healthcare

Article
Assessing Knowledge, Preventive Practices, and Depression
among Chinese University Students in Korea and China during
the COVID-19 Pandemic: An Online Cross-Sectional Study
Bo Zhao 1 , Fanlei Kong 2,3, * and Eun Woo Nam 1,4, *

1 Department of Health Administration, Graduate School, Yonsei University, 1 Yonseidae-gil,

Wonju 26493, Korea; zhaobo@yonsei.ac.kr
2 Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine,
Shandong University, Jinan 250012, China
3 NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan 250012, China
4 Health City Research Center, Institute of Health and Welfare, Yonsei University, 1 Yonseidae-gil,
Wonju 26493, Korea
* Correspondence: kongfanlei@sdu.edu.cn (F.K.); ewnam@yonsei.ac.kr (E.W.N.)

Abstract: To investigate the knowledge, preventive practices, and depression of Chinese university
students living in South Korea and Mainland China during the COVID-19 outbreak and explore the
determinants of depression among these students, an online cross-sectional questionnaire survey
was conducted from 23 March to 12 April 2020. The online questionnaire included questions on
knowledge and preventive practices related to COVID-19, and the Patient Health Questionnaire-9





 was used to diagnose depressive symptoms. A total of 420 Chinese university students were finally
included in the study (171 students from South Korea and 249 students from Mainland China). The
Citation: Zhao, B.; Kong, F.; Nam,
majority of these students had a good level of knowledge of COVID-19. Students living in South Korea
E.W. Assessing Knowledge,
Preventive Practices, and Depression
displayed better preventive practices than those living in Mainland China; however, the proportion
among Chinese University Students of students (28.7%) with moderate-to-severe depression in this group was relatively higher than that
in Korea and China during the (18.9%) of the Mainland Group (χ2 = 5.50, p < 0.05). More severe depression was related to high
COVID-19 Pandemic: An Online levels of concern about family members and contracting COVID-19 as well as suspecting themselves
Cross-Sectional Study. Healthcare of having come into contact with patients. Displaying more preventive behaviors decreased the
2021, 9, 433. https://doi.org/ depressive symptoms in both groups. These data could be used as a reference for further studies in
10.3390/healthcare9040433 different regions to take measures (e.g., psychological counseling and encouragement for physical
activities) to reduce depressive symptoms in university students.
Academic Editor: Mariyana Schoultz

Keywords: COVID-19; Chinese university students; China; Korea; preventive practices; depression
Received: 24 February 2021
Accepted: 1 April 2021
Published: 8 April 2021

1. Introduction
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
An increasing number of infectious diseases have recently led to serious economic and
published maps and institutional affil- social consequences globally [1,2]. These emergent public-health events not only result in
iations. physical pain but also have a profound psychological impact [3,4], such as inducing panic,
anxiety, and depression (see the examples of the Middle East Respiratory Syndrome [5]
and Ebola virus disease [6] outbreaks). Links between anxiety/depression and viral
diseases such as influenza A and other influenza viruses have also been proven [7]. Further,
Copyright: © 2021 by the authors.
psychological stress may lead to immune dysfunction, which has a negative impact on
Licensee MDPI, Basel, Switzerland.
human health [8]. For instance, the SARS virus caused a series of psychological problems
This article is an open access article
such as post-traumatic stress disorder in patients [9]. Therefore, it is necessary to determine
distributed under the terms and the population’s mental health status during a health emergency as early as possible as
conditions of the Creative Commons well as make recommendations and provide interventions.
Attribution (CC BY) license (https:// The coronavirus disease 2019 (COVID-19) first broke out in Wuhan, Hubei Province,
creativecommons.org/licenses/by/ China, in December 2019 and had been found in 188 countries and regions worldwide as of
4.0/). 20 May 2020 [10]. On 30 January 2020, the World Health Organization (WHO) declared it a

Healthcare 2021, 9, 433. https://doi.org/10.3390/healthcare9040433 https://www.mdpi.com/journal/healthcare

