Knowledge, Psychological Impacts, and Protective Behaviors During the First Wave of COVID-19 Pandemic Among Chinese Immigrants with School-Age Children in Canada

Background : The impact of COVID-19 on the emotions and behaviors of overseas Chinese immigrants and their families living in Canada has been poorly studied. The purpose of this study was to describe the knowledge, protective behaviors, and psychological impact of COVID-19 on Chinese immigrants and determine whether having school-age children was associated with adverse psychological outcomes. Methods: Using an online survey of 757 Chinese immigrants in Canada from April 2020, data regarding the perceptions of COVID-19, psychological impact, protective behaviors, and sociodemographic characteristics were collected and analyzed. A total of 747 eligible respondents were nally included in the analysis. Most of the participants (65.8%) were female and 77.2% had a university degree or higher. Results: There were no signicant differences in knowledge of COVID-19 in participants with or without children aged 16 years or under. Participants with children aged 16 years or under were more likely to perceive themselves as being at greater risk of contracting COVID-19 than those without (P=0.023). Participants with children aged 16 years and under were also more likely to feel depressed (P = 0.007) or stressed (P = 0.010). In addition, parents with children aged 16 years and under were more likely to adopt protective behaviors, for example, washing and sanitizing hands frequently or disinfecting work and living spaces. Conclusions: For the most part, Chinese immigrants with children aged 16 years and under were more prone to negative emotions, such as stress, anxiety, and fear. These ndings may assist key stakeholders with the identication and implementation of policies and interventions to support the needs of parents with young children, during and after the COVID-19 pandemic.

describe the knowledge, behaviors, and psychological impacts of COVID-19 in a sample of Chinese immigrants in Canada, and to evaluate the impact of having children aged 16 years of age and under on these factors.

Design
An online cross-sectional survey was conducted from April 2 to April 20, 2020.

Participants
Participation was anonymous and informed consent was required before participants could start the survey. A total of 757 participants were recruited in the study. The questionnaire consisted of two parts. The rst part collected general information about the participants. The second part asked generic questions about perceptions and actions related to COVID-19, including protection, psychological impacts, knowledge of COVID-19, and appraisal of crisis management by Canadian health authorities. Participants with children aged 16 years and under were also asked to describe speci c actions they would take to protect their children from COVID-19. To better understand the participants' perceptions of COVID-19, the survey included questions about the virus source, transmission routes, and disease susceptibility. Participants were asked to describe their likelihood of getting COVID-19 on a 5-point scale, from "Impossible" (=1) to "Very likely" (=5). Responses of 1 or 2 were coded as perceiving their likelihood as "unlikely", 3 was coded as "neutral", and responses 4 or 5 were coded as "likely". Participants were also asked about the psychological impacts of COVID-19 (including feeling at ease, scared, anxious, depressed, stressed, indecisive, and confused) on a ve-point Likert-type scale. For the convenience of analysis, we combined the ve categories of psychological feelings into three categories: agree, neutral, and disagree.

Data analysis
A descriptive analysis was conducted to report the sociodemographic characteristics of participants with or without children aged 16 years and under. Chisquare tests were conducted to compare the knowledge and psychological impacts of COVID-19 between participants with or without children aged 16 years and under . Spearman rank correlation analysis was used to compare the perceived likelihood of getting COVID-19 between participants with or without children aged 16 years and under. Missing data was not imputed. The two-sided analysis used a statistical signi cant level of 0.05. Data analyses were performed using SPSS statistical software (version 21.0, IBM company, Armonk, NY, USA, 2014). The forest plot was drawn with STATA software (version 16.0, Stata Corp, USA, 2019).
This study was approved by the Health Research Ethics Board, Memorial University of Newfoundland, le number 20201772-ME.
All methods were performed in accordance with the relevant guidelines and regulations.

