A moderated-mediation model of fear of illness and subjective psychological well-being during COVID-19 pandemic

A sudden outbreak of diseases poses a serious threat to mental health. Relying on strengths might mitigate negative mental health outcomes and promote positive mental health. Prior research suggests a potential moderated mediation effect between fear of illness and subjective psychological well-being. Based on the Complete State Model and the Competence-Based Model of mental health, this study examined the relationship between fear of illness and subjective psychological well-being through perceived distress moderated by resilience in the context of COVID-19 pandemic. A cross-sectional survey using questionnaires was employed. Data were collected online from 384 participants ( 270 females and 114 males, age range= 15 to 29 years). The participants had indirect exposure to COVID-19 through information from the media. Results demonstrated that fear of illness signicantly predicts subjective psychological well-being both directly and indirectly. In addition, the moderated mediation effect of resilience was conrmed. Resilience moderated the indirect effect between fear of illness and subjective psychological well-being through perceived distress. The magnitude of the indirect effect was contingent on resilience. Further, the effect of perceived distress on subjective psychological well-being is weakened as the level of resilience increases. This study contributes theoretically to a better understanding of the salutogenic effect of resilience on positive mental health during a pandemic. Based on the ndings, implications and future directions are discussed. a group of four statements requiring the to describe their feelings item I I ill.” ndings of our study contribute to the understanding of the factors responsible for subjective psychological well-being during traumatic and adverse conditions. It has become evident that the level of subjective psychological well-being during pandemics accrues from fear of illness which increases perceived distress but is buffered by the presence of resilience. Interestingly, Charney (2004) emphasized that the fear experienced due to traumatic stress could be dealt with resilience. Our results conrmed that resilience is an important resource that acts in adverse life situations. Importantly, this study shows that persons high on resilience are not swayed by the traumatic experiences rather their well-being is harnessed. Further, resilient people do not succumb to adversity and are able to evolve out of it. Bolier et al. (2013) suggested that positive psychology interventions could be effective in reducing psychological distress and enhancing subjective well-being among the general population. These results reiterate the importance of building resilience to promote and maintain positive mental health and mitigate the effects of negative mental health.


