The authors have declared that no competing interests exist.
Korea failed in its risk communication during the early stage of the Middle East Respiratory Syndrome (MERS) outbreak; consequently, it faced difficulties in managing MERS, while disease-related worry increased. Disease-related worry can help disease prevention and management, but can also have a detrimental effect. This study measured the overall level of disease-related worry during the MERS outbreak period in Korea and the influencing factors and levels of disease-related worry during key outbreak periods.
The cross-sectional survey included 1,000 adults who resided in Korea. An ordinal logistic regression was performed for the overall level of MERS-related worry, and influencing factors of worry were analyzed. A reliability test was performed on the levels of MERS-related worry during key outbreak periods.
The overall level of MERS-related worry was 2.44. Multivariate analysis revealed that women and respondents w very poor subjective health status had higher levels of worry. Respondents with very high stress in daily life had higher levels of worry than those who reported having little stress. The reliability test results on MERS-related worry scores during key outbreak periods showed consistent scores during each period.
Level of worry increased in cases having higher perceived susceptibility and greater trust in informal information, while initial stage of outbreak was closely associated with that at later stages. These findings suggest the importance of managing the level of worry by providing timely and accurate disease-related information during the initial stage of disease outbreak.
Korea recently experienced an outbreak of Middle East Respiratory Syndrome (MERS). According to the Korea Center for Disease Control and Prevention (KCDC), 186 people were definitively diagnosed with MERS between May 20 and November 30, 2015; of those, 38 died from the disease. The people diagnosed with MERS consisted of 82 hospital patients, 65 family member or visitors, and 39 hospital workers. Moreover, 16,752 individuals were quarantined for infection management [
The Korea-WHO MERS Joint Mission determined that the MERS outbreak in Korea was due to initial response failure by the Korean government. The cause of this initial response failure was attributed a lack of transparent disclosure and timely information [
According to the Crisis and Emergency Risk Communication (CERC) guidelines from the US Center for Disease Control and Prevention (CDC), when a national crisis, such as infectious epidemic, occurs, the most important action is timely dissemination spread of information and communication. However, the Korean government was unable to disclose information immediately after the MERS outbreak, which resulted in outbreak spread and increased levels of worry about MERS among its citizens [
Disease-related worry plays an important role in disease management, especially with contagious disease management. Disease-related worry is an emotional response to a disease and it is known to have a positive effect on disease management by providing individuals with motivation to participate in health promotion activities [
Due to the government’s failure to share timely information in the early stage of the MERS outbreak in Korea, the outbreak increased worries among Korean citizens and presented difficulties in disease management. Therefore, in order to effectively manage future disease outbreaks, it is important to understand the levels of disease-related worry and its influencing factors. Moreover, assessment of the levels of disease-related worry by key outbreak periods may also inform effective intervention points.
However, virtually no studies to date in Korea have examined disease-related worry, particularly contagious disease-related worry, during disease outbreak and its influencing factors. To our knowledge, no study has investigated disease-related worry according to specific outbreak periods. Accordingly, the objective of the present study was to identify the overall level of MERS-related worry during the MERS outbreak period as well as the levels of disease-related worry during key MERS outbreak periods. Structure of the study is shown in
The participants in this study consisted of 1,000 adults more than 18 years old who resided in Korea. The sample was selected by proportional stratified sampling between panels of professional research agency (Research & Research Cooperation). For the representativeness, the sample proportion of was determined by sexual, regional, age population ratio in Korea. Anyone who submitted his or her E-mail address and reply 2–3 simple questions via website of our research agency could be a panel. The survey was conducted in an online format from August 24th, 2015 to September 11th, 2016.
This study received a review exemption from the institutional review board (IRB) of Seoul National University Hospital (IRB No.1508-064-694).
So the dependent variables in the study were the overall level of worry during the MERS outbreak and the level of worry during specific outbreak periods. The overall level of worry during the MERS outbreak was surveyed with a five-point scale, using the question (
Demographic variables for identification of participant characteristics included age, sex, education level, average income per month, type of medical insurance and occupation type. In addition, to assess the physical and mental status of the participants, self-rated health status, chronic disease status (hypertension, diabetes) and daily life stress level were surveyed (
A univariate analysis using t-test and one-way analysis of variance (AVOVA) was performed to examine the relationships between the overall level of MERS-related worry and each independent variable. Moreover, to control for confounding variables, a multivariate analysis was performed through an ordinal logistic regression. The reliability of the level of MERS-related worry by outbreak periods was analyzed via Fleiss Kappa and intra-class correlation (ICC). IBM SPSS Statistics for Windows, version 20.0 was used for all analyses.
