Fear of COVID-19 and PTSD: The Protective Function of Problem-Solving Appraisals in Mental Health

Fear of COVID-19 and PTSD: The Protective Function of Problem-Solving Appraisals in Mental Health

1. Introduction

The COVID-19 pandemic represents a global public health emergency. The outbreak led to governments around the world implementing a range of measures to curb the spread of infection, including national lockdowns, restrictions on movement, mandatory social distancing policies, and work-from-home mandates [1]. The current study was undertaken in South Africa, where pandemic-related restrictions were particularly stringent, affecting various aspects of daily life and exacerbating existing socio-economic challenges. These restrictions had a significant impact on the higher education sector and university students [2]. In response to the pandemic, universities swiftly transitioned to online platforms to continue educational activities. This shift involved a range of adaptations, including virtual classrooms, digital submission of assignments, and online examinations. While necessary, these changes introduced new stressors for students, such as digital divide issues, the adjustment to remote learning, and loss of direct social interactions, potentially exacerbating feelings of isolation and anxiety [3,4].
During the pandemic, the experiences of students regarding access to mental health care resources varied widely [5,6,7]. While physical restrictions limited traditional in-person engagement with social networks and health care providers, leading to reduced access for some, the crisis also catalyzed the expansion of online mental health services [8]. Many countries saw a surge in digital health initiatives, with experts and therapists offering online consultations and therapy sessions for the first time [8,9]. This shift compensated for the loss of face-to-face interactions and introduced new avenues for mental health support, making services more accessible to some student populations. Nevertheless, the effectiveness and accessibility of these online services varied, reflecting disparities in digital literacy, internet access, and personal preferences for types of mental health care engagement [5,6,7]. The characteristics of the outbreak, including unprecedented infection rates, high numbers of critically ill patients, and the occurrence of different variants of the disease, aggravated psychological distress [10]. In developing countries, challenges with the provision of personal protective equipment, an economic down-turn, inequalities in access to digital resources, job losses, and concerns about food security added to the mental health burden associated with the pandemic [2,11].
Fear has been identified as a central emotional response to the pandemic [12,13]. A Jordanian study reported a 52.7% prevalence rate for fear among the population, and this was related to concerns about the health implications of being infected and worries about the wellbeing of loved ones in the event of contagion [14]. A cross-sectional study in Bangladesh found a prevalence rate of 86.3% among employed adults, and these elevated levels of fear were attributed to the negative economic impact of the pandemic on the employment sector and concerns about job security [15]. A South African study reported higher levels of fear among a sample of school teachers compared to studies undertaken in other low-to-middle income countries [16]. A systematic review and meta-analysis of studies on psychological distress among student populations reported a prevalence rate of 33% for fear [17]. Difficulties engaging with emergency remote online learning, delayed academic progress, and prolonged lack of social engagement were some of the factors contributing to heightened fear among this population group.
Although fear can be adaptive when faced with a significant and potentially life-threatening stressor, excessive levels of fear can adversely impact on mental health and lead to heightened levels of anxiety following disease outbreaks [18,19]. Anxiety, particularly as a trait, predisposes individuals to perceive a range of situations as threatening, thereby amplifying the stress associated with the pandemic’s uncertainties [20]. Individuals with high trait anxiety are more likely to perceive situations as threatening, even when they might not be, and this heightened sensitivity can lead to increased stress and worry about the pandemic’s consequences [20]. Furthermore, trait anxiety can potentially influence cognitive processes involved in evaluating one’s ability to manage or cope with stressful situations. Individuals with high trait anxiety might be more prone to negative appraisals of their coping abilities, viewing challenges as insurmountable or beyond their control, which can further contribute to psychological distress [20].
