Geomatics, Natural Hazards and Risk

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Public reactions to the disaster COVID-19: a

comparative study in Italy, Lebanon, Portugal, and
Serbia

Adem Öcal, Vladimir M. Cvetković, Hoda Baytiyeh, Fantina Maria Santos

Tedim & Miodrag Zečević

To cite this article: Adem Öcal, Vladimir M. Cvetković, Hoda Baytiyeh, Fantina Maria Santos
Tedim & Miodrag Zečević (2020) Public reactions to the disaster COVID-19: a comparative study
in Italy, Lebanon, Portugal, and Serbia, Geomatics, Natural Hazards and Risk, 11:1, 1864-1885,
DOI: 10.1080/19475705.2020.1811405

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GEOMATICS, NATURAL HAZARDS AND RISK
2020, VOL. 11, NO. 1, 1864–1885
https://doi.org/10.1080/19475705.2020.1811405

Public reactions to the disaster COVID-19: a comparative

study in Italy, Lebanon, Portugal, and Serbia
€ a, Vladimir M. Cvetkovicb, Hoda Baytiyehc, Fantina Maria Santos
Adem Ocal
Tedim and Miodrag Zecevice
d

a
Independent Researcher, Ankara, Turkey; bFaculty of Security Studies, University of Belgrade,
Belgrade, Serbia; cDepartment of Education, American University, Beirut, Lebanon; dFaculty of Arts
and Humanities, University of Porto, Porto, Portugal; eFaculty of International Engineering
Management, European University, Belgrade, Serbia

ABSTRACT ARTICLE HISTORY

A new coronavirus emerged in December 2019 and quickly Received 22 June 2020
spread globally, causing unprecedented social, psychological, and Accepted 12 August 2020
economic damage. This study aimed to investigate people’s emo-
KEYWORDS
tional reactions to the COVID-19 pandemic. The dataset for this
Pandemic; stress; anxiety;
study consisted of 2,013 adults (962 males and 1,053 females) in depression; adult; COVID-19;
four countries (Italy, Lebanon, Portugal, and Serbia). A snowball emotion; disaster; disease
sampling technique that focused on recruiting the general public
living in countries during the COVID-19 epidemic was utilized. An
online survey was disseminated at the same time, in March–April
2020, when many countries were exposed to COVID-19. Results
indicated that, with regard to gender, females had more psycho-
logical reactions to COVID-19 than did males. People who had
one child were more stressed than people with no children.
Extensive knowledge of COVID-19 was found to trigger more anx-
iety. Results showed that stress and overall emotional reactions
increased with age. The findings can be used to develop psycho-
logical interventions to improve mental health and psychological
resilience during the COVID-19 epidemic.

1. Introduction
A previously unknown virus and disease were identified after an outbreak in
December 2019 in Wuhan, China. The novel virus was designated by the World
Health Organization (WHO) as the 2019-novel coronavirus (nCoV). The WHO for-
mally named the disease caused by the nCoV as ‘COVID-19’ (novel coronavirus
2019) on 11 February 2020 (WHO 2020a). Since this disease spread globally, affected
many people of all ages, and it was shown that early symptoms vary and may depend
on one’s age and pre-existing conditions, the WHO declared COVID-19 a pandemic

CONTACT Vladimir M. Cvetkovic [email protected]

Supplemental data for this article is available online at https://doi.org/10.1080/19475705.2020.1811405.
ß 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
 GEOMATICS, NATURAL HAZARDS AND RISK 1865

on 11 March 2020, resulting in the 2019–2020 coronavirus pandemic (CDC 2020a).

The initial COVID-19 outbreak spread globally much faster than previous outbreaks
(Peeri et al. 2020). Today the COVID-19 outbreak continues to spread all over the
world. The total number of COVID-19 cases has surpassed 15 million with more
than 620,000 virus-related deaths (WHO 2020b). While some communities appear to
be more prepared than others for such biological hazards, all governments around
the world are racing to understand and limit the spread of the new coronavirus as
part of their response phase. During this ongoing response phase, major side effects
have often been overlooked, namely the anxiety and fear of citizens.
People can show various psychological reactions to extraordinary events in the
world. Some of them are weak, but others can be strong and have deadly results.
Anxiety is defined as a concern to do something or for something to happen with an
uncertain outcome. Many previous studies have shown that anxiety is an inseparable
part of life among people facing the unknown. In the medical field, it has been specu-
lated that ‘fear of pain and what we do about it may be more disabling than pain
itself’ (Waddell et al. 1993, p. 164). Anxiety is built on fear, the source of which
depends on the underlying conditions. For example, in chronic pain, the highest cor-
relations were found among pain-related fear measures and measures of self-reported
disability and behavioral performance (Crombez et al. 1999). Stress is a type of psy-
chological pain that occurs in response to various physical, professional, or emotional
frustrations. These frustrations become stressors when they exceed normal limits of
one’s sense of well-being. Consequently, the sustained experience of stress may lead
to physical and mental symptoms, such as anxiety and depression (King et al. 1987).
Researchers believe that anxiety-prone people tend to appraise any situation they
face as threatening (Spielberger et al. 1970; Gregory 2000). People who are inclined to
be anxious have increased attention to external signals with a high tendency to inter-
pret uncertain information in a threatening manner; thus, they continuously scan the
environment for possible threats (Beck 1976; Tellegen 1985). Lazarus (1966) believes
that threat perception may lead to one of two statuses: a fight or a flight response.
Non-anxious people are the ones who adopt a fight response, and they would be
ready to exhibit some preparedness behavior in response to an imminent danger. The
anxious-prone persons are the ones who adopt a flight response filled with emotions,
but at the same time they may look for options and precautions to implement in
times of danger.
Overall, the available literature does not allow one to draw a substantial conclusion
on the role of anxiety in the preparedness behavior of communities in times of pan-
demic. Some studies examined risk perceptions and emotions during the early stage
of the 2009 (H1N1) influenza pandemic in Britain, Hong Kong, Australia, Malaysia,
Europe, and the US (Chor et al. 2009; Seale et al. 2010). These studies found that pre-
cautionary behaviors were associated with anxiety about H1N1 influenza (Goodwin
et al. 2009; Jones and Salathe 2009; Rubin et al. 2009; Lau et al. 2010; Setbon and
Raude 2010), risk perceptions (Chor et al. 2009; Jones and Salathe 2009; Lau et al.
2010), and the efficacy of the precautionary behaviors (Rubin et al. 2009; Lau et al.
2010). It was also found that the incidence of H1N1 influenza in the US has substan-
tial geographical variation; consequently, the real risk of infection varies
1866 A. ÖCAL ET AL.

