Abstract
Children and adolescents are greatly impacted by the tremendous changes during COVID-19 epidemic. Rural primary and middle school students, as a relatively less concerned population, owing to their inconvenience of accessing epidemic-associated information, might have more serious impact on mental health. From 11 May, 2020 to 20 May, 2020, a multicenter cross-sectional study was performed through a unified field questionnaire in 12 rural schools in Shantou, Hezhou and Nanchong. There were 20.02%, 8.56%, 5.26% of respondents suffering from mild, moderate, and severe anxiety during COVID-19 epidemic. The protective factors encompassed spraying bleach water for environmental disinfection (OR=0.604, 95% CI=0.425-0.858) and disinfecting unmanned environments with ultraviolet radiation (OR=0.351, 95% CI=0.193-0.639), while risk factors included female(moderate anxiety: OR=1.703, 95% CI=1.082-2.682; severe anxiety: OR=2.821, 95% CI=1.479-5.381), cognition about the rage of susceptible population (OR=1.554, 95% CI=1.028-2.34), going outside during the epidemic (OR=3.194, 95% CI=1.430-7.136), epidemic-related information acquisition via publicity of community and village committee (OR=2.142, 95% CI=1.187-3.866), and not wearing masks (OR=22.210, 95% CI=3.987-123.717). The anxiety disorder is more prevalent among rural primary and middle school students, female in particular, than the general population. Cognition regarding protective measures and effective precautionary measures are both helpful against anxiety. It is highly advised for policymakers to formulate psychological supports and interventions targeting this vulnerable group.
Keywords: COVID-19; anxiety; mental health; rural students
Abbreviations
Covid-19: Coronavirus Disease 2019; CSs: College Students; GP: General Population; HPs: Healthcare Professionals; GAD-7: Generalized Anxiety Disorder 7-Item
Introduction
Coronavirus Disease 2019 (COVID-19) initially broke out in Wuhan in late December 2019 and spread rapidly around the world, which has become a global health disaster [1]. The causative microorganism has been recognized as severe acute respiratory syndrome coronavirus 2, an RNA virus belonged to the β-family coronavirus [2]. Infected patients mainly manifest inflammatory respiratory symptoms such as fever, sore throat, cough, dyspnea, and even progress into respiratory distress syndrome and acute respiratory failure [3]. In comparison to the 2003 severe acute respiratory syndrome, COVID-19 may be less pathogenic but more contagious, which poses a big challenge to global health security [4,5].
Actually, the epidemic not only threatens infectious patients’ lives but also leads to unbearable psychological impacts for those who are exposed to negative epidemic-related information. The objective and precise evaluation of public mental status is of paramount importance during the epidemic, which does benefit the principle formulation of mental intervention as well as the promotion of policy decisions. A series of studies have been conducted to investigate how the emergency of the COVID-19 outbreak influences the mental health of different populations such as College Students (CSs) [6], general population (GP) [7], and Healthcare Professionals (HPs) [8]. Noticeably, there was also a cross-sectional study that analyzed the prevalence of anxiety and depression among HPs, CSs and GP, and appealed for further mental interventions [9]. Nevertheless, less is known about how the ongoing COVID-19 affects the psychological status of rural students, who is a special population partly owing to their inconvenience of accessing epidemic-associated information and improperness of precautionary measures against the epidemic. Primary and middle school students in particular, as a younger group of adolescents, are much easier to develop mental illnesses than general population, such as depression, anxiety, eating disorders, substance use disorders, and psychosis [10]. They are more vulnerable to the psychological impact of COVID-19 and are weak in dealing with psychological problems [11]. Therefore, it is supposed to gain more mental support under the epidemic due to their immature mental status [11,12]. Fail to deal with the psychological problems in time may lead to poor education, health, and economic status in the future [13]. However, compared to urban students, rural primary and middle school students are often ignored during COVID-19 epidemic, exactly how COVID-19 influences the psychological status of rural primary and middle school students is rarely investigated. To address this problem, this study tended to investigate the anxiety status of rural primary and middle school students and to further examine the relationship between their psychological impact and probable factors in terms of sociodemographic, knowledge, and precautionary measures under this sensitive period. An in-depth understanding of the impact will do benefit further mental monitoring and intervention.
Materials and Methods
Procedures and participants
A multicenter cross-sectional study was performed through a field questionnaire survey to investigate the psychological status of rural students during the ongoing epidemic of COVID-19. Strict multistage stratified cluster sampling was adopted to select participants in southern China. Firstly, three undeveloped cities in southern China (Shantou, Guangdong; Hezhou, Guangxi; Nanchong, Sichuan) were selected by multiple-stage cluster sampling. All of these three regions have a great number of villages both in central and non-central districts. Secondly, a primary school and a middle school were randomly selected respectively from central and noncentral rural districts. Thirdly, approximately 100 students from two classes of each grade, including Grade 5-6 in primary school and Grade 7-8 in middle school, were invited to fill in the united questionnaires. The inclusion criteria of respondents are as followed: 1) were informed and voluntarily participated in the survey; 2) could read and understand the questionnaire; 3) lived in the investigated districts and studied in the investigated school during the outbreak of the epidemic; 4) have not been infected with COVID-19 by the end of the data collection; 5) have not been diagnosed with other mental disorders except mild, moderate and severe anxiety, or taking medications for mental diseases. Only if all conditions are met can they be included. All the participants were informed that their participation was voluntary and had signed the informed consent before they filled in the questionnaire. The whole study processed in 12 schools was restricted in 2 weeks (from 11 May, 2020 to 22 May, 2020). This study was approved by the ethics committee of Shantou University Medical College (Approval No.SUMC-2020-81).
Instrumentations
Data were collected by designed questionnaire, which was pre investigated, modified, analyzed and reviewed by experts. The designed questionnaire was mainly composed of 4 parts: a) sociodemographic information of respondents; b) cognition about COVID-19; c) precautionary measures against COVID-19; d) anxiety level exposed to the pandemic.
