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Tutorial: Choose a research article on adolescent/adult population of your choice. Work in pairs to find out strengths and limitation of the research method used to research on adolescent/adult population

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Tutorial: Choose a research article on adolescent/adult population of your choice. Work in pairs to find out strengths and limitation of the research method used to research on adolescent/adult population

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Group 5: Review of The Association Between Atypical Speech Development and Adolescent Self-Harm

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Group 5: Review of The Association Between Atypical Speech Development and Adolescent Self-Harm

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Members: Aisyah, Kok Kai Kee, Thet Paing, Terence

Methodology

longitudinal prospective secondary analysis of community sample

Strength

use a lot of participants

speech data was acquired through direct assessment rather than parent report.

Limitation

because it is a secondary analysis, the data might be old and some variables may change over time

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Article Title: The Association Between School Stress, Life Satisfaction and Depressive Symptoms in Adolescents: Life Satisfaction as a Potential Mediator

Members: Ken, Carmen, Chzuelynn, Jean

Research Method : Self report

Strengths: Large Sample Size, Large response rate

Limitations: Reliance on individual self honesty that could be a potential bias

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Abstract

The aim of the present study was to investigate the interrelationships between school-related stress (school performance, teacher interaction), life satisfaction, and depressive symptoms, as well as the potential mediating role of life satisfaction on the association between school-related stress and depressive symptoms. A total of 1,239 adolescents (13-18 years of age) from public elementary and secondary schools in mid-Norway participated in the school-based survey. The data were analysed using structural equations modelling. The present study showed that stress of school performance was significantly and positively related to depressive symptoms and significantly and inversely related to life satisfaction. At the bivariate levels, stress of teacher interaction was associated with more depressive symptoms and reduced life satisfaction. However, these associations were non-significant in the multivariate analyses, controlled for stress of school performance. A significant inverse association was found between life satisfaction and depressive symptoms. Further, life satisfaction partly mediated the association between stress of school performance and depressive symptoms. The results reflect the complexity of the interaction between adolescents' experience of school performance stress and mental health, and the role of life satisfaction as a potentially relevant mediator of this association.

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References

Löhre, A., Moksnes, U. K., & Lillefjell, M. (2013). Gender differences in predictors of school wellbeing? Health Education Journal,. doi: 10.1177/0017896912470822.

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Moksnes, U. K., & Espnes, G. A. (2013). Self-esteem and life satisfaction in adolescents-gender and age as potential moderators. Quality of Life Research,. doi: 10.1007/s11136-013-0427-4.

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Moksnes, U. K., Löhre, A., Byrne, D. G., & Haugan, G. (2013). Satisfaction with life in adolescents: Evaluation of the factor structure in a Norwegian sample. Social Indicators Research,. doi: 10.1007/s11205-013-0451-3.

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Suldo, S. M., Shaunessy, E., Thalji, A., Michalowski, J., & Shaffer, E. (2009). Sources of stress for students in high school college preparatory and general education programs: Group differences and associations with adjustment. Adolescence, 44, 925-948.

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Author information

Authors and Affiliations

1. Center for Health Promotion Research, Mauritz Hansens gt 2, 7030, Trondheim, Norway

Unni K. Moksnes, Audhild Løhre, Monica Lillefjell, Don G. Byrne & Gørill Haugan

2. Faculty of Nursing, Sør-Trøndelag University College, Trondheim, Norway

Unni K. Moksnes & Gørill Haugan

3. Department of Teacher and Interpreter Education, Sør-Trøndelag University College, Trondheim, Norway

Audhild Løhre

4. Department of Occupational Therapy, Faculty of Health Education and Social Work, Sør-Trøndelag University College, Trondheim, Norway

Monica Lillefjell

5. Research School of Psychology, Australian National University, Canberra, Australia

Don G. Byrne

Corresponding author

Correspondence to Unni K. Moksnes.

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Moksnes, U.K., Løhre, A., Lillefjell, M. et al. The Association Between School Stress, Life Satisfaction and Depressive Symptoms in Adolescents: Life Satisfaction as a Potential Mediator. Soc Indic Res 125, 339-357 (2016). https://doi.org/10.1007/s11205-014-0842-0
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DOI: https://doi.org/10.1007/s11205-014-0842-0

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Keywords

# data[].attributes.attachment_link.title
The Association Between School Stress, Life Satisfaction and Depressive Symptoms in Adolescents: Life Satisfaction as a Potential Mediator - Social Indicators Research

# data[].attributes.attachment_link.description
The aim of the present study was to investigate the interrelationships between school-related stress (school performance, teacher interaction), life satisfaction, and depressive symptoms, as well as the potential mediating role of life satisfaction on the association between school-related stress and depressive symptoms. A total of 1,239 adolescents (13-18 years of age) from public elementary and secondary schools in mid-Norway participated in the school-based survey.

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Methodology:

Open ended in-depth interview

Purposeful sampling strategy

Limitation:

More males than females

Strength:

One researcher joined all of the three workshops when collecting and analysing data

Link: https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-024-01522-1

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“A bit lost”—Living with attention deficit hyperactivity disorder in the transition between adolescence and adulthood: an exploratory qualitative study - BMC Psychology

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Background Attention deficit hyperactivity disorder (ADHD) begins in childhood and in many cases persists into adulthood. The transition from adolescence to adulthood for young people with ADHD is a vulnerable time and can be associated with comorbid conditions and unfavorable outcomes. Thus, further studies are needed to explore the characteristics of the transition period in emerging adulthood. The overall aim of this study was to gain increased knowledge of emerging adults’ experience of living with ADHD in the transition from adolescence to adulthood. This is a follow-up from a previous qualitative study that examined how young people experience receiving and living with a diagnosis of ADHD. Method The study has a qualitative retrospective design. Seven participants were included in this study using a purposive sampling method. We re-invited the same participants who were interviewed in 2015–2016 and conducted in-depth interviews. The data were subjected to Malterud’s systematic text condensation (STC). Results Four crosscutting themes were identified from our analysis: (1) low level of knowledge about ADHD and treatment options; (2) barriers to seeking and accessing help; (3) developing self-help strategies; and (4) a preference to discontinued medication use. Conclusion The participants emphasized a need for more information about ADHD in transition phases and support, both from professionals and peers, about finding ways to live meaningful lives. The treatment they had been offered was particularly linked to symptom reduction and medication use. A more appropriate focus would have been linked to how they, as citizens, could gain knowledge and skills to live meaningful lives with ADHD.

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https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-024-01629-5

Method

Convenience sampling

Strength

Easy for data collection, everyone participate in the research, efficient and simple to implement.

Limitation

Narrow age range of participants, it is suggested that future research relax the age restrictions and not only study the current state of variables in different age groups but also examine whether self-compassion moderates the effect of evaluation fear on ambivalence over emotional expression and if this moderation effect becomes more significant with age.

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BMC Psychology 12, Article number: 128 (2024) Cite this article

Abstract

Background

This study focuses on college students as research subjects, exploring the relationship between fear of evaluation, ambivalence over emotional expression, and self-care, as well as the moderating effect of self-care on the prediction of ambivalence over emotional expression by fear of evaluation.

Methods

This study selected physical education college students in Sichuan Province as the research participants. Convenience sampling was used to recruit participants through public recruitment information and questionnaire links on online platforms commonly used by college students. The questionnaire was distributed at two different time points to reduce the effect of common method bias. A total of 858 questionnaires were distributed, after excluding duplicate responses, a total of 743 valid questionnaires were obtained.

Results

The result as following: (1) College students exhibit a moderate to high level of negative fear of evaluation, ambivalence over emotional expression, and self-care, with female students having higher negative fear of evaluation; (2) There are significant correlations between fear of evaluation, ambivalence over emotional expression, and self-care; (3) Fear of evaluation and self-care can predict ambivalence over emotional expression, but self-care does not have a moderating effect on the prediction of ambivalence over emotional expression by fear of evaluation; (4) Self-care and negative self-care both have a moderating effect on the prediction of emotion rumination by positive fear of evaluation.

Conclusions

In the past, rumination has often been considered a manifestation of excessive rumination and anxiety. However, this study found that self-compassion's modulation on fear of positive evaluation intensifies its impact on emotional rumination. Research suggests that moderate emotional rumination may not necessarily be a negative outcome and reflects a positive emotional adjustment process to some extent. Therefore, future studies can further explore the growth and decline of internal rumination processes in self-compassion or counseling, and potentially gain a better understanding of key elements of personal growth.

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Introduction

Individuals experiencing fear of negative evaluation feel anxious and worried when facing negative evaluations. They tend to anticipate criticism and avoid situations where they may be evaluated. Those with fear of negative evaluation often perceive themselves as being unlikeable and susceptible to negative evaluations [ 10]. They are particularly sensitive to others' negative emotions and feedback in interpersonal interactions, perceiving them as threats. In addition to the fear of being scrutinized, they also engage in avoidance behaviors and reduce self-expression. These behaviors not only reflect distorted perceptions of reality and an amplified view of the consequences of negative evaluations but also contribute to a diminished sense of self-worth [ 11].

Fredrick and Luebbe [ 12] found that positive feedback in interpersonal interactions not only undermines individuals with social anxiety's self-evaluation of their social abilities but also increases anxiety by making them feel the need to perform even better to meet higher expectations. Furthermore, studies by Sajjadi et al. [ 13] suggested that individuals with social anxiety tend to interpret positive events negatively. While these studies argue that the fear of positive evaluation is simply a delayed form of the fear of negative evaluation, where anxiety arises from concerns about subsequent performance leading to negative feedback. Weeks et al. [ 6] offer an alternative view based on Psycho-Evolutionary Theory. They propose that the fear of positive evaluation and fear of negative evaluation have inherent differences, introducing the concept of "fear of positive evaluation" to distinguish them.

To sum up, those who are emotionally sensitive and accustomed to ruminating, suppressing, and avoiding emotions may be troubled by the contradiction between emotional expression and non-expression. Ambivalence over emotional expression not only cause personal psychological distress, but may also hinder interpersonal interaction. This is caused by the impact of interpersonal expectations and evaluations on individuals. Therefore, the motivation of this study was to explore whether caring about college student's feelings and thoughts involves the perspective of interpersonal evaluation and reflects the degree of conflict in personal emotional expression.

Fear of evaluation

Individuals with fear of positive evaluation drawing attention to themselves through exceptional performance, which could place them in a competitive disadvantage where they feel they must compare themselves to more accomplished individuals and may even face retribution from competitors [ 7]. Consequently, they may prefer to remain average and avoid attention, thus experiencing fear of positive evaluation.

Prior research indicated a positive correlation between fear of negative evaluation and self-consciousness, particularly public self-consciousness [ 7, 13]. Public self-consciousness refers to individuals' awareness of themselves as social objects in a social context, being scrutinized and evaluated by others. Those with higher levels of public self-consciousness are more concerned with how they present themselves to others and tend to be more vulnerable when facing criticism [ 14]. Therefore, the essence of fear of negative evaluation lies in the fear of receiving criticism and excessive concern about one's public image, similar to maladaptive perfectionism. Those who are highly concerned about others' evaluations often lack self-affirmation and rely heavily on feedback from others, expending significant effort to meet high external standards and being worried about negative evaluations representing failure. Under immense pressure, not only are they unable to fully utilize their abilities, but they also increase the risk of anxiety and depression [ 13, 15, 16, 17].

