Original Investigation | Public Health

Prevalence and Risk Factors Associated With Self-reported Psychological DistressAmong Children and Adolescents During the COVID-19 Pandemic in ChinaZuguo Qin, MPH; Lei Shi, MD; Yaqing Xue, MD; Huang Lin, MPH; Jinchan Zhang, MPH; Pengyan Liang, MPH; Zhiwei Lu, MPH; Mengxiong Wu, MPH; Yaguang Chen, MPH;Xiao Zheng, MD; Yi Qian, MD; Ping Ouyang, MD; Ruibin Zhang, PhD; Xuefeng Yi, MD; Chichen Zhang, MD

Abstract

IMPORTANCE Schools have been suspended nationwide in 188 countries, and classes have shiftedto home-based distance learning models to control the spread of the coronavirus disease 2019(COVID-19) pandemic. Additional information is needed to determine mental health status amongschool-aged children and adolescents during this public health crisis and the risk factors associatedwith psychological distress during the pandemic.

OBJECTIVE To assess self-reported psychological distress among school-aged children andadolescents associated with the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study using data from a survey on themental health of school-aged children and adolescents in Guangdong province, China, conductedby using a stratified cluster random sampling method between March 8 to 30, 2020. To estimateoutcomes associated with location of districts, only data from students with internet protocoladdresses and current addresses in Guangdong were included. Data were analyzed from April 5 toJuly 20, 2020.

EXPOSURE Home-based distance learning during the COVID-19 pandemic.

MAIN OUTCOME AND MEASURES The main outcome was self-reported psychological distress,measured using the total score on the 12-item General Health Questionnaire of 3 or greater.Multivariate logistic regression was used to analyze risk factors associated with mental health status.Odds ratios (ORs) were used to analyze the associations of factors with psychological distress.

RESULTS Among 1 310 600 students who completed the survey, 1 199 320 students (mean [SD]age, 12.04 [3.01] years; 619 144 [51.6%] boys) were included in the final analysis. A total of 126 355students (10.5%) self-reported psychological distress. Compared with students in primary school,high school students had increased risk of psychological distress (OR, 1.19 [95% CI, 1.15-1.23]).Compared with students who wore a face mask frequently, students who never wore a face mask hadincreased risk of psychological distress (OR, 2.59 [95% CI, 2.41-2.79]). Additionally, students whospent less than 0.5 hours exercising had increased odds of self-reported psychological distresscompared with students who spent more than 1 hour exercising (OR, 1.64 [95% CI, 1.61-1.67]).

CONCLUSIONS AND RELEVANCE These findings suggest that the prevalence of self-reportedpsychological distress among students during the COVID-19 pandemic was relatively high. Frequencyof wearing a face mask and time spent exercising were factors associated with mental health.Therefore, it may be necessary for governments, schools, and families to pay attention to the mentalhealth of school-aged children and adolescents during the COVID-19 pandemic and take

(continued)

Key PointsQuestion What factors are associated

with self-reported psychological distress

among school-aged children and

adolescents during the COVID-19

pandemic?

Findings In this cross-sectional study

including 1 199 320 children and

adolescents, the prevalence of self-

reported psychological distress was

10.5%. Students who never wore a face

mask were at higher risk for

psychological distress compared with

students who wore a face mask

frequently, as were students who spent

less than 0.5 hours exercising compared

with students who spent more than 1

hour in exercising.

Meaning These findings suggest that

the prevalence of self-reported

psychological distress among school-

aged children and adolescents during

the COVID-19 pandemic was

relatively high.

+ Supplemental content

Author affiliations and article information arelisted at the end of this article.

Open Access. This is an open access article distributed under the terms of the CC-BY License.

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Abstract (continued)

corresponding countermeasures to reduce the impact of the COVID-19 pandemic on students’mental health.

JAMA Network Open. 2021;4(1):e2035487. doi:10.1001/jamanetworkopen.2020.35487

Introduction

Since the first case of coronavirus disease 2019 (COVID-19) was reported in Wuhan, China,1 severeacute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the causative virus for theglobal pandemic.2 On March 11, 2020, the World Health Organization declared that the COVID-19outbreak was a pandemic. Widespread outbreaks of COVID-19 were associated with psychologicaldistress and symptoms of mental illness.3 Previous studies have observed moderate to severepsychological distress symptoms, such as depression and anxiety, among the populations in areasseverely affected by the COVID-19 pandemic.4,5 Moreover, compounding factors, such as highmortality rate, shortage of medical protective materials, social isolation, and media informationoverload, could be associated with further adverse mental health outcomes during the pandemic.6

