Sun et al.

Globalization and Health (2021) 17:15

https://doi.org/10.1186/s12992-021-00663-x

RESEARCH Open Access

Psychiatric symptoms, risk, and protective

factors among university students in
quarantine during the COVID-19 pandemic
in China
Shufang Sun1,2, Simon B. Goldberg3, Danhua Lin4*, Shan Qiao5 and Don Operario1,2

Abstract
Background: The COVID-19 pandemic has made unprecedented impact on the psychological health of university
students, a population vulnerable to distress and mental health disorders. This study investigated psychiatric
symptoms (anxiety, depression, and traumatic stress) during state-enforced quarantine among university students in
China (N = 1912) through a cross-sectional survey during March and April 2020.
Results: Psychiatric symptoms were alarmingly prevalent: 67.05% reported traumatic stress, 46.55% had depressive
symptoms, and 34.73% reported anxiety symptoms. Further, 19.56% endorsed suicidal ideation. We explored risk
and protective factors of psychological health, including demographic variables, two known protective factors for
mental health (mindfulness, perceived social support), four COVID-specific factors (COVID-19 related efficacy,
perceived COVID-19 threat, perceived COVID-19 societal stigma, COVID-19 prosocial behavior) and screen media
usage. Across symptom domains, mindfulness was associated with lower symptom severity, while COVID-19 related
financial stress, perceived COVID-19 societal stigma, and perceived COVID-19 threat were associated with higher
symptom severity. COVID-19 threat and COVID-19 stigma showed main and interactive effects in predicting all
mental health outcomes, with their combination associated with highest symptom severity. Screen media device
usage was positively associated with depression. Female gender and COVID-19 prosocial behavior were associated
with higher anxiety, while COVID-19 self-efficacy associated with lower anxiety symptoms.
Conclusions: Findings suggest high need for psychological health promotion among university students during
the COVID-19 pandemic and inform an ecological perspective on the detrimental role of stigma during an
emerging infectious disease outbreak. Interventions targeting multi-level factors, such as promoting mindfulness
and social support at individual and interpersonal levels while reducing public stigma about COVID-19, may be
particularly promising. Attending to the needs of disadvantaged groups including those financially impacted by
COVID-19 is needed.
Keywords: COVID-19, Psychiatric symptoms, Stigma, Young adult, China

* Correspondence: [email protected]
4
Institute of Developmental Psychology, Beijing Normal University, Beijing,
China
Full list of author information is available at the end of the article

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Sun et al. Globalization and Health (2021) 17:15 Page 2 of 14

Introduction mental health among students who may suffer from the
The 2019 novel coronavirus virus (COVID-19) pandemic psychological consequences of massive quarantine mea-
has become a major public health crisis globally. In sures in China and other low- and middle-income coun-
addition to the physical health consequences, public try (LMIC) context.
health authorities across the globe have expressed grow- The current study investigates the prevalence of men-
ing concerns over an international mental health crisis tal health issues among university students in China dur-
due to quarantine, social isolation, financial strain, and ing state-ordered quarantine and explores risk and
the threat of infection [49, 62]. The mental health im- protective factors. Three domains of psychiatric symp-
pact of a pandemic of this scale is yet to be understood, toms were surveyed, including anxiety, depression, and
and such an understanding is valuable for characterizing traumatic stress. Several demographic and contextual
and ultimately addressing the psychological fallout of the factors were explored as symptom correlates, including
current and future pandemics in the age of increased socioeconomic status, as COVID-19 has disproportion-
global and local human mobility as well as increasing a ately impacted families from low-income backgrounds
basic scientific understanding of the psychiatric conse- and financial hardship may affect mental health [1]. Two
quences of extreme stress [29, 56]. widely studied protective factors were explored, includ-
Across the globe, university students are not consid- ing mindfulness and perceived social support. Mindful-
ered a priority group in terms of COVID-19 prevention, ness, defined as “paying attention in a particular way, on
yet they may be a particularly vulnerable population to purpose, in the present moment, and nonjudgmentally”
the psychological consequences of the COVID-19 pan- ([31], p. 4), has been consistently identified as a protect-
demic. Mental health of young people has long been rec- ive factor for psychological distress [11, 25, 32]. Per-
ognized as a global public health challenge [47]. ceived social support is another established protective
Developmentally, many mental disorders have symptoms factor for well-being [8, 28], and it may be particularly
that first occur during young adulthood, which can crucial during the COVID-19 pandemic due to increased
negatively impact developmental trajectories through re- social isolation. Screen media usage was explored as a
duced educational achievement, increased substance use, potentially relevant factor for the mental health of young
and poor health behaviors [5, 47]. In China, lockdowns adults in the pandemic context. Scholars have raised
through “Level-1 Public Health Emergency Response” concerns regarding increased internet and smartphone
across the nation occurred between January 23rd, 2020 addiction during the COVID-19 pandemic and the nega-
and January 29th, 2020, a time when students were tive mental health impact of increased usage [24, 56].
spending the traditional Chinese New Year holiday (i.e., However, to our knowledge, no empirical research has
Spring Festival) with their families during the winter explored its role.
break [41]. The pandemic has led to massive disruption In addition, four COVID-19 related factors were ex-
in the lives and education of university students in plored as potential predictors, including COVID-19 pro-
China, through prolonged school closure, and transition social behavior, COVID-19 self-efficacy, perceived
to internet-based learning, and social isolation from COVID-19 threat, and perceived COVID-19 societal
peers during state-enforced quarantine [43]. Available stigma. Altruistic and prosocial social behavior appears
evidence has indeed noted elevated psychiatric symp- to promote well-being for the helpers [18, 39]. From an
toms among university students in China during quaran- evolutionary perspective, prosocial behavior in response
tine. Two studies conducted in two different universities to public health threats can be advantageous for both
found rates of clinically elevated anxiety symptoms to be the group and individual [34]. COVID-19 self-efficacy
15.4% [59] and 24.9% [14] during the early outbreak of was explored as a predictor of mental health, as belief in
COVID-19. Another study with students from six uni- one’s capacity to prevent COVID-19 and take necessary
versities in southwest China during February 2020 found steps for treatment may facilitate an increased sense of
2.7 and 9.0% students reported moderate to severe forms control in an evolving outbreak [48]. Consistent with
of traumatic stress and depression, respectively [57]. prior work showing perceived SARS threat predicted
While highlighting high levels of distress, more research emotional exhaustion among frontline nurses during the
is needed to fully understand the psychological impact SARS outbreak [23], we examined perceived COVID-19
of the COVID-19 pandemic among university students threat (i.e., perception of one’s likelihood of contracting
in China. Beyond estimating prevalence, research identi- COVID-19) as a risk factor. Stigma was also examined
fying risk and protective factors is essential for increas- as a potential factor related to mental health problems,
ing scientific understanding of the varied psychological as the early phase of an emerging outbreak tends to be
reactions to large-scale infectious disease outbreaks, pro- characterized by intense disease-related stigma and fear
vide guidance to policies and intervention strategies, and due to its evolving nature and scientific uncertainties
ultimately move the bell-shaped curve of population [20, 48]. A recent study found 90% of respondents in
Sun et al. Globalization and Health (2021) 17:15 Page 3 of 14

