key: cord-0893858-bvlefso5 authors: Gong, Wei Jie; Sit, Shirley Man Man; Wong, Bonny Yee Man; Wu, Socrates Yong Da; Lai, Agnes Yuen Kwan; Ho, Sai Yin; Wang, Man Ping; Lam, Tai Hing title: Associations of Face-to-Face and Instant Messaging Family Communication and Their Contents With Family Wellbeing and Personal Happiness Amidst the COVID-19 Pandemic date: 2022-03-29 journal: Front Psychiatry DOI: 10.3389/fpsyt.2022.780714 sha: 532bf0a41df2d1e47aa069d69d1d867b1503e919 doc_id: 893858 cord_uid: bvlefso5 BACKGROUND: Both face-to-face and instant messaging (IM) communication are important for families, but face-to-face communication has reduced amidst the COVID-19 pandemic. We examined the use and contents of both communication methods amidst the pandemic, their associations with family wellbeing and personal happiness, and the mediation effects of communication quality in Hong Kong Chinese adults. METHODS: This population-based online survey enrolled 4,921 respondents in May 2020, who reported (i) any face-to-face or IM family communication when the pandemic was severe; (ii) communication contents being classified as neutral, positive, supportive, and negative; and (iii) communication quality, family wellbeing and personal happiness (score 0–10). Associations of family wellbeing and personal happiness with communication methods and contents (no communication excluded) were examined using linear regressions (β), adjusting for each other, sex, age, socioeconomic status, and the number of cohabitants. Mediating effects of communication quality on these associations were examined. Prevalence estimates were weighted by sex, age, and education of the general population. Interactions of methods and contents were examined. RESULTS: Of 4,891 included respondents (female: 52.9%, 45–54 years: 37.7%, ≥65 years: 21.3%), 7.1% reported no communication, 12.7% face-to-face communication only, 26.7% IM only, and 53.4% both methods. More males and those at younger ages, had lower socioeconomic status, or fewer cohabitants showed no family communication or face-to-face only. More respondents reported neutral (83.1–99.3%) than positive (42.1–62.2%), supportive (37.5–54.8%), and negative (10.9–34.5%) contents despite communication methods. Communication quality was higher with both methods than IM only, face-to-face only, and no communication (scores: 6.7 vs. 4.5–6.6, all P ≤ 0.02). Better family wellbeing and personal happiness were associated with using IM only (adjusted βs: 0.37 and 0.48) and both methods (0.37 and 0.42) than face-to-face only, and positive (0.62 and 0.74) or supportive (0.45 and 0.46) contents (all P ≤ 0.001). Communication quality mediated 35.2–93.5% of these associations. Stronger associations between positive contents and family wellbeing showed in both methods and face-to-face only than IM only (P for interaction = 0.006). CONCLUSIONS: We have first shown that, amidst the COVID-19 pandemic, family IM communication and positive and supportive contents may promote family wellbeing and personal happiness. People with no family communication may need assistance. The Hong Kong Jockey Club SMART Family-Link project (2018-2022) is a large cross-sectoral collaboration between The University of Hong Kong and 26 local family service providers, aiming to advance information and communication technology (ICT) use in family services and to promote family wellbeing and happiness in local people (27) . Under this project, the Family amidst COVID-19 survey (FamCov1) was designed to examine ICT related behaviors, attitudes and concerns toward the COVID-19 pandemic, and personal and family wellbeing in Hong Kong families. It was a population-based, cross-sectional survey conducted during 26-31 May 2020 to recruit a sample as large as possible within 6 days when the second wave of COVID-9 outbreak was under control. The target population was Chinese adults in Hong Kong aged 18 years or above who can read and write in Traditional Chinese. Those who were psychologically or physically unable to complete the whole online questionnaires were excluded. Email invitations to join the online survey were sent to both probability and non-probability-based online panels of the Hong Kong Public Opinion Research Institute, a well-known local survey agency (28) . Respondents voluntarily answered the questionnaires with no incentive. Among the 20,103 opened invitation emails, 4,921 (24.5%) respondents completed the whole survey. After excluding 30 respondents that had no family members, 4,891 respondents (99.4%) were included in this study. Details of the methods have been reported in three of our papers using the same data (3, 16, 29) , showing that the perceived benefits and harms of COVID-19 were associated with sociodemographic factors (3) , the fear of COVID-19 showed socioeconomic differences and was associated with perceived benefits and harms of COVID-19 (29) , and that the use of different IM functions in family e-chat groups amidst the pandemic was associated with family wellbeing and personal happiness (16) . Ethics approval was obtained from the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (Reference Number: UW 20-238). All respondents gave informed consent before starting the survey. This study was carried out in accordance with the Declaration of Helsinki and all its amendments. The definitions of family ("family members who are related through biological, marital, cohabitation, or/and emotional bonding") and IM e-chat group ("a group of 3 or more people in IM communication applications such as