{'fraction_non_alphanumeric': 0.03413790974751528, 'fraction_numerical': 0.0224087906660905, 'mean_word_length': 5.08564988730278, 'pattern_counts': {'":': 0, '<': 1, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
COVID-19 impact on high school student’s education and mental health: A cohort survey in China

BACKGROUND The ongoing coronavirus disease 2019 (COVID-19) pandemic and the universal implementation of control measures are fundamentally affecting every aspect of our society and daily lives. AIM To evaluate the prevalence of post-traumatic stress disorder symptoms and their associated factors as well as the effects and attitudes towards online education in Chinese high school students. METHODS A total of 883 students were included. The first, second and third-year students of a high school in Lanzhou, Gansu province of China were invited to participate in this study. They were requested to involve their parents to complete the survey together. A detailed questionnaire of 65 questions was designed and divided into five sections. The survey was anonymously conducted via WeChat, a Chinese multipurpose messaging, social media and mobile payment app. RESULTS Overall, 32.94% of students experienced post-traumatic stress disorder due to the COVID-19 epidemic. The majority of students (60.82%) felt that online education was not (10.76%) or less effective (50.06%) in terms of gaining knowledge and improving practical and communications skills. Correlation analysis revealed that the class level, residential background and whether living with parents were significantly linked with the effectiveness and satisfaction of the online education system. Of the final year students, 74.2% said that the COVID-19 outbreak has negatively affected their preparation for the college entrance exam, and 68% of students felt that this outbreak increased psychological pressure for their college entrance examination preparation. In case of having COVID-19 symptoms during the exam, 50.7%, 13.3%, and 10.2% would notify the proctor, teacher and parents, respectively. CONCLUSION We found a high prevalence rate of post-traumatic stress disorder symptoms in high school students. Thus, our results call for urgent attention from both government and schools to implement effective interventions to cope with the psychological effects and the disturbance of education by COVID-19 on children.


INTRODUCTION
The ongoing coronavirus disease 2019 (COVID-19) pandemic and the universal implementation of control measures are fundamentally affecting every aspect of our society and daily lives. School closure is one of the most important measures widely implemented worldwide. According to UNESCO's estimates, more than 190 countries have adopted nationwide school closures, resulting in roughly 90% of the global student population out of school and confined at home [1]. The classroom syllabus has been swiftly changed into an online education system. However, the education sector was not well-prepared to launch such large-scale online education programs. Thus, the effectiveness of this new education format and the effects on students remain largely uncertain.
According to epidemiological research after a traumatic event, about 5%-12% of individuals may develop post-traumatic stress disorder (PTSD) [2]. School closure, living in confinement and risk of the infection are creating anxiety and are affecting education, psychological health and well-being of students [1]. According to Chinese government estimates approximately 220 million teenagers were not allowed to go out during the COVID-19 epidemic in China. However, the consequences and the degrees of impact could vary among different levels of students.
In China, the schooling system includes primary school (6 years), junior middle school/secondary school (3 years) and senior middle school/ high school (3 years). Afterwards, students have the opportunity to continue to higher education by passing the college entrance examination, a nine-hour national higher education entrance exam. It is offered once a year and taken by around 10 million students annually. It is the sole determinant for admission to virtually all Chinese colleges and universities. Because of a limited amount of university spots available, it is an ultra-competitive exam and imposes tremendous pressure on the third-year high school students.
The COVID-19 epidemic was first reported in China. The teenagers were restricted at home for a long time and were the first to switch to online education. Although the rises of psychosomatic issues caused by COVID-19, especially in teenagers, have been widely reported [3][4][5], innovative investigation into this issue remains scarce. In this study, we conducted a large cohort survey in a high school at the end of the COVID-19 epidemic in China. We evaluated the prevalence of PTSD symptoms and their associated factors as well as the effects and attitudes towards online education. We further investigated the impact on the final year high school students relating to the college entrance examination.

Study population
The first, second and third-year students of a high school in Lanzhou, Gansu province of China were invited to participate in this study. They were requested to complete the survey with their parents. The study was conducted from April 20 to April 30, 2020.