The sociodemographic data includes genders, ages, grades, academic achievements, parents’ educational background, parents’ occupations, whether lives with parents, and family income. Based on the new coronavirus prevention and control guidelines of Chinese Center for Disease Control and Prevention (5th Edition), we raised several questions about the knowledge and precautionary measures of COVID-19 to details understand the participants’ cognition level and adopted protective measures against the epidemic. Specifically, knowledge about COVID-19 covered sources of infection, routes of transmission, susceptible population, symptoms, treatments, quarantine, and disinfection methods. Regarding precautionary measures, questions were included their eagerness for pandemic information, initiatives and approaches for getting epidemic-related information, frequency of going outside during the epidemic, wearing masks or not when going outside, frequency of changing masks, occasions of wearing masks, frequency of exercise since Wuhan was blockaded, nutrition supplement, covering mouth and nose when coughing or sneezing, frequency occasions of washing hands, and detergent on washing hands.
Generalized Anxiety Disorder 7-Item (GAD-7) Scale is currently one of the most commonly used instruments in detecting and assessing anxiety disorders owing to the satisfactory efficiency and reliability [9,14,15], which consists of 7 items: 1) Feeling nervous, anxious, or on edge; 2) Not being able to stop or control worrying; 3) Worrying too much about different things; 4) Trouble relaxing; 5) Being so restless that it’s hard to sit still; 6) Becoming easily annoyed or irritable; 7) Feeling afraid as if something awful might happen. The total GAD-7 score was divided into Normal (0-4), Mild Anxiety (5-9), Moderate Anxiety (10-14) and Severe Anxiety (15-27). Considering the English reading level of the rural primary and middle school students, we adopted the translated version of the GAD-7 scale to assess the anxiety level of the respondents. The Cronbach’s alpha was 0.90 and KMO was 0.88 [16].
Data analysis
Descriptive statistics were used to describe participants’ demographic characteristics, knowledge regarding COVID-19, and precautionary measures against the pandemic. Quantitative data were reported as mean ± standard deviation. A chi-square test was used to assess the significance between anxiety and sociodemographic, knowledge, as well as precautionary measures. A multivariate logistic regression analysis was further used to analyze the significant factors associated with anxiety in the chi-square test. A two-sided P-value <0.05 indicated the statistical significance. Statistical analysis was performed using SPSS ver. 25.0.
Results
Sociodemographic characteristics of participants
Of 1204 collected questionnaires, 25 respondents did not complete the questionnaires, with the response rate of 97.9%. The baseline characteristics of the participants are presented in Table 1. There was a total of 559 males and 620 females, 31.84% from Shantou, Guangdong, 33.76% from Hezhou, Guangxi, and 34.86% from Nanchong, Sichuan. The average age of respondents was 12.83±1.27. More than half reported their fathers (57.17%) and mothers (58.61%) have a low level of education (under junior school). Additionally, the most common occupations of their parents are business and service practitioners (34.61% for fathers and 32.23% for mothers), while healthcare professionals accounted for 3.90% respectively. Most respondents (61.49%) live with their parents together, only a minority living with just mother or father. The difference in sociodemographic data by gender was also listed in Table 1.
Variables, n (%)
Overall (n=1179)
Male 559 (47.41)
Female 620 (52.59)
Age (Years)
12.83±1.27
12.86±1.23
12.80±1.31
Region
Shantou, Guangdong
370 (31.38)
167 (45.14)
203 (54.86)
Hezhou, Guangxi
398 (33.76)
174 (43.72)
224 (56.28)
Nanchong, Sichuan
411 (34.86)
218 (53.04)
193 (46.96)
Grade
Grade 5
316 (26.80)
153 (48.42)
163 (51.58)
Grade 6
325 (27.57)
163 (50.15)
162 (49.85)
Grade 7
272 (23.07)
125 (45.96)
147 (54.04)
Grade 8
266 (22.56)
118 (44.36)
148 (55.64)
Academic achievement
Excellent (Top 10%)
147 (12.47)
61 (41.50)
86 (58.50)
Fine (10~30 %)
387 (32.82)
168 (43.41)
219 (56.59)
Average (30-50 %)
400 (33.93)
201 (50.25)
199 (49.75)
Others (50-100 %)
96 (8.14)
50 (52.08)
46 (47.92)
Unknown
149 (12.64)
79 (53.02)
70 (46.98)
Father's education level
674 (57.17)
307 (45.55)
367 (54.45)
Senior school
172 (14.59)
93 (54.07)
79 (45.93)
Undergraduate
30 (2.54)
16 (53.33)
14 (46.67)
Master degree or above
303 (25.70)
143 (47.19)
160 (52.81)
Mother's education level
Under junior high school
691 (58.61)
311 (45.01)
380 (54.99)
Senior school
132 (11.20)
75 (56.82)
57 (43.18)
Undergraduate
24 (2.03)
14 (58.33)
10 (41.67)
Master degree or above
332 (28.16)
159 (47.89)
173 (52.11)
Father's occupation
Health worker
46 (3.90)
22 (47.83)
24 (52.17)
Civil servant or employee of non-medical institution
185 (15.69)
98 (52.97)
87 (47.03)
Business and service practitioner
408 (34.61)
184 (45.10)
224 (54.90)
Migrant worker
196 (16.62)
97 (49.49)
99 (50.51)
Farmer
344 (29.18)
158 (45.93)
186 (54.07)
Mother's occupation
Health worker
46 (3.90)
26 (56.52)
20 (43.48)
Civil servant or employee of non-medical institution
181 (15.35)
99 (54.70)
82 (45.30)
Business and service practitioner
380 (32.23)
187 (49.21)
193 (50.79)
Migrant worker
262 (22.22)
109 (41.60)
153 (58.40)
Farmer
310 (26.30)
138 (44.52)
172 (55.48)
Whether lives with parents
Father only
86 (7.30)
48 (55.81)
38 (44.19)
Mother only
127 (10.77)
70 (55.12)
57 (44.88)
Both parents
725 (61.49)
315 (43.45)
410 (56.55)
Neither
241 (20.44)
126 (52.28)
115 (47.72)
Low-income family
Yes
146 (12.38)
80 (54.79)
66 (45.21)
No
551 (46.74)
256 (46.46)
295 (53.54)
Unknown
482 (40.88)
223 (46.27)
259 (53.73)
Table 1: Demographics of Respondents of Primary and Middle School Students in Southern China.
