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. 2022 Dec 13;69:151664. doi: 10.1016/j.apnr.2022.151664

Fear of COVID-19 and social distancing on the health behavior of coronary heart disease patients

Kyungsook Kim a, Jungok Yu b,⁎
PMCID: PMC9747228  PMID: 36635018

Abstract

Purpose

This study aimed to provide basic data to improve the health behavior of patients diagnosed with coronary artery disease during pandemics such as that caused by coronavirus disease 2019 (COVID-19) by identifying the fear of COVID-19 and the degree of social distancing behavior of coronary patients.

Methods

In this study, 162 patients diagnosed with coronary artery disease who received follow-up care at the cardiovascular center of Dong-A University Hospital in Busan were selected. The variables examined in this study included subjects' general characteristics and disease-related characteristics, fear of COVID 19, social distancing behavior, and health behavior. Data were collected from June 8–25, 2021, and data analysis was performed using the IBM SPSS26.0 program.

Results

The results showed that older participants, those who were religious, those with cohabitants, and those who showed better compliance with social distancing showed better health behavior practice. Factor with the greatest influence on the health behavior of patients with coronary artery disease was social distancing behavior (β = 0.299, p < .001).

Conclusion

After the COVID-19 pandemic, it is necessary to develop a health care program to promote the health behavior of high-risk patients, including coronary artery disease, in preparation for the COVID-19 era. The younger the patient, the fewer health activities are undertaken when living alone, so appropriate education and support for these individuals should increase the rate of implementation of health activities for coronary artery disease.

Keywords: Coronary artery disease, Fear of COVID-19, Social distancing behavior, Health behavior

1. Introduction

The World Health Organization, on March 11, 2020, declared the coronavirus disease 2019 (COVID-19) pandemic as the incidence and mortality of COVID-19 increased worldwide (World Health Organization, 2020). Many nations have implemented stringent social distancing policies to minimize the spread of COVID-19, and more people stayed at home for longer periods. Although patients with chronic diseases, including those with coronary artery disease (CAD), should make regular hospital visits to check their health condition and get prescriptions, planned hospital admissions and outpatient visits were canceled due to fear of infection of COVID-19 (Sokolski et al., 2021).

CAD is the number one cause of death, disability, and human suffering globally (Khan et al., 2020). Due to the nature of the disease, patients with CAD are at high risk of recurrence and require continuous management (Meier & Timmis, 2012). Active health behavior of patients with CAD is essential to prevent the mortality and recurrence rates from increasing (Korea Center for Disease Control and Prevention Agency, 2021a, Korea Center for Disease Control and Prevention Agency, 2021b).

Fear of COVID-19 positively affected infection prevention behavior, such as hand washing and social distancing (Harper et al., 2020). Fear of COVID-19 also negatively affected health behavior as smoking and drinking increased with higher fear of COVID-19 (Nguyen et al., 2020). Social distancing is an effective and key way to prevent COVID-19 infection (Painter & Qiu, 2021). One study showed that patients with illnesses complied more with social distancing than health professionals or the general public by postponing or canceling going out, gathering, or traveling and coming straight home after their business if they had to go out (Kim, 2020). However, people have suffered from mental health problems, such as psychological stress, anxiety, and depression due to social distancing (Brooks et al., 2020), and daily and physical activities decreased (Schuch et al., 2020). Isolation restrictions increased the intake of delivered food at home and led to irregular eating habits, increasing obesity (Ahmed, 2020). These are associated with an increased risk of cardiovascular diseases (Lavie et al., 2018).

Health behaviors, such as quitting smoking, stopping drinking, physical activities, dietary control, and exercise for managing obesity and maintaining a healthy weight, reduce mortality and the risk of recurrence in patients with CAD. However, it is not known how the COVID-19 pandemic affects health behaviors in these patients. This study aimed to investigate how the fear of COVID-19 and social distancing behaviors affect health behaviors in patients with CAD.

