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“… The Beach Boys weren’t just a fun 1960s surf band …Once you’ve absorbed [Pet Sounds], you find yourself going back through songs like ‘Don’t Worry Baby,’ ‘The Warmth of the Sun,’ and ‘I Get Arou...

Objectives: Efforts to educate men about the controversy surrounding prostate cancer screening are well intended but rarely evaluated rigorously. We evaluated an evidence-based (EB) booklet for men designed to promote informed decision-making. We also determined whether men's preference for involvement in decision-making ("passive", "collaborative" or "active") modified its impact. Setting and methods: Men aged 40-70 years were recruited from the practices of 13 local general practitioners (GPs) in Sydney, Australia. They completed a self-administered questionnaire before seeing their GP, who, according to pre-randomised codes, distributed either our EB booklet or conventional information. Post-test questionnaires were mailed to men three days later. Of the 248 eligible men recruited, 214 (86% response rate) returned post-test questionnaires. Knowledge of evidence and of risk of developing and dying from prostate cancer, attitudes, interest in screening for prostate-specific antigen (PSA), worry and decisional conflict were the main outcome measures. Results: Compared with those receiving conventional information, men receiving the EB booklet had significantly improved knowledge (50% of items correct, 95% CI 46-53%; vs 45% correct, 95% CI 42-48%) (p=0.048) and lower levels of decisional conflict (mean 21.6, 95% CI 20.7-22.5; vs mean 24.3, 95% CI 23.4-25.2) (p Conclusions: Our findings show the benefits of providing evidence-based information to men about PSA screening. Our EB booklet facilitated informed choice, even among "passive" decision-makers.

Background The coronavirus (COVID-19) pandemic and the social distancing protocols used to impede the spread of the virus may have severe mental health consequences. The purpose of this study was to investigate the network of components of pandemic-related negative psychological states (i.e., fear of infection, financial worries, loneliness) and symptoms of major depressive disorder (MDD) and generalized anxiety disorder (GAD). Methods Data from 10,061 Norwegian adults recruited through an online survey during a period of strict social distancing protocols were analyzed by cross-sectional network methods. Results Of the infection fears, fear of being infected, fear of dying from the coronavirus and fear of significant others dying from it had notable connections to the GAD symptoms anxiety and/or fear of awful events. The financial worry component worry about personal economy was connected to the MDD symptom sleep problems and to the GAD symptom generalized worry. Each of the loneliness components was connected to a specific MDD symptom. Depressed mood, low energy and worthlessness had the highest strength centrality among the MDD symptoms; generalized worry, uncontrollability of worry, and trouble relaxing among the GAD symptoms; fear of dying from the virus among the fear of infection components; and feeling isolated among the loneliness components. Limitations Full random sampling was not conducted, although the sample turned out to be relatively representative of the Norwegian population. Conclusions Some components of the pandemic-related distressing states of fear of infection, financial worry and loneliness seem to be associated with specific symptoms of MDD and GAD.

Background Among people with musculoskeletal disorders, much of the variation in magnitude of incapability and pain intensity is accounted for by mental and social health opportunities rather than severity of pathology. Current questionnaires seem to combine distinct aspects of mental health such as unhelpful thoughts and distress regarding symptoms, and they can be long and burdensome. To identify personalized health strategies, it would be helpful to measure unhelpful thoughts and distress regarding symptoms at the point of care with just a few questions in a way that feels relevant to a person's health. Questions/purposes (1) Do questions that address unhelpful thoughts and distress regarding symptoms independently account for variation in accommodation of pain? (2) Which questions best measure unhelpful thoughts and distress regarding symptoms? Methods This is a cross-sectional questionnaire study of people seeking care regarding upper and lower extremity conditions from one of eight specialist clinicians (one upper extremity, one arthroplasty, and one sports surgeon and their three nurse practitioners and two physician assistants) in one urban office. Between June 2020 and September 2020, 171 new and returning patients were approached and agreed to participate, and 89% (153) of patients completed all questionnaires. The most common reason for noncompletion was the use of a pandemic strategy allowing people to use their phone to finish the questionnaire, with more people leaving before completion. Women and divorced, separated, or widowed people were more likely to not complete the survey, and we specifically account for sex and marital status as potential confounders in our multivariable analysis. Forty-eight percent (73 of 153) of participants were women, with a mean age 48 ± 16 years. Participants completed demographics and the validated questionnaires: Pain Catastrophizing Scale, Negative Pain Thoughts Questionnaire, Tampa Scale of Kinesiophobia, Intolerance of Uncertainty Scale, and Pain Self-Efficacy Questionnaire (a measure of accommodation to pain). In an exploratory factor analysis, we found that questions group together on four topics: (1) distress about symptoms (unhelpful feelings of worry and despair), (2) unhelpful thoughts about symptoms (such as worst-case thinking and pain indicating harm), (3) being able to plan, and (4) discomfort with uncertainty. We used a multivariable analysis, accounting for potential confounding demographics, to determine whether the identified question groupings account for variation in accommodation of pain-and thus are clinically relevant. Then, we used a confirmatory factor analysis to determine which questions best represent clinically relevant groupings of questions. Results After accounting for sex, marital status, work, and income, we found that distress and unhelpful thoughts about symptoms were independently associated with accommodation of pain, and together, they explained 60% of its variation (compared with 52% for distress alone and 40% for unhelpful thoughts alone). Variation in symptoms of distress was best measured by the question "I feel I can't stand it anymore" (76%). Variation in unhelpful thoughts was best addressed by the question "I wouldn't have this much pain if there wasn't something potentially dangerous going on in my body" (64%). Conclusion We found that distress (unhelpful feelings) and unhelpful thoughts about symptoms are separate factors with important and comparable associations with accommodation to pain. It also appears that these two factors can be measured with just a few questions. Being attentive to the language people use and the language of influential questions might improve clinician identification of mental health opportunities in the form of distress and unhelpful thoughts about symptoms, which in turn might contribute to better accommodation and alleviation of symptoms. Level of evidence Level II, prognostic study.

Objectives This study evaluates the effectiveness of a mindfulness-based intervention (MBI), called Koru mindfulness, among college students. Methods Undergraduate students (N = 34) participated in a 4-week mindfulness curriculum embedded within a college course, while a control group (N = 35) taking a different course did not. Notably, the intervention coincided with the start of a state-wide lockdown due to the COVID-19 pandemic. Results Despite the additional external stress, there was a significant main effect and a significant interaction between the intervention and time for state mindfulness, (the treatment group experienced increased state mindfulness). There was a significant main effect (higher for the control group) on coronavirus worry and a significant interaction between the intervention and time for perceived stress, with the treatment/control group experiencing decreased/increased stress over time. There was also a significant interaction between the intervention and time for sleep problems with the intervention group experiencing declines in sleep problems over time and also being more likely to experience optimal amounts of sleep over time. Conclusions The Koru intervention effectively increased state mindfulness, decreased stress, and improved sleep, suggesting that it is robust even under extremely stressful conditions. This study adds to the growing evidence that MBIs can play an important role in addressing rising concerns regarding the mental health of college students.

The main characteristics of panic disorder (PD) include recurrent panic attacks and persistent worry, accompanied by other physical and cognitive symptoms. While recent studies have revealed that gut bacteria play an important role in anxiety and depression, little is known about the relationship between oral microbiota and PD. Therefore, the objective of this study was to explore a possible correlation between oral microbiota and PD. We conducted 16S rRNA sequencing to compare differences in the oral microbiota of patients with PD (n = 26) and healthy controls (n = 40). Patients with PD exhibited higher alpha diversity (abundance and evenness) in their oral microbiota than healthy controls, while analysis of beta diversity revealed that the two groups differed in microbial community composition. Moreover, the relative abundance of 61 genera differed between them. Overall, PD resulted in distinct oral microbial profiles that could be potential diagnostic markers and therapeutic targets.

Background Anxiety sensitivity (AS) is a well-studied transdiagnostic risk construct that is believed to amplify responses to many forms of stress. The COVID-19 pandemic is a broad stressor with significant physical and social threats. In the current study, we were interested in ascertaining the degree to which AS would relate to distress and disability in the context of COVID-19. We hypothesized that AS would be associated with increased distress and disability. Moreover, we hypothesized that AS would be uniquely predictive while controlling for other relevant risk factors such as age, race, and perceived local COVID-19 infection rates. Method Participants (N = 249) were U.S. adults assessed using online data resourcing and re-assessed one month later. Results At the first time point, during the beginning phases of the COVID-19 pandemic, AS was significantly related to COVID-19 distress and disability with a moderate effect size. AS was longitudinally associated with higher COVID-19 worry and depression. Limitations Our findings are limited by the use of a relatively small online sample. Additionally, assessment of pre-pandemic and post-pandemic symptoms and functioning would be beneficial for future research. Conclusions Taken together, the current study provided evidence consistent with AS as a causal risk factor for the development of distress and depression during the COVID-19 pandemic.

