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Research Paper vs. Research Article: What’s the Difference?

Research papers and research articles are two different forms of academic writing, with distinct characteristics. Although they share some similarities in terms of format and purpose, there are important distinctions between the two types that should be understood by students who wish to write either form effectively. This article will explain the differences between a research paper and a research article, outlining their unique features and applications. Furthermore, it will offer guidance on how best to approach each type when crafting an effective piece for scholarly consumption.

I. Introduction to Research Paper vs. Research Article

Ii. defining a research paper and a research article, iii. comparative analysis of structure, content, and writing styles between the two types of scholarly documents, iv. pros & cons of conducting either a formal or an informal study, v. concluding remarks: how to choose between the different approaches when completing academic assignments, vi. limitations in comparing these texts as distinct forms of scholarly outputs, vii. future directions for understanding similarities & differences across all kinds of academic writings.

Research Paper vs. Research Article

The academic world is full of a variety of different writing styles, each with its own unique purpose and goals. Two particularly important forms are the research paper and the research article. Each has their own distinct features that make them uniquely suited to certain tasks within academia – let’s take a closer look at what sets them apart from one another!

A research paper , as you might expect, presents in-depth analysis on an issue or topic using evidence gathered through primary sources such as field work, laboratory experiments, surveys, interviews etc., whereas a research article , typically published in scholarly journals or online publications like websites & blogs addresses specific findings derived from secondary sources like books or other papers related to said subject matter. The former requires more effort & dedication from the author due to it being time consuming & involving careful structuring along with rigorous citation format adherence; while the latter focuses mainly on providing succinct yet comprehensive overviews regarding topics which have already been extensively discussed by experts in depth previously elsewhere – taking into account present day developments/breakthroughs if necessary before finally offering opinionated conclusions pertaining to said subjects.

Exploring the Characteristics of a Research Paper and Article

Research paper:
Research article:

A research paper is an extended form of writing that presents and supports an argument on a particular topic. It provides evidence for the opinion or idea in the form of facts, data, analysis, opinions from authorities in specific fields etc. The objective is to make original claims based on careful evaluation of information available on a given subject. It requires significant effort as one needs to be able to distill complex topics into concisely articulated points that are supported by solid evidence.

On the other hand, a research article is usually written for publication either online or printed through journals or magazines. These articles have been peer-reviewed which means they follow certain academic standards established within their discipline while presenting factual conclusions related to ongoing debates and arguments raised by preceding works. They generally provide new insight into existing knowledge rather than build upon it using more primary sources such as surveys and experiments conducted independently by authors themselves.

Comparison of Structure, Content and Writing Styles between Research Papers and Articles For the purpose of scholarly communication, both research papers and articles play a vital role. Though there is no hard-and-fast rule that distinguishes them from each other in terms of structure or content, they usually differ significantly in their style. In comparison to research papers, articles typically have a much smaller length requirement. They can range anywhere from 1 page to as many as 30 pages depending on the journal guidelines – making them more accessible for readers who are seeking concise summaries with quick insights into topics. On the contrary, research papers tend to be longer documents that delve deeper into an issue by providing extensive background information; detailed analysis; arguments bolstered by sources such as peer-reviewed journals or interviews; conclusion sections tying up any loose ends etc.

Research Papers: Longer documents which provide extensive coverage about an issue.
Articles: Short pieces covering high level overviews without going too deep.

When it comes down to writing styles used for these two types of documents – Authors generally follow formal academic language while creating research paper whereas article writers tend to use more casual tones in order to appeal wider audience groups. Additionally authors will often adopt conversational elements like anecdotes when crafting articles so that readers can get better understanding about specific points being discussed within context.

Formal vs. Informal Study: A Critical Analysis The choice between conducting a formal or informal study may be difficult for researchers due to the advantages and drawbacks of each approach. Depending on their research topic, scientists must carefully weigh up the pros and cons before deciding which course of action is most suitable for them.

A formal study , as conducted in many research papers and articles, often requires more time-consuming effort from researchers than an informal one because it involves using specific methodologies such as surveys, interviews, experiments etc., gathering quantitative data that needs to be statistically analyzed by employing reliable statistical methods. On the other hand, a formal investigation allows researchers to obtain objective information from well-defined populations about predetermined variables through systematic procedures that can yield precise results with larger external validity – making it possible to make generalizations beyond those studied in this particular case.

Conversely, an informal study , also known as participant observation or field work requires less structured approaches where collecting qualitative data is usually achieved via conversations with informants instead of strict instrumentations; thus allowing greater interaction between researcher and subjects resulting in increased understanding of contextually situated phenomena within its natural setting rather than artificially created ones used in laboratories’ studies – leading to deeper insights into complex social processes . Also noteworthy is its lower financial cost when compared against highly expensive equipment needed for undertaking large scale scientific investigations.. However despite yielding valuable first person accounts which might not have been obtained elsewhere , such observations are sometimes criticized due challenges related accuracy given reliance on subjective interpretations while generating evidence without significant use of control variables .

Selecting the Optimal Approach for Academic Assignments When it comes to completing academic assignments, there are various approaches one can take. In order to ensure success and optimal results, it is important that students consider all of their options carefully before making a choice.

Research papers often require extensive research and careful consideration when selecting an approach. Using primary sources such as books or peer-reviewed articles may be more reliable in comparison to secondary sources such as websites or blogs which are usually less credible due to lack of credibility checks by professionals within the field. Additionally, data analysis can help strengthen arguments while also adding clarity to any work produced during the course of completion; however, understanding how best utilize this analytical tool effectively requires additional practice and experience on behalf of the student undertaking it. For research articles, detailed knowledge about particular topics may lead towards better outcomes but general familiarity with content areas is sufficient enough for success here too. The key lies in being able identify appropriate methods quickly through use critical thinking skills coupled with clear objectives pertaining specifically each assignment itself at hand prior its execution – this way mistakes are avoided thus delivering quality results each time..

Comparative Analyses of Scholarly Outputs

Scholarly output, such as research papers and articles, are subject to scrutiny when attempting to make comparisons.
Due to the differences between these two types of outputs, it can be difficult or impossible to achieve a true comparison.

Comparing scholarly outputs is not always possible due to their distinct forms. Research papers typically have more depth than an article on the same topic which may mean that even though both documents might discuss similar topics in some aspects they will differ greatly in others. Furthermore, the format of each type of document contributes further complexities; for example, a research paper is often much longer and requires extensive background information before any conclusions can be drawn while articles tend towards presenting results with little room left for interpretation. The style used by authors also adds difficulty; many times research papers include complex jargon necessary for understanding specific points whereas an article strives for simplicity so its target audience can comprehend all material without excessive effort. These limitations prevent proper analysis from being done since one piece could provide certain details while another provides only bits related thereto leading readers into confusion if attempting to compare them directly despite intentions otherwise. It then becomes clear that academic pieces should instead remain separate entities rather than compared against each other since doing so would lead only too frustration given current constraints therein found.

Exploring the Similarities and Differences Between Academic Writings

As our understanding of academic writings continues to evolve, so too must our appreciation for both their similarities and differences. From research papers to research articles, it is important to consider how each one contributes unique insight into a given topic or issue.

The research paper and research article may look similar on the surface, but upon closer inspection one can see significant differences in their format, purpose, and audience. The key distinctions between these two forms of written work are scope of content covered, type of analysis used to draw conclusions or develop knowledge from data or evidence presented, and intended readership. Ultimately, understanding the essential characteristics that distinguish a research paper from a research article is beneficial for anyone who produces such texts as it will help them craft an effective product that aligns with its desired purposes.

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Types of journal articles

It is helpful to familiarise yourself with the different types of articles published by journals. Although it may appear there are a large number of types of articles published due to the wide variety of names they are published under, most articles published are one of the following types; Original Research, Review Articles, Short reports or Letters, Case Studies, Methodologies.

Original Research:

This is the most common type of journal manuscript used to publish full reports of data from research. It may be called an Original Article, Research Article, Research, or just Article, depending on the journal. The Original Research format is suitable for many different fields and different types of studies. It includes full Introduction, Methods, Results, and Discussion sections.

Short reports or Letters:

These papers communicate brief reports of data from original research that editors believe will be interesting to many researchers, and that will likely stimulate further research in the field. As they are relatively short the format is useful for scientists with results that are time sensitive (for example, those in highly competitive or quickly-changing disciplines). This format often has strict length limits, so some experimental details may not be published until the authors write a full Original Research manuscript. These papers are also sometimes called Brief communications .

Review Articles:

Review Articles provide a comprehensive summary of research on a certain topic, and a perspective on the state of the field and where it is heading. They are often written by leaders in a particular discipline after invitation from the editors of a journal. Reviews are often widely read (for example, by researchers looking for a full introduction to a field) and highly cited. Reviews commonly cite approximately 100 primary research articles.

TIP: If you would like to write a Review but have not been invited by a journal, be sure to check the journal website as some journals to not consider unsolicited Reviews. If the website does not mention whether Reviews are commissioned it is wise to send a pre-submission enquiry letter to the journal editor to propose your Review manuscript before you spend time writing it.

Case Studies:

These articles report specific instances of interesting phenomena. A goal of Case Studies is to make other researchers aware of the possibility that a specific phenomenon might occur. This type of study is often used in medicine to report the occurrence of previously unknown or emerging pathologies.

Methodologies or Methods

These articles present a new experimental method, test or procedure. The method described may either be completely new, or may offer a better version of an existing method. The article should describe a demonstrable advance on what is currently available.

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Q. What's the difference between a research article (or research study) and a review article?

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Answered By: Priscilla Coulter Last Updated: Jul 29, 2022 Views: 230880

A research paper is a primary source ...that is, it reports the methods and results of an original study performed by the authors . The kind of study may vary (it could have been an experiment, survey, interview, etc.), but in all cases, raw data have been collected and analyzed by the authors , and conclusions drawn from the results of that analysis.

Research papers follow a particular format. Look for:

A brief introduction will often include a review of the existing literature on the topic studied, and explain the rationale of the author's study. This is important because it demonstrates that the authors are aware of existing studies, and are planning to contribute to this existing body of research in a meaningful way (that is, they're not just doing what others have already done).
A methods section, where authors describe how they collected and analyzed data. Statistical analyses are included. This section is quite detailed, as it's important that other researchers be able to verify and/or replicate these methods.
A results section describes the outcomes of the data analysis. Charts and graphs illustrating the results are typically included.
In the discussion , authors will explain their interpretation of their results and theorize on their importance to existing and future research.
References or works cited are always included. These are the articles and books that the authors drew upon to plan their study and to support their discussion.

You can use the library's article databases to search for research articles:

A research article will nearly always be published in a peer-reviewed journal; click here for instructions on limiting your searches to peer-reviewed articles.
If you have a particular type of study in mind, you can include keywords to describe it in your search . For instance, if you would like to see studies that used surveys to collect data, you can add "survey" to your topic in the database's search box. See this example search in our EBSCO databases: " bullying and survey ".
Several of our databases have special limiting options that allow you to select specific methodologies. See, for instance, the " Methodology " box in ProQuest's PsycARTICLES Advanced Search (scroll down a bit to see it). It includes options like "Empirical Study" and "Qualitative Study", among many others.

A review article is a secondary source ...it is written about other articles, and does not report original research of its own. Review articles are very important, as they draw upon the articles that they review to suggest new research directions, to strengthen support for existing theories and/or identify patterns among exising research studies. For student researchers, review articles provide a great overview of the existing literature on a topic. If you find a literature review that fits your topic, take a look at its references/works cited list for leads on other relevant articles and books!

You can use the library's article databases to find literature reviews as well! Click here for tips.

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Difference Between Research Article and Research Paper

This article will discuss both writings formats and discuss Difference Between Research Article and Research Paper.

It’s likely that you will hear a lot about research papers and research articles, whether you are a student at a college or university or working towards a profession.

Both types of writing are common techniques used by educators and businesses to get feedback from coworkers and students on a topic or subject. One must understand each form and how people use it in to differentiate between the two types of writing.

The majority of assignments require a specific working framework and exploration because research is seen as a movement that has gained substantial popularity in the academic world. The research papers and research articles serve as a compilation that is required for the essential certification, as well as for comprehending and demonstrating outstanding aptitude for research and study.

The research articles and research papers are the parts of the writing which need investigation, critical analysis, insight, and presentation of few particular skills from the scientists and students. When the teacher assigns the class to write a research paper, it actually overwhelms the students. Research articles and research papers have many similarities, which causes students to become confused. Here, we shall highlight the fundamental differences between the two terms.

Table of Contents

Research Article

What will a researcher or scientist do after they have found the answer to a question or made a discovery they wish to share with the world?

Well, writing a research paper is the ideal way to share your knowledge and expertise with the world. An authentic study topic, together with pertinent findings and data, are all included in a research article. It is published by renowned scientific journals that are concerned with the field of work to which your study relates. You can refer to a research paper as a writing or a paper that informs readers of a new line of enquiry or a discovery that is supported by evidence.

A research article gets a touch of building with original research, pertinent data, and disclosures. It is a particular study article that informs readers who are worried about the finding being broken or who are looking for information to support the finding.

A research article, according to Simon Fraser University, is a piece of writing that is written about a specific topic. A research article written by an expert in a certain field is frequently written by another expert in the same field. Peer reviews are another term for this kind of writing.

A research article is a concise piece of writing on a certain subject that is typically published in issues or periodicals. Current research on the topic, including new advances, analyses of a technique or item, and brief studies previewing concepts are frequently included.

A Research article may contain details on the most recent techniques or methods in a certain industry. Peer reviews, case studies, scholarly articles, scientific, and social science articles are further types of research articles. A journal publishes research articles only after conducting a substantial amount of research in the related field. Research articles are classified as primary literature or review articles in the Publication Manual.

Purpose of Research Article

A research article may be a significant source, making it a valuable resource for creating the thesis for the relevant topic. It includes a report on the methods and results of the researchers’ original research.

The type of study conducted may vary (it may take the form of an experiment, interview, meeting, etc.), but in every instance, the researcher gathers the raw data, breaks it down, and then draws conclusions based on the investigations carried out throughout the study.

As a result, each project is different, and regardless of the language you use, your article must be able to effectively convey all of your research and findings.

Format of Research Article

Create a title that is specific enough to summarize the entire article’s content while being understandable. The article’s title ought to be relevant for the target audience.

Article titles, such as “ Effect of Alcohol on Academic Performance ,” typically describe the article’s topic matter.

The initial author of an article is typically considered to be a researcher who conducted the research and produced the paper.

Other people have made significant contributions in writing the research article that is published, and as a result, they are considered authors. Before listing your mentor’s name as a co-author or author, you can get their permission.

It gives readers a sneak peek at the entire study. By allowing other scientists to quickly scan a sizable portion of the scientific literature, they can then choose which research articles they want to study in-depth. A research article’s abstract should be a little less technical than the article’s content.

An abstract must be one paragraph long (between 100 and 250 words), summarizing the objective, methods, results, and conclusion of the study.

Giving all the information in a single paragraph is not very simple. Start by including the overview of what you feel is vital to mention, and then gradually reduce the length by omitting the unimportant details while keeping the crucial information.

In your abstract, avoid using citations or abbreviations. Without any footnotes, it must be readable.

→INTRODUCTION

What is the objective of your research?
What are the research questions?
Which problem your research has addressed?

In order for your reader to comprehend the aim of the topic and what makes it so intriguing, this section of the essay provides a synopsis of the relevant literature.

A two- to four-paragraph introduction is appropriate. Finish it up with a statement that clarifies the question.

This section describes how you will respond to your question. Here, there must be enough information to let the reader understand the research.

Look for related articles that were published before yours to get a sense of this section of the article.

If you have a complicated method, it can be beneficial to include diagrams, flowcharts, or tables to describe how you use it.

Include the relevant moral considerations as well.

Do they permit participation if you use human subjects?

What pain-reduction measures would you adopt if you used animals?

Read More: Population vs Sample | Examples

This part is a presentation of the findings you came to. If necessary, use graphs and charts; nevertheless, this part should also provide a summary of the key findings.

Don’t discuss the outcomes or speculate as to why anything occurred. None of the information you discovered from research needs to be mentioned. Employ appropriate techniques to explain the data. Don’t try to distort your facts to make it appear that you have accomplished more than you have.

→TABLES AND GRAPHS

Instead of just stating, “Here are the results that are drawn,” if you are presenting the data in the form of graphs or tables, explain a little bit about what the graphs or tables indicate, such as, “This graph or table represents the activity of enzyme at different temperatures.”

→DISCUSSION

Mention the most significant findings in discussion. Try to avoid just restating those from the results section.

How are your findings related to your question?
Do your data give support to the proposed theory?
Are the findings in line with the areas you looked at for the article?

Provide reasons if the results are surprising.

Is there another way to understand the outcomes?
What additional study is necessary to respond to your question?
How do your findings relate to the larger context?

→ACKNOWLEDGMENTS

The acknowledgements section is optional. You can express gratitude to anyone who helped you during an experiment or who provided any other substantial assistance, such as discussing your methodology or offering suggestions on a manuscript.

→REFERENCES

There are only a handful possible arrangements for this section. You could, for instance, cite the text at main points. Alternatively, include a list of references in alphabetical order at the end of the article.

Research Paper

When referring to research papers, Dr. Jane Simonsen, a history professor, once said, “The work and design are your own, but you can’t do it without relying on the efforts and wisdom of others.”

Simonsen’s assumption is accurate. A research paper is a type of writing that is typically utilized in academic settings by college or university students who have been asked to look into and research a topic before coming to their conclusion.

The use of data from reliable sources to back up the student’s conclusions is both encouraged and frequently necessary. The length of research paper is affected by the complexity of the topic. A standard research paper can be anywhere from 50 to 200 pages long.

After gathering all necessary information from sources, a student’s work will be organized into the structure. Teachers frequently use this method to help students develop a balance in their writing abilities while promoting structural discipline and standard formatting.

According to A Research Guide for Students, research papers also use the subject’s original information, and after the student has gathered the data from the investigative stage, they are summarized with a clear and simple analysis and disposition, or thesis. In fact, the thesis statement for most research papers comes from the assigned topic.

Purpose of Research Paper

Writing an outstanding research paper is not merely a non-related task that you must complete in order to pass the examination. It is a task that teaches you a lot including:

How to research a specific topic?
How to fully express your understanding, conclusions, and analysis to a reader?

The more you focus on paper quality while in college or university, the more you’ll need to practice writing and research skills, which will enhance both your analytical and writing abilities. Nevertheless, if you perform poorly, the competition will be weaker, and it’s more possible that you’ll look back on this period and feel regret in the future for having missed your chance. Gaining the advantages of having the best writing abilities is crucial for this reason.

Format for Research Papers

There is a set format for research papers.

A brief introduction that often includes an overview of recent literature on the given topic researched and explains the author’s motivation for undertaking the research. This is significant because it indicates that the authors are aware of the current body of research and intend to contribute to it appropriately and they are not only conducting research on the topics that other people have already conducted.

The authors describe in detail how they can gather and evaluate the data in this section. The statistical analysis is also provided. The method section is very thorough since it is crucial for other researchers to be able to verify or employ the same methods.

Read More: Reliability vs Validity | Examples

The findings of your analysis can be discussed in this section. To demonstrate your findings, use graphs and charts.

Here, the authors provide an explanation of how the results were interpreted as well as a theory outlining the significance of current and future research.

References and citations can be added here. References are genuine books and articles that authors use to conduct their research and support their arguments.

Difference Between Research Paper and Research Article

1- A student at a university or college generally writes research papers as part of their coursework. A research paper is completed for review by a teacher or instructor. Whereas, a research article is a piece of writing that has recently undergone research or review by a professional in the field.

2- The number of references used also differs slightly. A reader can typically anticipate finding a lengthy bibliography in a research article, whereas a research paper won’t call for a reference list so extensive.

3- A research paper isn’t published in any publication unless it’s a guideline on how to write one, whereas a research article is submitted to periodicals, magazines or peer-reviewed journal.

4- A research article examines a potential or existing concept and discusses its effects. A thesis may be provided in a research paper, although it will not be as detailed.

5- Both differs in terms of formatting and length. A Longer in length whereas research article might be 15 pages long, but it’s not always the case. The structure used to convey the research will be different from that of a research paper, which might use double spacing and indenting. In contrast to a journal article, which explains its original findings to the reader, a research paper is written to demonstrate empirical data rather than to provide original research.

6- The title of the research paper will be centered, and the student’s name, class, date, and teacher will be in the left corner. Whereas the title will be top and centre in the research article. The names of the author(s) are listed below.