2. Methods

2.1. Study design

This was a cross-sectional study conducted in a single institution to identify the effects of fear of COVID-19 and social distancing behaviors on health behaviors in patients with CAD.

2.2. Participants

The study included patients diagnosed with CAD and received follow-up at an outpatient clinic of the Cardiovascular center of Dong-A University Hospital located in Busan. The inclusion criteria included subjects: 1) aged ≥20 years; 2) diagnosed with angina or myocardial infarction per the International Classification of Disease, Tenth Revision; 3) who were receiving drug therapy or being followed at our outpatient clinic after percutaneous coronary intervention (PCI) or coronary artery bypass grafting; 4) who fully understood the purposes of the study and voluntarily agreed to participate in the study.

The minimum sample size for multiple regression analysis was calculated to be 157, Using G*power software, considering the effect size (f) of 0.15, significance level (α) = 0.05, power = 0.90, and 12 variables. In the present study, 162 copies of a questionnaire were distributed. Since there were no missing answers, all 162 participants were included in the final analysis.

2.3. Measures

Different measures were used to achieve the objectives of this study. These include the Fear of COVID-19, social distancing behaviors and cardiovascular-related health behaviors.

2.4. Fear of COVID-19

To assess fear of COVID-19, the Fear of COVID-19 Scale, which consists of a total of seven items and was developed by Ahorsu et al. (2020), was considered; we used its Korean version translated by Seong et al. (2020), and its validity and reliability were tested. Higher scores on this scale indicate a higher level of fear of COVID-19. Cronbach's α was 0.87 in a study by Seong et al. (2020), while Cronbach's α was 0.86 in the present study.

2.5. Social distancing behaviors

To assess social distancing behaviors against COVID-19, a scale with 15 items, developed by Heo et al. (2021), was used. Higher scores indicate better compliance with social distancing behaviors against COVID-19. Reliability testing of the scale in a study by Heo et al. (2021) revealed a Cronbach's α of 0.91. In this study, Cronbach's α was 0.90.

2.6. Health behaviors

To assess health behaviors, the Health Promoting Lifestyle Profile, first developed by Walker et al. (1987), was considered: we used its modified version with added cardiovascular-related health behaviors by Song et al. (2018). The scale comprises 21 items (health responsibility: five items; exercise: four; diet: six; stress management: three; and smoking: three), and higher scores indicate better compliance with health behaviors. Cronbach's α for this measure was 0.83 in the study by Song et al. (2018) and 0.85 in the present study.

2.7. Ethical considerations

This study was conducted after approval by the Institutional Review Board of Dong-A University Hospital (DAUHIRB-21-119).

2.8. Data collection

Data were collected from June 8 until 25, 2021. The study included patients being followed up for CAD at the outpatient clinic of our Cardiovascular Center. With the cooperation of responsible doctor and the nursing department, we described the purposes and methods of the study directly to the patients and obtained their consent to participate in the study. Participants completed the questionnaire while they were waiting for the doctor. It took approximately 10–20 min to complete the questionnaire.

2.9. Data analysis

The collected data were analyzed as follows using the IBM SPSS 26.0 program. The frequency, percentage, mean, and standard deviation (SD) were used to analyze the participants' domographic and disease-related characteristics, fear of COVID-19, social distancing behaviors, and health behaviors. Differences in the level of fear of COVID-19, social distancing behaviors, and health behaviors by demographic and disease-related characteristics were analyzed by a t-test and an analysis of variance. Scheffe's test was used for posthoc testing. The correlation between fear of COVID-19, social distancing behaviors, and health behavior was analyzed using Pearson's correlation coefficient. A multiple regression analysis was performed to identify factors affecting participants' health behavior.