Introduction The aim of this systematic review was to examine studies describing the association of cognitive representations with psychological adjustment or maladjustment during the experience of infertility and its treatment in light of the Common-Sense Model. According to this theoretical model cognitive perceptions about an illness can be associated with emotional adaptation. Methods A systematic search of four electronic databases (PubMed, APA PsycINFO, SCOPUS, ScienceDirect) was performed. This review considered only quantitative, primary studies in the English language without geographical limitations, published during the period 1996-2020 and relevant to the objective. The population of interest was infertile individuals who are having or not having infertility treatment. Only studies that examined the association between independent variables, such as perceived causes, timeline, controllability, consequences, symptoms, illness coherence and emotional representations, with psychological variables, such as anxiety, worry, distress, depression and well-being, were included. Two authors performed an independent extraction of articles using predefined data fields. Relevant articles were critically appraised and a narrative synthesis was conducted. Results Seven cross-sectional studies met the inclusion and methodological criteria and were included in the review. The review results revealed that all components of cognitive representations of infertility and its treatment may correlate with psychological adaptation of people who deal with a fertility problem, at intrapersonal and interpersonal level. Conclusions This systematic review suggested that the Common-Sense Model is an appropriate theoretical model to be applied in the experience of infertility and health professionals can make interventions based on modifying cognitive perceptions of a fertility problem that may increase levels of psychological well-being and decrease levels of distress.

Purpose This study aims to explore the psychological effects of lockdown during the early stages of the COVID-19 pandemic on people living in an Italian prison. The suspension of family visits and most activities, along with the difficulties in applying social distancing to this vulnerable population was associated with increased psychological distress. Riots broke out over two days in more than 22 prisons across Italy at the beginning of March 2020, highlighting the negative psychological impact of the pandemic and the country’s emergency policies. Design/methodology/approach The research involves 17 men (Italians and foreigners) detained in a Lombardy prison from 1 March to 4 May 2020, corresponding to the lockdown phase in Italy. The qualitative content analysis (CA) of 27 posts, written by participants during that period and published on the blog “L’Oblò”, were analysed. The analysis allowed the identification of topics and subtopics that are related to two major categories of content: cognitions and emotional connotations about the COVID-19 lockdown in prison. Findings Analysis showed that blog post content was predominately negative in terms of emotional connotations. The most frequent coded negative emotional connotations were: missing, worry, psychological pain and fear, whilst the most frequent coded positive emotional connotations were: hope and gratitude for the support they received from prison workers. The rest of the blog content was coded as “cognitions”. Cognitions were coded as descriptions of lockdown effect on detention; prison during the COVID-19 emergency; the pandemic situation in general; and comparison between inside and outside prison. Originality/value The current study is original as it describes through blog CA the psychological condition of prisoners during the first COVID-19 pandemic lockdown in the most affected region in Italy.

Objective To explore reasons for variations in anxiety in women testing positive for human papillomavirus (HPV) with normal cytology at routine HPV primary cervical cancer screening. Methods In‐depth interviews were conducted with 30 women who had tested HPV‐positive with normal cytology, including 15 with low‐to‐normal anxiety and 15 with high anxiety. Data were analysed using Framework Analysis to compare themes between low and high anxiety groups. Results Several HPV‐related themes were shared across anxiety groups, but only highly anxious women expressed fear and worry, fatalistic cognitions about cancer, fertility‐related cognitions, adverse physiological responses and changes in health behaviour(s). In comparison to those with low anxiety, women with high anxiety more strongly voiced cognitions about the 12‐month wait for follow‐up screening, relationship infidelity, a lower internal locus of control and HPV‐related symptom attributions. Conclusions Receiving an HPV‐positive with normal cytology result related to various emotional, cognitive, behavioural and physiological responses; some of which were specific to, or more pronounced in, women with high anxiety. If our observations are confirmed in hypothesis‐driven quantitative studies, the identification of distinct themes relevant to women experiencing high anxiety can inform targeted patient communications and HPV primary screening implementation policy., Highlights To our knowledge, this is the first qualitative study to explore anxiety in women testing human papillomavirus (HPV)‐positive with normal cytology at routine HPV primary screening.Our comparative qualitative design allowed thematic nuances to emerge between women who had experienced low versus high anxiety following their result.Only highly anxious women expressed fear and worry, fatalistic cognitions about cancer, fertility‐related cognitions, adverse physiological responses and changes in health behaviour(s).Highly anxious women also more strongly voiced cognitions about the 12‐month wait for follow‐up screen, reltionship infidelity, a lower internal locus of control and HPV‐related symptom attributions.These distinct themes can be used to minimise unnecessary anxiety through the development of evidence‐based patient communications at HPV primary screening.

Objective This study aimed to assess psychological functioning, quality of life, and regret about screening after a positive fecal immunochemical test (FIT) and subsequent colonoscopy, and to evaluate changes over time. Methods This is a prospective cohort study. Individuals aged 55 to 75 with a positive FIT that were referred for colonoscopy between July 2017 and November 2018, were invited to complete questionnaires related to psychological distress and health‐related quality of life at three predefined time points: before colonoscopy, after histopathology result notification, and after 6 months. Four questionnaires were used: the Psychological Consequences Questionnaire (PCQ), the six‐item Cancer Worry Scale (CWS), the Decision Regret Scale (DRS), and the 36‐item Short‐Form (SF‐36). Results A total of 1066 participants out of 2151 eligible individuals were included. Patients with cancer showed a significant increase in psychological dysfunction (P = .01) and cancer worry (P = .008) after colonoscopy result notification, and a decline to pre‐colonoscopy measurements after 6 months. In the no‐cancer groups, psychological dysfunction and cancer worry significantly decreased over time (P 25). A good global quality of life was reported in participants with no cancer. Conclusion Some psychological distress remains up to 6 months after colonoscopy in participants who tested false‐positive in the Dutch bowel cancer screening program.

Mental health impacts of the COVID-19 pandemic for people living with HIV are poorly understood, especially in low-income settings. We conducted qualitative semi-structured in-depth interviews among people living with HIV (n = 16) and health workers (n = 10) in rural Rakai, southcentral Uganda. Data were analyzed thematically. We found mental stress during COVID-19 was compounded by worry about antiretroviral therapy (ART) access, distress over inadvertent disclosure of HIV status, fear that coronavirus infection would have more severe outcomes for immunocompromised individuals, and exacerbated poverty and economic stress. Mental health support for people living with HIV deserves greater attention during the COVID-19 pandemic and beyond.

Background: The 2019 coronavirus disease (COVID-19) pandemic has impacted the mental health and well-being of medical personnel, including nursing students. Network analysis provides a deeper characterization of symptom-symptom interactions in mental disorders. The aim of this study was to elucidate characteristics of anxiety and depressive symptom networks of Chinese nursing students during the COVID-19 pandemic. Method: A total of 932 nursing students were included. Anxiety and depressive symptom were measured using the seven-item Generalized Anxiety Disorder Scale (GAD-7) and two-item Patient Health Questionnaire (PHQ-2), respectively. Central symptoms and bridge symptoms were identified via centrality indices and bridge centrality indices, respectively. Network stability was examined using the case-dropping procedure. Results: Irritability, Uncontrollable worry, Trouble relaxing, and Depressed mood had the highest centrality values. Three bridge symptoms (Depressed mood, Nervousness, and Anhedonia) were also identified. Neither gender nor region of residence was associated with network global strength, distribution of edge weights or individual edge weights. Limitations: Data were collected in a cross-sectional study design, therefore, causal relations and dynamic changes between anxiety and depressive symptoms over time could not be inferred. Generalizability of findings may be limited to Chinese nursing students during a particular phase of the current pandemic. Conclusions: Irritability, Uncontrollable worry, Trouble relaxing, and Depressed mood constituted central symptoms maintaining the anxiety-depression network structure of Chinese nursing students during the pandemic. Timely, systemic multi-level interventions targeting central symptoms and bridge symptoms may be effective in alleviating co-occurring experiences of anxiety and depression in this population.

