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In today’s technologically advancing society, widespread and rapid digitization has led to a substantial increase in the use of social media and the internet. This, in turn, has facilitated the rapid dissemination of all types of information. Although this can be beneficial in filling information gaps quickly, it has its drawbacks. A prominent drawback is the amplification of harmful messages, which can have negative effects on individuals [,]. The World Health Organization (WHO) acknowledged the presence of an infodemic during the COVID-19 pandemic and subsequent responses. WHO defines an infodemic as an excessive amount of information, including both accurate and inaccurate content []. This abundance of information makes it difficult for individuals to distinguish reliable sources from unreliable sources and to find trustworthy guidance when they need it.
Excessive use of health care services can have adverse effects on individuals and the overall sustainability of health care systems. Although challenges associated with the overuse of health care services were evident before the COVID-19 pandemic [,], the urgent need for sustainable health care systems was exacerbated by the pandemic. Because large portions of the population were instructed to self-isolate at home and had limited access to health care professionals during the pandemic, the internet became the primary source of information for numerous individuals seeking answers to health-related questions. However, the abundance of web-based information, including both true and false content, can leave individuals feeling overwhelmed and struggling to make informed choices. This information overload can lead to depression because individuals bombarded with conflicting messages may feel unsure of what to believe [-].
Besides depression, cyberchondria has also emerged as a significant public health challenge since the onset of the COVID-19 pandemic. This refers to the repeated and excessive search for health-related information on the internet, leading to a significant increase in distress or anxiety []. Although the global emergency caused by the COVID-19 pandemic is over, telehealth remains a growing trend. An increasing number of studies have indicated that telehealth can improve health care access, outcomes, and affordability by offering a bridge to care and an opportunity to reinvent web-based care models []. However, increasing internet exposure increases the risk of cyberchondria, especially under conditions of uncertainty and increased risk, due to the large volume of information it contains. Thus, it is crucial to understand how to provide support and guidance to help people adopt appropriate strategies for using web-based resources safely in the context of an infodemic.
Current Research on the COVID-19–Related InfodemicThe harms of infodemic are well documented. An Italian study suggested developing early warning signals for an infodemic, which can provide important cues for implementing effective communication strategies to mitigate misinformation []. Other studies have shown that successful use of coping strategies can help individuals manage stressful events and reduce negative emotions during a pandemic. For example, Yang [] found a positive correlation between emotion-focused coping and cyberbullying and depression during the COVID-19 pandemic. A large-scale UK study indicated that supportive coping was associated with a faster decrease in depression and anxiety symptoms []. Shigeto et al [] emphasized the importance of training young adults to develop resilience, flexibility, and specific coping skills to offset the psychological effects of significant lifestyle changes resulting from pandemics or other health crises in the future. A recent study used machine learning technology to enhance the accuracy and efficiency of automated fact-checking and infodemic risk management at a strategic level []. However, the impact of coping strategies on the relationship among the infodemic, cyberchondria, and anxiety at an individual level during the COVID-19 pandemic is still unknown.
Importance of Coping StrategiesThe ability of individuals to discern and adopt appropriate coping strategies can have a profound impact on their mental health, particularly in relation to conditions such as depression and anxiety. The ability to select and implement coping strategies is not uniform across all individuals, and these differences can significantly influence the trajectory of their mental health outcomes. For some, the ability to effectively choose and implement coping strategies can serve as a protective factor, mitigating the severity of the symptoms of depression or anxiety and promoting overall health and well-being. Conversely, for others, inability or difficulty in selecting and implementing effective coping strategies can exacerbate mental health conditions, leading to increased severity of depression and anxiety. This, in turn, can have detrimental effects on individuals’ overall health and well-being. Therefore, understanding the factors that influence individuals’ ability to select and implement effective coping strategies is of paramount importance in the field of mental health research and intervention [].
