Background
On January 30, 2020, the coronavirus disease 2019 (COVID-19) pandemic was declared a public health emergency of international concern (PHEIC) by the World Health Organization, and it has caused severe economic, educational, and social ramifications [
1,
2]. During the early epidemic, Chinese health authorities implemented a series of immediate measures to control the disease, and all Chinese people were required to stay at home for isolation; hence, normative teaching activities in universities were forced to stop. These measures, together with fear of infection and uncertainty regarding the consequences of the COVID-19 pandemic, undoubtedly had adverse psychological effects on people, especially university students [
3,
4].
Colleges and universities have reported unprecedented numbers of students in psychological distress in recent years. This might be because inexperienced college students are incapable of solving problems in interpersonal relationships, academic challenges, and career development [
5]. Several studies indicated that among university students, 9.7% in the eastern and western areas of China, 11.7% in Harbin, 11.8% at 6 universities in Wuhan, 16.8% in Anhui, and 32.82% in the western part of Liaoning experienced depression symptoms [
6‐
10]. The COVID-19 pandemic may increase the stress of undergraduate students or expose them to new stressors that can be frustrating and lead to a range of mental health problems. The frequent contributors to increased stress/anxiety were general uncertainty regarding the pandemic, the precipitous transition to and participation in online classes, and the COVID-19-related influences on their lives [
11‐
13]. The results of a recent study confirmed that students are at high risk of developing depression and suicidality in relation to the COVID-19 outbreak [
14]. With the quick closures of universities, students encountered uncertainty and concern about their academic future, social isolation and lack of support, such as limited access to and receipt of mental health services for many vulnerable youths, which were barriers to relieving their stress or negative thinking [
15‐
17].
People’s mental health is affected in many ways. Social support and coping strategies have been proven to be protective factors for mental health in previous studies [
18‐
21]. Social support refers to the provision of practical help, emotional support and information assistance by meaningful groups around an individual when the individual is in distress, such as family members, friends, colleagues, relatives and neighbors [
22]. Several studies have shown that younger adults and people with greater social strain or less social support have worse mental health and that perceived social support influences the overall outcome of depression and plays a key role in recovery from affective disorders [
23‐
26]. Coping refers to the thoughts and behaviors people use to manage the internal and external demands of stressful events [
27]. Positive coping and negative coping are diametrically opposed coping styles. Individuals who adopted mainly positive coping strategies suffered less emotional distress, while those who adopted negative coping strategies experienced the opposite [
28]. Therefore, when people face difficult or complex negative events, the coping style they choose is of the utmost importance, which will affect their psychosocial outcomes and, especially, their mental health.
According to a narrative review, there are numerous pandemic-related mental health risks for children and adolescents, and the subsequent restrictions produce more threats, which may lead to adverse psychological problems [
29]. While previous studies have explored the effects of social support and coping style on mental health, they did not identify their impacts on Chinese college students’ mental health during the COVID-19 pandemic, and they had various limitations, such as the use of unstandardized psychological measures, the assessment of single mental health symptoms, and the use of samples that were selected mostly from a single city or university [
22,
30‐
32]. On this basis, the current study is a multicenter (7 cities) study in China, covers a larger population in terms of sample size, and the purpose of it is to better understand the impacts of coping style and perceived social support on mental health and associated risk factors in undergraduate students to inform effective intervention strategies in similar public health events.
