Emotional Regulation, Adult Attachment Orientations, and Risk of COVID-19 Infection: Virtual Reality Simulation

Abstract

(1) Background: To mitigate COVID-19 transmission, global public health interventions were swiftly implemented. However, a comprehensive understanding of individual variations in adhering to these recommendations remains elusive. Addressing this gap is crucial for effectively managing future epidemic and pandemic scenarios. This study aims to explore individual differences in attachment, emotion regulation, and risk for COVID-19 infection using virtual reality (VR). (2) Methods: The sample included 73 (88%) university students and 10 (12%) university staff. Participants completed questionnaires on sociodemographic information, the Difficulties in Emotion Regulation Scale, the Experiences in Close Relationships—Relationship Structures Questionnaire, and the fear of COVID-19 Scale. Additionally, each participant engaged in five daily situations using a VR simulator to assess the risk of COVID-19 infection. (3) Results: Our study revealed that high levels of attachment anxiety, difficulties controlling impulsive behaviors, and limited access to emotion regulation strategies were strong predictors of elevated risk of COVID-19 infection. Conversely, high levels of fear of COVID-19 and attachment avoidance were associated with lower risk of COVID-19 infection. (4) Conclusions: We discuss the importance of policymakers and health professionals being aware of some psychological characteristics that make it difficult for some individuals to adhere to public health measures involving social distancing.

1. Introduction

The COVID-19 pandemic has posed a significant threat to public health, presenting numerous challenges for healthcare providers, governments, and populations worldwide. The infection and mortality rates associated with the disease necessitated the implementation of various public health measures by governments. The effectiveness of these measures largely depended on the degree of public adherence. Consequently, a key challenge has been to understand the factors influencing why some individuals comply with health recommendations while others do not. Previous studies found that individual differences in fear of COVID-19 infection were positively associated with complying with the public health measures (e.g., social distancing, improved hand hygiene) [1,2,3]. This suggests that increased perceptions of threats may act as triggers for protective action [4].

Although risk perceptions act as triggers for precautionary action, the engagement in preventive health behaviors is not merely determined by the risk perception [5] but also influenced by other factors, such as emotional regulation [6,7], impulsivity [8,9], and adult attachment [10,11,12,13,14]. Some empirical evidence has shown that these factors are related to several disorders, such as Borderline Personality Disorder [15], Post-Traumatic Stress Disorder [16], and Compulsive Sexual Behavior [17]. Emotional regulation and impulsivity are also related to executive function irregularities that characterize autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) [18,19]. An integrative theory addressing these factors [16] explains that individuals with insecure attachment, in the presence of stressful situations, use fewer (or maladaptive) emotional regulation strategies and have an inability to control impulsive behaviors [20], which in turn contribute to risk-taking behaviors [21,22,23]. Attachment security-based strategies aim to alleviate distress and enhance personal resources. In contrast, secondary attachment strategies manage attachment-system activation, focusing on reducing or eliminating pain from frustrated proximity-seeking. Here, distress regulation is secondary to either hyperactivating or deactivating the attachment system. Hyperactivating strategies keep the attachment system constantly alert for threats, while deactivating strategies suppress it, impacting cognitive and emotional openness [24]. Furthermore, the involvement in risky behavior may serve to modulate one’s response following a life-threatening situation and so modify the emotional experience, without necessarily changing the nature of the threat [6]. For instance, individuals with poorly regulated emotions often turn to food or alcohol to escape from or down-regulate their emotions [25].