The results of univariate analysis between the general characteristics of the participants and the overall level of MERS-related worry are shown in
Characteristics | N(%) | MERS |
P-value |
---|---|---|---|
Age (years) | |||
• <29 |
• 231(23.1%) |
• 2.45 |
0.322 |
Sex | |||
• Male |
• 520(52.0%) |
• 2.36 |
0.003 |
Self-rated health status | |||
• Very bad |
• 12(1.2%) |
• 1.92 |
0.002 |
Medical insurance | |||
• Medical aid |
• 76(7.6%) |
• 2.32 |
0.280 |
Education | |||
• Below high school graduation |
• 177(17.7%) |
• 2.32 |
0.088 |
Income (per month) | |||
• <$2,000 |
• 132(13.2%) |
• 2.32 |
0.072 |
Stress in daily life | |||
• Little |
• 21(2.1%) |
• 1.95 |
0.007 |
Chronic disease (HTN |
|||
• Not present |
• 828(82.8%) |
• 2.46 |
0.228 |
Job | |||
• Blue-collar |
• 220(22.0%) |
• 2.40 |
0.388 |
aMERS, Middle East Respiratory Syndrome
bHTN, Hypertension
cDM, Diabetes Mellitus
Ordinal logistic regression analysis results also revealed statistically significant associations with overall level of MERS-related worry with respect to sex, self-rated health status, and daily life stress, just as in the univariate analysis. Men showed lower odds ratios (ORs) than women. The group that responded as having ‘very good’ self-rated health status showed lower ORs than all other groups, except for the group that responded ‘very bad’. Moreover, the group that responded as having ‘little’ daily life stress showed lower ORs than the group that responded as having ‘very much’ daily life stress (
Characteristics | B(SE |
ORs |
P-value |
---|---|---|---|
Age (years) | |||
• <29 |
• 0.075(0.187) |
• 1.078 |
• 0.688 |
Sex | |||
• Male |
• -0.319(0.130) |
• 0.727 |
• 0.014 |
Self-rated health status | |||
• Very Bad |
• -0.195(0.622) |
• 0.823 |
• 0.754 |
Medical insurance | |||
• Medical aid |
• -0.287(0.237) |
• 0.751 |
• 0.226 |
Education | |||
• Below high school graduation |
• -0.140(0.258) |
• 0.869 |
• 0.588 |
Income (per month) | |||
• <$2,000 |
• -0.080(0.237) |
• 0.923 |
• 0.736 |
Stress in daily life | |||
• Little |
• -1.106(0.463) |
• 0.331 |
• 0.017 |
Chronic disease (HTN |
|||
• Present |
• 0.167(0.167) |
• 1.182 |
• 0.319 |
Job | |||
• Blue-collar |
• -0.154(0.174) |
• 0.857 |
• 0.379 |
aMERS, Middle East Respiratory Syndrome
bHTN, Hypertension
cDM, Diabetes Mellitus
dORs, Odds Ratios
eSE, Standard Error
The levels of MERS-related worry by MERS outbreak periods showed scores of 2.32, 2.45, 2.73, and 2.24 when the first patient with MERS had a definitive diagnosis (index case), the first patient with MERS died (first death), the number of patients continued to rise (increasing patients), and the MERS outbreak ended (end of outbreak), respectively (
Key periods | Levels of MERS-related worry | |||||
---|---|---|---|---|---|---|
1 | 2 | 3 | 4 | 5 | Average | |
Not worried | Very worried | |||||
Index case | 197(19.7%) | 395(39.5%) | 316(31.6%) | 75(7.5%) | 17(1.7%) | 2.32 |
First death | 165(16.5%) | 379(37.9%) | 326(32.6%) | 104(10.4%) | 26(2.6%) | 2.45 |
Increasing patients | 114(11.4%) | 290(29.0%) | 393(39.3%) | 159(15.9%) | 44(4.4%) | 2.73 |
End of outbreak | 246(24.6%) | 391(39.1%) | 262(26.2%) | 78(7.8%) | 23(2.3%) | 2.24 |
The scores from the levels of MERS-related worry by MERS outbreak periods were compared via a reliability test. Fleiss Kappa and intra-class correlation test results showed that worry scores from each period were statistically significantly consistent (
Coefficient | P-value | |
---|---|---|
Fleiss Kappa | 0.430 | <0.001 |
Intra class correlation | 0.689 | <0.001 |
The objective of the present study was to investigate the overall level of MERS-related worry among the Korean population during the MERS outbreak, its influencing factors, and levels of worry during key outbreak periods, in order to assist management of future disease outbreaks.
