Punjab, Multan Pakistan, Postal Code: 66000, Tel: +923414486350, Email
Punjab, Multan Pakistan, Postal Code: 66000, Tel: +923414486350, Email
Punjab, Multan Pakistan, Postal Code: 66000, Tel: +923414486350, Email
13
School of Management, Jiangsu univeriety, zhenjiang, China
2
Department of Psychology, Institute of Southern Punjab
Abstract
COVID -19 epidemic can be associated with variety of anxious responses and safety behaviors.
Present research explored the psychological implications associated with covid-19 during the
outbreak in 2020 till date. Pakistani media has given particular attention to this outbreak in the
region. Three hundred and forty-seven undergraduate university students from Pakistan
completeda battery of questionnaires focusing fear of Covid -19, associated safety behaviors,
factual knowledge of covid-19and other psychological pointers hypothesized to be as predictors
of anxious responses to covid-19 threat. The sample appeared to be fearful of covid-19 and this
fear was related to disgust sensitivity, anxiety sensitivity-related physical concerns, body
vigilance, contamination cognitions and general distress. Results suggested that tendency of
overestimating severity of contamination and anxiety sensitivity towards physical concerns are
significant predictors of Covid-19 related fear and consequent safety behaviors. Implications are
discussed in the light of managing and conceptualizing clinical symptoms related to serious
epidemic.
Introduction
According to the notions, health anxiety is collectively defined as compulsive inappropriate and
extreme thoughts about status of one’s health compared to the actual state of his health
(Abramowitz and Braddock 2010). The health anxiety is commonly dealt through behaviors that
work in reducing the distress for a short time (Abramowitz & Moore 2007), like frequent visit to
clinics or hospitals, undue researching of symptoms through online sites, or continuously asking
for reassurance from loved ones. However, in the long term these behaviors are known to further
enhance or maintain the anxiety (Helbig-Lang and Petermann 2010). Illness anxiety disorder is
although known to be a diagnostic unit itself, health anxiety may still be seen in other
psychological illnesses like somatic symptom disorder, obsessive compulsive disorder and other
anxiety disorders (APA, 2013). Further it was stated that health anxiety with clinical severity
along with linked safety behaviors can produce significant functional abnormality and distress. It
is an established phenomenon that cases of health anxiety are high during the time when a
disease gets mass media coverage, for example when Ebola outbreak was observed in late 2014.
World Health Organization declared coronavirus as a Pandemic in 2019. The confirmed cases
reported across the globe have reached 200,000 patients with 8000 confirmed death cases across
160 countries (World Health Organization Coronavirus disease outbreak webpage). Initially the
disease was originated and reported from Wuhan, China, after that in Europe, Italy was hit and
the immensely affected the country (Pellino & Spinelli, 2020). The spread of virus is
dangerously rapid such that after two weeks of first case, 1000 patients were diagnosed. Another
week passed by and the number of patients reached 46000 and until March, 2020, the number of
patients was 30,000 and death count was 2500 (World Health Organization Coronavirus disease
outbreak webpage and Italian National Civil Protection Department, 2020). Lombardy is so far
known to be the most affected region in the world, which forced the local institutes to reset the
complete health care system and nationwide lockdown in Italy (Gazzetta Ufficiale della
Repubblica Italiana GU Serie Generale, 2020). Afterwards, Spain declared the state of
emergency on 14th March 2020 and announced special health care measures to be taken by the
public (Cuè CE. Cabinet considering banning all journeys in Spain apart from travel to work or
COVID-19 is known to have spread from China to 26 more countries through the globe. World
Health Organization states that COVID-19 does not appear to be as deadly as other
coronaviruses like MERS and SARS. However, covid-19 has caused more demises (1871) than
SARS and MERS (1632) both despite the notion of being less deadly (Centers for Disease
Control and Prevention, 2005). Mowbray and Beijing (2019), states that coronavirus is more
digital than viral as information being shared by social media, government and health agencies is
certainly reaching a record level in human history. For the moment death count is being closely
monitored and stories of self or forced quarantine are being shared everywhere. Consequently,
the risk of health appears to be rather scary and uncontrollable and eventually fuels the epidemic
of fear. Gigerenzer (2015), unbalanced and unfiltered information often blurs the sound decision
about health.
