On 11 March 2020, the World Health Organization (WHO) declared the COVID-19 infection a pandemic; from that moment on, the world was plunged into a state of unprecedented fear and uncertainty. The coronavirus disease, COVID-19, is a highly contagious respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Within only three months, the COVID-19 pandemic became the most severe global health challenge since the Spanish Flu one century ago [1
]. The novel coronavirus has grown exponentially throughout the world, reaching globally over 117 million confirmed cases and 2.6 million deaths; in Italy, more than 3 million cases and 100 thousand deaths (status quo on 12 March 2021) [1
As a primary defense emotion, fear plays an important role in adopting preventive behaviors and is used or even abused as a lever in communication, as it is thought that it can increase the effectiveness of a message. Fear is defined as a basic, intense emotion aroused by the detection of imminent threat, involving an immediate alarm reaction that mobilizes the organism by triggering a set of physiological changes. These include rapid heartbeat, redirection of blood flow away from the periphery toward the gut, tensing of the muscles, and a general mobilization of the organism to act [3
]. Although there are differences with respect to anxiety, the terms are often used interchangeably in everyday language and our research does not aim to distinguish.
Multiple factors linked to culture, economy, ethics, health systems and environmental conditions play a role in the evolution of the pandemic. Individual and social dynamics interact in shaping the coping capacity of each community, and knowledge of psychological reactions is crucial for understanding the impact of COVID-19. It is also useful for designing and implementing appropriate initiatives to support coping strategies and psychological aspects related to the pandemic. Knowledge, education level and socioeconomic status (SES) can influence perception COVID-19 risk in a digital world [4
]. Along with the epidemic, fear has been spreading and growing [5
]. The global dimension of the present crises is unprecedent, and the negative impact is strongly influenced by personal and social emotions and behaviors typical of the “global risk society” [6
The elements that characterize the risk perception of infectious diseases and the differences with non-communicable diseases must be fully understood in order to effectively manage risk communication and governance during a public health crisis. The links between fear and risk perception are multiple and largely inextricable, depending on social, cultural and contextual factors [8
The elements that increase or mitigate fear can be classified into the following: voluntariness (if the risk is perceived as being voluntary it seems less dangerous); knowledge (a new risk evokes more fear); trust (faith in those who are managing the risk, such as public health institutions, makes the risk seem lower); and visibility (an invisible risk evokes more fear than a visible one) [9
As the crisis develops, research has been progressing rapidly in a number of related areas such as the transmission modality, contagion risk, initial and specific symptoms and complications, the most effective treatment strategies, long-term effects and the preparation for the next pandemic wave. In a recent research study, a rapid COVID-19 screening based on self-reported symptoms was developed by a short diagnostic scale to detect subjects within a population, with specific symptoms potentially associated with COVID-19 [10
While excessive fear hinders good management, insufficient fear can also play a negative role, leading individuals to ignore or reluctantly accept government measures to delay or prevent the spread of the virus or even facilitate reckless behaviors, oblivious to the risks they entail [8
Other studies revealed that fear is an adaptive response in the presence of danger and can become chronic and burdensome when the threat is uncertain and continuous, as in the case of the Coronavirus disease (COVID-19) pandemic [14
]. Fear is in any case a subjective conscious experience linked to numerous psychological and sociological factors [4
The risk of contracting COVID-19 can increase with greater morbidity in the area, with crowding and mobility of the population, with less social distance, less access to health care and less education, which is linked to risky social behaviors [17
]. The spread of the disease is influenced by people’s willingness to adopt preventative public health behaviors, linked to public risk perception. Personal experience with the virus, individualistic and prosocial values, hearing about the virus from friends and family, trust in government, science, and medical professionals, personal knowledge of government strategy, and personal and collective efficacy can be considered predictors of risk perception. Individualistic worldviews, personal experience, prosocial values, and social amplification through friends and family in particular are features that are related to risk perception and communication and to the adoption of preventative health behaviors [5
]. Efforts to change behavior are critical in minimizing the spread of highly transmissible pandemics such as COVID-19, and the importance of risk perception in early interventions during large-scale pandemics is a crucial issue [18
As fear may be a crucial construct in explaining individual and social behavior with reference to the COVID-19 pandemic, it is important to understand what people are exactly afraid of and which factors are triggering it. Therefore, it is essential to investigate the extent the fear relates to the individual her/himself or to people close to her/him, such as family members (FMs). The recommendations of “social distancing” have deeply influenced interpersonal relationships, and the physical distancing it entails not only protects, but also makes people who are physically close appear threatening. On the other hand, some people feel responsible for the good health of family and individuals in their community and for avoiding the spread of the virus. These behaviors can have profound consequences on relationships with significant others and may threaten an individual’s sense of security and the need to be a reference point for loved ones [19
In light of these considerations, this study investigated how people in Italy were dealing with their risk perception and fears related to their own health as well as that of close FMs in the period of the COVID-19 pandemic. The research questions addressed are the following:
Which demographic and SES factors are linked to the fear of contracting the COVID-19 disease?
