Study on the stress level and coping channels of Chinese urban and rural senior high school students learning on-campus after their return to school during the post-COVID-19 pandemic period

Ming-Yuan Wu,Xin-Yi Qin,Xiao-Min Luo,Ye-Huan Yang,Shu-Lan Wu,Jing Ma,Rui-Min Zheng*

1Fountain Valley School of Colorado,Colorado,USA.

2Middlesex High School,Massachusetts,USA.

3National Center for Women and Children’s Health,Chinese Center for Disease Control and Prevention,Beijing,China.

4Johns Hopkins Bloomberg School of Public Health,Baltimore,USA.

5Tsinghua University Hospital Management Research Institute,Beijing,China.

#These two authors contributed equally to this work.

Abstract Objective:The study aims to understand the level of perceived stress and related influencing factors among the urban and rural senior high school students in China and their channels of coping with the stress,when they shifted from home-based online learning to on-campus learning after their return to school during the post-Coronavirus disease 2019(COVID-19)pandemic period.Methods:From January to March 2021,the Chinese Perceived Stress Scale(SSCPs-14)and a self-designed questionnaire were used for the online survey among the senior high school students from six secondary schools(three from cities and three from counties)in three provinces of China(Shandong,Shanghai and Sichuan)who were selected by convenient sampling.Descriptive analysis,t-test,χ2 test and multivariate logistic regression were used to analyze the data.Results:A total of 1,462 respondents were enrolled in the study,of which 41.66% were urban students and 58.34% were rural ones.Their overall average score of CPSS-14 was 21.69±7.65.The respondents reported the following influencing factors of perceived stress,including“Change of their learning and sleep schedule(OR=1.426,95%CI:1.056~1.927,P=0.021),“Communication with their family members(OR=2.820,95%CI:1.971~4.034,P＜0.001)and“The family’s financial status”(OR=1.675,95%CI:1.181~2.376,P=0.004).Their coping strategies when facing with the stress were ranked from high to low frequency as follows:"Talk to friends(34.63%)","Talk to parents(26.88%)","Seek help from teachers(14.53%)","Deal with it on my own(13.21%)","Seek help from a psychological counsellor(7.95%),"Others(1.42%)"and"Ignore the problem(1.39%)".Rural students with three and more than three coping channels(44%)were more than urban students(36%),with a statistically significant difference between the two(χ2=10.878,P=0.012).A higher proportion of respondents(49.4%)with fewer coping channels reported high level of perceived stress,compared with those with multiple coping channels(33.4%).The difference between the two groups was statistically significant(χ2=55.956,P<0.001).Conclusion:Senior high school students were faced with the stress brought about by the shift from the on-line learning to on-campus learning after their return to school during the post-COVID-19 pandemic period.The change of their learning and sleeping schedule,communication with family and their family’s financial status were the main influencing factors of senior high school students'stress after their return to school.Senior high school students with more coping channels had lower level of stress.Therefore,it is suggested that stress relief measures should be taken to promote the mental health of senior high school students in the post-COVID-19 pandemic period.

Keywords:COVID-19,Urban and rural,Senior high school students,Stress,Psychology

Background

As one of the response measures to the Coronavirus disease 2019(COVID-19)outbreak at the beginning of 2020,the education department at all levels of the government in China implemented the policy of"Suspension of School but Not Learning"in all the primary and secondary schools.From February to June 2020,all primary and secondary schools in China adopted the home-based online learning.With the better control of the pandemic and the shift to the"post pandemic period",all primary and secondary schools resumed the on-campus learning in schools in September 2020.Therefore,such shift from online learning to on-campus learning posed a challenge for students to be re-adapted to on-campus learning.Moreover,senior high school students already had heavy learning tasks and great academic pressure,so they were faced with a multitude of challenges,including adaptability,self-control and autonomy.Some studies argue that COVID-19 and the associated restrictions may have a negative impact on the mental health of adolescents,such as fear of the infection risk,family financial instability and food insecurity caused by the pandemic.The reduction or lack of outdoor physical exercise or recreational activities with peers due to isolation at home were significantly correlated with stress,anxiety,depression and post-traumatic symptoms of adolescents.Therefore,psychological issues of adolescents were more frequent during the COVID-19 pandemic[1-3].

Focusing the stress level and related influencing factors of senior high school students shifting from online learning during the pandemic to learning on-campus after their return to school,the study conducted an online survey on senior high school students in Shandong,Sichuan,Shanghai to understand the level of perceived stress of this group of students in this special period.At the same time,the study explored the possible influencing factors related to the stress level and coping strategies of this group of students,in order to inform with evidences how to strengthen the mental health service of Chinese senior high school students and promote their physical and mental health growth.