7- Research paper is for writing practice, while the research article is a specific practice for other practitioners. A research paper is more utilized to teach students how to write clearly and effectively on a subject, whereas the research article is designed to educate the reader on a subject or topic.

Journal Article vs Research Paper: Difference and Comparison

A journal article presents original research findings in a concise format, focusing on a specific topic within a broader field. It undergoes peer review before publication, ensuring quality and validity. On the other hand, a research paper is a comprehensive document that may include multiple experiments, analyses, and discussions, aimed at contributing to the advancement of scientific knowledge.

Key Takeaways A journal article is a shorter scholarly writing published in a specific academic journal. A research paper is a more extended, comprehensive academic writing presenting original research. Journal articles are more focused and present specific findings, while research papers are broader and present a more comprehensive study.

Journal Article vs Research Paper

A journal article is a piece of published work that presents the research findings and may include analysis, remark, or discussion. A research paper is a detailed account of the research that may be published or unpublished and includes an introduction, literature review, methods, results, and conclusion.

Comparison Table

What is journal article.

A journal article is a scholarly publication that presents the findings of original research, analysis, or review within a particular academic field. These articles serve as fundamental units of scholarly communication, disseminating new knowledge, theories, and insights to the academic community and beyond. Here’s a detailed breakdown:

Content and Structure

1 Abstract: A journal article begins with an abstract, a concise summary of the study’s objectives, methods, results, and conclusions. The abstract provides readers with a quick overview of the article’s content and findings.

2 Introduction: Following the abstract, the introduction sets the context for the study by reviewing relevant literature, identifying gaps or controversies in existing knowledge, and stating the research objectives or hypotheses.

3 Methods: The methods section outlines the procedures, materials, and techniques used to conduct the study. It should provide sufficient detail to enable replication of the experiment or analysis by other researchers.

4 Results: This section presents the findings of the study, using tables, figures, or graphs to illustrate data. Authors describe the results objectively, without interpretation or speculation.

5 Discussion: In the discussion section, authors interpret the results in light of the study’s objectives and existing literature. They may address the implications of their findings, suggest future research directions, and discuss limitations or potential sources of bias.

6 Conclusion: The conclusion summarizes the main findings of the study and highlights their significance. It may also reiterate the study’s contribution to the field and offer final reflections or recommendations.

Peer Review Process:

1 Submission: Authors submit their articles to scholarly journals for publication consideration, adhering to the journal’s guidelines and formatting requirements.

2 Peer Review: Upon submission, the journal’s editor assigns the manuscript to peer reviewers—experts in the field—who evaluate the article’s quality, originality, methodology, and significance. Peer review helps ensure the rigor and credibility of the research.

3 Revision: Based on the reviewers’ feedback, authors may revise their article to address any concerns or criticisms raised. This iterative process of revision and reevaluation continues until the article meets the journal’s standards for publication.

4 Acceptance and Publication: If the article meets the journal’s criteria, it is accepted for publication and undergoes final editing and formatting. Once published, the article becomes part of the journal’s archive and is accessible to readers worldwide.

What is Research Paper?

A research paper is a comprehensive document that presents the findings, analysis, and interpretations of original research conducted by the author(s) within a specific academic discipline. These papers serve as a means for scholars to contribute new knowledge, theories, and insights to their respective fields. Here’s a detailed breakdown:

1. Content and Structure

1 Introduction: The introduction of a research paper provides background information on the topic, reviews relevant literature, and outlines the research objectives or hypotheses. It establishes the context for the study and justifies its significance.

2 Methods: The methods section describes the procedures, materials, and techniques employed in the research. It should provide sufficient detail to enable other researchers to replicate the study and verify its results.

3 Results: This section presents the empirical findings of the research, using tables, figures, or graphs to illustrate data. Authors report their observations or measurements objectively, without interpretation or speculation.

4 Discussion: In the discussion section, authors interpret the results in light of the research questions or hypotheses, comparing them to previous studies and addressing their implications. They may also explore alternative explanations, limitations of the study, and avenues for future research.

5 Conclusion: The conclusion summarizes the main findings of the research and highlights their significance. It may reiterate the study’s contribution to the field, offer final reflections, and suggest directions for further inquiry.

Characteristics and Scope

1 Original Research: Unlike review papers or essays, research papers are based on original research conducted by the authors. They contribute new data, insights, or interpretations to the academic discourse.

2 Rigorous Methodology: Research papers adhere to rigorous scientific or scholarly methodologies, employing systematic approaches to data collection, analysis, and interpretation. They prioritize objectivity, validity, and reliability in their findings.

3 Length and Complexity: Research papers vary in length and complexity, depending on the scope of the study and the requirements of the target publication venue. They may range from concise reports of preliminary findings to comprehensive analyses of multi-year research projects.

4 Contribution to Knowledge: Research papers aim to advance knowledge within their respective fields by addressing research gaps, testing hypotheses, or generating new theories. They contribute to the cumulative growth of scholarship through the dissemination of original research findings.

Main Differences Between Journal Article and Research Paper

Journal articles focus on a specific aspect or finding within a broader topic.
Research papers provide a comprehensive analysis of a research project, including multiple experiments, analyses, and discussions.
Journal articles are concise, containing essential findings, methods, and interpretations in a limited space.
Research papers tend to be longer and more detailed, offering exhaustive exploration of the research topic, methodology, results, and implications.
Journal articles undergo peer review by experts in the field before publication, ensuring quality and validity.
Research papers may or may not undergo formal peer review, depending on the publication venue or academic requirements.
Journal articles present findings objectively, without extensive interpretation or speculation.
Research papers include in-depth interpretation of results, discussion of implications, and exploration of potential limitations or biases.
Journal articles contribute to the scholarly conversation by presenting new findings, analyses, or reviews within a specific topic area.
Research papers advance knowledge within a field by offering comprehensive analyses, testing hypotheses, or generating new theories through original research.

Difference Between Journal Article and Research Paper

https://gssrr.org/index.php/gssrr/How-to-Publish-Research-Paper
https://www.springer.com/gp/authors-editors/journal-author/types-of-journal-manuscripts/1356
https://owl.purdue.edu/owl/general_writing/common_writing_assignments/research_papers/index.html

Last Updated : 05 March, 2024

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21 thoughts on “journal article vs research paper: difference and comparison”.

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Absolutely, understanding the nuances between these two types of publications is essential for academic and scholarly work. This article does an excellent job of breaking it down.

The structure of a research paper outlined in the article serves as a helpful guide for researchers looking to compose comprehensive and well-organized scholarly documents. It offers a clear framework for presenting original research findings.

I found the breakdown of the structure of a research paper to be particularly enlightening. It offers a roadmap for researchers to follow when crafting their academic work.

Yes, understanding the structure of a research paper is essential for effectively communicating the results of a study. This article provides a detailed overview of what to include in a research paper.

The detailed explanation of the structure and content of a journal article and a research paper is beneficial for researchers seeking to refine their academic writing skills and publish their work.

Indeed, the article provides valuable insights into the components and organization of journal articles and research papers, aiding researchers in producing high-quality scholarly publications.

White papers, working papers, preprints, journal articles: What’s the difference?

In this updated piece, we explain the most common types of research papers journalists will encounter, noting their strengths and weaknesses.

Republish this article

This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License .

by Denise-Marie Ordway, The Journalist's Resource February 25, 2022

This <a target="_blank" href="https://journalistsresource.org/media/working-papers-research-articles/">article</a> first appeared on <a target="_blank" href="https://journalistsresource.org">The Journalist's Resource</a> and is republished here under a Creative Commons license.<img src="https://journalistsresource.org/wp-content/uploads/2020/11/cropped-jr-favicon-150x150.png" style="width:1em;height:1em;margin-left:10px;">

This tip sheet, originally published in May 2018, has been updated to include preprint research, a type of research featured often in news coverage of the coronavirus pandemic.

Journalists rely most often on four types of research in their work. White papers, working papers, preprints and peer-reviewed journal articles.

How are they different? And which is best?

Below, we explain each, pointing out its strengths and weaknesses. As always, we urge journalists to use care in selecting any research to ground their coverage and fact-check claims.

Peer-reviewed article

Peer-reviewed research — the kind that appears in academic journals and that we highlight here at The Journalist’s Resource — has undergone a detailed critique by scholars with expertise in the field. While peer-reviewed research is generally the most reliable, journalists should keep in mind that publication in a prestigious journal is no guarantee of quality and that no single university or research organization always does the best research on a given topic.

It is safe to assume, however, that articles published in top-tier journals have been reviewed and given a stamp of approval by a number of accomplished scholars. For journalists who are uncertain, we’ve put together a list of 13 questions to ask to gauge the quality of a research article.

Keep in mind that not everything that appears in a scholarly journal has been peer reviewed. Journals publish various types of content, including book reviews, editorials, letters to the editor and, sometimes, even poetry.

Working paper

This broad category describes research papers that have not been peer reviewed or published in a journal. Working papers can be in various stages of completion. One might be ready for publication in a prestigious journal while another requires significant editing and other changes that could actually alter its main findings. Sometimes, working paper findings are so preliminary, authors will advise against citing their work .

Even so, working papers are a great way for journalists to gain access to new research quickly. The peer-review and publication process can take months to a year or longer, which means that by the time studies get published, their findings are sometimes not as useful or the data are old.

In choosing working papers, journalists should communicate with scholars about the progress of their research and how confident they are in their findings. It’s a good idea to seek corroboration from peer-reviewed research and to ask other researchers for help assessing a study.

A preprint is similar to a working paper in that it has not been vetted through a formal peer-review process. However, preprints tend to be more complete . Also, preprints submitted to public servers such as the Social Science Research Network and the health sciences server medRxiv get a cursory screening before they’re published online for public view.

Preprints, like academic journal articles, are assigned a Digital Object Identifier , or DOI, and become a permanent part of the scientific record.

White paper

A white paper is a report, often compiled by government agencies, businesses and nonprofit organizations, that outlines an issue and often explores possible solutions to a problem. For example, in November 2021, the federal Office of Community Oriented Policing Services released a white paper looking at factors that help or hinder law enforcement recruitment of Black Americans. Earlier in the year, the Advanced Technology Academic Research Center published a white paper on the American Rescue Plan ‘s widespread implications for government agencies.

In the business world, white papers also are used for marketing purposes — to describe a new product or approach, for instance, or diagnose a problem.

While a white paper can help journalists get up to speed quickly on an issue, it’s important to note some white papers advocate a specific position or policy change. Some rely on incomplete research or research that has not been peer reviewed.

Looking for more guidance on writing about research? Check out our tip sheets on covering biomedical research preprints amid the coronavirus and what journalists should know about peer review .

The Journalist’s Resource would like to thank Matthew Baum , the Marvin Kalb professor of global communications and professor of public policy at Harvard Kennedy School, for his help preparing this tip sheet.

About The Author

Denise-Marie Ordway

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Methodology

Types of Research Designs Compared | Guide & Examples

Types of Research Designs Compared | Guide & Examples

Published on June 20, 2019 by Shona McCombes . Revised on June 22, 2023.

When you start planning a research project, developing research questions and creating a research design , you will have to make various decisions about the type of research you want to do.

There are many ways to categorize different types of research. The words you use to describe your research depend on your discipline and field. In general, though, the form your research design takes will be shaped by:

The type of knowledge you aim to produce
The type of data you will collect and analyze
The sampling methods , timescale and location of the research

This article takes a look at some common distinctions made between different types of research and outlines the key differences between them.

Types of research aims, types of research data, types of sampling, timescale, and location, other interesting articles.

The first thing to consider is what kind of knowledge your research aims to contribute.

Prevent plagiarism. Run a free check.

The next thing to consider is what type of data you will collect. Each kind of data is associated with a range of specific research methods and procedures.

Finally, you have to consider three closely related questions: how will you select the subjects or participants of the research? When and how often will you collect data from your subjects? And where will the research take place?

Keep in mind that the methods that you choose bring with them different risk factors and types of research bias . Biases aren’t completely avoidable, but can heavily impact the validity and reliability of your findings if left unchecked.

Choosing between all these different research types is part of the process of creating your research design , which determines exactly how your research will be conducted. But the type of research is only the first step: next, you have to make more concrete decisions about your research methods and the details of the study.

Read more about creating a research design

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

Normal distribution
Degrees of freedom
Null hypothesis
Discourse analysis
Control groups
Mixed methods research
Non-probability sampling
Quantitative research
Ecological validity

Research bias

Rosenthal effect
Implicit bias
Cognitive bias
Selection bias
Negativity bias
Status quo bias

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the citation to our free Citation Generator.

McCombes, S. (2023, June 22). Types of Research Designs Compared | Guide & Examples. Scribbr. Retrieved April 9, 2024, from https://www.scribbr.com/methodology/types-of-research/

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Distinguishing between different types of journal articles

When writing a paper or conducting academic research, you’ll come across many different types of sources, including periodical articles. Periodical articles can be comprised of news accounts, opinion, commentary, scholarly analysis, and/or reports of research findings. There are three main types of periodicals that you will encounter: scholarly/academic, trade, and popular. The chart below will help you identify which type of periodical your article comes from.

Text and chart adapted from the WSU University Libraries' How to Distinguish Between Types of Periodicals and Types of Periodicals guides

What makes information peer-reviewed vs. scholarly vs. non-scholarly? Which type of source should I use?

What makes information peer-reviewed vs. scholarly vs. non-scholarly?
Which type of source should I use?

There is a nuanced distinction between peer-review and scholarship, which typically doesn't matter when evaluating sources for possible citation in your own work. Peer-review is a process through which editors of a journal have other experts in the field evaluate articles submitted to the journal for possible publication. Different journals have different ways of defining an expert in the field. Scholarly works, by contrast have an editorial process, but this process does not involve expert peer-reviewers. Rather, one or more editors, who are themselves often highly decorated scholars in a field, evaluate submissions for possible publication. This editorial process can be more economically driven than a peer-review process, with a greater emphasis on marketing and selling the published material, but as a general rule this distinction is trivial with regard to evaluating information for possible citation in your own work.

What is perhaps a more salient way of thinking about the peer-review / scholarship distinction is to recognize that while peer-reviewed information is typically highly authoritative, and is generally considered "good" information, the absence of a peer-review process doesn't automatically make information "bad." More specifically, the only thing the absence of a peer-review process means is that information published in this manner is not peer-reviewed. Nothing more. Information that falls into this category is sometimes referred to as "non-scholarly" information -- but again, that doesn't mean this information is somehow necessarily problematic.

Where does that leave you in terms of deciding what type of information to use in producing your own work? That is a highly individual decision that you must make. The Which type of source should I use? tab in this box offers further guidance on answering this question, though it is important to be aware that many WSU instructors will only consider peer-reviewed sources to be acceptable in the coursework you turn in . You can ask your instructor for his or her thoughts on the types of sources s/he will accept in student work.

Image: Martin Grater. (2017, Nov. 1). Deep Thought. Retrieved from https://www.flickr.com/photos/152721954@N05/24304490568/. Used under the Creative Commons License.

Your topic and research question or thesis statement will guide you on which resources are best. Sources can be defined as primary, secondary and tertiary levels away from an event or original idea. Researchers may want to start with tertiary or secondary source for background information. Learning more about a topic will help most researchers make better use of primary sources.

While articles from scholarly journals are often the most prominent of the sources you will consider incorporating into your coursework, they are not the only sources available to you. Which sources are most appropriate to your research is a direct consequence of they type of research question you decide to address. In other words, while most university-level papers will require you to reference scholarly sources, not all will. A student in an English course writing a paper analyzing Bob Dylan's lyrics, for example, may find an interview with Dylan published in Rolling Stone magazine a useful source to cite alongside other scholarly works of literary criticism.

The WSU University Libraries' What Sources Should I Use? handout, as well as the other sub-tabs under the Evaluating information section of this guide (which is indeed the section you are currently viewing) offer further guidance on understanding and identifying scholarly resources, and comparing them against different criteria to evaluate if they will be of value to your research. How many non-scholarly works (if any) you are at liberty to cite alongside scholarly ones is often a question to ask of your professor. Some may not want you to cite any, whereas others may be ok with some non-scholarly works cited alongside scholarly ones.

Image: Brett Woods. (2006, Jan. 6). Deep Thoughts. Retrieved from https://www.flickr.com/photos/brettanicus/87653641/. Used under the Creative Commons License.

<< Previous: Types of Sources
Next: Components of a scholarly article, and things to consider when reading one >>
Last Updated: Dec 13, 2023 4:36 PM
URL: https://libraries.wichita.edu/health-research

Difference between Research Paper and Research Article

Research paper and research articles are bits of composing that require inquiry, critical analysis, demonstration and insight of few special abilities from understudies and researchers. This article endeavors to see whether the two terms are synonymous or there is any contrast between the two.

Research paper

Research can be said as activity which is specified much significance in scholastics. Be that as it may, research papers are not only these task papers composed by understudies as those composed by scholars and researchers and also published in different journals are additionally alluded to as research papers.

Research Article

Research article is a bit of composing that have original research thought with the pertinent data and discoveries. A research article is a composing or paper that advises individuals of a way breaking a finding or research with data to bolster the finding.

Research Paper VS Research Article

There is a pattern to allude to academic papers and term papers composed by understudies in schools as a research paper

The articles presented by researchers and scholars with their noteworthy examination are known as research articles.

Research papers composed by the students mostly not take in journals.

Research articles composed by researchers or scholars mostly published in prestigious scientific journals.

A research paper depends on the original research. The sort of research may fluctuate, contingent upon your field or topics that include survey, experiments, questionnaire, interview and so on; yet authors require gathering and investigating raw data and make an original and real study. The research paper will be founded on the investigation and understanding of this raw data.

A research article depends on other different published articles. It is usually not depend on original study. Research articles for the most part condense the current writing on a point trying to clarify the present condition of comprehension on topic.

A research paper can be said as the primary source that means, it studies the techniques and consequences of original study performed by the writers.

A research article can be said as secondary source that means it is composed about different articles, and does not studies actual research of its own.

Importance:

In research paper, every part of this has its own importance. A concise is important in light of the fact that it shows that the writers know about existing literature, and want to add to this presented research definitively. A methods part is usually detailed and it is important in a way that different analysts have the capacity to check and/or duplicate these strategies. A result segment depicts the results of the analysis.

Research articles can be considered very important because they describe upon different articles that they analyze to propose new research bearings, to give powerful support for presented theories or distinguish designs among presented research studies. For understudy analysts, these research articles give an excellent review of presented literature on that topic. In the event that you discover a literature review that can be fit in study, investigate its references/works referred to list for guide on other articles.

From the above article we can conclude that research paper is the primary source whereas research articles are secondary.

17 Comments Already

good article but which of them is more useful when we conduct a research

both. but research paper is more useful.

Nice explanation

There is a little difference but both are different.

Nice but i have a confusion that can a guys of Bachelors level can write Research Papers?

YEs they can if they do research project instead of development project and do something new in their project.

Thank you 😊

do you have something in your mind then please share with us. We will appreciate that.

Though it may be fairly easy to learn to speak English well enough to be understood, learning to write English correctly is very difficult, as this article so clearly illustrates. Though I greatly admire all those who are making an effort to learn another language, like English, as a non-native speaker, it is wrong for these same individuals to assume they can write English well enough to publish articles.

This article is so poorly written that I cannot understand most of it. For instance, the following phrases are utter nonsense: “A research paper can be said as the primary source that means,” — “A concise is important in light of the fact that it shows that . . .” — “A methods part is usually detailed” — “A result segment depicts the results . . .” — “they describe upon different articles that they analyze to propose new research bearings . . . or distinguish designs among presented . .. studies” — “to clarify the present condition of comprehension” — “Research papers and . . . articles require inquiry, critical analysis, demonstration and insight of few special abilities from . . .”

This article also states that “[a] research article . . . is usually not depend (sic) on original study,” then contradicts that in the next sentence with “[r]esearch articles . . . condense the current writing on a point . . .” Most studies these days are current. But, even if a study was conducted 50 years ago, it’s a cardinal rule that one should always use the original source of information rather than relying on the articles of other authors who may have misquoted something from the original study.

Articles like this one do a grave disservice to the viewing and researching public. To present this article as informative is disingenuous. To ask people who are seeking useful information to struggle with reading and trying to make sense of this poor English is so unkind and inconsiderate that I feel compelled to bring it to the author’s and publisher’s attention.

I would be honored to help anyone with their efforts to write English, but, please, be honest with yourselves about your lack of knowledge, so you will cease and desist the writing of anything online until your English skills have improved significantly. Thank you.

Thanks for such a detail input. Best wishes.