Latinxs are vulnerable to experiencing housing insecurity and less likely to receive public benefits, such as health insurance, which can impact a household’s economic resources. We inform homelessness prevention by examining the association of social risks and healthcare access with housing insecurity for Latinxs. Our sample consisted of 120,362 participants under the age of 65, of which 17.3% were Latinx. Weighted chi-squared tests and logistic regression were used to examine predictors of housing insecurity. Housing insecurity was measured as worry about paying for housing. Latinxs were almost twice as likely as non-Latinxs to worry about paying for housing. Excellent/fair health status, health service use, and having health insurance decreased the likelihood of housing insecurity for Latinxs. Access to health insurance, regardless of citizenship status, and use of preventative healthcare to maintain good health can be protective against housing insecurity. Supplementary Information The online version contains supplementary material available at 10.1007/s10903-021-01258-9.

TiO2 in the food industry, designated as E171, is widely used in the production of chewing gums, sweets, and icing. It is absorbed through food ingestion and the respiratory tract. There are also reports that TiO2 nanoparticles can reach the dermis through damaged epidermis. It demonstrates the ability to accumulate in some internal organs, like spleen, liver, and kidneys, depending on its size and structure. It may have pro-inflammatory, cytotoxic, and genotoxic effects. A change in the composition of the host’s intestinal microflora is also observed after exposure to high doses of TiO2. There are some differences in TiO2 intake with food around the world, but most data indicate higher consumption of this additive by children. Due to the small amount of research and the fact that most of the analyses were carried out using animal models, it is necessary to plan future observations of long-term exposure of the TiO2 molecule.

Background Generalised anxiety disorder (GAD) is the most common anxiety disorder in older people. First-line management includes pharmacological and psychological therapies, but many do not find these effective or acceptable. Little is known about how to manage treatment-resistant generalised anxiety disorder (TR-GAD) in older people. Objectives To examine the acceptability, feasibility and preliminary estimates of the effectiveness of acceptance and commitment therapy (ACT) for older people with TR-GAD. Participants People aged ≥65 years with TR-GAD (defined as not responding to GAD treatment, tolerate it or refused treatment) recruited from primary and secondary care services and the community. Intervention Participants received up to 16 one-to-one sessions of ACT, developed specifically for older people with TR-GAD, in addition to usual care. Measurements Co-primary outcomes were feasibility (defined as recruitment of ≥32 participants and retention of ≥60% at follow-up) and acceptability (defined as participants attending ≥10 sessions and scoring ≥21/30 on the satisfaction with therapy subscale). Secondary outcomes included measures of anxiety, worry, depression and psychological flexibility (assessed at 0 and 20 weeks). Results Thirty-seven participants were recruited, 30 (81%) were retained and 26 (70%) attended ≥10 sessions. A total of 18/30 (60%) participants scored ≥21/30 on the satisfaction with therapy subscale. There was preliminary evidence suggesting that ACT may improve anxiety, depression and psychological flexibility. Conclusions There was evidence of good feasibility and acceptability, although satisfaction with therapy scores suggested that further refinement of the intervention may be necessary. Results indicate that a larger-scale randomised controlled trial of ACT for TR-GAD is feasible and warranted.

Background: Increased stress among medical personnel had been reported in previous virus outbreaks. The novel coronavirus disease (COVID-19) emerged in December 2019, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). No qualitative assessment has yet described the physical and mental health conditions of frontline medical personnel in the COVID-19 outbreaks. Methods: Here, 251 frontline medical personnel involved in COVID-19 missions completed electronic questionnaires, consisting of 31 categorical variables related to their physical and mental health status, medical history and environmental conditions. We constructed a correlation amongst these variables through pairwise Kendall rank correlation coefficient test. Then, clusters of highly correlated variables were identified using the leading eigenvector. Finally, we used the network and clusters to clarify the correlations amongst variables. Results: This qualitative study identified the six clusters. Cluster 1 was characterized by skin allergy. Cluster 2 was predominantly associated with anxiety. Cluster 3 consisted mostly of respiratory symptoms. The participants in cluster 4 had medical history. Cluster 5 and cluster 6 were characterized by disinfection and demography, respectively. Finally, we revealed three major findings. First, more than 80% of medical personnel worry about COVID-19-related infection and experience newly appearing anxiety (56.2%), airway or heart symptoms (34.3%) and skin allergies (20.3%). Second, COVID-19- related worry significantly associates with all variables in the anxiety and respiratory symptom clusters. Third, new-onset skin allergies did not associate with either disinfection or anxiety, but did associate with a previous history of allergies. Conclusions: COVID-19-related worry leads to physical and mental health problems amongst medical personnel. Effective responses and interventions could relieve a series of new-onset physical and mental health problems.

Background: Barrett's oesophagus (BO), a precursor to oesophageal adenocarcinoma, requires long-term endoscopic surveillance. The rising incidence of this chronic disease has implications for service provision and patient burden. Few studies have explored BO patients’ personal burden, care delivery experience and participation in health-care delivery decisions. Objective: To identify and explore factors impacting BO patients’ health-related quality of life, follow-up needs and views on new models of follow-up care. Design: An exploratory qualitative approach was adopted using semi-structured, in-depth, one-to-one interviews, audio-recorded and transcribed verbatim. Patients undergoing BO surveillance, at a single NHS hospital, were recruited using purposive sampling with the aim of achieving maximum variation. Data were analysed using framework analysis approach, supported by NVivo Pro 11. Results: Data saturation occurred after 20 participant interviews. Ten subthemes and three main themes emerged from the analysis: (a) burden of disease—symptom control, worry of oesophageal cancer and surveillance endoscopy; (b) follow-up experiences—follow-up care, at this NHS hospital, was found to be inconsistent and often inadequate to meet patients’ needs, in particular a lack of disease-specific information; and (c) follow-up needs—participants sought enhanced communication, organization and structure of care. They highly valued face-to-face interaction with a specialist, and the concept of direct secondary care access in-between endoscopies was reassuring to participants. Conclusions: This qualitative research provides an in-depth account of the patients’ perspective of BO, the effectiveness of follow-up care and patient opinion on new follow-up systems.

Highlights • Students report moderate-to-severe psychological impact of the COVID-19 pandemic. • Timely and adequate health information has protective psychological effect. • Health care workers are less likely to be psychologically affected. • Home quarantine is associated with depression, anxiety and stress symptoms., Background The 2019 coronavirus disease (COVID-19) pandemic poses a threat to societies’ mental health. This study examined the prevalence of psychiatric symptoms and identified the factors contributing to psychological impact in the Philippines. Methods A total of 1879 completed online surveys were gathered from March 28-April 12, 2020. Collected data included socio-demographics, health status, contact history, COVID-19 knowledge and concerns, precautionary measures, information needs, the Depression, Anxiety and Stress Scales (DASS-21) and the Impact of Events Scale-Revised (IES-R) ratings. Results The IES-R mean score was 19.57 (SD=13.12) while the DASS-21 mean score was 25.94 (SD=20.59). In total, 16.3% of respondents rated the psychological impact of the outbreak as moderate-to-severe; 16.9% reported moderate-to-severe depressive symptoms; 28.8% had moderate-to-severe anxiety levels; and 13.4% had moderate-to-severe stress levels. Female gender; youth age; single status; students; specific symptoms; recent imposed quarantine; prolonged home-stay; and reports of poor health status, unnecessary worry, concerns for family members, and discrimination were significantly associated with greater psychological impact of the pandemic and higher levels of stress, anxiety and depression (p

Aim Coronavirus Disease 2019 (COVID‐19) changed the delivery of medical education in Turkey by moving to an emergency remote teaching system and led to many challenges for future doctors. In this study, we aimed to explore the impact of the COVID‐19 pandemic on medical students, to assess their anxiety level and their main anxiety sources related to this pandemic. Methods A Google Form was distributed to medical students using the virtual snowball sampling method. The form included the Beck Anxiety Inventory and additional 19 questions on sociodemographic characteristics, perceived level of knowledge about the epidemic, self‐risk perceptions of COVID‐19 and their anxiety levels about some other topics related to COVID‐19. Results Overall, 3105 medical students with a mean age of 22.37 ± 2.46, took the survey. Amongst the participants, only 32% of the students defined their knowledge about the precautions that should be taken during an epidemic disease as acceptable. Students reported highest anxiety level for the continuing spread of COVID‐19 in Turkey and transmitting coronavirus to another person. Clinically significant anxiety prevalence was 23.2%. Regression analysis revealed that factors that increased the risk of being anxious included being female, being other than a 5th‐year student, thinking that being a medical student would increase the risk of coronavirus transmission or being uncertain about it, being exposed to a patient with COVID‐19 or being uncertain about it, being anxious about the continuing spread of COVID‐19 in Turkey, being anxious about acquiring COVID‐19, being anxious for graduating and being on active duty, being anxious about a medical training interruption. Conclusion Our results suggest that anxiety is prevalent amongst Turkish medical students during the COVID‐19 pandemic and they have a weak preparedness for a pandemic such as COVID‐19. Based on our results, new strategies should be implemented for medical education and for alleviating students’ anxiety levels.

