Patterns of Psychological Responses among the Public During the Early Phase of COVID-19: A Cross-Regional Analysis

Context and Objectives

During the COVID-19 pandemic, numerous meta-analyses have documented that approximately one-third of the global population reported symptoms of depression, anxiety, stress, and insomnia. These adverse mental health symptoms were more severe among individuals with pre-existing mental health problems, patients diagnosed with COVID-19, and healthcare professionals. Significant variations in public health and policy responses among countries and regions suggest that psychological responses to the perceived impact of COVID-19 may differ considerably by geographical location.

This study employed Leventhal's Common Sense Model of Self-Regulation as a theoretical framework to examine the mediating roles of psychological flexibility, prosociality, and coping strategies (social support seeking, problem-solving, avoidance, and positive thinking) in the relationship between illness perceptions toward COVID-19 and mental health. A previous study based on a specific Hong Kong sample (514 adults) found that psychological flexibility was the only significant mediating factor. The primary objective was to extend this finding through a cross-sectional multicultural analysis to determine whether similar coping patterns were replicated across multiple worldwide geographical regions during the initial phase of the pandemic.

Method

Participants

A multilingual online cross-sectional survey, designated the COVID-19 IMPACT SURVEY, was conducted during the initial phase of the pandemic (April to June 2020). Convenience sampling recruited 9,565 individuals from 78 countries through local press, social media, media platforms, professional group email lists, participating universities, and radio stations. Participants had to be aged 18 years or older and have internet access. The survey was available in 15 languages (English, Greek, German, French, Spanish, Turkish, Dutch, Latvian, Italian, Portuguese, Finnish, Slovenian, Polish, Romanian, Chinese, Hungarian, Montenegrin, and Persian).

After excluding 435 participants (4.5%) whose country responses had fewer than 100 completed survey responses, the final sample comprised 9,130 participants from 21 countries distributed across seven geographical regions: Eastern Asia (Hong Kong, n=514), Western Asia (Cyprus and Turkey, n=1,657), North and South America (Colombia and United States, n=753), Northern Europe (United Kingdom, Finland, Ireland, and Latvia, n=1,956), Western Europe (Switzerland, Germany, Austria, and France, n=1,507), Southern Europe (Greece, Spain, Italy, Portugal, and Montenegro, n=1,996), and Eastern Europe (Poland, Romania, and Hungary, n=747).

The sample was predominantly female (77.6%, range=70.5%-84.9% by region), middle-aged (55%, range=43.0%-64.1%), employed full-time (53.7%, range=42.2%-63.1%), and educated to tertiary level (66.9%, range=47.8%-83.9% by region). Less than one-fifth were healthcare professionals except in Western Europe where this proportion exceeded 30%. Approximately one-third of participants (33.6%) reported their financial situation had worsened, 1.5% had been infected with COVID-19, 0.8% had infected partners, and 5.7% reported infected significant others.

Design

The design was an online, multicultural, and multilingual cross-sectional study conducted during the initial phase of the COVID-19 pandemic (April-June 2020). The recruitment methodology and data collection procedures were reported previously. Informed consent was obtained from all participants before completing a 20-minute online survey via a secured Google platform. Recommendations from the Population Division of the United Nations Department of Economic and Social Affairs were followed to classify the 78 participating countries into seven geographical regions.

Intervention/Conditions

There was no intervention. The study was descriptive and correlational, examining naturally occurring psychological responses to illness perceptions toward COVID-19 in contexts of different public health policies and restrictions across regions.

Instruments

Participants completed a battery of standardized measures:

1. Mental Health Continuum Short Form for Adults (MHC-SF): 14 items on a 6-point Likert scale assessing emotional, social, and psychological well-being, providing a global mental health score.

2. Brief Illness Perception Questionnaire (IPQ): Items assessing perceived consequences ("How much does COVID-19 affect your life?"), timeline ("How long do you think COVID-19 will continue?"), concern ("How much worry does COVID-19 cause you?"), and emotional responses ("How does the pandemic affect you emotionally?"), with 10-point Likert scales.

3. Health Belief Model: 6-item measures evaluating perceived susceptibility (6-point Likert scale) and severity of COVID-19 (6-point Likert scale).

4. Brief Coping Orientation to Problems Experienced (COPE): 28 items assessing 14 coping strategies consolidable into four dimensions: social support (emotional support seeking, instrumental support seeking, religious belief), problem-solving (active coping, planning), avoidance (behavioral disengagement, self-distraction, substance use, denial, self-blaming), and positive thinking (humor, positive reframing, acceptance).