3. Results

3.1. Participants characteristics

Participants' demographic and disease-related characteristics are summarized in Table 1 . A total of 162 participants (107 [66.0 %] men and 55 [34.0 %] women) engaged in this study and the average age was 66.9 (±12.23) years. Most participants (118 [72.8 %]) lived with a family, while 44 participants (27.2 %) lived alone. Regarding participants' vaccination status, 84 (51.9 %) were unvaccinated, while 78 (48.1 %) were vaccinated. 111 participants (68.5 %) were diagnosed with CAD 1 year ago or before.

Table 1.

Differences in health behaviors according to the participants' general characteristics (N = 162).

Characteristics Categories n % COVID-19 fear
 Social distancing
 Health Behavior
Mean ± SD t or F p Mean ± SD t or F p Mean ± SD t or F p
16.44 ± 5.84 65.38 ± 8.79 65.61 ± 9.71
Gender Male 107 66 15.28 ± 5.45 −3.64 <0.001 64.44 ± 9.12 −1.91 0.580 65.26 ± 9.72 1.19 0.236
Female 55 34 18.69 ± 5.95 67.21 ± 7.87 63.34 ± 9.67
Age (years) 20–40a 4 2.5 11.75 ± 5.50 0.77 0.380 56.25 ± 12.84 8.71 0.004 (b,c,d > a) 46.75 ± 5.05 9.23 0.003 (b,c,d > a)
41–60b 42 25.9 16.28 ± 5.46 63.59 ± 9.00 61.85 ± 9.75
61–80c 93 57.4 16.70 ± 6.09 65.79 ± 8.66 66.79 ± 9.05
81–90d 23 14.2 16.47 ± 5.84 68.60 ± 6.80 63.91 ± 8.59
Educational level None 5 3.1 17.60 ± 8.14 1.04 0.308 64.40 ± 7.40 3.65 0.580 55.20 ± 2.58 2.00 0.158
Elementary 23 14.2 16.82 ± 4.40 66.91 ± 8.22 62.91 ± 9.46
Middle school 31 19.1 17.48 ± 6.22 67.25 ± 9.13 66.00 ± 9.06
High school 59 36.4 15.94 ± 6.06 65.94 ± 7.85 65.06 ± 10.11
≥College 44 27.2 16.04 ± 5.79 62.63 ± 9.82 64.97 ± 9.89
Living alone Yes 44 27.2 15.95 ± 6.82 0.65 0.516 64.88 ± 9390 0.44 0.658 61.72 ± 9.90 2.33 0.021
No 118 72.8 16.62 ± 5.45 65.57 ± 8.38 65.68 ± 9.46
Religion Yes 105 64.8 16.50 ± 5.88 −0.17 0.859 66.01 ± 8.70 −1.23 0.217 66.58 ± 9.50 −3.63 <0.001
No 57 35.2 16.33 ± 5.81 64.22 ± 8.92 60.98 ± 9.10
Occupation No 87 53.7 17.26 ± 5.83 1.81 0.071 67.17 ± 7.86 2.91 0.004 65.48 ± 8.26 5.68 0.213
Yes 75 46.3 15.60 ± 5.69 63.20 ± 9.41 63.51 ± 11.19
Monthly income (10,000 won) <100 53 32.7 17.58 ± 5.73 1.36 0.244 67.43 ± 7.09 7.41 0.007 62.73 ± 8.65 0.53 0.466
100–199 37 22.8 15.08 ± 5.25 66.21 ± 9.05 67.35 ± 10.21
200–299 35 21.6 17.00 ± 6.02 64.28 ± 10.14 64.37 ± 9.84
≥300 37 22.8 15.44 ± 5.84 62.67 ± 8.87 64.78 ± 10.25
Covid-19 Vaccine Yes 78 48.1 16.69 ± 6.14 0.51 0.604 65.83 ± 8.34 1.62 0.537 65.97 ± 9.11 1.73 0.085
No 84 51.9 16.21 ± 5.57 64.97 ± 9.23 63.34 ± 10.13
Diagnosis (Months) <3 14 8.6 16.71 ± 5.63 0.58 0.447 67.71 ± 7.45 0.01 0.891 64.21 ± 11.28 0.50 0.478
3 ∼ 6 12 7.4 17.75 ± 5.83 64.58 ± 6.96 62.08 ± 11.04
6 ∼ 12 25 15.4 16.92 ± 5.13 62.84 ± 8.66 64.32 ± 11.16
>12 111 68.5 16.16 ± 6.05 65.75 ± 9.11 65.00 ± 9.10
Comorbidities Yes 71 43.8 14.97 ± 5.85 −2.89 0.005 64.09 ± 9.59 −1.65 0.990 63.98 ± 9.77 −0.72 0.471
No 91 56.2 17.59 ± 5.60 66.39 ± 8.03 65.09 ± 9.69
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3.2. Level of fear of COVID-19, social distancing behaviors, and health behavior in patients with CAD