Research has demonstrated the importance of appropriate coping mechanisms in managing mental health problems. Coping strategies, which are essential for dealing with stress or challenging situations, can be categorized into 3 primary types: emotion focused, problem focused, and avoidant focused []. Emotion-focused strategies are centered around managing and regulating emotions. They serve as a means to cope with stress or difficult situations. These strategies might involve seeking emotional support from others, using relaxation techniques, or practicing mindfulness. In contrast, problem-focused strategies actively address the problem or stressor. These strategies might encompass problem-solving, devising a plan of action, or seeking information and resources to effectively tackle the situation. Avoidant-focused strategies involve evading or distancing oneself from the stressor or problem. These strategies might include denial, distraction, or engaging in activities to escape or avoid contemplating the issue []. The effectiveness of different coping strategies can vary depending on the situation. Individuals often use different or a combination of strategies, tailoring their approach to their circumstances.
Coping Strategies in the COVID-19–Related InfodemicFrom a social perspective, this study underscores the importance of mental health in the context of public health emergencies such as the COVID-19 pandemic. It highlights the need for society to recognize and address the mental health burden that such emergencies can place on individuals, particularly in relation to the phenomenon of cyberchondria, which is the unfounded escalation of concerns about common symptoms based on reviews of web-based literature and resources.
Practically, this study provides valuable insights for policy makers and practitioners. It emphasizes the need for the development of effective coping strategies and programs to manage the negative impact of an overload of misinformation and disinformation on mental health. This is particularly relevant in the digital age, where individuals have access to a plethora of information, not all of which is accurate or reliable. Policy makers and practitioners can use the findings of this study to design interventions that not only provide accurate information but also equip individuals with the skills to distinguish reliable sources from unreliable sources and to cope with the anxiety that misinformation can cause. From a research standpoint, this study fills a gap in the literature by assessing the impact of the infodemic on cyberchondria and the moderating effect of coping strategies in this relationship. It opens up new avenues of research into the complex interplay among public health emergencies, infodemic, cyberchondria, and coping strategies. Future research could build on the findings of this study to further explore these relationships and develop and test interventions aimed at mitigating the negative impact of infodemic on mental health.
Objective of the StudyCurrently, the association between the overuse of health care services and mental health problems in the context of an infodemic remains unclear, as is the moderating effect of different coping strategies on this association. Thus, this study investigated the moderating effect of coping strategies on the relationship between the infodemic-driven misuse of health care and depression and cyberchondria.
Hypotheses of the StudyThe study used a hypothesis-driven format. Specifically, there are five hypotheses: (1) a positive relationship exists between infodemic and the misuse of health care, (2) a positive relationship exists between the misuse of health care and depressive disorders, (3) a positive relationship exists between the misuse of health care and cyberchondria, (4) coping strategies mitigate the negative effect of the misuse of health care on depression, and (5) coping strategies mitigate the negative effect of the misuse of health care on cyberchondria. Hypotheses 2-5 are separately evaluated for the three types of coping strategies: problem focused (H2.1), emotion focused (H2.2), and avoidant focused (H2.3).
The data used in this study were obtained from a cross-sectional and web-based survey conducted between April and May 2023 in China.
There is no gold standard for sample estimation in partial least squares structural equation modeling (PLS-SEM). Following Hair et al [], we set the significance level at 5% and the minimum path coefficients to between 0.05 and 0.1. Based on these criteria, a minimum sample size of 619 was determined.
