Anxiety symptoms and coping strategies used by older adults during COVID-19: A national e-study of linkages among and between them.

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Gail Low, Alex Bacadini França, Zhiwei Gao, Gloria Gutman, Sofia von Humboldt, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3846824/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background During the COVID-19 pandemic older adults experienced a variety of symptoms of anxiety. They employed a number of different strategies to deal with these. The aim of this study was to create a blueprint of older Canadians’ symptoms of pandemic-related anxiety and coping strategies, and linkages among and between them. Particular attention was paid to identifying the most-pernicious symptoms and variables that might facilitate application of the most beneficial coping strategies. Methods An e-survey was conducted with 1,327 older Canadians in the Summer of 2022, when public health measures were lifting across Canada. Anxiety was measured using the Geriatric Anxiety Scale − 10. Participants also completed the Coping with Stress and Anxiety personal assessment tool. Network analysis permitted us to examine linkages among respondents’ self-reported symptoms, and between their most pernicious symptoms of anxiety and the strategies to cope with them. Results Findings revealed a troubling trio of anxiety symptoms of central importance to our respondents: feelings of restlessness, muscle tension and having no control over their lives. Restless and no control over my life were particularly pernicious because they explained between 64–68% of the variance in 8 other anxiety symptoms. Coping seemed to occur through trial and error. Some strategies appeared to work in tandem and others in opposition to each other. Responders remembering resilience and staying active functioned as bridges shielding older people from worry, restlessness, and tension through spurning other remedial actions. Discussion This study provides evidence of a stable and predictable network of anxiety symptoms containing three particularly pernicious symptoms. Coping strategies, some seemingly working in tandem and some in opposition, or as bridges to recovery speak to the complex and arduous nature of mentally healthy recovery work. A visual representation of how anxiety symptoms can operate as a network might help older people better understand their own symptom experiences. Combining the two networks offers a blueprint of what within-person recovery might look like and a visual teaching tool for practitioners and program developers; older people could gain added insight into their own recovery experience. Older people network analysis anxiety COVID-19 Figures Figure 1 Figure 2 Figure 3 Figure 4 Background A pandemic is an unprecedented event typically not falling within the everyday scope of experiences of the general public [ 1 , 2 ]. In the first year of the COVID-19 pandemic, governments worldwide were asked to activate emergency response mechanisms, including keeping a distance from others for one’s own physical health preservation [ 3 , 4 ]. While one of the most frightening consequences of large-scale traumatic events are threats to people’s physical safety [ 5 ], mental health threats also occur; some of both types of threats are disproportionate for certain subgroups. For example, during COVID-19, while older people were less likely than younger or midlife adults to experience family [ 6 ] and financial [ 7 ] discord, they were most at risk for infections, hospitalizations, and death [ 8 ]. With mental health harms being a realistic secondary consequence of COVID-19 [ 9 ], Canadians were deluged with an expert-driven “flood of wellness and self-care information”, most of it virtually delivered [ 10 ]. It appears however that while a minority of older Canadians were accessing e-support [ 11 ], others exercised their inner capacity for resourcefulness rather than seeking an expert rescue fix [ 12 ]. Subsequent research tells us older people rated their mental health and well-being significantly higher than midlife adults [ 6 , 7 , 13 , 14 ] and younger adults [ 15 , 16 , 17 ]. Still others were happier and more satisfied with life [ 18 , 19 ], and less anxious [ 20 , 21 , 22 ] and depressed [ 19 , 22 , 23 ] than midlife adults. However, older people also spoke of emotional meltdowns over health service delays [ 24 ], feeling lonely and without a companion [ 6 ], and frustrated over having idle ‘capable of helping others’ hands [ 13 , 25 ]. Qualitative researchers drew attention to older people’s accounts of a variety of coping strategies, while survey researchers estimated their impacts, usually assessing one or a few strategies at a time. In Hong Kong, older people were reported to have prioritised time and energy for family and friends [ 18 ]. Portuguese age contemporaries persevered enough to appreciate e-connectedness [ 24 ]. Older Brits welcomed less busyness in life and took comfort in routine activities [ 26 ]. Older Canadians exercised outside [ 25 ]. Older Americans found solace in connecting with close friends [ 27 ]. Older Italians gained some satisfaction from doing housework [ 28 ]. For older German people, this meant opting for quality social interactions, not spreading themselves too thin [ 19 ]. In Canada, some older people found seeking credible COVID-19 information [ 29 ], leisure activities [ 30 ], and eating and sleeping well [ 31 ] mentally beneficial. What is needed now is research that will help us to better understand what optimal structures for mentally healthy living in pandemic times might look like and what lessons have been learned that can be applied when faced with future pandemics [ 32 ]. In the first year of COVID-19, some studies pointed to the merits of sticking to past coping strategies to protect one’s mental health [ 18 , 33 ]. In a pandemic, people’s health and social circumstances can also quickly shift and demand unanticipated concomitant remedial actions [ 34 ]. COVID-19 has trickled into many nooks and crannies of people’s lives and for example, through the loss of loved ones and disrupted everyday routines, and posed threats to their physical health, and social and economic livelihoods [ 1 , 35 ] and in simultaneity [ 36 ]. We know little about optimal structures for mentally healthy living, particularly at key points in the COVID-19 pandemic. In the first year, we learned of older people pivoting away from a familiar community gym to the novelty of an at-home art easel [ 25 ] and mapping out what they thought a post-pandemic social life might look like [ 13 ]. With the lifting of public health measures, many community organisations have evolved from being completely virtual into a mix of face-to-face and virtual support. Older Canadians rating these options have indicated that they generally prefer in-person or phone contact [ 8 ]. During an unprecedented pandemic, people are likely to use a variety of strategies and perhaps through a process of trial and error, stay mentally healthy and well [ 37 ]. The aim of this study was to create a visual representation of older Canadians’ symptoms of anxiety experiences and another of the linkages between their most pernicious symptoms and the strategies they used to cope with them. Knowing how contemporaries experienced and managed their anxiety could motivate others into action and give them a sense of hope [ 34 , 38 ]. Good COVID-19 research supports mentally healthy recoveries for within and between people [ 32 ]. Methods Participants and procedures Survey data were collected using an e-survey co-designed with Qualtrics and launched for completion between July 1st, 2022 and August 15, 2022. Respondents were recruited by sending a study advertisement to a survey panel composed of individuals from all 10 Canadian provinces. Stratified sampling was used to achieve a representative sample with respect to age, sex and education and approximate the population of older Canadians at large [ 39 ] and according to national census definitions [ 40 ]. Persons responding to the advertisement were first taken to the Qualtrics survey platform for a detailed study information letter. Personal participation was completely voluntary. Informed consent was obtained from all respondents, and confidentiality was guaranteed. Respondents consenting to answer the e-survey were given national mental health support URLs and phone numbers, their own e-survey password, and $ 4 in consumer rewards points. The Health Ethics Committee of the University of Alberta approved the study (Pro00118512). Measures Our e-survey tool included questions about respondents’ sociodemographic characteristics and self-perceived health and were in keeping with national census definitions [ 40 ]. Anxiety was measured using the GAS-10 [ 41 , 42 ] It comprises 10 items each of which is rated on a 4-point Likert scale (0 = ‘not at all’ to 3 = ‘all of the time’). Item examples are ‘I was irritable’ and ‘I could not control my worry’. This tool showed good reliability (Cronbach’s α = .921). Participants also completed the Coping with Stress and Anxiety [ 43 ] personal assessment tool. The 16 strategies in this tool (Cronbach’s α = .747) were meant for public consumption, to help everyday people take stock of what they were doing to transition into opened spaces. Respondents answered ‘YES’ or ‘NO’ to whether they used each strategy. This part of the survey was strategically placed so that responders would move from reflecting on their anxiety symptoms to thinking about their capacity for managing or mitigating them. Statistical analysis To investigate the relationship between the strategies captured by the Coping with Stress and Anxiety personal assessment tool and anxiety symptoms as measured by the GAS-10, we constructed two networks. The first network exclusively incorporated symptoms of anxiety from the GAS-10, with a view to identifying the most central or pernicious symptoms. A subsequent network analysis combined responders’ most pernicious GAS-10 symptoms and with their Coping with Stress and Anxiety strategies. Network estimation Our networks were explored using a Gaussian Graphical Model. We estimated the network by applying the Least Absolute Shrinkage and Selection Operator (LASSO) regularization technique to control for spurious interactions. The LASSO parameter was selected through the Extended Bayesian Information Criterion (EBIC), with the hyperparameter gamma set to the default value of .50 for model selection [ 44 ]. Nodes represent questionnaire items. In our case, we would have 10 symptoms of anxiety nodes and 16 coping behaviour nodes. Relationships