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Ying L, Yuyu D, Qinqin Z, Zhihuan Z. Quality of life and death anxiety among caregivers of patients with advanced cancer: the mediating effect of trait anxious personality and the moderating effect of social support. Support Care Cancer 2024; 32:471. [PMID: 38949725 DOI: 10.1007/s00520-024-08653-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 06/11/2024] [Indexed: 07/02/2024]
Abstract
PURPOSE To explore the mediating role of trait anxious personality in the association between quality of life (QoL) and death anxiety (DA), as well as to test the moderating effect of social support in the mediation model. METHODS The Death Anxiety Scale, Quality of Life Scale, State-Trait Anxiety Scale, and Social Support Rating Scale were used to measure 588 family caregivers of advanced cancer patients. We then constructed a moderated mediation model. RESULTS The presence of QoL was negatively associated with DA (β = - 0.67, p < 0.01). Trait anxious personality partially mediated the relationship between QoL and DA (indirect effect β = - 0.08, p < 0.01). Social support moderated both the antecedent and subsequent segments of the mediating paths of "QoL → trait anxious personality → DA" and the direct relationship between QoL and DA. Among caregivers with a low level of social support, the mediating effect coefficient of trait anxious personality was higher at 0.25 (95% confidence interval (CI): 0.059-0.182), in contrast to caregivers with a high level of social support, where the mediating effect coefficient of trait anxious personality was 0.11 (95% CI: 0.029-0.072). CONCLUSION QoL is directly associated with an increased risk of DA and indirectly related to DA by increasing the risk of trait anxious personality among caregivers. Social support can moderate the mediating effect of trait anxious personality and the relationship between QoL and DA. The intervention strategy for preventing DA among caregivers who have encountered QoL reduction should focus on reducing trait anxious personality and social support.
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Affiliation(s)
- Li Ying
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangdong, China
- Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, Guangdong, China
- Department of Neurosurgery, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China
| | - Duan Yuyu
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangdong, China
- Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, Guangdong, China
- Department of Neurosurgery, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China
| | - Zhao Qinqin
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangdong, China
- Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, Guangdong, China
- Department of Neurosurgery, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China
| | - Zhou Zhihuan
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangdong, China.
- Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, Guangdong, China.
- Department of Neurosurgery, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China.
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Wang Z, Yu S, Liu Y, Han Y, Zhao W, Zhang W. Effectiveness of family centred interventions for family caregivers: A systematic review and meta-analysis of randomized controlled trials. J Clin Nurs 2024; 33:1958-1975. [PMID: 38439168 DOI: 10.1111/jocn.17091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 01/11/2024] [Accepted: 02/19/2024] [Indexed: 03/06/2024]
Abstract
AIMS AND OBJECTIVES To examine the effectiveness of family-centred interventions among family caregivers. BACKGROUND Family-centred interventions are an emerging form of intervention that can be effective at improving physical and mental health outcomes for patients and family caregivers. To date, no reviews have examined the effectiveness of family-centred interventions for family caregivers. DESIGN A systematic review, including a meta-analysis, was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA 2020) checklist. METHODS Seven English and two Chinese electronic databases were compressively searched from the outset to March 2023. Two researchers independently reviewed the abstracts and full texts, extracted the data and assessed the risk of bias independently by using the Cochrane 'Risk of bias assessment tool'. RESULTS This systematic review and meta-analysis included 20 articles. The results of the meta-analysis showed that family-centred interventions could significantly improve caregiver burden (p=0.003), quality of life (p = 0.007), depression (p = 0.0002), and stress (p < 0.0001) but not anxiety or family functioning. According to our subgroup analysis, the family-centred empowerment model (p = 0.009) was superior to the other family intervention (p=0.004) in reducing caregiver burden. Family-centred interventions are more effective at reducing the burden of caregiving on family caregivers of adolescent patients (SMD=-0.79, 95% CI[-1.22,-0.36], p = 0.0003) than on adult patients (SMD=-0.37, 95% CI [-0.61,-0.12], p = 0.004). CONCLUSIONS Family-centred interventions could enhance family caregivers' burden, quality of life, stress and depression but had no significant impact on anxiety or family functioning. RELEVANCE TO CLINICAL PRACTICE Family-centred interventions have the potential to improve the health status and caregiving burden of family caregivers. Rigorous and high-quality evidence is needed to confirm the long-term effects of these interventions on family caregivers. TRIAL REGISTRATION DETAILS The protocol has been registered in the PROSPERO international prospective register of systematic reviews (Protocol registration ID: CRD42023453607).