Trait anxiety not only strains an individual’s mental health but can also lead to long-term consequences such as chronic anxiety disorders, depression, or PTSD, especially when combined with direct or indirect experiences of loss, illness, or significant life changes due to the pandemic [21,22]. Various studies have highlighted the prevalence of PTSD following disease outbreaks. For example, Gao and colleagues assessed for PTSD among SARS survivors and reported rates of PTSD ranging from 38.8% to 46.2% [23]. Kaputu-Kalala-Malu and colleagues found the prevalence of PTSD was at 24.3% among survivors of Ebola disease in Sierra Leone [24]. A systematic review and meta-analysis on the prevalence of PTSD following infectious disease pandemics, including COVID-19, reported a 26.2% and 27.2% pooled prevalence of PTSD among males and females, respectively [25]. Based on their meta-analysis of studies undertaken in a wide range of countries (e.g., Bolivia, China, Italy, Spain, France, and the United States), Cénat and colleagues reported a pooled prevalence rate of 21.94% and 13.29% for PTSD and psychological distress, respectively [26]. In their meta-analysis, Yunitri and colleagues found that the average PTSD prevalence across 24 countries, including France, Greece, Norway, and Italy, was 17.52% [27].
Several studies have also confirmed the prevalence of PTSD among university students during the COVID-19 pandemic [26,28]. PTSD is a complex psychiatric disorder characterized by intrusive memories of the traumatic event or its sequalae, alternations in cognition and mood, physiological hyper-arousal, and cognitive and behavioral avoidance of reminders of trauma [29]. If untreated, the condition can severely impact on interpersonal, occupational, and educational functioning. Pandemic-related factors that have been found to increase fear, anxiety, and vulnerability to PTSD include appraisals of increased risk of contagion to oneself and loved ones, having family members or significant others who have been infected, quarantine and social isolation due to infection, and economic loss that impacts on livelihood [25,30].
This study is grounded in the Cognitive Transactional Model (CTM) of stress and coping, which proposes that cognitive appraisals are central in determining emotional responses to stressors and influencing outcomes [31]. Appraisals entail an evaluation of the stressful event or situation as relevant to the individual’s goals and determining how to negotiate the stressor so as to improve chances of coping effectively. This approach involves continuous interactions or ‘transactions’ between the individual and environment [31]. Different types of cognitive appraisals have been found to be differentially associated with emotional and behavioral responses [32,33]. For example, Padmanabhanunni and Wiid [33] reported that fortigenic or adaptive appraisals of self, family, and significant others were associated with reduced levels of PTSD symptoms, including decreased intrusive re-experiencing and avoidance behaviors. Li and colleagues [34] reported that appraisals of controllability were influential in predicting levels of distress and behavioral responses towards the COVID-19 outbreak among the Chinese population. A Turkish study [35] found that appraisals of self-efficacy were related to mental health, while Prasetyo and colleagues [36] reported that perceptions of the effectiveness of COVID-19 prevention measures and appraisals of vulnerability influenced mental health outcomes among Filipinos. Using the CTM framework, the current study aimed to advance research on the role of cognitive appraisals in mental health outcomes, by examining the potential mediating role of problem-solving appraisal in the relationship between fear of COVID-19 and PTSD.
Problem-solving appraisal refers to the individual’s perception of their problem-solving abilities rather than their actual problem-solving skills [37]. The majority of studies on the role of problem solving in mental health have focused on problem-solving ability [38,39]. However, appraisal of problem-solving ability influences the choice of coping responses and actual problem-solving skills. Individuals who appraise themselves as inadequate in problem solving may be hesitant and unmotivated to engage in solving problems. Hepper and colleagues [40], in a review and synthesis of the literature focusing on the relationship between problem-solving appraisal and psychological adjustment, concluded that there was a strong association between problem-solving appraisal and a wide range of indices of psychological wellbeing. Subsequent studies have confirmed this finding [41,42]. We hypothesized that problem-solving appraisal will mediate the association between fear of COVID-19 and the dimensions of PTSD as well as the association between anxiety and PTSD.