What role does self-perceived health play?
What role do chronic diseases, acute general symptoms, specific COVID-19-like symptoms or positive swab test results play?
The study’s main research goal was to analyze the participants’ fear of contagion for themselves and FMs, and to investigate the weight of different demographic, social and health status characteristics, including the presence of COVID-19-like symptoms and positive SARS-CoV-2 swab test, in association with fear.
Verifying these elements should allow us to understand the specificity of the situation in Italy, which has never experienced a phenomenon like the one in progress. The results were discussed in the light of recent scientific literature referring to other countries affected by the pandemic to obtain take home messages for pandemic governance and decision making.
The differences between fear for oneself and for FMs were discussed in the light of the achieved results.
2.1. Study Design and Setting
The present study is based on EPICOVID19 (https://epicovid19.itb.cnr.it/
, accessed on 19 March 2021), an extensive national research study carried out in 2020 during the peak of the pandemic in Italy. EPICOVID19 is a national internet-based, cross-sectional survey led by a multidisciplinary research team operating in three biomedical Institutes of the National Research Council, in the Sacco Hospital, University of Milan, the Italian Society of Geriatrics and Gerontology (SIGG) and the Italian Society of Infectious and Tropical Diseases (SIMIT) [10
]. The survey was launched on 13 April 2020 and data were collected until 2 June 2020; it targeted adult volunteers living in Italy during the first lockdown period set by the Italian Government (from 9 March to 18 May 2020) in response to the growing pandemic of COVID-19 in the country. The survey began approximately one month after the start of the first lockdown due to the necessary trigger time and ran for a reasonable time after its end, having reached 200,000 responses and in the presence of a declining epidemic curve. The study was registered in the international repository for clinical and epidemiological investigations (ClinicalTrials.gov NCT04471701). EPICOVID19 is still an active study, investigating new aspects of the health emergency, in particular the ongoing vaccination campaign and the performance of serological tests and molecular swabs.
To encourage participation in the EPICOVID19 study, the link to the online survey was shared using social media (Facebook, Twitter, Instagram and WhatsApp), press releases, web pages, local radio and television stations and institutional channels. The inclusion criteria were age >18 years; access to a mobile phone, computer, or tablet with internet connectivity; and provision of web-based consent to participate in the study.
2.3. Development of the Web-Based Questionnaire
EPICOVID19 was developed by the working group after a literature review of existing research into COVID-19 and already available standard and validated instruments, as described in detail elsewhere [10
The questionnaire was adapted to the national context and implemented using the European Commission’s open-source official EU Survey management tool (https://ec.europa.eu/eusurvey/
, accessed on 12 February 2021). The participants were asked to complete the self-administered 38-item questionnaire, which mainly contained mandatory and closed questions divided into six sections: (1) demographic and SES data; (2) clinical evaluation; (3) personal characteristics and health status; (4) housing conditions; (5) lifestyle; (6) behaviors following the first lockdown period [20
] (see the Supplementary Materials
2.4. Data Collection and Variables
The demographic and SES information included sex (men and women), age (categorized as 18 to 39, 40 to 59 and ≥60 years), educational level (primary school or less, middle or high school and university degree or postgraduate degree), and occupational status (unemployed, employed, retired, student and other). The COVID-19 related symptoms included fever >37.5 °C for at least three consecutive days; headache, chest pain, myalgia, olfactory and taste disorders, shortness of breath, and heart palpitations; gastrointestinal disturbances, including nausea, vomiting and diarrhea; conjunctivitis; and sore throat, rhinorrhea, and cough (all dichotomized as present/absent). The self-reported chronic conditions investigated were the diseases of heart, lung, kidney, liver, immune system, metabolism, hypertension, tumors, depression and/or anxiety. Self-perceived health status had five possible answers: very bad, bad, adequate, good and very good.
