Influencing Factors of International Students’ Anxiety Under Online Learning During the COVID-19 Pandemic: A Cross-Sectional Study of 1,090 Chinese International Students

Abstract

Objective
We conducted the following cross-sectional study to comprehensively assess the anxiety among Chinese international students who studied online during the COVID-19 pandemic and its influencing factors.

Methods
Questionnaires were distributed through “Sojump,” and a total of 1,090 valid questionnaires were collected. The questionnaire was divided into two parts: general situation and anxiety assessment of students. The former used a self-made questionnaire, and the international general GAD-7 scale was used to measure anxiety. Chi-square test was used to analyze the differences between groups, and logistic regression analysis was performed for the factors with differences.

Results
Anxiety was found in 707 (64.9%) of 1,090 international students. Chi-square test and multivariate Logistic regression analysis showed that the incidence of anxiety was higher in the group under 22 years of age than in the group over 22 years of age (68% vs. 61%, p = 0.015; OR = 1.186, 95% CI 1.045–1.347, p = 0.008); International students living in big cities had a higher incidence of anxiety than those living in rural areas (67% vs. 60%, p = 0.022; OR = 1.419, 95%CI 1.038–1.859, p = 0.011); international students who socialized 3 times or less monthly had a higher incidence of anxiety than those who socialized more than 3 times per month (68% vs. 58%, p = 0.003; OR = 1.52, 95%CI 1.160–1.992, p = 0.002); international students who expected purely online teaching had a higher incidence of anxiety than those who expected purely offline teaching or dual-track teaching (72% vs. 64%, p = 0.037; OR = 1.525, 95%CI 1.069–2.177, p = 0.02); international students with a subjective score of online learning experience of 6 or less had a higher incidence of anxiety than those with subjective scores of more than 6 (70% vs. 60%, p = 0.001, OR = 1.25, 95%CI 1.099–1.422, p = 0.001). However, gender, emotional status, BMI, major of study, vaccination status, and degree type had no significant difference in the incidence of anxiety among international students who studied online during the COVID-19 pandemic.

Conclusion
During COVID-19, international students who were younger, came from big cities, had low social frequency, expected purely online teaching, and had poor experience of online classes were risk factors for anxiety during online classes.

Full text

Frontiers in Psychology | www.frontiersin.org 1 April 2022 | Volume 13 | Article 860289
ORIGINAL RESEARCH
published: 14 April 2022
doi: 10.3389/fpsyg.2022.860289
Edited by:
David Aparisi,
University of Alicante, Spain
Reviewed by:
Vsevolod Konstantinov,
Penza State University, Russia
Vincent Hooper,
Xiamen University, China
*Correspondence:
Jin Kang
kangjin2015@csu.edu.cn
Specialty section:
This article was submitted to
Educational Psychology,
a section of the journal
Frontiers in Psychology
Received: 22 January 2022
Accepted: 28 March 2022
Published: 14 April 2022
Citation:
Tan Y, Wu Z, Qu X, Liu Y, Peng L,
Ge Y, Li S, Du J, Tang Q, Wang J,
Peng X, Liao J, Song M and
Kang J (2022) Inuencing Factors of
International Students’ Anxiety
Under Online Learning During the
COVID-19 Pandemic: A
Cross-Sectional Study of 1,090
Chinese International Students.
Front. Psychol. 13:860289.
doi: 10.3389/fpsyg.2022.860289
Inuencing Factors of International
Students’ Anxiety Under Online
Learning During the COVID-19
Pandemic: A Cross-Sectional Study
of 1,090 Chinese International
Students
YejunTan
1,2, ZhijianWu
3, XiangnanQu
4, YuzhuoLiu
5, LelePeng
6, YanGe
1, ShuLi
1,
JinfengDu
1, QiTang
1, JiaWang
1, XiaofeiPeng
1, JiafenLiao
1, MeiyanSong
1 and JinKang
1
*
1 Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, China,
2 School of Mathematics, University of Minnesota Twin Cities, Minneapolis, MN, United States, 3 Department of
Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, Changsha, China, 4 Xiangya School of
Medicine, Changsha, China, 5 Department of Psychiatry, The Second Xiangya Hospital of Central South University,
Changsha, China, 6 Department of Endocrinology, Wangwang Hospital of Hunan, Changsha, China
Objective: We conducted the following cross-sectional study to comprehensively assess
the anxiety among Chinese international students who studied online during the COVID-19
pandemic and its inuencing factors.
Methods: Questionnaires were distributed through “Sojump,” and a total of 1,090 valid
questionnaires were collected. The questionnaire was divided into two parts: general
situation and anxiety assessment of students. The former used a self-made questionnaire,
and the international general GAD-7 scale was used to measure anxiety. Chi-square test
was used to analyze the differences between groups, and logistic regression analysis was
performed for the factors with differences.
Results: Anxiety was found in 707 (64.9%) of 1,090 international students. Chi-square
test and multivariate Logistic regression analysis showed that the incidence of anxiety
was higher in the group under 22 years of age than in the group over 22 years of age (68%
vs. 61%, p= 0.015; OR = 1.186, 95% CI 1.045–1.347, p= 0.008); International students
living in big cities had a higher incidence of anxiety than those living in rural areas (67%
vs. 60%, p= 0.022; OR = 1.419, 95%CI 1.038–1.859, p= 0.011); international students
who socialized 3 times or less monthly had a higher incidence of anxiety than those who
socialized more than 3 times per month (68% vs. 58%, p= 0.003; OR = 1.52, 95%CI
1.160–1.992, p= 0.002); international students who expected purely online teaching had
a higher incidence of anxiety than those who expected purely ofine teaching or dual-track
teaching (72% vs. 64%, p= 0.037; OR = 1.525, 95%CI 1.069–2.177, p= 0.02); international
students with a subjective score of online learning experience of 6 or less had a higher
incidence of anxiety than those with subjective scores of more than 6 (70% vs. 60%,

