Anxiety Risk Factors and Socia

Walden University
College of Health Sciences and Public Policy
This is to certify that the doctoral dissertation by
Jennifer S. Clancy
has been found to be complete and satisfactory in all respects,

and that any and all revisions required by
the review committee have been made.
Review Committee
Dr. Clarence Schumaker, Committee Chairperson, Public Health Faculty
Dr. Leah Miller, Committee Member, Public Health Faculty
Dr. Sanggon Nam, University Reviewer, Public Health Faculty
Chief Academic Officer and Provost

Sue Subocz, Ph.D.
Walden University
2023
Abstract
Anxiety Risk Factors and Social Isolation Among Young Adults
by
Jennifer S. Clancy
MPH, Grand Canyon University, 2015
BS, University of Mississippi, 2002
Dissertation submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Philosophy
Public Health
Walden University
August 2023
Abstract
The COVID-19 pandemic is a public health concern that impacted the world. Increased
feelings of loneliness and social isolation during the pandemic were reported to be
associated with those seeking help for symptoms of anxiety and depression. Though
symptoms of anxiety have been associated with social isolation, research is limited on the
association between the anxiety risk factors and social isolation among young adults in
the United States. Using the socioecological model, the association between social
isolation (dependent variable) with financial stress, health anxiety, and perceived impact
of COVID-19 (independent variable), and the influence of gender, race, and household
status on predicting the likelihood of social isolation were examined. This cross-sectional
analysis included results from 446 U.S. young adults aged 18-29 years old who
completed an online survey. Chi-square and ordinal logistic regression analyses showed
that the independent variables were predictors of social isolation. However, there were
negative associations when controlled for gender, race, and household status. This study
has implications for social change because it showed through the strength of association
whether financial stress, health anxiety, and perceived impact of COVID-19 are anxiety
risk factors for social isolation among young adults. Moreover, it indicated the need for
future studies of the association between the anxiety risk factors and social isolation to
determine whether financial stress, health anxiety, and perceived impact of COVID-19 is
causal for social isolation. These studies could lead to the development of public health
interventions that reduce and prevent social isolation and its associated outcomes such as
suicide and long-term mental health.

Anxiety Risk Factors and Social Isolation Among Young Adults
by
Jennifer S. Clancy
MPH, Grand Canyon University, 2015
BS, University of Mississippi, 2002
Dissertation submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Philosophy
Public Health
Walden University
August 2023
Dedication
This work is dedicated to my parents, Dorothy M. Swint, and Robert Swint.
Thank you for teaching me the value of education and being a guiding light to help me
accomplish my dreams.
To my husband, Lakendrick, thank you for your love, sacrifice, and motivation to
reach my full potential. I am forever grateful.
Lastly, to my children, Lakendrick Jr, Miley Jaye, and Jewel Belle, thank you for
your patience, unwavering support, and understanding my emotions and purpose to
achieve this goal. I hope I have instilled in you to have a passionate pursuit of knowledge.
Acknowledgments
This has been long, emotional, and challenging journey. I am so grateful for the
support and encouragement from my family, friends, and professors.
I would like to thank my Heavenly Father for blessing me with the focus, passion,
and skills to accomplish this incredible journey.
Thank you to my siblings, Robert and Stephanie for the laughs, support, and love.
An extra thanks to my sister for being a listening ear and reminding me to remain positive
and to celebrate my progress. Thank you to my niece, Ava Jade for sharing her patience
and love during the summer visits.
I would like to thank my network of support, including Dr. Kashley Brown and
Kenya Murray Morris for their generous help and kindness of being available for me to
share my ideas.
Lastly, I would like to thank Dr. Clarence Schumaker, my dissertation chair, for
his mentorship, compassion, valuable feedback, and encouragement. To my committee
members, I am sincerely grateful for the support and guidance provided to me
throughout this process.

Table of Contents
List of Tables ..................................................................................................................... iv
List of Figures ......................................................................................................................v
Chapter 1: Introduction to the Study....................................................................................1
Background of Study .....................................................................................................3
Problem Statement .........................................................................................................3
Purpose of the Study ......................................................................................................4
Research Questions and Hypotheses .............................................................................4
Theoretical Framework ..................................................................................................6
Nature of Study ..............................................................................................................6
Definitions......................................................................................................................7
Assumptions ...................................................................................................................7
Scope and Delimitations ................................................................................................8
Limitations .....................................................................................................................8
Significance....................................................................................................................8
Summary ........................................................................................................................9
Chapter 2: Literature Review .............................................................................................11
Literature Search Strategy............................................................................................12
Theoretical Framework ................................................................................................13
Microsystem.......................................................................................................... 14
Mesosystem........................................................................................................... 15
Exosystem ............................................................................................................. 15
i
Macrosystem ......................................................................................................... 16
Theoretical Connection to the Study............................................................................16
Literature Review Related to Key Variables and Concept ..........................................17
Anxiety Risk Factors among Young Adults ......................................................... 17
Social Isolation Among Young Adults ................................................................. 21
Anxiety Risk Factors and Social Isolation ............................................................ 22
Summary ......................................................................................................................23
Chapter 3: Research Method..............................................................................................25
Research Design and Rationale ...................................................................................25
Methodology ................................................................................................................26
Population ............................................................................................................. 26
Sampling and Sampling Procedures ..................................................................... 27
Data Collection, Confidentiality, and Management Procedures ........................... 28
Instrumentation and Operationalization of Constructs ......................................... 29
Data Analysis Plan ................................................................................................ 30
Threats to Validity .......................................................................................................35
Ethical Procedures .......................................................................................................36
Summary ......................................................................................................................36
Chapter 4: Results ..............................................................................................................37
Data Collection ............................................................................................................39
Baseline Descriptive and Demographic Characteristics of the Sample ................ 39
Statistical Assumptions ......................................................................................... 43
ii
Research Questions and Hypotheses .................................................................... 44
Summary ......................................................................................................................51
Chapter 5: Discussion, Conclusions, and Recommendations ............................................53
Interpretation of the Findings.......................................................................................53
Research Question 1 ............................................................................................. 53
Limitations of the Study...............................................................................................57
Recommendations ........................................................................................................58
Implications For Professional Practice and Social Change .........................................59
Conclusion ...................................................................................................................60
References ..........................................................................................................................61
Appendix A: Survey Questionnaire for PROMIS Social Isolation 6a ...............................72
Appendix B: Survey Questionnaire for Financial Anxiety Scale (FAS) ...........................74
Appendix C: Survey Questionnaire for Short Health Anxiety Inventory (SHAI) .............75
Appendix D: Survey Questionnaire for Perceived Impact of COVID-19 .........................77
Appendix E: Permission and Approval to Use Financial Anxiety Scale (FAS) ................78
Appendix F: Permission and Approval to Use Short Health Anxiety Inventory
(SHAI)....................................................................................................................79
Appendix G: Permission and Approval to Use PROMIS Social Isolation 6a ...................80
Appendix H: Permission and Approval to Use Perceived Impact of COVID-19..............80
iii
List of Tables
Table 1. Frequency Analysis for Gender .......................................................................... 40
Table 2. Frequency Analysis for Household Status ......................................................... 40
Table 3. Frequency Analysis for Race .............................................................................. 40
Table 4. Descriptive Statistics for Main Study Variables ................................................. 41
Table 5. Chi-Square Test (Gender and Social Isolation) .................................................. 42
Table 6. Chi-Square Test (Race and Social Isolation) ...................................................... 42
Table 7. Chi-Square Test (Household Status and Social Isolation) .................................. 42
Table 8. Collinearity Diagnostics ..................................................................................... 44
Table 9. Chi-Square Test (Financial Stress and Social Isolation) .................................... 45
Table 10. Chi-Square Test (Perceived Impact of COVID and Social Isolation) .............. 46
Table 11. Chi-Square Test (Health Anxiety and Social Isolation) ................................... 47
Table 12. Test of Parallel Lines ........................................................................................ 50
Table 13. Goodness-of-Fit ................................................................................................ 50
Table 14. Ordinal Logistic Regression Model Estimates ................................................. 51
iv
List of Figures
Figure 1. Image of Socio-ecological Model......................................................................14
v
1
Chapter 1: Introduction to the Study
The coronavirus disease 2019 (COVID-19) or SARS-CoV-2 is a contagious
disease that emerged in December 2019 and rapidly spread throughout the world. The
widespread of the virus led to a global pandemic, creating challenges and concerns about
the welfare of the world. In efforts to control and minimize the virus, the government
imposed social distancing and full lockdown restrictions on communities (Poudel et al.,
2022). The lockdown caused nonessential businesses and common gathering places such
as parks and churches to close. Research showed that COVID-19 caused a variety of
symptoms that could lead to prolonged illnesses (Poudel et al., 2022). For instance, the
virus caused pneumonia and could affect the respiratory system, resulting in possible
organ failure (Zhou et al., 2020). In addition to affecting organs and other body systems,
mental health could also be affected causing depression, anxiety, and sleep disturbance
(Zhou et al., 2020). Regarding mental health, the prevalence of anxiety and depression
increased by 25% globally during the first year of the COVID-19 pandemic (World
Health Organization [WHO], 2022). This increase prompted countries to look deeper into
mental health and the impact of COVID-19 on mental health. Research found that the
increase in stress was caused by social isolation during the pandemic. Loneliness,
financial worries, and losing loved ones were among the multiple stress factors that led to
anxiety and depression (WHO, 2022). WHO (2022) reported that women and young
people were significantly impacted by the pandemic and were excessively at risk of self-
harming and suicidal behaviors, which is associated with increased anxiety and
depression. According to the National Alliance on Mental Illness (NAMI, 2022), suicide
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is the second leading cause of death among teens and young adults. Young adults not
having the same connections during the pandemic, mentally and socially, as older adults
were cited as possible risk factors (Cohen, 2022). For example, anxiety increased among
young adults that were unmarried, had low income, and less educated (Goodwin et al.,
2020). In this study, I examined the association between anxiety risk factors (financial
stress, health anxiety, and the perceived impact of COVID-19) and social isolation.
Examining the impact of the above anxiety risk factors when it comes to social isolation
among young adults has several positive social change implications. First, contributing to
research on hard-to-reach young adults across the United States aged 18-29 by providing
a perspective not yet explored—particularly whether there is an association between
social isolation and financial stress, health anxiety, and perceived impact of COVID-19.
Secondly, it indicated the need for future studies to determine whether financial stress,
health anxiety, and perceived impact of COVID-19 is causal for social isolation. This
study can guide public health professionals to address the negative impact of anxiety risk
factors and social isolation among young adults with efforts of reducing and preventing
suicide and long-term mental health outcomes. In this chapter, I introduce the research
study by discussing the background and purpose of the study, and describing the problem
statement, research questions, and hypotheses. I also present the theoretical framework,
nature and significance of the study, and the assumptions, limitations, and scope of
delimitations.
3
Background of Study
Significant associations between loneliness, social isolation, and
anxiety/depression have been reported in older adults. Goodman et al. (2020) explained
that the increase of anxiety in young adults would be expected to have a greater impact
on longer-term mental health outcomes than the increase of anxiety in older adults. Smith
et al (2020) concluded that the linear association between age and mental health may be
disproportionately affecting young people during the pandemic. They suggested that
research was required to understand whether the association is due to declining economic
prospects or diminished social contacts. The gap is that there is limited research on
whether social isolation is associated with the anxiety among U.S. young adults during
the COVID-19 pandemic. Young adults aged 18-29 years old are in the key period of
vulnerability for the onset of mental health conditions and lead among other age groups
struggling with symptoms of anxiety and depression (United States Census Bureau,
2020). Anxiety is a precursor to the severity of many mental health conditions and is a
significant element of health-related quality of life during a pandemic (Clair et al., 2021).
Therefore, it is important to reduce anxiety among this age group to prevent longer-term
mental health outcomes in the future.
Problem Statement
Mental Health America (2021) explained that, before the COVID-19 pandemic,
poor mental health among adults increased by 19% (1.5 million individuals) in 2017-
2018 and the number of adults seeking for help with anxiety increased by 93% since
2019. It was concluded that 70% of those seeking help with moderate to severe
4
symptoms of anxiety or depression reported that loneliness or isolation contributed to
their mental health concerns. United States Census Bureau (2020) presented data
collected from the Household Pulse Survey, a rapid-response online survey used to
measure the social and economic impact of the COVID-19 pandemic on U.S. household.
Data showed that the age group of 18-29 years old lead in reporting symptoms of anxiety.
It was unknown whether the symptoms of anxiety were associated with the extended
social distancing required during the pandemic. In a study by Goodwin et al. (2020), it
was concluded that younger age groups with anxiety were at a higher risk of developing
longer-term mental health outcomes than older adults with anxiety. Data suggested that
mental health among young adults aged 18-29 is a public health concern. The effects of
social isolation, loneliness, and anxiety have been established in older adults, but research
lacks in the association between social isolation and anxiety in young adults, especially
during COVID-19.
Purpose of the Study
In this quantitative study, I examined the association between anxiety risk factors
and social isolation among young adults across the United States aged 18-29 years old.
The independent variables were financial stress, perceived impact of COVID, and health
anxiety and the dependent variable was social isolation. Covariates in this study were
gender, race, and household status.
Research Questions and Hypotheses
RQ1: To what extent is financial stress related to social isolation among young
adults during COVID-19?