Research has significant empirical support that among the medically sound people, mass hysteria
and health anxiety is led by publicizing of disease outbreak (Taylor and Asmundson 2004).
Anecdotally, in the clinics and hospitals of Pakistan, it has been seen that number of patients
with presentations of OCD or IAD stated concerns for having COVID-19 (Mukhtar, & Mukhtar,
response to threat of a disease because it can facilitate the treatment plans and preventative
strategies for health anxiety (Bish and Michie 2010). Heightened anxiety level can also
washing) that are done to lessen the possibility of illness. Consequently, functional impairment
and distress accompanies these safety behaviors and disturbs the natural homeostasis (Olatunji et
al. 2011).
Accordingly, present research was designed during the time when concern of government is high
about the psychological factors like fear and safety behaviors accompanied by COVID-19
epidemic because these factors eventually disturb the balance of health resources. The limited
body of research is found on the topic of anxiety among students and youngsters as a response to
pandemic illnesses like Ebola (Blakey, Reuman, Jacoby, & Abramowitz, 2016), avian flu (Lau et
al. 2008), H1N1 (Wheaton et al. 2012) and SARS (Wong, Gao & Tang. 2007). In the present
research we predict a number of constructs that are likely to determine the fear of COVID-19.
One of the probable predictors could be general stress like anxiousness or depressive symptoms.
According to previously established notions, general stress along with anxiousness and
depressive symptoms are strong predictors of physical health deterioration (Scott et al. 2007;
Niles et al. 2014) and negative interpretative biases (like catastrophizing) that further enhance
anxiety about health and other illnesses (Reif et al. 1998). Second predictor is proposed as
be transmitted through the bodily fluids. Moreover, the fear of COVID-19 could be the
proposed as propensity to experience disgust against fear of COVID-19 (Cisler et al. 2010;
predictor of not just contamination aversion but specifically for fear of COVID-19.
carefully monitoring bodily sensations (Schmidt et al. 1997). Olatunji et al. (2007) suggest that
chance to notice an otherwise benign condition and translating them as catastrophic is high
among people who frequently and intensively scan their physical appearance or sensations. It
was also found in their research that body vigilance is a significant correlate of health anxiety
between clinical and no-clinical adults. Furthermore, anxiety sensitivity is a predictor to fear of
COVID-19 and safety behaviors because people with high sensitivity to anxiety are known to
possess the tendency to misread benign sensations of arousal as a danger alert (Taylor et al.
2007). Specifically, the degree to which a person concentrates on his body sensations like nausea
etc, is related to the urges against variety of safety behaviors. Alternatively, according to the
propositions of American psychological association about safety behaviors of people against an
epidemic, people who possess greater understanding of the disease are less likely to feel anxious
As discussed above, the extent of literature provides suggestions towards the factors that could
predict COVID-19 related fear and the consequent behaviors. Hence, it is hypothesized that
higher level of general distress, disgust sensitivity, body vigilance, contamination cognition, and
anxiety sensitivity along with decreased level of factual knowledge about an epidemic can
Method
Participants
Three hundred and ninety undergraduate university students from Pakistan participated in
present research. The research was advertised for data collection through the online participant
pool monitored by Department of Psychology, Institute of Southern Punjab. At first, data was
screened, and 40 participants were excluded based on incomplete questionnaires, bringing the
final sample size to 350 respondents. Mostly female representation was shown in the data
(n=194; 56%). Mean age noticed from the sample was 18.43-year-old (ranged 18- 21 years).
Procedure
Undergraduate students from central public universities of Pakistan were contacted and consents
were taken to participate in present survey research. The duration for data collection was
between March 4th, 2019 to April 6th, 2020. Respondents were asked to complete the
questionnaires including a demographic Performa. Following the instructions from Meade and
Craig (2012), the validity of responses were assured by quoting four questions with instructions,
“Answer Always True for this question”. The study was conducted after sorting approval from
university’s review board and consents were taken from respondents after they were informed
Questionnaires
Corona-19 Fear Inventory (CFI). CFI was specifically constructed for present research and
constituted of 9 items. The purpose of developing this inventory was to analyze the fear
associated with covid-19. Psychometric properties were analyzed and presented in the following
section of preliminary analyses. Items were rated on 5 point likert scale, options stating 1 (Not at
all) to 5 (Very much). The questionnaire was inspired by previously constructed questionnaire
for H1N1 (Wheaton et al., 2012). CFI showed satisfactory internal consistency (α =.88) for the
present sample.