The psychological impact by sociodemographic characteristics
Among 1179 respondents, 399 students experienced anxiety at different levels (mild anxiety: 20.02%, moderate anxiety: 8.56%, severe anxiety: 5.26%). Table 2 showed the association between sociodemographic data and the anxiety level of rural students in southern China. The chi-square test showed that there was a significant difference in anxiety level between males and females (Χ²=18.888, p<0.001). Specifically, male students were comprised of 22.72% respondents with mild anxiety, 6.98% respondents with moderate anxiety, and 2.86% respondents with severe anxiety. In female students, the data were 17.58%, 10.00%, and 7.42% respectively. A significant difference in anxiety level between 3 cities could also be observed (Χ²=13.079, p<0.05). No significant effect was observed between students’ anxiety level and other sociodemographic characteristics (p>0.05).
Variables, n (%)
Total
n=1179Anxiety level
c2
p
Normal
780 (66.16)Mild
236 (20.02)Moderate
101 (8.56)Severe
62 (5.26)Gender
18.888
<0.001
Male
559 (47.41)
377 (67.44)
127 (22.72)
39 (6.98)
16 (2.86)
Female
620 (52.59)
403 (65.00)
109 (17.58)
62 (10.00)
46 (7.42)
Region
13.079
0.042
Shantou, Guangdong
370 (31.38)
259 (70.00)
73 (19.73)
25 (6.76)
13 (3.51)
Hezhou, Guangxi
398 (33.76)
251 (63.06)
86 (21.61)
31 (7.79)
30 (7.54)
Nanchong, Sichuan
411 (34.86)
270 (65.69)
77 (18.74)
45 (10.95)
19 (4.62)
Grade
6.403
0.699
Grade 5
316 (26.80)
219 (69.30)
57 (18.04)
28 (8.86)
12 (3.80)
Grade 6
325 (27.57)
214 (65.85)
59 (18.15)
32 (9.85)
20 (6.15)
Grade 7
272 (23.07)
175 (64.34)
61 (22.43)
21 (7.72)
15 (5.51)
Grade 8
266 (22.56)
172 (64.66)
59 (22.18)
20 (7.52)
15 (5.64)
Academic achievement
5.331
0.805
Excellent (Top 10%)
147 (14.27)
96 (65.31)
32 (21.77)
12 (8.16)
7 (4.76)
Fine (10~30 %)
387 (37.57)
256 (66.15)
77 (19.90)
29 (7.49)
25 (6.46)
Average (30-50 %)
400 (38.84)
267 (66.75)
80 (20.00)
37 (9.25)
16 (4.00)
Others (50-100 %)
96 (9.32)
61 (63.54)
17 (17.71)
11 (11.46)
7 (7.29)
Father's education level
14.091
0.119
Under junior high school
674 (57.17)
457 (67.81)
122 (18.10)
54 (8.01)
41 (6.08)
Senior school
172 (14.59)
111 (64.54)
37 (21.51)
14 (8.14)
10 (5.81)
Undergraduate
30 (2.54)
15 (50.00)
12 (40.00)
2 (6.67)
1 (3.33)
Master degree or above
303 (25.70)
197 (65.02)
65 (21.45)
31 (10.23)
10 (3.30)
Mother's education level
15.148
0.087
Under junior high school
691 (58.61)
466 (67.44)
129 (18.67)
55 (7.96)
41 (5.93)
Senior school
132 (11.20)
88 (66.66)
30 (22.73)
9 (6.82)
5 (3.79)
Undergraduate
24 (2.03)
11 (45.83)
7 (29.17)
2 (8.33)
4 (16.67)
Master degree or above
332 (28.16)
215 (64.76)
70 (21.08)
35 (10.54)
12 (3.62)
Father's occupation
7.727
0.806
Health workers
46 (3.90)
31 (67.39)
8 (17.39)
5 (10.87)
2 (4.35)
Civil servants or employees of non-medical institutions
185 (15.69)
122 (65.95)
41 (22.16)
15 (8.11)
7 (3.78)
Business and service practitioners
408 (34.61)
265 (64.95)
83 (20.34)
33 (8.09)
27 (6.62)
Migrant workers
196 (16.62)
131 (66.84)
40 (20.41)
20 (10.20)
5 (2.55)
Farmers
344 (29.18)
231 (67.15)
64 (18.61)
28 (8.14)
21 (6.10)
Mother's occupation
10.766
0.549
Health workers
46 (3.90)
35 (76.09)
5 (10.87)
4 (8.69)
2 (4.35)
Civil servants or employees of non-medical institutions
181 (15.35)
124 (68.51)
32 (17.68)
16 (8.84)
9 (4.97)
Business and service practitioners
380 (32.23)
243 (63.95)
85 (22.37)
30 (7.89)
22 (5.79)
Migrant workers
262 (22.22)
165 (62.98)
59 (22.52)
28 (10.69)
10 (3.81)
Farmers
310 (26.30)
213 (68.71)
55 (17.74)
23 (7.42)
19 (6.13)
Whether lives with parents
11.269
0.258
Father only
86 (7.30)
52 (60.46)
18 (20.93)
10 (11.63)
6 (6.98)
Mother only
127 (10.77)
75 (59.06)
26 (20.47)
18 (14.17)
8 (6.30)
Both parents
725 (61.49)
493 (68.00)
144 (19.86)
56 (7.73)
32 (4.41)
None
241 (20.44)
160 (66.39)
48 (19.92)
17 (7.05)
16 (6.64)
Low-income family
2.394
0.495
Yes
146 (20.95)
93 (63.70)
27 (18.49)
17 (11.64)
9 (6.17)
No
551 (79.05)
363 (65.88)
114 (20.69)
43 (7.80)
31 (5.63)
Table 2: Associations between Demographics and Anxiety Level of Primary and Middle School Students in Southern China.