Survey instrument
A detailed questionnaire comprising of 65 questions was designed and divided into five sections. The first four sections were designed for all the students, comprising of 11 demographic, 11 COVID-19, 9 online educations and 22 PTSD related questions. The final section consisted of 11 college entrance examination related questions specific for the final year students. The survey was anonymously conducted via WeChat, a Chinese multipurpose messaging, social media and mobile payment app.
The 9 online education related questions were designed to assess effectiveness (3 questions), efficiency (3 questions) and satisfaction (3 questions). Each question was comprised of five options including no, low, average, good and excellent.
In this study, we used Impact of Events Scale-Revised (IES-R) self-questioner to examine the psychological impact [6,7]. Further detail has been documented previously [5]. IES-R questioner was translated into Chinese language. IES-R questioner validity and reliability has been extensively reported [8][9][10].

Statistical analysis
Descriptive statistical analysis was done to demonstrate the demographic characteristics of the participants. First, a univariate analysis was done to screen statistically signicant variables, which were subsequently subjected to multivariate logistic regression analyses. The estimations of the strengths of associations were revealed by the odds ratio with a 95% condence interval. Descriptive and inferential statistics were calculated using SPSS version 20.0 for Windows (SPSS Inc., Chicago, IL, United States). All statistical tests were two-sided, and a P value < 0.05 was considered statistically significant.

RESULTS
In total, 893 students participated in the survey. Ten students declined to continue. Therefore, 883 students were included. Participant demographic characteristics were given in Table 1. There were 33.4% first-year, 23.6% second-year and 43.0% final year students. Most students were from the Han ethnic background (98.1%), and 53.2% were girls and 46.8% were boys. The majority of the students were living with parents (96.3%) in urban areas (85.4%) ( Table 1).
The majority of students (683 of 866) reported that their families are fully aware of COVID-19. Overall, students reported that they were affected economically (41.6%), psychologically (22.1%), emotionally (6.8%), socially (6.8%) and physically (6.8%) by the COVID-19 epidemic. In contrast, 14.9% of students reported that they were unaffected. A large percentage (93.0%) reported that they have gone back to their normal routine ( Table 2). The outbreak negatively affected 68.3% of student's studies. Although 96.5% of the respondents were willing to returning back to schools, 63.0% of students have concerns regarding the risk of getting COVID-19 once back to school. Knowledge about the signs and symptoms of COVID-19 such as fever, difficulty/shortness of breath, cough, flu-like symptoms, diarrhea, fatigue, sore throat and chills were found to be known by 65.2%, 12.9%, 7.6%, 4.4%, 1.6%, 1.0%, 0.9% and 0.1% of participants, respectively. When students suspect infection, 51.0% of the participants prefer to inform their teachers, whereas 29.7% would go into self-isolation (Table 2). In this study, a total of 33.0% students had an IES-R score above 20 (Table 3). PTSD symptoms were significantly higher in rural (P = 0.001) compared to urban students. PTSD symptoms were also significantly more prevalent in students whose parents have lower education and profession levels (Table 3).
Students felt that online education was not (10.8%) or less effective (50.1%) for acquisition of knowledge, enlightening practical as well as communication skills. Students reported that it was not (17.9%) or less (43.9%) effective that students were not able to complete their homework, communicate with teachers and take advantages of the multimedia setup. Over half (64.8%) of the students reported that they were not or less satisfied and had difficulties adapting to the online education system (Supplementary Table 1). Correlation analysis revealed that the class level, residential background and whether they lived with parents were significantly associated with satisfaction and effectiveness of the virtual tutoring system (Supplementary Table 2).
This study showed that IES-R scores were substantially associated with residential background, the education level and profession of parents and family monthly income (Supplementary Table 2). According to univariate analysis, residential background, family monthly income and the professions of mother and father were significantly linked with PTSD symptoms. For multiple logistic regression analysis, only residential background remained as a significant factor relating to PTSD symptoms in children (  Supplementary Table 3).
In this study, 380 participants were final year students and thus were eligible to fill in the college entrance examination section of the questionnaire. Twenty-seven participants did not complete all questions and were excluded, resulting in 353 students for final analysis. Among them, 74.2% said that the COVID-19 outbreak negatively affected their preparation for the college entrance exam. The outbreak increased psychological pressure for the college entrance examination preparation in 68.0% of students. Although 54.7% students regarded the online learning system as helpful to their preparation, 97.7% said that school opening would be beneficial for preparing for the college entrance examination. The postponement of the college entrance examination was favored by 90.4% of students. There were concerns regarding the risk of getting COVID-19 during the exam from 61.8% of students. To minimize the risk, 41.6% participants said that they would follow strict personal hygiene during the college entrance examination. A face mask would be worn during the exam by 19.5%, and 17.8% would use the mask on the way to the exam and to home. If a student had COVID-19 symptoms during the exam, then 50.7%, 13.3% and 10.2% would notify the proctor, teacher and parents, respectively (Supplementary Table 4).

