Psychological state and its correlates of local college students in Wuhan during COVID‐19 pandemic

Abstract In 2020, the lockdown of Wuhan due to the outbreak of COVID‐19 impacted various aspects of local college students' life and may further negatively affect their psychological state. This study was conducted among 652 Wuhan local college students during the quarantine of this city. We assessed their psychological state using Depression‐Anxiety‐Stress Scale 21 and evaluated their living condition including diet, schedule, recreational activities, social contact, academic life, and attention paid to pandemic news. Results showed that 16.87% of the students reported stress, 28.68% with anxiety, and 35.12% had depression. According to multivariate logistic regression analysis, having a medical background was associated with higher stress levels; students who had an irregular diet and schedule were more likely to develop stress, anxiety, and depression; students with their academic life affected had a higher prevalence of anxiety and depression. By studying local students in the hardest‐hit area during the pandemic, our findings can provide references for the improvement of college students' mental health in the long term.


| General condition questionnaire
The general condition questionnaire investigated college students' general information such as gender, grade, school location, medical background, and health condition of oneself, family members, relatives, and friends.
Moreover, two items "Where is your hometown?" and "Where have you been during the pandemic?" were to measure the validity of students. Those who chose "Wuhan" for both items were identified as valid respondents.

| Living condition questionnaire
The living condition questionnaire asked about college students' living information such as diet, schedule, recreational activities, social contact, academic life, and attention paid to pandemic news. Some of these were quantified and classified.

| Depression-Anxiety-Stress Scale 21 (DASS-21)
DASS was first proposed by Lovibond and Lovibond (1995) and it has been proven to have a high degree of internal consistency and reliability which was later reduced to 21 questions by Antony et al. (1998). In this study, the reduced version was used to quantify the negative emotion of the respondents and to evaluate their prevalence and level of depression, anxiety, and stress.

| Statistical methods
All data were analyzed using SPSS 24.0 (IBM). Number, composition ratio, and mean value (with standard deviation) were used as descriptive indicators. For categorical data, the χ 2 test was performed to examine the differences in the prevalence of depression, anxiety, and stress between different demographic factors and living conditions. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated to explore the influencing factors of the prevalence of three symptoms by multivariate logistic regression analysis. A p < .05 was considered statistically significant.

| General information
Of the 652 respondents, 47.09% were males; 4.75% were in senior and above while the grades of students before senior year were evenly distributed; 34.05% had a medical background, among which 20.27% majored in medicine, 83.33% of them had families engaged in medical-related career; 99.69% and 97.55% self-reported good physical health of themselves and their family, while only 61.35% reported their relatives and friends not infected with COVID-19 (Table 1).

| Description of the living condition factors
There were 16.9% of the local college students with irregular diets, 17.64% of the students had difficulty storing enough food in 1 week. 29.6% of the students have an irregular schedule. The proportion of students with low satisfaction with social contact and recreational activities was 37.4% and 53.4%. 81.3% of the local college students were delayed in academic life.

| Factors correlated with stress
In the unadjusted model, it is found that the risk of stress was significantly correlated with having a medical background, relatives or friends being ill, an irregular diet or schedule, academic life being delayed, and lower satisfaction with social contact and recreational activities (p < .05). However, after adjusting for other factors, students with a medical background (aOR = 1.674, 95% CI = 1.066-2.631) were more likely to develop stress.
Besides, compared to having an irregular diet and schedule, a regular diet (aOR = 0.409, 95%

| Factors correlated with anxiety
As shown in Table 3, the risk of anxiety in college students was significantly correlated with having an irregular diet or schedule, lower satisfaction with social contact and recreational activities, and delayed academic life (p < .05).
However, college students whose academic life were affected were twice as likely to be anxious as those who did not (aOR = 2.045, 95% CI = 1.210-3.454).

| Factors correlated with depression
Whether college students had depression or not was significantly correlated with diet, schedule, satisfaction with social contact and recreational activities, and academic life (p < .05). Students with a regular diet (aOR = 0.402, 95% CI = 0.233-0.692) presented less depression. Having a regular schedule (aOR = 0.401, 95% CI = 0.241-0.666) was possibly associated with depression. College students whose academic life was delayed (aOR = 1.964, 95% CI = 1.211-3.185) were more likely to get depressed (Table 3).

