Prevention and control measures

China implemented a wide range of prevention and control measures to eliminate the spread of COVID-19 (see Table 1). In response, Chinese education institutions acted swiftly during the COVID-19 outbreak, implementing various precautions to protect their students’ safety and health [13]. As one of the earliest and hardest hit countries, Chinese universities were at the forefront of efforts to control the pandemic. Many universities implemented online learning to replace in-person classes to respond to the outbreak. They expected such methods to help control the coronavirus spread between students, teachers, and the wider population [14]. Students and faculty members would have otherwise been at a higher risk of contracting the virus through close contact in crowded classrooms and lecture halls. Additionally, Chinese universities implemented strict entry and exit controls, such as temperature checks and health screening questionnaires, to identify potential cases and prevent infected individuals from entering campus [15]. These measures were crucial in identifying potential cases early on and preventing spread within the university community.

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Table 1. Prevention and control measures for COVID-19 pandemic in China.

https://doi.org/10.1371/journal.pone.0296309.t001

To further reduce the risk of transmission, many universities required students, faculty, and staff who had travelled to areas with high numbers of COVID-19 cases or who had come into contact with infected individuals to quarantine for 14 days before returning to campus [16]. This strategy ensured that those who may have been introduced to the virus could be isolated and, if necessary, receive medical care reducing the risk of further transmission within the university community. These control measures were instrumental in preventing the spread of the virus on campus and protecting students, faculty, and staff. However, the stringent measures and COVID-19 altered the normal academic life of Chinese university students, which impacted their mental health.

Mental health context

According to UNESCO [18], national lockdowns have impacted around 60% of students worldwide. The transition to online instruction due to COVID-19 lockdown measures adversely affected students’ mental health well-being, as shown by numerous studies [19]. Amerio found that social isolation during the lockdown negatively affected students’ mental health [9]. Adding to this understanding, Patelarou found that approximately one-third of nursing students in Spain, Greece, and Albania experienced moderate depression during the pandemic [20]. Interestingly, students in Spain had a significantly higher impact (59.1%) followed by Albania (34.5%) and Greece (21.8%). This might be attributed to the increasing number of COVID-19 cases in the region, which led to heightened public concern and anxiety. Similarly, a survey of university students in Bangladesh reported increased levels of agitation (28.5%), anxiety (33.3%), and depression (46.9%) during the pandemic [21]. In Japan, Ueda noted that the economic consequences of the pandemic, along with the direct health effects of COVID-19, impacted the mental well-being of university students [22]. Likewise, Lee found that students in Daegu, South Korea, experienced higher levels of depression and anxiety during the pandemic [23]. Similar finding across the global student community indicate that lockdown measures have had negative impacts on students’ mental health and suggest that interventions specific to this group are needed.

As the coronavirus spread, Chen found that a majority of Chinese students were at high or moderate risk of stress management, psychological state, risk perception, behavioural patterns, family relationships, academic stress, and peer relationships [15]. This was illustrated in particular among Chinese medical students, who experienced an increase in anxiety, melancholy, and sleep disturbances [24]. The prevalence of post-traumatic stress disorder (PTSD) in Wuhan, the region most affected by the pandemic, was 7% [25]. Notably, there were differences on the impact on mental health, particularly regional variations, with some regions reporting a greater impact on mental health. This can be seen in the Guangdong province where the rate of depression was 21.2%, and the rate of anxiety was 26.6%, both significantly higher than the national rate for students [26]. Furthermore, Gao found that depression and anxiety levels were higher than pre-covid levels [27]. This corresponds to findings that students may experience mental health issues when exposed to severe public health events.

Data sources and search strategy

This rapid review used the PICO framework (population, intervention, comparison and outcome,) to guide the literature search process [28, 29]. The PICO framework was used to focus the search and define search terms. Examples of search terms used to locate literature on the psychological well-being and coping strategies of Chinese university students include: ‘China’ or ‘Chinese*’ or ‘Asia’ and ’mental health’ or ‘emotional’ or ‘psychological*’ and ‘university students’ or ‘postgraduate’ or ‘undergraduate*’ or ‘college students’ and ‘adaptation’ or ‘(coping strategies)*’ or ‘coping skills’ and ‘COVID-19*’ or ‘2019 nCov infection’ or ‘SARS- Cov-2’ or ‘coronavirus disease-19’. Literature search results were restricted to peer-reviewed articles, with the year of publication limited from 2019 to 2023. During the search process, an asterisk (*) symbol after a keyword was used as truncations to facilitate the capture variations of the term. In addition, Boolean operators such as "or" and "and" were used to obtain an exact search range, including articles matching any search terms. As the target group of this study was Chinese university students, both Chinese and English language articles were included in the review.