Subjects and methodol ogy

Subjects

The study conducted an online survey from February 1 to March 31,2021,using Wenjuanxing,an online survey tool similar to Amazon Mechanical Turk.Based on the consideration that the survey should reflect all eastern,southern,western and northern regions of China,the survey selected three provinces as Shandong,Sichuan and Shanghai.Then based on convenient sampling,the study included one city and one rural senior high school from each province,thus total three senior high schools from the counties and three senior high schools from the cities respectively from the three provinces.Three classes of 11th or 12 grades from each school were selected by random cluster sampling.Then,students in each class who met the inclusion criteria were selected as the survey subjects who received the survey link.The study subjects were included per the following inclusion criteria;they should be the students of the 11th or 12 grade from the selected senior high school and voluntarily participated in the survey.For the exclusion criteria,students with serious diseases taking long-term sick leave from school were not enrolled in the study.

Before filling in the survey,the respondents were told that the survey was completely anonymous and confidential,and informed consent was obtained from the students and their parents.This study was granted the ethical approval of the author's institution(Code:S356).The study collected a total of 1,707 responses to the survey,of which 1,462 valid responses or 85.64% of the total responses were included in the analysis,after excluding those with missing information and invalid entries.

Investigation method

The study used Wenjuanxing,an online survey tool to conduct the quantitative survey,which consisted of the basic demographic information and the Chinese version of the Perceived Stress Scale(PSS)[4],a classic stress assessment instrument used globally,and a self-designed questionnaire containing two types of questions:1)the influencing factors of the stress;2)the coping strategies adopted.The Perceived Stress Scale-14(PSS)was used in this study,which was developed by an American psychologist Sheldon Cohen in 1983,including two subscales of perceived stress and perceived lack of control[5].The scale has 14 items(PSS-14)and each item has five options:0=never,1=almost never,2=sometimes,3=fairly often,and 4=very often.Items 1,2,3,8,11,12 and 14 are the negative statement measuring“the perceived stress",and they are scored in a positive way.That is,option 0=0 point;1=1 point,2=2 points,and so on;items 4,5,6,7,9,10 and 13 are the positive statements measuring"one’s perceived ability to coping with stress",and are scored in a reverse direction.That is,option 0=4 points;option 1=3 points,option 2=2 points,and so on.Finally,the scores of 14 items are added to calculate the total score(0-56 points),with the higher total score indicating a higher stress of the individual.Yang TZ,et al.analyzed the effectiveness of this scale in discriminating perceived stress in the Chinese population[6]and determined 25 as the cut-off value of the Perceived Stress Scale,Chinese version(CPSS).That is,the total score of the scale≤25 means stress without any health risks,and>26 is the indicator of stress with health risk implication.As the CPSS has been used in a number of quantitative assessment and clinical researches on psychological stress of general population or special population groups[7],it is widely used in China and has a Cronbachαcoefficient of 0.91.In this study,the CPSS was used to investigate into the current perceived stress level of the respondents and their perceived stress level during the period of online learning in 2020.This study also designed a questionnaire consisting of two parts,including the influencing factors of perceived stress,and coping channels of the respondents.

Influencing factors of the self-perceived stress level.The respondents selected to what extent the seven different influencing factors negatively affected their stress level,from no influence,slight influence,certain influence to great influence and extremely great influence.The influencing factors included health concerns about themselves and their loved ones,changes in their learning and sleeping routine,family financial difficulties,changes in the living environment,academic pressure,social isolation from friends,and interaction with family members.In this study,according to the degree of influence,the variables were combined into two categories:"mild and below","moderate and above".The coping channels under high stress included seven options,including“Talk to friends","Talk to parents","Seek help from teachers","Seek help from psychological counsellors","Deal with it by myself","Ignore problems"and"Others".

Statistical methods

SPSS 26.0 was used for statistical analysis in this study,and bilateralP<0.05 was considered statistically significant.Continuous variable was shown by xˉ±s,categorical variables by the frequency and percentage(%).T-test was employed to compare the continuous variables between groups,whileχ2test to compare the categorical variables between groups.General socio-demographic information and selected influencing factors were included in the multiple regression equation for multi-variate analysis.All data met the test conditions.

Results

General demographic information of the respondents

In this study,1,462 valid survey responses were included,including 503(34.0%)from Shandong,462(34.4%)from Sichuan,497(31.6%)from Shanghai,41.7% from urban areas and 58.3% from rural areas.The average age of the subjects was 17.0±20.0 years old.There were 803 girls(54.9%)and 659 boys(45.1%)(Table 1).The Cronbach'sα of CPSS-14 in this study was 0.827.