between anxiety symptoms and between anxiety and coping symptoms are represented by edges. The weight of the edges represented the strength of association between two variables after controlling for all others in the network. Network description and node characteristics We evaluated the relative importance of nodes representing GAS-10 anxiety symptoms using Strength Centrality, which is the sum of all the weights connected to a symptom in absolute value. This index tells how well connected a particular anxiety symptom is to all other nodes or GAS-10 symptoms in the network. Strength Closeness and Betweenness were not reported because neither have generally shown stability and so they can be problematic measures since they treat associations as distances [ 44 , 45 , 46 ]. In our combined symptoms-coping network, Bridge Strength (i.e., the sum of the absolute value of all edges between a GAS-10 symptom and a Coping with Stress and Anxiety behaviour) was estimated. Nodes that best foster interconnections between symptoms and coping networks possess higher bridge centrality scores. If ‘seeking support from loved ones’ had high bridge centrality, much like a bridge connecting two lands separated by a body of water, seeking support would connect responders’ most pernicious GAS-10 symptoms with possibly beneficial coping behaviours. We also generated a Predictability Index. Predictability is the variance in a node as explained by all other nodes in the network. In a network plot, ring-shaped pie charts represent predictability [ 47 ]. High predictability in a GAS-10 network would indicate that responders’ anxiety is primarily explained by the presence of strong interactions between the symptoms within that network, whereas low predictability is indicative of there being other factors missing from this GAS-10 network [ 47 ]. The robustness of strength centrality and predictability was examined by calculating indices of stability. Stability within our GAS-10 network and our combined network were estimated using a case-dropping bootstrap procedure. We focused on the correlation stability coefficient (CS-coefficient), the proportion of the sample that could be dropped while still retaining with 95% probability a correlation between the index computed on the full sample and the index computed on the reduced sample. A value below 0.25 indicates insufficient stability; a value larger than 0.50 is preferred [ 44 ]. All statistical analyses were performed using RStudio 2023.06.1 [ 48 ], and packages bootnet version 1.5.3 [ 44 ], and graph version 1.9.3 [ 49 ]. Results Table 1 shows the sociodemographic characteristics of the 1,327 respondents who consented to taking part in this e-survey study. Table 1 Sociodemographic characteristics of the studied sample (n = 1,327). Variables n % a Age 60–64 384 28.9 65–69 335 25.2 70–74 264 19.9 75–79 131 9.9 80–84 145 10.9 85+ 61 4.6 Sex at Birth Female 671 b 50.6 Male 620 46.7 Marital Status Widowed/not living common law 191 14.4 Divorced/separated/not living common law 217 16.4 Living common law 89 6.7 Married 671 50.6 Never married/not living common law 154 11.6 Gender CIS gender woman 502 37.8 CIS gender man 516 38.9 Transgender/non-binary 178 13.4 Province British Columbia 226 17.0 Prairie Provinces 312 23.5 Ontario 510 28.4 Quebec 148 11.2 Maritime Provinces 129 9.7 Education status University certificate, diploma, degree below/at bachelor level 275 20.7 College, CEGEP or other non-university certificate or diploma 238 17.9 Apprenticeship, trades certificate or diploma 168 12.7 Secondary (high) school or equivalent 392 29.5 No degree, certificate, or diploma 251 18.9 Perceived Health Poor/fair 407 30.7 Good 604 45.5 Very good/Excellent 298 22.5 a Frequency proportions do not sum to 100% due to missing values. [insert Table 1 here] Anxiety symptoms network As indicated by CS coefficients for Strength (CS = 0.60) and Predictability (CS = 0.95), the GAS-10 anxiety symptoms network was stable. This stable GAS-10 network had 37 non-zero edges out of 45 possible edges (see Fig. 1). Especially strong connections emerged between Node 1 (‘ Irritable ’) and Node 6 (‘ Restless ’), and between Node 5 (‘ Not control my worry ’) and Node 4 (“ Hard time sitting still ”). Strong connections were also observed between Node 7 (‘ Tired ’) and Node 8 (‘ Muscle tension ’), and between Node 9 (‘ Had no control over my life ’) and Node 10 (‘ Apprehensive ’). Other connections, such as between Nodes 1 and 10, were absent. This missing connection suggests that apprehension and irritability are statistically independent sources of bother, in their own right [ 50 ]. [insert Fig. 1 here] Figure 1 Anxiety symptoms network (n = 1,224). Ring-shaped pie charts represent predictability. The nodes are arranged in order according to the legend and represent anxiety symptoms (GAS-10 items). The size and density of edges between nodes represent the strength of connectivity. As shown below in Fig. 2, the three symptoms with the highest standardised strength centrality in the GAS-10 anxiety symptoms network) were ‘ Restless ’, ‘ No control over my life’ and ‘ Muscle tension ’. In terms of mean predictability, 55% of the variance in all GAS-10 nodes was explained by neighbouring symptoms. Symptoms with the highest predictability were Node 5 (‘ Not control my worry ’; 68%), Node 6 (‘ Restless ’; 68%), and Node 9 (‘ No control over my life ’; 64%). [insert Fig. 2 here] Figure 2 Strength centrality of GAS-10 symptoms, shown as standardised z-scores. Combined anxiety symptoms and coping strategies network A visual representation of the combined network is shown in Fig. 3. As indicated by CS coefficients for Strength (CS = 0.85) and Predictability (CS = 0.85), the combined anxiety symptoms and coping strategies network is stable. Overall, the combined network shows clear associations both within and between Coping with Stress and Anxiety strategies and GAS-10 symptoms of Anxiety. The mean predictability across all nodes in this combined network was 21%. Node 1 (‘ Restless’ ), Node 2 (‘ Muscle tension’ ), and Node 3 ( ‘No control over my life’ ) were strongly positively connected. Across this network, Node 3 ( ‘No control over my life’ ) had the highest predictability (49%). Strong positive connections emerged between Node 12 (‘ Relaxing and meditating’ ) and Node 13 ( ‘Seeking loved ones’ support’) , and between Node 5 ( ‘Seeking credible information’ ) and Node 6 (‘ Tuning in and breaking away from news’ ). Other strong connections were between Node 15 (‘ Eating healthy’ ) and Node 19 (‘ Staying active’ ). There were negative connections between, for example, Node 14 (‘Kind to myself’ ) and Node 5 (‘ Seeking credible information’ ), and Node 15 (‘ Eating healthy’ ) and Node 6 (‘ Tuning in and breaking away from news’ ). [insert Fig. 3 here] Figure 3 The top 3 GAS-10 symptoms and Coping with Stress and Anxiety strategies network. Ring-shaped pie charts represent predictability. The nodes are arranged in order according to the legend and represent anxiety symptoms and coping strategies. The size and density of edges between nodes represent the strength of connectivity. Blue edges are positive relationships and red edges are negative relationships. We also analysed bridge strength (see Fig. 4) among the combined networks of symptoms and coping strategies. In this respect, Node 9 (‘ Remembering self as resilient’ ) and Node 19 (‘ Staying activ e’) were particularly pivotal strategies. The importance of both such strategies is further depicted in Fig. 3 as a positive association between Node 9 (‘ Remembering self as resilient’ ) and Node 2 (‘ Muscle tension’ ). Negative associations emerged between Node 9 (‘ Remembering self as resilient’ ) and Node 3 (‘ No control over my life’ ), and between Node 19 (‘ Staying activ e’) and Node 3 (‘ No control over my life’ ). [insert Fig. 4 here] Figure 4 Bridge strength centrality shown as standardised z-scores Discussion This study employed Network Analysis to create a visual representation of older Canadians’ symptoms of anxiety experiences and another of the linkages between their most pernicious symptoms and the strategies they used to cope with them. Novel discoveries of linkages among and between them are summarised and discussed below. Network of Anxiety Symptoms In the first year of COVID-19, older Canadians were generally least prone to high anxiety [8,20,21,51]. The loss of local contemporaries can make the threat of physical health harms more self-relevant [ 5 ], let alone on a global level [ 52 ]. This may partially explain the observed strong connections between anxiety symptoms (e.g., ‘ Irritable ’ and ‘ Restless ’, ‘ Not control my worry ’ and ‘ Hard time sitting still ’, ‘ Tired ’ and ‘ Muscle tension ’, ‘ No control over my life ’ and ‘ Apprehensive ’). These pairs might represent clusters wherein one symptom can exacerbate the other or they might arise from common underlying factors. No one is immune to unfavourable shifts in anxiety [ 34 ]. This past year alone, the lifetime prevalence of pernicious anxiety among older adults has doubled (5.2–13.3%) and 1 in 3 report unmet mental health needs [ 8 ]. Our respondents were moving into opened spaces while living most at risk for becoming infected with and dying from COVID-19. This is a rather precarious position to be in. Central to their precarity were feelings of restlessness, muscle tension, and of having no control over their lives. Restlessness and no control were particularly pernicious as they explained 64–68% of the variability in 8 other anxiety symptoms. Learning of their connectedness from age-peers in similar circumstances could be a source of good mentally healthy recovery work [ 9 , 53 , 54 ]. Much like long-COVID [ 40 ], pernicious anxiety can impair our everyday functional ability and be a source of emotional distress [ 8 ]. Strategies to disempower this trio are thus pivotal. Combined Network of Anxiety and Coping Strategies We examined connections between older Canadians’ restlessness, muscle tension, and perceived lack of control over their lives, and mental and behavioural strategies to manage or mitigate this troubling trio. This combining helped us build a blueprint showing what within-person recovery might look like for other older people. Positively Connected Coping Strategies Three sets of strategies were positively connected and appeared to be used in tandem, with one spurning on a significant other. The positive association between ‘ seeking credible information’ and ‘tuning in and breaking away from news’ [ 5 ] remind us that unbalanced information about hypothetical sources of harm or displayed images of threat in the news can undermine peoples’ sense of safety. COVID-19 evoked uncontrolled and near constant streams of news [ 54 , 58 ]. For older people in particular, public discourse through social media, popular press, and government official messaging set the stage for being characterised as vulnerable COVID-19 carriers [ 55 ]. Those indirectly affected through media exposure could personalise it and/or see illness potential in themselves [ 56 ]. Our associations suggest that credible sources might curb people seeking out news elsewhere. This is important because anxiety comes from realistic dangers and information from assumptive or misinformed sources [ 57 , 58 ]. Credible sources such as organisational officials can stunt rumours and encourage return information seeking [ 59 ]. In the first year of the pandemic, through Canada.ca, all Canadians were strongly encouraged to limit everyday news media exposure, even from authoritative sources. The linkage between seeking credible information and COVID-19 news suggests that our respondents heeded such advice. This observed pairing of ‘ relaxing and meditating ’ and ‘ seeking loved ones’ support ’ could have been a means for our respondents to avoid or mitigate family conflicts or perhaps to mask their own COVID-related worries. Meditation has been found to be used more by older Canadians with no or minimal to mild symptoms of anxiety [ 62 ]. While some research [ 33 ] indicates some older people made strategic use of their resources to lessen loneliness and isolation and some [ 25 ] describe ‘pivoting’ or substituting pre-COVID routines with novel activities to stay mentally well, our responders did so through strategic pairing, with in tandem ‘ eating healthy’ and ‘staying active’ perhaps being another means by which respondents further minimise loved ones’ stress. Negatively Connected Coping Strategies. Negative associations suggest that coping behaviours to manage or mitigate anxiety can also work in opposition. One such case-in-point is ‘being kind to yourself’ and ‘seeking credible information’ . In the first year of COVID-19, misleading, false, or inaccurate information about COVID-19 was found to increase older Canadians’ anxiety [ 62 ]. A recent literature review also linked being privy to risk-related COVID-19 news with poorer mental health [ 63 ], and with higher symptoms of anxiety [ 64 , 65 ]. Others’ unhappiness and symptoms of depression seems to be associated with news following frequency [ 66 ]. Sharing negative news appears to trigger anxiety [ 67 ]. In the context of this study, perhaps being kind to yourself means shielding yourself from distressing facts, particularly while moving into open spaces at a heightened risk for physical health harms. There was a negative association between ‘ tuning in and breaking away from news’ and ‘eating healthy’ . We could not find any published studies about older Canadians’ eating habits in relation to COVID-19 news following. In the first year of COVID-19, some older Canadians named [ 68 ] and found [ 20 , 31 ] eating healthy food mentally beneficial. A meta-analysis across some 40 countries, including Canada [ 69 ], revealed associations between unhealthy eating behaviours and anxiety in individuals between 18 and 74 years of age, albeit more so in younger age groups. In one study [ 6 ], older Canadians found not having or knowing how to access food particularly distressing. As with ‘being kind to myself’, these are cross-sectional associations. Future qualitative research is warranted to better understand these relationships. Some larger implications The positive and negative associations observed in our combined network may be explained by people managing or mitigating anxiety through a process of trials and errors [ 37 ]. Resilient people are flexible people with an ability to reframe how they think, act, and feel about what is in front of them, whether this concerns precarious health, work, and/or family matters [ 70 ] In the first year of COVID-19, resilient older people appeared to be better able to weather its many impacts [ 35 , 71 ]. Qualitative [ 61 , 72 ] and quantitative [ 31 , 73 ] researchers partly attributed more favourable mental health and well-being of older people to personal resilience. ‘ Remembering self as resilient ’ was an asset for our respondents on several fronts when they were moving into open spaces. Such recollections were negatively associated with feeling a ‘ lack of control over my life ’. Much like in the first pandemic year, positive reframing circumvented the negative impacts that intolerable uncertainty had on anxiety [ 74 ]. Being wise to life’s physical uncertainties and open-minded has also been helpful to older people well before COVID-19 [ 75 , 76 ]. Resilience was also important because a ‘ lack of control over my life ’ seemed to either deter ‘ staying active ’, or vice-versa. Resilient older people are likely to be flexible about how often they stay active and what they gain from it. Simply getting outside has brought older people closer to nature [ 77 ] and has given them some kind of social life [ 33 ] and helped them feel less isolated in general [ 72 ]. This kind of reframing has led others to find contentment with small social circles [ 19 , 63 ] and in befriending technology [ 78 ]. Our respondents’ remembering resilience seemingly strongly shielded them from feeling restless, tense, and as if they had no control over their lives. Future network analyses should include a measure of resilience such as the Brief Resilience Scale [ 79 ] to shed further light on its associations with symptoms of anxiety and strategies to manage or mitigate them. Programs or interventions to bolster resilience might benefit older people feeling restless, tense, and as if they have no control over their lives. Ideally, interventions strengthen resilience and active propensities. Taken together, the findings of this study suggest that mental health recovery work requires a wide variety of coping strategies, with some working in tandem and some in opposition. Mental health recovery work is hard work, particularly in the presence of pernicious anxiety symptoms. As was learned during the first year of COVID-19, very few older people accessed digital resources [ 11 ] and others felt bewildered as to where to find resources tailored to their needs [ 9 ]. A visual representation or blueprint showing how symptoms of anxiety can be connected and between strategies to manage or mitigate particularly pernicious ones could be helpful to practitioners, program developers, and older people, as they navigate through the complexities of mentally healthy recovery work now as COVID-19 lingers [ 80 , 81 ] and later, in the event of other large-scale traumatic events. This study has limitations, including our reliance on cross-sectional data collected at one point in time. We found associations between and among symptoms and coping behaviours. We cannot say with any degree of certainty that a troubling trio of anxiety symptoms evoke any one strategic action, nor a chain reaction in others. While our observed network associations provide valuable insights, it would be important to investigate their directionality. For instance, does increasing resilience decrease feelings of tension or lack of control, or do these feelings prompt individuals to become more resilient? Thus, it is also crucial to consider external factors or other internal processes that might influence these associations. This includes life events, other coping strategies not in the network, or sociodemographic factors like personal income [ 73 ] and personality [ 27 ]. Research also tells us that older people have a greater capacity to better regulate negative emotions [ 27 , 82 ], even through the simplest domestic tasks [ 28 ] and by taking disrupted routines in stride [ 83 ]. Acknowledging and expressing negative emotions helped older Canadians persevere early in the pandemic [ 72 ]. Conclusions Our study is the first study to offer evidence of what an optimal mentally healthy living structure might look like for older people, and at a pivotal point in the COVID-19 pandemic. Mental health practitioners and program developers, and older people should find such discoveries intriguing. A combined blueprint of older Canadians’ most pernicious anxiety symptoms and strategies to manage or mitigate them could be a helpful visual teaching tool that offers older people a better understanding of their own anxiety recovery work. As COVID-19 lingers, seeing what contemporaries’ mentally healthy recovery work looks like might also offer a much-needed sense of hope. Abbreviations APA American Psychological Association CAMH Center for Addiction and Mental Health CMHA Canadian Mental Health Association GOC Government of Canada IASCRGMHPSES Inter-Agency Standing Committee Reference Group on Mental Health and Psychosocial Support in Emergency Settings IPCC Infection Prevention and Control Canada MHCC Mental Health Commission of Canada MHRC Mental Health Research Canada NCIRD(U.S.)DVR National Center for Immunization and Respiratory Diseases (U.S.). Division of Viral Diseases PHAC Public Health Agency of Canada WHO World Health Organization Declarations Acknowledgements We thank our e-survey responders for their shared wisdom and resourcefulness. Authors' contributions G.L. and G.G. conceived of within-person recovery; A.B.F. and G.L. conceptualized the analytical approach. G.L., Z.G., and A.B.F. co-identified the sampling methodology; G.L., Z.G., and A.H. acquired the data; G.L., H.A., G.G., Z.G., and D.M.W. collaborated on e-survey platform logistics and scripts; A.B.F. conducted the Network Analysis and prepared figures 1-4; A.B.F., G.L., G.G. and S.v.H. interpreted the data. G.L. and A.B.F. prepared the original draft of the manuscript text; G.G., S.v.H., Z.G., H.A., and D.M.W. reviewed and edited the original draft. All authors read and approved the final manuscript. Funding The project described was funded by RTOERO Foundation [Grant #056223]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the RTOERO Foundation. Availability of data and materials The data analysed in this study is available upon reason request from the Primary Investigator, Dr. Gail Low. Ethics approval and consent to participate This project received ethical approval from the University of Alberta Human Research Ethics Board [Pro00118512]. All participants gave informed consent to participate prior to filling the survey, online. All methods were performed in accordance with the relevant guidelines and regulations such as the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Chirico F. Spirituality to cope with COVID-19 pandemic, climate change and future global challenges. J Health Soc Sci. 2021 Oct;6(2):151-8. https://journalhss.com/wp-content/uploads/jhhs_62_151-158.pdf Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention. JAMA Intern Med. 2020 Jun 1;180(6):817-8. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764404 Public Health Agency of Canada. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3846824","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":267699701,"identity":"e767f6e6-895b-4f33-a6c5-4cb5b41e0083","order_by":0,"name":"Gail Low","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIie2PsQrCMBBATwqdWrqei/5CiiAO3f2NFKFdFAouDqIRQceu/QxFcA4c6NIP6CSWrg4dncRWXVxiR4e8IYRwj3cB0Gj+ktZKQgTgVDdqqggJDKAtAGoFG0kvhcmmSndIdcXzD9noStHssnCEkZcqxU39Wgn8YxYwStIpojR7ypQrXgpNjhlnZG84grTU27lx/lYOSViS/eDYlZZxV/4FP5UdjquK4MikZSorDKsKZ8EySW8RJSfe3pPZHygrcZhfy5nXc7bhvojm3Omc10WmrMjq4F9Phmq+rogfAxqNRqOBJ227UQVqhd2sAAAAAElFTkSuQmCC","orcid":"","institution":"University of Alberta","correspondingAuthor":true,"prefix":"","firstName":"Gail","middleName":"","lastName":"Low","suffix":""},{"id":267699702,"identity":"0bef16c5-36dd-4c59-bc33-c2495180628c","order_by":1,"name":"Alex Bacadini França","email":"","orcid":"","institution":"Federal University of São Carlos","correspondingAuthor":false,"prefix":"","firstName":"Alex","middleName":"Bacadini","lastName":"França","suffix":""},{"id":267699703,"identity":"4642190c-25db-4db2-a22b-5f3b07932d23","order_by":2,"name":"Zhiwei Gao","email":"","orcid":"","institution":"Memorial University of Newfoundland","correspondingAuthor":false,"prefix":"","firstName":"Zhiwei","middleName":"","lastName":"Gao","suffix":""},{"id":267699704,"identity":"f3a0889b-2e21-4188-9a93-c4c49faae2ab","order_by":3,"name":"Gloria Gutman","email":"","orcid":"","institution":"Simon Fraser University","correspondingAuthor":false,"prefix":"","firstName":"Gloria","middleName":"","lastName":"Gutman","suffix":""},{"id":267699705,"identity":"25eeb301-aab0-41e8-88c0-add83a7c1ee9","order_by":4,"name":"Sofia von Humboldt","email":"","orcid":"","institution":"ISPA—Instituto Universitário","correspondingAuthor":false,"prefix":"","firstName":"Sofia","middleName":"","lastName":"von Humboldt","suffix":""},{"id":267699706,"identity":"2882b33e-c178-4a15-b7e0-3554e1aba1d3","order_by":5,"name":"Hunaina Allana","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Hunaina","middleName":"","lastName":"Allana","suffix":""},{"id":267699707,"identity":"a797eebe-e098-43e1-b7c8-2ab4caf4d35f","order_by":6,"name":"Donna Marie Wilson","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Donna","middleName":"Marie","lastName":"Wilson","suffix":""}],"badges":[],"createdAt":"2024-01-09 01:30:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3846824/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3846824/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49895128,"identity":"00e78a48-41f3-4c27-b476-469bf345e0b2","added_by":"auto","created_at":"2024-01-19 21:38:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":249038,"visible":true,"origin":"","legend":"\u003cp\u003eAnxiety symptoms network (n = 1,224). Ring-shaped pie charts represent predictability. The nodes are arranged in order according to the legend and represent anxiety symptoms (GAS-10 items). The size and density of edges between nodes represent the strength of connectivity.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3846824/v1/cc53304b31a571ec85df89ae.png"},{"id":49896052,"identity":"f3440c0c-b408-40b3-8ee7-fafc37cc0b9d","added_by":"auto","created_at":"2024-01-19 21:46:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":55544,"visible":true,"origin":"","legend":"\u003cp\u003eStrength centrality of GAS-10 symptoms, shown as standardised z-scores.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3846824/v1/00f7fd75cb9538b3cdf9a219.png"},{"id":49896053,"identity":"7de96f98-11bc-4f8b-8ff9-ea6bcc50d9a2","added_by":"auto","created_at":"2024-01-19 21:46:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":369822,"visible":true,"origin":"","legend":"\u003cp\u003eThe top 3 GAS-10 symptoms and Coping with Stress and Anxiety strategies network. Ring-shaped pie charts represent predictability. The nodes are arranged in order according to the legend and represent anxiety symptoms and coping strategies. The size and density of edges between nodes represent the strength of connectivity. Blue edges are positive relationships and red edges are negative relationships.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-3846824/v1/81b5de432f905fc94591d038.png"},{"id":49895126,"identity":"67a66652-1c1e-4177-85a9-b618095a9f27","added_by":"auto","created_at":"2024-01-19 21:38:58","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":99967,"visible":true,"origin":"","legend":"\u003cp\u003eBridge strength centrality shown as standardised z-scores\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-3846824/v1/312b355c06e3736acd22472d.png"},{"id":61635978,"identity":"2203add3-4b4f-4609-855b-bd3061bbc500","added_by":"auto","created_at":"2024-08-02 08:59:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1340601,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3846824/v1/7710279c-b101-4fb8-a373-b8a67fb8b5f2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anxiety symptoms and coping strategies used by older adults during COVID-19: A national e-study of linkages among and between them.","fulltext":[{"header":"Background","content":"\u003cp\u003eA pandemic is an unprecedented event typically not falling within the everyday scope of experiences of the general public [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In the first year of the COVID-19 pandemic, governments worldwide were asked to activate emergency response mechanisms, including keeping a distance from others for one\u0026rsquo;s own physical health preservation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. While one of the most frightening consequences of large-scale traumatic events are threats to people\u0026rsquo;s physical safety [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], mental health threats also occur; some of both types of threats are disproportionate for certain subgroups. For example, during COVID-19, while older people were less likely than younger or midlife adults to experience family [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and financial [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] discord, they were most at risk for infections, hospitalizations, and death [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith mental health harms being a realistic secondary consequence of COVID-19 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], Canadians were deluged with an expert-driven \u0026ldquo;flood of wellness and self-care information\u0026rdquo;, most of it virtually delivered [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. It appears however that while a minority of older Canadians were accessing e-support [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], others exercised their inner capacity for resourcefulness rather than seeking an expert rescue fix [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSubsequent research tells us older people rated their mental health and well-being significantly higher than midlife adults [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and younger adults [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Still others were happier and more satisfied with life [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], and less anxious [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and depressed [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] than midlife adults. However, older people also spoke of emotional meltdowns over health service delays [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], feeling lonely and without a companion [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and frustrated over having idle \u0026lsquo;capable of helping others\u0026rsquo; hands [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eQualitative researchers drew attention to older people\u0026rsquo;s accounts of a variety of coping strategies, while survey researchers estimated their impacts, usually assessing one or a few strategies at a time. In Hong Kong, older people were reported to have prioritised time and energy for family and friends [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Portuguese age contemporaries persevered enough to appreciate e-connectedness [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Older Brits welcomed less busyness in life and took comfort in routine activities [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Older Canadians exercised outside [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Older Americans found solace in connecting with close friends [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Older Italians gained some satisfaction from doing housework [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. For older German people, this meant opting for quality social interactions, not spreading themselves too thin [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In Canada, some older people found seeking credible COVID-19 information [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], leisure activities [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], and eating and sleeping well [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] mentally beneficial.