The psychological impact and cognition about COVID-19
With regards to cognition about COVID-19, Table 3 showed a vast majority of respondents (95.17%) thought that the coronavirus can spread from person to person, and the sources of infection were asymptomatic coronavirus infection (74.81%) and symptomatic coronavirus infection (88.89%). The most routine perceived approach of transmission was through droplet spread (92.62%) and contact transmission (72.26%). Additionally, the susceptible populations covered the elderly, the middle-aged, the young, and the kids (86.4%). Even for those apparent infections, there was a latent period of 1~14 days (49.62%). Therefore, a suspected infection should be under quarantine for 14 days (89.14%). Vital correct approaches towards sterilization included spraying alcohol to disinfect the air (16.88%), disinfecting surfaces with alcohol (77.78%), spraying bleach water for environmental disinfection (22.90%), and disinfecting unmanned environments with ultraviolet radiation (32.74%). Moreover, most respondents thought avoidance of gathering (93.81%), wearing masks (98.56%), frequent hand-washing (98.39%), and frequent room ventilation (93.04%) were effective precautionary measures against the transmission of COVID-19.
Variables, n (%)
Total
n=1179Anxiety level
c2
p
Normal
780 (66.16)Mild
236 (20.02)Moderate
101 (8.56)Severe
62 (5.26)Will the coronavirus spread from person-to-person?
6.911
0.075
Correct (Yes)
1122 (95.17)
748 (66.67)
225 (20.05)
91 (8.11)
58 (5.17)
Error (No, unclear)
57 (4.83)
32 (56.14)
11 (19.30)
10 (17.54)
4 (7.02)
Which of the following groups will spread COVID-19?
With fever, dry cough and other symptoms
2.7
0.44
Correct (Will not spread)
173 (14.67)
119 (68.79)
36 (20.81)
13 (7.51)
5 (2.89)
Error (Will spread, unclear)
1006 (85.33)
661 (65.70)
200 (19.88)
88 (8.75)
57 (5.67)
Asymptomatic coronavirus infection
5.096
0.165
Correct (Will spread)
882 (74.81)
583 (66.10)
180 (20.41)
68 (7.71)
51 (5.78)
Error (Will not spread, unclear)
297 (25.19)
197 (66.33)
56 (18.86)
33 (11.11)
11 (3.70)
Symptomatic coronavirus infection
1.182
0.757
Correct (Will spread)
1048 (88.89)
691 (65.93)
212 (20.23)
88 (8.40)
57 (5.44)
Error (Will not spread, unclear)
131 (11.11)
89 (67.94)
24 (18.32)
13 (9.92)
5 (3.82)
Will the coronavirus spread through the following channels?
Droplet transmission
2.451
0.484
Correct (Yes)
1092 (92.62)
724 (66.30)
215 (19.69)
93 (8.52)
60 (5.49)
Error (No, unclear)
87 (7.38)
56 (64.37)
21 (24.14)
8 (9.19)
2 (2.30)
Mosquito-borne transmission
3.389
0.335
Correct (Yes)
513 (43.51)
346 (67.45)
106 (20.66)
40 (7.80)
21 (4.09)
Error (No, unclear)
666 (56.49)
434 (65.16)
130 (19.52)
61 (9.16)
41 (6.16)
Contact transmission
1.893
0.595
Correct (Yes)
852 (72.26)
559 (65.61)
168 (19.72)
77 (9.04)
48 (5.63)
Error (No, unclear)
327 (27.74)
221 (67.58)
68 (20.80)
24 (7.34)
14 (4.28)
Who may be infected with the coronavirus?
9.872
0.02
Correct (Everyone)
1019 (86.43)
685 (67.22)
193 (18.94)
83 (8.15)
58 (5.69)
Error (The elder, the young, children)
160 (13.57)
95 (59.38)
43 (26.88)
18 (11.25)
4 (2.50)
How long does it take for a person infected with the coronavirus to develop symptoms?
1.686
0.64
Correct (1~14 days)
585 (49.62)
390 (66.67)
119 (20.34)
44 (7.52)
32 (5.47)
Error (<12 hours, 12-24 hours, 14-28 days, unclear)
594 (50.38)
390 (65.66)
117 (19.70)
57 (9.59)
30 (5.05)
How long is the quarantine of COVID-19?
2.323
0.508
Correct (14 days)
1051 (89.14)
694 (66.03)
212 (20.17)
87 (8.28)
58 (5.52)
Error (No need of quarantine, 1 day, 7 day, unclear)
128 (10.86)
86 (67.19)
24 (18.75)
14 (10.94)
4 (3.12)
Which of the following is the correct disinfection methods?
Spraying alcohol to disinfect the air
3.423
0.331
Correct (Error)
199 (16.88)
136 (68.34)
43 (21.61)
14 (7.04)
6 (3.01)
Error (Correct, unclear)
980 (83.12)
644 (65.71)
193 (19.69)
87 (8.88)
56 (5.72)
Disinfecting surfaces with alcohol
2.255
0.521
Correct (Correct)
917 (77.78)
603 (65.76)
183 (19.96)
78 (8.50)
53 (5.78)
Error (Error, unclear)
262 (22.22)
177 (67.56)
53 (20.23)
23 (8.78)
9 (3.43)
Spraying bleach water for environmental disinfection
9.875
0.02
Correct (Correct)
270 (22.90)
162 (60.00)
72 (26.67)
23 (8.52)
13 (4.81)
Error (Error, unclear)
909 (77.10)
618 (67.99)
164 (18.04)
78 (8.58)
49 (5.39)
Disinfecting unmanned environments with ultraviolet radiation
15.732
0.001
Correct (Correct)
386 (32.74)
231 (59.84)
85 (22.02)
38 (9.85)
32 (8.29)
Error (Error, unclear)
793 (67.26)
549 (69.23)
151 (19.04)
63 (7.95)
30 (3.78)
Which of the following methods can effectively prevent coronavirus infection?
