Global Public Health

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Impact of SARS-CoV-2 outbreak on physical and mental

health, psychological distress, and suicidal ideation, and the
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mediating role of stressors

Journal: Global Public Health

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Manuscript ID Draft
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Manuscript Type: Original Article

COVID-19, mental health, psychological distress, suicidal ideation,

Keywords:
mediation
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Page 1 of 18 Global Public Health

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Impact of SARS-CoV-2 outbreak on physical and mental health,
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psychological distress, and suicidal ideation, and the mediating role of
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stressors
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11 This study investigated the physical and psychological impacts, both directly and
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14 demographic data in Japan immediately following the rescinding of the state of
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emergency declaration accompanying the SARS-CoV-2 outbreak. An online
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17 survey was administered to 1,500 residents of Japan registered with an online
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19 outsourcing service. Data were analyzed with structural equation modeling using
20 Mplus. Total effects were observed for “insufficient exercise” on physical health
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22 (β = -0.24, SE = 0.03), for “mental health issues related to COVID-19” on mental

23 health (β = -0.25, SE = 0.03), for neuroticism on psychological distress (β = 0.36,
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25 SE = 0.02), for “mental health issues related to COVID-19” (β = 0.24, SE = 0.03),

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and for social support on suicidal ideation (β = -0.32, SE = 0.03). It will be
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possible to mitigate the harm resulting from the ongoing impact of the SARS-
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30 CoV-2 outbreak by raising awareness of risk factors and promoting social
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34 Keywords: COVID-19, mental health, psychological distress, suicidal ideation,
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36 mediation
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39 Introduction
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42 Studies have already been published in many countries regarding the psychological
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44 impact of the SARS-CoV-2 outbreak. An early-stage review of four cross-sectional
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46 studies from China suggests that anxiety, depression, stress, and sleep disorders may be
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observed during the COVID-19 pandemic (Rajkumar, 2020). Following this review,
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51 several countries have published studies reporting the results of general public surveys.
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53 For example, a large-scale study from the U.S. found that fear is particularly high in
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55 areas with many reported cases of COVID-19, and observed a correlation between
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58 being socially vulnerable (female, Asian, Hispanic, born abroad, family with children)
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60 and fear (Fitzpatrick et al., 2020). Further, longitudinal studies from China and

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 Global Public Health Page 2 of 18

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3 Australia starting before the SARS-CoV-2 outbreak have demonstrated that people’s
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psychological responses are occurring as a result of the outbreak (Li et al., 2020; van
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8 Agteren et al., 2020).
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10 The harm of the SARS-CoV-2 outbreak on mental health is slowly becoming
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clear. Thus, the current challenge for research is to determine what elements impact
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15 these negative psychological responses. Further, the risk of suicide, the worst possible
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17 psychological response in a disaster situation, is unclear.
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19 Considering a stress model of psychological response during a disaster suggests

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22 that social support and coping style can influence the level of psychological response. In
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24 fact, studies have shown that social support reduces anxiety and depression amid the
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26 SARS-CoV-2 outbreak (Cao et al., 2020; Ni et al., 2020). Separate reports have also
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found that negative thinking and avoidant behavior accompanying negative coping are
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31 associated with depression and psychological distress (Guo et al., 2020; Wang et al.,
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33 2020).
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Although there is limited research pertaining to the SARS-CoV-2 outbreak,
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38 personality traits may also impact a stress response. A past meta-analysis found a
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40 negative association between neuroticism and mental health (Strickhouser et al., 2017).
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42 Further, it is hypothesized that people with high extraversion experience greater
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45 psychological stress amid circumstances limiting social interaction, such as the SARS-
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47 CoV-2 outbreak.
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49 From the above, it is clear that there is insufficient detailed research on
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psychological responses to the SARS-CoV-2 outbreak in the general public focusing on
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54 residents of Japan. Moreover, many studies from other countries and regions have used
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56 adjusted correlations between variables; however, few have focused on mediated
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correlations between variables. Thus, this study aimed to investigate the impact, both
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Page 3 of 18 Global Public Health

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3 direct and mediated by stressors, of demographic data, elements related to COVID-19
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infection, personality, social support, and coping on physical and psychological states
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8 using structural equation modelling (SEM).
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12 Methods
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15 Subjects
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18 An online survey was administered to residents of Japan who were 18 years or older
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20 registered with an online outsourcing service provided by Crowd Words, Inc. Responses
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22 were received from 1,500 subjects between May 26 and May 27, 2020 (viewed by 2,594
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individuals, acceptance rate: 57.8%). Lacking the literacy or cognitive function required
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27 to undergo an online survey was the only exclusion criteria for subjects. To screen for
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29 these subjects, responses were carefully examined to identify clearly random or

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consistently contradictory responses. No responses meeting the exclusion criteria were
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34 identified, and all data were used for analysis.
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Survey items
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41 Basic demographic information

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Subjects were asked basic demographic information including age (multiple choices
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46 from under 19 years old to 70 years old or older), sex (female, male, other), prefecture
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48 of residence, highest level of education completed (middle school graduate, high school
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50 graduate, junior college/vocational school/technical school graduate, college graduate,
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53 graduate school graduate), marital status (unmarried, divorced/widowed, married (do
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55 not live with partner), married (live with partner)), ethnicity (Asian, black, multiethnic,
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57 white, Chinese, Middle Eastern/Arab, other), employment status before the outbreak
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(student, self-employed/sole proprietorship, operating a company, full-time, part-time,

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 Global Public Health Page 4 of 18