DISCUSSION
To minimize the spread of COVID-19, China has implemented strict quarantine measures including school closures, travel bans, lockdowns and within-population quarantine. These measures have majorly impacted the mental health of young June 19, 2021 Volume 11 Issue 6 children and adolescents [3,4]. Here, we first measured the COVID-19 epidemic effects on the mental health of high school students. Further, we identified the potential risk factors linked with PTSD symptom development in this youth cohort. Our results showed that 33.0% of students experienced PTSD signs and symptoms due to the COVID-19 epidemic. The high PTSD symptom incidence rate is likely attributed to several factors, including confinement at home, worrying about their academic progress and future plans as well as fearing the risk of infection [3,4,11-15]. We found that PTSD symptoms were significantly higher in rural students and students whose parents have lower levels of education and professions. This is in line with the fact that COVID-19 has had a substantial effect on the global economy, including an increase in the unemployment rate [16]. Families with low social economic status having such economic loss will likely experience immediate effects on their daily livelihood. This will subsequently increase psychological and economic pressure on their children [17].
To minimize education losses, the authorities have swiftly launched online portals and web-based applications and switched the education system to a virtual education system. However, virtual education systems need an efficient and well-organized learning environment and implementation. However, the sudden outbreak of COVID-19 in China caused a substantial variance in virtual systems among schools of different provinces. In this study, the majority of students were not satisfied with online education. The class level of the students, residential background and living with parents were significantly linked with the online education system effectiveness. There are two possible reasons. First, students from higher classes are skilled enough to adapt the virtual education system. Provinces or families with an advanced socioeconomic background are more equipped with the latest technologies. Second, the majority of the participants were not happy with the virtual teaching system. The education department officials should take this issue seriously to improve the virtual education system effectiveness and ensure all students have access to the digital devices and its use.
The final year high school students are facing with mounting pressure of the national college entrance exam. The results of this exam often have a lifelong effect on most Chinese citizens [18]. The college entrance examination usually takes place from June 7 to June 8 every year. The Chinese Ministry of Education postponed the exam by 1 mo due to the COVID-19 epidemic. In our survey, over half of the final year students felt that the COVID-19 outbreak negatively affected their preparation for the exam and increased their psychological pressure. Although half of the students thought the online learning system helped their preparation, almost all the students preferred school opening for better preparation of the college entrance examination. Over 90.0% of students favored the postponement of the college entrance examination. Over half have concerns of the potential risk of getting COVID-19 during the exam, but they are prepared to take precaution measures.
A limitation in this study is that this survey was conducted in a single school in China in a region with a low number of confirmed COVID-19 cases. Therefore, the findings in this study may not represent other schools and regions in China. Finally, we did not study the content of online education in detail in our cohort as it cannot represent the format of other regions because it varies markedly among different schools and regions in China.

CONCLUSION
In this study, we found that 33.0% of high school students have experienced PTSD symptoms due to the COVID-19 epidemic. These symptoms are significantly more common in students living in rural areas and whose parents have a low education level and low grade jobs. The epidemic has affected the preparation of the national college entrance exam for the final year students, but they appreciate the postponement of the exam by 1 mo. Notably, a large proportion of respondents were not satisfied with online education. Therefore, it is suggested that the authorities optimize the online education program and ensure equal opportunities for the students to get access to the digital learning. Our results call for urgent attention from both government and schools to implement effective interventions to manage the psychological effects and the disturbance of education by COVID-19 on children.