Risk communication during Corona: Information collection and fear in people with pre-existing mental illnesses

The pandemic caused by SARS-CoV-2 began in Germany in March 2020 and, according to the Robert Koch Institute's retrospective phase classification, has a course consisting of six waves and two summer plateau phases in 2020 and 2021 (1). Due to the pandemic spread and the high number of infected and deceased people, the corona pandemic is viewed by both the media and experts as a time of crisis (2). To successfully manage a crisis such as the pandemic, numerous measures are necessary, which must be communicated to the population to an appropriate extent so that individuals implement the recommended protective measures and are supported in their health-related behavior (3–5). In past crises it has been shown that media use increased (3) and therefore information and communication play an important role in control and coping, with the use of information and communication technology playing an essential role (6). Central questions when implementing a communication strategy include how the population uses media to provide information about the respective crisis, for example the corona pandemic, and how this behavior is related to the perception of the actual risk (7). Monitoring the media to “identify trends and misinformation” and the subjective perspective of users is also essential (4, 8).

>> There is evidence that the amount of reporting on a specific, potentially threatening topic (regardless of quality and content) leads to an increase in risk perception, which in turn leads to increased fear among the population (7) and could influence media use . For this reason, it is important to continuously monitor the population's risk perception (5) and adapt strategies accordingly.
At this point in time, the pandemic is considered to be over, but crises still exist (Ukraine conflict, energy crisis) and similar crises are foreseeable (due to zoonoses, but also other causes). Accordingly, crisis communication should be able to learn from the experiences of the corona pandemic (5).
As a result of comparable natural disasters, economic crises and terrorist attacks that have so far been overcome, two different effects typically appear on those affected or survivors (9-11): While some people have a high level of resilience, and in times of crisis they also have positive experiences and developments such as For example, if people perceive a high level of social support, other people experience psychological symptoms and illnesses that affect particularly vulnerable groups such as people who are already mentally ill (12–14). Accordingly, the number of mentally ill people of all ages has increased significantly (e.g. 15-17).
Since people with mental illnesses can experience increased symptoms and loss of control due to inadequate risk communication, the communication of relevant messages should be easy to understand and repeated, especially for this group of people (3, 18), and should include not only the risk but also appropriate treatment approaches (3, 4 , 8, 19). To further individualize the communication strategy for people with mental illnesses, the connection between the use of different media and the presence of psychological symptoms should be examined (20).
In order to be able to specifically address crisis communication in the current and subsequent crises (see 5), this article focuses on media use and the fear felt by people with pre-existing mental illnesses during the various Covid waves.
The present study therefore examines the following research questions:
(1) Which media did people with mental-psychosomatic illnesses use to obtain information about the corona pandemic during the first three waves?
(2) How is the use of different media during the first three waves related to the fear of infection?
(3) Which media made mentally ill people feel objectively informed and which media caused a subjective feeling of fear?
methodology

Design and sampling
The participants in this study were recruited if they underwent a psychosomatic rehabilitation measure in one of four Dr. Becker Clinic Group took part. They were informed about the study in writing in the clinic group's own online portal. Therefore, only patients who had access to this digital portal via smartphone, tablet or PC were included. Participation was only possible after the patients had read the participation information before beginning the rehabilitation and given their informed consent in writing. Participation was voluntary and the data was pseudonymized. The data was collected from 6 weeks before the start until the first day of rehabilitation. The ethics committee of Jacobs University Bremen (now: Constructor University) approved the study design.
As part of the survey, the use of media to collect information about the corona pandemic, fear of becoming infected yourself or infecting others, the feeling of being well and objectively informed, the occurrence of fear while using the media and socio-demographic information were recorded (e.g. B. Gender, age, presence of an underlying physical illness).
Sample description
A total of N = 2150 of a total of 7529 patients took part in the survey, of which 1397 (65.3%) were female and 22.7% with a high school diploma. The most common age category was the group of 50-59 years old (range = 20-79 years) with 45.8%. Most respondents were employed (n = 1571; 73.3%). A total of n = 254 people were unemployed (11.9%), n = 23 (1.1%) retired, n = 21 (1.0%) “exclusively housewife/househusband”. 41% of the study participants (n=878) reported an underlying physical illness such as: B. Cardiovascular diseases, diabetes, diseases of the respiratory system, liver, kidney or cancer. Every sixth study participant (n = 294, 13.7 %) had a severely disabled person's ID card.