Introduction
The current pandemic of novel coronavirus disease (COVID-19) is spreading and affecting people exponentially day after day. Novel diseases are traumatic as they give a sense of unpredictability, uncertainty, ambiguity, and a threat to life which triggers fear of illness (Vahedian-Azimi 2020). Extant literature reveals negative mental health outcomes are sequelae of exposure to traumatic events (Pine et al. 2005;Su and Chen 2015). Exposure to traumatic events can be direct or indirect. With the social disruption caused during lockdown to contain coronavirus, people increasingly relied on information related to coronavirus and pandemic from media (Laato et al. 2020). In fact, during the locked-down period, there was greater indirect exposure to the information related to infection. Otu et al. (2020) acknowledged that prolonged exposure to the information on COVID-19 has the potential to impact mental well-being.
Nevertheless, continuous exposure to COVID-19 related information has acted as a major stressor thus developing a fear of contracting an infection (Lin 2020). In addition, Duncan et al. (2009) assert that perceived vulnerability to infectious diseases is responsible for a spectrum of psychological responses. A growing body of empirical studies reveals that the information from media creates health related anxiety (Gao et al. 2020;Roy et al. 2020; Thompson et al. 2017). Due to the deadly nature of the virulent infection, the people are grappled with fear of death (Xiang, et al. 2020), getting infected, and being in the areas where others are tested positive Lin 2020). Fears pose a serious threat to our well-being, hence, cannot be left unattended (Pappas et al. 2009). Undeniably, the fear of illness may translate into a range of mental health outcomes.
During a pandemic, it is atypical to exhibit symptoms of negative mental health (Boyraz and Legros 2020).
In the grim situation of COVID-19, psychological distress might increase whereas well-being might decrease (Rashid and McGrath 2020). Hence, during pandemics along with mitigating the negative mental health, it has become necessary to build on the strengths to enhance positive mental health. Vahedian-Azimi et al. (2020) conveyed that COVID-19 is adversity which has a swingeing negative effect that can potentially spillover in the post-pandemic period. Given this, the researchers have expressed concern for an urgent need to minimize mental health issues (e.g. Kar et al. 2020;Satici et al. 2020;Thakur and Jain 2020). Furthermore, considering the immediate and long-term harmful effects of the pandemic it will be worthwhile to focus on the promotion of well-being (Yang and Ma 2020), and improvement of mental health (Vahedian-Azimi et al. 2020). However, the burgeoning literature shows that the majority of the research in the current pandemic has focused on the identi cation of the factors responsible for mental health problems (Boyraz and Legros 2020;Hiremath et al. 2020;Rahman and Jahan 2020;Thakur and Jain 2020). It is a vociferous call of the researchers (e.g. Chen et al. 2020;Mamun and Gri ths 2020) to identify preventive factors to curb negative mental health repercussions of the pandemic, which is still untapped. Therefore, the exploration of possible factors for the promotion of positive mental health needs more consideration during the acute outbreak of diseases.
Literature is replete with empirical studies carried out on the negative outcomes of the pandemic. With regard to positive mental health, a large and su cient amount of empirical evidence demonstrates that the COVID-19 pandemic has lowered subjective well-being (e.g., Ahuja et al. 2020;Blasco-Belled et al. 2020;Satici et al. 2020;Yildirim and Arslan 2020;Zacher and Rudolph 2020). So far, while the greater emphasis has been given to the pathogenic aspect, very little attention has been paid to the positive mental health and salutogenic factors. Moreover, studies assessing both psychological distress and psychological well-being in the same sample are scant (e.g., Jiang 2020; Paredes et al. 2020;Tecson et al. 2019). Nevertheless, the aforementioned studies revealing an inverse relationship between psychological well-being and psychological distress were carried out in different contexts, other than pandemics or outbreak of diseases.
Hence, the ndings though could set the ground for the need for measurement of both psychological wellbeing and psychological distress in the same sample but we fail to ascertain its relevance for pandemic-like situations. For this reason, the present study intended to ll these gaps and assess the indispensable role of resilience in enhancing subjective psychological well-being even when symptoms of psychological distress are evident. We propose that the relationship between fear of illness and subjective psychological well-being is moderated by resilience and mediated through perceived distress. The purpose of the present study is to understand the conditional indirect effect of fear of illness on subjective psychological well-being through perceived distress and to examine how salutogen resilience buffers this relationship (moderated-mediation model). In line with the Strength and Competence Based Model of mental health, and the Complete State Model, ampli cation of resilience is expected to mitigate the effect of perceived distress and increase one's subjective psychological well-being. The exploration of these linkages will help in understanding the relevance of each variable in designing protective and preventive interventions to combat COVID-19 and similar pandemics.
The contribution of this study lies in testing the applicability of Competence Based Model of mental health and Complete State Model in the context of COVID-19 pandemic. Further, it extends the Complete State Model (Keyes 2005) by including distress as a precursor of subjective psychological well-being. It clearly explains the distinctiveness of both constructs. In addition, it clearly spells out the requirement of focusing on maximizing positive mental health through the adoption of a preventive stance. It also provides evidence on the salutogenic effect of resilience thereby diminishing perceived distress and augmenting subjective psychological well-being which in turn is affected by the fear of illness.
In the following sections, we review the existing literature on fear of illness, subjective psychological wellbeing, perceived distress, and resilience. We then describe the method of the study and ndings. We conclude by discussing the implications of our work and offering suggestions for future research.

Complete State Model
Positive psychology holds that negative and positive outcomes co-occur. The Complete State Model (Keyes 2005) posits the presence of a high level of psychological well-being and low level of mental illness as important components of mental health which co-exist (Diener and Lucas 2000). Researchers argue that negative mental health and positive mental health are two distinct unipolar constructs which interact (Keyes 2005;Suldo andShaffer 2008). Further, Wine eld et al. (2012) opine that perceived distress and psychological well-being are not unidimensional and need to be measured separately. Consequently, it requires an assessment of both components of mental health so as to promote positive and prevent negative mental health outcomes. Psychological distress and subjective psychological well-being are indicators of negative and positive mental health respectively (Kane 2019;Suldo and Shaffer 2008). In this study self-perceived subjective aspects of both negative and positive mental health are studied.

