Key words
stress - cognition - information - SARS-CoV-2
Introduction
Life across the globe has been dramatically altered by the coronavirus disease 2019
(COVID-19) pandemic, posing numerous mutual risks to public physical and mental
health [1]. An adequate and balanced response
to stress is detrimental to human health as excessive or chronic activation of the
hypothalamus-pituitary-adrenal axis and the sympathoadrenal system, also known as
the endocrine stress system, is associated with the pathogenesis of various human
diseases and psychological disorders, including metabolic syndrome, anxiety, or
post-traumatic stress disorder (PTSD) [2]
[3]
[4]
[5]. Recent studies have
demonstrated that patients with severe COVID-19 have a pronounced elevation in the
plasma stress hormones [6]. Interestingly, an
elevation of adrenal glucocorticoids in the plasma might persist long after the
initial infection with coronavirus, as shown in the case of survivors of the
SARS-CoV-1 pandemic [7]. In addition to the
actual coronavirus infection and treatment affecting the endocrine stress axis,
psychological stress occurs due to pandemic restrictions and fear of infection, as
has been observed particularly among health care workers [2]
[8].
The complexity and low predictability of COVID-19 not only threaten the physical
health of people but also affect their mental health, especially in terms of
emotions and cognition [9]. There is an
abundance of research demonstrating the deleterious effects of stress and anxiety on
cognitive functioning [10]
[11]
[12]
[13]
[14]. Therefore, it is highly probable that the
recent increases in stress and anxiety due to COVID-19 are likely to affect
cognitive functioning [15] possibly through
mechanisms involving mind wandering [10].
Particularly, because repeated exposure to social media/news relating to
COVID-19 might be an important source of anxiety and stress symptoms [16]. Moreover, reports of infectious diseases
often use risk-elevating information, which can amplify the perception of risk,
stress, anxiety, and impaired functioning [17]
[18].
While healthcare workers battle the coronavirus, social and behavioral science
insights can help align human behavior with public health professionals’
recommendations and promote pandemic preparedness [19]. These recommendations from health experts and the promotion of
pandemic response were disseminated through the media [20]
[21]
[22]. Evans and Hargittai have
highlighted that news media are influential and not only function as a source of
information, but also shape public perceptions [23]. It has been supposed, in the early stages of the pandemic, that news
media may function as a comfort, reducing uncertainty about COVID-19 and the
consequences of the pandemic. Thus, it was easy to suppose also that the more people
know about what is happening around them, the safer they may feel. However, during
periods of uncertainty about what could occur in the future, for example, rising
infections and deaths, lack of vaccine, losing jobs, evidence from the literature
showed that increasing media exposure, on one hand, amplify risk perception [17]
[24],
and on the other hand, amplify population distress [16]
[18]
[25]. Since the first lockdown, which started in
many countries worldwide in March 2020, the empirical evidence has highlighted that
repeated exposure to social media/news relating to COVID-19 is acting as
increase in anxiety and psychological distress [16]
[26]
[27]
[28].
During the COVID-19 outbreak, media attention typically included a variety of
stress-inducing elements, such as rumors, false representation, and fear messages,
particularly image graphic pictures (e. g., diagnosed patients on
ventilators), all of which put the public under a great deal of psychological stress
[29]. Therefore, we assumed that being
exposed to COVID-19-related information might induce cognitive distortion and
enhance stress levels.
To our knowledge, only a few studies have been conducted on this issue worldwide and
those that included the population of Kosovo, supported the relation between the
COVID-19 pandemic and incidence of cognitive distortion (e. g., anxiety and
depressive symptoms) among healthcare professionals [30] and students [31]. However, to
the best of our knowledge, no study has investigated the effects of
media/news exposure about COVID-19 on cognitive distortion and anxiety in
Kosovo.
Subjects and Methods
Subjects
In total, thirty-two first-year female medical sciences students (speech therapy
and nursing) attending the Heimerer College in Prishtina, Kosovo were recruited
to the study. The women were aged 18–21 years, of single marital status,
and of Albanian nationality. None of them had ever given birth, had not been
imprisoned, and had not been divorced.
General study design
This is a cross-sectional study based on data acquired from self-completed
questionnaires assessing cognitive distortion and stress levels among students
who were either exposed (experimental group) or not (control group) to specific
interventions related to COVID-19.