Frontiers in Psychology | www.frontiersin.org 2 April 2022 | Volume 13 | Article 860289
Tan et al. International Students’ Anxiety
INTRODUCTION
In January 2020, the World Health Organization listed COVID-19
as a public health emergency of international concern (Yue
et al., 2020). As of 2 August 2021, COVID-19 has rapidly
spread to 208 countries and territories, making it a global
pandemic with over 200 million infections and over 4 million
deaths worldwide. Studies have shown that COVID-19 has
caused a psychological crisis in the public that urgently needs
to be addressed (Choi et al., 2020; Dong and Bouey, 2020;
Gao etal., 2020; Gómez-Salgado etal., 2020; Huang and Zhao,
2020; Wang et al., 2020; Yang et al., 2020). e COVID-19
pandemic has triggered a psychological crisis among the public
because of the increased prevalence of mental illness, including
anxiety and depression (Asmundson and Taylor, 2020; González-
Sanguino et al., 2020; Kola, 2020; Ozamiz-Etxebarria et al.,
2020; Ahn et al., 2021). e public’s positive psychological
response to COVID-19 has played a crucial role in reducing
anxiety. Positive thoughts and attitudes can help individuals
cope with stressors (Görgen etal., 2014). A recent study found
that the hope helps prevent anxiety (Mirhosseini et al., 2020).
e theory of rational emotive behavioral therapy suggests
that rational beliefs can relieve anxiety and other symptoms
of mental distress (David etal., 2018; Eseadi, 2019). In addition,
cognitive-behavioral models of health anxiety suggest that
negative emotions and misunderstanding of health-related stimuli
may increase the chance of developing anxiety (Gautreau etal.,
2015; Hagger et al., 2017; Schäfer et al., 2017). erefore,
promoting positive psychological response, initiating emotional
regulation, and positive cognition of health-related information,
such as maintaining a positive attitude and rationality, is
necessary for the public to better cope with stress (Grecucci
et al., 2015). It is worth noting that the psychological impact
of COVID-19 on students is signicant. Previous studies have
also shown that aer the government blockaded the city for
a week, the rating of anxiety and depression among students
increased signicantly and reached a stable state in the second
week but remained at a poor level (Jin and Fung, 2021). Two
months aer online learning, the anxiety and depression among
students still increased signicantly (Magson etal., 2021). So,
aer implementing online courses for a year, what is the
students’ psychological state? However, no relevant literature
has been reported so far.
International students, primarily college students, are a huge
and leading group for world cultural and academic exchanges.
According to the Ministry of Education, PRC, there were
700,000 Chinese students studying abroad in 2019. With the
increasing demand for academic qualications in society,
international students have increased yearly. e mental health
of this particular group has attracted more and more attention
(Wang et al., 2015).
To avoid infection or implement border blockade policies,
many schools worldwide have transferred traditional oine
teaching to online. e outbreak of COVID-19 has also forced
many Chinese international students to stay in China for online
learning. When the teaching mode changed from the expected
foreign campus to the computer at home, such large-scale
online teaching came as suddenly as COVID-19, international
students were signicantly aected both physically and mentally.
erefore, as a particular group, the anxiety and its inuencing
factors of international students under online learning during
the COVID-19 pandemic are worthy of our attention. However,
for example, previous studies have not focused on issues of
mental health among international students or the context of
online learning among international students during the
COVID-19 pandemic. To better understand the anxiety among
international students under online learning and its inuencing
factors during the COVID-19 pandemic, weconducted a cross-
sectional study on the anxiety and its inuencing factors of
international students.
e main objective of this study was to assess anxiety and
its inuencing factors in a sample of 1,090 Chinese international
students who studied online during the outbreak of COVD-19.
In this study, A standardized mental health measure (GAD-7)
was used to assess acute anxiety symptoms. Our study found
that age, cities of residence, the frequency of socialization,
expected teaching mode, and subjective experience of online
learning inuenced the anxiety of international students.
MATERIALS AND METHODS
Research Object and Procedures
To investigate the anxiety among international students who
studied online during the COVD-19 pandemic, weadopted a
Abbreviations: GAD-7, Generalized Anxiety Disorder 7-item; OR, Odds ratio.
p= 0.001, OR = 1.25, 95%CI 1.099–1.422, p= 0.001). However, gender, emotional status,
BMI, major of study, vaccination status, and degree type had no signicant difference in
the incidence of anxiety among international students who studied online during the
COVID-19 pandemic.
Conclusion: During COVID-19, international students who were younger, came from big
cities, had low social frequency, expected purely online teaching, and had poor experience
of online classes were risk factors for anxiety during online classes.
Keywords: international students, anxiety, COVID-19, online learning, public health emergency, mental health,
online survey, cross-sectional study