5. PsyFlex Scale: 6 items on a 5-point Likert scale assessing psychological flexibility, including contacting the present moment, defusion, acceptance, self-as-context, values, and committed action.

6. Prosocialness Scale: 6 items on a 5-point Likert scale assessing prosocial behaviors (sharing, helping, taking care of, and feeling empathic with others) engaged in during the COVID-19 pandemic.

Participants also reported sociodemographic characteristics (age, gender, marital status, education, employment, occupational health status), COVID-19-related measures (lockdown impact, financial situation, infection status), and the COVID-19 Government Response Stringency Index (OxCGRT) for each country.

Analysis

United Nations recommendations were followed to classify countries into seven geographical regions. Descriptive analyses and ANOVA tests were conducted to examine significant differences in main study variables across regions. Multiple-group structural equation modeling (SEM) analysis was performed using SPSS AMOS version 23.0 (IBM Corp., Chicago, IL, USA). The tested model was a mediation model examining whether four coping factors derived from COPE (social support seeking, problem-solving, avoidance, positive thinking) and two additional factors (prosociality and psychological flexibility) mediated the relationship between illness perceptions toward COVID-19 and mental health.

Measurement models for all latent variables were first established, and the full mediation model was tested in the total sample. A chi-square difference test was performed comparing an unconstrained model (no constraints specified) with a constrained model (equal parameters across subgroups) to determine cross-group invariance. Mediation effects were analyzed across all subgroups using bootstrapping method (5,000 replications) with 95% bias-corrected confidence intervals. A chi-square difference test was employed to determine cross-group invariance. Sociodemographic variables (age, gender, educational level, employment status) and OxCGRT Government Stringency Index scores were included as covariates. A two-tailed p-value < 0.05 was considered statistically significant.

Results

Descriptive Statistics

Of the 9,867 respondents who accessed the survey website, 9,565 provided complete data (completion rate 88.1-100% by region). The final sample included 9,130 participants from 21 countries across seven regions.

Participants were predominantly female (77.6%, range=70.5%-84.9% by region), middle-aged (55%, range=43.0%-64.1%), employed full-time (53.7%, range=42.2%-63.1%), and educated to tertiary level (66.9%, range=12.4%-34.0% with upper secondary education or below). Less than one-fifth were healthcare professionals except Western Europe (>30%). More than two-thirds attained at least tertiary education. When social distancing and isolation measures began (April-June 2020), 47.1% of participants stayed at home, but only 20.6% from Western Europe adhered to measures. Approximately one-third of participants (33.6%) reported financial situation deterioration, 1.5% were infected with COVID-19, 0.8% had infected partners, and 5.7% reported infected significant others. The mean OxCGRT Index score was lower in Eastern Asia (mean=59.34, SD=8.71) compared with other regions (mean range=67.63-79.76), indicating relatively less stringent COVID-19 precautionary measures implementation during the survey period.

Illness Perceptions, Coping, Prosociality, Psychological Flexibility, and Mental Health by Region

When compared with other geographical regions, analysis of variance followed by post-hoc comparisons showed that Eastern Asia (Hong Kong) participants reported the lowest mental health scores (mean=34.23, SD=12.54; mean difference [MD] range=-4.12 to -8.81, all p<0.001), psychological flexibility (mean=19.43, SD=4.02; MD range=-1.7 to -3.4, all p<0.001), and prosociality (mean=20.72, SD=3.93; MD range=-2.12 to -3.73, all p<0.001). Hong Kong also reported stronger perceptions of COVID-19 severity (mean=-14.55, SD=3.02; MD range=0.99-3.43, all p<0.001). Hong Kong achieved the highest scores in behavioral disengagement (mean=3.40, SD=1.26; MD range=0.32-0.84, all p<0.001) and self-blaming (mean=-3.46, SD=1.45; MD range=0.24-1.56, all p<0.001), implying tendencies to use maladaptive coping strategies. In contrast, Western Europe participants reported the highest scores in active coping (mean=6.11, SD=1.45; MD range=0.33-1.92, all p<0.001) and prosociality (mean=24.38, SD=3.94; MD range=0.52-3.71, all p<0.001).

Mental health scores across European regions (except Eastern Europe: mean=37.18, SD=14.09) were generally similar (mean range=41.29-43.31, SD range=12.98-14.09). All participants reported similar levels of social support seeking across European regions (except Eastern Europe). Similarly, Hong Kong participants reported social support seeking as a non-significant mediator in their sample (p=0.06), and prosociality as a significant mediator (beta=0.05, SE=0.01, p=0.016). Regional analysis also showed that Eastern Europe participants additionally demonstrated social support seeking as a mediator (beta=0.08, SE=0.03, p=0.005).