5
H01: There is no relationship between financial stress and social isolation among
young adults during COVID-19.
H11: There is a relationship between financial stress and social isolation among
RQ2: To what extent is perceived impact of COVID related to social isolation
among young adults during COVID-19?
H02: There is no relationship between perceived impact of COVID and social
isolation among young adults during COVID-19.
H12: There is a relationship between perceived impact of COVID and anxiety
among young adults during COVID-19.
RQ3: To what extent is health anxiety related to social isolation among young
H03: There is no relationship between health anxiety and social isolation among
H13: There is a relationship between health anxiety and social isolation among
RQ4: To what extent do financial stress, perceived impact of COVID, and health
anxiety predict social isolation among young adults during COVID-19 controlling for
gender, race, and household status?
H04: There is no relationship between financial stress, perceived impact of
COVID, and health anxiety and social isolation among young adults during
COVID-19 while controlling for gender, race, and household status.

6
H14: There is a relationship between financial stress, perceived impact of COVID,
and health anxiety and social isolation among young adults during COVID-19
while controlling for gender, race, and household status.
Theoretical Framework
Since it has been well-established that COVID-19 has impacted the population in
many ways, I used the socioecological model (SEM) for the theoretical framework of this
study (see Sheinbein et al., 2019). SEM theorizes that numerous factors can affect or be
related to human development by focusing on interrelations among personal and
environmental factors (Sheinbein et al., 2019). Those factors could include social,
physical, and political factors that may exist in overlapping levels that influence each
other (Centers for Disease Control and Prevention [CDC], 2020). This theoretical model
is a good fit for investigating the association between social isolation and anxiety risk
factors since has been successfully utilized to address a range of health issues (CDC,
2020). I offered a more detailed description of this model in Chapter 2.
Nature of Study
The study was a quantitative cross-sectional analysis with the use of primary data.
The sample was American young adults, across the United States, aged 18-29. They
responded to an online survey, which was accessed via social media and flyer. The
design of this study was a cross-sectional analysis which allowed the computation of
ordinal logistic regression to detect the strength of association between the variables
under study. The independent variables were financial stress, health anxiety, and
perceived impact of COVID-19. The dependent variable was social isolation. The
7
covariates were gender, race, and household status. A thorough description of the
methods used in this study was presented in Chapter 3.
Definitions
Anxiety: Feelings of tension, worried thoughts, and physical changes (American
Psychological Association [APA], 2022).
COVID-19: An infectious disease caused by the SARS-CoV-2 virus. Also
recognized as coronavirus (WHO, 2022).
Financial Stress: Occurs when financial and/or economic events create anxiety,
worry, or a sense of inadequacy, and is accompanied by a physiological stress response
(Financial Health Institute, 2022)
Gender: Defined as either male or female.
Health Anxiety: Having excessive worry and fear of being sick or getting sick
with illness (Kosic, 2020).
Race: A person’s identification with one or more racial groups (United States
Census Bureau, n.d.).
Social Isolation: The objective absence of contacts and interactions between a
person and a social network (Gardner et al., 2018).
Assumptions
The first assumption in this study was that anxiety among young adults during the
pandemic is a serious public health concern and one that is worth investigating. My
second assumption was that participants would have experienced some level of anxiety
during the COVID-19 lockdown. The third assumption was that participants would be
8
able to recall their experience during the pandemic lockdown and provide honest and
accurate answers. These assumptions were addressed by collecting data from a
substantial sample size to reduce any negative outcomes in this study.
Scope and Delimitations
This study included American young adults (18-29 years) across the United States
population. Participants had to be able to read English well enough to take the survey. I
examined anxiety risk factors and social isolation during the COVID-19 pandemic. I
developed the survey using existing survey tools for social isolation, financial stress,
health anxiety, and perceived impact of COVID-19 (see Appendix A, Appendix B,
Appendix C, and Appendix D). It was accessible via social media and flyer.
Limitations
A potential barrier was not having the measurement of anxiety before the
COVID-19 lockdown and physical distancing measures were directed. Therefore, change
in anxiety cannot be assessed other than from current and self-reported change. Another
barrier was recruiting enough participants among the ages 18-29 years old to reach the
power sample needed. A challenge in surveying this age group was getting them to
complete the survey in its entirety (Canilang et al., 2020). Limitations were expanded
once the research was conducted and completed.
Significance
Findings from this study provided vital insights on whether financial stress,
perceived impact of COVID, and health anxiety predict social isolation among young
adults in the United States. This research has the potential to impact positive social
9
change in the United States by providing key information for decision making and
planning to reduce anxiety among this age group to prevent suicide and longer-term
mental health outcomes in the future. The results of this study may be useful for
identifying and making connections between the anxiety risk factors and social isolation
among young adults. Identifying these connections will be beneficial for improving
awareness and interventions within the communities. The results are also beneficial for
closing a gap in the current literature and providing a need for future studies to determine
the casual relationship between the anxiety risk factors and social isolation among the
young adult population.
Summary
Anxiety has been established to be associated with social isolation, suicide, and
long-term mental health illness. Studies show that anxiety has increased among young
adults during the COVID-19 pandemic lockdown, but limited research exists on the
associations of anxiety risk factors and social isolation among the age group. In this
quantitative cross-sectional study, I explored three anxiety risk factors and social
isolation among U.S. young adults using an online survey developed from existing survey
tools. The independent variables were financial stress, health anxiety, and perceived
impact of COVID-19. The dependent variable was social isolation. The covariables were
gender, race, and household status. Chapter 1 provided a synopsis of the study. Chapter 2
presented a thorough review of the literature pertaining to the association of anxiety risk
factors and social isolation, the theories available to support or disprove this relationship,
and the methods used to obtain the literature reviewed. Chapter 3 presented the methods
10
used to conduct the study. Chapter 4 presented the results of this research and Chapter 5
provided a comprehensive discussion of the interpretation of the data, including the study
limitations and potential social implications of this research.

