Evaluating the Mental Health Impacts of parents during the Adjustment of China’s Pandemic Policy: Roles of Socioeconomic Factors, Existing COVID-19 Experiences, and Lifestyles

doi:10.21203/rs.3.rs-4887106/v1

In December 2022, China announced easing measures for COVID-19 as part of a pandemic policy adjustment. Uncertainty following adjustment and widespread infection had negative impacts on parents' mental health. In the present study, we aimed to evaluate the impact of policy change on mental health and identify risk and protective factors linked to parental mental health outcomes in the context of pandemic policy change and widespread public infection. During the first three weeks following the policy adjustment, a sample of 2385 Chinese parents' demographic data, infection conditions, preexisting COVID-19 experiences, perceived impacts, lifestyles, and mental health conditions (anxiety, depression, and parenting stress) were examined. The results revealed that 92.8% of the parents experienced infection after the policy adjustment. After the policy adjustment, parents with worse mental health conditions were linked to younger parents, lower social status scores, lower household income, and more children, and mothers. Parents who were classified as medium to high risk for COVID-19 reported higher levels of depression and felt that policy adjustment had more negative impacts. Quarantined parents experienced less depression, anxiety, and parenting stress. As a protective factor, greater sleep duration was associated with lower levels of depression, anxiety, and parenting stress, as well as more positive perceived impacts of policy adjustment among Chinese parents. Our findings support policy efforts that aid families with socioeconomic disadvantages and unfavorable prior COVID-19 experiences, and that have wide-ranging impacts on Chinese parents related to the adjustment of the COVID-19 pandemic policy. Our findings also imply that parents can support their own physical and mental health during a public mental health crisis by providing enough sleep, which is a straightforward yet effective strategy.

COVID-19

policy adjustment

anxiety

depression

parental stress

1.1 Adjustment of the Pandemic Policy in China

The global emergence of coronavirus disease 2019 (COVID-19) has resulted in an exceptional public health crisis that has never been witnessed before (Ali et al., 2020; WHO, 2020; Panchal et al., 2021; Rajkumar, 2020). As the world’s most populous country, China has implemented extensive and stringent measures to prevent the virus from spreading throughout the nation, including widespread nucleic acid testing, contact tracing, lockdowns, school closings, the requirement to use the health code, bans on public gatherings, and obligatory quarantine measures (Bian & Zhao, 2020; Hussain et al., 2020; Leigh-Hunt et al., 2017).

China announced various COVID-19 easing measures in a pandemic policy adjustment that was published in December 2022 (National Health Commission of the People’s Republic of China, 2022). For example, focused and scientifically based risk regions are classified on the basis of buildings, units, floors, and homes rather than enormous residential compounds. With the elimination of mass nucleic acid testing, people don’t need to pass negative nucleic acid tests or health code inspections to enter public spaces or travel, with the exception of a few particular locations. With the repeal of mandatory quarantine regulations, home quarantine is advised for carriers who are asymptomatic or have minor symptoms. High-risk area designation, mandatory quarantine, nucleic acid testing, and health codes were all abolished in China until January 2023. With the loosening of the COVID-19 policy, people have unrestricted access to supermarkets, shopping malls, and other public places, but many Chinese people were infected in a short period of time when exposed to the COVID-19 virus. Cities and towns experienced rapid viral outbreaks.

1.2 Mental Health Condition of Parents during COVID-19 Pandemic

Parents’ mental health has been negatively impacted by the pandemic as they deal with the stress of parenting, financial issues, and worries for the well-being and safety of their families and themselves (Adams et al., 2021; Karlsson et al., 2021; McGill et al., 2022). Parental worry and despair increased as a result of the unknown nature of the pandemic's beginning, according to preliminary findings from international research on the COVID-19 outbreak in 2020 (Johnson et al., 2022; Sharif-Esfahani et al., 2022; Westrupp et al., 2021). Research on the effects of the pandemic and widespread infection on mental health has revealed striking increases in the risk of depression, anxiety, posttraumatic stress disorder, and other mental disorders (Marroquín et al., 2020; Morgan et al., 2022; Westrupp et al., 2021). Furthermore, prior research has shown that changes in COVID-19-related rules and regulations could place considerable stress on families and parents (Vargova et al., 2022; Westrupp et al., 2021). Thus, during the period of policy adjustment and the national outbreak of infection in China, family life may have undergone significant changes. However, little information available about the mental health of Chinese parents during this particular period.