Background Generalized anxiety disorder (GAD) is characterized by excessive worry that is difficult to control and has high comorbidity with mood disorders including depression. Individuals experience long wait times for diagnosis and often face accessibility barriers to treatment. There is a need for a digital solution that is accessible and acceptable to those with GAD. Objective This paper aims to describe the development of a digital intervention prototype of acceptance and commitment therapy (ACT) for GAD that sits within an existing well-being app platform, BioBase. A pilot feasibility study evaluating acceptability and usability is conducted in a sample of adults with a diagnosis of GAD, self-referred to the study. Methods Phase 1 applied the person-based approach (creation of guiding principles, intervention design objectives, and the key intervention features). In Phase 2 participants received the app-based therapeutic and paired wearable for 2 weeks. Self-report questionnaires were obtained at baseline and posttreatment. The primary outcome was psychological flexibility (Acceptance and Action Questionnaire-II [AAQ-II]) as this is the aim of ACT. Mental well-being (Warwick-Edinburgh Mental Well-being Scale [WEMWBS]) and symptoms of anxiety (7-item Generalized Anxiety Disorder Assessment [GAD-7]) and depression (9-item Patient Health Questionnaire [PHQ-9]) were also assessed. Posttreatment usability was assessed via self-report measures (System Usability Scale [SUS]) in addition to interviews that further explored feasibility of the digital intervention in this sample. Results The app-based therapeutic was well received. Of 13 participants, 10 (77%) completed the treatment. Results show a high usability rating (83.5). Participants found the digital intervention to be relevant, useful, and helpful in managing their anxiety. Participants had lower anxiety (d=0.69) and depression (d=0.84) scores at exit, and these differences were significantly different from baseline (P=.03 and .008 for GAD-7 and PHQ-9, respectively). Participants had higher psychological flexibility and well-being scores at exit, although these were not significantly different from baseline (P=.11 and .55 for AAQ-II and WEMWBS, respectively). Conclusions This ACT prototype within BioBase is an acceptable and feasible digital intervention in reducing symptoms of anxiety and depression. This study suggests that this intervention warrants a larger feasibility study in adults with GAD.

Background Current evidence indicates physical activity wearables could support persons with knee osteoarthritis (OA) to be more physically active. However, recent evidence also identifies some persons with arthritis experience guilt or worry while using a wearable if they are not as active as they feel they should be. Questions remain around how persons with knee OA experience benefits or downsides using a wearable in their everyday lives. Better understanding is needed if wearables are to be incorporated in arthritis self-management in ethically aware ways. Objective Using an ethics lens, we aimed to describe a range of experiences from persons with knee OA who used a wearable during a physical activity counseling intervention study. Methods This is a secondary analysis of qualitative interviews nested within a randomized controlled trial. Guided by phenomenography, we explored the experiences of persons with knee OA following participation in a physical activity counseling intervention that involved using a Fitbit Flex and biweekly phone calls with a study physiotherapist (PT) in an 8-week period. Benefits or downsides experienced in participants’ relationships with themselves or the study PT when using the wearable were identified using a relational ethics lens. Results Interviews with 21 participants (12 females and 9 males) aged 40 to 82 years were analyzed. Education levels ranged from high school graduates (4/21, 19%) to bachelor’s degrees or above (11/21, 52%). We identified 3 categories of description: (1) participants experienced their wearable as a motivating or nagging influence to be more active, depending on how freely they were able to make autonomous choices about physical activity in their everyday lives; (2) some participants felt a sense of accomplishment from seeing progress in their wearable data, which fueled their motivation; (3) for some participants, sharing wearable data helped to build mutual trust in their relationship with the study PT. However, they also expressed there was potential for sharing wearable data to undermine this trust, particularly if this data was inaccurate. Conclusions Findings provide an early glimpse into positive and negative emotional impacts of using a wearable that can be experienced by participants with knee OA when participating in a randomized controlled trial to support physical activity. To our knowledge, this is the first qualitative study that uses a relational ethics lens to explore how persons with arthritis experienced changes in their relationship with a health professional when using a wearable during research participation.

We evaluated mental health and substance use during the COVID-19 pandemic in 196 participants from the Miami Adult Studies on HIV (MASH) Cohort. A survey was administered between July-August of 2020, including validated measures of resilience and anxiety, a scale to measure COVID-19-related worry, and self-reported substance use. Compared to HIV-uninfected participants (n = 80), those living with HIV (n = 116) reported fewer anxiety symptoms, less COVID-19-related worry, and higher resilience. Those with more anxiety symptoms and lower resilience engaged in more frequent alcohol consumption, binge drinking, and cocaine use. Alcohol misuse was more common among HIV-uninfected participants. Cocaine use was reported by 21% fewer participants during the pandemic compared with 7.3 ± 1.5 months earlier. Possibly due to their experiences with HIV, PLWH responded with higher resilience and reduced worry and anxiety to the adversities brought by the COVID-19 pandemic.

Background Behavioral mitigation strategies to slow the spread of COVID-19 have resulted in sweeping lifestyle changes, with short- and long-term psychological, well-being, and quality of life implications. The Attitudes About COVID-19 and Health (ATTACH) study focuses on understanding attitudes and beliefs while considering the impact on mental and physical health and the influence of broader demographic and geographic factors on attitudes, beliefs, and mental health burden. Objective In this assessment of our first wave of data collection, we provide baseline cohort description of the ATTACH study participants in the United Kingdom, the United States, and Mexico. Additionally, we assess responses to daily poll questions related to COVID-19 and conduct a cross-sectional analysis of baseline assessments collected in the UK between June 26 and October 31, 2020. Methods The ATTACH study uses smartphone app technology and online survey data collection. Participants completed poll questions related to COVID-19 2 times daily and a monthly survey assessing mental health, social isolation, physical health, and quality of life. Poll question responses were graphed using 95% Clopper–Pearson (exact) tests with 95% CIs. Pearson correlations, hierarchical linear regression analyses, and generalized linear models assessed relationships, predictors of self-reported outcomes, and group differences, respectively. Results By October 31, 2020, 1405, 80, and 90 participants had consented to participate in the UK, United States, and Mexico, respectively. Descriptive data for the UK daily poll questions indicated that participants generally followed social distancing measures, but worry and negative impacts on families increased as the pandemic progressed. Although participants generally reported feeling that the reasons for current measures had been made clear, there was low trust that the government was doing everything in its power to meet public needs. In the UK, 1282 participants also completed a monthly survey (94.99% [1326/1396] White, 72.22% [1014/1404] female, and 20.12% [277/1377] key or essential workers); 18.88% (242/1282) of UK participants reported a preexisting mental health disorder, 31.36% (402/1282) reported a preexisting chronic medical illness, and 35.11% (493/1404) were aged over 65; 57.72% (740/1282) of participants reported being more sedentary since the pandemic began, and 41.89% (537/1282) reported reduced access to medical care. Those with poorer mental health outcomes lived in more deprived neighborhoods, in larger households (Ps Conclusions Communities who have been exposed to additional harm during the COVID-19 pandemic were experiencing worse mental outcomes. Factors including having a medical condition, or living in a deprived neighborhood or larger household were associated with heightened risk. Future longitudinal studies should investigate the link between COVID-19 exposure, mental health, and sociodemographic and residential characteristics.