geographically (CDC 2020b). Previous research suggested that both psychological and
medical interventions are necessary to improve the quality of life in patients (Nikolic
et al. 2019; Cvetkovic 2020). Therefore, such an investigation would add to the exist-
ing self-report measures targeting the psychological impacts of the pandemic on com-
munities. Understanding individuals’ behavior and their relation to their perceived
risk is, therefore, important in terms of effective control of an infectious disease out-
break (Leung et al. 2003).
The relationship between anxiety and perception of other disasters has been incon-
sistent in the literature. Recent COVID-19 studies found that precautionary measures
were associated with lower levels of anxiety, especially in the workforce (Tan et al.
2020). A little anxiety related to COVID-19 caused some positive situations in different
countries, such as improvements in health and air and water quality (Chauhan and
Singh 2020; Kumari and Toshniwal 2020; Singh and Chauhan 2020). Previous research-
ers found that anxiety was negatively related to the expectation of flooding (de Man
et al. 1984). Later, researchers reported that elevated anxiety scores were positively
related to the expectation of greater household flood damage (Simpson-Housley et al.
1986; Cvetkovic et al. 2018). It was also found that people with high anxiety scores
tended to expect more earthquake and volcanic damage than subjects with low anxiety
scores (Larraın and Simpson-Housley 1990). Furthermore, Kushnir (1982) indicated
that estimates of the probability of suffering an injury from a falling satellite were sig-
nificantly associated with high anxiety scores. Other researchers believe that anxiety is a
cognitive bias; thus, people with high anxiety are likely to develop clinical anxiety while
under stress (Mogg and Bradley 1999). Such cognitive bias may negatively affect their
preparedness behavior. For example, Johnson (1997) showed that high anxiety, coupled
with feelings of low self-efficacy, may lead to denial, anger, guilt, or hopelessness.
Stress and depression, or ‘depressogenic vulnerabilities’, are theorized to share a
transactional relation where each influences the other in a bidirectional manner. In
fact, Hammen (1991) posited the ‘stress generation hypothesis’, which suggests that
depressed individuals are mostly influenced by negative beliefs and expectations of
experiencing negative events in their lives. Therefore, these individuals are not only
vulnerable to depression when confronted with life stressors but also generate the
stressors that increase their risk for depression.
The hopelessness theory, defined as a cognitive vulnerability–stress theory of
depression, suggests that a negative prediction will lead to depression when individu-
als encounter negative life events (Abramson et al. 1989). According to the cognitive
vulnerability–stress component of this theory, the depressogenic style is hypothesized
to interact with negative life events and lead to increased depressive symptoms.
In this model, some cognitive processes, such as the combination of both helpless-
ness and hopelessness, would lead to both anxiety and depression. However, it is
assumed that hopelessness without helplessness would lead to only depression. Later,
Hankin and Abramson (2001) suggested that the interaction of cognitive vulnerability
with negative events would lead to specific risk factor for depression. Nonetheless,
the occurrence of negative events without high cognitive vulnerability would lead to
general negative affect such as externalizing and internalizing associated with anxiety
and depression (McMahon et al. 2003).
 GEOMATICS, NATURAL HAZARDS AND RISK 1867

Table 1. Some socio-economic information of the study countries.

GDP per capita (USD) Gini coefficient 65 and older population Median age
Italy 34.488 0.359 22.08 46.5
Lebanon 8.270 0.318 7.96 33.7
Portugal 23.403 0.338 20.92 44.6
Serbia 7.246 0.362 20.0 43.4
CIA (2020).
WB (2020).

As COVID-19 resulted from an unexpected outbreak, the current situation may

provide an opportunity to examine how new information affects risk perceptions and
hence, how changes in risk perceptions influence behavior. This is an under-
researched area during the COVID-19 pandemic (Tran et al. 2020). Because anxiety
plays a role in the preparedness and the response to any disaster (Rico 2019), the
objective of this paper is to investigate the level of adults’ anxiety related to the
COVID-19 outbreak in four countries: Italy, Lebanon, Portugal, and Serbia.

1.1. Context of the study

Serbia and Lebanon have the lowest GDP per capita, compared to Italy and Portugal.
However, the elderly population in Lebanon is only 7.0%. Serbia has respectively
lower 65 and older age population than Portugal and Italy (Table 1). Italy and
Portugal have older populations (median age; Portugal ¼ 44.6, Italy ¼ 46.5), respect-
ively. The median age of the countries ranges from 33.7 years old (Lebanon) to
46.5 years old (Italy) (CIA 2020; WB 2020).
The information on the countries in which the study was conducted is not limited
to the above. To better understand the situations related to the effects of the COVID-
19 pandemic in these countries, their specific cases are also summarized.

1.1.1. Italy
Italy’s population is about 60.3 million, and its population density is higher than that
of most Western European countries. The novel infectious disease, COVID-19, was
first confirmed to have spread to Italy on 31 January 2020, when two Chinese tourists
in Rome tested positive for the virus. A cluster of cases was later detected, starting
with 14 confirmed cases in Lombardy on February 21, and the first deaths occurred
on February 22 (Balmer 2020). By the beginning of March, the virus was spreading
rapidly and had reached all regions of Italy. The Italian government suspended all
flights to and from China and declared a state of emergency on January 31. The
prime minister expanded the quarantine to all of Lombardy and 14 other northern
provinces on 8 March 2020, and on the following day to all of Italy.
Despite these measures, the outbreak continued to spread, so the Italian govern-
ment prohibited nearly all commercial activity except for supermarkets and pharma-
cies. After 11 March 2020, the government ordered the closure of all non-essential
businesses and industries, with additional restrictions on the movement of people
from March 21. The virus in the country has mostly affected those aged 50 and over.
As of 24 July 2020, the total number of confirmed cases was 245,032 with 35,082
deaths in Italy (WHO 2020b).
1868 A. ÖCAL ET AL.

1.1.2. Lebanon
Lebanon’s population is around 6 million, including Palestinian refugees and dis-
placed Syrian communities. The first COVID-19-positive case in Lebanon was offi-
cially identified on February 21 as a 45-year-old woman traveling from Iran (Francis
2020). Other cases were later reported, with those infected arriving from other coun-
tries such as Egypt, the United Kingdom, and France. On February 28, the minister
of education announced the closure of all educational institutions. On March 10, the
first virus-related death case was reported, and on the evening of March 18 the
Beirut Rafic Hariri International Airport was shut down and Lebanon went into lock-
down. Although the spread of the virus appears to be under control and officials in
Lebanon are striving to use all means to contain the pandemic, its evolution remains
uncertain for most physicians, especially since the health sector has been negatively
impacted by the latest economic crisis in the country (Huot 2020). The COVID-19
virus additionally burdened the Lebanese government and community, which have
been struggling since the fall 2019 revolution. The Lebanese lira has lost around 40%
of its value against the US dollar in recent months, which means goods are becoming
more expensive, including medicine and medical supplies. As of 24 July 2020, the
total number of confirmed cases is 3,105, with 43 deaths in Lebanon (WHO 2020b).

