key: cord-0732242-rcwg9cps
authors: Kurcer, Mehmet A.; Erdogan, Zeynep; Cakir Kardes, Vildan
title: The effect of the COVID‐19 pandemic on health anxiety and cyberchondria levels of university students
date: 2021-05-20
journal: Perspect Psychiatr Care
DOI: 10.1111/ppc.12850
sha: 0ffd0d15fc8ea493999556be2801ccab3d262188
doc_id: 732242
cord_uid: rcwg9cps

OBJECTIVE: Our study hypothesizes that the fear and panic of COVID‐19 triggers cyberchondria (CYB) in students thus increasing health anxiety. In this way, we aim to determine the effect of the belief of previously having had and not having had COVID‐19 on health anxiety and CYB levels of the university students. METHODS: Our study is a descriptive cross‐sectional study. The target population of our study consisted of 950 students who were continuing their education in the Vocational School of Health Services, an associate degree program of a university, and the samples consisted of 794 students (85.5%) who filled out our questionnaire (n = 794). The questionnaire form included the information regarding sociodemographic characteristics and the symptoms of COVID‐19, and the obtained data were electronically collected altogether with Cyberchondria Scale (CS) and Health Anxiety Inventory. FINDINGS: Health anxiety mean scores were significantly higher in people who lived alone, had a chronic disease, searched for symptoms online, and took herbal supplements against COVID‐19 (p < 0.05). The mean total scores of Health Anxiety Inventory, CS, Anxiety‐Increasing Factors Subscale of the students who believe they have had COVID‐19 were significantly lower compared to the scores of those who believe they have not had COVID‐19. Nevertheless, women and people living alone and in cities had significantly high CS scores (p < 0.05). CONCLUSION: The increase in infodemia can be prevented with the services offered by specialists through mental health helpline or websites to people with high health anxiety or CYB levels, especially to women, and to people living alone and in urban areas.

management of the pandemic, and this led to elevated levels of cyberchondria (CYB). 4, 5 CYB is defined as the people's excessive and repetitive search of health information on the Internet with the urge of relieving the health anxiety thus becoming more anxious and fearful as a result. 6 It is still being investigated to what extent CYB represents a novel, distinct, and autonomous disorder or a common phenomenological sign that exists in several established psychiatric disorders. 7 People started to seek information online to fulfill their knowledge, entertainment, and communication needs after the development in information and communication technologies and the widespread use of the Internet. They can get through to various health sources and expert opinions easily through the Internet. 8 Internet is a vital source for individuals seeking health information, including new symptoms or diagnoses, treatment choices, and medication. 9, 10 Although the Internet has many time-saving and cost-effective benefits for individuals to access information, telemedicine, and online psychotherapy, 11, 12 it may also have disadvantages like spreading inconsistent, vague, or false information and it may even harm the doctor-patient relationship. 13 When an online health source is perceived as reliable, it is more likely to trigger health concerns. 14 Regardless of the leading cause of seeking medical information online, the search results may cause the individual to seek more information, thus the person develops more fear and anxiety. 15 In their study, Wang et al. 16 investigated the effect of the COVID-19 pandemic in China on the mental health of the general population and reported that the Internet, TV, radio, and other family members were primary sources of information. And in the same study, the spread of medical information through radio was associated with high levels of anxiety and depression. 3 COVID-19 pandemic also presents a significant worldwide threat. Interpersonal relationships are getting negatively affected not only by the strict measures taken by governments but also by loneliness, the fear of becoming infected, and of dying. Dealing with these fears on an individual level is critical, and the most effective way of coping with them is to support society during the management of the pandemic. 4 Studies carried out on students reported that students with health concerns seek online medical information more frequently and for a longer duration, and these anxious individuals were reported to make more online research for diagnosed or undiagnosed conditions because they were feeling more distressed and more anxious after their research. 14, 17 In the present study, our hypothesis is that the fear and panic caused by the COVID-19 pandemic may trigger CYB levels and increase health anxiety, and we aim to determine the effect of the belief of previously having had and not having had COVID-19 on health anxiety and CYB levels of university students.

The population of this cross-sectional study included a total of 940 students who were continuing their education in the Vocational School of Health Services, an associate degree program of a university. The study sample (83.5%) included 794 students who filled out the Cyberchondria Scale (CS), Health Anxiety Inventory, and the questionnaire prepared by the researchers, including sociodemographic characteristics and information on their belief of having previously had COVID-19 infection (n = 794).

Inclusion criteria were as follows: to be over 18 years of age, to accept to participate in the research, and not to have a mental or cognitive disorder. The data was collected online between April 7, 2020 and April 25, 2020.

In the 2020-2021 Academic Year spring semester, the questionnaire was sent to the students by e-mail for them to fill out at the given dates. Most of the students completed the questionnaire. The data was collected through the CS, Health Anxiety Inventory, and Student Information Form that included the student's sociodemographic data (age, sex, economic situation), the symptoms of COVID-19, the precautions taken against it, and the characteristic of the Internet use. 18 In our study, Cronbach's alpha internal consistency coefficient of the scale was found to be 0.91.

Developed by Salkovskis et al., 19 the inventory is a self-report scale with 18 items. The scale is two-dimensional. The range of the scale score is between 0 and 3 for each item, and higher scores indicate higher levels of health anxiety. The reliability and validity study of the Health Anxiety Inventory was carried out by Aydemir et al. 20 Cronbach's alpha internal consistency coefficient of the scale is 0.918. In our study, Cronbach's alpha internal consistency coefficient of the scale was found to be 0.82.

Permissions were taken for the use of both scales.

SPSS software package was used for the evaluation of the data and mean ± SD and percentages (%) were presented. The data was shown to be normally distributed with The Shapiro-Wilk and Kolmogorov-Smirnov tests. Student's t-test and analysis of variance test were used for the analysis of continuous variables.

Permission was given by the Vocational School of Health Services, and ethical approval was obtained from the Human Research Ethics Committee of a university on April 6, 2020, with approval number 772.

The mean age of the students included in the study was 20.6 ± 2.17 and most of them (75.4%) were female. Of all the students, 22.3% were smoking, 24.6% were consuming alcohol, and 8.2% had at least one chronic disease ( Table 1 ).

The distribution of the students' consulting to doctor, having been tested, and of their contact with an infected person in terms of their symptoms are shown in Table 2 . According to Table 2 , 29.6% of the students believe that they previously had COVID-19 as they had an illness in 2020 with symptoms, including cough, shortness of breath, fever, and fatigue. Of these students, 66.8% were reported not consulting a doctor, 22.7% were reported to consult a doctor for examination but not having been tested for COVID-19 diagnosis, and only 0.5% were reported to have been tested for COVID-19 and their test results were negative. Of the students, 70.4% reported no COVID-related complaints; however, of these students, 1.4% were tested for COVID-19 due to having had contact with an infected person, and all of them tested positive for COVID-19. So, a total of 10 students were tested for COVID-19 ( Table 2 ).

The mean health anxiety scores of students in terms of sociodemographic data and some variables are shown in Table 3 . According to Table 3 , the mean Health Anxiety scores of the students are significantly higher in females than in males, in people living alone than in those living with family, friends, and in dormitories, in students with chronic disease than in those without any chronic disease, in students who seek online health information than in those who do not seek online health information and in students who used herbal medicines against COVID-19 in the last 2 months than in those who did not use any herbal medicine (p < 0.05). There was no significant difference between the mean Health Anxiety scores and the age and university year of the students, the city that they live in, their smoking, nonsmoking, and alcohol consumption status, the use of unprescribed drugs, and the frequency of handwashing (p > 0.05) ( Table 3) .

Distribution of the CYB scores of the students according to sociodemographic data and some variables are shown in Table 4 .

CYB scores of the students were significantly higher in females than in males, in students living in urban areas than those living in rural areas, in the students living alone than in those living with their families, friends, and in dormitories (p < 0.05). There was no significant difference between mean CYB scores and the age of the students, the frequency of seeking online health information, the presence of chronic disease, the use of unprescribed drugs, their smoking, nonsmoking, and alcohol consumption status, and the use of herbal medicine against COVID-19 in the last 2 months (p < 0.05) ( Table 4 ).

The distribution of the mean scores of the Health Anxiety Inventory and CYB subscales of the students in terms of their belief of having previously had COVID-19 are shown in Table 5 . According to Table 5 , the mean total scores of Health Anxiety Inventory, CS, Anxiety-Increasing Factors Subscale of the students who believe they have had COVID-19 are significantly lower compared to the scores of those who believe they have not had COVID-19 (p < 0.02) ( Table 5 ).

Health anxiety is the somatic and mental concerns about having a severe illness and is triggered by the perceived bodily changes. 21 Dysfunctional beliefs have an impact on health anxiety. In their study, Salkovskis and Warwick 22 defined four types of dysfunctional beliefs associated with health anxiety: (1) likelihood of experiencing a health problem, (2) awfulness of experiencing a health problem, (3) inability to cope with an experienced health problem, and (4) inadequacy of medical resources to treat an experienced health problem. 22 In a study, the beliefs of "inability to cope with an experienced health problem" and "likelihood of experiencing a health problem" were found to be predictive of health anxiety in a group of individuals without the diagnosis of a physical condition. 23 Similarly, a positive relationship was found between university students T A B L E 1 The distribution of the students' sociodemographic data and some variables (n = 794) without the diagnosis of a physical condition and the beliefs; "likelihood of experiencing a health problem" and "inability to cope with an experienced health problem," and these beliefs were found to be predictive of health anxiety. 24 Higher scores were reported in most of the previous studies evaluating health anxiety in people who were temporarily ill or diagnosed with a severe medical condition. 25, 26 However, the definition of COVID-19 as a highly contagious and deadly virus leads to a perception of a high possibility of getting infected and to worse case scenarios in case of being infected. In our study, the participants who believe that they have had COVID-19

(infected, recovered, and moving forward) were already tested regarding their beliefs of "likelihood of experiencing a health problem"

and "inability to cope with an experienced health problem" and thus, we think that the anxiety scores of these participants might have been reported lower than those who believe they have not had COVID-19. The unique features of pandemics, such as incubation period, altering clinical pictures, and having no pharmacological interventions, may especially increase health anxiety. 27 Intolerance of uncertainty (IU) is remarkable in studies investigating psychological factors that may be associated with anxiety during a pandemic. In the literature, IU is related to increasing health anxiety. 28 In this context, the unpredictable clinical picture of COVID-19 and related IU may be associated with high levels of anxiety of the participants who believe they have not had COVID-19 due to their having no experience with the infection.

In our study, the mean Health Anxiety scores of the students were reported to be significantly higher in females than in males, in people living alone than in those living with family, friends, and in dormitories, in students with chronic disease than in those without any chronic disease. In literature, females are more at risk than males regarding the general anxiety forms. 29 Females can be more anxious than males due to many factors, such as biological factors like imbalances in reproductive hormones, sociocultural factors, personality traits like increasing anxiety sensitivity, and cognitive factors like a high tendency to ruminate. 29, 30 Likewise, Lim et al. 31 4%. 31 In a recent study, the possibility of anxiety and depression were found to escalate significantly with younger age, female gender, urban living, pre-existing medical conditions, health status about COVID-19, and concern on COVID-19. 32 Similar to the literature, we also found that health anxiety was higher in females compared to males in our study.

A negative correlation was found between mean Health Anxiety Inventory scores and the number of households in a study carried out on health anxieties of nurses working in a university hospital in

Turkey. The number of households and health anxiety were reported to have an inverse relationship. 33 Similarly, we reported a higher rate of health anxiety in students living alone. In addition, no significant difference was found between the health anxiety scores of the students and their accommodation, year, and department in a study carried out in a public university in Turkey. 34 The impact of the pandemic on elevated anxiety levels can also be considered in our study.

In a study conducted in Australia, the participants with at least one physical disorder were found to be 4.6 times more likely to meet health anxiety criteria than those who were relatively healthy. 35 Similarly, we also found that students with chronic disease had higher levels of health anxiety. Also, a study conducted in China on 1590 patients diagnosed with COVID-19 reported that an associated chronic comorbid disease increased COVID-19 infection risk by 1.7 times, and two or more comorbid diseases by 2.5 times. 36 Given the above, the students with a chronic disease included in our study had higher health anxiety during the pandemic, and we believe the reason for that may be the frequent emphasis of media and specialists on the information on COVID-19.

In our study, Health Anxiety scores of the students who frequently seek online health information were found to be higher than the scores of those who do not seek online health information. This finding shows that patients with health anxiety increasingly treat the Internet as a source of medical information even if there are many other sources of health information out there, such as books and magazines. 37 People who were more concerned about their health were reported to seek online health information more often on a health-related website in Canada. 38 People with indigestion, back pain, irritable bowel syndrome, and somatoform disorders are reported to seek more online health information. 39 Le et al. 40 T A B L E 3 The mean health anxiety scores of students in terms of sociodemographic data and some variables (n = 794) showing that individuals with higher health anxiety may search for more online health information. 17 According to the cognitivebehavioral model, 41 the cognition which is common in individuals with health anxiety may be regarded as false beliefs about the possibility of having a serious illness and the dangerousness of the uncertainty. Intolerance to uncertainty may also trigger online healthseeking in individuals with health anxiety. Individuals with health anxiety may be different in their health-related Internet use and may have different attitudes toward seeking health information when compared to those without any health anxiety. 42 The fact that individuals who are more health anxious seek online health information more frequently and for longer periods can be approached as part of cognitive-behavioral concept with its controlling and safetyseeking behaviors. 17 Studies support the idea that health anxious individuals find reassurance by examining the relationship between their online health search results and their own symptoms. 41 In the present study, the Health Anxiety scores of the students who took herbal medication were found to be significantly higher than the scores of those who did not take any herbal medication. and not to catch the illness due to infection risk in hospitals.

In this study, the health anxiety and CYB scores of the students living in urban areas and alone were found to be significantly high. In previous outbreaks and pandemics, people living in quarantine were reported to develop feelings of loneliness and anger. 46 In addition, people in quarantine lose their face-to-face communication and traditional social support, thus their stress level increases. 47 Santini et al. 48 pointed out that loneliness and isolation during COVID-19 could trigger anxiety. However, lockdown came into effect for young people both in the world and in our country, and the loneliness and isolation that the lockdown brought has triggered health anxiety, and thus any attempt to get over it created a vicious cycle, so CYB levels increased. 49, 50 This finding shows that the young group gets affected by loneliness and isolation as much as old and they need specific psychological and psychiatric health consultation. With this information in hand, psychological interventions against these crises are a part of the health system within the context of public health emergencies. 51 The finding regarding CYB levels of the students living in urban areas was significantly higher than those living in rural areas might have been due to living alone, being less with family because of the pandemic, not being able to share concerns with someone, having less opportunity for outdoor pastime activities. Therefore, we believe that within the precautions taken by WHO and the Ministry of Health in our country, after the formal education was moved to Our study found an increase in CYB scores of females like in health anxiety scores. However, we found no effect of age on the scores. Similar to our study, Laato et al. 52 also found that the ones with high levels of perceived susceptibility to COVID-19 and the female gender had high levels of CYB and found no relationship between age and CYB. In a study by Andreassen et al., 53 females were found to seek online health information often, which is similar to our results.

In their study, Ivanova 54 evaluated the CYB scores of the participants and found that 33% were seeking information on diagnosed conditions and 26% were searching for information on serious illnesses. Besides, Internet use was found to be related to loneliness and this finding is similar to our results. 54 Sharing false information in social media is explained by feeling higher levels of trust toward online sources. To solve the problem of false information sharing, it is essential to determine why people are spreading fake news. 55 However, in studies on sharing inaccurate information during a massive health crisis like COVID-19, people were reported to act differently when they were led by fear and anxiety. 56 For instance, there is evidence that online health information seeking during pandemics is more common among people who feel more concerned and fearful. 57 In case social media users encounter a situation that makes them feel frightened or stressed, their Internet use behaviors change, and they experience fatigue due to perceived information overload. 58 

As a result of our study, health anxiety scores of females and students who frequently sought online information, had a chronic disease, took herbal medication to protect their health, and lived alone were found to be high, and CYB scores of females and students who lived in urban areas and alone were reported to be high as well. So, to prevent infodemia and the spread of fake news during the pandemic, individuals should be informed by legal arrangements and public service announcements (PSAs Also, it is remarkable to see an increase in herbal medication use to support the immune system with the increase in health anxiety. Irrational use of drugs may have adverse effects on liver and renal health. Therefore, PSAs and websites can be created about herbs with a high level of evidence to inform people during this period.

Although our study provides useful information on health anxiety 

Pandemic fear and COVID-19: mental health burden and strategies

A Systematic review of the ımpact of viral respiratory epidemics on mental health: an ımplication on the coronavirus disease 2019 pandemic. Front Psychiatry

A longitudinal study on the mental health of general population during the COVID-19 epidemic in China

Empirical studies assessing the quality of health information for consumers on the world wide web: a systematic review

Cyberchondria: towards a better understanding of excessive health-related Internet use

new" psychopathologies for the 21st century? World Psychiatry

Searching for health information online: characteristics of online health seekers

Cyberchondria: too much information for the health anxious patient?

Consumer health information seeking on the Internet: the state of the art

Telemedicine in the COVID-19 pandemic: motivations for ıntegrated, ınterconnected, and community-based health delivery in resource-scarce settings? Front Psychiatry

Moodle: the cost effective solution for internet cognitive behavioral therapy (I-CBT) interventions. Technol Health Care

The impact of internet use on the public perception of physicians: a perspective from the sociology of professions literature

Health-related internet habits and health anxiety in university students

The psychological impact of quarantine and how to reduce it: rapid review of the evidence

Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China

Cyberchondriasis: fact or fiction? A preliminary examination of the relationship between health anxiety and searching for health information on the Internet

Senkal-Erturk I. Cyberchondria Scale (CS): Development, validity and reliability study

The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis

Reliability and validity of the Turkish version of the Health Anxiety Inventory

Health anxiety and cyberchondria among Ege University health science students

Making sense of hypochondriasis: a cognitive model of health anxiety

Core cognitions related to health anxiety in self-reported medical and non-medical samples

Of variables associated with health anxiety in adults an analysis within the cognitive behavioral model

The Short Health Anxiety Inventory: A systematic review and meta-analysis

Is health anxiety a significant problem for individuals with multiple sclerosis?

The prospective influence of COVID-19 affective risk assessments and intolerance of uncertainty on later dimensions of health anxiety

Intolerance of uncertainty as a factor linking obsessive-compulsive symptoms, health anxiety and concerns about the spread of the novel coronavirus (COVID-19) in the United States

Women and anxiety disorders: implications for diagnosis and treatment

Gender differences in health anxiety: an investigation of the interpersonal model of health anxiety

Prevalence of depression in the community from 30 countries between 1994 and 2014

Anxiety, depression, traumatic stress, and COVID-19 related anxiety in the UK general population during the COVID-19 pandemic

The level of health anxiety and the healthy lifestyle behaviors of nurses at a university research hospital

A study on determınıng health anxıety levels of unıversıty students

Health anxiety in Australia: prevalence, comorbidity, disability and service use

Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis

Understanding and treating health anxiety: a cognitivebehavioral approach

Determinants of internet use as a preferred source of information on personal health

Type of illness and use of the Internet for health information

Demand for health information on COVID-19 among Vietnamese

Health anxiety and internet use: a thematic analysis

Dietary supplement use in gastrointestinal symptom management and effect on hopelessness levels in patients with ırritable bowel syndrome

Use of dietary supplements for weight loss in obese patients in Zonguldak

Use of complementary and alternative medicine methods among elderly people living in nursing homes

Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed

Recommended psychological crisis intervention response to the 2019 novel coronavirus pneumonia outbreak in China: a model of West China Hospital

Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): a longitudinal mediation analysis

key-messages-and-actions-for-covid-19-prevention-and-control-in-schools-march-2020.pdf?sfvrsn= baf81d52_4

Patterns of posttraumatic stress disorder and posttraumatic growth among women after an earthquake: a latent profile analysis

What drives unverified information sharing and cyberchondria during the COVID-19 pandemic?

European citizens' use of E-health services: a study of seven countries

Internet addiction and cyberchondria. Their relationship with well-being

Why do people share fake news? Associations between the dark side of social media use and fake news sharing behavior

Information sharing and interoperability: the case of major incident management

What have we learned about communication inequalities during the H1N1 pandemic: a systematic review of the literature

Giving too much social support: social overload on social networking sites

Is boredom proneness related to social media overload and fatigue? A stress-strain-outcome approach

Mental health strategies to combat the psychological ımpact of COVID-19 beyond paranoia and panic

The effect of cognitive behavioral therapy on depression, anxiety, and stress in patients with COVID-19: a randomized controlled trial. Front Psychiatry

Efficacy of digital cognitive behavioural therapy for insomnia: a meta-analysis of randomised controlled trials