Yes you are saying right. So if you have the skills to deliver the answer in an efficient manner so kindly type it for me. Because I really want to know the difference between research paper and research article

Yes I agree with Martha. I myself found difficulty in going through the article. Although the topic is very important to be discussed because being the student of graduate, I must know the difference. But the way of delivering has dispirited me that now what other website should I visit to get accurate answer.

we need Published example of a scientific research article and another for a scientific research

how can I cite this?

“Difference between Research Paper and Research Article”, Reserachpedia.info, https://researchpedia.info/difference-between-research-paper-and-research-article/ , [27 December 2021].

I don’t understand anything. I am confused more than i came. Otehrwise, thank you for a trial. Simplify this communication.

DIFFERENCE BETWEEN RESEARCH PAPER AND JOURNAL ARTICLE

Difference between research paper and journal article.

Research Paper

Research writing and publication services

Argumentative Research Paper

Analytical research paper, journal article, the differences, research paper:, journal article:.

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Difference between Paper and Article for Scientific Writings

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Difference between Journal Article and Research Paper

Specific education reading is an important tool that will enhance your academic excellence. To keep excelling, you will need to read relevant articles, papers, documents, and books. Journals, Journal articles, and research papers are important mechanisms for professional and academic learning.

Journal Article Vs. Research Paper

The difference between a journal article and a research paper is that the journal article is well researched and extensive. It is also conceptual and well-suited for the academic audience. Research papers on the other hand focus on a specific viewpoint and substantiate the viewpoint with relevant theories. Research papers require many extensive studies to ensure the viewpoint is fully supported.

Comparison between the Journal Article and the Research Paper

The journal article is an overall publication while a research paper can be cited.
Journal articles are written based on knowledge and experience while research papers require an in-depth study of the specific topic.
Journal articles are short while research papers are long and always ongoing.
You cannot patent a journal article but you can patent a research paper.
While a research paper does not have a specific domain, journal articles have a broader spectrum.
There is an impact rating needed for journal articles while no specific rating is needed for the research paper.

What is a Journal Article?

When publishing a journal article, more than one author can be used to give their specific conclusions. Journal articles are of different natures and they can be experiential. Journal articles can be academic or non-academic.

Journal articles can be presented differently as research papers and on different platforms.

What is a Research Paper?

Writing a research paper can take a lot of time. This is because it involves something that has already been published but needs to be reopened again. The first step to writing a research paper is sitting with the thought and why exactly you want to research it. The research will involve the timeframe, type of data collection method to use, and most importantly, in-depth research.

To write a research paper, you will need to do a literature review. This includes the reading of various case studies, findings, newspapers, all containing the topic of research or question to be answered.

Journal articles are written to show special or enhanced knowledge in a certain field. It is useful to bring understanding to a particular field. Journals cannot be written by just anyone. Instead, they are written by experts. A research paper on the other hand revolves around a particular topic or question. The question may contain other questions within it that need to be researched on, re-found, or re-visited. The research paperwork is done using a specific format and supports every point with tactical findings. In short, a research paper is written to answer a question or get findings of something that was already initially researched and written about.

Journals can be a paper written based on something that is currently trending or new ideologies that could be personal experiences and learnings. Research papers on the other hand are more extensive. They involve a particular topic and questions that can be presented using diagrams, graphs, and case studies.

Due to the level of research needed to write a research paper, a lot of time is needed. The findings need to be factual, totally supporting the topic or question in place. Journal papers on the other hand take a short time. That is, they can be completed within a week. A journal can go to a month but does not take as much time as a research paper.

When an organization, department, or domain writes a research paper, it needs to be patented. What this means is that it cannot be published without due permission. A journal paper on the other hand does not require rights or permissions. It is open for people and can be reviewed, shared, and presented without necessarily touching the copyrights. Journals do not need to be patented.

Writing a journal requires generality and broad visibility. While a journal paper can be a research paper, it does not always apply to be one. A journal’s content can be written within a short period and needs to flow to be understood. A research paper on the other hand needs to have extensive rough work on the side. It is a paper that is written systematically and with relevant citations. A literature review is an important aspect of the research paper. You need to have proof of the data collection method that includes raw data collection, interview transcripts and so much more.

While everything going digital in today’s world and rating is required for everything, a journal article will not require ratings. What journals need are views as the ones most viewed get the best footage. A research paper, being a component of the journal, can be limited as to who gets access to the same. It also does not require ratings but its presentations and findings are what make it known to the audience.

In conclusion, we can see that both the journal papers and research papers have different audiences. That makes them different in terms of research, language used, and the kind of presentation in the end.

It is also good to understand the purpose of both papers. While a journal is mainly open to the masses and does not have restrictions as to who gets access, research papers have their specific audience. This is because it entails answering certain questions that audiences would love to know and discussing certain topics in depth.

As such, it takes a longer time to research and write a research paper than it does to write a journal. A research paper is systematic and requires various citations that help to support your facts. A journal paper on the other hand is writing thoughts and explaining that particular thought in depth.

Research papers require skills in doing research. A journal mostly requires a creative mind.

Academic Research: Differences between MLA and APA Formats

This essay about the distinctions between MLA and APA formats offers a clear guide on when and why to use each in academic writing. It explains that MLA format is preferred in humanities and liberal arts for its focus on authorship and streamlined in-text citations, whereas APA format is favored in the social sciences, emphasizing recent research through citations that include the publication year. Structural differences in title pages, headings, and reference details are highlighted to show how each format caters to the specific needs of its discipline. The essay underscores the importance of choosing the correct format based on the academic field, assignment requirements, or publication standards, illustrating how these formats facilitate clear, organized scholarly communication within their respective areas of study.

How it works

In the world of academic writing, adhering to a specific formatting style is not just about preference but a necessity for clarity, consistency, and scholarly integrity. Among the most widely used styles are the Modern Language Association (MLA) and the American Psychological Association (APA) formats. Each serves its unique purpose and is tailored to the requirements of different fields of study. This comparison seeks to demystify the primary distinctions between MLA and APA formats, guiding students and researchers in choosing the appropriate style for their work.

At the heart of the MLA format is the liberal arts and humanities discipline. It emphasizes authorship because these fields prioritize individual ideas and interpretations. The MLA format uses parenthetical in-text citations with the author’s last name and the page number from which the information was taken, alongside a Works Cited page at the end of the document. This approach facilitates a direct, seamless integration of sources, allowing readers to engage with the text without interruption.

Conversely, the APA format is predominantly used in the social sciences. It focuses on the date of publication, reflecting the importance of recent research in these fields. APA citations include the author’s last name and the year of publication within the text and a reference list at the document’s end. This method underscores the timeliness of the information, which is crucial in disciplines where knowledge constantly evolves.

The structural differences between the two formats extend to the title page, headings, and layout. MLA does not require a title page for most student papers, whereas APA typically requires a title page that includes the paper’s title, the author’s name, and the institutional affiliation. APA also has specific guidelines for headings that help organize the paper into sections and sub-sections, making it easier to navigate through complex studies. MLA’s approach is more straightforward, with fewer requirements for section division, reflecting the often more narrative nature of humanities writing.

Another notable difference lies in the presentation of the reference list. MLA’s Works Cited page is concerned primarily with ensuring readers can find the sources. In contrast, APA’s References page offers more detailed publication information, including the city of publication and the publisher for books, and even the DOI (Digital Object Identifier) for journal articles. This comprehensive approach in APA is designed to facilitate the replication of research, a core aspect of the scientific method.

Choosing between MLA and APA formats ultimately depends on the disciplinary context and the specific requirements of the assignment or publication. Educators and journals usually specify the preferred format, but understanding the rationale behind each style can enhance the writer’s ability to engage with the academic community more effectively.

In conclusion, while MLA and APA formats share the common goal of promoting clear and organized scholarly communication, their differences are tailored to the needs of their respective disciplines. MLA’s streamlined, author-focused approach supports the interpretive nature of the humanities, whereas APA’s detailed, date-focused style is designed to highlight the evolution of knowledge in the social sciences. Recognizing these distinctions not only aids in proper citation but also in appreciating the diverse ways in which knowledge is constructed and shared across the academic landscape. As students and researchers navigate the complex world of academic writing, an understanding of these formats becomes a critical tool in their scholarly arsenal, enabling them to contribute their voices to the ongoing dialogue within their fields.

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Hallucinations and delusions can be symptoms of psychiatric illness, but more often—though less commonly known—are actually part of a healthy range of experiences found throughout the general population. The studies in this Special Collection paint a picture of the wide range of hallucinatory and delusional experiences across diverse populations, as well as comparative perspectives between clinical and non-clinical samples. In this editorial, I make three related points that are exemplified in the articles published here. First, that hallucinations and delusions are part of a normal distribution of human diversity; their mere presence does not indicate psychosis or psychiatric illness. Second, that the ubiquity of hallucinatory and delusional experiences across clinical and non-clinical populations suggests common cognitive and neural mechanisms. Finally, despite these commonalities, it is important to understand the difference between psychiatric symptoms and healthy experience. In summary, I conclude that it is important to investigate both common mechanisms and distinguishing factors to comprehensively elucidate these oft-misunderstood experiences. This Special Collection provides a showcase of the cutting-edge research that encompasses these objectives.

Hallucinations and delusions are two cornerstones of psychosis, a collection of symptoms that can occur across a range of psychiatric disorders and stems from a reduced ability to disentangle reality from fantasy 1 , 2 . Although it may seem that a Special Collection called Hallucinations and Delusions would mainly report studies of psychosis, these experiences are surprisingly common throughout the general population. So although psychosis is defined by hallucinatory and delusional experiences, the presence of hallucinations and delusions are not indicative of a psychotic disorder. Together, the studies in this Special Collection paint a picture of the wide range of hallucinatory and delusional experiences across diverse populations, as well as comparative perspectives between clinical and non-clinical samples. In this editorial, I would like to make three related points that are exemplified in the articles published here:

Hallucinations and delusions are part of a normal distribution of human diversity; their mere presence does not indicate psychosis or psychiatric illness.

The ubiquity of hallucinatory and delusional experiences across clinical and non-clinical populations suggests common cognitive and neural mechanisms.

Despite the aforementioned commonalities, it is important to understand the difference between psychiatric symptoms and healthy experience.

A normal distribution of human diversity

Hallucinations and delusions are pat of a normal distribution of human diversity; their mere presence does not indicate psychosis or psychiatric illness. Experimentally-induced hallucinations are safe, controlled, and have no negative consequences 3 ; confabulating memories sometimes is perfectly normal 4 ; and despite the insistence of some individuals, simply having conspiracy beliefs is not a sign of pathology 5 .

The study by Shenyan et al. 3 demonstrates that hallucinations can be reliably induced in non-clinical samples using experimental techniques called Ganzfeld 6 and Ganzflicker 7 , 8 . Prolonged, unstructured (Ganzfeld) or repetitive (Ganzflicker) stimulation to the visual system can elicit both simple and complex hallucinatory experiences, such as geometric patterns, illusory colors, or even meaningful real-world objects and scenes. The authors, for the first time, quantified the onset and frequency of Ganzfeld- and Ganzflicker-induced hallucinations, and included participant drawings to reveal diverse, individualized visual experiences.

In another study highlighting psychosis characteristics in the general population, Stephan-Otto et al. 4 found that hallucination proneness is associated with false memories of novel words during a word recall task. The researchers asked participants to complete a series of questionnaires, memorize lists of high- and low-frequency words, then tested their recall while collecting fMRI data. Behaviorally, hallucination scores correlated with response bias for both high- and low-frequency words. Interestingly, neuroimaging data revealed a significant association between specifically verbal hallucination proneness and activation of brain areas related to language during false recognition of novel words. This points to individual differences in susceptibility to confabulated inner speech in the general population.

Finally, conspiracy beliefs are generally related to psychopathological characteristics (e.g., paranoia, anxiety) and erratic behavior such as volatility in decision-making 9 ; however, in a paper published in this Collection, Suthaharan and Corlett 5 found that these negative effects are reduced in individuals who have a strong social network around their beliefs. This interestingly suggests that social and environmental factors contribute to the (positive or negative) impact of conspiracy beliefs on mental health and behavior. In contrast to the stereotype of a ‘crazy conspiracy theorist’, the authors conclude that conspiracy beliefs are not inherently pathological.

Common cognitive and neural mechanisms

The ubiquity of hallucinations and delusions across clinical and non-clinical populations suggests common cognitive and neural mechanisms. We are developing techniques to experimentally induce hallucinations, which could potentially elucidate how they can develop into psychotic experiences 3 , 7 , 8 . In the study by Shenyan et al. 3 , the authors purport that a (cortically hierarchical) low-level hallucinatory mechanism may be responsible for simple hallucinations, whereas top-down processes (such as mental imagery or beliefs) may contribute to complex hallucinations. These same mechanisms are proposed to be involved in different kinds of hallucinatory experiences in clinical populations, as well 10 . Further, Stephan-Otto and colleagues 4 propose common mechanisms for reality monitoring of inner speech in both clinical and non-clinical populations. These techniques could therefore be used to better understand the cognitive and neural mechanisms that contribute to hallucinatory experience across diverse populations.

Comparative studies in this Collection highlight similarities in the content and organization of psychotic symptoms across different populations. For example, Fleming and colleagues 11 modeled a data-driven profile of symptoms experienced in first-episode psychosis (FEP) and persistent psychotic illness. Individuals with FEP are those that have only recently begun to experience symptoms of psychosis, which may or may not progress into persistent psychotic illness, specifically schizophrenia or schizoaffective disorder. Interestingly, the multidimensional profile of symptoms is quite similar between the two groups: auditory hallucinations tended to cluster with delusions that the patient was under another agent’s control; religious and grandiose delusions both clustered with thought disorder symptoms; and other reality and perceptual distortions formed a separate cluster of symptoms to these. Therefore, the content and organization of psychotic experiences in this clinical population is not indicative or predictive of illness severity or longevity, and supports the proposition that these experiences are part of the normal distribution of diverse thinking.

Sheffield and colleagues 12 investigated the relationship between cognitive biases, delusional thinking, and game-based decision-making between individuals with schizophrenia spectrum conditions and healthy controls. Interestingly, across multiple self-report measures and various games, both groups showed similar relationships between beliefs and behavior: specifically, volatile decision-making (e.g., changing strategies multiple times) was positively correlated with paranoid thinking, and hasty decision-making was related to having unusual beliefs (e.g., mind reading, alien abduction), in both individuals with schizophrenia spectrum conditions and healthy controls. These findings further support the idea that the same cognitive mechanisms contribute to individual differences in both clinical and non-clinical populations.

Psychiatric versus healthy experience. Despite potential common mechanisms for these experiences, and their prevalence across clinical and non-clinical populations, it is important to distinguish psychiatric symptoms from healthy experience . Perhaps the single most important difference between clinically-relevant and clinically-irrelevant experience is its impact on quality of life.

Environmental and social factors importantly contribute to this impact: conspiracy beliefs under a ‘sacred canopy’ (i.e., a social support buffer) can benefit an individual to a similar extent as being part of a religious or social organization; but these beliefs can exacerbate psychopathological characteristics if social support is lacking 5 . As another example, individuals who purposefully seek hallucinatory experiences are able to choose the environment, onset, and duration of the event; and can attribute the experience to an explicable source, such as Ganzflicker 3 . Controlling an unusual experience in this way can neutralize its potential negative effects. On the other hand, individuals who experience clinical hallucinations have little to no control over their experiences and cannot easily attribute them to a known source. The onset, duration, and environment of the experience are unpredictable, and can be embarrassing (e.g., at a social event) or even dangerous (e.g., while driving). All of these factors can lead to an extreme negative reaction to hallucinations and a debilitating impact on quality of life. So although much of the behavioral and cognitive bases of these divergent experiences are ubiquitous, this does not mean that these experiences should be treated the same for both clinical and non-clinical populations. The critical questions, then, concern how and why such experiences might develop into psychiatric illness.

In summary, hallucinations and delusions are part of a healthy range of diverse experiences found throughout the general population, but they can develop into more severe symptoms of psychiatric illness. It is important to investigate both common mechanisms (that contribute to our understanding of their cognitive and neural bases) and distinguishing factors (that separate clinically-relevant from clinically irrelevant symptoms) to comprehensively elucidate these often misunderstood experiences. This Special Collection provides a showcase of the cutting-edge research that encompasses these objectives.

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Watch CBS News

Why is looking at a solar eclipse dangerous without special glasses? Eye doctors explain.

By Sara Moniuszko

Edited By Allison Elyse Gualtieri

Updated on: April 8, 2024 / 8:54 AM EDT / CBS News

The solar eclipse will be visible for millions of Americans on April 8, 2024, making many excited to see it — but how you watch it matters, since it can be dangerous for your eyes.

A solar eclipse occurs when the moon passes between the sun and Earth, blocking the sun's light . When the moon blocks some of the sun, it's a partial solar eclipse, but when moon lines up with the sun, blocking all of its light, a total solar eclipse occurs, NASA explains . Either way, you need eye protection when viewing.

"The solar eclipse will be beautiful, so I hope that everyone experiences it — but they need to experience it in the right way," said Dr. Jason P. Brinton, an ophthalmologist and medical director at Brinton Vision in St. Louis.

Here's what to know to stay safe.

Why is looking at a solar eclipse dangerous?

Looking at the sun — even when it's partially covered like during an eclipse — can cause eye damage.

There is no safe dose of solar ultraviolet rays or infrared radiation, said Dr. Yehia Hashad , an ophthalmologist, retinal specialist and the chief medical officer at eye health company Bausch + Lomb.

"A very small dose could cause harm to some people," he said. "That's why we say the partial eclipse could also be damaging. And that's why we protect our eyes with the partial as well as with the full sun."

Some say that during a total eclipse, it's safe to view the brief period time when the moon completely blocks the sun without eye protection. But experts warn against it.

"Totality of the eclipse lasts only about 1 to 3 minutes based on geographic location, and bright sunlight suddenly can appear as the moon continues to move," notes an eclipse viewing guide published in JAMA , adding, "even a few seconds of viewing the sun during an eclipse" can temporarily or permanently damage your vision.

Do I need special glasses for eclipse viewing?

Yes. Eclipse glasses are needed to protect your eyes if you want to look at the eclipse.

Regular sunglasses aren't protective enough for eclipse viewing — even if you stack more than one.

"There's no amount of sunglasses that people can put on that will make up for the filtering that the ISO standard filters and the eclipse glasses provide," Brinton said.

You also shouldn't look at the eclipse through a camera lens, phone, binoculars or telescope, according to NASA, even while wearing eclipse glasses. The solar rays can burn through the lens and cause serious eye injury.

Eclipse glasses must comply with the ISO 12312-2 international safety standard , according to NASA, and should have an "ISO" label printed on them to show they comply. The American Astronomical Society has a list of approved solar viewers.

Can't find these, or they're sold out near you? You can also make homemade viewers , which allow you to observe the eclipse indirectly — just don't accidentally look at the sun while using one.

How to keep kids safe during the solar eclipse

Since this eclipse is expected to occur around the time of dismissal for many schools across the country, it may be tempting for students to view it without the proper safety precautions while getting to and from their buses. That's why some school districts are canceling classes early so kids can enjoy the event safely with their families.

Dr. Avnish Deobhakta, vitreoretinal surgeon at New York Eye and Ear Infirmary at Mount Sinai, said parents should also be careful because it can be difficult for children to listen or keep solar eclipse glasses on.

"You want to actually, in my opinion, kind of avoid them even looking at the eclipse, if possible," he said. "Never look directly at the sun, always wear the right eclipse sunglasses if you are going to look at the sun and make sure that those are coming from a reliable source."

Brinton recommends everyone starts their eclipse "viewing" early, by looking at professional photos and videos of an eclipse online or visiting a local planetarium.

That way, you "have an idea of what to expect," he said.

He also recommends the foundation Prevent Blindness , which has resources for families about eclipse safety.

What happens if you look at a solar eclipse without eclipse glasses?

While your eyes likely won't hurt in the moment if you look at the eclipse without protection, due to lowered brightness and where damage occurs in the eye, beware: The rays can still cause damage .

The harm may not be apparent immediately. Sometimes trouble starts to appear one to a few days following the event. It could affect just one or both eyes.

And while some will regain normal visual function, sometimes the damage is permanent.

"Often there will be some recovery of the vision in the first few months after it, but sometimes there is no recovery and sometimes there's a degree to which it is permanent," Brinton said.

How long do you have to look at the eclipse to damage your eyes?

Any amount of time looking at the eclipse without protection is too long, experts say.