Ambivalence over emotional expression (AEE)

King and Emmons [ 18] described ambivalence over emotional expression as the contradictory experience individuals may go through when they want to express suppressed emotions. This includes the desire to express but suppressing the desire, expressing without truly wanting to express, or expressing and subsequently feeling regret. Their study introduces the Ambivalence over Emotional Expressiveness Questionnaire (AEQ) to measure and differentiate between two different types of non-expression: comfortable non-expression (low expression, low ambivalence) and inhibited non-expression (low expression, high ambivalence). This research highlights the importance of focusing on the experience of internal conflict, rather than solely observing the degree of emotional expression.

The decision to express emotions or not also involves gender differences and the psychological complexities of interpersonal interactions. For example, men tend to suppress their emotional expressions more than women [ 14]. Individuals with higher levels of ambivalence over emotional expression find it challenging to establish meaningful connections in relationships, often experiencing feelings of loneliness [ 19], and perceiving lower levels of social support [ 13, 20, 21]. Moreover, university students who are more concerned with others' feelings and thoughts tend to have reservations about expressing their emotions, further exacerbating the level of ambivalence over emotional expression [ 10, 22, 23, 24].

Self-compassion

Neff [ 25] sought a new approach to maintain self-worth without criticism and comparison, leading to the concept of self-compassion. Self-compassion refers to the ability to be kind to oneself and hold a non-judgmental attitude and an open perspective when faced with difficulties and challenging experiences. It involves understanding the current situation and experiencing one's own hardships with kindness, while recognizing suffering as a common human experience, thereby avoiding getting caught up in the spiral of failure and setbacks. Self-compassion consists of three opposing dimensions: self-kindness and self-judgment, common humanity and isolation, mindfulness and over-identification [ 18, 23, 25].

Self-kindness involves being understanding and compassionate towards oneself in difficult circumstances, without being influenced by harsh self-judgment. When individuals believe they are worthy of love and care, even in the face of setbacks, they can comfort themselves with tolerant and compassionate attitudes, understanding that self-blame in vulnerable moments only causes further harm [ 18, 19, 24]. Being self-kind means having the ability to pause and provide solace to oneself rather than rushing to blame and dismiss oneself. Recognizing common humanity involves understanding that everyone is imperfect and experiences embarrassment from making mistakes and suffering from unexpected events. However, when individuals focus solely on their own flaws and misfortunes, they tend to feel narrow-minded and absorbed in their own suffering, falling into the trap of "shoulding" themselves [ 21, 23]. Mindfulness refers to accepting present experiences with equanimity and an open attitude, without avoidance, judgment, or excessive reactivity to painful experiences. On the other hand, over-identification amplifies fears, distorts reality, and weakens awareness. Once individuals perceive themselves as threatened, the situation appears more severe [ 26].

The hypothesis development

The psychological process of ambivalence over emotional expression includes two factors. Firstly, individuals tend to overly focus on the consequences of emotional expression, leading to an emotional rumination dilemma in expression. This condition causes individuals to excessively focus on negative self-evaluations and attributions, resulting in the amplification of negative effects. Secondly, individuals consciously attempt to control their perceived emotional experiences through emotional suppression, which eliminates possible social support [ 19, 22, 26]. Higher levels of ambivalence over emotional expression may also be associated with excessive interpretation of external emotional stimuli, resulting in misinterpretation of others' expressions and difficulties in perceiving the support provided by the external environment [ 27], or choosing to avoid facing problems and emotions rather than seeking support, indirectly leading to others' inability to provide appropriate assistance [ 28]. Research on depressive emotions has also found that the more individuals experience ambivalence over emotional expression, the more prone they are to depression [ 29, 30].

Individuals who are sensitive to emotional experiences and tend to use rumination, suppression, and avoidance to cope with emotions may experience conflicts between expressing and not expressing their emotions. Ambivalence over emotional expression not only cause individual psychological distress but may also hinder interpersonal connections. Individuals who excessively care about others' opinions are unable to express their emotions freely. Those with high ambivalence over emotional expression often find it difficult to express their feelings freely [ 10, 17]. Combined with their tendency to over interpret interpersonal information, they experience emotional confusion and cognitive rumination.

Self-compassion is an effective way of managing emotions that enhances cognitive reappraisal skills, indirectly reducing the impact of ambivalence over emotional expression [ 30, 31, 32]. Self-compassion involves acknowledging internal emotions and emphasizing experiencing painful emotions and expressing inner thoughts in a way that aligns with reality to alleviate the impact of negative experiences, rather than ignoring emotional needs [ 30, 33, 34].

Both positive and fear of negative evaluations are negatively correlated with self-compassion [ 35]. High levels of self-compassion help individuals maintain stable emotions that are not easily influenced by evaluations [ 36]. College students with high self-compassion have higher intrinsic motivation. They focus on the rewards brought by their own learning, and curiosity and enthusiasm drive their learning. Therefore, when they encounter setbacks, they do not perceive failure as a threat but as an opportunity for acceptance and reinterpretation with a growth mindset, replacing harsh self-criticism [ 37]. Several studies have shown that interventions targeting self-compassion can effectively alleviate the impact of negative events on individuals [ 34, 38, 39].

In terms of gender differences, research suggests that due to women being more sensitive to external criticism, they tend to fear negative evaluation more than men [ 40, 41, 42], while there is no gender difference in fear of positive evaluations [ 43]. In terms of self-compassion, research shows that women have significantly lower levels of self-compassion than men, with higher levels of self-criticism, feelings of isolation, and overidentification [ 44, 45, 46, 47]. Based on the above information, the following hypotheses are proposed in this study:

Hypothesis 1

There are significant gender differences in ambivalence over emotional expression and self-compassion among college students, with significant differences in fear of negative evaluations but not in fear of positive evaluations.

Hypothesis 2

Fear of evaluation, self-compassion, and ambivalence over emotional expression are significantly correlated with each other.

Hypothesis 3

Fear of evaluation and self-compassion can predict ambivalence over emotional expression.

Hypothesis 4

Self-compassion plays a moderating role between fear of evaluation and ambivalence over emotional expression.

Study method

Participants

This study selected physical education college students in Sichuan Province as the research participants. Convenience sampling was used to recruit participants through public recruitment information and questionnaire links on online platforms commonly used by college students. The researchers provided detailed information about the research purpose, instructions for completing the questionnaire, and principles of anonymity and confidentiality in the recruitment information posted on the online platforms. The participants were also informed about their rights and privileges. To avoid social desirability bias, the questionnaires were only differentiated by "part number" in addition to the research purpose and basic information instructions, without explicitly indicating the measured variables.

Podsakoff, MacKenzie, Lee, and Podsakoff [ 48] noted that different constructs measured at the same point in time may produce art factual covariance, independent of the content of the constructs themselves. That is, if all variables in the questionnaire were measured at the same point in time, this could have increased the CMB of the study. Thus, to reduce the CMB problem of CMB, the questionnaire was distributed at different times. To match the data of the two phases, respondents were asked to enter the last four digits of their mobile phone numbers in the questionnaire. The first set was distributed on April 10, 2023, to measure the demographic variables, fear of evaluation, and self-compassion. 1000 copies of questionnaires were distributed, and 858 were returned, with a return rate of 85.8%. The second distribution was performed on May 7, 2023, and aimed to measure the ambivalence over emotional expression. This distribution was conducted on withe employees who had returned the questionnaires in the first stage. A total of 858 questionnaires were distributed, and 743 were returned, with a return rate of 86.6%. After excluding duplicate responses, a total of 743 valid questionnaires were obtained. There were 568 male (76.4%) and 175 female (23.6%). There were 177 freshmen (23.8%), 188 s-year (25.3%), 158 third-year (21.3%), and 220 seniors and above (29.6%), and the average age is 20.74.

Measurement

The brief fear of negative evaluation (BFNE)

Brief Fear of Negative Evaluation Scale (BFNE) revised by Leary [ 41] was used to assess individuals' concerns, fears, and expectations of negative evaluations from others. The scale consists of 12 items and measured by Likert-5 point scale (1 =  strongly disagree to 5 =  strongly agree). The Cronbach's α is 0.89.

Fear of positive evaluation

The Fear of positive evaluation Scale was developed by Weeks et al. [ 6]. There are 10 items designed to capture individuals' reactions to changes in their social status within a group. And they measured by Likert-10 point scale (1 =  strongly disagree to 10 =  strongly agree). Higher scores indicate a higher fear of positive evaluation. The Cronbach's α is 0.87.

Ambivalence over emotional expression

The Ambivalence over emotional expression Scale developed by Chen et al. [ 20] to assess individuals' ambivalence over emotional expression in daily life. There are totally 14 items, and it consists of 7 items measuring "emotional rumination" and 7 items measuring "emotional suppression". It measured by Likert-5 point scale (1 = strongly disagree to 5 = strongly agree), and higher scores indicate a higher level of ambivalence over emotional expression. The internal consistency analysis resulted in Cronbach's α values of 0.89 for emotional rumination and 0.83 for emotional suppression. The overall scale of Cronbach's α is 0.88, and the cumulative total explained variance is 66.72%.

Self-compassion

The Self-Compassion Scale (SCS) was adapted from Neff [ 25]. The revised scale consists of 25 items and contains three dimensions with six bipolar factors: self-kindness (5 items) - self-judgment (5 items), common humanity (4 items) - isolation (4 items), and mindfulness (3 items) - over-identification (4 items). It measured by Likert-5 point scale (1 = strongly disagree to 5 = strongly agree). Exploratory factor analysis identified six factors, with a cumulative total explained variance of 71.34%. The internal consistency reliability analysis resulted in Cronbach's α values of 0.81, 0.83, 0.78, 0.82, 0.84, and 0.77, respectively. A second-order confirmatory factor analysis revealed that treating the six factors as positive and negative self-compassion resulted in a better fit compared to the first-order factor analysis results. The factors were named as "positive self-compassion" and "negative self-compassion", with Cronbach's α is 0.85 and 0.91.

The following analysis methods were used in this study: (1) Descriptive statistics to examine the distribution of college students' fear of evaluation, ambivalence over emotional expression, and self-compassion. (2) Independent sample t-tests to test the differences in evaluation between genders and to test Hypothesis 1. (3) Correlation analysis to assess the relationships between variables and test Hypothesis 2. (4) Regression analysis to test the proposed predictive and moderating models and examine Hypotheses 3 and 4.

In the regression analysis, first, stepwise regression was used to test whether the independent variable (fear of evaluation) and the moderating variable (self-compassion) have a significant impact on the dependent variable (ambivalence over emotional expression). Then, hierarchical regression analysis was performed to test whether the interaction effects of positive and fear of negative evaluation and self-compassion have a significant impact on the dependent variable, ambivalence over emotional expression.

