The coronavirus disease 2019 (COVID-19) is a new infectious disease that has swept the world more than 2 years. According to reports from the World Health Organization (WHO), there have been 620,878,405 confirmed cases globally by 14 October, 2022 including 6,543,138 death (WHO, 2022). To prevent virus transmission, the Chinese government adopted unprecedented, extreme measures to mitigate the outbreak, such as nationwide or regional lockdowns were linked with increased stressful events and limited social interactions. This situation has also triggered a wide variety of psychological problems, such as anxiety, depression and posttraumatic stress disorder (PTSD) (Xiong et al., 2020).

Posttraumatic stress disorder is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event. Based on Life Events Checklist for DSM-5 (Sun et al., 2021), being involved in a life-threatening illness might be a traumatic experience. Findings from recent studies have shown that COVID-19 can be identified as a traumatic stressor and can cause PTSD symptoms in the general public (Forte et al., 2020). A meta-analysis of 14 studies conducted during the first wave of the pandemic, between February and April, revealed a high rate of COVID-19 related PTSD (23.88%) in the general population (Cooke et al., 2020). A nationwide survey in China with more than 50 thousand participants found that the prevalence was 35% (Qiu et al., 2020).

China has around 33 million students studying on college campuses. The psychological impact of the new COVID-19 is a public health concern (Tang et al., 2020). College students are particularly susceptible to mental health deterioration during the ongoing pandemic. Chinese college students have been exposed to a significant number of COVID-19-related stressful events during the outbreak, including disruptions in their academic studies, entertainment, and family and social lives. But the prevalence rate of PTSD in college students from different regions presents a wide range of variety. In the group of home-quarantined Chinese university students in Chengdu (n = 2,485) 1 month after the breakout, the prevalence was 2.7% (Tang et al., 2020). However, Chi et al. (2020) revealed that in a sample of Chinese students distributed across 29 provinces and cities of China (n = 2,038), the prevalence of clinically relevant PTSD reached 30.8% during the pandemic. In other parts of the world, the rate of probable PTSD 1 month after the COVID-19 lockdown was 19.5% among a large sample of French university students (n = 22,883) (Wathelet et al., 2021), one quarter (25.4%) of American medical students, 29.0% in Asian medical students and 51.0% in Europe medical students (Peng et al., 2022). It has been demonstrated that population in different regions may have different prevalence rates of PTSD.

Posttraumatic stress disorder symptom is a core criterion for the diagnosis of PTSD, which could last for at least 1 month. Most people can recover from initial symptoms naturally, while others’ symptoms may worsen, lasting for months or even years and interfering with daily life functioning. Previous studies, the samples from Chengdu and 29 provinces and cities of China, were conducted 1 month after the breakout (Tang et al., 2020). However, they were not focused on the population mainly in Hubei province most affected by the COVID-19 outbreak in the initial wave of the pandemic.

This study aimed to evaluate the prevalence and risk factors of PTSD symptoms in the college students’ data. To meet PTSD duration criteria, data were mainly collected in Hubei province more than 1 month after the peak outbreak. The main findings of this study would offer useful early detection and intervention methods to PTSD, and provide helpful insight into planning for future outbreaks of emerging infectious diseases.

This study, which was conducted more than 1 month after the COVID-19 high-incidence period, focused on the PTSD symptoms prevalence and risk factors among college students in China. The prevalence of PTSD symptoms in Chinese public 1 month after the COVID-19 outbreak was 4.6% (Sun et al., 2021). Our study showed a higher prevalence 13.1%. It mainly resulted from the samples in our study mainly come from Hubei province, the original and worst disaster-affected area. In fact, the pandemic is associated with other mental health symptoms and disorders. A meta-analysis has shown that population have mental health problems such as anxiety, depression, insomnia, PTSD and so on caused by COVID-19 outbreak, prevalence of which in populations affected by COVID-19 is much more times than in general population. Even without infection, many people believed that this unknown new virus was highly contagious that could cause death or disability. Unknown transmission routes of virus and uncertainty treatment made them feel fear, worry, and helpless. In addition, financial pressure triggered by the pandemic like job losses, wage losses, and uncertainty about the future (Nicola et al., 2020) also effected mental health.

Several studies have shown the prevalence of PTSD among college students in response to COVID-19. Around the world, PTSD prevalence rates in American, Asian, and Europe medical students are higher than that in our study. It may be because of effective and strict control of the epidemic in China (Peng et al., 2022). In China, from six universities of two large cities in southwest China, the PTSD prevalence was 2.7% in a sample of home-quarantined students (Tang et al., 2020), much lower than our results. This may because the samples in our study mainly come from Hubei province, the original and worst disaster-affected area. In addition, these inconsistent data regarding the prevalence of PTSD in the student population may also result from using different measurement. Previous studies used the PCL-5 (Cutoff Score 32) (Sun et al., 2021), or PCL-C (Tang et al., 2020), while IES-R was used in our study.

