key: cord-1042501-nc5n7cl0
authors: Zhang, Yan; Cao, Xiaochen; Aashiq,; Xie, Yufei; Zhong, Qiongyao; Lei, Guanghui; Zhang, Jingyuan; Xiao, Qiang; Wang, Guixiang; Bian, Yueran; Xie, Simiao; Huang, Fei
title: Psychological Stress of University Students in the Hardest-hit Areas at Different Stages of the COVID-19 Epidemic
date: 2021-03-12
journal: Child Youth Serv Rev
DOI: 10.1016/j.childyouth.2021.105980
sha: c460e064f9d23c29e32d0bf25b7782b6f97b49c1
doc_id: 1042501
cord_uid: nc5n7cl0

Background The outbreak of COVID-19 has caused extremely many serious consequences for the country and the world. In fact, it has seriously affected people's mental health. The purpose of this study is to understand the psychological stress among college students in different stages of epidemics in hard-hit areas such as Hubei. Moreover, to highlight the factors that influencing, their psychological conditions with the emphasis of further corresponding suggestions. Methods This study includes self-designed questionnaires in order to assess and analyze the psychological state of over 17,000 college students during the outbreak period in January and home quarantine in February. The questionnaire contains three aspects and six dimensions: pressure responses: stress susceptibility (SS), stress adjustment (SA), risk cognition: cognition of danger (CD), cognition of illness (CI) and stress reactions: emotional responses (ER), somatic responses (SR). This survey was done by an online questionnaire (www.wjx.cn) to investigate the psychological stress information of college students, and analyzed the data by SPSS 22.0 for Windows. Results Regarding the stress susceptibility, participants were more likely stressed in February than in January. Regarding the stress adjustment, the number of participants requiring pressure regulation or release in the February survey was significantly lower than that the effective in the January survey. The mean of the cognition of danger reduced significantly in February than in January, in other words, participants were highly worried about the epidemic in January than in February. Regarding the cognition of illness, participants in January had a more pessimistic attitude towards the epidemic than those in February. The emotional responses of the participants in February were more severe than those in January, while the somatic responses reduced significantly in February compared with January. Furthermore, females have stronger stress reactions than males. However, the SR doesn’t have significant differences between females and males. Conclusion After two surveys in January and February, it was found that the psychological stress of college students in Hubei were significantly different at different stages of the epidemic, where the epidemic developped, the psychological stress of college students become more severe. The psychological stress of the college students in Hubei Province, as a severely affected area, should be paid more attention.

Since December 2019, there has been a large-scale outbreak of the new coronavirus pneumonia in Wuhan [1] . None of the 34 provincial administrative regions in the country have been spared, and patients with confirmed pneumonia have appeared in all regions [2] . The scale and severity of the pneumonia outbreak caused many cities, including Wuhan [3] , to close, especially the prefecture-level cities in Hubei Province. Since the outbreak of the pneumonia, university students across the country have been trembling, few people are on the streets, and most of the shops are closed, which is unprecedented. This sudden public health incident has made Wuhan, Hubei, China the focus of the world [4] . On 11 th February 2020, the World Health Organization (WHO) proposed the new coronavirus pneumonia named COVID-19.

Public health emergencies include major infectious disease outbreaks, mass unexplained diseases, major food and occupational poisoning and other events that cause or are likely to cause serious damage to and affect public health. The COVID-19 epidemic is a public health emergencies which has brought devastation to the entire world ， relatively high rates of symptoms of anxiety (6.33% to 50.9%), depression (14.6% to 48.3%), posttraumatic stress disorder (7% to 53.8%), psychological distress (34.43% to 38%), and stress (8.1% to 81.9%) are reported in the general population during the COVID-19 pandemic in China, Spain, Italy, Iran, the US, Turkey, Nepal, and Denmark [5] , as a result, the COVID-19 epidemic has had a significant impact on the mental health of people around the world. Other researchers have also shown that many people have been affected emotionally after the COVID-19 outbreak, during the initial phase of the COVID-19 outbreak in China, more than half of the respondents rated the psychological impact as moderate-to-severe, and about one-third reported moderate-to-severe anxiety, and students were found to experience a psychological impact of the outbreak and higher levels of stress, anxiety, and depression than adults [6] . Some researchers have revealed similar pattern, they identified the specific target groups (young and students) prone for the psychological impact of the current COVID-19 outbreak in China [7] .

