Coping strategies of students for anxiety during the COVID-19 pandemic in China: a cross-sectional study

Introduction

The COVID-19 outbreak infected mainland China and the surrounding regions drastically at the end of 2019. To cope with the infection, the Chinese government executed severe control measures, including an expansion of the national holiday, immediate lockdown and strict post-lockdown measures as part of an effort to prevent a second coronavirus wave. In addition, the mobility of the population was controlled with severe restrictions at a national level, and social distancing was monitored as well as encouraged with a compulsory quarantine period of two weeks for returning migratory personnel. Reflecting these containment measures, the economy contracted by 6.8% in the first quarter (CNBC 2020¹). The increasing number of cases of COVID-19 in China between January and June 2020 can be seen in Figure 1.

Figure 1. Increasing trend of COVID-19 in China².

This chart has been reproduced under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

In the middle of February, the Chinese government gradually decided to remove restrictions on mobility of the population and other activities, prioritizing some provinces and various groups of people based on risk calculations. Most trade and universities reopened countrywide with careful observation during the stages of reopening. However, social distancing rules remained in place as did the mandatory use of a facial mask. Entering the country from overseas also remained restricted in some situations to control the importation of cases. The danger of new infections from imported cases has been highlighted by the local community and the government has taken the matter seriously and restricted foreign entry to China¹. Apart from that, regular temperature checking and personal health QR codes were imposed on a compulsory basis for traveling locally and entering public places in order to cope with the pandemic (WHO 2020²).

Figure 2 shows the Chinese government’s response stringency index. The government response included the closure of universities and other academic institutions, factories and offices, and travel restrictions. The responses are measured on a scale of 10 to 100, and the graph in Figure 2 shows a very high rate of restrictions from March to May, 2020.

Figure 2. Government response stringency index².

This chart has been reproduced under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Figure 3. Daily confirmed COVID-19 cases².

This chart has been reproduced under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Figure 3 shows the daily confirmed cases of COVID-19 in China; February had the highest number of confirmed cases. Even though the daily confirmed cases has decreased recently, strategies for coping with the pandemic are still under the control of the Chinese government. For example, no international students have been allowed to return to university. If a student returned, they would receive serious penalties, as announced by some universities³. As a result, students are struggling to complete their studies on time, and many students are affected. Even if students are not infected with the virus, they may be depressed as their studies have been disrupted and they cannot finish their studies on time. Online teaching and graduation opportunities have been provided by some universities, but many students are not capable of finishing their studies in this way. Therefore, this study aimed to shed light on the coping strategies used by university students in China during the COVID-19 outbreak. A coping strategy in this article is defined as the behaviors, thoughts, and emotions that students use to adjust to the changes that occur in their life, e.g. writing issues down in order to process them during COVID-19.

Literature review

Methods

Results

We received 559 responses. The demographic details of the participants are represented in Table 1. Among the 559 respondents, 40.4% were women and 50.3% were in the 18–22 age group. In total, 58.5% of respondents were economic management students and more than half were undergraduate students. While 26.8% of respondents stayed in the university dormitory, 17.9% lived in a rented apartment without family members.

Factors associated with students' anxiety and coping strategies during the epidemic

In this study, we wanted to know what strategies the students used in coping with anxiety during the COVID-19 pandemic. In total, 66.90% of the students reported experiencing “normal” anxiety, and 23.80% reported it as “severe to extreme” (Figure 4). Table 2 shows the results showing how much each of the four coping strategies was used by the respondents. Overall, the usage of all four strategies was moderate to low. The distributions were fairly normal (skewness < 2, kurtosis < 7). Overall, the students practiced more mental engagement strategies and fewer social support strategies.

Figure 4. Levels of anxiety reported by students.

Table 2. Coping strategies used by students during the COVID-19 pandemic.

Coping strategy	Mean ± SD	Median	Skewness	Kurtosis
Seek social support	2.28 ± 0.95	2.00	0.356	1.033
Avoidance	2.34 ± 0.92	2.00	0.275	1.019
Mental disengagement	2.55 ± 0.75	2.50	0.361	0.641
Humanitarian	2.33 ± 0.90	2.00	0.391	0.947

In the ANOVA analyses, the variances were similar (Table 3). All four strategies were significantly associated with levels of anxiety. The usage of all four coping strategies was higher in the “severe to extreme” group compared to the “normal” and “minimal to moderate” groups.

Table 3. Anxiety level and coping strategies in students during the COVID-19 pandemic.

Coping strategy	Anxiety Level	Mean ± SD	F	P
Seek social support	Normal Minimal to moderate Severe to extreme	1.90 ± 0.70a,b 1.98 ± 0.56a 3.48 ± 0.95b	278.482	<0.001
Avoidance	Normal Minimal to moderate Severe to extreme	1.98 ± 0.73a,b 2.13 ± 0.44 a 3.45 ± 0.59b	233.283	<0.001
Mental disengagement	Normal Minimal to moderate Severe to extreme	2.27 ± 0.54a,b 2.20 ± 0.45a 3.48 ± 0.55b	266.619	<0.001
Humanitarian	Normal Minimal to moderate Severe to extreme	1.99 ± 0.66a,b 2.01 ± 0.62 a 3.42 ± 0.90b	246.697	<0.001

Note: ^{a, b} pairwise differences

Discussion

The findings of the study indicate that the mental or cognitive health condition of university students in China needs to be further ascertained in order to elucidate the actual psychological impact due to the COVID-19 pandemic.