Attachment style is an important individual difference that influences how we behave not only in interpersonal situations but also in response to threats. Adult attachment orientations and individual differences in the functioning of the attachment system [26] are conceptualized as two independent/orthogonal dimensions of attachment anxiety and avoidance [27,28]. Individuals with low attachment anxiety and avoidance, are classified as securely attached, indicating they are comfortable depending on others and can use effective coping/emotion regulation efforts that attenuate distress. However, individuals with insecure attachment orientations are typically unable to obtain the support and felt security that they need. More specifically, people with an anxious attachment orientation use intense secondary strategies that are called hyperactivating strategies [29] which require constant vigilance, concern, and effort until an attachment figure is perceived to be available and a sense of security is attained [30]. Individuals employing hyperactivating strategies exhibit a strong approach orientation toward their relationship partners. They actively seek involvement, care, and support due to concerns about relationships and a fear of rejection [30]. These individuals tend to exaggerate the seriousness of threats and their inability to cope and intensify mental rumination on threat-related concerns [31,32], producing a self-amplifying cycle of distress, which interferes with engagement in non-attachment-related activities [32]. In contrast, people with an avoidant attachment orientation engage in deactivation strategies that lead to denying their need for support, avoidance of closeness, intimacy, and dependence in close relationships. These individuals maintain their independence by downplaying or suppressing painful thoughts and negative emotions and denial of threats and their distress [26]. Both the anxious and avoidant styles are characterized by the failure of proximity-seeking in relieving distress and the consequent adoption of secondary attachment strategies [24].

According to Gratz and Roemer’s model [33], emotion regulation involves several key components, namely awareness and understanding of emotions, acceptance of emotions, controlling impulsive behaviors, and acting in alignment with goals despite negative emotions. Additionally, it includes the ability to use appropriate strategies to modulate emotional responses to meet personal goals and situational demands. However, self-regulation can fail when conflicting goals arise during distress. For instance, achieving long-term outcomes requires ignoring immediate stimuli to pursue strategies that offer delayed but significant benefits [34].

In a context of social distancing, emotional regulation assumes a social regulatory role, benefiting from empathy, cooperation, and harmony with others [35]. Theories of emotional intelligence suggest that individuals can better regulate their emotions by using cognitive processes such as attention, problem-solving, and perception [36]. These processes enhance emotional self-awareness—recognizing one’s emotions and their effects, understanding one’s strengths and limits, and maintaining confidence in one’s self-worth and capabilities—as well as social awareness, which includes sensing others’ feelings and perspectives and taking an active interest in their concerns [37]. According to the nine-layer pyramid model of emotional intelligence [35], effective emotional regulation in response to situations is achieved only when individuals progress through specific stages. Initially, they must process the emotional stimulus and recognize the associated emotion. Subsequently, they must integrate this emotion into their sense of self, encompassing personality, motivations, and behaviors. It is only after these stages that individuals become capable of recognizing and understanding the emotions of others, thereby developing social awareness and empathy.

During the COVID-19 pandemic, some studies examined adult attachment orientations and emotional regulation strategies concerning adherence to COVID-19 public health measures. However, the evidence was contradictory. For example, one study found that both attachment-related anxiety and avoidance were associated with low adherence [38]. In contrast, another study discovered that attachment-related anxiety was linked to low adherence to social distancing, while attachment-related avoidance was not associated with adherence after the inclusion of social trust [39]. Conversely, another study found that attachment avoidance correlated with larger interpersonal distances, but no such associations were found for attachment anxiety [40]. Additional evidence from another study suggests that high levels of anxious attachment predict a higher perceived risk, whereas high levels of avoidant attachment predict a lower perception of risk [41]. This information may help explain the contradictory findings across studies.

Regarding emotion regulation strategies, most studies focused on the psychological impact of the COVID-19 pandemic [42,43,44,45]. However, less attention was given to the relationship between emotional regulation strategies and compliance with COVID-19 health guidelines. Evidence suggests that emotion regulation skills contribute to increased adherence to health guidelines [46].

Despite the contradictory evidence regarding the relationship between adult attachment orientations and adherence to public health measures, as well as the lack of evidence concerning emotion regulation strategies and adherence to such measures, previous studies have predominantly relied on self-report measures to assess compliance [38,39]. Social desirability bias may influence respondents’ reports of their adherence to public health guidelines [47].

