Background What are the health and wellbeing of people in China during the COVID-19 outbreak? We aim to assess the health and wellbeing of normal adults living and working after one month of confinement to contain the COVID-19 outbreak in China. Interpretation Our findings support the need to pay attention to the health of people who were not affected by the virus epidemiologically. We especially need to support people who stopped working during the outbreak. Our results also highlight that physically active people, as indicated by more hours of exercise, might be more susceptible to wellbeing issues due to the lockdown. Policymakers who are considering introducing restrictive measures to contain COVID-19 may benefit from understanding such health and wellbeing implications. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint
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We have searched the leading journals (e.g. Lancet and New England Journal of Medicine), which have published articles on restrictive measures to contain COVID-19 epidemiologically. However, such restrictive measures disrupt people's normal work and life, with many people having to stop working or working from home, which in turn may impact the health and wellbeing of people. These concerns have triggered Lancet COVID-19 series to publish one article that reviewed the psychological impact of quarantine in general to inform the impact of COVID-19 and another article that warned of the possible impact of home confinement on children. To our best knowledge, no study has provided field evidence on the health and wellbeing of people who did not have the virus but have been confined in varying degrees over a month due to COVID-19.
This study provides the implications of the restrictive measures during COVID-19 on the health and wellbeing of people who were not infected by the virus themselves but resided in affected areas. This study identifies that people who stopped working in the outbreak had worse health (SF12), more distress (K6) and less life satisfaction. Moreover, the severity of COVID-19 predicts life satisfaction more for people with chronic health issues or who exercised more.
Since the escalation of COVID-19 to a public health emergency in China on Jan 21, 2020, over a billion people across China have faced restrictions due to varying degrees of confinement such as . CC-BY-ND 4.0 International license It is made available under a perpetuity.
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The copyright holder for this this version posted March 16, 2020. . https://doi.org/10.1101/2020.03.13.20034496 doi: medRxiv preprint banning public transport, restricting movement, and imposing a 14-day quarantine after travel. 1,2 One month into the outbreak, many people were still not working or exercising as usual, which may have associated implications on health and wellbeing. Yet, the implications of the unusually prolonged state of not working and exercising on individuals' health and wellbeing remain unknown. It is important to understand not only the implications of the restrictions on COVID-19 disease prevalence rates but also the implications of such unprecedented disruptions on the health and wellbeing of the community. 3 To control the COVID-19 outbreak, China has enacted restrictive measures "unprecedented in public health history" as stated by WHO. 5 On January 23, 2020, China locked down Wuhan, a metropolitan area of 12 million people. 6 The lockdown in Wuhan soon triggered similar measures in all 15 other cities in Hubei province with a total of 57 million people. Other prefectures (the administrative areas of a city) in China subsequently implemented varying levels of restrictive measures. For instance, the prefecture of Wenzhou in Zhejiang province restricted its citizens in such a way that only one person per household could leave home once every two days.
Such restrictive measures in China seemed to be effective in containing the spread of COVID-19 by mid-February and were applauded by WHO. 7 However, those measures have disrupted people's jobs and lives immensely and hence may have important implications for their health and wellbeing. 8 For example, evidence from the SARS crisis indicated that reduced mobility affected the wellbeing of quarantined residents in a complex manner. An article in Lancet COVID-19 series specifically highlighted that people who had been in quarantine reported a high prevalence of symptoms of psychological distress and disorder and some of these symptoms seem to stay long after the quarantine. 2 Relatedly, another Lancet article argued we need to pay attention to the psychological issues of children who are not able to go to school. 9 This issue is important not only for children or suspected cases under quarantine but also for other people, as over one billion people in China who did not carry the virus epidemiologically but had their work and life disrupted to varying degrees. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint
The copyright holder for this this version posted March 16, 2020. . https://doi.org/10.1101/2020.03.13.20034496 doi: medRxiv preprint Therefore, we aim to provide the first analysis of the health and wellbeing of people one month into the COVID-19 outbreak.
Understanding the health and wellbeing implications of the measures introduced to reduce the COVID-19 infection allows better-informed decisions. As many parts of the world are starting to consider measures to contain COVID-19, with South Korea and Italy having introduced lockdowns in early March 2020, 10 we may benefit from understanding the health and wellbeing implications of the measures implemented early on in China.
We conducted a cross-sectional survey one month into the COVID-19 outbreak on February 20-21, 2020, about one month into the COVID-19 emergency in China. All the participants were adults not affected by the virus epidemiologically but they lived in locations that were affected by COVID-19 to varying degrees. To cover people in areas of varying severity of COVID-19, we surveyed adults from 64 prefectures across China. The 64 prefectures were chosen to cover a wide spectrum of regions based on the severity of COVID-19 and should not be taken as a representative national sample. All respondents agreed to participate in the study, which was approved by the ethics committee at Tongji University. We reached 529 adults, and 369 of them answered the survey, with a response rate of 69·8%.
