Relationship between intolerance of uncertainty and symptom severity in Covid-19 patients: the mediating role of illness perception and Covid-19 fear.

The dynamic nature of coronavirus-19 (Covid-19) has caused a wreaked havoc globally, with millions of confirmed cases and deaths. Therefore, it is important to understand the psychological impact of the Covid-19 on the patients. In the present study, we examine whether intolerance of uncertainty was related to the severity of symptoms and whether this relationship is mediated by perception of illness and covid-19 fear. The study sample comprised of 98 Covid-19 patients (Mean = 35.17 SD = 12.89). Mediation analysis was conducted using the PROCESS macro for SPSS. Results of mediation analysis showed that the direct effect of intolerance of uncertainty on symptom severity was insignificant. However, the indirect effect via illness perception was significant, reflecting full mediation. The findings add knowledge to our understanding of the psychological consequences of Covid-19. The present study has implications for mental health services for patients with Covid-19, which will play a vital role in recovery from the illness.

Introduction

The rapid spread of Covid-19 has proven to be a worldwide stressor that poses a threat to humankind (Balkhair, 2020; Krishnamoorthy et al., 2020). This had led to a surge in research across the globe regarding the humanitarian crisis precipitated. Due to its life-threatening nature, its mental health ramifications has vital implication for covid-19 patients and caregivers (Rajkumar, 2020; Salari et al., 2020). Lack of proper knowledge has created a lot of uncertainty, stigma, guilt and shame regarding the illness, which further impact their mental health (Dar et al., 2020; Hamama & Levin-Dagan., 202; Freeston et al., 2020). However, there is still a dearth of research on the psychological impact of Covid-19 among individuals infected with the virus. Fewer studies focused on the mental health of Covid-19 patients have reported higher psychopathology than the general population (Guo et al., 2020; Zhang et al., 2020). Given the uncertainty of the Covid-19 pandemic, it becomes essential to explore the role of an individual's ability to tolerate the uncertainty and role of related constructs such as perception of illness and covid-19 fear in covid-19 patients for better management of this disease.

The current study drew on the uncertainty and anticipation model of anxiety (UAMA), which suggest neurobiological and psychological processes are involved in adaptive anticipatory responding under conditions of uncertainty. This model posits that increased expectancies of threat under uncertainty can take the form of biased estimates of threat and an increased subjective feeling about negative future events. These biased expectancies result in a feedback loop in which anxious individuals are increasingly vigilant and even more attentive towards a perceived threat that underlies maladaptive responses to future uncertainty (Grupe & Nitschke, 2013). In line with UAMA, we explored a mediational model which examines the direct link between intolerance of uncertainty and symptom severity. In addition, we also examined the indirect link between intolerance of uncertainty and symptom severity via the perception of illness and fear of Covid-19 among Covid-19 patients.

In the situation, like Covid-19, uncertainties about the disease and its management are rampant. A complex, ambiguous and unpredictable situation like Covid-19 has a profound impact on the physical and mental health of the patient and their families (Carleton, 2016; Mishel, 1990). The pandemic threatens everyone’s life, and individual’s reactions to this threat depend on their perceptions of the likelihood that they might get infected and to their tolerance of these uncertainties. Recent results have also suggested that intolerance of uncertainty might be a significant factor related to the significant changes in one’s routine during this pandemic (Satici et al., 2020). So it becomes essential to address their uncertainties associated with covid-19 to respond to this pandemic optimally. As asserted by the researcher, intolerance to uncertainty is one crucial factor that has affected mental health. Many studies have reported an association between the intolerance of uncertainty and stress in people (Ferreira et al., 2020). Intolerance of uncertainty models suggests that ability to tolerate uncertainty can influence a person's coping in a negative way, which in turn may result in psychological distress (Einstein, 2014; Rettie & Daniels, 2020). It is also associated with different psychopathologies (Dugas et al., 1997; Morriss et al., 2016).

