Relationships among COVID-19 phobia, health anxiety, and social relations in women living with HIV in Iran: A path analysis.

INTRODUCTION: The COVID-19 pandemic and its consequences have caused fear and anxiety worldwide and imposed a significant physical and psychological burden on people, especially women living with HIV (WLHIV). However, WLHIV were not studied as well as others during the pandemic. Hence, this study aimed to determine the relationships between COVID-19 phobia, health anxiety, and social relations in WLHIV.
MATERIALS AND METHODS: This cross-sectional study enrolled 300 WLHIV who had records at the Iranian Research Center for HIV/AIDS of Tehran University of Medical Sciences. Data were collected using sociodemographic questionnaire, the fear of COVID-19 scale, the social relations questionnaire, the socioeconomic status scale and the health anxiety inventory. Path-analysis was used to assess the direct and indirct associations between variables.
RESULTS: Based on the path analysis, among variables that had significant causal relationships with social relations, socioeconomic status (β = -0.14) showed the greatest negative relationship, and health anxiety (β = 0.11) had the strongest positive relationship on the direct path. On the indirect path, fear of COVID-19 (β = 0.049) displayed the greatest positive relationship. The level of education (β = 0.29) was the only variable showing a significant positive relationship with social relations on both direct and indirect paths.
CONCLUSION: Our result showed that increased fear and health anxiety related to a higher social relations score in WLHIV. Hence, due to their vulnerability, these people require more support and education to adhere to health protocols in future pandemics and similar situations.

1. Introduction

The COVID-19 pandemic has affected the psychological status of many people [1]. Based on the Inter-Agency Standing Committee (IASC) report, people are, directly and indirectly, impacted by stressful experiences in this period; and their most prevalent responses to these stressful experiences include fear (of illness, death, loss of livelihood, social isolation, and being quarantined) and fear-related behaviours, e.g., limited social relations, distance from treatment centers (fear of going to a health facility), health anxiety, depression, and stress [2].

Fear is an adaptive feeling needed to cope with potential threats, but excessive fear has negative impacts on the personal (mental health issues and anxiety disorders) and social levels (seclusion, isolation, xenophobia) [3]. Researchers have discussed the pathological fear of COVID-19 (COVID-19 phobia) due to the nature and wide-ranging impacts of the pandemic [4].

Various factors may affect the degree of psychological vulnerability to COVID-19 phobia, including personal variables such as tolerance, lack of trust, vulnerability to the diseases, anxiety, and concerns [4]. Reports suggest that older adults and those with underlying diseases, including HIV, are at greater risk [5]. Hence it seems that the COVID-19 pandemic imposes a more significant physical and psychological burden on women living with HIV (WLHIV) [6, 7], as WLHIV have severe early death anxiety, different disease-related fears, and mental disturbances ranging from indifference and hopelessness to severe reactions such as anxiety and depressive disorders [8].

Health anxiety is a wide-ranging cognitive disorder formed by incorrect perceptions regarding physical changes and symptoms resulting from one’s beliefs about illness or health [9]. Some researchers say severe health anxiety can arise from COVID-19 phobia [4]. Almost everyone has experienced some degree of health anxiety, low levels of which are not pathological but rather help people perform and commit to preventive behaviours. However, severe degrees are associated with maladaptive coping behaviours leading to distress, social incompetence (social disability), disrupted job performance, and having a fear of going to health centers (even in situations when it is necessary) or having an obsession with going to the health centers repeatedly without any necessity [10].

In social science, a social relation is any relationship between two or more individuals. People inherently need and thus create opportunities to experience social relations. Social relations also affect mental health, health-related behaviours, and physical health. Studies show that social relations have short- and long-term effects on health that emerge during childhood and throughout one’s life [11].

During the COVID-19 pandemic, the World Health Organization (WHO) recommended precautionary measures, including quarantine, limiting social relations by increasing physical distance, wearing a mask when visiting others, and avoiding overcrowding [12]. Due to the importance of this topic, the vulnerability of WLHIV, and the absence of a model examining all the mentioned variables together, especially for this group, the current study aimed to determine relationships among COVID-19 phobia, health anxiety, and social relations in WLHIV via path analysis.

2. Materials and methods

2.1. Study design

In this cross-sectional study, 300 WLHIV who had records at the Iranian Research Center for HIV/AIDS affiliated to Tehran University of Medical Sciences were included.

2.2. Study population

The sample size was calculated according to Maria Pizzirusso et al. [13] study, by considering type I (α) and type II (β) errors of 0.05 and 0.2, respectively, and the correlation (r) of 0.16 for social relations and anxiety, by using the following formula:

Total sample size [(Zα+Zβ)/C] 2 + 3

When C = 0.5 * ln [(1+r)/ (1-r)]

Inclusion criteria

Iranian women with records at the Iranian research center for HIV/AIDS of Tehran University of Medical Sciences, with minimum literacy, absence of mental and physical problems (as reported by the patient/registered in their records) that would preclude them from participation, and no history of psychotropic medications.