To date, the increasing attention toward on mental health status has shown that subsyndromalmental health problems are a common response to the COVID-19 pandemic.3 For example, a study byWang et al7 found moderate to severe depressive symptoms in 16.5% of the general population inChina, while moderate to severe anxiety symptoms were observed in 28.8% of the population andmoderate to severe stress symptoms were observed in 8.1% of the population. Although manystudies have focused on the general population,7 the mental health status of specific populationsduring the COVID-19 outbreak is attracting an increasing amount of attention. For example, Chenet al8 found that there was a negative association between internet-related behaviors andpsychological distress among children in China during the COVID-19 pandemic. However, the powerto determine the impacts of this unprecedented pandemic on the mental health status ofadolescents is limited by the small sample size of previous studies. In addition, it is unclear whatpotential factors may be associated with risk of or protection from adverse outcomes in adolescents’mental health status, and this lack of knowledge might impede the use of proper psychologicalinterventions for adolescents.

Although children and adolescents are generally healthy and do not require much health careoutside of regular checkups and immunizations, mental health care is critical for children andadolescents. Studies have consistently indicated that early identification and treatment is essentialduring this sensitive time in child development, or there may be adverse health and socialoutcomes.9 The COVID-19 pandemic may worsen existing mental health problems and be associatedwith more mental health problems among children and adolescents because of the uniquecombination of the public health crisis and social isolation.10 A 2020 study by Oosterhoff et al11

suggested that social distancing procedures involving minimizing social and physical contactbetween people during the COVID-19 pandemic was associated with significant mental healthimpacts. According to the United Nations Educational, Scientific and Cultural Organization,12 schoolshave been suspended nationwide in 188 countries, and classes have been shifted to home-baseddistance learning models to contain the spread of COVID-19. These unprecedented social distancingmeasures have affected more than 90% of enrolled learners, or approximately 1.5 billion youngpeople worldwide. Although massive efforts are being made by schools and teachers at all levels tocreate online courses and deliver them through television broadcasts and the internet, prolongedschool closure and home confinement during the COVID-19 pandemic may be associated withadverse mental health outcomes.11 Prolonged duration of shelter-in-place orders, fears of infection,inadequate information, lack of personal space at home, the efficacy of online learning, uncertaintyabout examinations and matriculation arrangements, family financial loss, and lack of in-personcontact with classmates, friends, and teachers are examples of stressors that could have adverse and

JAMA Network Open | Public Health Self-reported Psychological Distress Among Children During the COVID-19 Pandemic in China

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enduring outcomes among children and adolescents.13 A 2013 study found that posttraumaticstress disorder scores were 4-fold higher in children who had been quarantined than in those whowere not quarantined.14 Moreover, the stress of routine daily life and the psychosocial stress associ-ated with home confinement could further aggravate the detrimental impacts on mental health.11

Beyond mental health problems associated with home confinement, there is little knowledge aboutthe mental health status and risk factors associated with the mental health of children anadolescents during the COVID-19 pandemic, which could impede educators, administrators, andpolicy makers from developing effective interventions to prevent adverse effects of homeconfinement.

To fill this gap, we examined data from a sample covering a wide age range from 1 Chineseprovince with more than 1 million school-aged children and adolescents. The aims of this studywere to understand the self-reported psychological distress status among school-aged childrenand adolescents and to identify the risk and protective factors associated with self-reportedpsychological distress during the COVID-19 pandemic using a cross-sectional study withlarge sample.

Methods

This study was approved by the ethics committee of Southern Medical University. A parent orguardian assented to student participation before they completed the survey. This study is reportedfollowing the American Association for Public Opinion Research (AAPOR) reporting guideline.

Study PopulationThe target population comprised school-aged students in Guangdong province, China, which is 1 ofthe most developed provinces and has had the most cases of COVID-19 in China. A stratified clusterrandom sampling method was used to collect data between March 8 to 30, 2020. To build oursample, a 10% of primary and secondary schools from each city in Guangdong province wererandomly selected sampling with equal probabilities method, then a cluster sampling method wasused to extract students from these schools, and the probability of each student being selected wasthe same. Owing to the impact of the pandemic, the respondents in the target population completedthe Chinese version of the electronic questionnaire through an online survey platform (SurveyStar;Changsha Ranxing Science and Technology). The questionnaires were anonymous to ensure theconfidentiality and reliability of data. A total of 1 310 600 students completed the form, and1 199 320 valid questionnaires were returned, resulting in a response rate of 91.5%. The survey linkwas sent to the cell phone of the child’s parent or guardian, and parents or guardians were asked toassent to their child’s participation in the survey before the child could participate.