11
Chapter 2: Literature Review
There is an increasing concern of poor mental health among young adults,
especially during the COVID-19 pandemic (Mental Health America, 2021). The physical
distancing policies introduced to control COVID-19 were associated with the emergence
of increased feelings of loneliness and social isolation during the COVID-19 pandemic
(Smith et al., 2020). Mental Health America (2021) concluded that 70% of those seeking
treatment with symptoms of anxiety or depression reported that loneliness or isolation
contributed to their mental health concerns. During the pandemic, data from the 2020
National Survey on Drug Use and Health (NSDUH) showed that the number of adults
living with any mental health illness increased to 21% by 2020. The prevalence of mental
illness was found to be higher in young adults aged 18-29 years old compared to the other
age groups (National Institute of Mental Health, 2022).
The literature has identified common anxiety risk factors as well as the
association between social isolation and long-term mental illness (Goodwin et al., 2020).
It has also been established that it is unknown whether symptoms of anxiety among
young adults are associated with social isolation (United States Census Bureau, 2020).
These findings prompted the need to address the association between anxiety risk factors
and social isolation among young adults, since social isolation has been linked to long-
term mental illness and suicide risk (Catali et al., 2019). The SEM was appropriate to use
to investigate the interaction between anxiety risk factors and social isolation across
individual, relationship, community, and societal levels of young adults. In this chapter,
12
the literature search strategy, theoretical framework, theoretical connection to this study,
and review of key variables were discussed.
Literature Search Strategy
The literature presented in this chapter supports the proposed quantitative research
and relevant studies on anxiety risk factors and social isolation among young adults. I
used the Walden University Library to access literature for this research study. The
multidisciplinary databases that I searched were APA Psych Info, Medline, Google
Scholar, EBSCOHost, ProQuest, Thoreau, and Academic Search Complete. I searched
for peer-reviewed articles published between the years of 2017 to 2022 and used the
following keywords: anxiety, anxiety risk factors, social isolation, ostracism, loneliness,
and mental health. Combinations of keywords included “young adults and anxiety,”
“anxiety and social isolation,” social isolation and young adults,” “anxiety risk factors
among young adults”,” social isolation among young adults,” “mental health among
U.S young adults,” and “mental health and COVID-19”. Searches were also completed
for the additional variables in the study. Keywords included in the search were financial
stress and social isolation among young adults, health anxiety and young adults, health
anxiety and social isolation among young adults, impact of COVID-19 among young
adults, and perceived impact of COVID-19 and social isolation among young adults.
Government websites and databases such as National Institute of Mental Health, CDC,
Mental Health America, and the United States Census Bureau were included in locating
data from published reports. The literature search focused on the most recent and relevant
13
studies published within the last 5 years. Older research studies are included due to their
relevance to the research interest of this study.
Theoretical Framework
SEM was used to address the research questions in this study. The SEM is a
theory-based framework developed by Bronfenbrenner to understand various factors that
can affect or be related to human development by focusing on interrelations among
personal and environmental factors (Sheinbein et al., 2019). The model theorizes that
human development is influenced by the interaction between the characteristics of the
individual, the community, and their environment which includes social, physical, and
political factors (Sheinbein et al., 2019). The construct of health has since been
conceptualized in the SEM and successfully used to address a range of health issues and
the effectiveness of preventive strategies (CDC, 2022). Woodgate et al. (2020) explained
that the SEM served as a framework to examine and understand factors associated with
anxiety and depression symptoms. The use of the SEM in my study served as a
framework to investigate the interplay among anxiety risk factors within and between the
various levels and their role on social isolation.
The SEM is a four-tier model that focuses on the interaction between individual,
relationship, community, and societal factors (CDC, 2020). The model emphasizes that
health is affected by various factors that exist in overlapping levels which influence each
other at another level (Figure 1). The SEM is structured into four systems: microsystem,
mesosystem, exosystem, and macrosystem.

14
Figure 1
Image of Socioecological Model
Note. From “Applying a Socio-Ecological Framework to Thematic Analysis Using a
Statewide Assessment of Disproportionate Minority Contact in the United States” by D.
X. Henderson and T.D. Baffour, 2015, Qualitative report, 20(12), p. 1963.
(https://doi.org/10.46743/2160-3715/2015.2405)
Microsystem
The microsystem is the first and innermost level of the SEM (Kilanowski, 2017).
It contains the individual and their immediate surroundings of strong interactions,
relationships, and influences such as parents, siblings, and teachers. Those interactions,
relationships and influences are direct and bi-directional contacts with the individual and
are crucial for fostering the individual’s development (Kilanowski, 2017). This means
that the individual can be influenced by the people in their immediate surroundings and
15
can also influence them as well. In addition, the reaction of the individual to the people in
their microsystem can also influence how they treat them in return (Guy-Evans, 2020).
Mesosystem
The mesosytem is the second level of the SEM and focuses on the
interrelationships among the microsystems of the individual’s life (Guy-Evans, 2020).
For example, the relationship that the individual has at home can impact the relationship
that they have at school and vice versa (Campos-Gil, 2020). In this example, the
microsystem consists of the individual’s classroom, classmates, and teacher while the
mesosystem is composed of the school, student body, and staff. The interactions between
the settings (home and school) can directly affect the individual and his/her behavioral
and educational outcomes. Crawford (2020) explained that mesosystems are created by
how microsystems (e.g., home and school) interact.
Exosystem
Exosystem is the third level of the SEM and shares similarities with the
mesosystem. It is made up of microsystems that interact with each other but excludes the
individual from one of the microsystems (Crawford, 2020). The interaction among the
microsystems does not directly impact the individual but does influence them in a
positive or negative way. An example of an individual’s exosystem would be a parent’s
workplace. The individual is not included in this setting but could be indirectly affected
by the long hours worked by the parent.

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Macrosystem
The macrosystem is the outermost level of the SEM. This level includes all the
elements contained in the microsystem, mesosystem, and exosystem (Guy-Evans, 2020).
Additionally, it involves cultural, religious, and societal values and influences that affect
an individual. Legal systems, political systems, nationality, economic conditions, and
taboos are examples of macrosystems (Guy-Evans, 2020). In this level, an individual
living in a low-income country might develop differently than an individual living in a
high-income country.
Theoretical Connection to the Study
The SEM was appropriate for this study since it focuses on different factors that
affect health. The SEM conceptualizes that health is affected by the interactions between
the individual, the community, and the physical, social, and political environments (CDC,
2015). The framework is well-established and has been commonly used to analyze the
multidimensional interactions among individuals and their social settings across various
levels (Ramey-Moore et al., 2021). The application of the SEM to understand and address
mental health at socioecological levels has introduced new modalities (Ramey-Moore et
al., 2021). Research showed that mental health may be related to or caused by the
reactions from environmental stressors, genetics, head injuries, or biochemical
imbalances (Singh et al., 2019). The socioecological perspective offers a concept for
organizing and evaluating health-promotion interventions for mental health by
simultaneously examining the individual, the systems, and the interplay between the
systems. In this study, I applied the SEM as a theoretical framework to examine the
17
association between anxiety risk factors and social isolation among young adults across
the four systems: microsystem, mesosystem, exosystem, and macrosystem.
Literature Review Related to Key Variables and Concept
The key concept explored in this study was the association between anxiety risk
factors and social isolation among young adults. The key variables investigated were
anxiety risk factors (financial stress, health anxiety, and perceived impact of COVID-19)
and social isolation. The prevalence of anxiety among adults increased during the
COVID-19 pandemic, particularly for young adults aged 18-29 years old (Jia, 2022). The
isolation of the pandemic worsened social disconnection among the age group as reports
of anxiety and loneliness increased. The effects of social isolation, loneliness, and anxiety
have been established in older adults, but research is limited in the association between
social isolation and anxiety in young adults, especially during COVID-19 (Goodwin et
al., 2020).
Anxiety Risk Factors among Young Adults
Anxiety has been associated with mortality and as a strong predictor of negative
health outcomes (Goodwin et al., 2020). It is an internalizing disorder characterized by
subjective feelings of nervousness and worry, apprehension, tension, and changes to the
autonomic nervous system (Spielberger, 2022). According to Mental Health America
(2022), anxiety disorders are among the most common mental illnesses in the United
States. Anxiety among young adults aged 18-29 has become a serious public health
concern with the significant increase of anxiety during the COVID-19 pandemic. In a
study based on U.S. Census Bureau Household Pulse Survey (HPS) data, adults aged 18
18
and older reported symptoms of anxiety and depressive disorders during the months of
the pandemic (August 19, 2020–February 1, 2021; Jia, 2021). Findings from the HPS data
showed the largest increase were among young adults aged 18-29 years old and those
with less than a high school education (Jia, 2021). It is important to understand the time
period of vulnerability for anxiety among young adults. It can be challenging for some as
they transition into adulthood with variables that may affect their mental health as they
reach their developmental competencies. Variables that may influence mental health in a
negative way are called risk factors (American Mental Wellness Association, 2022). In
my study, risk factors were identified to address the problem of elevated anxiety among
young adults. Financial stress, health anxiety, and perceived impact of COVID-19 were
the risk factors identified in the literature. These risk factors were examined based on
four domains of SEM (microsystem, mesosystem, exosystem, and macrosystem).
Financial Stress
The COVID-19 pandemic had a huge economic impact on adults within the
United States. In a study by Hasler et al. (2021), young adults were three times more
likely to report stress due to financial difficulty during the pandemic than older adults.
This possibly could have been the first time some young adults experienced financial
uncertainties. Hasler et al. (2022) also found that 91% of the young adults surveyed in the
study reported stress experienced about their financial uncertainties had a negative impact
on their mental health. Tran et al. (2018) examined the association between financial
stress and anxiety among 304 college students and concluded that financial stressors were
linked to mental health issues such as anxiety and depression. Over the past 2 decades,
19
literature has shown a focus on the association between financial stressors and mental
health disorders such as anxiety on individual and societal levels. Mofatteh (2020)
conducted a study to identify risk factors associated with stress, anxiety, and depression
among undergraduate students in developed and developing countries. One conclusion
was that financial stressors such as the lack of adequate financial support, poverty, and
low family income during childhood were risk factors of stress, anxiety, and depression
(Mofatteh, 2020). A study supported by National Institutes of Health (NIH) found that
individuals exposed to stressors (as mentioned above) during childhood were most likely
to report elevated levels of anxiety when confronted with a stressful life event during
young adulthood, such as the COVID-19 pandemic (Simon, 2021).
Health Anxiety
Health anxiety is described as having excessive worry and fear of being sick or
getting sick with illness (Kosic, 2020). To some degree, most people experience health
anxiety which can positively affect their health by their early detection of health issues,
encouraging healthier behaviors. On the other hand, health anxiety can be detrimental
when it is excessive. In a study by Kosic (2020), the difference between low and high
levels of health anxiety were explained based on contemporary cognitive-behavioral
models. The models suggested that the misinterpretation of body sensations and changes
as dangerous tends to occur with people who experience high levels of health anxiety.
Those misinterpretations also contribute to their elevated anxiety. For example, in the
context of COVID-19, people with high health anxiety are likely to misinterpret any
20
bodily sensations or changes as being infected with the virus. This, in return, increases
their anxiety.
Haig-Ferguson (2021) discussed health anxiety among young adults during the
COVID-19 pandemic as a risk factor. Research showed that college students that had
anxiety sensitivities before the pandemic experienced an increase in health-related
worries. Health anxiety tends to increase in those that experienced watching someone in
their personal or social network suffer or die from a serious disease (Haig-Ferguson,
2021). Literature showed that the internet use has also increased health anxiety and
anxiety levels among young adults. A study conducted to investigate the effect of
COVID-19 on health anxiety and cyberchondria levels among 794 students found that
health anxiety was higher in students who frequently used the internet to gain health
information on COVID-19 (Kurcer et al., 2021). Kurcer et al. (2021) explained that
cyberchondria is the excessive and repetitive search of online health information with
hopes of reducing health anxiety. Instead, anxiety and fear are increased from the
information gathered and from the spread of excessive and false information of the virus.
Perceived Impact of COVID-19
There is limited research on the perceived impact of COVID-19 among young
adults, particularly in the United States. In this study, the perceived impact of COVID-19
was measured by asking to what extent has the situation with COVID-19 affected the
way of life. It was necessary to include perceived impact of COVID-19 as an anxiety risk
factor because of the lack of focus in research as well as a chance to measure the
perceptions of young adults toward the major disruption of work and daily life caused by
21
COVID-19. Tull et al. (2020) examined the association of psychological outcomes and
perceived impact of COVID-19 on daily life among a sample of 500 U.S adults.
Researchers found that the perceived impact of COVID-19 was positively associated with
elevated anxiety and worry about health and finances (Tull et al., 2020). In a similar
study, Cao et al. (2020) investigated the psychological impact of COVD-19 on 7143
undergraduate students in China. The perceived impact of COVID-19 was alternately
measured by economic stressors, effect on daily life, and academic delays. Findings
concluded that they were positively associated with anxiety symptoms.
Social Isolation Among Young Adults
One essential component of human life is having a social network. A positive
social network provides support and guidance, which can influence health outcomes of an
individual. When social networks are absent, social isolation occurs. Social isolation is
defined as the objective absence of contacts and interactions between a person and a
social network (Gardiner et al., 2018). Shvedko et al. (2018) described social isolation as
the lack of belonging socially and engaging with others, having minimal number of social
contacts, and are deficient in quality relationships. Clair et al. (2021) explained that
external isolation refers to the frequency of contact or interactions with other people,
while internal or perceived social isolation refers to the person’s perceptions of loneliness
and satisfaction with their relationships. This distinction is important to understand
because a person can experience being isolated or lonely even when they have frequent
contact with other people and conversely may not feel isolated or lonely when their
contact with others is limited (Clair et al., 2021).