Exclusion criteria

Returning incomplete questionnaires, migration, and hospitalization due to COVID-19.

2.3. Data collection and definition of terms

The data were collected via four questionnaires: The fear of COVID-19 scale [14]; The health anxiety inventory [15]; the social relations questionnaire; the socioeconomic status (SES) scale [16]; as well as a sociodemographic information checklist.

2.3.1. The fear of COVID-19 scale

Pakpour, Griffiths, et al. developed the fear of COVID-19 scale in 2020 with seven items. 1-I am most afraid of COVID-19. 2-It makes me uncomfortable to think about COVID-19. 3-My hands become clammy when I think about COVID-19. 4-I am afraid of losing my life because of COVID-19. 5-When watching the news and stories about COVID-19on social media, I become nervous or anxious.6-I cannot sleep because I’m worried about getting COVID-19-19.7-My heart races or palpitates when I think about getting COVID-19 [14]. The responses range from "strongly disagree" (1) to "strongly agree" (5). All items’ scores yield a total score ranging from 7–35. The original version has a Cronbach’s alpha of 0.82, test-retest coefficient of 0.88, and appropriate validity. In Iran, its reliability was confirmed with a Cronbach’s alpha of 0.86 [17]. The scale’s reliability was confirmed in the current study with a Cronbach’s alpha of 0.84.

2.3.2. The health anxiety inventory

The health anxiety inventory was developed by Salkovskis and Warwick (2002) with 18 items to measure health anxiety. Each question consists of a group of four statements describing a person’s health or feelings about health and illness over the past six months. There are no right or wrong answers. The questions are scored on a four-point Likert scale (never = 0 to often = 3). Salkovskis reported the test-retest reliability of 0.90 and Cronbach’s alpha of 0.70–0.82 [15]. The Persian version of the inventory showed a Cronbach’s alpha of 0.75, demonstrating optimal validity [18].

2.3.3. Social relations questionnaire

This questionnaire evaluates communication skills and social functioning with others/community and consists of 11 items like "I don’t worry about dealing with people, I have competence and ability in social affairs, I am interested in joining a private group, I can be successful in verbal communication with others, Weak social connections can be due to failures caused by the living environment and society", and it’s scored on a five-point Likert scale from very low to very high (1–5). The score ranges from 11 to 55. Its reliability was confirmed with a Cronbach’s alpha of 0.87 (Mousavi, 2013). The current study confirmed its reliability with a Cronbach’s alpha of 0.89.

2.3.4. Socioeconomic status (SES) scale

SES consisted of 6 questions, including parental education, income, economic class, and housing status, which are scored based on a Likert scale from 1 to 5, and a total score ranging from 6 to 30. Validity and reliability was approved in Iranwith a Cronbach’s alpha of 0.83 (2013) [16].

2.3.5. Socio-demographic checklist

Sociodemoghraphic characteristics including age, duration of the disease, the number of children, having sex partners, education, and having health insurance were collected via self-constructed checklist.

2.4. Procedure

The study began after obtaining the required permissions and approval from the Ethics Committee of Alborz University of Medical Sciences (IR.ABZUMS.REC.1400.022). The researchers visiting the centre of the behavioural diseases who were identified as eligible participants were briefed about the study’s objectives. The eligible participants signed a written informed consent form if they were willing to participate. Due to the COVID-19 pandemic and to adhere to distancing and minimal presence at the center, the questionnaires were sent to those who had Internet access over the Pars Online platform, and they were requested to fill them out in one week. For those who did not have Internet access, a separate room was allocated for filling out the questionnaires. The respondents could ask their questions regarding questionnaire items and resolve any ambiguities by phone for those who used the Internet and in person for those who filled out the questionnaire in the center.

They were all ensured that their data would remain confidential, that participation was not obligatory, and that they would not be deprived of any services if they did not participate.

2.5. Statistical analysis

This study examined the fitness of a conceptual model for the relationship between fear of COVID-19, health anxiety, and social relations in WLHIV. Path analysis is an extension of conventional regression that shows each variable’s direct and indirect effects on the dependent variables. The results can be used to provide a rational interpretation of the relationships and correlations observed. It can consider a causal modelling technique; it can be performed with cross-sectional data [19]. Direct and indirect effects of independent variables included age, education, child number, SES, partner number, health anxiety, COVID-19 phobia on social relations was assessed using the path model. The results of path model was reported as standardized and unstandardized β coefficient. In the path model, the significance level was set at a T-value >1.96.