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Affiliation(s)
- Ziqi Wang
- School of Nursing, Jilin University, Changchun, China
| | - Shuanghan Yu
- School of Nursing, Jilin University, Changchun, China
| | - Yantong Liu
- School of Nursing, Jilin University, Changchun, China
| | - Yujie Han
- School of Nursing, Jilin University, Changchun, China
| | - Wei Zhao
- School of Nursing, Jilin University, Changchun, China
| | - Wei Zhang
- School of Nursing, Jilin University, Changchun, China
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Low NJH, Leow DGW, Klainin-Yobas P. Effectiveness of Technology-Based Psychosocial Interventions on Psychological Outcomes Among Adult Cancer Patients and Caregivers: A Systematic Review and Meta-Analysis. Semin Oncol Nurs 2024; 40:151533. [PMID: 37977974 DOI: 10.1016/j.soncn.2023.151533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE Technology-based psychosocial interventions (TBPIs) have increasingly gained intention. However, the effectiveness of TBPIs on psychological outcomes remains inconclusive. This review aimed to evaluate the effectiveness of TBPIs on health-related quality of life (HRQOL), coping, self-efficacy, and depression among adult cancer patients and caregivers. DATA SOURCES Randomised controlled trials (RCTs) evaluating the effectiveness of TBPIs targeting adult cancer patients, caregivers, or patient-caregiver dyads were included. English articles dated from 2012 to 2022 were retrieved from eight electronic databases, three clinical trial registries, and six grey literature databases. Two reviewers independently screened, appraised, and extracted data. The Cochrane risk of bias assessment tool and GRADE were used to appraise the methodological quality of included studies. Meta-analyses and subgroup analyses were undertaken with statistical pooling of standardized mean differences based on the random-effects model. CONCLUSION Totally, 37 RCTs were included in the review, with 35 trials for meta-analysis. Results demonstrated improvements in HRQOL, self-efficacy, and depression among cancer patients and caregivers with varying pooled effect sizes. Subgroup analyses suggested that dyadic TBPIs were more effective in improving HRQOL among cancer patients and caregivers, compared with those solely targeted at cancer patients or caregivers. IMPLICATION FOR NURSING PRACTICE Findings value-added to the existing evidence base on TBPIs. An interactive patient-caregiver dyadic program integrating TBPIs into routine oncology care is recommended to improve health outcomes for cancer patients and caregivers. Well-designed future RCTs are required to further evaluate the effectiveness of dyadic TBPIs, with emphasis on coping and self-efficacy outcomes among cancer patients and caregivers.
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Affiliation(s)
| | - Darryl Ge Wei Leow
- Staff Nurse, Woodlands Health Campus, Yishun Community Hospital, Singapore
| | - Piyanee Klainin-Yobas
- Associate Professor, Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore
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Liu X, Wang C, Li Y, Wang Y. Effects of cognitive behavioral and psychological intervention on social adaptation, psychological resilience and level of hope in patients with nasopharyngeal carcinoma in radiotherapy. Pak J Med Sci 2024; 40:95-100. [PMID: 38196484 PMCID: PMC10772449 DOI: 10.12669/pjms.40.1.7421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/27/2023] [Accepted: 08/30/2023] [Indexed: 01/11/2024] Open
Abstract
Objective To evaluate the effects of cognitive behavioral and psychological intervention(CBPI) on social adaptation, psychological resilience, and the level of hope in patients with nasopharyngeal carcinoma(NPC) in radiotherapy. Methods This is application research. Eighty patients undergoing radiotherapy for NPC at Affiliated Hospital of Hebei University from November 20, 2020 to November 15, 2022 were randomized into control and study groups at a 1:1 ratio. While the control group was provided with standard specialized nursing care, the study group was offered CBPI in addition to the exact nursing care. Differences in quality of life, psychological resilience, level of hope, emotional state, and patient satisfaction between the groups were compared and analyzed before and after treatment. Results After an intervention, significantly improved physical, mental, and social functions and material living conditions were observed in the study group compared with the control group (all p< 0.05). Although both groups scored higher on the selected psychological resilience scale following the intervention, the study group showed better results as compared to control group in adaptability, tenacity, control, and goal orientation (all p< 0.05). While both groups had elevated scores of temporality and future, interconnectedness, and positive readiness and expectancy at the end of the intervention, the improvements were more pronounced in the study group (all p< 0.05). Conclusion CBPI supports radiotherapy for NPC by improving patients' quality of life, confidence in treatment, the hope of recovery, psychological resilience, anxiety, depression, and patient satisfaction. Therefore, this treatment strategy is worthy of wide application in clinical settings.