Within a week after completing initial questionnaires on cognitive distortion and
the level of stress, participants were randomly assigned to two parallel groups
based on their birth months. The experimental group of 16 students was given a
lecture by a clinical psychologist on the risk and consequences of COVID-19,
whereas the control group did not receive any intervention. Both groups were
required to re-complete the same questionnaires afterwards. The lecture
consisted of global data obtained from WHO on the number of infected and deaths
as a result of COVID-19 hitherto, on health consequences including the effects
of COVID-19 on mental health as well as national statistics data obtained from
the National Institute of Public Health of Kosovo (NIPH) regarding the spread
curve of the virus during 2020 within the last months. The whole session lasted
50 minutes (20 min of lectures and 30 min of completing
the questionnaires). The procedures of this study complied fully with the
provisions of the Helsinki Declaration regarding research on human participants.
All participants provided informed consent before enrolment. Participation in
the study was on a voluntary basis.
Questionnaire characteristics
Data were collected through a structured, anonymous, self-directed questionnaire,
including socio-demographic characteristics (age, marital status, and living
setting), and past exposure to different traumas. The Stress Assessment
Questionnaire (SAQ) [32], and the Post
Traumatic Cognitions Inventory (PTCI) were used to assess the stress level and
the posttraumatic cognitions [33].
SAQ is a 7-item self-report measure for stress. SAQ is a subscale from the
Depression Anxiety Stress Scales (DASS). The stress scale is sensitive to levels
of chronic nonspecific arousal. It assesses difficulty in relaxing, nervous
arousal, being easily upset/agitated, irritable/over-reactive,
and impatient. Each item is scored on a 4-point Likert scale, ranging from 0
(did not apply to me at all) to 3 (applied to me very much, or most of the
time). Total scores are calculated by summing the items and giving a score range
of 0–42 [32]. The DASS shows good
convergent and discriminant validity, and high internal consistency and
reliability with Cronbach’s alpha, reported at 0.94 for Depression, 0.87
for Anxiety, and 0.91 for Stress [34].
The PTCI is a 36-item self-report measure with three subscales that assess
cognitions (i. e., beliefs about self and others) that can form as a
result of experiencing trauma. The measure consists of three subscales: negative
cognitions about self (PTCI-Self, 21 items), negative cognitions about the world
(PTCI-World, 7 items), and self-blame (PTCI-Blame, 5 items). Likert scale
ranging from 1 (totally disagree) to 7 (totally agree). The PTCI-Self measured
the extent to which individuals had a negative view of him/herself and
symptoms and thoughts of helplessness and alienation. The PTCI-World measured
the degree to which individuals lack trust in others and believe the world to be
unsafe. The PTCI-Blame scale measured the extent to which individuals attribute
the occurrence of the event to something he/she did or did not do. The
three PTCI subscales and total score have demonstrated excellent internal
consistency as follows: total score (α=0.97); Negative
Cognitions About Self (α=0.97); Negative Cognitions About the
World (α=0.88); Self Blame (α=0.86) as well as
good test retest reliability ranging from 0.74–0.89. In addition, the
PTCI has demonstrated excellent convergent validity and discriminant validity
[33].
Statistical analyses
The Statistical Package for the Social Sciences software (SPSS version 21.0) was
used for data analysis [35]. Frequencies
(n) and percentages (%) were used to summarize categorical
variables, and continuous variables are summarized with mean±standard
deviation (SD). The chi-square (χ2) test and contingency
tables were used to compare the frequency of categorical variables. The Student
t-test (for two groups), and the repeated measures ANOVA test were
used to analyze continuous variables. For all statistical tests, a p-value
of<0.05 was considered statistically significant.
Results
There was no statistically significant difference between the experimental group
(n=16) and the control group (n=16) on mean age, living setting,
witnessing a traumatic situation, suffering from a severe disease, and the loss of
loved ones (p>0.05) ([Table 1]).
Table 1 Sociodemographic and stress related factors by
groups.