1.1.3. Portugal
Portugal’s population is about 10.3 million. The first COVID-19-positive cases were
recorded on March 2 and were imported from Italy and Spain (DGS 2020a). The
number of imported cases slowly increased in the following weeks, and on April 22,
imported cases from 51 countries had been recorded. They originated mainly from
Spain (171 positive cases), France (130), the United Kingdom (82), the United Arab
Emirates (46), and Switzerland (45). The first victim of COVID-19 was registered on
March 16, and on April 27, Portugal had reached 880 fatalities. About 67% of those
fatalities were people over the age of 80. No victims under 40 years old have been
recorded so far (DGS 2020b). Despite the progressive spread of COVID-19 across the
country, its impact continues to be characterized by high regional heterogeneity,
mainly when one takes into account, in addition to the absolute numbers of cases
and deaths, relative indicators according to the size of administrative units and their
population density (INE 2020). The mass media, television programs, provide daily
information on COVID-19 and the measures to be adopted by the population to
combat this disease. Portuguese society, similar to many others, has adapted to a new
way of life, and most members of the community follow the recommendations pro-
vided by the government. The total number of confirmed cases as of July 24, 2020 is
267,551, with 1,702 deaths in Portugal (WHO 2020b).

1.1.4. Serbia
Serbia’s population is about 7.1 million. The first COVID-19 case was registered (offi-
cially on March 6), and a state of emergency was declared on March 15.
Subsequently, a significant number of provisions and orders were formulated in
Serbia. First, citizens older than 65 years in urban areas and those aged 70 and above
in rural areas were prohibited from leaving their households all day, with permission
 GEOMATICS, NATURAL HAZARDS AND RISK 1869

granted to go shopping only early in the morning on Sundays. Starting from April
21, this category of citizens was granted the right to leave their household three times
a week. Various economic and trade measures have been enacted, including restric-
tions on the prices of basic groceries, bans on exports of medicines and medical
equipment, etc. The government closed cafes and restaurants, casinos, bookmakers,
hairdressers and beauty salons, car wash facilities, all markets (both outdoors and
indoors), all facilities and outlets within shopping malls except supermarkets, grocery
stores, and pharmacies. Caterers were obliged to establish a delivery service that
would deliver take-out food and drink or to arrange a counter through which food
and drink would be sold without entering the catering facility. Social media and net-
works monitoring and delivering government representative announcements indicated
problems in adhering to the envisaged measures, especially in the first weeks of the
state of emergency. These could probably be the consequence of the change in per-
spective in this less than a month-long period, which could lead to confusion among
the general public. The total number of confirmed cases as of 24 July 2020 is 22,031
with 499 deaths in Serbia (WHO 2020b).

1.2. Theoretical framework

Lazarus (1999) suggested a complex cognitive model of stress to understand subjects’
responses when facing extremely stressful events that include three principal compo-
nents: primary appraisal, secondary appraisal, and coping resources. Primary assess-
ment is defined as the perception of the threat, which is the process of assessing the
impact of the situation on one’s physical and psychological well-being. Secondary
appraisal is a temporary stage that occurs following primary assessment and is
defined as the cognitive evaluation concerned with what the individual can do to
handle the present threat, such as blame or credit, as well as future expectancies.
Coping potential is highly related to control status, especially how much people
believe can be done to reduce or eliminate the source of threat. Coping resources are
essential for proactive coping such as health, income, and social support (Hobfoll and
Lerman 1989). Moreover, available societal resources may increase the feeling of con-
trol, which consequently enhances coping potential and may result in better disaster
preparedness.
For this study, a scale was tailored to the COVID-19 pandemic. It was also
assumed that the inconsistent relation between a rise in anxiety score and the percep-
tion of potential disaster might be due to other factors such as demographics and
social characteristics (e.g. gender, age, education, number of children, and country).
Therefore, this set of hypotheses is based on the following assumptions:

 women tend to show more anxiety and concern than men;

 younger individuals tend to show lower anxiety scores;
 less-educated individuals may have a poor understanding of COVID-19 and its
associated risks, which may lead to exaggerated anxiety;
 married individuals and those with children are more likely to be concerned about
the threat of the virus and its consequences on their families;
1870 A. ÖCAL ET AL.

Figure 1. Study countries – Italy, Lebanon, Portugal, and Serbia.

 finally, each country possesses different levels of preparedness in their health sec-
tor for response and recovery, which may lead to different anxiety scores across
the four countries with social, cultural, and economic differences.

2. Methods and data

2.1. Study area
The significance of the present study lies in testing the anxiety level related to
COVID-19 in four countries (Figure 1) that differ in culture, population size, and age
structure. However, all countries are located between 33  47 N latitude, and
almost all have similar climates (subtropical climate zone – Mediterranean climate),
except Serbia (temperate climate zone). Also, the study countries were similar in
terms of the distribution of inequality, in that all countries have a little low Gini coef-
ficient (Italy, 0.354; Lebanon, 0.318, Portugal, 0.355; Serbia, 0.396). The Gini coeffi-
cient ranges from 0 to 1, with 0 representing perfect equality and 1 representing
perfect inequality (WPR 2020). It can be said that all countries have similar inequality
properties, which means that the wealth or income distribution in each country is
similar, while the countries’ overall wealth or income differed.

2.2. Instrumentation and data collection

An online questionnaire in the four national languages was prepared for each of the
four countries. A snowball sampling strategy, focused on recruiting the general public
 GEOMATICS, NATURAL HAZARDS AND RISK 1871