Assessment of the Mental Health OutcomeThe mental health status of students was assessed using the Chinese version of 12-item GeneralHealth Questionnaire (GHQ-12).15 We chose the GHQ-12 because even if a diagnosis could not bedetermined from the GHQ-12, it could identify people who might be inclined to experience mentalhealth problems (ie, depression, anxiety, or both). The GHQ-12 includes 6 negative questions and 6positive questions, with responses ranging from not at all, no more than usual, rather more thanusual, to much more than usual. The Chinese version of the GHQ-12 is a practical tool for assessing themental health status of children and adolescents with good internal reliability and external validity16

and has been widely used in children and adolescents from different cultural backgrounds.17,18

Although several scoring formats have been proposed for the GHQ-12, in this study, we used a binaryformat (0 or 1). The total scores ranged from 0 to 12, with higher scores indicating worsepsychological problems. GHQ-12 scores 3 or greater were determined to indicate self-reportedpsychological distress, but the score may trade off sensitivity and specificity for detecting individualswith mental distress.19 The Cronbach α coefficient for this scale in this present study was 0.75.

JAMA Network Open | Public Health Self-reported Psychological Distress Among Children During the COVID-19 Pandemic in China

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Factors Associated With Mental Health During the COVID-19 OutbreakWe examined factors associated with mental health as 2 categories. The first category wascharacteristics not associated with the COVID-19 pandemic, ie, trait-like features unrelated toCOVID-19. The second category was characteristics that may be influenced by the COVID-19pandemic, ie, state-like features during the COVID-19 pandemic.

Characteristics not associated with the COVID-19 pandemic were sociodemographiccharacteristics that are typically found in school-aged youths, such as their sex, age, grade level, onlychild (yes or no), economic status (high, medium, or low, provided by the parent or guardian),location of residence (urban or suburb), and region of residence: Pearl River Delta, East Guangdong,West Guangdong, and North Guangdong. These 4 regions are divided according to the economicdevelopment level of Guangdong province.

Characteristics associated with the COVID-19 pandemic, such as weekly exercise time whileconfined at home (>1 hour, 0.5-1 hour, <0.5 hours), sources for COVID-19 information (1, 2-3, 4-5, >5),and frequency of face mask use (always, most of the time, sometimes, few, or never) on occasionswhen it would be recommended to wear a mask (eg, when shopping), were included. RegardingCOVID-19 information sources, students were asked to make choices about possible sources forinformation about COVID-19, including through family members, friends, publicity in thecommunity, broadcasts, television, internet, and or another means. Beyond knowledgetransmission, students from undeveloped areas also might have limited resources to access onlinecourses during the COVID-19 outbreak, which might further impact mental health status due to asense of falling behind in learning. To test whether economic level was associated with mental status,we classified the living areas into 4 regions: Pearl River Delta, East Guangdong, West Guangdong,and North Guangdong. Finally, we coded each district with a different rank of risk for COVID-19following the guidelines for partitioned and graded prevention and control of COVID-19 inGuangdong province.20

Statistical AnalysisCategorical variables were presented as numbers and percentages and compared using a Pearson χ2

test or Fisher exact test between poor mental health (GHQ score �3) and good mental health (GHQscore <3) groups. P values for trends were calculated using the mental health variable as a binarycategorical variable (1 = GHQ score �3, 0 = GHQ score <3) in the Pearson χ2 trend test andregression model trend test. P values were 2-sided, and statistical significance was set at P < .05.

To further examine potential factors associated with risk or protection for mental health status,a multivariate logistic regression analysis was used, and odds ratios (ORs) and 95% CIs werecalculated. In this model, we included potential variables and set the significance level at P < .05. Allanalyses were performed with Stata statistical software version 15.0 (StataCorp) and R statisticalsoftware version 4.0.3 with forestplot package (R Project for Statistical Computing). To account forthe clustering of participants, we weighted by geographic area of residence and stratified by sex.Data were analyzed from April 5 to July 20, 2020.

Results

A total of 1 310 600 students completed the questionnaire, and 1 199 320 respondents (mean [SD]age, 12.04 [3.01] years; 619 144 [51.6%] boys) respondents were included in the final analysis. A totalof 126 355 students (10.5%) reported psychological distress, among whom 65087 (51.5%) were girls.A flowchart of the respondents can be found in Figure 1. Figure 2 shows the prevalence estimate forself-reported psychological distress among school-aged children and adolescents in 21 cities ofGuangdong province. Pearson χ2 trend tests found that all examined characteristics, including thoseassociated with the COVID-19 pandemic and those not associated with the pandemic, wereassociated with mental health status in a significant linear trend (Table 1). Based on these results, we

JAMA Network Open | Public Health Self-reported Psychological Distress Among Children During the COVID-19 Pandemic in China

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conducted an additional analysis using multivariate logistic regression to identify risk factorsassociated with mental health status (Figure 3).