22
Literature explained that the exposure to social isolation can have a long-term
negative effect on mental health over time. Some negative health outcomes related to
social isolation include depression, anxiety, stress, and insomnia (Robb et al., 2020).
Social isolation has been recognized as one of the main risk factors associated with
suicidal outcomes (Catali et al., 2019). In a narrative review of literature by Catali et al.
(2019), social isolation (objectively and subjectively) was strongly associated with
suicidal outcomes.
Anxiety Risk Factors and Social Isolation
The COVID-19 pandemic forced a crucial implementation of unprecedented
“social distancing” procedures to limit the spread of the virus. In addition to the social
distance procedures, those who had been exposed or infected with the virus were required
to quarantine and isolate themselves from the general population to reduce to the
transmission of COVID-19. Since the restrictive measures of the pandemic, evidence has
emerged with a focus on the increase of poor mental health outcomes such as anxiety and
depression. Literature showed that there is an established association between poor
mental health outcomes and social isolation for the older populations, while research is
limited regarding young adults in the United States. Christiansen et al. (2021) examined
data from 2017 Danish Health and Morbidity Surveys to determine the associations and
the effects of age and gender between loneliness, social isolation, poor physical, and
mental health among adolescents and young adults. Findings indicated that loneliness and
social isolation among adolescents and young adults were strongly associated with
mental health problems. Adolescents and young adults who feel lonely experienced
23
poorer physical and mental health, while socially isolated individuals experienced poorer
mental health. This study provided evidence that young socially isolated adults
experienced poor mental and physical health outcomes. Smith et al. (2020) explained that
there is a linear association between age and mental disproportionately affecting young
people during the pandemic. Researchers explored the impact of COVID-19 self-
isolation/social distancing on the mental health among a sample from the United
Kingdom (UK) population and found that high levels of anxiety and depression and low
levels of mental health were reported while under the governmental requirement of self-
isolation/social distancing during the COVID-19 pandemic. Results showed that younger
females (smokers, low income, and with physical multimorbidity) were associated with
higher levels of poor mental health (Smith et al., 2020). In a similar study, Hubbard et al.
(2021) found that younger adults, especially women and those living in the most deprived
areas have greater anxiety and depression. Social and psychological risk factors
influencing mental health in Scotland during COVID-19 pandemic were investigated and
data showed that young adults living in socioeconomically deprived communities
experienced higher levels of anxiety.
Summary
Poor mental health among young adults has become a growing public health
concern. Young adults are reporting elevated levels of anxiety and leading in suicide rates
since the onset of COVID-19 (Cohen, 2022). During the COVID-19 pandemic, the need
for social distancing has exacerbated the isolation of many older adults and exposed
younger adults to a similar experience of isolation. Evidence has established that social
24
isolation is strongly associated with poor mental health outcomes among older adults
(Malcolm et al., 2019). Similar studies conducted with young adults also established that
socially isolated individuals experience poor mental health outcomes such as anxiety
(Smith et al., 2020). Despite of the evidence, research remains limited among young
adults in the United States. It is important to address the increase in anxiety among young
adults by identifying risk factors and examining their association with social isolation
during COVID-19. Key information for decision making and planning to reduce anxiety
among this age group to prevent longer-term mental health outcomes in the future are
needed. Findings from my research study may provide vital insights on whether the
anxiety risk factors (financial stress, perceived impact of COVID, and health anxiety)
predict social isolation among young adults.
To address this gap, a quantitative research approach was used to examine the
association between anxiety risk factors and social isolation. This research design was
used to pinpoint the association between financial stress, perceived impact of COVID,
and health anxiety and social isolation during the COVID-19 lockdown among young
adults. Chapter 3 discussed the research method used to answer the research questions.
Additionally, the population, sampling procedures, data collection, and data analysis plan
were discussed.
25
Chapter 3: Research Method
In this quantitative cross-sectional study, I explored the association of anxiety risk
factors and social isolation among young adults across the United States. Covariates in
this association were included and a multivariable analysis was conducted to examine the
association. In this chapter, I explain the research design that was employed and my
reasoning for selecting this design. Further, the methodology to conduct the study
including the population, sampling procedures, data collection processes, and the data
analysis plan is provided. In addition, I examine the potential threats to validity and
provided the ethical procedures used in this research.
Research Design and Rationale
The dependent variable was social isolation. The independent variables were the
anxiety risk factors (financial stress, perceived impact of COVID, and health anxiety).
The covariates were gender, race, and household status. A cross-sectional design was
used in this study to examine the association between the variables. Cross-sectional
designs are observational study designs that look at data (exposure and outcome) from a
population at one point in time and are mainly used to investigate the prevalence of a
disease (Wang & Cheng, 2020). This design is ideal for this study because self-reported
anxiety risk factors and social isolation would be examined among a sample of U.S.
young adults during the COVID-19 lockdown. The cross-sectional design was also
appropriate for this study because it enabled me to understand the prevalence or high
frequency of the anxiety risk factors and social isolation among young adults across the
United States. When deciding which methodology to use, cross-sectional was the primary
26
choice because of the time and inexpensive benefits it offers. Another observational
research design that I considered was the cohort design. A cohort design involves
comparing two groups of subjects based on their exposure to a particular risk factor over
a long period of time. This design can be conducted from a prospective (forward-looking)
or retrospective (backward-looking) viewpoint of data (Barrett & Noble, 2019). The
cohort design was ruled out as a methodology for my study because of the amount of
time and funding that would be necessary to complete the longitudinal study. For
example, the cohort design would have been ideal for my study if I wanted to investigate
anxiety risk factors and social isolation among two groups of young adults over a long
period time. This methodology would have provided me with a great amount of exposure
data from young adults who are not experiencing anxiety risk factors during COVID-19
and later follow up with them in the future and examine whether those experiencing
anxiety risk factors during COVID-19 were more likely to become socially isolated.
Methodology
Population
The target population was young adults aged 18-29, living in the United States
during the COVID-19 pandemic. The United States is comprised of approximately 331
million people (United States Census Bureau, 2021). Participants in this study were
recruited via social media, flyer and by the snowball sampling method. Any young
American adult, living in the United States, from the ages of 18-29 years old was eligible
to voluntarily participate in this survey.