living in countries during the COVID-19 epidemic, was utilized. The online survey was
distributed to the sample during the same period, March–April 2020, after the WHO
declared (on March 11) COVID-19 as a pandemic. All countries were exposed to
COVID-19 while the scale was being conducting. As governments recommended the
public to minimize face-to-face interactions and isolate themselves at home, existing
study respondents electronically invited potential respondents. The participants were
reached via social media tools (Twitter, Facebook, Instagram, etc.) and e-mails to pre-
sent the questionnaire in each country, and they responded in their local languages
through an online survey platform (Google.doc). Our research conformed to the
Helsinki Declaration, outlining the principles for socio-medical research involving
human subjects. Participants provided informed consent to participate in the study. All
variables used tick boxes to determine the reasons for the acceptance or refusal of the
items. The structured scale consisted of items that covered two sections: a) demographic
data, b) the psychological impact of the COVID-19 outbreak and mental health status.
Demographic data were collected on gender, age, educational level, marital status,
country, having a child or children, and level of COVID-19 knowledge.
In the process of preparing the questionnaire, previous surveys on the psychological
impacts of pandemic diseases were reviewed (Lovibond and Lovibond 1995; Buhr and
Dugas 2002; Leung et al. 2003; Rubin et al. 2009). The Anxiety of Coronavirus
(COVID-19) Scale (ACS) was adopted based on both the Intolerance of Uncertainty
Scale (IUS) and the Depression, Anxiety and Stress Scale (DASS-21), which were self-
report measures of anxiety, depression, and stress. The authors included additional
items (11 items) related to the COVID-19 outbreak. The revised scale consisted of 32
items to measure anxiety related to the COVID-19 pandemic, 2019–2020.
For the reliability study, the questionnaire was administered on 150 adults in
Belgrade/Serbia. The internal consistency (Cronbach’s alpha) of the overall scale was
0.918. Each subscale ranged from .84 for the Anxiety subscale, .85 for the Stress sub-
scale, and .86 for the Depression subscale.
The correlation results between total scores and the subscales were investigated
using Pearson’s linear correlation coefficient. Preliminary analyses were performed to
prove that the assumptions of normality, linearity, and homogeneity of variance were
satisfied. A strong positive correlation between total scores and all subscales scores
was found. Anxiety (r ¼ .833, p < .01), Stress (r ¼ .907, p > .01), and Depression (r
¼ .796, p < .01) increase with total scores of the scale (Table 2). It means each sub-
scale had a strong relation to the overall scale.
The main scale was assessed on a four-point Likert-type scale to determine the
level of anxiety to a possible COVID-19 pandemic (1 ¼ ‘did not apply to me at all’
and 4 ¼ ‘applied to me very much, or most of the time’). Respondents were asked to
rate (1 to 4) their emotional statements related to COVID-19 illness. The scale was
first translated into Serbian, Portuguese, Arabic, and Italian, and then conducted in
the respective national language of each country.

2.3. Basic socio-economic and demographic information of the respondent

The authors spent great effort in each country to reach the participants selected
through snowball sampling. The questionnaire was answered by adults aged 18 and
1872 A. ÖCAL ET AL.

Table 2. Basic socio-economic and demographic information of respondents (n ¼ 2,013).

Variable Category (f) %
Country Portugal 971 48.3
Lebanon 429 21.3
Serbia 408 20.3
Italy 205 10.2
Gender Male 962 47.7
Female 1,053 52.3
Age 18–30 937 46.5
31–45 674 33.5
46–64 388 19.3
65þ 14 0,7
Marital status Single 804 39.9
In connection 396 19.7
Married 733 36.4
Divorced or widow 80 4.0
Education Primary Sch. (grade 4–5) 34 1.7
Secondary Sch. (grade 8–9) 111 5.5
High school (grade 11–12) 658 32.7
Undergraduate 687 34.1
Master/doctorate 523 26.0
Number of children 1 319 15.8
2–3 408 20.3
4þ 91 4.5
None (0) 1,195 59.4
COVID-19 knowledge Very poor 15 0.7
Poor 79 4.0
Moderate 857 42.6
Good 916 45.5
Excellent 146 7.3
TOTAL 2,013 100

over. Participants were excluded if the researcher experienced communication diffi-

culties with them. In total, 2,073 participants completed the questionnaire. Before the
analysis, all data were controlled, and multivariate outliers of the data were separated
from the data set. Finally, our data set for this study constituted 2,013 adults: 962
male and 1,053 female (Table 2). There were 205 participants from Italy, 429 from
Lebanon, 971 from Portugal, and 408 from Serbia. Of the participants 46.5% are
18–30 and 33.5% are 31–45 years old. In terms of marital status, 39.9% are single,
and 36.4% are married. For educational status, 32.7% had finished high school, 34.1%
had a bachelors or undergraduate school, and 26.0% had a masters/doctorate. Most
of the participants had no dependent child (59.4%); however, 20.3% had 2–3 children,
and 15.8% had only one child.
The participants generally defined their COVID-19 knowledge as ‘good’ (45.5%),
and ‘moderate’ 42.6%.

2.4. Statistical analysis

In this study, for the demographic characteristics of the participants, descriptive sta-
tistics, were calculated. Statistical analyses included analysis of variance (one-way
ANOVA), Pearson’s correlation coefficient (r), and the multivariate linear regression
model. To examine the relationship between the variables (except age) and the partic-
ipants’ anxiety scores, one-way ANOVA was used (Figure 2). For the age variable,
the relationship was analyzed with the Pearson correlations coefficient. Besides, the
 GEOMATICS, NATURAL HAZARDS AND RISK 1873

Figure 2. The study design.

Table 3. Results of a multivariate regression analysis concerning total scores and subscales scores
(anxiety, stress and depression) (n ¼ 2,013).
Total score Anxiety Stress Depression
Predictor variables B SE b B SE b B SE b B SE b
Gender 5.22 .628 .187 2.24 .275 .183 2.03 .254 .179 1.02 .212 .109
Age 1.93 .740 .069 .114 .324 .009 1.32 .300 .116 .573 .250 .061
Marital .420 .744 .015 1.14 .326 .092 .026 .301 .002 .744 .251 .078
Education .594 2.38 .005 1.87 1.04 .039 .777 .968 .018 .290 .807 .008
Children 1.53 .902 .040 .278 .395 .017 1.16 .366 .075  .635 .305 .050
Knowledge 1.73 .623 .062 1.25 .272 .102 .555 .253 .049 .072 .208 .008
p  .05.
p  .01 B: unstandardized (B) coefficients; SE: std. error; b: standardized (b) coefficients.
Note: males, the youngest, single-headed households, secondary educated respondents, having no children, and hav-
ing very poor knowledge (having lowest scores in ANOVA) coded as 0; 1 has been assigned otherwise.

multivariate linear regression model was used to determine the predictors of overall
anxiety scores and subscale scores. All tests were two-tailed, with a significance level
of p < 0.05. Statistical analysis was performed using SPSS Statistic 17.0 (IBM SPSS
Statistics, New York, United States).

3. Results
Starting from the abovementioned methodological framework, the results were div-
ided into two categories:

 The predictors of anxiety, stress, and depression related to COVID-19;

 The relations between the variables and anxiety, stress, and depression about
COVID -19.

3.1. Predictors of anxiety, stress, and depression related to COVID-19

To examine the factors associated with the overall scale and subscales, we performed
regression analyses, with the four scales as the dependent variable (Table 3). We
1874 A. ÖCAL ET AL.