Strength/Competence Based Model of Mental Health
In adverse life situations, it is important to face challenges and mitigate negative outcomes. During a crisis, the presence of negative mental health or outcomes cannot be ignored, thus requiring repair of damage to complement negative by building strengths (Luthans and Church 2002). Due to this reason, attention should be paid to positive mental health for it is relevant in the COVID-19 pandemic. Positive mental health is evident through subjective psychological well-being (Suldo and Shaffer 2008). The theoretical grounding for building on the inherent capacities of an individual to reduce suffering is provided by the strength/competence-based model of mental health (Southwick et al. 2014). Strengths act as salutogens and help in managing the demands of negative life events (Rashid and McGrath 2020). Possibly, resilience acts as a salutogen and maximizes positive outcomes. Resilience is an individual's capacity to adapt or recover from threatening or destructive forces (Masten 2001;Smith et al. 2008). Färber and Rosendahl (2018) a rmed that resilience can enhance positive mental health as it helps in adaptation to the stressors.
Moreover, resilience acts as a buffer to mental health problems. In line with the strength based approach, individuals with a higher level of resilience might experience better subjective psychological well-being irrespective of the extent of the perceived psychological distress (Rashid and Seligman 2018).
Fear of Illness as Predictor of Perceived Distress and Subjective psychological Well-being Huppert (2009) proposed that the same factors might act as precursors for both positive and negative mental health. There is loads of evidence to suggest that fear of illness predicts negative and positive mental health. More recently, in the context of the COVID-19 pandemic, the positive relationship between fear of illness and psychological distress has become apparent (Ahorsu et al. 2020;Harper et al. 2020;Newby et al. 2020;Parlapani et al. 2020;Satici et al. 2020). Further, Shigemura et al. (2020) found an association between heightened fear of illness and the potential development of mental health disorders even among healthy people during the current pandemic. It could be said that due to increased fear of illness there is potential to see deterioration in mental health, predisposing the general population to develop symptoms of psychological distress. The fear of illness can also be a challenge to maintain positive mental health during adversity. In a study conducted on 1772 Turkish adults during the COVID-19 pandemic, Satici et al. (2020) not only reported a signi cant positive relationship between fear of COVID-19 and indicators of psychological distress namely depression, anxiety, and stress but also found that the fear of COVID-19 negatively predicted well-being. Empirical ndings show that with the fear of COVID-19, well-being was inversely related (Ahuja et al. 2020;Amin, 2020;Hsing et al. 2020). Sera ni et al. (2020) con rmed that fear of illness deteriorates subjective psychological well-being. Thus, it appears that fear of illness is a precursor of positive and negative mental health. Based on the empirical evidence and theoretical support given above, the following hypotheses have been framed: H1: Fear of illness relates negatively to subjective psychological well-being. Nayar 2020). The ndings of these studies provide an insight that indirect exposure to traumatic life situations develops signs of psychological distress even in the general population (Hsing et al. 2020;Pine et al. 2005). Hence, indirect exposure to COVID-19 related information through media increases perceived distress which in turn might affect subjective psychological well-being. The relationship between perceived distress and psychological well-being has been supported by previous researchers. Jiang (2020); Meng and D'Arcy (2016); Mankiewicz et al. (2013); Tecson et al. (2019) have provided empirical evidence that perceived psychological distress is signi cantly and inversely related to psychological well-being. Therefore, the aforementioned studies show that psychological distress has a negative impact on subjective psychological well-being.
Previous empirical studies support the mediating role of psychological distress between fear of illness and subjective psychological well-being. As emerged by the recent literature, depression, anxiety, and stress which are the symptoms of negative mental health, play a mediating role in the relationship between the fear of COVID-19 and life satisfaction (Satici et al. 2020). In addition, the fear of COVID-19 was shown to increase negative mental health outcomes and to decrease positive mental health. Based on these ndings the following hypothesis has been framed: H3: Perceived distress mediates the relationship between fear of illness and subjective psychological wellbeing.
Perceived Distress and Subjective Psychological Well-being: The Moderating Role of Resilience According to Huppert (2009) psychological well-being tends to decline in case an individual remains in a negative state for a long period of time. Hence, understanding the pathways to enhance well-being becomes important especially when positive and negative mental health share the same drivers. Resilience has been researched extensively in the context of stressful and adverse life situations (Polizzi et al. 2020). As per Bakioğlu et al. (2020) during COVID-19, the protection of mental health and enhancement of psychological resilience is of prime importance. Researchers propose an exploration of the moderating role of resilience between adverse conditions and positive mental health (Min et al. 2015). Researchers hold that resilience gets activated in adversity (Bonanno et al. 2008;Southwick et al. 2014) and facilitates coping (Connor and Davidson 2003). Further, Polizzi et al. (2020) argued that people endowed with resilience inevitably are able to survive and overcome the fear of being pulverized and persevere. Hence, resilience is associated with both positive and negative mental health (Shapero et al. 2019;Srivastava 2011). Resilience has revealed to result in lowering symptoms of negative mental health (Tecson et al. 2019). Further, researches indicated that resilience enhances positive mental health (Cuhadar et al. 2016;Vieselmeyer et al. 2017) in particular subjective well-being (Satici 2016;Tecson et al. 2019;Yildirim and Arslan 2020) and it acts as a protective factor (Sera ni 2020). Based on the above discussion the following hypothesis has been framed: H4a: Interaction of perceived distress and resilience has a positive impact on subjective psychological wellbeing.
Presence of resilience during adverse life situations acts as a salutogen and helps in coping with the stressors thus diminishing negative consequences so that positive mental health improves. It could be said that, during pandemics activation of resilience, is the conditional factor that affects the mediated relationship between fear of illness and subjective psychological well-being. In the presence of high resilience, the effect of mediator perceived distress gets weaker between the relationship of fear of illness and subjective psychological well-being. Therefore, resilience may in uence the mediated relation between perceived distress and subjective psychological well-being. Hence, we propose that: H4b: The indirect relationship between fear of illness and subjective psychological well-being via perceived distress is moderated by resilience, such that the relationship is weaker with increasing levels of resilience.
By integrating mediation and moderation relationships, we propose a moderated mediation model. As demonstrated in Fig.1, in our model resilience moderates the path from perceived distress to subjective psychological well-being in a mediated relationship. So, in the integrated model, we shall be evaluating the indirect effect of the interaction of perceived distress and resilience on subjective psychological well-being in the mediated relationship between fear of illness and subjective psychological well-being.