To address the limitations of previous research, we investigated the associations between individual differences in fear of COVID-19, adult attachment orientations, emotion regulation, and the risk of COVID-19 infection. Unlike prior studies that relied on self-report measures, we employed virtual reality (VR) technology to assess compliance with COVID-19 public health measures, such as social distancing, mask usage, and hand washing. Previous research established VR as a valuable tool for both public health and mental health interventions [48]. Furthermore, VR was shown to be beneficial as a psychological intervention for individuals with mental health issues during the COVID-19 pandemic [49]. We hypothesized that a greater fear of COVID-19 would be associated with a lower risk of COVID-19 infection, whereas maladaptive adult attachment orientations and emotion dysregulation would be significantly associated with a higher risk of COVID-19 infection.

2. Materials and Methods

2.1. Participants

A priori power analysis was conducted using G Power 3.1.9.6 with a moderate effect size (f² = 0.15), an α level of 0.05, and a power of 0.80, using F tests. Based on these parameters, approximately 85 participants were needed to reject the null hypothesis when considering approximately four predictors. The sample included 73 (88%) university students and 10 (12%) university staff, with a mean age of 23 years (M = 23.49; SD = 1.94), ranging from 17 to 47 years old. The participants were 56 (67.5%) females and 27 (32.5%) males. The current marital status was 73 (88%) single, 8 (9.6%) married, and 2 (2.4%) in civil union. In terms of educational level, most of the participants (n = 58; 69.9%) are currently attending higher education (bachelor’s or equivalent level), 21 (25.3%) are attending at the master’s or equivalent level, and 4 (4.8%) are attending at the doctoral or equivalent level. Concerning family income, the largest percentage of participants (n = 37, 44.6%) reported a monthly household income between USD 500 and 1000, 17 (20.5%) USD 1000 to 1500, 11 (13.3%) USD 1500 to 2000, and 18 (21.7%) above USD 2000.

2.2. Procedure

This is a non-experimental, correlational study using a non-probabilistic data collection methodology (convenience sample). The participants were university students and university staff recruited from a university in northern Portugal, one of the countries that was severely affected by the pandemic and that ended up under a nationwide first lockdown on 17 April 2020, and a second lockdown on 17 March 2021. All procedures performed in this study were in accordance with the APA ethical standards. The study was approved by the Ethics Committee of the Faculty of Psychology, Lusófona University. The data collection occurred after the second lockdown between the months of April and July 2021. The formal authorization for data collection was requested from the Dean of the university. No monetary compensation was awarded for participation in this study. The recruitment process involved direct contact with potential participants in a classroom setting. The researcher presented the study, including its objectives and procedures. Interested individuals provided their email addresses to schedule individual sessions. On the scheduled day, participants signed informed consent forms and completed self-report questionnaires in a private university room. The researcher was available to assist with any queries during this process. Following completion of the questionnaire, participants were invited to participate in a 10 min virtual reality experience assessing the risk of COVID-19 infection. Two researchers assisted the participation in the avatar. If a participant showed any reaction or discomfort during participation, the virtual task was stopped immediately. Fortunately, no incidents were observed. At the end of the participation, the participants were informed about the full objectives of the study. In the case of participants who wanted to obtain information about their results, they received their results in an email. Participants were informed that the email address was only used for the communication of the results and it would be deleted after that. The data collected were recorded in electronic format and stored on hardware protected by a password, whose access will be limited to the investigation team. The data collected will be preserved only during the period of dissemination of results, not exceeding the maximum limit of 5 years. After this period, data will be deleted ensuring the principles of confidentiality and anonymity.

2.3. Measures

A sociodemographic questionnaire was used to collect information about age, gender, marital status, occupation, education, and family income.