Discussion
Experiencing epidemics or natural disasters could lead to long-term psychological disorders in various populations [
42,
43]. The rates of probable anxiety, depression and stress symptoms among Chinese undergraduate students in our investigation were 13.3, 15.4 and 6.8%, respectively. Among the symptoms, the prevalence of depression symptoms was higher than the 9.7% prevalence in the eastern and western areas of China, 11.7% prevalence in Harbin, and 11.8% prevalence at 6 universities in Wuhan and lower than the prevalence (32.82%) in the western part of Liaoning, as reported in previous studies during the pre-COVID-19 era [
6‐
8,
10]. Our study was conducted during the early stages of the COVID-19 pandemic and during the traditional “Chinese New Year” festival, when college students stop their work or study plans to enjoy the holiday and might experience less stress and negative emotions than usual. Thus, the rate of depressive symptoms in the current study during this period may be lower than those reported in studies that were conducted in other areas during other periods. In addition, while the smoking rate among all Chinese individuals was approximately 26.6% in 2018 with an overall declining trend in recent years, it is possible that some started to smoke or drink in the extreme situation due to the pandemic as a coping strategy. The current smoking rate of 5.5% (16.3% of male students) and current drinking rate of 25.2% (48.3% of male students) were higher than the rates before the outbreak among college students [
44‐
46].
During the COVID-19 pandemic, tobacco and alcohol misuse are additional public health issues that can cause risk-taking behaviors and mental health issues, especially among undergraduate students, who are still undergoing intellectual and social skill development. Consistent with other studies, students who were current smokers or drinkers were more likely to be anxious, depressive and stressed. In addition, mentally ill people were more likely to be current smokers or substance users than those who did not have a mental illness, and large proportions of smokers (88.7%) and past smokers (97%) reported the onset of smoking before their mental illness was diagnosed in another study [
47]. Some of the college students who were current smokers or drinkers might already have had worse psychological health than their counterparts, and the pandemic might have aggravated their problems and caused them to suffer from huge mental health crises. The findings of a recent study revealed that a deterioration of mental health occurred among smokers and binge drinkers during the COVID-19 pandemic and that their tobacco and alcohol consumptions increased since the lockdown [
48]. Therefore, the current study highlights the need to screen both mental health status and substance use behaviors among undergraduate students when a similar pandemic or public health emergency occurs. Apart from providing suitable mental health counseling services, family members and school administrators should also pay attention to smoking and drinking behaviors in such circumstances and provide effective smoking cessation and binge drinking interventions if necessary.
Stress is a highly individual reaction, and its effect on mental health varies from person to person. When people face various levels of stress, they might either be motivated and perform effectively or cope inappropriately and be overwhelmed by the stress. The stressors for students while quarantined were diversiform, and the sources of stress included academic pressure, campus relationships, loneliness and COVID-19-related uncertainty [
49]. Coping strategy is a critical factor that affects psychological well-being. In this research, passive coping strategies had a negative role in regulating students’ mental health, which were frequently utilized by young people aged 14–35 [
50]. During the COVID-19 pandemic, students used their preferred coping strategy to alleviate the increasing amount of stress they experienced, such as seeking help from others (friends, family, school teachers and experts), attempting to solve their problems on their own or coping passively. Negative coping is always emotion-focused or avoidant coping and refers to attempts to avoid actively confronting the problem or to indirectly reduce emotional tension via various behaviors, such as eating or smoking [
51,
52]. In the passive coping subscale that was used in the current study, there was an item named “relieve worries by smoking, drinking, taking drugs and overeating”, and 29.4% of the respondents self-reported that they had adopted this strategy. It seems that if students have psychological disorders or are under levels of stress, they are likely to develop health risk behaviors such as the use of cigarettes, liquor, or marijuana, if available. Hence, the higher rates of smoking and drinking among the study participants can be interpreted as indicating that these indirect and evasive behaviors were performed to reduce emotional tension, which may be a sign of negative coping. In contrast, an active coping style positively contributed to adjustment to psychological distress and relief of negative feelings. Coping styles are based on the cognitive evaluation of stressful situations where the relationship between an individual and the stressful situation constantly changes with the individual’s actions [
53]. Evidence suggests that depression and anxiety symptoms can, in turn, exert deleterious effects on the ability of late adolescents to effectively cope with daily stressors [
54]. It is necessary for interventions to focus on helping students avoid negative coping strategies and cultivate optimistic thinking styles to reduce the risk of the onset of mental health problems.