The outbreak of COVID-19 may be stressful and significantly affect individuals’ mental health. Symptoms of mental health issues, as well as social stressors such as uncertainty due to COVID-19, affect the coping tendency of students. The results of this study reveal that coping strategies are diverse based on demographic and regional difference in China.

The world has occasionally observed numerous life-threatening epidemics, such as COVID-19. It is worth noting that a failure to adopt coping strategies may seriously affect students’ academic achievement due to the unpredictability of COVID-19¹⁸. Financial problems, a lack of health care facilities and safety issues are also major concerns affecting coping strategies in China. Current research¹⁹ has conducted a parallel study based on Indian citizens. In that study in India, the authors mentioned a high demand for and shortages of hand sanitizers, hand wash, and facial masks, indicating people’s growing concern to avoid COVID-19 infection. Every epidemic has its unique characteristics in terms of causality, risk and control measures. COVID-19 is not different; however, socio-psychological pressure is acute. Back in 2015, during the Ebola virus outbreak in Ethiopia, coping measures and awareness were less satisfactory than the results of this study found in China.

Coping strategies are directly associated with anxiety levels. The most extreme anxiety level in this study is reported by 20.9% of students, which is more than one-fifth of the total sample size. Students’ ability to seek social support, their isolation and mental disengagement and responsiveness to humanitarian issues are all assessed when measuring their copying strategies. For all the four cases, p-value is <0.001 between coping strategies and anxiety levels. This result indicates a strong positive relationship between coping strategies and the anxiety level of students. The contributors in this study had a satisfactory level of awareness concerning COVID-19 and the majority of them took the recommended preventive measures²⁰.

In China, local government and community members emphasized preventive measures such as movement control, temperature checks, wearing respiratory masks, and so on. The study participants reported that most of their school or academic unit were using online teaching during the epidemic. A total of 93.92% reported that their academic institution conducted online lectures, training sessions, video conferencing, competitions and award ceremonies and so on via online links. A total number of 246 participants (44.01%) reported that their academic institutions started online classes in the second month of the outbreak. Due to uncertainty about future study continuation, students reported more anxiety than usual (more than 63%). Similarly, sleeping problems and nightmares were also reported at a higher percentage than before (more than 40%). In this study, 68.87% of students reported unclear learning tasks in the current academic year or semester due to COVID-19. Results from the univariate analysis indicate that female students were more affected than male students in terms of anxiety and stress. However, it is interesting to note that 66.9% of students reported their anxiety level as normal during COVID-19. This is consistent in the sense that knowledge can be recovered from any disruption²¹ like a pandemic. On the other hand, mental disengagement seems crucial in the analysis. Students from business and management majors have a higher level of anxiety, which contradicts previous studies claiming that music students were more anxious²². Those staying in rented apartments were prone to severe anxiety compared to those staying at home, which indicates that students may feel psychologically worse if they did not stay with their families. The discussion is consistent with the result of the overall study in terms of level of anxiety and coping strategies presented in Table 3.

Limitations, conclusion and future research

The study has a few limitations that can be addressed in order to further investigate the phenomenon. First, the study is limited to students in China from different universities and majors. Also, the respondents are selected randomly due to online data collection from various provinces that were not affected equally. The respondents are Chinese students mostly from various recognized universities. Thus, findings should not be generalized to the overall student group. Future studies should investigate a proportional study among school, college and university students. In addition, the most affected and least affected areas should be separately investigated to fully analyze the phenomenon. In the future, a mixed methodology approach may further help with in-depth investigation of the phenomenon in a bibliometric context. This research is based on empirical analysis, which may affect the generalizability of the research. A more in-depth technique, such as interviews or other qualitative measures, in the future may assist a more thorough investigation of the students’ coping strategies. Furthermore, if the university authority, administrative staffs and teachers could be selected as respondents, the study might produce more interesting findings. An epidemiologically robust survey on a specific group of people can discover the phenomenon further.

Despite some limitations, the study indicates numerous implications for society. First, the university authority should be aware of the students’ coping strategies. In particular, students who live without parents or relatives should be taken care of properly during the outbreak. Second, to help students cope with the mental pressure, university authorities may think about arranging or organizing programs such as an online experience-sharing competition, and encourage students by offering rewards or financial aids. Finally, required food and healthcare materials should be supplied to ensure the students’ safety.

The study sheds light on the coping strategies of Chinese students during the COVID-19 pandemic. Due to the lockdown policy, many students have had to stay in university hostels with no permission to go out. The coping strategy was as challenging for students at various universities in China for COVID-19 as for any other pandemic⁵. The overall findings of the study clearly indicate a significant relationship between university students and their coping strategies during the COVID-19 in China. Increasing psychological pressure on students – consistent with our study finding that 48.3% of respondents believed that during the epidemic period everything would collapse – affect the students’ usual coping strategies and also their regular academic activities such as class attendance and assignments. As a result, ideal and safe coping strategies should be identified for the students in order to face any epidemic challenges in the future¹⁰, which may help to ensure sustainable educational development in the world. Prioritizing research on mental health, anxiety and students’ coping strategies along with psychological effects is necessary.

Data availability