Tan et al. International Students’ Anxiety
Frontiers in Psychology | www.frontiersin.org 3 April 2022 | Volume 13 | Article 860289
cross-sectional study design and questionnaires through the
“Sojump,” an Internet-based questionnaire application in
mainland China. Wedistributed questionnaires on the platform
of 15 WeChat international student groups with a total of
about 15*500 = 7,500 people. is survey adopted the principle
of voluntary participation, and 1,101 questionnaires were
collected. 11 questionnaires were invalid for interfering with
common sense problems, and 0 were excluded within 2 min.
A total of 1,090 valid questionnaires were collected, and the
recovery rate was 99%. e WeChat group of international
students was established spontaneously by Chinese international
students to facilitate communication in all aspects of study
and life abroad. e person in charge of this survey is in
charge of the WeChat group mentioned above. During the
outbreak of COVID-19, we distributed questionnaires in the
name of the person in charge to understand the psychological
conditions of the students during online learning.
e survey was conducted from August 15 to 25, 2021,
during which weobtained a sucient sample size in accordance
with previous related studies (Hu et al., 2007; Kamangar and
Islami, 2013; Zhang etal., 2017; Liu etal., 2020). e questionnaire
consisted of two parts: the internationally recognized Chinese
Version of the Generalized Anxiety Disorder Scale (GAD-7)
and the self-designed general situation of international Students
who studied online due to the outbreak of the COVID-19
pandemic. It takes about 3–5 min to complete the questionnaire.
e inclusion criteria for participating in this study were:
international students who have taken online courses for a
certain period, have Chinese reading and writing ability, can
use smartphones to complete the questionnaire, and were willing
to participate. Exclusion criteria were any treatment for mental
illness, any history of drug dependence, and any diagnosis of
illness or injury that might prevent them from completing the
questionnaire independently.
e questionnaire was submitted aer the participants had
answered all the questions. Only data from the complete
questionnaires were analyzed.
Moral Statement
e study was carried out by the Declaration of Helsinki (1989).
is study was approved by the Ethics Committee of Xiangya
Hospital of Central South University. In the process of informed
consent in the preamble of the questionnaire, wele the contact
information of the project team members for the respondents.
If the international students need professional psychological
consultation, they can contact us through our contact information.
Demographics and the General Situation
of International Students Who Studied
Online During the COVID-19 Pandemic
Demographic characteristics of participants were collected in
this study, including gender, age, emotional status, BMI, city
of residence, the location of the school they attended, major
of study, vaccination status, and degree type. During the
COVID-19 pandemic, the general situation of international
students who studied online included advantages and
disadvantages of online learning, time dierence, average daily
study duration, average daily sleep duration, the frequency of
physical exercise, the frequency of socialization, primary ways
to relieve stress, measures to deal with infection risk, expected
teaching modes in coming semesters, concerns about COVID-19
infection, and subjective ratings of the online learning experience.
e signicant advantages and disadvantages of online learning,
the primary ways to relieve stress, and the primary measures
to deal with the risk of infection were multiple-choice questions.
Participants chose at least one of these multiple choices and
could choose up to ve. e subjective score of online learning
experience during the COVID-19 pandemic was 10 points,
with 0 points for completely dissatised and 10 points for
completely satised.
Measurement of Anxiety
Gad-7 is one of the most reliable measures of generalized
anxiety disorder. Anxiety-related psychological problems were
assessed on the Likert-4 scale, with options ranging from
“totally uncertain = 0,” “a few days =1,” “more than half the
time = 2,” and “almost every day =3” on a scale of 0 to 21.
e threshold of anxiety was set to higher than 5 based on
the Gad-7 score (Ahn et al., 2021; Park et al., 2021; Yo o
et al., 2021).
Statistical Analysis
SPSS soware (version 23.0) used to perform all statistical
analysis. e Chi-square test was used to analyze the dierence
in anxiety degree among groups. Anxiety was assessed using
a binary variable (anxiety or non-anxiety, measured on the
GAD-7 scale). e variables included in multivariate logistic
regression analysis included age, city of residence in China,
subjective experience score of online learning, the frequency
of socialization, and expected teaching method, all of which
were two variables. When the two-tail p-value was less than
0.05, the result was considered to be statistically signicant.
RESULTS
Demographic Characteristics and
Prevalence of Anxiety Among International
Students Who Studied Online During the
COVID-19 Pandemic
Our study found anxiety in 707 (64.9%) of 1,090 international
students. 1,101 international students participated in the survey,
of which 1,090 were valid questionnaires with an eective rate
of 99.0%. e general situation of international students and
their opinions toward online learning are shown in Ta b l e  1 .
Students from schools in Europe and Hong Kong, Macao, and
Taiwan accounted for 37.8 and 27.1%, respectively, while those
from schools in Oceania accounted for less than 10%(6.3%).
e top three majors chosen by international students were
economics and nance, management, and engineering, accounting
for 21, 15, and 12%, respectively. History, agriculture, and
military science were the least popular, accounting for less