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3 contract worker, housewife/househusband, on leave (childcare leave, sick leave, etc.,
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unemployed)), and annual household income before the outbreak (selected from <18600
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8 USD, 18600 USD to 37200 USD, 37300 USD to 74500 USD, 74600 USD to 111800
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10 USD, 111900 USD to 149000 USD, and ≥149000 USD).
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Regarding the SARS-CoV-2 outbreak, subjects were asked how often they went
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15 to their workplace under the state of emergency declaration (almost never, half the week
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17 or less, more than half the week, almost every day), amenities in their residence and the
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19 surrounding environment (whether they had a garden or balcony; whether there were
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22 parks or botanical gardens), the number of preschool age children in the home, whether
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24 they had underlying physical or psychiatric disorders, whether they had been infected
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26 with COVID-19 (recovered, recovering, infection suspected, not infected), about
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contact with infected persons in the past week (had contact, suspected contact, no
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31 contact), and extent of voluntary restriction of outside activity (did not leave home at
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33 all, did not leave home unless exercising or shopping for food, went out for work in
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addition to shopping when needed, did not refrain from going out but practiced social
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38 distancing, or did not refrain from going out and did not practice social distancing.)
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40 Concerning stressors, subjects were asked to assess 15 items pertaining to life
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42 events likely to occur under the state of emergency declaration on a four-point scale of
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45 “did not happen,” “happened, but was not stressful or difficult,” “was a little stressful or
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47 difficult,” “was very stressful or difficult” (see Table 3 for the list of items). Each item
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49 was scored from 0 to 3 points.
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Lastly, subjects were asked about whether they performed any of seven
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54 intentional behaviors intended to bolster mental health or change mood to evaluate
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56 “coping” (see Table 3 for the list of items).
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Page 5 of 18 Global Public Health

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3 Psychological scales
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6 The Ten-Item Personality Inventory (Gosling et al., 2003) was used as a personality
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8 index. This scale measures an individual’s personality based on the five-factor model
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11 (the Big Five). The Japanese version (TIPI-J) was developed, and its validity was
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13 confirmed by Oshio (Oshio et al., 2012). Subjects’ responses to two questions for each
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15 of the five factors were rated on a seven-point scale (Extraversion (EXT),
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Agreeableness (AGR), Conscientiousness (CON), Neuroticism (NEU), Openness
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20 (OPE)). Each factor was scored from 0 to 14 points.
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22 A shortened version (Iwasa et al., 2007) of the Japanese edition of the

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24 Multidimensional Scale of Perceived Social Support (Zimet et al., 1988), comprising of
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27 seven items with high factor loadings taken from the original scale, was used as an
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29 index of social support. Subjects responded to items such as “my family lend a hand to
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31 support me mentally when I need it” rated on a seven-point scale. Total score ranged
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34 from 7 to 49 points.
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36 The SF-8TM was used as an index of mental and physical health (Ware et al.,
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38 2001). The Japanese version of the SF-8TM was developed by Fukuhara (Fukuhara &
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Suzukamo, 2004). A standard physical component summary (PCS) and mental
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43 component summary (MCS) with a mean score of 50 and SD of 10 were calculated
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45 based on an algorithm derived from the standard scores of 2,284 Japanese individuals
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47 (Fukuhara & Suzukamo, 2004). A higher score indicated better health for both summary
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50 scores.
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52 The Kessler (K6) scale was used as an index of psychological distress(Kessler et
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54 al., 2002). The Japanese version of the K6 was developed by Furukawa (Furukawa et
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57 al., 2008). Scores on the six-item scale range from 0 to 24 points. A higher score
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59 indicates higher psychological distress. The mean ± SD from a community sample of
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 Global Public Health Page 6 of 18

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3 85,154,382 Japanese persons aged 15 or older was 3.34±3.39 (National Information
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Center of Stress and Disaster Mental Health, 2010).
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8 The Suicide Behaviors Questionnaire-Revised (SBQ) was used as an index of
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10 suicidal ideation (Osman et al., 2001). This scale measures level of suicidal ideation and
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is comprised of 4 questions each assessed on a five- to seven-point scale. Total score
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15 ranges from 3 to 18 points. This scale was translated into Japanese using back
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17 translation.
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21 Statistical analysis
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24 Variables used for statistical analysis were determined based on a previous
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26 (unpublished) analysis (see Table 4 for a list). Categorical variables were converted into
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binary for analysis. The following responses were entered as 1 while any other response
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was entered as 0. Sex: female and other; highest level of education: junior college
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33 graduate and so forth; employment status: unemployed (excluding student, etc.);
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35 preschool age children in the home: 3; having been infected with COVID-19: infection
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37 suspected; contact with infected persons: had contact; extent of voluntary restriction of
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40 outside activity: did not refrain from going out and did not practice social distancing.
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42 First, Spearman's rank correlation coefficient was calculated using IBM SPSS 26, and a
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44 two-tailed significance test was performed to explore correlations between variables.
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47 The significance level was p < 0.0001. Subsequently, a mediation model was
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49 considered SEM using Mplus 8.4. A hypothetical model of the direct and indirect
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51 effects mediated by stressors of demographic characteristics, COVID-19-related
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elements, coping, personality, and social support was created on PCS, MCS, K6, and
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56 SBQ, respectively, as objective variables. Paths that did not reach the significance level
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58 (p < 0.0001) were temporarily removed after which paths deemed necessary based on χ2
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60 value were reincorporated to obtain the optimal model. Standards for model fitting

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Page 7 of 18 Global Public Health

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3 were: SRMR ≤ .08, CFI ≥ .95, and RMSEA ≤ .06 (Hu & Bentler, 1999).
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7 Results
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10 At least one response was collected for each of the 47 prefectures of Japan. Participant
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12 characteristics are shown in Tables 1 through 3. According to Japan’s February 2020
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14 Labour Force Survey, 51.7% of the population aged 15 years or older are female and
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17 4.5% are self-employed/sole proprietors (Statistics Bureau of Japan, 2020). Compared
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19 to the Japanese workforce population, there were slightly more females and self-
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21 employed/sole proprietors among the participants in this study. Further, mean scores for
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24 MCS and K6 (43.43 and 6.49, respectively) were less than the standard scores in Japan
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26 under ordinary circumstances.
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Tables 4 and 5 show the results of SEM. AGR (total/indirect b = 0.1, Cl