8.367
0.039
Correct (Yes)
1106 (93.81)
732 (66.18)
224 (20.25)
89 (8.05)
61 (5.52)
Error (No, unclear)
73 (6.19)
48 (65.75)
12 (16.44)
12 (16.44)
1 (1.37)
Wearing mask
0.465
0.926
Correct (Yes)
1162 (98.56)
770 (66.26)
232 (19.97)
99 (8.52)
61 (5.25)
Error (No, unclear)
17 (1.44)
10 (58.82)
4 (23.53)
2 (11.77)
1 (5.88)
Frequent hand-washing
1.127
0.77
Correct (Yes)
1160 (98.39)
767 (66.12)
232 (20.00)
99 (8.53)
62 (5.35)
Error (No, unclear)
19 (1.61)
13 (68.42)
4 (21.05)
2 (10.53)
0 (0.00)
Frequent room ventilation
1.771
0.621
Correct (Yes)
1097 (93.04)
729 (66.45)
215 (19.60)
95 (8.66)
58 (5.29)
Error (No, unclear)
82 (6.96)
51 (62.19)
21 (25.61)
6 (7.32)
4 (4.88)
Can patients with COVID-19 be cured?
2.776
0.427
Correct (Yes)
953 (80.83)
639 (67.05)
187 (19.62)
81 (8.50)
46 (4.83)
Error (No, unclear)
226 (19.17)
141 (62.39)
49 (21.68)
20 (8.85)
16 (7.08)
Table 3: Association between Knowledge of COVID-19 and Anxiety Level of Primary and Middle School Students in southern China.
The chi-square test revealed a statistically significant difference in anxiety level among respondents knowing which kinds of population might be infected with coronavirus or not (χ²=9.872, p<0.05). Furthermore, a significant difference in anxiety level could also be observed among respondents who thought it correct or not to spray bleach water for environmental disinfection, disinfect unmanned environment with ultraviolet radiation, and not aggregate against coronavirus transmission. Other variables in cognition were not significantly associated with anxiety level.
The psychological impact and precautionary measures against COVID-19
As was shown in Table 4, a vast majority of respondents would take initiative to obtain epidemic situations (72.77%). Among diverse information sources, the mobile phone, tablet or other electronic equipment (84.05%) and television (77.44%) were the most common accesses for the acquisition of relevant information. Only a few respondents would ask to go out during the outbreak (5.51%).
Variables, n (%)
Total
n=1179Anxiety level
c2
p
Normal
780 (66.16)Mild
236 (20.02)Moderate
101 (8.57)Severe
62 (5.26)Do you take the initiative to obtain the epidemic situations?
6.41
0.093
Yes
858 (72.77)
557 (64.92)
171 (19.93)
77 (8.97)
53 (6.18)
No
321 (27.23)
223 (69.47)
65 (20.25)
24 (7.48)
9 (2.80)
How do you get information about the epidemic situation?
Mobile phone, tablet or other electronic equipment
1.485
0.686
Yes
991 (84.05)
655 (66.09)
203 (20.48)
83 (8.38)
50 (5.05)
No
188 (15.95)
125 (66.49)
33 (17.55)
18 (9.57)
12 (6.38)
Television
1.201
0.753
Yes
913 (77.44)
598 (65.50)
185 (20.26)
82 (9.98)
48 (5.26
No
266 (22.56)
182 (68.42)
51 (19.17)
19 (7.14)
14 (5.27)
Newspapers, magazines or other traditional paper media
0.775
0.856
Yes
267 (22.65)
179 (67.04)
49 (18.35)
25 (9.36)
14 (5.25)
No
912 (77.35)
601 (65.90)
187 (20.51)
76 (8.33)
48 (5.26)
Information from parents
2.282
0.516
Yes
637 (54.03)
412 (64.68)
129 (20.25)
58 (9.10)
38 (5.97)
No
542 (45.97)
368 (67.90)
107 (19.74)
43 (7.93)
24 (4.43)
School education
3.495
0.321
Yes
629 (53.35)
404 (64.23)
130 (20.67)
56 (8.90)
39 (6.20)
No
550 (46.65)
376 (68.37)
106 (19.27)
45 (8.18)
23 (4.18)
Publicity of community and village committee
18.846
<0.001
Yes
420 (35.62)
266 (63.33)
82 (19.52)
34 (8.10)
38 (9.05)
No
759 (64.38)
514 (67.72)
154 (20.29)
67 (8.83)
24 (3.16)
Did you ask to go out during the outbreak?
10.656
0.014
Yes
65 (5.51)
32 (49.23)
17 (26.16)
11 (16.92)
5 (7.69)
No
1114 (94.49)
748 (67.14)
219 (19.66)
90 (8.08)
57 (5.12
How many times a week do you go out on average during the outbreak?
22.496
0.007
Every day
22 (1.87)
19 (86.36)
2 (9.09)
0 (0.00)
1 (4.55)
Two to three times a week
87 (7.38)
49 (56.32)
25 (28.74)
11 (12.64)
2 (2.30)
Table 4: Association between Preventive Behavior for COVID-19 and Anxiety Level of Primary and Middle School Students in Southern China.
Once a week
300 (25.44)
178 (59.33)
73 (24.33)
29 (9.67)
20 (6.67)
Never
770 (65.31)
534 (69.35)
136 (17.66)
61 (7.92)
39 (5.07)
Since the blockade of Wuhan, do you wear a mask when you go out?
6.297
0.71
Never
36 (3.05)
26 (72.22)
8 (22.22)
1 (2.78)
1 (2.78)
Mainly in the early period
166 (14.08)
109 (65.66)
35 (21.09)
12 (7.23)
10 (6.02)
Mainly in the recent period
75 (6.36)
50 (66.67)
12 (16.00)
6 (8.00)
7 (9.33)
Every time
902 (76.51)
595 (65.96)
181 (20.07)
82 (9.09)
44 (4.88)
How often do you change the mask?
10.581
0.306
Don't wear a mask
7 (0.59)
5 (71.43)
2 (28.57)
0 (0.00)
0 (0.00)
Use a mask more than three times
65 (5.51)
44 (67.69)
14 (21.54)
4 (6.15)
3 (4.62)
Change after two to three times uses
359 (30.46)
246 (68.52)
78 (21.73)
22 (6.13)
13 (3.62)
Change a mask every time
748 (63.44)
485 (64.84)
142 (18.98)
75 (10.03)
46 (6.15)
When do you wear a mask?
When playing sports
5.976
0.426
Wear
399 (33.84)
262 (65.66)
77 (19.30)
42 (10.53)
18 (4.51)
Don't wear
598 (50.72)
396 (66.22)
120 (20.07)
50 (8.36)
32 (5.35)
Not exercise
182 (15.44)
122 (67.03)
39 (21.43)
9 (4.95)
12 (6.59)
When going to the hospital
5.604
0.469
Wear
887 (75.23)
580 (65.39)
175 (19.73)
82 (9.24)
50 (5.64)
Don't wear
12 (1.02)
7 (58.33)
2 (16.67)
2 (16.67)
1 (8.33)
Don't go to the hospital
280 (23.75)
193 (68.93)
59 (21.07)
17 (6.07
11 (3.93)
When going to crowded places
17.403
0.008
Wear
906 (76.84)
599 (66.11)
180 (19.87)
83 (9.16)
44 (4.86)
Don't wear
16 (1.36)
11 (68.75)
0 (0.00)
1 (6.25)
4 (25.00)
Don't go to crowded places
257 (21.80)
170 (66.15)
56 (21.79)
17 (6.61)
14 (5.45)
When going to an open place
4.548
0.603
Wear
406 (34.44)
269 (66.26)
78 (19.21)
36 (8.87)
23 (5.67)
Don't wear
293 (24.85)
197 (67.24)
58 (19.80)
19 (6.48)
19 (6.48)
Don't go to an open place
480 (40.71)
314 (65.42)
100 (20.83)
46 (9.58)
20 (4.17)
How can you prevent the spread of droplets when you cough or sneeze in public?
11.129
0.084
Cover your mouth and nose with palms
119 (10.09)
79 (66.39)
20 (16.81)
16 (13.44)
4 (3.36)
Cover your mouth and nose with a tissue or elbow
925 (78.46)
621 (67.14)
178 (19.24)
75 (8.11)
51 (5.51)
Turn your head to the unmanned side
135 (11.4)
80 (59.26)
38 (28.15)
10 (7.40)
7 (5.19)
How often do you wash your hands every day?
17.615
0.04
More than 15 times
208 (17.64)
126 (60.58)
38 (18.27)
26 (12.50)
18 (8.65)
11-15 times
147 (12.47)
94 (63.95)
32 (21.77)
17 (11.56)
4 (2.72)
6-10 times
493 (41.82)
330 (66.94)
99 (20.08)
37 (7.50)
27 (5.48)
0-5 times
331 (28.07)
230 (69.49)
67 (20.24)
21 (6.34)
13 (3.93)
When go home
6.599
0.086
Yes
910 (77.18)
599 (65.83)
179 (19.67)
76 (8.35)
56 (6.15)
No
269 (22.82)
181 (67.29)
57 (21.19)
25 (9.29)
6 (2.23)
After coughing or sneezing
3.565
0.312
Yes
919 (77.95)
605 (65.83)
180 (19.59)
80 (8.70)
54 (5.88)
No
260 (22.05)
175 (67.31)
56 (21.54)
21 (8.07)
8 (3.08)
Before wearing mask and after taking off the mask
7.849
0.049
Yes
753 (63.87)
492 (65.34)
142 (18.86)
72 (9.56)
47 (6.24)
No
426 (36.13)
288 (67.60)
94 (22.07)
29 (6.81)
15 (3.52)
After exposure to public things
9.703
0.021
Yes
759 (64.38)
486 (64.03)
153 (20.16)
70 (9.22)
50 (6.59)
No
420 (35.62)
294 (70.00)
83 (19.76)
31 (7.38)
12 (2.86)
After touching animals
12.483
0.006
Yes
805 (68.28)
521 (64.72)
154 (19.13)
78 (9.69)
52 (6.46)
No
374 (31.72)
259 (69.25)
82 (21.93)
23 (6.15)
10 (2.67)
When you feel your hands dirty
8.512
0.037
Yes
853 (72.35)
552 (64.71)
176 (20.63)
71 (8.33)
54 (6.33)
No
326 (27.65)
228 (69.94)
60 (18.41)
30 (9.20)
8 (2.45)
What detergent do you use when washing your hands?
25.175
0.003
Disinfectant
374 (31.72)
228 (60.96)
74 (19.79)
41 (10.96)
31 (8.29)
Liquid soap
510 (43.26)
351 (68.82)
107 (20.98)
29 (5.69)
23 (4.51)
Soap
167 (14.16)
116 (69.46)
26 (15.57)
20 (11.98)
5 (2.99)
Tap-water only
128 (10.86)
85 (66.41)
29 (22.66)
11 (8.59)
3 (2.34)
How long have you exercised on average every week since Wuhan was blockaded?
22.745
0.007
More than seven hours a week
108 (9.16)
74 (68.52)
18 (16.67)
6 (5.55)
10 (9.26)
Three to seven hours a week
178 (15.10)
96 (53.93)
44 (24.72)
22 (12.36)
16 (8.99)
One to three hours a week
416 (35.28)
288 (69.23)
79 (18.99)
34 (8.17)
15 (3.61)
Less than one hour a week
477 (40.46)
322 (67.50)
95 (19.92)
39 (8.18)
21 (4.40)
Table 4 of 1:
Significant differences in anxiety level were observed among individuals who accessed epidemic-related information from the publicity of community and village committee or not (χ²=18.846, p<0.001), who asked to go out during the outbreak or not (χ²=10.656, p<0.05), and wore a mask or not when going to crowded places (χ²=17.403, p<0.05). Besides, the development of anxiety was significantly associated with the frequency of going outside (χ²=22.496, p<0.05), the frequency of washing hands (χ²=17.615, p<0.05), categories of detergent when washing hands (χ²=25.175, p<0.05), the condition of washing hands, and the frequency of exercise (χ²=22.745, p<0.05).