Sample and Data Collection
The cross-sectional survey was conducted online after the continuous nation-wide lockdown in India. Data were collected by sending a survey link created in 'Google forms' via social media. The survey included demographic pro le, details of exposure to COVID-19 related information through the media, and a battery of questionnaires. Con dentiality, anonymity, and no potential threat of participation was assured at the outset.
Voluntary participation was sought and informed consent was obtained electronically. Through snowball sampling, 450 prospective participants in the age range 15 to 29 years (youth) were contacted in Jammu (India) of which 432 participants responded to the survey with an 88.89 percent response rate. Additionally, 48 respondents gave unengaged responses, therefore were not retained for further analysis. Hence, the nal sample size of 384 respondents.
Using 'G*Power 3.1.9.2' (Faul et al. 2007) the minimum sample size required based on statistical power to test the moderated mediation model with three predictors was calculated. It suggested that we required a minimum sample size of 89, with a medium effect size (f 2 = 0.15) (Cohen 1988), the probability of error=0.05 at the 95 percent signi cance. Therefore, given that our nal sample size was much higher than 89, the power value of this study exceeded 0.95. Hence, it could be concluded that the sample of 384 was adequate for the PLS-SEM based study.

Measures
Fear of illness. This construct was adopted from the Short Health Anxiety Scale (SHAI) (Alberts et al. 2011).
The construct fear of illness comprises of ve items (item 5, 8, 9, 11, 12) of the original 18-item SHAI (Salkovskis et al. 2002). The items consist of a group of four statements requiring the respondent to describe their feelings over the past six months. Items are scored from 0 to 3. A sample item is "I never think I have a serious illness; I sometimes think I have a serious illness; I often think I have a serious illness; I usually think that I am seriously ill." Cronbach alpha .726 was obtained for the construct.
Perceived distress. Six negatively worded items (1, 2, 3, 6, 9, 10) to measure perceived distress (Hewitt et al. 1992) were borrowed from the Perceived Stress Scale (Cohen et al. 1983). The scale applies to the ongoing life conditions (Cohen and Williamson 1988). The responses are based on the feelings and thoughts in the last one month. Items are scored on a 5-point Likert scale, from 0 to 5 ('never' to 'very often'). For example, "In the last month, how often have you been upset because of something that happened unexpectedly?" The Cronbach's alpha obtained for this construct was .809.
Subjective psychological well-being. The World Health Organization Well-Being Index (WHO-5 Well-being Index; Staehr 1998) is a measure of subjective psychological well-being. The scale assesses the hedonic aspects of psychological well-being. The ve items of the scale are on 6-point Likert scale ranging from 0 to 5 ('not present' to 'constantly present'). Positively worded ve items in this scale cover positive mood, vitality, and general interest; such as "I have felt cheerful in good spirits." The Cronbach alpha reliability coe cient .836 was calculated for the scale in this study.
Resilience. The Brief Resilience Scale (BRS) consists of six items measuring trait resilience and assesses an ability to bounce back after exposure to stress (Smith et al. 2008). The items are scored on a 5-point Likert scale, ranging from 1 to 5 ('strongly disagree' to 'strongly agree'). A sample item is "I tend to bounce back quickly after hard times". Cronbach alpha reliability for the six items measuring resilience was .827.
To identify the factor structure of borrowed items for the two constructs, fear of illness and psychological distress, exploratory factor analysis (EFA) was used. The detailed results are given in Table1 EFA was done on the data collected from 100 respondents separately. Kaiser-Meyer-Olkin (KMO) value was found to be greater than the threshold .50 (Hair et al. 2010). This indicated the adequacy of the sample for further analysis. As expected, the items loaded on a single factor 'fear of illness' comprising ve items (Alberts et al. 2011). Further, six items of Perceived Stress Scale also converged under one factor 'perceived distress'. Therefore, these items in two constructs were used for the nal data collection. In the last month, how often have you been upset because of something that happened unexpectedly? .719 In the last month, how often have you felt that you were unable to control the important things in your life? .674 In the last month, how often have you felt nervous and "stressed"? .762 In the last month, how often have you found that you could not cope with all the things that you had to do? .602 In the last month, how often have you been angered because of things that were outside of your control? .640 In the last month, how often have you felt di culties were piling up so high that you could not overcome them? .699

Sample Descriptive
The sample comprised of 270 females (70.31 %) and 114 males (29.68%). The age ranged from 15 to 29 years (M = 24.39, SD = 3.33). This study was carried out in the context of COVID-19. The participants provided information on media exposure.  This con rms that during the lockdown, participants were continually seeking COVID-19 related information from media through various sources. The reliance on the sources not considered to be authentic and the frequency of seeking information have exposed them to a lot of misinformation, and bad news related to COVID-19. This might have been overwhelming and hence the development of fear of illness.