Healthcare 2021, 9, 433 2 of 14

worldwide pandemic [11]. The disease is contagious, widespread, and has no known drugs
to target it [12,13]. The increasing numbers of confirmed patients, suspected cases, and
provinces affected by the outbreak made Chinese people feel worried and scared [14,15].
Coupled with the ongoing social distancing and isolation measures implemented in several
countries and regions, this outbreak has led to additional mental health problems such
as stress, anxiety, depressive symptoms, insomnia, and fear globally [16–18]. The World
Health Organization has also noted that mental health and psychological well-being in
different target groups must be considered during the COVID-19 outbreak [19].
As college students are transitioning to adulthood, this is a crucial time in their
personal development [20]. They may not only have to face stress related to their academic
performance but also tackle adult-like responsibilities without having yet achieved the
skills and cognitive maturity of adulthood [21]. For example, research has found that some
college students lack the experience to handle emergencies, lack analytical and forecasting
skills, and display impulsive behavior or a vulnerable and unstable mood [22,23]. Moreover,
several researchers have proposed that mental health problems are becoming increasingly
common among college students [24–26], which can be tackled by receiving clear and
consistent information [27]. Potential problems such as anxiety, stress, and depression can
negatively affect academic performance [28,29].
Students in China and South Korea were directly or indirectly affected because the
COVID-19 outbreak coincided with the Chinese lunar New Year holiday and opening
of South Korean universities. To prevent the outbreak from escalating, universities in
China and South Korea postponed the beginning of the semester in the first half of 2020;
canceled all campus events such as workshops, conferences, sports, and other activities [30];
and changed to an online learning model [31]. Nonetheless, the mental health of college
students forced to stay at home for a long time because of fewer collective activities may
be affected, leading to anxiety and depressive symptoms [32,33]. Thus, the psychological
condition of university students cannot be overlooked and must be monitored.
Since the viral outbreak was first reported in China, the Chinese have been targeted
and blamed for the spread of COVID-19. An example of this is the use of the terms “China
virus” and “Wuhan virus” by the media [34]. Chinese students account for the largest
proportion of foreign students studying in South Korea [35]. Given their remoteness from
their interpersonal networks and low contact with relatives and friends, international
students have to rely on themselves when studying abroad [36]; they often live alone or
with one other person in a room or dormitory [37]. Moreover, these young adults have
never known or experienced a severe disease outbreak in China before. Previous research
shows that studying abroad adds another layer of stress that can exacerbate pre-existing
mental problems [38]. Hence, there is a high probability that loneliness abroad along with
global discrimination and stress over the pandemic may affect their academic performance
and mood [39].
The risk and protective factors contributing to the depression and anxiety of uni-
versity students during the COVID-19 pandemic have been well researched. A study of
university students in the United Arab Emirates and Jordan demonstrated that adequate
knowledge, good attitudes, and low-risk practices can protect them against contracting
COVID-19 [40,41]. Moreover, having relatives and acquaintances infected with COVID-19
is a risk factor for increasing anxiety among university students [42,43]. In their study of
Nigerian university students, Rakhmanov and Dane found that an increase in knowledge
may help decrease anxiety levels [44]. In addition, a study of French university students
showed that knowledge of the pandemic may reduce its negative impact (e.g., stress and
anxiety) in the vulnerable populations [45]. Even when anticipatory coping behaviors are
active, many people remain afraid of distressing situations and their awareness of coping
strategies is poor [46]. Young adults practicing social distancing and undertaking low levels
of activities have poorer mental health [47]. Hence, although some university students
have a good level of knowledge about COVID-19 and its preventive practices, health
authorities still should take their depressive status seriously [48]. However, no research
Healthcare 2021, 9, 433 3 of 14

has thus far examined the extent to which knowledge of COVID-19 and the risk factors
leading to depression during the pandemic affect Chinese university students domestically
and overseas [49]. Therefore, using an online questionnaire survey, this study was aimed
at exploring the conditions and determinants of knowledge, preventive practices, and
depression among Chinese university students in Mainland China and South Korea during
the COVID-19 pandemic.

2. Materials and Methods

2.1. Participants
An online cross-sectional survey was used to collect data from respondents through an
anonymous questionnaire. We conducted the online survey from 23 March to 12 April 2020
(According to the World Health Organization, as of 31 March 2020, there were 82,545 con-
firmed cases in China (total deaths: 3314) and 9786 confirmed cases in South Korea (total
deaths: 162)) during the COVID-19 pandemic and 420 university students were finally
included in the analysis. Of these, 171 were Chinese university students studying in South
Korea (referred to as the International Group hereafter) and 249 were studying in Mainland
China (Mainland Group).