China divides events into four levels according to the severity of the event, and this COVID-19 is a particularly significant level I event. China has moved quickly to contain the outbreak [8] . Live animal markets throughout the country have been suspended [9] .

Previous studies showed that public events would devastate communities in terms of lives and property, and they are difficult to recover from without help. For example, a study of PTSD after earthquake over half of people exhibited internalizing problems requiring clinical intervention [10] . In a recent study on the new crown epidemic, it was shown that during the outbreak of COVID-19, for the population, severe PTSD has also emerged, with 10.8% of workers experiencing psychological stress in a survey of returning workers [11] ，but the stress response of workers can be mitigated by personal protection and ensuring ventilation. While focusing on the stress response of the population, some researchers have also focused on the mentally ill. Are people who are already suffering from mental disorders suffering more negative effects than normal when exposed to a new epidemic? The answer is "yes". During the peak of the COVID-19 epidemic with strict lockdown measures, psychiatric patients scored significantly higher on the total IES-R, DASS-21 anxiety, depression, and stress subscales and, total ISI scores. More than onequarter of psychiatric patients reported PTSD-like symptoms and moderate to severe insomnia. Psychiatric patients were significantly more likely to report worries about their physical health, anger, impulsivity, and suicidal ideation [12] . During the SARS period in 2003, the disease caused more severe psychological stress reactions to the public. This time, the spread of the new coronavirus pneumonia was wider, the mortality rate was higher, the people were more panicked, and it was more likely to cause severe psychological stress. This study used a self-administered questionnaire intended to explore the participants' perceptions of the epidemic, their stress responses to the epidemic, and how they coped with the stress generated by the epidemic, we used specific 6 questionnaire questions to explore each of these three aspects. The survey was conducted from three aspects: pressure responses, risk cognition and stress reactions.

We chose these there aspects because the three topics were mentioned most frequently by the college students in the pre-interviews, we considered the study variables mentioned more frequently in the interviews to be more meaningful.Therefore, we need to pay more attention to the PTSD caused by public health emergencies. In addition, some researchers pointed out that the optimization of the pain control may reduce the risk of the subsequent development of PTSD and be effective for the secondary prevention of PTSD [13] .

It is well known that the COVID-19 is a devastating catastrophe worldwide, and other countries besides China have suffered from it. This is the first time in Vietnam that people have undergone "social distancing" to minimize the spreading of infectious disease, COVID-19. These deliberate preemptive strategies may have profound impacts on the mental health of the population [14] . A similar situation is also seen in the Philippines: 16.3% of respondents rated the psychological impact of the outbreak as moderate-to-severe; 16.9% reported moderate-to-severe depressive symptoms; 28.8% had moderate-to-severe anxiety levels; and 13.4% had moderate-to-severe stress levels [15] .

Public events will cause psychological stress, a previous research found that participants were exposed to unprecedented horror and a serious stress response following the Indian Ocean tsunami in Khao Lak, Thailand [16] , which is similar to the mechanism of development of this COVID-19 epidemic, they were sudden, natural and caused great harm, it can also influence the emotion. Although emotion is a subjective psychological reaction, it often affects people's external performance and people's cognition,in contemporary society, people are under great pressure, and crises such as this new coronavirus pneumonia are prone to cause psychological stress [17] . Some researchers [18] found that great psychological status can affect students' learning strategies to a certain extent. 7 Psychological research has also found that people usually experience four stages of contempt, panic, helplessness, and acceptance after a disaster. Especially in high-risk areas, the psychological stress of the population is more serious. People in the disaster-stricken areas are calmer and even despise those who are not [19] . With the development of the epidemic, people in disaster-stricken areas will experience several stages of panic, helplessness, and acceptance. To investigate the stress reaction of people in severely affected areas in different stages of the epidemic (outbreak period, isolation period, recovery period, and acceptance period), a questionnaire survey was conducted in the outbreak period in January and the isolation period in February.

This survey selected college students (age 18-30) as the research sample. College students are an important backbone of social development. Their psychological state affects the direction of social development, and the mental state of college students is easily affected [20] , their psychological status is not stable [21] . Public health crisis events are sudden and unpredictable. The psychological stress reaction of university students is the focus of society. Before this survey, several scholars have investigated the social stress reaction after a public crisis event, but university students are rarely used as research samples, and so this investigation is necessary. We should focus on their mental health, and it deserves the attention of society.