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(99.99%): 0.01 to 0.18), social support (total/indirect b = 0.03, Cl: 0.01 to 0.06), and
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33 psychiatric disorder (total b = -2.69, Cl: -5.32 to -0.07; indirect b = -0.3, Cl: -0.78 to
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35 0.19 ns.; direct b = -0.14, Cl: -0.39 to 0.11 ns.) had significant total effects on PCS.
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37 EXT (total/indirect b = -0.1, Cl: -0.18 to -0.03), NEU (total b = -0.9, Cl: -1.19 to
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40 -0.61; indirect b = -0.4, Cl: -0.55 to -0.25), social support (total b = 0.1, Cl: 0.02 to 0.18;
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42 indirect b = 0.03, Cl: 0 to 0.07), being female (total/indirect b = -1.05, Cl: -1.64 to -
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44 0.45), psychiatric disorder (total/indirect b = -0.82, Cl: -1.61 to -0.03), C1 (total b = -
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47 3.86, Cl: -7.58 to -0.14; indirect b = -0.28, Cl: -0.79 to 0.22 ns.; direct b = -3.58, Cl: -
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49 7.28 to 0.12 ns.), C5 (total/indirect b = -2.09, Cl: -3.16 to -1.01), and C7 (total/indirect b
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51 = -3.76, Cl: -6.9 to -0.62) had significant total effects on MCS.
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AGR (total b = -0.19, Cl: -0.37 to -0.02; indirect b = -0.04, Cl: -0.08 to 0), NEU
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56 (total b = 0.7, Cl: 0.52 to 0.88; indirect b = 0.26, Cl: 0.17 to 0.36), social support (total b
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58 = -0.11, Cl: -0.16 to -0.06; indirect b = -0.04, Cl: -0.06 to -0.02), being female
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60 (total/indirect b = 0.52, Cl: 0.2 to 0.84), psychiatric disorder (total b = 1.89, Cl: 0.05 to

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 Global Public Health Page 8 of 18

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3 3.73; indirect b = 0.73, Cl: 0.11 to 1.35), C5 (total b = 1.78, Cl: 0.69 to 2.88; indirect b
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= 1.3, Cl: 0.62 to 1.98), C7 (total b = 4.84, 99.99% Cl: 0.36 to 9.31; indirect b = 2.37,
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8 Cl: 0.68 to 4.05), C16 (total/direct b = -0.79, Cl: -1.55 to -0.04), and C30 had significant
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NEU (total b = 0.19, Cl: 0.08 to 0.29; indirect b = 0.05, Cl: 0.01 to 0.09), social
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15 support (total b = -0.1, Cl: -0.14 to -0.07; indirect b = -0.01, Cl: -0.03 to 0 ns.; direct b =
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17 -0.09, Cl: -0.12 to -0.05), psychiatric disorder (total b = 2.1, Cl: 0.67 to 3.53; indirect b
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19 = 0.29, Cl: -0.02 to 0.6 ns.; direct b = 1.81, Cl: 0.37 to 3.25), suspected COVID-19
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22 infection (total b = 2.89, Cl: 0.77 to 5.01; indirect b = 0.48, Cl: -0.28 to 1.24 ns.; direct b
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24 = 2.41, Cl: 0.51 to 4.32), and C8 (total b = 0.8, Cl: 0.03 to 1.58; indirect b = 0.1, Cl: -
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26 0.09 to 0.28 ns.; b = 0.71, Cl: -0.08 to 1.49 ns.) had significant total effects on SBQ.
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30 Discussion
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33 This study investigated the effects of demographic characteristics, elements related to
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35 SARS-CoV-2, coping, personality, and social support on physical and mental health,
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37 psychological distress, and suicidal ideation in Japan immediately after the rescinding
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40 of the seven weeks of restrictions on outings, inter-prefectural travel, and business
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42 activities which began on April 7, 2020 due to the state of emergency declaration. The
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44 results identified several direct and indirect relationships presumed to be due to the
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47 influence of the outbreak.
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49 Physical health was found to have a positive relationship with AGR and social
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51 support, and a negative relationship with psychiatric disorder. The effects of AGR and
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social support were completely mediated by stressors. AGR was suggested to promote
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56 physical health by weakening “difficulty in receiving medical care for a chronic
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58 disease,” “problems with interpersonal relationships online,” and “insufficient
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60 exercise,” while social support did the same by weakening “problems with interpersonal

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Page 9 of 18 Global Public Health

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3 relationships online,” “reduction in sleep time and quality,” and through “being unable
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to meet people,” respectively.
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8 Mental health was found to have a positive relationship with social support, and
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10 a negative relationship with EXT, NEU, being female, psychiatric disorder, “using
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psychotropic drugs,” “talking about one’s mental health,” and “participating in remote
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15 programs.” The effects of social support and NEU were partially mediated by stressors,
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17 while the effects of EXT, being female, psychiatric disorder, “talking about one’s
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19 mental health,” and “participating in remote programs” were completely mediated. The
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22 factor that mostly impacted mental health was “mental health issues related to COVID-
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24 19.” This factor was in turn influenced by NEU, social support, being a junior college
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26 graduate and so forth, psychiatric disorder, and “talking about one’s mental health.”
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Increasing awareness in people with regard to these characteristics and offering social
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31 support may be useful in promoting mental health.
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33 Psychological distress was found to have a negative relationship with AGR,
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social support, and “reading for pleasure,” and a positive relationship with NEU, being
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38 female, “talking about one’s mental health,” “participating in remote programs,” and
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40 “15-minute naps.” The effects of NEU, psychiatric disorder, “talking about one’s
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42 mental health,” and “participating in remote programs” were partially mediated by
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45 stressors, while the effects of being female and “15-minute naps” were completely
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47 mediated by stressors. NEU and “mental health issues related to COVID-19” had
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49 relatively large impacts on psychological distress. The effects of NEU were partially
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mediated by “large reduction in household income,” “difficulty receiving medical care
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54 for a chronic disease,” “problems with interpersonal relationships in the workplace,”
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56 “mental health issues related to COVID-19,” “uncertainty about the future,” “reduction
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in sleep time and quality,” “insufficient exercise,” and “increased time online.” People
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 Global Public Health Page 10 of 18

