Canadian Journal of Behavioural Science /

Revue canadienne des sciences du comportement

ISSN: 0008-400X 2023, Vol. 55, No. 4, 300–312
© 2022 Canadian Psychological Association https://doi.org/10.1037/cbs0000331

The Impact of COVID-19 Anxiety on Quality of Life in Canadian

Adults: The Moderating Role of Intolerance of Uncertainty and
Health Locus of Control
Gillian Shoychet, Ariella P. Lenton-Brym, and Martin M. Antony
Department of Psychology, Ryerson University

The coronavirus disease (COVID-19) pandemic has contributed to a global increase in mental health
problems including “COVID-19 anxiety,” the presence of dysfunctional anxiety about the novel coronavi-
rus (e.g., fear of contracting or spreading the virus). The present study investigated potential moderators of
the relationship between COVID-19 anxiety and (a) daily functioning and (b) quality of life, to determine
which individuals are most susceptible to these negative outcomes. Intolerance of uncertainty and health
locus of control were examined as possible moderators. This study recruited 193 Canadian adults using
crowdsourcing platforms during the third wave of COVID-19. Participants completed online questionnaires
assessing demographics and the constructs of interest. Regression analyses found that neither intolerance of
uncertainty nor health locus of control significantly moderated the relationships between COVID-19 anxiety
and daily functioning. However, both intolerance of uncertainty and health locus of control were significant
moderators between COVID-19 anxiety and quality of life. These findings extend past research by
emphasizing the need to target specific risk factors, such as intolerance of uncertainty and health locus
of control, in therapeutic settings to better support individuals’ quality of life during this difficult and
unpredictable time.

Public Significance Statement

High coronavirus disease (COVID) anxiety during Canada’s third wave of the pandemic was associated
with reduced quality of life in individuals. Specific risk factors such as intolerance of uncertainty and
internal health locus of control resulted in a greater vulnerability to the psychological consequences of
COVID-19. These findings highlight potential areas for clinical intervention to support Canadians
suffering during and after the pandemic.

Keywords: COVID-19, anxiety, quality of life, health locus of control, intolerance of uncertainty

The global spread of coronavirus disease (COVID-19) resulted
in pervasive anxiety and fear as countries were unprepared for the
physical, emotional, and financial burden associated with the surge
in virus cases. After the World Health Organization (2020)
declared COVID-19 a pandemic on March 11, 2020, researchers
began to explore the physiological and psychological effects of the
pandemic, and many found a pandemic-related rise in mental
health problems.
Canada’s third wave of the COVID-19 pandemic peaked in April
2021 as variants of concern spread rapidly (Government of Canada,
2021). Both federal and provincial governments across Canada
responded to the surge in cases by placing heavy restrictions on
the population (e.g., closing schools and workplaces, canceling
This article was published Online First March 17, 2022.
Gillian Shoychet https://orcid.org/0000-0002-2856-257X
Martin M. Antony https://orcid.org/0000-0002-3508-377X
The authors declare that they have no conflicts of interest. This research
did not receive any funding.
Correspondence concerning this article should be addressed to Martin
M. Antony, Department of Psychology, Ryerson University, 350 Victoria
Street, Toronto, ON M5B 2K3, Canada. Email: mantony@ryerson.ca
certain hospital procedures, limiting public gatherings, and institut-
ing lockdowns; e.g., Katawazi, 2021). By the end of May 2021,
Canada had close to 1.3 million COVID-19 cases and over 25,000
deaths (Government of Canada, 2021).
The long-term implementation of strict public health guidelines
exacerbated symptoms of COVID-19 anxiety and reduced well-
being. A survey by the Centre for Addiction and Mental Health
(2021) reported that at least one in five Canadian adults experi-
enced heightened mental distress 1 year into the pandemic, and that
COVID-19 significantly aggravated Canada’s prepandemic mental
health crisis. Moreover, Robillard et al. (2021) found that nearly
one half and one third of their Canadian sample (N = 2,562)
without a psychiatric history had clinically significant levels of
depression and generalized anxiety, respectively. COVID-19 has
had a significant negative impact on life satisfaction, daily func-
tioning, and quality of life (QoL; e.g., Helliwell et al., 2020;
Shamblaw et al., 2021), yet there is limited research examining
specific risk factors that make individuals with COVID-19 anxiety
more susceptible to negative outcomes. Investigating potential
moderators of the relationship between COVID-19 anxiety and
(a) daily functioning, and (b) QoL may assist in predicting who is
most likely to be adversely impacted and guiding potential points
of intervention.