China exhibited discriminatory attitudes toward people Ethical consideration and approval
and regions associated with the COVID-19 outbreak Eligibility criteria and a consent form were provided on
[27]. However, the role of societal stigma of an emerging the survey’s welcome page. Participants were encouraged
infectious disease (i.e., perceived negative public attitude to take the survey on a personal device (e.g., computer,
toward people and regions associated with the outbreak) phone) in a private space. Participants received no mon-
on mental health outcomes of a general population is etary compensation. Following completion of the survey,
still unknown. Lastly, we examined potential interaction participants were provided with suggestions for coping
between perceived COVID-19 threat and perceived with psychological distress during the COVID-19 pan-
COVID-19 societal stigma. This was informed by the demic. The study was approved by the Institutional Re-
ecological model (person X context) [9, 17]. Given the view Board at Beijing Normal University. Data were
large-scale impact of COVID-19 reaching all individuals collected via an anonymous online survey.
in the society, perceived COVID-19 societal stigma (a
environmental-level factor) may amplify the association Instruments
between perceived personal threat of COVID-19 and The survey included demographic information (e.g., age,
mental health outcomes. gender, region, socioeconomic status). Participants were
We hypothesized that the following would function as asked how much financial stress the COVID-19 pan-
risk factors, indicated by their positive association with demic has brought to their family, from 1 (no financial
psychiatric symptoms: COVID-related financial stress, stress) to 5 (significant financial stress). A single-item
screen media usage, perceived COVID-19 threat, per- question assessed screen media usage: in the past 2
ceived COVID-19 societal stigma. We also hypothesized weeks, outside of school and work time, how many hours
an interactive relationship between perceived threat and daily on average have you spent on screen media (e.g.,
perceived stigma, such that the link between perceived phone, computer)?
threat and psychiatric symptoms is increased in the pres- Anxiety symptoms were measured by the 7-item Gen-
ence of perceived stigma. We hypothesized the following eralized Anxiety Disorder Scale (GAD-7; Chinese ver-
as protective factors, indicated by their negative associ- sion) [54, 65], a widely used screening tool for common
ation with psychiatric symptoms: mindfulness, perceived anxiety disorders (e.g., Generalized Anxiety Disorder,
social support, and COVID-19 prosocial behaviors. Panic Disorder). GAD-7 assesses symptoms of anxiety in
the past 2 weeks (e.g., “feeling nervous, anxious, or on
edge,” “feeling afraid as if something awful might hap-
Methods pen”), from 0 (not at all) to 3 (nearly every day). Recom-
Study design and sampling mended clinical cut-off values are 5–9 (mild), 10–14
Recruitment took place online through advertisements (moderate), and ≥ 15 (severe) [54]. The scale has demon-
on websites and WeChat-based platforms targeting strated good reliability and validity in outpatient settings
Chinese university students. This included advertise- in China [65]. Cronbach’s α was 0.96.
ments distributed by academic advisors in WeChat- Depression was measured by the Patient Health
based group forums for students in 19 Chinese univer- Questionnaire-9 (PHQ-9; Chinese version), a depression
sities located in various regions of China (seven in south screening tool [33, 61] that assesses depressive symp-
central China, six in north China, five in east China, and toms in the past 2 weeks. Each item reflects one of the
one in south west China); all of these universities have nine DSM-IV criteria for major depressive episode (e.g.,
students from various provinces. Advertisements en- “little interest or pleasure in doing things”) [4], from 0
couraged students to distribute the study information to (not at all) to 3 (nearly every day). Recommended clin-
their peers in other universities. Data collection occurred ical cut-off values are 5–9 (mild), 10–14 (moderate), 15–
between March 20th and April 10th 2020, approximately 19 (moderately severe), and ≥ 20 (severe) [33]. The scale
2 months following the official announcement of the has demonstrated good reliability and validity among the
COVID-19 outbreak in China (January 20th, 2020) while general population in China [61]. Cronbach’s α was 0.93.
people were under state-enforced strict quarantine. The COVID-19 related traumatic stress was assessed by
study employed a cross-sectional research design. the Impact of Events scale (IES; Chinese version) [30,
66], a 15-item, widely used measure of event-specific dis-
tress. Participants were asked to indicate symptom se-
Inclusion criteria verity in the context of the COVID-19 pandemic, from 0
Inclusion criteria for participation included (a) being at (not at all) to 5 (often). Items assessed intrusion and
least 18 years of age, (b) currently enrolled in a Chinese avoidance clusters of posttraumatic stress disorder
college or university as an undergraduate or graduate (PTSD) (e.g., “pictures about it popped into my mind,” “I
student, and (c) fluency in the Chinese language. tried not to talk about it.”). Recommended clinical cut-
Sun et al. Globalization and Health (2021) 17:15 Page 4 of 14