We assessed individual health by the Short Form-12 (SF12), a standard scale on mental and physical health function. 11 The scale had been translated into Chinese and validated in China. 12 SF12 contains 12 items and 8 dimensions: physical functioning (2 items), role physical (2 items), bodily pain (1 item), general health (1 item), vitality (1 item), social functioning (1 item), role emotional (2 items) and mental health (2 items). The eight dimensions form two composite scores of physical and mental composite scale (PCS and MCS), with a possible score ranging from 0 to 100. 13 As a formative score, a higher SF12 score indicates a better health condition.
We measured distress by the six-item Kessler psychological distress scale (K6) with a Cronbach's alpha of 0·79. 14 We measured life satisfaction with the Satisfaction With Life Scale (SWLS), 15 which consists of five items with a Cronbach's alpha of 0·72. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The adults also provided their socio-demographic characteristics, such as gender, age, education, and their location (prefecture). Using their locations, we searched for the number of confirmed COVID-19 cases in their prefectures on February 20 as well as the total population to calculate the number of confirmed cases per 10,000 people as an indicator of the severity of COVID-19 at their location. The number of cases per 10,000 people (i.e. infected rate) varied from 42·45 (Wuhan) to 0·01 on February 21. 16 Because COVID-19 is more dangerous for people with comorbidity, 17 it is likely that people who have ongoing medical issues would suffer more during the outbreak and therefore we asked whether the participants had any chronic disease. On the contrary, people who lead a healthy lifestyle and exercise often would be expected to fare better during the outbreak. Hence, we also asked the participants to indicate 'how many hours did you exercise per day during the past week'.
The restrictive measures of COVID-19 also caused major disruption to people's work. By the time of our survey on February 20, the growth rate of COVID-19 cases in China had fallen to single percentages per day. Some people still stopped work, while some had returned to work in offices, and others were working at home. All individuals reported their work status.
We report the descriptive statistics of the study variables and the regression models to examine the relationships. All analyses were done on unweighted data with STATA 16·0, and statistical significance was assessed by p < 0·05. Table 1 and 139 (37·7%) resorted to working from home; 32 (8·7%) participants had not been working before the outbreak started; and 6 (1·6%) reported losing their work during the COVID-19 outbreak. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint In terms of exercise, 51 (13·8%) people had not exercised at all during the past week; 226 (61·2%) exercised but for less than 1 hour per day; 63 (17·1%) exercised 1 to 2·5 hours per day; and 29 (7·9%) exercised more than 2·5 hours per day. Of the participants, 45 (12·2%) had chronic diseases.
Based on the scoring algorithm of SF12, 7 the participants scored 48·74 (SD 9·30) in mental health (MCS) and 49·55 (SD 7·00) in physical health (PCS). The mean values of distress and life satisfaction of the participants were 1·41 (SD 0·46) and 3·22 (SD 0·64) respectively.
People who worked in the office, worked at home, or had stopped working differed in health (SF12) and distress (K6) Table 2 shows the results of regressing SF12 on the job status of the participants one month into the COVID-19 outbreak. Compared with people who stopped working during the outbreak, people who worked at their office had better mental health (β=3·46, p=0·01, 95% CI 0·79-6·14) and physical health (β=2·19, p=0·01, 95% CI 0·20-4·18). Moreover, people who worked at home also had better mental health than those who stopped working (β=2·60, p=0·03, 95% CI 0·45-5·16).
We did further analysis on the eight specific dimensions of SF12. Compared with people who returned to work at their office, those who stopped working reported lower general health (β=-0·28, p=0·03, 95% CI -0·55--0·03), mental health (β=-0·38, p=0·002, 95% CI -0·63--0·14), and increased limitations for physical issues (β=-0·16, p=0·009, 95% CI -0·28--0·04) and emotional issues (β=-0·13, p=0·035, 95% CI -0·26--0·01). There were fewer differences between people who worked at home and worked at offices, except those who worked at home reported more limitations for physical issues than those who worked at offices (β=-0·13, p=0·02, 95% CI -0·24--0·02).
There were also certain dimensions of SF12 that did not vary much by job status. For instance, people who stopped working and those who worked at their offices did not differ in bodily pain (β=0·16, p=0·160, 95% CI -0·06-0·39), physical function (β=0·10, p=0·141, 95% CI -0·03-0·24), and social function (β=0·22, p=0·260, 95% CI -0·16-0·59). Those who stopped working and those who worked at home respectively also did not differ in the same dimensions of bodily pain (β=0·15, p=0·186, 95% CI -0·07-0·36), physical function (β=0·00, p=0·961, 95% CI -0·13-0·13), and social function (β=0·19, p=0·294, 95% CI -0·17-0·55). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint
The copyright holder for this this version posted March 16, 2020. . https://doi.org/10.1101/2020.03.13.20034496 doi: medRxiv preprint Similar findings emerged from the regression results on distress (K6) and life satisfaction (Table 3) .