Characteristics Not Related to the COVID-19 Pandemic and Self-reportedPsychological DistressWe found that sociodemographic factors, including age, sex, only child status, residence, economicstatus, school class, and areas where the students lived were significantly associated with theself-reported psychological distress before assigning weights. However, only child status and area ofresidence were not significantly associated with the self-reported psychological distress afterassigning weights (Table 2). Older students were more likely to experience psychological distress, ashigh school students were more likely to report psychological distress compared with primaryschool students (OR, 1.19 [95% CI, 1.15-1.23]) (Figure 3), and those in their final year of highschool had the highest prevalence of self-reported psychological distress (eFigure 2 in theSupplement). Furthermore, a positive linear association between age and the prevalence of self-reported psychological distress was found (eFigure 1 in the Supplement). Compared with students

Figure 1. Flowchart of Participant Selection

1 310 600 Students fill out forma

26 469 With IP address not in Guangdong

6887 With current address not in Guangdong

1 199 320 Included

77 924 Had IP address without districtb

1 284 131 Included

1 277 244 Included

a Owing to the coronavirus disease 2019 pandemicoccurring during the winter vacation, some studentswent back to their hometown outside of Guangdongprovince.

b Some internet protocol (IP) addresses were inGuangdong province, but the city name was blocked,which would block the analysis of the geographicassociations with psychological distress.

Figure 2. Prevalence of Psychological Distress Among School-Aged Children and Adolescentsin Guangdong Province

Guangzhou

Shaoguan

Zhuhai

Shenzhen

Shantou

Foshan

Jiangmen

Zhanjiang

Maoming

Zhaoqing

Huizhou

Meizhou

Shanwei

Heyuan

Yangjiang

Qingyuan

Dongguan

Zhongshan

Chaozhou

Jieyang

Yunfu

Prevalence, %

0 to 8.5

≤8.5

>9.5 to 10.5

>10.5 to 11.5

>11.5 to 12.5

>12.5

JAMA Network Open | Public Health Self-reported Psychological Distress Among Children During the COVID-19 Pandemic in China

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Table 1. Sociodemographic and COVID-19–Related Factors of Survey Respondents

VariablesGHQ ≥3 (n = 126 355[10.5%])

GHQ <3 (n = 1 072 965[89.4%])

P valuefor trend

Age, y

<8 6561 (7.5) 80 627 (92.5)

<.001

8-10 24 625 (8.1) 278 580 (91.9)

11-13 39 100 (9.6) 367 630 (90.4)

14-16 41 630 (13.3) 270 415 (86.7)

>16 14 439 (16.0) 75 713 (84.0)

Sex

Boys 61 268 (9.9) 557 876 (90.1)<.001

Girls 65 087 (11.2) 515 089 (88.8)

Only child

Yes 12 982 (9.4) 124 472 (90.6)<.001

No 113 373 (10.7) 948 493 (89.3)

Economic status

High 9079 (9.2) 89 914 (90.8)

<.001Medium 87 080 (9.6) 817 927 (90.4)

Low 30 196 (15.5) 165 124 (84.5)

Grade level

Primary school 63 363 (8.7) 666 643 (91.3)

<.001Secondary school 41 069 (12.6) 284 795 (87.4)

High school 21 923 (15.3) 121 527 (84.7)

Residence

Urban 57 956 (9.8) 535 920 (90.2)<.001

Suburb 68 399 (11.3) 537 045 (88.7)

Districta

Pearl River Delta 46 347 (9.5) 442 553 (90.5)

<.001East Guangdong 17 914 (10.4) 154 894 (89.6)

West Guangdong 48 418 (11.6) 368 453 (88.4)

North Guangdong 13 676 (11.3) 107 065 (88.7)

Risk rank of COVID-1920

I NA NA

II 6248 (9.0) 63 407 (91.0)

<.001III 44 774 (10.8) 368 574 (89.2)

VI 75 333 (10.5) 640 984 (89.5)

Physical exercise, h/d

>1 30 870 (8.4) 335 808 (91.6)

<.0010.5-1 42 806 (8.7) 447 053 (91.3)

<0.5 52 679 (15.4) 290 104 (84.6)

Sources for COVID-19 information, No.