off values are 9–25 (mild), 26–43 (moderate), and ≥ 44 19 prevention”) rated as 1 (strongly disagree) to 4
(severe). The Chinese version has been used following (strongly agree). Cronbach’s α was 0.90.
natural disasters (e.g., earthquake) and has demonstrated Perceived COVID-19 societal stigma was measured via
good reliability and validity [60, 66]. Cronbach’s α was an adapted version of the Perceived External Stigma
0.95. Subscale of the Ebola-related Stigma Questionnaire [46],
Mindfulness was measured by the Chinese version of which itself was derived from Berger’s HIV Stigma Scale
the Mindful Attention Awareness Scale (MAAS) [11, [6]. Six items assessed perceived societal stigma against
19]. The scale consists of 15 items and assesses disposi- COVID-19, rated as 1 (strongly disagree) to 5 (strongly
tional mindfulness, namely receptive awareness of and agree). Sample items include “most people are afraid of a
attention to experience in the present moment (e.g., “I person who has had COVID-19 or from regions severely
find it difficult to stay focused on what’s happening in affected by COVID-19”, “most people think that a per-
the present.”). Participants indicated frequency from 1 son who has had COVID-19 is disgusting.” Higher total
(almost always) to 6 (almost never), with a higher score scores indicate higher levels of stigma. Cronbach’s α was
indicating higher dispositional mindfulness. The MAAS 0.91.
has demonstrated good reliability and validity among Perceived COVID-19 threat was adapted from a meas-
Chinese people [19]. Cronbach’s α was 0.94. ure assessed Chinese people’s perceived threat by SARS
Perceived social support was measured by an adapted [35]. Seven items assessed perceived infection threat by
version of the Multidimensional Scale of Perceived So- COVID-19 (e.g., “I don’t think I could get COVID-19”,
cial Support (MSPSS)- Chinese version [67]. The original “I think COVID-19 will threaten my health”) rated as 1
MSPSS assesses perceived social support from three re- (strongly disagree) to 4 (strongly agree). Higher total
sources (family, friends, significant other). Considering scores indicate higher perceived COVID-19 threat.
that not all young adults are in a romantic relationship, Cronbach’s α was 0.72.
only the eight items assessing perceived social support
from family and friends were used (e.g., “my family really Data Analysis
tries to help me,” “I can count on my friends when Prior to conducting the analysis, data normality was
things go wrong”), which participants rated on a 5-point assessed. No continuous variables exhibited non-normal
Likert scale (1 = strongly disagree; 5 = strongly agree). distribution (skewness values > |2|, [52]). We took three
Cronbach’s α was 0.93. steps to examine proposed hypotheses. First, bivariate
COVID-19 prosocial behavior was assessed by items analysis (correlation for continuous predictors, inde-
adapted from the 4-item Empathic Responding to pendent sample t-test for binary predictor) was con-
SARS scale [35] and Prosocialness Scale [15]. Specific- ducted to identify variables that had significant
ally, all four items on the Empathic Responding to associations with psychiatric symptoms (i.e., anxiety, de-
SARS scale were adapted to the COVID-19 context pression, and traumatic stress). Second, variables identi-
(e.g., “Tried to understand other people’ concerns fied in the first step as having significant bivariate
about SARS” was changed to “Tried to understand associations with psychiatric symptoms were entered to
other people’s concerns about COVID-19”). Five out a regression model simultaneously in order to identify
of the sixteen items from the Prosocialness Scale that significant factors on a multivariate level (Model 1). A
involved specific behaviors were selected for adapta- second model for each outcome only included variables
tion to the COVID-19 context (e.g., “I try to console significant (p < .05) in Model 1 (Model 2). This approach
those who are sad” was changed to “Tried to console allows us to identify significant predictors, build a model
those who were sad due to COVID-19”). Participants with these factors (Model 2), and subsequently compare
rated a total of nine items assessing prosocial behav- it with the regression model with the interaction term
ior specific to COVID-19, ranging from 1 (strongly and controlled for significant covariates [2, 16]. Third, to
agree) to 5 (strongly disagree). This newly adapted investigate the interactive effects of perceived COVID-19
scale has not been validated. Exploratory factor ana- threat and societal COVID-19 stigma, we conducted
lysis (EFA) and confirmatory factor analysis (CFA) in- multiple regression analyses examining their interaction
dicated a one-factor structure, with all items having covarying significant predictors from Model 2 (Model 3).
sufficient loadings (≥ .40, all items had a standardized All continuous predictors were mean-centered in all
loading > .70). Cronbach’s α was 0.93. models to avoid potential multicollinearity and for ease
COVID-19 Self-Efficacy was measured through an of understanding (i.e., a one-unit difference means one
adapted version of the Ebola-related Self-Efficacy scale SD difference). Gender as a binary variable was dummy
[13]. Five items assessed perceived ability in adhering to coded (male = 0, female = 1). For models that yielded sig-
COVID-19 prevention measures (e.g., “I am confident nificant interaction effects, simple slopes analysis was
that I can understand health instructions about COVID- employed to probe interactions at ±1 SD from the mean
Sun et al. Globalization and Health (2021) 17:15 Page 5 of 14

