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Letter to the Editor
The dynamic network relationships of obsession and death from COVID-19 anxiety among Peruvian university students during the second quarantine
Las relaciones dinámicas de red de la obsesión y la ansiedad ante la muerte por COVID-19 durante la segunda cuarentena en universitarios peruanos
Cristian Ramos-Vera
Área de investigación, Facultad de Ciencias de la Salud, Universidad Cesar Vallejo, Lima, Peru
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The 2019 coronavirus disease &#40;COVID-19&#41; outbreak caused by severe acute respiratory syndrome coronavirus 2 &#40;SARS-CoV-2&#41; has affected virtually every country and territory in the world&#44; leading it to be declared a global pandemic on 11 March 2020&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Eleven months since the outbreak of the infectious disease&#44; people around the world continue to struggle without definitive measures to prevent or treat COVID-19&#44; except for the widely proposed measures of social distancing&#44; mask and hand hygiene&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> At the time of writing &#40;27 February 2021&#41;&#44; the number of confirmed COVID-19 cases exceeds 108&#46;2 million worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The long period of quarantine&#44; along with the increasing number of deaths and confirmed cases&#44; has caused many people to suffer from serious emotional problems&#44; resulting in psychological disorders such as depression&#44; anxiety and fear of death&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> An increase has also been found in the number of suicide deaths due to the psychological and social effects of the COVID-19 pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Brooding about this infectious disease can be harmful and unhealthy&#46; In fact&#44; the above psychological health conditions can be influenced by excessive and repetitive thinking about COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Social isolation and repeated exposure to information about COVID-19 in the news can stimulate obsessive thoughts in some people&#44; ultimately resulting in psychological distress and&#44; in severe cases&#44; mental disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> University students are particularly vulnerable to mental health issues and obsessive thinking about COVID-19&#44; as strict social distancing measures and lockdowns left many students not only unsure about their health&#44; but also about their academic status and their career plans&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> University students are also prone to psychological problems due to the highly stressful and often overwhelming challenges they face in adjusting to a new lifestyle and a whole set of academic responsibilities resulting from closure of the universities and online teaching<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#44; all of which has greatly changed their approach to academic tasks and organisation of their personal and social lives&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Death anxiety &#40;DA&#41; is a reaction people have when faced with death or a chronic or life-threatening illness&#46; DA is expressed as the perception of hazard to life in day-to-day interactions&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Due to its inherent adverse nature&#44; death generates various types of attitude and emotion&#44; and fear and anxiety are the most common findings&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Nevertheless&#44; the conceptualisation of death is abstract and complex and has multiple meanings&#44; so approaching and understanding it will depend on many factors&#46; Moreover&#44; people&#39;s concepts of death are relative and temporary&#44; and vary with the development of the individual during the different stages of life&#46; Death during the COVID-19 pandemic is the thought that haunts the most and causes anguish and anxiety&#46; Nobody feels good when faced with people infected by this virus or at risk of dying from complications&#44; perhaps because it makes them think of their own death&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Menzies et al<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> argue that the COVID-19 situation presents unique challenges for our species because of the constant reminders of death&#46; They report that images of death are ever present in daily updates of SARS-CoV-2 transmissions&#44; while other signs of death &#40;e&#46;g&#46;&#44; face masks&#41; mean that there is essentially a significant experience of global mortality in progress&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">At the same time&#44; a relationship has been found between death anxiety and obsession&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> As the perception of a high risk of infection due to the pandemic causes symptoms of distress&#44; the death of loved ones and the recommendation to wash hands repeatedly can create disturbing thoughts and behaviours related to the infectious disease&#44; and this can then lead to obsessive-compulsive disorder &#40;OCD&#41;&#46; OCD is a psychiatric disorder involving persistent and intrusive thoughts and compulsive behaviours that consume a great deal of time and energy&#44; and an escalation in the symptoms has been seen in the context of COVID-19&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">After a brief review of the scientific literature&#44; we found no Latin American studies that include dynamic evaluation of obsession and death anxiety due to COVID-19 through network analysis&#46; We believe it is essential to explore how the elements of both concepts are mutually reinforcing&#46; Our objective was therefore to explore the correlation networks of obsession and death anxiety due to COVID-19 in Peruvian health science students&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We conducted an exploratory&#44; correlational&#44; cross-sectional study in the metropolitan city of Lima&#44; Peru&#44; during the second Peruvian lockdown in February 2021&#46; We used the Spanish versions of the following instruments&#58; Obsession with COVID-19 Scale &#40;OCS&#41;&#44; composed of four items that assess the symptoms of higher risk of obsession with COVID-19<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#59; and the Peruvian version of the Death Anxiety Scale&#44; COVID-19 version &#40;DAS&#41;&#44; composed of 12 items<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46; However&#44; three of these items were eliminated due to being written with the opposite meaning and deemed redundant &#40;2&#44; 5 and 6&#41;&#44; leaving nine items&#46; We estimated the alpha and omega reliability of the instruments&#44; with the values being &#62;0&#46;83&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">This study included 546 university health science students &#40;69&#46;35&#37; female&#59; mean age&#44; 24&#46;45 years&#41;&#46; Due to the social distancing and restricted mobility measures introduced by the government&#44; it became necessary to use online survey methods&#46; Participants were recruited using a snowball sampling technique through social media&#44; such as WhatsApp groups&#44; Facebook and Google groups&#44; and were encouraged to invite their family and friends to taken part in the survey&#46; The survey was created and administered using Google Forms and included informed consent&#44; which was obtained from all participants enrolled in the study&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Through the R qgraph package and the graph-fused LASSO &#40;least absolute shrinkage and selection operator&#41;&#44; the patterns of the interactive system whose connections represent partial correlations on the network graph were assessed graphically&#59; LASSO estimator allowed spurious relationships to be eliminated&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> The items &#40;nodes&#41; are interconnected by lines or edges that represent the partial correlations that tend to be located in the network according to the sum of connections with other nodes&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> The interpretation of the partial correlation measures shows effect sizes&#44; interpretation of which in the health sciences is explained by Sullivan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The network approach includes centrality measures&#59; the expected strength index is the most stable measure for determining the importance of the components in dynamic correlations&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the descriptive statistics of the participants&#39; responses to the measures used&#46; These data indicate a higher report of items O1 and O3 of the Obsession with COVID-19 Scale and items A1&#44; A2 and A9 of the DAS-COVID-19&#44; which in turn reported the best network strength centrality measures&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The most central components of greatest strength in the network belong to the death anxiety domain &#40;A1&#44; A2 and A9&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the highest relationships between symptoms O1&#8211;O4 and O1&#8211;O3 with respect to the symptom dynamics of obsession&#44; and higher associations between items A3&#8211;A7&#44; A2&#8211;A9 and A5-A8 in the death anxiety domain&#46; Inter-domain relationships indicate that each obsessive symptom reports four causal associations with the components of death anxiety&#46; Standing out for their greater size are items A1 &#40;&#8220;I&#8217;m really scared of dying from COVID-19&#8221;&#41; and O2 &#40;&#8220;I had disturbing thoughts that some people I know may have COVID-19&#8221;&#41;&#44; showing a higher prevalence of fear of death and thoughts that the people around them are infected&#59; this denotes the state of anguish reported by Peruvian university students&#46; This indicator of DA also showed a major dynamic association with item O1 &#40;&#8220;I had disturbing thoughts that I may have caught COVID-19&#8221;&#41;&#44; suggesting that fear of death is also reinforced by obsession about being infected&#44; which together can lead to cognitive difficulties and increased mistrust&#44; which limits social relationships&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Another significant relationship was between the measures of A9 &#40;&#8220;I get scared when I hear people talking about epidemics or pandemics&#8221;&#41; and O4 &#40;&#8220;I dreamed about COVID-19&#8221;&#41;&#44; which implies that a higher state of nervousness when receiving pandemic information can even affect sleep status&#46; Two of the most central items &#40;A1 and A9&#41; show a greater association with the symptoms of obsession&#44; which points to a new area for research in the psychiatric field from the perspective of complex models of comorbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Such connections reinforce possible activation routes of both variables of negative impact due to COVID-19&#46; We therefore recommended that future interventions consider targeting these indicators&#44; with the aim of reducing their intensity and preventing the development of potentially serious psychopathological disorders such as OCD&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Obsession with COVID-19 Scale&#44; Spanish version&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Strength&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">O1&#46; I had disturbing thoughts that I may have caught COVID-19&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;591&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">O2&#46; I had disturbing thoughts that some people I know may have COVID-19&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;1&#46;607&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">O3&#46; I could not stop thinking about COVID-19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;438&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">O4&#46; I dreamed about COVID-19&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;0&#46;562&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">DAS-COVID-19&#44; Peruvian version</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">A1&#46; I&#39;m really scared of dying from COVID-19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;068&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">A2&#46; It makes me nervous when people talk about death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;133&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">A3&#46; I dread to think about ending up in intensive care&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">A4&#46; Thinking about death bothers me&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;0&#46;482&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">A5&#46; I am almost always distressed by the way time flies so quickly&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;54&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;148&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">A6&#46; I am scared of dying a painful death&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;1&#46;527&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">A7&#46; I am scared of being short of breath and not being able to breathe because of COVID-19&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;59&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">A8&#46; I often think about how short life really is&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;1&#46;191&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">A9&#46; I get scared when I hear people talking about epidemics or pandemics&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;87&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;368&nbsp;\t\t\t\t\t\t\n
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