Results
Among 757 eligible participants, 742 (258 males and 484 females) were included in the subsequent data analysis and responded to the question on whether they have a child 16 years of age or under. 39.4% [292/742] of respondents stated they had at least one child 16 years of age or under. Nearly 60 percent of participants ranging in age from 35 to 54 had children aged 16 years and under. Of those participants who said they had poor health, less than one third had children aged 16 years and under. Further details on participant characteristics are presented in Table 1.  transmission. Although more than 60% of the participants agreed that the elderly and immunosuppressed were vulnerable populations, more than half of them also agreed that "in general, all populations are susceptible to COVID-19" (note that these were not mutually exclusive options). As shown in participants were asked about their perceived likelihood of contracting COVID-19, a signi cant difference was observed between those with and without children aged 16 years and under (χ 2 (2) = 7.513, P=0.023).   (Table 3). To assess the psychological impact of the pandemic, we asked participants about how they felt the pandemic had affected their psychological wellbeing..
Overall, more than half of them did not feel relaxed, nearly half felt anxious and stressed, and more than one-third felt scared and confused (Table 4). Consistent with our hypothesis, more parents of children aged 16 years and under suffered from negative emotions such as not feeling at ease (χ2 = 6.077, P = 0.047), depressed (χ2 = 10.033, P = 0.007), and stressed (χ2 = 9.253, P = 0.010). In terms of protective behaviors against COVID-19, parents of children aged 16 years and under were found to have adopted protective behaviors, such as covering a sneeze with elbows or tissue paper, washing hands frequently (with soap), wearing a mask in public, maintaining social distance, limiting use of public transportation, avoiding or canceling group activities, and educating children about preventative behaviors (Figure 1, Additional le 1: Table S1).
Although fathers performed well, mothers performed signi cantly better at wearing masks in public places and maintaining social distance (P=0.034 and P=0.001, respectively). Almost all participants claimed they wash their hands frequently, while only two-thirds of them used alcohol-based hand sanitizer. More than three in four mothers (>75 percent) said they would disinfect their surroundings, while only approximately 60 percent of fathers responded that they would (χ 2 (1) =10. 13 In response to the COVID-19 epidemic, the Canadian government has adopted various policies and measures to promote epidemic-related research, for example, the CIHR 2020 supported by New Frontiers in Research Fund (NFRF). Due to the high contagious and fatality rate of COVID-19, all schools and daycare institutions in Canada were closed at the beginning of the COVID-19 outbreak [28 29,30]. Although the government has developed a guideline for school-age children, and education systems have offered online courses and psychological support to minimize the impact of the pandemic on students and their families, some of these measures have had unintended consequences [31].
This current research was part of a large research project in the Chinese community in Canada. This study was conducted during the second month of Canada's nationwide lockdown of the COVID-19 pandemic. During this period, there was a general state of confusion and panic about COVID-19 both within and outside Canada [31,32,33]. This is the rst comprehensive study on the knowledge, behaviors, and psychological impacts related to COVID-19 in an overseas Chinese population. It is also one of the preliminary studies focusing on parents or guardians of young school age children from an overseas immigrant population. These ndings may help governments with identifying and supporting the unique needs of parents with young children.
Our study demonstrates the bene t of the Canadian government's effort to promote knowledge related to COVID-19 through various channels and methods, as most participants had basic knowledge of COVID-19, such as the transmission routes and main prevention measures [34]. Nonetheless, parents with and without children aged 16 years and under, were found to hold both accurate and inaccurate views about the COVID-19 pandemic. These ndings are like those reported in previous literature [35,36,37]. In the initial stages of the pandemic, many participants panicked and actively sought out as much information as possible from reliable and unreliable sources [38,39].
More than half of our participants believed that all people are equally susceptible to COVID-19. They assumed that no one is exempt from the COVID-19 pandemic, which was possibly a re ection of people's fear of the pandemic [40,41]. When participants were asked about their perceived likelihood of getting infected with COVID-19, those who had children aged 16 years and under were more likely to believe they would get infected, suggesting a greater degree of pessimism. As mentioned in previous literature, parents of minors are usually more sensitive to major external events which are more likely to generate negative emotions such as stress and anxiety [42,43].
Consistent with our hypothesis, most of the participants had different levels of negative psychological emotions [44,45,46]. Speci cally, being a parent of children aged 16 years and under was associated with stronger negative psychological impacts. Similar ndings have since been observed in other populations of parents outside of Canada [44,45,46]. Because COVID-19 is the most serious global infectious disease outbreak in the past century [47,48], persistent fears about the pandemic and uncertainty about the future will inevitably lead to negative emotions. This trend is like that observed in previous literature on other outbreaks of infectious diseases [48,49,50,51,52]. Children under the age of 16 often require more companionship and support from families and friends than older children. Therefore, parents need to devote substantive time and energy on them [53]. The innate behaviors of children and the necessity for social interaction in development present unique challenges to social distancing or isolation. These behaviors and needs probably contribute to their parents' feelings of unease, depression, and stress.
Despite their pessimistic emotions, most parents with children aged 16 years and under were still willing to actively respond to the WHO's protective-behavior guidance on effective prevention of COVID-19 during the pandemic. They were also willing to implement corresponding health protective-behaviors.
Compared with other ethnic groups in Western countries, Chinese immigrants were more likely to use masks in public places to help prevent coronavirus infection at the beginning of the pandemic [54]. This behavior may have been inspired by the quick, large-scale control of COVID-19 spread using effective measures, including wearing masks, seen in China [55,56,57]. Most parents undertook protective behaviors to protect their family members during the pandemic, including mask wearing, social distancing, limiting group activities, limiting use of public transit, educating their children about preventive behaviors, and stocking up on non-perishable food and supplies. We also observed some gender differences with mothers being more likely than fathers to agree to undertaking certain protective behaviors.

Conclusions
There were several limitations in our research. First, this research was based on an online survey, as it was the only feasible method to reach this subpopulation during the pandemic. Therefore, the survey subjects do not represent the entire population of Chinese immigrants in Canada. Furthermore, it is likely that people who were willing to participate in the survey may have been more concerned about the pandemic which may have resulted in selection bias. In addition, our research is a cross-sectional study which began to recruit participants during the start of the second month of the pandemic. Due to the lack of longitudinal data, we cannot comment on changing trends in participants' beliefs, behaviors, and psychological impacts over time. Finally, the focus of this paper is descriptive and so our univariate analyses do not control for confounding variables.
In conclusion, Chinese immigrants with children aged 16 years and under were more prone to negative emotions during the COVID-19 pandemic, than those without children aged 16 years and under. This may have been partly due to the intrinsic nature of these children and their need for social interaction which made isolation and social distancing more di cult for them than for adults. The di culties in keeping them isolated and maintaining their social distance, may have exacerbated the anxiety, frustration, and stress of their parents who are obligated to keep them safe. Despite these negative psychological impacts, most parents surveyed reported taking numerous effective measures to protect themselves and their families. Gender differences were observed for some measures and activities.
Abbreviations and Data; USA: United States of America Declarations