Pearson’s correlation coefficient was used to assess correlation between variables. P-value less than 0.05 was considered as statistically significant. Data were analyzed in SPSS-25 and Lisrel-8.8.

3. Results

Demographic characteristics are presented in Table 1. The participants’ mean age was 39.4 ± 7.5 years. Mean (SD, minimum, maximum) of the health anxiety score, the fear of COVID-19 score, and social relations score (35.1 ± 3.80) was 20.6 (7.3, 5,52), 22.4 (5.3,7,35) and 35.1 (3.80, 26, 48) respectively.

Table 1

Sociodemographic characteristics of participants.

Variable		Value
Age (year)1		39.4 (7.5)
HIV duration (year)1		7.88 (4.98)
Education (year)1		10.07 (3.65)
Social-economic status (score)1		9.5 (2.61)
Health anxiety (score)1		20.6 (7.3)
Corona Phobia (score)1		22.4 (5.3)
Social relation (score)1		35.1 ± 3.8
Covid-19 positive history 2		72 (23.8)
Having insurance		95 (31.5)
Number of children2	0	116 (38.4)
	1	81 (26.8)
	2	60 (19.9)
	3 and more	45 (14.9)
Job2	Housekeeper	83 (27.5)
	Worker	84 (27.8)
	Employee	23 (7.6)
	Unemployed	47 (15.6)
	Retired	11 (3.6)
	Self-employed	54 (17.9)

1 are reported as mean (SD)

2 are reported as number (%)

Based on Pearson’s correlation analysis, among independen variables education had the strongest significant positive correlation (r ≈ 0.37), and the number of children displayed the strongest significant negative correlation (r ≈ -0.26) with social relations (Table 2).

Table 2

The correlation matrix of sociodemographic variables, health anxiety, COVID-19 phobia, and social relations in PLWH.

	Age	Partner number	Child number	HIV duration	Health anxiety	SES	Covid-19 phobia	Education	Social relations
Age	1	-0.152**	0.587**	0.448**	-0.034	0.034	0.124*	-0.356**	-0.235**
Partner number		1	-0.129*	-0.091	-0.069	0.141*	-0.035	0.153**	0.173**
Child number			1	0.289**	0.026	-0.039	0.184**	-0.343	-0.255**
HIV duration				1	-0.081	0.025	0.037	-0.170**	-0.167**
Health anxiety					1	-0.009	0.424**	-0.013	-0.108*
SES						1	0.034	0.184**	0.192**
Covid-19 phobia							1	-0.1	-0.033
Education								1	0.365**
Social relations									1

**: P 0.01

*: P>0.05, SES: social-economic statuse

Based on the path analysis, among variables with significant and causal relationships on the direct path with social relations, socioeconomic status (β = -0.27) had a negative relationship, while health anxiety (β = 0.75) and HIV duration(β = 0.51) had a positive relationship. In other words, with a one-score increase in SES, the social relations score decreased, and with a rise in the health anxiety score and duration of HIV, the social relations score increased. On the indirect path, the fear of COVID-19 (β = 0.32) had a significant and positive relationship with social relations; in other words, a rise in fear of COVID-19 score was associated with a rise in social relations score. Level of education was the only variable showing a significant and positive relationship with social relations on both direct and indirect paths (B = 0.32), meaning that a higher level of education was associated with a higher social relations score (Table 3) and Figs 1 and 2.

Table 3

The direct and indirect effects of sociodemographic variables, health anxiety, COVID-19 phobia and social relations in PLWH.

	Standardized β coefficient			Unstandardized β coefficient			R2
	Direct effects	Indirect effects	Total effect	Direct effects	Indirect effects	Total effect	0.96
Age	0. 1*	0.06	0.1*	0. 5*	0. 4	0.5 *
Education	0.37*	-0.048*	0.32*	0.5*	-0.06*	0.44*
Child number	0.13*	-0.02	0.13*	0.5*	-0.09	0.5
SES	-0.27*	-0.015	-0.27*	-0.5*	-0.025	-0.5*
Partner number	-	-0.05	-0.05	-	-0.145	-0.145
Health anxiety	0.75*	-	0.75*	0. 5*	-	0. 5*
HIV duration	0.51*	-0.061	0.51*	0.5*	-0.059	0.5*
COVID-19 phobia	-	0.322*	0.322*		0. 3*	0. 3*

*Statistically significant, SES: social economic statuse

Fig 1

Full empirical path model between health anxiety, COVID-19 phobia, and social relationsaccording to T-value.

(T-value>1.96 is considered as significant). AGE: Age, PN: Partner number, CN: Child number, HA: Health anxiety, HIVY = HIV duration (year), SES: Socioeconomic status; EDU: Education, SR: Social relations; CPH: COVID-19 phobia.