In patients with CAD, the mean score for the level of fear of COVID-19 was 2.15 ± 1.10/5 points, while the mean score for social distancing behaviors was 4.35 ± 0.86/5 points. The mean score for health behavior was 3.07 ± 0.88/5 points. Among the sub-categories of health behavior, the highest score was 3.79 ± 0.46 points for smoking, followed by 3.18 ± 0.57 points for diet, 3.04 ± 0.66 points in health responsibility (health monitoring), 2.69 ± 0.79 for exercise, and 2.69 ± 0.71 points for stress management.

3.3. Differences in the level of fear of COVID-19, social distancing behaviors, and health behavior by general and disease-related characteristics

In terms of differences in fear of COVID-19 by demographic and disease-related characteristics, gender and presence of comorbidities were found to be significantly influential factors. In terms of differences in social distancing behaviors by demographic and disease-related characteristics, age, occupation, and income were significantly influential factors. In terms of differences in health behavior by demographic and disease-related characteristics, age, living alone, and religion were significantly influential factors (Table 1).

3.4. Correlations between fear of COVID-19, social distancing behaviors, and health behavior

Correlations between fear of COVID-19, social distancing behaviors, and health behavior in patients with CAD revealed that health behavior was positively correlated with social distancing behaviors. Fear of COVID-19 was not seen to be significantly correlated with either health behavior or social distancing behaviors (Table 2 ).

Table 2.

Correlation between the fear of COVID-19, social distancing behavior, and health behavior (N = 162).

Variables Fear of COVID-19 r(p) Social distancing behavior r(p)
Fear of COVID-19
Social distancing behavior 0.127 (0.106)
Health behavior 0.001 (0.990) 0.366 (<0.001)
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3.5. Factors affecting health behavior in patients with CAD

The tolerance and variance inflation factor (VIF) were calculated to investigate factors affecting health behavior in patients with CAD to test collinearity among independent variables. The tolerance of each variable was 0.922–0.996 (≤1.0) and the VIF was 1.004–1.085 (≤10), indicating that there was no multicollinearity among independent variables. Since the Durbin Watson statistic was 2.019, indicating that autocorrelation did not exist, regression analysis results were reliable. The variable with the greatest influence on health behavior adherence in patients with CAD was social distancing behaviors, followed by religion, age, and living alone. The total explanatory power of the variables was 22.5 % (F = 12.67, p < .001, R2 = 0.244, Adjusted R2 = 0.225; Table 3 ).

Table 3.

Factors influencing health behaviors of patients with coronary artery disease (N = 162)

B SE β t p
Social distancing behavior 0.330 0.079 0.299 4.16 <0.001
Religion (ref: no) 4.319 1.429 0.213 3.02 0.003
Age 0.135 0.057 0.170 2.34 0.020
Living alone (ref: no) −3.36 1.514 −0.155 −2.22 0.028
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4. Discussion

This study aimed to provide basic information for improving health behavior in patients with CAD in the COVID-19 pandemic by assessing the level of fear of COVID-19 and social distancing behavior and determining how the factors affect health behavior in patients with CAD.