With a wide range of uncertainties, perception of Covid-19 illness may play an important role in adaptation to Covid-19 infection, outcome, and satisfaction with the health care system (Hagger & Orbell, 2003a, b; Petrie et al., 2007). Perception of illness has been defined as "patient's cognitive appraisal and personal understanding of a medical condition and its potential consequences" (Broadbent et al., 2015). The illness representation models suggest that individuals create a mental representation (both cognitive and emotional) of their illness based on their information to adapt to their illness (Leventhal et al., 2001). Threatening perception of illness is significantly related to the physical and mental health outcomes (Evers et al., 2001; Hu et al., 2020; Hamama & Levin-Dagan, 2021; Man et al., 2020; Var & Rajeswaran, 2012) and modifying such perception has been shown better outcome (Petrie et al., 2002; War & Rajeswaren, 2013).

The worldwide spread of Covid-19 has resulted in a high degree of uncertainty and threatened perception of Covid-19, as discussed above, and heightened fear of Covid-19 illness (Asmundson & Taylor, 2020). Evidently, Covid-19-related fears multiply as the transmission rate increases, causing chronic and disproportionate fear among people (Ahorsu et al., 2020). Getting infected by the Covid-19 virus leads to a multitude of issues, including stigma, shame, guilt and discrimination (Hamama & Levin-Dagan, 2021). Therefore, the worldwide Cocid-19 pandemic has arguably resulted in a psychologically chaotic and gloomy environment. This time of heightened uncertainty has led to radical changes in individuals' daily routines. Due to impaired socio-occupational functioning, high mortality and threat to our existence, it has impacted our mental health and well-being (Satici et al., 2020). Therefore, it becomes important to understand the role the Covid-19 fear in Covid-19 patients.

Based on the limited data and literature, the present study tries to explain the relationship between intolerance of uncertainty and symptom severity as well as the role of perception of illness and covid-19 fear in mediating the association among covid-19 patients. From the previous studies (Carleton, 2012; Grupe & Nitschke, 2013), we developed a mediational model presented in Fig. 1. We hypothesized that intolerance of uncertainty would directly predict symptom severity, and this relationship would be mediated by perception of illness and covid-19 fear.

Fig. 1

Hypothetical mediational model

Method

Participants

A total of 106 subjects participated in the study. Of these, 98 (48 females) participants with Covid-19 diagnosis gave consent to participate in this study. The participants' age ranged between 18–65 years (Mean = 35.17 SD = 12.89). Cross-sectional data were collected using the snowball sampling method via Google Forms.

A priori power analysis was done using the G*Power computer program (Faul et al., 2007). A total of 98 participants were indicated for a medium-size effect (f2 = 0.15) with 80% power and an alpha of 0.05 using hierarchical multiple regression, fixed model, R2 increase.

Measures

Intolerance of Uncertainty Scale (Carleton et al., 2007)

The IUS-12 is a self-report measure that assesses an individual's propensity to find uncertain situations unpleasant. It measures the prospective and inhibitory dimensions of uncertainty (Carleton et al., 2007). Items were scored on a five-point scale ranging from 1 (Not at all characteristic of me) to 5 (Entirely characteristic of me). The high scores obtained from the scale indicate that the individual has a high intolerance of uncertainty. It has excellent internal consistency (α = 0.91), and a strong correlation between the 12-item IUS and the original 27-item IUS (r = 0.96). In the present study, the internal consistency reliability (Cronbach’s alpha) was found to be 0.89.

Somatic Symptoms scale (Gierk et al., 2014)

It is a self-report measure, which assesses the participants for stomach problems, fatigue, back pain, headache, sleeping troubles, dizziness, shortness of breath, and pain in arms, legs, and joints. It is derived from the frequently used Patient Health Questionnaire–15 (PHQ–15), developed by Spitzer and colleagues under Pfizer, INC (Kroenke et al., 2010). It has a good reliability (Cronbach α = 0.81) (Gierk et al., 2014). For the interest of our present study, we added some of the symptoms commonly reported by Covid-19 patients. The internal consistency relability (Cronbach’s alpha) was found to be 0.87 in the present study.