This survey utilized a self-designed questionnaire, we produced this questionnaire by following several steps: First, information was collected through small-scale interviews, the initial items were generated by interviewing a part of college students in Hubei, the interview relates to their psychological status and their disorders, for example, their awareness of the COVID-19, their current physical and emotional state whether they feel a lot of stress and whether they need help, etc. Next, after the interviews, the researchers sorted out the problems and mentioned disorders 8 mentioned by these college students, such as whether they were so afraid of being infected that they have trouble sleeping, and they thought the COVID-19 was hard to defeat, etc. Then we compiled a stress response questionnaire, and determined the questionnaire topics and factors using exploratory factor analysis (EFA). After constructing a stress reaction questionnaire with good reliability and validity, we used confirmatory factor analysis (CFA) to validate the validity of the questionnaire and to make the questionnaire reach the ideal standard. Finally, we obtained the final psychological stress questionnaire.

In the initial test, 32-item questionnaire was divided into three aspects (pressure response, risk cognition, and stress reaction) were collected for the exploratory factor analysis (EFA) through online questionnaires to determine the dimensions of the questionnaire. Among the 363 participants in the exploratory factor analysis, 223 were males and 140 were females, with an average age of 19.07 ± 0.08. The results of the fitness test showed that the KMO value was 0.86, and the Chi-squared value of the Bartlett spherical test was 3000.58 (df = 210, p <0.001), which proves that the exploratory factor analysis is feasible. Using the principal component extraction method (PCA) and the maximum variance method, we finally obtained 6 factors and a total of 21 items, and the items explained 64.57% of the variance in the results. The results are shown in Table 1 SPSS 22 .0 for Windows (SPSS Inc., Chicago, Illinois) was used to calculate the internal consistency reliability (Cronbach's α coefficient), split-half reliability, and the correlation between each factor score and the total score. The internal consistency reliability is 0.82.

To ensure the structural validity of the questionnaire, we conducted correlation analysis using the questionnaire and estimated the structural validity of the questionnaire based on the correlation between the dimensions. As can be seen from the table, the correlation coefficients between the dimensions of the questionnaire are less than 0.55, showing a moderate degree of correlation. It shows that there is a good degree of discrimination among the dimensions of this questionnaire, which indicates that there is a certain degree of independence between variables and that there is a certain relationship, which indicates that the structure of the questionnaire meets the basic requirements for questionnaire preparation. The results are shown in Table 2 .

To verify the suitability of the ideal model with respect to the actual data, data from 461 participants (223 males and 238 females) were collected for confirmatory factor analysis (CFA). CFA establishes a latent variable model based on the results of the EFA. That is, the six dimensions are used as the latent variables to estimate each item in the dimension, and each dimension is further classified into six sub-questionnaires to estimate the overall psychological stress questionnaire. The results of the model fitting index in this study show that χ2 / df = 2.885, CFI = 0.908, GFI = 0.894, NFI = 0.866, and RMSEA = 0.064, which meet the standard for a good model. Therefore, 21

items are in the confirmatory factor analysis. The constructed latent variable model fits the data well, as shown in Figure 1 .

This self-made questionnaire can effectively measure the psychological stress response of university students (age 20.45 ± 1.84) in the face of public emergencies, including risk cognition, physiological stress response, stress adjustment, etc.

A total of 20,280 questionnaires were collected using the final questionnaire survey.

In the first survey, the second week after Wuhan was closed, that is, January 29-31,2020, a total of 8,607 people filled out the questionnaire (age 19.56 ± 1.79, 54.19% female) in Hubei, and in the second survey, in the fourth week, February 17-20, 2020, 21,581 questionnaires were collected, and 8,876 people around the Hubei province filled out the questionnaire (age 20.99 ± 2.19, 57.59% female).

The study was designed in accordance with the tenets of the Declaration of Helsinki.

Approval from the ethical authority of School of Educational Science, Huazhong University of Science and Technology was granted. Confidentiality was managed by assigning anonymous codes to the self-report questionnaires, This survey used online questionnaire (www.wjx.cn) to investigate the psychological information of college students in January and February [22, 23] . We distributed questionnaires online through Wechat, QQ, and Sina microblog. Participants provided informed consent, then provided socio-demographic information and completed measures of their psychological status.