Results

Table 1 is a summary of the score and difference comparison of the variable scales of fear of evaluation, ambivalence over emotional expression and self-compassion among college student. The result showed: (1) The average score of fear of negative evaluation among college students who participated in the study was 44.50, the total score shows that college students have a high fear of negative evaluation; the average score of fear of positive evaluation is 34.01, indicating that college students have a moderate fear response to positive evaluation. (2) In terms of ambivalence over emotional expression, the average scores of emotional rumination and emotional suppression of college students participating in the study were 24.24 and 25.42, showing that the degree of ambivalence over emotional expression was high. (3) In terms of self-compassion, the average positive and negative self-compassion scores of college students participating in the study were 35.40 and 38.66, the degree of self-compassion among college students was high. In terms of mean differences, there was a significant difference in fear of negative evaluation (t = -3.78, p  < 0.001), with females (M = 48.35, SD = 8.47) scoring significantly higher than males (M = 40.98, SD = 9.52), while there were no significant differences in other evaluation variables. So, the H1 is partially supported.

The results of the correlation analysis showed that participants had significant moderate positive correlations in both positive and fear of negative evaluation with all aspects of ambivalence over emotional expression. Specifically, fear of negative evaluation had significant positive correlations with emotional rumination ( r = 0.48, p < 0.001) and emotional suppression ( r = 0.41, p < 0.001), and fear of positive evaluation had significant positive correlations with emotional rumination ( r = 0.43, p < 0.001) and emotional suppression ( r = 0.39, p  < 0.001).

Participants' self-compassion showed a significant negative correlation with ambivalence over emotional expression ( r = -0.42, p < 0.001). Specifically, positive self-compassion had a significant negative correlation with emotional rumination ( r = -0.25, p < 0.01), while the correlation with emotional suppression ( r = -0.09, p > 0.05) was not significant. Negative self-compassion had significant positive correlations with emotional rumination ( r = 0.37, p < 0.001) and emotional suppression ( r = 0.42, p < 0.001). Both positive and fear of negative evaluations showed significant negative correlations with self-compassion ( r = − 0.34, p < 0.001, r = − 0.44, p < 0.001). Specifically, fear of negative evaluation had a negative correlation with positive self-compassion ( r = − 0.23, p < 0.01) and a positive correlation with negative self-compassion ( r = 0.41, p < 0.001), while fear of positive evaluation had a negative correlation with positive self-compassion ( r = -0.17, p < 0.05) and a positive correlation with negative self-compassion ( r = 0.36, p  < 0.001). The results partially support H2.

The results of the regression analysis, fear of negative evaluation, fear of positive evaluation, and self-compassion as predictors of ambivalence over emotional expression. In Table 2, the fear of negative evaluation (β = 0.36, t = 9.12, p < 0.001), fear of positive evaluation (β = 0.31, t = 7.93, p < 0.001), and self-compassion (β = -0.19, t = -4.42, p  < 0.001). This indicates that all three variables have significant predictive for ambivalence over emotional expression. The results support H3, that fear of evaluation and self-compassion can predict ambivalence over emotional expression, with fear of positive evaluation positively predicting ambivalence over emotional expression and self-compassion negatively predicting ambivalence over emotional expression.

Table 2 Regression analysis result

In order to understand the moderating effect of self-compassion in the prediction of emotional expression by fear of evaluation, we use hierarchical regression to analysis. In addition to considering that there is no significant difference in emotional expression between gender, gender is not included in the control. The analysis revealed that self-compassion did not have a moderating effect on the prediction of ambivalence over emotional expression by fear of evaluation. To explore the possible reasons for this finding, this study further examined whether there were other moderation models among the sub-dimensions of the variables. The results showed that both "negative self-compassion" and "self-compassion" had significant moderating effects on the relationship between "fear of positive evaluation and emotional rumination".

Table 3 showed the fear of positive evaluation and negative self-compassion on emotional rumination. After including the interaction "fear of positive evaluation × negative self-compassion" (β = -0.18, t = -2.88, p < 0.05). As shown in Fig. 1, high levels of negative self-compassion attenuate the impact of fear of positive evaluation on emotional rumination. Negative self-compassion primarily contributes to increasing emotional rumination but its interaction with fear of positive evaluation shifts individuals' focus towards self-criticism and identification with difficulties, thereby attenuating the impact of fear of positive evaluation on emotional rumination.

Table 3 Moderate effect analysis

Moderating effect of negative self-compassion on the emotional rumination by fear of positive evaluation

The overall analysis of self-compassion in the hierarchical regression analysis of fear of positive evaluation on emotional rumination is shown in Table 3. The interaction term "fear of positive evaluation × self-compassion" (β = 0.21, t = 3.39, p < 0.01). As depicted in Fig. 2, when self-compassion is high, fear of positive evaluation actually strengthens the impact on emotional rumination. Although self-compassion has a main effect in reducing overall emotional rumination, its interaction with fear of positive evaluation gives rise to another experience of emotional expression rumination.

Moderating effect of self-compassion on the emotional rumination by fear of positive evaluation

In the regression models, fear of evaluation positively predicted ambivalence over emotional expression, while self-compassion negatively predicted ambivalence over emotional expression. The ability to practice self-compassion plays an important role in mental and physical health. However, the hierarchical regression analysis results showed that self-compassion did not have a significant moderating effect on the prediction of ambivalence over emotional expression by fear of evaluation. H4 was not supported.

Discussion

Additionally, the average score for ambivalence over emotional expression reaches around 70%. This could be related to the cultural emphasis on harmonious interpersonal relationships in the sample's society, where individuals are cautious in expressing emotions in order to avoid damaging relationships and conform to role expectations. Therefore, they may have reservations in expressing their true emotions and often experience conflicting emotions or express their dissatisfaction only after leaving a particular situation. The average score for self-compassion reaches around 60%, aligning with the findings of Neff et al. [ 46]. Furthermore, this study finds that female college students exhibit significantly higher levels of fear of negative evaluation compared to their male counterparts. This could be due to females placing higher value on interdependence and relationships as opposed to male individuals who tend to prioritize independence [ 14].

As for fear of positive evaluation, there is no significant gender difference. This may be due to individuals being more likely to actively conceal their behavior and selectively avoid situations that elicit positive evaluations. In situations where they feel a sense of control, they are more willing to proactively confront problems. The study also discovers no gender difference in ambivalence over emotional expression, which differs from the majority of studies on ambivalence over emotional expression in romantic relationships. This suggests that there may be gender differences in ambivalence over emotional expression among college students or other influencing factors. The finding that there is no gender difference in self-compassion contradicts the results of Neff et al. [ 50], indicating that there may be cultural differences in this phenomenon [ 51, 52].

This study reveals significant correlations between evaluation fear, ambivalence over emotional expression, and self-compassion. Specifically, evaluation fear exhibits a positive correlation with ambivalence over emotional expression, while self-compassion negatively correlates with both evaluation fear and ambivalence over emotional expression. However, positive self-compassion is not significantly correlated with emotional suppression. Although positive self-compassion is related to emotional rumination and ambivalence over emotional expression, it is not significantly associated with emotional suppression. This result reflects that ambivalence over emotional expression and emotional suppression are distinct concepts within ambivalence over emotional expression, as proposed by King and Emmons [ 18], which encompasses both emotional rumination and emotional suppression factors.

The results indicate that higher levels of positive self-compassion are associated with lower levels of emotional rumination following emotional expression. However, the situation differs for emotional suppression. In other words, when facing difficulties, individuals who prioritize self-care are able to acknowledge and honor their own emotions, leading to lower levels of emotional rumination and the ability to handle emotions without the need for deliberate suppression or expression. This may explain why positive self-compassion is not significantly related to emotional suppression.

Although Hypothesis 4 was not supported, the study found two different moderation models. This may be because individuals fear that receiving positive evaluations from others may lead to trouble and, consequently, experience fear of positive evaluation. This situation, which is related to interpersonal interactions and personal experiences, leads individuals to have more concerns when expressing emotions. High levels of negative self-compassion attenuate the impact of fear of positive evaluation on emotional rumination. This may be because individuals with high levels of negative self-compassion feel fear in the face of positive evaluations, leading to self-criticism, feeling isolated in difficult situations, and excessive identification with their circumstances, which results in more negativity. Consequently, they are less inclined to expend effort considering the consequences of emotional expression. Individuals with high levels of self-compassion are able to approach themselves with kindness, understanding the universality of suffering and avoiding getting stuck in self-criticism. When facing the fear of positive evaluation and experiencing understanding through self-compassion, this self-caring thought process reflects the adjustment process from evaluation fear to self-acceptance.

Implications

Pay attention to the influence of interpersonal evaluations on emotional expression

College students' fear of others' evaluations is closely related to their rumination and suppression of emotions. Therefore, whether it is a state of fear of evaluation or ambivalence over emotional expression, it is closely related to interpersonal issues such as learning, life, work, and society. Moreover, knowing how to view other's evaluations, identify the meaning of evaluations, and express emotions appropriately in relationships to reduce the impact of theirs evaluation, it is an important issue. Same with previous research, we found that female students have higher fear of negative evaluations compared to male. Therefore, it is important to pay more attention to the criticism that female students may face and assess whether it exceeds their psychological capacity. We suggest various activities can be implemented in college mental health education to assist students in understanding the meaning of evaluations, and placing value on personal beliefs rather than relying solely on feedback from others, which will help mitigate the negative impact of others' evaluations.

Enhance college students' self-compassion

Although the moderating effect of self-compassion in this study is limited, it can still help reduce the distress associated with ambivalence over emotional expression in college students. Therefore, it is recommended that schools, in their mental health promotion activities, invite individuals from various fields to share their experiences of setbacks, career uncertainties, workplace pressures, and relationship difficulties to help students develop a broader perspective on life's challenges. This will reduce their isolated experiences and self-criticism when encountering similar difficulties. In the process of practical companionship, the students can also be made to feel tolerance and care, help them understand the context of their difficulties, and treat themselves with kindness. In addition, mindfulness is also one of the important concepts of self-care. This part can lead students to learn mindfulness skills and attitudes by organizing lectures, workshops, groups and reading clubs, etc.

Pay attention to subjective experiences of positive evaluations in individual cases

Practitioners often respond to individuals' efforts in a positive manner, aiming to enhance their coping abilities and promote self-acceptance. However, this study finds an interaction effect between fear of positive evaluation and self-compassion, which increases the influence on emotional rumination. This suggests that students may experience anxiety due to excessive attention or receiving positive feedback that deviates significantly from their self-perception. Therefore, it is suggested that teachers and counseling professionals actively monitor changes in students' emotions when receiving positive feedback, inquire about their feelings towards the positive feedback, understand the inner processes of emotional rumination, and guide them towards a more integrated and consistent understanding and state.

Limitation and future research directions

Expand the sample to include individuals of different ages

It is suggested that future research relax the age restrictions and not only study the current state of variables in different age groups but also examine whether self-compassion moderates the effect of evaluation fear on ambivalence over emotional expression and if this moderation effect becomes more significant with age. Similarly, it is worth exploring whether the impact of evaluation fear on ambivalence over emotional expression varies with age.

Include major fields of study or professional categories as background variables

This study collected background variables of students' gender, grade, and location of their schools. In terms of gender differences, only fear of negative evaluation showed a significant difference. Given that different learning experiences and environments may have different effects on individual behavior, and considering the demands of counseling practice for working with different groups, it is suggested to include students' major fields of study or professional categories in the analysis. This would explore whether there are differences in evaluation fear, self-compassion, and ambivalence over emotional expression among individuals from different professional backgrounds and observe the changes in prediction and moderation effects across different professional groups.