2.2. Procedure
First, the English version of the COVID-19 questionnaire used by Wang and col-
leagues [16] was adopted. Second, the sample size needed for the study was calculated
using the G*Power 3.19 program. Based on the parameters of a two-sided test and χ2 test,
a residual variance of 0.83, α probability = 0.05, and power = 0.95 for F tests and linear
multiple regression analysis, the minimum total sample size was estimated to be 356.
Because of the limited accessibility to respondents owing to the social distancing policy
during the COVID-19 outbreak, we conducted an online cross-sectional survey. With the
help of collaborators and native speakers, a Chinese version of the questionnaire written in
simplified Chinese characters was created and placed on survey platforms (Naver Form
Tool in South Korea, Surveystar in Mainland China). Before conducting the survey, we
revised and verified the content of the questionnaire through an online pilot survey among
several students to ensure that the statements were appropriate and understandable. Native
researchers in both countries checked its readability, comprehension, and convenience for
the respondents to answer.
Potential respondents were sent a link to participate in the questionnaire. During the
initial screening, a statement of the purpose of the research and assurance of the confiden-
tiality and privacy of individuals was placed on the first page of the survey questionnaire.
Participants could only complete the questionnaire after reading this statement and click-
ing “AGREE” to confirm their consent. Hence, we ensured that consent forms had been
completed and participants had been informed about the questionnaire before the survey
was conducted. All participants were told that they had the right to stop the survey at any
time. In addition, we stipulated that the main questions in the survey were mandatory
questions (as shown below in Section 2.4). In other words, participants had to answer the
questions before they submitted the online questionnaire. Any question left blank made
the final submission of the online questionnaire impossible. All these measures resulted in
a 100% response rate for our study.
In total, 461 respondents were recruited via snowball sampling, wherein we recruited
further respondents among their acquaintances. There were 180 responses from Chinese
students in South Korea collected from 23 March to 8 April 2020 and 281 responses from
Chinese students in Mainland China collected from 2 to 12 April 2020 (461 in total). To
ensure that we only surveyed university students, 41 respondents who answered employed,
unemployed, or other to the occupation question were removed, leaving 420 students
(171 in the International Group and 249 in the Mainland Group). All respondents expressed
their willingness to participate and understood the background and purpose of the study.
Healthcare 2021, 9, 433 4 of 14

2.3. Measurements
The questionnaire (see Supplementary File) used in our study included two sections:
(1) a questionnaire on COVID-19 and (2) the Patient Health Questionnaire-9 (PHQ-9). First,
the questionnaire on COVID-19 consisted of questions that covered (1) demographic and
physical health data, (2) knowledge and perceptions of COVID-19, and (3) preventive
practices against COVID-19 in the past 14 days. Most questions in this questionnaire
show reasonable validity and reliability according to Wang et al.’s research on the Chinese
population [16]. The Yonsei Global Health Center changed Part E (preventive measures)
and Part F (additional information) according to the specific situations in the two countries.
Second, the PHQ-9, which has been validated for use in primary care [50], was adopted
to provide a baseline for the incidence of depression. After data collection, we compared
the knowledge and preventive practices of COVID-19 and depression among Chinese
university students in South Korea and China.

2.4. Description of the Variables

2.4.1. General Demographics
In this study, to reflect the demographic characteristics of the respondents, the basic
survey asked questions related to respondents’ sex, age, education level, marital status,
family size, whether they had medical insurance, whether they had chronic diseases,
whether they had traveled abroad in the past 14 days, and whether they had experienced
quarantine. The choices for educational level were undergraduate and graduate and the
choices for marriage status were single and married. In terms of family size, the choices
were 1-person family, 2-person family, 3–5 persons family, and more than a 6-member
family. Questions about having medical insurance, chronic illnesses, traveled abroad, and
self-quarantined were answerable by either yes or no. Respondents were also asked about
their self-assessed physical condition, which was answerable by either good or above and
fair or below.

2.4.2. Knowledge and Perception of COVID-19

Knowledge and perception of COVID-19 and other topics were evaluated, which
included questions on the student’s knowledge of transmission pathways, satisfaction with
the information, sources of related information, confidence about being diagnosed, degree
of concern about this disease, perceived probability of becoming infected, and concern
about family members.

2.4.3. Preventive Practices of COVID-19

Nine basic preventive practices were incorporated into the questionnaire. The re-
sponses to these questions corresponded to the degree to which a measure was practiced
on a daily basis (1 = never do this and 5 = do this every day). The total score indicated how
well preventive practices were performed. The reliability (Cronbach’s α) of the preventive
practices of the COVID-19 scale in this study was 0.72 and the validity was 0.78.

2.4.4. Patient Health Questionnaire-9

Depressive symptoms were diagnosed based on the nine criteria for depression in
the Diagnostic and Statistical Manual of Mental Disorders published by the American
Psychiatric Association [51]. Each question on the PHQ-9 was answered as follows (with
their corresponding score): not at all (0 points), several days (1 point), more than half
the days (2 points), and almost every day (3 points) [52]. Respondents were divided into
five groups according to their total score (0–4, 5–9, 10–14, 15–19, and 20–27), which corre-
sponded to minimal or none, mild, moderate, moderately severe, and severe depression,
respectively [53]. The higher the score, the more severe the depression.
With a sensitivity of 88% and a specificity of 88% for detecting major depressive
disorders, a score of 10 is recommended as the cut-off for diagnosing depression [54]. Thus,
in this study, respondents who scored 10 or more points were classified as moderate-to-
Healthcare 2021, 9, 433 5 of 14

severe, and respondents who scored fewer than 10 points were classified as “minimal-to-
mild”. The reliability and validity of the PHQ-9 were 0.89 and 0.90, respectively.

