Posttraumatic stress symptoms among Chinese university students during the COVID-19 pandemic: Prevalence, correlates, and mental health help-seeking

Abstract

BACKGROUND

Revisiting the epidemiology of posttraumatic stress symptoms (PTSSs) among university students during the coronavirus disease 2019 (COVID-19) pandemic as well as understanding the mental health help-seeking behavior of individuals with PTSSs has critical implications for public mental health strategies in future medical pandemics.

AIM

To investigate the prevalence and correlates of PTSSs among university students during the first wave of the COVID-19 pandemic in China and to examine mental health help-seeking behaviors among these students.

METHODS

A total of 2507 Chinese university students were recruited via snowball sampling. The students completed the Seven-item Screening Scale for Post-traumatic Stress Disorder during the first wave of the COVID-19 pandemic in China. Sociodemographic characteristics, pandemic-related characteristics, and mental health help-seeking behaviors of students with PTSSs were also collected.

RESULTS

The prevalence of PTSSs among the participants was 28.0%. Seven significant correlates of PTSSs were identified (odds ratio = 1.23-3.65, P ≤ 0.024): Female sex, being 19 years old or older, living with others or alone, a low level of family economic status, fair or poor interpersonal relationships, severe or very severe local pandemic, and having family members diagnosed with COVID-19. However, only 3.28% of the students with PTSSs reported seeking help from mental health specialists. Among the 23 students who sought help from mental health specialists, 13 opted for online or telephone-based psychological consultation.

CONCLUSION

Our data suggest that there was a high risk of PTSSs among university students and a high level of unmet mental health needs during the COVID-19 pandemic. The delivery of mental health services online or via telephone is a promising approach to address these unmet needs.

Key Words: Posttraumatic stress symptoms; University students; COVID-19; Mental health help-seeking; China

Core Tip: The present study examined posttraumatic stress symptoms (PTSSs) among university students during the coronavirus disease 2019 pandemic and the mental health help-seeking behavior of individuals with PTSSs. As high as 28.0% of the university students had PTSSs. However, only 3.28% of the students with PTSSs reported seeking help from mental health specialists. Among those who used mental health services, 56.5% opted for online or telephone-based psychological consultations. In the context of potential future pandemics, the provision of mental health services online or via telephone is a promising approach for addressing the unmet mental health needs of individuals with PTSSs.

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic, which lasted from December 2019 to May 2023, was the most severe and unprecedented public health crisis since the 1918 flu pandemic[1]. In addition to the staggering numbers of COVID-19 cases and fatalities, the pandemic has also exerted significant negative effects on the mental health of individuals across all age groups worldwide, particularly during the peak of the outbreak[2-4]. Posttraumatic stress symptoms (PTSSs) and posttraumatic stress disorder (PTSD) are often common mental health sequelae in populations affected by major disasters and pandemics[5,6]. For example, a meta-analysis of 63 studies conducted during the COVID-19 pandemic found that prevalence rates of PTSSs were 15.5% among COVID-19 patients, 17.2% among healthcare workers, and 17.3% among the general population[7].

Studying at university is a challenging transition period marked by a shift from familial dependence to increased socialization. This phase is also characterized by high levels of academic and employment stress, along with prevalent interpersonal, romantic, and emotional problems[8,9]. During the pandemic, the daily routines of university students were significantly disrupted. The closure of campuses made accessing learning resources such as libraries difficult and disrupted academic progress and plans. Mandatory self-quarantine and physical distancing led to social isolation. In addition, the economic downturn caused uncertainties about future employment, and students grappled with the challenges of adjusting to remote learning. These difficulties, combined with the inherent stress of the pandemic itself, increased the risks of PTSD and PTSSs among university students. Accordingly, a meta-analysis comprising 38 studies with a total sample of 95375 college students from 16 countries reported an overall 25% prevalence of PTSSs among university students worldwide during the pandemic[10].

Nevertheless, the majority of previous studies investigated PTSSs in university students following the initial COVID-19 pandemic in China[10]. Given the exceptionally high levels of fear and uncertainty surrounding the emergent virus, coupled with the high mortality rate of COVID-19 and the overwhelmed healthcare system, the potentially elevated PTSSs among university students during the first-wave outbreak period warrant dedicated research attention. Another limitation of previous studies is the inconsistent findings concerning factors associated with PTSSs in university students. For example, a survey of Chinese university students during the pandemic revealed that being an only child, being a senior student, living in the epicenter, experiencing high fear levels, and having short sleep durations were significantly associated with PTSSs[11]. In contrast, another survey of Chinese university students reported that PTSSs were associated with being female, studying medicine, living in communities with confirmed cases of COVID-19, and having poor parental relationships[12]. These inconsistencies hinder the correct identification of high-risk subgroups of university students for PTSSs.

