The 2019 coronavirus disease (COVID‐19) has become a public health emergency on a global scale. Fortunately, due to efforts on all parts from Chinese governmental bodies, medical workers, and local citizens, the peak has passed but the effects of COVID‐19 on the mental health of Chinese people are ongoing and need to be further analyzed, especially those experienced by adolescents, who may have been overlooked during this public health emergency. 1 Anxiety is the most common form of mental illness among children and adolescents. 2 The risk of anxiety for adolescents is thought to be increasing due to the strict measures put in place during the COVID‐19 outbreak, including the shutdown of schools, quarantine at home, cancelation of sporting events, and distance learning. Therefore, this study aims to illustrate anxiety and its associated factors among adolescents in China during the outbreak of COVID‐19, which may provide a basis for further recommendations of psychological interventions for adolescents in China as well as other countries.
A cross‐sectional online survey was administered to assess levels of anxiety and associated factors among Chinese adolescents from 20 to 27 February 2020. The WeChat software platform and WJX.cn website platform (Changsha Renxing Science and Technology, Shanghai, China) were used to conduct the online survey through snowball sampling. Adolescents aged between 11 and 20 years who were living in Mainland China, attending junior or senior secondary schools, and were willing to participate were included in this study. Ethics approval for this study was obtained from the Medical Ethical Committee in the Beijing Anding Hospital of the Capital Medical University in China. All participants and their guardians provided informed consent before participating in the study. The self‐reported seven‐item Generalized Anxiety Disorder (GAD‐7) Scale was used to assess the symptoms of generalized anxiety disorder and the severity during the preceding 2 weeks according to the DSM‐IV criteria. Participants were asked about seven core symptoms of generalized anxiety and responses were scored from 0 (not at all) to 3 (nearly every day), with a total score range from 0 to 21. Cut‐off values for mild, moderate, and severe anxiety were 5, 10, and 15, respectively. 3
A total of 9744 responders completed the questionnaire and 9554 were included in the analysis after removing unqualified data. In this study, 1814 adolescents suffered from anxiety (19.0%, 95% confidence interval = 18.2–19.8%; GAD‐7 score ≥ 5). The prevalence rates of mild, moderate, and severe anxiety were 14.5%, 3.1%, and 1.5%, respectively. The multiple logistic regression revealed that female sex, senior secondary school students, sleep duration < 6 h every day, being concerned about graduation, and having more homework than before were all significantly associated with an increased risk of anxiety. However, living in areas with 100–999 or 1000–9999 confirmed cases (divided according to the classification of the cumulative confirmed cases reported by the National Health Commission of the People's Republic of China), being very concerned about COVID‐19, sleep duration >8 h every day, and exercise duration of 30–60 min every day were associated with a decreased risk of anxiety (Table 1).
Table 1.
Multiple logistic regression of associated factors with anxiety in adolescents during the outbreak of COVID‐19
| 95%CI for OR | ||||
|---|---|---|---|---|
| Variables | P | OR | Lower | Upper |
| Female sex | <0.001 | 1.298 | 1.164 | 1.448 |
| Senior secondary school | <0.001 | 1.475 | 1.317 | 1.653 |
| Living area at provincial level (No. of infected patients) | ||||
| 10–99 | Ref. | |||
| 100–999 | 0.005 | 0.830 | 0.729 | 0.944 |
| 1000–9999 | <0.001 | 0.687 | 0.578 | 0.817 |
| ≥10 000 | 0.956 | 0.993 | 0.775 | 1.273 |
| Acquaintance got infected | 0.122 | 1.232 | 0.946 | 1.606 |
| Being concerned about COVID‐19 | 0.008 | 0.840 | 0.739 | 0.956 |
| Sleep duration/day | ||||
| 6–8 h | Ref. | |||
| <6 h | <0.001 | 2.270 | 1.844 | 2.795 |
| >8 h | <0.001 | 0.756 | 0.673 | 0.850 |
| Exercise duration/day | ||||
| <30 min | Ref. | |||
| 30–60 min | <0.001 | 0.715 | 0.638 | 0.802 |
| >60 min | 0.215 | 0.886 | 0.732 | 1.073 |
| Study duration/day ≥4 h | 0.398 | 0.939 | 0.811 | 1.807 |
| Participation in distance learning | 0.646 | 0.951 | 0.767 | 1.179 |
| Being concerned about graduation | <0.001 | 1.752 | 1.575 | 1.950 |
| Quantity of homework | ||||
| About the same | Ref. | |||
| Lower than before | 0.285 | 1.073 | 0.943 | 1.220 |
| Higher than before | <0.001 | 1.916 | 1.664 | 2.207 |
Due to collinearity between age and grade, age group was not entered in the multiple logistic regression analysis.
Bolded values, P < 0.05.
CI, confidential interval; OR, odds ratio.
Regarding grade level, adolescents in senior secondary school and students who were worried about graduation reported higher risks of anxiety than junior school students, which might be attributed in part to the Chinese educational system. 4 Adolescents in senior secondary school are often faced with significant academic pressure related to the university entrance examination, which could possibly increase the level of anxiety. 5 Additionally, enough sleep, moderate physical exercise, and regular study duration (participating in distance learning) were found to be associated with decreased risks of anxiety for adolescents. Moreover, adolescents who were more concerned about the COVID‐19 outbreak had a lower risk of anxiety, which was consistent with previous evidence showing that improving knowledge about the epidemic could reduce the fear and anxiety many individuals face. 6 These results support the finding that having routines for study and daily life activities could work to reduce the risks of anxiety in adolescents. 7 There were several limitations in this study. First, the participants were recruited through an online survey, so the sample cannot truly represent all Chinese adolescents. Second, some factors associated with anxiety, such as social support and physical health, could not be examined due to logistical reasons. Finally, this study used a cross‐sectional study design and, therefore, causality between variables could not be examined.
In conclusion, anxiety was prevalent among adolescents during the COVID‐19 outbreak, especially in girls and in senior secondary school students, suggesting that timely screening and appropriate interventions are urgently needed to reduce anxiety in adolescents.
Disclosure statement
The authors declare no conflict of interest.
Acknowledgments
The study was supported by the National Key R&D Program of China (2017YFC1311100) and the Beijing Municipal Science & Tech Commission (D171100007017001).
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