\u003c/p\u003e \u003cp\u003eWhat is needed now is research that will help us to better understand what optimal structures for mentally healthy living in pandemic times might look like and what lessons have been learned that can be applied when faced with future pandemics [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In the first year of COVID-19, some studies pointed to the merits of sticking to past coping strategies to protect one\u0026rsquo;s mental health [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In a pandemic, people\u0026rsquo;s health and social circumstances can also quickly shift and demand unanticipated concomitant remedial actions [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. COVID-19 has trickled into many nooks and crannies of people\u0026rsquo;s lives and for example, through the loss of loved ones and disrupted everyday routines, and posed threats to their physical health, and social and economic livelihoods [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and in simultaneity [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe know little about optimal structures for mentally healthy living, particularly at key points in the COVID-19 pandemic. In the first year, we learned of older people pivoting away from a familiar community gym to the novelty of an at-home art easel [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and mapping out what they thought a post-pandemic social life might look like [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. With the lifting of public health measures, many community organisations have evolved from being completely virtual into a mix of face-to-face and virtual support. Older Canadians rating these options have indicated that they generally prefer in-person or phone contact [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDuring an unprecedented pandemic, people are likely to use a variety of strategies and perhaps through a process of trial and error, stay mentally healthy and well [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The aim of this study was to create a visual representation of older Canadians\u0026rsquo; symptoms of anxiety experiences and another of the linkages between their most pernicious symptoms and the strategies they used to cope with them. Knowing how contemporaries experienced and managed their anxiety could motivate others into action and give them a sense of hope [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Good COVID-19 research supports mentally healthy recoveries for within and between people [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and procedures\u003c/h2\u003e \u003cp\u003eSurvey data were collected using an e-survey co-designed with Qualtrics and launched for completion between July 1st, 2022 and August 15, 2022. Respondents were recruited by sending a study advertisement to a survey panel composed of individuals from all 10 Canadian provinces. Stratified sampling was used to achieve a representative sample with respect to age, sex and education and approximate the population of older Canadians at large [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] and according to national census definitions [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePersons responding to the advertisement were first taken to the Qualtrics survey platform for a detailed study information letter. Personal participation was completely voluntary. Informed consent was obtained from all respondents, and confidentiality was guaranteed. Respondents consenting to answer the e-survey were given national mental health support URLs and phone numbers, their own e-survey password, and \u003cspan\u003e$\u003c/span\u003e4 in consumer rewards points. The Health Ethics Committee of the University of Alberta approved the study (Pro00118512).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cp\u003eOur e-survey tool included questions about respondents\u0026rsquo; sociodemographic characteristics and self-perceived health and were in keeping with national census definitions [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnxiety was measured using the GAS-10 [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] It comprises 10 items each of which is rated on a 4-point Likert scale (0 = \u0026lsquo;not at all\u0026rsquo; to 3 = \u0026lsquo;all of the time\u0026rsquo;). Item examples are \u0026lsquo;I was irritable\u0026rsquo; and \u0026lsquo;I could not control my worry\u0026rsquo;. This tool showed good reliability (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.921).\u003c/p\u003e \u003cp\u003eParticipants also completed the Coping with Stress and Anxiety [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] personal assessment tool. The 16 strategies in this tool (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.747) were meant for public consumption, to help everyday people take stock of what they were doing to transition into opened spaces. Respondents answered \u0026lsquo;YES\u0026rsquo; or \u0026lsquo;NO\u0026rsquo; to whether they used each strategy. This part of the survey was strategically placed so that responders would move from reflecting on their anxiety symptoms to thinking about their capacity for managing or mitigating them.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eTo investigate the relationship between the strategies captured by the Coping with Stress and Anxiety personal assessment tool and anxiety symptoms as measured by the GAS-10, we constructed two networks. The first network exclusively incorporated symptoms of anxiety from the GAS-10, with a view to identifying the most central or pernicious symptoms. A subsequent network analysis combined responders\u0026rsquo; most pernicious GAS-10 symptoms and with their Coping with Stress and Anxiety strategies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eNetwork estimation\u003c/h2\u003e \u003cp\u003eOur networks were explored using a Gaussian Graphical Model. We estimated the network by applying the Least Absolute Shrinkage and Selection Operator (LASSO) regularization technique to control for spurious interactions. The LASSO parameter was selected through the Extended Bayesian Information Criterion (EBIC), with the hyperparameter gamma set to the default value of .50 for model selection [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Nodes represent questionnaire items. In our case, we would have 10 symptoms of anxiety nodes and 16 coping behaviour nodes. Relationships between anxiety symptoms and between anxiety and coping symptoms are represented by edges. The weight of the edges represented the strength of association between two variables after controlling for all others in the network.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eNetwork description and node characteristics\u003c/h2\u003e \u003cp\u003eWe evaluated the relative importance of nodes representing GAS-10 anxiety symptoms using Strength Centrality, which is the sum of all the weights connected to a symptom in absolute value. This index tells how well connected a particular anxiety symptom is to all other nodes or GAS-10 symptoms in the network. Strength Closeness and Betweenness were not reported because neither have generally shown stability and so they can be problematic measures since they treat associations as distances [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our combined symptoms-coping network, Bridge Strength (i.e., the sum of the absolute value of all edges between a GAS-10 symptom and a Coping with Stress and Anxiety behaviour) was estimated. Nodes that best foster interconnections between symptoms and coping networks possess higher bridge centrality scores. If \u0026lsquo;seeking support from loved ones\u0026rsquo; had high bridge centrality, much like a bridge connecting two lands separated by a body of water, seeking support would connect responders\u0026rsquo; most pernicious GAS-10 symptoms with possibly beneficial coping behaviours.\u003c/p\u003e \u003cp\u003eWe also generated a Predictability Index. Predictability is the variance in a node as explained by all other nodes in the network. In a network plot, ring-shaped pie charts represent predictability [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. High predictability in a GAS-10 network would indicate that responders\u0026rsquo; anxiety is primarily explained by the presence of strong interactions between the symptoms within that network, whereas low predictability is indicative of there being other factors missing from this GAS-10 network [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe robustness of strength centrality and predictability was examined by calculating indices of stability. Stability within our GAS-10 network and our combined network were estimated using a case-dropping bootstrap procedure. We focused on the correlation stability coefficient (CS-coefficient), the proportion of the sample that could be dropped while still retaining with 95% probability a correlation between the index computed on the full sample and the index computed on the reduced sample. A value below 0.25 indicates insufficient stability; a value larger than 0.50 is preferred [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAll statistical analyses were performed using RStudio 2023.06.1 [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], and packages bootnet version 1.5.3 [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], and graph version 1.9.3 [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the sociodemographic characteristics of the 1,327 respondents who consented to taking part in this e-survey study.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of the studied sample (n\u0026thinsp;=\u0026thinsp;1,327).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60\u0026ndash;64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e65\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e335\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e70\u0026ndash;74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e75\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e80\u0026ndash;84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e85+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex at Birth\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e671\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003eb\u003c/sup\u003e50.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e620\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed/not living common law\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/separated/not living common law\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving common law\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e671\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever married/not living common law\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCIS gender woman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e502\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCIS gender man\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e516\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransgender/non-binary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProvince\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBritish Columbia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrairie Provinces\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOntario\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e510\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuebec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaritime Provinces\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity certificate, diploma, degree below/at bachelor level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege, CEGEP or other non-university certificate or diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApprenticeship, trades certificate or diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary (high) school or equivalent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo degree, certificate, or diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived Health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor/fair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e604\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery good/Excellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eFrequency proportions do not sum to 100% due to missing values.