**1. Introduction**

As the coronavirus has spread across the world, so too the misinformation about it was exploded. The first cases of COVID-19 in Romania emerged in March 2020. By October, there were 222,559 infected, 6681 deaths, and 27,280 people in isolation. As the virus spreads across the country, the need for information has become a daily preoccupation for many people. Romanian Government created a Strategic Communication Group, which is qualified to communicate information about COVID-19 cases, treatment, and other social and medical implications. Nevertheless, most people rely on social media and look for information on social media platforms instead of using official communication channels.

Before the outbreak of COVID-19, people in many countries already relied on social media to gather information and news. Since the outbreak at the end of 2019, people worldwide return to social media, online press, or television to obtain as much information as they can [1]. A previous study showed that social media played an essential role in the COVID-19 outbreak in most countries. This role is highlighted in three areas: accurate information about the novel coronavirus was published on social media all over the world; fake news and misinformation about the outbreak were published daily on the internet, and social media has played an important role in creating and disseminating fear and panic about the outbreak worldwide [2].

According to *The New York Times*, medical misinformation about the novel coronavirus has been spread by ideologues who do not believe in modern medicine and scientifically proven treatments, like vaccines, and by profiteers who found an opportunity to promote cures or other wellness products [3]. Furthermore, specialists talk about an infodemic of misinformation. Infodemic is a blend of "information" and "epidemic", that refers to disseminating information, both accurate and inaccurate, about an important subject, as a disease. Once the information is spread, it becomes challenging to learn essential information about the topic. The word infodemic was first used in 2003 and has seen renewed usage since the outbreak of the COVID-19 crisis [4].

According to the World Health Organization (WHO), the COVID-19 related infodemic is just as dangerous as the virus itself. Misinformation, disinformation, and rumors during a health emergency, false preventive measures, fake remedies, conspiracy theories, and other incorrect information may have consequences beyond public health [5]. Since the COVID-19 outbreak in Romania, false information is spreading faster than the virus itself. The Romanian governmen<sup>t</sup> and medical public health experts repeatedly warned against the negative consequences of some of the most viral false medical information, such as: the virus does not exist, the pharmaceutical giants invented the pandemic, vitamin C treats coronavirus, 5G is the source of the virus, people are paid to declare that they are infected with the novel coronavirus, and other misinformation. Infodemics can hamper a significant public health response and create confusion and distrust among people [6]. A past study illustrated the potential of using social media to conduct "infodemiology" studies for public health. Influenza A virus subtype H1N1 (H1N1) pandemic-related tweets on Twitter were used to disseminate o fficial information from credible sources to the public and a source of opinions and experiences. The researchers proved the correlation between the prevalence of misinformation, terminology use, fear, and panic spread publicly, and the correlation between case incidence and public preoccupation [7]. During a pandemic, healthcare professionals should cooperate with the mass media and help identify the inaccurate, and misleading headlines that agitate members of the public, cause fear, impinge on public communication, and diminish countermeasures for the outbreak [8]. In a pandemic, people's emotional reactions are likely to be very complicated and extensive, such as extreme fear and uncertainty. Furthermore, anxiety and distorted perceptions of risk will lead to negative social behaviors [9].

To our knowledge, little evidence is available on the impact of false information during the outbreak of the novel coronavirus (SARS COV2) on the general population and healthcare workers. Misinformation and fake health news in social media may constitute a potential threat to public health. Patients are more likely to mistrust the medical information and disrespect the preventive measures and the medical experts' policies. Furthermore, considering previous studies on misinformation's impact on mental health, false news may negatively impact medical sta ff. During the COVID-19 outbreak, faced with unprecedented challenges, doctors and nurses must manage levels of stress and trauma similar to ones usually experienced in war zones [10]. We already know from previous studies that during the outbreak of COVID-19, healthcare workers screened positive for moderate to severe levels of depression, anxiety, and stress [11].

Considering these factors, the sample of frontline healthcare workers were split into two groups based on the self-evaluated criteria: if they were or were not a ffected by infodemia in their activity, we aimed to investigate whether frontline healthcare workers who declared to be a ffected by false news show di fferent levels of stress, anxiety, depression, and insomnia than frontline clinicians who do not consider themselves to be a ffected by infodemia related to the COVID-19 pandemic.

In summary, we hypothesize that frontline workers who were declared to be affected by false news are more likely to experience stress, anxiety, depression, and insomnia than healthcare workers who were not affected by fake news in their professional activity.

