key: cord-0799271-b5r9t0wy authors: Feng, Shiyin; Zhang, Qiaochu; Ho, Samuel M. Y. title: Fear and anxiety about COVID‐19 among local and overseas Chinese university students date: 2021-04-06 journal: Health Soc Care Community DOI: 10.1111/hsc.13347 sha: 1999f7308e687377a661462a7215a23e14a84137 doc_id: 799271 cord_uid: b5r9t0wy This study aimed to establish a new COVID‐19 Fear (Higher Education) scale to investigate the relationship between fear and generalised anxiety symptoms among Chinese students in mainland China, Hong Kong, and other countries. 219 Chinese university students studying in universities in mainland China (n = 76, 34.7%), Hong Kong (n = 66, 30.1%), and overseas (i.e., outside of China as international students, n = 77, 35.2%) participated in an online study from March 31, 2020 to April 4. Participants completed a newly developed COVID‐19 Fear (Higher Education) scale to measure three domains of fear including fear of infection, fear of instability and fear of insecurity related to the COVID‐19 pandemic. They also completed the Generalized Anxiety Disorder 7‐item scale (GAD‐7) on the severity of anxiety symptoms. About 9.6% of the participants could be classified as exhibiting high anxiety level according to the GAD‐7. More students studying overseas (about 15%) were classified into the high GAD group when compared to students studying in both mainland China (6.6%) and Hong Kong (6.1%). MANOVA results showed that students studying in Hong Kong and overseas had more concerns related to preventive measures related to COVID‐19 than their mainland counterparts did. We concluded that international students studying away from their home country would have higher risk to develop anxiety problems during a collective trauma such as the COVID‐19 pandemic. Education institutions should provide support services including online support groups, social media groups for mutual support to alleviate the fear and anxiety of international students. The outbreak of a new coronavirus was declared by the World Health Organization as a Public Health Emergency of International Concern (PHEIC) on 30 January 2020 (World Health Organization, 2020a) . The new coronavirus pneumonia caused by the highly infectious COVID-19 is an acute infectious disease which has led to millions of infected cases and thousands of death (Zhang, 2020) . To prevent the spread of the virus, many cities worldwide have implemented preventive measures including quarantine and lockdown. Threats related to the pandemic and its related preventive measures have significant adverse impact on the mental health of individuals. For instance, Huang and Zhao (2020) studied the factors influencing the mental health of the Chinese public during showed that younger Chinese generations and people who spent too much time getting updates from the COVID-19 outbreak were prone to developing anxiety symptoms. Uncertainties about the pandemic would cause higher stress level and have higher chance of developing mental disorder symptoms (Huang & Zhao, 2020) . Besides, Choi et al. (2020) investigated how COVID affected the Hong Kong population's psychological well-being. The prevalence of anxiety and depression among Hong Kong people was higher during the pandemic than before (Choi et al., 2020) . Because of these measures, university students from different areas are facing various threatening situations. Students studying in China were among the first being affected by the virus outbreak. Chinese students studying in other countries faced similar threats later when the virus spread to their studying areas. Besides, these students might have to expose themselves to a high risk of infection on flights back to China. Zhou et al. (2020) conducted a cross-sectional online survey and reported that the prevalence of a combination of depressive and anxiety symptoms was 31.3% among Chinese high school students during the COVID-19 outbreak. Older students tended to exhibit more anxiety and depressive symptoms. Another study reported that Chinese college students tend to experience more anxiety if someone they know is tested positive for COVID (Cao et al., 2020) . In Hong Kong, Li and Leung (2020) reported that one-third of high school students, especially female students experienced more mental distress. Furthermore, senior high school students were more likely to display psychological distress than younger forms due to stress coming from the potential interference of COVID to the upcoming public examination. Besides, Chinese students at universities in Hong Kong were in a more complicated situation where they have been exposed to both the COVID-19 pandemic and the Hong Kong social movement happening in 2019 (Hou & Hall, 2019) in two consecutive years. Being in an uncertain and threatening situation, students' mental health may be seriously compromised (Hou & Hall, 2019; Ni et al., 2020; Torales et al., 2020) . Anxiety is a complex emotional state where people feel anxious, disturbed, worried and annoyed in face of impending danger or threat such as an infectious disease outbreak (Robinson et al., 2013) . Stressful life events were found to be positively associated with anxiety and depressive symptoms (Meng et al., 2011) . In times of COVID-19, Zhang et al. (2020) revealed that the detection rate of anxiety symptoms was about 15% in medical students from Mongolia medical colleges in mainland China, and 77% of the students had shown distress symptoms in the past 7 days. Fear is an emotion that is often related to anxiety (Van Bockstaele et al., 2014) . While anxiety arises from expectations or concerns about the occurrence of some fearful situation, fear is an affective reaction