The mean score for the level of participants' fear of COVID-19 in this study was 2.15/5 points. The mean score was 3.54 in a study in healthy adults using the same scale (Seong et al., 2020), and it was 3.15 in a study in older adults aged ≥65 years (Kwon & Seong, 2021). The reason the mean fear of COVID-19 score reported in this study was lower than that from previous studies is that data were collected during the period when infection control was stable; and the number of daily confirmed COVID-19 cases was approximately 500 (Korea Center for Disease Control and Prevention Agency, 2021b) due to the government's successful quarantine response.

This discrepancy may also be attributable to the fact that the study was conducted after COVID-19 vaccination began and before variants, such as the delta variant, emerged when participants' fear of COVID-19 was relatively mild. In a study on fear of COVID-19 by country (Lin et al., 2021), among 10 countries, the highest scores were reported in Iran, at 3.9 points, and the lowest score was reported in New Zealand, at 2.02 points. These results are deemed to be associated with infection control; the number of confirmed COVID-19 cases and the mortality rate were high in Iran with poor infection control measures, resulting in high fear of COVID-19, while the confirmed cases and mortality rates were low in New Zealand with good infection control measures.

Since the 2015 Middle East Respiratory Syndrome outbreak, the Korean Government designated central and local hospitals specializing in infectious diseases, made the designation of temporary isolation facilities by city and province mandatory, and expanded the number of epidemiological investigation centers as part of the government's reform plan for effective countermeasures against novel infectious diseases (Ministry of Health and Welfare, 2015). With a high-quality medical system and countermeasures, the mortality rate due to COVID-19 was low in Korea, which might have contributed to the low levels of fear of COVID-19 in this study, similar to those seen in New Zealand.

In terms of fear of COVID-19 according to participants' characteristics, women showed higher levels of fear of COVID-19 than men, consistent with the results of several previous studies (Kwon & Seong, 2021). In one study, since women were more likely than men to be psychologically vulnerable, women showed higher levels of stress, anxiety, depression, and sleep problems during the COVID-19 pandemic (Broche-Pérez et al., 2020), and fear of COVID-19 can be interpreted in the same context. Patients with co-morbidities (hypertension, diabetes and dyslipidemia) had higher levels of fear of COVID-19 than without comorbidities. The higher level of fear of COVID-19 may have resulted from information stating that patients with chronic diseases were more vulnerable to COVID-19 infection than the healthy population (Bae et al., 2021).

The mean score for social distancing behaviors in participants in this study was 4.35/5 points. In a previous study, which used the same scale as in this study to assess social distancing behaviors in patients, healthy persons, and healthcare professionals (Heo et al., 2021), the mean scores were 4.61, 4.39, and 4.35 points in patients, healthcare professionals, and healthy individuals, respectively. Han and Choi (2021) reported that since social distancing behaviors are important to prevent the spread of infection during the pandemic period, Korea, with a strongly collectivist culture, may have adopted social distancing behaviors without resistance amid the COVID-19 pandemic. The high social distancing behavior score in this study was thought to result from such norms' effects on social distancing behaviors.

The level of compliance with social distancing was relatively lower among younger participants with jobs and relatively high incomes. The level of compliance with social distancing in Korean adults assessed in a study (Han & Choi, 2021) is consistent with that in adults in North America and Europe assessed in a previous study (Coroiu et al., 2020). Since young people are more involved in social and economic activities than older adults, it is more difficult for them to comply with a code of conduct that promotes isolation.

In this study, the participants' mean health behavior score was 3.07/4 points, similar to that in recent studies using the same scale to assess health behaviors in patients with CAD. The mean score was 3.13 in a study by Jeong (2021) and 2.92 in a study by Jung et al. (2021). Compliance is high regarding health behaviors related to smoking and eating habits in patients with CAD. However, compliance was low for health behaviors related to exercise, showing that exercise was not performed sufficiently or regularly. Education on the importance of exercise and continuous public relations and education for practicing exercise even during the COVID-19 pandemic are thought to be required to promote healthy behavior in patients with CAD.

