The recent outbreak of coronavirus disease (COVID-19) in China and worldwide is a major public health emergency of international concern and has been characterized by the World Health Organization as one of the most challenging outbreaks to date. As of 11 June 2020, around 7.2 million confirmed cases globally, 84,652 in China, with 413,372 deaths (5.68%) had been reported by the WHO. Reviews in the field of exposure to COVID-19 and mental health problems have called for research to test the relationship between them and to identify the mechanism underlying this relationship [26, 51, 52]. The present study examined the risk perception factors that may explain how the level of exposure to COVID-19 in China contributes to mental health problems.
Many organizations and researchers have highlighted concerns about mental health problems in affected communities. Major public health emergencies, such as the severe acute respiratory syndrome coronavirus (SARS-CoV) in 2002, the Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012, the West Africa Ebola virus disease (EVD) pandemic in 2013–2016, and the global COVID-19 pandemic typically lead to widespread fear and panic. For example, a critical review indicated that SARS survivors consistently reported high rates of emotional distress persisting for years [10]. During the West Africa EVD pandemic, there were increasing risks for new-onset psychological distress and psychiatric disorders [37]. Psychosocial effects include adjustment disorders, symptoms of PTSD, anxiety, and depression [18, 22, 32]. To date, several studies have indicated the influence of COVID-19 on mental health problems. For instance, the pandemic has burdened a major psychological stress on the medical workforce [28] and could cause distress and leave many people vulnerable to mental health problems and suicidal behavior [13]. Thus, the influence of COVID-19 on mental health problems cannot be ignored. To manage psychological sequelae, it is important to detect the antecedents of mental health problems.
The antecedents of mental health problems during public health emergencies include many factors, such as the exposure level, quarantine, social support, social rejection or isolation, and the news media conveying risk-elevating messages about the public health crisis [2, 27, 35, 42]. Specific to COVID-19, some studies have revealed that risk perception, health anxiety, social media use and more media engagement are predicators to mental health problems [1, 4, 31]. Among these factors, an obvious objective variable is the extent to which people are exposed to emergencies and disasters in their daily life, i.e., the exposure level. According to the ripple effect found in the seminal study by Slocvic (1987), the impact of an unfortunate event decays gradually as ripples spread outward from the center; the closer people are to the center (i.e., the higher the exposure level), the stronger their mental distress is.
However, a few studies have found that this is not the case [25, 51]. Studies have found that proximity to the center of the epidemic or devastated area was negatively related to anxiety levels [51], epidemic-related safety and health concerns [26]. This phenomenon was termed the “Psychological Typhoon Eye” effect to describe the public’s psychological response, e.g., anxiety levels, safety and health concerns, to major emergencies and disasters.
To date, the “Psychological Typhoon Eye” effect has been detected after the Wenchuan earthquake [51], during the SARS epidemic [25] and in relation to lead-zinc mining risk [53]. Researchers have proposed three major possible explanations for this effect [52]. The first explanation is psychological immunization theory, which assumes that resistance to a stressful event is naturally acquired through repeated exposure [16]. People become desensitized by repeated exposure and can better prepare for stressful events. The second explanation is cognitive dissonance theory [8]. Cognitive dissonance is an uncomfortable psychological state in which the individual attempts to restore consistency or consonance by changing his or her beliefs and attitudes. When someone is at risk or in crisis, it is easier to change their beliefs and attitudes towards potential risk than to change their location [25, 26, 52]. Thus, people who are at the center of emergencies and disasters are presumably more likely than people living far away to believe that the risk is low and therefore continue to live nearby. The third explanation is the gap between experiencing/involving and imagining [25, 52], in which people in the center have a more accurate estimate of the risks based on real experience and involvement.
To date, few empirical studies has tested these explanations. However, all the explanations suggest that the influence of the level of exposure to an unfortunate event on mental health problems may be mediated by subjective risk perceptions. Risk perceptions are intuitive risk judgments [39] that include “the process of collecting, selecting, and interpreting signals about uncertain impacts of events, activities, or technologies” ([45], p.1049). A meta-analysis by Sheeran and his colleagues showed that risk perceptions have a close association with people’s health behavior [36].
According to protection motivation theory (PMT [29];), health attitudes and behavior depend on two key psychological factors of risk perception, including one’s perceived threat due to the risk and coping efficacy with regard to the ability to cope with the risk. Perceived threat consists of estimates of the chance of contracting a disease (perceived vulnerability) and estimates of the seriousness of a disease (perceived severity). Coping efficacy refers to beliefs about whether responses are available and effective in averting the threat (response efficacy) and whether people and groups can effectively respond to the risk and protect themselves from the hazard (self-efficacy).