Further explore the relationship between fear of positive evaluation, self-compassion, and emotional rumination

In the past, rumination has often been considered a manifestation of excessive rumination and anxiety. However, this study found that self-compassion's modulation on fear of positive evaluation intensifies its impact on emotional rumination. We also found that moderate emotional rumination may not necessarily be a negative outcome and reflects a positive emotional adjustment process to some extent. Therefore, future studies can further explore the growth and decline of internal rumination processes in self-compassion or counseling, and potentially gain a better understanding of key elements of personal growth.

Data availability

No datasets were generated or analysed during the current study.

References

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Acknowledgements

The authors thank the reviewers for their valuable comments.

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Authors and Affiliations

School of Physical Education and Sports, Sichuan University, Chengdu, Sichuan Province, China

Tian Huang & Wenbo Wang

Contributions

Huang and Wang had the research idea, conceptualized and designed the research. Huang collected and curated the data. Huang and Wang wrote the main manuscript text. Wang reviewed and edited the paper. Wang supervised the process and acquired the funds needed for the study. All authors have read and approved the final draft.

Corresponding author

Correspondence to Wenbo Wang.

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The study procedures were approved by the Ethics Committee of Sichuan University and were in line with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was signed and obtained from all individual participants included in the study.

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Huang, T., Wang, W. Relationship between fear of evaluation, ambivalence over emotional expression, and self-compassion among university students. BMC Psychol 12, 128 (2024). https://doi.org/10.1186/s40359-024-01629-5
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DOI: https://doi.org/10.1186/s40359-024-01629-5

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# data[].attributes.attachment_link.title
Relationship between fear of evaluation, ambivalence over emotional expression, and self-compassion among university students - BMC Psychology

# data[].attributes.attachment_link.description
Background This study focuses on college students as research subjects, exploring the relationship between fear of evaluation, ambivalence over emotional expression, and self-care, as well as the moderating effect of self-care on the prediction of ambivalence over emotional expression by fear of evaluation.

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Global Changes and Factors of Increase in Caloric/Salty Food Intake, Screen Use, and Substance Use During the Early COVID-19 Containment Phase in the General Population in France: Survey Study

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Global Changes and Factors of Increase in Caloric/Salty Food Intake, Screen Use, and Substance Use During the Early COVID-19 Containment Phase in the General Population in France: Survey Study

# data[].attributes.body
Article Title:

Global Changes and Factors of Increase in Caloric/Salty Food Intake, Screen Use, and Substance Use During the Early COVID-19 Containment Phase in the General Population in France: Survey Study

Members:

Shamminisri,Preissha,Deveshwar

Methodology

open web-based survey

Strenghts

Short period of time

Low cost

Ability to find large sample

Limitations

Although the analyses were weighted based on several basic sociodemographic parameters, we cannot exclude the possibility that important parts of the French population were overrepresented or underrepresented, which may have had an impact on the findings.

# data[].attributes.attachment_link.readable_text
Original Paper

Benjamin Rolland1, 2, MD, PhD;

Frédéric Haesebaert3, MD, PhD;

Elodie Zante3, MD;

Amine Benyamina4, 5, MD, PhD;

Julie Haesebaert6, MD, PhD;

Nicolas Franck5, MD, PhD

¹ Service Universitaire d'Addictologie de Lyon, CH Le Vinatier, Hospices Civils de Lyon, Bron, France

² Inserm U1028, CNRS UMR5292, Université Claude Bernard Lyon 1, Bron, France

³ Centre Ressource de Réhabilitation Psychosociale, CH Le Vinatier, Lyon, France

⁴ PSYCOMADD 4872, Université Paris-Saclay, Paris, France

⁵ CH Le Vinatier, Pôle Centre Rive Gauche, Bron, France

⁶ Service de recherche et d'épidémiologie, Pôle de santé publique, Hospices Civils de Lyon, Lyon, France

Corresponding Author:

Benjamin Rolland, MD, PhD

Service Universitaire d'Addictologie de Lyon

CH Le Vinatier

Hospices Civils de Lyon

Bâtiment 502

Bron, 69500

France

Phone: 33 0437915075

Email: benjrolland@gmail.com

Background: The international outbreak of coronavirus disease (COVID-19) has led many countries to enforce drastic containment measures. It has been suggested that this abrupt lockdown of populations will foster addiction-related habits such as caloric/salty food intake, screen use, and substance use.

Objective: Our aim was to assess the global changes and factors of increase in addiction-related habits during the early COVID-19 containment phase in France.

Methods: A web-based survey was provided from day 8 to day 13 of the containment and was completed by 11,391 participants. The questions explored sociodemographic features, psychiatric/addiction history, material conditions of lockdown, general stress, mental well-being, and reported changes in several addiction-related behaviors. Global changes were described and factors of increase were explored using population-weighted and adjusted logistic regression models, providing adjusted odds ratios (aORs) and their 95% confidence intervals.

Results: Overall, the respondents reported more increases in addiction-related habits than decreases, specifically 28.4% (caloric/salty food intake), 64.6% (screen use), 35.6% (tobacco use), 24.8% (alcohol use), and 31.2% (cannabis use). Reduced well-being scores and increased stress scores were general factors of increase in addiction-related habits ( P<.001 for all habits). Factors of increase in caloric/salty food intake (n=10,771) were female gender (aOR 1.62, 95% CI 1.48-1.77), age less than 29 years ( P<.001), having a partner (aOR 1.19, 95% CI 1.06-1.35), being locked down in a more confined space (per 1 square meter/person decrease: aOR 1.02, 95% CI 1.01-1.03), being locked down alone (aOR 1.29, 95% CI 1.11-1.49), and reporting current (aOR 1.94, 95% CI 1.62-2.31) or past (aOR 1.27, 95% CI 1.09-1.47) psychiatric treatment. Factors of increase in screen use (n=11,267) were female gender (aOR 1.31, 95% CI 1.21-1.43), age less than 29 years ( P<.001), having no partner (aOR 1.18, 95% CI 1.06-1.32), being employed ( P<.001), intermediate/high education level ( P<.001), being locked down with no access to an outdoor space (aOR 1.16, 95% CI 1.05-1.29), being locked down alone (aOR 1.15, 95% CI 1.01-1.32), living in an urban environment ( P<.01), and not working ( P<.001). Factors of increase in tobacco use (n=2787) were female gender (aOR 1.31, 95% CI 1.11-1.55), having no partner (aOR 1.30, 95% CI 1.06-1.59), intermediate/low education level ( P<.01), and still working in the workplace (aOR 1.47, 95% CI 1.17-1.86). Factors of increase in alcohol use (n=7108) were age 30-49 years ( P<.05), a high level of education ( P<.001), and current psychiatric treatment (aOR 1.44, 95% CI 1.10-1.88). The only significant factor of increase in cannabis use (n=620) was intermediate/low level of education ( P<.001).

Conclusions: The early phase of COVID-19 containment in France led to widespread increases in addiction-related habits in the general population. Reduced well-being and increased stress were universal factors of increase. More specific factors were associated with increases in each of the explored habits.

JMIR Public Health Surveill 2020;6(3):e19630

doi:10.2196/19630

Keywords

In March 2020, the outbreak of coronavirus disease (COVID-19) led the national authorities of most countries worldwide to implement extraordinary measures that dramatically restricted the mobility and social interactions of their populations with the aim of limiting transmission of the virus []. In this respect, many countries, including Italy, France, and Spain, decided to establish total or at least very strict lockdown. In France, this containment was announced by the President on March 16, and it went into effect at noon ECT on March 17, 2020 []. Only activities deemed "essential" were maintained; these included some medical activities but also activities related to the food supply, including access to alcohol as well as to tobacco and electronic cigarette shops. In France, as in other countries, due to this unprecedented situation, a large majority of the population became locked down at home overnight.

These containment measures, as well as the abrupt international health and economic crises caused by COVID-19, may have caused substantial stress in the population and thus may have significantly impacted people's general health and, more specifically, their mental well-being. Previous situations of reduced well-being and impaired social environment have been found to be associated with overeating and being overweight as well as increased substance and screen use [-]. In this context, it has been suggested that at-risk behaviors that are in the spectrum of addiction are likely to be exacerbated by the COVID-19 outbreak and the related containment but that this should be confirmed by studies [].

The LockUwell study is a nationwide web-based survey aiming to assess the overall effects of the official containment on the French general population with respect to mental well-being and general health conditions, including eating habits as well as screen and substance use. In this study, we describe the containment-related changes in the respondents' daily habits of eating, screen use, and substance use, and we explore the main characteristics of the participants who reported the most substantial changes.

Type of Study

An open web-based survey was launched on March 25, 2020, that is, 8 days after the official implementation of the containment in France.

The reporting of the survey follows the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) []. The completed checklist can be found in .

Recruitment

Any French-speaking person older than 16 years was invited to participate in the survey without restriction criteria provided they could complete the questionnaire autonomously. The link leading to the online survey was disseminated on the internet using social media (ie, Twitter, LinkedIn, and Facebook) and national media. The recruitment strategy thus followed a convenience sampling method. To prevent individuals from completing the questionnaire multiple times, only one questionnaire could be submitted from a particular IP address.

Questionnaire

The English version of the full questionnaire is available in . There was no preliminary assessment of the test-retest reliability or the internal consistency of the questionnaire; however, several tools included in it were previously validated in international studies.

The survey questions aimed to comprise a large range of items related to mental well-being and psychological distress and to collect sociodemographic and environmental data related to the situation of containment, such as total living space or number of persons sharing the house during the containment. The questionnaire was divided in six consecutive sections: 1) sociodemographic features; 2) the French version [] of the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS), which is a validated scale of 14 items that are rated from 1 to 5, leading to a single total score ranging from 14 (ie, minimum possible well-being) to 70 (ie, maximum possible well-being) to measure mental well-being in the general population []; 3) overall and specific (eg, professional, health-related, family) levels of stress, using a visual analog scale ranging from 0 (no stress) to 10 (maximum possible stress) []; 4) medical history, in particular the history of psychiatric and addiction treatment; 5) perceptions and apprehensions about COVID-19 and the related official measures; and 6) personal and environmental conditions under which participants were facing the lockdown and their consequences.

In particular, question F-25 explored whether respondents had changed their intake of caloric/salty food, their use of screens, and their use of substances (tobacco, alcohol, cannabis, and other drugs). The response modalities were 1) no usual use; 2) no change in use; 3) decrease with craving/withdrawal; 4) decrease without craving/withdrawal; 5) increase (moderate); and 6) increase (difficult to control).

Data Extraction and Preprocessing

The data were extracted on March 30, 2020, that is, 5 days after the start of the survey. For the present analysis, we included only respondents aged 16 years and older who completed the questionnaire and were living in France at the time when containment was declared. Among the 20,235 participants who started the questionnaire, 11,742 (58.0%) completed it. After excluding inoperable questionnaires and respondents from countries other than France, 11,391/20,235 questionnaires (56.3%) were included in the analyses. A complete flowchart is displayed in . Only the responses to questions A-1 to A-7, A-12 to A-14, A-16, B-1, C-1c, D-4b and D-4c, F-6 to F-9, F-17, and F-25 were used in this preliminary investigation.