Tan et al. International Students’ Anxiety
Frontiers in Psychology | www.frontiersin.org 4 April 2022 | Volume 13 | Article 860289
than 1%. e top three advantages of online learning were
eectively reducing the risk of COVID-19 infection, saving
living and commuting expenses, and saving commuting time,
with a cumulative selection rate of 80, 69, and 69%, respectively.
e two signicant disadvantages of online learning were the
diculty of concentration and the lack of campus atmosphere
TABLE1 | General situation of 1,090 Chinese international students who studied online during the COVID-19 pandemic.
Variables Frequency Chi-square p-value
The location of schools
North America 151(13.9) 1945.68 0
Europe 412(37.8)
Asia 163(15)
Oceania 69(6.3)
Hong Kong, Macao and Taiwan 295(27.1)
Major of study
Philosophy 13(0.01) 702.04 0
Economics and nance 230(0.21)
Law 39(0.04)
Pedagogy 122(0.11)
Literature 123(0.11)
History 12(0.01)
Science 101(0.09)
Engineering 133(0.12)
Agronomy 10(0.01)
Medicine 61(0.06)
Management 166(0.15)
Art 79(0.07)
Military science 1(0)
Advantages of online learning
Saving living and commuting expenses 747(0.69) 1369.86 0
Saving commuting time 751(0.69)
Effectively reduce the risk of COVID-19 infection 872(0.8)
No extra time needed to get used to the new environment 387(0.36)
No social fear 329(0.3)
Online courses can beplayed repeatedly for easy understanding
and review 582(0.53)
Online courses are fast paced and more efcient 130(0.12)
Translation software/plug-ins can beused to solve the language
barrier 296(0.27)
Online courses may have higher grades 101(0.09)
Disadvantages of online learning
Time difference can easily lead to a chaotic daily routine 337(0.31) 918.7 0
The Difculty of concentration 744(0.68)
Poor network connection 557(0.51)
Unable to interact with teachers immediately 552(0.51)
Inconvenience to exchange ideas with classmates 560(0.51)
The lack of campus atmosphere of studying abroad 768(0.7)
Lack of social interaction 312(0.29)
Inconvenience for scientic research 189(0.17)
The trouble of Preparing for exams 129(0.12)
The ways to relieve stress
Chatting with friends online 719(0.66)
Watching TV series& movies 841(0.77)
Shopping and dining out 539(0.49)
Doing physical exercise 480(0.44)
Playing video games 377(0.35)
Massage 125(0.11)
Watching ASMR videos 96(0.09)
Primary measures to address the risk of COVID-19 infection
Vaccination 894(0.82) 1922.38 0
Wearing a mask 971(0.89)
Washing your hands regularly 806(0.74)
Keeping Social distance 832(0.76)
Avoid visiting crowded places 772(0.71)
Gap year/delay until the epidemic stabilizes 190(0.17)
Drop out of school 33(0.03)
Transfer to another schools in areas where the epidemic is stable 83(0.08)