| DISCUSSION
This study aims to present the prevalence of stress, anxiety, and depression of local college students in Wuhan and their correlates during the quarantine. Results showed that the population of respondents who had stress, anxiety, and depression accounted for 16.87%, 28.68%, and 35.12%, with the rate decreasing from mild to severe. The trend of prevalence distribution is consistent with what was found in Chinese college students (J. Liu, Zhu, et al., 2020), which can be explained by the mechanism of psychological symptoms under stressful life events. Previous research about refugees (von Werthern et al., 2018) and college students with adverse childhood experiences (Karatekin, 2018) found that the prevalence of stress, anxiety, and depression correlates with the time of isolation and the number of stressors. As fewer college students got a higher extent of stimulation from stressors, the prevalence of psychological symptoms decreased with severity. However, the overall prevalence of psychological symptoms of local college students in Wuhan is different from other places in China. Compared with this study, C.  , Pan, Wan, Tan, McIntyre, et al. (2020) previously found that only 8.1%, 28.8%, and 16.5% of the Chinese general population had the above symptoms, also, a study conducted among 746 217 college students in China found a lower prevalence of anxiety (11.0%) and depression (21.1%) (Ma et al., 2020), which suggests that the psychological state of college students living in the hardest-hit areas are more worrying. This result is consistent with what was previously found during SARS (Lau et al., 2006), the Wenchuan and Lushan earthquakes (Xie et al., 2017), and the Ebola outbreak (Jalloh et al., 2018) that the psychological problems of the general population in the hardest-hit areas during public health incidents are more prominent than other places.
Among 222 students with medical backgrounds who were stressed, 45 (20.27%) majored in medicine, 185 (83.33%) had families engaged in medical-related careers, and 8 (3.6%) got both. This is inconsistent with previous research that higher health literacy could reduce medical students' negative emotions and medical college students during the pandemic were at lower risk of depression, anxiety, and insomnia (Nguyen et al., 2020). The difference can be related to the higher academic pressure on medical students (Gazzaz et al., 2018) and worries about their family members working on the frontline due to the full investment of medical resources in Wuhan.
Disrupted living rhythm during the pandemic can lead to irregular diet and rest, which were risk factors for stress, anxiety, and depression. 16.9% of the local college students reported having an irregular diet and 29.6% reported having an irregular schedule. An irregular diet includes unhealthy eating habits and food choices. Ammar et al. (2020) found that the behaviors of gluttony, snacking, and unhealthy food intake increased during the COVID-19 pandemic, which corroborated the increasing incidence of irregular diet. The result of He Ling, et al. (2020) on the Chinese population shows that emotional eating can lead to stress, anxiety, and depression . Moreover, a high-fat and highsugar diet can lead to a process similar to "addiction" and further aggravate the symptoms (Carter et al., 2019). This study also found that it took more than 1 week for 17.64% of the respondents to stock up on enough food, difficulty in obtaining fresh food may also trigger negative emotions. An irregular schedule contains circadian rhythm disorder and decreased sleeping quality. Quarantine under the COVID-19 pandemic can cause circadian rhythm disorder by disturbing major life events which can keep the biological clock synchronized (Morin et al., 2020). According to Goldstein & Walker (2014), lack of sleep will lead to a series of emotional disorders by influencing the regulation of emotions.
Consistently, Ghrouz et al. (2019) found that poor sleeping quality is significantly correlated with anxiety and depression and it has been proven by Riemann (2018) that sleeping problems including insomnia and nightmares have a decisive negative impact on mental health. Thus, it can be inferred that the poor psychological state of college students in Wuhan is inseparable from an irregular schedule.
Additionally, although online teaching was adopted due to the pandemic, this new form of learning brought out many problems, and other related academic activities including laboratory experiments, social examinations, graduation projects, and job hunting had to be postponed to a certain extent. We found that college students whose academic arrangements were negatively affected were more likely to be stressed and anxious, which is identical to the findings of Fruehwirth et al. (2021) that distance learning is a risk factor for anxiety and depression.
It is worth mentioning that the impact on the respondents differed in grades. Among all the students, the proportion of students considering pandemics as negative events to their academic progression was particularly high in the graduation grade (77.42%), which was consistent with a previous study (Zhai & Du, 2020). Notably, despite graduation students got the highest proportion of being negatively affected, the prevalence of stress, anxiety, and depression was higher in students in other grades. One possible explanation was that they had a more tightly packed curriculum and were not used to online learning .

| LIMITATIONS AND STRENGTH
The strength of this study lies in its target city, population, and time. Previous studies have proven that place of residence (hit hardest or not by pandemics) was a risk factor for negative psychological responses (Talevi et al., 2020) and students' status was significantly associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety, and depression (C. . We provide a figure of the psychological state of college students who lived in the hardest-hit place in China and went through the sudden quarantine at the peak time of the outbreak.
There are also several limitations to this study. The first is snowball sampling based on social networks, forwarding, and voluntary participation may introduce selection bias, resulting in an unbalanced proportion of students above the fourth grade compared with that of others. Second, this study based on self-report tools may introduce some systematic deviations compared with the survey measures based on interviews. Third, due to the nature of the cross-sectional study, causal relationships between the variables can not be determined.

| CONCLUSION AND CLINICAL IMPACTS
This study showed that during the unexpected quarantine, different levels of stress, anxiety, and depression symptoms were prevalent among local college students in Wuhan. These acute mental disorders were found to be associated with having a medical background, having relatives or friends confirmed or suspected, having an irregular diet or schedule, and academic progression being disrupted.
To improve the psychological state of college students, measures should be taken by the departments concerned. For policymakers and science popularization workers, they should try their best to reduce the spread of rumors, let students have a more accurate understanding of COVID-19, and at the same time, vigorously encourage students to actively carry out pandemic prevention and control work, such as getting vaccinated, insisting on wearing masks, keeping social distance and so on, so as to reduce the possible risk of sickness for themselves and their families. For school administrators, they should make efforts on coordinating students' academic life (especially graduation arrangements) and helping them achieve a better adaption to online study as soon as possible.
Because the virus will coexist with humans for a long time in the future, pandemic prevention and control will surely enter a phase of normalcy, all these notable factors found in this study and efforts should be taken into consideration for the intervention and improvement of college students' psychological state in the long term.