|
Experimental Group
|
Control Group
|
p
|
|
n=16
|
n=16
|
|
|
Age (years)
|
19.9±0.8
|
20.4±0.6
|
0.079
|
|
Living setting
|
|
Rural
|
4 (12.5)
|
2 (6.3)
|
0.651
|
|
Urban
|
12 (37.5)
|
14 (43.8)
|
|
|
Witnessing traumatic situations
|
|
Yes
|
4 (12.5)
|
4 (12.5)
|
0.117
|
|
No
|
12 (37.5)
|
12 (37.5)
|
|
|
Having Financial difficulties
|
|
Yes
|
2 (6.3)
|
2 (6.3)
|
0.087
|
|
No
|
14 (43.8)
|
14 (43.8)
|
|
|
Exposed to natural disaster
|
|
Yes
|
1 (3.1)
|
2 (6.3)
|
0.382
|
|
No
|
15 (46.9)
|
14 (43.8)
|
|
|
Have had an accident of injury
|
|
Yes
|
3 (9.4)
|
4 (12.5)
|
0.732
|
|
No
|
13 (40.6)
|
12 (37.5)
|
|
|
Being exposed to crime or abuse
|
|
Yes
|
0 (0.0)
|
1 (3.1)
|
0.625
|
|
No
|
16 (50.0)
|
15 (46.9)
|
|
|
Suffering from severe disease
|
|
Yes
|
1 (3.1)
|
3 (9.4)
|
0.732
|
As shown in [Table 2], there were no
statistically significant differences in the mean points of the SAQ and the PTCI
among groups (p>0.05). The first and second measurements showed no change in
the stress and cognition points of the participants (p>0.05) ([Table 3]). The chi-square test comparison of
the first and second measurements of groups of the Stress Assessment Questionnaire
(SAQ) categories showed no statistical difference between the experimental group and
a statistically difference within the control group ([Table 4]). Analyzed with repeated measures
ANOVA test there was no statistically significant difference among groups when
considering the time*group factor (F=0.147, p=0.704,
η²p=0.005).
Table 2 The Stress Assessment Questionnaire (SAQ) and the
posttraumatic cognitions inventory (PTCI) results for both groups a
priori.
|
Group
|
n
|
Mean
|
Std. Deviation
|
|
|
SAQ total points
|
Experimental
|
16
|
18.37
|
7.7
|
t=1.197, p=0.241
|
|
Control
|
16
|
15.12
|
7.66
|
|
PTCI-Self
|
Experimental
|
16
|
2.95
|
0.79
|
t=1.724, p=0.095
|
|
Control
|
16
|
2.42
|
0.93
|
|
PTCI-World
|
Experimental
|
16
|
4.14
|
0.66
|
t=1.938, p=0.062
|
|
Control
|
16
|
3.58
|
0.95
|
|
PTCI-Blame
|
Experimental
|
16
|
2.71
|
0.96
|
t=1.803, p=0.081
|
|
Control
|
16
|
2.06
|
1.07
|
|
PCTI total points
|
Experimental
|
16
|
104.56
|
22.98
|
t=1.933, p=0.063
|
|
Control
|
16
|
86.31
|
29.97
|
Table 3 The comparison of the Stress Assessment Questionnaire
(SAQ) and the posttraumatic cognitions inventory (PTCI) results by
groups.
|
Group
|
|
Mean
|
Std. Deviation
|
t
|
p
|
|
Experimental
|
First measurement SAQ total points
|
18.37
|
7.7
|
0.859
|
0.404
|
|
Second measurement SAQ total points
|
16.87
|
8.1
|
|
First measurement PTCI-Self
|
2.95
|
0.79
|
1.917
|
0.074
|
|
Second measurement PTCI-Self
|
2.74
|
0.93
|
|
First measurement PTCI-World
|
4.14
|
0.66
|
1.647
|
0.12
|
|
Second measurement PTCI-World
|
3.92
|
0.64
|
|
First measurement PTCI-Blame
|
2.71
|
0.96
|
–0.889
|
0.388
|
|
Second measurement PTCI-Blame
|
2.87
|
0.93
|
|
First measurement PCTI total points
|
104.56
|
22.99
|
1.396
|
0.183
|
|
Second measurement PCTI total points
|
99.31
|
26.82
|
|
Control
|
First measurement SAQ total points
|
15.12
|
7.66
|
0.426
|
0.676
|
|
Second measurement SAQ total points
|
14.5
|
8.02
|
|
First measurement PTCI-Self
|
2.42
|
0.93
|
–0.14
|
0.891
|
|
Second measurement PTCI-Self
|
2.45
|
0.82
|
|
First measurement PTCI-World
|
3.58
|
0.95
|
0.739
|
0.471
|
|
Second measurement PTCI-World
|
3.48
|
0.84
|
|
First measurement PTCI-Blame
|
2.06
|
1.07
|
–1.615
|
0.127
|
|
Second measurement PTCI-Blame
|
2.46
|
0.94
|
|
First measurement PCTI total points
|
86.31
|
29.97
|
–0.346
|
0.734
|
|
Second measurement PCTI total points
|
88.12
|
26.53
|
Table 4 The chi-square test comparison of first and second
evaluation by groups of the Stress Assessment Questionnaire (SAQ) based
on categories.