variables
All questions were adapted to the target group in pilot studies. The survey took place as an online questionnaire for self-completion. All items are listed in Tables 1 and 2.
Three Covid waves occurred during the survey period (1): Wave 1 (W1) in the period March 2, 2020 - May 17, 2020 (n = 564), Wave 2 (W2) in the period September 28, 2020 - February 21, 2021 (n = 915 ), wave 3 (W3) in the period March 1, 2021-June 6, 2021 (n = 671).
The use of media was divided into television, newspaper and Internet use and asked about its frequency on a 6-point Likert scale (1 – “never/less often than once a month” to 6 – “daily or several times a day”). It was also recorded how often the participants felt “well and objectively” informed about Covid-19 (“objective information”) and how often they experienced fear while following the news (“fear of news”). Both items could be rated on a 5-point rating scale (1 – “never” to 5 – “always”).
Fear of oneself or others becoming infected was measured with two items on a 5-point Likert scale (1 – “never” to 5 – “always”). Regarding demographic information, age was collected in 5 categories (20–29 years, 30–39 years, 40–49 years, 50–59 years, 60 years and older). When presenting the results, gender is only presented dichotomously as “female” and “male” because “diverse” was not specified. The participants were asked to indicate whether they had a severely disabled person's card and whether they had any underlying physical illnesses.