Data analysis and synthesis

Following the search for literature, search results were screened. As shown in Fig 1, literature matching the criterion for screening and inclusion was included in this study. A PRISMA diagram was used to systematically document the search results, screening, and selection using the inclusion and exclusion criteria. Duplicate articles were removed, and titles and abstracts of the studies were evaluated for their applicability, and any article that was not relevant was excluded. This process avoided collecting repeated data to avoid bias in the outcomes [30]. In addition, the rapid review was conducted in accordance with the guidelines outlined in the PRISMA checklist (see S1 Checklist).

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Fig 1. PRISMA flow diagram.

https://doi.org/10.1371/journal.pone.0296309.g001

Thematic analysis

Thematic analysis (TA), using six steps noted by Braun and Clarke, was used to identify patterns, organize them, and draw meaningful insights from the data [31]. During the first step, the researcher studied the textual material multiple times to develop familiarity with the data. Following this, initial codes were generated, and the data were analysed systematically by coding. In the third step, themes were generated from the code. This allowed for the analysis to take shape. In the fourth step, the themes were reviewed and refined. Some themes were expanded while others collapsed following the review. The themes were then named and defined, clearly stating what makes each topic unique and specific. During the final step, a report was generated based on the analysis. The use of this approach allowed for the minimization of biases in the analysis process. The themes of the review articles were coded and organized according to different categories.

Mental health status

Lockdowns and subsequent restrictions on movement and gathering during the COVID-19 period significantly impacted the mental health of Chinese university students. The literature revealed three broad impacts: (i) anxiety (ii) post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) (iii) suicidal ideation and depression (see Table 4).

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Table 4. Mental health issues among Chinese college students during the COVID-19 pandemic.

https://doi.org/10.1371/journal.pone.0296309.t004

Anxiety symptoms

Cao found that before implementing the Dynamic Zero COVID-19 policy in 2020, approximately 25% of university students expressed pandemic-related concerns, with most experiencing mild anxiety [32]. As COVID-19 cases increased and spread to more provinces, students’ anxiety levels heightened. Factors such as impact to parental income sources, living arrangements, and infected relatives were associated with increased anxiety levels [34, 38, 42, 43]. Control measures implemented during the spring semester delayed students’ return to campus, worsening their anxiety symptoms and increasing the proportion of affected students [45, 46]. Online courses further fuelled uncertainty about future education, increasing reports of sleep problems, nightmares, and stress levels [49]. This was further heightened by increased isolation and reduced social interactions [48]. Contrary to these findings, Lin reported that university students experienced less anxiety but higher perceived stress during isolation [39]. The disparity was more pronounced among students who were in the later stages of their studies, particularly medical students. Additionally, increased anxiety levels were reported in August 2020, coinciding with the normalization of pandemic prevention measures and causing uncertainty about students’ return to campus [50].

Post-traumatic stress disorder (PTSD) and acute stress disorder (ASD)

When specific preventive measures were not implemented at the beginning stage of the pandemic, evidence suggests that less than 5% of college students had symptoms of PTSD [47, 52]. While long-term home isolation was not related to PTSD or depression, there was a direct correlation between stressors associated with the pandemic and elevated ASD symptom levels. Liao found that in August 2020, after the implementation of the dynamic zero policy, the PTSD level among Chinese university students increased to moderate to high-levels [44]. While PTSD symptoms at the early stages of the pandemic could be attributed to misdiagnoses and attributed to other stressors, the study demonstrated a direct impact of the dynamic zero policy on Chinese university students. Anxiety did not vanish in students; instead more symptoms associated with PTSD showed up over time. Similar results were noted about four months after the outbreak, indicating that COVID-19-infected university students were more likely to have PTSD compared to students who are COVID-19-negative [43, 46].

Suicidal ideation and depression

In February 2020, following the strict lockdown measures, as much as 5% of university students had depression [47]. In March 2020, a follow-up survey revealed that nearly half of the university students had substantially worsened symptoms of depression [46]. This was a significant increase, and students reported extreme dread during the outbreak. The literature indicated a link between shorter sleep duration and poor mental outcomes. Those who resided in areas with high infection rates, and were in the later stages of their studies had the highest risk of developing depression. Interestingly, results indicated gender differences, which may be attributed to the pandemic prevention policies of the universities [10, 54]. Universities implemented specific measures and support systems for male and female students. Variations in these strategies and resources provided by universities may be linked to the differences in mental health outcomes for male and female students. Additionally, approximately one-fifth of university students reported having suicidal thoughts between March and April 2020. This was attributed to social and economic status, COVID-19-related family financial pressure, perceived social support, along with perceived COVID-19 danger [37, 38].