Figure 3. The predictors for emotional reactions about Covid-19.

tested the central hypothesis of which gender and age are predicting variables of citi-
zen preparedness for a pandemic disaster. A multivariate regression analysis was
used, identifying the extent to which total scores of the main dependent variables
(anxiety, stress and depression) were associated with seven socio-economic variables:
gender, age, marital status, education level, number of children, and COVID-19
knowledge. Previous analyses showed that the assumptions of normality, linearity,
multicollinearity and homogeneity of variance had not been violated.
The multivariate regression analyses indicated that gender was the most effective
predictor of the overall scale and subscales. Further analysis showed that the most
important predictor for total score is gender (b ¼ .187), which explains the 18.7%
variance in total score, followed by the age (b ¼ .069, 6.9%), and COVID-19 know-
ledge (b ¼ .062, 6.2%). The remaining variables did not have significant effects on
the total score. This model (R2 ¼ .072, Adj. R2 ¼ .069, F ¼ 22.34, t ¼ 74.60, p ¼ .000)
with all mentioned independent variables explains the 6.9% variance of total score
(Figure 3).
The results of the multivariate regressions of anxiety show that the most important
predictor is gender (b ¼ .183), which explains the 18.3% variance in anxiety, fol-
lowed by COVID-19 knowledge (b ¼ .102, 10.2%) and marital status (b ¼ .092,
9.2%). The remaining variables (e.g. age, education level, number of children) did not
have significant effects on anxiety. This model (R2 ¼ .63, Adj. R2 ¼ .60, F ¼ 19.34,
t ¼ 85.68, p ¼ .000) with all mentioned independent variables explains the 60% vari-
ance of anxiety (Table 3).
Concerning to stress subscale, analyses showed that the most important predictor
is gender (b¼ .179), which explains the 17.9% variance in anxiety; followed by age
(b ¼ .116, 11.6%), number of children (b ¼ .075, 7.5%) and COVID-19 know-
ledge (b ¼ .049, 4.9%). The remaining variables did not have significant effects on
stress. This model (R2 ¼ .69, Adj. R2 ¼ .66, F ¼ 21.31, t ¼ 76.85, p ¼ .000) with all
mentioned independent variables explains the 66% variance of stress (Table 3).
In addition, the results of the multivariate regressions of depression show that the
most important predictor is gender (b ¼ .109), which explains the 10.9% variance
in depression, followed by marital status (b ¼ .078, 7.8%) and age (b ¼ .061, 6.1%).
 GEOMATICS, NATURAL HAZARDS AND RISK 1875

The remaining variables did not have significant effects on depression. This model
(R2 ¼ .56, Adj. R2 ¼ .53, F ¼ 16.9, t ¼ 66.83, p ¼ .000) with all mentioned independ-
ent variables explains the 53% variance of depression (Table 3).

3.2. The relations between the variables and anxiety, stress, and depression
about COVID -19
Considering the importance of citizens’ anxiety, stress, and depression due to
COVID-19, respondents were asked to rate varying attitudes on the Likert scale rang-
ing from 1 to 5. With respect to the total scores, the respondents mostly pointed out
that they had been washing their hands all the time for fear of getting the virus
(X ¼ 2.95), and they felt life was meaningless (X ¼ 1.29). In relation to each country,
respondents in Portugal had the most scores (X ¼ 3.16) to wash their hands all the
time because of fear of getting COVID-19. After Portugal, Lebanon (X ¼ 3.10) and
Italy (X ¼ 2.62) most frequently reported washing their hands.
Although Italian participants do the least amount of exercise for antivirus purposes
(X ¼ 1.20), in this regard, Lebanese participants have the highest average (X ¼ 1.55),
compared to other countries. Among all respondents, the Italians mostly thought that
life was meaningless (X ¼ 1.43), while the Serbian participants did not share this sen-
timent (X ¼ 1.20). Respondents in Serbia, for the most part, pointed out that they
wear masks while having face-to-face conversation (X ¼ 2.54), while those in Portugal
had the lowest mask usage (X ¼ 1.46) (Table 4).
In this study, we conducted an analysis in relation to gender and found that
females have higher scores than men in total scores [male/female (X) ¼ 56.68/61.43,
p  .01], anxiety [male/female (X) ¼ 23.46/25.65, p  .01], stress [male /female (X)
¼ 19.08/20.74, p  .01], and depression [male/female (X) ¼ 14.14/15.05, p  .01]
subscales (Table 5).
The ANOVA results reveal that respondents from Serbia have lower scores than
respondents from Lebanon, Portugal, and Italy compared to total scores (X ¼ 55.13),
stress (X ¼ 18.34), and depression subscales (X ¼ 12.95) (p < .01). The obtained
results showed a higher degree of resilience to psychological impacts from COVID-19
among Serbian respondents compared with those in other countries in the study.
Concerning anxiety levels, Lebanese respondents have higher anxiety scores
(X ¼ 27.34) than respondents in other countries. Respondents from Italy have higher
anxiety scores (X ¼ 25.15) than respondents from Portugal (X ¼ 23.59) (p < .01). In
the stress subscale, Lebanese respondents have lower scores (X ¼ 19.70) than
Portuguese respondents (X ¼ 20.69) (p < .01). Additionally, Lebanese respondents
have lower scores (X ¼ 14.12) than Portuguese respondents (X ¼ 15.23) and Italians
(X ¼ 16.01) in the depression subscale (p < .01) (Table 6).
Regarding marital status, it was found that single persons (X ¼ 24.07) have lower
scores than married persons (X ¼ 25.02) for anxiety. Also, single persons (X ¼ 19.50)
have lower scores than married persons (X ¼ 20.44) in the stress subscale (Table 6).
In the education dimension, secondary school respondents (X ¼ 54.82) have lower
scores than masters/doctorate respondents (X ¼ 60.99) in total scores. It was also
found that secondary (X ¼ 18.03) school respondents have lower scores than masters/
1876 A. ÖCAL ET AL.

Table 4. Results of descriptive analysis of attitudes (n ¼ 2,013).