"If someone briefly looks at the eclipse, if it's extremely brief, in some cases there won't be damage. But damage can happen even within a fraction of a second in some cases," Brinton said. He said he's had patients who have suffered from solar retinopathy, the official name for the condition.

Deobhakta treated a patient who watched the 2017 solar eclipse for 20 seconds without proper eye protection. She now has permanent damage in the shape of a crescent that interferes with her vision.

"The crescent that is burned into the retina, the patient sees as black in her visual field," he said. "The visual deficit that she has will never go away."

How to know if you've damaged your eyes from looking at the eclipse

Signs and symptoms of eye damage following an eclipse viewing include headaches, blurred vision, dark spots, changes to how you see color, lines and shapes.

Unfortunately, there isn't a treatment for solar retinopathy.

"Seeing an eye care professional to solidify the diagnosis and for education I think is reasonable," Brinton said, but added, "right now there is nothing that we do for this. Just wait and give it time and the body does tend to heal up a measure of it."

Sara Moniuszko is a health and lifestyle reporter at CBSNews.com. Previously, she wrote for USA Today, where she was selected to help launch the newspaper's wellness vertical. She now covers breaking and trending news for CBS News' HealthWatch.

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Introduction
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HIIT indicates high-intensity interval training; MICT, moderate-intensity continous training; PCC, post-COVID condition; and ST, strength training.

High-intensity interval training (HIIT), moderate-intensity continuous training (MICT), and strength training (ST) were conducted in a randomized crossover design in patients with post-COVID condition (PCC) (n = 30) and age- and sex-matched healthy controls (n = 31). Differences in changes from baseline to 48 hours following each exercise trial in the fatigue visual analog scale (VAS; score range, 0 [no feeling] to 10 [worst possible feeling]) (A) and the muscle pain VAS (B) were compared between patients with PCC and controls. Differences in changes 48 hours after exercise in the fatigue VAS score (C) and the muscle pain VAS score (D) among 3 exercise trials were compared in the group with PCC and the control group separately, and individual post hoc tests were used to compare exercise sessions when a main effect of exercise was found. Change in the muscle pain VAS score 48 hours after ST exercise was also compared between patients with PCC and controls. Horizontal bars indicate medians; lower and upper ends of the boxes, the first and third quartiles; and whiskers, minimum and maximum values.

a P < .05.

b P > .05 (not significant).

c P < .001.

A and B, Aerobic capacity, presented as the peak volume of oxygen consumption (V̇O 2 ), and the percentage of individuals reaching ventilatory threshold (VT), both of which were assessed via cardiopulmonary exercise testing 48 hours after 3 exercise sessions (high-intensity interval training [HIIT], moderate-intensity continuous training [MICT], and strength training [ST]) in patients with post-COVID condition (PCC) (n = 30) and age- and sex-matched healthy controls (n = 31). C and D, For group, P = .37; exercise, P = .18; time, P = .02; group × exercise, P = .04; group × time, P = .49; exercise × time, P = .31; group × exercise × time, P = .92. E and F, For group, P = .06; exercise, P < .001; time, P = .27; group × exercise, P = .52; group × time, P = .26; exercise × time P = .004; group × exercise × time, P = .054. Bars represent means; whiskers, SDs; and dots, individual data. CK indicates creatine kinase; IL-6, interleukin 6. To convert CK to U/L, divide by 0.0167.

Trial Protocol

eTable 1. Participant Demographics

eTable 2. Responses During Exercise Sessions

eTable 3. Median Group Differences in 10 Symptoms Assessed With Visual Analog Scale Symptoms

eTable 4. Median Exercise Differences in 10 Symptoms Assessed With Visual Analog Scale Symptoms

eTable 5. Results From Postexertional Symptoms as Assessed With MFI, POMS, and SPHERE Questionnaires

eTable 6. Mean Group Differences in Postexertional Symptoms Assessed With MFI, POMS, and SPHERE Questionnaires

eTable 7. Variables From Cardiopulmonary Exercise Testing at 48 Hours After Exercise Sessions

eTable 8. Mean Group Differences in Variables From the Cardiopulmonary Exercise Testing at 48 Hours After Exercise Sessions

eTable 9. Mean Exercise Differences in Variables From the Cardiopulmonary Exercise Testing at 48 Hours After Exercise Sessions

eTable 10. CK and IL-6 in Response to 3 Exercise Sessions

eTable 11. Mean Group Differences Baseline Characteristics

eTable 12. Supplementary Results From the Examinations Included in the Physiological Characterization

eFigure 1. Individual Changes for Fatigue as Assessed via Visual Analog Scale in Response to 3 Exercise Sessions

eFigure 2. Individual Changes for Muscle Pain as Assessed via Visual Analog Scale in Response to 3 Exercise Sessions

Data Sharing Statement

Exercise Therapy for Post–COVID-19 Condition JAMA Network Open Invited Commentary April 4, 2024 Peter Ladlow, PhD; Alexander N. Bennett, PhD; Oliver O’Sullivan, MBChB

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Tryfonos A , Pourhamidi K , Jörnåker G, et al. Functional Limitations and Exercise Intolerance in Patients With Post-COVID Condition : A Randomized Crossover Clinical Trial . JAMA Netw Open. 2024;7(4):e244386. doi:10.1001/jamanetworkopen.2024.4386

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Functional Limitations and Exercise Intolerance in Patients With Post-COVID Condition : A Randomized Crossover Clinical Trial

1 Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
2 Department of Life Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
3 Department of Clinical Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
4 Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
Invited Commentary Exercise Therapy for Post–COVID-19 Condition Peter Ladlow, PhD; Alexander N. Bennett, PhD; Oliver O’Sullivan, MBChB JAMA Network Open

Question Do nonhospitalized patients experiencing post-COVID condition (PCC) have exaggerated postexercise symptoms after high-intensity interval training (HIIT), moderate-intensity continuous training (MICT), and strength training (ST)?

Findings In this randomized crossover clinical trial of 31 patients with PCC and 31 matched control participants, the exercise response was largely comparable between groups, with no profound symptom exacerbation. Patients with PCC reported more muscle pain after HIIT and concentration problems after MICT and had lower aerobic capacity and less muscle strength; 62% showed myopathic signs.

Meaning The findings suggest that cautious exercise rehabilitation should be recommended to prevent further deconditioning among patients with PCC.

Importance Many patients with post-COVID condition (PCC) experience persistent fatigue, muscle pain, and cognitive problems that worsen after exertion (referred to as postexertional malaise). Recommendations currently advise against exercise in this population to prevent symptom worsening; however, prolonged inactivity is associated with risk of long-term health deterioration.

Objective To assess postexertional symptoms in patients with PCC after exercise compared with control participants and to comprehensively investigate the physiologic mechanisms underlying PCC.

Design, Setting, and Participants In this randomized crossover clinical trial, nonhospitalized patients without concomitant diseases and with persistent (≥3 months) symptoms, including postexertional malaise, after SARS-CoV-2 infection were recruited in Sweden from September 2022 to July 2023. Age- and sex-matched control participants were also recruited.

Interventions After comprehensive physiologic characterization, participants completed 3 exercise trials (high-intensity interval training [HIIT], moderate-intensity continuous training [MICT], and strength training [ST]) in a randomized order. Symptoms were reported at baseline, immediately after exercise, and 48 hours after exercise.

Main Outcomes and Measures The primary outcome was between-group differences in changes in fatigue symptoms from baseline to 48 hours after exercise, assessed via the visual analog scale (VAS). Questionnaires, cardiopulmonary exercise testing, inflammatory markers, and physiologic characterization provided information on the physiologic function of patients with PCC.

Results Thirty-one patients with PCC (mean [SD] age, 46.6 [10.0] years; 24 [77%] women) and 31 healthy control participants (mean [SD] age, 47.3 [8.9] years; 23 [74%] women) were included. Patients with PCC reported more symptoms than controls at all time points. However, there was no difference between the groups in the worsening of fatigue in response to the different exercises (mean [SD] VAS ranks for HIIT: PCC, 29.3 [19.5]; controls, 28.7 [11.4]; P = .08; MICT: PCC, 31.2 [17.0]; controls, 24.6 [11.7]; P = .09; ST: PCC, 31.0 [19.7]; controls, 28.1 [12.2]; P = .49). Patients with PCC had greater exacerbation of muscle pain after HIIT (mean [SD] VAS ranks, 33.4 [17.7] vs 25.0 [11.3]; P = .04) and reported more concentration difficulties after MICT (mean [SD] VAS ranks, 33.0 [17.1] vs 23.3 [10.6]; P = .03) compared with controls. At baseline, patients with PCC showed preserved lung and heart function but had a 21% lower peak volume of oxygen consumption (mean difference: −6.8 mL/kg/min; 95% CI, −10.7 to −2.9 mL/kg/min; P < .001) and less isometric knee extension muscle strength (mean difference: −37 Nm; 95% CI, −67 to −7 Nm; P = .02) compared with controls. Patients with PCC spent 43% less time on moderate to vigorous physical activity (mean difference, −26.5 minutes/d; 95% CI, −42.0 to −11.1 minutes/d; P = .001). Of note, 4 patients with PCC (13%) had postural orthostatic tachycardia, and 18 of 29 (62%) showed signs of myopathy as determined by neurophysiologic testing.

Conclusions and Relevance In this study, nonhospitalized patients with PCC generally tolerated exercise with preserved cardiovascular function but showed lower aerobic capacity and less muscle strength than the control group. They also showed signs of postural orthostatic tachycardia and myopathy. The findings suggest cautious exercise adoption could be recommended to prevent further skeletal muscle deconditioning and health impairment in patients with PCC.

Trial Registration ClinicalTrials.gov Identifier: NCT05445830

The COVID-19 pandemic has left a significant number of people experiencing longer-term health problems despite initially recovering from acute SARS-CoV-2 infection. The constellation of symptoms that these patients continue to experience after 3 or more months has been termed post-COVID condition (PCC) by the World Health Organization (WHO) and affects an estimated 10% to 20% of those infected with SARS-CoV-2, including nonhospitalized individuals. 1 , 2 The most common symptoms include persistent fatigue, myalgia, dyspnea, and neurologic or cognitive dysfunction. 1 These symptoms worsen after physical exertion, a phenomenon described as postexertional malaise (PEM) 1 or postexertional symptom exacerbation. 1 , 3

As a result of the reported exercise intolerance, key public health organizations, including the WHO, have advised against rehabilitation based on graded exercise in patients experiencing PEM to avoid symptom exacerbation. 3 - 5 This has led many health care professionals to be reluctant to incorporate exercise into rehabilitation programs for patients with PCC. However, there is ample evidence that physical inactivity negatively impacts health, including functional impairment within weeks and increased risk of cardiometabolic disease in the long term. 6 The latter represents a significant burden on health care systems worldwide. 6

While several plausible factors have been proposed to explain exercise intolerance in individuals with PCC, including muscle atrophy, physical deconditioning, dysautonomia, and increased inflammation, 7 , 8 current data are limited because most studies have been retrospective analyses of referred patients with only 1 to 2 examinations per study. 9 , 10 Most also lacked healthy controls for comparison and focused predominantly on patients hospitalized for COVID-19 or mixed cohorts, which often included individuals with concomitant diseases. 1 Hospitalization and/or intensive care treatment alone can significantly impair physical performance, 11 primarily through muscle wasting and even critical illness myopathy. 12 To elucidate the severity and specific mechanisms leading to exercise intolerance following SARS-CoV-2 infection, it is important to prospectively recruit in a controlled design and comprehensively investigate multiple factors in nonhospitalized patients with PEM.

Accordingly, the primary aim of this study was to investigate exercise intolerance in patients with well-defined PCC without prior comorbidities compared with age- and sex-matched healthy controls. Acute responses to 3 different commonly prescribed types of exercise (high-intensity interval training [HIIT], moderate-intensity continuous training [MICT], and strength training [ST]) were investigated in a randomized crossover design to assess whether exercise exacerbates symptoms and whether a particular type of exercise is preferable for patients with PCC. The secondary aim was to investigate the proposed physiologic mechanisms underlying PCC through a comprehensive characterization of physiologic functions.

This prospective randomized crossover clinical trial ( NCT05445830 ) was approved by the Swedish Ethical Review Authority and conformed to the Declaration of Helsinki. 13 The study followed the Consolidated Standards of Reporting Trials ( CONSORT ) guideline for randomized clinical trials (the trial protocol is given in Supplement 1 ). All participants gave written informed consent.

Patients with PCC were recruited from September 2022 to July 2023 via advertisements (Karolinska Institutet, Swedish Post–COVID-19 Patients’ Association) and the post–COVID-19 outpatient clinic at Karolinska University Hospital. Inclusion criteria were (1) age between 18 and 64 years; (2) laboratory-confirmed SARS-CoV-2 infection; (3) persistent PEM symptoms for 3 or more months, verified by the DePaul Symptom Questionnaire 14 ; (4) no hospitalization for COVID-19; (5) no history of cardiovascular or respiratory disease, generalized anxiety disorder, or somatic symptom disorder; and (6) no symptoms before March 2020. An equal number of age- and sex-matched healthy controls were also recruited from the general population.

All participants underwent comprehensive physiologic characterization at clinical physiology and neurophysiology units at Karolinska University Hospital. They then completed 3 acute exercise sessions in a randomized, counterbalanced order: HIIT, MICT, and ST ( Figure 1 ). The primary outcome was the difference in change in fatigue (from baseline to 48 hours after exercise) between groups, which was assessed within a panel of 10 symptoms associated with PEM and PCC using the visual analog scale (VAS; score range, 0 [no feeling] to 10 [worst possible feeling]).

REDCap software was used for random allocation and data collection. The data analysis was blinded, while the study personnel were blinded as far as possible during data collection. Adverse events associated with the study measures were recorded and clarified in consultation with the responsible physician.

All participants completed 3 exercise sessions (HIIT, MICT, and ST) in a randomized, balanced order with an approximately 2- to 4-week washout between sessions. Maximal workload from the baseline cardiopulmonary exercise testing (CPET) was used to determine exercise intensity for HIIT: 5 × 1-minute cycling at 90% maximal workload and a Borg Rating of Perceived Exertion (RPE) score higher than 16, 15 with 1-minute passive rest between intervals. Moderate-intensity continuous training consisted of 30-minute continuous cycling at 50% maximal workload (RPE score, 12-14). Strength training included 3 exercises: dead lifts (Kbox; Exxentric AB), push-ups, and knee extensions using flywheel technology (nHance), each with 3 sets of 10 repetitions and a 3-minute rest between sets.

Exercise sessions were closely monitored, including continuous measurements of oxygen saturation, heart rate (MAX-FAST-I; Nellcor), blood pressure (Minidop ES-100VX; Hadeco), RPE score, and lactate concentration. Participants completed the following questionnaires to assess symptoms of PEM before, immediately after, and 48 hours after exercise: VAS for 10 PCC symptoms (fatigue, muscle pain, joint pain, fever, chills, lymph node discomfort, sore throat, headache, memory, and concentration), Multidimensional Fatigue Inventory, 16 Profile of Mood States, 17 and Somatic and Psychological Health Report. 18 The 48-hour follow-up was selected based on peak fatigue at 24 to 72 hours in patients with myalgic encephalomyelitis–chronic fatigue syndrome. 19 Blood samples were collected at the same time points to quantify creatine kinase (CK) (cobas c 701; Roche Diagnostics) and interleukin 6 (IL-6) (D6050; R&D Systems) levels. At the 48-hour follow-up, participants also performed CPET.

All participants underwent standard spirometry (MasterScreen PFT; Jaeger) and echocardiography (Vivid E95 System; GE HealthCare) according to clinical guidelines. Cardiopulmonary exercise testing was performed on a cycle ergometer (Rodby Innovation AB; increments of 10-25 W/min) with a continuous gas analyzer (Vyntus CPX; Jaeger) to determine aerobic capacity as peak volume of oxygen consumption (V̇O 2 ) and ventilatory threshold (VT) using the V-slope method (verified by 2 independent observers, G.J. and N.A.). 20 Lactate concentration was measured at the earlobe before and every 2 minutes during CPET (Lactate Scout+; SensLab GmbH); the onset of blood lactate accumulation at 4 mmol/L was assessed. 21

Orthostatic tolerance was assessed by the head-up tilt test (HUTT) with continuous hemodynamic monitoring (Finapres NOVA; Finapres Medical Systems) according to guidelines. 22 Clinical outcomes, including postural orthostatic tachycardia syndrome (POTS), were determined based on consensus criteria. 23

Arterial stiffness was assessed by aortic pulse wave velocity using arteriography (TensioMed). The 6-minute walk test assessed physical function, 24 whereas upper- and lower-body muscle strength were measured using handgrip dynamometry (5030-J1; Sammons Preston Rolyan) and isokinetic dynamometry (System 4 Pro; BioDex Medical Systems), respectively. Blood tests, including for biochemical markers, were performed ( Table 1 ), and blood volume was estimated by carbon monoxide rebreathing. 25 The following questionnaires were used: Godin-Shephard Leisure-Time Physical Activity, 26 36-Item Short Form Health Survey (SF-36), 27 Modified Medical Research Council Dyspnea Scale, and Post–COVID-19 Functional Status. 28 Physical activity was monitored for 7 days via accelerometer (wGT3X-BT; ActiGraph) and evaluated with ActiLife software (ActiGraph) using guidelines from Choi et al (2011). 29

Neurophysiologic testing was conducted with the Sierra Summit EMG system (Cadwell Industries, Inc) and included (1) motor and sensory nerve conduction studies in the dominant limbs, (2) heart rate variability during normal and deep breathing, (3) sympathetic skin response in the hands and feet, and (4) needle electromyography (EMG) of 6 muscles using a 35-mm concentric needle (20 Hz to 10 kHz filter). The EMG data were analyzed qualitatively and quantitively for the duration, amplitude, and number of phases of more than 20 motor unit potentials (MUPs). Spontaneous activity was assessed at rest and interference pattern during slight and maximal contraction. The EMG outcomes were classified as (1) normal (MUPs without significant myopathic or neurogenic characteristics), (2) myopathic (>50% of displayed MUPs with short duration, small amplitudes, and polyphasia [≥5 phases]; the outcome was considered definitive myopathic if these characteristics were present in ≥2 muscles), (3) borderline myopathic (myopathic findings observed in only 1 muscle), (4) neurogenic (overrepresentation of MUPs with increased duration and amplitudes with or without increased polyphasia), or (5) mixed (both myopathic and neurogenic indices coexisted). 30

Analysis was performed using IBM SPSS, version 29.0 (IBM Corp) according to the intention-to-treat approach. Our a priori estimate (using G*Power, version 3.1; University of Dusseldorf) was that we would need at least 28 patients and 28 controls to detect a moderate effect size (critical F = 0.25) for the difference in fatigue between groups using a within-between interaction design with a power of 80% and an α of 5% ( Supplement 1 ). In the final analysis, however, the postexercise symptoms were compared between groups using nonparametric tests due to nonnormal distribution. A mixed linear model (fixed effects: group, time, and exercise; random effects: study identification number, exercise order) was used to analyze differences in continuous data (CPET variables and IL-6 and CK levels) following 3 exercise sessions (HIIT, MICT, and ST) between the 2 groups (patients with PCC, controls). Pairwise comparisons with Bonferroni correction were performed when significant main or interaction effects were detected. For physiologic characterization, χ 2 tests were used to compare categorical variables between patients with PCC and controls. Continuous variables were compared using 2-tailed Student t tests or nonparametric tests (Mann-Whitney, Kruskal-Wallis) when appropriate. Results are presented as means (SDs) or medians (IQRs). Statistical significance was defined as 2-sided P < .05.

This study included 62 participants (47 women [76%]; 15 men [24%]), with a mean (SD) age of 47.0 (9.4) years. Specifically, the study cohort consisted of 31 patients with PCC (mean [SD] age, 46.6 [10.0] years; 7 men [23%], 24 women [77%]) and 31 age- and sex-matched healthy controls (mean [SD] age, 47.3 [8.9] years; 8 men [26%], 23 women [74%]) ( Table 1 and eTable 1 in Supplement 2 ). For the PCC group, the mean (SD) symptom duration was 21.6 (9.2) months. Mean (SD) scores on the Post–COVID-19 Functional Status scale and the Modified Medical Research Council Dyspnea Scale were 2.6 (0.8) and 1.9 (1.0), respectively. Of 23 patients with PCC who responded to questions about work status, 18 (78%) were employed full time before SARS-CoV-2 infection, whereas 17 (74%) were on extended sick leave because of PCC (eTable 1 in Supplement 2 ). Results of the SF-36 health survey showed lower general, physical, emotional, and social function in patients with PCC compared with controls ( Table 1 ). During the study, there was 1 minor adverse event in 1 control participant (3%) (knee pain during isokinetic dynamometry) that resolved with sequelae, and the participant was able to complete the study.