of the moderator [2]. Model comparison using ANOVA Predicting anxiety symptoms
was conducted to further identify the proportion of vari- The final model without interaction term (Model 2) in-
ance explained by the interaction term. All regression cluded three demographic variables (age: β = 0.073, gen-
analyses complied with assumptions regarding variable der: β = 0.045, financial stress due to COVID-19: β =
distribution and there was no evidence for collinearity 0.124), two known protective factors for anxiety symp-
(VIF values ranged from 1.02 to 1.50). toms including mindfulness (β = − 0.190) and social sup-
port (β = − 0.143), and four COVID-19 specific factors
including COVID-19 prosocial behavior (β = 0.049),
Results COVID-19 self-efficacy (β = − 0.055), perceived COVID-
Descriptive and bivariate statistics 19 threat (β = 0.160), and perceived COVID-19 societal
The sample included 1912 Chinese university students. stigma (β = 0.199). Contrary to hypothesis, higher level
Average age was 20.28 (SD = 2.10, Median = 20, Range = of COVID-19 prosocial behavior positively associated
[18, 49]). The majority of participants were female (n = with more anxiety symptoms.
1334; 69.77%). Most participants (91.84%) were pursuing Accounting for all significant variables identified in
their undergraduate education. Participants resided in 30 Model 2, the interaction term of perceived COVID-19
out of the 36 provinces in China. Most participants threat X perceived COVID-19 societal stigma was sig-
noted some level of financial stress on their family due nificant in predicting anxiety symptoms (Table 3; Model
to COVID-19 (83%; Table 1). Students’ areas of study 3), β = 0.070, p < .001. Main effects of perceived COVID-
varied: 36.4% majored in medicine, 16.2% in science, 19 threat and perceived COVID-19 societal stigma
13.3% in engineering, 12.2% in economics, 8.5% in in- remained significant. Model 3 was superior to model 2,
dustrial organization, 6.8% in literature, 2.2% in art, 1.4% F = 12.09, p < .001, accounting for 5% more variance.
in education, 1.3% in law, 1.1% in history, and 0.4% in Simple slope analysis found that high levels of perceived
agriculture. COVID-19 societal stigma intensified the positive associ-
Psychiatric symptoms were notably prevalent. The ation between perceived COVID-19 threat and anxiety
majority of participants (67.05%) reported COVID-19- symptoms (β = 0.228 [0.173, 0.283], p < .001; Fig. 1a). At
related traumatic stress symptoms within the clinical 1 SD below the mean of perceived COVID-19 societal
range (i.e., mild or higher). Anxiety symptoms were stigma, it still heightened the detrimental effect of per-
clinical elevated among 34.73% participants and ceived COVID-19 threat on anxiety symptoms, β = 0.109
46.55% for depression. Approximately one in five [0.060, 0.159], p < .001.
(19.56%) reported some degree of suicidal ideation in
the past 2 weeks (from rarely to often). Most clinical Predicting depressive symptoms
elevations were in the mild range. Proportion with The final model without interaction (Model 2; Table 4)
moderate or higher clinical elevations were 17.67% for included six significant predictors of depressive symp-
traumatic stress, 15.58% for depression, and 9.62% for toms. Risk factors (i.e., positive correlates) for depressive
anxiety. symptoms included financial stress due to COVID-19
Socioeconomic status, family financial stress due to (β = 0.119), two COVID-specific risk factors (perceived
COVID-19, mindfulness, perceived social support, COVID-19 threat: β = 0.109; perceived COVID-19 soci-
COVID-19 self-efficacy, perceived COVID-19 societal etal stigma: β = 0.238), and screen media device usage
stigma, and perceived COVID-19 threat had significant (β = 0.058). Protective factors (i.e., negative correlates)
associations with all three outcomes (Table 2). As socio- for depressive symptoms included mindfulness (β = −
economic status and family financial stress due to 0.249) and perceived social support (β = − 0.153). The
COVID-19 were correlated (r = − .43, p < .001) and mea- full model explained 28.2% of variance in depression
sured related constructs, only family financial stress due (i.e., adjusted R2 = .282).
to COVID-19 was used as a predictor in regression. Age Perceived COVID-19 threat and perceived COVID-19
was weakly positively associated with anxiety. COVID-19 societal stigma had significant interaction (Model 3, β =
prosocial behavior and screen media usage were signifi- 0.076, p < .001), after accounting for all other significant
cantly associated with anxiety and depression. Anxiety variables identified in Model 2. As predicted, the positive
symptoms were higher for female participants (t association between perceived COVID-19 threat with
[1017] = − 2.10, p = .036, mean [M] for male = 3.27, M depressive symptoms was amplified in the presence of
for female = 3.74). Depressive symptoms and traumatic higher levels of perceived COVID-19 societal stigma.
stress did not differ based on gender. Symptom severity Model comparison indicated superiority of Model 3 to
across psychiatric domains did not differ based on re- Model 2, F = 15.38, p < .001, and the interaction term
gion of residence (Hubei, the hotspot of COVID-19 or accounted for 6% additional variance. Simple slope ana-
non-Hubei). lyses indicated that perceived COVID-19 threat
Sun et al. Globalization and Health (2021) 17:15 Page 6 of 14

Table 1 Sample characteristics Table 1 Sample characteristics (Continued)