2.5. Statistical Analysis

In this study, STATA 15.0 (Stata Corp., College Station, TX, USA.) and SPSS 24.0
(IBM Corp., Armonk, NY, USA) were used to conduct the statistical analysis as follows.
First, descriptive statistics, t-tests, and chi-squared tests were performed to compare each
variable between the International Group and Mainland Group. Second, to explore the
determinants of the different depression levels, hierarchical regression was performed.

3. Results
3.1. General Characteristics
As shown in Table 1, there were significant differences between the two groups in
terms of age, education level, marital status, family size, medical insurance, and self-
quarantine. The mean age of the International Group was 24.08 ± 4.14 years compared
with 22.12 ± 2.28 years in the Mainland Group. There were higher proportions of grad-
uate students, married respondents, and respondents with families comprising one to
two members in the International Group than in the Mainland Group. In addition, a
higher percentage of students did not have medical insurance (16.4%) in the International
Group. By contrast, nearly half (47.8%) of the Mainland Group had experienced being
self-quarantined. In total, more than 90% of respondents reported a good self-assessed
physical condition.

Table 1. Demographics and general characteristics of the respondents.

International Group Mainland Group Total

Variables (n = 171) (n = 249) (n = 420) t/χ2 (Pearson) p
n (%) n (%) n (%)
Sex
Male 57 (33.33) 76 (30.52) 133 (31.67)
0.370 0.543
Female 114 (66.67) 173 (69.48) 287 (68.33)
Age
Mean ± S.D. 24.08 ± 4.14 22.12 ± 2.28 22.90 ± 3.30 5.427 a <0.001
Education Level
Undergraduate 98 (57.31) 177 (71.08) 275 (65.48)
8.509 0.004
Graduate 73 (42.69) 72 (28.92) 145 (34.52)
Marital Status
Single 159 (92.98) 242 (97.19) 401 (95.48)
4.153 0.042
Married 12 (7.02) 7 (2.81) 19 (4.52)
Family Size
1 member 9 (5.26) 1 (0.40) 10 (2.38)
2 members 24 (14.04) 8 (3.21) 32 (7.62)
32.126 <0.001
3–5 members 134 (78.36) 221 (88.76) 355 (84.52)
6 members or more 4 (2.34) 19 (7.63) 23 (5.48)
Medical insurance
No 28 (16.37) 16 (6.43) 44 (10.48)
10.699 0.001
Yes 143 (83.63) 233 (93.57) 376 (89.52)
Chronic illness
No 159 (92.98) 232 (93.17) 391 (93.10)
0.006 0.940
Yes 12 (7.02) 17 (6.83) 29 (6.90)
Traveled abroad
No 166 (97.08) 244 (97.99) 410 (97.62)
0.366 0.545
Yes 5 (2.92) 5 (2.01) 10 (2.38)
Healthcare 2021, 9, 433 6 of 14

Table 1. Cont.

International Group Mainland Group Total

Variables (n = 171) (n = 249) (n = 420) t/χ2 (Pearson) p
n (%) n (%) n (%)
Self-quarantined
No 29 (16.96) 119 (47.79) 148 (35.24)
42.230 <0.001
Yes 142 (83.04) 130 (52.21) 272 (64.76)
Self-assessed physical condition
Good or above 153 (89.47) 227 (91.16) 380 (90.48)
1.206 0.752
Fair or below 18 (10.53) 22 (8.84) 40 (9.52)
Note: International Group refers to Chinese college students studying in South Korea and Mainland Group refers to Chinese college
students studying in Mainland China. a : t-test.

3.2. Knowledge of COVID-19

Table 2 shows the students’ responses about their knowledge of COVID-19. About
99.8% knew that the virus could spread through droplets, 88.8% knew that it could be trans-
mitted via contact with contaminated objects, and 66.9% knew that it could be transmitted
through air. The two groups were also up-to-date on information on infections, deaths and
recoveries. Regarding sources of information, 92.1% of respondents obtained information
from one to three sources such as the Internet, TV, and family members.

Table 2. Differences in knowledge of COVID-19.