Accurate estimates of PTSSs prevalence and data on the utilization of mental health services by students with PTSSs are essential for planning for mental health needs among university students during crisis periods. However, previous studies have reported a wide variation in estimated PTSSs prevalence rates among university students, ranging from 2.7% to 66.7%[10]. Moreover, no existing studies have reported on mental health help-seeking behaviors among students exhibiting clinically significant PTSSs[10].

While the COVID-19 pandemic is no longer considered a Public Health Emergency of International Concern, the possibility of a resurgence or pandemics of other infectious diseases still exists. Therefore, revisiting PTSSs among university students during the COVID-19 pandemic has public health implications for university students during future medical pandemics. This study reported the prevalence and associated factors of PTSSs among Chinese university students during the first wave of COVID-19 pandemic and examined the mental health help-seeking behaviors among these students.

MATERIALS AND METHODS

Participants and survey procedures

This cross-sectional study was conducted between March 4 and May 9, 2020. This period coincided with the second half of the first wave of the COVID-19 pandemic in China, when initial control was achieved and around the time when the lockdown in Wuhan was lifted (April 8). The consideration for this survey period was that it came just one month after the peak day (February 2) of the daily new COVID-19 cases in Wuhan[13]. Since a prerequisite for PTSD diagnosis is that symptoms should persist for a month or longer, this time interval is appropriate for assessing PTSSs[14].

Owing to the self-quarantine and physical distancing policies during the outbreak, we recruited a study sample of university students online via snowball sampling. Initially, we obtained permission from the head teachers of several Chinese universities in Wuhan to facilitate this survey. We sent these teachers an electronic invitation letter detailing the background, significance, assurance of anonymity, and voluntary participation, along with a QR code linked to our survey questionnaire. The teachers then disseminated this letter to the students' WeChat groups and forwarded it to other head teachers through their social networks. Students who confirmed their willingness to participate by clicking an "agree" button were instructed to complete the online questionnaire.

The study protocol and consent procedures were approved by the Institutional Review Board at the Wuhan Mental Health Center.

Survey questionnaire

The following sociodemographic variables were assessed: Sex, age, educational major (medicine vs nonmedicine), academic category (undergraduate vs postgraduate), cohabitation status (living with family vs living with individuals other than family members or alone), type of habitual residence (city, village, urban-rural fringe area), geographic region of current residence (Wuhan, other regions of Hubei, provinces apart from Hubei), residential or travel history in Wuhan from December 2019 to January 2020, self-rated level of family economic status (low, fair, high), and self-rated interpersonal relationship (poor, fair, good).

Two questions were used to assess participants' perceived severity of the pandemic in their current cities or counties. They were asked, "How severe do you feel the COVID-19 epidemic is in your current city/county of residence?" with response options of "very severe", "severe", or "mild". Additionally, respondents were asked if they had any family members/friends or classmates who had been confirmed to have COVID-19, with response options of "yes" or "no".

We used the Seven-item Screening Scale for PTSD (SSS-PTSD) to assess the presence of PTSSs. The SSS-PTSD was developed by Liu and colleagues and was initially used to assess PTSSs in victims of a blood disaster in Hunan, China[15]. The scale includes seven binary yes-no items: Two items about re-experiencing symptoms, four items about avoidance and numbing symptoms, and one item about hyperarousal symptom of PTSD. According to the original research, the recommended cutoff score for screening for PTSD in Chinese blood disaster victims was three or more[15]. This scale was subsequently used to screen for PTSD in healthcare workers who survived the Wenchuan earthquake in China, with the revised cutoff score recommended as four or higher[16]. However, in our pilot test of the accuracy of the SSS-PTSD among university students during the COVID-19 pandemic (unpublished data), we found that a score of two or more was the most accurate cutoff value for screening PTSD based on the DSM-IV. This cutoff value resulted in a sensitivity of 0.933 and a specificity of 0.819. Therefore, we set the cutoff score in this study as two or more. The Cronbach alpha coefficient of the SSS-PTSD in our study was 0.887.

Participants who were positive for PTSD were further questioned about their mental health help-seeking behaviors. They were asked, "Have you sought any help from mental health specialists for your mental health problems? These specialists could include psychiatrists, psychotherapists, and psychological counselors". If the participants reported having sought help, they were further asked, "How did you seek help from mental health specialists?". The response options for this third question were "offline face-to-face consultation", "online consultation via WeChat, QQ, and other social media platforms", "telephone consultation such as a psychological crisis hotline", and "others (please specify)".