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3 with high NEU were more likely to perceive life events accompanying the SARS-CoV-
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2 outbreak as stressors. “Mental health issues related to COVID-19” was impacted by
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8 NEU, social support, being female, psychiatric disorder, and “talking about one’s
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10 mental health.” Calling attention to people with high NEU and offering support to
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people experiencing these stressors may help to alleviate psychological distress.
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15 Suicidal ideation was found to have a negative relationship with social support,
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17 and a positive relationship with NEU, psychiatric disorder, suspected infection with
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19 SARS-CoV-2, and “talking with others online.” Although the total effects of the
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22 stressors “increased responsibilities at home” and “increased time online” were not
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24 significant, each of them was shown to reduce suicidal ideation in the optimal model
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26 (Table 4). Although neither of them are generally considered factors that promote
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health, they likely worked to lessen suicidal ideation by preserving connections with
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31 others.
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33 A positive total effect was found for “talking with others online.” The positive
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effect through the mediator “concerns about online relationships” and the negative
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38 effect through “increased time online” coupled with the positive direct effect were
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40 surmised to ultimately increase suicidal ideation.
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42 Social support had the greatest effect on suicidal ideation and was concluded to
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45 directly reduce suicidal ideation as no mediating effects were observed. Loss of

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47 connection is in some perspectives seen as a vital factor facilitating suicidal ideation
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49 (Klonsky et al., 2016). Experiencing social support, on the other hand, signifies a
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connection between the self and others and it may be in this way that social support
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54 reduces suicidal ideation.
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56 This study revealed novel findings about social support. Namely, the effects of
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social support were compared to other factors, and factors mediating the effects of
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Page 11 of 18 Global Public Health

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3 social support were clarified. The present results suggest that social support has a
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particularly marked effect of reducing suicidal ideation. Further, the results suggest that
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8 the effects of social support impact mental and physical health and psychological
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10 distress by reducing the stressors accompanying “problems with interpersonal
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relationships online,” “reduction in sleep time and quality,” “reduction in household
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15 income,” and “mental health issues related to COVID-19,” as well as increasing the
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17 stressors accompanying “being unable to meet people.”
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19 This study has provided many insights into the effects of the SARS-CoV-2
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22 outbreak on the mental and physical health of the general public. However, there are
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24 also some limitations that must be taken into account. First is the limited number of
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26 participants. Responses were collected from all over Japan, and looking at the subjects’
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attributes, sex, and employment status does not reveal any evident deviation from the
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31 attributes of the country as a whole. However, as data were collected from 1,500
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33 subjects to represent all persons aged 18 and older in Japan, with a population of
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approximately 108 million, and as subjects were recruited through an online
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38 outsourcing service, we must be careful in deciding that the results of this study
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40 represent the characteristics of all residents of Japan. Further, as a cross-sectional study
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42 design was applied, the results cannot be used to confirm causal relationships. For
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45 example, coping not only influences stressors, but experiencing stressors also results in
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47 coping. Thus, it is important to consider the order of these relationships. Longitudinal
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49 research or analysis of adjusted effects could deepen our understanding on this point.
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53 Conclusions
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56 This study investigated the complex relationships of demographic characteristics,
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58 factors related to SARS-CoV-2, personality, social support, coping, and stressors with
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60 mental and physical health in residents of Japan immediately after the request for

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 Global Public Health Page 12 of 18

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3 voluntary restrictions of outings and business activities due to the SARS-CoV-2
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outbreak was rescinded. The strength of the impact of each factor differed for physical
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8 health, mental health, psychological distress, and suicidal ideation. However, in all
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10 cases, the results suggested that some attributes such as sex and personality, and some
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elements related to infection such as suspected infection with SARS-CoV-2 had direct
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15 effects on physical and mental health, and that there may also be effects mediated by
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17 stressors such as “insufficient exercise” or “mental health issues related to COVID-19.”
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19 As the effects of the SARS-CoV-2 pandemic continue across the globe, it is essential to
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22 prioritize resources and provide support to those at particularly high risk, and to offer
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24 effective evidence-based psychosocial interventions.
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28 References
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30 Cao, W., Fang, Z., Hou, G., Han, M., Xu, X., Dong, J., & Zheng, J. (2020). The
31 psychological impact of the COVID-19 epidemic on college students in China.
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32 Psychiatry Research, 112934.

33 Fitzpatrick, K., Harris, C., & Drawve, G. (2020). Fear of COVID-19 and the mental
34 health consequences in America. Psychological Trauma: Theory, Research,
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Practice and Policy.
37 Fukuhara, S., & Suzukamo, Y. (2004). Manual of the SF-8 Japanese edition
38 [Japanese]. Institute for Health Outcomes & Process Evaluation Research.
39 Furukawa, T. A., Kawakami, N., Saitoh, M., Ono, Y., Nakane, Y., Nakamura, Y.,
40 Tachimori, H., Iwata, N., Uda, H., & Nakane, H. (2008). The performance of the
On

41 Japanese version of the K6 and K10 in the World Mental Health Survey Japan.
42 International Journal of Methods in Psychiatric Research, 17(3), 152-158.
43
44
Gosling, S. D., Rentfrow, P. J., & Swann Jr, W. B. (2003). A very brief measure of the
ly

45 Big-Five personality domains. Journal of Research in personality, 37(6), 504-

46 528.
47 Guo, J., Feng, X. L., Wang, X. H., & van IJzendoorn, M. H. (2020). Coping with
48 COVID-19: Exposure to COVID-19 and Negative Impact on Livelihood Predict
49 Elevated Mental Health Problems in Chinese Adults. International Journal of
50
Environmental Research and Public Health, 17(11), 3857.
51
52 Hu, L. t., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure
53 analysis: Conventional criteria versus new alternatives. Structural equation
54 modeling: a multidisciplinary journal, 6(1), 1-55.
55 Iwasa, H., Gondo, Y., Masui, Y., Inagaki, H., Kawai, C., Otsuka, R., Ogawa, M.,
56 Takayama, M., Imuta, H., & Suzuki, T. (2007). Reliability and Validity of the
57 Social Support Scale Japanese Version: A Study of Middle-aged and Older
58
59
Adults [Japanese]. Journal of health and welfare statistics, 54(6), 26-33.
60