Data Analysis
Using SPSS version 23 the exploratory factor analysis and descriptive analysis were performed. Since the current study aimed at theory building and prediction of endogenous variables, the partial least squares structural equation modeling (PLS-SEM) technique was applied (Hair et al. 2014) to test the research model.
Moreover, the use of PLS-SEM is appropriate as latent variable scores were analyzed for determining predictive relevance (Hwang et al. 2020). The two-stage approach for analysis (Hair et al. 2017) was followed. Data were analyzed using the 'Smart PLS software version 3.3.2' . Further, for the assessment of moderated mediation, PROCESS for SPSS was used (Hayes 2017).

Common Method Bias
Before testing the model, common method bias (CMB) for all the constructs was checked. As recommended by Kock (2015) for examining CMB in PLS-SEM, the variance in ation factor (VIF) was calculated through the full collinearity test for all latent variables in the model. Table 3 shows, full collinearity VIFs. The full collinearity VIF values for the constructs in the model in this study were below threshold 3.3 (Kock 2015). Also, the Harman Single Factor (Podsakoff et al. 2003) largest variance was 24.063% which was lesser than 50%. Hence, it con rms no CMB in this study and ascertains there is no possibility of misleading results.

Measurement Model
The constructs in our model are rst-order and re ective. The convergent validity was evaluated for the reliability of items and constructs. We looked into indicator loadings, composite reliability (CR), Dillion-Goldstein's rho (ρA), and average variance extracted (AVE) (see Table 3). Hair et al. (2017) has recommended 0.70 as the threshold value for indicator loadings. However, items with outer loadings between 0.40 and 0.70 can be retained and are considered for deletion if it enhances AVE so that the minimum criterion of 0.50 is achieved (Hair et al. 2010). We retained all the indicators with loadings within a speci ed range as AVE was above the threshold (Hair et al. 2014), except for FOI2 (Item 8 of the original SHAI) which was deleted due to low loading. As suggested by Hair et al. (2014), Cronbach's alpha being too conservative was not considered in the evaluation of internal consistency. Raykov (1998) recommended the evaluation of composite reliability (CR). As per Hair et al. (2017), CR between 0.60 and 0.70 is acceptable in exploratory research. The CR for all the constructs of the study is above 0.80 which is satisfactory (Hair et al. 2014). However, CR is considered liberal. Dillion-Goldstein's rho (ρA) is the exact measure of construct reliability (Dijkstra and Henseler 2015). In our measurement model, ρA values are within the acceptable range. This established the internal reliability of the measurement model.
In addition, convergent validity was assessed by examining AVE which should be higher than 0.5 (Hair et al. 2014). Table 3 indicates that the convergent validity was achieved with AVE more than the threshold value 0.50 (Hair et al. 2017).  . This established discriminant validity among all the constructs in the model. All the constructs in the model are distinct from each other.