The mean overall MERS-related worry score was 2.44 points. According to a 2006 study by Chapman et al., when American college employees were surveyed during 2001–2002 regarding their worry about influenza, the level of worry ranged from 1.93 to 2.24 points, depending on whether the person had been vaccinated for influenza [
Until now, no precedent studies have reported on MERS-related worry. However, many precedent studies have investigated the level of worry during influenza A (H1N1) pandemics. As these studies used different instruments from the ones used in this study, it couldn’t be compared directly. However, the overall trend showed higher levels of worry than the MERS-related worry found in the present this study. In a study conducted in the Netherlands, a five-point scale was used to investigate the level of worry, just as that used in the present study [
Ordinal logistic regression was used to analyze the influencing factors of the overall level of MERS-related worry, revealing statistically significant results for sex, self-rated health status, and daily life stress. With respect to sex, men showed lower ORs than women, indicating higher level of MERS-related worry among women. This finding was consistent with the results of a precedent study [
The group that reported their health status to be ‘very good’ had lower ORs than all other groups, a finding that can be interpreted two ways. First, the group that responded as having very good self-rated health status had confidence in their physical health, thereby having a lower perceived susceptibility than the other groups. The second reason may be attributed to differences in the level of trust in informal information. According to a precedent study, having greater trust in informal information correlates with increased levels of disease-related worry [
The group that reported having very high daily life stress showed higher ORs than the group that reported having little stress. This suggests that the group with very high daily life stress was mentally vulnerable and more sensitive to the MERS outbreak.
Investigation of level of worry by key outbreak periods demonstrated that the level of worry increased from the point of the index case, to the first death, and to the period when the disease was spreading. The level of worry then decreased at the point of outbreak ending. The reliability test results showed statistically significantly consistent for scores from all four periods. This finding can be interpreted to mean that the level of worry in the initial stage was closely associated with the level of worry in the stages that followed.
Increase in the level of worry over time contradicts findings in other studies. According to a study from the Netherlands conducted during an influenza A (H1N1) pandemic, the level of worry was highest in the initial stage, after which the level decreased and was maintained at a consistently low level. A study from Hong Kong also indicated that the level of perceived worry was high initially, but continued to decrease thereafter. The reason for these somewhat conflicting results in comparison to precedent studies is because the influenza A (H1N1) outbreak was touted early on by the government as a very serious disease, which resulted in high levels of worry. However, as people gradually realized that the disease was not much different than any previous influenza outbreaks, the level of worry decreased accordingly [
Precedent studies on emerging respiratory infectious disease also emphasize the importance of formal outbreak prevention information. A 2010 study by Cowling et al. attributed the lack of risk communication as the reason why the initial perceived susceptibility in the population did not change even when the 2009 influenza A (H1N1) outbreak in Hong Kong continued to spread [
The public health implications of this study are as follows. It is effective to control outbreaks by lowering the perceived susceptibility and successfully controlling the spread of informal information in the early stage of the epidemic. Recent research has shown that the changes of spatial diffusion of disease predict an epidemic, so it can be using early warning indicators. Therefore, continual checking the spatial spread of disease at the every stage is helpful to disease-related worry intervention [
The present study had several limitations. First, the present study was a cross-sectional study; as such, it may contain recall bias, which can especially influence the level of MERS-related worry during key outbreak periods. Because the worry scores for the four different periods were surveyed simultaneously, approximately three months had elapsed from the time of the index case to when the survey was conducted; therefore, the levels of worry during the corresponding periods may not have been recalled accurately, thereby resulting in inaccurate responses. Future studies should conduct prospective surveys throughout the duration of infection outbreaks in order to more accurately assess the levels of disease-related worry during key outbreak periods. Second, emotional responses to epidemics can be assessed using various questions. Besides the experienced worry assessed in the present study, various other questions, including anxiety level, may offer a deeper understanding of the emotional responses to epidemics.
This study analyzed factors associated with level of worry during the MERS outbreak period. The factors that decreased the level of MERS-related worry were being men and having very good self-rated health status, whereas having very high daily life stress increased the level of worry. These findings were to suggest that the level of worry increased among those with higher perceived susceptibility and with greater trust in informal information. Moreover, with respect to the levels of worry according to MERS outbreak periods, the level of worry in the initial stage was closely associated with the levels during the stages that followed. This observation underscores the importance of managing the level of worry in the early stage of outbreaks through proper intervention. Therefore, for proper disease management, it is necessary to make efforts to reduce the level of perceived susceptibility by disseminating timely and accurate information on disease prevention measures and current status through formal routes in the early stage of the outbreak, in addition to reducing the level of worry in the early stage by blocking distribution of informal information. For this, it is helpful to outbreak control by publishing disease information at the appropriate time and distributing it to the community, and to educate each group about disease prevention in a personalized manner.
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We thank for the research agency (Research & Research Cooperation) that took the survey. And also thank for the people who took part in the survey.