Model Testing and Multiple-Group Structural Equation Modeling Analysis

Similar to previous reports, measurement items corresponding to latent constructs were all adequately fitted to data representing the total sample. The hypothetical model was first tested in the total sample and demonstrated acceptable fit to data (χ²=1727.22, df=629, CFI=0.92, TLI=0.88, SRMR=0.05, RMSEA=0.04), supporting that this model could be retained for subsequent multiple-group SEM analyses. The chi-square difference test showed there was significant difference in model fit between the unconstrained model (no constraints specified) and constrained model (χ²=2188.75, Δdf=258, p<0.001), indicating parameter coefficients differed significantly across the seven subgroups.

The SEM model also demonstrated adequate fit to data (χ²=22386.96, df=4403, CFI=0.89, TLI=0.85, SRMR=0.05, RMSEA=0.02). Psychological flexibility was the only factor that significantly mediated the relationship between illness perceptions toward COVID-19 and mental health across all subgroups (beta range=-0.15 to -0.33, SE range=0.04-0.12, all p=0.001-0.021). Social support seeking showed significant mediating role across subgroups (beta range=0.06 to 0.08, SE range=<0.001-0.005, except Hong Kong sample [p=0.06] and North and South America sample [p=0.53]). Similarly, avoidance also demonstrated significant mediating role across subgroups (beta range=-0.05 to -0.32, SE range=<0.001-0.042, except Eastern Europe sample [p=0.07]).

No mediation was found for problem-solving (except Northern Europe sample, beta=-0.04, SE=0.01, p=0.009). In the Hong Kong sample, prosociality (beta=-0.05, SE=0.01, p=0.016) and psychological flexibility (beta=-0.15, SE=0.07, p=0.021) were core protective mediators of mental health. The Eastern Europe sample also showed similar coping patterns but additionally demonstrated social support seeking as a mediator (beta=0.08, SE=0.03, p=0.005). For each subgroup SEM, total variance explained by predictors ranged from 56% to 73%.

Discussion and Conclusions

This large-scale study provides evidence of how coping patterns and mental health outcomes differed across various geographical regions during the early phase of the COVID-19 pandemic. The multiple-group SEM analysis highlights the crucial role of psychological flexibility as the only robust factor that mediated the relationship between illness perceptions toward COVID-19 and mental health across all included geographical regions.

The findings suggest that despite differences in pandemic contexts, social situations, and health service capacities across geographical regions, psychological flexibility remained the only robust resilience factor against adverse mental health impacts arising from COVID-19. Notably, the study also found that avoidance showed a significant mediating role between illness perceptions toward COVID-19 and mental health, although it should not be considered simply as the inverse of psychological flexibility. As suggested by Dawson et al., avoidance behaviors are natural human responses to unknown threats, which can be adaptive in certain contexts (e.g., taking a break from the volume of COVID-19-related news that creates emotional disturbance), but could be a manifestation of psychological inflexibility if an individual fully engages in avoidance.

The significant mediating effect of social support seeking in the relationship between illness perceptions toward COVID-19 and mental health was consistent with recent evidence, supporting that increased social support has been found to protect individuals from developing mental health problems under COVID-19. Social support refers to a series of support measures accessible to an individual through social relationships with individuals, groups, or larger communities. In the literature, the protective benefits of social support on preventing mental health problem development under COVID-19 have been illustrated. Notably, the mediating role of social support seeking was not found among Eastern Asia (Hong Kong) participants, a result that can be explained by the norm in Eastern Asian culture that populations are less willing to seek explicit social support for dealing with stressful events. If the sample could include participants from Mainland China so as to increase representativeness under the Eastern Asia region, researchers might have been able to better examine whether social support could play a potential protective role in the adverse mental health impacts of COVID-19 across Western and Asian countries.

The mediating role of prosociality as hypothesized in this study was only partially supported, as such relationship was only found in Hong Kong and Eastern Europe samples. In the literature, studies have indicated that engaging in various forms of prosocial behaviors (i.e., helping for the benefit of others) would promote emotional well-being, empathy, and social consciousness, while such positive impacts could be brought through mechanisms via influencing oxytocin release and reward circuitry system in the brain. Furthermore, transcending self-interest to advance the welfare of others becomes an intrinsic motivation for adhering to public health measures against COVID-19 spread (e.g., physical distancing, face mask wearing, social isolation rules) to protect others from COVID-19 rather than oneself. It appears prosociality has not yet been studied and compared across multi-regional samples in the COVID-19 context, as well as outbreaks of other novel infectious diseases and disasters. This implies the need for future cross-cultural longitudinal studies to better understand the inter-relationships between prosociality and mental health, together with other known psychosocial and environmental factors of the pandemic.