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Affiliation(s)
- Xiaohui Liu
- Xiaohui Liu, Department of Radiotherapy, Affiliated Hospital of Hebei University, Baoding 071000, Hebei China
| | - Ce Wang
- Ce Wang, Department of Radiotherapy, Affiliated Hospital of Hebei University, Baoding 071000, Hebei China
| | - Yanhong Li
- Yanhong Li, Department of Radiotherapy, Affiliated Hospital of Hebei University, Baoding 071000, Hebei China
| | - Yue Wang
- Yue Wang, Department of Radiotherapy, Affiliated Hospital of Hebei University, Baoding 071000, Hebei China
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Okeke NM, Onah BN, Ekwealor NE, Ekwueme SC, Ezugwu JO, Edeh EN, Okeke PM, Ndille R, Onwuadi CC, Amedu AN, Nwaogaidu JC, Nnamani RG, Okolie CN, Okoro K, Solomon KC, Owonibi OE. Effect of a religious coping intervention of rational emotive behavior therapy on mental health of adult learners with type II diabetes. Medicine (Baltimore) 2023; 102:e34485. [PMID: 37773818 PMCID: PMC10545252 DOI: 10.1097/md.0000000000034485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/03/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Some previous studies have highlighted the high rate of mental health problems associated with type II diabetes (T2DM). The primary purpose of this study was to investigate the effect of a religious coping intervention of rational emotive behavior therapy (REBT) on the mental health of adult learners with T2DM. METHODS This study utilized a randomized controlled trial to select 146 adult learners with T2DM and mental health-related problems. The treatment group was made up of 73 adult learners, while the control group was also made up of 73 adult learners. The experimental group received 8 sessions of a religious coping intervention of REBT, while the control group received usual care. Data were collected using the patient health questionnaire, Warwick-Edinburgh mental well-being scale, and Kessler psychological distress scale. Repeated ANOVA and univariate analysis of covariance were used for data analyses. RESULTS The religious coping intervention of REBT substantially enhanced the mental health of adult learners with T2DM as measured by Warwick-Edinburgh mental well-being scale (P < .000) and patient health questionnaire (P < .000). The religious coping intervention of REBT significantly alleviated the psychological distress of adult learners with T2DM as measured by Kessler psychological distress scale (P < .000). CONCLUSION In this study, it has been demonstrated that a religious coping intervention of REBT effectively improves the mental health of adult learners with T2DM. The study concludes that the religious coping intervention of REBT is a practical alternative medicine approach to enhancing the mental health of adult learners with T2DM.