300
 COVID-19 ANXIETY AND QUALITY OF LIFE
Possible Risk Factors
Intolerance of uncertainty and locus of control (LOC) are poten-
tial moderators that may contribute to the relationship between
COVID-19 anxiety, daily functioning, and QoL.
Intolerance of Uncertainty
Intolerance of uncertainty is a transdiagnostic construct that de-
scribes the tendency for an individual to view the occurrence of a
negative event as extremely intolerable regardless of its likelihood
(Dugas et al., 2001). Individuals with high levels of intolerance of
uncertainty often experience excessive worry, which is exacerbated by
the unpredictability associated with many life events (Carleton et al.,
2012). Moreover, Carleton et al.’s (2012) findings support intolerance
of uncertainty as a transdiagnostic cognitive vulnerability for various
anxiety and mood-related disorders, where clinical samples scored
higher on intolerance of uncertainty than nonclinical samples. Studies
have found associations between intolerance of uncertainty and symp-
toms of various psychological disorders (Carleton et al., 2012), such as
obsessive–compulsive disorder (Holaway et al., 2006), social anxiety
disorder (Boelen & Reijntjes, 2009), panic disorder (Carleton et al.,
2014), and depression (Miranda et al., 2008). Moreover, high intoler-
ance of uncertainty contributes to the etiology and maintenance of
generalized anxiety disorder, which is characterized by excessive worry
(Carleton et al., 2012; Dugas et al., 2001).
Intolerance of uncertainty has been particularly relevant during the
COVID-19 pandemic as individuals were forced to cope with many
unknowns. For example, common concerns may include not knowing
whether one will become ill from the virus or transmit the virus to
loved ones, which public health protocols should be followed to
ensure safety, if there will be further lockdowns and restrictions, and
when life will return to normal. Milne et al.’s (2019) review on
intolerance of uncertainty and threat appraisal in anxiety confirmed
that individuals with high intolerance of uncertainty are more likely to
interpret ambiguous information in threatening ways. Accordingly,
since information about COVID-19 is constantly changing and
therefore ambiguous, it is likely that individuals with greater intoler-
ance of uncertainty would experience more negative emotions.
Moreover, past research during the H1N1 influenza (“Swine Flu”)
pandemic in 2009 found that individuals with greater intolerance of
uncertainty experienced increased H1N1-related anxiety (Taha et al.,
2014). Furthermore, the few studies conducted during the COVID-19
pandemic have found consistent findings that high intolerance of
uncertainty is associated with reduced mental well-being (Satici et al.,
2020) and decreased feelings of positivity (Bakioğlu et al., 2020).
Prior to COVID-19, studies established negative associations between
intolerance of uncertainty and both QoL (Wheaton & Ward, 2020) and
daily functioning, at least within the context of uncertain situations
(Buhr & Dugas, 2006). Accordingly, the present study was intended to
expand past literature by examining intolerance of uncertainty as a
moderator of the relationship between COVID-19 anxiety, daily func-
tioning, and QoL to better understand how COVID-19 anxiety interacts
with intolerance of uncertainty 1 year into the pandemic.
Locus of Control
LOC refers to the extent to which a person attributes life events to
internal (e.g., one’s own behavior) or external (e.g., Powerful Others
301
or Chance) factors (Rotter, 1966; Wallston et al., 1978). Similarly,
Health LOC (HLOC) refers to the extent to which a person makes
internal versus external attributions about the causes of personal
health outcomes (Wallston et al., 1978). Previous research has
demonstrated positive associations between symptoms of anxiety
and both external LOC (Gore et al., 2016; Kurtović et al., 2018) and
HLOC (Skidmore et al., 2014). Kurtović et al. (2018) explained
external LOC’s association with greater mental health symptoms
using a mediation model. Specifically, external LOC was associated
with reduced self-liking and increased emotion-focused coping (i.e.,
attempting to reduce negative emotional reactions in response to
stressful events), which in turn predicted greater mental health
problems (Kurtović et al., 2018). Emotion-focused coping is an
effective strategy to reduce short-term stress but can be maladaptive
as a long-term solution for managing stress (Kurtović et al., 2018).
Similarly, Gore et al. (2016) found that perceived environmental
constraints (i.e., perceived lack of control) was the strongest pre-
dictor of reduced well-being compared to other types of LOC.
Individuals experiencing COVID-19 anxiety may fare better if
they hold strong beliefs about their own ability to control personal
health outcomes. That is, individuals who are high in internal HLOC
may be able to mitigate their COVID-19 anxiety by adhering to
public health guidelines, such as by wearing a mask or limiting
proximal social contact. Conversely, individuals who believe that
they do not have control over personal health outcomes (i.e., low
internal HLOC), but rather, that their health status is dependent on
external, uncontrollable forces (i.e., high external HLOC) will not be
able to rely on these behaviors to mitigate anxiety. Consequently,
these individuals may demonstrate reduced QoL or daily function-
ing. In support of this assumption, recent research has revealed that
external LOC is related to reduced well-being during COVID-19
(Sigurvinsdottir et al., 2020). However, whether this pattern holds
true with HLOC has yet to be determined.
Accordingly, it would be beneficial to extend past literature by
specifically examining HLOC as a moderator of the relationship
between (a) COVID-19 anxiety and daily functioning, and (b)
COVID-19 anxiety and QoL to better understand factors contribut-
ing to mental health symptoms and support individuals during this
uncertain time.
The Present Study
The present study aimed to explore how COVID-19 anxiety
impacts mental health in a Canadian adult population. Consistent
with past research, five hypotheses were explored:
Hypothesis 1: COVID-19 anxiety will negatively predict QoL
and daily functioning, such that greater levels of COVID-19
anxiety will result in reduced QoL and daily functioning.
Hypothesis 2: Intolerance of uncertainty will moderate the
relationship between COVID-19 anxiety and QoL, where in-
dividuals with greater intolerance of uncertainty will have
reduced QoL in comparison to those with lower levels of
intolerance of uncertainty.
Hypothesis 3: Intolerance of uncertainty will be a significant
moderator in the relationship between COVID-19 anxiety and
daily functioning, such that higher levels of intolerance of
302 SHOYCHET, LENTON-BRYM, AND ANTONY

