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

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          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.


          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.


          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.

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          Most cited references 21

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          Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019

          Key Points Question What factors are associated with mental health outcomes among health care workers in China who are treating patients with coronavirus disease 2019 (COVID-19)? Findings In this cross-sectional study of 1257 health care workers in 34 hospitals equipped with fever clinics or wards for patients with COVID-19 in multiple regions of China, a considerable proportion of health care workers reported experiencing symptoms of depression, anxiety, insomnia, and distress, especially women, nurses, those in Wuhan, and front-line health care workers directly engaged in diagnosing, treating, or providing nursing care to patients with suspected or confirmed COVID-19. Meaning These findings suggest that, among Chinese health care workers exposed to COVID-19, women, nurses, those in Wuhan, and front-line health care workers have a high risk of developing unfavorable mental health outcomes and may need psychological support or interventions.
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            The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk.

            We examined the psychological impact of the 2003 outbreak of severe acute respiratory syndrome (SARS) on hospital employees in Beijing, China.
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              Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population.

              The 7-item Generalized Anxiety Disorder Scale (GAD-7) is a practical self-report anxiety questionnaire that proved valid in primary care. However, the GAD-7 was not yet validated in the general population and thus far, normative data are not available. To investigate reliability, construct validity, and factorial validity of the GAD-7 in the general population and to generate normative data. Nationally representative face-to-face household survey conducted in Germany between May 5 and June 8, 2006. Five thousand thirty subjects (53.6% female) with a mean age (SD) of 48.4 (18.0) years. The survey questionnaire included the GAD-7, the 2-item depression module from the Patient Health Questionnaire (PHQ-2), the Rosenberg Self-Esteem Scale, and demographic characteristics. Confirmatory factor analyses substantiated the 1-dimensional structure of the GAD-7 and its factorial invariance for gender and age. Internal consistency was identical across all subgroups (alpha = 0.89). Intercorrelations with the PHQ-2 and the Rosenberg Self-Esteem Scale were r = 0.64 (P < 0.001) and r = -0.43 (P < 0.001), respectively. As expected, women had significantly higher mean (SD) GAD-7 anxiety scores compared with men [3.2 (3.5) vs. 2.7 (3.2); P < 0.001]. Normative data for the GAD-7 were generated for both genders and different age levels. Approximately 5% of subjects had GAD-7 scores of 10 or greater, and 1% had GAD-7 scores of 15 or greater. Evidence supports reliability and validity of the GAD-7 as a measure of anxiety in the general population. The normative data provided in this study can be used to compare a subject's GAD-7 score with those determined from a general population reference group.

                Author and article information

                BMJ Open
                BMJ Open
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                8 October 2020
                8 October 2020
                : 10
                : 10
                [1 ]departmentSchool of Public Health , Fudan University, Key Laboratory of Public Health Safety, Ministry of Education , Shanghai, China
                [2 ]departmentKey Laboratory of Health Technology Assessment (Fudan University) , Ministry of Health , Shanghai, China
                [3 ]departmentWorld Health Organization (WHO) Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine , The University of Hong Kong , Hong Kong, China
                Author notes
                [Correspondence to ] Professor Hongjie Yu; yhj@
                © 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.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

                Funded by: National Science and Technology Major Project of China;
                Award ID: 2018ZX10201001-010; 2017ZX10103009-005; 2018ZX1071
                Funded by: FundRef, National Natural Science Foundation of China;
                Award ID: 71704027
                Funded by: Shanghai Municipal Education Commission and Shanghai Education Development Found for Chenguang Program;
                Award ID: 17CG03
                Funded by: National Science Fund for Distinguished Young Scholars;
                Award ID: 81525023
                Infectious Diseases
                Original research
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                public health, mental health, health policy


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