International Group Mainland Group Total

t/χ2
Variables (n = 171) (n = 249) (n = 420) p
(Pearson)
n (%) n (%) n (%)
Route of transmission
Droplets (agree) 171 (100) 248 (99.60) 419 (99.76) 0.688 0.407
Objects (agree) 145 (84.80) 228 (91.57) 373 (88.81) 6.213 0.045
Air (agree) 116 (67.84) 165 (66.27) 281 (66.90) 1.037 0.595
Updated information
Infections (yes) 168 (98.25) 249 (100) 417 (99.29) 4.400 0.036
Deaths (yes) 169 (98.93) 247 (99.20) 416 (99.05) 0.144 0.704
Recoveries (yes) 163 (95.32) 245 (98.39) 408 (97.14) 3.447 0.063
Number of information sources
1–3 161 (94.15) 226 (90.76) 387 (92.14)
1.608 0.205
4–6 10 (5.85) 23 (9.24) 33 (7.86)
Satisfaction with the information
Satisfied 157 (91.81) 239 (95.98) 396 (94.3)
3.274 0.070
Dissatisfied 14 (8.19) 10 (4.02) 24 (5.7)
Confidence about being diagnosed
High 101 (59.06) 192 (77.11) 293 (69.76)
15.647 <0.001
Low 70 (40.93) 57 (22.89) 127 (30.24)
Concern about this disease
High 123 (61.93) 155 (62.25) 278 (66.19)
4.246 0.039
Low 48 (38.07) 94 (37.75) 142 (33.81)
Perceived probability
Become infected (high) 59 (34.50) 48 (19.28) 107 (25.48) 12.379 <0.001
Survive after infection (high) 157 (91.81) 216 (86.74) 373 (88.81) 2.618 0.106
Concern about family members
High 139 (81.29) 192 (77.11) 331 (78.81)
1.060 0.303
Low 32 (18.71) 57 (22.89) 89 (21.19)
Knowledge score
Mean ± S.D 13.95 ± 1.88 13.99 ± 1.92 13.97 ± 1.90 −0.184 a 0.854
Note: a : t-test.
Healthcare 2021, 9, 433 7 of 14

Between the International Group and Mainland Group, there were significant differ-
ences in terms of confidence about being diagnosed, concerns about the disease, and high
perceived probability of becoming infected. Although relatively more respondents in the
Mainland Group were highly confident about being diagnosed and highly concerned about
the disease, more respondents in the International Group had a high perceived probability
of infection. Among International Group students, 34.5% thought they were highly likely
to be infected (19.3% in the Mainland Group). However, some also thought they were more
likely to survive after infection (91.8% in the International Group vs. 86.7% in the Mainland
Group). Furthermore, no statistically significant difference was found in terms of concern
about family members.

3.3. Differences in Preventive Practices between the Groups

Table 3 shows the performance of preventive measures against COVID-19 in the Inter-
national Group and Mainland Group. Overall, the two groups were significantly different
in terms of seven practices. The mean scores of the International Group were significantly
higher than those of the Mainland Group in five practices: covering mouth when coughing
and sneezing; washing hands with soap and water; washing hands immediately after
coughing, rubbing nose, or sneezing; washing hands after touching contaminated objects;
and avoiding public transportation. On the contrary, the Mainland Group achieved higher
levels of performance than that of the International Group in terms of the sitting in one
row while having a meal and avoiding meeting more than 10 people.

Table 3. Preventive practices taken against COVID-19 by Chinese university students in Mainland China and South Korea.
(Mean ± S.D).

International Group Mainland Group Total

Variables (Score: 1–5) t
(n = 171) (n = 249) (n = 420)
1. Wearing mask regardless of the presence or
4.32 ± 0.79 4.27 ± 0.89 4.30 ± 0.86 0.52
absence of symptoms
2. Covering mouth when coughing and sneezing 4.67 ± 0.80 4.36 ± 1.02 4.49 ± 0.95 3.28 ***
3. Washing hands with soap and water 4.84 ± 0.44 4.62 ± 0.66 4.71 ± 0.59 2.83 ***
4. Washing hands immediately after coughing,
4.18 ± 1.05 3.98 ± 1.13 4.06 ± 1.10 1.76 *
rubbing nose, or sneezing
5. Washing hands after touching contaminated
4.93 ± 0.38 4.47 ± 0.78 4.66 ± 0.69 7.11 ***
objects
6. Avoiding public transportation 4.73 ± 0.66 4.58 ± 0.72 4.65 ± 0.70 2.23 *
7. Avoiding elevators 3.44 ± 1.40 4.18 ± 1.19 3.88 ± 1.33 −5.81 ***
8. Sitting in one row while having a meal 2.80 ± 1.70 4.22 ± 1.18 3.64 ± 1.57 −10.13 ***
9. Avoiding meeting more than 10 people 4.74 ± 0.89 4.76 ± 0.62 4.75 ± 0.74 −0.22
Note: * p < 0.05; *** p < 0.001.