27
Sampling and Sampling Procedures
Data was collected via online surveys. Participants were provided with a survey
link from those who shared the research study on their social media platforms.
Participants entered their answers on their own. Security measures were in place to
ensure the participants that their identity and answers would remain anonymous. The
survey excluded people under the age of 18 and over the age of 29 as well as U.S.
citizens living in foreign countries. I performed a power analysis to determine the sample
size needed for this study. The GPower software is a free, online software tool that
allows the implementation of various types of power analyses (Kang, 2021). Sample size
calculators are also available online to compute the minimum samples needed to satisfy
desired statistical constraints in a research study (Calculator.net, 2022). For this study, an
online sample size calculator was used to determine the sample needed. The commonly
used confidence level of 95% was entered into the calculator, along with a 5% margin of
error. The population proportion was 50% as suggested by the calculator. The population
size was left blank as an indication for unlimited population size. Computations resulted
in a minimum of 385 participants needed to conduct this study (see Calculator.net, 2022).
To adjust for possible constraints such as the lack of completed surveys, I increased the
calculated sample size to a minimum of 400 participants. Compensation or other
incentives were not provided to encourage respondents to participate in the online survey.
As part of the sampling procedure, I recruited young American adults across the
50 states of the United States ranging from the ages of 18-29 years old to voluntarily
participate in the research study. This was done by using social media, flyers, and the
28
snowball sampling method. The snowball sampling method relied on sampled
participants to make referrals to those who may also share interest in the research study
(Atlas et al., 2021). For my study, the snowball sampling method involved sending the
survey link to a broad group of young adult contacts and to those who initially sampled to
request that they share the link with other participants that would be interested in
participating in the study.
Data Collection, Confidentiality, and Management Procedures
I recruited participants via social media, flyer, and the snowball sampling method.
Flyers included the purpose of the study, criteria for eligible participants, how the data
would be used, and a QR code and link to access the online survey. The flyers were
posted on my social media platform (Facebook) and inside of local businesses, with the
owners’ permission. My professional and personal groups on Facebook were asked to
share my flyer with those that meet the criteria as participants and with those that are
interested in my research study. Participants were able to scan the QR code or click the
survey link to access the consent form and survey. Data was collected anonymously
using SurveyMonkey, a password protected platform. Participant anonymity was ensured
by using the data security options available on the platform. I performed this by selecting
the anonymous response option and deselecting the save IP address option. Data was
collected and downloaded onto Microsoft Excel after the completion of the study. The
study link was then deactivated and deleted. Data was stored on my password-protected
laptop and USB flash drive and will be destroyed after 5 years. Participants were
29
informed of the anonymity of the survey and their protection as a participant during the
consent form of the survey (Walden IRB approval no. 01-20-23-0746378).
Instrumentation and Operationalization of Constructs
The independent variables were financial stress, perceived impact of COVID, and
health anxiety. As noted above, a survey needed to be designed to gather the specific data
points. Several survey instruments existed for measuring social isolation and the
independent variables in this study. The Patient-Reported Outcomes Measurement
Information System (PROMIS) developed a four-item scale to assess perceptions of
being avoided, excluded, detached, disconnected from, or unknown by others (Primack et
al, 2017). This tool was used to assess social isolation on a 5-point Likert scale ranging
from 1 to 5, corresponding to responses of never, rarely, sometimes, often, and always.
Raw scores for social isolation range from 4 to 20, with each item scored from 1 to 5 (See
Appendix A). The Financial Anxiety Scale (FAS) developed by Archuleta et al (2013)
was used to measure financial stress. This scale was designed based on criteria from the
General Anxiety Disorder-7 item scale (GAD-7) to specifically measure an individual’s
tendency to worry about his/her finances (See Appendix B). The FAS consists of seven
items on a 7-point Likert-type scale, ranging from 1 (never) to 7 (always) ( Basyouni et
al., 2021). Health anxiety was measured using the Short Health Anxiety Inventory
(SHAI), developed by Salkovskis et al. (2002). It is an 18-item self-reported scale
designed to assess an individual’s worry about health (See Appendix C). Health anxiety
was based on the sum of the point values of each of 18 items (Tull et al., 2020). The
perceived impact of COVID was measured by single item using a 5-point Likert-type
30
scale ranging from 1 (no impact at all) to 5 (impacted my life a great deal; Robb et al.,
2020; See Appendix D). Approval letters to use survey tools, FAS, (SHAI, PROMIS
Social Isolation 6a, and Perceived Impact of COVID-19 can be found in Appendix E, F,
G, and H, respectively. With the approval to use the four survey tools, I developed the
survey instrument for my study by combining the four survey tools into one questionnaire
in SurveyMonkey to be distributed among young adults (18-29 years old) to voluntarily
participate.
Data Analysis Plan
I began collecting data from each participant in the study by using the survey
instrument developed in SurveyMonkey to measure financial stress, perceived impact of
COVID, health anxiety, and social isolation. Data was transferred to the Microsoft Excel
spreadsheet for the data cleaning process. I coded each variable by using an alpha
numeric code for each variable and item. For example, financial stress was coded as FS1,
FS2, FS3, and so forth. Coding was composed of the first two letters of the variable and a
number to represent each item. The total score for each variable was represented by TL.
For instance, the total score for financial stress was coded as FSTL. This process of
coding created a dataset that was examined by univariate, bivariate and multivariate
analyses using the SPSS Version 28 software. The independent variables (financial stress,
perceived impact of COVID, and health anxiety) were ordinal levels of measurement, so
the descriptive statistics were minimum, maximum, mean, and standard deviation. The
dependent variable (social isolation) also had an ordinal level of measurement. The
descriptive statistics were minimum, maximum, mean, and standard deviation. The levels
31
of measurement for the covariates (gender, race, and household status) were nominal.
Therefore, the descriptive statistics for them were frequencies and percentages.
The inferential statistics for the research questions were bivariate and multivariate
analysis. The bivariate analysis for the independent variables (financial stress, perceived
impact of COVID, and health anxiety) and the dependent variable (social isolation) in
research questions 1-3 were the Pearson Chi-square test because these variables were
categorical. The Pearson Chi-square test was also used to analyze the relationship
between the covariates (gender, race, and household status) and the dependent variable
(social isolation). I included the covariates because they can influence the relationship
between the independent and dependent variables. Including the covariates in the
analyses was important to control their impact on the dependent variable, which can
increase statistical power and reduce bias (Frost, 2023). The multivariate analysis for the
dependent, independent, and covariate variables in research question 4 was ordinal
logistic regression because the dependent variable had an ordinal level of measurement.
The assumptions of the ordinal logistic regression model had to be met to ensure
the validity of the model (Sesay et al., 2021). The assumptions include that the dependent
variables are ordered, one or more of the independent variables are continuous,
categorical or ordinal, no multicollinearity, and the existence of proportional odds (Sesay
et al., 2021). Multicollinearity is a type of disturbance that occurs in the data when
multiple independent variables are correlated with each other (Sesay et al., 2021). I used
the variance inflation factor (VIF) statistic to determine whether multicollinearity existed.
To evaluate the proportional odds, I used the test of parallel lines. Proportional odds
32
means that the independent variables have identical effects at each level of the dependent
variable (Sun et al., 2018). The test of parallel lines shows whether the assumption of
proportional odds has been satisfied or violated through statistical significance (National
Centre for Research Methods, 2022).
Data Screening and Cleaning
Data screening and cleaning involved verifying the answered surveys for
completeness. I checked the scores for each variable that were out of range or missing.
Errors were managed by using the imputation method. Missing data can decrease the data
quality and reliable techniques such as imputation should be used to maintain the
completeness in a dataset (Khan et al., 2020). All surveys that contained 1-2%
completion was excluded from data analysis using listwise deletion. The techniques were
used to reduce the influence of missingness in this study (Khan et al., 2020). Completed
surveys were included in data analysis and in the results of the study. Once the data
cleaning was completed, I transferred the dataset to the SPSS software for data analysis.
Research Question and Hypotheses
The primary objective of this research study was to investigate the association
between anxiety risk factors and social isolation among young U.S adults aged 18-29
years old. Financial stress, health anxiety, and the perceived impact of COVID-19 were
the risk factors examined individually to determine whether there is an association with
social isolation. Lastly, associations were examined between the three anxiety risk factors
and social isolation while controlling for gender, race, and household status. The
33
following research questions and associated hypotheses (H0 = null hypothesis, H1 =
alternative hypothesis) were used in my research study:

34
RQ4: To what extent do financial stress, perceived impact of COVID, and health
COVID, and health anxiety and social isolation among young adults during COVID-19
and health anxiety and social isolation among young adults during COVID-19 while
controlling for gender, race, and household status.
Statistical Analysis Plan
The statistical analysis plan began with conducting descriptive analysis of the
dataset. Descriptive analysis of all the items presented in the survey were expressed using
tables and figures. For research questions 1-3, I conducted a chi-square test of
independence to examine the association between the categorical ordinal variables of
financial stress, health anxiety, perceived impact of COVID-19 and social isolation.
Nihan (2020) explained that the chi-square test is a commonly used statistic to evaluate
the hypothesis that there is no correlation among two categorical variables in a single
population and whether there is a significant association between the two variables. The
analysis of research questions 1-3 lead up to employing an ordinal regression model in
which the three independent variables were entered into analysis to predict social
isolation. For research question 4, the ordinal regression statistical model was conducted
to analyze the hypothesis and answer the research question. The key output of the ordinal
35
regression model included the p-value, the coefficients, the measures of association, and
the log-likelihood (Bürkner et al., 2019). This model was appropriate to use in my study
to determine whether the association between the response and the items in the survey are
statistically significant. For instance, I used the ordinal regression model to evaluate to
what extent do financial stress, perceived impact of COVID, and health anxiety predict
social isolation among young adults during COVID-19 controlling for gender, race, and
household status. The null hypothesis stated that there is no relationship between
financial stress, perceived impact of COVID, and health anxiety and social isolation
among young adults during COVID-19 while controlling for gender, race, and household
status, whereas the alternative hypothesis stated that there is an association. If the p-value
was .05 or less, the model was concluded as significant and the null hypothesis was
rejected, thereby accepting the alternative hypothesis. If the p-value was greater than .05,
the null hypothesis was retained, and the alternative hypothesis was deemed false. Lastly,
the research questions were addressed using the results of the analysis.
Threats to Validity
Validity of a research study is defined as how well the results among a study
population can be applied to a real-world setting (Patino et al., 2018). In my research
study, unknown confounders and the self-reporting design of the survey could pose a
threat to the internal validity of the study. Participants of the study could report
inaccurate data due to their lack of knowledge of the terms used in the survey questions
or their inability to recall their feelings or symptoms during the pandemic lockdown. To
36
increase internal validity, I made sure that the sample size, data collection, and data
analysis were carefully planned and adequate enough for this study.
Ethical Procedures
All data was protected and held in confidentiality along with the approval of the
Institutional Review Board (IRB). Data of the participants was anonymous and therefore
participants could not be identified. Data was password protected on my data storage and
will be destroyed 5 years after completing the study. Participants were provided with an
information sheet to read and sign to offer their consent of understanding and agreeing to
participate in the research study. Participants understood that data collected in this
research study was for statistical reporting and analysis purposes to satisfy the
dissertation requirements of obtaining the Doctor of Philosophy at Walden University.
Summary
In this chapter, I discussed the methodology, threats to validity, and the ethical
procedure of my research study. The methodology covered the sample population,
sampling procedures, data collection and confidentiality process, instrumentation and
operational constructs and the data analysis plan. The threats to validity and how those
threats could be prevented or limited were presented. Lastly, the ethical procedures were
discussed. Chapter 4 presented the results of the data analysis, including descriptive data
of the participants, results of the chi-square tests and ordinal regression model, and
appropriate data tables and figures.