Statistical Analysis

Statistical analyses were performed using SAS software version 9.4 (SAS Institute). To ensure respondents were representative of French residents aged 16 years and older, the data were weighted to French census targets for age and gender based on distributions reported in 2020 []. All descriptive and statistical tests were conducted using weighting variables. The descriptive statistics display categorical variables as the number and percentage of respondents (n, %), while quantitative variables are presented as mean (SD) or median (IQR). We explored caloric/salty food intake, screen use, and tobacco, alcohol, and cannabis use because insufficient data were collected regarding other substances. For each behavior and substance used, the different levels of subjective change (ie, no change, decrease with craving/withdrawal, decrease without craving/withdrawal, moderate increase, or difficult-to-control increase) are displayed.

Increase was expected to be a much more frequent pattern of change than decrease for all behaviors; therefore, we more deeply explored the parameters specifically associated with increase (both types of increase combined) in each type of behavior compared to other modalities of change using weighted logistic regression models. Respondents declaring no usual use were not included in the analyses. For each model, raw odds ratios (ORs) and adjusted odds ratios (aORs) are provided with their 95% confidence intervals. We entered the following variables in the model (each was adjusted with the others in the adjusted analyses): sociodemographic factors (age, gender, family, occupation, and educational level), psychiatric and addiction history, well-being (WEMWBS total score), stress (general stress VAS), housing conditions (surface, outdoor, geographical area) and working conditions during containment as explanatory variables. Multicollinearity was screened using the variance inflation factor and the COLLIN option in SAS.

The raw and weighted descriptive data of the 11,391 participants are shown in . The weighted sample consisted of 52.1% female respondents with a mean age of 47.47 years (SD 17.28).

The overall changes reported in the daily habits that were explored in the survey are displayed in .

Table 1. Descriptive characteristics of the survey population (N=11,391).

Characteristic

Values

Unweighted

Weighted

Age (years), mean (SD)

Gender, n (%)

Housing space (square meters/person), median (IQR)

34.67 (25-50)

40.00 (28-60)

Well-being (WEMWBS b score), mean (SD)

49.37 (8.12)

50.51 (8.17)

General stress (0-10 VAS c), mean (SD)

5.23 (2.35)

4.84 (2.43)

a ISCED: International Standard Classification of Education.

b WEMWBS: Warwick-Edinburgh Mental Well-Being Scale.

c VAS: visual analog scale.

‎
Figure 1. Changes in addiction-related habits in the early phase of COVID-19 containment in France from March 17 to 31, 2020.
View this figure

Regarding eating patterns, 6510/11,391 (57.14%) participants reported that they did not increase or decrease their average daily intake of caloric/salty food, whereas 2836 (24.89%) moderately increased their intake, 397 (3.49%) increased their intake in a difficult-to-control manner, 874 (7.67%) reduced their intake without craving, and 154 (1.35%) reduced their intake with craving.

With respect to screen use, 124/11,391 (1.09%) respondents declared that they did not usually use screens. Among the 11,267 remaining participants, 3784 (33.59%) reported that they did not change their average daily screen use, whereas 5545 (49.22%) declared having moderately increased their screen use, 1729 (15.35%) increased their screen use in a difficult-to-control manner, 179 (1.59%) reduced or stopped their screen use without craving/withdrawal, and 29 (0.26%) reduced their screen use with craving/withdrawal.

Concerning tobacco use, 2787/11,391 (24.47%) respondents reported that they were current smokers. Among the 2787 smokers, 1208 (43.27%) reported that they did not change their average daily use of tobacco, whereas 746 (26.72%) declared having moderately increased their tobacco use, 249 (8.92%) increased their tobacco use in a difficult-to-control manner, 432 (15.47%) declared that they reduced or stopped their tobacco use without craving/withdrawal, and 157 (5.62%) reduced their tobacco use with craving/withdrawal. Regarding alcohol use, 7108/11,391 (62.40%) respondents were found to use alcohol more or less regularly. Among them, 4109/7108 (57.82%) reported that they had not changed their average daily use of alcohol, whereas 1654 (23.27%) moderately increased their alcohol use, 107 (1.50%) increased their alcohol use in a difficult-to-control manner, 1167 (16.4%) declared having reduced or stopped without craving/withdrawal, and 70 (0.98%) having reduced with craving/withdrawal.

Finally, regarding cannabis use, 620/11,391 (5.44%) participants reported using cannabis. Among the, 263/620 (39.49%) reported that they had not changed their average daily use of cannabis, whereas 162 (24.32%) declared having moderately increased their cannabis use, 46 (6.91%) increased their cannabis use in a difficult-to-control manner, 150 (22.52%) reduced or stopped their cannabis use without craving/withdrawal, and 45 (6.76%) reduced their cannabis use with craving/withdrawal.

Raw and adjusted analyses of the factors associated with the increase in each of the explored habits can be found in and , respectively.

Table 2. Results of the unadjusted analyses exploring the increases in caloric/salty food, screen use, and substance use in the early phase of COVID-19 containment in France among the general population.

Characteristic

Caloric/salty food intake
(n=10,771; 3233 increase vs 7538 no increase)

Screen use (n=11,267; 7274 increase vs 3993 no increase)

Tobacco use (n=2787; 996 increase vs 1791 no increase)

Alcohol use (n=7108; 1761 increase vs 5347 no increase)

Cannabis use (n=666; 208 increase vs 458 no increase)

OR a (95% CI)

P value

OR (95% CI)

P value

OR (95% CI)

P value

OR (95% CI)

P value

OR (95% CI)

P value

Gender

Male

Reference

N/A b

Reference

N/A

Reference

N/A

Reference

N/A

Reference

N/A

Age (years)

50-64

0.50 (0.44-0.56)

<.001

0.50 (0.45-0.57)

<.001

0.71 (0.57-0.89)

.003

0.79 (0.67-0.93)

.005

0.36 (0.21-0.62) c

<.001

≥65

0.28 (0.23-0.31)

<.001

0.40 (0.35-0.45)

<.001

0.22 (0.16-0.31)

<.001

0.49 (0.41-0.59)

<.001

N/A

In a couple

Professional situation

Access to outdoor space

Living space

Confined with other people

Housing location

Working conditions

Not working

0.58 (0.51-0.65)

<.001

1.11 (0.99-1.24)

0.48 (0.39-0.59)

<.001

0.68 (0.58-0.79)

<.001

0.69 (0.43-1.11)

.13

Psychiatric treatment

Addiction treatment

a OR: odds ratio.

b N/A: not applicable.

c Due to power requirements, the age categories of 50-64 years and ≥65 years were pooled in the model exploring cannabis use increase.

d ISCED: International Standard Classification of Education.

e WEMWBS: Warwick-Edinburgh Mental Well-Being Scale.

f VAS: visual analog scale.

Table 3. Results of the adjusted analyses exploring the increase in caloric/salty food, screen use, and substance use in the early phase of COVID-19 containment in France among the general population.

Characteristic

Caloric/salty food intake (n=10,771; 3233 increase vs 7538 no increase)

Screen use (n=11,267; 7274 increase vs 3993 no increase)

Tobacco use (n=2787; 996 increase vs 1791 no increase)

Alcohol use (n=7108; 1761 increase vs 5347 no increase)

Cannabis use (n=666; 208 increase vs 458 no increase)

aOR a (95% CI)

P value

aOR (95% CI)

P value

aOR (95% CI)

P value

aOR (95% CI)

P value

aOR (95% CI)

P value

Gender

Male

Reference

N/A b

Reference

N/A

Reference

N/A

Reference

N/A

Reference

N/A

Other

1.17 (0.64-2.14)

.63

0.66 (0.35-1.25)

0.95 (0.32-2.78)

.93

0.26 (0.08-0.89)

.03

0.45 (0.07-2.74)

.39

Age (years)

50-64

0.54 (0.47-0.63)

<.001

0.68 (0.58-0.79)

<.001

0.71 (0.55-0.93)

.01

0.84 (0.69-1.01)

.07

0.48 (0.25-0.89) c

.02

≥65

0.42 (0.34-0.53)

<.001

0.65 (0.53-0.80)

<.001

0.32 (0.20 -0.50)

<.001

0.76 (0.56-1.07)

.10

In a couple

Professional situation

Educational level (ISCEDd 2011)

Access to outdoor space

Per 1-point increase

0.98 (0.97-0.98)

<.001

0.98 (0.97-0.98)

<.001

0.97 (0.96-0.98) c

<.001

0.97 (0.96-0.98)

<.001

0.96 (0.93-0.98)

<.001

Living space

Confined with other people

Housing location

Working conditions

Psychiatric treatment

Current

1.94 (1.62-2.31)

.31

0.92 (0.75-1.13)

.45

1.33 (0.94-1.88)

.10

1.44 (1.10-1.88) d

.008

1.12 (0.54-2.35)

.78

Addiction treatment

a aOR: adjusted odds ratio.

b N/A: not applicable.

c Due to power requirements, the age categories of 50-64 years and ≥65 years were pooled in the model exploring cannabis use increase.

d ISCED: International Standard Classification of Education.

e WEMWBS: Warwick-Edinburgh Mental Well-Being Scale.

f VAS: visual analog scale.

After adjustment, the respondents who reported increasing their caloric/salty food intake were more likely to be female, to be aged ≤30 years (see ), to have a partner, to be professionally active, a student, or a job seeker, to report a lower score of well-being and a higher score of general stress, to be locked down alone in a reduced space, and to report current or past treatment for psychiatric disorder (for ORs and 95% CIs, see ).

Based on the results of the multivariable logistic regression models, the respondents who reported increasing their screen use were more likely to be female, to be aged <30 years, to have no partner, to be professionally active, to have a relatively high level of education (ie, ISCED 4 or more), to report a lower score of well-being and a higher score of general stress, to be locked down alone, in a city, and with no access to an outdoor space, and to have stopped their professional activity because of the lockdown (for ORs and 95% CIs, see ).

After adjustment, the interviewees who reported increasing their use of tobacco were more likely to be female, to be aged <50 years, to have no partner, to be professionally active or a job seeker, to have a relatively low level of education (ie, ISCED 3 or less), to report a lower score of well-being and a higher score of general stress, and to continue working in the workplace (for ORs and 95% CIs, see ).

After adjustment, the individuals who reported increasing their alcohol use were more likely to be aged 30 to 49 years, to be professionally active or job seekers, to have a high level of education (ie, ISCED 5 or more), to report a lower score of well-being and a higher score of general stress, and to report current treatment for a psychiatric disorder (for ORs and 95% CIs, see ).

After adjustment, the participants who reported increasing their cannabis use were more likely to be aged <50 years, to have a relatively low level of education (ie, ISCED 4 or less), and to live in a dwelling with no access to an outdoor space (for ORs and 95% CIs, see ).

Principal Results

Overall, we found that increases were much more frequent than decreases for all the habits explored. Moreover, it appears that the use of screens increased greatly; 4125/11,391 (36.21%) of the survey population reported increased screen use, and 1729 (15.18%) noted difficulties in controlling their screen use.