URL: http:/mc.manuscriptcentral.com/rgph Email: gph-msph@columbia.edu

Page 13 of 18 Global Public Health

1
2
3 Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S.-L.,
4
Walters, E. E., & Zaslavsky, A. M. (2002). Short screening scales to monitor
5
6
population prevalences and trends in non-specific psychological distress.
7 Psychological Medicine, 32(6), 959-976.
8 Klonsky, E. D., May, A. M., & Saffer, B. Y. (2016). Suicide, suicide attempts, and
9 suicidal ideation. Annual review of clinical psychology, 12.
10 Li, H. Y., Cao, H., Leung, D. Y., & Mak, Y. W. (2020). The Psychological Impacts of a
11 COVID-19 Outbreak on College Students in China: A Longitudinal Study.
12
International Journal of Environmental Research and Public Health, 17(11),
13
14 3933.
15 National Information Center of Stress and Disaster Mental Health. (2010). 2010
16 National Basic Life Survey Special Summary K6 (
17 Ni, M. Y., Yang, L., Leung, C. M., Li, N., Yao, X. I., Wang, Y., Leung, G. M.,
18
Fo

Cowling, B. J., & Liao, Q. (2020). Mental health, risk factors, and social media
19 use during the COVID-19 epidemic and cordon sanitaire among the community
20
21
and health professionals in Wuhan, China: Cross-sectional survey. JMIR mental
rP

22 health, 7(5), e19009.

23 Oshio, A., Abe, S., & Cutrone, P. (2012). Development, reliability, and validity of the
24 Japanese version of Ten Item Personality Inventory (TIPI-J) [In Japanese].
ee

25 Japanese Journal of Personality, 21(1), 40-52.

26 Osman, A., Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kopper, B. A., & Barrios, F.
27
X. (2001). The Suicidal Behaviors Questionnaire-Revised (SBQ-R): validation
28
rR

29
with clinical and nonclinical samples. Assessment, 8(4), 443-454.
30 Rajkumar, R. P. (2020). COVID-19 and mental health: A review of the existing
31 literature. Asian Journal of Psychiatry, 102066.
ev

32 Statistics Bureau of Japan. (2020). Labour Force Survey 2020 Feb Statistical table I-2.
33 Strickhouser, J. E., Zell, E., & Krizan, Z. (2017). Does personality predict health and
34 well-being? A metasynthesis. Health Psychology, 36(8), 797.
iew

35
van Agteren, J., Bartholomaeus, J., Fassnacht, D. B., Iasiello, M., Ali, K., Lo, L., &
36
37 Kyrios, M. (2020). Using Internet-Based Psychological Measurement to Capture
38 the Deteriorating Community Mental Health Profile During COVID-19:
39 Observational Study. JMIR Mental Health, 7(6), e20696.
40 Wang, H., Xia, Q., Xiong, Z., Li, Z., Xiang, W., Yuan, Y., Liu, Y., & Li, Z. (2020). The
On

41 psychological distress and coping styles in the early stages of the 2019
42 coronavirus disease (COVID-19) epidemic in the general mainland Chinese
43
44
population: A web-based survey. PloS One, 15(5), e0233410.
ly

45 Ware, J., Kosinski, M., Dewey, J., & Gandek, B. (2001). How to score and interpret
46 single-item health status measures: a manual for users of the of the SF-8 health
47 survey Lincoln, RI. Boston: QualityMetric. Inc.
48 Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The
49 multidimensional scale of perceived social support. Journal of Personality
50
Assessment, 52(1), 30-41.
51
52
53
54
55
56
57
58
59
60

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 Global Public Health Page 14 of 18

1
2
3
4 Table 1. Characteristics of the study participants.
5
6 N % N %
Age Employment before epidemic
7
18 or 19 23 1.5 student 75 5
8 20-24 138 9.2 self-employed 157 10.5
9 25-29 240 16 company manager 9 0.6
10 30-34 314 20.9 full-time 528 35.2
11 35-39 256 17.1 part-time 180 12
40-44 232 15.5 temporary workers 158 10.5
12
45-49 125 8.3 housewives/husbands 254 16.9
13 50-54 95 6.3 leave of absence 36 2.4
14 55-59 42 2.8 unemployed 103 6.9
15 60-64 20 1.3 Annual household income
16 65-69 10 0.7 <18600 USD 292 19.5
≥70 5 0.3 18600 USD to 37200 USD 425 28.3
17
Sex 37300 USD to 74500 USD 598 39.9
18
Fo

female 969 64.6 74600 USD to 111800 USD 146 9.7

19 male 524 34.9 111900 USD to 149000 USD 27 1.8
20 other 7 0.5 ≥149100 USD 12 0.8
21 Education Workplace commutation
rP

junior high school 28 1.9 unemployed 445 29.7

22
high school 330 22 nearly none 430 28.7
23 junior college 355 23.7 half of the week or less 183 12.2
24 university 718 47.9 more than half of the week 118 7.9
ee

25 graduate degree 69 4.6 almost every day 324 21.6

26 Marital status Housing facilities and surrounding environment
unmarried 659 43.9 garden or balcony 1184 78.9
27
divorced/widowed 64 4.3 Number of preschool-age children
28
rR

married [separated] 50 3.3 　0 1181 78.7

29 living with partner 727 48.5 　1 221 14.7
30 Ethnicity 　2 87 5.8
31 Asian 1489 99.3 　3 11 0.7
ev

Black 1 0.1 Respondents’ own COVID-19 infection status

32
multiracial 3 0.2 fully recovered 2 0.1
33 White 2 0.1 undergoing treatment 1 0.1
34 Han Chinese 3 0.2 suspected to be infected 13 0.9
iew

35 Middle Eastern/Arab 1 0.1 none 1484 98.9

36 other 1 0.1 Recent contact with infected persons
Comorbidity none 1392 92.8
37
primary illness 152 10.1 suspected of having contact 70 4.7
38 psychiatric outpatient status 119 7.9 yes 38 2.5
39 Extent of voluntary restriction of outside activity
40 30 2
On

did not practice social distancing

41
67 4.5
42 practiced social distancing
43 went out for work
481 32.1
44
ly

862 57.5
45 only exercising or shopping
46 60 4
did not leave home at all
47
48
49 Note: N = 1500.
50
51
52
53
54
55
56
57
58
59
60