37
Chapter 4: Results
In this quantitative cross-sectional study, I explored the association between
anxiety risk factors (financial stress, health anxiety, and perceived impact of COVID) and
social isolation in U.S. young adults. I also included covariates involved in this
relationship. I used several statistical tests to identify associations between the variables,
and concluded the study with a multivariable logistic regression analysis to create a
model that would attempt to predict the likelihood of social isolation. The dependent
variable was social isolation. The independent variables were financial stress, health
anxiety, and perceived impact of COVID. The covariates were gender, race, and
household status. The primary research objective was to examine the association between
anxiety risk factors and social isolation. The secondary objective for this study was to
identify if the covariates are confounders for the potential association between the anxiety
risk factors and social isolation. The following research questions and associated
hypotheses (H0= null hypothesis, H1 = alternative hypothesis) used to guide this study
were:

38
RQ 4: To what extent do financial stress, perceived impact of COVID, and health
COVID, and health anxiety and social isolation among young adults during
COVID-19 while controlling for gender, race, and household status.

39
This chapter includes my assessment of the data analysis, results of the study, and a
summary. I discuss the data collection, demographic characteristics, and present
supporting tables and figures.
Data Collection
I collected data via online surveys between January 2023 and March 2023. The
data was generated and transferred into an Excel file. The missing data in this study were
managed by applying the listwise deletion and imputation methods. The techniques were
used to reduce the influence of missingness in this study. Cases that contained only 1-2%
completed items were removed from the analysis. The rationale for this was that
respondents may have experienced question fatigue or a loss of interest in the survey.
Therefore, including the cases would not have been a valid measure of quality (Khan et
al., 2020). Imputation was used to replace missing values for the remainder of the
participants. The clean dataset was then imported to a new file in SPSS Version 28 for
statistical analysis. The sample size was 385, as determined by using an online sample
size calculator. To adjust for constraints, I increased the sample size to 400. A dataset of
471 participants were assessed for missing data on the variables of interest. After I
removed the missing cases, the dataset consisted of 446 participants for statistical
analysis.
Baseline Descriptive and Demographic Characteristics of the Sample
The study sample included participants aged 18-29 years old currently living in
the United States and during the onset on COVID-19 pandemic (N=446). The results of
the sociodemographic characteristics of the sample are shown in Tables 1 - 3,

40
respectively. In Table 1, percentage of male participants were higher than female
participants. Table 2 shows the household status of participants living with others was
higher than those who lived alone, and the percentage of White/Caucasian participants
were higher than participants of other race groups in Table 3.
Table 1
Frequency Analysis for Gender
Cumulative
Frequency Percent Valid Percent Percent
Valid Male 249 55.8 55.8 55.8
Female 197 44.2 44.2 100.0
Total 446 100.0 100.0
Table 2
Frequency Analysis for Household Status
Cumulative
Frequency Percent Valid Percent Percent
Valid Live alone 170 38.1 38.1 38.1
Live with others 276 61.9 61.9 100.0
Total 446 100.0 100.0
Table 3
Frequency Analysis for Race
Frequenc Valid Cumulative
y Percent Percent Percent
Valid American Indian or 8 1.8 1.8 1.8
Alaskan Native
Asian/Pacific Islander 86 19.3 19.3 21.1
Black or African 74 16.6 16.6 37.7
American
Hispanic 12 2.7 2.7 40.4
White/Caucasian 266 59.6 59.6 100.0
Total 446 100.0 100.0
41
The descriptive statistics for the main study variables are summarized in Table 4.
The number of respondents for each variable was 446. The mean score was 2.14 (SD=
.890) for social isolation, 2.84 (SD=.989) for financial stress, 1.13 (SD=.418) for health
anxiety, and 3.77 (SD=1.062) for the perceived impact of COVID. Prior to conducting
the multivariate analyses, I conducted chi-square analyses to detect statistically
significant relationships between gender, race, and household status and the dependent
variable of social isolation. In Table 5, the chi-square value for gender was 18.739 with a
p-value of .005. As shown in Table 6, race had a chi-square value of 26.060 with a p-
value of .011 and household status had a chi-square value of 28.154 with a p-value of less
than .001 (Table 7). The p-values for the three covariates were less than 5, indicating that
gender, race, and household status are statistically related to social isolation (see Tables
5-7).
Table 4
Descriptive Statistics for Main Study Variables
Range Minimum Maximum Mean SD

SITL1 3 1 4 2.14 .890
FSTL 3 1 4 2.84 .989
PC1 4 1 5 3.77 1.062
HITL 2 1 3 1.13 .418
Note: SITL1=Social Isolation Total; FSTL=Financial Anxiety Scale Total; HITL=Short
Health Anxiety Inventory Total; PC1=Perceived Impact of COVID
42
Table 5
Chi-Square Test (Gender and Social Isolation)
Asymptotic
Significance (2-
Value df sided)
Pearson chi-square 18.739a 6 .005
Likelihood ratio 19.872 6 .003
Linear-by-linear association 16.823 1 <.001
N of valid cases 446
Note: Five cells (41.7%) have expected count less than 5. The minimum expected count is
.07.
Table 6
Chi-Square Test for (Race and Social Isolation)
Asymptotic
Significance (2-
Value Df sided)
Pearson chi-square 26.060a 12 .011
Likelihood ratio 26.375 12 .009
Linear-by-linear association 5.734 1 .017
N of Valid Cases 446

Note: Ten cells (50.0%) have expected count less than 5. The minimum expected
count is .20.
Table 7
Chi-Square Test (Household and Social Isolation)
Asymptotic
Significance (2-
Value Df sided)
Pearson chi-square 28.154a 3 <.001
Likelihood ratio 28.167 3 <.001

Note: One cell (12.5%) had expected count less than 5. The minimum expected
count is 4.19.
43
Statistical Assumptions
Four assumptions should be considered when running an ordinal logistic
regression analysis (Sesay et al., 2021). The first assumption is that the dependent
variable is measured on an ordinal level. In this study, the assumption was met since the
dependent variable, social isolation, was measured on an ordinal 5-point Likert scale
where 5 represented having normal symptoms and 1 represented having severe
symptoms. The second assumption states that dependent variables should be categorical,
ordinal, or continuous (University of St. Andrews, n.d.). In this study, there were three
predictor variables (financial stress, health anxiety, and the perceived impact of COVID)
and three confounding variables (gender, race, and household status). Financial stress,
health anxiety, and perceived impact of COVID were measured on an ordinal scale, while
gender, race, and household status were categorical variables. Therefore, the second
assumption was also met. The third assumption is that there should be no
multicollinearity among independent variables (University of St. Andrews, n.d.). I used
the variance inflation factor (VIF) statistics to test multicollinearity among the
independent variables. As shown in Table 8, all VIFs were less than the threshold of 10,
indicating there was no evidence for multicollinearity among the independent variables.
According to Senaviratna et al. (2019), values of VIF exceeding 10 or more indicate the
presence of multicollinearity among independent variables. This confirmed that the third
assumption was met. The last assumption is that there are proportional odds (Senaviratna
et al., 2019). Proportional odds are a key assumption in ordinal regression which assumes
that the effects of the independent variables are consistent across the different thresholds
44
(National Centre for Research Methods, 2022). To test for the proportional odds
assumption, I used the test of parallel lines. If the test of parallel lines shows statistical
significance, then the assumption of proportional odds has been violated (National Centre
for Research Methods, 2022). The proportional odds assumption was tested for the
ordinal regression model and is presented in the results section below.
Table 8
Collinearity Diagnostics
Collinearity statistics
Model Tolerance VIF
1 FSTL .778 1.285
PC1 .870 1.149
HITL .946 1.057
Race .977 1.024
Gender1 .950 1.052
Household status .894 1.118
a. Dependent Variable: SITL1
Research Questions and Hypotheses
I addressed four research questions in this study. The results of the chi-square and
ordinal logistic regression analyses were presented in this section. The statistical analysis
was performed to test the following research question and hypothesis:
Research Question 1

45
To investigate the first research question, the Pearson Chi-square test was
computed to determine whether financial stress is independent of social isolation. As
shown in Table 9, the results were significant with a chi-square value of 232.314 and p-
value of <.001. Due to the statistically significant results, the null hypothesis was
rejected. Therefore, the results indicated that there is an association between financial
stress and social isolation among young adults during COVID-19.
Table 9
Chi-Square Test (Financial Stress and Social Isolation)
Value df Asymptotic significance (2-sided)
a
Pearson chi-square 232.314 9 <.001
Likelihood ratio 243.918 9 <.001
Note: Four cells (25.0%) have expected count less than 5. The minimum expected count
is 1.13.
Research Question 2
RQ2: To what extent is the perceived impact of COVID related to social isolation