Statistical analysis

The percentage of PTSSs among the total student sample was calculated, as was the percentage of students who sought mental health help among the total sample with PTSSs. The χ² test was used to compare the rates of PTSSs across different subgroups based on sociodemographic and pandemic-related characteristics. Multiple logistic regression analysis (using the backward Wald method) was performed to identify factors significantly associated with PTSSs. This analysis treated the presence or absence of PTSSs as a binary outcome and considered statistically significant factors from the prior χ² test as potential independent predictors. Odds ratios (ORs) and their 95%CI were calculated to quantify the associations of PTSSs with identified factors. Statistical significance was set at P < 0.05 (two-tailed). All analyses were conducted via the SPSS software version 15.0 package (SPSS Inc., Chicago, IL, United States).

RESULTS

Sample characteristics

A total of 2507 Chinese university students completed the survey questionnaire. Among these students, 61.8% were male, and the mean age was 19.65 years (SD: 2.49, range: 16-31). The majority of the survey sample consisted of undergraduates (90.9%) and students with a residential or travel history in Wuhan before the outbreak (85.0%). Other sociodemographic and pandemic-related characteristics are shown in Table 1.

Table 1 Characteristics of the sample of university students, rates of posttraumatic stress symptoms among different subgroups, and factors associated with posttraumatic stress symptoms in multiple logistic regression analysis, n (%).

Characteristics		Respondents	Respondents with PTSSs	χ2	P value	OR (95%CI)	P value
Sex	Male	1550 (61.8)	412 (26.6)			1
	Female	957 (38.2)	290 (30.3)	4.067	0.044	1.24 (1.03, 1.49)	0.024
Age (years)	≤ 18	820 (32.7)	203 (24.8)			1
	≥ 19	1687 (67.3)	499 (29.6)	6.367	0.012	1.23 (1.01, 1.50)	0.023
Educational major	Medicine	106 (4.2)	36 (34.0)
	Non-medicine	2401 (95.8)	666 (27.7)	1.951	0.163
Category of students	Undergraduates	2278 (90.9)	622 (27.3)
	Postgraduates	229 (9.1)	80 (34.9)	6.008	0.014
Habitual residence	City	1323 (52.8)	363 (27.4)
	Village	856 (34.1)	243 (28.4)
	Urban-rural fringe	328 (13.1)	96 (29.3)	0.533	0.766
Geographic region of residence	Wuhan	137 (5.5)	49 (35.8)
	Other regions of Hubei	472 (18.8)	128 (27.1)
	Provinces apart from Hubei	1898 (75.7)	525 (27.7)	4.389	0.111
Residential or travel history in Wuhan from December 2019 to January 2020	Lived in/visited Wuhan before; now in Wuhan	210 (8.4)	80 (38.1)
	Lived in/visited Wuhan before; not in Wuhan now	1920 (76.6)	503 (26.2)
	Never lived in/visited Wuhan	377 (15.0)	119 (31.6)	16.085	< 0.001
Co-habitation status	Living with family	2449 (97.7)	670 (27.4)			1
	Living with others or alone	58 (2.3)	32 (55.2)	21.742	< 0.001	2.18 (1.25, 3.81)	0.006
Self-rated family economic status	High	473 (18.9)	103 (21.8)			1
	Fair	1474 (58.8)	402 (27.3)			1.14 (0.88, 1.48)
	Low	560 (22.3)	197 (35.2)	23.789	< 0.001	1.48 (1.10, 1.99)	0.009
Self-rated interpersonal relationship	Good	1839 (73.4)	435 (23.7)			1
	Fair	632 (25.2)	243 (38.4)			1.89 (1.55, 2.31)	< 0.001
	Poor	36 (1.4)	24 (66.7)	78.154	< 0.001	3.65 (1.72, 7.73)	0.001
Self-rated severity of local pandemic	Mild	2268 (90.5)	596 (26.3)			1
	Severe	163 (6.5)	68 (41.7)			1.75 (1.25, 2.45)	0.001
	Very severe	76 (3.0)	38 (50.0)	36.793	< 0.001	2.06 (1.25, 3.39)	0.004
Family members diagnosed with COVID-19	No	2411 (96.2)	651 (27.0)			1
	Yes	96 (3.8)	51 (53.1)	31.252	< 0.001	2.19 (1.40, 3.43)	0.001
Friends or classmates diagnosed with COVID-19	No	2202 (87.8)	586 (26.6)
	Yes	305 (12.2)	116 (38.0)	17.332	< 0.001

PTSSs: Posttraumatic stress symptoms; COVID-19: Coronavirus disease 2019; OR: Odds ratio.