The Difficulties in Emotion Regulation Scale (DERS) [33,50], Portuguese version [51] assesses individuals’ typical levels of emotion dysregulation across six domains: non-acceptance of negative emotions (e.g., “when I am upset, I become irritated with myself for feeling that way”), inability to engage in goal-directed behaviors when distressed (e.g., “when I am upset, I have difficulty getting work done”), difficulties controlling impulsive behaviors when distressed (e.g., when I am upset, I have difficulty controlling my behaviors”), limited access to emotion regulation strategies that are perceived as effective (e.g., “when I am upset, I believe that there is nothing I can do to make myself feel better”), lack of emotional awareness (e.g., “I take time to figure out what I am really feeling”), and lack of emotional clarity (e.g., “I have difficulty making sense out of my feelings”). It contains 36 items rated on a 5-point scale ranging from 1 (rarely applies to me) to 5 (almost always applies to me). Higher scores suggest greater problems with emotion regulation. Scores are presented as a total score as well as a score for each of the 6 subscales. The internal consistency for the current study, estimated by Cronbach’s alpha, was as follows: non-acceptance of negative emotions = 0.91; inability to engage in goal-directed behaviors when experiencing negative emotions = 0.85; difficulties controlling impulsive behaviors when experiencing negative emotions = 0.90; limited access to emotion regulation strategies that are perceived as effective = 0.87; lack of emotional awareness = 0.82; and lack of emotional clarity = 0.73.

The Experiences in Close Relationships—Relationship Structures Questionnaire (ECR-RS) [52], Portuguese version [53] is a nine-item self-report tool that measures attachment-related anxiety (Items 1–6) and avoidance (Items 7–9) in relationships with the respondent’s mother, father, romantic partner, and best friend. Respondents consider their feelings toward each relationship. If a parent has passed away, responses should reflect past feelings. For those not in a romantic relationship, responses should consider their most recent or imagined relationship. Each relational domain uses the same nine items, rated on a 7-point Likert scale from 1 (strongly disagree) to 7 (strongly agree). The global measures of anxiety and avoidance consist of the mean of the subscale scores of the four domains (e.g., the global avoidance score is the mean of avoidance with the mother, father, partner, and friend). The internal consistency for the current study, estimated by Cronbach’s alpha, was anxiety = 0.92 and avoidance = 0.90.

The fear of COVID-19 Scale (FCV-19S) [54] (Portuguese version [55])was used to assess participants’ fear of COVID-19. It is a unidimensional seven-item scale. Items are responded to on a five-point Likert-type scale (strongly disagree = 1 to strongly agree = 5). Its total score (sum of individual response items) ranges from 7 to 35 with higher scores indicating greater fear of COVID-19. The internal consistency for the current study, estimated by Cronbach’s alpha, was 0.76.

In the Risk of infection for COVID-19—Simulation task, an avatar simulated five daily situations. Participants were informed that they would have some tasks to perform that they normally do in everyday life, such as going shopping, going to the supermarket, or going to the café. They were not informed that the avatar was intended to assess the risk of COVID-19 infection. This was omitted to prevent attention from being intentionally directed to risky situations. Instead, we intended to evaluate behaviors that were automatically integrated into daily routines. So, the participant was just told to act as if it were a normal day as they went through the virtual scenarios with the avatar. The avatar began with the first scenario at home, showing a message that he/she would have dinner with friends at night, and he/she would have to go shopping for that purpose. Before leaving home, several objects were presented, which the participant could decide whether or not to take with them, including hand disinfectant and a mask (Figure 1). The second scenario involved giving a friend’s ride, in which he/she would have to choose whether or not to give a ride. In the case affirmative, he/she would have the option of wearing a mask or not. The third was a café. The fourth was a supermarket. Both of these scenarios involved the possibility of complying, or not, with the public health measures (e.g., social distancing and disinfecting the hands). The last scenario, at home, included the subject deciding whether or not to cancel dinner with friends. The prototype of the avatar was built based on a pilot study using a focus group of 8 university students to obtain qualitative feedback on what daily scenarios could involve the risk of COVID-19 infection, according to WHO guidelines [39]. This method allows us to explore whether ideas that underlie constructs of interest make sense to respondents [40] (p. 220). Later, a beta version of the avatar was presented to the focus group to rate the number of risks presented in each scenario, as well as feedback on the content, realism, and usability of the avatar. It was given a grid to rate the number of risks presented in each scenario. It accounted for five risks per scenario (k = 0.91), involving a total score of 25 risk points (highest risk score). These data were used to achieve the current version of the avatar that was used in this study (Figure 1).