Brief Illness Perception Questionnaire (Broadbent et al., 2006)

This is a self-report scale that measures patients' cognitive and emotional representations of their illness, including consequences, timeline, personal control, treatment, control, identity, coherence, concern, emotional response, and causes. Each dimension is rated on a scale of 0–10. A high score indicated a more threatening perception of the illness. The Brief Illness Perception Questionnaire demonstrated good psychometric properties (range 0.5–0.7), including concurrent, predictive, and discriminant validity (Broadbent et al., 2015). In the current study, the internal consistency relability (Cronbach’s alpha) was found to be 0.70.

Covid-19-Related Fear (Ahorsu et al., 2020)

This 7-item scale is used to measure fears related to the ongoing Covid-19 pandemic. Participants are asked to rate the extent to which they have been bothered by each item during the pandemic on a five-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). A higher score reflects higher levels of fear of Covid-19. It has been shown to possess robust psychometric properties, including internal consistency (Cronbach's alpha = 0.82), composite reliability (0.88), test–retest reliability (ICC = 0.72), and concurrent validity (Ahorsu et al., 2020). In the present study, the scale had good internal consistency reliability (Cronbach’s alpha = 0.92).

Procedure

The study was approved by the institutional review board. Moreover, the current study was conducted in accordance with the Helsinki Declaration as revised 2013. Due to the Covid-19 pandemic, this study was conducted online using Google Form because of the restrictions and safety of the participants. In the first section of the Google Form, the purpose of the study and informed consent was taken from the potential participants. The participants were contacted through the inpatient and outpatient Department of Pulmonary Medicine GMC, Srinagar. Participants who consent to participate in the study during data collection were included in the current study. Moreover, individuals with pre-existing physical and mental illnesses that required medication were excluded from participation.

Results

Preliminary analysis

Before inferential statistical analysis, we assessed the data for normality using skewness and kurtosis of the distribution for each measure. All study measures were deemed approximately normally distributed within the range of -2 to + 2. The variance inflation factor (VIF) was inspected and found to be less than 3, suggesting that multicollinearity was not high enough to cause instability in the estimates. Firstly, frequencies and percentages were calculated for socio-demographic variables. Then Pearson's correlation was used to establish the relationship between the variables under study. This was followed by mediation analysis using model 4 of Hayes PROCESS macro for SPSS (Hayes, 2018). Age, gender, and marital status were controlled for as covariates. Our sample comprised of 98 participants (49% males and 51% females) with a mean age of 35.17 years (SD = 12.89). Socio-demographics characteristics of the sample and their statistical values are presented in Table 1. Further analysis showed that perception of illness (t(96) = 2.27, p = 0.02) and symptom severity t(96) = 3.48, p = 0.001) were found to be significantly different in favor of females. Marital status is significantly different according to the individual's perception of illness (t(96) = 2.36, p = 0.02), favouring married.

Table 1

Socio-demographics information of the sample

Demographics		N	Percentage
Gender	Male	48	49
	Female	50	51
Marital status	Unmarried	48	49
	Married	50	51
Education	Below higher secondary	7	7.1
	Undergraduate	36	36.7
	Postgraduate	55	56.1
Income	Low	43	43.9
	High	55	56.1
Mode	Hospitalized	11	11.2
	Home isolation	87	88.8

Means, standard deviations, and Pearson's correlations of the variables are presented in Table 2. As can be seen in Table 2, the bivariate correlation analyses revealed that IUS was positively correlated with BIPQ (r = 0.23, p = 0.05) and Covid-19 fear (r = 0.25, p = 0.05. In addition, all the mediator variables were significantly positively correlated with symptom severity. Moreover, BIPQ was positively correlated with age (r = 0.25, p = 0.05), and negatively correlated with gender (r = -0.23, p = 0.05) and marital status (r = -0.24, p = 0.05).