Prevalence and correlates of PTSSs among university students

The prevalence of PTSSs in university students was 28.0% (702/2507). The χ² test results revealed a significantly higher prevalence of PTSSs among several subgroups than among their corresponding counterparts (P ≤ 0.044): Female students; students aged 19 years or older; postgraduates; students who either lived in or visited Wuhan before the outbreak and remained there when the survey was conducted; students living with others or alone; students with a low economic status; students with poor interpersonal relationships; students who rated the severity of the pandemic as high in their local area; students with family members diagnosed with COVID-19; and students with friends or classmates who were diagnosed with COVID-19 (Table 1).

Logistic regression analysis revealed seven significant correlates of PTSSs: Female sex (OR = 1.24, P = 0.024); being 19 years old or older (OR = 1.23, P = 0.023); living with others or alone (OR = 2.18, P = 0.006); having a low level of family economic status (OR = 1.48, P = 0.009); fair (OR = 1.89, P < 0.001) or poor (OR = 3.65, P = 0.001) interpersonal relationships; severe (OR = 1.75, P = 0.001) or very severe (OR = 2.06, P = 0.004) pandemic in one’s local area; and having family members diagnosed with COVID-19 (OR = 2.19, P = 0.001; Table 1).

Mental health help-seeking behaviors of university students with PTSSs

Among 702 students diagnosed with PTSSs, 23 (3.28%) reported seeking help from mental health specialists. Ten students sought help face-to-face, six students chose online consultation, and seven students opted for telephone-based services.

DISCUSSION

Findings from our study provide empirical data on the epidemiology of PTSSs and mental health help-seeking behaviors among university students during the COVID-19 pandemic. These insights can aid in the formulation of more effective response strategies for future pandemics. The main findings are the 28.0% prevalence of PTSSs and seven significant correlates: Being female, aged 19 years or older, living with others or alone, having a low level of familial economic status, having fair or poor interpersonal relationships, having a severe or very severe local pandemic, and having family members diagnosed with COVID-19. Additionally, we found an extremely low rate of mental health help-seeking behaviors (3.28%) among students presenting with PTSSs.

The 28.0% prevalence of PTSSs among Chinese university students reported in our study was higher than that reported in other studies. First, it exceeds the overall 25.0% prevalence reported in a meta-analysis of studies involving university students worldwide during the pandemic[10]. Additionally, it exceeds the rates reported in two other studies of Chinese university students during the COVID-19 pandemic (2.7% and 22%)[11,12]. Third, the prevalence reported herein exceeds the rates of 5.1% and 2% reported among Chinese university students in Macao and mainland China, who were impacted by the Typhoon Hato in 2017 and the 2009 influenza A virus (H1N1) influenza pandemic, respectively[17,18].

Generally, the likelihood of developing PTSSs is positively correlated with the severity of the stressful event. This severity is measured by factors such as intensity (i.e., property damage and loss of life), duration (i.e., events stretching over extended periods), frequency of exposure (i.e., repeated or chronic trauma), type of the event (i.e., combat exposure or sexual assault), and personal involvement (i.e., direct involvement as a victim)[19,20]. The COVID-19 pandemic was unprecedented – it affected people in numerous countries, required mass quarantine, pushed healthcare infrastructures to their brink, induced prolonged exposure with successive waves of outbreaks, and significantly disrupted daily routines. It also directly resulted in more than seven million deaths globally[21]. As a result of these extraordinary circumstances, we can expect a greater prevalence of PTSSs in university students during the COVID-19 pandemic than during the Typhoon Hato and H1N1 influenza pandemics.

The higher risk of PTSSs among Chinese university students compared with their global counterparts[10], may be attributed to the survey period in our study – i.e., the first wave of the COVID-19 pandemic. Owing to the lack of preparedness and information on how to control the spread of COVID-19 during the early stages of the pandemic, coupled with an overwhelmed healthcare system, high case fatality rates, and the sudden, severe restrictions imposed, including lockdowns, quarantine, and social distancing measures[22], Chinese individuals, including university students, were more likely to experience PTSSs.