On the basis of evidence from studies of parenting during pandemics, parents face numerous challenges in terms of parenting and self-emotional well-being during the pandemic (Lantsoght et al., 2021; Soriano-Ferrer et al., 2021). First and foremost, the widespread COVID-19 outbreak has severely disrupted family health, education, and parenting (Brown et al., 2020; Cluver et al., 2020). Several schools must close to prevent the spread of infection, and parents are now responsible for teaching their children at home. This has presented difficulties for parents who might lack the knowledge or finances necessary to provide their children with a high-quality education. Research has shown that parents with lower levels of education had higher levels of anxiety and sadness during the pandemic (Mikocka-Walus et al., 2021). Furthermore, parents' capacity to create a stimulating environment for their children to learn can be harmed by the fear of infection and the health problems that follow infection (Suffren et al., 2021). A cross-sectional study of hospitalized patients, COVID-19 infected patients and their family members revealed increased levels of depression, anxiety, and stress symptoms in these patients and their families (Prakash et al., 2021). During this difficult period, parents may also find it difficult to control their children's emotions and behaviors, particularly if those children are experiencing anxiety or frustration (Deng et al., 2021; Johnson et al., 2022). For parents, the high demands of parenting and their children's lack of regularity and social engagement can be extremely challenging, resulting in mood swings and behavioral problems (Morgan et al., 2022).

More importantly, the poorer mental health status of parents is a potential risk factor for worse psychiatric morbidity in children. Parental depression and anxiety are risk factors for children developing depression and anxiety symptoms (Cote et al., 2009; Glasheen et al., 2013). Babore and colleagues (2023) reported that mothers’ distress was positively correlated with their parenting stress and their children's depressive symptoms. Additionally, a previous study suggested that the physical and mental development of children and newborns are impacted by the level of parental anxiety (Ramchandani et al., 2005). Parental experiences during the COVID-19 pandemic and parents’ stress, depression, and anxiety levels could be predictive factors of children's behavioral problems (Sancili & Tugluk, 2022). Consequently, it is both theoretically and practically important to examine parents' mental health state and its predictive factors in the context of China's pandemic policy adjustment.

1.3 COVID-19 Related Risk Factors and Protective Factors for Parents’ Mental Health

Consistent evidence shows that parents experiencing socioeconomic disadvantage face increased mental health problems related to COVID-19 (Dean et al., 2021; Salari et al., 2020). Socioeconomic disadvantage, including poorer household income, worse educational attainment, having more children, and job loss, has been linked to greater rates of anxiety and depression during the COVID-19 pandemic (Kusuma et al., 2021; Lee et al., 2021; Tull et al., 2020). For example, a prior study revealed that parents from families with different economic levels had significantly different state anxiety levels. Specifically, the lower the income level is, greater the level of anxiety in Chinese families (Ren et al., 2020). A study indicated that families with fewer social and economic resources fared worse in terms of mental health during the early stages of the COVID-19 pandemic than did families with more of those resources (Ben Brik et al., 2022).

China, the nation with the strictest COVID-19 control measures, implemented a mandatory quarantine rule for COVID-19 infected individuals and their close contacts prior to the adjustment of the pandemic policy (Wang et al., 2020). It has been shown that preexisting COVID-19-related experiences, such as being quarantined (at home or in a centralized facility) and living in a community that has ever been designated a medium- to high-risk area, can amplify negative effects and precipitate adverse mental health outcomes during the pandemic (Bozdağ, 2021; Chi et al., 2020). For example, a prior study revealed that social isolation caused by lockdown procedures and other security measures has resulted in feelings of loneliness and social isolation (Ben Brik et al., 2022; Yue et al., 2022). Parents' stress levels have increased as a result of the financial effects of quarantine and lockdown, which include job losses and lower income (Johnson et al., 2022; McGill et al., 2022; Mikocka-Walus et al., 2021; Peng et al., 2023). The pressure of balancing work and family responsibilities has also intensified, leading to burnout and fatigue (Le Vigouroux et al., 2022; Mousavi, 2020). However, these studies have yet to examine how preexisting COVID-19 experience is associated with parents’ mental health conditions in the context of adjusting the pandemic policy and large-scale public infection.

During the COVID-19 pandemic, an unhealthy lifestyle—including a lack of exercise and inadequate sleep—has been linked to worse mental health conditions (Duong, 2021). For example, a previous study found that anxiety and fear of COVID-19 were strongly associated with psychological distress, sleep disturbance, and life satisfaction (Duong, 2021). Other studies also reported that having enough sleep and exercising regularly was linked to better mental health, including a greater predisposition for mental well-being and a decreased chance of mental disease (Kong et al., 2022; Liang et al., 2023). Therefore, it is important to understand whether different lifestyles play a protective role in how parents adjust to life changes with major policy changes during the pandemic.

1.4 The Present Study

With the adjustment of pandemic policies in China, people have more freedom in social life and fewer restrictions on COVID-19 measures. However, the majority of the public was infected with COVID-19 within one month after the policy adjustment in China (Fig. 1). Currently, the national public health problem is at its most serious stage. One important source of stress is the concern that they can obtain the virus and that it may affect their family's health and well-being (Sharif-Esfahani et al., 2022). At the beginning of the implementation of the new policy, the constant uncertainty surrounding the pandemic and the lack of control over the situation may have led to feelings of helplessness and anxiety (Marroquín et al., 2020). Furthermore, conflicting and ever-changing policies can be confusing, leading to a lack of trust in authorities and increasing anxiety (Qiu et al., 2020). Overall, parents are experiencing a range of psychological challenges. It is crucial to acknowledge and address these issues to promote the mental health and well-being of parents and their families during this unprecedented period.