Strategies for coping with the psychological impact

In response to the challenges posed by the COVID-19 pandemic, Chinese university students employed a number of coping strategies to minimise psychological impact. These strategies were categorized into three main themes, namely (i) social support, (ii) family support, and (iii) negative and positive response (see Table 5).

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Table 5. Mental health coping strategies among Chinese university students during the COVID-19 pandemic.

https://doi.org/10.1371/journal.pone.0296309.t005

Social support

There is a negative correlation between the prevalence of anxiety and depression symptoms for university students and social support. The research consistently demonstrated that social support positively correlates with reducing anxiety levels [33, 42, 53]. Moreover, these studies reveal that social support was crucial in mediating the relationship between cognitive and behavioural coping strategies and anxiety. This confirmed the role of social support in reducing anxiety and highlights its function in promoting anxiety reduction. Cao found that during the pandemic social support mechanisms reduced [32]. However, when comparing coping mechanisms among students in China, Bangladesh, Malaysia, Saudi Arabia, and Pakistan, Chinese university students were found to have more possibilities to use social support-seeking skills, which may be attributed to the widespread application of social media in China [34]. Furthermore, it is worth noting that adaptability, social support, and resilience have been identified as robust factors providing individual and social protection against acute stress disorder (ASD), as outlined by Ye [52]. In the context of our results, it’s important to highlight that social media platforms have emerged as one of the avenues where individuals have demonstrated adaptability, social support, and resilience.

Family support

Anxiety, depression, stress symptoms, and suicidal tendencies have substantial negative associations with family support [37, 38]. Family support has shown the potential to reduce mental illness severity, especially anxiety [42]. Moreover, perceived family support was an essential protective factor in preventing college students from experiencing negative mental health consequences and the exacerbation of suicidal tendencies during the pandemic. This was because family members are better positioned to communicate health needs, more inclined to support each other emotionally and have empathy for one another. In particular, benefits from family support arose from their ability to provide individualized care and support. This support appeared to demonstrate a more promising effect on lessening the severity of mental illness than help from a spouse or friend.

Clarifying further, Li suggested that family support and anxiety have an indirect relationship rather than a direct one [41]. This indirect relationship demonstrates that cognitive, emotional, and behavioural coping strategies could be helpful in mediating anxiety. The strong mediating effect suggests that living with family members may not be a key factor in reducing anxiety, but rather the adoption of appropriate coping strategies is necessary to activate the transmission of family support and reduce anxiety.

Negative and positive response

Positive coping strategies clearly reduced the mental health impact on Chinese students as a result of lockdowns and other prevention and control measures, particularly depressive symptoms [10, 41]. This suggests that active coping strategies can support students to address challenges and problems more rationally and may alleviate stress, thereby preventing depression. During the pandemic, mental health issues and hazardous behaviours caused by alcohol and cigarette abuse emerged as a new health concern, particularly among undergraduate students. Using unhealthy coping strategies such as smoking and excessive drinking can harm the mental health of students. Individuals aged 14 to 35 commonly employed passive defense strategies, including emotional suppression and substance abuse. Interestingly, according to a survey of university students, nearly one-third of respondents admitted to utilizing negative coping strategies such as “smoking, drinking, taking drugs, or overeating to reduce worry” during COVID-19 [38]. Worryingly, this suggests that students with mental health issues such as stress and anxiety could adopt harmful behaviours as a coping mechanism. In contrast, adopting positive coping strategies could constructively regulate psychological distress and alleviate negative emotions. Moreover, female students employed positive coping strategies more than male students. This was because they had better emotional regulation, higher cognitive evaluation, and lower expression inhibition than male students [43]. The study further revealed that male students experienced greater psychological stress than female students.

During COVID-19, physical activity was identified as a positive coping strategy for Chinese college students to reduce their negative mental health effects [44]. Several studies investigated the connection between psychological health and physical exercise during this period. Most students reported that physical exercise helped them relax and manage psychological stress [36, 55]. This suggests that psychological health issues resulting from the COVID-19 pandemic or other crisis events can be alleviated by increasing awareness of physical exercise [51].

