Effects of COVID-19 on Chinese overseas students' mental health: a multi-country cross-sectional analysis

Effects of COVID-19 on Chinese overseas students' mental health: a multi-country cross-sectional analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of COVID-19 on Chinese overseas students' mental health: a multi-country cross-sectional analysis Yingjun Nie, Yuanyan Ma, Ce Zhang, Yijia Gao, Jiahui Li, Xiangping Zheng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2314913/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: COVID-19 caused serious mental health burden for international students. However, only several international students obtained related mental health services. The topic of international students' mental health has the bigger jump among social and educational concerns during the pandemic. This study surveyed the effects of COVID-19 on the mental health of Chinese overseas students to provide essential reference for identifying mental health problems of Chinese overseas students, so that they can be targeted for timely crisis-oriented and tailoring mental health interventions during periods of public health emergencies. Methods: Descriptive statistics such as percentages, 95% CIs, means and standard deviations were calculated to reflect the demographic characteristics of the survey population. The Kolmogorov-Smirnov test was used to test the normality of continuous variables. The chi-square test was used to determine the statistical significance of the differences in participants' mental health status. Binary logistic regression was used to analyze the factors influencing on Chinese overseas students' mental health. The data were analyzed through quantitative and qualitative methods. Results: Chinese overseas students had several poor mental health status during the COVID-19 pandemic. Furthermore, the degree of mental health burden might differ between countries, but there were not notable differences in gender (p = 0.75) and in ant-pandemic duration. Some main factors caused an unhealthy psychological status, including epidemic severity in residence（67.94%, 95% CI：67.06% — 68.82%）, fear of being infected（64.54%, 95% CI：63.72% — 65.36%）, worries of academic performance（62. 43%, 95% C%I：60.64% — 64.22）, infection control policies of the host government（58. 09%, 95% CI：57. 16% — 59. 01%）, epidemic preventive measures of locals（56. 03%, 95% CI：55. 10% — 56. 96%）, obstruction of return trips（54.85%, 95% CI：53.91% — 55. 79%）, mutation of the epidemic virus（53. 75%, 95% CI：52. 71% — 54. 79%）. Conclusions: The main conclusion of this research is that Chinese overseas students experience mental health burdens during the COVID-19 pandemic and they need timely psychological services, positive support, and tailoring guidance to better manage mental health in this unusual situation. COVID-19 Chinese overseas students mental health effects multi-country cross-sectional analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Background COVID-19 has become a global public health emergency and is not effectively controlled in most countries now. Schools and Universities in various countries have implemented urgent strategies to prevent the spread of the pandemic and reduce the risk of infection for students, such as temporary closing school, postponing classes or switching to online classes, delaying examination. Student (especially international students) are facing unique challenges leading to serious burden of mental health during the pandemic, and 87 million students worldwide have been impacted (UNESCO 2020). It can clearly be seen that COVID-19 is not only an epidemiologic crisis but also a psychological crisis that leads to a spectrum of psychological burdens for students, and even likely induce unhealthy lifestyles including alcohol use and smoking for college students[ 1] . Due to the increase in globalization of the world, about 15.3 million Chinese students are studying abroad now（Chinese Ministry of Education, 2019）. Related research showed the Chinese international students who remained abroad would have higher risk and rates to experience mental health problems during the COVID-19 pandemic[ 2] , such as anxiety, frustration, and betrayal[ 3] , and even face discrimination and isolation in some countries due to being deemed as potential SARS-CoV-2 carriers[ 4] . During the pandemic, Song，B. (2020) found more than one-third of Chinese overseas students in their sample rated their psychological problem as moderate-to-severe, and nearly half of them reported moderate-to-severe[ 5] ; related research also showed that roughly half of Chinese overseas students have moderate psychological pressures in North America[6]. In the future, the COVID-19 epidemic may continue to affect Chinese overseas students' study and life. However, there is a severe lack of intervention strategies to improve Chinese overseas students' mental health in most countries, and only several Chinese overseas students obtained mental health services during the pandemic[ 6]. Their mental health is widely concerned and worried by the social, educational, and mental health fields, as well as their parents and teachers. Therefore, the study aimed to reveal the mental health status of Chinese overseas students who remained abroad during the COVID-19 pandemic through a large-sample survey. Investigations such as the present study are essential for assisting in identifying mental health problems of Chinese overseas students so that they can be targeted for timely crisis-oriented psychological services and tailoring guidance to better manage mental health in this unusual situation. Methods Study Population Chinese overseas students are mainly distributed in North America, Western Europe, Africa, Oceania (Chinese Ministry of Education, 2019). So the study recruited Chinese overseas students living in 37 foreign countries (Table 1 ) across Asia, North America, Oceania, Europe, Africa (Table 2 ) who were not infected with COVID-19 during the pandemic. The study sample include undergraduates, postgraduates, Ph.D. students, and visiting scholars (Table 3 ). The participants were divided into the following five groups based on their age: 18–24 years old, 25–29 years old, 30–39 years old, 40–49 years old (Table 4 ). Table 1 Distribution of respondents in counties Countries Count Countries Count Countries Count Canada 616 Estonia 52 1022 America 1279 Netherlands 170 India 32 New Zealand 872 Finland 256 Uzbekistan 19 Australia 1321 Bosnia and Herzegovina 132 Turkey 21 Cote D'Ivoire 52 Russia 879 Thailand 20 Lesotho 36 Italy 321 Malaysia 16 Tanzania 26 Czech Republic 89 Kazakhstan 49 Sudan 39 Albania 65 Korea 542 Mozambique 26 Germany 562 Georgia 32 Togo 93 Hungary 102 Philippines 12 Greece 21 France 467 Japan 598 Cyprus 16 Poland 369 Singapor 554 Montenegro 10 Table 2 Distribution of respondents in states states Frequency(%) Male(%) Female(%) Total(%) Asia 1008(53.19%) 887(46.81%) 1895(17.47) North America 1141(52.03%) 1052(47.97%) 2193(20.22%) Oceania 967(49.51%) 986(50.49%) 1953(18.01%) Europe 2350(51.84%) 2183(48.16%) 4533(41.79%) Africa 180(66.18%) 92(33.82%) 272(2.51%) Table 3 Education level of the respondents Education level Frequency Percent Undergraduate 5225 48.17% Postgraduate 2174 20.04% PhD student 1885 17.38% Visiting scholar 1562 14.40% Table 4 Age of the respondents Age (years) Frequency(%) Male(%) Female(%) Total(%) 18–24 2213(55.41%) 1781(44.59%) 3994(36.82%) 25–29 1652(53.53%) 1434(46.47%) 3086(28.45%) 30–39 1349(48.58%) 1428(51.42%) 2777(25.61%) 40–49 432(43.68%) 557(56.32%) 989(9.12%) Survey Methodology A multi-country cross-sectional study was conducted on Chinese overseas students from December 1, 2020 to February 28, 2021, using online-based survey questionnaires. All participants were asked to respond to a questionnaire about their mental health data and demographic information such as gender, age, education level, geographic location, school or college, and duration of anti-epidemic. The study used a snowball sampling strategy to recruit questionnaire respondents, and a questionnaire was distributed via the WeChat with high usage rate of all Chinese overseas students. In addition, some organizers of Chinese student societies in various college of oversea countries participated in questionnaire distribution via their social platforms. Written informed consent was obtained from all students who participated in the study. All participants were asked to recall their mental health during the pandemic within the questionnaire. Mental health was assessed using the 50-item Self-evaluation Table for Chinese overseas students' mental health during the COVID-19 pandemic, which was compiled based on the Symptom Checklist 90 (SCL-90). The Cronbach' s alpha coefficient was 0. 9, the test-retest reliability was above 0. 7, and the internal consistency was 0. 