As mentioned above, parents who are socioeconomically disadvantaged and have prior COVID-19 experience, or unhealthy lifestyles are likely to endure greater psychological effects than others in the context of adjusting pandemic policies and widespread public infection. However, most of the research evidence comes from studies in countries other than China (Ben Brik et al., 2022; Westrupp et al., 2021). Unlike other countries in the world, China has experienced a three-year comprehensive blockade of the pandemic and has never experienced a nationwide outbreak of infectious diseases. Identifying risk factors is the key to providing targeted prevention and intervention approaches in the context of adjusting the pandemic policies. However, few studies have investigated the full breadth of risk factors collectively and identified vulnerabilities specifically with respect to parents’ mental health during this unprecedented period. Increased parent vulnerability may have a domino effect on families, potentially affecting how children's mental health is protected in both direct and indirect ways (Clawson et al., 2022; Panchal et al., 2021) .

In the present study, we examined the impact of COVID-19 in China on the health and well-being of parents and identified risk and protective factors that are associated with parents’ mental health outcomes in the context of adjusting the pandemic policies and large-scale public infection. Specifically, we aimed to investigate infection conditions, preexisting COVID-19 experience, perceived impacts after the pandemic policy was adjusted, lifestyle during the pandemic, perceived social support, and mental health conditions (anxiety, depression,and parenting stress), in Chinese parents during the first 3 weeks after the pandemic policy was adjusted in December 2022. Moreover, we examine the extent to which a broad range of demographic factors, preexisting COVID-19 experience, and lifestyle, are associated with parents’ mental health outcomes during this unprecedented time.

2.1 Sample characteristics

A total of 2385 parents (Mage = 42.75 years, SD = 4.41, 74% mothers) participated in the study. Approximately 71.7% of the fathers and 66.20% of the mothers had received a college education, whereas other parents had received a high school or lower level of education. A total of 74.9% of the parents had an annual household income above RMB 100,000 (approximately USD$1, 3000). The mean self reported social status score was 5.74. The sample in the present study represented a wide range of socioeconomic statuses. All the parents were from Shenzhen, China. Shenzhen is one of the first large cities to implement the new pandemic policy.

[INSERT Table 1 ABOUT HERE]

Table 1

*Sample Characteristics for the Study*
Variables	Mean_(SD)/N_(%)
Demographic factors
Parent age (years)	42.75_(4.32)
Parent gender
Men	619 _(26%)
Women	1766_ (74%)
Number of children
1 child	824_(34.5%)
2 children	1369_(57.4%)
3 children	162_(6.08%)
4 or more children	29_(1.2%)
Education attainment of father
No school or primary school	8_(0.03%)
Junior High School	173_(7.30%)
High school or junior college	494_(20.70)
University and higher	1710_(71.70%)
Education attainment of mother
No school or primary school	26_(1.01%)
Junior High School	17_(7.30%)
High school or junior college	605_(25.40%)
University and higher	1580_(66.20%)
Annual household income (% attend)
Under 20,000 RMB	76_(5%)
20,000–50,000 RMB	127_(8.40%)
50,000–100,000 RMB	176_(11.60%)
100,000–150,000 RMB	209_(13.80%)
150,000–300,000 RMB	358_(23.70%)
More than 300,000 RMB	566_(37.40%)
Social status score (1–10)	5.74_(1.74)
COVID-19 experience before adjustment of the pandemic policy
Has the experience of being quarantined (home quarantine & centralized quarantine) to the pandemic
No	1128_(47.20%)
Yes	1257_(52.70%)
Knowing people who have been quarantined for this pandemic
No	1137_(47.7%)
Yes	1248_(52.3%)
The community ever been classified as a medium to high risk area for this pandemic
No	1440_(60.38%)
Yes	945_(39.62%)
The impact of children's online classes	2.557_(1.07)
Infection status
Whether infected with COVID-19 (%)
No	126(7.2%)
Yes	1611(92.8%)
Whether you or any elderly or children in your family have underlying disease.
No	1602_(69.21%)
Yes	713_(30.79%)
Post infection symptom scores	3.77_(2.43)
Parent outcomes
Depression	7.81_(4.72)
Anxiety	3.31_(3.95)
Parenting stress	86.04_(27.86)
Perceived social support	66.04_(11.57)
Perceived impact	-1.33_(6.57)
Household income	0.00_(1.36)
Personal Health and Safety	-0.49_(1.43)
Children's Health and Safety	-0.50_(1.46)
Children's Schooling	-0.28_(1.69)
Traveling	-0.06_(1.71)
Life Style
Sleep duration (h)	6.64_(1.78)
Daily exercise duration (h)	0.84_(1.34)

Note: N=2385, SD = standard deviation

2.2 Procedure

Parents were recruited from online communities of local schools. Informed consent was obtained online from the parents before survey completion. The research protocol was reviewed and approved by the Institutional Review Board of the University. The participants voluntarily participated in the study and did not receive any payment.

