Cyberchondria, Uncertainty, and Psychological Distress among Omanis during COVID-19: An Online Cross-Sectional Survey

Background: Frequent surng on the internet for self-diagnosis and treatment in association with quarantine during the COVID-19 pandemic leaves people with uncertainty and psychological distress. The aim was to explore the relationship between cyberchondria, psychological distress, and uncertainty in Oman. Methods: A descriptive correlational study was designed. Data was collected through an online survey from 393 Omani participants using the short-form version of the Cyberchondria Severity Scale, the Kessler Psychological Distress Scale, and the Intolerance of Uncertainty Scale. Descriptive and correlational analyses were conducted. Results: The majority of the participants were aged between 18-26 and 45-54 years (32.8% and 30.8% respectively). Almost three-quarters of the participants were female (n= 291, 74%) and half were single (n= 218, 55.5%). No signicant associations were found between cyberchondria and the socio-demographic factors or the COVID-19 status. However, signicant positive fair correlation was found between cyberchondriac experiences and psychological distress (r s =0.373), and cyberchondria and uncertainty (r s = 0.442). Conclusions: To the best of our knowledge, this study is the rst of its kind investigating the relationship between cyberchondria, physiological distress, and uncertainty in the Omani population. Policy makers and stakeholders are encouraged to facilitate the reporting and observation of accurate and up-to-date information distributed to the population to avoid misleading information, and thus reduce the distress and uncertainty related to cyberchondriac behaviors.


Background
With increased global health challenges and health illiteracy, individuals face new problems related to their health and the availability of the seemingly endless amount of internet-based information, with a possible increase in uncertainty, distress, and anxiety in relation to information-seeking behaviours. More people are using the internet as a source of knowledge about wellbeing. The estimated monthly retrieval of electronic health information for adults in the United States is 62%, making it the fth most popular online activity [1]. People seek the health-related websites for many reasons, such as learning about a particular disease and its treatment; comparing their prescribed treatment with others; exploring other higher-quality medication than that prescribed for them; shopping for non-prescription medicines and herbal remedies; and hunting for discounted products [2]. Nevertheless, people bene t from these interactive online services by joining therapy groups and chatting with those who are having similar symptoms to express feelings and share ideas [3]. While it is considered as a great technological bene t as well as a time-and money-saver, sur ng the internet for health-related information can have unfortunate consequences when it becomes the only source of diagnosis and treatment for individuals, increasing their anxiety about their health. The intensive or repetitive online searching for health information of particular real or imagined symptoms of illness is a new concept, known as cyberchondria, with potential negative psychological consequences for individuals [2,[4][5][6]. That is, when the individual looks on the internet for information related to their health concerns, this tends to increase their anxiety and distress [7]. A signature aspect of this disorder is compulsivity in the use of internet searching, which affects essential daily activities. It is understood that people with cyberchondria have limited health knowledge, leading them to seek information related to their condition and/or con rming their sickness.
As a result of extensive internet searching, they are overwhelmed by the quantity of information retrieved, increasing their psychological distress [4]. Another explanation is that there is a group of people who are subject to internet illness-related attentional bias in which they continue searching until they selectively nd themselves sick, which eventually increases their psychological distress. Cyberchondria can also be explained in the light of uncertainty. The in-depth searching and retrieval of a variety of health-related resources leave the individual with uncertainty and therefore more psychological distress [4]. Uncertainty pervades and motivates all practices relevant to healthcare. At its most basic, it is complexity of one type or another that promotes medical study, induces patients to pursue treatment, and promotes medical practice [4,8]. Meanwhile, social perception and confusion has been heightened by the increase in mainstream media reporting of medical controversies, from drug safety to brain tumour screening.
Uncertainty affects every part of patient treatment, including the history of collecting and understanding clinical symptoms, choosing a method of investigation, working out the factors of the differential diagnoses and determining the result of a condition [9,10].
Psychological distress is an important measure of mental health. It is de ned as a state of emotional suffering that has distinctive features, such as symptoms of depression and anxiety [11]. It is associated with several health problems like cardiovascular, endocrine, and gastrointestinal and arthritic diseases [12].
There is little literature exploring cyberchondria among people in the Middle East. However, with convenient access to the Internet, the availability of health-related information and the psychological distress associated with quarantine and the mysterious nature of COVID-19, the number of people with cyberchondria is likely to increase. Our aim is to examine the relationship between cyberchondria, physiological distress and uncertainty in Oman.