Data Source and CollectionA professional surveying company, WenJuanXing, was invited to collect the data through its web-based panel. The panel of WenJuanXing consists of 2.6 million members, with an average of over 1 million questionnaire respondents daily. At the beginning of the project, a survey manager collaborated with the research team to screen and recruit participants using the company’s internal social network platform. All of the eligible panel members received a survey invitation, and a voluntary response sampling method was used. The survey manager checked the data quality using WenJuanXing’s artificial intelligence data quality control system to ensure that respondents met our inclusion criteria and provided valid responses, thus ensuring a high level of data accuracy and integrity. The inclusion criteria were (1) aged older than 18 years, (2) able to understand and read Chinese, and (3) agreed to provide informed consent. All eligible respondents were invited to participate in a web-based survey. The first section of the survey was the informed consent, which the participants were required to read and agree to before proceeding. All the participants who agreed to participate in the survey were asked to complete six questionnaires covering (1) demographics and socioeconomic status, (2) COVID-19 information–related questions, (3) a cyberchondria questionnaire, (4) an eHealth literacy questionnaire, (5) an anxiety questionnaire, and (6) a coping strategy questionnaire. The English translations of the questionnaires are presented in . To ensure data quality, we collaborated with the survey company and implemented various indicators. We monitored completion time, excluding responses that took less than 6 minutes. We also tracked ID addresses, ensuring that each ID address could only complete the questionnaire once. To minimize random errors, we used an artificial intelligence formula developed by the survey company to identify and filter any response patterns that appeared to be generated in parallel.
Ethical ConsiderationsThe study protocol and informed consent process were approved by the institutional review board of the Hong Kong Polytechnic University (HSEARS20230502006). Informed consent was collected from all participants. The survey was conducted anonymously, and no personally identifiable information was collected. No compensation was provided by the research team.
InstrumentsCyberchondria Severity Scale-12The Cyberchondria Severity Scale-12 (CSS-12), derived from the 33-item CSS, was used to measure the severity of cyberchondria. The CSS-12 exhibited equally good psychometric properties as the original version and has been validated in Chinese populations []. The CSS-12 items are scored on a Likert-type scale ranging from 1=“never” to 5=“always,” giving total scores ranging from 12 to 60. A higher score indicates a higher severity of suspected cyberchondria. The psychometric properties of the Chinese version of the CSS-12 were reported by Peng et al [].
Generalized Anxiety Disorder AssessmentThe Generalized Anxiety Disorder Assessment-7 (GAD-7) was used to screen for generalized anxiety disorder and related anxiety disorders []. This scale consists of 7 items designed to assess the frequency of anxiety symptoms during the 2 weeks preceding the survey. The GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3 to the response categories of “not at all,” “several days,” “more than half the days,” and “nearly every day,” respectively. The scores of the 7 questions are then summed, giving a total ranging from 0 to 21, with higher scores indicating a higher severity of anxiety disorders. Many studies have reported the psychometric properties of the GAD-7 in Chinese populations, such as that conducted by Sun et al [].
Coping Orientation to Problems Experienced InventoryThe Coping Orientation to Problems Experienced Inventory (Brief-COPE) is a 28-item self-report questionnaire used to measure effective and ineffective strategies for coping with a stressful life event []. The Brief-COPE assesses how a person deals with stressors in their daily life. The questionnaire measures 3 coping strategy dimensions: problem focused, emotion focused, and avoidant focused []. Each item is rated on a 4-point scale. The scores for the 3 overarching coping styles are calculated as average scores. This is done by dividing the sum of the item scores by the number of items. These average scores indicate the extent to which the respondent engages in each coping style. A higher score indicates that the respondent does not have many coping skills. The Chinese version of the Brief-COPE and its psychometric properties in Chinese populations were reported by Wang et al [].
Infodemic- and Misinformation-Driven Overuse of Health Care ServicesThe COVID-19–related infodemic and misinformation-driven medical misbehavior were assessed using 2 self-developed items. The first item was “Do you believe there is an excessive amount of information regarding the COVID virus and vaccine on a daily basis?” The second item was “Has misinformation or disinformation about COVID-19 led you to engage in the overuse of health care services (eg, frequently visiting the doctor/psychiatrist or buying unnecessary medicine)?” The respondents were required to indicate their response to these 2 questions by selecting 1 of 2 options presented dichotomously: yes or no.
Statistical AnalysisDescriptive statistics were used to describe the participants’ background characteristics. Continuous variables (eg, age) were calculated as means and SDs. Categorical variables (eg, sex) were calculated as frequencies and proportions. The Pearson correlation coefficient (r) was used to examine the association between measures, where r≥0.3 and r≥0.5 indicated moderate and large effects, respectively [,].