Table 2

Mean, standard deviations and zero-order correlations between different variables (n = 98)

Variables	Mean	SD	1	2	3	4	5	6	7
1. IUS	40.23	10.04	1	0.13	0.23*	0.25*	0.16	-0.01	-0.02
2. SSS	17.47	10.49		1	0.40**	0.26**	0.12	-0.34**	-0.11
3. BIPQ	42.09	7.21			1	0.16	0.25*	-0.23*	-0.24*
4. C-19 fear	20.13	7.75				1	0.06	-0.07	-0.14
5. Age	35.17	12.89					1	0.06	-0.78**
6. Gender	na	na						1	-0.14
7.Marital status	na	na							1

* p < 0.05, ** p < 0.01 (2-tailed)

IUS Intolerance of Uncertainty Scale; SSS Somatic Symptoms scale; BIPQ Brief Illness Perception Questionnaire; C-19 fear COVID-19-Related Fear scale)

Results of the mediational analysis between the variables of interest are presented in Fig. 2. Participants with higher score on intolerance of uncertainty, perceived the covid-19 illness more threatening (a1 = 0.16, t(93) = 2.25, p = 0.02) and was subsequently related to higher symptoms severity, (a2 = 0.42, t(91) = 3.93, p = 0.004). The female gender revealed an association with a higher perceived threat of illness than males. Further, the indirect path of intolerance of uncertainty on symptom severity through illness perception was statistically significant (a1a2 = 0.07, SE = 0.036, 95% CI [0.005, 0.14]). In addition, participants with higher score on intolerance of uncertainty scored higher on Covid-19 fear (b1 = 0.21, t(93) = 2.83, p = 0.005) and was subsequently related to higher symptom severity (b2 = 0.24, t(91) = 1.91, p = 0.05). Married patients revealed an association with higher covid-19 fear than unmarried. Conversely, the indirect effect through covid-19 fear was statistically insignificant (b1b2 = 0.05, SE = 0.04, 95% CI [-0.002, 0.153]). The total (c2 = 0.13, SE = 0.10, 95% CI [-0.06, 0.33]) and direct effect (c1 = 0.01, SE = 0.10, 95% CI [-0.19, 0.21]) of intolerance of uncertainty on symptom severity was also insignificant, reflecting full mediation (Baron & Kenny, 1986). Hence, these results revealed that illness perception fully mediated the link between intolerance of uncertainty and symptom severity. Covariate gender was negatively related to perception of illness (d1 = -3.73, t(93) = -2.72, p = 0.007) and symptom severity (d2 = -5.51, t(91) = -2.77, p = 0.006); marital status was negatively related covid-19 fear (e1 = -5.24, t(91) = -2.10, p = 0.03).

Fig. 2

Summary of the mediation model shows the mediating effect of illness perception and covid-19 fear between intolerance of uncertainty and symptom severity

Discussion

The current study focused on people who contracted COVID-19 in Kashmir. In the present study, we investigated the relative impact of intolerance of uncertainty, perception of illness and covid-19 fear on symptom severity in Covid-19 patients. According to the findings, illness perception was significantly more threatening in females than males and married individuals than unmarried ones (Hamama & Levin-Dagan, 2021). Gender is one factor that affects health and well-being (Mroczek & Kolarz, 1998). Generally, females live longer due to their adaptability. However, since women are culturally perceived as vulnerable, weak, and delicate, it is culturally more acceptable for them to express their illnesses more easily. On the other hand, the role of the male gender emphasizes strength, bravery, and fearlessness (Bergdahl & Bergdahl, 2002; Gao et al., 2019; Limcaoco et al., 2020).

According to the uncertainty and anticipation model of anxiety (Grupe & Nitschke, 2013), an individual’s belief systems, expectancies and appraisals regarding the threat under uncertainty can take the form of biased estimates of threat which further leads to hypervigilance and more attention towards a perceived threat. This exaggerated perceived threat, for example, may result in inappropriate or excessive anxiety toward the symptom severity. Therefore, our study tried to explore the link between intolerance of uncertainty and symptom severity and the role of perception of illness and Covid-19 fear. Results showed an indirect link between intolerance of uncertainty and symptom severity via the perception of illness and not Covid-19 fear.