Background Emerging UV radiation (UVR) monitoring devices may present an opportunity to integrate such technology into skin cancer prevention interventions. However, little is known about the effects of using a wearable UVR monitor on adults’ and children’s sun protection–related behaviors and attitudes (eg, cancer worry and perceived risk). Understanding the potential role of reactivity and seasonal effects will help inform the use of objective monitors in the context of skin cancer prevention research, including intervention studies. Objective The aim of this study is to examine the potential reactivity associated with a wearable personal UVR monitor, specifically the effects associated with reported sun-protective behaviors and skin cancer–related attitudes, which are often the targets of skin cancer preventive interventions. Methods Child-parent dyads (n=97 dyads) were asked to wear a UVR monitoring device during waking hours for 2 weeks. Participants were asked to sync the device daily with a smartphone app that stored the UVR exposure data. Participants were blinded to their UVR exposure data during the 2-week period; thus, the smartphone app provided no feedback to the participants on their UVR exposure. Participants completed self-report questionnaires assessing sun-protective behaviors, sunburn, tanning, skin self-examination, skin cancer–related knowledge, perceived risk, cancer worry, response efficacy, and intentions to change behaviors over the 2-week period. Linear regressions were conducted to investigate changes in the outcomes over time and to account for the role of the season of study participation. Results Regression results revealed that there was a significant decrease over time for several sun protection outcomes in children, including time spent outdoors on weekends (P=.02) and weekdays (P=.008), sunscreen use (P=.03), reapplication (P Conclusions The findings from this study suggest that daily use of a UVR monitoring device over a 2-week period may result in changes in certain sun-protective behaviors. These results highlight the importance of identifying and addressing potential reactivity to UVR monitoring devices, especially in the context of skin cancer preventive intervention research. Ultimately, objectively assessed UVR exposure could be integrated into the outcome assessment for future testing of skin cancer prevention interventions.

The purpose of the study is to find out the psychological impact of the COVID‐19 pandemic on university students. The study focuses on the university students from different public and private universities of Bangladesh through a set of questionnaires according to the guideline of Generalized Anxiety Disorder Scale (GAD‐7). The result among 15 543 respondents shows that 44.59% are suffering from severe anxiety, 48.41% moderate anxiety, and only 3.82% mild anxiety. The results highlight that all epidemic‐related stressors are positively correlated with the level of anxiety. Among the epidemic‐related stressors, worry about economic influences during and after COVID‐19 (r = 0.342, p < 0.001) and worry about the influence of COVID‐19 on daily life (r = 0.340, p < 0.001) have a highly positive impact on the level of anxiety. Following these stressors, worry about academic delays due to COVID‐19 (r = 0.326, p < 0.001) and worry about the social support during COVID‐19 (r = 0.321, p < 0.001) have moderately and positively correlated with the level of anxiety. The study suggests that proper government support, as well as social awareness, should be monitored during epidemics for decreasing anxiety and maintaining a good mental health of the university students., The purpose of this study is to evaluate the psychological impact of the COVID‐19 pandemic among university students in Bangladesh. Through cluster sampling and a set of questionnaires based on Generalized Anxiety Disorder Scale (GAD‐7), the study attempts to determine the association. The results show that 44.59% are suffering from severe anxiety, 48.41% moderate anxiety, and 3.82% mild anxiety.

Background A review of Australian mental health services identified a gap in routine outcome measures addressing social, emotional and behavioural domains for pre-schoolers and infants. A Child and Adolescent Mental Health Information Development Expert Advisory Panel working group developed the Health of the Nation Outcome Scales for Infants (HoNOSI), a clinician-reported routine outcome measure for infants 0–47 months. Prior face validity testing showed that the HoNOSI was considered useful in measuring mental health outcomes. Aims To examine the concurrent validity of the HoNOSI. Method Mental health clinicians providing assessment and treatment to infants in routine clinical practice participated in the study. The mental health status of 108 infants were rated by a minimum of 26 clinicians with the HoNOSI, the Parent-Infant Relationship Global Assessment Scale (PIR-GAS) and measures of symptom severity and distress. Results The HoNOSI was statistically significantly correlated with the PIR–;GAS, rs = −0.73; Clinical Worry, rs = 0.77; and Severity Judgement ratings, rs = 0.85; P < 0.001. A good level of internal consistency was found. Using the COsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria for judging instrument acceptability, the HoNOSI meets the standard for both concurrent validity and internal consistency. Conclusions There has been a clear need for a routine outcome measure for use with infants. This study provides positive evidence of aspects of validity. These findings, along with those from the prior face validity study, support a controlled release of the HoNOSI accompanied by further research and development.

Background Excessive smartphone use is a new and debated phenomenon frequently mentioned in the context of behavioral addiction, showing both shared and distinct traits when compared to pathological gaming and gambling. Objective The aim of this study is to describe excessive smartphone use and associated factors among adolescents, focusing on comparisons between boys and girls. Methods This study was based on data collected through a large-scale public health survey distributed in 2016 to pupils in the 9th grade of primary school and those in the 2nd grade of secondary school. Bayesian binomial regression models, with weakly informative priors, were used to examine whether the frequency of associated factors differed between those who reported excessive smartphone use and those who did not. Results The overall response rate was 77% (9143/11,868) among 9th grade pupils and 73.4% (7949/10,832) among 2nd grade pupils, resulting in a total of 17,092 responses. Based on the estimated median absolute percentage differences, along with associated odds ratios, we found that excessive smartphone use was associated with the use of cigarettes, alcohol, and other substances. The reporting of anxiety and worry along with feeling low more than once a week consistently increased the odds of excessive smartphone use among girls, whereas anxiety and worry elevated the odds of excessive smartphone use among boys. The reporting of less than 7 hours of sleep per night was associated with excessive smartphone use in all 4 study groups. Conclusions The results varied across gender and grade in terms of robustness and the size of estimated difference. However, excessive smartphone use was associated with a higher frequency of multiple suspected associated factors, including ever having tried smoking, alcohol, or other substances; poor sleep; and often feeling low and feeling anxious. This study sheds light on some features and distinctions of a potentially problematic behavior among adolescents.

The current study examines differences between COVID-19 vaccine intention and delay. A survey was administered to 585 US respondents in late November 2020 as part of an online longitudinal study. Respondents provided information on whether they would obtain a COVID-19 vaccine, once available, and how long they intended to wait before obtaining it. In the negative intention group, 3.4% reported waiting a few weeks, 34.0% waiting a few months, and 62.6% never getting vaccinated. In multivariable models, social norms were a significant and independent predictor of all vaccine delay and intention models. Vaccine delay was associated with low levels of worry about becoming infected with COVID-19, political conservatism, concerns about vaccine side effects, and low levels of believing a vaccine would be effective. Negative vaccine intentions were associated with worries about becoming infected with COVID-19, concerns about vaccine side effects, beliefs that the vaccines were developed too quickly, and low endorsement of the altruistic belief that older people should have vaccination priority. The study results highlight the importance of a multifactorial approach to assessing vaccine attitudes. The findings suggest that uptake programs should focus on enhancing pro-vaccine norms.

Background The rapid diffusion of the internet has decreased consumer reliance on health care providers for health information and facilitated the patients’ ability to be an agent in control of their own health. However, empirical evidence is limited regarding the effects of health-related internet use among older adults, which is complicated by the proliferation of online health and medical sources of questionable scientific accuracy. Objective We explore the effects of health-related internet use, education, and eHealth literacy on medical encounters and patient-reported outcomes. Patient-reported outcomes are categorized into two dimensions: (1) self-reported health problem and (2) affective distress (feeling worried and anxious) due to information obtained. We were particularly interested in whether education and eHealth literacy moderate the association between perceived strain in medical encounters and patient-reported outcomes. Methods Our study sample consisted of online panel members who have used the internet as a resource for health information, randomly drawn from one of the largest probability-based online research panels. This paper specifically reports results obtained from older panel members (age≥60 years: n=194). First, we examined descriptive statistics and bivariate associations (Pearson correlations and independent samples t tests). We used hierarchical ordinary least squares regression analyses by running separate regressions for each patient-reported outcome. In model 1, we entered the main effects. In model 2, technology and medical encounter variables were included. Model 3 added the statistical interaction terms. Results Age (β=–.17; P=.02), gender (β=–.22; P=.01), and medical satisfaction (β=–.28; P=.01) were significant predictors of self-reported health problems. Affective distress was positively predicted by gender (β=.13; P=.05) and satisfaction with medical encounters (β=.34; P Conclusions This study provides evidence for the effect of health-related internet use on patient-reported outcomes with implications for medical encounters. The results could be used to guide educational and eHealth literacy interventions for older individuals.