uncertainty will predict diminished daily functioning in com- Table 1

parison to lower levels. Demographic Characteristics of the Sample
Hypothesis 4: HLOC will moderate the relationship between Variable n %
COVID-19 anxiety and QoL.
Gender
a. Greater levels of external HLOC will predict reduced Woman 95 49.2
QoL in comparison to individuals with lower levels. Man 93 48.2
Nonbinary 3 1.6
b. Lower levels of internal HLOC will predict reduced QoL Trans woman 1 0.5
Woman, genderqueer 1 0.5
compared to those with higher levels. Race/ethnicity
Indigenous/North American 4 2.1
Hypothesis 5: HLOC will be a significant moderator in the Arab/West Asian/North African 8 4.1
relationship between COVID-19 anxiety and daily functioning. Black/Afro-Caribbean/African 6 3.1
East Asian 26 13.5
Latin American 11 5.7
a. Individuals with high external HLOC will experience South Asian 18 9.3
poorer functioning than those with low external HLOC. Southeast Asian 12 6.2
White/European 115 59.6
b. Individuals with low internal HLOC will experience Other 2 1.0
poorer functioning than those with high internal HLOC. Missing 2 1.0
Sexual orientation
Heterosexual 141 73.1
Method Bisexual 19 9.8
Gay/Lesbian 13 6.7
Participants Pansexual 2 1.0
Asexual 1 0.5
A total of 193 participants ranging in age from 18 to 72 (M = Heterosexual demisexual 1 0.5
35.76, SD = 10.49) completed the study. Demographic character- Missing 16 8.3
istics of the sample are presented in Table 1. Participants were Education level
recruited from Amazon Mechanical Turk (MTurk) and CloudRe- Less than a high school diploma 2 1.0
search (i.e., TurkPrime), both of which are virtual crowdsourcing Completed high school/equivalent 20 10.4
Some college or university 20 10.4
marketplaces often used for diverse and large-scale research recruit- Completed college or university 99 51.3
ment. Participants were eligible for the study if they indicated they Some graduate/professional school 9 4.7
were (a) a minimum of 18 years old, (b) fluent English speakers, and Completed graduate/professional school 42 21.8
(c) geographically residing in Canada. This study was approved by Missing 1 0.5
Employment status
Ryerson University’s Research Ethics Board, and all participants Out of work and looking for work 16 8.3
provided informed consent prior to beginning the study. Out of work and not looking for work 11 5.7
Retired 4 2.1
Student 16 8.3
Measures and Materials Working part-time 38 19.7
Working full-time 116 60.1
COVID Stress Scales (Taylor et al., 2020) Missing 6 3.1
Workplace location
The COVID Stress Scales (CSS) is a 36-item self-report measure
In person 48 24.9
designed to assess COVID-19 anxiety in the past 1-week period. Virtual from home 78 40.4
Each item is assessed using a 5-point Likert scale [0 (never or not at Both in person and virtual 30 15.5
all) to 4 (extremely or almost always)] measuring how often the N/A 32 16.6
given statement applies (e.g., “I am worried about catching the Missing 5 2.6
Health care worker
virus”). Scores are summed to create a total score and six subscores: Yes 13 6.7
Danger, Socioeconomic Consequences, Xenophobia, Contamina- No 179 92.7
tion, Traumatic Stress, and Compulsive Checking. Possible total Missing 1 0.5
scores range from 0 to 144, where higher scores represent greater Essential worker
Yes 49 25.4
COVID-related stress. The CSS has good-to-excellent internal
No 142 73.6
consistency (subscale coefficients > .80), as well as good conver- Missing 2 1.0
gent and discriminant validity (Taylor et al., 2020). The CSS total Living alone
score also demonstrated high internal consistency in the present Yes 28 14.5
study (α = .96). No 163 84.5
Missing 2 1.0