to actual exposure to threats (Huberty, 2012) . In times of virus outbreak, fear is a common response to the threats of the invisible virus. During the SARS outbreak, healthcare workers who need to have close contact with SARS patients were reported to show strong fear towards SARS (Ho et al., 2005) . In combating Ebola, fear is an issue to overcome (Vega, 2016) . Research on fear and anxiety in young children has found that fear is a significant predictor for later social anxiety symptoms in young children and adolescents (Buss et al., 2013 (Buss et al., , 2020 . Also, generalised anxiety disorders are related to overgeneralised conditioned fear; the association between anxiety symptoms and constant high level of fear has also been reported (Duits et al., 2016; Lissek et al., 2014) . Due to the increase in globalisation of the world, more Chinese students were studying abroad than in 2003 during SARS. Similar to SARS, the COVID-19 outbreak is likely to evoke strong fearful reactions in university students. It is important to establish appropriate tools to measure anxiety-related to COVID-19 among the student populations as well as to investigate risk factors related to anxiety towards COVID-19. At the start of the COVID-19 pandemic, a 7-item Persian version of the Fear of COVID-19 scale (FCV-19S) was developed among a sample of Iranian participants (Ahorsu et al., 2020) , and later adapted to Turkish (Bakioğlu et al., 2020) , Russian (Reznik et al., 2020) and Bangla (Sakib et al., 2020) The total score represents the severity of anxiety which is similar to existing anxiety scales such as the Generalized Anxiety Disorder 7-item scale (Löwe et al., 2008) . There is a lack of a multidimensional COVID-19 Fear Scale tailored to university students that is more comprehensive in terms of measuring other symptoms of fear. Both SARS and COVID-19 are coronavirus and lead to contagious severe acute respiratory syndrome (Peiris et al., 2003; World Health Organization, 2020b) ; similar precaution and preventive measures are implemented in both SARS and COVID-19 pandemics (Ho, 2003; Lin et al., 2020) . Accordingly, it is logical to expect that similar dimensions of fear towards SARS could be applied to understand the fear related to COVID-19. Hence, the present study adapted the multidimensional SARS Fear Scale (Ho et al., 2005) Based on the above review, this study aimed to establish a new scale, This study investigated Chinese university students' fear and anxiety towards COVID-19. Using the new scale, the associations between fear and generalised anxiety, and risk factors of generalised anxiety disorder in university students were examined. No research has been conducted to compare the fear and anxiety of these three groups of students, to our best knowledge. The findings can inform university administrators, faculty members and mental health professionals in choosing appropriate services for local and international students to help them cope with infectious disease outbreaks and other crises. 219 Chinese university students, 55 males (25.1%) and 164 females (74.9%), with an average age of 23.17 years (SD = 2.66, range = 17-34 years) participated in the study. Due to the seriousness of the outbreak in China and time constraints at that time, we did not extend the data collection period to collect more samples. Statistical power analysis showed that a power of 0.8 was achieved by our current sample size with a medium effect size (Cohen's f 2 = 0.15) and an alpha value of 0.05. All students were born in mainland China, and they were studying at universities in mainland, Hong Kong, or an overseas country. Among the 219 participants, 76 (34.7%) students were from a university in mainland China; 66 (30.1%) were studying in one of the universities in Hong Kong and 77 (35.2%) were international students who were studying in an overseas uni- An online study was conducted because of infectious disease control measures. Convenience sampling was used by posting an invitation link to our study site on WeChat, which is a popular social media among Chinese young people, from 31 March to 21 April 2020. A link to the study site with the online questionnaires was included in the invitation. At the study website, informed consent was presented first on the screen. After the participants read the information sheet and gave consent, they were directed to complete the online questionnaires (see below). Participants clicked a button to submit their answers after completion of the questionnaires. Participants' fears about COVID-19 were measured by the COVID-19 Fear (Higher Education) scale. The scale was adapted from the 18item SARS Fear Scale (SFS) for healthcare workers (Ho et al., 2005) . Each item describes a specific issue related to COVID-19 (e.g., 'Fear that I will be infected' and 'Feel disturbed because of the complex procedure to go back to my country'). Items only relevant to healthcare workers such as 'feel distressed because the upsurge in workload', and 'worry if I will be assigned to SARS wards' were removed. Items applicable to university students such as 'fear being quarantine or forced to limit activities', and 'fear being quarantine or forced to limit activities', were added. Participants were asked to rate on a 4-point Likert Scale from 0 (definitely false) to 3 (definitely true) to what extent the issue applies to them. Participants of the present study completed the Chinese version of the COVID-19 Fear (Higher Education) scale, although it should be noted that both English and Chinese versions of the COVID-19 Fear (Higher Education) scale are available. The Chinese version of the General Anxiety Disorder 7-Item (GAD-7) Scale (Zeng et al., 2013) was translated from the original English version of GAD-7 (Löwe et al., 2008; Spitzer et al., 2006) to assess generalised anxiety disorder symptoms over the past 2 weeks on a four-point scale from 0 (never) to 3 (nearly every day). A total score with a range of 0-21 was calculated by summing up scores on each item, with higher total scores indicating higher anxiety severity. A GAD-7 total score of 10 or above is considered to be in the high anxiety range (Johnson et al., 2019; Spitzer et al., 2006) . This scale had excellent internal consistency with Cronbach's α = 0.92 according to the sample of the present study. Participants completed a self-developed questionnaire to provide personal information including gender, age, studying location, history of mental health, family history and personal history of COVID-19. A total of 25 locations, including different provinces, autonomous regions and municipalities directly under the Central government in China were collected. Participants who are under psychiatric treatment or have been diagnosed with COVID-19 were excluded from the study. Any family member of the participant diagnosed with COVID-19 was also excluded. There were four mainland students and two overseas students from Hubei. Exploratory factor analysis was conducted to explore the structure of the COVID Fear (Higher Education) scale. We performed independent samples t-tests and one-way ANOVA to investigate the differences in COVID-19 fear and anxiety between males and females and among the three groups of participants (i.e., mainland China, Hong Kong, overseas). Participants were grouped into high versus low anxiety groups according to the cut-off score of GAD-7. Correlations among age, COVID-19 fear and anxiety were also examined for gender and study places, respectively. Multivariate analysis of variances (MANOVA) was conducted with different dimensions of COVID-19 fear as a group dependent variable. Regression analysis was finally conducted to examine the relative association of different dimensions of COVID-19 fear, gender and study places with students' anxiety level. Exploratory factor analysis with varimax rotation was performed to identify the factor structure of the 18-item COVID-19 Fear (Higher Education) scale. Nine items were retained based on criteria that their loadings on a factor exceed 0.50 without loading above 0.40 on another factor, and the difference between an item's loading on two factors should be larger than 0.30 . The Kaiser-Meyer-Olkin (KMO) measure of sample adequacy was 0.82, indicating that the sample size (n = 219) was adequate for EFA (Kaiser, 1974) . A three-factor solution was revealed which accounted for 71.6% of the total variance (Table 1 ). The first factor was labelled as Infection (4 items, 23. We categorised each participant based on their score on the GAD-7 scale using the usual cut-off of 10 into high and low anxiety groups TA B L E 1 Factor structure of the COVID-19 fear (higher education) scale (n = 219) (Spitzer et al., 2006) . Chi-squared analysis showed no gender differences in the distribution of GAD high versus low anxiety groups, χ 2 (1) = 0.46, p = 0.50. Independent samples t-test revealed no age difference between the two groups too, t(217) = −1.42, p = 0.16. Table 2 shows the distribution of GAD high versus low groups. Overall, about one-tenth (9.6%) of the participants were categorised into the high anxiety group. About 15% of students studying overseas were grouped into the GAD high anxiety group. This percentage tended to be higher than both students in mainland China and Hong Kong (6.6% and 6.1%, respectively), although a marginally non-significant result was obtained, χ 2 (2, N = 219) = 4.94, p = 0.085, Wilk's Lambda = 0.042. Table 3 shows the mean (standard deviation) of COVID-19 fear scores by GAD group and place of study. We conducted partial correlations to examine the linear relationship between fear of COVID-19 and anxiety level. Since there was a gender difference in a GAD-7 score and a difference in COVID-19 infection Note: High anxiety group included those participants with a Generalized Anxiety Disorder 7-item scale total score of 10 or higher. Low anxiety group included those participants with a Generalized Anxiety Disorder 7-item scale total score below10. Note: High anxiety group included those participants with a Generalized Anxiety Disorder 7-item scale total score of 10 or above, Low anxiety group included those participants with a Generalized Anxiety Disorder 7-item scale total score below 10. score among students in the three places of study, these two variables were controlled as covariates. The results are shown in Table 4 . alone accounted for 12% of the GAD-7 score (r = 0.37, r 2 = 0.12). We examined the relative importance of the three COVID-19 Fear and insecurity were significant predictors of GAD-7 even after the effects of age, gender and study places were taken into account (Table 5) . Our results suggested that female students tended to score higher in the GAD-7 scale measuring potential GAD symptoms. This result was consistent with another study among Russian and Belarus university students that used the 7-item Fear of COVID-19 scale (Reznik et al., 2020) . These findings were consistent with previous research which has shown that females tend to feel a higher level of anxiety, worries and fear; they also have greater difficulty in emotional adjustment than males (Bender et al., 2012; Bottesi et al., 2018; Halbreich & Kahn, 2007; McLean & Hope, 2010) . Female students' higher anxiety levels and stronger COVID-19 fear may be explained by women's higher anxiety sensitivity and physiological