Structural Model and Hypotheses Testing
In the next stage of PLS-SEM, structural model results were assessed. It requires testing for the collinearity issues, structural relationships between constructs. Additionally, the model's in-sample predictive accuracy and model's out-of-sample predictive power is established (Shmueli et al. 2019).
First, the value of inner VIF was assessed. VIF should be between 0.20 and 5.00 (Hair et al. 2014). VIF values beyond 3.33 (Diamantopoulos and Sigouw 2006), and within 3 to 5 means collinearity issues (Mason and Perreault Jr 1991). Based on the inner VIF values in Table 5, all the values for the current model meets the aforementioned criteria. Hence, our model is free of collinearity issues.
Next, the signi cance of the proposed hypotheses was assessed. Bias accelerated bootstrap re-sampling technique with 5000 resamples was applied. The results in Table 5 show that all the hypotheses for the study were supported. Further, the results demonstrate the signi cant negative and direct effect of fear of illness on subjective psychological well-being (H1) whereas the fear of illness has a signi cant positive effect on perceived distress (H2).
In addition, we validated the mediation hypothesis (H3) using the product coe cients approach (Hayes and Scharkow 2013). The indirect effect of fear of illness on subjective psychological well-being through perceived distress was found to be negative (Table 5). The bias-corrected bootstrap con dence interval at 95% showed mediation of perceived distress in the relationship between fear of illness and subjective psychological well-being. Furthermore, the results con rm a stronger direct effect than the indirect effect.
Next, for the model's in-sample predictive accuracy (Dolce et al. 2017) coe cient of determination (R 2 ) for endogenous constructs was examined. R² value of 0.100 and 0.298 was obtained for perceived distress and subjective psychological well-being, respectively. 29.8% variance of subjective psychological well-being was jointly explained by fear of illness and perceived distress. The R² value 0.2, as advocated by Rasoolimanesh et al. (2017), is high in behavioral sciences research. However, R² of perceived distress also establishes substantial predictive accuracy. Next, effect size (f 2 ) for the signi cant path coe cients were considered (Table 5). f 2 value of 0.35, 0.15, and 0.02 re ects large, medium, and small effect size respectively (Cohen 1988). In explaining perceived distress and subjective psychological well-being, fear of illness indicated a small effect size. In producing R² of subjective psychological well-being, perceived distress showed a substantial effect. Finally, predictive relevance of the model for the endogenous construct was evaluated using Stone-Geisser's Q² (Geisser 1974;Stone 1974). Blindfolding with omission distance D=7 obtained Q 2 value for psychological well-being (0.173) and perceived distress (0.048). Q 2 value is to be higher than zero (Hair et al. 2014). This establishes predictive relevance for both endogenous constructs (Fornell and Cha 1994). Su cient predictive relevance for endogenous constructs in the model was established.    (Table 6). Therefore, the model has a medium out of sample predictive power.
The results re ect the indirect effect of fear of illness on the subjective psychological well-being through perceived distress. Next, the conditional process model was applied in which the mediation model was extended with the moderation of resilience on the relationship between perceived distress and subjective psychological well-being (Andrew Hayes Process Model No. 14). The interaction of perceived distress and resilience is signi cantly predicting subjective psychological well-being (Table 5). Therefore, we can conclude that resilience moderates between perceived distress and subjective psychological well-being relationship. Hence, the proposed moderating hypothesis 4a stands accepted. Subsequently, the index of moderated mediation was calculated to evaluate the conditional process (Hayes 2015). The calculated index came out to be 0.027, Boot SE = 0.014 with (95% BCa CI:0.001 to 0.056). As the null of zero does not fall between con dence interval, we infer that the indirect effect is conditional on the level of resilience. The result supports the moderated mediation hypothesis (H4b). Hence, resilience signi cantly moderated the indirect effect of fear of illness on subjective psychological well-being. Having established the existence of moderated mediation, the spotlight analysis was conducted next (Spiller et al. 2008). Table 7 shows all three indirect effects for subjective psychological well-being with low, medium and high resilience groups were negative and signi cant as the con dence interval does not include zero. Further, pairwise contrasts were also signi cant indicating that the indirect effects were conditional on the level of resilience. This leads to the conclusion that the fear of illness lowers subjective psychological well-being via perceived distress and the in uence of the mediator is reversed with an increase in subjective psychological well-being due to the increment of resilience. In addition, Fig. 2 shows that the slopes become less negative as we move from low to high resilience. Overall, these results support the conditional effect of the indirect effect of fear of illness on subjective psychological well-being.