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Page 15 of 18 Global Public Health

1
2
3 Table 2. Psychological measures: Descriptive statistics.
4
5 Min Max Average SD
TIPI-J
6 2 14 7.22 2.87
Extraversion
7
8 Agreeableness 2 14 9.69 2.22
9
Conscientiousness 2 14 7.18 2.61
10
11 Neuroticism 2 14 8.79 2.67
12
Openness 2 14 7.70 2.59
13
14 Social Support
15 7 49 35.18 9.19
16 SF-8
　PCS 19.91 68.27 51.04 6.70
17
　MCS 13.69 62.30 43.43 8.14
18
Fo

K6
19 0 24 6.49 5.34
20 SBQ
21 3 18 5.79 2.99
rP

22
23 Note: N = 1500. TIPI-J: Ten Item Personality Inventory Japanese version, PCS:
24
Physical component summary. MCS: mental component summary. SBQ: Suicide
ee

25
26 Behaviors Questionnaire-Revised Japanese version.
27
28
rR

29
30
31
ev

32
33
34
iew

35
36
37
38
39
40
On

41
42
43
44
ly

45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60

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 Global Public Health Page 16 of 18

1
2
3 Table 3. Frequency of life events, stressors and coping.
4
5 Life Events and Stressors Not happen Not stressful A little stressful Very stressful
6 NO. Contents N % N % N % N %
7
My household income significantly decreased (by 40%
8 E1 1022 68.1 148 9.9 201 13.4 129 8.6
or more).
9
10 I lost someone close to me (due to the novel
E2 1393 92.9 39 2.6 41 2.7 27 1.8
11 coronavirus or other causes).
12 I had difficulty getting a consultation with a doctor for
13 E3 1190 79.3 140 9.3 137 9.1 33 2.2
the treatment of a chronic disease I have.
14
I had to do things that put me at risk of infection (e.g.,
15 E4 438 29.2 578 38.5 357 23.8 127 8.5
commute to work, do my job, go shopping).
16
17 My workload increased quantitatively (e.g., increased
E5 1258 83.9 85 5.7 112 7.5 45 3.0
18
Fo

overtime).
19 I worried about relationships at work (e.g., everyday
20 E6 relationships, differences of opinion regarding 1097 73.1 148 9.9 162 10.8 93 6.2
21
rP

infection prevention).
22
I began to experience mental health issues resulting
23 E7 885 59.0 246 16.4 285 19.0 84 5.6
24 from the coronavirus outbreaks’ effects.
ee

25 Concerns about my relationship with my

26 boyfriend/girlfriend/a close friend (e.g., unable to get
27 E8 961 64.1 253 16.9 209 13.9 77 5.1
in contact with them, not getting along, concerns about
28
rR

infection).
29
My responsibilities at home increased, e.g., more
30 E9 912 60.8 229 15.3 243 16.2 116 7.7
31 childcare, eldercare, housework.
ev

32 Concerns about online relationships (hassles,

E10 1352 90.1 61 4.1 66 4.4 21 1.4
33 arguments, abuse).
34 E11 Being unable to meet people. 251 16.7 566 37.7 435 29.0 248 16.5
iew

35
E12 Uncertainty about the future. 209 13.9 311 20.7 540 36.0 440 29.3
36
E13 I slept less and the quality of my sleep decreased. 817 54.5 245 16.3 315 21.0 123 8.2
37
38 E14 Insufficient exercise. 326 21.7 631 42.1 381 25.4 162 10.8
39 The time I spent social networking, surfing the web,
E15 359 23.9 891 59.4 185 12.3 65 4.3
40
On

gaming, or shopping online increased.

41 Coping Implemented
42
NO. N %
43
44 Taking medication to improve my mental health such
ly

C1 67 4.5
45 as sleeping pills or antidepressants.
46 Talking about my mental health with friends and
C2 232 15.5
47 family.
48 Participating in an online mental health program
49 C3 11 0.7
(cognitive behavioral therapy, etc.)
50
51 Talking with others via social networking services,
C4 183 12.2
52 online bulletin boards or forums.
53 C5 Reading for enjoyment. 317 21.1
54 Playing games with children (board games and cards,
55 C6 240 16.0
etc.)
56
C7 Taking 15-minute naps, lying around. 566 37.7
57
58
59 Note. N = 1500.
60

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Page 17 of 18 Global Public Health

1
2
3 Table 4. Unstandardized path coefficients (b) estimated by structural equation
4
5 modeling.
6 E1 E2 E3 E4 E5 E6 E7 E8 E9 E10
7 b SE b SE b SE b SE b SE b SE b SE b SE b SE b SE
8 Extraversion 0.04 0.01 - - - - - - - - - - - - 0.03 0.01 - - - -
Agreeableness - - - - -0.02 0.01 - - - - -0.02 0.01 - - - - - - -0.03 0.01
9 Conscientiousness - - - - - - - - - - - - - - - - - - - -
10 Neuroticism 0.03 0.01 - - 0.02 0.01 0.06 0.01 - - 0.03 0.01 0.08 0.01 0.04 0.01 0.03 0.01 - -
Openness - - - - - - - - - - - - - - - - - - - -
11 SocialSupport -0.01 0 -0.01 0 -0.01 0 - - -0.01 0 -0.01 0 -0.01 0 - - - - -0.01 0
12 Age - - - - 0.02 0.01 - - - - - - - - -0.05 0.01 0.09 0.01 -0.02 0.01
Female - - - - - - 0.25 0.05 0.12 0.04 0.16 0.05 0.21 0.04 0.14 0.04 0.29 0.04 - -
13 Juniorcollege 0.15 0.06 - - - - - - - - - - - - - - - - - -
14 Psychiatricoutpatient - - - - 0.31 0.10 - - - - - - 0.38 0.09 0.19 0.09 - - 0.20 0.07
Full-time -0.14 0.05 - - - - - - 0.23 0.05 0.32 0.06 - - - - - - - -
15 Unemployed - - - - - - - - - - -0.15 0.05 - - - - -0.24 0.09 - -
16 Commutation - - - - -0.03 0.01 0.14 0.02 0.11 0.02 0.15 0.02 - - - - -0.03 0.02 - -
Garden -0.16 0.06 - - - - - - - - - - - - - - - - - -
17 NofPreschoolchildren -0.11 0.04 0.05 0.02 - - - - 0.08 0.03 - - - - - - 0.60 0.05 - -
18
Fo
Threepreschoolchildren 0.90 0.32 - - 0.55 0.29 - - - - - - - - - - -0.65 0.29 - -
SuspectedCOVID-19infection 0.45 0.24 0.32 0.22 - - - - - - - - 0.47 0.19 - - - - 0.34 0.21
19 Recentcontactwithpatients - - 0.23 0.10 0.25 0.13 - - - - - - - - - - - - 0.23 0.11
20 Novoluntaryrestriction - - - - - - - - - - - - - - - - - - - -
C1 - - - - 0.21 0.14 - - - - - - - - - - - - - -
21
rP

C2 0.23 0.08 - - 0.13 0.06 0.19 0.07 0.11 0.05 0.20 0.06 0.34 0.07 0.28 0.07 - - - -
22 C3 0.64 0.31 - - - - - - - - - - 0.92 0.21 1.12 0.23 0.69 0.23 0.70 0.31
C4 - - - - - - - - - - - - - - - - - - 0.27 0.06
23 C5 - - - - - - - - - - - - - - - - - - - -
24 C6 - - - - - - - - - - - - - - - - 0.58 0.07 - -
C7 - - - - - - - - - - - - - - - - - - 0.06 0.03
ee

25
26 E11 E12 E13 E14 E15 PCS MCS K6 SBQ
b SE b SE b SE b SE b SE b SE b SE b SE b SE
27 Extraversion 0.05 0.01 0.03 0.01 - - 0.02 0.01 0.01 0.01 - - - - -0.07 0.03 -0.05 0.02
28
rR

Agreeableness - - - - - - -0.04 0.01 - - - - - - -0.16 0.05 - -

Conscientiousness - - - - - - - - - - - - - - - - -0.09 0.03
29 Neuroticism 0.04 0.01 0.09 0.01 0.08 0.01 0.04 0.01 0.03 0.01 0.18 0.07 -0.5 0.07 0.44 0.04 0.14 0.03
30 Openness - - - - 0.02 0.01 - - - - - - -0.12 0.06 - - 0.05 0.03
SocialSupport 0.02 0 - - -0.02 0 - - - - - - 0.07 0.02 -0.07 0.01 -0.09 0.01
31 Age -0.06 0.01 - - - - -0.02 0.01 -0.05 0.01 -0.16 0.08 - - - - - -
ev

32 Female 0.18 0.05 0.29 0.05 - - - - - - - - - - - - 0.33 0.13

Juniorcollege - - - - - - - - - - - - - - - - - -
33 Psychiatricoutpatient - - - - - - - - - - -2.40 0.67 - - 1.16 0.46 1.81 0.37
34 Full-time - - - - - - - - - - - - - - - - - -
iew

Unemployed - - - - - - - - - - - - - - 0.79 0.35 - -

35 Commutation - - - - - - - - - - 0.31 0.10 - - - - - -
36 Garden - - - - - - - - - - 0.96 0.40 0.80 0.42 -0.82 0.23 - -
NofPreschoolchildren 0.08 0.03 0.12 0.03 0.17 0.04 - - - - - - -0.56 0.29 - - - -
37 Threepreschoolchildren - - - - - - - - - - - - - - - - 1.59 0.74
38 SuspectedCOVID-19infection - - - - - - - - - - -5.57 2.24 - - 3.70 1.30 2.41 0.49
Recentcontactwithpatients - - - - - - - - - - - - - - -1.70 0.58 - -
39 Novoluntaryrestriction - - - - - - - - - - - - - - 2.12 0.88 0.91 0.53
40 C1 - - - - 0.37 0.13 - - - - - - -3.58 0.95 1.85 0.64 0.94 0.50
On

C2 0.37 0.06 0.4 0.06 0.43 0.07 0.26 0.06 0.20 0.05 - - - - 0.48 0.25 0.33 0.18
41 C3 0.61 0.29 0.57 0.23 - - 0.32 0.27 - - - - - - 2.47 1.17 - -
42 C4 - - - - - - - - 0.18 0.05 - - - - - - 0.71 0.20
C5 - - - - - - - - - - - - - - -0.79 0.19 - -
43 C6 - - - - -0.14 0.06 - - - - - - - - - - - -
44 C7 - - 0.12 0.04 0.16 0.05 0.13 0.04 0.13 0.04 0.84 0.31 - - - - - -
ly

E1 - - - - - - - - - - - - -0.5 0.19 0.32 0.11 0.12 0.07

45 E2 - - - - - - - - - - -0.52 0.28 - - - - 0.46 0.14
46 E3 - - - - - - - - - - -0.55 0.25 - - 0.34 0.13 0.23 0.11
E4 - - - - - - - - - - - - - - - - - -
47 E5 - - - - - - - - - - -0.60 0.25 -0.44 0.24 - - - -
48 E6 - - - - - - - - - - - - - - 0.21 0.11 - -
E7 - - - - - - - - - - - - -2.12 0.23 1.30 0.14 0.26 0.09
49 E8 - - - - - - - - - - - - - - - - 0.16 0.08
50 E9 - - - - - - - - - - - - -0.30 0.17 - - -0.21 0.06
E10 - - - - - - - - - - -0.64 0.34 - - 0.63 0.20 0.46 0.14
51 E11 - - - - - - - - - - 0.53 0.22 -0.94 0.21 - - - -
52 E12 - - - - - - - - - - 0.38 0.19 -1.04 0.21 0.75 0.12 0.17 0.07
E13 - - - - - - - - - - -0.67 0.19 -0.76 0.22 0.60 0.12 0.14 0.08
53 E14 - - - - - - - - - - -1.77 0.21 -0.41 0.22 0.32 0.12 - -
54 E15 - - - - - - - - - - - - - - 0.32 0.14 -0.15 0.10
55
56 Note: Paths removed from the model are marked with a "-".
57
58
59 Model fit indices: χ2 (605) = 638.48, p = 0.168, CFI = .996, RMSEA = .006, SRMR
60
= .025.

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 Global Public Health Page 18 of 18

1
2
3 Table 5. Standardized total effects (β) estimated by structural equation modeling.
4
E1 E2 E3 E4 E5 E6 E7 E8 E9 E10
5 β SE β SE β SE β SE β SE β SE β SE β SE β SE β SE
6 Extraversion - - - - - - - - - - - - - - - -
7 Agreeableness
Conscientiousness
-
-
-
-
-
-
-
- - -
-
-
-
-
-
-
-
- - -
-
-
-
-
-
-
-
-
-
-
-
- - -
8 Neuroticism - - 0.18 0.02 - - 0.23 0.02 - -
9 Openness
SocialSupport
- - - - - - -
-
-
-
- - - - -
-0.13
-
0.02
-
-
-
-
-
-
-
-
-
-0.14
-
0.03
10 Age - - - - - - - - - - - - -0.11 0.02 0.18 0.02
11 Female
Juniorcollege
- - -
-
-
-
-
-
-
-
0.13
-
0.02
- - - - -
0.11
-
0.02
- - -
0.14
-
0.02
-
-
-
-
-
12 Psychiatricoutpatient - - - - - - - - - - 0.11 0.03 - -
13 Full-time
Unemployed - -
-
-
-
-
-
-
-
-
-
-
-
-
0.15
-
0.03
-
0.17 0.03 -
-
-
-
-
-
-
-
- - -
-
-
-
14 Commutation - - - - 0.22 0.02 0.23 0.03 0.26 0.03 - - - - - -
15 Garden
NofPreschoolchildren
- - -
-
-
-
-
-
-
-
- - -
-
-
-
-
-
-
-
-
-
-
-
-
0.36
-
0.03
-
-
-
-
16 Threepreschoolchildren - - - - - - - - - - - - - -
17 SuspectedCOVID-19infection
Recentcontactwithpatients - -
- - -
-
-
-
-
-
-
-
-
-
-
- - -
-
-
-
-
-
-
-
-
18
Fo

Novoluntaryrestriction - - - - - - - - - - - - - - - - - - - -
19 C1
C2
- - -
-
-
-
- - - - - - -
0.13
-
0.03
-
0.11
-
0.03
-
-
-
-
-
-
-
-
20 C3 - - - - - - - - - -
21 C4 - - - - - - - - - - - - - - - - - - 0.16 0.03
rP

C5 - - - - - - - - - - - - - - - - - - - -
22 C6 - - - - - - - - - - - - - - - - 0.22 0.03 - -
23 C7 - - - - - - - - - - - - - - - - - -

24 E11 E12 E13 E14 E15 PCS MCS K6 SBQ

ee

25 β SE β SE β SE β SE β SE β SE β SE β SE β SE
Extraversion 0.16 0.03 - - -0.04 0.01
26 Agreeableness - - - - - - - - 0.03 0.01 -0.08 0.02
27 Conscientiousness - - - - - - - - - - - - - - - -
Neuroticism 0.11 0.03 0.24 0.03 0.21 0.02 0.11 0.03 -0.30 0.02 0.36 0.02 0.17 0.02
28
rR

Openness - - - - - - - -
29 SocialSupport 0.17 0.02 - - -0.14 0.02 - - - - 0.05 0.01 0.11 0.02 -0.19 0.02 -0.32 0.03
Age -0.12 0.02 - - - - -0.15 0.02
30 Female 0.14 0.02 - - - - - - -0.06 0.01 0.05 0.01
31 Juniorcollege - - - - - - - - - - - -
ev

Psychiatricoutpatient - - - - - - - - - - 0.19 0.03

32 Full-time - - - - - - - - - -
33 Unemployed - - - - - - - - - - - -
Commutation - - - - - - - - - -
34 Garden - - - - - - - - - -
iew

35 NofPreschoolchildren 0.10 0.02 - - - -

Threepreschoolchildren - - - - - - - - - -
36 SuspectedCOVID-19infection - - - - - - - - - - 0.09 0.02
37 Recentcontactwithpatients - - - - - - - - - - - -
Novoluntaryrestriction - - - - - - - - - - - - - -
38 C1 - - - - - - - -
39 C2 0.14 0.02 0.14 0.02 0.15 0.03 0.10 0.03 -0.09 0.01 0.12 0.02
C3 - - - -
40
On

C4 - - - - - - - - - -
41 C5 - - - - - - - - - - - - - - - -
C6 - - - - - - - -
42 C7 - - 0.03 0.01
43 E1 - - - - - - - - - - - -
E2 - - - - - - - - - - - - - -
44
ly

E3 - - - - - - - - - - - -
45 E4 - - - - - - - - - - - - - - - - - -
E5 - - - - - - - - - - - - - -
46 E6 - - - - - - - - - - - - - - - -
47 E7 - - - - - - - - - - - - -0.25 0.03 0.24 0.03
E8 - - - - - - - - - - - - - - - -
48 E9 - - - - - - - - - - - - - -
49 E10 - - - - - - - - - - - -
E11 - - - - - - - - - - -0.11 0.03 - - - -
50 E12 - - - - - - - - - - -0.13 0.03 0.14 0.02
51 E13 - - - - - - - - - - 0.12 0.02
E14 - - - - - - - - - - -0.24 0.03 - -
52 E15 - - - - - - - - - - - - - -
53
54 Note: Paths removed from the model are marked with a "-". Only coefficients
55
56 significant at p < 0.0001 are shown.
57
58
59 Model fit indices: χ2 (605) = 638.48, p = 0.168, CFI = .996, RMSEA = .006, SRMR
60
= .025.

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