|
Group
|
After
|
Normal n (%)
|
Mildn (%)
|
Moderaten (%)
|
Severen (%)
|
p
|
|
Before
|
|
|
|
|
|
Experimental
|
Normal
|
4 (25)
|
0 (0)
|
0 (0)
|
1 (6.3)
|
0.055
|
|
Mild
|
0 (0)
|
1 (6.3)
|
0 (0)
|
0 (0)
|
|
Moderate
|
1 (6.3)
|
1 (6.3)
|
3 (18.8)
|
2 (12.5)
|
|
Severe
|
0 (0)
|
1 (6.3)
|
2 (12.5)
|
0 (0)
|
|
Control
|
Normal
|
6 (37.5)
|
1 (6.3)
|
1 (6.3)
|
0 (0)
|
0.049
|
|
Mild
|
1 (6.3)
|
3 (18.8)
|
0 (0)
|
0 (0)
|
|
Moderate
|
0 (0)
|
1 (6.3)
|
1 (6.3)
|
0 (0)
|
|
Severe
|
0 (0)
|
0 (0)
|
1 (6.3)
|
1 (6.3)
|
Discussion
In the present study, we examined the impact of being exposed to information about
COVID-19 on stress and cognitive distortions levels among medical sciences students
using two questionnaires, the SAQ and the PTCI. Our results demonstrated that
exposure to a lecture about COVID-19 and a 20-minute video about the dramatic events
of the patients infected with SARS-CoV-2 did not significantly impact stress and
cognitive distortion levels as shown by no significant changes in the mean points of
the SAQ and the PTCI among participants of the study (p>0.05). These
findings are unexpected and contradictory according to the previous results, which
have been found in the literature [16]
[27]
[28].
These studies showed that exposure to news and information about COVID-19 is a
source of psychological distress [20]
[36], especially when the content is negative
[37], and when the news provides
misinformation [21]. We would have expected a
higher stress and anxiety level among the experimental group compared to the control
group because of their exposure to media. Hence, being exposed to information about
COVID-19 would have explained, to a certain part, an increase in their stress and
anxiety. Moreover, these cognitive distortions would have been enhanced by tragic
images they would have watched in the video and listened to during the lecture.
However, no significant differences came out between the two groups of participants
on the SAQ and PTCI measures. Thus, we supposed the impact of media exposure could
be decreased according to the news-consuming process about COVID-19. Empirical
evidence has found the impact of media on anxiety and psychological distress differs
depending on how the information is consumed. The mode of information consumption
can be either active or passive [38].
Interestingly, Ryerson [39] included a
combination of items that assessed both the active and passive process of consuming
media. In this study, Ryerson used only one of the three factors of Coronavirus
Experiences Questionnaires [40]: The News
factors where the scale includes three items that assess exposure to media about
COVID-19 (i. e., “I watch a lot of news about COVID-19”,
“I purposefully try not to watch the news on COVID-19”, and
“I spend a huge percentage of my time finding updates online or on TV about
COVID-19”). Ryerson found that psychological health was not related to
active or passive media exposure. Moreover, Yang et al. [41] identified the lower frequency of passively
being exposed to pandemic media as a characteristic that is associated with lower
anxiety [42]
[43].
Furthermore, the results did not show changes in stress and cognition points in
participants across the first and the second measurement
(means=16.75–95.44 and 15.69–93.72 for SAQ and PTCI on the
first and the second measurement, respectively). This result is in line with the
interaction between time and group, which did not show significance. In accordance
with previous research, these findings suppose that the impact of media exposure on
anxiety and cognitive distortion can be influenced by the sanitary context,
specifically the fluctuations in COVID-19-related news [44]. Interestingly, Chisty et al. [45] found that people’s perception of
COVID-19 can be inconsistent with the fluctuating condition of the pandemic. Their
findings highlighted that the information sought about any risk could amplify or
reduce the level of perceived risk. Furthermore, previous studies that investigated
the impact of media consumption during the COVID-19 pandemic collected their data
during the first lockdown and the early post-lockdown period. Then, during this
uncertain period, populations were not aware of future perspectives (e. g.,
vaccine elaboration) to face this pandemic. These uncertainties and the media
exposure of COVID-19 have, in a way, shaped populations’ risk perceptions.
This risk perception did participate in the decline of mental health worldwide. In
contrast, the present study assessed the impact of media exposure on mental health
(i. e., stress and cognitive distortion) long after (in January 2021) these
lockdown periods were over, and the peak of infection and death rates were high.
Even if some measures stayed active (curfews, masks, social distance), we suppose
that risk perception, psychological distress, and cognitive distortions should have
been much lower during the experiment testing time. We suppose that this new return
to some sort of freedom (in contrast with lockdowns), may contribute to a certain
form of resilience in facing the stressors (i. e., stress, cognitive
distortion, risk perception) associated with COVID-19.