**Hypothesis 1 (H1).** *Frontline healthcare workers who are declared to be a*ff*ected by infodemia have a higher stress level than frontline clinicians who do not claim to be a*ff*ected by false news.*

**Hypothesis 2 (H2).** *Frontline medical clinicians a*ff*ected by infodemia presented a higher level of anxiety than healthcare workers who are not a*ff*ected by false information.*

**Hypothesis 3 (H3).** *Frontline medical professionals who are declared to be a*ff*ected by infodemia experienced a higher level of depression than their colleagues who are not a*ff*ected by misinformation.*

**Hypothesis 4 (H4).** *Frontline healthcare workers who claim to be a*ff*ected by infodemia have a higher incidence of insomnia than frontline professionals who are not a*ff*ected by false news.*

#### **2. Procedure and Participants**

We have surveyed frontline healthcare workers, emergency doctors, ICU doctors, and medical nurses from two Hospital Departments (Emergency and ICU) in Romania, namely the County Emergency Clinical Hospital Pius Brinzeu, Timisoara. The present study is a cross-sectional one; all data were collected from March to April 2020. The study was conducted following the Declaration of Helsinki and approved by the Ethics Committee of the County Emergency Clinical Hospital, No. 170/05.08.2019, as part of ongoing research considering the burnout syndrome and psychological implications healthcare profession. All gathered information was confidential; the participation was entirely voluntary, and written informed consent was obtained from all the participants.

The inclusion criteria concerned the categories of personnel who directly contact patients during the COVID-19 outbreak through the performed medical act, respectively, primary doctors, specialists, residents (trainees), ICU, and emergency medicine nurses. All data were collected online via a link sent by email. A total of 126 health professionals took part in the survey: 32 nurses and 94 physicians were questioned. Sociodemographic data were collected on gender (male or female), marital status (single, married, divorced, widowed), parental status (children; yes or no), profession (physician or nurse), technical title (trainee, specialist, primary or other), and specialty (ICU or emergency medicine specialist).

The Plan of measures for hospitals' preparation in the COVID-19 pandemic, stated by the Romanian Ministry of Health Order number 533/03.29.2020, disposed of by the end of March 2020, that The County Emergency Hospital Pius Brinzeu Timisoara, Romania will take over the critical cases of patients infected with the novel coronavirus. The usual hospital activity was decreased by 80% regarding chronic cases to increase the hospital's resources in treating COVID-19 patients [12]. By May 2020, 19,133 COVID-19 patients in Romania, 98,403 people in isolation, and 2993 people in official quarantine. Although Timis County had, by the end of May, 505 confirmed cases since the outbreak of the novel coronavirus crisis in Romania in early March, the increase in demand and changes to supply, redeployment of staff, extended work tasks the reorganization of hospital facilities, increase in donning and doffing personal protective equipment (PPE) and implementing new guidelines and protocols, caused tremendous psychological pressure for the frontline healthcare workers [13].

#### **3. Materials and Methods**

The Depression, Anxiety, and Stress Scale (DASS 21) is a reliable and suitable questionnaire to assess symptoms of common mental health problems, such as depression, anxiety, and stress. This scale's essential function is to evaluate the severity of the core symptoms of depression, anxiety, and stress; thus, it supports our research questions. The DASS 21, as a self-report questionnaire

consisting of 21 items, has 7 items per subscale: depression (e.g., "I couldn't seem to experience any positive feeling at all."—the Cronbach's alpha for this scale was α = 0.88), anxiety (e.g., "I was worried about situations in which I might panic and make a fool of myself."—the Cronbach's alpha for this scale was α = 0.88), and stress (e.g., "I felt that I was rather touchy."—the Cronbach's alpha for this scale was α = 0.91). Depression refers to depressed mood, dysphoria, loss of interest and pleasure, anhedonia, and increased fatigue; anxiety refers to agitation, impatience, trouble concentrating, irritability, restlessness, di fficulty relaxing, and di fficulty falling asleep, while the third factor labeled stress refers to emotional or physical tension. The items are evaluated on a Likert scale, from 0 (did not apply to me at all) to 3 (applied to me very much) [14].

The Insomnia Severity Index (ISI) is a valid a reliable instrument to assess cases of insomnia in the population, with a good psychometric properties The ISI is composed of seven items (e.g., "How worried/distressed are you about your current sleep problem?"), rated on a five-point Likert scale ('0'—not at all, '4'—extremely), and the time interval is 'in the last two weeks'. Cronbach's alpha for this scale was 0.91 [15].

Before the study's beginning, we organized a focus group with respondents from the ICU and Emergency Department, doctors, and nurses. We disseminated two directions and created custom-made questions following these recommendations. The frontline healthcare workers su ffered from the false news impact in two ways: they are exposed to medical misinformation and need to make an e ffort to discern the actual news, and on the other hand, the doctor-patient relationship is a ffected, patients been themselves exposed to false news and having troubles trusting the medical system and the healthcare specialists. Therefore, specific questions related to fake news influence on the frontline medical sta ff were created, such as: "Are you a ffected by fake news in the course of your professional activity?", "In what way fake news a ffects you?", "What is the word that best describes the media position (print, audiovisual, online press) regarding medical sta ff during the outbreak of COVID-19?".

We have used the Statistical Package for Social Science (SPSS) v. 21 program (IBM Corp., Armonk, NY, USA). to test our hypothesis. The significance level adopted was *p* ≤ 0.05. Independent Student *t*-tests between two independent groups for all the variables were calculated.