Tan et al. International Students’ Anxiety
Frontiers in Psychology | www.frontiersin.org 5 April 2022 | Volume 13 | Article 860289
of studying abroad. e cumulative selection rate was 70 and
68%, respectively. In addition, primary ways for international
students to release pressure were watching TV series & movies
(77%) and chatting with friends online (66%), followed by
dining out & shopping (49%) and physical exercise (44%).
e primary measures for these international students to deal
with the risk of infection were wearing masks (89%), getting
vaccinated (82%), maintaining social distance (76%), washing
hands frequently (74%), and reducing the times of visiting
crowded places (71%), while only 11% of them chose to drop
out (3%) or transfer to another school (8%).
Factors Inuencing the Anxiety Among
International Students Who Studied Online
During the COVD-19 Pandemic
Students with GAD-7 scores higher than or equal to 5 were
dened as the anxiety group, and the Chi-square test was
used to analyze the inuencing factors of anxiety among the
international students who studied online due to the outbreak
of COVD-19. e results are shown in Ta b l e  2 . Among the
international students who studied online, the incidence of
anxiety was 68%(383/561) among the international students
under the age of 22, compared with 61%(324/529) among
those higher or equal to the age of 22. ere was a statistical
signicance between the two groups (Chi-square = 5.893,
p = 0.015). Among the international students who studied
online, 67%(500/745) of those students living in rst-tier and
provincial capital cities and Hong Kong, Macao, and Taiwan
(hereinaer referred to as big cities) felt anxious. In comparison,
60%(207/345) of international students living outside rst-tier
and provincial capital cities and in rural areas (hereinaer
referred to as small cities and rural areas) felt anxious. ere
was a statistical signicance between the two groups
(Chi-square = 5.236, p = 0.02). Among the international students
who studied online, 68%(512/756) of them who socialized
three times or less monthly felt anxious about online learning,
compared with 58%(195/334) of students who socialized three
times or more monthly. ere was a statistical signicance
between the two groups (Chi-square = 8.87, p = 0.003). Among
the international students who studied online, the incidence
of anxiety among those who wished for purely oine teaching
or dual-track online and oine teaching was 64%(567/907),
compared with 72%(131/183) among those who wished purely
online teaching. ere was a statistical signicance between
the two groups (Chi-square = 4.361, p = 0.037). Among the
international students who studied online, 70%(341/484)
students with a subjective score of online learning experience
during the COVID-19 pandemic of 6 or less felt anxious,
while 60%(366/696) of them with a subjective score of more
than 6 felt anxious. ere was a statistical signicance between
the two groups (Chi-square = 11.945, p = 0.001). However,
gender, emotional status, BMI, vaccination or not, degree
type, time dierence, daily study duration, daily sleep duration,
and frequency of physical exercise had no signicant dierence
in the incidence of anxiety among international students who
studied online.
Logistic Analysis of Factors Inuencing
the Incidence of Anxiety Among
International Students Who Studied Online
During the COVID-19 Pandemic
Our study combined age, the resident city in China, the
frequency of socialization, expected teaching methods, and
subjective experience score of online courses to construct a
multi-factor Logistic regression equation (Ta b l e  3 ). We found
that international students under the age of 22 were at increased
risk of anxiety compared with those higher or equal to the
age of 22, and the dierence was statistically signicant
(OR = 1.186, 95%CI 1.045–1.347, p = 0.008). Compared with
international students in small cities and rural areas, the students
living in big cities were at increased risk of anxiety, and the
dierence was statistically signicant (OR = 1.419, 95%CI 1.038–
1.859, p = 0.01). Compared with the international students with
a subjective score of online learning experience during the
COVID-19 pandemic higher than 6, students with a subjective
score less than or equal to 6 were at increased risk of anxiety,
and the dierence was statistically signicant (OR = 1.25, 95%CI
1.099–1.422, p = 0.001). Compared with the international students
who socialized more than three times a month, those who
socialized less than three times per month were at increased
risk of anxiety, and the dierence was statistically signicant
(OR = 1.52, 95%CI 1.160–1.992, p = 0.002). Compared with the
international students who wished for purely oine or online
and oine dual-track teaching in coming semesters, those who
wished for purely online teaching were at increased risk of
anxiety, and the dierence was statistically signicant (OR = 1.525,
95%CI 1.069–2.177, p = 0.02).
DISCUSSION
With the development of globalization and increasingly erce
competition in society, international students are increasing
year by year. As a result, the mental health of this unique
group is also attracting more and more attention. Previous
studies have suggested that international students in higher
education are prone to mental health problems, such as depression
and anxiety (Wang etal., 2015). At the same time, international
students are the vulnerable group with apparent mental health
problems, which indicates that the research on international
students’ mental health is rapidly expanding and developing
toward a new research direction (Han etal., 2013; Wang etal.,
2015). Weobserved that 707 out of 1,090 Chinese international
students participating in the study felt anxious, accounting for
64.86%. e prevalence of these international students
signicantly exceeds the post-pandemic incidence of anxiety
among the general population (31.9%; Salari et al., 2020).
Apparently, the prevalence of anxiety among these international
students was twice that of the general population. Since
universities in many countries have been forced to switch from
oine to online teaching due to the high contagiousness of
COVID-19, international students were forced to return to
their home countries for online study. e mode of online

Tan et al. International Students’ Anxiety
Frontiers in Psychology | www.frontiersin.org 6 April 2022 | Volume 13 | Article 860289
teaching can be a challenge for many international students.
is survey was conducted 1 year aer the outbreak of
COVID-19 in China, mainly to understand the situation of
international students from China aer 1 year of online learning
and the inuencing factors of anxiety.
Our research showed that international students from schools
in Europe (37.8%) and Hong Kong, Macao, and Taiwan (27.1%)
accounted for the majority, while those from schools in Oceania
accounted for less than 10% (6.3%). From the perspective of
the regions chosen by international students, fewer international
students chose schools in Oceania. eir choices may be aected
by the border blockade policies of Oceanian countries, such as
Australia and New Zealand. As a result, many international
students can only study online in China for a long time and
therefore do not consider Oceania as their rst choice. In addition,
our results showed that the proportion of international students
who chose to study in Asia (Hong Kong, Macau, Taiwan, and
other parts of Asia) was as high as 42.1%. It is not hard to see
that Asia has become one of the new education centers, attracting
more international students. According to our results, the top
TABLE2 | Analysis of inuencing factors on the incidence of anxiety during online courses for international students.
Non-anxiety n (%) Anxiety n (%) Total Chi-square p-value
Gender
Male 95(0.37) 160(0.63) 255 0.665 0.48
Female 288(0.34) 547(0.66) 835
Age
≥22 years old 178(0.32) 383(0.68) 561 5.893 0.02
<22 years old 205(0.39) 324(0.61) 529
Relationship status
Single 256(0.34) 500(0.66) 756 1.760 0.19
Non-single 127(0.38) 207(0.62) 334
BMI
Low 103(0.31) 230(0.69) 333 3.734 0.16
Medium 242(0.37) 411(0.63) 653
Height 38(0.37) 66(0.63) 104
City of residence in China
Big cities 245(0.33) 500(0.67) 745 5.236 0.02
Small cities and rural areas 138(0.4) 207(0.6) 345
COVID-19 vaccination status
Completed vaccination 306(0.35) 572(0.65) 878 0.162 0.69
Incomplete vaccination 77(0.36) 135(0.64) 212
Degree type
Undergraduate and below 166(0.34) 318(0.66) 484 0.270 0.60
Postgraduate and above 217(0.36) 389(0.64) 606
Time difference in online courses
With time difference 121(0.33) 250(0.67) 371 1.571 0.20
Without time difference 262(0.36) 457(0.64) 719
The average daily study duration
≤5 h 236(0.35) 430(0.65) 666 0.067 0.80
>5 h 147(0.35) 277(0.65) 424
The average daily sleep duration
≤6 h 54(0.33) 111(0.67) 165 3.391 0.18
6–8 h 221(0.34) 432(0.66) 653
>8 h 108(0.4) 164(0.6) 272
Frequency of physical exercise
No physical exercise 98(0.32) 210(0.68) 308
1–2 times weekly 178(0.37) 308(0.63) 486 2.094 0.35
>3 times weekly 107(0.36) 189(0.64) 296
Frequency of socialization (e.g., shopping, eating, and going to the movies)
≤3 times monthly 244(0.32) 512(0.68) 756 8.870 0.00
>3 times monthly 139(0.42) 195(0.58) 334
The expected teaching mode in coming semesters (2021 fall & 2022 spring)
Pure ofine teaching/online
and ofine dual-track
teaching
331(0.36) 576(0.64) 907 4.361 0.04
Pure online teaching 52(0.28) 131(0.72) 183
The concerns about the risk after forcing mandatory on-campus teaching
Worry 341(0.34) 652(0.66) 993 3.112 0.08
No worry 42(0.43) 55(0.57) 97
Subjective score of the experience of online learning during the COVID-19 pandemic (from 1 to 10)
≤6 143(0.3) 341(0.7) 484 11.945 0.00
>6 240(0.4) 366(0.6) 606