The level of perceived stress of senior high school students learning on-campus after their return to school

The average CPSS-14 score obtained by the 1,462 senior high schools students resuming their on-campus learning after their return to school under this study was 21.69±7.65.Furthermore,we ranked the 14 CPSS items from high to low score according to the average score of each item,the top three items with the highest score were"Often found yourself think about things that you have to accomplish","Often found that you could not cope with all the things that you have to do"and"Do not deal successfully with irritating life hassles".

When all the items were ranked separately under the subscales of perceived stress and the perceived lack of control,the ranking showed that the top three items with the highest average score under the perceived stress subscales were“Often found yourself think about things that you have to accomplish”,“Often found that you could not cope with all the things that you have to do”,and“Often felt difficulties are piling up so high that you could not overcome them”.The top three items with the highest average score among the seven items under the lack of control subscale were“Do not feel that you are on the top of things”,“Do not deal successfully with irritating life hassles”,and“Not able to control irritations in your life”.The specific results were shown in Table 2.

Table 1 Study population and their CPSS-14 score during the on-campus learning(n=1,462)

Table 2 Ranking of CPSS-14 items by score

Table 3 Single-factor analysis results of influencing factors of CPSS-14 score

The influencing factors of the perceived stress level of senior high school students learning on-campus after their return to school

Ten possible influencing factors(3 general socio-demographic factors and 7 different types of worrying events)that can affect the perceived stress level of senior high school students when they resumed their learning on-campus after their return to school were selected to analyze the influencing factors.First,the single-factor analysis(Table 3)showed that seven worrying factors were the possible influencing factors of perceived stress of Chinese senior high school students(P<0.001).Socio-demographic factors(gender,age and urban and rural)were not the influencing factors of the perceived stress level of senior high school students when they resumed their learning on-campus after their return to school(P>0.05).

Ten factors were included in the multivariate logistic regression model(three socio-demographic factors used as control factors)(Table 4).The dependent variable was the CPSS-14 score,and the independent variable was the 10 factors.The results showed that the high level of worry for"Learning and sleeping routine"(OR=1.426,95% CI:1.056-1.927,P=0.021),"Communication with family"(OR=2.820,95% CI:1.971-4.034,P<0.001)and"Family’s financial status"(OR=1.675,95% CI:1.181-2.376,P=0.004)were the risk factors of the perceived stress level of senior high school students when they resumed on-campus learning after their return to school.

Stress coping channels of senior high school students after returning to school

The results of the survey on the coping channels of senior high school students when they resumed their on-campus learning after their return to school showed the following coping channels selected by different proportions of students(ranked from high to low proportion):"Talk to friends(34.6%)",“Talk to parents”(26.9%)","Seek help from teachers(14.5%)","Deal with the problem by myself”(13.2%)","Seek help from psychological counsellors(7.9%),"Others(1.4%)"and"Ignore the problem(1.4%)".The results of the selected number of coping channels showed that a higher proportion of urban students(39.3%)selected two channels,compared with the rural students(31.5%),while more rural students(44.6%)selected three and more channels,compared with the urban students(36.5%).The statistical differences were significant for both comparisons(χ2=10.878,P=0.012).

Based on the further analysis on the selected number of support channels and the level of senior high school students'perceived stress when they resumed on-campus learning(Table 5),it was found that compared with the students who selected three or more coping channels(33.4%),the proportion of senior high school students who selected one or two coping channels experienced higher level of perceived stress when they resumed on-campus learning(49.4%),and the difference between the two groups was statistically significant(χ2=55.956,P<0.001).

Table 4 Multivariate logistic regression analysis on the influencing factors of CPSS-14 score

Table 5 Relationship between the number of coping channels and CPSS-14 perceived stress level

Discussion

The level of perceived stress of senior high school students

The results of this study showed that 41.6% of Chinese senior high school students experienced a high level of stress when they shifted from the online learning to on-campus learning,which was similar to the results of previous studies on students'psychological impact during the COVID-19 pandemic[8,9].Moreover,Chinese senior high school students may experience a higher level of stress when they resumed on-campus learning after they learned online at home for a long period of time during the COVID-19 pandemic.Therefore,this alerts us with the necessity to provide students with the needed psychological support after their return to school.At present,most of the international researches published are focused on college students,and the average score of the stress scale of the researched groups was more than 25 points,[10,11]suggesting that although some group of the senior high school students in China experienced a high level of stress;the overall average stress level of such students was lower than that reported by the international researches.