People who worked at their office suffered less distress than people who stopped working (β=-0·13, p=0·048, 95% CI -0·25-0·00). Also, people who worked at their office reported higher life satisfaction than those who stopped working (β=0·23, p=0·024, 95% CI 0·03-0·43).
Are people in areas more affected by COVID-19 less satisfied with their life? It depends.
Next, we analyzed how the severity of COVID-19 in individual locations predicts individuals' life satisfaction. Table 4 shows that the relationship between the severity of COVID-19 and individual life satisfaction depends on individuals' existing health and exercise status. The severity of COVID-19 had a negative relationship with the life satisfaction only for people with chronic medical issues (β=-2·11, p=0·036, 95% CI -4·09 --0·13) but not for people without chronic medical issues (β=-0·01, p=0·510, 95% CI -0·02 -0·01). We plot the effect of the severity of COVID-19 on life satisfaction by whether the individuals had chronic medical issues in Figure 1 .
The results also indicate that the relationship between the severity of COVID-19 in a location and life satisfaction depends on individuals' level of exercise, but in a direction opposite to our expectation.
While we expected people who exercised more during the outbreak had a healthy lifestyle and would be less influenced, for people who exercised more than 2·5 hours per day during the outbreak, the relationship between the severity of COVID-19 in their location and life satisfaction was significantly negative (e.g. for people who exercised 3 hours per day: β=-0·02, p=0·043, 95% CI -0·04 -0·00).
The relationship is not significant for people who exercised between 1 and 2·5 hours a day during the outbreak. Surprisingly, for people who exercised 0·5 hours or less per day during the outbreak, their life satisfaction was significantly positively associated with more affected locations (e.g. for people who did not exercise: β=0·04, p=0·023, 95% CI 0·01-0·08). We plot the effect of the severity of COVID- is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Although the hardline restrictive measures in China showed success in containing COVID-19 after a month, there is little research on the extent to which the disruptions affected people in the community.
Our findings show that adults who were not working reported worse health, as captured by SF12 in certain dimensions as well as distress (K6). The insignificant differences in the dimensions of SF12 in bodily pain, physical function and social function are expected, because people who were not affected by the virus directly would not differ much in those dimensions.
The results on life satisfaction are more nuanced. Overall, the severity of COVID-19 in a prefecture did negatively predict people's life satisfaction in that prefecture, with this relationship depending on individuals' existing medical conditions and exercise levels. For individuals who exercised a lot during the outbreak (>2·5 hours per day), life satisfaction was significantly negatively associated with more affected locations; on the contrary, for individuals who exercised half an hour a day or less, life satisfaction was significantly positively associated with more affected locations. Maybe these people could better justify or rationalize their inactive lifestyles in more severely affected cities. The finding that those who exercised a lot (>2·5 hours per day) were less satisfied in more affected cities suggests we may need to pay attention to more physically active individuals, who might be more frustrated by the restrictions due to the outbreak.
The study has certain limitations. First, this study relied on an observational survey. Because the measures of the dependent variables of SF12, distress and life satisfaction used Likert scales, we tried to use predictors that were non-Likert scales, such as job status and severity of COVID-19 calculated based on archival data using the reported locations. Second, our sample is not a national representative sample. Our focus was to examine the differential effects on adults depending on the level of disruption, as captured by their job status, existing chronic issues, and exercise levels to identify who in the community of non-COVID-19 cases might need the most help for policymakers and potential caregivers. Third, even though we had data from people who had not been working even before the outbreak started (8·7%) and people who went out of work during the outbreak (1·6%), the sample size of those two groups was small and we are cautious not to report them in the findings.
Nevertheless, people with these two job statuses could be important targets for future studies. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint We provide preliminary evidence on the health conditions of adults in COVID-19 affected regions.
The identification of who might be more affected by COVID-19, not epidemiologically but simply by working and living in affected regions, carries important implications. Such identification can help to prioritize those who might need more help, and psychologists, mental health professionals and social workers can provide services to start addressing at least the mental health issues, even during the lockdown. Affected regions are growing globally by the day, and COVID-19 is no longer confined to China. 10, 18 To contain COVID-19 transimission, 19 policymakers in other countries are considering implementing restrictive measures. 20 We present this early evidence of disruptions one month into the outbreak to provide evidence on the health of the general community living and working under restrictive measures.
We declare no competing interests. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint
The copyright holder for this this version posted March 16, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint
The copyright holder for this this version posted March 16, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint 1 : 1 = people with a chronic health condition, 2 = people without a chronic health condition.
Note: N=369. *p < 0·05; **p < 0·01.
. CC-BY-ND 4.0 International license It is made available under a perpetuity.
is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint
The copyright holder for this this version posted March 16, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint
The copyright holder for this this version posted March 16, 2020. . https://doi.org/10.1101/2020.03.13.20034496 doi: medRxiv preprint