Tan et al. International Students’ Anxiety
Frontiers in Psychology | www.frontiersin.org 7 April 2022 | Volume 13 | Article 860289
three majors chosen by international students were economics,
management, and engineering, accounting for 21, 15, and 12%,
respectively. History, agriculture, and military sciences, by contrast,
accounted for less than 1%. e distribution of majors chosen
by international students is relatively consistent with the popular
majors chosen by Chinese college students (Wu et al., 2021).
e top three advantages of online learning were eectively
reducing the risk of COVID-19 infection, saving living and
commuting expenses, and saving commuting time, with the
cumulative selection rate of 80, 69, and 69%, respectively.
Online learning, where students are primarily at home, can
eectively reduce the probability of COVID-19 infection by
avoiding gatherings (Wu et al., 2021). At the same time, since
the price of necessities in Europe and the United States is
much higher than that in mainland China, students can save
a lot expenses. e two most signicant disadvantages of online
learning were the diculty of concentration and the lack of
campus atmosphere of studying abroad, with a cumulative
selection rate of 70 and 68%, respectively. It can be seen that
online courses without face-to-face supervision by teachers and
the atmosphere of studying together with other students is
likely to cause distraction in class, which is consistent with
the research of Mukhtar et al. (2020). is is why online
learning places higher demands on self-discipline of students.
At the same time, online learning, as the scope of activity for
international students is mainly at home, international students
who were unable to experience campus life have become the
regret of those who studied online during the
COVID-19 pandemic.
Nevertheless, international students can make up for this
by interacting with their peers in China. Gradually, with the
control of COVID-19 and the resumption of oine classes,
It is believed that these international students taking online
courses during the COVID-19 pandemic will cherish campus
life more aer returning to campus. erefore, in the long
run, short-term online learning may play a positive role in
promoting international students to experience the campus
culture and atmosphere.
Watching TV series & movies and chatting with friends
accounted for 77 and 66%, respectively. However, the proportion
of dining out & shopping and physical exercise was only 49
and 44%, respectively. According to our study, international
students tended to choose leisure activities that can becompleted
at home and on the Internet, such as watching TV series and
movies and chatting with friends online, while those that need
to be completed outdoors, such as dining out and shopping
and physical exercise were relatively low. On the one hand,
aected by the COVID-19, students may purposely avoid gathering.
On the other hand, most students may like to stay alone. With
the COVID-19 pandemic under control, students can subjectively
increase some recreational ways to interact with others.
e top ve measures to deal with risk of COVID-19
infection were wearing a mask, getting vaccinated, maintaining
social distance, washing hands frequently, and reducing visits
to crowded places (89, 82, 76, 74, and 71%, respectively). It
is not hard to see that more than a year aer the outbreak
of COVID-19, with the exception of vaccination, other anti-
epidemic measures were consistent with the measures taken
at the beginning of the COVID-19 outbreak (Liguori and
Winkler, 2020). At the same time, the results of this study
are consistent with the results of another study on Chinese
college students (Shen etal., 2021). Combining the two studies,
it can be concluded that Chinese college students, whether
studying in China or abroad, have high support and compliance
for non-drug intervention (NPI) prevention.
Our research (Tab l e  2 ) showed that age, geography, the
frequency of socialization, expected teaching methods, and
subjective experience of online learning were inuencing factors
for international students’ anxiety. ese related factors were
also the core of this study, which can provide part of the basis
TABLE3 | Logistic regression analysis of the incidence of anxiety during online courses for international students.
B
Wald p-value OR-value 95% condence
Chi-square value Interval
Age
≥22 years of age*0.171 6.931 0.008 1.186 1.045 1.347
<22 years of age
City of residence
Small cities and rural
areas*0.35 6.449 0.01 1.419 1.083 1.859
Big cities
Subjective score of the online learning (from 1 to 10)
>6*0.223 11.52 0.001 1.25 1.099 1.422
≤6
Frequency of socialization
>3 times monthly*0.419 9.204 0.002 1.52 1.16 1.992
≤3 times monthly
The expected teaching mode in coming semesters
Ofine teaching or
online and ofine
dual-track teaching*0.422 5.414 0.02 1.525 1.069 2.177
Pure online teaching
*Is the control group.