Discussions
The COVID-19 pandemic has affected the mental health of people across the world. With the outbreak of COVID-19, many studies have been carried out to assess the negative and positive mental health outcomes. This study highlights the process that weakens the negative relationship between fear of illness and subjective psychological well-being through resilience (moderator) and perceived distress (mediator) thus enhancing subjective psychological well-being. To our knowledge, this is the rst integrated moderated mediation model which has explained the process through which subjective psychological well-being is promoted. The present cross-sectional study has investigated the following empirically during the COVID-19 pandemic: 1. The direct effect of fear of illness on subjective psychological well-being and perceived distress.
2. The mediating role played by perceived distress in between fear of illness and subjective psychological well-being.
3. The moderating role played by resilience in between perceived distress and subjective psychological well-being relationship.
4. The moderated mediation of resilience between fear of illness and subjective psychological well-being relationship through perceived distress.
Results from the current study show the direct effect of fear of illness on subjective psychological well-being. The results of this study are consistent with previous evidence indicating the association between fear of illness and subjective psychological well-being (Amin 2020;Ahuja et al. 2020;Blasco-Belled et al. 2020;Paredes et al. 2020;Satici et al. 2020;Sera ni et al. 2020). Hereby, these results suggest that due to fear of illness perceived subjective psychological well-being decreases. We found that perceived distress was predicted positively by fear of illness, which is in line with previous studies showing that negative mental health outcomes increase and symptoms of distress are experienced during an outbreak of diseases (Hsing et al. 2020;Newby et al. 2020;Parlapani et al. 2020;Satici et al. 2020). This could act as a challenge in coping up with the adversity and pose a threat to positive mental health. Prior research demonstrates the negative effect of perceived distress on subjective psychological well-being (Jiang 2020;Meng and D'Arcy 2016;Tecson et al. 2019).
Fear is the prominent reaction to the pandemic (Ahorsu et al. 2020). With the lockdown, people spent time in the home but got exposure to pandemic through media. Thus, information on COVID-19 might have acted as a stressor resulting in fear of contracting illness (Lin 2020). Fear underlies all mental health problems (Polizzi et al. 2020). In the absence of any concrete evidence, it is all too apparent to overestimate, be unnerved, experience discomfort, and jump to extreme negative conclusions. Furthermore, exposure to unveri ed information is likely to exacerbate the mental health rami cations (Xiang et al. 2020). Notably, it is well established that the unchecked oating of rumors and inaccurate information owing from social media (Cinelli et al. 2020), blizzard of bad and fake news make people conscious of the looming appalling dangers (Torales et al. 2020;Kumar and Nayar 2020). Indeed, this creates a feeling of trepidation. Hence, due to apocalyptic views and irrational fear of illness people during pandemics are more prone to perceive distress. In the current pandemic, the risk of spread of infection, lethality, coupled with sudden lockdown has predisposed people to develop psychiatric disorders (Hiremath et al. 2020;Kumar and Nayar 2020;Satici et al. 2020). Albeit the passive stance with the feeling of helplessness has developed in the crevices of mind, making the people accept that they cannot control the virus and save themselves from any harm. For such people, if timely preventive steps are not taken, symptoms of psychological distress might develop signifying the possible development of psychiatric conditions.
The study ndings revealed that the effect of fear of illness on subjective psychological well-being is mediated by perceived distress. Perceived distress predicts subjective psychological well-being (Meng and D'Arcy 2016). The study ndings con rm the negative indirect effect of fear of illness on subjective psychological well-being. It implies subjective psychological well-being further deteriorates when fear of illness results in psychological distress. Recent studies have indeed reported psychological distress within the context of the COVID-19 pandemic (Boyraz and Legros 2020;Wang et al. 2020). During challenging times, these symptoms might be exacerbated. It is a matter of high concern and it cannot be left ignored. Furthermore, failure to implement timely measures and handle perceived distress might give rise to numerous other negative mental health outcomes even in post COVID-19 period.
Finally, this study revealed that resilience moderates the mediated relationship between fear of illness and subjective psychological well-being. These results corroborate previous empirical data on the role of resilience as a moderator of negative outcomes after exposure to stressful events. The interaction of perceived distress with resilience enhances subjective psychological well-being. This study has garnered more evidence in support of the protective function of resilience. Resilience has an inverse relationship with psychological distress and a positive relationship with various measures of subjective well-being such as happiness, quality of life, and life satisfaction (Tecson et al. 2019). With the introduction of resilience, the effect of perceived distress relinquishes. It could be said that resilience enables individuals to regulate the perceived distress in adversities. Hence, it helps in coping and diminishes perceived distress and enhances subjective psychological well-being especially during adverse life situations which act as a major threat to mental health.
Our study demonstrates that both indirect and direct relationship is signi cant and also it is conditional on resilience level. It could be said that resilience buffered the negative effect of fear of illness through perceived distress on subjective psychological well-being. Hence, in the presence of resilience, the perceived distress resulting from the fear of COVID-19 fails to further lower the positive mental health. The psychological distress fails to have any deleterious effect as resilience fosters psychological well-being.
Furthermore, positive mental health is attained as people might end up exhibiting better condition than the one experienced prior to exposure to trauma (Southwick et al. 2014). This outcome corresponds well with the Strength Model of positive psychology. Resilience is a strength (Färber and Rosendahl 2018) which contributes to enhancing well-being and mitigating the negative mental health outcomes (Tecson et al. 2019;Rashid and Seligman 2018;Yildirim and Arslan 2020). In adverse life circumstances, resilience acts as a protective agent hence the positive outcomes (Bonanno 2004;Nishikawa 2006). Resilient people can cope with the stressors during adversity (Connor and Davidson 2003). Therefore, in the face of adversity, it is possible to have positive outcomes.
The ndings of our study contribute to the understanding of the factors responsible for subjective psychological well-being during traumatic and adverse conditions. It has become evident that the level of subjective psychological well-being during pandemics accrues from fear of illness which increases perceived distress but is buffered by the presence of resilience. Interestingly, Charney (2004) emphasized that the fear experienced due to traumatic stress could be dealt with resilience. Our results con rmed that resilience is an important resource that acts in adverse life situations. Importantly, this study shows that persons high on resilience are not swayed by the traumatic experiences rather their well-being is harnessed. Further, resilient people do not succumb to adversity and are able to evolve out of it. Bolier et al. (2013) suggested that positive psychology interventions could be effective in reducing psychological distress and enhancing subjective well-being among the general population. These results reiterate the importance of building resilience to promote and maintain positive mental health and mitigate the effects of negative mental health.
Acute adversity sets in temporary dysfunction and a person experiences negative mental health outcomes.
The consequences of COVID -19 that are to be handled leave people puzzled. Exposure to several challenges during the prolonged period of COVID-19 might evoke negative perceptions making the person experience negative emotions such as fear of illness hence vulnerable to develop negative mental health. Further, positive mental health re ects positive adaptation and negative mental health outcomes are maladaptive.
However, not necessarily every person exposed to acute and chronic adversities develop psychiatric illnesses. Strength such as resilience helps in coping up successfully with stressors and thus enables enhanced well-being (Smaldone and Cullen-Drill 2011). Furthermore, it con rms the possibility of exhibiting and promoting positive mental health in an individual during the ongoing pandemic.
Therefore, it could be said that adverse life situations such as a sudden outbreak of diseases affect the mental health of the people even when they are not exposed to it directly. The fear of illness or contracting infection might arise through constant exposure to the information related to the disease. The fear of illness has a propensity to affect both positive and negative mental health. If timely measures are not taken to prevent the negative mental outcomes and mitigate its occurrence then it might further affect the subjective psychological well-being. The level of resilience is important for how well an individual copes with stress exposure. In terms of COVID-19 as a stressor, persons high on resilience are less likely to have poor mental health compared to those with low resilience factors.