Multidimensional Health LOC Scales—Shortened
Version (Malcarne et al., 2005)
The Multidimensional Health LOC Scales (MHLC) shortened
version is a 9-item self-report scale (adapted from the original 18-
item scale; Wallston et al., 1978), designed to study the extent to
Note. n = 193. Values rounded to nearest tenth.
which one believes they are in control of their health. It incorporates
a three-factor model: Internal HLOC (e.g., “I am in control of my
health”), Powerful Others HLOC (e.g., “Having regular contact with
 COVID-19 ANXIETY AND QUALITY OF LIFE
my physician is the best way for me to avoid illness”), and Chance
HLOC (e.g., “Luck plays a big part in determining how soon I will
recover from an illness”). The Powerful Others and Chance sub-
scales represent external HLOC. Participants respond using a 6-
point Likert scale ranging from 1 (strongly disagree) to 6 (strongly
agree). Item scores were summed to create three subscales, each
ranging from 3 to 18, where higher scores represent a stronger belief
in oneself, Powerful Others, or Chance in determining health. The 9-
item MHLC had somewhat low internal reliability in past research,
ranging from .66 to .76 for Internal HLOC, .50 to .61 for Powerful
Others HLOC, and .52 to .55 for Chance HLOC (Malcarne et al.,
2005). However, the current sample had acceptable reliability for
each subscale (Internal α = .85; Powerful Others α = .69; Chance
α = .73).1
Intolerance of Uncertainty Scale—Short Form
(Carleton et al., 2007)
The Intolerance of Uncertainty Scale—Short Form (IUS-12) is a
12-item self-report measure created to examine an individual’s
ability to cope with a potential negative event, regardless of its
likelihood. The IUS-12 was adapted from Freeston et al.’s (1994)
27-item IUS in response to psychometric problems regarding factor
structure and internal consistency (Carleton et al., 2007). Each item
is rated on a 5-point Likert scale [1 (not at all characteristic of me) to
5 (entirely characteristic of me)] assessing how much participants
agree with the given statement (e.g., “Unforeseen events upset me
greatly”). Total scores are calculated by summing all the items and
can range from 5 to 60. Higher scores represent greater intolerance
of uncertainty. The IUS-12 demonstrated excellent internal consis-
tency (α = .96) and good convergent validity (Carleton et al., 2007).
Moreover, the total score between the IUS-12 and the IUS-27 is
highly correlated (r = .96; Carleton et al., 2007). The current sample
also had high internal consistency (α = .92).
Illness Intrusiveness Ratings Scale
(Devins et al., 1983–1984)
The Illness Intrusiveness Ratings Scale (IIRS) is a 13-item self-
report measure designed to assess the degree to which illness
interferes with various aspects of one’s life (e.g., “How much
does your illness and/or its treatment interfere with your : : : health,
financial situation, and family relations”). The IIRS was used in the
present study as a measure of daily functioning. Consistent with past
research (e.g., Antony et al., 1998), the scale was adapted to assess
how anxiety (instead of illness) interferes with daily functioning.
Participants responded using a 7-point Likert scale [1 (not very
much) to 7 (very much)], with possible scores ranging from 13 to 91,
where higher scores represent reduced functioning. The current
sample had excellent internal consistency (α = .93) which is
comparable to levels found in other studies that have used the
IIRS to examine functioning in anxiety-disordered samples (e.g.,
Antony et al., 1998).
World Health Organization Quality of Life–BREF
(The WHOQOL Group, 1998)
World Health Organization Quality of Life–BREF (WHOQOL-
BREF) is a 26-item self-report cross-cultural measure of QoL.
303
The WHOQOL-BREF was adapted from the WHOQOL 100-
item questionnaire. Each item is assessed using a 5-point Likert
scale [1 (e.g., not at all) to 5 (e.g., completely)] measuring how
applicable the given statement is in the past 2-week period (e.g., “Do
you have enough energy for everyday life?”). Four domain scores
are calculated: Physical Health (e.g., mobility), Psychological (e.g.,
self-esteem), Social Relationships (e.g., social support), and Envi-
ronment (e.g., financial resources). Items one and two are not
included in the four domain scores. Domain scores are calculated
using the mean of the specified items, where higher scores represent
greater QoL. The WHOQOL-BREF appears to have acceptable
internal consistency for each of the four domains and has also
demonstrated good discriminant and content validity, as well as
test–retest reliability (Skevington et al., 2004; The WHOQOL
Group, 1998). Consistent with previous findings, the current sample
demonstrated acceptable levels of internal consistency: Physical
Health (α = .73), Psychological (α = .81), Social Relationships (α
= .74) and Environment (α = .80).
Demographics Form
Participants completed a questionnaire to collect basic demo-
graphic information (e.g., gender, race/ethnicity, sexual orientation,
education level, employment status, workplace location, type of
work [health care and/or essential], and living arrangement).
Procedure
The present study was advertised on MTurk and CloudResearch
(Litman et al., 2017), where potential participants were asked to
complete a study on mental health during COVID-19. Interested
participants were redirected to Qualtrics to complete the remainder of
the virtual study, which took an average of 30 min. After consenting,
participants completed various questionnaires assessing COVID-19
anxiety, HLOC, intolerance of uncertainty, QoL, and daily function-
ing. Following completion of the study, participants received a
debriefing form. Participants who were recruited via MTurk were
initially compensated $1.00 USD for 30 min of work, in accordance
with the literature (Keith et al., 2017; Mason & Suri, 2012). However,
when CloudResearch was added as a second method of recruitment,
the compensation increased to $3.00 USD for both MTurk and
CloudResearch users, which is in line with CloudResearch’s recom-
mended compensation (CloudResearch, 2020). Data were collected
between February 26 to April 6, 2021, which overlapped with the
third wave of COVID-19 in Canada (Government of Canada, 2021).
1
Although coefficient alphas ≥ .70 are preferred (Nunnally & Bernstein,
1994), the Powerful Others coefficient alpha was slightly lower (.69) than
desired. However, a low coefficient alpha may be attributed to a small
number of test items (e.g., the Powerful Others subscale had only 3 items;
Hayes & Coutts, 2020; Tavakol, 2018). Moreover, alpha may underestimate
the true reliability of a scale when the test’s assumptions are violated (Dunn
et al., 2014). McDonald’s (1999) coefficient omega is a common and robust
alternative to measuring internal consistency and is not restricted to the
impractical assumptions required to use coefficient alpha nor influenced by
the number of test items (Dunn et al., 2014; Tavakol, 2018). Thus, we reran
the reliability test for the Powerful Others subscale using McDonald’s
Omega and the results surpassed the .70 cut-off (ω = .72).
304 SHOYCHET, LENTON-BRYM, AND ANTONY