The Chinese government released adjustments to China’s pandemic policy on December 7th, 2022. Since then, there have been no compulsory nucleic acid inspections in public places. The compulsory quarantine policy was abolished. Home-based treatment for COVID-19 in infected people is recommended. Data were collected online through a Chinese questionnaire website (WJX.cn) between December 16th, 2022 (approximately one week after the adjustment of China’s pandemic policy) and December 30th, 2022. Approximately 92.8% of the parents in the present study reported that they were infected or under infection during data collection.

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2.3 Measures

Parents reported their demographic characteristics, COVID-19 experiences, and parental mental health outcomes after adjusting for China’s pandemic policy. See Table 2 for a summary of the study measures.

Table 2

*Study Measures*
Construct	Measure
Participant demographics and characteristics	Parent gender and age, number of children in the household, education levels of parents, career, annual household income, and self-assessed social status score.
COVID-19 experience before adjustment of the pandemic policy	Three items assessed preexisting COVID-19 experience (Yes/No): (1) Do you have the experience of being quarantined due to the pandemic? (2) Do you know closed people who have been quarantined for this pandemic? (3) Have your the community ever been classified as a medium to high risk area for this pandemic?
The impact of children's online classes	One item assessed the impact of children’s online classes during the pandemic on a five-point scale from ‘Not at all’ to ‘A great deal’.
Infection status	Three items assessed parents’ infection status: (1) Whether you and your family members are infected with COVID-19? (2) Whether you or any elderly or children in your family have underlying disease? Please rated the post infection symptoms on a scale of 1 to 10.
Parental outcomes	Ten items from the Center for Epidemiologic Studies Depression Scale (CESD) assessed parents’ depression (Radloff, 1977). Four-point Likert scale ranging from 0 = ‘Almost never’ to 3 = ‘Almost every day’, and add up the sum (α = 0.92).
Depression
Anxiety	Seven items from Generalized Anxiety Disorder (GAD-7) assessed parents’ anxiety (Spitzer et al., 2006). The GAD-7 is scored on a four-point Likert scale (from 0 to 3, e.g., “Feeling nervous, anxious or on edge.”). The scores ranged from 0 to 21, and higher scores indicate greater anxiety (α = 0.77).
Parenting stress	Thirty-six items from parenting stress index short form (PSI-SF) assessed parenting stress (Weng, 2003). Example: “I often feel unable to handle things well.” Terms are rated on a five-point scale ranging from 1 = ‘Strongly Disagree’ to 5 = ‘Strongly Agree’, and added up the sum (α = 0.97).
Perceived social support	Perceived social support was assessed by using twelve items from Perceived Social Support Scale (PSSS) (Yang et al., 2021). Example: “Some people (leaders, relatives, colleagues) will be there for me when I have a problem.” Items are rated on a seven-point Likert scale ranging from 1 = ‘Strongly Disagree’ to 7 = ‘Strongly Agree’, and added up the sum (α = 0.95).
Perceived impact	Five items assessed perceived impact after the policy adjustment: Household income, Personal Health and Safety, Children's Health and Safety, Children's Schooling, Traveling. Seven-point Likert scale ranging from − 3=’Greatly negative impact’ to 3=’Greatly positive impact’.
Life-style	Two items assessed the lifestyle. Sleep duration was measured using one item from the Pittsburgh Sleep Quality Index: “During the past month, how many hours of actual sleep did you get at night?” (Ho et al., 2021). Daily exercise duration was also assessed with the item from the Chinese version of the HBSC survey: “over the past month, what is the average duration of your daily vigorous physical activity (activities that increased your heart rate and made you breathe hard)?”(Liu et al., 2010)

[INSERT Table 2 ABOUT HERE]

2.4 Data analysis

The IBM Statistical Package for the Social Sciences (SPSS) 27.0 was used to analyze all the data statistically. For missing values, the regression imputation method was used to replace the missing data. Pearson correlations and multiple linear regression analyses were used to examine the associations between demographic factors, COVID-19 experience before the pandemic policy was adjusted, and parental mental health outcomes.

3.1 COVID-19 experience before adjustment of the pandemic policy

Descriptive statistics for the studied sample are presented in Table 1 and Fig. 2. About half of the parents (52.70%) had experienced quarantine (home quarantine & centralized quarantine) and were aware of people who had been quarantined due to the pandemic before the pandemic was adjusted. A total of 39.62% of the parents’ community had ever been classified as a medium- to high-risk area. 30.79% of the parents had underlying diseases.

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3.2 Predictors of parents’ depression after the pandemic policy was adjusted

Figure 3 presents a summary of the associations between demographic factors, COVID-19 experience before the pandemic policy was adjusted and parental mental health outcomes. Table 3 presents the results of the regression of predictors on parental outcomes. We found that parents’ self reported social status score (β = -0.058, p = 0.007, 95% CI -0.057– -0.009) was a significant predictor of parents’ depression level after adjustment for pandemic policies. The experience of their community was classified as a medium- to high-risk area (β = 0.055, p = 0.019, 95% CI 0.019–0.206) and the impact of children’s online classes (β = 0.127, p < 0.0001, 95% CI 0.081–0.155) was significantly related to parents’ depression. Sleep duration (β = -0.111, p < 0.0001, 95% CI -0.091–0.042) was also a significant predictor of parents’ depression. Higher social status scores and longer sleep duration predicted lower level of parents’ depression after the pandemic policy was adjusted. The experience of their community was classified as a medium- to high- risk area and the impact of children’s online classes was positively correlated with parents’ depression. The parents’ age, gender, number of children, household income, and experience of being quarantined did not predict their depression.