46
To investigate the second research question, the Pearson Chi-square test was
computed to determine whether the perceived impact of COVID is independent of social
isolation. As shown in Table 10, the results were significant with a chi-square value of
64.816 and p-value of <.001. Due to the statistically significant results, the null
hypothesis was rejected. Therefore, the results indicated that there is an association
between the perceived impact of COVID and social isolation among young adults during
COVID-19.
Table 10
Chi-Square Test (Perceived Impact of COVID and Social Isolation)
Value df Asymptotic Significance (2-sided)
Pearson Chi-Square 64.816a 12 <.001
Likelihood Ratio 62.758 12 <.001
Linear-by-Linear Association 41.070 1 <.001
a. 4 cells (20.0%) have expected count less than 5. The minimum expected count is .54.
Research Question 3
Research Question 3: To what extent is health anxiety related to social isolation
To investigate the third research question, the Pearson Chi-square test was
computed to determine whether health anxiety is independent of social isolation. As
shown in Table 11, the results were significant with a chi-square value of 35.720 and p-
47
value of <.001. Due to the statistically significant results, the null hypothesis was
rejected. Therefore, the results indicated that there is an association between health
anxiety and social isolation among young adults during COVID-19.
Table 11
Chi-Square Test (Health Anxiety and Social Isolation)
Value df Asymptotic Significance (2-sided)
Pearson Chi-Square 35.720a 6 <.001
Likelihood Ratio 35.854 6 <.001
Linear-by-Linear Association 28.617 1 <.001
a. 4 cells (33.3%) have expected count less than 5. The minimum expected count is .35.
Research Question 4
Research Question 4: To what extent do financial stress, perceived impact of
COVID, and health anxiety predict social isolation among young adults during
COVID-19 controlling for gender, race, and household status?
H0: There is no relationship between financial stress, perceived impact of COVID,
In research question 4, ordinal logistic regression was applied to assess the
association between the dependent variable (social isolation) and the independent
variables (financial stress, perceived impact of COVID, and health anxiety), while
48
controlling for gender, race, and household status (covariates). In addition to the first
three assumptions of ordinal logistic regression being met in this study, the data must
meet the fourth assumption with proportional odds (Laerd Statistics, n.d.). Proportional
odds indicates that each independent variable has an identical effect at each cumulative
split of the ordinal dependent variable (Laerd Statistics, n.d). The proportional odds
model is compared with a cumulative odds model without the proportional odds
constraint/assumption to generate a full likelihood ratio test. When the difference in
model fit between the two models is small and not statistically significant (p > .05), the
assumption of proportional odds is concluded as being met. The assumption of
proportional odd is violated when the difference of fit is large and statistically significant
(p < .05). As shown in Table 12, the assumption of proportional odds was met with a chi-
square (χ2) of 24.064 with a p-value of .458, as assessed by the full likelihood ratio test
comparing the fit of the proportional odds location model to the cumulative model with
varying location parameters. The deviance goodness-of-fit test indicated that the model
was a good fit to the observed data, χ2(507) = 378.473, p = 1.000, but most cells were
sparse with zero frequencies in 65.4% of cells (Table 13). However, the final model
statistically significantly predicted the dependent variable over and above the intercept-
only model, χ2(12) = 277.713, p < .001. This indicated that the independent variables add
statistical significance to the model or at least one independent variable is statistically
significant.
As per the regression estimates, there were three threshold estimates (Table 14).
Threshold 1, using the dependent variable of social isolation as a base, is the rank
49
between normal and mild symptoms/impairments. Threshold 2 is the rank between mild
and moderate symptoms/impairments, and Threshold 3 is the rank between moderate and
severe symptoms/impairments. The thresholds, also known as cut-point, determine how
close the variables are to the next level of the intervals and ranks. The estimate for
Threshold 1 was -6.737, while Threshold 2 estimate was -4.898 and Threshold 3 at -.174.
Health anxiety at location, HITL=2, was a statistically significant predictor of
social isolation (β = -1.988, p =.002). This means for every unit decrease in health
anxiety, there is a predicted decrease of 1.988 units in the log odds of a higher level of
social isolation (the lower the level, the worse the outcome). Health anxiety was rated on
a scale of 1 to 3 with 1 representing the lowest level of health anxiety while 3
representing the highest. HITL=1 ranked between no/mild and moderate health anxiety,
while HITL2 ranked between moderate and substantial health anxiety.
The perceived impact of COVID (PC1) was also a statistically significant
predictor of social isolation at locations PC1=1, PC1=2, and PC1=4. The variables were
ranked as: PC1=1 (no impact-rarely), PC1=2 (rarely-undecided), PC1=3 (undecided-
somewhat), and PC1=4 (somewhat-impacted my life a great deal). The odds of PC1=1
predicting social isolation were -1.940, p =<.001. The odds of PC1=2 predicting social
isolation were -.942, p= .015, while PC1=4 was -.597, p=.022.
Lastly, financial stress (FSTL) was ranked as: FSTL=1 (minimal-mild anxiety),
FSTL=2 (mild-moderate anxiety), and FSTL=3 (moderate-severe anxiety). Each location
of financial stress was statistically significant in predicting social isolation with p-values
50
of <.001. In addition, while controlling gender, race, and household status, gender was
found associated with social isolation (β = -.529, p =.011).
Table 12
Test of Parallel Lines for the Association between Financial Stress, Health Anxiety,
Perceived Impact of COVID, and Social Isolationa
Model -2 Log Likelihood Chi-Square df Sig.

Null Hypothesis 501.375
General 477.312b 24.064c 24 .458

The null hypothesis states that the location parameters (slope coefficients) are the same
across response categories.a
a. Link function: Logit.
b. The log-likelihood value cannot be further increased after maximum number of step-
halving.
c. The Chi-Square statistic is computed based on the log-likelihood value of the last
iteration of the general model. Validity of the test is uncertain.
Table 13
Goodness-of-Fit
Chi-Square Df Sig.
Pearson 743.018 507 <.001
Deviance 378.473 507 1.000
Link function: Logit.
51
Table 14
Ordinal Regression Model Estimates for the Association between Financial Stress,
Health Anxiety, Perceived Impact of COVID, and Social Isolation
95% Confidence
Interval
Std. Lower Upper
Estimate Error Wald Df Sig. Bound Bound
Threshold [SITL1 = 1] -6.737 .882 58.369 1 <.001 -8.465 -5.008
[SITL1 = 2] -4.898 .857 32.707 1 <.001 -6.577 -3.220
[SITL1 = 3] -.174 .793 .048 1 .826 -1.729 1.380
Location householdstatus -.411 .219 3.524 1 .060 -.839 .018
Gender1 -.529 .209 6.415 1 .011 -.938 -.120

Race .121 .078 2.384 1 .123 -.033 .274
[HITL=1] -1.988 .639 9.685 1 .002 -3.240 -.736
[HITL=2] -1.247 .736 2.870 1 .090 -2.690 .196
[HITL=3] 0a . . 0 . . .
[PC1=1] -1.940 .586 10.973 1 <.001 -3.088 -.792
[PC1=2] -.942 .388 5.915 1 .015 -1.702 -.183
[PC1=3] -.164 .392 .174 1 .676 -.932 .605
[PC1=4] -.597 .260 5.272 1 .022 -1.106 -.087
[PC1=5] 0a . . 0 . . .
[FSTL=1] -3.746 .445 70.790 1 <.001 -4.618 -2.873
[FSTL=2] -3.611 .332 118.019 1 <.001 -4.262 -2.959
[FSTL=3] -2.044 .295 48.141 1 <.001 -2.621 -1.466
[FSTL=4] 0a . . 0 . . .
Link function: Logit.
a. This parameter is set to zero because it is redundant.
Summary
In this section, the bivariate analyses of questions 1-3 showed that there were
statistically significant associations between the independent variables (financial stress,
health anxiety, and perceived impact of COVID), and the dependent variable (social
isolation). Multivariate analysis showed that there was an association between the
independent variables and social isolation while controlling for gender, race, and
52
household status. However, there was a statistically significant association between race
and social isolation among young adults in the United States. Chapter 5 introduced the
interpretation of these findings, limitations of the study, recommendations, and
implications for professional practice and social change.

53
Chapter 5: Discussion, Conclusions, and Recommendations
The purpose of this quantitative cross-sectional study was to examine the
association between financial stress, health anxiety, the perceived impact of COVID and
social isolation while controlling for gender, race, and household status among young
adults in the United States. The prevalence of anxiety and depression increased
worldwide during the COVID-19 pandemic (WHO, 2022). The increase prompted an
urgent need to investigate the impact of COVID-19 on mental health. Research found that
the increase in stress was associated with social isolation. However, there was limited
literature on the association between anxiety risk factors and social isolation among
young adults in the United States. In the current study, I used primary data with a cross-
sectional design. This study was beneficial because it indicated a significant association
between anxiety risk factors and social isolation. Also, there was a significant association
between anxiety risk factors and social isolation while controlling for gender, race, and
household status.
Interpretation of the Findings
Research Question 1
The findings of the study regarding RQ1 showed that there was a statistically
significant association between financial stress and social isolation. These results were
consistent with the literature. Previous studies showed that young people are at an
increased risk of poor mental health by factors such as loneliness, social isolation, and
financial distress (Varma et al., 2021). Young adults experiencing financial distress are
54
more likely to have anxiety and depression and are at a higher risk of reporting suicidal
thoughts, which is associated with social isolation (Varma et al. 2021).
Research Question 2
The findings in RQ2 illustrated that there is a statistically significant association
between the perceived impact of COVID and social isolation. The results were not
compatible with the literature. This could be because this study was the first one to assess
the perceived impact of COVID and social isolation among young adults. However, in a
study by Tull et al. (2020), the perceived impact of COVID was found to be negatively
associated with loneliness, whereas in the current study, the perceived impact of COVID
was found positively associated with social isolation. The difference between social
isolation and loneliness is that social isolation is the objective state of having the lack of
social relationships or infrequent social contact (Wu, 2020). It is associated with mental
and physical health risks even if a person does not feel lonely (Wu, 2020). On the other
hand, loneliness is a subjective feeling of being alone or disconnected from others, even
if the person has many social relationships (Wu, 2020).
Research Question 3
The findings regarding RQ3 revealed that there was a statistically significant
association between health anxiety and social isolation. These results were also consistent
with the literature. Past research showed that epidemic and pandemic events tend to
increase health anxiety, especially for those already prone to health anxiety as a trait
(Stone et al., 2022). Researchers found that the increase in health anxiety results in
behavioral and psychological changes such as increased cyberchondria and social