All participants reached the targeted exercise intensity during exercise sessions (eTable 2 in Supplement 2 ). Four questionnaires (VAS, Multidimensional Fatigue Inventory, Profile of Mood States, and Somatic and Psychological Health Report) showed higher overall symptom scores in patients with PCC compared with controls at all time points and sessions ( Table 2 and eTables 3-6 in Supplement 2 ). To assess persistent symptom exacerbation after each exercise mode, differences in changes from baseline to 48 hours after exercise were calculated and compared between patients with PCC and controls.

There was no difference in fatigue worsening between patients with PCC and controls after any of the exercise types (mean [SD] VAS ranks for HIIT: PCC, 29.3 [19.5]; controls, 28.7 [11.4]; P = .08; MICT: PCC, 31.2 [17.0]; controls, 24.6 [11.7]; P = .09; ST: PCC, 31.0 [19.7]; controls, 28.1 [12.2]; P = .49) ( Figure 2 A). Patients with PCC reported worse muscle pain (mean [SD] VAS ranks, 33.4 [17.7] vs 25.0 [11.3]; P = .04) ( Figure 2 B) and joint pain (mean [SD] VAS ranks, 33.6 [12.3] vs 24.9 [11.0]; P = .009) ( Table 2 ) after HIIT than the control group. After ST, there were no significant differences between the groups. Individual changes for fatigue and muscle pain are also presented in eFigures 1 and 2 in Supplement 2 . At 48 hours after MICT, patients with PCC reported higher concentration impairments compared with controls (mean [SD] VAS ranks, 33.0 [17.1] vs 23.3 [10.6]; P = .03). In contrast, lymph discomfort was lower at 48 hours after MICT in patients with PCC compared with controls (mean [SD] VAS ranks, 25.5 [12.0] vs 31.6 [4.9]; P = .02).

To examine which exercise mode was better tolerated in terms of symptom exacerbation, differences in changes from baseline to 48 hours after exercise for each symptom were compared among the 3 sessions (HIIT, MICT, and ST) in each group separately. Patients with PCC reported no worsening of fatigue after any of the exercise types ( Figure 2 C). However, after ST compared with the other modes, patients with PCC reported a greater increase in muscle soreness (mean [SD] VAS ranks for HIIT vs ST, 20.9 [13.7] vs 32.1 [13.6]; P = .007; for MICT vs ST, 17.9 [11.7] vs 33.1 [12.4]; P < .001) ( Figure 2 D) and lymph node discomfort (eg, mean [SD] VAS rank after MICT vs ST, 20.8 [9.3] vs 30.2 [11.9]; P = .005) ( Table 2 ). In contrast, MICT resulted in greater difficulty concentrating after 48 hours compared with ST (mean [SD] VAS ranks, 30.6 [13.0] vs 20.4 [13.7]; P = .01). Detailed results for VAS symptoms are provided in Table 2 , while median group and exercise differences and IQRs are given in eTables 3 and 4 in Supplement 2 , respectively. Results from the Multidimensional Fatigue Inventory, Profile of Mood States, and Somatic and Psychological Health Report questionnaires are provided in eTables 5 and 6 in Supplement 2 .

There were no significant differences between groups or exercises in peak heart rate, RPE score, lactate concentration, or respiratory exchange ratio (eTables 7-9 in Supplement 2 ). At 48 hours after each exercise session, the group with PCC had 20% lower peak V̇O 2 compared with controls independently of the preceding exercise type (mean difference, −6.2 mL/kg/min; 95% CI, −2.1 to −10.3 mL/kg/min; P = .004). The V̇O 2 at the VT was also 16% lower and onset of blood lactate accumulation at 4 mmol/L was 20% lower in patients with PCC than in controls 48 hours after all exercise sessions, while relative percentages were comparable between groups and exercises ( Figure 3 A and B).

Levels of IL-6 and CK were not significantly different between the groups ( Figure 3 C and D and eTable 10 in Supplement 2 ). For IL-6 release, there was a main time effect, with higher values at 48 hours after exercise compared with before exercise in both groups (mean difference, 3.2 pg/mL; 95% CI, 0.1-0.5 pg/mL; P = .005) ( Figure 3 C and D). A main effect of exercise and an interaction effect (exercise × time, P = .004) indicated that ST resulted in a CK increase 48 hours after exercise compared with baseline and was similar in both groups ( Figure 3 E and F).

Spirometry- and echocardiography-derived variables were within the normal range for all participants. However, patients with PCC had a 14% smaller stroke volume (mean difference, −2.6 mL; 95% CI, −4.9 to −0.2 mL; P = .02) and a 5% smaller left ventricular diameter (mean difference, −9.7 mm; 95% CI, −18.0 to −1.4 mm; P = .03) on echocardiography compared with control participants, with no differences in cardiac index or ventricular function (left ventricular ejection fraction, tricuspid annular plane systolic excursion). Arterial stiffness was also greater in the patients with PCC, with an 8.3% higher aortic pulse wave velocity (mean difference, 0.7 m/s; 95% CI, 0.0-1.4 m/s; P = .04). Full results are shown in Table 1 and mean group differences (95% CIs) in eTable 11 in Supplement 2 .

Baseline peak V̇O 2 was 21% lower in patients with PCC compared with controls (mean difference, −6.8 mL/kg/min; 95% CI, −10.7 to −2.9 mL/kg/min; P < .001). Maximal heart rate, lactate concentration, respiratory exchange ratio, and relative workload at the VT and at 4 mmol/L onset of blood lactate accumulation were similar between groups. The 6-minute walking distance did not differ between groups.

Isometric knee extension strength was 19% lower in the patients with PCC (mean difference, −37 Nm; 95% CI, −67 to −7 Nm; P = .02). However, knee extension isokinetic torque or handgrip strength did not differ between groups.

Blood and plasma volumes were slightly lower (blood by 7% and plasma by 8%) in patients with PCC but were not significantly different between the groups (blood volume, −5.2 mL/kg [95% CI, −11.8 to 1.3 mL/kg]; P = .12; plasma volume, −3.4 mL/kg [95% CI, −7.4 to 0.6 mL/kg]; P = .09). Blood status and biochemical blood markers, including C-reactive protein levels, were similar between the groups ( Table 1 ). Head-up tilt testing revealed POTS in 2 patients with PCC (6%) and borderline POTS in 2 others (6%); no POTS was present in control participants.

Accelerometry revealed similar total physical activity and sedentary behavior. However, patients with PCC spent 43% less time in moderate to vigorous physical activity (mean difference, −26.5 minutes/d; 95% CI, −42.0 to −11.1 minutes/d; P = .001).

Sensory and motor nerve conduction were within the normal range in all participants, with no differences between groups. Heart rate variability during normal breathing was comparable between groups. However, patients with PCC showed 19% less variability during deep breathing (mean difference, −5.7%; 95% CI, −11.3% to −0.1%; P = .05). The sympathetic skin response was normally elicited in all participants ( Table 1 ). Electromyography was performed in 29 patients with PCC (94%) and 28 control participants (90%). Myopathic findings were observed in 18 patients with PCC (62%) (13 [45%] had myopathic findings in ≥2 muscles and 5 [17%] in 1 muscle) compared with only 1 control participant (4%), who had myopathic indices in 1 muscle. Neuropathic findings were observed in 1 patient with PCC (4%) and 1 control participant (4%) in 1 muscle each. Quantitative analysis of MUPs and group comparisons are shown in eTable 12 in Supplement 2 .

This study investigated exercise intolerance in nonhospitalized, previously healthy patients with PCC compared with age- and sex-matched healthy controls. To elucidate possible mechanisms, we investigated the physiologic responses to acute exercise and performed a comprehensive physiologic characterization. The main finding was that participants with PCC generally tolerated all exercise sessions without significant worsening of symptoms or decline in aerobic performance after 48 hours. However, patients with PCC showed lower aerobic capacity and muscle strength compared with controls. We also observed a higher incidence of myopathic signs and indices of exaggerated orthostatic response in patients with PCC. While exacerbation of symptoms by exercise was not observed at the group level, our results indicate an underlying dysfunction in multiple organ systems that may have contributed to activity limitations in a subset of patients with PCC.

Preexercise to postexercise changes were largely comparable between patients with PCC and controls regardless of the type of exercise (overall increase of approximately 0.5-1 unit on the 0-10 VAS). While this indicates no general symptom exacerbation after exercise, it should be noted that changes in fatigue, pain, and concentration from baseline to 48 hours after exercise varied among individuals (eFigures 1 and 2 in Supplement 2 ). Nonetheless, the observation that nonhospitalized patients with PCC could tolerate various physical activities without escalation of symptoms is important. It implies that physical activity tailored for patients on an individual basis could be an essential component in rehabilitation to enhance physical function and counteract muscle deconditioning. This is in line with recent reports supporting symptom-guided exercise rehabilitation in individuals with PCC. 31 , 32

Notably, we observed no discrepancies between patients with PCC and control participants in exercise intensity corresponding to VT and onset of blood lactate accumulation at 4 mmol, indicating undisturbed metabolic exercise response at baseline and at the 48-hour follow-up. Previous suggestions that earlier lactate accumulation, possibly due to peripheral mitochondrial dysfunction leading to premature conversion to anaerobic glycolysis, occurs in the context of PCC and other postviral diseases have not been conclusively proven. 33 , 34 Two reports found decreased VT 35 and increased lactate levels 36 after COVID-19, whereas other studies found no difference in VT between patients with PCC and control participants. 37 , 38 Importantly, the former studies included patients with relevant comorbidities, hospitalizations, and occasionally intensive care or mechanical oxygen support, 35 , 36 factors that are known to have adverse effects on peripheral muscle tissue. 39 , 40

Patients with PCC participated less in moderate to vigorous physical activity and showed lower aerobic capacity, as previously shown 1 , 9 even in nonhospitalized patients. 38 , 41 The maximum heart rate was consistent across groups, and all individuals in the cohort met the peak V̇O 2 criteria (ie, reached >85% of their predicted maximum heart rate, respiratory exchange ratio >1.10, RPE >18, and lactate accumulation >8 mmol). 42 However, even though within normal ranges, patients with PCC had reduced stroke volume and left ventricular diameter and, although not significant, approximately 7% lower blood volume compared with controls. It is plausible that this was due to the reduced levels of high- and moderate-intensity physical activity, which are associated with decreased blood volume and venous return affecting left ventricular diameter and stroke volume, 43 and to increased resting heart rate, as observed in this study.

In addition to the higher resting heart rate, we also observed (with HUTT) that 13% of patients with PCC had an exaggerated heart rate response when standing, suggesting orthostatic intolerance. While deconditioning can partially explain the observed orthostatic intolerance (blood volume reduction can lead to a heart rate elevation), we cannot exclude the possibility that impaired autonomic function after viral infection 44 , 45 (ie, higher levels of autoantibodies against α and β adrenoreceptors and muscarinic receptors) 46 led to the exaggerated heart rate response. Patients with PCC also showed lower heart rate variability during deep breathing and increased foot latency as assessed in the sympathetic skin response test, suggesting parasympathetic nervous system involvement in a subgroup of patients with PCC. 47 Finally, patients with PCC showed higher pulse wave velocity, indicating increased arterial stiffness compared with controls. This vascular involvement points to possible mechanisms, such as inactivity, 48 direct viral damage, or cytokine-mediated effects on the vascular endothelium, 49 which should be further investigated.

Of patients with PCC, 62% showed myopathic signs compared with a single case in the control group. Our EMG results suggested myogenic-derived rather than neurogenic causes of the myopathies in patients with PCC, evident in characteristics such as early recruitment of small, short-duration, frequent, polyphasic MUPs. 30 Neurogenic disorders, typically indicated by signs of denervation, were not observed. The absence of peripheral nerve dysfunction in the nerve conduction assessments in conjunction with the presence of myopathic indices corroborates the predominantly myogenic nature of the EMG findings. This is consistent with other studies reporting changes of myogenic origin in patients with PCC, 10 , 50 although a recent study pointed to structural muscle problems and exercise-induced myopathy. 38 Collectively, these observations highlight muscular impairment in patients with PCC, which is further supported by the observed decrease in isometric muscle strength. Other factors, such as inflammation, capillary changes, and mitochondrial dysfunction, may also contribute to muscle impairments in patients with PCC and should be further investigated. 10 , 37 , 38

Although baseline C-reactive protein and IL-6 levels in the cohort with PCC were normal, it is plausible that dysregulation of the immune system in the acute phase or persistent systemic inflammation could cause long-lasting impairments in muscles or neurons, which could explain the observed peripheral tissue problems as well as severe fatigue and myalgia. 8 This phenomenon is not unique to COVID-19; persistent fatigue, cognitive problems, and mental difficulties have been observed for up to 4 years in patients after infections such as Middle East respiratory syndrome, 51 severe acute respiratory syndrome, 52 , 53 and Epstein-Barr virus. 54 Viral infections have long been considered a major cause of myalgic encephalomyelitis–chronic fatigue syndrome. 55 Although the exact mechanisms of postviral syndrome are unclear, viruses are thought to trigger aberrant immune responses that cause persistent mild inflammation and immune cell dysregulation, leading to long-lasting symptoms. 8 We speculate that COVID-19 may affect muscle cells and autonomic neurons directly or via inflammatory pathways, causing myopathy and/or dysautonomia in some patients. This muscle damage may also contribute to decreased muscle strength, possibly leading to difficulty exercising and exacerbation of symptoms.

A strength of the study was the comprehensive design including several clinical assessments and 3 different exercises, but the sample size was relatively small. We chose the 48-hour follow-up time point based on previous evidence in myalgic encephalomyelitis–chronic fatigue syndrome, 56 but we do not know whether symptoms may have peaked after this period.

The cohort with PCC included previously healthy individuals with persistent symptoms 3 or more months after SARS-CoV-2 infection, without relevant comorbidities or hospitalization. We felt it was important to include healthy controls matched for age and sex, but it would also be relevant to compare patients with PCC with other patient groups experiencing long-term illnesses and/or exercise intolerance. Although patients with PCC in this study did not have severe effects, they reported marked symptoms at baseline, including fulfilling the criteria for PEM and persistent physical and mental fatigue that affected their health and well-being. Our results should not be generalized to all patients with PCC, and we are aware of the serious problems faced by many individuals.

Myopathic indices were found in 62% of patients with PCC, in contrast to 1 case in the control group. Although this result seems clear and robust, we acknowledge that the study was not able to determine whether these myogenic changes were already present prior to the infection. Further analyses are essential to clarify the origin of these myopathic indices.

In this randomized crossover clinical trial, nonhospitalized patients with PCC generally tolerated all exercise types without reporting significant symptom exacerbation, performance reductions, or exacerbated inflammation after 48 hours. They had largely preserved respiratory and cardiovascular functions but showed lower aerobic capacity and muscle strength as well as signs of myopathy and orthostatic intolerance. It is plausible that our results represent a phenotype indicative of inactivity coupled with primary peripheral tissue damage and neurophysiologic changes leading to further difficulty in performing strenuous activity. However, given that exercise was generally well tolerated, guidelines cautioning against exercise in similar populations may need to be revised. It seems advisable to cautiously incorporate exercise into rehabilitation protocols and adjust the intensity progressively, considering patients’ symptoms and abilities.

Accepted for Publication: February 2, 2024.

Published: April 4, 2024. doi:10.1001/jamanetworkopen.2024.4386

Corresponding Author: Andrea Tryfonos, PhD, Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, 141 86 Stockholm, Sweden ( [email protected] ).

Author Contributions: Dr Tryfonos had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Tryfonos, Pourhamidi, Jörnåker, Mandić, Rullman, Hyllienmark, Rundqvist, Lundberg, Gustafsson.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Tryfonos, Pourhamidi, Asplund, Hyllienmark, Gustafsson.

Critical review of the manuscript for important intellectual content: Tryfonos, Pourhamidi, Jörnåker, Engvall, Eriksson, Elhallos, Mandić, Sundblad, Sepic, Rullman, Hyllienmark, Rundqvist, Lundberg, Gustafsson.

Statistical analysis: Tryfonos, Elhallos, Rullman, Hyllienmark, Rundqvist, Lundberg, Gustafsson.

Obtained funding: Tryfonos, Hyllienmark, Lundberg, Gustafsson.

Administrative, technical, or material support: Tryfonos, Pourhamidi, Jörnåker, Engvall, Eriksson, Mandić, Sepic, Rullman, Hyllienmark, Rundqvist, Lundberg, Gustafsson.

Supervision: Tryfonos, Pourhamidi, Engvall, Mandić, Sundblad, Hyllienmark, Rundqvist, Lundberg, Gustafsson.

Conflict of Interest Disclosures: None reported.

Funding/Support: The project received funding from the Karolinska Institute from Hannover (Dr Gustafsson), the Tornspiran Foundation (Dr Tryfonos), the Lars Hierta Memorial Foundation (Dr Tryfonos), and the Magnus Bergvalls Foundation (Dr Lundberg) and a grant from the CIMED (region Stockholm) (Dr Gustafsson).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3 .

Additional Contributions: We thank the staff at the Unit of Clinical Physiology and Department of Neurophysiology at Karolinska University Hospital in Huddinge for their support during participant recruitment and data collection. We thank all participants in this study.

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This paper is in the following e-collection/theme issue:

Published on 9.4.2024 in Vol 26 (2024)

Moderating Effect of Coping Strategies on the Association Between the Infodemic-Driven Overuse of Health Care Services and Cyberchondria and Anxiety: Partial Least Squares Structural Equation Modeling Study

Authors of this article:

Original Paper

Richard Huan Xu 1 , PhD ;
Caiyun Chen 2 , PhD

1 Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, Hong Kong Polytechnic University, Hung Hom, China (Hong Kong)

2 Nanjing Academy of Administration, Nanjing, China

Corresponding Author:

Richard Huan Xu, PhD

Department of Rehabilitation Sciences

Faculty of Health and Social Sciences

Hong Kong Polytechnic University

11 Yuk Choi Rd

China (Hong Kong)

Phone: 852 27664199

Email: [email protected]

Background: The COVID-19 pandemic has led to a substantial increase in health information, which has, in turn, caused a significant rise in cyberchondria and anxiety among individuals who search for web-based medical information. To cope with this information overload and safeguard their mental well-being, individuals may adopt various strategies. However, the effectiveness of these strategies in mitigating the negative effects of information overload and promoting overall well-being remains uncertain.

Objective: This study aimed to investigate the moderating effect of coping strategies on the relationship between the infodemic-driven misuse of health care and depression and cyberchondria. The findings could add a new dimension to our understanding of the psychological impacts of the infodemic, especially in the context of a global health crisis, and the moderating effect of different coping strategies on the relationship between the overuse of health care and cyberchondria and anxiety.

Methods: The data used in this study were obtained from a cross-sectional web-based survey. A professional survey company was contracted to collect the data using its web-based panel. The survey was completed by Chinese individuals aged 18 years or older without cognitive problems. Model parameters of the relationships between infodemic-driven overuse of health care, cyberchondria, and anxiety were analyzed using bootstrapped partial least squares structural equation modeling. Additionally, the moderating effects of coping strategies on the aforementioned relationships were also examined.

Results: A total of 986 respondents completed the web-based survey. The mean scores of the Generalized Anxiety Disorder-7 and Cyberchondria Severity Scale-12 were 8.4 (SD 3.8) and 39.7 (SD 7.5), respectively. The mean score of problem-focused coping was higher than those of emotion- and avoidant-focused coping. There was a significantly positive relationship between a high level of infodemic and increased overuse of health care (bootstrapped mean 0.21, SD 0.03; 95% CI 0.1581-0.271). The overuse of health care resulted in more severe cyberchondria (bootstrapped mean 0.107, SD 0.032) and higher anxiety levels (bootstrapped mean 0.282, SD 0.032) in all the models. Emotion (bootstrapped mean 0.02, SD 0.008 and 0.037, SD 0.015)- and avoidant (bootstrapped mean 0.026, SD 0.009 and 0.049, SD 0.016)-focused coping strategies significantly moderated the relationship between the overuse of health care and cyberchondria and that between the overuse of health care and anxiety, respectively. Regarding the problem-based model, the moderating effect was significant for the relationship between the overuse of health care and anxiety (bootstrapped mean 0.007, SD 0.011; 95% CI 0.005-0.027).