Table 3

*Regression of predictors on parental outcomes*
	Depression	Anxiety	Parenting stress	Perceived impact
Parent age	0.006 ± 0.005	0.007 ± 0.005	-0.133 ± 0.005***	0.035 ± 0.032
Parent gender	-0.007 ± 0.047	-0.032 ± 0.046	-0.108 ± 0.046***	-0.077 ± 0.312***
Number of children	-0.020 ± 0.032	0.015 ± 0.032	0.045 ± 0.031*	0.037 ± 0.215**
Annual household income	0.018 ± 0.018	-0.061 ± 0.017**	-0.036 ± 0.017	0.024 ± 0.117
Social status score	-0.058 ± 0.012**	-0.112 ± 0.012***	-0.122 ± 0.012***	0.019 ± 0.082
The experience of being quarantined	-0.025 ± 0.049	-0.001 ± 0.049	-0.069 ± 0.048**	-0.021 ± 0.329
Knowing people who have been quarantined	0.036 ± 0.044	-0.012 ± 0.043	-0.080 ± 0.043***	-0.012 ± 0.292
The community ever been classified as a medium to high risk area	0.055 ± 0.048*	0.034 ± 0.047	-0.024 ± 0.046	-0.050 ± 0.317*
The impact of children's online classes	0.127 ± 0.019***	0.143 ± 0.019***	0.173 ± 0.018***	-0.005 ± 0.126
Sleep duration	-0.111 ± 0.012***	-0.152 ± 0.012***	-0.075 ± 0.012***	0.060 ± 0.082**
R²	0.037	0.074	0.098	0.017
Note: β ± SD, standardized regression coefficients and posterior SDs are reported. All continuous variables were z score standardized before entry into the regression models. Gender was coded as 1 = male; and 2 = female.; “Has the experience of being quarantined (home quarantine & centralized quarantine) to the pandemic” coded as 0 = No, 1 = Yes; “Knowing people who have been quarantined for this pandemic” coded as 0 = No,1 = Yes; “The community ever been classified as a medium to high risk area for this pandemic” coded as 0 = No,1 = Yes. p < .05; p < .01; **p < .001.

[INSERT FIGURE 3 ABOUT HERE]

[INSERT Table 3 ABOUT HERE]

3.3 Predictors of parents’ anxiety after the pandemic policy was adjusted

As shown in Fig. 3 and Table 3, household income (β = -0.061, p = 0.004, 95% CI -0.084–0.016) was a significant predictor of parents’ anxiety level after the pandemic policy was adjusted. Parents’ self reported social status scores (β = -0.122, p < 0.0001, 95% CI -0.094– -0.047) was also a significant predictor of parents’ anxiety. The impact of children’s online classes (β = 0.143, p < 0.0001, 95% CI 0.097–0.170) were significantly related to parents’ anxiety. Sleep duration (β = -0.152, p < 0.0001, 95% CI -0.115–0.068) was also a significant predictor of parents’ anxiety. Higher social status scores, higher household income, and longer sleep duration predicted lower level of parents’ anxiety after the pandemic policy was adjusted. Parents’ age, parents’ gender, number of children, experience of being quarantined, and the experience of their community classified as a medium- to high-risk area did not predict parents’ anxiety.

3.4 Predictors of parenting stress after the pandemic policy was adjusted

As shown in Fig. 3 and Table 3, regarding the demographic factors, parents’ age (β = -0.133, p < 0.0001, 95% CI -0.040– -0.022), parents’ gender (β = -0.108, p < 0.0001, 95% CI -0.335– -0.156), number of children (β = 0.045, p = 0.023, 95% CI 0.010–0.133), and parents’ self reported social status scores (β = -0.122, p < 0.0001, 95% CI -0.094– -0.047) were significant predictors of parents’ parenting stress after the pandemic policy was adjusted. In terms of the COVID-19 experience, the experience of being quarantined (β = -0.069, p < 0.0001, 95% CI -0.094– -0.047), knowing people who have been quarantined (β = -0.069, p < 0.0001, 95% CI -0.232– -0.044) and the perceived impact of children’s online classes (β = 0.173, p < 0.0001, 95% CI 0.125– -0.197) were significantly related to parenting stress. Moreover, sleep duration (β = -0.075, p < 0.0001, 95% CI -0.069–-0.022) was also a significant predictor of parents’ parenting stress. Higher parents’ age, fathers, higher social status scores, experience of being quarantined, knowing people who have been quarantined and longer sleep duration predicted lower level of parenting stress after the pandemic policy was adjusted. The number of children and the impact of children’s online classes were positively correlated with parents’ parenting stress. Household income, and the experience of their community classified as a medium- to high- risk area did not predict parenting stress.