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eAnxiety symptoms network\u003c/h2\u003e \u003cp\u003eAs indicated by CS coefficients for Strength (CS\u0026thinsp;=\u0026thinsp;0.60) and Predictability (CS\u0026thinsp;=\u0026thinsp;0.95), the GAS-10 anxiety symptoms network was stable. This stable GAS-10 network had 37 non-zero edges out of 45 possible edges (see Fig.\u0026nbsp;1). Especially strong connections emerged between Node 1 (\u0026lsquo;\u003cem\u003eIrritable\u003c/em\u003e\u0026rsquo;) and Node 6 (\u0026lsquo;\u003cem\u003eRestless\u003c/em\u003e\u0026rsquo;), and between Node 5 (\u0026lsquo;\u003cem\u003eNot control my worry\u003c/em\u003e\u0026rsquo;) and Node 4 (\u0026ldquo;\u003cem\u003eHard time sitting still\u003c/em\u003e\u0026rdquo;). Strong connections were also observed between Node 7 (\u0026lsquo;\u003cem\u003eTired\u003c/em\u003e\u0026rsquo;) and Node 8 (\u0026lsquo;\u003cem\u003eMuscle tension\u003c/em\u003e\u0026rsquo;), and between Node 9 (\u0026lsquo;\u003cem\u003eHad no control over my life\u003c/em\u003e\u0026rsquo;) and Node 10 (\u0026lsquo;\u003cem\u003eApprehensive\u003c/em\u003e\u0026rsquo;). Other connections, such as between Nodes 1 and 10, were absent. This missing connection suggests that apprehension and irritability are statistically independent sources of bother, in their own right [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e[insert Fig.\u0026nbsp;1 here]\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure\u0026nbsp;1\u003c/b\u003e Anxiety symptoms network (n\u0026thinsp;=\u0026thinsp;1,224). Ring-shaped pie charts represent predictability. The nodes are arranged in order according to the legend and represent anxiety symptoms (GAS-10 items). The size and density of edges between nodes represent the strength of connectivity.\u003c/p\u003e \u003cp\u003eAs shown below in Fig.\u0026nbsp;2, the three symptoms with the highest standardised\u003c/p\u003e \u003cp\u003estrength centrality in the GAS-10 anxiety symptoms network) were \u0026lsquo;\u003cem\u003eRestless\u003c/em\u003e\u0026rsquo;, \u0026lsquo;\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003econtrol over my life\u0026rsquo;\u003c/em\u003e and \u0026lsquo;\u003cem\u003eMuscle tension\u003c/em\u003e\u0026rsquo;. In terms of mean predictability, 55% of the\u003c/p\u003e \u003cp\u003evariance in all GAS-10 nodes was explained by neighbouring symptoms. Symptoms\u003c/p\u003e \u003cp\u003ewith the highest predictability were Node 5 (\u0026lsquo;\u003cem\u003eNot control my worry\u003c/em\u003e\u0026rsquo;; 68%), Node 6\u003c/p\u003e \u003cp\u003e(\u0026lsquo;\u003cem\u003eRestless\u003c/em\u003e\u0026rsquo;; 68%), and Node 9 (\u0026lsquo;\u003cem\u003eNo control over my life\u003c/em\u003e\u0026rsquo;; 64%).\u003c/p\u003e \u003cp\u003e[insert Fig.\u0026nbsp;2 here]\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure\u0026nbsp;2\u003c/b\u003e Strength centrality of GAS-10 symptoms, shown as standardised z-scores.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eCombined anxiety symptoms and coping strategies network\u003c/h2\u003e \u003cp\u003eA visual representation of the combined network is shown in Fig.\u0026nbsp;3. As indicated by CS coefficients for Strength (CS\u0026thinsp;=\u0026thinsp;0.85) and Predictability (CS\u0026thinsp;=\u0026thinsp;0.85), the combined anxiety symptoms and coping strategies network is stable. Overall, the combined network shows clear associations both within and between Coping with Stress and Anxiety strategies and GAS-10 symptoms of Anxiety. The mean predictability across all nodes in this combined network was 21%. Node 1 (\u0026lsquo;\u003cem\u003eRestless\u0026rsquo;\u003c/em\u003e), Node 2 (\u0026lsquo;\u003cem\u003eMuscle tension\u0026rsquo;\u003c/em\u003e), and Node 3 (\u003cem\u003e\u0026lsquo;No control over my life\u0026rsquo;\u003c/em\u003e) were strongly positively connected. Across this network, Node 3 (\u003cem\u003e\u0026lsquo;No control over my life\u0026rsquo;\u003c/em\u003e) had the highest predictability (49%).\u003c/p\u003e \u003cp\u003eStrong positive connections emerged between Node 12 (\u0026lsquo;\u003cem\u003eRelaxing and meditating\u0026rsquo;\u003c/em\u003e) and Node 13 (\u003cem\u003e\u0026lsquo;Seeking loved ones\u0026rsquo; support\u0026rsquo;)\u003c/em\u003e, and between Node 5 (\u003cem\u003e\u0026lsquo;Seeking credible information\u0026rsquo;\u003c/em\u003e) and Node 6 (\u0026lsquo;\u003cem\u003eTuning in and breaking away from news\u0026rsquo;\u003c/em\u003e). Other strong connections were between Node 15 (\u0026lsquo;\u003cem\u003eEating healthy\u0026rsquo;\u003c/em\u003e) and Node 19 (\u0026lsquo;\u003cem\u003eStaying active\u0026rsquo;\u003c/em\u003e). There were negative connections between, for example, Node 14 \u003cem\u003e(\u0026lsquo;Kind to myself\u0026rsquo;\u003c/em\u003e) and Node 5 (\u0026lsquo;\u003cem\u003eSeeking credible information\u0026rsquo;\u003c/em\u003e), and Node 15 (\u0026lsquo;\u003cem\u003eEating healthy\u0026rsquo;\u003c/em\u003e) and Node 6 (\u0026lsquo;\u003cem\u003eTuning in and breaking away from news\u0026rsquo;\u003c/em\u003e).\u003c/p\u003e \u003cp\u003e[insert Fig.\u0026nbsp;3 here]\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure\u0026nbsp;3\u003c/b\u003e The top 3 GAS-10 symptoms and Coping with Stress and Anxiety strategies network. Ring-shaped pie charts represent predictability. The nodes are arranged in order according to the legend and represent anxiety symptoms and coping strategies. The size and density of edges between nodes represent the strength of connectivity. Blue edges are positive relationships and red edges are negative relationships.\u003c/p\u003e \u003cp\u003eWe also analysed bridge strength (see Fig.\u0026nbsp;4) among the combined networks of symptoms and coping strategies. In this respect, Node 9 (\u0026lsquo;\u003cem\u003eRemembering self as resilient\u0026rsquo;\u003c/em\u003e) and Node 19 (\u0026lsquo;\u003cem\u003eStaying activ\u003c/em\u003ee\u0026rsquo;) were particularly pivotal strategies. The importance of both such strategies is further depicted in Fig.\u0026nbsp;3 as a positive association between Node 9 (\u0026lsquo;\u003cem\u003eRemembering self as resilient\u0026rsquo;\u003c/em\u003e) and Node 2 (\u0026lsquo;\u003cem\u003eMuscle tension\u0026rsquo;\u003c/em\u003e). Negative associations emerged between Node 9 (\u0026lsquo;\u003cem\u003eRemembering self as resilient\u0026rsquo;\u003c/em\u003e) and Node 3 (\u0026lsquo;\u003cem\u003eNo control over my life\u0026rsquo;\u003c/em\u003e), and between Node 19 (\u0026lsquo;\u003cem\u003eStaying activ\u003c/em\u003ee\u0026rsquo;) and Node 3 (\u0026lsquo;\u003cem\u003eNo control over my life\u0026rsquo;\u003c/em\u003e).\u003c/p\u003e \u003cp\u003e[insert Fig.\u0026nbsp;4 here]\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure\u0026nbsp;4\u003c/b\u003e Bridge strength centrality shown as standardised z-scores\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study employed Network Analysis to create a visual representation of older Canadians\u0026rsquo; symptoms of anxiety experiences and another of the linkages between their most pernicious symptoms and the strategies they used to cope with them. Novel discoveries of linkages among and between them are summarised and discussed below.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eNetwork of Anxiety Symptoms\u003c/h2\u003e \u003cp\u003eIn the first year of COVID-19, older Canadians were generally least prone to high anxiety [8,20,21,51]. The loss of local contemporaries can make the threat of physical health harms more self-relevant [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], let alone on a global level [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. This may partially explain the observed strong connections between anxiety symptoms (e.g., \u0026lsquo;\u003cem\u003eIrritable\u003c/em\u003e\u0026rsquo; and \u0026lsquo;\u003cem\u003eRestless\u003c/em\u003e\u0026rsquo;, \u0026lsquo;\u003cem\u003eNot control my worry\u003c/em\u003e\u0026rsquo; and \u0026lsquo;\u003cem\u003eHard time sitting still\u003c/em\u003e\u0026rsquo;, \u0026lsquo;\u003cem\u003eTired\u003c/em\u003e\u0026rsquo; and \u0026lsquo;\u003cem\u003eMuscle tension\u003c/em\u003e\u0026rsquo;, \u0026lsquo;\u003cem\u003eNo control over my life\u003c/em\u003e\u0026rsquo; and \u0026lsquo;\u003cem\u003eApprehensive\u003c/em\u003e\u0026rsquo;). These pairs might represent clusters wherein one symptom can exacerbate the other or they might arise from common underlying factors. No one is immune to unfavourable shifts in anxiety [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. This past year alone, the lifetime prevalence of pernicious anxiety among older adults has doubled (5.2\u0026ndash;13.3%) and 1 in 3 report unmet mental health needs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur respondents were moving into opened spaces while living most at risk for becoming infected with and dying from COVID-19. This is a rather precarious position to be in. Central to their precarity were feelings of restlessness, muscle tension, and of having no control over their lives. Restlessness and no control were particularly pernicious as they explained 64\u0026ndash;68% of the variability in 8 other anxiety symptoms. Learning of their connectedness from age-peers in similar circumstances could be a source of good mentally healthy recovery work [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Much like long-COVID [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], pernicious anxiety can impair our everyday functional ability and be a source of emotional distress [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Strategies to disempower this trio are thus pivotal.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCombined Network of Anxiety and Coping Strategies\u003c/h2\u003e \u003cp\u003eWe examined connections between older Canadians\u0026rsquo; restlessness, muscle tension, and perceived lack of control over their lives, and mental and behavioural strategies to manage or mitigate this troubling trio. This combining helped us build a blueprint showing what within-person recovery might look like for other older people.