Conclusions: This study provides empirical evidence about the impact of coping strategies on the relationship between infodemic-related overuse of health care services and cyberchondria and anxiety. Future research can build on the findings of this study to further explore these relationships and develop and test interventions aimed at mitigating the negative impact of the infodemic on mental health.

Introduction

Covid-19–related mental health problems.

In today’s technologically advancing society, widespread and rapid digitization has led to a substantial increase in the use of social media and the internet. This, in turn, has facilitated the rapid dissemination of all types of information. Although this can be beneficial in filling information gaps quickly, it has its drawbacks. A prominent drawback is the amplification of harmful messages, which can have negative effects on individuals [ 1 , 2 ]. The World Health Organization (WHO) acknowledged the presence of an infodemic during the COVID-19 pandemic and subsequent responses. WHO defines an infodemic as an excessive amount of information, including both accurate and inaccurate content [ 3 ]. This abundance of information makes it difficult for individuals to distinguish reliable sources from unreliable sources and to find trustworthy guidance when they need it.

Excessive use of health care services can have adverse effects on individuals and the overall sustainability of health care systems. Although challenges associated with the overuse of health care services were evident before the COVID-19 pandemic [ 4 , 5 ], the urgent need for sustainable health care systems was exacerbated by the pandemic. Because large portions of the population were instructed to self-isolate at home and had limited access to health care professionals during the pandemic, the internet became the primary source of information for numerous individuals seeking answers to health-related questions. However, the abundance of web-based information, including both true and false content, can leave individuals feeling overwhelmed and struggling to make informed choices. This information overload can lead to depression because individuals bombarded with conflicting messages may feel unsure of what to believe [ 6 - 10 ].

Besides depression, cyberchondria has also emerged as a significant public health challenge since the onset of the COVID-19 pandemic. This refers to the repeated and excessive search for health-related information on the internet, leading to a significant increase in distress or anxiety [ 11 ]. Although the global emergency caused by the COVID-19 pandemic is over, telehealth remains a growing trend. An increasing number of studies have indicated that telehealth can improve health care access, outcomes, and affordability by offering a bridge to care and an opportunity to reinvent web-based care models [ 12 ]. However, increasing internet exposure increases the risk of cyberchondria, especially under conditions of uncertainty and increased risk, due to the large volume of information it contains. Thus, it is crucial to understand how to provide support and guidance to help people adopt appropriate strategies for using web-based resources safely in the context of an infodemic.

Current Research on the COVID-19–Related Infodemic

The harms of infodemic are well documented. An Italian study suggested developing early warning signals for an infodemic, which can provide important cues for implementing effective communication strategies to mitigate misinformation [ 13 ]. Other studies have shown that successful use of coping strategies can help individuals manage stressful events and reduce negative emotions during a pandemic. For example, Yang [ 14 ] found a positive correlation between emotion-focused coping and cyberbullying and depression during the COVID-19 pandemic. A large-scale UK study indicated that supportive coping was associated with a faster decrease in depression and anxiety symptoms [ 15 ]. Shigeto et al [ 16 ] emphasized the importance of training young adults to develop resilience, flexibility, and specific coping skills to offset the psychological effects of significant lifestyle changes resulting from pandemics or other health crises in the future. A recent study used machine learning technology to enhance the accuracy and efficiency of automated fact-checking and infodemic risk management at a strategic level [ 17 ]. However, the impact of coping strategies on the relationship among the infodemic, cyberchondria, and anxiety at an individual level during the COVID-19 pandemic is still unknown.

Importance of Coping Strategies

The ability of individuals to discern and adopt appropriate coping strategies can have a profound impact on their mental health, particularly in relation to conditions such as depression and anxiety. The ability to select and implement coping strategies is not uniform across all individuals, and these differences can significantly influence the trajectory of their mental health outcomes. For some, the ability to effectively choose and implement coping strategies can serve as a protective factor, mitigating the severity of the symptoms of depression or anxiety and promoting overall health and well-being. Conversely, for others, inability or difficulty in selecting and implementing effective coping strategies can exacerbate mental health conditions, leading to increased severity of depression and anxiety. This, in turn, can have detrimental effects on individuals’ overall health and well-being. Therefore, understanding the factors that influence individuals’ ability to select and implement effective coping strategies is of paramount importance in the field of mental health research and intervention [ 18 ].

Research has demonstrated the importance of appropriate coping mechanisms in managing mental health problems. Coping strategies, which are essential for dealing with stress or challenging situations, can be categorized into 3 primary types: emotion focused, problem focused, and avoidant focused [ 19 ]. Emotion-focused strategies are centered around managing and regulating emotions. They serve as a means to cope with stress or difficult situations. These strategies might involve seeking emotional support from others, using relaxation techniques, or practicing mindfulness. In contrast, problem-focused strategies actively address the problem or stressor. These strategies might encompass problem-solving, devising a plan of action, or seeking information and resources to effectively tackle the situation. Avoidant-focused strategies involve evading or distancing oneself from the stressor or problem. These strategies might include denial, distraction, or engaging in activities to escape or avoid contemplating the issue [ 18 ]. The effectiveness of different coping strategies can vary depending on the situation. Individuals often use different or a combination of strategies, tailoring their approach to their circumstances.

Coping Strategies in the COVID-19–Related Infodemic

From a social perspective, this study underscores the importance of mental health in the context of public health emergencies such as the COVID-19 pandemic. It highlights the need for society to recognize and address the mental health burden that such emergencies can place on individuals, particularly in relation to the phenomenon of cyberchondria, which is the unfounded escalation of concerns about common symptoms based on reviews of web-based literature and resources.

Practically, this study provides valuable insights for policy makers and practitioners. It emphasizes the need for the development of effective coping strategies and programs to manage the negative impact of an overload of misinformation and disinformation on mental health. This is particularly relevant in the digital age, where individuals have access to a plethora of information, not all of which is accurate or reliable. Policy makers and practitioners can use the findings of this study to design interventions that not only provide accurate information but also equip individuals with the skills to distinguish reliable sources from unreliable sources and to cope with the anxiety that misinformation can cause. From a research standpoint, this study fills a gap in the literature by assessing the impact of the infodemic on cyberchondria and the moderating effect of coping strategies in this relationship. It opens up new avenues of research into the complex interplay among public health emergencies, infodemic, cyberchondria, and coping strategies. Future research could build on the findings of this study to further explore these relationships and develop and test interventions aimed at mitigating the negative impact of infodemic on mental health.

Objective of the Study

Currently, the association between the overuse of health care services and mental health problems in the context of an infodemic remains unclear, as is the moderating effect of different coping strategies on this association. Thus, this study investigated the moderating effect of coping strategies on the relationship between the infodemic-driven misuse of health care and depression and cyberchondria.

Hypotheses of the Study

The study used a hypothesis-driven format. Specifically, there are five hypotheses: (1) a positive relationship exists between infodemic and the misuse of health care, (2) a positive relationship exists between the misuse of health care and depressive disorders, (3) a positive relationship exists between the misuse of health care and cyberchondria, (4) coping strategies mitigate the negative effect of the misuse of health care on depression, and (5) coping strategies mitigate the negative effect of the misuse of health care on cyberchondria. Hypotheses 2-5 are separately evaluated for the three types of coping strategies: problem focused (H2.1), emotion focused (H2.2), and avoidant focused (H2.3).

Study Design and Sample Size

The data used in this study were obtained from a cross-sectional and web-based survey conducted between April and May 2023 in China.

There is no gold standard for sample estimation in partial least squares structural equation modeling (PLS-SEM). Following Hair et al [ 20 ], we set the significance level at 5% and the minimum path coefficients to between 0.05 and 0.1. Based on these criteria, a minimum sample size of 619 was determined.

Data Source and Collection

A professional surveying company, WenJuanXing, was invited to collect the data through its web-based panel. The panel of WenJuanXing consists of 2.6 million members, with an average of over 1 million questionnaire respondents daily. At the beginning of the project, a survey manager collaborated with the research team to screen and recruit participants using the company’s internal social network platform. All of the eligible panel members received a survey invitation, and a voluntary response sampling method was used. The survey manager checked the data quality using WenJuanXing’s artificial intelligence data quality control system to ensure that respondents met our inclusion criteria and provided valid responses, thus ensuring a high level of data accuracy and integrity. The inclusion criteria were (1) aged older than 18 years, (2) able to understand and read Chinese, and (3) agreed to provide informed consent. All eligible respondents were invited to participate in a web-based survey. The first section of the survey was the informed consent, which the participants were required to read and agree to before proceeding. All the participants who agreed to participate in the survey were asked to complete six questionnaires covering (1) demographics and socioeconomic status, (2) COVID-19 information–related questions, (3) a cyberchondria questionnaire, (4) an eHealth literacy questionnaire, (5) an anxiety questionnaire, and (6) a coping strategy questionnaire. The English translations of the questionnaires are presented in Multimedia Appendix 1 . To ensure data quality, we collaborated with the survey company and implemented various indicators. We monitored completion time, excluding responses that took less than 6 minutes. We also tracked ID addresses, ensuring that each ID address could only complete the questionnaire once. To minimize random errors, we used an artificial intelligence formula developed by the survey company to identify and filter any response patterns that appeared to be generated in parallel.

Ethical Considerations

The study protocol and informed consent process were approved by the institutional review board of the Hong Kong Polytechnic University (HSEARS20230502006). Informed consent was collected from all participants. The survey was conducted anonymously, and no personally identifiable information was collected. No compensation was provided by the research team.

Instruments

Cyberchondria severity scale-12.

The Cyberchondria Severity Scale-12 (CSS-12), derived from the 33-item CSS, was used to measure the severity of cyberchondria. The CSS-12 exhibited equally good psychometric properties as the original version and has been validated in Chinese populations [ 21 ]. The CSS-12 items are scored on a Likert-type scale ranging from 1=“never” to 5=“always,” giving total scores ranging from 12 to 60. A higher score indicates a higher severity of suspected cyberchondria. The psychometric properties of the Chinese version of the CSS-12 were reported by Peng et al [ 22 ].

Generalized Anxiety Disorder Assessment

The Generalized Anxiety Disorder Assessment-7 (GAD-7) was used to screen for generalized anxiety disorder and related anxiety disorders [ 23 ]. This scale consists of 7 items designed to assess the frequency of anxiety symptoms during the 2 weeks preceding the survey. The GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3 to the response categories of “not at all,” “several days,” “more than half the days,” and “nearly every day,” respectively. The scores of the 7 questions are then summed, giving a total ranging from 0 to 21, with higher scores indicating a higher severity of anxiety disorders. Many studies have reported the psychometric properties of the GAD-7 in Chinese populations, such as that conducted by Sun et al [ 24 ].

Coping Orientation to Problems Experienced Inventory

The Coping Orientation to Problems Experienced Inventory (Brief-COPE) is a 28-item self-report questionnaire used to measure effective and ineffective strategies for coping with a stressful life event [ 25 ]. The Brief-COPE assesses how a person deals with stressors in their daily life. The questionnaire measures 3 coping strategy dimensions: problem focused, emotion focused, and avoidant focused [ 26 ]. Each item is rated on a 4-point scale. The scores for the 3 overarching coping styles are calculated as average scores. This is done by dividing the sum of the item scores by the number of items. These average scores indicate the extent to which the respondent engages in each coping style. A higher score indicates that the respondent does not have many coping skills. The Chinese version of the Brief-COPE and its psychometric properties in Chinese populations were reported by Wang et al [ 27 ].

Infodemic- and Misinformation-Driven Overuse of Health Care Services

The COVID-19–related infodemic and misinformation-driven medical misbehavior were assessed using 2 self-developed items. The first item was “Do you believe there is an excessive amount of information regarding the COVID virus and vaccine on a daily basis?” The second item was “Has misinformation or disinformation about COVID-19 led you to engage in the overuse of health care services (eg, frequently visiting the doctor/psychiatrist or buying unnecessary medicine)?” The respondents were required to indicate their response to these 2 questions by selecting 1 of 2 options presented dichotomously: yes or no.

Statistical Analysis

Descriptive statistics were used to describe the participants’ background characteristics. Continuous variables (eg, age) were calculated as means and SDs. Categorical variables (eg, sex) were calculated as frequencies and proportions. The Pearson correlation coefficient ( r ) was used to examine the association between measures, where r ≥0.3 and r ≥0.5 indicated moderate and large effects, respectively [ 28 , 29 ].

In this study, we used PLS-SEM to estimate the research model parameters, as it works efficiently with small samples and complex models. Compared with covariance-based structural equation modeling, PLS-SEM has several advantages, such as the ability to handle non-normal data and small samples [ 30 ]. Unlike covariance-based structural equation modeling, which focuses on confirming theories, PLS-SEM is a causal-predictive approach that explains variance in the model’s dependent variables [ 31 ]. To improve the model fit, we used the bootstrapping method with 10,000 replications to obtain the estimates of the mean coefficients and 95% CIs [ 32 ]. Composite reliability rho_a (>0.7), composite reliability rho_c (>0.7), and average variance extracted (>0.5) were used to examine the model performance.

PLS-SEM encompasses measurement models that define the relationship between constructs (instruments) and indicator variables and a structural model. The structural model used in this study is presented in Figure 1 . We hypothesized that the infodemic significantly affects misinformation-driven medical misbehavior, resulting in cyberchondria and high anxiety levels. Furthermore, we speculated that coping strategies significantly modify this relationship. To test these hypotheses, we used 3 models that used the full sample to separately investigate the moderating effect of the 3 types of coping strategies (problem focused, emotion focused, and avoidant focused). We analyzed the data and estimated the PLS-SEM parameters using the “SEMinR” package in R (R Foundation for Statistical Computing). A P value of ≤.05 was considered statistically significant.

Background Characteristics of Participants

A total of 986 respondents completed the web-based survey and provided valid responses, resulting in a response rate of 84%. Among the participants, 51.7% (n=510) were female, approximately 95% (n=933) had completed tertiary education or above, and 71.2% (n=702) resided in urban areas. The participants’ background characteristics are listed in Table 1 .

a A currency exchange rate of 7.23 CNY=US $1 applies.

Mean Scores and Frequency of Responses

The mean score of the GAD-7 was 8.4 (SD 3.8), while the mean score of the CSS-12 was 39.7 (SD 7.5). Problem-focused coping had a higher mean score than emotion- and avoidant-focused coping. Respondents with active employment reported statistically significantly higher mean scores on the GAD and avoidant-focused coping subscale compared to those with nonactive employment. A higher proportion of respondents with chronic diseases experienced an infodemic and exhibited the overuse of health care services relative to those without chronic diseases ( Table 2 ). The correlations between all of the measures are presented in Multimedia Appendix 2 .

a GAD-7: Generalized Anxiety Disorder Assessment-7.

b CSS-12: Cyberchondria Severity Scale-12.

c COPE: Coping Orientation to Problems Experienced Inventory.

g P <.001.

Measurement Models

Tables 3 - 5 present the performance of the measurement models for the 3 coping strategies. The values of rho_C and rho_A were above 0.7, indicating acceptable construct reliability. All 3 constructs had Cronbach α values exceeding the cutoff of 0.7, indicating adequate reliability. Table 2 presents the models’ convergent validity. All the bootstrapped item loadings exceeded 0.3 and were significant at <.05 for the problem- and avoidant-focused models. However, for cyberchondria and the Brief-COPE, none of the average variance extracted values were above 0.5, indicating unsatisfactory model convergent validity.

a AVE: average variance extracted.

b GAD-7: Generalized Anxiety Disorder-7.

d HC: health care.

b GAD-7: Generalized Anxiety Disorder.

Structural Models

The structural model analysis involved estimating path coefficients for the conceptual model. We performed PLS-SEM on the research model 3 times to estimate path coefficients for the models with different coping strategies. We found that H1 was supported. A significant and positive relationship was observed between a high level of infodemic exposure and increased overuse of health care services (coefficient=0.212, 95% CI 0.151-0.271). In addition, the overuse of health care services was correlated with more severe cyberchondria and higher anxiety levels in all the 3 models, supporting H2 and H3. The effect of the overuse of health care services on cyberchondria was larger than its effect on anxiety. All these relationships were statistically significant ( Tables 3 - 5 ).

Moderating Effects

In our moderation analyses ( Figure 2 and Tables 6 and 7 ), we found that emotion- and avoidant-focused coping strategies significantly moderated the relationship between the overuse of health care services and cyberchondria and that between the overuse of health care services and anxiety, respectively, supporting H5 and H6. For the problem-based model (H4), the moderating effect was not significant for the relationship between the overuse of health care services and cyberchondria (coefficient=0.002, 95% CI −0.011 to 0.006), indicating that H4.1 was not supported. Compared with the direct effects on the relationship between the overuse of health care services and cyberchondria or anxiety, a strong ability to cope with difficulties can effectively mitigate the negative effects of the infodemic-driven overuse of health care services on cyberchondria and anxiety.

a HC: health care.

b GAD: Generalized Anxiety Disorder Assessment.

b CS: coping strategy.

c GAD: Generalized Anxiety Disorder Assessment.

Principal Findings

We performed a series of PLS-SEM analyses to examine the relationships between the infodemic-driven overuse of health care services and cyberchondria and anxiety and determine the moderating effects of 3 types of coping strategies on these relationships. We observed that the individuals who were exposed to an overload of COVID-19–related information were more likely to seek and use extra and unnecessary health care services during the pandemic. Such behavior may lead to a considerable wastage of health resources that are particularly limited during a public health crisis. Although some studies have indicated that during the COVID-19 pandemic individuals with increasing mental health symptoms rarely used mental health services [ 33 - 35 ], we found that the overuse of health care services may contribute to higher levels of depression and cyberchondria during a pandemic. This finding has never been reported before. However, we did not differentiate between the types of health care services, either physical or mental, that the individuals overused during the pandemic. This limitation may affect the implications of our findings for policy making purposes.

Comparisons With Previous Studies

We observed that enhanced coping strategies can mitigate the adverse effects of overusing health care on depression and cyberchondria. Studies have confirmed the association between pandemics and depression, have identified several sources of depression [ 6 , 7 , 10 , 36 , 37 ], and have determined the relationship between depression and cyberchondria [ 38 ]. However, few studies have investigated the relationship between depression or cyberchondria and the infodemic-driven overuse of health care services. Our findings demonstrate that the adverse effects of the pandemic are diverse and require the investigation of individuals’ health from multiple perspectives (ie, infodemic in health communication, the use of health care in health service research, and depression in psychiatry). These effects might not be immediately apparent, but they are all linked to each other and collectively cause harm. Thus, policy makers should develop a comprehensive and cost-effective strategy to address the potential adverse effects of pandemics on people’s health and well-being and better prepare for the next public health crisis.

This study offers new insights into the role of coping strategies in mediating the relationship between health care overuse and depression or cyberchondria during the COVID-19 pandemic. Overall, individuals with strong coping abilities were more likely to report lower levels of depression or cyberchondria than those with weak coping abilities. However, the moderating effects of different coping strategies varied slightly. We discovered that problem-focused coping strategies resulted in lower levels of depression and cyberchondria than avoidant-focused coping strategies. Additionally, emotion-focused coping strategies led to lower levels of depression than the other 2 types of coping strategies. These findings partially align with previous studies. For instance, Li [ 39 ] demonstrated that using both problem-focused and emotion-focused coping strategies was beneficial for psychological well-being. However, previous studies have reported mixed findings. For example, AlHadi et al [ 40 ] indicated that emotion-focused coping strategies were associated with increased depression, anxiety, and sleep disorders in the Saudi Arabian population. Few studies have examined the effect of avoidant-focused coping strategies. In this study, we found that respondents who reported living with chronic diseases exhibited a higher ability to use avoidant-focused coping. This finding is partially consistent with a previous study that found a positive relationship between avoidance-focused coping strategies and mental health in women with heart disease [ 41 ]. Individuals with medical conditions are more likely to adopt avoidant coping strategies. Firouzbakht et al [ 42 ] explained that avoidance is an effective strategy for handling short-term stress and is more likely to be adopted by certain patient groups.