WhatsApp or WeChat, etc.") were given before related questions. Faceto-face communication with family was asked by the question, "When the pandemic was severe, on average per week, how many days did you communicate face-to-face with family members?". Respondents answering 0 days or 1-7 days were regarded as either having none or had face-to-face communication with family, respectively. IM communication was asked by two questions, "When the pandemic was severe, on average per week, how many days did you receive/send instant messages from/to family members in family e-chat groups?". Respondents answering 0 days for both questions or 1-7 days for one/both questions were regarded as having none or had IM communication with family, respectively. The corresponding contents of face-to-face and IM were asked using multiple-choice questions, "When the pandemic was severe, what contents did you communicate face-toface with family members?" or "When the pandemic was severe, what contents in the instant messages you receive or send from/to family members in family e-chat groups?". The answers include COVID-19-related information, self/familyrelated things in daily life, self/family-related and unrelated happy/funny things, and related unhappy things, showing care, encouragement, appreciation, good wishes, other health information, and others (e.g., daily life information, news, and current affairs, etc.,). Family communication quality was measured using a single item, "How do you find the quality of communication between you and your family members?", which has been used in our previous study (30) . Family health, harmony, and happiness (3Hs) were measured using the Family Wellbeing Scale, with validity shown in our previous studies (7, 31) . Family wellbeing was calculated as the average score of family 3Hs. Personal happiness was examined using a single item, "How happy do you think you are, "with reliability and validity shown in previous surveys (32) . All outcomes were measured on an 11-point scale (score 0-10), with higher scores indicating better outcomes, which allows more differentiation of the answers than Likert scales with fewer options (33) . Information on sociodemographic characteristics was collected, including sex, age group (18-24 years, 25-34 years, 45-64 years, and 65 years or above), education (primary or below, secondary, post-secondary, and university or above), monthly household income (no income, less than HK$ 4,000, HK$ 4,000-9,999, HK$ 10,000-19,999, HK$ 20,000-29,999, HK$ 30,000-39,999, and HK$ 40,000 or higher) (US$ 1.0 = HK$ 7.8), housing type (rented and owned), and household size (number of cohabitants, including the respondent). Education was dichotomized as secondary or below and tertiary. Monthly household income per person (income being divided by household size) was dichotomized as lower and higher using the median household income and household size of the 2019 Hong Kong census data (34). Socioeconomic status was calculated as a composite score of education (0 = secondary or below, 1 = tertiary), income (0 = lower, 1 = higher), and housing (0 = rented, 1 = owned) and analyzed as low (0-1), medium (2) , and high (3) . Communication methods were divided into four groups, including no communication, face-to-face only, IM only, and both methods. Contents in Frequencies may not add up tp the total numbers after weighting. b Socioeconomic status: a composite score of education (0 = secondary or below, 1 = tertiary), income (0 = lower, 1 = higher), and housing (0 = rented, 1 = owned), analyzed as low (0-1), medium (2) and high (3). c Pairwise comparisons using Chi-square test for categorical variables and t-test for continuous variables with Bonferroni adjusted level of significance: 0.05/3 = 0.017. d Score 0-10, higher scores indicate better outcomes. family communication were divided into four groups by their affective interpretation, including neutral (self/family-related things in daily life, COVID-19-related information, other health information, and others, e.g., daily life information, news, and current affairs, etc.,), positive (self/family-related and unrelated happy/funny things), supportive (showing care, encouragements, appreciations, and good wishes) and negative (self/family-related unhappy things) contents. Among them, neutral, positive, and negative contents have been used before (35, 36) . We especially distinguished supportive from positive contents, because Chinese people tend to have implicit and indirect expressions instead of direct verbal expressions of supportive contents (37) (38) (39) . The raw data and prevalence estimates were weighted by sex, age, and educational attainment of the 2019 Hong Kong census data (40, 41) . Pairwise comparisons using Chi-square tests for categorical variables and t-tests for continuous variables were used to compare the characteristics and outcomes of respondents having no family communication, face-to-face only, and IM only with those using both methods, and to compare the contents in the following 3 pairs of communication methods: face-toface only vs. IM only, both methods vs. face-to-face only, and both methods vs. IM only, with Bonferroni adjusted level of significance (0.05/3 = 0.017). Adjusted regression coefficients (βs) and their 95% confidence intervals (CIs) were estimated using multivariable linear regressions to estimate the associations of outcomes, including family wellbeing and personal happiness, with the four communication methods in Model I, with the four kinds of contents in Model II, and with both methods and contents in Model III, adjusted for sex, age groups, socioeconomic status, and the number of cohabitants. People having no family communication were excluded in Model II and Model III. Based on model III, we additionally examined the mediating effects of family communication quality on these associations using the Baron and Kenny approach (42) , and whether the mediating (indirect) effects were significant were examined using the Sobel tests. The bias-corrected bootstrap CIs of the total, indirect and direct effects were calculated with 1,000 replications, adjusted for sex, age group, socioeconomic status, and the number of cohabitants. The moderating effects of communication methods on the associations of contents with outcomes were examined by additionally including the interaction terms of methods and contents in corresponding regression models. A 2-sided P < 0.05 was considered statistically significant. All statistical analyses were performed using STATA version 15.0 (StataCorp LP, College Station, TX, USA). Of the 4,891 respondents included in this study, after weighting, 52.9% of them were female, with the mean age of 43.5 years (37.7% aged 45-64 years and 21.3% aged ≥65 years). Details of their sociodemographic characteristics have been previously reported (3, 29) . Table 1 shows that after weighting, over half of respondents (53.4%) communicated with family members using both methods (face-to-face and IM messages), followed by IM only (26.7%), face-to-face only (12.7%), and no family communication (7.1%). Compared with those using both CI, Confidence interval; IM, Instant messaging. * P < 0.05. ** P < 0.01. *** P < 0.001. a Score 0-10, higher scores indicate better outcomes, β is the score versus that for face-to-face only as reference. Table 2 shows that after weighting, in face-to-face communication, self/family-related things in daily life (79.5%) were the most frequent contents, followed by information of COVID-19 (78.2%), self/family-related happy/funny things (47.1%), others (e.g., daily life information, news, and current affairs, etc.,) (46.0%), showing care (42.8%), other health information (30.8%), self/family-related unhappy things (29.3%), self/family-unrelated happy/funny things (26.9%), encouragements (14.9%), appreciations (12.1%), and good wishes (11.9%). In IM messages, information of COVID-19 (80.6%) was the most common contents, followed by self/family-related things in daily life (59. 19 .4%) but more supportive contents (53.7 vs. 37.5%) (all P < 0.001). Using both methods included higher percentages of almost all contents than using one method only (all P ≤ 0.02) except good wishes compared with IM only (18.9 vs. 20.1%, P = 0.36). In general, using both methods contained more neutral, positive, and negative contents than using one method only (P < 0.001), except supportive contents (both 54.8% vs. IM only 53.7%) (P = 0.54). Table 3 shows that after excluding those with no communication, when communication methods and contents were included in the same models, compared with using face-toface communication only, using IM only and using both methods Table 4) . Communication methods moderated the associations of positive contents with family wellbeing (P for interaction=0.006) (Figure 1) . Positive contents had stronger associations with better family wellbeing in using both methods (estimated score changes: 0.71, 95% CI: 0.57-0.85) and face-to-face only (0.78, 95% CI: 0.53-1.03) than in IM only (0.37, 95% CI: 0.18-0.56) (P = 0.004 and 0.009, respectively). This is the first study to report family communication methods and contents were independently associated with family communication quality, family wellbeing, and personal happiness, showing that better family wellbeing and personal happiness were associated with using IM only and both methods than face-to-face communication only, and were associated with having positive and supportive contents in family communication. About half to almost all these associations were mediated by communication quality. Communication methods moderated the association between positive contents and family wellbeing, showing stronger associations of family wellbeing with both methods and face-to-face only than IM only. These results are consistent with our three hypotheses. Our results highlight the importance of using IM messages infodemic, pandemic fear, and mental health burdens (50, 51) . Previous studies have linked positive and supportive contents with confidence and competence among family members, while negative contents such as criticism were associated with lower self-esteem and defiance (20, 52) . While open and direct expression of affection, both verbal and non-verbal, are encouraged in Western families (53) , such as saying "I love you", this is not common in Chinese households, where strong emotions are typically held back, stemming from a historical emphasis on the regulation of social behaviors and expression of emotions (54, 55) . Such differences can also be observed in the discussion of funny and humorous topics within families (56) . Considering the relatively low weighted percentages of positive and supportive contents (positive: 42.1-62.2%; supportive: 37.5-54.8% vs. neutral: 83.1-99.3%), increasing these contents through IM first may lead to increased use in face-to-face communication, which may promote family wellbeing and personal happiness. Intervention studies on IM use to deliver such contents to promote family and individual wellbeing are warranted. The moderating effect