55
withdrawal (Stone et al., 2022). This supports the alternative hypothesis that health
anxiety predicts social isolation. The current study provides evidence to limited research
that health anxiety predicts social isolation among young adults in the United States.
Research Question 4
To investigate the last research question, I used ordinal logistic regression to
assess the association between financial stress, perceived impact of COVID, health
anxiety, and social isolation among young adults while controlling for gender, race, and
household status. Prior to conducting the statistical test, the proportional odds ratio
assumption was met (p = 0.458 is statistically significant). The findings of the ordinal
logistic regression showed that there was statistical significance between the anxiety risk
factors and social isolation among young adults while controlling for gender, race, and
household status. There is limited research to compare the findings of this study to
involving the association between anxiety risk factors and social isolation among young
adults in the United States, hence the reason for this study. In addition to the young adult
age group in the United States, the covariates (gender, race, and household status)
presented a new perspective that researchers had not considered for the combination of
financial stress, perceived impact of COVID, and health anxiety. Gender, race, and
household status were found statistically significant in predicting social isolation during
bivariate analysis. However, when controlled during ordinal logistic regression, gender
was the only covariate found to be significant in predicting social isolation. A previous
study found that men/boys tend to be more isolated than women/girls and gender
differences in isolation were depended on the timing and place they are in their life
56
course (Umberson et al., 2022). Findings in the current study also suggested that there
may be unknown confounders existing to produce negative estimates and significant p-
values during the analysis of the variables.
The theory that grounded this study was the SEM. The model focuses on the
multiple factors that affect health and understands health to be affected by the interaction
between the individual, the group/community, and the physical, social, and political
environments (UNC Center for Health Equity Research, 2023). The results of this study
were aligned with the public health prevention framework, which enables researchers to
analyze the range of factors that put young adults at risk of mental health illnesses and
social isolation. Since the model illustrates how factors at one level influence factors at
another level, it suggested that it is necessary to act across multiple levels of the model to
decrease the risk of social isolation, which is associated with suicide and suicidal
behavior (CDC, 2022). The results demonstrated the need for intervention on the
individual and interpersonal levels to target anxiety risk factors, such financial stress and
health anxiety, to educate young adults on healthy lifestyle behaviors such as wellness
checks and problem-solving skills that can reduce their risk for long term mental
illnesses. On a community level, employee assistance counselors, health coaches, health
care providers, and community leaders could assist in promoting mental health and
financial literacy, telehealth appointments, screenings for depression/anxiety, and the
acceptability of mental health treatment. On a society level, interventions are needed to
reduce anxiety and the risk factors that cause longer-term mental health outcomes.
57
Limitations of the Study
There are several limitations that one must consider with the results of this study.
One limitation in this study was the self-report of data. Ross et al. (2019) explained that
bias input happens in self-reporting data when respondents answer questions according to
what they think may be favorable to the researcher. Therefore, it was possible that
participants in the study may have indicated more socially acceptable responses rather
than their authentic response resulting in social desirability bias. A measure that was
taken to lessen this limitation and to encourage honest self-reporting was to maintain the
participants’ confidentiality by not collecting any information that could be used to
identify them. Recall bias may have also existed when participants were asked to recall
past events within the last six months. Recalling past events can pose a challenge with
participants not being able to adequately recall those events (Story & Tait, 2019).
Another limitation in this study was its cross-sectional design. This study was able to
determine if the independent variables of financial stress, health anxiety, and perceived
impact of COVID predicted social isolation, the data could not definitively determine the
causal direction for the link between the independent variables and social isolation. Wang
& Cheng (2020) described one weakness of the cross-sectional study design to be the
inability to establish causal relationships between variables. Lastly, unknown
confounders can produce negative estimates in ordinal logistic regression (McDonald,
2022), which was evident in the findings of this study. In this study, more confounding
variables should have been controlled to avoid erroneous conclusions.

58
Recommendations
Recommendations for how the findings of the study can be applied to practice are
in response to the statistically significant association between the independent variables
and social isolation among young adults. The first recommendation in response to the
ordinal logistic regression model offering predictive utility for social isolation is to
improve financial knowledge levels to help ease financial stress and anxiety. A recent
study showed that US adults reported anxiety and stress about their personal finances
before the onset of COVID-19 pandemic (Pierce and Williams, 2021). The results of the
current study showed that there is an association existing between financial stress and
social isolation among young adults, prompting a need for interventions that promote
financial literacy. Results also showed that there is an association between health anxiety
and perceived impact of COVID and social isolation. The recommendation for practice in
response to the ordinal logistic regression model offering predictive utility for social
isolation is for the need of interventions that offer treatments such as behavioral stress
management that teaches skills to manage health anxiety and how to function in daily
life. In regard to perceived impact of COVID, participants reported that the pandemic
affected their daily lives ranging from none at all to a great deal. To tackle this, actions
across individual, community, and societal levels may be required to address financial or
occupational uncertainty of the pandemic and provide adequate mental health resources
to address the growing mental health crisis among young adults.
Recommendations to mitigate the limitations of the study are mostly related to the
design of the study. This study failed to provide a deeper insight between the anxiety risk
59
factors and social isolation. I recommend that a different study design such as a
longitudinal study design is utilized to examine demographic characteristics, risk factors,
and social isolation. This design will allow researchers to examine the same sample over
a period of time (Fridman et al., 2021). The current study did not obtain the participant’s
mental health status and other essential information prior to COVID that could have
offered a better insight and conclusion from the results. I also recommend that more
confounding variables are controlled to avoid bias and erroneous conclusions. Lastly, I
recommend that other anxiety risk factors are considered to be identified and analyzed as
predictors of social isolation to understand the appropriate interventions needed to
address mental health among this age group.
Implications For Professional Practice and Social Change
My study suggested that identifying anxiety risk factors, as a predictor of social
isolation, can improve the mental health and the associated mental health outcomes
among young adults in the United States. Social isolation is a product of multiple
influences, therefore impact across the four levels of the SEM is most impactful for social
change. The use of the social ecological model supports the need for public health
practitioners to develop and implement programs addressing anxiety risk factors that may
lead to social isolation. Social change will be observed when young adults experiencing
anxiety and social isolation are cared for with interventions based on this study. When
mental health is prioritized, the outcomes associated with mental health of young adults
are expected to improve. This study is important to professional practice and creating
social change because it adds to the body of knowledge and literature by identifying
60
associations between anxiety risk factors and social isolation among a hard-to-reach age
group. Researchers should continue to identify other anxiety risk factors that may predict
social isolation among young adults to advance knowledge and practice in improving the
mental health of young adults in the United States.
Conclusion
To my knowledge, the current study was the first to examine the association
between anxiety risk factors (financial stress, health anxiety, and perceived impact of
COVID) and social isolation among young adults in the United States. The study
outcome showed a significant association between anxiety risk factors and social
isolation. Furthermore, the results revealed a significant, but negative association
between the anxiety risk factors and social isolation, while controlling for gender, race,
and household status. The significance of the findings suggested that further research is
needed to identify other anxiety risk factors that may lead to social isolation. Social
isolation is a risk factor of suicide, which is the second leading cause of death among
young adults in the United States (CDC, 2023). Based on this study, I suggest a need to
address mental health as it relates to social isolation across the four levels (individual,
community, organizational, and societal) of the socioecological model. The results of this
study support the need for interventions that can manage, treat, and prevent anxiety
among young adults to prevent longer-term mental health outcomes in the future.
61
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Appendix A: Survey Questionnaire for PROMIS Social Isolation 6a
74
Appendix B: Survey Questionnaire for Financial Anxiety Scale (FAS)
75
Appendix C: Survey Questionnaire for Short Health Anxiety Inventory (SHAI)
76
77
Appendix D: Survey Questionnaire for Perceived Impact of COVID-19
Participant will respond to the question using a 5-point Likert-type scale ranging from 1
(no impact at all) to 5 (impacted my life a great deal).
1. To what extent has the situation associated with COVID-19 affected the way
you live your life?
No Impact at all
Rarely Impact
Undecided
Somewhat Impact
Impacted my life a great deal

78
Appendix E: Permission and Approval to Use Financial Anxiety Scale (FAS)
79
Appendix F: Permission and Approval to Use Short Health Anxiety Inventory (SHAI)
80
Appendix G: Permission and Approval to Use PROMIS Social Isolation 6a
81
Appendix H: Permission and Approval to Use Perceived Impact of COVID-19
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Walden University

College of Health Sciences and Public Policy

This is to certify that the doctoral dissertation by

has been found to be complete and satisfactory in all respects,

Chief Academic Officer and Provost

Anxiety Risk Factors and Social Isolation Among Young Adults

MPH, Grand Canyon University, 2015

BS, University of Mississippi, 2002

Dissertation submitted in Partial Fulfillment

of the Requirements for the Degree of

suicide and long-term mental health.

MPH, Grand Canyon University, 2015

BS, University of Mississippi, 2002

Dissertation submitted in Partial Fulfillment

of the Requirements for the Degree of

This work is dedicated to my parents, Dorothy M. Swint, and Robert Swint.

reach my full potential. I am forever grateful.

your patience, unwavering support, and understanding my emotions and purpose to

support and encouragement from my family, friends, and professors.

and skills to accomplish this incredible journey.

and love during the summer visits.

his mentorship, compassion, valuable feedback, and encouragement. To my committee

members, I am sincerely grateful for the support and guidance provided to me

throughout this process.

List of Tables ..................................................................................................................... iv

List of Figures ......................................................................................................................v

Chapter 1: Introduction to the Study....................................................................................1

Background of Study .....................................................................................................3

Problem Statement .........................................................................................................3

Purpose of the Study ......................................................................................................4

Research Questions and Hypotheses .............................................................................4

Theoretical Framework ..................................................................................................6

Nature of Study ..............................................................................................................6

Scope and Delimitations ................................................................................................8

Chapter 2: Literature Review .............................................................................................11

Literature Search Strategy............................................................................................12

Theoretical Framework ................................................................................................13

Theoretical Connection to the Study............................................................................16

Literature Review Related to Key Variables and Concept ..........................................17

Anxiety Risk Factors among Young Adults ......................................................... 17

Social Isolation Among Young Adults ................................................................. 21

Anxiety Risk Factors and Social Isolation ............................................................ 22

Chapter 3: Research Method..............................................................................................25

Research Design and Rationale ...................................................................................25

Sampling and Sampling Procedures ..................................................................... 27

Data Collection, Confidentiality, and Management Procedures ........................... 28

Instrumentation and Operationalization of Constructs ......................................... 29

Data Analysis Plan ................................................................................................ 30

Threats to Validity .......................................................................................................35

Ethical Procedures .......................................................................................................36

Chapter 4: Results ..............................................................................................................37

Data Collection ............................................................................................................39

Baseline Descriptive and Demographic Characteristics of the Sample ................ 39

Statistical Assumptions ......................................................................................... 43

Chapter 5: Discussion, Conclusions, and Recommendations ............................................53

Interpretation of the Findings.......................................................................................53

Research Question 1 ............................................................................................. 53

Research Question 2 ............................................................................................. 54

Research Question 3 ............................................................................................. 54

Research Question 4 ............................................................................................. 55