3.5 Predictors of perceived impacts after the adjustment of the pandemic policy

As shown in Fig. 3 and Table 3, we found that parents’ gender (β = -0.077, p < 0.0001, 95% CI -1.770– -0.545) and number of children (β = 0.037, p = 0.007, 95% CI 0.032–0.811) were significant predictors of parents’ perceived impact after the pandemic policy was adjusted. Compared with father,s mothers had more negative perceived impacts. The number of children was positively correlated with parents’ perceived impact. The experience of their community classified as a medium- to high-risk area (β = -0.050, p = 0.036, 95% CI -1.289– -0.044) was also a significant predictor of parents’ perceived impact. Parents who had experienced the community classified as a medium- to high- risk area showed more negative perceived impact. In terms of lifestyle, sleep duration (β = 0.060, p = 0.004, 95% CI 0.074–0.397) was significantly related to parents’ perceived impact after the pandemic policy was adjusted. A longer sleep duration predicted more positive perceived impacts. Parents’ age, number of children, household income,self reported social status scores, experience of being quarantined, and impacts of children’s online classes did not predict parents’ perceived impacts after the pandemic policy was adjusted.

4.1 Adjustment of the Pandemic Policy and Parents’ Mental Health

Before the pandemic policy was adjusted, the outbreak of COVID-19 in China prompted the implementation of comprehensive and strict measures to limit the spread of the virus (Li et al., 2020). However, these measures had unintended consequences, with many parents experiencing heightened levels of parenting stress, anxiety, and uncertainty. Furthermore, the lack of social interaction and outdoor activities exacerbates parents' mental health issues (Liu et al., 2022). In December 2022, China adjusted its pandemic policies, canceling several control measures related to COVID-19 (Wilson & Flahault, 2023). This brought about a sense of relief and hope for many parents, as they were able to resume in-person schooling and social activities. These changes provided much-needed respite, allowing parents to feel more relaxed and less overwhelmed. Nevertheless, ongoing uncertainty surrounding the pandemic and the emergence of new variants have also contributed to lingering feelings of anxiety and stress(Canady, 2020). Importantly the potential mental health consequences of major societal changes resulting from changing COVID-19 restrictions in China cannot be directly compared with those in other countries. Our findings highlight a significant impact on parents' mental health during this unprecedented period, with varying levels of depression, anxiety, and parenting stress experienced depending on demographic factors, preexisting COVID-19 experiences, and lifestyles.

4.2 Socioeconomic Disadvantages and Increased Mental Health Risks during COVID-19

The present study examined the impact of socioeconomic disadvantages on Chinese parents during the first wave of nationwide infection, which occurred in the first three weeks after the adjustment of the pandemic policy. Our findings indicate that lower parent age, lower social status scores, lower household income, more children, and mothers were associated with worse mental health conditions among parents. These results are consistent with findings related to general adult samples in other countries (Moreland-Russell et al., 2022), but our study extends the literature by focusing specifically on parents and highlighting important associations with socioeconomic factors. Notably, 92.8% of the parents in our sample reported that they were infected or under infection during the first three weeks after the policy adjustment. Vulnerable families with socioeconomic disadvantages, such as those with lower social status scores and household income, were particularly affected during the pandemic and were at the highest risk of facing ongoing uncertainty surrounding the pandemic and the emergence of new variants. Douglas et al. (2020) reported that these effects are even more daunting for families with low incomes or limited employment options, families who face greater health risks, and families who face inequities in access to educational and health resources, deepening the racial and ethnic divide in educational attainment and overall health and well-being. Moreland-Russell et al. (2022) reported that being female or experiencing job or income loss were associated with worse mental health and working from home or part-time and job or income loss due to COVID-19 were associated with poor parental mental health. Our findings underscore the need for targeted interventions and support services to help vulnerable families cope with the negative impacts of the pandemic on their mental health.

Similarly, we found that the number of children in a household was associated with a higher level of parenting stress and the perceived impact of policy adjustment. It is possible that a larger household size was associated with fewer resources allocated to each family member. Kang and colleagues (2023) reported that family size was positively related to the use of violent discipline, because they faced job loss or reduced income due to COVID-19, which contributed to the worsening mental health status. Johnson and colleagues (2021) reported that parents who lived with more than one child in the household reported more parental stress. Disposable income decreases as family size increases. Therefore, families may be under more financial strain when the household size is larger.

Moreover, we found that parent age significantly predicted parenting stress. Specifically, we observed that young parents experienced greater parenting stress when facing large-scale public infections, possibly due to their lack of childcare experience and limited social and health resources, which are particularly relevant in the context of policy adjustments. Johnson and colleagues (2021) found that younger parents (ages 21–44) reported significantly higher levels of parental stress than older parents did. These findings may reflect a general vulnerability among younger parents, who have less experience with parenting combined with the increased burden of having younger children to take care of. These findings highlight the importance of considering parental age and related factors in understanding parenting stress in challenging circumstances.

