Background Many psychological factors play a role in the COVID-19 pandemic, including various forms of worry, avoidance, and coping. Adding to the complexity, some people believe the threat of COVID-19 is exaggerated. We used network analysis to investigate how these diverse elements are interrelated.
Methods A population-representative sample of 3075 American and Canadian adults completed an online survey, including measures of COVID-19-related worry, avoidance, self-protective behaviors, and other variables.
Results The network contained three major hubs, replicated across gender and age groups. The most important hub centered around worries about the dangerousness of COVID-19, and formed the core of the previously identified COVID Stress Syndrome. The second most important hub, which was negatively correlated with the first hub, centered around the belief that the COVID-19 threat is exaggerated, and was associated with disregard for social distancing, poor hand hygiene, and anti-vaccination attitudes. The third most important hub, which was linked to the first hub, centered around COVID-19-related compulsive checking and reassurance-seeking, including self-protective behaviors such as panic buying and use of personal protective equipment.
Conclusion Network analysis showed how various forms of worry, avoidance, coping, and other variables are interrelated. Implications for managing disease and distress are discussed.
Many psychological factors play a role in the COVID-19 pandemic, including various forms of worry, avoidance, and coping. Adding to the complexity, some people believe the threat of COVID-19 is exaggerated. Yet, recent conceptualizations of COVID-19-related distress tend to be narrow and unidimensional, focusing largely on fear of infection . Our previous research on the COVID Stress Syndrome suggests a broader, more nuanced conceptualization. The present study is, to our knowledge, the first comprehensive network analysis of COVID-19-related worry, avoidance, coping, and other COVID-19-related variables, conducted in order to determine how these diverse elements are interrelated.
Consistent with previous research, the present study found that worry about the dangerousness of COVID-19 was at the core of the COVID Stress Syndrome. This worry was at the core of the main hub in the network and was connected to various forms of fear, worry, avoidance, and other symptoms. The second most important hub, which was negatively correlated with the first hub, centered around the belief that the COVID-19 threat is exaggerated, and was associated with disregard for social distancing, poor hand hygiene, and anti-vaccination attitudes. The third most important hub, which was linked to the first hub, centered around COVID-19-related compulsive checking and reassurance-seeking. This hub was linked to self-protective behaviors, such as panic buying and use of personal protective equipment. COVID-19-related reexperiencing symptoms (e.g., intrusive thoughts or images, nightmares related to COVID-19) were also strongly linked to COVID-19-related checking and reassurance-seeking. This finding may reflect a dose effect whereby a greater degree of exposure to COVID-19-related news or social media (via checking) leads to a greater frequency of unwanted, intrusive thoughts, images, or nightmares about COVID-19.
The major hubs that were identified in the current study appear to be key factors to understanding the constellation of maladaptive and socially disruptive responses to COVID-19. As such, understanding the causal role of these major hubs as well as predictors (e.g., psychological vulnerability factors) or contextual (e.g., media messages) factors that contribute to the major hubs may be important avenues of future investigation. This line of research may have further implications as it may help identify potentially key targets for interventions (e.g., treatments, campaigns) aimed at reducing maladaptive or socially disruptive responses to COVID-19. For example, campaigns targeting the danger factor may be particularly relevant to address stigma towards foreigners and health care workers whereas those targeting the belief that the COVID-19 threat is exaggerated may be germane for campaigns addressing compliance with behavioral strategies designed to reduce viral spread.
The findings of the present study are consistent with previous theory and research concerning health anxiety in general . For example, as with pre-COVID-19 studies of health anxiety, we found that worries about COVID-19 were related to disease avoidance, safety behaviors (e.g., wearing personal protective equipment), and compulsive checking and reassurance-seeking. In this regard, COVID-19-related anxiety is similar to health anxiety in general. Our finding that worry about COVID-19 is associated with xenophobia is also consistent with previous research showing that xenophobia is correlated with the perceived vulnerability to disease. Our research further shows that COVID-19-related worry is associated with additional phenomena that have not been previously linked to health anxiety, such as worry about the socioeconomic impacts of COVID-19. Previous research on health anxiety (prior to COVID-19) has focused almost entirely on feared consequences such as suffering, physical impairment, and dying. The present study suggests that research on health anxiety should take a broader perspective by considering whether worry about the socioeconomic impacts of illness also plays an important, and possibly under-recognized, role in a person’s overall level of health anxiety.
This study has various strengths and limitations. In terms of strengths, the sample was large and population representative. The study was, to our knowledge, the first to use network analysis to investigate how the various forms of worry, fear, avoidance, self-protective behaviors, and other COVID-19-related variables are interrelated. With few exceptions, the links were consistent with cognitive-behavioral formulations of health anxiety, traumatic stress symptoms, and pandemic-related behaviors.
In terms of network replicability (generalizability), the present study provided preliminary evidence of replicability, but further research is needed using samples that are matched in size, so that the statistical power to detect significant edges is matched across samples. Statistical methods for comparing networks remain to be fully developed. Replicability can be assessed in terms of centrality values, patterns of significant edges, and magnitudes of edge values. In future research, networks can be compared across demographic variables (e.g., ethnicity, gender, age) as well as particular socio-cultural variables (e.g., political affiliation such as liberal versus conservative pollical views). Further research is also needed to determine whether the network structure changes as a function of whether particular health mandates are implemented (e.g., mandated wearing of face masks in public).
In terms of limitations, network analysis, as a statistical modeling method, is insufficient for determining the causal nature of the links between nodes. From a cognitive-behavioral perspective, it is plausible that worry about the danger of COVID-19 plays a causal role in promoting fear and avoidance of people, situations, or other stimuli associated with COVID-19. If this is the case, then cognitive-behavioral (or other) interventions targeting the core of the first hub (i.e., worry about the dangerousness of COVID-19) should influence other elements in the network, such as the various forms of fear and avoidance. This remains to be investigated in future research.
Another limitation of this study is that there are other potentially important variables that were not assessed. Our network analysis was the most comprehensive to date. To our knowledge, the only other COVID-19-related network analysis was in our previous study, which focused only on the five elements of the COVID Stress Syndrome. Other potentially relevant variables could be investigated in future network analyses. For example, future studies could be conducted to determine how drug and alcohol abuse is related to the elements in the network. The consumption of disinhibitory substances such as alcohol may be linked to elements of the COVID Stress Syndrome as well as the disregard for social distancing. Further studies using network analysis are needed to investigate this possibility.
An important issue for further investigation concerns the temporal stability of the network. Pandemics are dynamic events, unfolding over time, whereas our study was cross-sectional in nature. Pandemics and emotional responses to them may also unfold along different lines in different countries and even within a given country. Accordingly, further research is needed to investigate whether the network changes over time and whether the network changes with the rise and fall of COVID-19 in and across communities. Understanding whether and to what extent distress-related and other emotional responses to viral outbreaks are dynamic in nature is critical for the development and delivery of interventions that are appropriately responsive to the needs of those these services are intended for.
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