Fig 2

Full empirical model (Empirical path model between health anxiety, corona phobia, and social relations) according standard B.

AGE = age of the participants, PN = partner number, CN = Child Number, HA = Health anxiety, HIVY = HIV duration, EDU = Education, CPH = COVID-19 phobia, SES = Socioeconomic statues, SR = Social relation.

The model’s fitness indices demonstrate its goodness of fit and the reasonably adjusted relationships among the variables (Table 4).

Table 4

Goodnees of fit indecesof empirical path model between health anxiety, COVID-19 phobia, and social relations.

Fit Index	X2	df	X2/df	CFI	GFI	NFI	RMSEA
Model Index	18.47	8	2.308	0.97	0.98	0.095	0.048
Acceptablerange	X2/df < 5			> 0.9	> 0.9	> 0.9	< 0.05

CFI (comparative fit index), GFI (Goodness of fit index), NFI (Bentler-Bonett Normed fit index), RMSEA (root mean squared error of approximation)

4. Discussion

This study explored the relationship between fear of COVID-19, health anxiety, and social relations in WLHIV via path analysis. Among variables with significant causal relationships with social relations, SES showed the greatest negative relationship, and health anxiety demonstrated the greatest positive relationship on the direct path. Fear of COVID-19 showed the greatest positive relationship on the indirect path. Level of education was the only variable that had significant and positive relationships with social relations on both direct and indirect paths.

SES had the highest negative relationship with social relations; the poorer the socioeconomic status, the higher the social relations. Social relations means any relationship between two or more individuals, such as emotional and practical support provided by significant others [11]; in a special situation such as a pandemic, people with high SES decrease their relationship with the community and keep their distance. On the contrary, other studies reported fewer social relations in lower SES groups [20]. In another study, patients with HIV who had a lower SES were poorer or had lower living standards and had fewer social relations than others [21]. This difference in results can be attributed to the pandemic and differences among countries, as in our study, those with a higher SES were less in need of being in society to earn a living or visit healthcare centres. These factors limit social relations, especially for WLHIV.

Our study revealed that health anxiety had the greatest positive relationship with social relations. The main element of health anxiety is worry about health and the fear of disease. Commonly, the symptoms of worry and anxiety, which include many bodily symptoms, are misinterpreted as evidence of organic illness [22]. It causes great suffering for patients and those around them and is costly in terms of greater use of medical care utilization. For example, individuals suffering from health anxiety desperately seek to identify the physical causes of their symptoms and will often consult several medical professionals. Evidence suggests that the social costs of health anxiety are high. In undergraduates, health anxiety is linked to increased doctor visits [23]. We found no similar study on patients with HIV regarding this subject.

Nonetheless, according to previous studies, a possible cause of this finding could be that patients with more health anxiety visit healthcare centers more than others to check their health status. In Covid -19 pandemic, to ensure the diagnosis, they visit different doctors to make sure they are not infected with COVID-19 [9, 24], Which in turn may increase their social relations. The physical signs and symptoms of health anxiety during the pandemic may resemble the signs and symptoms of COVID-19 itself; in this case, people may mistake these physical changes as symptoms of COVID-19. People with high health anxiety regard any physical change as a sign of a disease, which exacerbates their anxiety and concern, and leads to repeated referrals [24].

People with severe immune deficiencies, such as HIV, face numerous side effects. They may be exposed to severe COVID-19 and have a higher mortality risk due to its complications, which can cause or exacerbate their stress and concern [25].

In the present study, fear of COVID-19 had the strongest positive relationship with social relations through the indirect path. Fear of COVID-19 positively affected health anxiety and thus increased the social relations of the patients. As noted before, WLHIV frequently visit diagnostic and treatment centers due to concerns and fear of COVID-19 complications, which increases their social relations [9, 24]. According to COVID-19 research and the media report, fear of COVID-19 affected has increased and fear of infection has become a concern in the context of the COVID-19 pandemic because it worsens emotion, cognition, and behavioral responses [26]. Although fear is a common psychological outcome during the pandemic, it is not limited to morbidity and mortality but may also emerge as social and occupational stress due to the evolving nature of the disease, its prevalence, and its unique risk factors. COVID-19 phobia is a hyper-reactive fear of contracting COVID-19 with three physiologic, cognitive, and behavioural components. Ongoing worry can induce symptoms such as tachycardia, tremor, breathing difficulty, vertigo, a changed appetite, obsession, and affective responses (sadness, guilt, anger). To prevent the consequences, people adopt avoidant behaviours that may disrupt the overall quality of their daily functioning [27]. Studies show that the complications and mortality caused by this disease are higher in people with chronic diseases, which induces or exacerbates fear and anxiety in them [28, 29].