1 16 950 (15.3) 93 767 (84.7)

<.0012-3 41 466 (11.6) 314 771 (88.4)

4-5 40 445 (9.8) 372 349 (90.2)

>5 27 494 (8.6) 292 078 (91.4)

Frequency of face mask using

Always 102 951 (9.7) 959 427 (90.3)

<.001

Most of time 16 188 (15.6) 87 550 (84.4)

Sometimes 3832 (19.6) 15 723 (80.4)

Rarely 2308 (23.4) 7562 (76.6)

Never 1076 (28.5) 2703 (71.5)

Abbreviations: COVID-19, coronavirus disease 2019;NA, not applicable.a The categorical variables were tested by Fisher exact

probability test.

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from the Pearl River Delta, students in West Guangdong (OR, 1.11 [95% CI, 1.09-1.12]) and NorthGuangdong (OR, 1.10 [95% CI, 1.07-1.12]) had higher odds of psychological distress. In line witheconomic development levels, compared with students who had high economic status, students withmedium economic status (OR, 1.04 [95% CI, 1.02-1.07]) and low economic status (OR, 1.71 [95% CI,1.66-1.75]) had higher odds of psychological distress (Figure 3).

Figure 3. Factors Associated With Risk of or Protection From Self-reported Psychological Distress

0.6 1.2 2.81 1.4 1.6 1.8 2 2.2 2.4 2.6OR (95% CI)

0.8

P value

Lower oddsof psychological

distress

Greater oddsof psychologicaldistress

Participantswith GHQ score≥3, No. (%)Subgroup

Overall 126 335 (10.5)Characteristics not related to COVID-19

Age, y<88-1011-1314-16>16

SexBoysGirls

Only childNoYes

ResidenceSuburbUrban

Socioeconomic status HighMediumLow

ClassPrimary schoolJunior schoolSenior school

DistrictPearl River DeltaEast GuangdongWest GuangdongNorth Guangdong

Characteristics related to COVID-19 Risk of COVID-19, rank

623

Physical exercise, h/d>10.5-1<0.5

Sources for COVID-19 information>512-34-5

Face mask use, frequencyAlwaysMost of timeSometimesFewNever

6561 (7.5)24 625 (8.1)39 100 (9.6)41 630 (13.3)14 439 (16.0)

61 268 (9.9)65 087 (11.2)

12 982 (9.4)113 373 (10.7)

57 956 (9.8)68 399 (11.3)

9079 (9.2)87 080 (9.6)30 196 (15.1)

63 363 (8.7)41 069 (12.6)21 923 (15.3)

46 347 (9.5)17 914 (10.4)48 418 (11.6)13 676 (11.3)

75 333 (9.0)44 774 (10.8)6248 (10.5)

30 870 (8.4)42 806 (8.7)52 679 (15.4)

27 494 (8.60)41 466 (11.6)40 445 (9.80)16 950 (15.3)

102 951 (9.7)16 188 (15.6)3832 (19.6)2308 (23.4)1076 (28.5)

<.001<.001<.001<.001

<.001

.003

.77

.001<.001

<.001<.001

<.001<.001<.001

.12

.008

.10<.001

<.001<.001<.001

<.001<.001<.001<.001

OR(95% CI)

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

1.20 (1.17-1.24)1.45 (1.40-1.51)1.61 (1.54-1.68)

1.14 (1.13-1.15)

0.97 (0.95-0.99)

1.00 (0.99-1.02)

1.04 (1.02-1.07)1.71 (1.66-1.75)

1.47 (1.21-1.17)1.16 (1.12-1.20)

0.96 (0.94-0.97)1.11 (1.09-1.12)1.10 (1.07-1.12)

1.02 (1.02-1.08)1.02 (1.01-1.03)

1.01 (1.00-1.03)1.64 (1.62-1.67)

1.59 (1.56-1.63)1.23 (1.21-1.26)1.02 (1.08-1.12)

1.44 (1.41-1.46)1.77 (1.70-1.83)2.19 (2.09-2.30)2.64 (2.45-2.83)

1.06 (1.03-1.09)