3.4. Depressive Symptoms Resulting from the Analysis

A chi-squared test was performed to determine the relationship between the level of
depressive symptoms and memberships of the International Group and Mainland Group.
Depressive symptoms were categorized into minimal-to-mild and moderate-to-severe
(cut-off score of 10) in this study. As Table 4 shows, the difference between the two groups
was confirmed as statistically significant (χ2 = 5.50, p < 0.05); the depression status of the
International Group was more severe than that of the Mainland Group.
A simple linear stepwise regression analysis was conducted to explore the factors
affecting the depression status of respondents, including all the variables. The results in
Table 5 show that satisfaction with the information, patients’ contact history, concern about
family members, and self-assessed physical condition were statistically significantly related
to respondents’ depression. These four variables were subjected to hierarchical regression
in different models in combination with variables such as demographic characteristics,
knowledge score, and preventive score.
Healthcare 2021, 9, 433 8 of 14

Table 4. Difference in depressive symptoms between the students in Mainland China and South Korea.

International Group Mainland Group Total

PHQ-9 (n = 171) (n = 249) (n = 420)
n (%) n (%) n (%)
Total score a 7.20 ± 0.41 6.20 ± 0.31 6.60 ± 5.14
Minimal-to-mild b 122 (71.35) 202 (81.12) 324 (77.14)
χ2 = 5.50 *
Moderate-to-severe b 49 (28.65) 47 (18.88) 96 (22.86)
Note: a : the total score of the PHQ-9 is mean ± SD; b : cut-off score of 10 points; * p < 0.05.

Table 5. Stepwise regression analysis of the factors of depression due to COVID-19.

Dependent
Independent Variables β S.E. β’ t p [95% C.I.]
Variable
Constant 13.793 3.186 4.329 0.000 7.501 20.084
Concern on family members 1.069 0.386 0.205 2.772 0.006 0.308 1.890
PHQ-9
Patients’ contact history 0.574 0.231 0.185 2.489 0.014 0.119 1.030
Scores
Satisfaction with the information −1.351 0.671 −0.148 −2.013 0.046 −2.676 −0.026
Self-assessed physical condition −1.491 0.594 −0.179 −2.509 0.050 −2.388 −0.002
Note: S.E. = Standardized Error; C.I. = Confidence Interval.

Table 6 displays the results of the hierarchical regression analysis of the determinants of
depression. In Models 1 and 2, there were no statistically significant relationships between
age, sex, education level, or marital status and the depression scores of respondents.
Students who had a better assessment of their health had lower depression scores. As
more variables were added into Models 3 and 4, the factors patients’ contact history,
highly concerned about family members, and highly concerned about the disease were
associated with statistically significant increases in depression scores. In the four models,
the preventive practice scores all had significantly negative relationships with depression
scores. In short, the better the performance of preventive practices by students, the lower
the depression score. The Durbin–Watson value was close to 2, indicating that the observed
value was independent. Although the R2 value was low, the p values of the F test in the
four models were all less than 0.01, showing a strong correlation of the interpretative power
of the models.

Table 6. Hierarchical regression analysis of the determinants of depression using the PHQ-9 (n = 420).

PHQ-9
Variables Model 1 Model 2 Model 3 Model 4
β t(p) β t(p) β t(p) β t(p)
Constant 12.122 3.439 *** 13.137 3.713 *** 11.586 3.296 *** 10.264 2.936 **
Preventive practice score −0.165 −3.221 *** −0.155 −3.027 ** −0.139 −2.745 ** −0.138 −2.749 **
Age 0.199 1.691 0.214 1.823 0.213 1.842 0.225 1.966 *
Sex
Male (ref) (ref) (ref) (ref)
Female −0.145 −0.547 −0.097 −0.178 −0.020 −0.037 −0.231 −0.431
Educational level
Undergraduate (ref) (ref) (ref) (ref)
Graduate −0.401 −0.531 −0.466 −0.620 −0.609 −0.820 −0.706 −0.963
Marital status
Single (ref) (ref) (ref) (ref)
Married −0.990 −0.0742 −1.186 −0.892 −0.938 −0.714 −0.898 −0.693
Knowledge belief score −0.142 −1.025 −0.149 −1.081 −0.109 −0.836 −0.165 −1.279
Satisfaction with the information
Low (ref) (ref) (ref) (ref)
High −1.517 −1.415 −1.486 −1.392 −1.316 −1.249 −1.486 −1.426
Healthcare 2021, 9, 433 9 of 14

Table 6. Cont.

PHQ-9
Model 1 Model 2 Model 3 Model 4
Variables
β t(p) β t(p) β t(p) β t(p)
Self-assessed physical condition
Fair or below (ref) (ref) (ref)
Good or above −1.865 −2.208 * −1.702 −2.040 * −1.501 −1.820
Patients’ contact history
No (ref) (ref)
Yes −2.842 −0.983 −2.900 −1.015
Not sure 4.413 3.539 *** 4.069 3.287 ***
Concern about family members
Low (ref)
High 1.580 2.624 **
Concern about this disease
Low (ref)
High 1.098 2.081 *
F 2.778 ** 3.063 ** 3.875 *** 4.456 ***
R2 0.045 0.056 0.087 0.116
Adjusted R2 0.029 0.038 0.064 0.090
Durbin–Watson 1.972
Note: * p < 0.05; ** p < 0.01; *** p < 0.001.