The early impact of the COVID-19 outbreak and the related lockdown thus appear to be associated with substantial increases in the intake of caloric/salty food as well as in screen and substance use among the French population. In animal models, it is well-demonstrated that reducing social connections enhances stress; as a result, increases are observed in both eating and weight [] as well as in substance use [,]. In humans, epidemiological studies on this topic are more limited, as situations of abrupt reduction in social interaction at the population level are relatively uncommon. However, analogies can be made to studies that investigated individuals enrolled in armed forces during conflicts, which revealed that the social interactions of the individuals were dramatically reduced and that their substance use increased in parallel. For example, studies by Lee Robins [] among US soldiers who were sent to Vietnam in the 1970s found an important reduction in social interactions accompanied by an important increase in the use of opioids by soldiers during their presence in the field; meanwhile, these patterns of use rapidly and almost completely disappeared after the soldiers returned home. A comparison with our findings should be made with caution, as a situation of war is in no way comparable with that of the COVID-19 lockdown. However, the results of our survey are in line with the fact that a substantial reduction of social habits can be associated with enhanced stress and boredom and thus with increases in addiction-related habits.

Furthermore, our findings enlighten both common aspects and singularities between habits in the profiles of respondents who reported increases. Overall, reduced mental well-being and greater overall stress were shared risk factors of increase for all habits. A current or past history of addiction treatment did not appear to impact the observed changes; this is noteworthy because the respondents were supposed to be more vulnerable to stress and were thus expected to increase or relapse in addictive behaviors []. More specifically, the typology of respondents who increased their habits substantially differed depending on the habit. Respondents who increased their intake in caloric/salty foods were primarily young women who were living in smaller dwellings and were locked down alone. Previous studies have demonstrated that emotional eating in stressful environments is more common in women [,]. It can thus be hypothesized that women who faced the stress induced by the COVID-19 crisis and the related containment coped more by consuming caloric/salty food relative to men. In this context, living alone in a smaller space or reporting past or current treatment for psychiatric disorder can be seen as additional sources of stress.

Survey respondents who reported increasing their screen use were more likely to be female, less than 30 years of age, single, locked down alone, living in an urban area, without access to an outdoor space, and not working. Stress is also a well-demonstrated risk factor of increasing screen use; it is more expressed in younger people, although usually more commonly in men [,]. Living alone is another known risk factor for increased screen use [,], and this factor was certainly accentuated during the lockdown. Similarly, not working was previously found to be associated with increased internet use []. Interestingly, a previous study found that increased use of the internet in a stressful environment was more frequent in young people living in urban areas []. This is in line with our findings, which can be explained by a more confined environment in this case. However, fewer respondents who were currently working in the workplace reported increased screen use compared to telecommuting respondents; this also suggests that enhanced screen use is related to telecommuting in some cases.

Among tobacco smokers, the main risk factors for increased smoking were also being female, age less than 50 years, being single, and low level of education. In line with these findings, female gender, younger age, lower socioeconomic status, and psychological distress are the main factors associated with tobacco use []. It thus appears that the same risk factors that are associated with tobacco use in general were associated with increasing tobacco use in the case of the COVID-19 lockdown.

The profile of respondents who increased their alcohol use was different, as this increase preferentially affected people aged 30 to 49 years with high levels of education. A possible explanation is that increased use of alcohol may be less stigmatized than that of tobacco or cannabis, as people who use cannabis and tobacco in France are globally younger, have lower income, and are less educated [,]. For this reason, alcohol use may have increased more than tobacco or cannabis use among more educated and middle-aged respondents. In line with this hypothesis, respondents who reported increased cannabis use more specifically consisted of very young workers with low levels of education. This reflects the population of regular users of cannabis in France, which is mainly aged less than 30 years []. Moreover, while no study has specifically explored this issue in France, international epidemiological studies have revealed that cannabis use is inversely correlated with level of education []. In sum, our findings suggest that increased stress and impaired well-being were common risk factors for increases in all types of addiction-related habits during the early phase of the COVID-19 lockdown in France. However, other sociodemographic characteristics and individual features related to lockdown conditions were associated with increases in more specific habits, thus reflecting a specific vulnerability of some parts of the French population with regard to the different habits explored, namely caloric/salty food intake, screen use, or tobacco, alcohol, or cannabis use.

Limitations

Our study was a web-based survey performed on a convenience sample with no a priori representativeness of the French population. Although our analyses were weighted based on several basic sociodemographic parameters, we cannot exclude the possibility that important parts of the French population were overrepresented or underrepresented, which may have had an impact on our findings. For example, although illiterate people represent a limited part of the French population, we acknowledge that participating in the survey would be difficult for them without external help. Given the context, however, it would be difficult to rapidly set up a study with more thorough methodological features. Despite this, the rate of tobacco smokers in our study (24.47%) was close to that observed in the French population (25.2% in 2018 []). Similarly, 62.40% of our sample declared that they used alcohol; meanwhile, the rate of French adults who used alcohol at least once per year in 2018 was 87%, while the rate of adults who used alcohol at least once a week was 49% []. However, a gap was found for cannabis use; 5.4% of our sample reported using this substance, whereas the rate of current users in the adult French population is estimated to reach 11% []. This gap may result from social desirability bias, which is the tendency to underreport socially undesirable attitudes and behaviors and to overreport more desirable attributes; this bias is more pronounced with illicit substances [].

Another limitation pertains to what is conveyed under the notion of "screen use," which can actually involve many habits, such as video gaming, social networking, or teleworking. The interview may thus have lacked precision on this point, and interpreting the participants' answers may thus have been more difficult. An additional limitation is that the data we analyzed only pertained to the early phase of the lockdown, and it is perfectly possible that several findings reflected short-term adjustment behaviors that may not be durably sustained over the remaining phase of the lockdown. Another limitation is that we did not explore the interrelations in the changes between habits; thus, we did not explore overlaps in terms of affected populations. Finally, the assessment of how individual habits had changed was entirely subjective with no precise quantification in either terms of amounts or time, which limits the accuracy of the data.

Comparison With Prior Work

To our knowledge, no previous study has assessed the impact of a national COVID-19 containment measure on eating habits, screen use, or substance use. The increases found in our survey were hypothesized in a recent literature report []; however, our contribution provides the first data supporting these assumptions.

Conclusions

The early phase of COVID-19 containment in France was associated with a substantial proportion of survey respondents reporting increased caloric/salty food intake, screen use, and tobacco, alcohol, and cannabis use. The increase was particularly large for screen use, which affected two-thirds of the sample. Furthermore, the profiles of individuals who increased their habits displayed shared features, particularly poorer well-being and increased stress; however, specificities between each type of increase also revealed some populational singularities, particularly related to gender, age category, and level of education. Thus, targeted prevention messages should be developed to address the types of habits to which subcategories of the population are more vulnerable during and after the containment period.

Conflicts of Interest

None declared.
‎ ‎ ‎

Multimedia Appendix 3

Flowchart demonstrating how questionnaires were selected for the analyses.
DOCX File , 27 KB

‎

CHERRIES: Checklist for Reporting Results of Internet E-Surveys

COVID-19: coronavirus disease

ISCED: International Standard Classification of Education

VAS: visual analog scale

WEMWBS: Warwick-Edinburgh Mental Well-Being Scale

Edited by G Eysenbach; submitted 26.04.20; peer-reviewed by M El Tantawi, A Hone-Blanchet, TH Kwan, MA Bahrami, C Basch; comments to author 04.05.20; revised version received 18.05.20; accepted 25.06.20; published 18.09.20

©Benjamin Rolland, Frédéric Haesebaert, Elodie Zante, Amine Benyamina, Julie Haesebaert, Nicolas Franck. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 18.09.2020.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete bibliographic information, a link to the original publication on http://publichealth.jmir.org, as well as this copyright and license information must be included.

Background: The international outbreak of coronavirus disease (COVID-19) has led many countries to enforce drastic containment measures. It has been suggested that this abrupt lockdown of populations will foster addiction-related habits such as caloric/salty food intake, screen use, and substance use.

Objective: Our aim was to assess the global changes and factors of increase in addiction-related habits during the early COVID-19 containment phase in France.

Methods: A web-based survey was provided from day 8 to day 13 of the containment and was completed by 11,391 participants. The questions explored sociodemographic features, psychiatric/addiction history, material conditions of lockdown, general stress, mental well-being, and reported changes in several addiction-related behaviors. Global changes were described and factors of increase were explored using population-weighted and adjusted logistic regression models, providing adjusted odds ratios (aORs) and their 95% confidence intervals.

Results: Overall, the respondents reported more increases in addiction-related habits than decreases, specifically 28.4% (caloric/salty food intake), 64.6% (screen use), 35.6% (tobacco use), 24.8% (alcohol use), and 31.2% (cannabis use). Reduced well-being scores and increased stress scores were general factors of increase in addiction-related habits ( P<.001 for all habits). Factors of increase in caloric/salty food intake (n=10,771) were female gender (aOR 1.62, 95% CI 1.48-1.77), age less than 29 years ( P<.001), having a partner (aOR 1.19, 95% CI 1.06-1.35), being locked down in a more confined space (per 1 square meter/person decrease: aOR 1.02, 95% CI 1.01-1.03), being locked down alone (aOR 1.29, 95% CI 1.11-1.49), and reporting current (aOR 1.94, 95% CI 1.62-2.31) or past (aOR 1.27, 95% CI 1.09-1.47) psychiatric treatment. Factors of increase in screen use (n=11,267) were female gender (aOR 1.31, 95% CI 1.21-1.43), age less than 29 years ( P<.001), having no partner (aOR 1.18, 95% CI 1.06-1.32), being employed ( P<.001), intermediate/high education level ( P<.001), being locked down with no access to an outdoor space (aOR 1.16, 95% CI 1.05-1.29), being locked down alone (aOR 1.15, 95% CI 1.01-1.32), living in an urban environment ( P<.01), and not working ( P<.001). Factors of increase in tobacco use (n=2787) were female gender (aOR 1.31, 95% CI 1.11-1.55), having no partner (aOR 1.30, 95% CI 1.06-1.59), intermediate/low education level ( P<.01), and still working in the workplace (aOR 1.47, 95% CI 1.17-1.86). Factors of increase in alcohol use (n=7108) were age 30-49 years ( P<.05), a high level of education ( P<.001), and current psychiatric treatment (aOR 1.44, 95% CI 1.10-1.88). The only significant factor of increase in cannabis use (n=620) was intermediate/low level of education ( P<.001).

Conclusions: The early phase of COVID-19 containment in France led to widespread increases in addiction-related habits in the general population. Reduced well-being and increased stress were universal factors of increase. More specific factors were associated with increases in each of the explored habits.

JMIR Public Health Surveill 2020;6(3):e19630

doi:10.2196/19630

Keywords

In March 2020, the outbreak of coronavirus disease (COVID-19) led the national authorities of most countries worldwide to implement extraordinary measures that dramatically restricted the mobility and social interactions of their populations with the aim of limiting transmission of the virus []. In this respect, many countries, including Italy, France, and Spain, decided to establish total or at least very strict lockdown. In France, this containment was announced by the President on March 16, and it went into effect at noon ECT on March 17, 2020 []. Only activities deemed "essential" were maintained; these included some medical activities but also activities related to the food supply, including access to alcohol as well as to tobacco and electronic cigarette shops. In France, as in other countries, due to this unprecedented situation, a large majority of the population became locked down at home overnight.