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePositively Connected Coping Strategies\u003c/h2\u003e \u003cp\u003eThree sets of strategies were positively connected and appeared to be used in tandem, with one spurning on a significant other.\u003c/p\u003e \u003cp\u003eThe positive association between \u0026lsquo;\u003cem\u003eseeking credible information\u0026rsquo; and \u0026lsquo;tuning in and breaking away from news\u0026rsquo;\u003c/em\u003e [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] remind us that unbalanced information about hypothetical sources of harm or displayed images of threat in the news can undermine peoples\u0026rsquo; sense of safety. COVID-19 evoked uncontrolled and near constant streams of news [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. For older people in particular, public discourse through social media, popular press, and government official messaging set the stage for being characterised as vulnerable COVID-19 carriers [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Those indirectly affected through media exposure could personalise it and/or see illness potential in themselves [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur associations suggest that credible sources might curb people seeking out news elsewhere. This is important because anxiety comes from realistic dangers and information from assumptive or misinformed sources [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Credible sources such as organisational officials can stunt rumours and encourage return information seeking [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. In the first year of the pandemic, through Canada.ca, all Canadians were strongly encouraged to limit everyday news media exposure, even from authoritative sources. The linkage between seeking credible information and COVID-19 news suggests that our respondents heeded such advice.\u003c/p\u003e \u003cp\u003eThis observed pairing of \u0026lsquo;\u003cem\u003erelaxing and meditating\u003c/em\u003e\u0026rsquo; and \u0026lsquo;\u003cem\u003eseeking loved ones\u0026rsquo; support\u003c/em\u003e\u0026rsquo; could have been a means for our respondents to avoid or mitigate family conflicts or perhaps to mask their own COVID-related worries. Meditation has been found to be used more by older Canadians with no or minimal to mild symptoms of anxiety [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. While some research [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] indicates some older people made strategic use of their resources to lessen loneliness and isolation and some [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] describe \u0026lsquo;pivoting\u0026rsquo; or substituting pre-COVID routines with novel activities to stay mentally well, our responders did so through strategic pairing, with in tandem \u0026lsquo;\u003cem\u003eeating healthy\u0026rsquo; and \u0026lsquo;staying active\u0026rsquo;\u003c/em\u003e perhaps being another means by which respondents further minimise loved ones\u0026rsquo; stress.\u003c/p\u003e \u003cp\u003e \u003cb\u003eNegatively Connected Coping Strategies.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eNegative associations suggest that coping behaviours to manage or mitigate anxiety can also work in opposition. One such case-in-point is \u003cem\u003e\u0026lsquo;being kind to yourself\u0026rsquo; and \u0026lsquo;seeking credible information\u0026rsquo;\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eIn the first year of COVID-19, misleading, false, or inaccurate information about COVID-19 was found to increase older Canadians\u0026rsquo; anxiety [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. A recent literature review also linked being privy to risk-related COVID-19 news with poorer mental health [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e63\u003c/span\u003e], and with higher symptoms of anxiety [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Others\u0026rsquo; unhappiness and symptoms of depression seems to be associated with news following frequency [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Sharing negative news appears to trigger anxiety [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. In the context of this study, perhaps being kind to yourself means shielding yourself from distressing facts, particularly while moving into open spaces at a heightened risk for physical health harms.\u003c/p\u003e \u003cp\u003eThere was a negative association between \u0026lsquo;\u003cem\u003etuning in and breaking away from news\u0026rsquo; and \u0026lsquo;eating healthy\u0026rsquo;\u003c/em\u003e. We could not find any published studies about older Canadians\u0026rsquo; eating habits in relation to COVID-19 news following. In the first year of COVID-19, some older Canadians named [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e68\u003c/span\u003e] and found [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] eating healthy food mentally beneficial. A meta-analysis across some 40 countries, including Canada [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e69\u003c/span\u003e], revealed associations between unhealthy eating behaviours and anxiety in individuals between 18 and 74 years of age, albeit more so in younger age groups. In one study [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], older Canadians found not having or knowing how to access food particularly distressing. As with \u0026lsquo;being kind to myself\u0026rsquo;, these are cross-sectional associations. Future qualitative research is warranted to better understand these relationships.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSome larger implications\u003c/h2\u003e \u003cp\u003eThe positive and negative associations observed in our combined network may be explained by people managing or mitigating anxiety through a process of trials and errors [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Resilient people are flexible people with an ability to reframe how they think, act, and feel about what is in front of them, whether this concerns precarious health, work, and/or family matters [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e70\u003c/span\u003e] In the first year of COVID-19, resilient older people appeared to be better able to weather its many impacts [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. Qualitative [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e72\u003c/span\u003e] and quantitative [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e73\u003c/span\u003e] researchers partly attributed more favourable mental health and well-being of older people to personal resilience.\u003c/p\u003e \u003cp\u003e\u0026lsquo;\u003cem\u003eRemembering self as resilient\u003c/em\u003e\u0026rsquo; was an asset for our respondents on several fronts when they were moving into open spaces. Such recollections were negatively associated with feeling a \u0026lsquo;\u003cem\u003elack of control over my life\u003c/em\u003e\u0026rsquo;. Much like in the first pandemic year, positive reframing circumvented the negative impacts that intolerable uncertainty had on anxiety [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Being wise to life\u0026rsquo;s physical uncertainties and open-minded has also been helpful to older people well before COVID-19 [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e76\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResilience was also important because a \u0026lsquo;\u003cem\u003elack of control over my life\u003c/em\u003e\u0026rsquo; seemed to either deter \u0026lsquo;\u003cem\u003estaying active\u003c/em\u003e\u0026rsquo;, or vice-versa. Resilient older people are likely to be flexible about how often they stay active and what they gain from it. Simply getting outside has brought older people closer to nature [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e77\u003c/span\u003e] and has given them some kind of social life [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and helped them feel less isolated in general [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. This kind of reframing has led others to find contentment with small social circles [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e63\u003c/span\u003e] and in befriending technology [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e78\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur respondents\u0026rsquo; remembering resilience seemingly strongly shielded them from feeling restless, tense, and as if they had no control over their lives. Future network analyses should include a measure of resilience such as the Brief Resilience Scale [\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e79\u003c/span\u003e] to shed further light on its associations with symptoms of anxiety and strategies to manage or mitigate them. Programs or interventions to bolster resilience might benefit older people feeling restless, tense, and as if they have no control over their lives. Ideally, interventions strengthen resilience \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eand\u003c/span\u003e active propensities.\u003c/p\u003e \u003cp\u003eTaken together, the findings of this study suggest that mental health recovery work requires a wide variety of coping strategies, with some working in tandem and some in opposition. Mental health recovery work is hard work, particularly in the presence of pernicious anxiety symptoms. As was learned during the first year of COVID-19, very few older people accessed digital resources [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and others felt bewildered as to where to find resources tailored to their needs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A visual representation or blueprint showing how symptoms of anxiety can be connected and between strategies to manage or mitigate particularly pernicious ones could be helpful to practitioners, program developers, and older people, as they navigate through the complexities of mentally healthy recovery work now as COVID-19 lingers [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e81\u003c/span\u003e] and later, in the event of other large-scale traumatic events.\u003c/p\u003e \u003cp\u003eThis study has limitations, including our reliance on cross-sectional data collected at one point in time. We found associations between and among symptoms and coping behaviours. We cannot say with any degree of certainty that a troubling trio of anxiety symptoms evoke any one strategic action, nor a chain reaction in others.