The mediating role of problem-solving was not found across all studied regions except Northern Europe. Problem-solving is one of the adaptive coping strategies focusing on adopting practical steps to eliminate stressors or reduce their impacts. However, evidence regarding whether problem-solving significantly correlates with mental health outcomes in the context of the COVID-19 pandemic remains mixed. The non-significant result could be explained by the potentially uncontrollable spread of fatal COVID-19, the pandemic context in which people are vulnerable to loneliness, and no effective treatments and vaccines were available at the time of survey implementation. Many people might be triggered by a sense of insecurity and inadequacy, which could be a potential stressor, and went beyond the use of problem-solving as a coping strategy to manage their psychological difficulties.

This study has limitations. Since the online survey was administered during the early phase of the COVID-19 pandemic (April to June 2020) and most participating countries were in partial or complete lockdown, the study relied on convenience sampling where participant recruitment was mainly carried out through social media and various online media platforms. Therefore, the sample representativeness has been considerably skewed toward adult online and European countries (i.e., 68% of total sample). As Hong Kong was the only city out of other Eastern Asian countries or regions participating in the survey, our findings may have limited generalizability to other Eastern Asian countries or other non-Western regions. The convenience sampling method might not be able to reach those COVID-19 patients who have been hospitalized or are under treatment, and those who relied on self-selection and response bias should be taken into account. Additionally, when constructing and testing the mediating roles of coping, prosociality, and psychological flexibility accounting for the relationship between illness perceptions toward COVID-19 and mental health, we followed theoretical bases derived from the Common Sense Model of Self-Regulation by selecting and analyzing latent variables as predictors, mediators, and outcomes, hence using cross-sectional data means we are unable to draw robust conclusions regarding the directionality of the aforementioned constructs. In each studied region, variance in mental health contributed by psychological flexibility, prosociality, and various significant coping factors ranged from 56% to 73%, although there could be other explanatory variables, such as other coping factors and self-compassion resources, that had been missed in our study. Even though the model was adjusted for sociodemographic variables and OxCGRT indicators, the possibility of other contextual factors affecting one's mental health, such as race, ethnicity, COVID-19-related morbidity and mortality outcomes, as well as social welfare systems across countries, cannot be ruled out.

The important findings provide avenues for developing mental health interventions in navigating the current global health crisis. The findings indicate that people across the globe adapting to upcoming COVID-19 or post-COVID-19 situational challenges, our primary health care efforts should shift to focus on fostering psychological flexibility, whether in addressing mental health needs as they arise within an individual, equipping groups (e.g., health professionals) with skills that may foster resilience, or promoting psychological health in the broader population. One of the strategic objectives determined by the World Health Organization (WHO) Special Initiative for Mental Health is the objective of increasing the quality and affordable community-based mental health services for 100 million more people by 2023, so as to reduce health inequalities. Additionally, a recent report that summarized international experiences in the early mental health response to COVID-19 has found that telehealth may soon become a core component of mental health services. Hence, to maximize the reach of psychotherapeutic interventions targeting psychological flexibility, various remote formats, such as social media platforms, mobile applications, or videoconferencing, should be adopted.

Importance and Contribution

This study is significant for several reasons:

1. Multicultural Scope: One of the first large-scale studies examining psychological responses to COVID-19 across multiple geographical regions (7 regions, 21 countries, 9,130 participants), providing cross-sectional evidence of global patterns.

2. Identification of Robust Mediating Mechanisms: Consistently demonstrates that psychological flexibility is the only robust mediator between illness perceptions and mental health across all regions, identifying a key universal resilience factor.

3. Clinical Implications: Suggests that interventions focused on fostering psychological flexibility may be particularly effective in protecting mental health in global crisis contexts, informing development of more effective mental health interventions.

4. Transcultural Differences: Identifies regional variations in coping patterns (e.g., limited role of social support in Eastern Asia, role of prosociality only in Hong Kong and Eastern Europe), highlighting importance of considering cultural contexts in interventions.

5. Use of Rigorous Methodology: Employed robust multiple-group SEM analysis with data of established psychometric reliability (alphas=0.76-0.85, construct validity rs=0.68-0.82), demonstrating adequate model fit across regions.

6. Practical Recommendations: Provides clear recommendations for adaptation of telehealth services and remote formats to disseminate psychological flexibility interventions to global populations, aligned with WHO objectives.

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