86. All participants were asked to recall the mainly influences on their mental health, as well as the mainly changes in anxiety, fear, depression, somatization, and stress during the pandemic. Each item was rated on a five-point Likert scale, ranging from 1 to 5, to assess the extent to which the participants felt that each mental health item pertained to them during the COVID-19 pandemic. The higher the total score indicated more serious the individual's psychological problems and the lower his or her mental health level. Statistical Analysis Descriptive statistics such as percentages, 95% CIs, means and standard deviations were calculated to reflect the demographic characteristics of the survey population. The Kolmogorov-Smirnov test was used to test the normality of continuous variables. The chi-square test was used to determine the statistical significance of the differences in participants' mental health status. Binary logistic regression was used to analyze the factors influencing on Chinese overseas students' mental health during the COVID-19 pandemic. The data were analyzed through quantitative and qualitative methods. Results Survey Respondents During the COVID-19 pandemic, a total of 10,846 participants were included in the final analysis, including 5200 female students and 5646 male; these participants were from 138 colleges in 37 countries (Table 1 ), including 1895 Chinese overseas students in Asia, 2193 in North America, 1953 in Oceania, 4533 in Europe, 272 in Africa (Table 2 ) ; and including 5225 undergraduates, 2174 postgraduates, 1885 PhD students, and 1562 visiting scholars (Table 3 ) . The impact of COVID-19 on mental health The mental health of Chinese overseas students was negatively affected to varying degrees (Table 5 ) during the COVID-19 pandemic, with somatization (2.901, 95% CI 2.883 — 2.918), anxiety (2.836, 95% CI 2.819 — 2.854), depression (2.412, 95% CI 2.394 — 2.430), stress (2.706, 95% CI 2.687 — 2.725), and fear (2.208, 95% CI 2.192 — 2. 224) . Table 5 Mental health status of Chinese overseas students during the COVID-19 pandemic M ± SD Variance 95% CI(LL) 95% CI(UL) CV Somatization 2.901 ± 0.933 0.871 2.883 2.918 32.161% Anxiety 2.836 ± 0.934 0.873 2.819 2.854 32.933% Depression 2.412 ± 0.958 0.918 2.394 2.430 39.718% Stress 2.706 ± 1.022 1.043 2.687 2.725 37.768% Fear 2.208 ± 0.861 0.741 2.192 2.224 38.995% M, mean; SD, standard deviation. Mental health Status among countries According the severity of COVID-19 impact for Chinese overseas students (Fig. 1 ) in 37 countries, we observed that the mental health burden of Chinese overseas students were different among countries during the COVID-19 pandemic, indicating the effects of COVID-19 on Chinese overseas students' mental health might varies by countries. The relationship between mental health and the gender The Pearson correlation coefficient was used to indicate the consistency of psychological impact severity between male and female students. The analysis showed that there wasn't magnificent difference between these two variables (p > 0. 05), indicating no significant difference in gender about the impact of COVID-19 on Chinese overseas students' mental health (Fig. 2 ). The relationship between mental health and the duration of ant-pandemic The Pearson correlation coefficient was used to indicate the degree of the correlation between mental health burden and duration of ant-pandemic. The analysis showed that there wasn't magnificently correlation between these two variables (p > 0.05), indicating the Chinese overseas students' psychological problems did not get worse with the increase in the duration of ant-pandemic (Fig. 3 ). Factors affecting mental health We observed multiple factors that could cause Chinese overseas students' mental health burden during the COVID-19 pandemic (Fig. 4 ), with the main factors including epidemic severity in residence(67.94%, 95% CI: 67.06% — 68.82%), fear of being infected༈64.54%, 95% CI༚63.72% — 65.36%༉, worries of academic performance༈62. 43%, 95% C%I༚60.64% — 64.22༉, infection control policies of the host government༈58. 09%, 95% CI༚57. 16% — 59. 01%༉, epidemic preventive measures of locals༈56. 03%, 95% CI༚55. 10% — 56. 96%༉, obstruction of return trips༈54.85%, 95% CI༚53.91% — 55. 79%༉, mutation of the epidemic virus༈53. 75%, 95% CI༚52. 71% — 54. 79%༉. Discussion Analysis of the impact of COVID-19 on mental health Our study showed that Chinese overseas students living abroad experienced adverse psychological symptoms during the COVID-19 pandemic, such as somatization, anxiety, depression, stress, and fear. An overwhelming body of evidence also has demonstrated oversea college students experience higher rates of mental health disorders than adults with an average age[ 7] . Overall, prolonged school closure, cancellation of classes, new modes of instruction, daily lifestyle changes and much more, might accentuates or creates new stressors for Chinese overseas students' mental health who lived aboard during the pandemic[ 8] . On one hand, intentional students can build a good sense of belongingness in college[ 9] . However, many college students have to cease their research projects, face academic delays[ 10] , and even subsequent displacement from their on-campus housing[ 11] during the pandemic. Those sudden and radical changes likely increase their fear and worry about academic performance and adversely effect on their sense of college belongingness. Reduction, destruction or deficits in belongingness might be linked with poorer levels of psychological adjustment for the pandemic[9]. So lower belongingness might be a potential mechanism explaining how COVID-19 is related to mental health for Chinese overseas students[9]. On the other hand, Chinese overseas students might face discrimination, alienation and isolation in some countries due to being deemed as potential SARS-CoV-2 carriers[4]. Research reported that since the WHO declared the COVID-19 outbreak in March 2020, stigma and discrimination against Chinese has been on the rise[ 12] , which may lead to stress, anxiety, and fear for Chinese overseas students. Moreover, students with a higher score of fear are more likely to have unhealthy lifestyles, such as drinking alcohol and smoking, even reported hopelessness and suicidal ideation[9], which could cause a vicious circle[ 13] . However, only several Chinese oversea students attained mental health services[ 14] . Thus, strategic mental health interventions are suggested to protect Chinese overseas students' health and well-being. Analysis of different mental health burdens among countries We found that differences might exist between countries in the mental health status of Chinese overseas students during the COVID-19 pandemic. Some research also showed the differences in the global prevalence of anxiety among students. For example, college students in Poland had higher scores in psychological distress compared to students from the UK and Germany[7]. The inconsistency of the psychological burden might be related to the differences of cross-culture[ 15] and social system[ 16] , as well as the development of the pandemic among countries. On the one hand, the differences in culture and norms might lead to inconsistent and even conflicting views on COVID-19 and various epidemic-prevention measures between Chinese overseas students and the locals. Firstly, Chinese is a collective society. Research have reported that Chinese people were more concerned about health and less concern for leisure during the COVID-19 pandemic outbreak[ 17] , and then the epidemic was effectively controlled within three months in China. Whereas in individualistic countries, it may need be fully considered about ant-pandemic policies in order to minimize the risk of infection spread while maximize the personal freedom. The uncontrollability of COVID-19 likely arouse international students worry too much about their health[7], which may be more dangerous factors causing Chinese overseas students' psychological burdens. Secondly, research showed that due to the cultural differences, the high levels of coronavirus anxiety may be associated with maladaptive religious coping for people living abroad[9]. This phenomenon may be generalisable to all international students studying abroad. Finally, the response and changes of population to the COVID-19 might inconsistent among countries. For example, an overwhelming body of evidence has demonstrated that adequate PA could improve mental health well-being during the COVID-19, but the changes of the PA intensity may be different in counties. Relate research have showed that the intensity of PA is significantly decreased among people in Asia, America, Africa, and Europe, whereas a general increase in Belgium and Canada during the COVID-19 outbreak[ 18] . This inconsistent changes of PA likely have the opposite effects on mental health of intentional students. The other explanation of the difference may be related to the stage of COVID-19 pandemic development in host countries. It is known that according to the development of COVID-19 pandemic, a series of urgent strategies have been implemented timely by many governments, which might play a key role in controlling the spread of the epidemic, reducing infection rate, and relieving stress, fear, and anxiety during the pandemic. However, countries differ politically and economically, the strategies adopted and the difficulties faced were vary within each country, as well as the pandemic severity. For example, the UK adopted a policy of herd immunity, students were required to move out on-campus housing in some college in the USA, some countries lacked sufficient epidemic-prevention supplies. Consequently, the impact of COVID-19 on Chinese overseas students' mental health in each country is different. On the whole, when being in threatening situation, international students' mental health could be seriously compromised[ 19]. Thus, positive interventions and preventive strategies in the short-term likely need to be tailored for Chinese overseas students' mental health within different countries. The relationship between mental health and the gender Research suggests that men and women have