of communication methods showed that positive contents in face-to-face communication only and both methods were more strongly associated with better family wellbeing than in IM messages, suggesting that sharing self/family-related and unrelated happy/funny things by IM only may be less effective for maintaining and nourishing family relationships. In face-to-face communication, non-verbal language, such as laughter and smiles, can give real-time positive feedbacks and immediately create a happy and enjoyable atmosphere (57) . According to the attachment theory, pleasant and frequent interactions with others contribute to individual mental and emotional wellbeing (45) , which may evoke better family wellbeing in family communication. The mediation effects of family communication quality can provide new evidence to Prime and Wade's framework (4) . Amidst the COVID-19 pandemic, family communication provides clear information, emotional sharing, collaborative problem-solving, and dyadic and family coping to connect family members and share beliefs. Quality communication, such as using both face-to-face and IM communication and including positive or supportive contents, can thus provide security and hope for vulnerable members during periods of stress (4), shown as higher perceived family wellbeing and personal happiness in the present study. In Hong Kong, the most westernized city in China, the high penetration rate of smartphones (91.5% in 2019) and the Internet (87.0% in 2019) means most people can conveniently use social media and IM messages (58, 59) . With 93.6% of the population being Chinese, Hong Kong people highly value family relationships, which are influenced by collectivism and Confucius ideals in traditional Chinese culture (31) . However, we found that 7.1% of people had no family communication and they reported the lowest family communication quality, family wellbeing, and personal happiness. They tended to be in low socioeconomic status and could be vulnerable and more adversely impacted by the pandemic than others. This is an example of digital inequality, shown as the inequality in terms of access, usage, skills, and self-perceptions to digital engagement in individual and macrolevel domains (60) . Urgent attention and assistance should be given to these vulnerable people from policymakers and social welfare organizations. Our study had some limitations. First, recall bias and social desirability bias could not be avoided in self-administered questionnaires. However, the use of communication methods and contents in family communication when the pandemic was severe was asked during the easing period of the pandemic, and recall errors would be little within such recent time periods. We used an online survey via emails without interviewers, which could help reduce social desirability bias (61) . Second, although we tried to provide a clearer temporal sequence by asking the perceived outcomes during the easing period and the communication methods and contents during an earlier period when the pandemic was severe, due to the crosssectional observational study design, we could not rule out reverse causality. Future prospective studies are needed to verify the associations and mediation effects we observed. Also, systematic bias due to residual confounding might exist. For example, people having face-to-face communication only could be lack of health literacy to share digital information with family, while sharing family life information through ICT tools were found to be associated with family wellbeing (17) . Also, those having IM only might live separately with their family so face-to-face communication was unavailable. Such separation from family, especially amidst the pandemic, could lead to low family wellbeing or personal happiness. Third, as the COVID-19 pandemic changes rapidly and unpredictably, we tried to collect the largest possible sample within a short period, non-response bias could be present as younger and better-educated respondents were included. Generalization could be limited. Finally, details of the contents were not asked, and more in-depth information should be collected in future studies. We have first shown that, amidst the COVID-19 pandemic, better family wellbeing and personal happiness were associated with family communication using IM only and both methods than face-to-face only, and with positive and supportive contents. These associations were partially or almost fully mediated by communication quality. Family IM communication and positive and supportive contents may promote family wellbeing and personal happiness. People with no family communication may need urgent attention and assistance. Prospective studies are needed to verify the associations and mediations. The dataset presented in this article is not readily available because the sharing of data to third parties was not mentioned in subjects' consent. Requests to access the dataset can be directed to the corresponding author. The studies involving human participants were reviewed and approved by Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (Reference Number: UW 20-238). Informed consent was obtained from all participants included in this study. WG and SS: formal analysis and writing-original draft. BW: data curation, project administration, and writingreview and editing. SW: methodology and writing-review and editing. AL: conceptualization and writing-review and editing. SH: conceptualization, methodology, and writingreview and editing. MW and TL: supervision, conceptualization, and writing-review and editing. All authors participated in the critical review of this study and provided final approval for publication submission. This study was funded by the Hong Kong Jockey Club Charities Trust. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China Canadian Perspectives Survey Series 1: Impacts of COVID-19 Perceived benefits and harms of the COVID-19 pandemic on family well-being and their sociodemographic disparities in Hong Kong: a cross-sectional study Risk and resilience in family wellbeing during the COVID-19 pandemic Critical theorizing in family communication studies: (Re) reading relational dialectics theory 2.0. Commun Theor Family Communication: Cohesion and Change Perspectives on family health, happiness and harmony (3H) among Hong Kong Chinese people: a qualitative study Family-centered care during the COVID-19 era Guardian Community Team. Tell us: Has Your Family Been Separated by Covid? : The Guardian Examining the impacts of the COVID-19 pandemic on family mental health in Canada: findings from a national cross-sectional study Changes in digital communication during the COVID-19 global pandemic: implications for digital inequality and future research Internet use and well-being: a survey and a theoretical framework Use of social network sites and instant messaging does not lead to increased offline social network size, or to emotionally closer relationships with offline network members Effects of duration and laughter on subjective happiness within different modes of communication Association of mobile instant messaging chat group participation with family functioning and well-being: population-based cross-sectional study Family e-chat group use was associated with family wellbeing and personal happiness in Hong Kong adults amidst the COVID-19 pandemic Sharing family life information through video calls and other information and communication technologies and the association with family well-being: Population-based survey Using information and communication technologies for family communication and its association with family well-being in Hong Kong: FAMILY project Circumplex model of marital and family systems Parents' use of praise and criticism in a sample of young children seeking mental health services The role of the family's emotional climate in the links between parent-adolescent communication and adolescent psychosocial functioning Consuming information related to COVID-19 on social media among older adults and its association with anxiety, social trust in information, and COVID-safe behaviors: Cross-sectional telephone survey Available online at New Normal" for Many Older Adults is on the Internet COVID-19 has Significantly Increased the Use of Many Technologies Among Older Canadians: Poll Available online at Fear of COVID-19 and its associations with perceived personal and family benefits and harms in Hong Kong The association of problematic smartphone use with family well-being mediated by family communication in Chinese adults: a population-based study Testretest reliability and validity of a single-item self-reported family happiness scale in Hong Kong Chinese: findings from Hong Kong Jockey club FAMILY project Measuring happiness with a single-item scale Census and Statistics Department. Table E034: Median Monthly Domestic Household Income of Economically Active Households by Household Size Determining the sentiment of opinions Does neutral affect exist? How challenging three beliefs about neutral affect can advance affective research Sociolinguistic competence in the complimenting act of native Chinese and American English speakers: a mirror of cultural value Understanding Chinese immigrant and European American mothers' expressions of warmth Verbal and nonverbal methods for expressing appreciation in friendships and romantic relationships: a cross-cultural comparison Table 002: Population by Age Group and Sex The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations Enacting intimacy and sociality at a distance in the COVID-19 crisis: the sociomaterialities of homebased communication technologies Shades of lightweight: supporting cross-generational communication through home messaging Understanding individual adoption of instant messaging: An empirical investigation Playfulness in mobile instant messaging: examining the influence of emoticons and text messaging on social interaction Social interactions across media: interpersonal communication on the Internet, telephone and face-to-face Stressful life events and depressive symptoms: social support and sense of control as mediators or moderators? Digital media and depressive symptoms among Chinese adolescents: a cross-sectional study Pandemic fear" and COVID-19: mental health burden and strategies Psychosocial impact of COVID-19 Intimate Relationships Parent-adolescent communication and the circumplex model Culture change and affectionate communication in China and the United States: evidence from google digitized books 1960-2008 Culture and emotion regulation To be or not to be humorous? Cross vultural perspectives on humor Emotion recognition in nonverbal face-to-face communication Thematic household survey report No. 69: Personal computer and Internet penetration Internet Penetration rate in Hong Kong From Digital inequalities and why they matter Social desirability bias We would like to thank the Hong Kong Public Opinion Research Institute for the fieldwork and the Jockey Club SMART Family-Link Project team. The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.