In the current study, level of education was the only variable that had significant and positive relationships with social relations on both direct and indirect paths. Likewise, Nojoomi et al. showed that HIV-positive patients who were educated and employed had a better status than other patients in most quality of life dimensions, especially mental health, social functioning, and environmental dimension [30]. Educated patients have a better attitude towards the disease and are better adjusted to it due to their better occupational and financial opportunities and high cultural status, which can expand their social relations, such as emotional and practical support provided by significant others and leads to a better quality of life. Studies show that people with a higher level of education run a longer and healthier life compared to people of the same age but with a lower level of education [11, 31].

Contrary to our study, a study in China demonstrated no significant relationship between the social relations of patients with HIV and their level of education [32]. Cultural differences, economic conditions, and living standards could explain these differences.

This study had some limitations. One of them was the time in which the survey was conducted (during the COVID-19 pandemic); when adhering to social distancing and limiting social relations was necessary. In addition, this study didn’t evaluate the patients’ comorbidities, and used questionnaires for data recording. Nonetheless, due to the use of Path analysis based on multiple regression techniques, all confounders were adjusted so that they would not affect the reults.

5. Conclusion

According to our result, increased fear, health anxiety score and the duration of HIV, related to a higher score of social relations. Based on their vulnerability, WLHIV requires more support and need proper education to adhere to health protocols in future pandemics and similar situations.

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23 May 2022

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Reviewer #1: This study examined the interrelationships of socioeconomic characteristics, fear against COVID-19, health anxiety with social relations among people living with HIV. This manuscript highlights an important public health topic. I hope the following comments clarify the areas of improvement in the reporting of this study.

1. The title and abstract do not have the information on the study site. In the Methods section of the Abstract has the description that “enrolled 300 PLHIV who had records at the Behavioral Diseases Center of Tehran University of Medical Sciences,” though. The international audience may not understand where this study was conducted.

2. Citation format is inconsistent with the authors’ guidelines.

3. Study design: What is a “descriptive-analytical study?” Epidemiologists often distinguish clearly between a descriptive study and a analytical study. Broadly speaking they regard that a descriptive study as a means of exploring a hypothesis and an analytical study as for testing a hypothesis (for example, see the following: United States Centers for Disease Control and Prevention. Principles of epidemiology in public health practice. 3rd edition: An introduction to applied epidemiology and biostatistics. Lesson 1, Chapters 6 and 7. Atlanta: U.S. Department of Health and Human Services; 2012). The authors may want to clarify the study design based on what is intended to do in this study.

4. Items of the scale: Readers cannot obtain explanations on the questionnaire items regarding fear of COVID-19, anxiety, and social relations. Particularly, social relations may have different aspects by “relations with whom.” The authors need to explain more about the items in these scales.

5. Table 2: It would be good to have social relation at the right end of the column so that readers can check the correlation coefficients of different variable with social relation (as an outcome variable according to the objective statement at the end of the Background section) vertically in the single column.

6. Correlation analysis: It is not clear how the authors used the results of Table 2. How is it meaningful to how the size and significance of correlation coefficients? The authors may note that a significant correlation with social relations indicates that it is likely that the correlation coefficient is not zero in the hypothesis testing, which does not imply that a marginal change of a variable had a substantial increase in social relations score. Among variables examined in Table 2, HIV duration does not appear in subsequent path analysis, although HIV duration was significantly correlated with social relation. The authors need to explain how the correlation analysis was used in this study.

7. Path analysis: Does path analysis can be used to infer a causal relationship between variables? The authors may want to add reference to a theoretical literature that guarantees that. Otherwise, the authors may want to remove all the descriptions that imply causal relationships from the entire manuscript.

8. Table 3: Should the total effect be the summation of the indirect and direct effects, even though they are not statistically significant? If so, please reexamine all the coefficients in Table 3 to ensure if they are correct. In addition,

9. Figure 1: It would be nicer to indicate if each of the coefficients was significant or not in Figure 1. Significance in the paths to social relations was presented in Table 3, although other paths do not have information on significance. It is important to interpret which indirect paths were significant (for example, according to Table 3, an indirect effect of corona phobia was significant, although readers do not know through which paths corona phobia might affect social relations.

10. Discussion: As it is unclear what the variable of social relations measured, it is difficult to examine if the interpretations in the Discussion section are relevant. Particularly, it is difficult to consider how repetition of visiting health facilities and physical signs and symptoms are important in the association between health anxiety and social relations.

11. Limitations: The authors may want to list the limitations of this study and explain how these limitations affected the results of this study and the interpretation of these results at the end of the Discussion section.

Reviewer #2: Please see attachment for specific comments.