\u003c/p\u003e \u003cp\u003eWhile our observed network associations provide valuable insights, it would be important to investigate their directionality. For instance, does increasing resilience decrease feelings of tension or lack of control, or do these feelings prompt individuals to become more resilient? Thus, it is also crucial to consider external factors or other internal processes that might influence these associations. This includes life events, other coping strategies not in the network, or sociodemographic factors like personal income [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e73\u003c/span\u003e] and personality [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Research also tells us that older people have a greater capacity to better regulate negative emotions [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e82\u003c/span\u003e], even through the simplest domestic tasks [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and by taking disrupted routines in stride [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. Acknowledging and expressing negative emotions helped older Canadians persevere early in the pandemic [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e72\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur study is the first study to offer evidence of what an optimal mentally healthy living structure might look like for older people, and at a pivotal point in the COVID-19 pandemic. Mental health practitioners and program developers, and older people should find such discoveries intriguing. A combined blueprint of older Canadians\u0026rsquo; most pernicious anxiety symptoms and strategies to manage or mitigate them could be a helpful visual teaching tool that offers older people a better understanding of their own anxiety recovery work. As COVID-19 lingers, seeing what contemporaries\u0026rsquo; mentally healthy recovery work looks like might also offer a much-needed sense of hope.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAPA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Psychological Association\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAMH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCenter for Addiction and Mental Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCMHA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCanadian Mental Health Association\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGOC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGovernment of Canada\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIASCRGMHPSES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInter-Agency Standing Committee Reference Group on Mental Health and Psychosocial Support in Emergency Settings\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIPCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInfection Prevention and Control Canada\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMHCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMental Health Commission of Canada\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMHRC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMental Health Research Canada\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCIRD(U.S.)DVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Center for Immunization and Respiratory Diseases (U.S.). Division of Viral Diseases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHAC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePublic Health Agency of Canada\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank our e-survey responders for their shared wisdom and resourcefulness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eG.L. and G.G. conceived of within-person recovery; A.B.F. and G.L. conceptualized the analytical approach. G.L., Z.G., and A.B.F. co-identified the sampling methodology; G.L., Z.G., and A.H. acquired the data; G.L., H.A., G.G., Z.G., and D.M.W. collaborated on e-survey platform logistics and scripts; A.B.F. conducted the Network Analysis and prepared figures 1-4; A.B.F., G.L., G.G. and S.v.H. interpreted the data. G.L. and A.B.F. prepared the original draft of the manuscript text; G.G., S.v.H., Z.G., H.A., and D.M.W. reviewed and edited the original draft. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project described was funded by RTOERO Foundation [Grant #056223]. \u0026nbsp;The content is solely the responsibility of the authors and does not necessarily represent the official views of the RTOERO Foundation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data analysed in this study is available upon reason request from the Primary Investigator, Dr. Gail Low.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project received ethical approval from the University of Alberta Human Research Ethics Board [Pro00118512]. All participants gave informed consent to participate prior to filling the survey, online. All methods\u0026nbsp;were performed in accordance with the relevant guidelines and regulations such as the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChirico F. Spirituality to cope with COVID-19 pandemic, climate change and future global challenges. J Health Soc Sci. 2021 Oct;6(2):151-8. https://journalhss.com/wp-content/uploads/jhhs_62_151-158.pdf\u003c/li\u003e\n\u003cli\u003eGalea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention. 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Gerontologist. 2016 Apr 1;56(2):256-65. https://doi.org/10.1093/geront/gnu041\u003c/li\u003e\n\u003cli\u003eTabrizi N, Lak A. Green space and the health of the older adult during pandemics: a narrative review on the experience of COVID-19. Front Public Health. 2023;11:1218091. https://doi.org/10.3389%2Ffpubh.2023.1218091\u003c/li\u003e\n\u003cli\u003evon Humboldt S, Mendoza-Ruvalcaba NM, Arias-Merino ED et al. The upside of negative emotions: How do older adults from different cultures challenge their self-growth during the COVID-19 pandemic? Front Psychol. 2022 May 9;13:648078. https://doi.org/10.3389/fpsyg.2022.648078\u003c/li\u003e\n\u003cli\u003eSmith BW, Dalen J, Wiggins K et al. The brief resilience scale: assessing the ability to bounce back. Int J Behav Med. 2008 Sep;15:194-200. https://doi.org/10.1080/10705500802222972.\u003c/li\u003e\n\u003cli\u003eInfection Prevention and Control Canada. Coronavirus (COVID-19) SARS-CoV-2. Infection Prevention and Control Canada [Internet]. Ottawa (ONT): Infection Prevention and Control Canada; 2022 [updated 2023 Oct 6; cited 2024 Jan 8]. Available from: https://ipac-canada.org/coronavirus-resources\u003c/li\u003e\n\u003cli\u003ePublic Health Agency of Canada. COVID-19: Prevention and risks [Internet]. Ottawa (ONT): Government of Canada; 2023 [updated 2023 Dec 19; cited 2024 Jan 5] https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks.html\u003c/li\u003e\n\u003cli\u003eWhatley MC, Siegel AL, Schwartz ST et al. Younger and older adults\u0026rsquo; mood and expectations regarding aging during COVID-19. Gerontol Geriatr Med. 2020 Sep 16;6:1-9. https://doi.org/10.1177/2333721420960259\u003c/li\u003e\n\u003cli\u003eCarney AK, Graf AS, Hudson G et al. Age moderates perceived COVID-19 disruption on well-being. Gerontologist. 2021 Feb;61(1):30-35. https://academic.oup.com/gerontologist/article/61/1/30/5893781\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Older people, network analysis, anxiety, COVID-19","lastPublishedDoi":"10.21203/rs.3.rs-3846824/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3846824/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDuring the COVID-19 pandemic older adults experienced a variety of symptoms of anxiety. They employed a number of different strategies to deal with these. The aim of this study was to create a blueprint of older Canadians\u0026rsquo; symptoms of pandemic-related anxiety and coping strategies, and linkages among and between them. Particular attention was paid to identifying the most-pernicious symptoms and variables that might facilitate application of the most beneficial coping strategies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn e-survey was conducted with 1,327 older Canadians in the Summer of 2022, when public health measures were lifting across Canada. Anxiety was measured using the Geriatric Anxiety Scale \u0026minus;\u0026thinsp;10. Participants also completed the Coping with Stress and Anxiety personal assessment tool. Network analysis permitted us to examine linkages among respondents\u0026rsquo; self-reported symptoms, and between their most pernicious symptoms of anxiety and the strategies to cope with them.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFindings revealed a troubling trio of anxiety symptoms of central importance to our respondents: feelings of restlessness, muscle tension and having no control over their lives. Restless and no control over my life were particularly pernicious because they explained between 64\u0026ndash;68% of the variance in 8 other anxiety symptoms. Coping seemed to occur through trial and error. Some strategies appeared to work in tandem and others in opposition to each other. Responders remembering resilience and staying active functioned as bridges shielding older people from worry, restlessness, and tension through spurning other remedial actions.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eThis study provides evidence of a stable and predictable network of anxiety symptoms containing three particularly pernicious symptoms. Coping strategies, some seemingly working in tandem and some in opposition, or as bridges to recovery speak to the complex and arduous nature of mentally healthy recovery work. A visual representation of how anxiety symptoms can operate as a network might help older people better understand their own symptom experiences. Combining the two networks offers a blueprint of what within-person recovery might look like and a visual teaching tool for practitioners and program developers; older people could gain added insight into their own recovery experience.\u003c/p\u003e","manuscriptTitle":"Anxiety symptoms and coping strategies used by older adults during COVID-19: A national e-study of linkages among and between them.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-19 21:38:54","doi":"10.21203/rs.3.rs-3846824/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2f773877-fbbb-4997-bce6-12d2467fbffd","owner":[],"postedDate":"January 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-02T08:51:25+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-19 21:38:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3846824","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3846824","identity":"rs-3846824","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}