2.4. Data Analysis

Data analyses were carried out using SPSS version 26 for Windows (IBM Corporation, New York, NY, USA). We conducted post hoc power analyses using GPower 3.1.9.7. Exploratory and descriptive statistics were calculated to examine the distribution of the data, characterization of the study variables, and the characteristics of the sample. Zero-order correlations were used to evaluate the associations among the independent variables and the score of the avatar (risk of infection). Only significant associations were entered into the regression analysis. Hierarchical multiple regression analysis assessed the independent contributions of the independent variables to predict the risk of COVID-19 infection. All key assumptions of the hierarchical regression were met, such as no perfect multicollinearity, homoscedasticity, and independent errors.

3. Results

Descriptive data and correlations of key measures are presented in

Table 1. Means and standard deviations of key measures.

Variable	M	SD	Min	Max
1. Avatar score	7.95	4.13	3	23
2. Fear of COVID-19	8.10	4.78	0	24
3. Global anxiety score	1.75	1.49	0	5.5
4. Global avoidance score	2.66	0.77	1.33	5.04
5. Non-acceptance of negative emotions	12.98	5.95	6	30
6. Inability to engage in goal-directed behaviors	17.28	4.17	10	26
7. Lack of emotional awareness	15.20	4.98	6	27
8. Limited access to emotion regulation strategies	16.10	6.31	8	33
9. Lack of emotional clarity	10.36	3.49	5	22
10. Difficulties controlling impulsive behaviors	11.82	5.40	6	27

and

Table 2. Correlations of key measures.

Variable	1	2	3	4	5	6	7	8	9	10
1. Avatar score (risk of infection)	-
2. Fear of COVID-19	−0.29 *	-
3. Global anxiety score	0.39 ***	0.24 *	-
4. Global avoidance score	−0.25 *	−0.11	0.38 ***	-
5. Non-acceptance of negative emotions	0.15	0.06	0.23 *	0.23 *	-
6. Inability to engage in goal-directed behaviors	0.07	0.25 *	0.07	0.13	0.56 ***	-
7. Lack of emotional awareness	0.05	0.14	0.31 **	0.53 ***	0.15	0.10	-
8. Limited access to emotion regulation strategies	0.30 **	0.21	0.22	0.37 ***	0.74 ***	0.68 ***	0.22 *	-
9. Lack of emotional clarity	0.11	0.18	0.38 ***	0.39 ***	0.45 ***	0.43 ***	0.45 ***	0.55 ***	-
10. Difficulties controlling impulsive behaviors	0.33 **	0.14	0.14	0.35 ***	0.63 ***	0.60 ***	0.17	0.67 ***	0.46 ***	-

Note. * = p < 0.05, two-tailed. ** = p < 0.01, two-tailed. *** = p < 0.001, two-tailed.

. The avatar score (risk of infection) was significantly associated with fear of COVID-19, r = −0.29, p = 0.013; global anxiety score, r = 0.39, p < 0.001; global avoidance score, r = −0.25, p = 0.037; difficulties controlling impulsive behaviors, r = 0.33, p = 0.005; and limited access to emotional strategies, r = 0.30, p = 0.01.

The results of hierarchical multiple regression analysis with the avatar score as a dependent variable are shown in

Table 3. Hierarchical regression analyses to explain the risk of COVID-19 infection.