Corona-19 Checklist for Safety Behaviors (CCSB) . CCSB was developed to inquire about the
safety behaviors associated with fear of Covid-19. The checklist constitutes of 9 items. This
inquire about the safety behaviors intended to prevent contacting Covid-19, examples include
“washing hands compulsively, continuously checking internet for Covid-19 and avoiding
people). This checklist was also inspired by previously constructed questionnaire for H1N1
(Wheaton et al., 2012). Respondents were asked to rate the extent to which they are engaging in
activities while having concerns about COVID-19 on a 10-point scale (0=none to 10 extreme
amount). The checklist showed satisfactory internal consistency (α =.89) for current data.
Depression Anxiety Stress Scales-21 (DASS-21; Antony et al. 1998). Subjective distress over
last few weeks were assessed through three subscales of DASS-21 (Depression, Anxiety and
Stress). The scale constitutes of 42 items originally, but present research used the short form
version comprised of 21 items by Lovibond and Lovibond (1995). Th respondents were asked to
rate how each of these 21 statements are applied on them. The rating was done on 4-point likert
scale ranging from 0=rarely to 4=very much. The scale showed satisfactory reliability and
construct validity for clinical and the non-clinical population in a previous study by Henry and
Crawford (2005). For present research the data responses showed α = .94
Contamination Cognitions Scale (CCS; Deacon and Maack 2008). CCS is an inventory
designed to assess the tendency of respondents to overestimate the chance of contamination from
a variety of common objects like stairway railing etc. The items are rated on 0= not at all to 100=
extremely. The scale was divided in terms of severity levels into two subscales of severity and
likelihood with each subscale consisting of 13 items and total 26 items. For current sample the
internal consistency of CCS-L and CCS-S was .95 and .96 respectively.
Disgust Scale- Revised (DS-R; Olatunji et al. 2007). The revised version of Haidt et al. (1994)
of used to analyze the propensity of sample to experience disgust across numerous domains. The
objective view of respondents was taken in terms of multiple scenarios like if you see maggots
on a piece of bread in an outdoor garbage pail, how disgusting do you find it on a scale of
0=strongly disagree to 4=strongly agree. Internal consistency was found satisfactory (α = .87)
Body Vigilance Scale (BVS; Schmidt et al. 1997). The scale was designed to analyze tendencies
of respondents towards attending anxiety related bodily sensation. First three items of the scales
are focused to analyze three dimensions focusing the attention, sensitivity towards change and
the duration devoted to monitor body sensations on a scale 0 (not at all) to 10 (extremely). Fourth
items separately inquired about fifteen bodily sensations and the extent to which attention is paid
on each of them. These representations of bodily sensations are than averaged to get a single
item’s score. Previously the scale has showed satisfactory reliability (Olatunji et al. 2007b;
Schmidt et al. 1997) and for present research the scale showed (α = .94).
Anxiety Sensitivity Index-3, Subscale for physical concerns (Taylor et al. 2007). The scale was
adopted from original version of Reiss et al. (2008). It consists of 18 items that measured beliefs
related to dangerousness of anxious thoughts along physical, cognitive, and social domains. The
items were rated on 4-point rating scales (0= very little to 4=very much). Previously Taylor et al.