Italy Lebanon Portugal Serbia Total scores
Variables X SD X SD X SD X SD X SD R
I feel that I have the virus whenever 1.75 .89 1.46 .63 1.57 .69 1.35 .66 1.52 .70 30
I cough.
A bad headache can be a sign of 1.86 .77 1.89 .89 2.00 .78 1.72 .89 1.91 .83 13
COVID-19.
I feel that I have fever whenever I 1.65 .76 1.64 .88 1.43 .66 1.43 .79 1.50 .75 26
am hot.
I think about hospitalization whenever 1.63 .80 1.79 .88 1.60 .78 1.21 .51 1.56 .79 28
I feel Shortness of breath.
Whoever coughs around me means 1.77 .78 2.00 .89 2.15 .80 1.66 .82 1.98 .85 9
that the disease will spread in
my body.
I do a lot of exercise because I am 1.20 .53 1.55 .75 1.45 .66 1.28 .61 1.41 .67 27
afraid to get the virus.
I wash my hands all the time because 2.62 .91 3.10 .92 3.16 .87 2.48 1.13 2.95 .98 1
I am afraid to get the virus.
I don’t get out from home in fear of 2.44 1.10 3.01 .96 2.42 .97 2.23 1.07 2.51 1.07 2
the virus.
I take vitamins because I am afraid to 1.41 .67 1.87 1.09 1.44 .76 1.98 1.05 1.64 .92 21
get the virus.
I don’t let anyone coming home 2.53 1.02 2.93 1.00 1.54 .80 2.20 1.16 2.07 1.10 7
because I am afraid to get
the virus.
I put a mask whenever I talk to 2.09 1.14 2.07 1.04 1.46 .78 2.54 1.20 1.87 1.07 14
anyone face to face.
I put gloves whenever I talk to 1.44 .88 1.72 1.06 1.27 .59 1.95 1.14 1.52 .91 31
anyone face to face.
Thinking about COVID-19 makes my 2.06 .94 1.90 .93 1.79 .87 2.20 1.11 1.92 .95 12
heart jitter.
If I get the virus, I will die. 1.28 .56 1.72 .97 1.83 .70 1.38 .69 1.66 .78 19
I find COVID-19 hard to wind down. 2.25 .80 2.07 .89 2.38 .93 2.32 1.00 2.29 .93 4
I find it difficult to work up the 2.03 .75 1.96 .75 1.93 .93 2.19 1.10 2.00 .92 8
initiative to do things.
I tend to overreact to situations. 2.03 .84 1.78 .81 1.78 .81 1.85 .96 1.82 .85 17
I feel that I have nothing to 1.71 .78 1.67 .88 1.74 .94 1.45 .84 1.66 .90 20
look forward.
I feel down-hearted and blue. 2.00 1.09 1.57 .81 2.00 .89 1.64 .87 1.83 .90 15
I feel that I am tired. 2.40 .84 2.22 .94 2.82 .91 1.89 .97 2.46 .99 3
I am worried about situations in 2.00 .91 1.68 .83 1.56 .78 1.31 .59 1.58 .79 23
which I may panic and make a fool
of myself.
I found myself getting agitated each 2.12 .92 2.11 .94 2.43 .92 2.02 .88 2.25 .93 5
time I hear about the new
infected cases.
I find it difficult to relax. 2.02 .90 1.90 .91 2.62 .89 1.72 .91 2.22 .98 6
I feel intolerant of anything. 1.84 .96 1.72 .79 1.72 .72 1.54 .79 1.70 .78 18
I feel that I am close to panic. 1.75 .74 1.66 .86 1.41 .65 1.31 .62 1.48 .72 25
I am unable to become enthusiastic 2.14 .81 1.80 .78 1.90 .89 1.54 .83 1.83 .86 16
about anything.
I feel I am not worth much as 1.97 1.03 1.58 .82 1.63 .85 1.24 .59 1.57 .84 24
a person.
I become obsessed of my 1.89 .71 2.11 .92 1.94 .82 1.73 .90 1.93 .86 11
individual cleanness.
I feel scared without any good reason. 1.73 .71 1.50 .80 1.67 .53 1.42 .72 1.59 .67 22
I feel that life is meaningless. 1.43 .66 1.36 .71 1.26 .57 1.20 .58 1.29 .62 32
I feel that I am rather very sensitive. 2.31 .95 1.93 .97 1.92 .88 1.77 .98 1.93 .94 10
The thought of having COVID-19 1.82 .97 1.74 1.07 1.55 .76 1.25 .65 1.56 .85 29
makes me cry.
Note: numbers are linked with questions from the questionnaire.
R – Range; X – mean; SD – mean.
 GEOMATICS, NATURAL HAZARDS AND RISK 1877

Table 5. Independent samples t-test results between gender and the anxiety, stress, and depres-
sion on COVID-19.
Variable N % Total scores X (SD) Anxiety X (SD) Stress X (SD) Depression X (SD)
Male (M) 960 47.7 56.68 (13.17) 23.45 (5.52) 19.08 (5.36) 14.13 (4.44)
Female (F) 1053 52.3 61.43 (14.28) 25.64 (6.46) 20.74 (5.84) 15.04 (4.82)
df 2010.73 2002.94 2010.94 2010.76
t 7.767 8.180 6.633 4.412
p .000 .000 .000 .000
p  .01.

doctorate respondents (X ¼ 20.01) in the stress subscale. Persons holding a masters/

doctorate degree (X ¼ 26.26) have higher scores than all the others in the anxiety sub-
scale. In contrast, bachelors/undergraduate degree holders (X ¼ 14.27) have lower
scores than those who finished high school (X ¼ 15.03) in the depression subscale.
It was also found that respondents who have no (0) children (X ¼ 16.65) have
lower scores than respondents having one child (X ¼ 20.98) in the stress subscale.
Respondents who have a moderate level (X ¼ 23.92) of COVID-19 knowledge have
lower scores than respondents who have good or excellent (X ¼ 26.68) knowledge of
the disease in the anxiety subscale (Table 6).
To examine the relation between age and the scale, we conducted two analyses.
ANOVA analyses (Table 6) indicated persons aged 18–30 years have lower scores
(X ¼ 58.26), than those aged 31–45 (X ¼ 60.18) in total scores (p < .05). In the stress
dimension, persons aged 18–30 years (X ¼ 19.27), have lower stress scores than those
31–45 (X ¼ 20.64), and those 46–64 years old (X ¼ 20.43) persons (p < .01).
Moreover, the correlation results between age and total scores and subscales were
investigated using Pearson’s linear correlation coefficient. Preliminary analyses were
performed to prove that the assumptions of normality, linearity, and homogeneity of
variance were satisfied. A slightly positive correlation between age and stress was
found, r ¼ .089 n ¼ 2,013, p < .0001, indicating that stress increases with age. A
slight positive correlation between age and total scores was also found; r ¼ .045,
n ¼ 2,013, p < .0005 (Table 7).

4. Discussion
Since early 2020, the entire world has been talking about the novel coronavirus (Sars-
CoV2), and its related disease, COVID-19. Continuous outbreaks of COVID-19 affect
those all over the world, resulting in negative health impacts, economic losses, death,
unemployment, etc. According to Kwok et al. (2020), high risk-perception toward
COVID-19 was found in the community, with anxiety levels higher than an influenza
pandemic but lower than Severe acute respiratory syndrome (SARS-2003).
Geographical risk perception differs according to various variables such as the cumu-
lative number of confirmed cases, cumulative confirmed number of deaths, structure
of the states (urban vs. rural), socio-economic status, sex, household size, population
structure, and level of preparedness when encountering a pandemic disease.
We investigated four countries in the study for a geographical perspective. Results
showed that Serbian respondents had higher resilience to COVID-19 than the other
1878 A. ÖCAL ET AL.