Two surveys utilized the same questionnaires, the researchers eventually produced a questionnaire with 29 items. Then we used WeChat, online questionnaires and other online surveys to investigate the psychological situation of college students in Hubei. 

The statistical analyses were performed using SPSS 20.0 for Windows (SPSS Inc., Chicago, Illinois). The statistical methods and data analysis results are described in detail as follows. As for the survey used the online questionnaire (www.wjx.cn), we can choose to refuse any empty questions during the questionnaire preparation, so the survey can ensure that each questionnaire collected is valid.

We used SPSS 22.0 for Windows (SPSS Inc., Chicago, Illinois) to conduct independent sample T-tests on the survey data of the participants in Hubei Province between January and February, and the results are shown in Table 3 . Comparing January and February shows that the higher the average is, the more severe the stress 12 reaction. Next, we will explain in detail according to the three parts and six dimensions.

The aspect of pressure responses includes two variables: the stress susceptibility (SS) and the stress adjustment (SA), that are the independent sample T-tests for results of the two surveys done in January and February revealed that there are differences in these two variables between January and February. As shown in Table 3 ,regarding the SS, participants were more likely to feel stress in February than in January, such as the participants in February said it was more difficult to concentrate on anything other than viruses (2.98 > 2.04, p < 0.001) (Q27). Whereas participants in February were far more stressed than those in January (3.46 > 2.51, p < 0.001) (Q29). Regarding the SA, the number of participants requiring pressure regulation or release in the February survey was significantly lower than that in the January survey. Such as in detail, participants in the January survey indicated that they needed professional psychological counseling more than in February (1.78 < 3.54, p < 0.001) (Q21).

Regarding the question of whether they need to talk with family and friends (Q22), the participants in January said they needed itmore than in February (2.37 < 3.14, p < 0.001).

The aspect of risk cognition includes two variables: the cognition of danger (CD) and the cognition of illness (CI). Regarding the risk cognition, there were significant differences between January and February in the CD and the CI.

The same independent sample T-test indicated that the mean of the CD reduced significantly in February than in January, in other words, participants were worried about the epidemic in January than in February. Such as participants in January considered the epidemic to be more serious, while participants in February were more optimistic 

Regarding stress reactions, the results for the emotional responses (ER) and somatic responses (SR) between January and February are quietly different. has decreased in February by comparing the data in January and February.

It can also have been found in the survey that the gender has a significant effect on stress responses, as shown in Table 4 . infecting family members, feelings of uncertainty, inadequate staffing levels [24] , the virulence of the disease and inappropriate equipment [25] , personal danger, and nosocomial spread.

After February, the central government sent an investigation team to Wuhan to uncover the truth so that it could be placed on the public. In the January survey, college students in Hubei were more optimistic than in February, they did not see the severity of the epidemic and felt that the virus was far away from them at the beginning [26] . The Hubei Provincial Government did not take strong measures in time [27] . The information received by people is not symmetrical with the facts, it will cause greater panic later [28] , because they were in the center of the epidemic, the one near the disaster was prone to be in panic [29, 30] . Only then did the public realize that the number of confirmed cases had skyrocketed, and the participants in Province, people can see the hope of ending the epidemic. While gradually coming back to normal, the cognition of danger and illness gradually has been lower.

Regarding gender differences, it has been found that the stress reactions of female in the face of epidemics are more severe than those of male. It is physiologically explained that female hormone levels are more likely to fluctuate, and they have stronger responses to emergencies than male. Stress reactions are also more likely to produce tension, anxiety, worry, stress and other stress reactions or emotions.

Previous research found that the proportion of female who have severe anxiety and other psychological stress is higher than that of male during the emergencies [31] [32] [33] .

Another research has found that point prevalence of depression was significantly higher in female (14.4%) [34] . From a psychological perspective, females are generally more sensitive than males and have stronger empathy in the face of major disasters. In addition, females are more likely to accept hints than males. The emotions of the people around them and the events that occur around them will trigger females' psychological responses.

Since the outbreak, a lot of negative information about the outbreak has appeared on the Internet and even on many mobile phone software programs. We usually learn negative information about the epidemic through the Internet or our peers in China, and it is the same in other countries, for exemple, mass media and peer-educators were the information channel most frequently accessed in Vietnam [35] . The public in Vietnam relied on online sources, whether through official websites or phone-based applications, to acquire up-to-date health information which provides accurate instructions, and limit misinformation [36] . We know that negative information will increase stress and anxiety for people that further may affect people's physical and mental health. As part of the New Era, as a whole, participants will deal with the negative information about the epidemic more rationally.