Data collection
A descriptive correlational study design was used to examine the relationship between cyberchondria, uncertainty, and psychological distress in Oman. A sample of 393 participants was recruited using a convenience sampling technique (non-probability sampling). With the aim of minimising the costs and time for the data collection, the researchers recruited the participants through social media. The sample consisted of those who met the eligibility requirements: (a) living in Oman, (b) willing to participate in the study, and (c) signing an informed consent for participating in the study.
Once ethical approval was obtained from all the required committees, the information sheet and survey questions were posted on social media platforms. The online survey, which was open throughout April 2020, took each participant about 20-25 minutes to complete.

Ethical considerations
Prior to data collection, ethical approval was obtained from the College of Nursing Scienti c Research and Ethics Committee, Sultan Qaboos University (Ref.nr.: CON/NF/2020/15). The survey page was introduced with a short description of the nature, objectives, methodology, and potential bene ts of the survey, ensuring the respondents' voluntary and con dential participation. By answering the survey, the participants gave their consent. No personal data was collected, so the participants' con dentiality was not an issue. All electronic data was saved on a password-protected computer, and only the members of the research team were able to identify the responses of individual subjects. The participants with COVID- 19 have not been reported in any other submission by this author team and to our knowledge not by anyone else.

Study Instruments
The researchers used a self-reporting questionnaire to measure the extents of the research phenomena, consisting of (1) demographic data; (2)  The short-form version of the Cyberchondria Severity Scale The CSS-12 is a brief, reliable, and valid tool to measure worry/anxiety attributable to excessive online health search [13]. The scale consists of 12 items that are rated on a 5-point Likert-scale ranging from 1 ("never") to 5 ("always"). An example item is "If I notice an unexplained bodily sensation, I will search for it on the internet." The CSS-12 scale demonstrated reliable internal consistency as stated by the authors, with higher scores indicating increased levels of awareness [13]. Permission to use the survey was obtained from the owner of the instrument prior to the data collection.

Kessler Psychological Distress Scale
The K10 scale is composed of ten questions concerning emotional states, measuring psychological distress. Each item has a response scale of ve levels, from 1 = "never" to 5 = "all of the time". The total score is the sum of the 10 questions, and a high score indicates a serious level of psychological distress. The scale demonstrates the strength of test-retest correlation coe cients, temporal stability, and internal consistency [14]. The survey is available in the public domain with permission to use if for non-pro t purposes.
Intolerance of Uncertainty Scale, short form This scale was developed by Carleton, Norton, and Asmundson (2007) to assess the responses of individuals to uncertainty and ambiguous situations. It consists of 12 items rated on a ve-point Likert scale from 1 (not at all characteristic of me) to 5 (entirely characteristic of me). Possible scores range between 12 and 60, with higher scores re ecting greater uncertainty. The scale demonstrated good validity and reliability (Cronbach's alpha is 0.85) [15]. Permission to use the survey was obtained in advance from the owner.

Statistical analysis plan
The data was downloaded from the Google forms in Excel format, then transferred to the Statistical Package for the Social Sciences (SPSS) program version 23 for the analysis. All variables, including age were on categorical level except for the total scores of the questionnaires (CSS-12, K10, and IUS-12). Means, standard deviations, percentages, and frequencies were used to describe the participants' demographic information. Independent t-test and Spearman correlation were used to draw conclusions. The statistical signi cance was set at p <0.05.
The Independent t-test was performed to explore whether there is a signi cant difference between the mean score of the cyberchondria experience as the dependent variable and selected sample characteristics as independent variables. The Spearman correlation coe cient was used to test for the bivariate relationship between the dependent variable cyberchondria experience and the dependent variables of experienced psychological distress, uncertainty, and hours spent sur ng the internet.