Previous studies showed that the COVID-19 pandemic had a greater impact on the psychological stress of women compared with men[11-14].However,there was no statistically significant difference in the stress score of the students with different genders,or from urban or rural areas in this study.This may be related to China's emphasis on the equalization of education resources and psychological services in recent years,which has reduced to a certain extent the disparities in education and socio-economic status related to gender and urban and rural areas[15].Moreover,the similar stress level among different groups of students also suggests that there exits a solid foundation for a relatively unified national intervention programme to be established to cope with the stress of senior high school students in China during the COVID-19 pandemic.

The influencing factors of perceived stress of senior high school students

By ranking the scores of all the items and items under the two subscales of CPSS,it was found that Chinese senior high school students scored the highest for the item“Often found yourself think about things that you have to accomplish”.This reflects the senior high school students'sense of tension and urgency,brought about by the feeling and also the greatest source of stress that there are always many tasks to complete.The sense of lack of control was reflected in senior high school students'perception that“they are not on the top of things”.This may be because Chinese senior high school students are not given enough autonomy to make decisions in other aspects in the face of heavy academic pressure,and this has led to the lack of confidence in their ability to make decisions independently.When facing changes,they are thus more prone to stress because of the lack of control.No similar studies have been found through the perusal of literature,indicating the innovative results of the study and the need to further explore and verify such findings among the senior high school students in China in the future.

The results showed that personal socio-demographic factors were not the influencing factors of senior high school students'perceived stress after returning to school,or rather the important factors causing senior high school students'perceived stress were the change in their learning and sleeping routine,communication with the family and the family’s financial status.To some extent,due to the pandemic control measures,students might reduce their outdoor physical exercise,they tended to sleep late and kept an irregular learning and sleep routine.Lack of exercise leads to increased stress,anxiety and depression[16-18].This finding suggests that efforts should be made to equip the senior high school students with the capacity to maintain a regular learning and sleep routine and develop sound planning of their learning tasks,which can in turn help to regulate their mental health.During the pandemic control period,parents may have found that their time spent with their adolescent children either became longer or shorter,and the family’s atmosphere and its financial status also registered major impacts on the stress level of senior high school students.

Targeted stress relief interventions

This study also investigated into the coping channels of senior high school students,including self-adaptation,communication with family and friends,and seeking support from school and professionals.The results showed that the most favoured way of stress coping for senior high school students was to talk to friends for help,and friends could be influenced by each other to develop correlated mood swings.Based on this finding,it suggests that adolescents need to share their feelings with their friends,and studies have shown that peer education can improve adolescents'awareness of mental health[19].Therefore,peer education or group psychological counselling may be an appropriate intervention to improve the mental health of adolescents.In the process of the group counselling,adolescents will relate to and influence each other,and this will ultimately help to improve the mental health status of the whole group of adolescents.In addition,some researches have shown that the intervention of psychological counsellors has a positive impact on the mental health of adolescents.The results of this study also found that seeking professional support was also considered by many senior high school students when they were under great stress.Therefore,follow-up measures can be taken to improve the accessibility and friendliness of the services provided by the professional mental health service providers to the adolescents.

The results of this study also showed that the senior high school students with more coping channels had lower level of stress,and among the students with three or more coping channels,there was a lower proportion of those with a high level of perceived stress,compared with students with one or two support channels.Friends remained the first coping channel selected by the senior high school students,followed by parents and teachers;when there were many coping channels available,senior high school students tended to seek more professional psychological support from psychological counsellors.

Therefore,on the one hand,we should strengthen the mental health literacy education of adolescents,so that they can have the awareness of seeking resources to relieve stress.At the same time,we should pay attention to the relevant mental health education of parents and teachers,enhance the professional training of school psychology teachers and psychological counsellors of relevant institutions,strengthen the cross-sectroral cooperation between education and medical institutions,so that they can jointly provide various channels for senior high school students to relieve stress and improve their mental health status.

Limitations of this study

Although this study analyzed the perceived stress scores of senior high school students shifting from the online learning to on-campus learning after their return to school,the survey on the psychological stress during the online learning was a retrospective one with certain retrospective bias,which may have a certain impact on the research results.In this study,although we considered the willingness of the senior high schools selected to participate into the survey,the representativeness of the sampled population may be biased,which cannot fully represent the senior high school students in all local schools.The influencing factors related to stress considered in the self-designed questionnaire had limitations,as some factors that cause the stress of the adolescents were not included.