Table 6. ANOVA results between demographic variables and the anxiety, stress, and depression
on COVID-19 (n ¼ 2,013).
Total scores Depression
Variables Categories N (%) X (sd) Anxiety X (sd) Stress X (sd) X (sd)
Country Serbia 408 (20.3) 55.13 (14.07) 23.84 (6.80) 18.34 (5.51) 12.95 (4.73)
Lebanon 429 (21.3) 61.17 (13.64) 27.34 (6.24) 19.70 (6.16) 14.12 (3.72)
Portugal 971 (48.3) 59.51 (13.43) 23.59 (5.14) 20.69 (5.34) 15.23 (4.83)
Italy (I) 205 (10.2) 61.34 (15.29) 25.15 (6.93) 20.17 (5.85) 16.01 (4.44)
F/Sig. 16.48 (.000) 42.55 (.000) 17.22 (.000) 32.04 (.000)
Age 18-30 937 (46.5) 58.26 (13.30) 24.47 (6.01) 19.27 (5.53) 14.51 (4.68)
31-45 674 (33.5) 60.18 (14.66) 24.94 (6.53) 20.64 (5.82) 14.60 (4.53)
46-64 388 (19.3) 59.60 (14.18) 24.31 (5.69) 20.43 (5.60) 14.86 (4.82)
65þ 14 (0.7) 58.50 (14.42) 24.71 (4.95) 19.21 (5.45) 14.57 (5.43)
F/Sig. 2.64 (.047) 1.12 (.337) 8.88 (.000) .496 (.685)
Marital status Single 804 (39.9) 58.42 (12.96) 24.07 (5.58) 19.50 (5.51) 14.84 (4.70)
In relationship 396 (19.7) 59.25 (15.08) 25.00 (6.74) 19.76 (5.81) 14.48 (4.84)
Married 733 (36.4) 59.82 (14.37) 25.02 (6.34) 20.44 (5.75) 14.35 (4.47)
Divorced 80 (4.0) 60.26 (14.01) 24.15 (5.77) 20.90 (5.54) 15.21 (5.00)
or widow
F/Sig. 1.47 (.219) 3.87 (.009) 4.46 (.001) 1.96 (.117)
Education Primary Sch. 34 (1.7 58.32 (11.23) 22.55 (3.80) 20.97 (5.13) 14.79 (4.63)
Secondary 111 (5.5) 54.82 (13.93) 23.09 (6.32) 18.03 (5.32) 13.70 (5.14)
Sch.
High Sch. 658 (32.7) 59.18 (13.52) 23.77 (5.55) 20.37 (5.56) 15.03 (4.46)
Bach./faculty 687 (34.1) 58.51 (13.55) 24.48 (5.90) 19.75 (5.52) 14.27 (4.65)
Master/PhD 523 (26.0) 60.99 (14.95) 26.26 (6.80) 20.01 (6.04) 14.71 (4.77)
F/Sig. 5.36 (.000) 15.71 (.000) 4.61 (.001) 3.37 (.009)
COVID- Very poor 15 (0.7) 58.46 (17.43) 23.13 (6.49) 21.26 (7.86) 14.06 (5.20)
19 knowledge Poor 79 (3.9) 58.81 (15.65) 24.24 (6.26) 19.26 (7.09) 15.30 (4.69)
Moderate 857 (42.6) 58.19 (12.87) 23.93 (5.47) 19.66 (5.32) 14.60 (4.52)
Good 916 (45.5) 59.85 (14.02) 24.95 (6.17) 20.24 (5.56) 14.64 (4.78)
Excellent 146 (7.3) 60.83 (17.77) 26.68 (8.34) 20.00 (7.09) 14.14 (4.64)
F/Sig. 2.13 (.074) 7.96 (.000) 1.65 (.158) .868 (.482)
The number 1.00 319 (15.8) 60.15 (14.30) 24.27 (5.78) 20.98 (5.69) 14.89 (4.67)
of children 2-3 408 (20.3) 59.08 (14.35) 24.89 (5.78) 20.00 (5.66) 14.18 (4.47)
4þ 91 (4.3) 60.25 (15.08) 26.05 (7.63) 20.02 (6.38) 14.17 (3.68)
None (0) 1195 (59.4) 58.85 (13.65) 24.47 (6.02) 19.65 (5.59) 14.71 (4.78)
F/Sig. .920 (.430) 2.49 (.058) 4.64 (.003) 2.02 (.109)
p  .05.
p  .01.

Table 7. Pearson correlation test results between age and total scores, anxiety, stress and depres-
sion (n ¼ 2,013).
Total_score Anxiety Stress Depression
Age .045 .089
Total_score .833 .907 .796
Anxiety .622 .423
Stress .680
p  .05.
p  .01.

countries’ participants (Lebanon, Portugal, and Italy) compared to total emotional

reactions scores, as well as in the anxiety, stress and depression dimensions. We can
assume that Serbian respondents had higher resilience because of specific socio-cul-
tural reasons, such as previous experience with epidemics and the Yugoslav War
period (1991 to 1999) (Hunter 1919; Mikic 2010; Ristanovic 2015).
 GEOMATICS, NATURAL HAZARDS AND RISK 1879