Tan et al. International Students’ Anxiety
Frontiers in Psychology | www.frontiersin.org 8 April 2022 | Volume 13 | Article 860289
for colleges and universities to quickly screen international
students with a high risk of anxiety. Colleges and universities
can carry out early intervention for students with risk through
health promotion and psychological education so that the limited
psychological consultation resources can reach the students who
are most likely to benet and then reduce the occurrence of
anxiety among international students (Gladstone et al., 2021).
Age Factors
Our ndings suggested that age was strongly associated with
positive psychological responses. e prevalence of anxiety was
higher among the international students under the age of 22
(68%) than those higher or equal to the age of 22 (61%),
suggesting that younger age may be a risk factor for anxiety
among these international students who studied online during
the COVID-19 pandemic. Our result is consistent with previous
studies showing that younger age is a risk factor for anxiety
(Brenes, 2006; Guo etal., 2016; Xiong etal., 2020). Compared
with older students, young international students have less
social cognition and future prediction because young international
students tend to have less social practice and experience. With
lower self-regulation and psychological resilience, the younger
group tends to be worried about the uncertain future and
negative academic impact of online teaching in the context
of COVID-19, such as the acceptance of online courses by
future employers. Conversely, due to their rich social experience
and cognition, international students in the older group have
stronger psychological endurance. As a result, they are less
worried about negative impacts. erefore, schools should pay
more attention to young international students or carry out
psychological counseling to relieve the anxiety of younger
international students.
Geographical Factors
Our study also found that geographical factors were an inuencing
factor for anxiety. Previous studies have pointed to a higher
prevalence of anxiety disorders in the urban area of China (7.6%)
than in rural China (4.66%; Guo et al., 2016). Our result is
also in line with the high incidence of anxiety disorders in
cities during the COVID-19 pandemic (Ren etal., 2020). Living
in big cities was a risk factor for anxiety for international students
who studied online during the COVID-19 pandemic. In addition,
according to our survey data, most of these international students
(745/1090) came from big cities, which is also related to the
developed economy, high education level, and active thinking.
is phenomenon reects that the distribution of educational
resources in China is relatively concentrated in big cities.
International students from big cities live in more developed
regions, where talent concentration leads to greater competition,
thus increasing risk factors for anxiety.
Moreover, the cost of living in big cities, such as housing
prices, is higher than in relatively small cities and rural areas,
which may also increase the stress of international students. Faced
with the pressure from erce competition and high living costs,
these international students who studied online in big cities may
worry about the lack of competitiveness caused by online learning
or other factors, thus increasing the risk of anxiety. erefore,
schools and health professionals should pay more attention to
the mental health of international students from big cities.
The Frequency of Socialization
In this study, the frequency with which international students
socialized with others (such as shopping and dining out and
watching movies) 3 times or less a month was a risk factor for
anxiety. Among international students who studied online during
the COVID-19 pandemic, the lower frequency of socializing
outside to some extent reduces the space and channels for releasing
stress, thus increasing the perception of stress, anxiety, and other
negative emotions. For these international students, instead of
staying in one environment for a long time, going out and
socializing with friends to get outside support is an eective way
to relieve and vent stress. Previous studies have suggested that
social support may reduce genetic and environmental vulnerability
and imbue resilience to stress through its eects on the
hypothalamic–pituitary–adrenal cortex (HPA) system, the
norepinephrine system, and the central oxytocin pathway, so social
support is essential for maintaining physical and mental health
(Ozbay etal., 2007). Conversely, those international students with
low frequency of socialization, lack of social support, and long-
term exposure to the same environment cannot relieve the stress
from online learning, thus increasing anxiety. Compared with
the frequency of socialization, the dierence in daily sleep duration,
the frequency of physical exercise, and daily study duration was
not signicantly correlated with anxiety. Our result also suggested
that the improving lifestyles, including sleep duration, physical
exercise, and study duration, was not as eective as increasing
the frequency of socialization in reducing anxiety. Our study is
partially consistent with a Malaysian study of Malaysian university
students (Mohamad et al., 2021). Our research suggested that
active participation in social activities can reduce anxiety in
students. e dierence is that local studies in Malaysia have
shown that sleep quality and BMI were the inuencing factors
of anxiety. In contrast, in our study, there was no correlation
between sleep and BMI and anxiety among international students.
On the one hand, this may be due to sample selection bias. On
the other hand, it also indicated that increasing social frequency
could be more signicant for international students in alleviating
anxiety than for local students. erefore, international students
should increase the frequency of social activities as possible, instead
of staying in the same environment every day, to relieve anxiety.
Expected Teaching Mode
In this study, the expectation that the teaching mode of the
coming semesters (2021 fall & 2022 Spring) would be purely
online was a risk factor for anxiety of these international
students. Notably, students expecting purely online teaching
were more anxious, suggesting that the main factor causing
anxiety among these students is not the online learning themselves
but the risk of COVID-19 infection brought by face-to-face
classes. Compared with those who expected pure face-to-face
teaching and online and oine dual-track teaching, international
students who expected purely online teaching may be more
worried about their health risks caused by the COVID-19
pandemic due to some reasons, such as poor physical tness