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Affiliation(s)
- Nkechi Mercy Okeke
- Department of Adult Education & Extra-Mural Studies, University of Nigeria, Nsukka, Enugu State, Nigeria
| | - Beatrice N. Onah
- Department of Adult Education & Extra-Mural Studies, University of Nigeria, Nsukka, Enugu State, Nigeria
| | - Nwakaego Ebele Ekwealor
- Department of Adult Education & Extra-Mural Studies, University of Nigeria, Nsukka, Enugu State, Nigeria
| | | | | | - Esther Nwarube Edeh
- Department of Adult Education & Extra-Mural Studies, University of Nigeria, Nsukka, Enugu State, Nigeria
| | - Polycarp M.D. Okeke
- Department of Adult Education & Extra-Mural Studies, University of Nigeria, Nsukka, Enugu State, Nigeria
| | - Roland Ndille
- Department of History, University of Buea Cameroon, Buea, Cameroon
| | - Charles C. Onwuadi
- Department of Adult Education & Extra-Mural Studies, University of Nigeria, Nsukka, Enugu State, Nigeria
| | - Amos N. Amedu
- Department of Educational Psychology, University of Johannesburg, Johannesburg, South Africa
| | - John Chidubem Nwaogaidu
- Institute of African Studies/Department of Sociology and Anthropology, University of Nigeria, Nsukka, Enugu State, Nigeria
| | | | - Charles Nkem Okolie
- Department of Philosophy and Religious and Cultural Studies, Alex Ekwueme Federal University Ndufu-Alike Ikwo, Ebonyi State, Nigeria
| | - Kingsley Okoro
- Department of Philosophy and Religious and Cultural Studies, Alex Ekwueme Federal University Ndufu-Alike Ikwo, Ebonyi State, Nigeria
| | - Kingsley Christopher Solomon
- Department of Philosophy and Religious and Cultural Studies, Alex Ekwueme Federal University Ndufu-Alike Ikwo, Ebonyi State, Nigeria
| | - Ola Elizabeth Owonibi
- Department of Sociology, Ibrahim Badamasi Babangida University, Lapai, Niger State, Nigeria
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Tan Y, Wu Z, Qu X, Liu Y, Peng L, Ge Y, Li S, Du J, Tang Q, Wang J, Peng X, Liao J, Song M, Kang J. Influencing Factors of International Students’ Anxiety Under Online Learning During the COVID-19 Pandemic: A Cross-Sectional Study of 1,090 Chinese International Students. Front Psychol 2022; 13:860289. [PMID: 35496158 PMCID: PMC9046590 DOI: 10.3389/fpsyg.2022.860289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/28/2022] [Indexed: 12/12/2022] Open
Abstract
Objective We conducted the following cross-sectional study to comprehensively assess the anxiety among Chinese international students who studied online during the COVID-19 pandemic and its influencing factors. Methods Questionnaires were distributed through “Sojump,” and a total of 1,090 valid questionnaires were collected. The questionnaire was divided into two parts: general situation and anxiety assessment of students. The former used a self-made questionnaire, and the international general GAD-7 scale was used to measure anxiety. Chi-square test was used to analyze the differences between groups, and logistic regression analysis was performed for the factors with differences. Results Anxiety was found in 707 (64.9%) of 1,090 international students. Chi-square test and multivariate Logistic regression analysis showed that the incidence of anxiety was higher in the group under 22 years of age than in the group over 22 years of age (68% vs. 61%, p = 0.015; OR = 1.186, 95% CI 1.045–1.347, p = 0.008); International students living in big cities had a higher incidence of anxiety than those living in rural areas (67% vs. 60%, p = 0.022; OR = 1.419, 95%CI 1.038–1.859, p = 0.011); international students who socialized 3 times or less monthly had a higher incidence of anxiety than those who socialized more than 3 times per month (68% vs. 58%, p = 0.003; OR = 1.52, 95%CI 1.160–1.992, p = 0.002); international students who expected purely online teaching had a higher incidence of anxiety than those who expected purely offline teaching or dual-track teaching (72% vs. 64%, p = 0.037; OR = 1.525, 95%CI 1.069–2.177, p = 0.02); international students with a subjective score of online learning experience of 6 or less had a higher incidence of anxiety than those with subjective scores of more than 6 (70% vs. 60%, p = 0.001, OR = 1.25, 95%CI 1.099–1.422, p = 0.001). However, gender, emotional status, BMI, major of study, vaccination status, and degree type had no significant difference in the incidence of anxiety among international students who studied online during the COVID-19 pandemic. Conclusion During COVID-19, international students who were younger, came from big cities, had low social frequency, expected purely online teaching, and had poor experience of online classes were risk factors for anxiety during online classes.