Theoretical Contributions
First, the ndings of our study are in alignment with the Competence-based Model of mental health proposed by positive psychology. Positive psychology demands a shift from a de cit-based model to a healthpromoting model that relies on protective functions for the promotion of positive mental health. Hence, the moderating role of resilience is in con rmation with the Strength Model which focuses mainly on the building of strengths and promotion of positive mental health. Resilience acts as a salutogen that mitigates the effect of perceived distress and increases subjective psychological well-being.
Second, it contributes to the Complete State model which emphasizes an assessment of positive and negative mental health simultaneously. The ndings of the current study reveal that perceived distress acts as a mediator between fear of illness and subjective psychological well-being. The perceived distress acts as an antecedent of subjective psychological well-being. Hence, researches must include indicators of both positive and negative mental health in an attempt to know about complete mental health.

Practical Implications
The speci c ndings have implications for counseling. First, our ndings suggest that resilience could serve as a buffer for people experiencing the signs of psychological distress due to the fear of illness during COVID-19 pandemic. In other words, resilience can prevent the development of psychiatric conditions during adverse life circumstances and can improve well-being. Second, the role played by resilience is of vital importance. Therefore, efforts aimed at enhancing resilience could accentuate levels of subjective psychological well-being. Thirdly, the ndings of the present study may be of relevance when studying the importance of resilience during a national and global crisis for developing preventive actions. In the context of pandemics characterized by sudden changes, abound by stressors, building resilience is important to attain positive mental health. Fourthly, prophylactic measures are desirable during prolonged adversity to combat the mental health problems arising due to exposure to media.

Limitations and Future Studies
There are some limitations in this study which future research could address.
Firstly, the study is cross-sectional in nature. A longitudinal study should be conducted in the future to bring out the long-term effects of resilience as a protective factor in the maintenance of mental health. We need to follow people over time to ascertain the relevance of resilience in post COVID-19 period as well as during the prolonged period of the ongoing pandemic.
Secondly, The current study is limited to a snowball sample of youth from the general population. Due to the online mode of administering questionnaires via social media children and the elderly were not contacted. The representation of a speci c age group may have affected the results. For generalizing the current ndings, studies are to be conducted on the representative samples of diverse age groups in the general population.
Thirdly, the results of this research, indicated R 2 of 0.200 for subjective psychological well-being, suggesting fear of illness, perceived distress and resilience explained 20% variance in subjective psychological wellbeing. This means, 80% variance in subjective psychological well-being is explained by factors that are not in the model. Future studies may explore the role of other variables that would act as protective factors and facilitate coping during adversities.
Fourthly, although fear of illness was assessed, our ndings bolster the suggestion that exposure to information about the pandemic through media is an important purveyor of mental health. Future research may wish to explore the extent of the impact of exposure to information from media on fear of illness and mental health.
Lastly, the current study underscored the augmentation of resilience in the promotion of positive mental health and prevention of negative mental health. Thus, well-designed intervention studies are needed to determine the e cacy of resilience in bringing about desirable outcomes in adverse life situations.

Conclusions
The study of the moderated-mediation resulting in enhanced psychological well-being seems timely and necessary within the context of the COVID-19 pandemic. Our ndings add to the existing literature by explaining the mechanism which makes it possible for an individual to remain unscathed even when distress is perceived especially during pandemics. In the current study, we have given due importance to both positive and negative mental health. Our ndings have provided an insight into the assessment of complete mental health. The results indicate that it will be bene cial to apply interventions to build resilience within the context of pandemics and similar adverse life situations. However, the interventions to build resilience for the promotion of positive mental health that might be given in the ongoing traumatic phase of COVID-19 or similar type of pandemics are yet to be tested and tried.

Declarations
Con ict of Interests: The authors declare that they have no con ict of interest.
Availability of data and material: Not applicable.