Tan et al. International Students’ Anxiety
Frontiers in Psychology | www.frontiersin.org 9 April 2022 | Volume 13 | Article 860289
or other psychological problems. at is because online classes,
compared with oine courses, provide a platform for
international students to avoid the risk of infection. In the
coming semesters, many schools have announced the resumption
and mandatory oine classes, which may increase the anxiety
of these students. erefore, the school had better make special
teaching arrangements, such as online and oine dual-track
teaching, for those who cannot participate in oine teaching
for various reasons rather than forcing completely face-to-face
teaching to relieve their anxiety.
Subjective Experience of Online Learning
In this study, poor subjective experience of online learning
(rating the subjective experience of online courses less than
6 out of 10) was a risk factor for anxiety of these international
students. Among the international students who studied online
during the COVID-19 pandemic, some were upset due to
various inconveniences from online classes, such as poor Internet
connection and the inability to interact with instructors
immediately. ese international students may beanxious about
their grades or the recognition of their qualications gained
through online teaching by future employers due to poor
experiences of online learning. In contrast, international students
who rated the experience of online learning higher than 6—
those who were more adaptable to online learning—were less
likely to experience anxiety. Moreover, there may bea correlation
between psychological stress, coping style, adaptability, and
mental health (Zimmermann et al., 2012; Zhou et al., 2017).
International students with pessimism or anxiety are also more
likely to experience poor online teaching.
On the contrary, students with solid adaptability tend to have
a better experience of online learning. Our result is also consistent
with previous studies that whether students adapt to online
courses signicantly aects anxiety (Zhao etal., 2021). In addition,
people with positive coping styles have better mental health than
those with negative coping styles (Wu et al., 2020). Students
with high psychological resilience can better understand the
meaning of positive coping styles, thus eectively overcoming
diculties in adversity (Hartley, 2011). erefore, schools should
continue to upgrade the facilities for online learning and take
other measures to improve the online teaching experience. At
the same time, schools can also increase communication with
students, genuinely understand the factors that aect students’
online teaching experience and make appropriate corrections.
While improving students’ experience of online courses, it is
also possible to improve students’ learning eciency, enthusiasm,
academic performance, and mental health. During the COVID-19
pandemic, students with anxiety should also seek outside support
during online study, such as reaching out to instructors or seeking
psychological counseling (Ozbay et al., 2007).
LIMITATIONS
Some limitations should beacknowledged. Firstly, data were collected
through online questionnaires on social platforms, leading to
information bias and misclassication. Participants may not have
provided accurate information, either included in the study or
quickly completed the survey. erefore, it is necessary to clean
and lter the collected questionnaires, check the consistency and
logicality of the answers, and adjust invalid and missing values.
Due to the international students who participated in this study
from the Internet, they did not complete it face-to-face. Secondly,
due to the groups to which the questionnaire was collected, the
number of international students in each region was not evenly
distributed, hence aecting the overall results.
CONCLUSION
In conclusion, younger age, living in big cities, low frequency
of socialization, the expectation of purely online teaching, and
poor subjective experience of online courses were the risk
factors for anxiety of these international students who studied
online during the COVID-19 pandemic. To minimize the
negative impacts of these risk factors of international students
who studied online requires the joint eorts of the school
and students. e school should provide psychological assistance
to the corresponding groups in time and continuously upgrade
the facilities to provide a better experience for online learning.
At the same time, students should socialize and communicate
more with their friends, trying to get more external support
to relieve anxiety and stress.
DATA AVAILABILITY STATEMENT
e original contributions presented in the study are included
in the article/supplementary material, further inquiries can
be directed to the corresponding author.
ETHICS STATEMENT
e studies involving human participants were reviewed and
approved by Medical Ethics Committee, Xiangya Hospital,
Central South University. e patients/participants provided
their written informed consent to participate in this study.
AUTHOR CONTRIBUTIONS
JK, YT, and ZW were responsible for the study design. YT was
responsible for collecting the data. YT and JK were responsible
for the explanation of the data, data analysis, and draing the
manuscript. XQ, YL, LP, YG, SL, JD, QT, JW, XP, JL, and MS
were responsible for the revision of the manuscript. All authors
contributed to the article and approved the submitted version.
FUNDING
is research was supported by Education Reform Research
Project of Central South University, No. 2020JY165.

Tan et al. International Students’ Anxiety
Frontiers in Psychology | www.frontiersin.org 10 April 2022 | Volume 13 | Article 860289
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