4. Discussion
4.1. Knowledge and Preventive Practices of International Group and Mainland Group Students
This study found that our sample university students had a certain degree of knowl-
edge of COVID-19, concurring with other research results [16,55]. Combined with the
findings on satisfaction with the information and information sources, most of them cor-
rectly understood how the virus is transmitted and have received detailed information
on cases. This shows that the publicity work and health education of schools, health
institutions, and the mass media are having an impact [56]. Although a high proportion of
students perceived themselves as having high confidence about being diagnosed and that
they would survive after infection, many reported being highly concerned about family
members in this study. This is also consistent with the fact that as confirmed and suspected
cases continue to increase, more provinces and countries are affected by the pandemic [14],
which increases public attention.
The effects of the COVID-19 outbreak on Chinese university students’ psychological
state and their associated factors have been studied [16,32,48]; however, these studies
have only included respondents from Mainland China. After the case of Patient No. 31
(a confirmed case who participated in a gathering in Daegu at the Shincheonji Church of
Jesus), a sudden outbreak in South Korea attracted worldwide attention and suggested
that upgraded quarantine and isolation measures were necessary [57,58]. Because most
International Group students in South Korea live alone, their fears are exacerbated by the
fact that they may have to experience a prolonged quarantine period by themselves (83.1%
had self-quarantined). This may also explain why students in both groups experienced
similar concerns about this disease and family members. In addition, a number of students
from the Mainland Group perceived a high probability of contracting the disease. This
is also consistent with the situation in Mainland China, where COVID-19 has spread
throughout almost every province since January 2020 [59]. Overall, both groups did well
in performing preventive practices. The Mainland Group only performed better than the
International Group in terms of avoiding using elevators and sitting in one row while
having a meal. Therefore, effective measures to prevent the virus should be continued,
such as propagandizing through health education and publicity work by health institutions
and the mass media in Mainland China.
Healthcare 2021, 9, 433 10 of 14

4.2. Depression Status of the International Group and Mainland Group Students
Depressive disorders are one of the most common mental disorders, with a lifetime
prevalence of 6.9% and a 12-month prevalence of 3.6% in the Chinese population [60].
The average PHQ-9 scores in these two groups were 7.20 (95% CI: 6.390–7.800) for the
International Group and 6.20 (95% CI: 5.583–6.819) for the Mainland Group, and the
proportion (28.7%) of the International Group who experienced mild-to-severe symptoms
was much higher than that of the Mainland Group (18.9%). Therefore, the prevalence of
depression in the college students who participated in this study (12.6%) was higher than
average [61]. Factors such as performing preventive practices, patients’ contact history,
concern about family members, and concern about the disease and their relationships
with the depression scores of these respondents also showed that the COVID-19 outbreak
may impact the psychological state of university students, especially International Group
students. Fearing that COVID-19 would have psychological consequences similar to
other infectious diseases [7,9], universities in South Korea need to provide the necessary
psychological interventions and health education measures for these students continuously.
Improving university students’ knowledge of the virus and related preventive prac-
tices by providing clear and consistent information during this pandemic improves their
psychological health [27]. A lack of knowledge of COVID-19 may cause students to be
excessively worried about the damage brought on by the pandemic, resulting in a higher
risk perception and more feelings of panic and anxiety [62]. As demonstrated in this study,
the more comprehensive the preventive measures, the better the psychological state of
university students, the lower their risk of mild depression, and the more positive their
response to the pandemic.
The thoughts and feelings of university students could also affect their mental health.
This study showed that students who felt good about their bodies and did not suspect
themselves as having come into contact with a patient, those with lower levels of stress, and
those who were not as worried about their families and the disease had lower depression
scores. During this outbreak, the influence of rumors cannot be overlooked [63]. Negative
and false information on the pandemic may result in great psychological consequences
for students because this may make them feel negative and require the companionship of
family and friends at this time [64], which may not be possible for those studying abroad
because of bans on transportation and migration. Thus, social and school support provided
by governments and universities is still needed to help them develop and maintain a
positive mindset.
Another point about the positive relationship between physical activities and mental
health is that social distancing and working at home are expected to play a role to a greater
or lesser degree in the short to medium term. Even light physical exercise could help
relieve some of the negative psychological health impacts among isolated older adults
due to COVID-19 [65,66]. To promote physical activity, public health initiatives should
target particular populations (e.g., men and young adults) that are more vulnerable to the
harmful impacts of physical distance and/or self-isolation [67].
In this battle of pandemic prevention and control, various coping strategies have been
developed for university students by the governments in China and South Korea. In China,
local governments and academic institutions emphasize the importance of preventive
measures (e.g., controlling movement and wearing masks) and the need for mental health
support (e.g., psychological consultation and aid)—and not only for young adults [68].
In South Korea, to help students cope with the mental pressure, university authorities
have organized programs such as online experience-sharing competitions and encouraged
students by offering rewards and financial aid. The required food and healthcare materials
are supplied to ensure the safety of international students who need to quarantine [69].
In addition, activities and postings on the online communities of Chinese international
students have had a positive effect on health information sharing and social support [70].
Healthcare 2021, 9, 433 11 of 14