In this study, we used PLS-SEM to estimate the research model parameters, as it works efficiently with small samples and complex models. Compared with covariance-based structural equation modeling, PLS-SEM has several advantages, such as the ability to handle non-normal data and small samples []. Unlike covariance-based structural equation modeling, which focuses on confirming theories, PLS-SEM is a causal-predictive approach that explains variance in the model’s dependent variables []. To improve the model fit, we used the bootstrapping method with 10,000 replications to obtain the estimates of the mean coefficients and 95% CIs []. Composite reliability rho_a (>0.7), composite reliability rho_c (>0.7), and average variance extracted (>0.5) were used to examine the model performance.
PLS-SEM encompasses measurement models that define the relationship between constructs (instruments) and indicator variables and a structural model. The structural model used in this study is presented in . We hypothesized that the infodemic significantly affects misinformation-driven medical misbehavior, resulting in cyberchondria and high anxiety levels. Furthermore, we speculated that coping strategies significantly modify this relationship. To test these hypotheses, we used 3 models that used the full sample to separately investigate the moderating effect of the 3 types of coping strategies (problem focused, emotion focused, and avoidant focused). We analyzed the data and estimated the PLS-SEM parameters using the “SEMinR” package in R (R Foundation for Statistical Computing). A P value of ≤.05 was considered statistically significant.
Figure 1. Conceptual framework of this study. A total of 986 respondents completed the web-based survey and provided valid responses, resulting in a response rate of 84%. Among the participants, 51.7% (n=510) were female, approximately 95% (n=933) had completed tertiary education or above, and 71.2% (n=702) resided in urban areas. The participants’ background characteristics are listed in .
Table 1. Respondents’ background characteristics (n=986).aA currency exchange rate of 7.23 CNY=US $1 applies.
Mean Scores and Frequency of ResponsesThe mean score of the GAD-7 was 8.4 (SD 3.8), while the mean score of the CSS-12 was 39.7 (SD 7.5). Problem-focused coping had a higher mean score than emotion- and avoidant-focused coping. Respondents with active employment reported statistically significantly higher mean scores on the GAD and avoidant-focused coping subscale compared to those with nonactive employment. A higher proportion of respondents with chronic diseases experienced an infodemic and exhibited the overuse of health care services relative to those without chronic diseases (). The correlations between all of the measures are presented in .
Table 2. Mean score of GAD-7a, CSS-12b, Brief-COPEc, frequency of infodemic, and overuse of health care in different groups of background characteristics (n=986).aGAD-7: Generalized Anxiety Disorder Assessment-7.
bCSS-12: Cyberchondria Severity Scale-12.
cCOPE: Coping Orientation to Problems Experienced Inventory.
dP=.04.
eP=.002.
fP=.05.
gP<.001.
hP=.03.
iP=.02.
jP=.009.
kP=.01.
Measurement Models- present the performance of the measurement models for the 3 coping strategies. The values of rho_C and rho_A were above 0.7, indicating acceptable construct reliability. All 3 constructs had Cronbach α values exceeding the cutoff of 0.7, indicating adequate reliability. presents the models’ convergent validity. All the bootstrapped item loadings exceeded 0.3 and were significant at <.05 for the problem- and avoidant-focused models. However, for cyberchondria and the Brief-COPE, none of the average variance extracted values were above 0.5, indicating unsatisfactory model convergent validity.
Table 3. Performance of the measurement model: problem-focused model.aAVE: average variance extracted.
bGAD-7: Generalized Anxiety Disorder-7.
cCOPE: Coping Orientation to Problems Experienced Inventory.
dHC: health care.
Table 4. Performance of the measurement model: emotion-focused model.aAVE: average variance extracted.
bGAD-7: Generalized Anxiety Disorder-7.
cCOPE: Coping Orientation to Problems Experienced Inventory.
dHC: health care.
Table 5. Performance of the measurement model: avoidant-focused model.
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