To a great extent, the three explanations for the “Psychological Typhoon Eye” effect emphasize the role of coping efficacy in risk perceptions. The essence of psychological immunization is an increase in coping efficacy. With repeated exposure, individuals develop new patterns of coping to deal with the crisis. These patterns become an integral part of their repertoire of problem-solving responses and increase the likelihood that these individuals will deal more or less realistically with future hazards. In this way, the satisfactory resolution of one crisis increases resistance to subsequent adverse experiences [16]. Similarly, the essence of the gap between experiencing and imagining is that people in the center have high response efficacy and self-efficacy when they have a large amount of embodied experience or involvement compared with those without experience or involvement. Additionally, cognitive dissonance theory emphasizes that after applying the cognitive strategies of rationalization (i.e., restoring consonance), the coping efficacy of people in the center is strengthened. Among the three explanations, coping efficacy may be viewed as an internal mental indicator of psychological immunization. Cognitive dissonance and experience act as two pathways to enhance people’s coping efficacy. The former is a cognitive pathway and the latter is a behavioral pathway.
Current study
The goal of this research was twofold. The first goal was to examine the robustness of the “Psychological Typhoon Eye” effect during the COVID-19 epidemic: the closer people are to the “center” of the epidemic (i.e., the higher the exposure level), the less serious their mental health problems are. To our knowledge, two studies have confirmed the “Psychological Typhoon Eye” effect with regard to the level of exposure to epidemics and mental health problems. These studies examined the relationship between the level of exposure and anxiety levels [51] and epidemic-related safety and health concerns [26]. In this study, we assessed mental health problems using a questionnaire adapted from the Psychological and Behavioral Questionnaire for SARS [9]. The questionnaire was designed to reflect the psychological state of the population during severe public health emergencies. It consists of five dimensions, i.e., depression, neurosism, phobia, compulsion-anxiety, and hypochondriasis. Compared to the two studies stated above, this study investigated broader facets of mental health problems rather than one specific aspect.
The second goal was to investigate the mechanism of the “Psychological Typhoon Eye” effect. As stated before, even though some possible mechanisms have been proposed, none of them have been verified by empirical studies. We draw on protection motivation theory to formulate a theoretical model of how the exposure level during the COVID-19 epidemic influences mental health problems.
According to protection motivation theory, we hypothesized that the association between the exposure level during the COVID-19 epidemic and mental health problems was mediated by both individuals’ perceived threat of COVID-19 risk and their coping efficacy (see Fig. 1). More importantly, we hypothesized that the valence of the mediating effects was distinct. Both perceived threat and coping efficacy are positively correlated with the exposure level. However, perceived threat, which tends to aggravate mental health, is positively correlated with mental health problems. This hypothesis is based on evidence from SARS studies and COVID-19 studies. These studies showed that the relatively high perceived threat (severity and vulnerability) of SARS/COVID-19 played a pivotal role in the development of fear for the pandemic [31] or psychological distress [5, 6, 48] and increased the odds of individuals having a high level of depressive symptoms 3 years later [27].
In contrast, we hypothesized that coping efficacy, which tends to buffer mental health, is negatively correlated with mental health problems. This hypothesis is based on the fact that numerous studies have indicated that self-efficacy is an effective factor to cope with a crisis and buffer psychological distress [34]. A cross-sectional study of 415 respondents in a community health care setting showed that mental health status was negatively correlated with coping strategies, which can increase self-efficacy [38]. A systematic review article [19] found that psychological distress was prevalent among Ebola survivors, whose coping strategies included engagement with religious faith, Ebola survivor associations and involvement in Ebola prevention and control interventions. All of these coping strategies are beneficial to enhance self-efficacy and response efficacy to relieve psychological distress. Additionally, both qualitative and quantitative studies suggest that social support is an effective coping strategy for psychological distress [33] because it can promote self-efficacy [30, 50].
To achieve the two aforementioned purposes, we conducted a survey in 31 provincial-level administrative divisions of China during 3–13 March 2020. Our first hypothesis is that a “Psychological Typhoon Eye” effect exists between the level of exposure to epidemics and mental health problems. The second hypothesis is that there are two parallel routes between the exposure level and mental health problems. Specifically, perceived threat mediates the positive relationship between the exposure level to epidemics and mental health problems, while coping efficacy mediates the negative relationship between them. In other words, coping efficacy could account for the “Psychological Typhoon Eye” effect.