Exposure to the COVID-19 news on social media and consequent psychological distress and potential behavioral change

Exposure to coronavirus disease 2019 (COVID-19) news pandemic is inevitable. This study aimed to explore the association between exposure to COVID-19 news on social media and feeling of anxiety, fear, and potential opportunities for behavioral change among Iranians. A telephone-based survey was carried out in 2020. Adults aged 18 years and above were randomly selected. A self-designed questionnaire was administered to collect information on demographic variables and questions to address exposure to news and psychological and behavioral responses regarding COVID-19. A multivariate logistic regression analysis was performed to assess the relationship between anxiety, fear, behavioral responses, and independent variables, including exposure to news. In all, 1563 adults participated in the study. The mean age of respondents was 39.17 ± 13.5 years. Almost 55% of participants reported moderate to high-level anxiety, while fear of being affected by COVID-19 was reported 54.1%. Overall 88% reported that they had changed their behaviors to some extent. Exposure to the COVID-19 news on social media was the most influencing variable on anxiety (OR 2.21, 95% CI 1.62–3.04; P < 0.0001), fear (OR 1.95, 95% CI 1.49–2.56; P < 0.0001), and change in health behaviors (OR 2.02, 95% CI 1.28–3.19; P = 0.003) in the regression model. The fear of being infected by the COVID19 was associated with the female gender and some socioeconomic characteristics. Although exposure to the COVID-19 news on social media seemed to be associated with excess anxiety and fear, it also, to some extent, had positively changed people’s health behaviors towards preventive measures.


Measures.
A self-designed questionnaire in Persian language consisting of two sections was administered.
The items were developed based on study objectives.The first section was about socio-demographic information included the recording of age, gender, marital status, education, economic status, and occupation.
The second part of questionnaire was developed based on literature review 7,[29][30][31][32] and expert opinion.This part contained three sections (Table 1): 1. Exposure to news on the COVID- 19  Each item was rated on a 5-point Likert scale.The questionnaire was evaluated for content and face validity by seven experts (three health psychologists, two epidemiologists, and two journalists) and found to be satisfactory.The internal consistency for the questionnaire was about acceptable level (Cronbach's alpha = 0.62).
At the begging of the phone interview, people were asked for consent.We informed the participant about the purpose of the study [exploring the association between exposure to COVID-19 news on social media and anxiety, fear, and compliance with healthy behavior].We also explained that we are independent non-governmental research group and we are not involved with any treatment or vaccination processes.The participants were ensured about the anonymity, confidentiality and voluntary participant in the study.After they accepted to take

Discussion
The media play a crucial role in response to crises by informing the public, making positive behavioral changes, and affecting mental health and well-being 33 .This study reported that exposure to the COVID-19 news on social media induced anxiety and fear, and also it showed some positive changes among participants.A schematic view of the mechanism of such observation is provided in (Fig. 1).This was proposed from the study findings, and from what one could find in the literature 24,34,35 .