These containment measures, as well as the abrupt international health and economic crises caused by COVID-19, may have caused substantial stress in the population and thus may have significantly impacted people's general health and, more specifically, their mental well-being. Previous situations of reduced well-being and impaired social environment have been found to be associated with overeating and being overweight as well as increased substance and screen use [-]. In this context, it has been suggested that at-risk behaviors that are in the spectrum of addiction are likely to be exacerbated by the COVID-19 outbreak and the related containment but that this should be confirmed by studies [].

The LockUwell study is a nationwide web-based survey aiming to assess the overall effects of the official containment on the French general population with respect to mental well-being and general health conditions, including eating habits as well as screen and substance use. In this study, we describe the containment-related changes in the respondents' daily habits of eating, screen use, and substance use, and we explore the main characteristics of the participants who reported the most substantial changes.

Type of Study

An open web-based survey was launched on March 25, 2020, that is, 8 days after the official implementation of the containment in France.

The reporting of the survey follows the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) []. The completed checklist can be found in .

Recruitment

Any French-speaking person older than 16 years was invited to participate in the survey without restriction criteria provided they could complete the questionnaire autonomously. The link leading to the online survey was disseminated on the internet using social media (ie, Twitter, LinkedIn, and Facebook) and national media. The recruitment strategy thus followed a convenience sampling method. To prevent individuals from completing the questionnaire multiple times, only one questionnaire could be submitted from a particular IP address.

Questionnaire

The English version of the full questionnaire is available in . There was no preliminary assessment of the test-retest reliability or the internal consistency of the questionnaire; however, several tools included in it were previously validated in international studies.

The survey questions aimed to comprise a large range of items related to mental well-being and psychological distress and to collect sociodemographic and environmental data related to the situation of containment, such as total living space or number of persons sharing the house during the containment. The questionnaire was divided in six consecutive sections: 1) sociodemographic features; 2) the French version [] of the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS), which is a validated scale of 14 items that are rated from 1 to 5, leading to a single total score ranging from 14 (ie, minimum possible well-being) to 70 (ie, maximum possible well-being) to measure mental well-being in the general population []; 3) overall and specific (eg, professional, health-related, family) levels of stress, using a visual analog scale ranging from 0 (no stress) to 10 (maximum possible stress) []; 4) medical history, in particular the history of psychiatric and addiction treatment; 5) perceptions and apprehensions about COVID-19 and the related official measures; and 6) personal and environmental conditions under which participants were facing the lockdown and their consequences.

In particular, question F-25 explored whether respondents had changed their intake of caloric/salty food, their use of screens, and their use of substances (tobacco, alcohol, cannabis, and other drugs). The response modalities were 1) no usual use; 2) no change in use; 3) decrease with craving/withdrawal; 4) decrease without craving/withdrawal; 5) increase (moderate); and 6) increase (difficult to control).

Data Extraction and Preprocessing

The data were extracted on March 30, 2020, that is, 5 days after the start of the survey. For the present analysis, we included only respondents aged 16 years and older who completed the questionnaire and were living in France at the time when containment was declared. Among the 20,235 participants who started the questionnaire, 11,742 (58.0%) completed it. After excluding inoperable questionnaires and respondents from countries other than France, 11,391/20,235 questionnaires (56.3%) were included in the analyses. A complete flowchart is displayed in . Only the responses to questions A-1 to A-7, A-12 to A-14, A-16, B-1, C-1c, D-4b and D-4c, F-6 to F-9, F-17, and F-25 were used in this preliminary investigation.

Statistical Analysis

Statistical analyses were performed using SAS software version 9.4 (SAS Institute). To ensure respondents were representative of French residents aged 16 years and older, the data were weighted to French census targets for age and gender based on distributions reported in 2020 []. All descriptive and statistical tests were conducted using weighting variables. The descriptive statistics display categorical variables as the number and percentage of respondents (n, %), while quantitative variables are presented as mean (SD) or median (IQR). We explored caloric/salty food intake, screen use, and tobacco, alcohol, and cannabis use because insufficient data were collected regarding other substances. For each behavior and substance used, the different levels of subjective change (ie, no change, decrease with craving/withdrawal, decrease without craving/withdrawal, moderate increase, or difficult-to-control increase) are displayed.

Increase was expected to be a much more frequent pattern of change than decrease for all behaviors; therefore, we more deeply explored the parameters specifically associated with increase (both types of increase combined) in each type of behavior compared to other modalities of change using weighted logistic regression models. Respondents declaring no usual use were not included in the analyses. For each model, raw odds ratios (ORs) and adjusted odds ratios (aORs) are provided with their 95% confidence intervals. We entered the following variables in the model (each was adjusted with the others in the adjusted analyses): sociodemographic factors (age, gender, family, occupation, and educational level), psychiatric and addiction history, well-being (WEMWBS total score), stress (general stress VAS), housing conditions (surface, outdoor, geographical area) and working conditions during containment as explanatory variables. Multicollinearity was screened using the variance inflation factor and the COLLIN option in SAS.

The raw and weighted descriptive data of the 11,391 participants are shown in . The weighted sample consisted of 52.1% female respondents with a mean age of 47.47 years (SD 17.28).

The overall changes reported in the daily habits that were explored in the survey are displayed in .

Table 1. Descriptive characteristics of the survey population (N=11,391).

Characteristic

Values

Unweighted

Weighted

Age (years), mean (SD)

Gender, n (%)

Housing space (square meters/person), median (IQR)

34.67 (25-50)

40.00 (28-60)

Well-being (WEMWBS b score), mean (SD)

49.37 (8.12)

50.51 (8.17)

General stress (0-10 VAS c), mean (SD)

5.23 (2.35)

4.84 (2.43)

a ISCED: International Standard Classification of Education.

b WEMWBS: Warwick-Edinburgh Mental Well-Being Scale.

c VAS: visual analog scale.

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Figure 1. Changes in addiction-related habits in the early phase of COVID-19 containment in France from March 17 to 31, 2020.
View this figure

Regarding eating patterns, 6510/11,391 (57.14%) participants reported that they did not increase or decrease their average daily intake of caloric/salty food, whereas 2836 (24.89%) moderately increased their intake, 397 (3.49%) increased their intake in a difficult-to-control manner, 874 (7.67%) reduced their intake without craving, and 154 (1.35%) reduced their intake with craving.

With respect to screen use, 124/11,391 (1.09%) respondents declared that they did not usually use screens. Among the 11,267 remaining participants, 3784 (33.59%) reported that they did not change their average daily screen use, whereas 5545 (49.22%) declared having moderately increased their screen use, 1729 (15.35%) increased their screen use in a difficult-to-control manner, 179 (1.59%) reduced or stopped their screen use without craving/withdrawal, and 29 (0.26%) reduced their screen use with craving/withdrawal.

Concerning tobacco use, 2787/11,391 (24.47%) respondents reported that they were current smokers. Among the 2787 smokers, 1208 (43.27%) reported that they did not change their average daily use of tobacco, whereas 746 (26.72%) declared having moderately increased their tobacco use, 249 (8.92%) increased their tobacco use in a difficult-to-control manner, 432 (15.47%) declared that they reduced or stopped their tobacco use without craving/withdrawal, and 157 (5.62%) reduced their tobacco use with craving/withdrawal. Regarding alcohol use, 7108/11,391 (62.40%) respondents were found to use alcohol more or less regularly. Among them, 4109/7108 (57.82%) reported that they had not changed their average daily use of alcohol, whereas 1654 (23.27%) moderately increased their alcohol use, 107 (1.50%) increased their alcohol use in a difficult-to-control manner, 1167 (16.4%) declared having reduced or stopped without craving/withdrawal, and 70 (0.98%) having reduced with craving/withdrawal.

Finally, regarding cannabis use, 620/11,391 (5.44%) participants reported using cannabis. Among the, 263/620 (39.49%) reported that they had not changed their average daily use of cannabis, whereas 162 (24.32%) declared having moderately increased their cannabis use, 46 (6.91%) increased their cannabis use in a difficult-to-control manner, 150 (22.52%) reduced or stopped their cannabis use without craving/withdrawal, and 45 (6.76%) reduced their cannabis use with craving/withdrawal.

Raw and adjusted analyses of the factors associated with the increase in each of the explored habits can be found in and , respectively.

Table 2. Results of the unadjusted analyses exploring the increases in caloric/salty food, screen use, and substance use in the early phase of COVID-19 containment in France among the general population.

Characteristic

Caloric/salty food intake
(n=10,771; 3233 increase vs 7538 no increase)

Screen use (n=11,267; 7274 increase vs 3993 no increase)

Tobacco use (n=2787; 996 increase vs 1791 no increase)

Alcohol use (n=7108; 1761 increase vs 5347 no increase)

Cannabis use (n=666; 208 increase vs 458 no increase)

OR a (95% CI)

P value

OR (95% CI)

P value

OR (95% CI)

P value

OR (95% CI)

P value

OR (95% CI)

P value

Gender

Male

Reference

N/A b

Reference

N/A

Reference

N/A

Reference

N/A

Reference

N/A

Age (years)

50-64

0.50 (0.44-0.56)

<.001

0.50 (0.45-0.57)

<.001

0.71 (0.57-0.89)

.003

0.79 (0.67-0.93)

.005

0.36 (0.21-0.62) c

<.001

≥65

0.28 (0.23-0.31)

<.001

0.40 (0.35-0.45)

<.001

0.22 (0.16-0.31)

<.001

0.49 (0.41-0.59)

<.001

N/A

In a couple

Professional situation

Access to outdoor space

Living space

Confined with other people

Housing location

Working conditions

Not working

0.58 (0.51-0.65)

<.001

1.11 (0.99-1.24)

0.48 (0.39-0.59)

<.001

0.68 (0.58-0.79)

<.001

0.69 (0.43-1.11)

.13

Psychiatric treatment

Addiction treatment

a OR: odds ratio.

b N/A: not applicable.

c Due to power requirements, the age categories of 50-64 years and ≥65 years were pooled in the model exploring cannabis use increase.

d ISCED: International Standard Classification of Education.

e WEMWBS: Warwick-Edinburgh Mental Well-Being Scale.

f VAS: visual analog scale.

Table 3. Results of the adjusted analyses exploring the increase in caloric/salty food, screen use, and substance use in the early phase of COVID-19 containment in France among the general population.