Interestingly, when we assessed with the chi-square test, the results did not show a
statistically significant difference in the participants’ distribution
within categories of stress levels before and after exposure to the COVID-19
stressful information (p>0.05). This finding does not corroborate the
previous evidence, which found that direct and indirect media exposure to COVID-19
has an impact on and increases the levels of mental health problems [46]. Regarding this result, it is possible that
being exposed to media for months (i. e., from the first peak of the
pandemic and the lockdown, the 12th of March 2020 in Kosovo and January 2021) made
the participants efficiently aware of the pandemic situation. We suppose this
awareness about COVID-19 (e. g., how the virus can spread, and which
behaviors should be adopted to avoid the spread: handwashing, opening the windows
every N-hours, wearing masks, keeping distance from other people) provided
participants the opportunity to adopt coping mechanisms, such as cognitive coping
behaviors [46]
[47]. This coping strategy highlighted that taking preventive actions and
learning about COVID-19 can accurately decrease the levels of cognitive distortion
and anxiety [46]. Thus, it is possible that
participants were protected from an acute mood change by the use of coping
mechanisms before being tested in our experimental condition.
Then, the chi-square results showed a slightly significant difference in the
distribution of frequencies in the control group among categories of stress levels
at the first and the second measurement. This finding showed the frequency of
participants from the control group was higher in the normal stress category
(37.5% of participants) than in other categories of stress levels. In line
with previous results in the present study, this finding confirms our explanations
about the non-significant results in the experimental groups. Indeed, it is probable
that the coping behaviors (e. g., emotional support from others, acceptance,
positive reframing, and religious coping) [48], in the control group, may have already been implemented by this group,
prior to the experiment. As it has been demonstrated in research on trauma and in
post-disaster mental health, that negative psychological effects are not always
present, and that traumatic events can occasionally lead to positive emotional
states and growth [49]. Thus, it has been
studied that through the constructs of resilience, post-traumatic growth (PTG) and,
coping strategies, the human being has also a faculty to cope with horrific
situations and to recover, more or less quickly, from trauma such as terrorism,
natural disaster and even pandemics [50]
[51]
[52]
[53]. As a result, it is
probable these strategies may have partially relieved stress and maintained active
coping resources in our sample of participants during the pandemic period.
Conclusion
Since the outbreak of COVID-19, the literature has primarily focused on the negative
impact of media exposure (i. e., stress level, anxiety, cognitive
distortion, PTSD). However, depending on some parameters that we highlighted
(e. g., passive/active mode consumption, fluctuations in
COVID-19-related news) our results showed different outcomes from the media exposure
to COVID-19 literature. These results can be aligned with research on resilience,
coping methods, and post-traumatic growth that has shown a positive outcome from
catastrophic tragedies and frightening experiences is entirely possible after being
exposed to unpleasant events. As a result, the media’s future work should
balance more their information between current facts and psychological aids. This
would be essential to better inform the population about psychological support that
can help people to implement coping strategies quickly after certain psychological
emergencies (e. g., follow-up of Ukrainian refugees’ psychological
state) in order to avoid, or at the very least, lessen the evolution, sometimes
insidious, of cognitive distortion, anxiety, or even PTSD.
Author Statement
ML: Conceptualization, Software, Writing – Original Draft Preparation,
Writing – Review & Editing; BT: Methodology, Software, Formal
Analysis, Data Curation, Writing – Original Draft Preparation; AH:
Validation, Writing – Original Draft Preparation, Supervision; NS:
Validation, Writing – Original Draft Preparation, Writing – Review
& Editing; RM: Investigation, Resources, Writing – Original Draft
Preparation, Visualization, Project Administration; LP: Investigation, Resources,
Writing – Original Draft Preparation. All authors have read and approved the
final manuscript; PS: Validation, Writing – Original Draft Preparation,
Writing – Review & Editing; CS: Validation, Writing –
Original Draft Preparation, Writing – Review & Editing; AI:
Investigation, Resources, Writing – Original Draft Preparation.
Ethics Approval and Consent to Participate
Ethics Approval and Consent to Participate
The studies involving human participants were reviewed and approved by the Heimerer
College. The participants provided their written informed consent to participate in
this study. The procedure of this study complied fully with the provision of the
Helsinki Declaration regarding research on human participants
Human and Animals Rights
All the human procedures used were in accordance with the ethical standards of the
committee responsible for human experimentation (institutional and national), and
with the Helsinki Declaration.