The researcher Lyrakos [37] has found that social events and education affect negative emotions such as stress and anxiety. The outbreak area of this epidemic was in Hubei Province which is the hardest-hit area where participants experienced terrible anxiety and worry. The government and society should pay more attention to these participants and provide psychological help. We thus make the following suggestions. ① To establish a psychological counseling hotline in major communities, answer psychological counseling calls, and conduct psychological counseling for participants in the hardest-hit areas. ② To set up a psychological protection team in each community to return to the hardest-hit participants regularly. ③ To exercise more hwo to maintain regular schedules and stabilize emotions. Long-term health problems and loss of function might play important roles in prolonging PTSD [38] . ④ When you are in a bad mood, you can use counseling, exercise, and intervention to guide you. ⑤ Follow up on the psychological conditions of the participants in the hardest-hit areas in a timely manner after the epidemic and provide the necessary post-traumatic psychological stress treatment.

The outbreak of COVID [39] . The time and place of treatment is limited due to the epidemic, and this is where Internet CBT emerges as a local adaptation ， researchers have indicated that the Internet CBT has been proven to be useful and efficacious for both psychiatric and medical conditions [40] , there are data which can provide strong support for the effectiveness of I-CBT in treating psychological and physical adverse reactions such as insomnia [41] .

Our suggestions are as follows: ① To cultivate the participants' core literacy, increase the participants' self-learning ability, and make the participants learn to arrange their study time rationally; and ② To cultivate the participants' interests or hobbies and guide the participants to continue their hobbies for a long time. ③ CBT can be conducted via the Internet or telephone for students with severe psychological stress to reshape their perceptions of themselves, things, and the epidemic, and to help them get rid of the adverse effects of negative information.

Stress is an emotional response that may be caused by emergencies. More diagnoses every day, urgent medical supply needs in major hospitals, and other negative news would increase the stress and negative emotions among participants. Furthermore, many participants in Hubei will also face discrimination, like with SARS when its associated psychiatric problems caused stigmatization [42] . In recent years, "stress" has become a term that has been mentioned increasingly. More often social competition has become increasingly more intense, and the stress of the participants has also increased. Increasingly, psychological pressures such as academic pressures, employment pressures, etc. can overwhelm a person. If they are not aware of the problem in time and do not actively solve it will cause serious consequences.

Therefore, for contemporary society, it is necessary to allow people to release stress through appropriate channels.

There are many ways to self-adjust, including seeking psychological intervention and speaking and talking to relatives and friends. Although the participants improved in February in terms of their cognition and physical responses, there were still a small number of participants who made self-adjustments by finding resources for psychological intervention. Most of the participants, nearly 80%, were not willing to 20 look for professional psychological intervention. This reflects the lack of the mental health education in China.

We suggest the following: add mental health courses at all levels of schools and educational institutions; organize group counseling regularly; teach people how to properly treat their emotional problems, how to control themselves, and what kind of help they should seek if they cannot control their psychological problems.

There are some limitations in this study, only small structured interviews were conducted at the beginning of the self-administered questionnaire, yet due to time and technical constraints, we were not able to do functional neuroimaging. This study mainly used self-reported questionnaires to measure psychiatric symptoms and did not make clinical diagnosis. The gold standard for establishing psychiatric diagnosis involved structured clinical interview and functional neuroimaging [43, 44] . Besiedes, there is non participation of the foreign students in the survey as they are the hardest hit. Therefore, in the future research, more scientific and accurate methods, such as brain imaging technology, fMRI, fNIRS, etc. are needed to accurately establish psychiatric diagnosis after the epidemic in different countries. At the same time, it is necessary to adopt different psychotherapy methods for different groups and for different psychosomatic problems to provide better mental health services for people.

By investigating the stress reactions of participants at different stages after the outbreak of COVID-19, it was found that in the face of public health emergencies, participants in the hardest-hit areas were more vulnerable to stress and emotional responses during the outbreak than those in other areas. As the epidemic developed, stress adjustments, somatic responses, danger cognition, and disease cognition improved. Furthermore, it was also found that females have stronger stress reactions

All the authors have approved the manuscript and agree with its submission to your esteemed journal. There are no conflicts of interest to declare. 

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