Data analysis
All calculations were carried out using the statistical program SPSS (version 27.0). Descriptive statistics were used to describe which media are used by psychosomatic rehabilitation patients depending on gender, age and underlying mental and physical illness. Differences between different groups were tested for significance using multivariate analysis of variance (MANOVA).
The frequency with which participants felt objectively informed or experienced fear was also evaluated descriptively. In order to examine the connection between fear of infection or general anxiety symptoms with media use in more detail, Pearson correlations were calculated and checked with an ANOVA.
The difference in the type of media use between patients with existing symptoms of generalized anxiety disorder and patients without such symptoms was tested for significance using an analysis of variance with post-hoc tests. To interpret the findings, we followed Cohen (1992): correlations of r = .10 are considered small, r = .30 are considered medium
r = .50 as large.
Results
In all three waves of the corona pandemic, the most common media use was “television” (W1: 4.29, W2: 4.66, W3: 4.44) and “internet” (W1: 4.34, W2: 4 .64, W3: 4.42) for collecting information about the corona pandemic compared to the usefulness of the “newspaper” medium (W1: 2.82, W2: 2.94, W3: 2.90; see Table 3). During the second wave, television was used significantly more often than in the first wave and less in the third wave than in the second wave (F(2,1962) = 7.709, p < .0001). There is no significant difference between the three waves with regard to the frequency of newspaper use (F(2,1962) = 0.192, p = .582). The Internet was used the most in the second wave compared to the other two waves; the difference is statistically significant (F(2,1962) = 6.047, p = .02), see Table 3).
Regardless of the waves surveyed, the various media sources were used more often by men than by women, by people over 50 more than by younger study participants and by patients with an underlying physical illness more than by people without (all variables evaluated in a MANOVA: FGender = 5.71; p < .01; Eta² = 0.02; Fage = 13.21; p < .01; Eta² = .04; FBasic disease = 2.71; p < .05; Eta² = 0.01). These results were also evident during individual waves (Supplementary material Tables 1-3).
Watching television was significantly associated with fear of infecting oneself (r = .216; p < .005) and fear of infecting others (r = .155). At the same time, using the Internet was also associated with fear of becoming infected (r = .153) or that of others (r = .155). It can be seen that in all waves, fear of one's own infection and that of others was significantly positively associated with increased television and Internet consumption (Additional material Tables 5–7). Regardless of the waves, the impression of being well and objectively informed was associated with the fear of becoming infected (r = .116). In general, people who use the various media (television, newspapers and the Internet) more often also feel that they are more objectively informed (r = .397 or r = .254 or
r = .243; Supplementary material Table 4).
Regardless of the waves collected, a more frequent feeling of fear when following news was also associated with fear of one's own infection (r = .515) and that of other people (r = .392), but not with the impression of being good and objective to be informed (Supplementary Material Tables 5-7). Likewise, people who used the media more often also felt more anxious (television: r = .114, newspaper: r = .066, Internet: r = .093; supplementary material Table 4).
These correlations could be replicated in ANOVAs: those who were afraid of becoming infected watched television more often; Those who were afraid of infecting others were more likely to use television or the Internet as a source of information (Supplementary Material Table 4).
discussion
The present study with 2,150 patients before starting psychosomatic rehabilitation shows that during the corona pandemic, television and the Internet were used more frequently to collect information about the current crisis than the newspaper. This is consistent with findings from previous crises (3); However, the use of the Internet carries the risk that uncontrolled and therefore insufficiently verified facts and one-sided opinions are spread (cf. 18), which can lead to increased uncertainty and a false perception of risk: alarming Twitter messages were spread significantly more frequently during the first wave as all-clear news (21). Therefore, reporters should be aware of their influence and how information spreads (18).
It is therefore all the more relevant to disseminate clear information about the crisis situation through the media at an early stage in easy-to-understand language (18, 22). Social media in particular can be suitable for necessary protective measures due to the speed at which information is disseminated for early information (5, 22). A study from China at the beginning of the pandemic shows that the study participants wanted additional information on individual aspects of the pandemic, such as protective measures and individual recommendations for action; when more information was provided about how to treat the pandemic, this was significantly associated with lower depression symptoms (13).
In the present study it was shown that men use media to gather information more often than women and older people more often than younger people. Something similar was already demonstrated at the beginning of the pandemic (20). A possible explanation for the more frequent search for information by older people is the connection with existing underlying physical illnesses: those who suffer from such diseases (which is more likely in older people) seek information more often. At the same time, people with an underlying physical illness are more afraid of infection, which can be explained by the fact that existing physical illnesses represent a risk factor for a more severe course of Covid-19 disease (23).
Furthermore, the present findings show that throughout the entire study period and regardless of the wave of the pandemic, the use of television and the Internet to search for information about the corona pandemic is related to the fear of one's own infection or of infecting others. Those who are more afraid of becoming infected themselves or of infecting others are more likely to find out more about these two media. The present results confirm findings from the influenza A epidemic that an increase in media reporting on this topic correlates with the occurrence of general anxiety symptoms (7).
Across the entire study period and therefore regardless of the waves, it was shown that people who feel objectively informed about the pandemic are more likely to be afraid of their own infection. This differs when looking at the individual waves: During the first wave, people who felt objectively informed were no longer afraid of their own infection or that of others; From the second wave onwards this fear appears. Conversely, people who were afraid of infection were more likely to feel objectively informed when using media. Subjective fear when using media is associated with the fear of infection, but not with the feeling of being objectively informed.
These findings show that information from the media is related to the processing and handling of the pandemic by people with previous mental and psychosomatic illnesses. Due to global distribution, a mass of information is available (so-called “infodemic”), so that in addition to containing the pandemic, the information must also be classified (24). This is relevant because a lot of information cannot be processed by a single person and accordingly leads to anxiety regarding the crisis causing it (cf. 25). The fear of infection examined in this study may be a possible indicator of the onset of generalized anxiety disorder, which can be prevented through appropriate communication. At the same time, it is known that people who are afraid of infection are more likely to adhere to the recommended protective measures (26).
Overall, the present results highlight the need to provide easily findable and objective information about the prevailing crisis situation through trustworthy channels (3, 4, 18, 15, 19, 27). Objectivity is particularly important (16) because dissatisfaction with available information is associated with higher levels of stress, anxiety and depression (13). In this regard, experts emphasized the need for individual-related information in the early stages of the pandemic, the effectiveness of which has already been proven in previous studies (28, 29). This could counteract some of the uncertainty that is central to the acceleration of mental illness in times of crisis (30). In particular, sufficient information must be made available that includes the individual risk and the necessary rules of behavior (5, 15) and thus counteracts the uncontrolled development of anxiety symptoms (cf. 13, 18).
Since risk communication is a relevant component of dealing with crises (31), it is imperative to develop (in advance) a communication strategy for crisis situations and to implement it when an acute crisis occurs (5) and to continuously adapt it to the current conditions (27).
limitations
The present study has some limitations that should be taken into account when interpreting the results and planning further studies. Media use exclusively by people with previous mental illnesses and the cross-sectional association with psychological symptoms were examined. In addition, there is a limitation in generalizability because only patients who had digital access to the clinic's internal online portal were included in the study. They are therefore probably more likely to use digital offerings than people who do not have this access, which is why Internet use may have been overestimated in this study.
In the future, a longitudinal, controlled study should be carried out to investigate the extent to which the use of classic and newer media and information and communication technology leads to a change in various psychological symptoms. Causal relationships need to be better understood, since the correlative relationships can only be used to make theoretical assumptions about how the general reporting situation contributes to more media use, fear and reaction behavior. Methodologically, experimental studies are therefore also necessary. In addition, it must be examined to what extent and how authorities distribute important information via appropriate media and how this information is perceived and used.
Conclusion
The use of media to seek information about threats such as the corona pandemic correlates with fear of infection. More frequent use of media is associated with increased fear of infecting yourself and others.
Future research should clarify to what extent objective, factually presented information can weaken this connection in order to prevent an increase in mental illness and a worsening of existing psychological symptoms in pre-stressed groups. To this end, concepts must be developed at an early stage on how suitable communication can be designed in crisis situations; Lessons can be learned from the current corona pandemic for future crises. <<