Background/Objectives attitudes toward life and health are emerging as important psychological contributors to health heterogeneity in ageing. We aimed to explore whether different psychological factors were associated with the rate of chronic disease and disability accumulation over time. Design population-based cohort study between 2001 and 2010. Setting Swedish National study on aging and care in Kungsholmen. Subjects adults aged 60 and older (N = 2293). Methods linear mixed models were employed to study the association of life satisfaction, health outlook, resistance to illness, sickness orientation, and health worry with the rate of accumulation of chronic diseases and impaired basic and instrumental activities of daily living. Models were adjusted for demographic, clinical, social, personality and lifestyle factors. Analyses were repeated after excluding individuals with multimorbidity or disability at baseline. Results high life satisfaction and positive health outlook were consistently associated with a lower rate of accumulation and progression of multimorbidity (β −0.064 95% confidence interval [CI] −0.116, −0.011; β −0.065 95% CI −0.121, −0.008, respectively) and disability (β −0.063 95% CI −0.098, −0.028; β −0.042 95% CI −0.079, −0.004, respectively) over time. This was true even for people without multimorbidity or disability at baseline and after adjusting for all covariates. Conclusions positive attitudes toward life in general and health in particular may be especially important in old age, when the cumulative effects of biological and environmental deficits lead to accelerated health decline. These findings should encourage researchers to use measures of psychological well-being to better understand the multifactorial and diverse process of ageing.

Background It is important to maintain the psychological well-being of front-line healthcare staff during the coronavirus disease 2019 (COVID-19) pandemic. Aims To examine COVID-19-related stress and its immediate psychological impact on healthcare staff. Method All healthcare staff working in the fever clinic, from 20 January 2020 to 26 March 2020, of a tertiary general hospital were enrolled. Stress management procedures were in place to alleviate concerns about the respondents’ own health and the health of their families, to help them adjust their work and to provide psychological support via a hotline. Qualitative interviews were undertaken and the Sources of Distress and the Impact of Event Scale-Revised (IES-R) were administered. Results Among the 102 participants (25 males; median age 30 years, interquartile range (IQR) = 27–36), the median IES-R total score was 3 (IQR = 0–8), and 6 participants (6.0%) scored above the cut-off on the IES-R (≥20). Safety and security were acceptable or better for 92 (90.2%) participants. The top four sources of distress were worry about the health of one's family/others at 0.88 (IQR = 0.25–1.25), worry about the virus spread at 0.50 (IQR = 0.00–1.00), worry about changes in work at 0.50 (IQR = 0.00–1.00) and worry about one's own health at 0.25 (IQR = 0.25–0.75). There was a moderate correlation between the IES-R score and the Sources of Distress score (rho = 0.501, P = 0.001). Conclusions The stress levels of healthcare staff in the fever clinic during the COVID-19 epidemic were not elevated. Physio-psychosocial interventions, including fulfilment of basic needs, activation of self-efficacy and psychological support, are helpful and worth recommending in fighting COVID-19.

Background COVID-19 is an emerging infectious disease that has created health care challenges worldwide. Pregnant women are particularly affected by this disease. Objective The aims of this study are to assess the levels of perceived threat (susceptibility, severity, impact), negative emotions (fear, worry), and self-efficacy of pregnant women in China related to COVID-19 and to examine their associations with mental health (depression and anxiety) and personal protective behavior (wearing a face mask). Methods A total of 4087 pregnant women from China completed a cross-sectional web-based survey between March 3 and 10, 2020. Results The prevalence of probable depression and anxiety was 48.7% (1989/4087) and 33.0% (1347/4087), respectively; 23.8% participants (974/4087) reported always wearing a face mask when going out. Of the 4087 participants, 32.1% (1313) and 36.4% (1490) perceived themselves or their family members to be susceptible to COVID-19 infection, respectively; 3216-3518 (78.7%-86.1%) agreed the disease would have various severe consequences. Additionally, 2275 of the 4087 participants (55.7%) showed self-efficacy in protecting themselves from contracting COVID-19, and 2232 (54.6%) showed efficacy in protecting their family members; 1303 (31.9%) reported a high level of fear of the disease, and 2780-3056 (68.0%-74.8%) expressed worry about various aspects of COVID-19. The results of the multivariate multinominal logistic regression analyses showed that perceived severity, perceived impact, fear, and worry were risk factors for probable depression and anxiety, while self-efficacy was a protective factor. The results of the multivariate logistic regression analysis showed that perceived susceptibility was associated with always wearing a face mask. Conclusions Chinese pregnant women showed high levels of mental distress but low levels of personal protective behavior during the COVID-19 pandemic. Interventions are needed to promote the mental health and health behavior of pregnant women during the pandemic.

Background The COVID-19 pandemic has been declared an international public health emergency, and it may have long-lasting effects on people’s mental health. There is a need to identify effective health behaviors to mitigate the negative mental health impact of COVID-19. Objective The objectives of this study were to (1) examine the regional differences in mental health and COVID-19–related worry, attention to news, and stress, in light of the state-level prevalence of COVID-19 cases; (2) estimate the associations between mental health and COVID-19–related worry, attention to news, and stress and health behavior engagement (ie, physical activity, mindfulness meditation); and (3) explore the mediating effect of health behavior engagement on the associations between mental health and COVID-19–related worry, attention to news, and stress. Methods A cross-sectional survey was distributed to a sample of US adult paying subscribers to the Calm app (data were collected from April 22 to June 3, 2020). The survey assessed COVID-19–related worry, attention to news, and stress; health behavior engagement; and mental health (ie, perceived stress, posttraumatic stress disorder, and anxiety and depression). Statistical analyses were performed using R software. Differences in COVID-19–related worry, attention to news, and stress and mental health by location were assessed using t tests and chi-square tests. Logistic and ordinary least squares models were used to regress mental health and health behavior on COVID-19–related worry, attention to news, and stress; moreover, causal mediation analysis was used to estimate the significance of the mediation effects. Results The median age of the respondents (N=8392) was 47 years (SD 13.8). Participants in the Mid-Atlantic region (New Jersey, New York, and Pennsylvania) reported higher levels of stress, more severe depression symptoms, greater worry about COVID-19, paying more attention to COVID-19–related news, and more stress related to social distancing recommendations than participants living in other regions. The association between worry about COVID-19 and perceived stress was significantly mediated by changes in physical activity (P Conclusions Our findings describe the mental health impact of COVID-19 and outline how continued participation in health behaviors such as physical activity and mindfulness meditation reduce worsening of mental health due to the COVID-19 pandemic. These data have important implications for public health agencies and health organizations to promote the maintenance of health habits to reduce the residual mental health burden of the COVID-19 pandemic.

Background COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020, and as of this writing, Texas, United States, has reported >675,000 cases with over 14,000 deaths. Many of the preventive measures implemented during the pandemic can increase sedentary lifestyles, which can lead to the development of chronic diseases, including obesity, among the general population and cause serious threats to people’s physical health and overall quality of life. Individuals with pre-existing comorbidities are at an increased risk of COVID-19 and may hence have higher levels of stress. Objective This study aimed to investigate the relationship between physical activity levels and mental health status on an individual level and to compare them between those with and those without comorbidities in a cohort of Texas residents, before and after COVID-19 was declared a pandemic. Methods An electronic survey was disseminated throughout various regions of Texas. In total, 160 individuals were asked questions about their demographic characteristics, time spent on daily physical activities, and daily mental health status before and after COVID-19 was declared a pandemic. Frequency distributions and descriptive statistics were analyzed. Results Overall, 94 (58%) participants reported having ≥1 medical condition, and 31 (13.1%) had >3 medical conditions. Physical activity levels among participants with ≥1 pre-existing comorbidity drastically—but not significantly—decreased, as evident from a 10% increase in sedentary lifestyles after COVID-19 was declared a pandemic. On the contrary, we observed a 9% increase in the number of individuals without a pre-existing comorbidity who reported 30-60 min of physical activity per week. There was a 2-fold increase in the number of participants reporting more frequent feelings of nervousness, too much worry, trouble relaxing, and the fear of something awful happening after the pandemic. More specifically, individuals with pre-existing medical conditions reported, on average, a 10% higher incidence of feelings of stress, anxiety, and sadness compared to their healthy counterparts after COVID-19 was declared a pandemic. Conclusions Stressful life conditions and chronic comorbidities are risk factors that can affect mental health and reduce the ability to perform activities of daily life. Therefore, when implementing pandemic protocols, municipalities should consider providing mental health support to their citizens to protect them from this rather inconspicuous adverse effect.