validity for Anxiety Sensitivity Index-3. For current research, only physical concerns were
analyzed because they were related to the aims of this research. The internal consistency of the
Covid-19 Fast Quiz (CFQ; Uk’s Independent Fact Checking Authority). CFQ is a ten-item yes
or no based measure of knowledge about the Covid-19 and 2019 global outbreak. High score
indicated high knowledge about the virus and the outbreak. The quiz was originally share on
march, 2020 by Uk’s Independent Fact Checking Authority.( https:// fullfact. Org / quiz /
coronavirus/)
Initially for CFI and CCSB the item analysis was conducted in order to test psychometric
properties, item total correlation and internal consistency. Afterwards in order to explore the
relationship of constructs, CFI and CCSB were correlated with other study variables. To
determine the predictability of psychological variables for COVID-19 fear and safety behaviors,
researcher has used linear regression model. Among 350, 2 participants did not qualify for three
distractor items and were excluded from further data analysis. Data was further screened for
concordance with statistical assumptions. On the CCS-S item range, one case did not properly
come within the acceptable range as possible range was 0 till 100, the case showed a score of
740, therefore it was excluded from final data. All values appeared to be free of significant skew
i.e. less than 2 and the kurtosis less than 4. Univariate outliers were not observed, however, two
multivariate outliers were observed for whom Mahalanobis distances was beyond critical X 2
df=8 value of 26.12. Outliers status for multivariate outliers was driven by the infrequent
combination of scores on BVS, CCS-L, CCS-S and DASS for two participants. Such
multivariate cases were excluded due to chance of bias in regression estimation points and
sufficiently large sample. Distribution of scores for remaining sample of 347 respondents were
tested again and no significant skew, kurtosis, univariate or multivariate outlier indices were
found.
Results
Descriptive Data and statistics. Following table (table 1) suggest that although respondents were
fearful on a high scale but were at least fearful on a moderate level. According to the data
collected on safety behaviors employed by respondents in the result of covid-19 fear, it is seen
that respondents were performing moderate level of COVID-19 related safety behaviors.
Remaining measures showed score ranged within a typical scale of non-clinical population. In
table 1, it is also showed that respondents appeared to have a variable degree of knowledge
Following the outline of DeVellis (1991), the Corona-19 Fear Inventory (CFI) was assessed for
psychometric acceptability. For the measure of CFI, two items appeared to be falling below the
acceptable level of .30 as suggested by Nunnally and Bernstein (1994). Items number 6 and 8
were removed and it was seen that total scale reliability significantly improved. Final scale was
based on 9 items and reliability was α = .78. The distribution of scores without any significant
skew and kurtosis (1.36 and 1.39 respectively. Items that were removed from the scale, “If you
were infected by Covid-19, to what extent are you concerned that you would die” and “How
much information do you think you have about covid-19”. Similarly, DeVillis (1991) was
followed to establish the Corona-19 Checklist for Safety Behaviors (CCSB) and its psychometric
properties. For this measure, no items were removed, and all showed an acceptability level
higher than .30 according to the suggestions of Nunnally and Bernstein (1994). Final scale
showed reliability of α = .88. The distribution of scores was also without any significant skew
examined by two-tailed zero-order correlation. The results in Table-3 suggest that CFQ is not
significantly related to any of the study variables. However, other study variables showed
Table 3. Correlation between CFI, CCSB, DASS-21, CCS, DS-R, BVS, ASI-3, AND CFQ
ASI-3
.37*** .51*** .45*** .30* .28** .28** .47*** --
Physical
Note: Corona-19 Fear Inventory; Corona-19 Checklist for Safety Behaviors; Depression Anxiety
Stress Scales-21; Contamination Cognitions Scale-Likelihood average, Contamination
Cognitions Scale-Severity average, Disgust Scale-Revised average, Physical Anxiety Sensitivity
Inventory-3 Physical Concerns Subscale, BVS Body Vigilance Scale, ASI-3 Anxiety Sensitivity
Inventory-3, Covid-19 Fast Quiz * p < .05; ** p < .01; *** p < .005
Regression Analysis for Predicting Covid-19 Fear
To explore the predicting capacity of psychological variables towards covid-19 fear, liner
regression analysis was used (Table 4). Multicollinearity indices were satisfactory but suggested
a lack of redundancy in the predictors of model. The model suggests all tolerance values ≥.57
and the VIF ≤ 1.75. The overall model apparently accounts for 30% of the variance in CFI, F
(7,99) = 5.10, p<. 001.Within the complete model two predictors appeared to significantly or
edict the fear of Covid -19with p ≤ .05. Table 4 shows that Contamination Cognitions Scale-
Severity average accounted for 8% of the variability in CFI and the sensitivity to anxiety
accounts for 4%of the variation in CFI. None of the other variables, DASS, DS-R, EFQ, CCS-L,
or BVS were significantly predicting Covid-19 fear in the population from Pakistan in current
study.