Exposure to COVID-19 news.
During the pandemic of COVID-19, people tend to use the social media more often 36 .Perhaps spending more time on social media during the COVID-19 pandemic could be due to two major reasons: quarantine and physical/social distancing (isolation, in-home lockdown, closure of services and public spaces, and loneliness) 37 .One might argue that these factors contributed to the increased use of social media.In addition, during pandemic social media was a major source for communication between families and friends.Even the use of social media for educational activity or office works contributed to extra use of the social media for news and views.
Anxiety.The finding showed that more exposure to the news on COVID-19 on social media was associated with greater anxiety.Evidence suggests that more access to information on social media could be stressful and  www.nature.com/scientificreports/induce more anxiety 19,38,39 .A study from Iran confirmed that online news played a critical role in COVID-19 anxiety 40 .A cross-sectional study conducted in China reported similar results, where more exposure to news on social media was significantly associated with greater anxiety 7 .Contrary to the majority published papers, a study conducted in Romania revealed that depression and anxiety were not associated with exposure to information regarding COVID-19 41 .Possible explanations for this may include differences in measures used or might be due t o cultural or socioeconomic differences.However, when individuals read the news and cannot do anything to prevent or reduce the risk of the disease, they begin to see themselves as vulnerable, and anxiety emerges.One other possible explanation is the fact that at the time the study commenced, the nature of COVID-19 was unknown, and thus it seemed a scary phenomenon and induced anxiety, fear and uncetainties.As such, one might argue that it is essential to see when and how psychological distress, including anxiety, depression, distress, or fear, is measured.The current study did not assess the possible relationship between anxiety and exposure duration.Evidence suggests that more exposure to social media was associated with more psychological distress about the virus 24 .A study showed that more than four hours of using social media was related to a higher level of anxiety 42 .One argument is that more exposure to social media leads to more exposure to fake news and misinformation.
Fear.The current study showed that exposure to news on social media was related to higher levels of fear.This leads us to believe that social media exposure could be an indicator of even other negative emotions.Similar findings have been reported in other investigations in various settings 15,25,26,43,44 .For instance, a report from Hong Kong revealed that social media provoked fear in society 45 .The current study was conducted at the beginning of the COVID-19 pandemic when social media was full of negative news such as high daily statistics of the disease and deaths.Besides, social media users were facing a massive amount of information, where most of them did not have enough knowledge and health literacy to distinguish true information from fake news.Furthermore, usually, the governments also did not have an effective strategy to manage this situation.Thus, combining the above factors led to an increased fear among users.Experiencing fear and its association with positive preventive www.nature.com/scientificreports/behaviors during the COVID-19 pandemic has been reported previously in several studies 15,36,44,46 .Although the current study did not assess the possible relationship between fear and preventive behaviors, it seems that the implementation of educational interventions, including mass media campaigns such as 'Together we will beat the covid-19' , might explain why people took preventive behaviors while they were frightened.

Psychological factors and independent variables.
The current study did not show a significant relationship between most independent variables and anxiety.However, a study from Iran reported that anxiety was associated with female gender, younger age, and experience of the COVID-19 among family members or friends 47 .Similarly, a study reported that psychological factors were associated with being female, having cardiovascular diseases, smoking, and having a history of the COVID-19 symptoms, including fever, cough, and shortness of breath 48 .The role of independent variables in anxiety is undeniable.We found that different factors, including female gender, intermediate economic status, being employed, following the COVID-19 statistics and formal news released by the state, and exposure to news on social media, had a significant relationship with fear.A study showed that COVID-19 has significantly affected people's fear due to incidents like economic slowdown, loss of jobs, losing loved ones, and so on 49 .Perhaps such observation also was true for the current study where due to economic sanction and some limitations for providing vaccine supply those who followed news on social media were more likely to experience ore fear as expected.
Behavioral responses.The findings showed that exposure to social media could positively influence health behaviors related to COVID-19 prevention.Similarly, some studies have demonstrated that frequent social media exposure regarding COVID-19 was associated with adopting preventive measures (e.g., face maskwearing and handwashing) 20,27,29 .An online survey among American people showed that news monitoring was associated with greater social responsibility, more disinfecting, and greater caution about the severity of COVID-19 50 .It might be the result of the efforts of official departments to increase the public's awareness of prevention www.nature.com/scientificreports/strategies by providing updated information about COVID-19 on websites and social media 51 .According to behavioral models, exposure to social media increasing the users' awareness about how protecting themselves against COVI-19.Therefore, besides increases the perceived threat, it is a cue to action that encourages individuals to change their behaviors.So, the effect of social media on individuals' protective behaviors can be influenced www.nature.com/scientificreports/by different factors such as the type of information that users are exposed to, the level of the perceived threat, and the self-efficacy of individuals to copping the stress and manage the control of risk.