We found that individuals who favor emotion-focused coping strategies to overcome difficulties are able to effectively mitigate the adverse effects of excessive health care use on depression and cyberchondria relative to those who opt for the other 2 coping strategies. This finding is not entirely surprising or unexpected. It is, in fact, quite reasonable when one considers that scholars and researchers in the field have previously indicated that people have a tendency to adopt emotion-focused strategies, especially when they find themselves in situations that are uncontrollable or unpredictable, such as the ongoing global pandemic [ 43 ]. Some studies have found that age can have a significant impact on an individual’s coping strategy preferences. For instance, younger adults were more likely to use emotion-focused coping strategies during the acute phase of the SARS outbreak, whereas older adults used this particular strategy several months after the outbreak had initially occurred [ 44 ]. This suggests that the coping strategies adopted by individuals can vary greatly depending on their age and the stage of the crisis they are experiencing. However, in the context of this study, we did not observe any significant differences in the coping strategy preferences of the different age groups. This could be due to a variety of factors, but a possible explanation is that our model incorporated the COVID-19 infodemic. In this context, it is understandable that providing emotional support might be more important than providing real solutions. This is particularly true in the current digital age, where the internet offers unlimited information sources for people to explore, which can often lead to information overload and increased anxiety. Therefore, emotion-focused coping strategies could be more beneficial in helping individuals navigate the sea of information and manage their emotional responses effectively.

In this study, we used self-developed items to measure the infodemic and overuse of health care services. While this approach allowed us to collect data that were directly related to the research questions, it may have introduced some potential issues. First, self-developed items may have less validity and reliability than standardized questionnaires. This could affect the accuracy of measurements and the validity of findings. Second, using self-developed items may limit comparability with other studies that use standardized questionnaires. Standardized questionnaires allow for easy comparison across studies and populations. The lack of a common metric may make it challenging to compare the findings of this study to other studies or to aggregate them in future meta-analyses. Finally, self-developed items may be more susceptible to response bias. They may not have considered factors like social desirability bias or acquiescence bias as standardized questionnaires do. This could have skewed the responses and affected the accuracy of the findings. Despite these limitations, the study’s findings provide valuable insights and pave the way for future research in this area.

Main Contributions of This Study

The importance of preparedness, prevention, and emergency response to infodemiology is highly encouraged by the WHO [ 45 ]. This study makes a significant contribution by exploring and empirically evaluating the relationship between the infodemic, the overuse of health care services, cyberchondria, and anxiety in the context of the COVID-19 pandemic. It provides empirical evidence supporting the assertion that a high level of infodemic can lead to the increased overuse of health care services, resulting in more severe cyberchondria and heightened anxiety levels. This finding adds a new dimension to our understanding of the psychological impacts of the infodemic, especially in the context of a global public health crisis. Additionally, this study highlights that adopting appropriate coping strategies can potentially reduce the severity of cyberchondria and anxiety, even among people facing high levels of the infodemic and the overuse of health care services.

Future Research

The study’s findings emphasize the importance of coping strategies in reducing the negative effects of the infodemic and the excessive use of health care. Future research could focus on developing and testing interventions to improve coping skills, such as cognitive-behavioral, mindfulness-based, or psychoeducational approaches. Additionally, other factors like social support, personality traits, or health literacy may moderate the relationship between infodemic, health care overuse, cyberchondria, and anxiety. Future research could further explore these variables. This study’s findings may not apply to all populations, so future research could investigate these relationships in different groups, including those with pre-existing mental health conditions, health care professionals, or diverse cultural contexts. By pursuing these future directions, researchers could build on this study’s findings, thereby enhancing our understanding of the psychological impact of infodemic and developing effective interventions.

Limitations

This study has several limitations that need to be addressed. A primary limitation is that the data were cross-sectional and self-reporting, which can introduce several biases. Social desirability bias may occur when respondents provide answers they believe are socially acceptable rather than truthful. Recall bias may also be present, as the respondents were asked to recall experiences from months or even a year ago. The data are also prone to response bias, as respondents may agree or disagree with statements regardless of their content. These biases may have affected the accuracy of the findings. In the future, we will try to collect data at multiple time points to reduce the biases and identify changes over time. Second, the data used in this analysis were obtained from a web-based survey, which excluded individuals who are not familiar with web-based surveys or do not have access to the internet. This could have resulted in selection bias. Additionally, due to the nature of the web-based survey, the demographic information of our sample was highly skewed. The majority of the respondents were young and highly educated and were frequent internet users who may have experienced more infodemic effects than older and less educated individuals. This may have affected the reliability of our findings. A quota sampling method could be used in future studies to improve the representativeness of the sample. Third, the study was conducted in China; thus, it is important to consider the unique context of China when interpreting the results. It is necessary to conduct further research in different cultural and regional contexts to determine the generalizability of the results. Finally, the evaluation of health care service overuse and strength of the infodemic relied on 2 self-developed items, which may have affected the measurement properties and limited the reliability of our findings. The development of standardized questionnaires to measure the infodemic and the overuse of health care services during a pandemic would be a valuable contribution to future research in this field.

Conclusions

This study is the first to demonstrate a significant correlation between the infodemic-driven overuse of health care services and high levels of depression and cyberchondria in the Chinese population during the COVID-19 pandemic. We find that 3 types of coping strategies can effectively mitigate the adverse effects of infodemic-driven health care overuse on depression and cyberchondria. Among them, emotion-focused coping strategies have stronger moderating effects than the other 2 types of coping strategies. These findings provide empirical evidence that can guide policy makers in developing strategies to reduce cyberchondria, provide accurate information about public health crises, and promote adaptive coping strategies to effectively manage future public health crises.

Data Availability

The data sets generated and analyzed during this study are available from the corresponding author on reasonable request.

Authors' Contributions

RHX contributed to developing the study concept and design, data analysis and interpretation, software, writing the original draft, and review and editing. CC contributed to data collection, software, and review and editing. Both authors approved the submitted version.

Conflicts of Interest

None declared.

English-translated questionnaire.

Correlations between measures.

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Abbreviations

Edited by G Eysenbach, T de Azevedo Cardoso; submitted 05.10.23; peer-reviewed by K Wang, J Chen, CN Hang, E Vashishtha, D Liu; comments to author 06.11.23; revised version received 14.11.23; accepted 22.03.24; published 09.04.24.

©Richard Huan Xu, Caiyun Chen. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 09.04.2024.

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

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Original research article, associations between monitor-independent movement summary (mims) and fall risk appraisal combining fear of falling and physiological fall risk in community-dwelling older adults.

1 Department of Mechanical Engineering, University of Central Florida, Orlando, FL, United States
2 Disability, Aging and Technology Cluster, University of Central Florida, Orlando, FL, United States
3 College of Medicine, University of Central Florida, Orlando, FL, United States
4 School of Kinesiology and Rehabilitation Sciences, College of Health Professions and Sciences, University of Central Florida, Orlando, FL, United States
5 Department of Statistics and Data Science, University of Central Florida, Orlando, FL, United States
6 College of Nursing, University of Central Florida, Orlando, FL, United States

Introduction: Fall Risk Appraisal (FRA), a process that integrates perceived and objective fall risk measures, serves as a crucial component for understanding the incongruence between fear of falling (FOF) and physiological fall risk in older adults. Despite its importance, scant research has been undertaken to investigate how habitual physical activity (PA) levels, quantified in Monitor-Independent Movement Summary (MIMS), vary across FRA categories. MIMS is a device-independent acceleration summary metric that helps standardize data analysis across studies by accounting for discrepancies in raw data among research-grade and consumer devices.

Objective: This cross-sectional study explores the associations between MIMS (volume and intensity) and FRA in a sample of older adults in the United States.

Methods: We assessed FOF (Short Falls Efficacy Scale-International), physiological fall risk (balance: BTrackS Balance, leg strength: 30-s sit-to-stand test) and 7-day free-living PA (ActiGraph GT9X) in 178 community-dwelling older adults. PA volume was summarized as average daily MIMS (MIMS/day). PA intensity was calculated as peak 30-min MIMS (average of highest 30 non-consecutive MIMS minutes/day), representing a PA index of higher-intensity epochs. FRA categorized participants into following four groups: Rational (low FOF-low physiological fall risk), Irrational (high FOF-low physiological fall risk), Incongruent (low FOF-high physiological fall risk) and Congruent (high FOF-high physiological fall risk).

Results: Compared to rational group, average MIMS/day and peak 30-min MIMS were, respectively, 15.8% ( p = .025) and 14.0% ( p = .004) lower in irrational group, and 16.6% ( p = .013) and 17.5% ( p < .001) lower in congruent group. No significant differences were detected between incongruent and rational groups. Multiple regression analyses showed that, after adjusting for age, gender, and BMI (reference: rational), only irrational FRA was significantly associated with lower PA volume (β = −1,452.8 MIMS/day, p = .034); whereas irrational and congruent FRAs were significantly associated with lower “peak PA intensity” (irrational: β = −5.40 MIMS/day, p = .007; congruent: β = −5.43 MIMS/day, p = .004).

Conclusion: These findings highlight that FOF is a significant barrier for older adults to participate in high-intensity PA, regardless of their balance and strength. Therefore, PA programs for older adults should develop tailored intervention strategies (cognitive reframing, balance and strength exercises, or both) based on an individual’s FOF and physiological fall risk.

Introduction

In the United States (US), over 14 million adults aged 65 years or older fall each year ( Moreland et al., 2020 ; Kakara et al., 2023 ). According to the US Centers for Disease Control and Prevention, about 20% of falls in older adults cause serious injuries, which results in limited functional mobility, loss of independence, reduced quality of life, and premature death ( Ambrose et al., 2013 ). Fear of falling (FOF) has been recognized as an important psychological aspect associated with falls in older adults ( Jansen et al., 2021 ). However, studies report that many older adults might show a discrepancy between their FOF and physiological fall risk, known as maladaptive fall risk appraisal (FRA) ( Thiamwong et al., 2021a ), and such discrepancies can lead to adverse consequences. For example, individuals with low physiological fall risk but high FOF may overestimate their actual fall risk and restrict their daily activities, which can further lead to physical deconditioning and loss of muscle strength ( Deshpande et al., 2008 ). On the contrary, those with high physiological fall risk but low FOF may underestimate their actual fall risk and engage in unnecessary risky behavior beyond their physical capacity, making them even more vulnerable to falling ( Delbaere et al., 2010 ).

Therefore, FRA combining subjective and objective fall risk measures is important for understanding the discrepancy between FOF and physiological fall risk in older adults to inform more targeted interventions for fall prevention ( Thiamwong et al., 2020a ; Thiamwong et al., 2020b ). FRA is a two-dimensional fall risk assessment matrix that classifies older adults into four groups based on their FOF and physiological fall risk status ( Thiamwong, 2020 ). In FRA matrix, as shown in Figure 1 , two groups have their FOF level aligned with their physiological fall risk status, which are denoted as Rational (low FOF-low physiological fall risk) and Congruent (high FOF-high physiological fall risk). The other two groups show a mismatch between their FOF level and physiological fall risk status and are denoted as Incongruent (low FOF-high physiological fall risk) and Irrational (high FOF-low physiological fall risk).

Figure 1 . Fall Risk Appraisal (FRA) based on Fear of Falling (FOF) and physiological fall risk. Maladaptive FRA = mismatch between FOF and physiological fall risk; Adaptive FRA = FOF aligned with physiological fall risk.

Prior research has mostly focused on exploring the independent associations of FOF and objective fall risk measures with physical activity (PA) participation in older adults ( Gregg et al., 2000 ; Chan et al., 2007 ; Zijlstra et al., 2007 ; Heesch et al., 2008 ; Mendes da Costa et al., 2012 ). To date, only a small number of studies have investigated the combined effects of FOF and objective fall risk on PA engagement. For example, one study examined the joint associations of FOF and objective fall risk with everyday walking activities in older adults. This study used a four-group categorization from ( Delbaere et al., 2010 ), and found that the number of steps/day in their study sample was in accordance with objective fall risk rather than FOF ( Jansen et al., 2021 ). Another study examined accelerometry-based PA levels between FRA categories using the intensity cut-point approach and found that participants with high FOF accumulated significantly less time in moderate-to-vigorous PA (MVPA) compared to those with rational FRA, regardless of their balance performance ( Thiamwong et al., 2023 ). However, there exists a lack of evidence on how habitual PA levels, expressed in Monitor-Independent Movement Summary (MIMS) units, differ between FRA categories in older adults.

MIMS is used to summarize the acceleration measurements obtained on the x-, y-, and z-axes of wrist-worn activity monitors. This PA metric was first introduced in 2019 to summarize participant-level PA data for the 2011-2012 and 2013-2014 cycles of the US National Health and Nutrition Examination Survey (NHANES) ( John et al., 2019 ). The major benefit of using MIMS is that it is generated by a nonproprietary device–independent universal algorithm, allowing us to compare the total movement across studies regardless of the heterogeneity introduced by different brands, models and device types (such as consumer vs. research-grade) ( John et al., 2019 ). Similar to other traditional PA metrics such as steps/day or daily activity counts, PA volume can be expressed as daily MIMS (i.e., total MIMS unit accumulated per day) across valid days of assessment, where larger MIMS/day indicates higher daily PA volume ( Wolff-Hughes et al., 2014 ).

Traditionally, quantification of accelerometer-measured PA intensity has been predominantly based on minutes/day (or minutes/week) spent in MVPA, using either manufacturer-specific or device-specific cut points corresponding with ≥3 Metabolic Equivalents of Task (METs) ( Troiano et al., 2008 ). Recently, to establish an intensity-based expression for MIMS units, the concept of peak 30-min MIMS has been introduced ( Zheng et al., 2023 ). It is analogous to the concept of peak 30-min cadence, i.e., the average of 30 highest cadence (steps/minutes) values within a day, representing an individual’s best efforts ( Tudor-Locke et al., 2012 ). Similar to cadence (steps/minutes), MIMS/minutes values were shown to have a strong correlation with higher PA intensity ( John et al., 2019 ). Therefore, peak 30-min MIMS (i.e., the average of the highest 30 non-consecutive MIMS [minutes/day] values within a day) can be used as a measure of higher-intensity epochs across the PA monitoring period ( Zheng et al., 2023 ). Evaluating daily MIMS (volume) and peak 30-min MIMS (intensity) can facilitate a more comprehensive assessment of PA and its relationship with FRA.

Thus, the aim of this study is to investigate the associations between wrist-worn accelerometer-measured PA (expressed as daily MIMS and peak 30-min MIMS) and FRA in a sample of community-dwelling older adults. We are particularly interested in the question: “Which of the maladaptive FRA groups, i.e., Incongruent (low FOF-high physiological fall risk) and Irrational (high FOF-low physiological fall risk), differ more from the Rational (low FOF-low physiological fall risk) group in terms of habitual PA level?.” This will allow us to understand which of the two factors—FOF or physiological fall risk—has a stronger relationship with reduced PA participation among older adults.

Materials and methods

Study design and participants.

In this cross-sectional study, purposive sampling was used to recruit 178 community-dwelling older adults from the region of Central Florida, United States, between February 2021 and March 2023. The inclusion criteria were: i) 60 years of age or older; ii) being able to walk with or without an assistive device (but without the assistance of another person); iii) no marked cognitive impairment [i.e., Memory Impairment Screen score ≥5 ( Buschke et al., 1999 )], iv) fluency in English or Spanish, and v) living in their own homes or apartments. The exclusion criteria were: i) medical conditions that prevent PA engagement (e.g., shortness of breath, tightness in the chest, dizziness, or unusual fatigue at light exertion), ii) unable to stand on the balance plate, iii) currently receiving treatment from a rehabilitation facility, and iv) having medical implants (e.g., pacemakers). This study was approved by the Institutional Review Board at the University of Central Florida (Protocol No: 2189; 10 September 2020). All subjects provided written informed consent to participate. This cross-sectional assessment required one visit to the study site during which participants completed a demographic survey and anthropometric measurements, followed by assessments of FOF and physiological fall risk. At the end of the visit, each participant was fitted with a wrist-worn accelerometer for 7-day PA monitoring in free-living conditions.

Measurements

Fear of falling (fof).

FOF was assessed using the Short Falls Efficacy Scale-International (FES-I) questionnaire ( Yardley et al., 2005 ; Kempen et al., 2008 ). It is a 7-item, self-administered tool that uses a 4-point Likert scale to measure the level of concern about falling while performing seven activities (1 = not at all concerned to 4 = very concerned). The total scores ranged from 7 to 28. Short FES-I scores of 7–10 indicated low FOF, while scores of 11–28 indicated high FOF.

Physiological fall risk

Physiological fall risk was assessed using balance test and lower limb strength assessment. BTrackS Balance System (Balance Tracking Systems, San Diego, CA, United States) was used to measure static balance. This system includes a portable BTrackS Balance Plate and BTrackS Assess Balance Software running on a computer. It has shown high test–retest reliability (intraclass correlation coefficient, ICC = 0.83) and excellent validity (Pearson’s product-moment correlations, r > 0.90) in evaluating static balance ( Levy et al., 2018 ). The test protocol included four trials (each trial taking 20 s) with less than 10 s of inter-trial delays. During the trials, participants were asked to stand still on the BTrackS Balance Plate with their eyes closed, hands on their hips, and feet placed shoulder-width apart. BTrackS balance plate is an FDA-registered, lightweight force plate that measures center of pressure (COP) excursions during the static stance. The first trial was done for familiarization only. Results from the remaining three trials were used to calculate the average COP path length (in cm) across trials. COP path length is considered as a proxy measure for postural sway magnitude; thus, the larger the COP path length, the greater the postural sway is ( Goble et al., 2017 ). COP path length of 0–30 cm was used to indicate normal balance, while ≥31 cm indicated poor balance ( Thiamwong et al., 2021b ).

Lower limb strength was assessed using the 30-s sit-to-stand (STS) test, in accordance with the established protocol ( Yee et al., 2021 ; Choudhury et al., 2023 ). Participants were instructed to keep their arms folded across their chest, rise from a seated position on a chair to a standing posture and return to the sitting position as many times as possible within 30 s. The number of chair stands completed was counted and recorded. If a participant used his/her arms to stand, the test was stopped, and the score was recorded as zero. Age- and gender-specific STS normative scores were used as cut-offs to classify participants into below-average and average STS scores, as shown in Table 1 ( Rikli and Jones, 1999 ). A below-average STS score was indicative of a higher risk of fall. Meeting both normal balance and average STS score criteria was defined as low physiological fall risk, while not meeting either or both criteria was defined as high physiological fall risk.

Table 1 . Age and gender-specific below average scores for 30-s sit-to-stand test.

Fall risk appraisal (FRA) matrix

The FRA matrix was obtained using a combination of FOF and physiological fall risk status. Participants were grouped into the following four categories based on their FOF and physiological fall risk according to existing literature ( Thiamwong et al., 2020a ): i) Rational (low FOF-low physiological fall risk), ii) Irrational (high FOF-low physiological fall risk), iii) Incongruent (low FOF-high physiological fall risk), and iv) Congruent (high FOF-high physiological fall risk).

Physical activity (PA)

PA was assessed using ActiGraph GT9X Link (ActiGraph LLC., Pensacola, FL, United States), which contains a triaxial accelerometer with a dynamic range of ±8 gravitational units (g). The device was initialized to record acceleration data at 30 Hz sampling frequency. Participants wore the ActiGraph on their non-dominant wrists for seven consecutive days in free-living conditions. They were given instructions to wear it during waking hours and remove it only during sleeping, showering, swimming and medical imaging tests. After 7-day of PA monitoring, ActiGraph devices were collected from participants. Participants with ≥4 valid days were included in the analysis, and a day was considered valid if participants wore the device for at least 14 h or more ( Choudhury et al., 2023 ).

Raw acceleration data were downloaded as “.csv” files using ActiLife software v6.13.4 (ActiGraph LLC, Pensacola, FL, United States) and converted into MIMS units using MIMSunit package ( John et al., 2019 ) in R statistical software (R Core Team, Vienna, Austria). The data processing steps included: i) interpolating data to a consistent sampling rate (i.e., 100 Hz ) to account for inter-device variability in sampling rate, ii) extrapolating data to extend maxed-out signals to account for inter-device variability in dynamic range, iii) band-pass filtering to remove artifacts from acceleration signals that do not pertain to voluntary human movement, and iv) aggregation of processed signals from each axis into a sum of MIMS-units that represents the total amount of movement activity [details on MIMS-unit algorithm are published elsewhere ( John et al., 2019 )].

PA volume, denoted by daily MIMS (MIMS/day), was calculated by summing up all triaxial MIMS/minutes accumulated throughout a day and averaged across all valid days. PA intensity, expressed as peak 30-min MIMS, was obtained by (a) first rank ordering a participant’s triaxial MIMS/minutes values within each valid day, (b) calculating the average of the highest 30 MIMS/minutes values within each day, and (c) finally taking the average of the resulting MIMS/minutes values across all valid wear days.

Anthropometric measurements

Height (in cm) was measured using a stadiometer. Body mass (in kilograms) was measured using a digital scale with no shoes. Body mass index (BMI) was calculated as the weight (kg) divided by the square of height (m 2 ).