reactivity than men (Norr et al., 2016; Stoyanova & Hope, 2012) . Partial correlations showed that age was positively correlated with both GAD scores and Fear of COVID-19 Instability score (re Table 4 ). Senior year students might have more concerns about the negative effects of the COVID-19 outbreak and the school's preventive measures than junior year students. As seniors are about to graduate from universities outside mainland China, they may be more anxious about missing out on in-person commencement, or they may be more anxious about not being able to get a plane ticket back to their hometown. Another objective of this study is to compare anxiety levels and fear towards COVID-19 among mainland China, Hong Kong, and overseas university students. Hong Kong students from mainland China are of particular interest because their mental health might be negatively affected by both the social events in 2019 (Hou & Hall, 2019) and the COVID-19 outbreak in 2020 (Hou & Hall, 2019; Ni et al., 2020; Torales et al., 2020) . During the social events in 2019, Hong Kong was in a state of chaos. University students were particularly affected since they were evacuated from residential halls, and classes were suspended (Chan, 2020) . We did not, however, collect any information about the social events influences because of time urgency and the highly stressful data collection period of this study. However, this social event is assumed to be affecting all students in Hong Kong. Our results showed that a higher percentage of those overseas students (15%) were categorised into GAD high anxiety group when compared to both mainland China (6.6%) and Hong Kong (6.1%) students (re Table 3 ). MANOVA results also showed that those with international student status had a higher fear of instability (i.e., changes related to infectious disease measures) than those local students. It has been reported that Asian international students are more inclined to exhibit severe mental health symptoms including suicide ideation and they are less inclined to seek help when compared to local American students and other international students (Xiong, 2018) . Being in an unfamiliar place away from family during a crisis of infectious disease outbreak might make international students more prone to psychopathology. Based on our findings that fear of instability is higher for university students away from family, preventive measures or infection control policies may be another important source of international students' higher anxiety levels. Increased severity of COVID-19 in many countries outside China at the time of survey completion (World Health Organization, 2020c) may also contribute to higher international university students' anxiety. Support for international students including remote counselling, free mask and COVID-19 testing are among some ways a university can offer to help international students (Durrani, 2020) . Hierarchical regression analysis for variables predicting GAD-7 total score (GAD-7 total) (n = 219) Step Partial correlations controlling for gender and place of study ( However, the study has several limitations. First, about 75% of participants were females, which might affect the results and lead to insignificant findings within male participants. Second, we were particularly interested in comparing students in three locations including mainland China, Hong Kong, and other countries. As a result, we failed to collect the data that indicates the county where the overseas participants were studying. Besides, we did not consider the outbreak status and medical readiness of different overseas countries due to time constraints during the data collection period. Consequently, the lack of background information of those overseas countries may affect the result. Also, the findings might not be applied to students studying at primary or secondary schools. socioeconomic status was not collected in the questionnaire. This might contribute to a biased sample as we failed to show the sample characteristics by place of study. Furthermore, our sample size of 219 could not allow us to do both exploratory and confirmatory factor analyses to confirm the factor structure. We are not able to calculate the response rate since there was no way to record how many people visited the WeChat study site and decided not to participate. Lastly, due to the pandemic situation and lack of knowledge at that time, we did not collect data about the outbreak severity, medical equipment supplies and infection control policies in each county. However, those data can also explain the phenomenon of a higher risk of anxiety in overseas students. Despite the above limitations, this study has several contributions to understanding and fighting against the negative psychological impact of the COVID-19 outbreak among university students. First, a 9-item COVID-19 Fear (Higher Education) Scale consisting of three domains is established specifically for students in higher education to facilitate future research. Second, our findings highlight the difficulty of international university students during a critical situation such as the COVID-19 outbreak. Thirdly, the results showed that fear of infection and fear of insecurity were significantly related to generalised anxiety symptoms. Interventions to reduce these two dimensions of fear such as increasing self-efficacy, social support, and addressing some existential issues triggered by the crisis would be effective to reduce anxiety. However, further research should be conducted to inform the development of psychological interventions for university students. Samuel M. Y. 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