Background\ud This study examined the associations between components of psychological resilience with mental health at different levels of exposure to COVID-19 stressors.\ud \ud Methods\ud A population-representative sample of 4,021 respondents were recruited and assessed between February 25th and March 19th, 2020. Respondents reported current anxiety symptoms (7-item Generalized Anxiety Disorder scale [GAD-7]), cognitive components (perceived ability to adapt to change, tendency to bounce back after adversities) and behavioral components (regularity of primary and secondary daily routines) of resilience, worry about COVID-19 infection, and sociodemographics.\ud \ud Results\ud Logistic regression revealed that cognitive and behavioral components of resilience were not correlated with probable anxiety (GAD-7≥10) among those reporting no worry. Among respondents who were worried, all resilient components were inversely associated with probable anxiety. Specifically, propensity to bounce back and regular primary routines were more strongly related to lower odds of probable anxiety among those reporting lower levels of worry.\ud \ud Limitations\ud The cross-sectional design limits causal inference. Second, other resilient components and some key daily routines that could be related to better mental health were not assessed. Third, generalizability of the findings to other similar major cities is uncertain because cases and deaths due to COVID-19 in Hong Kong have been comparatively lower.\ud \ud Conclusions\ud To foster mental health, cultivation of confidence in one's ability to adapt to change and a propensity to bounce back from hardship should be coupled with sustainment of regular daily routines. Such assessment and intervention protocols are more relevant to those who suffer heightened levels of exposure to COVID-19 stressors.

Background SARS-CoV-2 has rapidly spread worldwide, threatening public health and financial and social life. Aims The current study's aim was to determine the prevalence of psychological distress and post-traumatic stress symptoms in the Greek population during the first COVID-19 lockdown, and to detect potential correlates. Method An anonymous online survey was conducted between 10 April and 4 May 2020, to collect information regarding people's psychological functioning and COVID-19-related perceptions. Results A total of 1443 individuals completed the survey; 293 (20%) reported clinically significant anxiety symptoms, 188 (12.9%) reported clinically significant depressive symptoms and 506 (36.4%) suffered from definite post-traumatic stress disorder. Anxiety symptoms were independently associated with female gender (β = 1.281, 95% CI 0.808–1.755, P < 0.001), educational level (β = −1.570, 95% CI −2.546 to −0.595, P = 0.002), perceived severity (β = −1.745, 95% CI −3.146 to −0.344, P = 0.015) and COVID-19-related worry (β = 7.633, 95% CI 6.206–9.060, P < 0.001). Depressive symptoms were strongly correlated with educational level (β = −1.298, 95% CI −2.220 to −0.377, P = 0.006), perceived severity (β = −1.331, 95% CI −2.579 to −0.082, P = 0.037) and COVID-19-related worry (β = 4.102, 95% CI 2.769–5.436, P < 0.001). Finally, post-traumatic stress symptoms were linked to female gender (β = 6.451, 95% CI 4.602–8.299, P < 0.001), educational level (β = −5.737, 95% CI −9.479 to −1.996, P = 0.003), psychiatric history (β = −4.028, 95% CI −6.274 to −1.782, P < 0.001) and COVID-19-related worry (β = 23.865, 95% CI 18.201–29.530, P < 0.001). Conclusions A significant percentage of the population reported clinically important anxiety, depressive and post-traumatic stress symptoms. Women, less-educated individuals and people with a psychiatric history appeared more vulnerable to the pandemic's psychological impact.

Background The COVID-19 infodemic, a surge of information and misinformation, has sparked worry about the public’s perception of the coronavirus pandemic. Excessive information and misinformation can lead to belief in false information as well as reduce the accurate interpretation of true information. Such incorrect beliefs about the COVID-19 pandemic might lead to behavior that puts people at risk of both contracting and spreading the virus. Objective The objective of this study was two-fold. First, we attempted to gain insight into public beliefs about the novel coronavirus and COVID-19 in one of the worst hit countries: the United States. Second, we aimed to test whether a short intervention could improve people’s belief accuracy by empowering them to consider scientific consensus when evaluating claims related to the pandemic. Methods We conducted a 4-week longitudinal study among US citizens, starting on April 27, 2020, just after daily COVID-19 deaths in the United States had peaked. Each week, we measured participants’ belief accuracy related to the coronavirus and COVID-19 by asking them to indicate to what extent they believed a number of true and false statements (split 50/50). Furthermore, each new survey wave included both the original statements and four new statements: two false and two true statements. Half of the participants were exposed to an intervention aimed at increasing belief accuracy. The intervention consisted of a short infographic that set out three steps to verify information by searching for and verifying a scientific consensus. Results A total of 1202 US citizens, balanced regarding age, gender, and ethnicity to approximate the US general public, completed the baseline (T0) wave survey. Retention rate for the follow-up waves— first follow-up wave (T1), second follow-up wave (T2), and final wave (T3)—was high (≥85%). Mean scores of belief accuracy were high for all waves, with scores reflecting low belief in false statements and high belief in true statements; the belief accuracy scale ranged from –1, indicating completely inaccurate beliefs, to 1, indicating completely accurate beliefs (T0 mean 0.75, T1 mean 0.78, T2 mean 0.77, and T3 mean 0.75). Accurate beliefs were correlated with self-reported behavior aimed at preventing the coronavirus from spreading (eg, social distancing) (r at all waves was between 0.26 and 0.29 and all P values were less than .001) and were associated with trust in scientists (ie, higher trust was associated with more accurate beliefs), political orientation (ie, liberal, Democratic participants held more accurate beliefs than conservative, Republican participants), and the primary news source (ie, participants reporting CNN or Fox News as the main news source held less accurate beliefs than others). The intervention did not significantly improve belief accuracy. Conclusions The supposed infodemic was not reflected in US citizens’ beliefs about the COVID-19 pandemic. Most people were quite able to figure out the facts in these relatively early days of the crisis, calling into question the prevalence of misinformation and the public’s susceptibility to misinformation.

Supplemental Digital Content is Available in the Text. The CARE Scale-7 is the first validated instrument to assess self-care difficulty in both sexes and may promote individualized care planning among chronic pain patients., Objectives: Social and interpersonal factors impact the trajectory of chronic pain. We previously developed and validated a 2-factor, 7-item measure to assess interpersonal factors, including relationship guilt and worry and difficulty prioritizing self-care in chronic pain. Here, we confirm the factor structure and examine the sex invariance of the two-factor structure of the CARE Scale-7. Methods: Data were collected as part of routine clinical care at a tertiary pain clinic using the Collaborative Health Outcomes Information Registry. Patient participants (67% women) were predominantly middle-aged (M = 50.9 years, SD = 17.8), married (55.2%), and White/non-Hispanic (55.7%). Data included demographics, pain characteristics, CARE Scale-7, pain catastrophizing, and Patient-Reported Outcomes Measurement Information System psychological and physical function measures. Confirmatory factor analysis was conducted to validate the factor structure of the CARE Scale, and a stepwise approach to measurement invariances by sex examined configural, metric, and scalar invariance. Results: Internal consistency of the scale items ensured suitability for factor analyses. Confirmatory factor analysis findings revealed an overall good fit of the 2-factor model among males and females and that CARE Scale-7 is in fact sex invariant. Finally, CARE Scale-7 showed convergent validity with pain-related outcomes. Discussion: The CARE Scale is the first validated instrument to assess self-care in both sexes among patients with chronic pain. The subscale of difficulty prioritizing self-care emerged as a potentially unique factor that should be integrated in clinical assessment. CARE Scale may facilitate standardized measurement in research and clinical contexts, which may inform a comprehensive treatment focus that integrates individualized self-care planning.

Background The success of government-recommended mitigation measures during the COVID-19 pandemic depends largely on information uptake and implementation by individual citizens. Objective Our aim was to assess citizens’ knowledge and perceptions about COVID-19 recommendations in the Canton of Vaud, Switzerland. Methods A cross-sectional electronic survey with open and closed questions was disseminated by community-based partners prior to the relaxation of government restrictions. Outcomes included citizen knowledge (9-question measure) and worry about the virus, perception of government measures, and recommendations for improvements. Comparisons used linear regression, controlling for age, sex, education, and health literacy. Free-text answers were analyzed thematically. Results Of 807 people who accessed the survey, 684 (85%) completed all questions and 479 (60%) gave free-text recommendations. Overall, 75% were female, the mean age was 48 years, and 93% had high health literacy. Knowledge scores were high, with a median score of 8 out of 9. Mean levels of worry about the COVID-19 pandemic were higher in women than men (55/100 versus 44/100, P Conclusions Knowledge, adherence, and satisfaction regarding government recommendations and response were high in this sample, but many desired greater access to personal protective equipment. Those with lower health literacy and those who have been in self-isolation reported greater concerns about the pandemic.