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Characteristics Related to the COVID-19 Pandemic and Self-reportedPsychological DistressWe observed that the factors related to COVID-19 were significantly associated with self-reportedpsychological distress (Table 2). Specifically, compared with students from areas coded as low risk forCOVID-19 (rank VI), students from an area coded as high risk (rank II) had higher odds ofpsychological distress (OR, 1.02 [95% CI, 1.01-1.03) (logistic model: AUC = 0.641; Pseudo R2 = 0.037).Additionally, knowledge about sources for information on COVID-19 was associated with mentalhealth status. Compared with students who knew more than 5 ways of finding knowledge aboutCOVID-19, students who knew 1 way had higher odds of psychological distress (OR, 1.59 [95% CI,1.56-1.63]), as did students who knew 2 to 3 ways (OR, 1.23 [95% CI, 1.21-1.26]), and those who knew4 to 5 ways (OR, 1.10 [95% CI, 1.08-1.12]). Interestingly, we found that frequency of wearing a facemask and time spent exercising were associated with protection from adverse mental health.Compared with students who always wore face masks, students who rarely wore face masks hadsignificant higher odds of self-reported psychological distress (OR, 2.59 [95% CI, 2.41-2.79]).Compared with students who spent more than 1 hour exercising. students who spent less than 0.5hours exercising also had higher odds of self-reported psychological distress (OR, 1.64 [95% CI, 1.62-1.67]) (Figure 3).

Discussion

This cross-sectional study examined prevalence and risk factors associated with self-reportedpsychological distress among primary and secondary students during the COVID-19 pandemic basedon a large sample from Guangdong province, China. To our knowledge, few studies have exploredfactors associated with mental health status among children and adolescents during the COVID-19pandemic using a sample of more than 1 million participants. This study found an overall prevalenceof self-reported psychological distress of 10.5%. Moreover, our findings indicated that the frequencyof wearing a face mask and time spent exercising had protective associations with mental health.

The prevalence of self-reported psychological distress among school-aged children andadolescents during the COVID-19 pandemic was higher than the prevalence of mental healthproblems among children and adolescents in Guangzhou reported in a 2017 study,21 before theCOVID-19 pandemic, but lower than psychological distress reported in the general population ofGuangzhou during the COVID-19 pandemic.22 This could be the result of numerous factors. First, theCOVID-19 pandemic forced school-aged children and adolescents to stay at home, and they couldnot play with their friends, which may have increased the incidence of perceived loneliness and

Table 2. Multivariate Logistic Regression Analysis of Characteristics Associatated With Psychological DistressAmong School-Aged Children and Adolescents During the COVID-19 Pandemic in Guangdong Province, China

Variables Unadjusted OR (95% CI)a P value Adjusted OR (95% CI) P valueCharacteristics not related to COVID-19

Age 1.16 (1.15-1.17) <.001 1.16 (1.10-1.23) .008

Sex 1.12 (1.10-1.13) <.001 1.12 (1.10-1.14) .002

Only child 0.97 (0.95-0.99) .002 0.96 (0.79-1.15) .41

Economic status 1.43 (1.42-1.45) <.001 1.44 (1.27-1.64) .006

Grade 1.10 (1.08-1.11) <.001 1.10 (1.06-1.14) .008

Residence 0.96 (0.95-0.97) <.001 0.97 (0.90-1.04) .18

District 1.05 (1.04-1.06) <.001 1.05 (1.04-1.06) .004

Characteristics related to COVID-19

Risk rank of COVID-1920 1.02 (1.01-1.03) <.001 1.02 (1.00-1.04) .03

Physical exercise 1.32 (1.31-1.33) <.001 1.33 (1.21-1.46) .006

Sources for COVID-19 information 1.01 (1.01-1.02) <.001 1.01 (1.01-1.02) .008

Frequency of face mask use 1.37 (1.36-1.39) <.001 1.39 (1.18-1.64) .01

Abbreviations: COVID-19, coronavirus disease 2019;OR, odds ratio.a AUC = 0.624 and Pseudo R2 = 0.029 in the

logistic model.

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exacerbated its affects. During the outbreak of COVID-19, schools were suspended, and all studentswere instructed to study at home through online videos. In such cases, outdoor activities and socialinteraction were largely reduced, which could increase depressive symptoms.23 A study byOosterhoff et al11 suggested that the government’s social distancing policy during the COVID-19outbreak was associated with psychological distress among adolescents. Second, exposure to familymembers continually discussing the numbers of COVID-19 cases and deaths, may have led toincreased anxiety among children and adolescents. In addition, a study by Campbell24 suggested thatactions attempting to reduce the spread of COVID-19, such as social distancing, sheltering in place,restricted travel, and closures of key community resources, were likely to dramatically increase therisk of family violence.24 Furthermore, students who take online course by smartphone or computerduring the school suspension, especially if parents and teachers do not monitor smartphone andsocial media use, might engage in problematic application or social media use. A study by Chen et al8

found greater associations between problematic smartphone-application use, problematic socialmedia use, and psychological distress during the COVID-19 pandemic compared with findings amongadolescents who participated in online learning at home prior to the pandemic.