This is an interesting study. In general, the recommendations and the importance of the study are missing, so I am unable to understand the significance on a global scale. Also the limitations for interpretation are needed.

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Reviewer #1: Yes: Akira Shibanuma

Reviewer #2: No

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22 Aug 2022

Dear Editor,

Thanks for your respectful comments. We correct all of them as follows:

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2. During your revisions, please note that a simple title correction is required: change "Corona" to "COVID-19". Please ensure this is updated in the manuscript file and the online submission information.

Answer: thanks for your comment .it was corrected and are highlighted in green.

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Answer: thanks for your comment, we have added that “Accession numbers and/or DOIs will be made available after acceptance.” Hence if this manuscript was accepted, we will male the data publicaly available.

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Answer: thanks for your comment. We wrote the ethics statement in "2.4. Procedure of 2. Methods section".

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Answer: thanks for your comment; all figures and tables were moved to the end of the manuscript.

Thanks for the reviewer's respect and comments. We correct all of them as follows:

Reviewer #1:

1. The title and abstract do not have the information on the study site. In the Methods section of the Abstract has the description that "enrolled 300 PLHIV who had records at the Behavioral Diseases Center of Tehran University of Medical Sciences," though. The international audience may not understand where this study was conducted.

Answer: thanks for your comment.

We added a sentence in the background for more information with attention to word limitations.

Behavioral Diseases Center of Tehran University of Medical Sciences corrected as "Iranian research center for HIV/AIDS of Tehran University of Medical Sciences".

Moreover Iran was added to the title as well. Do illustrate the site of the study

2. Citation format is inconsistent with the authors' guidelines.

Answer: thanks for your comment. Citations were corrected.

3. Study design: What is a "descriptive-analytical study?" Epidemiologists often distinguish clearly between a descriptive study and a analytical study. Broadly speaking they regard that a descriptive study as a means of exploring a hypothesis and an analytical study as for testing a hypothesis (for example, see the following: United States Centers for Disease Control and Prevention. Principles of epidemiology in public health practice. 3rd edition: An introduction to applied epidemiology and biostatistics. Lesson 1, Chapters 6 and 7. Atlanta: U.S. Department of Health and Human Services; 2012). The authors may want to clarify the study design based on what is intended to do in this study.

Answer: thanks for your comment. We corrected it to cross-sectional study.

4. Items of the scale: Readers cannot obtain explanations on the questionnaire items regarding fear of COVID-19, anxiety, and social relations. Particularly, social relations may have different aspects by "relations with whom." The authors need to explain more about the items in these scales.

Answer: thanks for your comment. The scale has been further elaborated.

5. Table 2: It would be good to have social relation at the right end of the column so that readers can check the correlation coefficients of different variable with social relation (as an outcome variable according to the objective statement at the end of the Background section) vertically in the single column.

Answer: thanks for your comment. These were implemented.

6. Correlation analysis: It is not clear how the authors used the results of Table 2. How is it meaningful to how the size and significance of correlation coefficients? The authors may note that a significant correlation with social relations indicates that it is likely that the correlation coefficient is not zero in the hypothesis testing, which does not imply that a marginal change of a variable had a substantial increase in social relations score. Among variables examined in Table 2, HIV duration does not appear in subsequent path analysis, although HIV duration was significantly correlated with social relation. The authors need to explain how the correlation analysis was used in this study.

Answer: thanks for your attention. According to MUNRO'S Statistical Methods for Health Care Research book (2013) (1), one of the Statistical Assumptions for doing Path analysis is a correlation between variables. So we have to this analysis between variables

About HIV duration, it is correct. Excuse me. I analyzed it again, and we made all changes. If T-Value is under 1.96, the pathway isn't significant. So we put both images with T-value and standard B for better understanding.

7. Path analysis: Does path analysis can be used to infer a causal relationship between variables? The authors may want to add reference to a theoretical literature that guarantees that. Otherwise, the authors may want to remove all the descriptions that imply causal relationships from the entire manuscript.

Answer: thanks for your attention. According to the majority of references, some of which are cited here, path analysis can be used as a statistical method to examine the effect of variables on one another, in other words, the causal relationship between variables, including:

MUNRO'S Statistical Methods for Health Care Research book (2013) explained that:

Path analysis is considered a causal modelling technique; it can be performed with either cross-sectional or longitudinal data. Path models are considered a type of causal model, and path analysis is referred to as a causal modelling technique. Path models depict theorized, directional relationships among a set of variables.