Discussion
The aim of this study was to investigate the relationship between cyberchondria, psychological distress and uncertainty among the adult population of Oman. Our results show no signi cant difference between the cyberchondria and the socio-demographic factors. However, there is a signi cant fair correlation between cyberchondria and psychological distress as well as uncertainty.
The relationship between cyberchondria and psychological distress has been studied previously, and our ndings are similar to those from other populations in the region. The most recently published study from Bahrain [16] showed that information-seeking behaviours through the internet caused moderate to severe anxiety problems in 18% of the participants during the COVID-19 pandemic. They further showed that the frequency of exposure to COVID-19 information was signi cantly associated with general anxiety disorders [16]. Although our sample answered questions about general health-seeking behaviours, our results show that cyberchondria is related to psychological distress. Regardless of the fact that cyberchondria is compulsive, reassurance often characterises online information-seeking behaviours [17].
Cyberchondria and uncertainty were found to have a fair association in our sample. No previous studies have investigated this relationship in the Middle Eastern context, although international studies have shown that inhibitory uncertainty has signi cant associations with cyberchondria dimensions [5]. Evidence for a unique relationship between the intolerance of uncertainty inhibitory factors and mistrust of medical professionals, which was interpreted as a cyberchondria-relevant construct [18]. Thus, the relationship between cyberchondria and uncertainty is an important aspect to consider when encountering anxious or worried patients in clinical settings. Healthcare providers need to adjust their approach to the needs of patients to gain their trust and thus their adherence and compliance to the medical and self-care guidance.
There were no signi cant associations between cyberchondria and socio-demographic factors in our sample. These ndings are in line with other studies showing, for example, no association between gender and cyberchondria [6] or between age and cyberchondria [19]. However, similar accurate studies have identi ed positive associations between cyberchondria, health anxiety, and COVID-19 anxiety [20], anxiety and health information-seeking behaviours [16], and cyberchondria and gender [19]. The results of the current study suggest the need for wider investigation of socio-demographic factors, such as level of education and health literacy, on the information-seeking behaviours of different populations.
It is worth mentioning that the results of the current study are somewhat limited by the nature of the cross-sectional design, the convenience sampling technique, and self-reporting, all of which may affect the generalisability of the results to other populations. However, the variety of the study sample in relation to age and gender distribution may be considered as representative of the local Omani population.

Conclusions
The current study's ndings shed some light on the status of cyberchondria in the general Omani population, with implications for further studies, practical healthcare provision, and policy making. In future research, the current study should be repeated, with the sample size increased, to con rm our ndings. Further, for the healthcare and public health sectors, emphasis should be on the possible distress and uncertainty that cyberchondria may lead to, especially in times of global pandemics, hence affect the relationship between the healthcare provider and the client. Last but not least, policy makers and stakeholders need to develop reliable sources of health information at the national level, creating a social media platform that provides accurate and up-to-date information about the current situation, and taking measures to combat any source spreading of misinformation through the traditional or social media.

Declarations
Ethics approval and consent to participate Prior to data collection, ethical approval was obtained from the College of Nursing Scienti c Research and Ethics Committee, Sultan Qaboos University (Ref.nr.: CON/NF/2020/15). The survey page was introduced with a short description of the nature, objectives, methodology, and potential bene ts of the survey, ensuring the respondents' voluntary and con dential participation. The informed consent was obtained through information on the rst survey page in which it was clearly stated that the participants will give their written consent to participate by clicking the link to the survey, entering the survey page, answering the survey, and submitting it.

Consent for publication
Not applicable.

Availability of data and materials
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
This research did not receive any funding.