Model	B	β	t	95% CI		ΔR2adj
Step 1						0
Sex	0.30	0.03	0.28	−1.80	2.41
Age	−0.03	−0.04	−0.31	−0.19	0.14
Step 2						0.20 ***
Constant	10.97
Fear of COVID-19	−0.20	−0.23	−2.10 *	−0.38	−0.01
Global anxiety score	1.01	0.37	3.30 **	0.40	1.63
Global avoidance score	−1.61	−0.30	−2.21 *	−3.07	−0.16
Difficulties controlling impulsive behaviors	0.49	0.34	3.11 **	0.18	0.80
Limited access to emotion regulation strategies	0.17	0.26	2.09 *	0.008	0.33

Note. * = p < 0.05, ** = p < 0.01, *** = p < 0.001, two-tailed.

. All predictors significantly associated with the avatar score were included in the equation model. After adjusting for age and gender, the regression model was statistically significant and explained 20% of the variance: F(7, 75) = 3.85, p < 0.001, Cohen’s f² = 0.16, observed power (1 − β = 0.78). All predictors were statistically significant, including fear of COVID-19, β = −0.23; global anxiety score, β = 0.37; global avoidance score, β = −0.30; difficulties controlling impulsive behaviors, β = 0.34; and limited access to emotion regulation strategies, β = 0.26. High levels of attachment anxiety, difficulties controlling impulsive behaviors, and limited access to emotion regulation strategies significantly predicted high levels of risk of COVID-19 infection. Conversely, high levels of fear of COVID-19 and attachment avoidance significantly predicted low levels of risk of COVID-19 infection.

4. Discussion

Developing effective public health campaigns in future pandemics is crucial in hindering an accelerating growth in infections. Therefore, there is a great deal of academic and societal interest in understanding what explains people’s compliance with health-protective measures. In the current study, we build upon and extend prior research by examining how fear about COVID-19 infection and the individual characteristics of adult attachment orientation and emotion regulation are associated with the risk of COVID-19 infection.

Our findings indicate that elevated levels of attachment anxiety significantly predict an increased risk of COVID-19 infection. This result is consistent with prior research [38,39], which demonstrated that individuals with higher attachment anxiety are less likely to adhere to public health measures. However, our results diverge from those of another study [40], which reported no association between attachment anxiety and interpersonal distance.

To explain our findings, we can refer to the nine-layer pyramid model of emotional intelligence proposed by Drigas and Papoutsi [35]. According to this model, individuals with high attachment anxiety likely encounter difficulties in reaching the social awareness level. Social awareness entails understanding one’s reactions to various social situations and effectively modifying interactions with others to achieve optimal outcomes. These individuals may focus more on reducing anxiety related to abandonment and rejection rather than on adjusting their interactions for mutual benefit. Social distancing could have amplified the threat of abandonment or rejection as it may have decreased the opportunity for confirmation of closeness and availability of others. Participants with high levels of attachment anxiety could have placed more value on seeking physical contact and the short-term reward of confirmation of others’ availability than on the potential long-term reward of fewer restrictions obtained through compliance with protective measures, namely, social distancing. This finding is consistent with a previous study [39] that identified a relationship between anxiety and interpersonal relationships, rather than generalized anxiety. Additionally, this disregard for risks aligns with studies demonstrating correlations between anxious attachment and the prevalence of sexually transmitted infections, unintended pregnancies, and substance-related disorders (e.g., [9,10,56]).

In addition, limited access to emotion regulation strategies significantly predicted high levels of risk of COVID-19 infection. This finding is similar to a previous study which showed that emotion regulation skills contribute to increased adherence to COVID-19 health guidelines [46]. This finding is also coherent with studies showing the influence of emotional regulation on engagement in preventive health behaviors [6,7]. Also, studies have reported that people with high neuroticism who are strongly vulnerable to negative emotions and are unable to handle negative arousal, showed less compliance with COVID-19 protective measures [13,57].