Sociodemographic variables N (%) Sociodemographic variables N (%)
Gender Suicide ideation
Female 1334 Never 1538
(69.77) (80.44)
Male 578 Rarely 261
(30.23) (13.65)
Socioeconomic status compared to classmates in school Sometimes 93 (4.86)
Lower than average 675 Often 20 (1.05)
(35.30)
Region
On average 1166
North China (Beijing, Tianjin, Hebei, Shanxi, Inner 275
(60.98)
Mongolia) (14.38)
Higher than average 71 (3.71)
Northeast China (Liaoning, Jilin, Heilongjiang) 61 (3.19)
Financial stress on family due to COVID-19
East China (Shanghai, Jiangsu, Zhejiang, Anhui, Fujian, 541
Very significant stress 70 (3.66) Jiangxi, Shandong) (28.29)
Significant stress 300 South Central China (Henan, Hubei, Hunan, Guangdong, 856
(15.69) Guangxi, Hainan) (44.77)
Moderate stress 782 Southwest China (Chongqing, Sichuan, Guizhou, Yunan, 109 (5.70)
(40.90) Tibet)
Little stress 435 Northwest China (Shaanxi, Gansu, Qinghai, Ningxia, 67 (3.50)
(22.75) Xinjiang)
No stress 325 Hong Kong, Macau, or living abroad 3 (0.16)
(17.00)
Education (currently pursuing)
remained a significant predictor of depression when per-
Undergraduate 1756
(91.84) ceived COVID-19 societal stigma was 1 SD above (β =
0.182 [0.129, 0.235], p < .001) or below the mean (β =
Master’s education 139 (7.27)
0.053 [0.005, 0.101], p = .029), although depression was
Doctorate education 17 (0.89)
notably higher when perceived COVID-19 societal
Anxiety stigma was increased (Fig. 1b).
No symptoms (0–4) 1248
(65.27) Predicting traumatic stress
Mild symptoms (5–9) 480 COVID-19 related traumatic stress was significantly pre-
(25.10)
dicted by financial stress due to COVID-19 (β = 0.100),
Moderate symptoms (10–14) 158 (8.26) mindfulness (β = − 0.178), perceived COVID-19 threat
Severe symptoms (≥ 15) 26 (1.36) (β = 0.136), and perceived COVID-19 societal stigma
Depression (β = 0.341) (Table 5; Model 2). Model’s adjusted R2 =
No symptoms (0–4) 1022 0.238, F = 150.0, p < .001 (Table 5; Model 2).
(53.45) Accounting for significant variables identified in
Mild symptoms (5–9) 592 Model 2, as well as main effects of perceived COVID-19
(30.96) threat and perceived COVID-19 societal stigma, their
Moderate symptoms (10–14) 169 (8.84) interaction term significantly predicted traumatic stress,
Moderately severe (15–19) 102 (5.33) β = 0.059. The model accounted for 24.1% of the vari-
ance in traumatic stress, F = 122.2, p < .001. Model 3 was
Severe symptoms (20–27) 27 (1.41)
superior to model 2, F = 8.70, p = .003, and accounted
Traumatic stress
for 3% additional variance. Simple slope analysis revealed
No symptoms (0–8) 630 similar patterns: high levels of perceived COVID-19 so-
(32.95)
cietal stigma intensified the positive association between
Mild symptoms (9–25) 944 perceived COVID-19 threat and traumatic stress (β =
(49.37)
0.182 [0.128, 0.237], p < .001; Fig. 1c). At 1 SD below the
Moderate symptoms (26–43) 119 (6.22)
mean of perceived COVID-19 societal stigma, it still
Severe symptoms (≥ 44) 219 heightened the positive association between perceived
(11.45)
COVID-19 threat and traumatic stress, though to a less
degree (β = 0.082 [0.033, 0.131], p = .001).
Table 2 Correlations among continuous variables
Depression Anxiety Traumatic Age SES Financial stress Mindfulness Social COVID-19 COVID-19 Perceived Perceived Screen
Sun et al. Globalization and Health

stress due to COVID-19 support prosocial self-efficacy COVID-19 COVID-19 media

behavior stigma threat usage
Anxiety .69*** –
Traumatic stress .47*** .43*** –
Age .04 .06** .03 –
(2021) 17:15

SES −.15*** −.13*** −.09*** −.07** –

Financial stress .24*** .24*** .20*** .08*** −.43*** –
due to COVID-19
Mindfulness −.39*** −.31*** −.29*** .02 .12*** −.20*** –
Social support −.30*** −.26*** −.11*** .01 .16*** −.17*** .28*** –
COVID-19 −.13*** −.10*** .01 .03 .10*** −.06* .21*** .47*** –
Prosocial
behavior
COVID-19 −.18*** −.20*** −.10*** .01 .12*** −.14*** .20*** .43*** .36*** –
efficacy
Perceived .37*** .32*** .42*** −.01 −.08*** .17*** −.24*** −.22*** −.14*** −.23*** –
COVID-19 stigma
Perceived .18*** .22*** .20*** −.08*** −.04 .09*** −.008*** −.01 .06*** .02 .14*** –
COVID-19 threat
Screen media .11*** .06* .04 −.10*** −.04 .03 −.10*** −.09*** −.07** −.02 .02 .01 –
usage
M 5.20 3.59 19.83 20.38 1.68 2.66 67.14 32.40 26.70 16.44 11.94 17.68 6.18
SD 5.33 4.35 15.98 2.10 0.54 1.05 13.27 5.86 5.61 2.50 3.98 3.52 3.05
Note. p < .05 *, p < .01 **, p < .001***
Page 7 of 14
Sun et al. Globalization and Health (2021) 17:15 Page 8 of 14

Table 3 Predictors of anxiety symptoms

B 95%CI SE beta p Model R2 F
Model 1 .236 59.9
Age 0.327 [0.154, 0.501] 0.089 0.075 < .001***
Gender 0.416 [0.039, 0.792] 0.192 0.044 .030*
Financial stress due to COVID-19 0.538 [0.360, 0.716] 0.091 0.124 < .001***
Mindfulness −0.818 [−1.003, − 0.634] 0.094 − 0.188 < .001***
Social support − 0.614 [− 0.827, − 0.404] 0.107 − 0.141 < .001***
COVID-19 prosocial behavior 0.216 [0.018, 0.415] 0.101 0.050 .033*
COVID-19 self-efficacy −0.244 [− 0.440, − 0.048] 0.100 − 0.056 < .001***
Perceived COVID-19 threat 0.699 [0.524, 0.873] 0.089 0.161 < .001***
Perceived COVID-19 societal stigma 0.867 [0.684, 1.049] 0.093 0.199 < .001***
Screen media usage 0.109 [−0.064, 0.282] 0.088 0.025 .218
Model 2 (with significant variables identified in Model 1) .235 66.4
Age 0.317 [0.144, 0.490] 0.088 0.073 < .001***
Gender 0.423 [0.047, 0.800] 0.192 0.045 .027*
Financial stress due to COVID-19 0.539 [0.362, 0.717] 0.091 0.124 < .001***
Mindfulness −0.827 [−1.011, −0.643] 0.094 −0.190 < .001***
Social support −0.621 [−0.830, − 0.412] 0.106 −0.143 < .001***
COVID-19 prosocial behavior 0.213 [0.014, 0.412] 0.101 0.049 .0236*
COVID-19 self-efficacy −0.240 [−0.436, − 0.044] 0.100 − 0.055 .016*
Perceived COVID-19 threat 0.698 [0.523, 0.873] 0.089 0.160 < .001***
Perceived COVID-19 societal stigma 0.866 [0.683, 1.048] 0.093 0.199 < .001***
Model 3 (with interaction) .240 61.3
Age 0.325 [0.152, 0.497] 0.088 0.075 < .001***
Gender 0.424 [0.049, 0.799] 0.191 0.045 .027*
Financial stress due to COVID-19 0.532 [0.355, 0.710] 0.090 0.122 < .001***
Mindfulness −0.839 [−1.022, −0.655] 0.094 −0.193 < .001***
Social support −0.623 [− 0.832, − 0.415] 0.106 −0.143 < .001***
COVID-19 prosocial behavior 0.196 [−0.002, 0.394] 0.101 0.045 .053
COVID-19 self-efficacy −0.238 [− 0.433, − 0.043] 0.099 −0.055 .017*
Perceived COVID-19 threat 0.733 [0.558, 0.909] 0.089 0.169 < .001***
Perceived COVID-19 societal stigma 0.840 [0.658, 1.022] 0.093 0.193 < .001***
COVID-19 threat X COVID-19 stigma 0.258 [0.112, 0.403] 0.074 0.070 < .001***
Note. All continuous variables were mean-centered. p < .05 *, p < .01 **, p < .001***