Statistical analyses

All statistical analyses were performed in R statistical software (version 4.1.2, R Core Team, Vienna, Austria) with statistical significance level set at .05. Descriptive characteristics of participants were summarized as mean (standard deviation, SD) for normally distributed continuous variables, as median (Interquartile Range, IQR) for non-normally distributed continuous variables, and as frequency (percentage) for categorical variables, stratified by FRA categories. The Shapiro-Wilk test was performed to check if a continuous variable followed a normal distribution. Differences across groups were examined using one-way analysis of variance (ANOVA) for normally distributed data and Kruskal–Wallis test for non-normally distributed data, with Bonferroni adjustment for post hoc comparisons.

Multiple linear regression was conducted for each outcome variable (i.e., daily MIMS and peak 30-min MIMS) using the four FRA groups—“Rational,” “Irrational,” “Incongruent” and “Congruent”—as explanatory variables, controlled by age, gender and BMI. A priori sample size calculation for multiple linear regression revealed that the minimum number of samples for 8 explanatory variables at a statistical power level of 0.8, α = 0.05, and a medium effect size (Cohen f 2 = 0.15) would be 108; therefore, our sample size (i.e., N = 178) had sufficient statistical power for multiple regression. The rational group (i.e., low FOF-low physiological fall risk) was selected as the reference group in the regression analysis.

Among 178 participants, 163 samples were included in the analyses, after retaining only those who had at least 4 days of valid PA data and completed both FOF and physiological fall risk assessments. The mean (SD) age of participants was 75.3 (7.1) years, and 73.6% of participants were in 60–79 years of age group ( n = 120) and 26.4% were above 80 years of age ( n = 43). Figure 2 shows the scatterplot of participants’ age (years) and FOF scores, stratified by physiological fall risk status. The proportion of participants with low FOF was 71.7% ( n = 86) in the 60–79 years of age group and 48.8% ( n = 21) in the ≥80 years of age group. The median (IQR) BMI of participants was 26.6 (6.3) kg/m 2 and majority of participants were female (79.1%). The median (IQR) Short FES-I score was 9 (5) and 34.4% of participants had high FOF. The median (IQR) COP path length was 27 (15) cm , and the median (IQR) sit-to-stand score was 13 (6) reps. 38.0% of participants had poor balance, 27.0% had below average lower limb strength, and 48.5% showed both poor balance and below average lower limb strength. Finally, 37.4% of participants were screened as rational ( n = 61), 14.2% were irrational ( n = 23), 28.2% were incongruent ( n = 46) and 20.2% were congruent ( n = 37). Table 2 summarizes the characteristics of study participants according to FRA categories.

Figure 2 . Scatterplot of Age (years) across Fear of Falling scores, stratified by physiological fall risk status. Low physiological fall risk = meeting both normal static balance cut-off and average sit-to-stand score cut-off. High physiological fall risk = not meeting normal static balance cut-off or average sit-to-stand score cut-off or both.

Table 2 . Participant characteristics stratified by Fall Risk Appraisal matrix.

In Figure 3A , the variations in average MIMS (MIMS/hours) over 24-h by FRA categories are shown. The average MIMS across all groups was in general low at night, then substantially increased during morning hours and gradually decreased as the day progressed and evening approached. In Figure 3B , the mean (line) and standard error (shaded area) of MIMS/hours for each FRA group is shown. Overall, rational group showed the highest average MIMS/hours across the day hours, while congruent had the lowest average MIMS/hours. Among maladaptive FRA groups, the peak was higher in incongruent group than their irrational counterparts, which indicates the potential role of FOF in limiting high-intensity PA participation.

Figure 3 . (A) Daily patterns of average MIMS per hour by Fall Risk Appraisal (FRA) groups. (B) Mean (line) and standard error (shaded area) of MIMS per hour for each FRA group.

The mean (SD) age in congruent group was 78.8 (7.6) years, which was higher than both rational (74.3 [5.8] years, p = .005) and incongruent (74.3 [7.0] years, p = .010) groups, as shown in Supplementary Figure S1 . This suggests that prevalence of high FOF, irrespective of balance performance and lower limb strength, may increase with advanced age. Also, the median (IQR) BMI in congruent group (28.9 [5.8]) kg/m 2 ) was higher in comparison to rational (24.9 [6.4] kg/m 2 , p = .001) and incongruent (26.9 [4.7] kg/m 2 , p = .018) groups (shown in Supplementary Figure S2 ), indicating that higher BMI in older adults may result in high FOF. However, no significant group differences were observed between rational and irrational groups in terms of age and BMI.

The mean (SD) daily MIMS in rational group was 10,408 (2,439) MIMS/day, which was 15.8% higher than irrational ( p = .025) and 16.6% higher than congruent ( p = .013) groups, as shown in Figure 4 . Also, the mean (SD) peak 30-min MIMS in rational group was 39.9 (8.3) MIMS/day, which was 14.0% higher than irrational ( p = .004) and 17.5% higher than congruent ( p < .001) groups ( Figure 5 ). Compared to rational group, incongruent participants showed no significant differences in PA volume and intensity, despite having poor balance and below average lower limb strength.

Figure 4 . Average daily MIMS (MIMS/day) across categories of Fall Risk Appraisal combining FOF and physiological fall risk, * p < .05.

Figure 5 . Peak 30-min MIMS per day across categories of Fall Risk Appraisal combining FOF and physiological fall risk, ** p < .01, *** p < .001.

Table 2 presents the regression models for daily MIMS. In comparison to reference group (i.e., rational), lower PA volume was associated with irrational ( β [SE] = −1,463.2 [687.7] MIMS/day, p = .035) and congruent ( β [SE] = −1,579.5 [582.9] MIMS/day, p = .007) FRAs in Model 1 (unadjusted). In model 2, after adjusting for age, gender and BMI, only irrational FRA was significantly associated with lower PA volume ( β [SE] = −1,476.41 [582.26] MIMS/day, p = .025; regression coefficients of covariates are presented in Supplementary Table S1 ).

Results for regression analysis for peak 30-min MIMS are presented in Table 3 . In model 1 (unadjusted), lower ‘peak PA intensity’ was associated with irrational ( β [SE] = −5.63 [1.99] MIMS/day, p = .005) and congruent FRAs ( β [SE] = −7.06 [1.76] MIMS/day, p < .001) compared to the reference group. In Model 2 ( Table 4 ), after adjusting for age, gender and BMI, both irrational and congruent FRAs were still significantly associated with lower “peak PA intensity”(irrational: β [SE] = −5.40 [1.97] MIMS/day, p = .007; congruent: β [SE] = −5.43 [1.86] MIMS/day, p = .004; regression coefficients of covariates are presented in Supplementary Table S2 ).

Table 3 . Association between Fall Risk Appraisal groups and average daily MIMS (MIMS/day) using linear regression. Model 2 was adjusted for age, gender and BMI.

Table 4 . Association between Fall Risk Appraisal groups and peak 30-min MIMS per day (MIMS/day) using linear regression. Model 2 was adjusted for age, gender and BMI.

This is the first study, to our knowledge, to evaluate the associations of FRA with daily MIMS and peak 30-min MIMS in a sample of community-dwelling US older adults. In general, both the volume and intensity of PA were highest in the rational group and lowest in the congruent group. In maladaptive FRA groups, high FOF (i.e., irrational FRA) was associated with lower PA volume and intensity compared to the reference group (i.e., rational FRA), but no significant differences were observed for high physiological fall risk (i.e., incongruent FRA).

Prior research has shown that FOF is associated with reduced PA levels in community-dwelling older adults using objectively measured PA data ( Jefferis et al., 2014 ; Choudhury et al., 2022 ). Our results broadly agree with it, showing that total daily PA volume was significantly lower in two high FOF groups (i.e., irrational and congruent) than the rational group. This suggests that regardless of balance performance and lower limb strength, low FOF was associated with high PA volume in our study sample. In linear regression analysis, after accounting for age, gender and BMI, reduced daily MIMS was significantly associated with irrational FRA, but not with congruent FRA. It can be attributed to the fact that the average age and BMI of congruent participants were higher than all other groups, and evidence suggests that that increasing older age and higher BMI contribute to lower PA levels in older adults ( Smith et al., 2015 ).

We did not observe any significant difference between two low FOF groups (i.e., rational and incongruent) in terms of daily PA volume. This suggests that, for maladaptive FRA, high physiological fall risk (not high FOF) had a stronger association with reduced daily PA accumulation in our study sample. In contrast to our findings, a recent study found that low physiological fall risk was more strongly associated with increased walking activity (steps/day) than low perceived fall risk in a sample of community-dwelling German older adults ( n = 294) ( Jansen et al., 2021 ). However, it should be noted that Jansen et al. used multiple independent risk factors (i.e., previous falls, balance impairment, gait impairment, and multimedication) to distinguish between high and low physiological fall risk, whereas they used only one tool (Short FES-I) to assess perceived fall risk. Furthermore, participants with low FOF and high physiological fall risk in that German older adult cohort ( Jansen et al., 2021 ) were relatively older than those in our study sample [mean (SD) age: 81.6 (5.5) years vs. 74.3 (7.0) years in our study]. Previous studies indicate that the likelihood of reduced participation in PA gradually increases with advanced age, because of age-related declines in muscle mass, muscle strength, and functional fitness (i.e., the physical capacity to perform activities of daily living independently and without the early onset of fatigue) ( Milanović et al., 2013 ; Westerterp, 2018 ; Suryadinata et al., 2020 ). Therefore, future research should examine how age-related functional declines mediate the relationship between maladaptive FRA and daily PA volume in older adults.

In our study, the peak PA intensity in both high FOF groups (i.e., irrational and congruent) was significantly lower than the rational group. Despite the differences in the PA metrics, this is in general agreement with the previous findings that showed older adults with irrational and congruent FRAs were more likely to spend less time in MVPA ( Thiamwong et al., 2023 ). Interestingly, after adjusting for confounders, the decrease in peak 30-min MIMS for irrational and congruent groups was almost equivalent in our study. This suggests that older adults with high FOF may restrict their participation in high intensity PA, irrespective of their physiological fall risk status. Our findings extend the previously reported association between PA intensity and FOF in older adults ( Sawa et al., 2020 ), highlighting the need to integrate cognitive behavioral therapy to reduce FOF in fall intervention programs.

For peak 30-min MIMS, we did not find any significant difference between two low FOF groups (i.e., rational and incongruent). This suggests that, similar to total PA volume, peak PA intensity was more strongly associated with high FOF (rather than high physiological fall risk) for maladaptive FRA in our sample. Unlike MVPA cut points that exclude PA intensities ≤3 METs or equivalent, peak 30-min MIMS considers acceleration magnitudes ranging from lower to higher peak efforts within a day, enabling comparison over the whole spectrum of PA intensity levels (e.g., light vs. vigorous) ( Zheng et al., 2023 ). Further research should investigate domains of peak PA efforts across different FRA groups, so that informed strategies can be developed to promote high-intensity PA participation according to the perceived and physiological risk of fall.

Based on the findings of our study, it can be conferred that the FRA assessment may be useful in designing customized PA interventions to promote an active lifestyle in older adults. For example, to increase PA participation in older adults with irrational FRA, cognitive behavioral therapy can be integrated into PA programs to improve their self-efficacy and sense of control over falling ( Tennstedt et al., 1998 ). For incongruent FRA, PA recommendations should include exercise regimens specifically designed to reduce physiological fall risk, such as high intensity balance and strength training, in addition to aerobic activities ( Sherrington et al., 2008 ). On the other hand, older adults with congruent FRA may benefit from PA programs that combine both balance and strength exercises, and cognitive behavioral therapy ( Brouwer et al., 2003 ).

A strength of our study is the use of MIMS metric to provide a comprehensive PA assessment (volume and intensity) enabling reliable, cross-study comparisons of our findings with other MIMS-based studies regardless of the device type, model or manufacturer. Furthermore, we used evidence-based cut-off points to determine FOF level (low vs. high FOF), balance status (poor vs. normal balance) and lower limb strength (below average vs. average strength) to categorize participants into FRA groups. However, our study has several limitations. First, to determine physiological fall risk status, we didn’t use the Physiological Profile Assessment ( Delbaere et al., 2010 ) or multiple independent risk factors ( Jansen et al., 2021 ), which might have led to different group formations than those studies. Instead, we used static balance and lower limb strength as physiological fall risk indicators. While balance and strength deficits are important predictors of falls in older adults, they might not account for all aspects of physiological fall risk (such as gait impairment, visual and sensory deficits, use of multi-medications etc.) ( Fabre et al., 2010 ). Second, it is to be noted that the balance performance measure (i.e., static balance) used in this study may not capture the full spectrum of an individual’s balance capabilities. There are different measures of balance performance, including static steady-state balance (i.e., the ability to maintain a steady position while standing or sitting), dynamic steady-state balance (i.e., the ability to maintain a steady position while performing postural transitions and walking), proactive balance (i.e., the ability to anticipate and mitigate a predicted postural disturbance), and reactive balance (i.e., the ability to recover a stable position following an unexpected postural disturbance) ( Shumway-Cook and Woollacott, 2007 ). Therefore, future studies may consider using more comprehensive assessments of balance performance in older adults to define physiological fall risk in FRA. Third, our study only considered FOF as the psychological fall risk measure in FRA and did not investigate other psychological constructs such as falls efficacy or balance confidence ( Moore et al., 2011 ). FOF and falls efficacy are two major fall-related psychological constructs in preventing and managing fall risks in older adults. It is to be noted that, though FOF and falls efficacy are correlated, they represent theoretically distinct concepts ( Hadjistavropoulos et al., 2011 ). FOF is defined as “the lasting concerns about falling that leads to an individual avoiding activities that one remains capable of performing.” Some common instruments for FOF measurement include FES-I, Short FES-I, Iconographical Falls Efficacy Scale (ICON-FES), Geriatric Fear of Falling Measure (GFFM), Survey of Activities and Fear of Falling in the Elderly (SAFE), Fear of Falling Avoidance Behaviour Questionnaire (FFABQ) etc., ( Soh et al., 2021 ). On the other hand, falls efficacy is defined as the perceived confidence in one’s ability to carry out activities of daily living without experiencing a fall ( Moore and Ellis, 2008 ). Existing instruments for measuring falls efficacy include Falls Efficacy Scale (FES), modified FES (MFES), Perceived Ability to Prevent and Manage Fall Risks (PAPMFR), and Perceived Ability to Manage Risk of Falls or Actual Falls (PAMF) ( Soh et al., 2021 ). Prior research has reported that, compared to FOF, falls efficacy shows stronger relationship with measures of basic and instrumental activities of daily living (ADL-IADL), and physical and social functioning ( Tinetti et al., 1994 ). Therefore, future studies should consider exploring the combined effects of falls efficacy and physiological fall risk measures on habitual PA level to determine whether FOF or fall efficacy should be considered as a target for PA interventions in older adults. Fourth, to date, there exists no established cut-offs for the MIMS metric to categorize total PA volume and intensity that correspond to meeting national PA guidelines, and it is still unknown how well MIMS/minute can estimate energy expenditure ( Vilar-Gomez et al., 2023 ). Our study just provided a first step toward the use of a standardized metric to associate PA behavior with FRA in a community-dwelling older adult sample in the US. Future studies should examine such associations in large, nationally representative populations to establish benchmark values for daily MIMS and peak 30-min MIMS in different FRA categories. Fifth, the cross-sectional design of the study didn’t allow us to determine a causal relationship between FRA and PA, so reverse and/or bidirectional causality might still be present. Sixth, although we controlled for age, gender, and BMI in the regression analyses, there remains the possibility of additional residual confounding [such as neuropsychological constructs that have been associated with FOF, which include depression, anxiety, neuroticism, attention, and executive function ( Delbaere et al., 2010 )]. Finally, our sample size was relatively small and 79% of participants were female. The generalizability of our findings might be restricted by the small, female dominant nature of our sample.

In conclusion, compared to rational FRA, the habitual PA level (daily MIMS and peak 30-min MIMS) was lower in both high FOF groups (i.e., irrational and congruent), but not in incongruent group. This suggests that, for maladaptive FRA in our study sample, high perceived fall risk had a stronger association with reduced PA level, rather than high physiological fall risk. When controlled for covariates, decrease in peak PA intensity remained significantly associated with irrational and congruent FRAs, indicating that older adults with high FOF performed PA at lower peak efforts, irrespective of their physiological fall status. Future prospective studies should focus on identifying the optimal habitual PA level (total PA volume and peak PA intensity) in accordance with an older adult’s FOF and physiological fall risk to better inform public health policies for sustainable, effective PA framework.

Data availability statement

The raw data supporting the conclusion of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by the Institutional Review Board, University of Central Florida. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

RC: Data curation, Formal Analysis, Investigation, Methodology, Software, Visualization, Writing–original draft. J-HP: Conceptualization, Funding acquisition, Investigation, Methodology, Resources, Supervision, Writing–review and editing. CB: Formal Analysis, Visualization, Writing–review and editing. MC: Data curation, Investigation, Writing–review and editing. DF: Conceptualization, Funding acquisition, Writing–review and editing. RX: Conceptualization, Funding acquisition, Writing–review and editing. JS: Conceptualization, Funding acquisition, Supervision, Writing–review and editing. LT: Conceptualization, Funding acquisition, Project administration, Resources, Supervision, Writing–review and editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. The research was funded by the National Institute on Aging (R03AG06799) and the National Institute on Minority Health and Health Disparities (R01MD018025) of National Institutes of Health. This research also received financial support from the University of Central Florida CONNECT CENTRAL (Interdisciplinary research seed grant; AWD00001720 and AWD00005378).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fragi.2024.1284694/full#supplementary-material

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Keywords: falls, physical activity, accelerometry, aging, fear of falling, fall risk, MIMS

Citation: Choudhury R, Park J-H, Banarjee C, Coca MG, Fukuda DH, Xie R, Stout JR and Thiamwong L (2024) Associations between monitor-independent movement summary (MIMS) and fall risk appraisal combining fear of falling and physiological fall risk in community-dwelling older adults. Front. Aging 5:1284694. doi: 10.3389/fragi.2024.1284694

Received: 28 August 2023; Accepted: 20 March 2024; Published: 09 April 2024.

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Copyright © 2024 Choudhury, Park, Banarjee, Coca, Fukuda, Xie, Stout and Thiamwong. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Joon-Hyuk Park, [email protected]

This article is part of the Research Topic

Insights into Falls Efficacy and Fear of Falling

Impact of Environmental Protection Tax on carbon intensity in China

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Published: 08 April 2024

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Shen Zhong 1 ,
Zhicheng Zhou 1 &
Daizhi Jin ORCID: orcid.org/0009-0002-5540-8583 2

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In the context of increasingly severe global climate change, finding effective carbon emission reduction strategies has become key to mitigating climate change. Environmental Protection Tax (EPT), as a widely recognized method, effectively promotes climate change mitigation by encouraging emission reduction behaviors and promoting the application of clean technologies. Based on data from 282 cities in China, this paper takes the official implementation of the EPT in 2018 as the policy impact and the cities with increased tax rates for air taxable pollutants as the treatment group and uses DID model to systematically demonstrate the relationship between the implementation of the EPT and carbon intensity (CI) and further explores the possible pollutant emissions and green innovation mediating effects. The findings show that (1) the implementation of EPT can effectively reduce CI by about 4.75%, and this conclusion still holds after considering the robustness of variable selection bias, elimination of other normal effects, policy setting time bias, and self-selection bias. (2) The implementation of EPT can reduce CI by reducing pollutant emissions and improving the level of green innovation. (3) There is obvious regional heterogeneity in the carbon reduction effect of EPT, and the implementation of EPT has a more significant effect on CI in medium-tax areas, low environmental concern areas, general cities, and eastern regions. This paper not only provides a new analytical perspective for systematically understanding the carbon emission reduction effect of EPT but also provides policy insights for promoting regional green transformation and advancing carbon peak carbon neutralization.

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Data Availability

All data used in this study are available from the corresponding author upon request. Readers interested in the data presented in this article or seeking further information are encouraged to contact the corresponding author directly for data support. We commit to providing the necessary data as much as possible, according to research needs and subject to adherence to relevant data protection regulations.

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Abbreviations

Environmental Protection Tax
Carbon intensity
Green innovation

Pollutant emissions

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This study appreciates support for a fund: 2023 Ministry of Education Humanities and Social Sciences Planning Fund Project “Research on the Dilemma of Labor Rights and Interests Protection for Employees in New Businesses and Governance” (Project Approval No. 23YJA840007).

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