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Affiliation(s)
- Yejun Tan
- Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, China
- School of Mathematics, University of Minnesota Twin Cities, Minneapolis, MN, United States
| | - Zhijian Wu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | | | - Yuzhuo Liu
- Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Lele Peng
- Department of Endocrinology, Wangwang Hospital of Hunan, Changsha, China
| | - Yan Ge
- Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Shu Li
- Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jinfeng Du
- Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Qi Tang
- Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jia Wang
- Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xiaofei Peng
- Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jiafen Liao
- Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Meiyan Song
- Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jin Kang
- Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, China
- *Correspondence: Jin Kang,
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The Effectiveness of e-Health Interventions on Caregiver Burden, Depression, and Quality of Life in Informal Caregivers of Patients with cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Int J Nurs Stud 2022; 127:104179. [DOI: 10.1016/j.ijnurstu.2022.104179] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 01/19/2023]
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Zou C, Zhang W, Sznajder K, Yang F, Jia Y, Ma R, Cui C, Yang X. Factors Influencing Anxiety Among WeChat Users During the Early Stages of the COVID-19 Pandemic in Mainland China: Cross-sectional Survey Study. J Med Internet Res 2021; 23:e24412. [PMID: 33878025 PMCID: PMC8130820 DOI: 10.2196/24412] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/28/2020] [Accepted: 04/17/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The rapid outbreak of COVID-19 around the world has adversely affected the mental health of the public. The prevalence of anxiety among the public has increased dramatically during the COVID-19 pandemic. However, there are few studies evaluating the effects of positive psychological responses and information-seeking behaviors on anxiety experienced among social media users during the COVID-19 pandemic. OBJECTIVE This study evaluated the prevalence of anxiety and its associated factors among WeChat users in mainland China during the early stages of the COVID-19 pandemic. METHODS From February 10 to February 24, 2020, a nationwide, web-based cross-sectional survey study was carried out using convenience sampling. Participants' levels of anxiety, positive psychological responses, and information-seeking behaviors were assessed. The survey was distributed among WeChat users via the WeChat smartphone platform. Chi-square tests and multivariable logistic regression analyses were performed to examine the factors associated with anxiety. RESULTS This study found that the prevalence of anxiety (Generalized Anxiety Disorder 7-item [GAD-7] scale score ≥7) among WeChat users in China was 17.96% (446/2483) during the early stages of the COVID-19 pandemic. Results of multivariable logistic regression analysis showed that information-seeking behaviors such as cannot stop searching for information on COVID-19, being concerned about the COVID-19 pandemic, and spending more than 1 hour per day consuming information about the pandemic were found to be associated with increased levels of anxiety. Additionally, participants who chose social media and commercial media as the primary sources to obtain information about the COVID-19 pandemic were found more likely to report anxiety. Conversely, participants who were confident or rational about the COVID-19 pandemic were less likely to report anxiety. CONCLUSIONS This study found that positive psychological responses and information-seeking behaviors were closely associated with anxiety among WeChat users during the COVID-19 pandemic in China. It might be paramount to enhance mental well-being by helping people respond to the COVID-19 pandemic more rationally and positively in order to decrease symptoms of anxiety.
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Affiliation(s)
- Changqing Zou
- Department of Humanities and Social Sciences, China Medical University, Shenyang, China
| | - Weiyu Zhang
- Department of Social Medicine, School of Public Health, China Medical University, Shenyang, China
| | - Kristin Sznajder
- Department of Public Health, College of Medicine, Pennsylvania State University, Philadelphia, PA, United States
| | - Fengzhi Yang
- Department of Social Medicine, School of Public Health, China Medical University, Shenyang, China
| | - Yajing Jia
- Department of Social Medicine, School of Public Health, China Medical University, Shenyang, China
| | - Ruqing Ma
- Department of Social Medicine, School of Public Health, China Medical University, Shenyang, China
| | - Can Cui
- Department of Social Medicine, School of Public Health, China Medical University, Shenyang, China
| | - Xiaoshi Yang
- Department of Social Medicine, School of Public Health, China Medical University, Shenyang, China
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