Mental health impacts and interventions

During the COVID-19 pandemic, Chinese university students experienced elevated anxiety levels, impacting their mental health [32, 42, 45, 49]. Despite variations in assessment methods, the findings consistently noted the substantial mental health impact of the pandemic on Chinese university students. Stressors such as financial constraints, distance learning, and uncertain future career prospects emerged as major contributors to anxiety among students [34]. Additionally, it was observed that female students exhibited higher anxiety levels, suggesting the need for further investigation into the underlying factors.

A significant number of Chinese university students also displayed symptoms of anxiety-related disorders such as ASD (Acute Stress Disorder) and PTSD (Post-Traumatic Stress Disorder) during the pandemic [43, 44]. International studies support these findings, indicating that university students globally were at risk of developing PTSD due to pandemic prevention and control measures [56, 57]. This emphasized the need for early screening tools to identify and address PTSD symptoms related to COVID-19. It is important to note that the gravity of the problem may be larger than reported in studies. Evidence suggests that early studies may have underestimated the prevalence of PTSD symptoms due to limited awareness and societal stigma surrounding mental health issues [58, 59]. As the pandemic progressed, the prevalence of PTSD increased, suggesting that ongoing mental health monitoring and interventions are crucial to address the long-term impact of the pandemic on university students’ mental well-being [46].

Moreover, the studies highlighted the role of intrinsic and interpersonal factors in mitigating the connection between COVID-19 stressors and elevated levels of ASD symptoms [52]. Factors such as social support, adaptive coping strategies, and resilience attenuated the impact of stressors on mental health outcomes. This underscores the importance of implementing effective coping strategies, emotional control techniques, and providing adequate social support to mitigate the mental health consequences experienced by Chinese university students.

Furthermore, the pandemic led to a notable increase in reports of depressive symptoms and suicidal tendencies among Chinese university students. Male students were more likely to develop depression symptoms, influenced by cultural and societal factors [60, 61]. The availability of social support and financial stress played important roles in exacerbating or mitigating the effects of the pandemic on mental health outcomes [32]. Additionally, sleep disturbances and shorter sleep duration were reported by students during the pandemic and were associated with negative psychological consequences, including depressive symptoms [62]. Understanding the bidirectional relationship between mental health and sleep, addressing cultural factors, providing social support, and alleviating financial stress are essential in promoting the well-being of Chinese university students in the context of the pandemic.

The cumulative impact of the pandemic on the mental health of Chinese university students highlights the need for comprehensive interventions. This includes addressing social and economic inequalities, promoting healthy sleep habits, and ensuring equitable access to mental health care. Efforts should focus on providing necessary resources and support, particularly for vulnerable populations from lower socioeconomic backgrounds. By strengthening mental health support systems and taking proactive measures, universities and policymakers can create an environment that prioritizes the well-being of university students, fostering resilience in the face of future challenges.

Coping strategies and social support

The mental health of Chinese university students during the COVID-19 pandemic was influenced by various factors, including social support, family support, and coping strategies. Social support played a crucial role in supporting the mental well-being of these students. There are strong links between social support and the prevalence of anxiety and depressive symptoms, where poor support systems have increased prevalence [32, 33, 63]. By reducing psychological stress, social support effectively mitigates depression and anxiety among university students. This highlights the importance of fostering social support and creating a supportive community within educational institutions.

Interestingly, Chinese university students preferred to seek social support online, utilizing platforms such as WeChat, QQ, and other social media platforms [64]. This suggests that social media can provide a convenient and accessible way for students to seek support during times of crisis. Leveraging technology and social media in supporting students is an important understanding, and can have benefits beyond the Chinese student population. It is therefore important to raise awareness of and potential benefits of leveraging social media and technology to emulate support mechanisms during times of crisis. By utilizing social media platforms, educational institutions can create online communities that foster connection and facilitate open discussions about mental health and combating feelings of isolation. Social support exhibits a strong association with anxiety reduction, making it vital for institutions to emphasize its importance and provide guidance on using technology to access support networks [59, 65]. Through targeted campaigns and resources, universities can create a supportive online environment encouraging students to connect with peers, seek help, and reduce anxiety levels.