Discussion 19 societal stigma showed synergistic interaction, such

Results of this large-scale, cross-sectional study are that the presence of both were associated with additive
largely consistent with prior studies in China and else- effects when predicting all three symptom domains,
where highlighting the adverse psychological conse- highlighting the importance of contextual factors (i.e.,
quences in the general population of both quarantine ecological perspective [9];). Both mindfulness and per-
and disease outbreak [10, 14, 57]. This study extends ceived social support emerged as protective factors, with
prior work by highlighting several risk and protective mindfulness negatively associated with all three forms of
factors related to mental health in the context of the psychopathology and perceived social support negatively
COVID-19 pandemic. Across symptoms domains (anx- associated with anxiety and depression. Screen media
iety, depression, traumatic stress), COVID-related finan- usage was weakly associated with depressive symptoms.
cial stress, perceived threat, and perceived societal The prevalence on anxiety, depression, and traumatic
stigma emerged as consistent positive correlates of psy- stress among university students uncovered from this
chopathology. Perceived COVID-19 threat and COVID- study is similar yet slightly higher than findings reported
Sun et al. Globalization and Health (2021) 17:15 Page 9 of 14

Fig. 1 Interaction of Perceived COVID-19 threat X perceived COVID-19 societal stigma when predicting psychiatric symptoms

Table 4 Predictors of depressive symptoms

B 95%CI SE beta p Model R2 F
Model 1 .286 95.2
Financial stress due to COVID-19 0.624 [0.413, 0.834] 0.107 0.117 < .001***
Mindfulness −1.348 [−1.567, −1.129] 0.112 −0.253 < .001***
Social support −0.898 [−1.146, − 0.650] 0.126 −0.168 < .001***
COVID-19 prosocial behavior 0.212 [−0.024, 0.447] 0.120 0.040 .078
COVID-19 self-efficacy −0.030 [− 0.263, 0.202] 0.118 − 0.006 .799
Perceived COVID-19 threat 0.570 [0.363, 0.776] 0.105 0.107 < .001***
Perceived COVID-19 societal stigma 1.274 [1.058, 1.491] 0.110 0.239 < .001***
Screen media usage 0.314 [0.109, 0.518] 0.104 0.059 .003**
Model 2 (with significant variables identified in Model 1) .282 126.4
Financial stress due to COVID-19 0.632 [0.422, 0.842] 0.107 0.119 < .001***
Mindfulness −1.329 [−1.547, −1.111] 0.111 −0.249 < .001***
Social support −0.817 [−1.033, − 0.602] 0.110 − 0.153 < .001***
Perceived COVID-19 threat 0.583 [0.378, 0.789] 0.105 0.109 < .001***
Perceived COVID-19 societal stigma 1.272 [1.057, 1.486] 0.109 0.238 < .001***
Screen media usage 0.307 [0.103, 0.511] 0.104 0.058 .003**
Model 3 (with interaction) .288 111.3
Financial stress due to COVID-19 0.622 [0.413, 0.832] 0.107 0.117 < .001***
Mindfulness −1.347 [−1.564, −1.130] 0.111 −0.252 < .001***
Social support −0.829 [−1.044, − 0.614] 0.110 − 0.155 < .001***
Screen media usage 0.311 [0.108, 0.515] 0.104 0.058 .003**
Perceived COVID-19 threat 0.627 [0.421, 0.833] 0.105 0.118 < .001***
Perceived COVID-19 societal stigma 1.238 [1.023, 1.452] 0.109 0.233 < .001***
COVID-19 threat X COVID-19 stigma 0.344 [0.172, 0.517] 0.088 0.076 < .001***
Note. All continuous variables were mean-centered. p < .05 *, p < .01 **, p < .001***
Sun et al. Globalization and Health (2021) 17:15 Page 10 of 14

Table 5 Predictors of traumatic stress

B 95%CI SE beta p Model R2 F
Model 1 .238 100.7
Financial stress due to COVID-19 1.675 [1.026, 2.323] 0.331 0.105 < .001***
Mindfulness −2.995 [−3.666, −2.324] 0.342 −0.187 < .001***
Social support 0.602 [−0.114, 1.318] 0.365 0.038 .100
COVID-19 self-efficacy 0.123 [−0.581, 0.827] 0.356 0.008 .732
Perceived COVID-19 threat 1.976 [1.341, 2.612] 0.324 0.124 < .001***
Perceived COVID-19 societal stigma 5.570 [4.902, 6.238] 0.341 0.349 < .001***
Model 2 (with significant variables identified in Model 1) .238 150.0
Financial stress due to COVID-19 1.604 [0.959, 2.249] 0.329 0.100 < .001***
Mindfulness −2.844 [−3.498, − 2.190] 0.333 −0.178 < .001***
Perceived COVID-19 threat 2.011 [1.377, 2.645] 0.323 0.136 < .001***
Perceived COVID-19 societal stigma 5.450 [4.797, 6.104] 0.333 0.341 < .001***
Model 3 (with interaction) .241 122.2
Financial stress due to COVID-19 1.584 [0.941, 2.228] 0.328 0.099 < .001***
Mindfulness −2.892 [−3.546, −2.239] 0.333 −0.181 < .001***
Perceived COVID-19 threat 2.113 [1.476, 2.749] 0.324 0.132 < .001***
Perceived COVID-19 societal stigma 5.375 [4.721, 6.029] 0.335 0.336 < .001***
COVID-19 threat X COVID-19 stigma 0.801 [0.268, 1.333] 0.271 0.059 .003**
Note. All continuous variables were mean-centered. p < .05 *, p < .01 **, p < .001***

