Anxiety levels, precautionary behaviours and public perceptions during the early phase of the COVID-19 outbreak in China: a population-based cross-sectional survey

Mengcen Qian, Qianhui Wu, Peng Wu, Zhiyuan Hou, Yuxia Liang, Benjamin J Cowling, Hongjie Yu, Mengcen Qian, Qianhui Wu, Peng Wu, Zhiyuan Hou, Yuxia Liang, Benjamin J Cowling, Hongjie Yu

Abstract

Objective: To investigate psychological and behavioural responses to COVID-19 among the Chinese general population.

Design, setting and participants: We conducted a population-based mobile phone survey between 1 February and 10 February 2020 via random digit dialling. A total of 1011 adult residents in Wuhan (n=510), the epicentre and quarantined city, and Shanghai (n=501) were interviewed. Proportional quota sampling and poststratification weighting were used. Multivariable logistic regression models were used to investigate perception factors associated with the public responses.

Primary outcome measures: We measured anxiety levels using the 7-item Generalised Anxiety Disorder Scale (GAD-7) and asked respondents to report their precautionary behaviours before and during the outbreak.

Results: The prevalence of moderate or severe anxiety was significantly higher (p<0.001) in Wuhan (32.8%) than Shanghai (20.5%). Around 79.6%-88.2% residents reported always wearing a face mask when they went out and washing hands immediately when they returned home, with no discernible difference across cities. Only 35.5%-37.0% of residents reported a handwashing duration above 40 s as recommended by the WHO. The strongest predictor of moderate or severe anxiety was perceived harm of the disease (OR 1.8, 95% CI 1.5 to 2.1), followed by confusion about information reliability (OR 1.7, 95% CI 1.5 to 1.9). None of the examined perception factors were associated with odds of handwashing duration above 40 s.

Conclusions: Prevalence of moderate or severe anxiety and strict personal precautionary behaviours was generally high, regardless of the quarantine status. Our results support efforts for handwashing education programmes with a focus on hygiene procedures in China and timely dissemination of reliable information.

Keywords: health policy; mental health; public health.

Conflict of interest statement

Competing interests: HY has received research funding from Sanofi Pasteur, GlaxoSmithKline, Yichang HEC Changjiang Pharmaceutical Company and Shanghai Roche Pharmaceutical Company. None of that research funding is related to COVID-19. BJC has received honoraria from Roche and Sanofi. All other authors report no competing interests. All authors have completed the Unified Competing Interest Form.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
The timeline of the COVID-19 outbreak compared with the survey dates is presented for Wuhan and other parts of China (Panel A) and Shanghai (Panel B). Note that different scales are used in the two panels. The vertical axis for Panel A is the number of reported cases and that for Panel B is the number of confirmed cases. Diagnostic criteria were changed in Hubei Province (Wuhan is the capital city of Hubei Province) on 12 February 2020. Since then confirmed cases are based on clinical diagnosis instead of laboratory testing in Hubei province. NHC, National Health Commission of China; PHEIC, Public Health Emergency of International Concern.