Path analysis is literally the analysis of the paths or lines in a model that represent the influence of one variable on another. It is used to answer research questions about the effect of a given independent (X1) variable on the dependent variable (Y) in the model. however, path analysis typically involves testing a causal or path model with data that do not result from an experimental Design, For example, path analysis can be done with survey data, data produced by a review of medical records, and so forth.(1)

B Shipley et al. (2016) suggested that some statistical methods can be used to investigate causal hypotheses and questions observational studies; one of these statistical methods is path analysis(2).

Vieira A (2011) also stated that path analysis is a type of multiple regression statistical analysis used to examine causal models by examining the relationships between a dependent variable and two or more independent variables. We can use this method to estimate the extent and importance of causal relationships between variables. (3)

In other word Path analysis is a statistical technique that discern and assess the effects of a set of variables acting on a specified outcome via multiple causal pathways. This method allows users to investigate patterns of effect within a system of variables. It is one of several types of the general linear model that examine the impact of a set of predictor variables on multiple dependent variables. (3)

In this statistical method, as explained in the working method, path analysis is an extension of conventional regression that shows not only the direct effects but also the indirect effects of each variable on the dependent variables, and the results can be used to provide a rational interpretation of the relationships and correlations observed. Also, according to reviewer comments, we explained more and added a reference.

8. Table 3: Should the total effect be the summation of the indirect and direct effects, even though they are not statistically significant? If so, please reexamine all the coefficients in Table 3 to ensure if they are correct.

Answer: thanks for your attention. The total effect is the summation of the indirect and direct effects, but in this way:

If both, direct and indirect paths, are significant(according to T-value>1.96), the total effect, which is the summation of the indirect and direct effects, is significant too.

If both direct/indirect pathways aren't significant, the total effect, which is the summation of direct and indirect paths, isn't significant.

If one path is significant, direct or indirect, that way we may not sum.

Nonrtheless, Table 3 and all its findings were re-assessed and evaluated

9. Figure 1: It would be nicer to indicate if each of the coefficients was significant or not in Figure 1. Significance in the paths to social relations was presented in Table 3, although other paths do not have information on significance. It is important to interpret which indirect paths were significant (for example, according to Table 3, an indirect effect of corona phobia was significant, although readers do not know through which paths corona phobia might affect social relations.

Answer: thanks for your attention. According to the reviewer's comments, we put two figures; figure1 is according to T-value. If T-value is above 1.96, which indicates the significance of the paths (shown in red color). Figure 2 is the B standard of the paths

10. Discussion: As it is unclear what the variable of social relations measured, it is difficult to examine if the interpretations in the Discussion section are relevant. Particularly, it is difficult to consider how repetition of visiting health facilities and physical signs and symptoms are important in the association between health anxiety and social relations.

Answer: thanks for your attention. According to the reviewer's comments, we explained it in "2.3. Data collection and definition of terms." This questionnaire evaluates communication skills and social functioning with others/community and consists of 11 items like "I don't worry about dealing with people, I have competence and ability in social affairs, I am interested in joining a private group, I can be successful in verbal communication with others, Weak social connections can be due to failures caused by the living environment and society." And we added some references in the discussion part for more explanation.

11. Limitations: The authors may want to list the limitations of this study and explain how these limitations affected the results of this study and the interpretation of these results at the end of the Discussion section.

Answer: thanks for your attention. According to the reviewer's comments, we added it at the end of the discussion.

Reviewer #2: Please see attachment for specific comments.

This is an interesting study. In general, the recommendations and the importance of the study are missing, so I am unable to understand the significance on a global scale. Also the limitations for interpretation are needed.

Answer: thanks for your attention. According to the reviewer's comments, we added some references in the background, methods, and discussion parts. And we answered all of the questions in the attachment as follows respectively:

Q1=Does this mean staying away from or fear of going to a health facility?

Answer: thanks for your attention, yes. Because it was done during pandemic of covid

Q2=Which disease? COVID or HIV?

Answer: This group which live with HIV , it was substituted with PLHIV

Q3=Is this recognised in DSM?

Answer: Some theorists indicate that health anxiety would be better categorized as part of the OCD spectrum disorders and in DSM-5 added a new category of disorders called Obsessive-Compulsive and Related Disorders aswell (OCRDs) (also called Obsessive-Compulsive Spectrum Disorders in the research literature)

Q4=This contradicts earlier statements about avoidance of facilities.

Answer: these are a variety of theories about health anxiety.In both OCD and health anxiety individuals experience distressing intrusive repetitive thoughts that are difficult to resist and result in high levels of anxiety . it means some people with this disturbance have a fear of going to health centers and some people have an obsession to go to the health centers. This was added to the text as well.

Q5=What is social incompetence?

Answer: social incompetence , is the same as social disability. This was added to the text aswell.

Q6=Define social relations.

Also it its written in singular in some places and plural in others so make sure its consistent.

