Prevalence and Psychosocial Correlates of Mental Health Outcomes Among Chinese College Students During the Coronavirus Disease (COVID-19) Pandemic

To investigate the prevalence and risk factors for poor mental health of Chinese university students during the Corona Virus Disease 2019 (COVID-19) pandemic.Chinese nation-wide on-line cross-sectional survey on university students, collected between February 12th and 17th, 2020. Primary outcome was prevalence of clinically-relevant posttraumatic stress disorder symptoms. Secondary outcomes on poor mental health included prevalence of clinically-relevant anxiety and depressive symptoms, while posttraumatic growth was considered as indicator of effective coping reaction.Of 2,500 invited Chinese university students, 2,038 completed the survey. Prevalence of clinically-relevant PTSD, anxiety, and depressive symptoms, and post traumatic growth (PTG) was 30.8, 15.5, 23.3, and 66.9% respectively. Older age, knowing people who had been isolated, more ACEs, higher level of anxious attachment, and lower level of resilience all predicted primary outcome (all p < 0.01).A significant proportion of young adults exhibit clinically relevant posttraumatic stress disorder (PTSD), anxious or depressive symptoms, but a larger portion of individuals showed to effectively cope with COVID-19 pandemic. Interventions promoting resilience should be provided, even remotely, to those subjects with specific risk factors to develop poor mental health during COVID-19 or other pandemics with social isolation.

section_content: 1. COVID-19 has and is likely to affect people from many countries, in many geographical locations. When referring to people with COVID-19, do not attach the disease to any particular ethnicity or nationality. Be empathetic to all those who are affected, in and from any country. People who are affected by COVID-19 have not done anything wrong, and they deserve our support, compassion and kindness. 

2. Do not refer to people with the disease as "COVID-19 cases", "victims" "COVID-19 families" or "the diseased". They are "people who have COVID-19", "people who are being treated for COVID-19", or "people who are recovering from COVID-19", and after recovering from COVID-19 their life will go on with their jobs, families and loved ones. It is important to separate a person from having an identity defined by COVID-19, in order to reduce stigma. 

3. Minimize watching, reading or listening to news about COVID-19 that causes you to feel anxious or distressed; seek information only from trusted sources and mainly so that you can take practical steps to prepare your plans and protect yourself and loved ones. Seek information updates at specific times during the day, once or twice. The sudden and near-constant stream of news reports about an outbreak can cause anyone to feel worried. Get the facts; not rumours and misinformation. Gather information at regular intervals from the WHO website and local health authority platforms in order to help you distinguish facts from rumours. Facts can help to minimize fears. 

4. Protect yourself and be supportive to others. Assisting others in their time of need can benefit both the person receiving support and the helper. For example, check by telephone on neighbours or people in your community who may need some extra assistance. Working together as one community can help to create solidarity in addressing COVID-19 together. 

5. Find opportunities to amplify positive and hopeful stories and positive images of local people who have experienced COVID-19. For example, stories of people who have recovered or who have supported a loved one and are willing to share their experience. 

6. Honour carers and healthcare workers supporting people affected with COVID-19 in your community. Acknowledge the role they play in saving lives and keeping your loved ones safe. 

Messages for healthcare workers 7. Feeling under pressure is a likely experience for you and many of your colleagues. It is quite normal to be feeling this way in the current situation. Stress and the feelings associated with it are by no means a reflection that you cannot do your job or that you are weak. Managing your mental health and psychosocial well-being during this time is as important as managing your physical health. 

8. Take care of yourself at this time. Try and use helpful coping strategies such as ensuring sufficient rest and respite during work or between shifts, eat sufficient and healthy food, engage in physical activity, and stay in contact with family and friends. Avoid using unhelpful coping strategies such as use of tobacco, alcohol or other drugs. In the long term, these can worsen your mental and physical well-being. The COVID-19 outbreak is a unique and unprecedented scenario for many workers, particularly if they have not been involved in similar responses. Even so, using strategies that have worked for you in the past to manage times of stress can benefit you now. You are the person most likely to know how you can de-stress and you should not be hesitant in keeping yourself psychologically well. This is not a sprint; it's a marathon. 9. Some healthcare workers may unfortunately experience avoidance by their family or community owing to stigma or fear. This can make an already challenging situation far more difficult. If possible, staying connected with your loved ones, including through digital methods, is one way to maintain contact. Turn to your colleagues, your manager or other trusted persons for social support -your colleagues may be having similar experiences to you. 10. Use understandable ways to share messages with people with intellectual, cognitive and psychosocial disabilities. Where possible, include forms of communication that do not rely solely on written information. 11. Know how to provide support to people who are affected by COVID-19 and know how to link them with available resources. This is especially important for those who require mental health and psychosocial support. The stigma associated with mental health problems may cause reluctance to seek support for both COVID-19 and mental health conditions. The mhGAP Humanitarian Intervention Guide includes clinical guidance for addressing priority mental health conditions and is designed for use by general healthcare workers.

section_content: 12. Keeping all staff protected from chronic stress and poor mental health during this response means that they will have a better capacity to fulfil their roles. Be sure to keep in mind that the current situation will not go away overnight and you should focus on longer-term occupational capacity rather than repeated short-term crisis responses. 

13. Ensure that good quality communication and accurate information updates are provided to all staff. Rotate workers from higher-stress to lower-stress functions. Partner inexperienced workers with their more experienced colleagues. The buddy system helps to provide support, monitor stress and reinforce safety procedures. Ensure that outreach personnel enter the community in pairs. Initiate, encourage and monitor work breaks. Implement flexible schedules for workers who are directly impacted or have a family member affected by a stressful event. Ensure that you build in time for colleagues to provide social support to each other. 

14. Ensure that staff are aware of where and how they can access mental health and psychosocial support services and facilitate access to such services. Managers and team leaders are facing similar stresses to their staff and may experience additional pressure relating to the responsibilities of their role. It is important that the above provisions and strategies are in place for both workers and managers, and that managers can be role-models for self-care strategies to mitigate stress. 

15. Orient all responders, including nurses, ambulance drivers, volunteers, case identifiers, teachers and community leaders and workers in quarantine sites, on how to provide basic emotional and practical support to affected people using psychological first aid. 

16. Manage urgent mental health and neurological complaints (e. g. delirium, psychosis, severe anxiety or depression) within emergency or general healthcare facilities. Appropriate trained and qualified staff may need to be deployed to these locations when time permits, and the capacity of general healthcare staff capacity to provide mental health and psychosocial support should be increased (see the mhGAP Humanitarian Intervention Guide). 17. Ensure availability of essential, generic psychotropic medications at all levels of health care. People living with long-term mental health conditions or epileptic seizures will need uninterrupted access to their medication, and sudden discontinuation should be avoided. 

Messages for carers of children 18. Help children find positive ways to express feelings such as fear and sadness. Every child has his or her own way of expressing emotions. Sometimes engaging in a creative activity, such as playing or drawing can facilitate this process. Children feel relieved if they can express and communicate their feelings in a safe and supportive environment. 

19. Keep children close to their parents and family, if considered safe, and avoid separating children and their careers as much as possible. If a child needs to be separated from his or her primary carer, ensure that appropriate alternative care is provided and that a social worker or equivalent will regularly follow up on the child. Further, ensure that during periods of separation, regular contact with parents and carers is maintained, such as twice-daily scheduled telephone or video calls or other age-appropriate communication (e. g. social media). 20. Maintain familiar routines in daily life as much as possible, or create new routines, especially if children must stay at home. Provide engaging age-appropriate activities for children, including activities for their learning. Where possible, encourage children to continue to play and socialize with others, even if only within the family when advised to restrict social contact. 

21. During times of stress and crisis, it is common for children to seek more attachment and be more demanding on parents. Discuss COVID-19 with your children in an honest and age-appropriate way. If your children have concerns, addressing them together may ease their anxiety. Children will observe adults' behaviours and emotions for cues on how to manage their own emotions during difficult times. Additional advice is available here. 

Messages for older adults, people with underlying health conditions and their carers 22. Older adults, especially in isolation and those with cognitive decline/dementia, may become more anxious, angry, stressed, agitated and withdrawn during the outbreak or while in quarantine. Provide practical and emotional support through informal networks (families) and health professionals. 

23. Share simple facts about what is going on and give clear information about how to reduce risk of infection in words older people with/without cognitive impairment can understand. Repeat the information whenever necessary. Instructions need to be communicated in a clear, concise, respectful and patient way. It may also be helpful for information to be displayed in writing or pictures. Engage family members and other support networks in providing information and helping people to practise prevention measures (e. g. handwashing, etc. ). 

24. If you have an underlying health condition, make sure to have access to any medications that you are currently using. Activate your social contacts to provide you with assistance, if needed. 25. Be prepared and know in advance where and how to get practical help if needed, like calling a taxi, having food delivered and requesting medical care. Make sure you have up to two weeks of all your regular medicines that you may require. 

26. Learn simple daily physical exercises to perform at home, in quarantine or isolation so you can maintain mobility and reduce boredom. 

27. Keep regular routines and schedules as much as possible or help create new ones in a new environment, including regular exercising, cleaning, daily chores, singing, painting or other activities. Keep in regular contact with loved ones (e. g. via telephone, e-mail, social media or video conference). 

for people in isolation 28. Stay connected and maintain your social networks. Try as much as possible to keep your personal daily routines or create new routines if circumstances change. If health authorities have recommended limiting your physical social contact to contain the outbreak, you can stay connected via telephone, e-mail, social media or video conference. 29. During times of stress, pay attention to your own needs and feelings. Engage in healthy activities that you enjoy and find relaxing. Exercise regularly, keep regular sleep routines and eat healthy food. Keep things in perspective. Public health agencies and experts in all countries are working on the outbreak to ensure the availability of the best care to those affected 30. A near-constant stream of news reports about an outbreak can cause anyone to feel anxious or distressed. Seek information updates and practical guidance at specific times during the day from health professionals and WHO website and avoid listening to or following rumours that make you feel uncomfortable.
section_name: Messages for team leaders or managers in health facilities

section_name: Stay informed

section_content: Find the latest information from WHO on where COVID-19 is spreading: https://www. who. int/emergencies/diseases/novel-coronavirus-2019/situation-reports/ Advice and guidance from WHO on COVID-19 : https://www. who. int/emergencies/diseases/novel-coronavirus-2019 https://www. epi-win. com/ Addressing social stigma: https://www. epi-win. com/sites/epiwin/files/content/attachments/2020-02-24/COVID19%20Stigma%20Guide%2024022020_1. pdf Briefing note on addressing mental health and psychosocial aspects of COVID-19: https://interagencystandingcommittee. org/other/interim-briefing-note-addressing-mental-health-andpsychosocial-aspects-covid-19-outbreak
section_name: Stay informed