References

    1. Zhu N, Zhang D, Wang W, et al. . A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med Overseas Ed 2020;382:727–33. 10.1056/NEJMoa2001017
    1. National Health Commission Latest situation of new coronavirus pneumonia as of April 19 2020 (in Chinese). Available:
    1. World Health Organization Available:
    1. Lau JTF, Yang X, Tsui H, et al. . Monitoring community responses to the SARS epidemic in Hong Kong: from day 10 to day 62. J Epidemiol Community Health 2003;57:864–70. 10.1136/jech.57.11.864
    1. Brug J, Aro AR, Oenema A, et al. . Sars risk perception, knowledge, precautions, and information sources, the Netherlands. Emerg Infect Dis 2004;10:1486–9. 10.3201/eid1008.040283
    1. Wu P, Fang Y, Guan Z, et al. . The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry 2009;54:302–11. 10.1177/070674370905400504
    1. Rubin GJ, Amlôt R, Page L, et al. . Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey. BMJ 2009;339:b2651. 10.1136/bmj.b2651
    1. Yeung NCY, Lau JTF, Choi KC, et al. . Population Responses during the Pandemic Phase of the Influenza A(H1N1)pdm09 Epidemic, Hong Kong, China. Emerg Infect Dis 2017;23:813–5. 10.3201/eid2305.160768
    1. Bayham J, Kuminoff NV, Gunn Q, et al. . Measured voluntary avoidance behaviour during the 2009 A/H1N1 epidemic. Proc Biol Sci 2015;282:20150814. 10.1098/rspb.2015.0814
    1. Lau JTF, Griffiths S, Choi KC, et al. . Avoidance behaviors and negative psychological responses in the general population in the initial stage of the H1N1 pandemic in Hong Kong. BMC Infect Dis 2010;10:139. 10.1186/1471-2334-10-139
    1. Wang L, Cowling BJ, Wu P, et al. . Human exposure to live poultry and psychological and behavioral responses to influenza A(H7N9), China. Emerg Infect Dis 2014;20:1296–305. 10.3201/eid2008.131821
    1. Wu P, Wang L, Cowling BJ, et al. . Live Poultry Exposure and Public Response to Influenza A(H7N9) in Urban and Rural China during Two Epidemic Waves in 2013-2014. PLoS One 2015;10:e0137831. 10.1371/journal.pone.0137831
    1. Wu P, Fang VJ, Liao Q, et al. . Responses to threat of influenza A(H7N9) and support for live poultry markets, Hong Kong, 2013. Emerg Infect Dis 2014;20:882–6. 10.3201/eid2005.131859
    1. Cheng C, Tang CS-K. The psychology behind the masks: psychological responses to the severe acute respiratory syndrome outbreak in different regions. Asian J Soc Psychol 2004;7:3–7. 10.1111/j.1467-839X.2004.00130.x
    1. Vartti A-M, Oenema A, Schreck M, et al. . SARS knowledge, perceptions, and behaviors: a comparison between finns and the Dutch during the SARS outbreak in 2003. Int J Behav Med 2009;16:41–8. 10.1007/s12529-008-9004-6
    1. de Zwart O, Veldhuijzen IK, Elam G, et al. . Perceived threat, risk perception, and efficacy beliefs related to SARS and other (emerging) infectious diseases: results of an international survey. Int J Behav Med 2009;16:30–40. 10.1007/s12529-008-9008-2
    1. Lai J, Ma S, Wang Y, et al. . Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976. 10.1001/jamanetworkopen.2020.3976
    1. Rossi R, Socci V, Pacitti F, et al. . Mental health outcomes among frontline and second-line health care workers during the coronavirus disease 2019 (COVID-19) pandemic in Italy. JAMA Netw Open 2020;3:e2010185. 10.1001/jamanetworkopen.2020.10185
    1. Kong X, Zheng K, Tang M, et al. . Prevalence and factors associated with depression and anxiety of hospitalized patients with COVID-19.
    1. Wu JT, Leung K, Leung GM. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study. Lancet 2020;395:689–97. 10.1016/S0140-6736(20)30260-9
    1. Read JM, Bridgen JRE, Cummings DAT, et al. . Novel coronavirus 2019-nCoV: early estimation of epidemiological parameters and epidemic predictions, 2020. Available:
    1. Health Commission of Hubei Province Update on the outbreak of novel coronavirus-infected pneumonia as of 31 January 2020 (in Chinese). Available: [Accessed 15 Feb 2020].
    1. National Health Commission of the People’s Republic of China Update on the outbreak of novel coronavirus-related pneumonia as of 31 January 2020 (in Chinese). Available: [Accessed 15 Feb 2020].
    1. Shanghai Municipal Health Commission Shanghai municipal administration of traditional Chinese medicine. 18 new confirmed cases of novel coronavirus-infected pneumonia in Shanghai (in Chinese). Available: [Accessed 15 Feb 2020].
    1. Spitzer RL, Kroenke K, Williams JBW, et al. . A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092–7. 10.1001/archinte.166.10.1092
    1. Löwe B, Decker O, Müller S, et al. . Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population. Med Care 2008;46:266–74. 10.1097/MLR.0b013e318160d093
    1. Guo X, Meng Z, Huang G, et al. . Meta-analysis of the prevalence of anxiety disorders in mainland China from 2000 to 2015. Sci Rep 2016;6:28033. 10.1038/srep28033
    1. Yu W, Singh SS, Calhoun S, et al. . Generalized anxiety disorder in urban China: prevalence, awareness, and disease burden. J Affect Disord 2018;234:89–96. 10.1016/j.jad.2018.02.012
    1. World Health Organization Hand hygiene: why how & when? Available: [Accessed 15 Feb 2020].
    1. Fenichel EP, Kuminoff NV, Chowell G. Skip the trip: air travelers’ behavioral responses to pandemic influenza. PLoS One 2013;8:e58249. 10.1371/journal.pone.0058249
    1. Sadique MZ, Edmunds WJ, Smith RD, et al. . Precautionary behavior in response to perceived threat of pandemic influenza. Emerg Infect Dis 2007;13:1307–13. 10.3201/eid1309.070372
    1. Rubin GJ, Wessely S. The psychological effects of quarantining a City. BMJ 2020:m313 10.1136/bmj.m313

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa