Mental distress and its associations with behavioral outcomes during the COVID-19 pandemic: a national survey of Chinese adults

Objectives: This study aimed to evaluate associations between mental distress and COVID-19-related changes in behavioral outcomes and potential modifiers (age, gender, educational attainment) of such associations. Study design: This was a cross-sectional study. Methods: An online survey using anonymous network sampling was conducted in China from April to May 2020 using a 74-item questionnaire. A national sample of 10,545 adults in 31 provinces provided data on sociodemographic characteristics, COVID-19-related mental distress, and changes in behavioral outcomes. Structural equation models were used for data analyses. Results: After adjusting for covariates, greater mental distress was associated with increased smoking (odds ratio [OR] = 1.42, 95% confidence interval [CI]: 1.20–1.68 and OR = 1.54, 95% CI: 1.31–1.82 per one standard deviation [SD] increase in mental distress) and alcohol consumption (OR = 1.67, 95% CI: 1.45–1.92 and OR = 1.47, 95% CI: 1.24–1.75 per one SD increase in mental distress) among current smokers and drinkers and with both increased and decreased physical activity (ORs ranged from 1.32 to 1.56). Underweight adults were more likely to lose body weight (≥1 kg; OR = 1.63, 95% CI: 1.30–2.04), whereas overweight adults were more likely to gain weight (OR = 1.61, 95% CI: 1.46–1.78) by the same amount. Association between mental distress and change in physical activity was stronger in adults aged ≥40 years (ORs ranged from 1.43 to 2.05) and those with high education (ORs ranged from 1.43 to 1.77). Mental distress was associated with increased smoking in males (OR = 1.60, 95% CI: 1.37–1.87) but not females (OR = 1.11, 95% CI: 0.82–1.51). Conclusions: Greater mental distress was associated with some positive and negative changes in behavioral outcomes during the pandemic. These findings inform the design of tailored public health interventions aimed to mitigate long-term negative consequences of mental distress on outcomes.