The prevalence in our study was lower than that of earthquake-associated PTSD (from 15.6 to 24.2%) (Wang et al., 2000; Xi et al., 2017) and flood-associated PTSD (15.4%) (Zhou et al., 2013) reported in studies conducted 6 months, 9 months, or more than 10 years after disaster outbreaks, much longer than the 1-month period in our study. Previous research on the mental health during infectious disease outbreaks. Medical staff involved in the 2003 severe acute respiratory syndrome (SARS) outbreak found that about 10% of the sample reported high levels of PTSD symptoms (Wu et al., 2009). Another study showed that about 2% Chinese university students met symptom criteria for PTSD during 2009 H1N1 pandemic (Xu et al., 2011). Differences in the prevalence of PTSD symptoms may be attributed to differences in the intensity and type of trauma exposure. Although the psychological impact of disasters may evolve over time (Hu et al., 2015), earthquakes and floods are often much more devastating and destructive than infectious diseases and occur unexpectedly. The infectiousness could be seen everywhere, but people cannot find where the real threats come from. People could not realize where the source of the infection is, so they need to prevent infectious diseases everywhere, which could become chronic and unpredictable stressors (d’Ettorre et al., 2021).

A high probability of PTSD symptoms development was found among college students who had strained relationships with family (OR = 3.5). During the COVID-19 epidemic, college students were instructed not to go out, meet people, organize or attend mass gatherings. Family members seemed to be the first choice to provide any kind of social support. Our results imply that improving relationship with family may decrease the incidence of PTSD symptoms. Other event exposure factors were ranked according to risk intensity as follows: close contact with COVID-19 patients, dropping out, death of a relative or friend from COVID-19, high study pressure, changed life pattern, financial difficulties and any quarantining. It is suggested that among college students, a wide range of stressors occur concurrently during traumatic exposure and are often causally related, which the features of stressful events among college students are.

Some demographic factors may also influence PTSD symptoms development during the COVID-19 pandemic. Senior student and lower income was identified as two risk factors. These may be attributed to the fact that senior students face to pressure of employment after graduation, academic pressure and economic hardship.

Positive coping style and negative coping style were all entered the regression model. Active coping involves focusing on the cause of the stress and attempting to do something actively in order to reduce the stress. Individuals often use avoidant coping when they wish to reduce the emotional stress elicited by a problematic situation rather than deal with the stress at its source (Carver et al., 1989). Previous studies have demonstrated that coping style is depended upon the controllability of stressors (Main et al., 2011). For example, coping with SARS-related stressors, college students reported avoidant coping may be more adaptive than active coping (Main et al., 2011). Like SARS-related stressors, COVID-19-related stressors may also be regarded as uncontrollable stressors. It is speculated that avoidant coping may be more adaptive for college students during COVID-19 pandemic. Further studies could be focused on the relations between coping and individuals’ psychological adjustment during COVID-19 outbreak.

This study also showed that neuroticism and psychoticism were two significant predictors in the personality dimension. This finding of neuroticism in the context of the pandemic is in line with previous findings in various contexts, such as fights, transportation accidents, industrial and domestic accidents, terrorism, violent crimes and explosions (Liang et al., 2019). The relationship between neuroticism and stress might be due to a low ability of individuals with high neuroticism scores to cope effectively with stressors, which would increase the amount of stress (Yin et al., 2019). Similar to our results, research has found a strong correlation between traffic accident-related PTSD and flood-related PTSD and psychoticism. Overall, negative emotions, including neuroticism, avoidance, hostility, anger, and anxiety, are likely to predict PTSD (Su et al., 2018).

The following recommendations for psychological prevention and interventions were proposed according to our present findings:

The strengths of this study include its large sample size and the special study period. The results of this survey indicate that PTSD symptoms may have been relatively high incidence among Chinese college students, especially among senior students with lower income. Strained relationship with family was the most probably associated with PTSD. The findings identify populations of college students at risk for PTSD symptoms during the COVID-19 pandemic and may help in implementing mental health intervention policies in other countries and regions.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Human Subjects Committee at Zhongshan School of Medicine, Sun Yat-sen University. The patients/participants provided their written informed consent to participate in this study.

J-YW and QL collected and analyzed the data and wrote the manuscript. WL, YY, X-GW, C-YL, and X-JS collected the data. Y-WS and LX conceived, designed, and organized the study in addition to interpreting the results and revising the manuscript. All authors read and approved the final manuscript.