Family support has been found to impact the psychological health of Chinese university students during the pandemic. Specifically, perceived family support protects against negative mental health consequences [38, 42]. In particular, family support and good functioning reduces feelings of loneliness and anxiety among students and safeguards against the exacerbation of suicidal tendencies [37, 41]. Good family functioning is characterized by a strong adaptation to the pandemic, supportive communication and good social connections. Family ties and support are important in Chinese culture, where filial piety, the Confucian principle of respecting and caring for one’s parents and ancestors, is considered a fundamental virtue [66]. The strong emphasis on family relationships and intergenerational support in Chinese society reflects the importance of filial piety, which has significant implications for social support function in Chinese university students’ mental health.

However, while family support is important, addressing mental health issues during the pandemic may not be sufficient. Appropriate coping strategies are necessary to activate the transmission of family support and decrease anxiety levels. Effective coping strategies, including cognitive, emotional, and behavioural approaches, can reduce anxiety levels and increase resilience. Cognitive strategies involve reframing negative thoughts and adopting more adaptive thinking patterns, while emotional strategies involve managing and expressing emotions in healthy ways [67]. Behavioural strategies focus on taking proactive actions, such as engaging in physical exercise, practicing relaxation techniques, or seeking professional help when needed [36]. Educational institutions and mental health professionals should focus on promoting cultural connections to family, tapping into family connections and support to equip students with effective coping strategies to manage stress and reduce anxiety. As a result, many educational institutions have launched mental health awareness campaigns to destigmatize mental health issues and encourage students to seek family support [68]. These campaigns aim to educate students, faculty, and staff about the importance of family support and coping strategies in managing stress and anxiety. Implementing support services such as family counselling, peer support, and mentoring programs can also strengthen family relationships and create a more supportive community [69].

Positive coping strategies were found benefit Chinese university students’ mental health, while negative coping mechanisms were associated with hazardous behaviours and worsened mental health outcomes [10]. Active coping strategies, such as problem-solving and stress reduction, enhanced mental health outcomes more effectively than avoidant coping. Students with positive coping strategies dealt with problems more rationally, reduced stress, and prevented depression. However, some students resorted to negative coping strategies such as substance abuse or overeating to alleviate worry, leading to harmful behaviours and worsened mental health outcomes [38].

Seeking social and familial support has been associated with lower reactions to post-traumatic stress disorder (PTSD) symptoms. Numerous studies have shown that having a strong support system from family members and peers can mitigate the negative impacts of traumatic experiences on mental health outcomes [70, 71]. This highlights the importance of promoting social connections and fostering supportive relationships for individuals experiencing PTSD symptoms, including Chinese university students during the pandemic and future crisis events. Physical activity has also been recognized as an effective coping mechanism for reducing negative mental health effects among university students. Engaging in regular exercise has been associated with improved psychological well-being, stress reduction, and increased resilience [72, 73]. The positive effects of physical exercise can be attributed to its ability to help individuals relax, release tension, and cope with psychological stress. Notably, physical exercise has been found to exhibit a negative correlation with stress levels, emphasizing its potential as a valuable coping strategy for Chinese university students facing mental health challenges during the pandemic [36, 51, 55].

However, it is crucial to acknowledge the presence of gender differences in coping strategies and psychological stress levels. Evidence indicates that women tend to exhibit higher positive coping strategies, including seeking social support and engaging in emotional expression [74, 75]. Conversely, men often report experiencing greater psychological stress and may rely on alternative coping mechanisms, such as avoidance or substance use [76, 77]. These gender differences underscore the need for gender-specific support and intervention strategies to address the unique challenges faced by female students and promote their mental well-being.

Strengths and limitations

In this rapid review, we acknowledged both its strengths and limitations. The strengths of this study were rooted in its timeliness and adaptability. As the research focused on the rapidly evolving COVID-19 pandemic’s impact on Chinese university students, a rapid review was well-suited for efficiently and cost-effectively investigating limited literature. The study’s potential to bridge knowledge gaps, inform policy and practice, and offer timely insights into the mental health of this population added to its relevance and impact. However, some limitations to this review should be noted. First, due to the rapid nature of this review, we may have missed some relevant studies that were not included in our search. Additionally, the studies’ reviewed varied in quality and there were some inconsistencies in the methods used to measure mental health and coping strategies. This could impact the accuracy of our findings and conclusions. Finally, the review focused solely on Chinese university students and may not be generalisable to other populations or settings, given the uniqueness of the Chinese dynamic zero policy.

Although limitations still existed, the review formulated a useful summary of the current research on the coping strategies and mental health of Chinese university students. By synthesizing the existing research, it was possible to identify research gaps and devise targeted interventions to support the mental health of students during and after the pandemic.