Previous studies have shown that the prevalence of psychological distress is variable.25,26 It ischallenging to compare the prevalence of psychological distress among school-aged children andadolescents from different studies11 owing to inconsistencies in the culture context, samples,methods or scales used, or use of same scales but different cutoff values to measure psychologicaldistress. Our results from a sample of more than 1 million participants from 1 province suggest thegeneral mental health status of primary and secondary students showed consistency with otherstudies set in China.21,22 This would further support the need for psychological interventionstrategies for students during COVID-19 that go beyond the usual care practiced before the COVID-19pandemic.

Regarding the sociodemographic factors not related to the COVID-19 pandemic, we found thatolder students were more likely to experience psychological distress, and those in their final year ofhigh school had the highest prevalence of self-reported psychological distress. One possible reason isthat in the context of Chinese culture, the college entrance examination is not only important for thestudents themselves but also is a pivotal event for the family.27 High school students, especially thosein their final year of high school, may be not only worried about their review plans being disruptedduring the COVID-19 pandemic, but also may experience pressure from their parents, relatives, andfriends, which may further exacerbate any psychological distress. In addition, students from lessdeveloped areas had a higher incidence of psychological distress. In line with these results, studentswith a low family economic status may face more serious psychological problems during theCOVID-19 pandemic. This phenomenon may be attributed to the fact that families with pooreconomic conditions may be facing even more financial difficulty during the COVID-19 pandemic andmay be restricted in living standards and diet or nutrition, so that negative emotions from the parentsmay be spread to children and adolescents, which may in turn increase psychological burden. Studieshave demonstrated that individuals from families with low economic status are more likely toexperience psychological distress.28,29 In addition, students who come from less developed areasand have a poor economic status might have limited resources to access the online courses, whichmight further impact the mental health status owing to a sense of falling behind in learning.

Regarding the factors associated with the COVID-19 pandemic, we found higher odds ofpsychological distress among school-aged children and adolescents in a high-risk area (ie, rank II)compared with those in a low-risk areas (ie, rank VI). In line with these findings, the results from astudy by Xie et al23 that recruited children from Hubei province showed that the children fromWuhan, China, the city where COVID-19 was first recorded and with the most cases of COVID-19 inHubei province, had significantly higher depression status scores than children in Huangshi, anothercity in Hubei with fewer COVID-19 cases. Some potential reasons for this difference include thatschool-aged children and adolescents in high-risk areas may worry about their families, relatives, andfriends being infected, in addition to worrying about themselves getting infected. Meanwhile,

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school-aged children and adolescents in high-risk areas also may receive negative information aboutthe number of people infected in the area every day, which may further increase their psychologicaldistress.

However, other COVID-19–related factors, such as knowledge about COVID-19, face mask–wearing frequency, and time spent exercising were associated with protection from psychologicaldistress. Students who had more sources for information on COVID-19 were less likely to experiencepsychological distress. Often it is the unknown that is frightening, so students who have multiplesources for COVID-19–related information (eg, how to prevent COVID-19, transmission mechanismsof SARS-CoV-2) that they can understand may reduce psychological distress. Interestingly, we foundthat the frequency of wearing a face mask and time spent exercising had a protective associationwith mental health. Moreover, the association of overall frequency of mask use with self-reportedpsychological distress may reflect whether students are leaving their home frequently. It might alsoreflect the preference of the student or of their parents and the cost of masks at that time. Wearing aface mask is one of the main ways individuals can prevent infection.30,31 Students who wear facemasks frequently might feel less likely to contract COVID-19, which could further reduce worry andanxiety levels and promote mental well-being. Therefore, wearing a mask may be more conducive tomental health. Of course, there are various potential reasons for the associations of mental healthwith COVID-19 knowledge and face mask use, some of which imply no causal effect. For example,lower COVID-19 knowledge could reflect lower intelligence of the student or householdcharacteristics that may in turn be associated with poor mental health. At the same time, studentswith preexisting mental health problems may pay less attention to COVID-19 and therefore be lesslikely to learn about its transmission or be concerned about mask use. In addition, children andadolescents who spent less time exercising were more likely to experience psychological distress,which is consistent with a previous large sample study in the United States between 2011 and 2015.32

During home confinement, exercise could improve mood and self-confidence of children andadolescents, as exercises has been shown to have beneficial associations with the prevention andtreatment of psychiatric diseases and could promote mental well-being.33

LimitationsThis study has some limitations. The cross-sectional nature of this study limits the ability to establishthe direction of causality for the association between the risk factors and mental health. In otherwords, a more distressed person might be less inclined to take self-protective steps. It is necessary toperform further longitudinal research to provide additional explanations for these associations.Additionally, we used an internet survey because of the COVID-19 pandemic, but the reliability of thesurvey results is greatly affected by the participants. However, our study covered all students fromprimary school to senior high school in Guangdong province, and the overall sample size was largeand representative, which can help extend our results to reflect the mental health of school-agedchildren and adolescents during the COVID-19 pandemic.