Answer: Thank you for your comments,we added its definition and corrected the errors

Q7,8,9=Relations?

Answer: thanks .corrected

Q10=How was the correlation calculated?

Answer: Thanks for your comment .as we wrote in samplesize ,it determined according to paper of Pizzirusso, M., Carrion-Park, C., Clark, U. S., Gonzalez, J., Byrd, D., & Morgello, S. (2021). Physical and mental health screening in a New York City HIV cohort during the COVID-19 pandemic: A preliminary

Q11=Please check the table because these scores are written with SD first in the table

Answer: Thanks for your attention. we corrected it.

Q12=Also possible that the relationship goes the other way - due to necessitated social relations, these people may have higher anxiety as the result of perceived risk and exposure?

Answer: Thanks for your comment. it is correct these can affect oneanother, but in the path analysis, is based on one way assessment and according to the result, health anxiety had an effect on social relations, so had to discuss our findings based on these results (this way), However we elaborated the paragraph further.

Q13= Might be useful to contrast this with information on health service utilisation to show whether this was the case?

Answer: Thanks for your comment.it is a great recommendation which we are preparing an other article to evaluate the above.

Q14=The rest of this paragraph does not tie in well. The reason why fear may result in increased social relations should be explored more.

Answer. thanks for your comments. we explained more as follow:According to COVID-19 research and the media report, fear of COVID-19 affected was increased. fear of infection has become a concern in the context of the COVID-19 pandemic because it worsens emotion, cognition, and behavioral responses(Quadros, Garg, Ranjan, Vijayasarathi, & Mamun, 2021)

Q15=This contradicts the earlier statement about increased care seeking

Answer:thanks for your comment. We added ” It causes great suffering for patients and those around them and is costly in terms of greater use of medical care utilization. For example, individuals suffering from health anxiety desperately seek to identify the physical causes of their symptoms and will often consult several medical professionals. Evidence suggests that the social costs of health anxiety are high. In undergraduates, health anxiety is linked to increased doctor visits. (Kobori, Okita, Shiraishi, Hasegawa, & Iyo, 2014)” their life affected by this situation and suffered which effect on their function ,quality of life and etc. to further elaborate what we ment, moreover based on the 4th comment we added that “some have a fear of going to health centers and some people have an obsession to go to the health centers. This was added to the text as well.” To avoid controversies

Q16=This part about financial status contradicts the earlier statement that increased SES led to decreased social relations, esp since education and SES are linked - how do you explain this?

Answer: Thanks for your comment. this part explained the effect of the education level on social relations. it is correct that education level is related to SES and good financial situation but as we explained about social relations (in instrument and in Background), it means that a person with a high level of education and a suitable SES situation, can use their relations, such as emotional and practical support provided by significant others, and stay home so they keep their distance from the community in this situation (Umberson & Karas Montez, 2010) We added some references.

Q17= The recommendations or areas for further consideration are a bit sparse. I am left wondering "So What" - what does one do with this info?

Answer: thanks for your attention we corrected and changed according to the title.

According to our result, increased fear, health anxiety score and duration of HIV affected, are related to a higher score of social relations. Based on their vulnerability, PLHIV requires more support and education to adhere to health protocols. This was added to the conclusion.

Q18 This differs from text. Also write what the minimum and maximum score COULD be so that we know where in the range of possible scores the mean falls.

Answer: thanks for your comment .we corrected and we wrote the minimum and maximum score in result part.

Q19=Why are these qualitative variables - they are reported quantitatively?

Also the table is a bit confusing to read. Rather have all the variables in rows instead of two columns

Answer: thanks for your comment. we collect data in both forms, quantity and quality. For path analysis, because we have to use the quantity we use that form but for reporting for better understanding we report the quality form of them.

Q20= Why only women? Whats the sample of men and the distribution of men vs women?

Answer: thank you for the point. We corrected all terms in the manuscript. Since most male patients did not consent to participate, or they did not respond to us or were unreachable, unlike the women. We had no choice but to include the female patients.

references

1. Plichta SB, Kelvin EA, Munro BH. Munro's statistical methods for health care research: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013.

2. Shipley B. Cause and correlation in biology: a user's guide to path analysis, structural equations and causal inference with R: Cambridge University Press; 2016.

3. Jupp V. The Sage dictionary of social research methods: Sage; 2006.

Submitted filename: answer.docx

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19 Sep 2022

Relationships among COVID-19 phobia, health anxiety, and social relations in women living with HIV in Iran: A path analysis

PONE-D-22-08845R1

Dear Dr. Qorbani,

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23 Sep 2022

PONE-D-22-08845R1

Relationships among COVID-19 phobia, health anxiety, and social relations in women living with HIV in Iran: A path analysis

Dear Dr. Qorbani:

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