Health behavior according to participants' characteristics was significantly influenced by age, cohabitants, and religion. Fear of COVID-19 was not significantly correlated with health behavior, but social distancing behavior has the greatest impact on health behavior. Isolation due to social distancing promotes a decrease in daily activities, such as work, leisure activity, shopping, and walking (Schuch et al., 2020), and can cause obesity due to increased intake of delivered food and irregular eating habits (Ahmed, 2020). But, in this study, the level of practice of health behavior was higher as the level of compliance with social distancing behaviors was better, contrary to the results from previous studies. Individuals who attempt to willingly comply with health behavior, such as social distancing, during the epidemic are also willing to comply with other health behaviors for CAD.

In a previous study assessing the significant effects of religion, religion was not clearly associated with health behavior in patients with CAD. However, in a study investigating the effects of religion in older adults on health-promoting behavior (Yi & Kim, 2016), regardless of the type of religion, those who attended any worship were more likely to better comply with health behavior than those without religion, supporting the results of this study.

Participants with a spouse or child were found to practice better health behavior than those living alone. This is consistent with the results from a previous study (Jeong, 2021) and implies that family members' practical help and emotional support contribute to improving health-promoting behavior. Accordingly, specific and practical health-promoting policies and support for patients who live alone during the pandemic are required.

This study has some limitations. First, this study collected the data for assessment after vaccination against COVID-19 began and before any viral variants emerged when the participants' fear of COVID-19 was relatively mild, which should be considered when interpreting the study results. Second, since participants in this study overcame their fear of COVID-19 and were willing to visit the hospital during the pandemic, we did not include those who could not visit the hospital. CAD patients who did not visit the hospital during the COVID-19 pandemic may have higher fear of COVID-19 than patients who visited the hospital, and the characteristics of diseases such as CAD severity scores may be different. Third, this study collected data about patients with CAD who visited the outpatient clinic of one university hospital, so the study findings cannot be generalized to explain the health behaviors of every patient with CAD. Therefore, future studies are required by expanding participants. Despite these study limitations, this study is significant in that it provides basic data to improve health behavior in patients with CAD during the COVID-19 pandemic by determining the level of fear of COVID-19 and compliance with social distancing in these patients and investigating how those variables affect health behavior.

5. Conclusion

This study was conducted to provide basic data to improve health behavior in patients with CAD in pandemic situations, such as COVID-19, by determining the levels of fear of COVID-19 and compliance with social distancing and identifying how those variables affect health behaviors. The results showed that older participants, those who were religious, those with cohabitants, and those who showed better compliance with social distancing showed better health behavior practices.

Based on this study's results, we would like to make the following suggestions: first, patients with CAD showed poorer health behaviors at younger ages and when living alone. For those patients, a program of appropriate education and support should be developed to improve their health behaviors. Second, since there is a lack of studies on the effects of fear of COVID-19 and social distancing behaviors on health behaviors in patients with CAD, repeated and expanded studies are required to elucidate this. Lastly, a health management program should be developed to promote health behaviors in patients with CAD, which is appropriate for the COVID-19 endemic era following the COVID-19 pandemic.

Ethical considerations

This study was conducted after approval by the Institutional Review Board of Dong-A University Hospital (DAUHIRB-21-119).

CRediT authorship contribution statement

K.S. Kim conceptualized and designed the study, designed the data collection instruments, collected data, draf- ted the initial manuscript, and reviewed and revised the manuscript. J.0.Yu assisted with design of the study and data collection instruments, drafted initial manuscript and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Declaration of competing interest

There are no conflicts of interest to declare.

Acknowledgments

The authors would like to thank all patients who participated in this study.

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