Multivariate logistic regression analysis
Table 5 indicated that individuals clear about who could be infected with coronavirus (OR=1.554, 95% CI: 1.028-2.348), who went out once a week (OR=1.599, 95% CI: 1.134-2.255) and 2-3 times a week (OR=1.897, 95% CI: 1.103-3.263) during the outbreak were more likely to develop mild anxiety. In contrast, those considering it correct to spray bleach water for environmental disinfection (OR=0.604, 95% CI: 0.425-0.858) were less likely to develop mild anxiety. Additionally, individuals who thought no aggregation could effectively prevent coronavirus infection (OR=2.262, 95% CI: 1.051-4.870), who asked to go outside during the outbreak (OR=3.194, 95% CI: 1.430-7.136) and who washed hands more than 15 times every day (OR=2.122, 95% CI: 1.071-4.204) were easier to experience moderate anxiety. Moreover, those who lived in Hezhou (OR=2.098, 95% CI: 1.034-4.255), who got epidemic-related information through publicity of community and village committee (OR=2.142, 95% CI: 1.187-3.866), who didn’t wear masks in crowded places (OR=22.210, 95% CI: 3.987-123.717) and used disinfectant when washing hands (OR=4.768, 95% CI: 1.200- 18.944) were more tended to experience severe anxiety. Individuals who thought it correct to disinfect unmanned environments with ultraviolet radiation were less likely to experience severe anxiety (OR=0.351, 95% CI: 0.193-0.639). Noticeably, gender might have a key impact on the development of anxiety. Female respondents were more likely to develop moderate anxiety (OR=1.703, 95% CI: 1.082- 2.682) and severe anxiety (OR=2.821, 95% CI: 1.479-5.381) than male respondents.
Variables
n
SE
OR
p
OR (95% CI)
Mild
Who may be infected with the coronavirus?
Correct (Everyone)
43
0.211
1.554
0.036
(1.028, 2.348)
Error (The elder, the young, children)
193
-
-
-
-
Which of the following is the correct disinfection methods?
Spraying bleach water for environmental disinfection
Correct (Correct)
164
0.179
0.604
0.005
(0.425, 0.858)
Error (Error, unclear)
72
-
-
-
-
How many times a week do you go out on average during the outbreak?
Every day
2
0.799
0.37
0.212
(0.077, 1.766)
Two to three times a week
25
0.277
1.897
0.021
(1.103, 3.263)
Once a week
73
0.175
1.599
0.007
(1.134, 2.255)
Never
136
-
-
-
-
How long have you exercised on average every week since Wuhan was blockaded?
More than seven hours a week
31
0.311
0.772
0.406
(0.419, 1.422)
Three to seven hours a week
23
0.234
1.421
0.134
(0.898, 2.249)
One to three hours a week
5
0.184
0.952
0.79
(0.665, 1.365)
Less than one hour a week
3
-
-
-
-
Moderate
Gender
Female
62
0.232
1.703
0.022
(1.082, 2.682)
Male
39
-
-
-
-
Which of the following methods can effectively prevent coronavirus infection?
No aggregation
Correct (Yes)
12
0.391
2.262
0.037
(1.051, 4.870)
Error (No, unclear)
89
-
-
-
-
Did you ask to go out during the outbreak?
Yes
11
0.41
3.194
0.005
(1.430, 7.136)
No
90
-
-
-
-
How often do you wash your hands every day?
More than 15 times
26
0.349
2.122
0.031
(1.071, 4.204)
11-15 times
17
0.372
1.662
0.172
(0.802, 3.443)
6-10 times
37
0.299
1.154
0.632
(0.642, 2.073)
0-5 times
21
-
-
-
-
How long have you exercised on average every week since Wuhan was blockaded?
More than seven hours a week
6
0.495
0.496
0.157
(0.188, 1.309)
Three to seven hours a week
22
0.319
1.533
0.181
(0.820, 2.867)
One to three hours a week
34
0.265
0.944
0.829
(0.562, 1.587)
Less than one hour a week
39
-
-
-
-
Severe
Gender
Female
16
0.329
2.821
0.002
(1.479, 5.381)
Male
46
-
-
-
-
Region
Shantou, Guangdong
13
0.423
0.847
0.695
(0.370, 1.939)
Hezhou, Guangxi
30
0.361
2.098
0.04
(1.034, 4.255)
Nanchong, Sichuan
19
-
-
-
-
How do you get information about the epidemic situation?
Publicity of community and village committee
Yes
38
0.301
2.142
0.011
(1.187, 3.866)
No
24
-
-
-
-
Which of the following is the correct disinfection methods?
Disinfecting unmanned environments with ultraviolet radiation
Correct (Correct)
30
0.305
0.351
0.001
(0.193, 0.639)
Error (Error, unclear)
32
-
-
-
-
When do you wear a mask?
When going to crowded places
Wear
44
0.349
0.774
0.463
(0.391, 1.522)
Don't wear
4
0.876
22.21
<0.001
(3.987, 123.717)
Don't go to crowded places
14
-
-
-
-
What detergent do you use when washing your hands?
Disinfectant
31
0.704
4.768
0.026
(1.200, 18.944)
Liquid soap
23
0.696
2.14
0.274
(0.547, 8.371)
Soap
5
0.816
1.585
0.572
(0.320, 7.847)
Tap-water only
3
-
-
-
-
How long have you exercised on average every week since Wuhan was blockaded?
More than seven hours a week
10
0.477
2.185
0.101
(0.858, 5.563)
Three to seven hours a week
16
0.4
1.895
0.11
(0.864, 4.154)
One to three hours a week
15
0.379
0.689
0.326
(0.328, 1.449)
Less than one hour a week
21
-
-
-
-
*Previous significant variables calculated by chi-square test were further analyzed by multivariate logistic regression analysis, and only meaningful variables were shown here.
Table 5: Multivariate Logistic Regression Analysis on Anxiety Level of Primary and Middle School Students in Southern China*.
Discussions
As the epidemic continues, mental health has emerged as another concern in addition to physical health. People continuously exposed to the negative epidemic-related information may suffer from anxiety, depression, and stress disorders [17]. This study aims to evaluate the psychological impact and probable factors in terms of sociodemographic, knowledge, and precautionary measures among rural primary and middle school students during the ongoing period of COVID-19. In general, 33.84% of the study participants had a different level of anxiety. Among them, female students were more likely to develop anxiety than male students. Participants’ cognition about COIVD-19 are average with an overall correct rate of 64.50%. In particular, cognition towards protective measures, such as correct disinfection methods were conducive to reduce anxiety.