The psychological impact caused by multiple COVID-19-related stressors (e.g., economic, daily-life, social, and relational stressors) might have overburdened individuals’ capacity for emotional regulation, which could have interfered with higher cognitive function and rational decision-making. This hypothesis is consistent with research demonstrating the active role of emotion in decision-making [7] and showing that negative emotions, such as anxiety, impair decision-making optimization (e.g., [58]). Therefore, difficulties in emotional regulation make people more vulnerable to not taking into account the risk—namely, the risk of COVID-19 infection—associated with certain behaviors. Also, risk-taking behaviors can be seen in terms of defensive reactions employed to regulate and repair negative mood, for instance, through experiential avoidance [59]. Engaging in behaviors that pose a higher risk of COVID-19 behaviors could potentially be viewed as a form of emotional regulation, though a risky and inadaptive one.

Finally, difficulties controlling impulsive behaviors were also associated with a high risk of COVID-19 infection. This was expected considering that impulsive individuals would have more difficulty in making health-conscious decisions (e.g., [60]). A previous study that assessed emotional regulation difficulties, psychological distress, and peritraumatic stress symptoms among adults during the pandemic showed that limited access to effective emotion regulation strategies, as well as difficulty in controlling impulsive behaviors, made a unique contribution to explaining distress and trauma-related symptoms [61], similar to the present study. Another study during the pandemic found that impulse control difficulties when upset were related to both alcohol use and problems and binge eating [62]. This is consistent with research conducted in non-pandemic times that showed that individuals with poorly regulated emotions often turn to food or alcohol to escape from or down-regulate their emotions [25]. This propensity towards impulsive behavior may arise from a conflict between regulatory goals during states of distress [34]. It is possible that those who experience intense stress during the pandemic may have a more difficult time regulating their emotions and therefore act impulsively to gain immediate relief from emotional distress [63], for instance, to seek attention from others to reduce anxiety [64]. Despite the awareness that the virus is spread through human-to-human contact, individuals may act impulsivity to seek out interpersonal contact to reduce negative emotions rather than the long-term reward of staying safe.

High levels of fear of COVID-19 and attachment avoidance were associated with a low risk of COVID-19 infection. Regarding the fear of COVID-19 finding, this is in line with other studies showing that feeling scared was positively associated with reported compliance with public health measures (e.g., [1,65,66]). This suggests that activating thoughts of the threat of COVID-19 infection may prompt people to engage in self-protecting behaviors [4].

Along the same line, participants with higher levels of avoidant attachment were more prone to make low-infection risk decisions. This finding is in line with previous studies which found that attachment-related avoidance was associated with high adherence to COVID-19 measures [39,40]. In particular, the study of Brulin and colleagues [39] concluded that an increased sense of distrust may lead people to question the compliance of others with health guidelines, consequently diminishing their own willingness to follow these guidelines. Social trust appears to act as a mediator between attachment-related avoidance and adherence. This is not surprising as contrary to people with high levels of anxious attachment, here a pattern of coping by retreating from others and avoiding closeness is more likely. This type of behavior is much aligned with the public health measure of social distancing and the use of masks that have been shown to hinder interpersonal communication and connection (e.g., [67]). Although, in this sense, the deactivation of attachment behavior can be perceived as protective against COVID-19 infection, it does come at severe costs for the individual when used rigidly as a generalized coping strategy, especially in the absence of a significant threat, such as the risk of infection. The pandemic may reinforce the beliefs and strategies that underlie individuals with avoidant attachment, since it protected them from the risk of COVID-19 infection, but the cost may be that they then have difficulty returning to a normal social life after the pandemic since their attachment style was reinforced during the pandemic. It would be important to examine how these individuals would turn out after the pandemic in terms of mental health and interpersonal relationships.