Despite having fewer deaths and confirmed cases of COVID-19, Serbia had more
emotional resilience than the others statistically. Also, having a relatively smaller 65
and older population caused Serbians to be more resilient than others. COVID-19
hindered international trading almost all over the world. However, since the economy
in Serbia is largely market-based and relies heavily on manufacturing and state-owned
companies, the participants had more confidence in the state.
Lebanon had the youngest population (median age) among the countries in this
study (CIA 2020), as well as the lowest proportion of 65 and older population.
Moreover, Lebanon had the lowest death rate and number of cases of COVID-19
among all countries in the sample. This explains why Lebanese respondents were
more resilient than Portuguese respondents in the stress dimension. Besides this, the
Lebanese had more resilience than the Portuguese and Italians in the depres-
sion dimension.
However, Lebanon respondents had more anxiety than the other countries’ partici-
pants. The population density is high (667 people in per square kilometer) in this
small country. Besides, Lebanon also hosts close to 1 million refugees and asylum
seekers, most notably those from Palestine, Iraq, and Syria. The Lebanese economy
depends on international trade support for some products. Owing to having a small
and crowded country, social and economic problems, deteriorating health, economic
issues and some political gains, Lebanese participants had more anxiety than the
others in relation to COVID-19.
Italy is the eighth-largest economy in the world. In terms of gross domestic prod-
uct (GDP) Italy’s economy is worth $2.4 trillion and its per capita GDP is much
higher than that of other countries in the study. At the time of writing, Italy had the
third most deaths and confirmed cases in the world from COVID-19 (Kwok et al.
2020). It also has the highest proportion of 65 and older, compared to the other
countries of this study. For these reasons, Italian participants had more anxiety than
respondents from Portugal. Previous studies showed that perceived likelihood of pan-
demic infection tracked objective risk both dynamically and geographically (Ibuka
et al. 2010).
Regarding to familial situations, marital status, and number of children were asso-
ciated with emotional reactions to COVID-19. Peoples pay more importance to their
family and children in normal situations. But in extraordinary times the parents can
gain more anxiety and the stress (sometime depression) for their family and children.
Otherwise, it was found that parental and marital status was not associated with
DASS subscale scores (Sharpley et al. 1997; Wang et al. 2020a).
Gender was the most important predictor on overall scores; and the all sub-
scales related to a pandemic disease (COVID-19), females had more emotional
reactions than men. Females mentioned more fear across all disaster types in com-
parison to male (Norris et al. 2002; Paradise 2005; Cvetkovic et al. 2019).
Additionally, it is possible that males are less inclined to express their fears com-
pared to females, especially in some cultures (Baytiyeh and Naja 2015; Baytiyeh
€
and Ocal 2016; Ocal 2019). However, some previous studies have found that males
(Abebe et al. 2010; Ramzan et al. 2015) and elderly respondents are more know-
ledgeable (Abebe et al. 2010).
1880 A. ÖCAL ET AL.

The age and the COVID-19 knowledge were the other predictors, respectively, for total
emotional reaction scores. Also, it was found a slightly positive correlation between age
and stress (Graham et al. 2006). We can say that emotional behaviors, stress, and depres-
sion increase with age related to pandemic outbreak (COVID-19). But Wang et al.
(2020a) found different results that age was not associated with DASS subscale scores.
Education level was not a significant predictor of overall score or subscales in the
study; however, some interesting results were found in the education dimension.
People with master/PhD degree had lower anxiety than all the others; also, people
with a bachelor (undergraduate) degree had lower depression scores than those who
graduated high school On the other hand, people with master’s/PhD degrees had
more overall emotional reactions and stress to COVID-19 than the respondents who
had finished only secondary school. These results show that there was a decrease in
anxiety (mild emotional reactions) and depression associated with the COVID-19
pandemic, as awareness increases with education. There was, however, an increase in
general COVID-19 psychological reactions and stress. As the level of knowledge
would increase with education under normal conditions, it would be expected that
the level of anxiety would be low, as educated people would learn about the measures
to be taken with regard to possible pandemics (Cvetkovic et al. 2018; Kumiko and
Shaw 2019; Cvetkovic et al. 2020). However, in this study, it is thought that the panic
atmosphere associated with COVID-19 disease continues at the time of the study and
this disease still constitutes an ‘unknown threat’.

5. Conclusions
This study provides timely assessment of the risk perception of adults during the
COVID-19 epidemic in Italy, Lebanon, Portugal, and Serbia. During the study, the
respondents rated their psychological situation to the COVID-19 pandemic. Lessons
learned from the COVID-19 pandemic can provide valuable insights into how to
handle future epidemics. These include proper hand hygiene, isolation of infected
individuals, isolation of individuals with suspected symptoms or fever, and preventing
direct contact with suspected animal reservoir hosts.
Our results have several immediate and significant public health implications.
First, female gender, being more educated and knowledgeable, married, older, and
geographical differences were associated with a greater psychological impact of the
outbreak and higher levels of stress, anxiety, and depression at various levels.
Second, male gender, being single, being less educated and knowledgeable, younger,
and geographic differences were associated with a smaller psychological impact of the
outbreak and lower levels of stress, anxiety, and depression at various levels. Specific
conditions of countries could be associated with lower or higher psychological impacts.
Countries with aging populations and social and political issues may have more stress,
anxiety, and depression while countries with younger populations and few political
problems may have less psychological impact related to pandemic diseases.
More research should be carried out on the development of effective methods to
provide early and timely detection of such diseases’ psychological symptoms. A num-
ber of future studies can be conducted to collect more scientific information on this
 GEOMATICS, NATURAL HAZARDS AND RISK 1881

area. First of all, research based on direct experience with the disease can be con-
ducted in the future, which can make a significant contribution to better understand-
ing adults or children’s fear of pandemics. Second, the relationship between the
economic situation and emotional reactions of participants to the pandemic can be
investigated.
Our findings can be used to formulate psychological interventions to improve
mental health and psychological resilience during the COVID-19 epidemic, such as
cognitive behavior therapy and mindfulness-based therapy (Ho et al. 2020). Our find-
ings directly inform on the emotional reactions during the COVID-19 outbreak.
This study has several limitations. In consideration of the time-sensitivity of the
COVID-19 outbreak, we adopted an online survey with snowball sampling strategy.
This sampling strategy is not based on a random selection; thus, the study popula-
tions do not reflect the actual pattern of the general population. To preserve individ-
ual rights, we were not allowed to collect personal information from the respondents.
As our study does not reflect the actual pattern of the general population, the conclu-
sion was less generalizable. Furthermore, a longitudinal study would show temporal
changes during the COVID-19 pandemic (Wang et al. 2020b). Besides this, the partic-
ipants’ self-reported levels of emotional reactions may be insufficient evidence to fully
assess their psychological situation.

Author contributions
€ conceived the study idea, developed the study design and developed the scale with H.B.
A.O.
€ V.M.C., H.B., and F.T. contrib-
while V.M.C. conducted the pilot and reliability studies. A.O.,
€
uted to questionnaire dissemination. A.O. managed and drafted the methodology; managed all
data, and assisted V.M.C. in analyzing and interpreting the data. H.B. also contributed to
€ and M.Z. drafted the discussion, V.M.C. and H.B. contributed
drafting the introduction; A.O.
€ V.M.C., H.B., and F.T. critically reviewed the data analysis and contrib-
to the discussion; A.O.
uted to the content for revising and finalizing the manuscript. M.Z. also edited the entire
manuscript. Acknowledgments

Acknowledgments
The authors thank all citizens from the four countries for collaborations in the study. The
authors also express their gratitude to the anonymous reviewers for their comments, and
Scientific-Professional Society for Disaster Risk Management in Serbia, Belgrade, for its scien-
tific and funding support.

Disclosure statement
The authors declare there are no conflict of interest.

Funding
This research was funded by Scientific-Professional Society for Disaster Risk Management
(http://upravljanje-rizicima.com/), Belgrade, Serbia, 003/2020.
1882 A. ÖCAL ET AL.

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