It was reported that there were 5.8%, 2.1%, and 0.4% of the general population suffering from mild, moderate, and severe anxiety in China [18]. The prevalence was lower than our findings (mild anxiety: 20.02%, moderate anxiety: 8.56%, severe anxiety: 5.26%). The reasons for this phenomenon are multifold. Firstly, compared with general population, rural students might be more vulnerable and sensitive to the side psychological impact of the epidemic, which might be the reason why they are more likely to develop anxiety during this period. Secondly, the different study-conducting periods may subsequently lead to a change in prevalence. The afore-mentioned study was conducted on the initial outbreak of the epidemic, while ours was performed during the ongoing period. People during the ongoing epidemic period may worry more about when the epidemic could be terminated. Meanwhile, the epidemic also led to the abrupt withdrawal from school, which might be one of the reasons. Finally, it is worth noting that the self-evaluated tool in anxiety level (selfrating anxiety scale) is different from ours (GAD-7), although both of them possess evident reliability and validity. The results indicated that anxiety is more prevalent among the rural primary and middle school students than among the general population, and therefore, the government should implement more directed measures applicable to rural students when providing mental support for the general population.
Our findings indicated that female students show higher anxiety levels, which is fundamentally consistent with the previous studies [19,20]. Additionally, a systematic review also revealed that female was a significant risk factor associated with anxiety disorders [21]. It might attribute to that female students from low-income families had significantly more mental health problems over time compared to male students [22]. Priority may thereby be attached to females when providing mental support and intervention for the targeted population.
Not all knowledge about COVID-19 contribute to reduce anxiety. In contrast, knowledge concerning population susceptibility and severity of COVID-19 would result in mild and moderate anxiety, which was in good accordance with previous studies [23,24]. Indeed, on one hand, people having basic understandings of COVID-19, are well aware of self-protection, driving them far away from anxiety of getting an infection. On the other hand, they may also develop anxiety because knowledge associated with susceptibility and severity could result in fear of potential risks and negative assessment of infection [23], which might explain washing hands too frequently and using disinfectant instead of normal cleanser were risk factors. However, anxiety is not always deleterious. It has been reported that moderate anxiety was beneficial to knowledge learning and disease prevention [25]. In our study, we similarly found that individuals experiencing mild or moderate anxiety knew more about effective methods against the coronavirus infection. Therefore, more attention should be paid to those who had a severe anxiety. It is of great significance to early identify and assist them in coping with severe anxiety. Adopting anxiety assessment questionnaire in school is possibly an effective approach to early diagnose possible anxious students. Besides, promoting mental health application of mobile phone may also be a convenient and timely method for daily use.
Although it was not statistically significant in our study, most studies considered that regular physical activities regarding forms and intensities could relieve anxiety and depression. Some researchers even worried about the potential of cardiovascular disease increased globally due to a lack of sports during the epidemic [26,27]. However, as for rural students in China, outdoor exercise is more prevalent. Our results indicated that going out was a risk factor for mild and moderate anxiety groups. And going to crowded places without masks was even a strong risk factor in the severe group. Therefore, indoor exercises such as yoga and bodyweight training are recommended during the sensitive period [28-30].
To the best of our knowledge, this is the first study focusing on the psychological impact of COVID-19 epidemic among rural primary and middle school students during the pandemic of COVID-19. Our findings would serve as an evident reference for policy decisions in monitoring and supporting the mental health of rural students. The large sample size (1179 respondents) and the multicentersourced data (12 schools from Shantou, Hezhou, and Nanchong) raised the generalizability to public rural students in southern China. Additionally, we were concerned that some rural students didn’t possess their Internet products or they may not answer the questionnaire according to the actual. Therefore, in contrast to most online surveys, we conducted a field paper questionnaire monitored by local well-trained investigators, which may consequently reduce selection bias and increase the reliability of answers.
However, there were several limitations in our study. Firstly, we were not allowed to perform a prospective study due to this sensitive period. This cross-sectional research not only inevitably brought some recall bias, such as the inaccurate answers to some questions about frequency, but also failed to establish causality between the cognition of COVID-19 and mental health. As consequences, we were unable to infer whether anxiety is the cause or the consequence of the variables. Secondly, we conducted the study among 12 schools at different time, which may have subtle changes in the psychological impact of rural students. To minimize the impact of time on psychological status, we have strictly restricted the whole study period to less than 2 weeks.
Despite several limitations mentioned above, our findings provided a key insight into how the ongoing epidemic affects the anxiety level among rural primary and middle school students, which would draw public attention towards them for mental health care. And future studies could be further performed to probe the comprehensive mental status integrating stress, anxiety, and depression disorder among this particularly vulnerable group.
Conclusion
Anxiety disorder is more prevalent among primary and middle school students from rural areas than among the general population during the ongoing COVID-19 epidemic. In particular, female students, as a more sensitive population, should also arouse public attention on mental health care. Meanwhile, cognition concerning protective measures and effective precautionary measures are both helpful to prevent the development of anxiety. Future studies are needed to better understand the comprehensive mental status via integrating stress, anxiety, and depression disorder targeting this particularly vulnerable group. Policymakers such as the government and schools are strongly advised to formulate psychological support and intervention applicable to this group.
Author Contributions
Conceptualization, Liping Li and Wanbao Ye; Formal analysis, Yongxin Zhang and Haijie Xu; Investigation, Yongxin Zhang, Haijie Xu, Menglai Gan, Jianrui Ma, Jiarong Liu, Xiner Tan, Wenjing Hou and Wanbao Ye; Project administration, Yongxin Zhang; Supervision, Liping Li; Writing - original draft, Menglai Gan and Jianrui Ma; Writing – review & editing, Yongxin Zhang and Jianrui Ma.
Funding
This research was funded by Special Project for Prevention and Treatment of Pneumonia Infected by COVID-19 in Shantou City (SFK[2020]16-5, SFK[2020]23-24).
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Acknowledgment
We thank principals and teachers from 12 primary and middle schools in rural areas for their permission and assistance in conducting field questionnaire surveys.
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