in two other recent studies concerning the initial phase on those infected or most vulnerable to infection (e.g.,
of the outbreak [14, 57]. The prevalence of clinically ele- anticipated HIV stigma among gay and bisexual men)
vated depressive symptoms in our sample (46.6%) is [55]. However, our study found that in the context of
roughly twice as high as meta-analytic estimates of clin- COVID-19, perceived societal stigma adversely affects
ical elevations among Chinese college students prior to the mental health of the general public (i.e., university
the pandemic (23.8%) [36]. To our knowledge, no meta- students, not a group particularly vulnerable for infec-
analyses or nationally representative survey data are tion or death). The mechanism through which perceived
available estimating rates of clinically elevated anxiety or COVID-19 societal stigma operates to effect mental
traumatic stress symptoms among Chinese university health is unclear; it might be related to the potential de-
students. Prevalence rates indicate continued mental teriorating impact of societal stigma on people’s collect-
health needs within this population during the early ive self-esteem and societal belonging, as well as
phase of the pandemic. increased survivor guilt and empathic concerns for those
The COVID-19 pandemic has evolved into a serious affected in a high stigma environment [45, 58]. Further,
threat to public health given its geographic reach, pro- perceived COVID-19 stigma and perceived COVID-19
longed impact, and lack of cure or effective treatment. threat had a synergetic effect on all mental health out-
As hypothesized, perceived COVID-19 threat, namely comes, supporting an ecological perspective (person X
the felt sense of threat to one’s health and life by context) [9, 17] in understanding and addressing conse-
COVID-19, predicted elevated psychiatric symptoms, quences of stigma.
highlighting the role of health concerns in psychological As the economic consequences of COVID-19 have
health during the pandemic. Public health interventions continued to unfold, it has become clear that individuals
may need to balance strategies to increase preventive be- from lower socioeconomic background have been dis-
haviors against COVID-19 (e.g., social distancing, wear- proportionately burdened across the globe [1, 12]. In
ing masks) while attending to potentially detrimental keeping, we found that family financial stress due to
mental health effects due to an increased sense of COVID-19 consistently predicted psychiatric symptoms.
COVID-19 threat. This relationship is not new; past economic recessions
The significant role of perceived societal stigma on have witnessed increased rates of common mental disor-
mental health, both alone and in interaction with per- ders and suicidal behavior in other global regions [44,
ceived threat, is a novel and potentially important find- 50]. In addition to financial stress, being older and fe-
ing. Research on infectious disease stigma has focused male were also identified as risk factors of anxiety
Sun et al. Globalization and Health (2021) 17:15 Page 11 of 14

symptoms. Students who are older may experience more representative of the larger Chinese university student
pandemic-related stress related to employment and car- population. Second, given the study’s cross-sectional
eer development. Female students reported greater levels method, causal directions of the observed relationships
of anxiety, which is consistent with existing evidence cannot be ascertained. For instance, COVID-19 prosocial
that women report greater anxiety and more likely to de- behavior was associated with heightened anxiety, and
velop anxiety disorders than men [40]. this could be due to those who experience higher anxiety
Mindfulness was identified as a protective factor across during the pandemic being more likely to engage in pro-
all three symptoms domains. In the midst of great un- social actions as a coping. Future longitudinal and ex-
certainty, anxiety, and despair during the COVID-19 perimental studies may further explore these
pandemic, dispositional attentiveness to the present mo- associations. Third, the Impact of Events Scale (IES) [30]
ment may protect young adults from excessive worries, only measured two clusters of PTSD symptoms (intru-
rumination, and fear. This is supported by evidence sug- sion and avoidance), missing negative alternations in
gesting decreased rumination may be one of the key cognition or mood and hyperarousal symptoms. Fourth,
mechanisms underlying the efficacy of mindfulness- it would have been preferable to use clinician-rated mea-
based interventions [26]. Perceived social support also sures to more accurately define prevalence rates. Simi-
emerged as a protective factor for anxiety and depres- larly, given the self-report method, all variables are at
sion. Loneliness and social isolation from peers may risk to known biases (e.g., social desirability).
contribute to heightened distress for young adults during We also note several strengths. We collected a large,
quarantine. geographically diverse sample during the early phase of
Excessive screen time has been linked to a variety of the COVID-19 pandemic and included a variety of psy-
health concerns including obesity, sleep disturbance, and chiatric symptoms. Importantly, as current knowledge
mental health issues [7, 22]. In our sample, participants’ regarding psychological health during the COVID-19
self-reported an average of 6 h of daily screen media pandemic is largely descriptive [14, 57], this research
time outside of school and work purposes in the past 2 represents an initial effort to identify risk and protective
weeks. In the context of the pandemic, young adults factors, which is critical to our understanding and ad-
may consume more screen media due to restricted ac- dressing of the psychological consequences of the
cess to other avenues of entertainment, increased media COVID-19 pandemic. Informed by previous research on
exposure related to COVID-19 (e.g., news, report), and infectious disease (e.g., HIV) [6], we investigated the
the need for connection with peers. Screen media usage roles of psychosocial variables specific to COVID-19 to
weakly predicted depression but not other symptoms. It inform our knowledge on the mental health of a general
is possible that screen media engagement may have a population (i.e., university students) during massive
mixed role during the pandemic. For instance, videocon- lockdown in the midst of a rapidly spreading disease.
ferencing with friends could be important to enhance Further, the significant interaction between perceived
social support and mental health while excessive TV COVID-19 societal stigma and personal sense of
watching by oneself may increase risk. COVID-19 threat informs a theory-driven, ecological
perspective in understanding the role of stigma on psy-
Study limitations and strengths chiatric symptoms during an emerging pandemic.
The current study has several limitations. First, although
the current study recruited a geographically diverse na- Implications for research and clinical interventions
tional sample compared to previous studies in this area This study highlights several directions for future re-
of research [14, 57, 59], the open recruitment method search. First, longitudinal research is needed to examine
via the internet has its drawbacks. In particular, those the trajectory of psychiatric symptoms over time as the
highly impacted by COVID-19 may be particularly inter- COVID-19 pandemic continues to evolve. Due to
ested in participation, which could upwardly bias esti- China’s success in containing the outbreak [51], most
mates of psychiatric symptom severity. Similar to universities have resumed in-person classes in May
previous studies regarding mental health of university 2020, yet caution regarding potential COVID-19 out-
students during the pandemic [14, 57, 59], our sample breaks and public health policies such as mandate on
was disproportionately female participants (69.77%). Po- mask wearing remain [42]. It is possible that the unin-
tentially, female students may be more willing to volun- tended psychological consequences of lockdowns, as we
tarily participate in these research projects. The higher documented in this paper, may be reduced in some indi-
proportion of women could have skewed the estimates viduals as concerns over the pandemic lessen whereas in
in anxiety, given the higher prevalence of anxiety in fe- others, leaving untreated, psychiatric symptoms may
male students. Additionally, the gender makeup and re- continue to persist. Longitudinal research is also ideal to
cruitment method may lead to findings not being investigate how risk and protective factors identified in
Sun et al. Globalization and Health (2021) 17:15 Page 12 of 14