Results significantly more influential in determining model fit, thereby

Data Preparation
The data were analyzed using IBM SPSS Statistics (Version 28.0)
and R (Version 4.1.1). The original sample included 242 partici-
pants. Only participants who completed 98%–100% of the study
were included in the analyses, and those who completed the study in
less than 10 min were removed (Curran, 2016). The final sample
included 193 participants.
Missing Data
Missing values ranged from 0% to 7.3%, where only three items
(IIRS item 7, IIRS item 8, and WHOQOL-BREF item 21) exceeded
5%. Little’s missing completely at random (MCAR) test (Little,
1988) was not significant for the adapted IIRS total score or the
WHOQOL-BREF social domain score, thereby demonstrating that
data were missing at random (MAR). Moreover, Schafer (1999)
suggests that data with less than 5% missingness are unlikely to
contribute to biased parameter estimates (Dong & Peng, 2013).
Missing data were accounted for using full information maximum-
likelihood (FIML), a statistical technique that can be used with data
MAR or MCAR (Dong & Peng, 2013; Enders & Bandalos,
2001).This statistical method was selected for its ability to generate
unbiased parameter estimates and standard errors (Enders &
Bandalos, 2001).
Assumptions, Influential Observations, and
Control Variables
The assumption of no multicollinearity was met as all variance
inflation factor (VIF) values were less than 10. Normal P–P plots and
scatterplots were inspected to assess normality, linearity, and het-
eroscedasticity. All residuals followed relatively normal distribu-
tions and thus normality was assumed. Similarly, residuals followed
a linear path and were mostly equally distributed, thereby meeting
the linearity and homoscedasticity assumptions. Moreover, Cook’s
distance was evaluated for each analysis to estimate how much each
individual observation influenced the regression models (Cook,
1977). A large value would indicate that a specific datapoint was
warranting further investigation into whether the observation should
be removed (Cook, 1977; Stevens, 1984).
Workplace location (i.e., in-person, virtual, both) and essential
worker status were controlled for due to their potential influence on
the variables of interest. Specifically, Ruiz-Frutos et al. (2021) found
that essential (nonhealth) workers working away from home expe-
rienced more unhappiness, depression, and reduced sleep compared
to those working virtually during COVID-19. Thus, both demo-
graphic variables were included in each regression model to account
for possible unique variance in QoL and daily functioning.
Hypothesis 1: COVID-19 Anxiety, QoL, and
Daily Functioning
Correlation analyses revealed significant associations between
COVID-19 anxiety and physical QoL, environment QoL, and daily
functioning ( p < .01; see Table 2). Hypothesis 1 was partially
supported as two out of four QoL domains had significant negative
associations with COVID-19 anxiety, such that greater anxiety was
related to reduced QoL. Moreover, COVID-19 anxiety was posi-
tively associated with daily functioning, such that a higher score on
the CSS was related to greater anxiety intrusiveness (i.e., reduced
daily functioning).
Hypothesis 2: COVID-19 Anxiety, Intolerance
of Uncertainty, and QoL
Linear regression analyses revealed that both COVID-19 anxiety
and intolerance of uncertainty negatively predicted physical QoL
( p < .001; see Table 3). Additionally, intolerance of uncertainty was
a significant moderator of the relationship between COVID-19
anxiety and physical QoL (CSS × Intolerance of uncertainty inter-
action: p = .002; see Figure 1). The model accounted for 27% of
variance in physical QoL. Simple slopes revealed that greater
COVID-19 anxiety predicted reduced physical QoL for individuals
with low (i.e., 1 SD below the mean; B = −.05, SE = .01, p < .001),
average (B = −.04, SE = .01, p < .001), and high (i.e., 1 SD above
the mean; B = −.02, SE = .01, p = .008) intolerance of uncertainty,
though this relationship was strongest for low levels.

Table 2
Correlations Between Predictors, Moderators, and Outcome Variables

HLOC
Variable COVID-19 anxiety Intolerance of uncertainty Internal Powerful others Chance

COVID-19 anxiety
Intolerance of uncertainty .394***
HLOC Internal .340*** .218**
Powerful others −.025 .081 .153*
Chance −.109 −.137* −.026 .230**
QoL Physical health −.368*** −.392*** −.430*** −.055 .075
Environment −.214** −.129* −.326*** −.019 .102
Psychological −.063 −.372*** −.203** −.106 .181**
Social relationships −.025 −.217** −.105 −.051 .140*
Anxiety intrusiveness/Daily functioning .549*** .544*** .286*** .065 −.127*
Note. COVID-19 = coronavirus disease; HLOC = health locus of control; QoL = quality of life. Significant values are illustrated in boldface.
* p < .05. ** p < .01. *** p < .001.
 COVID-19 ANXIETY AND QUALITY OF LIFE 305

Table 3
Regression Analyses

Unstandardized coefficients
Hypotheses Outcomes B SE p

2a Physical QoL
COVID-19 anxiety −.04 .01 <.001***
Intolerance of uncertainty −.08 .02 <.001***
Interaction .002 .001 .002**
Workplace −.38 .16 .019*
Essential worker .33 .39 .386
2b Environment QoL
COVID-19 anxiety −.03 .01 .001**
Intolerance of uncertainty −.01 .02 .487
Interaction .001 .001 .015*
Workplace −.15 .18 .399
Essential worker .40 .43 .354
2c Psychological QoL
COVID-19 anxiety .003 .01 .712
Intolerance of uncertainty −.12 .02 <.001***
Interaction .001 .001 .079
Workplace −.02 .19 .928
Essential worker −.02 .45 .972
2d Social QoL
COVID-19 anxiety .01 .01 .441
Intolerance of uncertainty −.09 .03 .001**
Interaction .000 .001 .965
Workplace −.22 .25 .382
Essential worker −.51 .60 .395
3 Functioning
COVID-19 anxiety .27 .05 <.001***
Intolerance of uncertainty .67 .11 <.001***
Interaction −.002 .004 .556
Workplace .05 1.11 .966
Essential worker −1.78 2.55 .484
4a Physical QoL
COVID-19 anxiety −.03 .01 <.001***
Internal HLOC −.29 .06 <.001***
Interaction .003 .001 .022*
Workplace −.31 .16 .051
Essential worker .23 .38 .553
4b Environment QoL
COVID-19 anxiety −.02 .01 .003**
Internal HLOC −.26 .06 <.001***
Interaction .003 .002 .116
Workplace −.12 .16 .442
Essential worker .17 .40 .665
4c Psychological QoL
COVID-19 anxiety −.01 .01 .402
Internal HLOC −.21 .07 .002**
Interaction .004 .002 .017*
Workplace .02 .20 .903
Essential worker −.10 .48 .830
4d Social QoL
COVID-19 anxiety −.01 .01 .480
Internal HLOC −.14 .09 .109
Interaction .004 .002 .064
Workplace −.25 .25 .312
Essential worker −.50 .60 .413
5 Functioning
COVID-19 anxiety .33 .05 <.001***
Internal HLOC .57 .42 .176
Interaction −.002 .01 .886
Workplace −.68 1.22 .580
Essential worker −1.51 2.87 .599
Note. COVID-19 = coronavirus disease; HLOC = health locus of control. QoL = quality of life. Workplace and essential worker status were controlled for in
each regression model. Hypothesis 4b is reported with one outlier removed. Significant values are illustrated in boldface.
* p < .05. ** p < .01. *** p < .001.
306 SHOYCHET, LENTON-BRYM, AND ANTONY

Figure 1
Interaction Effects Between COVID-19 Anxiety and IU on Physical QoL

Note. COVID-19 = coronavirus disease; IU = intolerance of uncertainty; QoL = quality of life.

a
Simple slope estimates of IU: High (B = −.02), average (B = −.04), low (B = −.05).