Note: Corona-19 Fear Inventory; Corona-19 Checklist for Safety Behaviors; Depression Anxiety
Stress Scales-21; Contamination Cognitions Scale-Likelihood average, Contamination
Cognitions Scale-Severity average, Disgust Scale-Revised average, Physical Anxiety Sensitivity
Inventory-3 Physical Concerns Subscale, BVS Body Vigilance Scale, ASI-3 Anxiety Sensitivity
Inventory-3, Covid-19 Fast Quiz sr 2 squared semi-partial correlation
To explore the predicting capacity of psychological variables towards safety behaviors against
covid-19, the linear regression analysis was done (Table 5). Multicollinearity indices were
satisfactory with tolerance value ≥.57 and all the VIF ≤ 1.75. The regression model was overall
The model suggest that Contamination Cognitions Scale-Severity average and Disgust Scale-
Revised average were the only significant predictors for covid-19 safety behaviors (p ≤ .05).
Moreover, the concerns of people regarding contamination accounted for 8.7% of the variance in
the model and sensitivity to disgust accounted for 2.8% of the total variance in the model. None
of the other study variables appeared to be significantly predicting the safety behaviors for
Note: Corona-19 Fear Inventory; Corona-19 Checklist for Safety Behaviors; Depression Anxiety
Stress Scales-21; Contamination Cognitions Scale-Likelihood average, Contamination
Cognitions Scale-Severity average, Disgust Scale-Revised average, Physical Anxiety Sensitivity
Inventory-3 Physical Concerns Subscale, BVS Body Vigilance Scale, ASI-3 Anxiety Sensitivity
Inventory-3, Covid-19 Fast Quiz sr 2 squared semi-partial correlation
Discussion
This research intended to explore the psychological determinants of fear and anxious behavioral
responses to the Corona Virus outbreak 2019. It was hypothesized that among the selected
respondents from our sample of university students, some of the predictors would be general
psychological distress, disgust sensitivity, anxiety sensitivity, body vigilance and the concerns
for contamination. Moreover, factual knowledge about the covid-19 outbreak was hypothesized
to be a significant predictor for decrease in covid-19 related fear and safety behaviors. In order to
meet the aims of this research, the researcher designed the measures for covid-19 related fear
inventory and an inventory for safety behaviors. The measures were reported to possess
acceptable psychometric properties. Variables were tested for correlation among each other and
it was found that contamination cognition, disgust sensitivity, body vigilance, anxiety sensitivity
towards physical concerns and general distress positively correlated with fear and safety
behaviors associated to covid-19. However, the hypothesis regarding the relationship between
factual knowledge of covid-19 and fear of disease was not significant. The model was tested as a
significantly predict the fear of covid-19 and its associated safety behavior. Sensitivity to
physical anxiety significantly determined fear of covid-19 but only marginally predict covid-19
related safety behaviors. Body vigilance was also marginally significant in predicting covid-19
related safety behaviors. Generally, it can be stated that our results partially support our initial
hypothesis.
Till date, researchers have rarely focused on anxious responses to a threat of viral illnesses such
as covid-19 outbreak in Pakistan. Given the fact that the country has been exposed to the virus
and we were well positioned to identify the predictors of fear and safety behaviors among young
adults who are continuously getting information from media coverage about the outbreak in
Pakistan. The purpose of this research was to enlighten the clinical practitioners and the
psychologists who are continuously dealing with referrals for panic and anxiety symptoms
regarding covid-19. The research further highlights the behavioral responses of public towards a
threat of pandemic and specially those people who are already vulnerable towards maladaptive
responses such as health anxiety. Should a threat of another global panic surface in future, this
research could also help in developing preventative programs and the clinical management
systems. The results of research highlight that the contamination concern and the physical
concerns about anxiety sensitivity might be essential in this experience of covid-19 fear and
related safety behaviors such as compulsive hand washing. However, covid-19 related anxiety
and behaviors were not found to be related to factual understanding of this pandemic.
significant predictor of Covid-19 fear and safety behaviors. Findings of this research are cross-
sectional, one of the ways through which anxiety sensitivity contributes to fearful responses
something threatening. Such a misunderstanding could lead to increased fear because number of
bodily sensations that are associated with anxiety often mirror the symptoms of covid-19 (such
as nausea) (Zu, Jiang, Xu, Chen, Ni, Lu, & Zhang, 2020). As previously hypothesized by
researcher, concerns to severity of contamination predict covid-19 fear and safety behaviors.