Conclusions

In this cross-sectional study in a large sample from Guangdong province, the prevalence ofpsychological distress among school-aged children and adolescents during the COVID-19 pandemicwas relatively high. Age, family economic status, and risk level for a COVID-19 outbreak were riskfactors associated mental well-being. Additionally, the frequency of wearing a face mask and timespent exercising had protective associations for mental health. Based on these findings, it isnecessary for governments, schools, and families to pay attention to the mental health of school-aged children and adolescents during the COVID-19 pandemic and take appropriatecountermeasures to reduce the impact of the COVID-19 pandemic on mental health for children andadolescents.

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ARTICLE INFORMATIONAccepted for Publication: December 8, 2020.

Published: January 26, 2021. doi:10.1001/jamanetworkopen.2020.35487

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Qin Z et al.JAMA Network Open.

Corresponding Author: Chichen Zhang, MD, Southern Medical University, No. 1023-1063, Shatai S Rd, BaiyunDistrict, Guangzhou 510515, China (zhangchichen@sina.com); Xuefeng Yi, MD, Health Publicity and EducationCenter of Guangdong Province, Guangzhou, Guangdong, China (yixuefeng123@21cn.com); Ruibin Zhang, PhD,Southern Medical University, Guangzhou, Guangdong, China (ruibinzhang@foxmail.com).

Author Affiliations: Health Publicity and Education Center of Guangdong Province, Guangzhou, China (Qin, Liang,Lu, Wu, Yi); School of Health Services Management, Southern Medical University, Guangzhou, China (Shi, Xue,Zheng, Qian, C. Zhang); School of Public Health, Southern Medical University, Guangzhou, China (Xue, Zheng,R. Zhang); Department of Prevention and Health Care, Shantou Central Hospital/Affiliated Shantou Hospital of SunYat-sen University, Shantou, China (Lin); Department of Medical Dispute, Maternal and Child Health Hospital,Heyuan, China (J. Zhang); Health Education Center of Maoming City, Maoming, China (Chen); Department ofHealth Management, Nanfang Hospital, Southern Medical University, Guangzhou, China (Ouyang, C. Zhang);Department of Psychiatry, Zhujiang Hospital, Southern Medical University, Guangzhou, China (R. Zhang); Instituteof Health Management, Southern Medical University Guangzhou, Guangzhou, China (C. Zhang).

Author Contributions: Drs Yi and C. Zhang had full access to all of the data in the study and take responsibility forthe integrity of the data and the accuracy of the data analysis. Drs Qin and Shi contributed equally as co–firstauthours. Drs R. Zhang, Yi, and C. Zhang contributed equally as co–corresponding authors.

Concept and design: Yi, C. Zhang.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Qin, Shi, Xue, Liang, Lu, Zheng, R. Zhang, Yi, C. Zhang.

Critical revision of the manuscript for important intellectual content: Qin, Shi, Lin, J. Zhang, Liang, Lu, Wu, Chen,Zheng, Qian, Ouyang, R. Zhang, Yi, C. Zhang.

Statistical analysis: All authors.

Obtained funding: C. Zhang.

Administrative, technical, or material support: Qin, Shi, Lin, J. Zhang, Liang, Lu, Wu, Chen, Zheng, Qian, Ouyang, R.Zhang, Yi, C. Zhang.

Supervision: Wu, Yi.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by grant No. 20ZD018 from the Key Projects for Research on YouthDevelopment of Central Committee of the Communist Youth League, grant No. 2020KZDZX1046 from the SpecialResearch Project of Prevention and Control during COVID-19 Epidemic in Universities of Guangdong, grant No.G620369695 from the Key Laboratory Development Project for Philosophy and Social Sciences in Guangdong,grant No. C2020062 from the Directive Project of Medical Scientific Research Foundation in Guangdong, andgrant Nos. 31900806 and 71874104 from the National Nature Science Foundation of China.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection,management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; anddecision to submit the manuscript for publication.

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SUPPLEMENT.eFigure 1. Prevalence and Risk Factors Associated With Psychological Distress Among School-Aged StudentsDuring the COVID-19 PandemiceFigure 2. Association of Grade Level With Risk of Psychological DistresseTable. 12-Item General Health Questionnaire

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