Findings further demonstrated that although there was no signifi- Hypothesis 4: COVID-19 Anxiety, Internal HLOC,
cant main effect of intolerance of uncertainty on environment QoL and QoL2
( p = .487), there was a significant main effect of COVID-19 anxiety
Regression analyses revealed significant main effects of COVID-
( p = .001). Moreover, intolerance of uncertainty significantly
19 anxiety and internal HLOC on physical QoL ( p < .001; see
moderated the relationship between COVID-19 anxiety and envi-
Table 3). Moreover, there was a significant interaction ( p = .022)
ronment QoL ( p = .015; see Figure 2). Approximately 8% of
between COVID-19 anxiety and internal HLOC on physical QoL
variance in environment QoL was accounted for by the model.
(see Figure 3). Approximately 29% of variance in physical QoL was
Additional simple slope analyses demonstrated that greater COVID-
accounted for by this model. Simple slope analyses demonstrated
19 anxiety predicted reduced environmental QoL for individuals
that greater COVID-19 anxiety predicted reduced physical QoL for
with low (B = −.04, SE = .01, p = .001) and average (B = −.03,
individuals with low (B = −.04, SE = .01, p < .001), average (B =
SE = .01, p = .001) levels of intolerance of uncertainty. However,
−.03, SE = .01, p < .001), and high (B = −.02, SE = .01, p = .002)
this relationship was not significant for individuals with high
internal HLOC, though this relationship was strongest for those with
intolerance of uncertainty (B = −.01, SE = .01, p = .102).
Regression analyses further revealed that neither COVID-19 low HLOC.
Additionally, when investigating the relationship between
anxiety nor the interaction term significantly predicted psychologi-
COVID-19 anxiety and internal HLOC on environment QoL, there
cal and social QoL ( p > .05). However, there was a main effect of
was one observation with a large Cook’s distance value relative to
intolerance of uncertainty on both psychological ( p < .001) and
the others, signifying a need for further exploration. When the
social ( p = .001) QoL. Hypothesis 2 was partially supported as
extreme value was removed, there were significant main effects of
intolerance of uncertainty was a significant moderator of COVID-19
COVID-19 anxiety ( p = .003) and internal HLOC ( p < .001) on
anxiety and two of the four QoL domains (i.e., physical health and
environment QoL. However, their interaction was not significant
environment).
( p = .116). When the model was estimated using all observations,
the interaction was significant. The exclusion of this one observation
Hypothesis 3: COVID-19 Anxiety, Intolerance of changed the results of the interaction, thereby demonstrating the
Uncertainty, and Daily Functioning observation’s large influence on the model. Thus, the datapoint was
deemed an outlier and the results were reported without that
Regression analyses revealed main effects of COVID-19 anxiety observation.
and intolerance of uncertainty on daily functioning ( p < .001; see
Table 3). However, contrary to Hypothesis 3, intolerance of uncer-
tainty did not significantly moderate the relationship between 2
Powerful Others and Chance HLOC were not reported in the results as
COVID-19 anxiety and daily functioning ( p = .556). none of the moderation analyses were significant.
 COVID-19 ANXIETY AND QUALITY OF LIFE 307

Figure 2
Interaction Effects Between COVID-19 Anxiety and IU on Environment QoL

Note. COVID-19 = coronavirus disease; IU = intolerance of uncertainty; QoL = quality of life.

a
Simple slope estimates of IU: High (B = −.01), average (B = −.03), low (B = −.04).

Although there was no main effect of COVID-19 anxiety (p = .402) analyses revealed that the interaction between COVID-19 anxiety and
on psychological QoL, there was a main effect of internal HLOC (p = internal HLOC on psychological QoL was not significant at high (B =
.002) and a significant interaction (p = .017; see Figure 4). The model .01, SE = .01, p = .442), average (B = −.01, SE = .01, p = .402), or low
accounted for 7% of variance in psychological QoL. Simple slope levels of the moderator (B = −.02, SE = .01, p = .071).

Figure 3
Interaction Effects Between COVID-19 Anxiety and Internal HLOC on Physical QoL