Covid-19 is indeed an illness with its severity in unpleasant symptoms like myalgia (muscle
pain), cough, fever or fatigue (World Health Organization, 2020) but it is also a possibility that
increased media coverage led people to overestimate the severity of this disease. Similar pattern
was discussed in a research with undergraduate students by Wheaton et al. (2012). They studied
the fearful responses of youngsters towards H1N1 pandemic known to be existed from 2009 to
2010. Though, findings of present research can’t suggest a causal relationship of increased media
knowledge ofcovid-19 and fear and engagement in safety behaviors of covid-19. However, the
findings go consistent with the previous research of Moritz and Pohl (2009), where illness
related information like statistics of incidence did not show a significant relationship with
anxiety related symptoms. Our covid-19 information quiz was taken from an online reliable
source for which the psychometric properties were unknown, but the score distribution in our
data was without skew or kurtosis and showed normality. Covid-19 is an ongoing pandemic in
the world and has been declared as a public health emergency on international level (World
Health Organization, 2020). Yet as the National Institute of Health, Islamic Republic of Pakistan,
throughout the country which include closing of outpatient departments in the hospitals, bans on
the intra and inter city public transports as well as the gatherings in public or private places,
which rose the concern and fear among general population and made covid-19 fear a greater
threat than the covid-19 itself (COVID-19 Daily Situation Report – NIH Pakistan", 25 March
2020).
The results suggest that the efforts to increase the knowledge of covid-19 outbreak might not
alleviate the covid-19 related fear and safety behaviors. This understanding brings some clinical
relevance in a way that cognitive models highlighting dysfunctional beliefs like threat
overestimation are of great importance as etiological factors for pathological anxiety which
explanation it can be said that respondents coped with the fear of covid-19 by seeking the
required knowledge and the hypothesized effect was washed out. Consequently, results of our
research might seed cognitive interventions by stating that educating an anxiety patient about the
epidemic alone, cannot become a strong method against dysfunctional health related beliefs. As
clinical population with health anxiety of clinical severity in order to see if providing knowledge
about the epidemic could mitigate the fear and anxiousness among people.
The design of this research was basically inspired by Wheaton et al. (2012), where anxious
responses against H1N1 were explored after 2009 outbreak. The authors suggested that
likelihood and severity in contamination cognition, health anxiety and disgust sensitivity
significantly predicted fear of H1N1. However, it was reported that physical concerns regarding
anxiety sensitivity, general distress and body vigilance was not connected to fear of illness
(H1N1). Therefore, it can be stated that our result is somewhat in consistency with the previous
research of Wheaton and colleagues. It is recommended for future researches that comparison
study should be conducted to see the amount of perceived dangerousness, disgusting and
Some of the limitations of this research should be considered while citing this research in future.
Firstly, the participants were undergraduate students from Pakistan, and they were apparently
physically and psychologically healthy. Therefore, the findings cannot be applied to individuals
with clinical symptoms like OCD or hypochondriasis. Secondly, participants were recruited from
undergraduate university students from Pakistan and the results cannot be implicated to all the
youngsters from Pakistan with otherwise similar demographic properties because people
experience differentiated level of concerns according to the level of incidence in that region. It
would be desirable if a similar research with global representation can be conducted in future.
Another limitation would be, that data was based on subjective representations which could
At last, the research provides directional conclusions. It is suggested that people with greater
concern of contamination are likely to respond fearfully tocovid-19 and that people with higher
fear ofcovid-19 are likely to feel contamination concerns. In future, longitudinal research would
response to global epidemics or threat of serious diseases. Likewise, the chances that safety
behaviors could generate or increase covid-19 concerns is important in the light of study
suggesting that intentional engagement in health-related safety activities makes individuals more
concerned about the risk of contamination (Olatunji et al. 2011). Present research provides data
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