In any illness individual's beliefs, experiences, assumptions and appraisal regarding that illness determine the outcome (Bonsaksen et al., 2015). Some events activate these beliefs, and any distorted interpretation of the event may result in maladaptive reactions or excessive anxiety (Clark & Beck, 2011). Therefore, it becomes essential to explore psychological aspects (intolerance of uncertainty, perception of illness and covid-19 fear) of Covid-19 illness. With respect to intolerance of uncertainty, results showed a significantly positive correlation with perception of illness and covid-19 fear. Intolerance of uncertainty has been conceptualized as "a dispositional characteristic that results from a set of negative beliefs about uncertainty and its implications and involves the tendency to react negatively on an emotional, cognitive, and behavioural level to uncertain situations and events" (Buhr & Dugas, 2009, p. 216). Disruption of our daily activities, social isolation and loss of perceived control due to Covid-19 fueled uncertainty among people (Satici et al., 2020). This unpredictability of the situation combined with misinformation and biased news further worsened the situation (Su et al., 2021). The fear of the unknown may be the fundamental component of pathological anxiety (Carleton et al., 2007). Thus, conceptual analysis indicates that difficulty tolerating uncertainty fuels the threatening perception regarding Covid-19 illness and can make individuals phobic toward the illness (Carleton, 2016).

Further, results showed a significant positive association between illness perception and symptom severity. Threatening perception of illness is found associated with both physical and mental health outcomes (Aqeel et al., 2020; Hu et al., 2020; Hamama & Levin-Dagan, 2021; Man et al., 2020; Var & Jamuna, 2012). Covid-19 is a contagious disease with no definitive treatment or vaccine available currently with life-threatening outcomes (Krishnamoorthy et al., 2020). Illness perception may act as a filter that guides the responses of an individual (Leventhal et al., 1980). The course of Covid-19 and its symptoms are perceived as never-ending due to misinformation about the illness, which increases their psychological burden and elicits a range of psychological responses (Su et al., 2021). Furthermore, we found that Covid-19 fear was also positively associated with symptom severity. In line with previous studies, it has been found positively related to pathological worry and health anxiety (Alizadehfard & Alipour, 2020; War & Jamuna, 2013).

With regard to the perception of illness and Covid-19 fear as mediators in our proposed model, our findings revealed that intolerance of uncertainty was not directly linked to symptom severity. However, the relationship was mediated by perception of illness and not by Covid-19 fear. To the best of our knowledge, we didn't come across any study which has examined the possibility of such a relation. Intolerance to uncertainty is a cognitive vulnerability for worry and anxiety (Bottesi et al., 2016). These negative beliefs about uncertainty and illness commonly interfere with our ability to deal with the situation or event effectively, leading to poor outcomes (Behar et al., 2009; Dugas et al., 1998; Koerner & Dugas, 2008).

Limitations

This study has certain limitations. It is a cross-sectional mediational study, making it impossible to conclude cause-effect relations (Cole & Maxwell, 2003). It is a preliminary study, so a longitudinal design is warranted to reveal the causal effect. All the variables of interest were assessed using self-report measures via online mode, which can lead to bias in reporting, so a multimethod approach may help reduce the bias. The study sample is small and not representative. So one needs to be careful in generalizing the findings.

Conclusion

Despite the limitations, the results demonstrate a need to build the proper awareness about the disease among the public and, more importantly, among the patients and their families (Koffman et al., 2020). Our primary findings suggest that intolerance of uncertainty is linked to symptom severity via their perception of illness. Perception plays a significant role in the physical and mental health of the infected people with Covid-19 and should be addressed appropriately. Finally, further research should concentrate on using qualitative methods to understand the psychological aspects of this illness in a better way.