Our study examined the impact of the COVID-19 pandemic on mothers and fathers, who are the primary caregivers of families. We found that mothers experienced greater negative impacts of policy adjustment and parenting stress than fathers did, likely due to the increased amount of time spent at home by both parents and children during the pandemic. This dynamic led to greater interaction between mothers and children, which in turn contributed to higher levels of parenting stress among mothers. Our findings are in line with those of a previous study in which female sex was associated with poor mental health (Moreland-Russell et al., 2022). This may be derived from the disproportionate care thken by women and the associated greater burden in overcoming challenges related to the pandemic. These findings highlight the unique challenges faced by mothers during the pandemic and the importance of considering gender in research on the effects of public health crises on families.

4.3 Preexisting COVID-19 experience and Mental Health Risks

Since the outbreak of COVID-19 in 2020, China has implemented a markedly different approach to address the pandemic than other countries around the world have. One key difference is the level of government control and enforcement of public health measures. China has implemented strict measures, including lockdowns, travel restrictions, and mandatory quarantine, with severe penalties for noncompliance. In addition, China implemented widespread testing and contact tracing early in the pandemic, which helped contain the spread of the virus. While these measures were effective in controlling the outbreak, they also had a significant impact on individuals, as many people experienced lockdowns, travel restrictions, and quarantine(Wu et al., 2021) .

In the present study, preexisting COVID-19 experience was differently associated with Chinese parents’ mental health conditions during the first wave of nationwide infection following the policy adjustment. In line with previous studies, the COVID-19 pandemic has had a profound impact on individuals through the impacts of environmental stressors (Westrupp et al., 2021). In our study, parents who lived in areas previously designated as medium to high risk for COVID-19 reported higher levels of depression and perceived more negative impacts of the policy adjustment. The experience of living in high or medium risk areas may contribute to depression, anxiety, and increased stress related to parenting in the context of a pandemic (Chi et al., 2020). The negative experience from the environmental stressors caused by the pandemic may also contribute to increased tension within families (Ben Brik et al., 2022). Additionally, the negative experience of living in an area of heightened risk can cause parents to become overly cautious or fearful when facing new challenges and uncertainty after policy adjustment, leading to social isolation and a reduced sense of community, which could be a possible cause of depression (Johnson et al., 2022; Yue et al., 2022). The uncertainty and fear associated with the virus, combined with the added responsibility of managing home-based learning for children, can exacerbate these negative feelings and expectations during the early stages of policy adjustment (Morgan et al., 2022).

During the COVID-19 pandemic, many parents and children in China experienced remote learning due to quarantine measures (Deng et al., 2021). However, our study found that this experience had negative impacts on parents' mental health after policy adjustment, which is in line with prior research (Adams et al., 2021). Specifically, parents reported increased levels of depression, anxiety, and parenting stress (Moreland-Russell et al., 2022). It is possible that the added responsibility of managing their children's education at home, combined with potential disruptions to work schedules and increased financial stress, contributed to these negative feelings (Douglas et al., 2020; Killgore et al., 2021). Furthermore, parents from socioeconomically disadvantaged backgrounds, may feel pressure to ensure that their children receive adequate education, and may experience guilt or frustration if they perceive their own limitations in supporting their child's learning. In addition, the lack of social interaction and increased isolation associated with remote learning may exacerbate feelings of loneliness and depression for both parents and children in the face of ongoing uncertainty and the threat of infection.

The COVID-19 pandemic has led to unprecedented disruptions in daily life and increased isolation, including periods of quarantine (Demaria & Vicari, 2021; Johnson et al., 2022). While being quarantined or isolated can be challenging for many parents, it also presents opportunities to build resilience and coping skills within family lives (Pugliese et al., 2022). Research has shown that parents spend significantly more time at home during quarantine, which may increase opportunities for parent-child interaction and strengthen their relationships (Khoory et al., 2022). Furthermore, parents reported a greater sense of connection to their children during quarantine (Wozniak-Prus et al., 2023).

In this context, the experience of quarantine may help parents explore creative approaches to home-based education and parenting. It can provide an opportunity for reflection on parents’ own parenting styles and perspective-taking, which may lead to improved mental health and a more positive outlook on the future, even in the face of uncertainty (Wozniak-Prus et al., 2023). Additionally, quarantine can foster adaptability and resilience, which are valuable skills for navigating future challenges (Pugliese et al., 2022). Therefore, our findings suggest that the experience of quarantine was associated with alleviating the depression, anxiety and pressure associated with home-based education and parenting during the policy adjustment.

4.4 Protective Factor of Parents’ Mental Health: Sleep

The present study revealed that sleep duration is a comprehensive protective factor against the mental health challenges faced by Chinese parents during the COVID-19 policy adjustment. Higher sleep duration was associated with lower levels of depression, anxiety, and parenting stress, as well as more positive perceived impacts of policy adjustment among Chinese parents. Research has consistently demonstrated that adequate sleep and good sleep habits are associated with overall health and well-being, including improved mood, cognitive function, and physical vitality (AlDabal & BaHammam, 2011). Notably, 92.8% of the Chinese parents in our study reported being infected or having family members infected within the first three weeks after the policy adjustment. Adequate sleep has been shown to have a positive effect on immune function, which is especially important when facing ongoing uncertainty surrounding the pandemic and nationwide infection (Wearick-Silva et al., 2022). Therefore, prioritizing sleep is an important protective factor for maintaining healthy mental and physical conditions after pandemic policy adjustment.