3. Results

The descriptive statistics, intercorrelations, and reliability of study variables are reported in Table 1. The indices of skewness and kurtosis indicated that the scores for all instruments were approximately normally distributed, as these indices were in the recommended range. All the scales demonstrated satisfactory reliability, ranging from 0.82 to 0.89.
Table 1 also reflects that fear of COVID-19 was positively associated with problem-solving appraisal (r = 0.12, p = 0.04) and all the dimensions of PTSD (re-experiencing: r = 0.28, p p p p p p p p p p
The mean scores for re-experiencing, avoidance, negative alterations in mood and cognition, hyper-arousal, and anxiety, expressed in terms of the 5-point scale of the PCL-5, were 1.9, 2.15, 1.93, and 1.87, respectively. In terms of the prevalence of PTSD, a cut-off score of 31 was used, as suggested by Ashbaugh and colleagues, and it was found that 62.1% might meet a provisional diagnosis of PTSD [52].
The direct effects of the fear of COVID-19 and problem-solving appraisal on the indices of PTSD are presented in Table 2. All of the effects were significant and confirm the associations obtained with the zero-order correlations.

The mediation analysis confirmed a significant mediating role for problem-solving appraisal in the relationship between fear of COVID-19 and all the dimensions of PTSD, namely, re-experiencing (β = 0.03, 95% CI [0.002, 0.065]), avoidance (β = 0.01, 95% CI [0.000, 0.026]), negative alterations in mood and cognition (β = 0.06, 95% CI [0.002, 0.111]), and hyper-arousal (β = 0.04, 95% CI [0.001, 0.087]).

The results of the moderated mediation analysis found a significant interaction effect (fear of COVID-19 X anxiety: β = −0.08, p = 0.02)), indicating that anxiety moderated the relationship between fear of COVID-19 and problem-solving appraisal. The nature of the moderation effect is demonstrated in Figure 1.

For respondents with high levels of anxiety, the regression line is in the opposite direction of the regression lines for low or medium levels of anxiety. This might indicate that for participants with high anxiety, increased levels of fear of COVID-19 are associated with a decrease in problem-solving appraisal (i.e., perceptions of effective problem-solving skills). Simple slope tests indicated that, at low levels of anxiety, there was a significant positive association between fear of COVID-19 and problem-solving appraisal (β = 0.46, p = 0.04), while at medium (β = 0.10, p = 0.50) and high (β = −0.24, p = 0.24) levels of anxiety, the association between fear of COVID-19 and problem-solving was not significant.

The moderated mediation model is shown in Figure 2.
The indices of moderated mediation for all the dimensions of PTSD are presented in Table 3. All the indices were significant, which indicates that the indirect effect of fear of COVID-19 on the dimensions of PTSD was moderated by anxiety.
The conditional indirect effects of fear of COVID-19 on the dimensions of PTSD for different levels of anxiety are presented in Table 4. For all the dimensions of PTSD, the indirect effects of fear of COVID-19 were significant for respondents with low levels of anxiety but not for those with medium or high levels of anxiety. This confirms that the mediating role of problem-solving appraisal was moderated by anxiety. Thus, while a significant mediation effect was found for problem-solving appraisal for all the indices of PTSD in the mediation analysis, the effect was only significant for respondents with low levels of anxiety in the moderated mediation analysis.