Note. COVID-19 = coronavirus disease; HLOC = health locus of control; QoL = quality of life.
a
Simple slope estimates of internal HLOC: High (B = −.02), average (B = −.03), low (B = −.04).
308 SHOYCHET, LENTON-BRYM, AND ANTONY
Figure 4
Interaction Effects Between COVID-19 Anxiety and Internal HLOC on Psychological QoL
Note. COVID-19 = coronavirus disease; HLOC = health locus of control; QoL = quality of life.
a
Simple slope estimates of internal HLOC: High (B = .01), average (B = −.01), low (B = −.02).
Lastly, there were no significant main effects of COVID-19
anxiety ( p = .480), internal HLOC ( p = .109), or their interaction
term ( p = .064) on social QoL. Hypothesis 4 was partially sup-
ported, as internal HLOC was a significant moderator of the
relationship between COVID-19 anxiety and two of the four
domains of QoL (i.e., physical and psychological health).
Hypothesis 5: COVID-19 Anxiety, Internal HLOC,
and Daily Functioning
Linear regression analyses revealed that although the main effect
of COVID-19 anxiety on daily functioning ( p < .001) was signifi-
cant, the main effect of internal HLOC was not ( p = .176; see
Table 3). Hypothesis 5 was not supported as there was no significant
interaction between COVID-19 anxiety and internal HLOC on daily
functioning ( p = .886).
Discussion
Although the implementation of strict public health regulations
were effective in reducing case counts during Canada’s third wave
of COVID-19 (Davidson, 2021; Government of Canada, 2021),
these implementations may have exacerbated negative psychologi-
cal outcomes. Thus, the present study examined the impact of
COVID-19 anxiety on daily functioning and QoL in Canadian
adults. Given the rapid and unpredictable nature of COVID-19,
intolerance of uncertainty and HLOC were analyzed as potential
moderators in the relationship between COVID-19 anxiety and (a)
daily functioning, and (b) QoL.
The study’s findings partially supported the five hypotheses.
Specifically, heightened COVID-19 anxiety was significantly related
to reduce daily functioning and QoL for two of the four domains (i.e.,
physical health and environment). The nonsignificant relationship
between COVID-19 anxiety and the other two QoL domains (i.e.,
psychological health and social relationships) may be attributed to
protective factors that reduce the negative impact of COVID-19
anxiety on these facets of QoL. For example, supportive relationships
and living with partners have been found to play a protective role in
predicting psychological resilience (Killgore et al., 2020) and reduc-
ing loneliness during the pandemic (Li & Wang, 2020).
Moreover, there was partial support for the second hypothesis, as
intolerance of uncertainty significantly moderated the relationship
between COVID-19 anxiety and two of the four QoL domains (i.e.,
physical health and environment). Further analyses revealed that
high COVID-19 anxiety significantly predicted (a) reduced physical
QoL for all levels of intolerance of uncertainty, and (b) reduced
environmental QoL for only low and average levels of intolerance of
uncertainty. In both analyses, individuals with high pandemic
anxiety and low intolerance of uncertainty experienced the worst
QoL. Results from Pan et al.’s (2021) longitudinal study may
explain these unexpected findings. Specifically, although indivi-
duals with preexisting mental health conditions experienced more
mental health symptoms during the pandemic compared to nonclin-
ical controls, the worsening of symptom severity was greater from
prepandemic to the present period for individuals without previous
mental health conditions. This is noteworthy as high intolerance of
uncertainty has been linked to various mental health conditions
(Carleton et al., 2012) and, therefore, Pan et al.’s (2021) findings
may suggest that change in symptom severity could have a greater
influence on QoL than current COVID-19 anxiety levels.
Conversely, Hypotheses 3 and 5 were not confirmed (i.e., neither
intolerance of uncertainty nor HLOC moderated the relationship
 COVID-19 ANXIETY AND QUALITY OF LIFE
between COVID-19 anxiety and daily functioning). One possibility
for this finding could be that QoL tends to be more subjective than
daily functioning (i.e., one may experience poor subjective QoL but
still function). Additionally, QoL may be a more sensitive measure
in that it decreases more quickly during adverse experiences in
comparison to functioning.
Lastly, there was partial support for the fourth hypothesis as HLOC
was a significant moderator between COVID-19 anxiety and QoL.
However, the observed direction of the associations between vari-
ables contradicted expectations. Specifically, high internal HLOC
predicted reduced QoL for two of the four domains (i.e., physical
and psychological health). This finding is surprising as past research
has repeatedly confirmed the opposite; that high external LOC
predicts greater negative mental health outcomes (Sigurvinsdottir
et al., 2020).
One explanation for this finding is that the increased unpredict-
ability surrounding the pandemic made it harder for individuals to
remain in control of their health. Supporting this explanation, Njus
and Brockway (1999) examined LOC and perceptions of compe-
tence for both negative (e.g., “I have little control over the bad
things that happen to me”) and positive (e.g., “I am responsible for
my own successes”) events, finding that perceived internal LOC
was related to lower levels of depression for positive events only.
Specifically, participants were classified into four attributional
styles: Instrumentalists (high internal LOC for both positive and
negative events), self-defenders (high internal LOC for positive
events only), self-blamers (high internal LOC for negative events
only), and fatalists (external LOC for both positive and negative
events). Instrumentalists and self-defenders were significantly less
depressed than self-blamers and fatalists, and there were no
significant differences in depression between the former two
and latter two styles. Njus and Brockway (1999) explained this
relationship using defense theory, which states that although
perceived control over positive events is advantageous, perceived
control over negative events is not necessarily adaptive. Defense
theory is a possible explanation for the present study’s findings, as
individuals reporting higher internal HLOC during COVID-19
(i.e., a negative event) experienced reduced QoL. Additionally,
Njus and Brockway (1999) found that perceived competence (i.e.,
self-efficacy: One’s confidence in their ability to alter outcomes)
was just as important in predicting depression as was LOC alone.
Accordingly, someone who believes they generally have high
internal HLOC may experience low perceived competence in
unpredictable situations (e.g., pandemic) and therefore may expe-
rience a reduction in QoL.
Also, although high COVID-19 anxiety significantly predicted
reduced physical QoL for individuals with varying levels of internal
HLOC, this relationship was strongest for those with the lowest