4.5 Implications

Overall, this study highlights the importance of considering the mental health of parents in the context of pandemics. We identified several factors connected with poorer mental health outcomes when facing infection threat and the uncertainty of future pandemic conditions during policy adjustment, most notably socioeconomic disadvantages, preexisting COVID-19 experiences and inadequate sleep. Our findings provide empirical evidence for policy actions to support and protect families from the likely adverse impacts of the pandemic. For example, additional support should be provided for older parents, mothers, and families with many children. Parents with socioeconomic disadvantages may experience more pressure to ensure that their children receive adequate education and health support during the pandemic, leading to guilt or frustration if they perceive their own limitations in supporting their children during public health emergencies. Mothers and parents of older age and large family sizes should prioritize their own self-care and seek support from others, as they appear to be susceptible to the negative psychological impact of policy adjustment. Special attention should be given to socioeconomically disadvantaged parents, as they are at high risk for mental health problems.

Our results suggest that parenting stress and mental health concerns (e.g., depression and anxiety) are associated with greater perceived impacts among children in online classes, schools, and educational institutions. Therefore, schools should play a role in supporting parents by providing resources and guidance to support remote learning. Programs that focus on home-based learning and finding new ways to support children's education should also be developed for vulnerable parents. Furthermore, our findings support increased investment in evidence-based mental health interventions for parents, children, and families who have negative preexisting COVID-19 experiences. Governments and healthcare institutions should provide support and resources to help families cope with the ongoing effects of the pandemic.

While a large majority of participants reported their infection during the study, as a protective factor, our results highlight the importance of adequate sleep for parents in a policy adjustment context. Parents should be aware of the potential positive effects of sleep, particularly when they and their children are at risk for mental health problems during pandemic. Maintaining adequate sleep can be an effective strategy for parents to promote both mental and physical health at a minimal cost.

4.6 Limitations and Future Directions

Several limitations of the present study should be noted. First, prepandemic mental health data were not collected, which may have influenced our results as preexisting mental health conditions and other factors related to the impact of COVID-19 were not taken into account. Second, our sample consisted of Chinese parents from urban areas, limiting the generalization of our findings to more diverse socioeconomic backgrounds. Future research should aim to recruit a more diverse sample of parents to better understand the mental health challenges faced by parents from different backgrounds. Finally, our study examined only the mental health of Chinese parents within the first three weeks following the policy adjustment. As pandemic policies continue to change and evolve, future research should consider using longitudinal designs to examine how the predictive factors identified in our study relate to changes in parents' mental health outcomes over a longer period of time. It is important for researchers to identify both risk and protective factors that impact parents' mental health during highly stressful public health crises on a longer time scale.

To our knowledge, this is the first large-scale study examining the impacts of socioeconomic status, preexisting COVID-19 experience, and lifestyle on Chinese parents during the adjustment of pandemic policy in China. During this unprecedented period, parents may feel that restrictions are easing and anxious about the risks associated with increased social contact and the potential for the virus to spread. Our results suggest that socioeconomic disadvantages, such as being older, being a mother, having more children, and having a lower perceived socioeconomic status, may increase the risk of depression, anxiety, parenting stress, and a negative perceived impact of the policy adjustment during the outbreak. Additionally, parents who had lived in communities classified as medium- to high-risk areas were more likely to report mental health concerns such as depression and anxiety related to policy adjustment. However, quarantine experience may promote parental engagement in parenting during quarantine and predict less parenting stress in the face of nationwide infection and policy changes. As an important protective factor, longer sleep duration was associated with better mental health and a more positive perceived impact of policy adjustment, highlighting the importance of prioritizing sleep for parents during public health crises. Our findings suggest that sleep is a simple yet powerful way for parents to support their own mental and physical health, which can positively affect the entire family during challenging times.

Funding Acknowledgement:

This work was supported by Shenzhen Natural Science Fund（the Stable Support Plan Program 20231121142527001）.

Data availability

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Conflict of Interest:

The authors declare no conflict of interest.

Acknowledgments:

We wish to thank all participants in this study as well as all members of the research team.

Ethical approval:

The survey was approved by the Research Ethics Committee of Shenzhen University (SZU_PSY_2023_018). All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the Institutional Review Board of Shenzhen University and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Statement of the Authors’ Contributions

Dr. Deng is the first and corresponding author of this paper. She made contributions to conception and design of the study, acquisition of data, analysis on data, interpretation of data, drafting the article and finalizing the article.

Ms. Liu mainly contributes to the study by data collection and analyses.

Informed consent:

Informed consent was obtained from all individual participants included in the study.

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No competing interests reported.

Evaluating the Mental Health Impacts of parents during the Adjustment of China’s Pandemic Policy: Roles of Socioeconomic Factors, Existing COVID-19 Experiences, and Lifestyles

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Abstract

Figures

1 Introduction