different experiences when faced with a fearful object[ 20] . Moreover, female student might suffer a greater psychological impact than males during the COVID-19[ 21][22] . For example, research reported that both anxiety and depression among Ukrainian students are related to gender during the COVID-19 pandemic[22], as well as among college freshmen in China[ 23] . However, we found that females students didn't scored significantly higher in psychological health problems than males among Chinese overseas students during the COVID-19. Maybe because if studying in same area, there was the basic consistency about their living situation and facing difficulties during the pandemic. Some research also did not find gender differences in the mental health among college students during the COVID-19 outbreak[ 24] , which is consistent with our findings. Therefore, more research is necessary to explain such inconsistent findings. The relationship between mental health and the duration of ant-pandemic Research has showed that time spent focusing on COVID-19 may be potential risk factors for the psychological problems[ 25] . Nevertheless, we found that the longer the duration of ant-pandemic might not lead to more serious the Chinese overseas students' psychological burden. Due to the sudden and radical lifestyle changes, studying in an uncertain and threatening situation, infection fears, inadequate supplies, and much more, the level of students' psychological problems may be the highest at the beginning of the COVID-19 outbreak[7] or at spikes occur in COVID-19 cases and deaths. Over time, Chinese overseas students' psychological burden likely be gradually eased or even slightly reduced. The main reason might be that Chinese overseas students have gradually acquired more competence in dealing with the COVID-19 and higher positive psychological adjustment for the changed daily-life. Firstly, they might gradually have more reliable information and knowledge about COVID-19, used to epidemic prevention behavior of people around, and mastered more basic measures of avoiding themself exposure to the virus and being infected, which were important stressors for international students during the pandemic[ 26] . Secondly, Chinese education institutions, social media groups, and families provided online support services to alleviate psychological problems of Chinese overseas students living abroad during the COVID-19. For example, the Chinese government provided timely special planes back to China, epidemic prevention equipment, remote counselling for them during the epidemic. Protective support from China can play a key role in controlling stress and anxiety for Chinese overseas students[ 27] . Finally, as limitations are eased, and some campuses reopen gradually, worried about their learning process might be alleviated, and finding more support from student societies (especially Chinese overseas student societies) and college may also reduce psychological burden of Chinese overseas students. However, it is unknown how long this negatively affected for Chinese overseas students' psychological problems will last and what new impact will be on their mental health. Analysis of factors affecting mental health We observed that multiple stressors might contributed to the increased levels of Chinese overseas students' mental health burden during the pandemic. Firstly, epidemic severity might be the most important factor causing negative psychological impacts. COVID-19 has undergone several mutations. Various factors could lead to more serious psychological symptoms of Chinese overseas students living abroad, including the most possible of being asymptomatic carriers for youth[ 28] , the growing numbers of confirmed COVID-19 cases and deaths, the increasing population being infected after vaccination, and some Covid-19 recovered persons being re-infected. The worry of being infected positively correlates with depression, anxiety and virus aversion among Chinese overseas students. Secondly, the worry about academic performance might positively correlates with Chinese overseas student' psychological problem during the COVID-19, and mental health issues also are the leading impediment to academic success[ 29] , which could cause a vicious circle. Similar problems occurred worldwide. For example, prolonged school closure and class postponed might have negative effects on the contact with lecturers and the support from classmates, then lead to increased fear of passing their examinations[ 30] . In addition, disruptions of their research projects and internships during school closure might delay their graduation and undermine their competitiveness in the job market, which could cause negative effects on Chinese overseas students' mental health during the COVID-19. Furthermore, many colleges switched to online classes during the COVID-19 pandemic, but some students were unfamiliar with the new online learning methodology. The virtual classes were stressful for them to adapt to web-based teaching platforms and technology rapidly[ 31] . These procedures for passing course exams and presenting their work via online platforms might also be stressful for them[ 32] . Moreover, the significant increase in screen time mainly being spent on computer and internet usage may be an additional source of psychological symptoms[ 33] . Thirdly, epidemic prevention environment of the host government, including infection control policies and preventive measures, are generally different among counties, which may be additional challenges to assess the impact of COVIN-19 on Chinese overseas students' psychological well-being. In fact, COVID-19 has caused a massive burden on governments and individuals in the word. Governments in various countries have implemented urgent national containment policies to prevent the spread of the pandemic. However, the spread of the pandemic is not effectively controlled, and the number of COVID-19 cases and deaths is increasing significantly in some countries[ 34] . Related studies have reported that Chinese college students tend to experience more anxiety if someone they know is tested positive for COVID[ 35] . In addition, populations differ on many dimensions between and within countries, such as socioeconomic status, views about COVID-19, and religious beliefs, which all may lead to different preventive measures between Chinese overseas students and locals, such as whether to wear a mask outdoor and whether to get vaccinated. That is to say if Chinese overseas students cannot accept or adjust to epidemic prevention environment of the host government, their level of anxiety likely increase. Finally, obstruction of return trips might make some Chinese overseas students more prone to psychopathology. Because some counties closed or reduced international air at the beginning of the COVID-19 outbreak or at spikes occur in COVID-19 cases, it was difficult for many Chinese overseas students to buy air tickets to China on time. Some students even have concerns about infection, COVID-19 tests, and fears of being quarantine on the way back to China. Moreover, some students might also struggle with the expensive cost of returning to China[ 36] . Implications and Limitations of the Study Our study has several limitations. Firstly, due to the large Chinese overseas students living aboard during the pandemic, Chinese overseas students in different countries also varies. The questionnaires were distributed through WeChat and Chinese overseas student social platforms to ensure that students from different countries participated and to maximize the diversity and representativeness of the students participating in the survey. However, these participants were from 37countries, there was certain unevenness and incompleteness in the regional distribution. Secondly, the study solely relies on online self-reported questionnaires. Although we chose the WHO-approved the SCL-90, which has high reliability and validity, recall and reporting bias cannot be excluded. Finally, due to time constraints during the data collection period, we did not collect data about the epidemic severity including COVID-19 infection rate and deaths, infection control policies, and medical readiness of different countries, these background information can also explain the psychological problems of Chinese overseas students. Conclusions During the COVID-19 pandemic, Chinese overseas students showed mental health burdens, such as anxiety, depression, stress, fear and somatization. The degree of mental health burden may be differ between countries, but no significantly different in gender and in ant-pandemic duration. The mainly identified factors which severely affected mental health are (1) epidemic severity in residence, (2) fear of being infected, (3) worries of academic performance, (4) infection control policies of the host government, (5) epidemic preventive measures of locals, (6) obstruction of return trips, and (7) mutation of the epidemic virus. Declarations Ethics approval and consent to participate The study was approved by the Research Ethics Committee of Wuhan Sports University, and voluntary participation was given informed consent and not compensated. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due the risk of identifying participants, but extracts are available from the corresponding author on reasonable request. Competing interests All authors made relevant contributions to and approved the final manuscript.The authors report no conflicts of interest in this work. Funding This work was supported by grants from the young and middle-aged scientific research team of Wuhan Sports University. Grant Agreement No. 21KT13. Authors' contributions Yingjun Nie and Xiangping Zheng: conceptualization. Yingjun Nie, Yuanyan Ma, and Xiangping Zheng: methodology and writing—original draft preparation. Ce Zhang, Jiahui Li, and Yijia Gao: formal analysis.Yingjun Nie: funding acquisition. Yingjun Nie, Jiahui Li, Ce Zhang, Yijia Gao, and Yuanyan Ma: investigation. Yingjun Nie, Xiangping Zheng, and Yuanyan Ma: writing—review and editing. Yijia Gao: project administration. Yingjun Nie and Yuanyan Ma share first authorship. Yingjun Nie and Xiangping Zheng share Corresponding authorship. Acknowledgments We would like to acknowledge the support of Wuhan Sports University.We also would like to express our sincere thanks to the editor and reviewers for their helpful comments. References Nguyen HT, Do BN, Pham KM, Kim GB, Dam HTB, Nguyen TT, et al.Fear of COVID-19 Scale-Associations of Its Scores with Health Literacy and Health-Related Behaviors among Medical Students. Int J Environ Res Public Health. 2020 Jun 11;17(11):4164 [FREE Full text][doi: 10.3390/ijerph17114164]. [Medline: 32545240] Zhao Y. 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Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2314913","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":155612802,"identity":"e74cf2c6-09bb-4614-9216-005a91adce14","order_by":0,"name":"Yingjun Nie","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYBACfvbmA4f/VNTI8ROtRbLnWOIDnjPHjCUbiNVicCPH2IC3jTlxwwGirbmRYyYh2caWuPl48gaGHxXbCOtg7HlWJmFwTsZ425lnBYw9Z24T1sLMnrxNIqGMTXbbjRwDZsY2IrSwMSSYSRxgY2bcPINYLTwcKcaGDW3MihskiNUiwXMs8TEDMJAlgH45SJRf7I8Do5IBFJXtyRsf/KggQgsSSDA4QJJ6sBZSdYyCUTAKRsEIAQCvKkCDo1HpZgAAAABJRU5ErkJggg==","orcid":"","institution":"Wuhan Sports University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yingjun","middleName":"","lastName":"Nie","suffix":""},{"id":155612803,"identity":"3cf2f6ce-f972-4a60-b844-e2c024f545d8","order_by":1,"name":"Yuanyan Ma","email":"","orcid":"","institution":"Huazhong Normal University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuanyan","middleName":"","lastName":"Ma","suffix":""},{"id":155612804,"identity":"7780bc33-4a6e-406b-8ec8-e73859e7f7bb","order_by":2,"name":"Ce Zhang","email":"","orcid":"","institution":"Wuhan Sports University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ce","middleName":"","lastName":"Zhang","suffix":""},{"id":155612805,"identity":"512a81a0-352a-42a9-b177-6b1d0a489bf7","order_by":3,"name":"Yijia Gao","email":"","orcid":"","institution":"Wuhan Sports University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yijia","middleName":"","lastName":"Gao","suffix":""},{"id":155612806,"identity":"a22de6e3-8fcd-4d0d-8155-e30c7f0edcd7","order_by":4,"name":"Jiahui Li","email":"","orcid":"","institution":"Wuhan Sports University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jiahui","middleName":"","lastName":"Li","suffix":""},{"id":155612807,"identity":"65ac377a-08f7-4156-937a-a53c30626e15","order_by":5,"name":"Xiangping Zheng","email":"","orcid":"","institution":"Wuhan Sports University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiangping","middleName":"","lastName":"Zheng","suffix":""}],"badges":[],"createdAt":"2022-11-26 09:59:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2314913/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2314913/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":29730151,"identity":"d77320e9-bbad-4774-a7e0-687b9a399398","added_by":"auto","created_at":"2022-11-30 16:18:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":144155,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMental health burden in different country\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2314913/v1/19270c7e419c1de24818620f.png"},{"id":29730538,"identity":"904bc41f-fd1f-4b74-b320-fc64e6f4d539","added_by":"auto","created_at":"2022-11-30 16:26:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":21277,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMental health burden of male and female\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2314913/v1/6fd6bde68772dc373ec2622f.png"},{"id":29730149,"identity":"233e9d49-60c5-439f-9aee-f7c9c0ad3014","added_by":"auto","created_at":"2022-11-30 16:18:40","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":25242,"visible":true,"origin":"","legend":"\u003cp\u003eMental health burden at different duration of ant-pandemic\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2314913/v1/72f17ac6adc156e7d6d304a0.png"},{"id":29730148,"identity":"cfd58592-a8e9-4795-b199-856ba41a1a16","added_by":"auto","created_at":"2022-11-30 16:18:40","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":39195,"visible":true,"origin":"","legend":"\u003cp\u003eFactors affecting mental health during the COVID-19 pandemic\u003c/p\u003e\n\u003cp\u003eIK = Insufficient knowledge and understanding of COVID-19; PH = Prolonged home quarantine; RO = Restrictions on social interaction; PO = Spread of large amounts of negative information about COVID-19; LO = Lack of epidemic prevention equipment; MO = Mutation of the epidemic virus; OO = Obstruction of return trips; EP = Epidemic preventive measures of locals; IC = Infection control policies of the host government; WO = Worries of academic performance; FO = Fear of being infected; ES = Epidemic severity in residence.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-2314913/v1/90bbfb150d3b8bff41746f3c.png"},{"id":29857774,"identity":"58bcd6dd-5c24-448e-bc9d-314171fa05a1","added_by":"auto","created_at":"2022-12-03 14:14:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":663916,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2314913/v1/82d1e5dd-0b4b-452d-8331-250b1d5dd022.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of COVID-19 on Chinese overseas students' mental health: a multi-country cross-sectional analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eCOVID-19 has become a global public health emergency and is not effectively controlled in most countries now. Schools and Universities in various countries have implemented urgent strategies to prevent the spread of the pandemic and reduce the risk of infection for students, such as temporary closing school, postponing classes or switching to online classes, delaying examination. Student (especially international students) are facing unique challenges leading to serious burden of mental health during the pandemic, and 87 million students worldwide have been impacted (UNESCO 2020). It can clearly be seen that COVID-19 is not only an epidemiologic crisis but also a psychological crisis\u0026nbsp;that leads to a spectrum of psychological burdens for students, and even likely induce unhealthy lifestyles including alcohol use and smoking for college students[\u003csup\u003e1]\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDue to the increase in globalization of the world, about 15.3 million Chinese students are studying abroad now（Chinese Ministry of Education, 2019）. Related research showed the Chinese international students who remained abroad would have higher risk and rates to experience mental health problems during the COVID-19 pandemic[\u003csup\u003e2]\u003c/sup\u003e, such as anxiety, frustration, and betrayal[\u003csup\u003e3]\u003c/sup\u003e, and even face discrimination and isolation in some countries due to being deemed as potential SARS-CoV-2 carriers[\u003csup\u003e4]\u003c/sup\u003e. During the pandemic, Song，B. (2020) found more than one-third of Chinese overseas students in their sample rated their psychological problem as moderate-to-severe, and nearly half of them reported moderate-to-severe[\u003csup\u003e5]\u003c/sup\u003e; related research also showed that roughly half of Chinese overseas students have moderate psychological pressures in North America[6]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the future, the COVID-19 epidemic may continue to affect Chinese overseas students' study and life. However, there is a severe lack of intervention strategies to improve Chinese overseas students' mental health in most countries, and only several Chinese overseas students obtained mental health services during the pandemic[\u003csup\u003e6].