In line with our hypotheses, family support was a protective factor for the psychological well-being of undergraduate students, while support from friends and others did not significantly affect their well-being, which was inconsistent with previous studies that reported that people could be inspired by friends [
30,
55]. As face-to-face interactions and random encounters are minimized due to social distancing measures, it is likely that individuals focus on relationships that are spatially close, most meaningful, or most established [
16]. During the early COVID-19 pandemic, almost all undergraduate students were on winter holiday and quarantined or isolated at home. They spent most of their time with their family members and had much less contact with friends or other people. Therefore, we should pay attention to the role of family support in maintaining college students’ mental health in such a special context, particularly among students who live with dysfunctional families or divorced families or orphans who lack sufficient family support, as they may be more prone to develop health risk behaviors and mental illness [
56,
57]. Effective communication between parents and their undergraduate children has been proven to play an important role in maintaining good psychological health in terms of self-esteem, socioemotional adjustment and well-being [
58]. However, parent-child communication gaps are quite common due to the widespread use of electronic devices, the special life stages of undergraduate students and the advanced society. A lack of communication between parents and their children may be one risk factor that increases their vulnerability if parents use more maladaptive coping strategies or if their family atmosphere is characterized by irritability after the disaster [
59]. Parents should have the ability to identify the differences they have with their children and overcome those barriers to understanding each other. Meanwhile, support from health educators and public health specialists should be provided in early intervention programs to promote better mental health and prevent the initiation of health risk behaviors such as substance use.
This survey also explored other risk factors that are related to the psychological problems of undergraduate students. The results indicated that the scores of stress symptoms were significantly higher in minorities than in students of Han ethnicity, which is partly because these poorer minorities are more likely to have more difficulty implementing prevention measures and their overall burdens of disease were heavier [
60]. On the other hand, ethnic minorities in remote areas may have more concerns about household income, inconvenience of online teaching activities, scarce living resources and shortages of medical resources. Moreover, areas that are close to the border were in a more severe situation during the pandemic due to cases that were imported from abroad. The results also showed a positive relationship between good physical health and mental health among the participants, and obviously, good physical condition might give participants more power to face emergency public health events and enable them avoid exposure to the dual burden of the COVID-19 pandemic and other chronic diseases [
31]. Moreover, it appeared that a worsening of mental health was associated with more worries about one’s family and friends, especially when their friends or family members were infected with COVID-19, which was also consistent with other relevant studies [
32,
61].
The current study showed that COVID-19 does have negative psychological effects on college students, and we found that adopting active coping styles can improve their psychological problems. In particular, during the COVID-19 pandemic, family support was a significant protective factor for the psychological well-being of undergraduate students, while support from friends and others was not effective in this case. According to our results, college students should adopt positive coping styles when facing difficulties, setbacks or unexpected events to reduce their probability of suffering from psychological disorders. Social support is one source of positive coping for students, particularly family support in the current study. However, at present, there are an increasing number of dysfunctional families, and many students lack communication with their parents. These students are in urgent need of attention to their psychological status. Therefore, it is crucial for college students to have a positive way of thinking and avoid negative strategies (e.g., tobacco and alcohol use) to cope with challenges, and suitable psychological assistance or intervention is necessary to maintain their well-being and reduce the severity of their psychological problems.
Limitations
Although this study provided essential findings, it has various limitations. The convenient sampling method and the nature of the survey (internet-based) limit the generalizability of the survey results by generating selection bias. However, during rapidly evolving infectious disease outbreaks, an online survey could produce meaningful results. Second, all the measurements in the current study were assessed by self-report; thus, response bias may exist. Third, females and medical students comprised the majority of the sample in this study, and these two groups may be at additional risk for psychological distress during the COVID-19 pandemic. Therefore, the generalizability of the study results to the general student population may be limited.
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