A few limitations of this study should be noted. First, although VR technology provides the participants an immersive experience of exposure to virtual routines and scenes, it is not the same as the real world. Second, only five conditions of daily life scenes were included in this study, which is not as exhaustive as the number of other situations in the real world. Third, participation in this study was limited to university students and staff. Thus, it is not clear to what extent our findings can be generalized to the general population. Fourth, we did not control for the extent to which participants talked about scenarios, and therefore, we do not know whether the results were influenced by the prior knowledge of the study objectives among the participants. Fifth, the sample size was small and has limited statistical power. Lastly, the reported findings were based on a cross-sectional design, which is not adequate to draw causal-effect conclusions about the relationship between variables.

Despite the limitations, this study has strengths and practical implications. First, the employment of VR could provide a more immersive experience of exposure to a risk of infection because it would be very difficult to apply this study in the real world. Virtual reality made it possible to examine how people behave in their daily lives, considering whether protective measures against COVID-19 were applied. This approach has many advantages compared to self-report measures where people could respond according to social desirability. Second, this study has practical applications. Our findings showed that high levels of attachment anxiety, limited access to emotion regulation strategies, and difficulties controlling impulsive behaviors significantly predicted high levels of risk of COVID-19 infection. Individuals with these characteristics may have difficulties adhering to public health measures against COVID-19. This is unlikely to be because they want to break the rules, but more that it is difficult for them to follow these rules given their attachment style and struggles with emotion regulation. For them, the priority may be to relieve symptoms in the short term, rather than looking after their health and the others in the long term. In a pandemic, we have learned that social distancing policies are a lifesaver not only for individuals but also for economies across the world. Therefore, in order to increase compliance with pandemic-related policies, this study’s findings suggest it is important to raise awareness in health professionals about individual differences that may make it difficult for some to follow pandemic health guidance. For example, reducing attachment anxiety and impulsive behaviors, along with promoting emotion regulation strategies, can enhance social distancing and health compliance for future pandemics. On the other hand, for individuals with attachment avoidance, despite having developed a sense of security during the pandemic because of social distancing restrictions, it is important to analyze how they are functioning in a post-pandemic context since these restrictions no longer exist. The pandemic may have positively reinforced these people’s strategies and beliefs, but they may be more maladaptive in the post-pandemic context.

Future research should focus on developing and testing targeted interventions based on these findings. Implementing VR-based training programs aimed at improving emotion regulation and reducing attachment anxiety could be a promising avenue. With eHealth interventions becoming increasingly used in public health [48], VR is one of the most exciting recent developments. The increasing accessibility and affordability of VR technology further support its potential as a widespread tool for promoting mental health and enhancing compliance with public health measures.

Future implementation should enhance compliance with public health measures, focusing on those with emotional regulation difficulties and attachment anxiety. Utilizing VR technology to create immersive training programs can help individuals improve emotion regulation skills and reduce attachment anxiety. Public health campaigns should include workshops, online courses, and apps for teaching effective strategies. Providing targeted support, with mental health professionals offering personalized interventions, is crucial for these individuals. Tailoring public health messages to address psychological factors and offering practical tips for managing attachment anxiety and impulsive behaviors can improve adherence to guidelines. Additionally, monitoring individuals with attachment avoidance post-pandemic and providing resources for social reintegration can mitigate long-term negative effects.

5. Conclusions

Our study highlights the critical role of individual psychological factors in compliance with health-protective measures during pandemics. Specifically, high levels of attachment anxiety and limited emotion regulation skills increase the risk of COVID-19 infection. Individuals with high attachment anxiety may prioritize immediate emotional comfort over long-term health benefits, and those with limited emotion regulation skills are less likely to adhere to guidelines due to impaired decision-making from emotional distress. Fear of COVID-19 and attachment avoidance can reduce infection risk, as fear motivates compliance and attachment avoidance aligns with social distancing. However, these protective behaviors may negatively impact social functioning post-pandemic.