\u003c/sup\u003e Their mental health is widely concerned and worried by the social, educational, and mental health fields, as well as their parents and teachers. Therefore, the study aimed to reveal the mental health status of Chinese overseas students who remained abroad during the COVID-19 pandemic through a large-sample survey. Investigations such as the present study are essential for assisting in identifying mental health problems of Chinese overseas students so that they can be targeted for timely crisis-oriented psychological services and tailoring guidance to better manage mental health in this unusual situation. \u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv class=\"Section2\" id=\"Sec3\"\u003e\n \u003ch2\u003eStudy Population\u003c/h2\u003e\n \u003cp\u003eChinese overseas students are mainly distributed in North America, Western Europe, Africa, Oceania (Chinese Ministry of Education, 2019). So the study recruited Chinese overseas students living in 37 foreign countries (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) across Asia, North America, Oceania, Europe, Africa (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) who were not infected with COVID-19 during the pandemic. The study sample include undergraduates, postgraduates, Ph.D. students, and visiting scholars (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). The participants were divided into the following five groups based on their age: 18\u0026ndash;24 years old, 25\u0026ndash;29 years old, 30\u0026ndash;39 years old, 40\u0026ndash;49 years old (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDistribution of respondents in counties\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCountries\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCount\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCountries\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCount\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCountries\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCount\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCanada\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e616\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEstonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmerica\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1279\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNetherlands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNew Zealand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e872\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUzbekistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1321\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBosnia and Herzegovina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTurkey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCote D\u0026apos;Ivoire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRussia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e879\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThailand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLesotho\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eItaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e321\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalaysia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTanzania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCzech Republic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKazakhstan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSudan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlbania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKorea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e542\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMozambique\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGermany\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e562\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGeorgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTogo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHungary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhilippines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGreece\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e467\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJapan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e598\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCyprus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePoland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e369\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingapor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e554\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMontenegro\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDistribution of respondents in states\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003estates\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eFrequency(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMale(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFemale(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1008(53.19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e887(46.81%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1895(17.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorth America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1141(52.03%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1052(47.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2193(20.22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOceania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e967(49.51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e986(50.49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1953(18.01%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2350(51.84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2183(48.16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4533(41.79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfrica\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e180(66.18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e92(33.82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e272(2.51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eEducation level of the respondents\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercent\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5225\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.04%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhD student\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1885\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17.38%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVisiting scholar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1562\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.40%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab4\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAge of the respondents\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eFrequency(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMale(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFemale(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u0026ndash;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2213(55.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1781(44.59%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3994(36.82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u0026ndash;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1652(53.53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1434(46.47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3086(28.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1349(48.58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1428(51.42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2777(25.61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u0026ndash;49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e432(43.68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e557(56.32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e989(9.12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec4\"\u003e\n \u003ch2\u003eSurvey Methodology\u003c/h2\u003e\n \u003cp\u003eA multi-country cross-sectional study was conducted on Chinese overseas students from December 1, 2020 to February 28, 2021, using online-based survey questionnaires. All participants were asked to respond to a questionnaire about their mental health data and demographic information such as gender, age, education level, geographic location, school or college, and duration of anti-epidemic. The study used a snowball sampling strategy to recruit questionnaire respondents, and a questionnaire was distributed via the WeChat with high usage rate of all Chinese overseas students. In addition, some organizers of Chinese student societies in various college of oversea countries participated in questionnaire distribution via their social platforms. Written informed consent was obtained from all students who participated in the study. All participants were asked to recall their mental health during the pandemic within the questionnaire.\u003c/p\u003e\n \u003cp\u003eMental health was assessed using the 50-item Self-evaluation Table for Chinese overseas students\u0026apos; mental health during the COVID-19 pandemic, which was compiled based on the Symptom Checklist 90 (SCL-90). The Cronbach\u0026apos; s alpha coefficient was 0. 9, the test-retest reliability was above 0. 7, and the internal consistency was 0. 86. All participants were asked to recall the mainly influences on their mental health, as well as the mainly changes in anxiety, fear, depression, somatization, and stress during the pandemic. Each item was rated on a five-point Likert scale, ranging from 1 to 5, to assess the extent to which the participants felt that each mental health item pertained to them during the COVID-19 pandemic. The higher the total score indicated more serious the individual\u0026apos;s psychological problems and the lower his or her mental health level.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec5\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eDescriptive statistics such as percentages, 95% CIs, means and standard deviations were calculated to reflect the demographic characteristics of the survey population. The Kolmogorov-Smirnov test was used to test the normality of continuous variables. The chi-square test was used to determine the statistical significance of the differences in participants\u0026apos; mental health status. Binary logistic regression was used to analyze the factors influencing on Chinese overseas students\u0026apos; mental health during the COVID-19 pandemic. The data were analyzed through quantitative and qualitative methods.