HLOC scores. One explanation may be the buffering effect of risk
aversion for those with higher internal HLOC. In a recent study,
greater risk aversion was related to a stronger belief in the utility of
lockdowns which, in turn, lead to reduced distress (Petrocchi et al.,
2021). Accordingly, those with higher internal HLOC may feel
more protected by the increase in government restrictions during the
third wave of COVID-19 in Canada and thus experience a greater
physical QoL than those with low internal HLOC. Another inter-
esting finding was that although internal HLOC affected how
COVID-19 anxiety related to psychological QoL, none of the simple
effects (low, average, or high internal HLOC) were significant. That
309
is, the significant interaction occurred because the simple effects
were different from each other, yet they were not significantly
different from zero.
Strengths, Limitations, and Future Directions
This study filled a gap in the literature by specifically researching
the mental health of Canadians during the pandemic. Uncertainty
and unpredictability have characterized the third wave of the
pandemic in Canada, particularly as the country’s vaccine rollout
lagged far behind that of the United States and the United Kingdom
between March and May 2021, necessitating the opening of field
hospitals, school closures, and further government-imposed restric-
tions. These unique characteristics of Canada’s COVID-19 trajec-
tory suggest a need for further research exploring the impact of the
pandemic on Canadians’ mental health.
Additionally, this study sought to investigate individuals who are
most impacted by the mental health consequences of the current
pandemic. This study is one of the first to examine intolerance of
uncertainty and HLOC as potential factors that may be associated
with greater COVID-19 anxiety and reduced well-being. In addition,
this study used the MTurk and CloudResearch crowdsourcing plat-
forms, which tend to include greater diversity within the Canadian
population in comparison to typical undergraduate samples (Sheehan,
2018). In the present sample, 40% of participants reported non-White/
non-European racial/ethnic backgrounds, and there was a relatively
equal representation of men and women. Diverse samples strengthen
the generalizability of the results as they more accurately represent the
intended population of study (Sheehan, 2018).
There were also several limitations that could guide future work in
this area. Specifically, the sample was limited in its recruiting
methods. Self-selection has the possibility to bias a study’s findings
and therefore future studies should use multiple recruiting methods.
Moreover, although CloudResearch and MTurk allow for more
diverse samples, both platforms have limitations. Specifically, the
samples collected from both crowdsourcing platforms may still
slightly differ from the Canadian population as they tend be better
educated (Sheehan, 2018). For example, approximately 78% of
participants in the current sample completed college or university
compared to 62% of Canadians 25–34 years old (Organisation for
Economic Cooperation & Development, 2019). This is an important
consideration as research demonstrates associations between lower
levels of education, lower socioeconomic status (SES), and reduced
mental well-being (Niemeyer et al., 2019). Another limitation of
using MTurk is that experienced survey takers may respond to
questionnaires very quickly and with less thought (Sheehan, 2018).
In the present study, this problem was mitigated by removing any
participants who completed the study in under 10 min. However,
future research could incorporate attention checks or implement
minimum time limits to prevent participants from “speeding”
through the surveys (Sheehan, 2018). Additionally, expanding
data collection techniques (i.e., incorporating interviews with
self-reports) may provide a more comprehensive understanding
of the relationships between the variables of interest. Lastly, the
study’s cross-sectional design limits its ability to capture changes in
mental health across time during COVID-19. Thus, future research
should employ repeated measures to evaluate the progression of
long-term psychological functioning.
310 SHOYCHET, LENTON-BRYM, AND ANTONY
Conclusion
COVID-19 has had immense consequences on the QoL of
Canadians; yet, limited studies have explored the adverse effects
of COVID-19 anxiety during the third wave of the pandemic in
Canada. Findings from this study suggest a need for further investi-
gation into the myriad psychological vulnerabilities that may leave
certain individuals at greater risk of experiencing reduced QoL
during the COVID-19 pandemic. Furthermore, the present study
provides initial evidence that intolerance of uncertainty and HLOC
may reflect two such risk factors and may, therefore, represent key
areas for clinical intervention among those suffering with COVID-
19 anxiety. These findings have potential global implications post-
pandemic as individuals with COVID-19 anxiety, intolerance of
uncertainty, and internal HLOC may experience long-term negative
psychological effects that require intervention.
Résumé
La pandémie de coronavirus (COVID-19) a contribué à une aug-
mentation mondiale des problèmes de santé mentale, dont l’«
anxiété liée à la COVID-19 », c'est-à-dire la présence d'une anxiété
dysfonctionnelle associée au nouveau coronavirus (par exemple, la
peur de contracter ou de propager le virus). La présente étude a
examiné les modérateurs potentiels de la relation entre l'anxiété liée
à la COVID-19 et (a) le fonctionnement quotidien et (b) la qualité de
vie, afin de déterminer quelles personnes sont les plus susceptibles
de subir ces effets négatifs. L'intolérance à l'incertitude et le locus de
contrôle de la santé ont été examinés comme modérateurs possibles.
Cette étude a recruté 193 adultes canadiens en utilisant des plate-
formes de production participative (crowdsourcing) pendant la
troisième vague de COVID-19. Les participants ont rempli des
questionnaires en ligne évaluant les données démographiques et les
constructions d'intérêt. Les analyses de régression ont montré que ni
l'intolérance à l'incertitude ni le locus de contrôle de la santé ne
modèrent de manière significative les relations entre l'anxiété liée à
la COVID-19 et le fonctionnement quotidien. Or, l'intolérance à
l'incertitude et le locus de contrôle de la santé étaient tous deux des
modérateurs significatifs entre l'anxiété liée à la COVID-19 et la
qualité de vie. Ces résultats prolongent les recherches antérieures en
soulignant la nécessité de cibler des facteurs de risque spécifiques,
tels que l'intolérance à l'incertitude et le locus de contrôle de la santé,
dans des contextes thérapeutiques afin de mieux soutenir la qualité
de vie des individus durant cette période difficile et imprévisible.
Mots-clés : COVID-19, anxiété, qualité de vie, locus de contrôle de
la santé, intolérance à l’incertitude
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Received August 19, 2021
Revision received February 3, 2022
Accepted February 7, 2022 ▪