Characteristic

Caloric/salty food intake (n=10,771; 3233 increase vs 7538 no increase)

Screen use (n=11,267; 7274 increase vs 3993 no increase)

Tobacco use (n=2787; 996 increase vs 1791 no increase)

Alcohol use (n=7108; 1761 increase vs 5347 no increase)

Cannabis use (n=666; 208 increase vs 458 no increase)

aOR a (95% CI)

P value

aOR (95% CI)

P value

aOR (95% CI)

P value

aOR (95% CI)

P value

aOR (95% CI)

P value

Gender

Male

Reference

N/A b

Reference

N/A

Reference

N/A

Reference

N/A

Reference

N/A

Other

1.17 (0.64-2.14)

.63

0.66 (0.35-1.25)

0.95 (0.32-2.78)

.93

0.26 (0.08-0.89)

.03

0.45 (0.07-2.74)

.39

Age (years)

50-64

0.54 (0.47-0.63)

<.001

0.68 (0.58-0.79)

<.001

0.71 (0.55-0.93)

.01

0.84 (0.69-1.01)

.07

0.48 (0.25-0.89) c

.02

≥65

0.42 (0.34-0.53)

<.001

0.65 (0.53-0.80)

<.001

0.32 (0.20 -0.50)

<.001

0.76 (0.56-1.07)

.10

In a couple

Professional situation

Educational level (ISCEDd 2011)

Access to outdoor space

Per 1-point increase

0.98 (0.97-0.98)

<.001

0.98 (0.97-0.98)

<.001

0.97 (0.96-0.98) c

<.001

0.97 (0.96-0.98)

<.001

0.96 (0.93-0.98)

<.001

Living space

Confined with other people

Housing location

Working conditions

Psychiatric treatment

Current

1.94 (1.62-2.31)

.31

0.92 (0.75-1.13)

.45

1.33 (0.94-1.88)

.10

1.44 (1.10-1.88) d

.008

1.12 (0.54-2.35)

.78

Addiction treatment

a aOR: adjusted odds ratio.

b N/A: not applicable.

c Due to power requirements, the age categories of 50-64 years and ≥65 years were pooled in the model exploring cannabis use increase.

d ISCED: International Standard Classification of Education.

e WEMWBS: Warwick-Edinburgh Mental Well-Being Scale.

f VAS: visual analog scale.

After adjustment, the respondents who reported increasing their caloric/salty food intake were more likely to be female, to be aged ≤30 years (see ), to have a partner, to be professionally active, a student, or a job seeker, to report a lower score of well-being and a higher score of general stress, to be locked down alone in a reduced space, and to report current or past treatment for psychiatric disorder (for ORs and 95% CIs, see ).

Based on the results of the multivariable logistic regression models, the respondents who reported increasing their screen use were more likely to be female, to be aged <30 years, to have no partner, to be professionally active, to have a relatively high level of education (ie, ISCED 4 or more), to report a lower score of well-being and a higher score of general stress, to be locked down alone, in a city, and with no access to an outdoor space, and to have stopped their professional activity because of the lockdown (for ORs and 95% CIs, see ).

After adjustment, the interviewees who reported increasing their use of tobacco were more likely to be female, to be aged <50 years, to have no partner, to be professionally active or a job seeker, to have a relatively low level of education (ie, ISCED 3 or less), to report a lower score of well-being and a higher score of general stress, and to continue working in the workplace (for ORs and 95% CIs, see ).

After adjustment, the individuals who reported increasing their alcohol use were more likely to be aged 30 to 49 years, to be professionally active or job seekers, to have a high level of education (ie, ISCED 5 or more), to report a lower score of well-being and a higher score of general stress, and to report current treatment for a psychiatric disorder (for ORs and 95% CIs, see ).

After adjustment, the participants who reported increasing their cannabis use were more likely to be aged <50 years, to have a relatively low level of education (ie, ISCED 4 or less), and to live in a dwelling with no access to an outdoor space (for ORs and 95% CIs, see ).

Principal Results

Overall, we found that increases were much more frequent than decreases for all the habits explored. Moreover, it appears that the use of screens increased greatly; 4125/11,391 (36.21%) of the survey population reported increased screen use, and 1729 (15.18%) noted difficulties in controlling their screen use.

The early impact of the COVID-19 outbreak and the related lockdown thus appear to be associated with substantial increases in the intake of caloric/salty food as well as in screen and substance use among the French population. In animal models, it is well-demonstrated that reducing social connections enhances stress; as a result, increases are observed in both eating and weight [] as well as in substance use [,]. In humans, epidemiological studies on this topic are more limited, as situations of abrupt reduction in social interaction at the population level are relatively uncommon. However, analogies can be made to studies that investigated individuals enrolled in armed forces during conflicts, which revealed that the social interactions of the individuals were dramatically reduced and that their substance use increased in parallel. For example, studies by Lee Robins [] among US soldiers who were sent to Vietnam in the 1970s found an important reduction in social interactions accompanied by an important increase in the use of opioids by soldiers during their presence in the field; meanwhile, these patterns of use rapidly and almost completely disappeared after the soldiers returned home. A comparison with our findings should be made with caution, as a situation of war is in no way comparable with that of the COVID-19 lockdown. However, the results of our survey are in line with the fact that a substantial reduction of social habits can be associated with enhanced stress and boredom and thus with increases in addiction-related habits.

Furthermore, our findings enlighten both common aspects and singularities between habits in the profiles of respondents who reported increases. Overall, reduced mental well-being and greater overall stress were shared risk factors of increase for all habits. A current or past history of addiction treatment did not appear to impact the observed changes; this is noteworthy because the respondents were supposed to be more vulnerable to stress and were thus expected to increase or relapse in addictive behaviors []. More specifically, the typology of respondents who increased their habits substantially differed depending on the habit. Respondents who increased their intake in caloric/salty foods were primarily young women who were living in smaller dwellings and were locked down alone. Previous studies have demonstrated that emotional eating in stressful environments is more common in women [,]. It can thus be hypothesized that women who faced the stress induced by the COVID-19 crisis and the related containment coped more by consuming caloric/salty food relative to men. In this context, living alone in a smaller space or reporting past or current treatment for psychiatric disorder can be seen as additional sources of stress.

Survey respondents who reported increasing their screen use were more likely to be female, less than 30 years of age, single, locked down alone, living in an urban area, without access to an outdoor space, and not working. Stress is also a well-demonstrated risk factor of increasing screen use; it is more expressed in younger people, although usually more commonly in men [,]. Living alone is another known risk factor for increased screen use [,], and this factor was certainly accentuated during the lockdown. Similarly, not working was previously found to be associated with increased internet use []. Interestingly, a previous study found that increased use of the internet in a stressful environment was more frequent in young people living in urban areas []. This is in line with our findings, which can be explained by a more confined environment in this case. However, fewer respondents who were currently working in the workplace reported increased screen use compared to telecommuting respondents; this also suggests that enhanced screen use is related to telecommuting in some cases.

Among tobacco smokers, the main risk factors for increased smoking were also being female, age less than 50 years, being single, and low level of education. In line with these findings, female gender, younger age, lower socioeconomic status, and psychological distress are the main factors associated with tobacco use []. It thus appears that the same risk factors that are associated with tobacco use in general were associated with increasing tobacco use in the case of the COVID-19 lockdown.

The profile of respondents who increased their alcohol use was different, as this increase preferentially affected people aged 30 to 49 years with high levels of education. A possible explanation is that increased use of alcohol may be less stigmatized than that of tobacco or cannabis, as people who use cannabis and tobacco in France are globally younger, have lower income, and are less educated [,]. For this reason, alcohol use may have increased more than tobacco or cannabis use among more educated and middle-aged respondents. In line with this hypothesis, respondents who reported increased cannabis use more specifically consisted of very young workers with low levels of education. This reflects the population of regular users of cannabis in France, which is mainly aged less than 30 years []. Moreover, while no study has specifically explored this issue in France, international epidemiological studies have revealed that cannabis use is inversely correlated with level of education []. In sum, our findings suggest that increased stress and impaired well-being were common risk factors for increases in all types of addiction-related habits during the early phase of the COVID-19 lockdown in France. However, other sociodemographic characteristics and individual features related to lockdown conditions were associated with increases in more specific habits, thus reflecting a specific vulnerability of some parts of the French population with regard to the different habits explored, namely caloric/salty food intake, screen use, or tobacco, alcohol, or cannabis use.

Limitations

Our study was a web-based survey performed on a convenience sample with no a priori representativeness of the French population. Although our analyses were weighted based on several basic sociodemographic parameters, we cannot exclude the possibility that important parts of the French population were overrepresented or underrepresented, which may have had an impact on our findings. For example, although illiterate people represent a limited part of the French population, we acknowledge that participating in the survey would be difficult for them without external help. Given the context, however, it would be difficult to rapidly set up a study with more thorough methodological features. Despite this, the rate of tobacco smokers in our study (24.47%) was close to that observed in the French population (25.2% in 2018 []). Similarly, 62.40% of our sample declared that they used alcohol; meanwhile, the rate of French adults who used alcohol at least once per year in 2018 was 87%, while the rate of adults who used alcohol at least once a week was 49% []. However, a gap was found for cannabis use; 5.4% of our sample reported using this substance, whereas the rate of current users in the adult French population is estimated to reach 11% []. This gap may result from social desirability bias, which is the tendency to underreport socially undesirable attitudes and behaviors and to overreport more desirable attributes; this bias is more pronounced with illicit substances [].

Another limitation pertains to what is conveyed under the notion of "screen use," which can actually involve many habits, such as video gaming, social networking, or teleworking. The interview may thus have lacked precision on this point, and interpreting the participants' answers may thus have been more difficult. An additional limitation is that the data we analyzed only pertained to the early phase of the lockdown, and it is perfectly possible that several findings reflected short-term adjustment behaviors that may not be durably sustained over the remaining phase of the lockdown. Another limitation is that we did not explore the interrelations in the changes between habits; thus, we did not explore overlaps in terms of affected populations. Finally, the assessment of how individual habits had changed was entirely subjective with no precise quantification in either terms of amounts or time, which limits the accuracy of the data.

Comparison With Prior Work

To our knowledge, no previous study has assessed the impact of a national COVID-19 containment measure on eating habits, screen use, or substance use. The increases found in our survey were hypothesized in a recent literature report []; however, our contribution provides the first data supporting these assumptions.

Conclusions

The early phase of COVID-19 containment in France was associated with a substantial proportion of survey respondents reporting increased caloric/salty food intake, screen use, and tobacco, alcohol, and cannabis use. The increase was particularly large for screen use, which affected two-thirds of the sample. Furthermore, the profiles of individuals who increased their habits displayed shared features, particularly poorer well-being and increased stress; however, specificities between each type of increase also revealed some populational singularities, particularly related to gender, age category, and level of education. Thus, targeted prevention messages should be developed to address the types of habits to which subcategories of the population are more vulnerable during and after the containment period.

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Global Changes and Factors of Increase in Caloric/Salty Food Intake, Screen Use, and Substance Use During the Early COVID-19 Containment Phase in the General Population in France: Survey Study

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Background: The international outbreak of coronavirus disease (COVID-19) has led many countries to enforce drastic containment measures. It has been suggested that this abrupt lockdown of populations will foster addiction-related habits such as caloric/salty food intake, screen use, and substance use.

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https://link.springer.com/article/10.1186/s12955-022-01968-0

Research Method:

1. Random stratified sampling

Strength: Accurately represent population

Weakness: Imbalanced representation of population in the subgroups

2. Self-report

a. Social Support Rating Scale

b. Short form 36 health survey (S-36)

c. Health Promoting Lifestyle Profile

Strength: Allows a larger sample size (e.g. the study had a sample size of N=8526)

Weakness: Bias (e.g. Participants may be dishonest in their responses)