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv class=\"Section2\" id=\"Sec7\"\u003e\n \u003ch2\u003eSurvey Respondents\u003c/h2\u003e\n \u003cp\u003eDuring the COVID-19 pandemic, a total of 10,846 participants were included in the final analysis, including 5200 female students and 5646 male; these participants were from 138 colleges in 37 countries (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e), including 1895 Chinese overseas students in Asia, 2193 in North America, 1953 in Oceania, 4533 in Europe, 272 in Africa (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) ; and including 5225 undergraduates, 2174 postgraduates, 1885 PhD students, and 1562 visiting scholars (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) .\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003ch2\u003eThe impact of COVID-19 on mental health\u003c/h2\u003e\n \u003cp\u003eThe mental health of Chinese overseas students was negatively affected to varying degrees (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e) during the COVID-19 pandemic, with somatization (2.901, 95% CI 2.883 \u0026mdash; 2.918), anxiety (2.836, 95% CI 2.819 \u0026mdash; 2.854), depression (2.412, 95% CI 2.394 \u0026mdash; 2.430), stress (2.706, 95% CI 2.687 \u0026mdash; 2.725), and fear (2.208, 95% CI 2.192 \u0026mdash; 2. 224) .\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab5\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMental health status of Chinese overseas students during the COVID-19 pandemic\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariance\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI(LL)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI(UL)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCV\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSomatization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.901\u0026thinsp;\u0026plusmn;\u0026thinsp;0.933\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.871\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.883\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.918\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32.161%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.836\u0026thinsp;\u0026plusmn;\u0026thinsp;0.934\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.873\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.819\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.854\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32.933%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.412\u0026thinsp;\u0026plusmn;\u0026thinsp;0.958\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.918\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.394\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.430\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39.718%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.706\u0026thinsp;\u0026plusmn;\u0026thinsp;1.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.687\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.725\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37.768%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.208\u0026thinsp;\u0026plusmn;\u0026thinsp;0.861\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.741\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.192\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.224\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38.995%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eM, mean; SD, standard deviation.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec9\"\u003e\n \u003ch2\u003eMental health Status among countries\u003c/h2\u003e\n \u003cp\u003eAccording the severity of COVID-19 impact for Chinese overseas students (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) in 37 countries, we observed that the mental health burden of Chinese overseas students were different among countries during the COVID-19 pandemic, indicating the effects of COVID-19 on Chinese overseas students\u0026apos; mental health might varies by countries.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec10\"\u003e\n \u003ch2\u003eThe relationship between mental health and the gender\u003c/h2\u003e\n \u003cp\u003eThe Pearson correlation coefficient was used to indicate the consistency of psychological impact severity between male and female students. The analysis showed that there wasn\u0026apos;t magnificent difference between these two variables (p\u0026thinsp;\u0026gt;\u0026thinsp;0. 05), indicating no significant difference in gender about the impact of COVID-19 on Chinese overseas students\u0026apos; mental health (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec11\"\u003e\n \u003ch2\u003eThe relationship between mental health and the duration of ant-pandemic\u003c/h2\u003e\n \u003cp\u003eThe Pearson correlation coefficient was used to indicate the degree of the correlation between mental health burden and duration of ant-pandemic. The analysis showed that there wasn\u0026apos;t magnificently correlation between these two variables (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating the Chinese overseas students\u0026apos; psychological problems did not get worse with the increase in the duration of ant-pandemic (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec12\"\u003e\n \u003ch2\u003eFactors affecting mental health\u003c/h2\u003e\n \u003cp\u003eWe observed multiple factors that could cause Chinese overseas students\u0026apos; mental health burden during the COVID-19 pandemic (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e), with the main factors including epidemic severity in residence(67.94%, 95% CI: 67.06% \u0026mdash; 68.82%), fear of being infected༈64.54%, 95% CI༚63.72% \u0026mdash; 65.36%༉, worries of academic performance༈62. 43%, 95% C%I༚60.64% \u0026mdash; 64.22༉, infection control policies of the host government༈58. 09%, 95% CI༚57. 16% \u0026mdash; 59. 01%༉, epidemic preventive measures of locals༈56. 03%, 95% CI༚55. 10% \u0026mdash; 56. 96%༉, obstruction of return trips༈54.85%, 95% CI༚53.91% \u0026mdash; 55. 79%༉, mutation of the epidemic virus༈53. 75%, 95% CI༚52. 71% \u0026mdash; 54. 79%༉.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eAnalysis of the impact of COVID-19 on mental health\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study showed that Chinese overseas students living abroad\u0026nbsp;experienced adverse psychological symptoms during the COVID-19 pandemic, such as somatization, anxiety, depression, stress, and fear. An overwhelming body of evidence also has demonstrated oversea college students experience higher rates of mental health disorders than adults with an average age[\u003csup\u003e7]\u003c/sup\u003e. Overall, prolonged school closure, cancellation of classes, new modes of instruction, daily lifestyle changes and much more, might accentuates or creates new stressors for Chinese overseas students' mental health who lived aboard during the pandemic[\u003csup\u003e8]\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn one hand, intentional students can build a good sense of belongingness in college[\u003csup\u003e9]\u003c/sup\u003e. However, many college students have to cease their research projects, face academic delays[\u003csup\u003e10]\u003c/sup\u003e, and even subsequent displacement from their on-campus housing[\u003csup\u003e11]\u003c/sup\u003eduring the pandemic. Those sudden and radical changes likely increase their fear and worry about academic performance and adversely effect on their sense of college belongingness. Reduction, destruction or deficits in belongingness might be linked with poorer levels of psychological adjustment for the pandemic[9]. So lower belongingness might be a potential mechanism explaining how COVID-19 is related to mental health for Chinese overseas students[9].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the other hand, Chinese overseas students might face discrimination, alienation and isolation in some countries due to being deemed as potential SARS-CoV-2 carriers[4].\u0026nbsp;Research reported that since the WHO declared the COVID-19 outbreak in March 2020, stigma and discrimination against Chinese has been on the rise[\u003csup\u003e12]\u003c/sup\u003e, which may lead to stress, anxiety, and fear for Chinese overseas students. Moreover, students with a higher score of fear are more likely to have unhealthy lifestyles, such as drinking alcohol and smoking, even reported \u0026nbsp;hopelessness and suicidal ideation[9],\u0026nbsp;which could cause a vicious circle[\u003csup\u003e13]\u003c/sup\u003e.\u0026nbsp;However, only several Chinese oversea students attained mental health services[\u003csup\u003e14]\u003c/sup\u003e.\u0026nbsp;Thus, strategic mental health interventions are suggested to protect Chinese overseas students' health and well-being.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of different mental health burdens among countries\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe found that differences might exist between countries in the mental health status of Chinese overseas students during the COVID-19 pandemic. Some research also showed the differences in the global prevalence of anxiety among students. For example, college students in Poland had higher scores in psychological distress compared to students from the UK and Germany[7]. The inconsistency of the psychological burden might be related to the differences of cross-culture[\u003csup\u003e15]\u003c/sup\u003eand social system[\u003csup\u003e16]\u003c/sup\u003e, as well as the development of the pandemic among countries. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the one hand, the differences in culture and norms might lead to inconsistent and even conflicting views on COVID-19 and various epidemic-prevention measures between Chinese overseas students and the locals. Firstly, Chinese is a collective society. Research have reported that Chinese people were more concerned about health and less concern for leisure during the COVID-19 pandemic outbreak[\u003csup\u003e17]\u003c/sup\u003e, and then the epidemic was effectively controlled within three months in China. Whereas in individualistic countries, it may need be fully considered about ant-pandemic policies in order to minimize the risk of infection spread while maximize the personal freedom. The uncontrollability of COVID-19 likely arouse international students worry too much about their health[7], which may be more dangerous factors causing Chinese overseas students' psychological burdens. Secondly, research showed that due to the cultural differences, the high levels of coronavirus anxiety may be associated with maladaptive religious coping for people living abroad[9]. This phenomenon may be generalisable to all international students studying abroad. Finally, the response and changes of population to the COVID-19 might inconsistent among countries. For example, an overwhelming body of evidence has demonstrated that adequate PA could improve mental health well-being during the COVID-19, but the changes of the PA intensity may be different in counties. Relate research have showed that the intensity of PA is significantly decreased among people in Asia, America, Africa, and Europe, whereas a general increase in Belgium and Canada during the COVID-19 outbreak[\u003csup\u003e18]\u003c/sup\u003e. This inconsistent changes of PA likely have the opposite effects on mental health of intentional students.\u003c/p\u003e\n\u003cp\u003eThe other explanation of the difference may be related to the stage of COVID-19 pandemic development in host countries. It is known that according to the development of COVID-19 pandemic, a series of urgent strategies have been implemented timely by many governments, which might play a key role in controlling the spread of the epidemic, reducing infection rate, and relieving stress, fear, and anxiety during the pandemic. However, countries differ politically and economically, the strategies adopted and the difficulties faced were vary within each country, as well as the pandemic severity. For example, the UK adopted a policy of herd immunity, students were required to move out on-campus housing in some college in the USA, some countries lacked sufficient epidemic-prevention supplies. Consequently, the impact of COVID-19 on Chinese overseas students' mental health in each country is different. On the whole, when being in threatening situation, international students' mental health could be seriously compromised[\u003csup\u003e19].\u003c/sup\u003e Thus, positive\u0026nbsp;interventions and preventive strategies\u0026nbsp;in the short-term likely need to be tailored for Chinese overseas students'\u0026nbsp;mental health\u0026nbsp;within different countries.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe relationship between mental health and the gender\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch suggests that men and women have different experiences when faced with a fearful object[\u003csup\u003e20]\u003c/sup\u003e. Moreover, female student might suffer a greater psychological impact than males during the COVID-19[\u003csup\u003e21][22]\u003c/sup\u003e. For example, research reported that both anxiety and depression among Ukrainian students are related to gender during the COVID-19 pandemic[22], as well as among college freshmen in China[\u003csup\u003e23]\u003c/sup\u003e. However, we found that females students didn't scored significantly higher in psychological health problems than males among Chinese overseas students during the COVID-19. Maybe because if studying in same area, there was the basic consistency about their living situation and facing difficulties during the pandemic. Some research also did not find gender differences in the mental health among college students during the COVID-19 outbreak[\u003csup\u003e24]\u003c/sup\u003e, which is consistent with our findings. Therefore, more research is necessary to explain such inconsistent findings.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe relationship between mental health and the duration of ant-pandemic\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch has showed that time spent focusing on COVID-19 may be potential risk factors for the psychological problems[\u003csup\u003e25]\u003c/sup\u003e.\u0026nbsp;Nevertheless,\u0026nbsp;we found that the longer the duration of ant-pandemic might not lead to more serious the Chinese overseas students' psychological burden. Due to the sudden and radical lifestyle changes, studying in an uncertain and threatening situation, infection fears, inadequate supplies, and much more, the level of students' psychological problems may be the highest at the beginning of the COVID-19 outbreak[7] or at spikes occur in COVID-19 cases and deaths. Over time, Chinese overseas students' psychological burden likely be gradually eased or even slightly reduced. The main reason might be that Chinese overseas students have gradually acquired more competence in dealing with the COVID-19 and higher positive psychological adjustment for the changed daily-life. Firstly, they might gradually have more reliable information and knowledge about COVID-19, used to epidemic prevention behavior of people around, and mastered more basic measures of avoiding themself exposure to the virus and being infected, which were important stressors for international students during the pandemic[\u003csup\u003e26]\u003c/sup\u003e. Secondly, Chinese education institutions, social media groups, and families provided online support services to alleviate psychological problems of Chinese overseas students living abroad during the COVID-19. For example, the Chinese government provided timely special planes back to China, epidemic prevention equipment, remote counselling for them during the epidemic. Protective support from China can play a key role in controlling stress and anxiety for Chinese overseas students[\u003csup\u003e27]\u003c/sup\u003e. Finally, as limitations are eased, and some campuses reopen gradually, worried about their learning process might be alleviated, and finding more support from student societies (especially Chinese overseas student societies) and college may also reduce psychological burden of Chinese overseas students. However, it is unknown how long this negatively affected for Chinese overseas\u0026nbsp;students'\u0026nbsp;\u0026nbsp;psychological problems will last and what new impact will be on their mental health. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of factors affecting mental health\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe observed that multiple stressors might contributed to the increased levels of Chinese overseas students' mental health burden during the pandemic. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFirstly, epidemic severity might be the most important factor causing negative psychological impacts. COVID-19 has undergone several mutations. Various factors could lead to more serious psychological symptoms of Chinese overseas students living abroad, including the most possible of being asymptomatic carriers for youth[\u003csup\u003e28]\u003c/sup\u003e, the growing numbers of confirmed COVID-19 cases and deaths, the increasing population being infected after vaccination, and some Covid-19 recovered persons being re-infected. The worry of being infected positively correlates with depression, anxiety and virus aversion among Chinese overseas students. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSecondly, the worry about academic performance might positively correlates with Chinese overseas student'\u0026nbsp;psychological problem during the COVID-19, and mental health issues also are the leading impediment to academic success[\u003csup\u003e29]\u003c/sup\u003e, which could cause a vicious circle. Similar problems occurred worldwide. For example, prolonged school closure and class postponed might have negative effects on the contact with lecturers and the support from classmates, then lead to increased fear of passing their examinations[\u003csup\u003e30]\u003c/sup\u003e. In addition, disruptions of their research projects and internships during school closure might delay their graduation and undermine their competitiveness in the job market, which could cause negative effects on Chinese overseas students'\u0026nbsp;mental health during the COVID-19. Furthermore, many colleges switched to online classes during the COVID-19 pandemic, but some students were unfamiliar with the new online learning methodology. The virtual classes were stressful for them to adapt to web-based teaching platforms and technology rapidly[\u003csup\u003e31]\u003c/sup\u003e. These procedures for passing course exams and presenting their work via online platforms might also be stressful for them[\u003csup\u003e32]\u003c/sup\u003e. Moreover, the significant increase in screen time mainly being spent on computer and internet usage may be an additional source of psychological symptoms[\u003csup\u003e33]\u003c/sup\u003e. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThirdly,\u0026nbsp;epidemic prevention environment of the host government, including infection control policies and preventive measures,\u0026nbsp;are generally different among counties, which\u0026nbsp;may be additional challenges to\u0026nbsp;assess the impact of COVIN-19 on Chinese overseas students' psychological well-being. In fact, COVID-19 has caused a massive burden on governments and individuals in the word. Governments in various countries have implemented urgent national containment\u0026nbsp;policies\u0026nbsp;to prevent the spread of the pandemic.\u0026nbsp;However, the spread of the pandemic is not effectively controlled, and the number of COVID-19 cases and deaths is increasing significantly in some countries[\u003csup\u003e34]\u003c/sup\u003e. Related studies have reported that Chinese college students tend to experience more anxiety if someone they know is tested positive for COVID[\u003csup\u003e35]\u003c/sup\u003e. In addition, populations differ on many dimensions between and within countries, such as socioeconomic status, views about COVID-19, and religious beliefs, which all may lead to different preventive measures between Chinese overseas students and locals, such as whether to wear a mask outdoor and whether to get vaccinated. That is to say if Chinese overseas students cannot accept or adjust to epidemic prevention environment of the host government, their level of anxiety likely increase.\u003c/p\u003e\n\u003cp\u003eFinally, obstruction of return trips might make some Chinese overseas students more prone to psychopathology. Because some counties closed or reduced international air at the beginning of the COVID-19 outbreak or at spikes occur in COVID-19 cases, it was difficult for many Chinese overseas students to buy air tickets to China on time. Some students even have concerns about infection, COVID-19 tests, and fears of being quarantine on the way back to China. Moreover, some students might also struggle with the expensive cost of returning to China[\u003csup\u003e36]\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications and Limitations of the Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study has several limitations. Firstly, due to the large Chinese overseas students living aboard during the pandemic, Chinese overseas students in different countries also varies. The questionnaires were distributed through WeChat and Chinese overseas student social platforms to ensure that students from different countries participated and to maximize the diversity and representativeness of the students participating in the survey. However, these participants were from 37countries, there was certain unevenness and incompleteness in the regional distribution. Secondly, the study solely relies on online self-reported questionnaires. Although we chose the WHO-approved the SCL-90, which has high reliability and validity, recall and reporting bias cannot be excluded. Finally, due to time constraints during the data collection period, we did not collect data about the epidemic severity including COVID-19 infection rate and deaths, infection control policies, and medical readiness of different countries, these background information can also explain the psychological problems of Chinese overseas students. \u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDuring the COVID-19 pandemic, Chinese overseas students showed mental health burdens, such as anxiety, depression, stress, fear and somatization. The degree of mental health burden may be differ between countries, but no significantly different in gender and in ant-pandemic duration. The mainly identified factors which severely affected mental health are (1) epidemic severity in residence, (2) fear of being infected, (3) worries of academic performance, (4) infection control policies of the host government, (5) epidemic preventive measures of locals, (6) obstruction of return trips, and (7) mutation of the epidemic virus. \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Research Ethics Committee of Wuhan Sports University, and voluntary participation was given informed consent and not compensated.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due the risk of identifying participants, but extracts are available from the corresponding author on reasonable request.\u003cbr\u003e\u0026nbsp;\u0026nbsp;\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made relevant contributions to and approved the final manuscript.The authors report no conflicts of interest in this work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from the young and middle-aged scientific research team of Wuhan Sports University. \u0026nbsp;Grant Agreement No. 21KT13. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYingjun Nie and Xiangping Zheng: conceptualization. Yingjun Nie, Yuanyan Ma, and Xiangping Zheng: methodology and writing\u0026mdash;original draft preparation. Ce Zhang, Jiahui Li, and Yijia Gao: formal analysis.Yingjun Nie: funding acquisition. Yingjun Nie, Jiahui Li, Ce Zhang, Yijia Gao, and Yuanyan Ma: investigation. Yingjun Nie, Xiangping Zheng, and Yuanyan Ma: writing\u0026mdash;review and editing. Yijia Gao: project administration. Yingjun Nie and Yuanyan Ma share first authorship. Yingjun Nie and Xiangping Zheng share Corresponding authorship.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the support of Wuhan Sports University.We also would like to express our sincere thanks to the editor and reviewers for their helpful comments.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eNguyen HT, Do BN, Pham KM, Kim GB, Dam HTB, Nguyen TT, et al.Fear of COVID-19 Scale-Associations of Its Scores with Health Literacy and Health-Related Behaviors among Medical Students. Int J Environ Res Public Health. 2020 Jun 11;17(11):4164 [FREE Full text][doi: 10.3390/ijerph17114164]. [Medline: 32545240]\u003c/li\u003e\n \u003cli\u003eZhao Y. Psychological impacts of the COVID-19 outbreak on Chinese international students: Examining prevalence and associated factors[J]. 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Health \u0026amp; Social Care in the Community, 2021, 29(6): e249-e258[FREE Full text][doi：10.1111/hsc.13347][Medline:33825220]\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COVID-19,Chinese overseas students, mental health, effects, multi-country cross-sectional analysis","lastPublishedDoi":"10.21203/rs.3.rs-2314913/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2314913/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eCOVID-19 caused serious mental health burden for international students. However, only several international students obtained related mental health services. The topic of international students' mental health has the bigger jump among social and educational concerns during the pandemic. This study surveyed the effects of COVID-19 on the mental health of Chinese overseas students to provide essential reference for identifying mental health problems of Chinese overseas students, so that they can be targeted for timely crisis-oriented and tailoring mental health interventions during periods of public health emergencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Descriptive statistics such as percentages, 95% CIs, means and standard deviations were calculated to reflect the demographic characteristics of the survey population. The Kolmogorov-Smirnov test was used to test the normality of continuous variables. The chi-square test was used to determine the statistical significance of the differences in participants' mental health status. Binary logistic regression was used to analyze the factors influencing on Chinese overseas students' mental health. The data were analyzed through quantitative and qualitative methods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eChinese overseas students had several poor mental health status during the COVID-19 pandemic. Furthermore, the degree of mental health burden might differ between countries, but there were not notable differences in gender (p = 0.75) and in ant-pandemic duration. Some main factors caused an unhealthy psychological status, including epidemic severity in residence（67.94%, 95% CI：67.06% — 68.82%）, fear of being infected（64.54%, 95% CI：63.72% — 65.36%）, worries of academic performance（62. 43%, 95% C%I：60.64% — 64.22）, infection control policies of the host government（58. 09%, 95% CI：57. 16% — 59. 01%）, epidemic preventive measures of locals（56. 03%, 95% CI：55. 10% — 56. 96%）, obstruction of return trips（54.85%, 95% CI：53.91% — 55. 79%）, mutation of the epidemic virus（53. 75%, 95% CI：52. 71% — 54. 79%）.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe main conclusion of this research is that Chinese overseas students experience mental health burdens during the COVID-19 pandemic and they need timely psychological services, positive support, and tailoring guidance to better manage mental health in this unusual situation.\u003c/p\u003e","manuscriptTitle":"Effects of COVID-19 on Chinese overseas students' mental health: a multi-country cross-sectional analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-11-30 16:18:35","doi":"10.21203/rs.3.rs-2314913/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0df074f8-7b24-428c-ae30-c8b1935ed63b","owner":[],"postedDate":"November 30th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-12-16T13:44:11+00:00","versionOfRecord":[],"versionCreatedAt":"2022-11-30 16:18:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2314913","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2314913","identity":"rs-2314913","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}