The month of onset of the first symptoms (February/March/April 2020), nasopharyngeal swab (NPS) test results (categorized as not performed, performed with a negative result, performed with a positive result and performed with an unknown result), flu and pneumococcal vaccinations in 2019, contact with COVID-19 confirmed or suspected individuals were collected and included in the analysis. A heterogeneity evaluation among results in the 20 Italian regions was also carried out.
2.5. Outcome Variable
To evaluate the association with the selected variables of the EPICOVID19 questionnaire, the dichotomous classification of perceived fear of COVID-19 contagion was considered: None or Low level vs. Medium or High level of fear. The specific questions about the experience of fear were the following: “Do you fear getting infected with the coronavirus (COVID-19)?” and “Do you fear your family being infected with the coronavirus (COVID-19)?” with the possible answers formulated as follows: No; Just a little bit; Neutral; Quite enough; Yes, a lot.
2.6. Statistical Analysis
The descriptive analyses were carried out using t tests for continuous variables (age, number of symptoms, number of diseases), Chi-square tests for categorical variables (sex, education, occupation, health, contacts, swab, vaccines, symptoms and diseases) to evaluate whether the level of fear of contagion differed by the abovementioned variables. The multivariate analysis carried out through logistic regression provided results on the association between the level of fear and the variables above, expressed as adjusted Odds Ratios (aORs), with 95% Confidence Intervals (CIs). All the analyses, adjusted for sex, age, educational level and occupational status, were performed using Stata 15.0 version (StataCorp LP, College station, Texas, USA) and a two-sided p-value < 0.05 was considered statistically significant.
2.7. Ethics and Consent Form
The Ethics Committee of the National Institute Infectious Diseases I.R.C.C.S. Lazzaro Spallanzani, Italy (Protocol No. 70, 4 December 2020) approved the EPICOVID19 study protocol. When participants first accessed the web-based platform, they were informed about the purpose of the study, the data to be collected, and the methods of data storage before filling in the informed consent form. The planning, conduction and reporting of the studies was in line with the Declaration of Helsinki, as revised in 2013. Data were handled and stored in accordance with the European Union General Data Protection Regulation (EU GDPR) 2016/679, and data transfer was safeguarded by encrypting/decrypting and password protection.
It is well known that fear and the connected risk perception directly and indirectly plays a role in the preventive behaviors that individuals adopt and the interventions they agree with. Studying fear is also important because of its links with people’s health conditions, considering the protective significance of fear as personal and collective assumption of responsibility in the face of an uncertain future [57
The present research, developed during the first outbreak of the COVID-19 pandemic in Italy, suggested an overall acknowledgement of responsibility in the population which showed that participants were more worried about FMs than for themselves. Fear was higher among women than men and decreased with higher levels of education (fear for oneself was lower in those with higher levels of education but no differences by education were observed for fear for FMs) and in those who perceived themselves as having good health.
Some results show that uncertainty is an important determinant of fear, in particular it is interesting that unawareness of having had contact with people suspected of being infected is a greater source of fear than known contacts; similarly, those who were waiting for a response to the nasopharyngeal swab had an intermediate fear between negative and positive responses. The finding that people previously vaccinated for influenza or pneumococcal disease were more afraid than the unvaccinated is an indication that frailty prevails as a higher risk compared to vaccination protection.
Fear increased when one or more chronic diseases and symptoms were declared, and in particular those recognized as being associated with COVID-19.
The results of this study, in agreement with other authors, showed a link between fear and depression/anxiety which confirms the importance of taking mental health needs into account, and this may also be particularly relevant when using a personalized approach to reduce health inequalities [57
In addition to demographic and SES characteristics, the positive association between health status and the fear of becoming infected should be taken into serious consideration when protective measures for the most vulnerable people are being designed and implemented.
The knowledge gained form these results should be used to produce tailored messages and shared public health decisions.
Special caution should be applied in communicating about the COVID-19 pandemic to avoid using fear as a lever of emotions instead of rationality as a tool to impose behaviors and decisions. Even when managing fear, communication should improve trust between institution and citizens, promoting involvement and collaboration.