Exposure to COVID-19 misinformation.
A number of social media users produce, release and transfer information that may lead to the dissemination of misinformation on social media 52,53 .So social media news often contains widespread misinformation, fake news and rumors 54 , that may cause many users psychological problems 55 .By analyzing the phenomenon of fake news in health, it was observed that false information could cause psychological disorders, panic, fear, depression, and fatigue 14 .For instance, one study showed that fear of COVID-19 and misunderstanding were associated with problematic social media usage, which led to direct or indirect psychological distress and insomnia 13 .Thus, the governments should consider the adverse consequence of misinformation during the COVID-19 pandemic on people's mental health 47 and implment appropirate interventions.In such situations, the existence of the 'infodemics' team is necessary to deliver right information to the right people or a broader public audiences.
Risk perception.Risk perception is an important component of behavioral change 56 .According to the health behavioral models, information provides cues that influence perceptions regarding health threats 35,57 .
According to the extended parallel process model (EPPM) as one of the relevant behavioral change models, individuals undergo two cognitive appraisals during exposure to a risky situation: the ability to respond to the recommended message (efficacy) and the perceived threat 24 .When the threat of COVID-19 is high and efficacy is low, people usually act to protect themselves from the fear rather than the danger itself 58 .A study showed that fear was positively associated with forming risk perceptions during an outbreak 36,59,60 .Individuals utilize psychological defense strategies to manage their fears in this situation 57 .A number of studies showed that when individuals obtain information from social media about COVID-19, they may perceive COVID-19 as a health threat and experience subsequent anxiety, depression, and fear 61 .Conversely, when perceived efficacy is high, people usually are motivated to protect themselves from danger and might follow the recommended massages 58 .
In this regard, risk perception is related to adopting preventive behaviors such as social distancing and mask use 36,60 .Finding of a previous study revealed that self-efficacy was significantly associated with trust in government and media information on the pandemic 7 .Therefore, producing appropriate and reliable information would be necessary.

Strengths and limitations.
Although the study benefited from a relatively good sample size and was selected based on a random sampling method, generalizing the findings might be challenging.This was a crosssectional study in nature and thus could not indicate causality, and the findings should be interpreted with caution.People with mental health disorders might experience higher fear and anxiety regardless of social media exposure.Since we did not collected information in this regard, this should be considered as limitation.This study was conducted at the start of the COVID-19 pandemic, and the anxiety, fear, and behavioral responses might have been influenced by the novelty and uncertainty of the situation rather than social media exposure pre se.Thus the findings should be interpreted with caution.We did not ask participants how much time they were spending on social media.Also, we did not explore 'infodemic' and how much did misinformation contributed to fear, anxiety, and behavioral responses.This could be a significant factor that study has missed.It is recommending that a such variable be investigated in future studies.Our study did not distinguish between social media platforms.Different platforms may induce different levels of fear, anxiety, and behavioral responses due to their varied ways of information dissemination, user demographics, and misinformation controls.

Conclusion
The findings demonstrated that exposure to the COVID-19 news on social media was associated with increased anxiety and fear.Yet, it might bring some positive behavioral changes.Therefore, improving people's media literacy in order to make them be able in identifying trusted information and share reliable content on social media seems necessary.Also, the governments should deal with 'infodemic' by providing timely up-to-dated and reliable information to prevent spread of misinformation.They are also responsible to introduce credible sources for reliable information.
pandemic with three items including 'to what extent do you follow the statistics and information on COVID-19?' , 'to what extent do you follow formal news on COVID-19 released by the state?' and 'to what extent do you follow the news on COVID-19 on social media?' 2. Psychological response with two items related to anxiety and fear including 'to what extent exposure to the news on COVID-19 made you feel anxious and worry?' , and 'To what extent do you fear being infected with COVID-19?' 3. Behavioral response with one item 'to what extent fear of being infected provoked you to stick to healthy behavior (hand washing, wearing face mask, social distancing)?'

Table 1 .
Exposure to news on the COVID-19 pandemic and psychological and behavioral responses.

Table 2 .
Characteristics of Iranian adults who participated in the study (n = 1563).

Table 4 .
The results obtained from logistic regression analysis for feeling anxiety.*Bold values are significant.

Table 5 .
The results obtained from logistic regression analysis for feeling of fear.*Bold values are significant.

Table 6 .
The results obtained from logistic regression for self-reported behavior change. Vol:.(1234567890)