The increased prevalence of PTSSs among our sample of Chinese university students, compared with their domestic counterparts[11,12], may be related to the notably high proportion of students who had resided or traveled in Wuhan before the outbreak (85%). This potential exposure history likely led others to fear potential COVID-19 transmission from these students upon their return to hometowns or other locations. This, in turn, could have resulted in discrimination and isolation, thus reducing their social support and amplifying feelings of loneliness[23]. As a result, the risk of experiencing PTSSs was likely elevated.

Consistent with the findings of positive associations between the severity of PTSSs and age and the greater risk of PTSSs in females than in males among university students during pandemics[11,18], we found a higher risk of PTSSs in students aged 19 years or older than in those aged 18 years or younger as well as a higher risk among females than among males. Two previous studies have indicated the potential buffering effect of family support on the relationship between trauma exposure and PTSSs or PTSD[24,25]. Therefore, we hypothesize that the higher risk of PTSSs among students living with nonfamily members or alone in our study could be due to their lower level of family support than those living with family members.

Our findings revealed a significant association between low family financial status and PTSSs among university students during the COVID-19 pandemic, mirroring the significant link between low family socioeconomic status and PTSSs observed in veterans and Ukrainian civilians exposed to war[26,27]. In general, good interpersonal relationships, offering emotional support, coping resources, and a sense of belonging and security, are crucial in mitigating the negative impact of traumatic events and reducing the risk of PTSSs and other mental health problems[28,29]. Accordingly, we anticipated and found a significant correlation between poor interpersonal relationships and PTSSs in our study.

As previously mentioned, the perceived severity of a pandemic is a strong predictor of PTSSs. Hence, we found that students who rated the local pandemic situation as severe or very severe had a higher risk for PTSSs. Furthermore, experiencing a family member's diagnosis with COVID-19 introduced extra stress within the pandemic context, increasing the potential risk of PTSSs among university students. This is substantiated by our findings highlighting the significant association between COVID-19 infection among family members and PTSSs.

Low rates of mental health help-seeking behaviors among individuals with mental health problems during the pandemic have been reported in several studies. For example, during the first wave of the COVID-19 pandemic in China, only 1.4% of the adult residents sought help from mental health workers[30]. Similarly, only 10.6% of older adults experiencing suicidal ideation and 2.7% of lonely residents sought help from mental health professionals[31,32]. Our study paralleled these findings, with only 3.28% of university students with PTSSs seeking mental health assistance. A variety of barriers could account for this extremely low level of mental health service utilization. The most prominent among these difficulties were the unavailability of routine mental health services and the difficulties in accessing online mental health services, especially during the sudden outbreak[33]. Interestingly, our findings revealed that more than half (13/23) of the mental health help-seeking behaviors were online services (online and telephone consultations). This indicates that, despite their limited provision, online services served as a major alternative for mental health assistance during the outbreak.

This study is subject to several limitations. First, owing to the impracticality of random sampling during the crisis period, our survey sample was recruited via snowball sampling. Caution is advised when generalizing the current findings to the whole population of Chinese university students, as well as students from other countries or cultural contexts. Second, we did not collect additional data on participants’ help-seeking behaviors from individuals other than mental health specialists, such as self-regulation and psychosocial support from friends or other medical professionals. Such data would contribute to a more accurate planning of mental health services. Third, cross-sectional studies cannot be used to draw causal inferences; therefore, longitudinal studies are needed to validate the potential causal relationships between the identified correlates and PTSSs in this study. Finally, we did not conduct psychiatric interviews to diagnose PTSD among students experiencing PTSSs. These data would be critical for the suitable planning of mental health services during the pandemic.

CONCLUSION

In summary, 28.0% of Chinese university students experienced PTSSs during the first wave of the COVID-19 pandemic; however, among those with PTSSs, only 3.28% sought help from mental health professionals. These data suggest a high risk of PTSSs among university students and a significant level of unmet mental health needs during the COVID-19 pandemic. In the event of future pandemics, university students with PTSSs should be considered a priority for mental health services, especially during the early stages of the pandemic. The delivery of mental health services online, whether via the internet, social media, telephone, or other contactless channels, holds promise for addressing these unmet needs. It is also crucial to periodically screen university students for PTSSs, provide psychosocial support to those at high risk, and, when necessary, refer them to psychiatric specialists for crisis intervention and treatment. Based on correlates identified herein, priority should be given to certain subpopulations of university students, specifically females, those aged 19 and over, those living with others or alone, those with a low socioeconomic status, those with poor interpersonal relationships, those experiencing severe local pandemics, and those with family members diagnosed with COVID-19.

ACKNOWLEDGEMENTS

The authors thank all the class teachers and university students involved in this study for their cooperation and support.