4.3. Implications
Considerable effort and support by the universities of the two countries should be
ongoing to help students thrive in this pandemic. Governments and local authorities
should be conscious of the significance of providing adequate guidance and protection
to international students in such uncertain and frightening times. The mental health of
Chinese university students in both China and South Korea needs to be further ascertained
to elucidate the psychological impact in different regions due to the COVID-19 pandemic.

4.4. Limitations and Future Research

This study had several limitations. Owing to the restrictions on activities brought
on by the COVID-19 pandemic, several adjustments had to be made. First, a web-based
questionnaire was adopted in this study, which may have some shortcomings. One example
is that self-assessed levels of physical condition and depression scores may not always
be aligned with the real situation, because respondents may choose a socially desirable
response. Second, the snowball sampling method was employed; therefore, it may not be
possible to make statistical inferences from the sample that are applicable to the population
since respondents were not randomly selected. Third, the importance and effect of beliefs
on depression have been emphasized by many studies. Given that the study populations in
the two countries in this research are both young Chinese university students (i.e., ethnically
homogeneous), the relationship between beliefs and depressive status was not analyzed.
Fourth, the severity of the pandemic varies by region; thus, the effects of the pandemic on
depression among university students may also differ by region. Therefore, it is necessary
to conduct further studies of their depression status, and we are planning to conduct a
prospective study on a comparable group. Notwithstanding the above limitations, this
study provides useful information on knowledge, preventive practices, and depressive
symptoms among Chinese students in two countries (China and South Korea), which
had suffered the largest COVID-19 outbreaks at the time this study was conducted. Our
results could be used as an evidence-based reference in the provision of psychological
interventions for university students in different areas during the outbreak.

5. Conclusions
The present study investigated the knowledge, preventive practices, and depression
symptoms of Chinese university students living in South Korea and Mainland China
during the COVID-19 outbreak as well as explored the determinants of depression among
both groups. The results showed that the majority of respondents had a satisfactory level of
knowledge of COVID-19. International Group students displayed better preventive practice
than Mainland Group students; however, the percentage of students with moderate-to-
severe depression was higher in the International Group. Depression was associated
with high levels of concern about family members and about contacting COVID-19, and
worry about having had contact with patients. Performing preventive behaviors may
be associated with a decrease in the depressive state in both groups. As an initial study
of the impact of COVID-19 on Chinese university students in two countries, these data
could be used as a reference for further studies in different regions to take measures (e.g.,
psychological counseling and encouragement for physical activities) to reduce depressive
symptoms in university students.

Supplementary Materials: The following are available online at https://www.mdpi.com/article/10

.3390/healthcare9040433/s1, Study Questionnaire.
Author Contributions: Conceptualization, E.W.N. and B.Z.; methodology, B.Z.; software, B.Z.;
validation, F.K., E.W.N., and B.Z.; formal analysis, B.Z.; investigation, F.K. and B.Z.; resources, F.K.
and B.Z.; data curation, B.Z.; writing—original draft preparation, B.Z.; writing—review and editing,
F.K. and E.W.N.; supervision, F.K. and E.W.N. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Healthcare 2021, 9, 433 12 of 14

Institutional Review Board Statement: Ethical review and ethical approval for the study was
obtained from the Yonsei University Institutional Review Committee (Task No. 1041849-202005-SB-
057-02) and the Institutional Review Board of Public Health and Preventive Medicine at Shandong
University (No. LL20210201). Written informed consent was obtained from respondents for inclusion
before they participated in the study. Confidentiality was maintained throughout the study by not
recording participants’ names on questionnaires.
Informed Consent Statement: Informed consent was obtained from all the subjects involved in the
study.
Data Availability Statement: The questionnaire used in the study and datasets can be made available
upon request from the corresponding author.
Acknowledgments: The authors would like to thank all respondents for their participation in this
research and the researchers from the Yonsei Global Health Center for their cooperation.
Conflicts of Interest: The authors declare no conflict of interest.

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