this study may affect psychological health over time. Sec- pandemics, such as HIV/AIDS [21], can inform such ef-
ond, findings suggest new areas of research concerning forts in the context of well-being and disease prevention
stigma and health in the context of pandemic-related for COVID-19. For instance, public health professionals
stress. As noted by Allport [3], stigma is derived from may use strategies proven to be effective in addressing
the separation of human groups (“us” vs. “them”) and stigma of other infectious diseases globally, such as anti-
stereotypes associated with group membership [3]. Thus stigma campaigns, crowdsourcing, and community en-
far, stigma research has focused on victimized groups. gagement. Third, attending to the needs of disadvan-
Findings from this study highlight the relevance of taged groups is important, including those who are
stigma in the mental health of the general public during financially vulnerable. Given the dual burden of financial
an infectious disease outbreak. It is possible that stigma- stress and COVID-19 infection vulnerability, combin-
tizing attitudes harm everyone, though the degree of im- ation of both psychological and economic interventions
pact may vary based on perceived infection likelihood to may be warranted.
the individual (i.e., ecological perspective). It is also
plausible that due to the highly transmissible nature and Conclusions
large-scale impact of COVID-19, the psychological ex- Assessing psychiatric symptom prevalence and identify-
perience and consequences of COVID-19 societal stigma ing risk and protective factors during the COVID-19
among the general public is fundamentally different outbreak are critical to understanding and addressing
from stigma based on other types of group memberships the short-term and long-term psychological conse-
that may be perceived as more fixated states (e.g., race, quences of the COVID-19 pandemic. In addition to
sexual orientation, HIV/AIDS). Future studies are informing current and future pandemic responses, this
needed to clarify these relationships. research can also clarify the psychological consequences,
Most mental health systems in LMIC context, includ- risk, and protective factors of acute stress more gener-
ing in China, are often overburdened by high demand ally. Conducted in March and April 2020 during
yet inadequately funded [63]. While there have been ef- massive, state-enforced quarantine, the current study
forts to address the mental health crisis during the pan- found high rates of psychiatric symptoms in a sample of
demic in China and other global regions, they have often internet-recruited university students in China. Findings
largely focused on psychiatric patients and frontline highlight the high need for psychological health promo-
health workers [64]. Findings of the study highlight the tion in this population. In addition, findings inform an
need to promote mental health among university stu- ecological-driven understanding regarding the detrimen-
dents during a large-scale quarantine and offer insights tal role of public stigma on psychological health in the
to public health policy and intervention strategies in the general population during an emerging infectious disease
LMIC context. First, there is a high need address the outbreak. Interventions targeting multi-level factors, in-
highly prevalent psychiatric symptoms among university cluding promoting mindfulness and social support at in-
students during quarantine. National and local govern- dividual and interpersonal levels while reducing societal
ments, public health officials, and educational units may stigma, may be particularly promising. Attending to
work together to raise public awareness of mental health needs of disadvantaged groups most financially vulner-
issues in young adults. Policy makers and stakeholders able may require both psychological and economic
need to allocate resources to strengthen the mental interventions.
health system for university students. University health
services should consider outreach efforts to effectively Acknowledgements
reach those in need, such as via websites, webinars and Not applicable.

internet-based psychoeducation programs, and mobile

Authors’ contributions
health-based interventions [38]. Given the increased bur- SS conceptualized of the study, contributed to building the questionnaire,
den of care for mental health professionals, especially in analyzed the data, and wrote the paper. SG provided editorial and critical
the LMIC context, stakeholders may consider efficient feedback to the paper. DL initiated the study, allocated funding, collected
data, and provided critical feedback to the paper. SQ provided critical
and empirically-proven approaches to address the high feedback to the paper. DO contributed to conceptualization and provided
volume of mental health need. This may include training critical feedback to the paper. All authors contributed to and have approved
lay mental health providers and organization of peer the final manuscript.
support groups [53]. Second, mental health interventions
Funding
targeting multi-level factors, including promoting mind- This research project is supported by the Fighting COVID-19 Research Fund
fulness (e.g., via internet-based mindfulness programs) by Beijing Normal University awarded to the third author. Work by the first
[37] and social support at individual and interpersonal author was supported by the Providence/Boston Center for AIDS Research
(P30AI042853), the National Institute of Health (T32MH078788;
levels while reducing societal stigma, may be particularly K23AT011173). Work by the second author was supported by the National In-
promising. Lessons from stigma reduction for other stitute of Health (K23AT010879). The funders had no role in study design,
Sun et al. Globalization and Health (2021) 17:15 Page 13 of 14

data collection and analysis, decision to publish, or preparation of the 14. Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, Zheng J. The psychological
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