4. Discussion

The COVID-19 pandemic has been associated with a range of adverse mental health outcomes [3,53]. Fear has been identified as a dominant emotional response to the outbreak of the disease, and elevated levels of fear have been associated with adverse mental health outcomes, including anxiety, depression, and PTSD [17,54]. Existing research has highlighted the critical role of cognitive appraisals in emotional regulation and psychological distress. The bulk of this research has focused on the role of negative appraisals, with less focus on the protective function of adaptive appraisals [55,56]. These types of appraisals can serve a protective function and mitigate the development of adverse mental health outcomes. The current study aimed to extend research in this area by examining the potential mediating role of problem-solving appraisal in the relationship between fear of COVID-19 and PTSD. There were several important findings.
First, the study confirmed that fear of COVID-19 was positively associated with all dimensions of PTSD. It is well established that fear is a dominant emotional reaction to traumatic events, and theoretical models of PTSD have proposed that impaired processing of the traumatic event in memory and the acquisition of fear through classical conditioning processes underlie the persistence of the disorder [57,58,59]. In the context of the COVID-19 pandemic, fear may be related to uncertainty about the course of the outbreak, the rapid transmissibility of the virus, the high mortality rates, and concerns about the health consequences of infection for oneself and family members. Those infected with the virus, or who suspect that they may have been infected, have been found to experience more intense levels of fear and PTSD [60]. Furthermore, individuals with a prior history of exposure to trauma are more vulnerable to experiencing fear and developing PTSD after exposure to subsequent potentially traumatic situations [23]. The current study consisted of students from a South African HDI, and prior research has confirmed increased levels of trauma exposure among this group because they reside in high-risk environments characterized by community violence, unemployment, poverty, and substance abuse [61]. Furthermore, limited access to personal protective equipment and health care resources in such settings may have aggravated their fears of COVID-19 and increased their risk of PTSD. It is possible that prior exposure to trauma may have enhanced their vulnerability to fear and PTSD in the context of COVID-19.
Second, the study found that stronger cognitive appraisals of being an effective problem solver were associated with lower levels of both fear of COVID-19 and PTSD. This finding underscores the protective role of adaptive appraisals in promoting emotional regulation and coping. Individuals who appraise themselves as ineffective problem solvers are more likely to engage in maladaptive emotion regulation strategies such as ruminative thinking (i.e., passive focusing on stressors and their causes), thought suppression, and behavioral avoidance [62]. These types of strategies have been implicated in the maintenance of fear and PTSD because they prevent individuals from processing traumatic events [57]. In contrast, the use of strategies such as the positive re-appraisal of stressful situations has been found to promote effective coping and enhance wellbeing [63].
Third, the study found that anxiety moderated the relationship between fear of COVID-19 and problem-solving appraisal. This suggests that for individuals with high anxiety, increased levels of fear of COVID-19 were associated with a decrease in problem-solving appraisal (i.e., perceptions of effective problem-solving skills). In the absence of the moderator (anxiety), problem-solving appraisal mediated the relationship between fear of COVID-19 and the dimensions of PTSD. Furthermore, when the moderator (anxiety) was introduced, the indirect effects of fear of COVID-19 on PTSD were only significant for those with low levels of anxiety. Cognitive models of emotional regulation have proposed that strong negative emotional experiences can interfere with executive functions such as cognitive processing, appraisal, and planning [57,58]. When applied to our findings, it is probable that high levels of anxiety may have negatively impacted cognitive appraisals of self and problem-solving ability.
The findings that anxiety moderated the relationship between fear of COVID-19 and problem-solving appraisal also aligns with personality theories suggesting that individuals with high trait anxiety are more likely to experience diminished perceptions of their problem-solving abilities in the face of stress [64]. This is particularly relevant in the context of the COVID-19 pandemic, where the unprecedented nature of the outbreak and drastic changes to the educational sector have presented significant stressors. Students with high trait anxiety may perceive these challenges as more threatening, impacting their cognitive appraisals and, consequently, their ability to engage in effective problem solving. This relationship underscores the importance of considering personality-based explanations in understanding how students cope with pandemic-related stress, highlighting the need for interventions that are tailored to individual personality profiles to enhance resilience and coping mechanisms in the face of ongoing and future stressors [64].
The findings of the study have potential implications for interventions aimed at promoting adaptive coping among university students. Existing studies have demonstrated that problem-solving ability can be cultivated through training and practice, signifying that this protective factor can be a target of intervention efforts [65,66]. Evidence-based treatments for psychological disorders, such as cognitive behavioral approaches, emphasize increasing emotional regulation strategies and effective coping through positive reappraisals of potentially stressful situations [66]. Based on our findings, an important component of such an approach entails identifying and actively targeting maladaptive appraisals of problem-solving ability. This has the potential to generate more positive emotions, enhance confidence, and broaden an individual’s range of coping responses. Research-based support for the role of problem-solving training has been growing in recent years, and a central component of this approach entails focusing on enhancing appraisals of problem-solving ability [67]. The finding that anxiety moderated the relation between fear of COVID-19 and problem-solving appraisal implies that assessing for anxiety needs to be a part of intervention efforts.
The findings of the study need to be viewed in the context of several limitations. First, the study used a predominantly homogenous sample of students from the same institution, and additional research using a more diverse sample is warranted. Second, the study design is cross-sectional, limiting the extent to which causal inferences can be made. Longitudinal studies that assess student trajectories over time are needed to better understand the interplay of protective factors and mental health outcomes. Third, the study used an electronically distributed self-report instrument, and it is probable that students with access to information technology and interest in the topic may have been more likely to complete it. This may have contributed to selection bias and social desirability bias. Finally, the study did not assess trauma exposure or adverse events, and, while our use of the PCL-5 is commensurate with other studies involving university students [55], interpretations of the findings of the PCL as indicators of PTSD need to be made with caution. Furthermore, it is possible that factors apart from the COVID-19 pandemic may have contributed to anxiety and traumatic stress symptoms. Future studies might need to assess the influence of factors not measured in this study, including trauma exposure.

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