BackgroundThe COVID-19 pandemic has broader geographic spread and potentially longer lasting effects than those of previous disasters. Necessary preventive precautions for the transmission of COVID-19 has resulted in delays for in-person health care services, especially at the outset of the pandemic.ObjectiveAmong a US sample, we examined the rates of delays (defined as cancellations and postponements) in health care at the outset of the pandemic and characterized the reasons for such delays.MethodsAs part of an internet-based survey that was distributed on social media in April 2020, we asked a US–based convenience sample of 2570 participants about delays in their health care resulting from the COVID-19 pandemic. Participant demographics and self-reported worries about general health and the COVID-19 pandemic were explored as potent determinants of health care delays. In addition to all delays, we focused on the following three main types of delays, which were the primary outcomes in this study: dental, preventive, and diagnostic care delays. For each outcome, we used bivariate statistical tests (t tests and chi-square tests) and multiple logistic regression models to determine which factors were associated with health care delays.ResultsThe top reported barrier to receiving health care was the fear of SARS-CoV-2 infection (126/374, 33.6%). Almost half (1227/2570, 47.7%) of the participants reported experiencing health care delays. Among those who experienced health care delays and further clarified the type of delay they experienced (921/1227, 75.1%), the top three reported types of care that were affected by delays included dental (351/921, 38.1%), preventive (269/921, 29.2%), and diagnostic (151/921, 16.4%) care. The logistic regression models showed that age (PConclusionsThe lessons learned from the initial surge of COVID-19 cases can inform systemic mitigation strategies for potential future disruptions. This study addresses the demand side of health care delays by exploring the determinants of such delays. More research on health care delays during the pandemic is needed, including research on their short- and long-term impacts on patient-level outcomes such as mortality, morbidity, mental health, people’s quality of life, and the experience of pain.

Objective The aim of this study was to investigate practice behaviours of Swedish physicians with regard to discussing the impact of cancer treatment on fertility with paediatric oncology patients and their parents, and to identify factors associated with such discussions. Methods A cross‐sectional survey study was conducted targeting all physicians in Sweden working in paediatric oncology care settings. Participants responded to a questionnaire measuring practice behaviour, attitudes, barriers, and confidence in knowledge. Multivariable logistic regression was used to determine factors associated with seldom discussing fertility. Results More than half of the physicians routinely talked with their patients/parents about the treatment's potential impact on fertility (male patients: 62%; female patients: 57%; P = 0.570). Factors associated with less frequently discussing fertility with patients/parents were working at a non‐university hospital (male patients: OR 11.49, CI 1.98–66.67; female patients: OR 33.18, CI 4.06–271.07), concerns that the topic would cause worry (male patients: OR 8.23, CI 1.48–45.89; female patients: OR 12.38, CI 1.90–80.70), and perceiving the parents as anxious (male patients: OR 7.18, CI 1.20–42.85; female patients: OR 11.65, CI 1.32–103.17). Conclusions Based on our findings, we recommend structured training in how to communicate about fertility issues in stressful situations, which in turn might increase fertility‐related discussions in paediatric oncology.

Background Medical information is often conflicting and consequently perceived as ambiguous. There are individual differences both in how much people perceive ambiguity and in their tolerance for such ambiguity. Little is known about how these constructs are related to each other and with other beliefs. Objective To examine the association between (a) perceived medical ambiguity, (b) tolerance for medical ambiguity and (c) their associations with various medical and cancer-specific judgement and decision-making correlates. Method and participants We conducted secondary data analyses using the cross-sectional, nationally representative Health Information National Trends Survey 4, Cycle 4 (n = 3,433, 51.0% female, Mage = 46.5). Analyses statistically controlled for age, sex, race, education and health-care coverage. Main variables studied Perceived medical ambiguity, tolerance for medical ambiguity, cancer perceptions, health-care experiences and preferences, and information-seeking styles and beliefs. Results Perceived medical ambiguity and tolerance for medical ambiguity were statistically independent. Higher perceived ambiguity was associated with lower perceived cancer preventability, lower reliance on doctors, lower perceived health and information-seeking self-efficacy, lower perceived quality of the cancer information-seeking process, and greater cancer information avoidance. Lower tolerance for ambiguity was associated with lower cancer worry, lower trust in doctors, lower likelihood of seeking health information, and lower engagement in medical research. Discussion and conclusions Perceived medical ambiguity and tolerance for medical ambiguity seem to be distinct constructs. Findings have implications for how people make medical decisions when they perceive and prefer to avoid conflicting medical information.

We propose a theoretical model of insomnia symptoms and non‐suicidal self‐injury (NSSI) that posits bidirectional linkages. We hypothesised that heightened depressive symptoms and impulsivity that result from insomnia increase NSSI. We also posit that the shame associated with NSSI triggers repetitive negative thinking, in turn increasing insomnia. Using three longitudinal waves of questionnaire data collected annually from a sample of Swedish adolescents (n = 1,457; M age = 13.2, SD = 0.43; 52.7% boys), we assessed the mediating role of depressive symptoms, impulsivity, rumination, and worry on the link between insomnia and NSSI. After controlling for depressive symptoms, we found that insomnia was related to increases in NSSI from the second to the third time point (ß 23 = 0.09, p = .01). NSSI was consistently related to increased insomnia (ß 12 = 0.09, p = .01; ß 23 = 0.11, p

Background During pandemics, effective containment and mitigation measures may also negatively influence psychological stability. As knowledge about COVID-19 rapidly evolves, global implementation of containment and mitigation measures has varied greatly, with impacts to mental wellness. Assessing the impact of COVID-19 on the mental health needs of health care workers and other workers may help mitigate mental health impacts and secure sustained delivery of health care and other essential goods and services. Objective This study assessed the self-reported prevalence of stress, anxiety, depression, and obsessive-compulsive symptoms in health care workers and other workers seeking support through Text4Hope, an evidence-based SMS text messaging service supporting the mental health of residents of Alberta, Canada, during the COVID-19 pandemic. Methods An online cross-sectional survey gathered demographic (age, gender, ethnicity, education, relationship, housing and employment status, employment type, and isolation status) and clinical characteristics using validated tools (self-reported stress, anxiety, depression, and contamination/hand hygiene obsessive-compulsive symptoms). Descriptive statistics and chi-square analysis were used to compare the clinical characteristics of health care workers and other workers. Post hoc analysis was conducted on variables with >3 response categories using adjusted residuals. Logistic regression determined associations between worker type and likelihood of self-reported symptoms of moderate or high stress, generalized anxiety disorder, and major depressive disorder, while controlling for other variables. Results Overall, 8267 surveys were submitted by 44,992 Text4Hope subscribers (19.39%). Of these, 5990 respondents were employed (72.5%), 958 (11.6%) were unemployed, 454 (5.5%) were students, 559 (6.8%) were retired, 234 (2.8%) selected “other,” and 72 (0.9%) did not indicate their employment status. Most employed survey respondents were female (n=4621, 86.2%). In the general sample, the 6-week prevalence rates for moderate or high stress, anxiety, and depression symptoms were 85.6%, 47.0%, and 44.0%, respectively. Self-reported symptoms of moderate or high stress, anxiety, and depression were all statistically significantly higher in other workers than in health care workers (P Conclusions Assessing symptoms of prevalent stress, anxiety, depression, and obsessive-compulsive behavior in health care workers and other workers may enhance our understanding of COVID-19 mental health needs. Research is needed to understand more fully the relationship between worker type, outbreak phase, and mental health changes over time, as well as the utility of validated tools in health care workers and other workers during pandemics. Our findings underscore the importance of anticipating and mitigating the mental health effects of pandemics using integrated implementation strategies. Finally, we demonstrate the ease of safely and rapidly assessing mental health needs using an SMS text messaging platform during a pandemic. International Registered Report Identifier (IRRID) RR2-10.2196/19292