The Relationship between Psychological Impact and Self-control in Chinese Residents outside Hubei Province during the Epidemic of COVID-19: The mediation of self-regulated fatigue

Lian Xiong Department of Psychology, School of Educational Science, Hunan normal university Liangshi Yan (  yanliangshi@hunnu.edu.cn ) Research Center for Cultural Psychology and Behavior ,School of Educational Science Hunan normal university Xin Wang Mental Health Educatianal Center, Changsha University of Science and Technology Chu Yang Department of Psychology, School of Educational Science, Hunan normal university


Introduction
COVID-19 had become an globally epidemic disease over the past few months (Wang 2020). Zhong Nanshan, a national specialist who had fought against SARS in 2004 , made it clear that there might be human to human transmission Jan 2020. Then the Chinese government had enforced a blockade of Wuhan city in Hubei province immediately. WHO determined the epidemic disease as Public Health Events of international concern on 30 Jan 2020 (Wilder-Smith et al. 2020). The cumulative con rmed cases was increasing fast, and the growth went on. The cumulative con rmed cases went over 10 thousand on 31 Jan 2020, and the increase went on. All was listed in table 1 and Figure 1(NHC of the People's Republic of China 2020a,b,c,d). Some researches had shown that people who were exposed to an environment of being prone to be infected felt disturbed (Alecu 2020). Thousands of information poured in from everywhere such as the actual mortality rate, the quantity of con rmed cases and suspected cases, which had led to widespread uncertainty, insecurity with direct implications for the Chinese residents' daily life and mental health outside the Hubei province (Ornell et al. 2020). Chinese residents outside the Hubei province also felt so widespread fear of being infected. A recent research had examined 1,210 Chinese residents from 194 cities in January and February 2020 by using the Chinese version of Impact of Event Scale-Revised and had found that 24.5% of all respondents reported minimal psychological impact; 21.7% rated mild impact; and 53.8% reported a moderate or severe impact ).
Chinese people were advised to cut down on going out to crowded places and wear a mask when they have a fever or cough(State Council Information O ce of the People's Republic of China 2020). Thus people start to stay at home as long as they can until the epidemic disease came to an end, which we called home quarantine.
It is perceived the self as a goal-directed organism always making various self-regulatory adjustments in thought and action to match the reference value and goal (Earl 2008),such as maintaining a healthy sleep, diet and lifestyle under home quarantine. The residents had needed to avoid excessive exposure to COVID-19 news, maintain a healthy sleep, diet and lifestyle in order to maintain mental health (Shah et al. 2020).
That means people should control themselves effectively to escape the attack of emotional and behavioral disorder. Previous researches have revealed that self-control is not only a kind of ability or trait, but also a kind of resource or state (Baumeister et al. 1998;Baumeister 2002). Baumeister et al.(1998) proposed a theory called the strength model, which assumed that self-control was a kind of nite resources for regulating one's thoughts, emotions and behaviors. And previous researches have revealed that people of high trait self-control can produce more ego-depletion than low trait self-control (Liu and Zhang 2016). Once the resources was depleted, it was di cult for people to employ all the resources in the subsequent work and the performance became poorer (Vohs and Faber 2007). And one would be more self-regulated fatigue over time when one kept performance at a consistently high level (Lindner et al. 2017).And Loss of control could be one important variables that could account for the distress level were fear during SARS (Wong et al. 2005).
To sum up, we inferred people who exposed themselves in the COVID-19 might more or less suffer from psychological impact, and people of higher level of self-control will produce more self-regulated fatigue and more psychological impact. And self-regulatory fatigue might mediate the relationship between impact of event and self-control.

Methods
Participants and data collection The questionnaires had been collected from 30th January to and 2nd February in 2020 when the epidemic situation was severe. We adopted cross-sectional research design and random sampling method, and used an anonymous questionnaire on an online survey platform called "Survey Star"(https://www.wjx.cn).It had collected 472 questionnaires from 18 provinces until 2nd February . All participants provided gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki. Then we eliminated the questionnaires from Hubei or whose completion time is less than 300 seconds and obtained 400 valid questionnaires with an effective rate of 84.746% eventually. The age of participants ranged from 16 to 65 with an average age of 33.046(SD=12.479).

Questionnaire design
This survey was composed of four parts including personal Information and three structured questionnaires: (1) sociodemographic data; (2)the psychological impact of the COVID-19 outbreak; (3) self-regulated fatigue; (4) self control.
The Impact of Event Scale (IES) was developed by Horowitz et al.(1979) and was revised to IES-R by Weiss and Marmarit(1997). IES-R was used to measure the psychological in uence of COVID-19. It is a self-report questionnaire to examine one's feeling after catastrophic life event, which included 22 items and three subscales called avoidance, intrusion, and hyperarousa .It had been well-validated in the Chinese population and used a 5-point rating scale on a range of 1-5(Zhang 2014), Whose total score was divided into >37(severe impact), 33-36 (moderate impact), 24-32 (mild impact), 0-23 (normal), and (Creamer et al. 2003).
Self-regulated fatigue was measured through Self-Regulatory Fatigue Scale(SRF-S) in the study, which was developed rst in 2013 and consisted of 18 items measuring self-regulatory capacity with cognitive, emotional, and behavioral components. The internal consistency and reliability was acceptable Self-control was measured through Self control scale(SCS) which had a full version with 36 items and a simpli ed version with 13 items (Tangney et al. 2004

Statistical analysis
The scores of three structured questionnaires were expressed as mean and standard deviation. One-Way ANOVA and Independent-Sample T Test were used to estimate the differences in sociodemographic characteristics on IES-R,SRF-S, SCS, and Independent-Sample T Test were used to compare current study and previous research, high-score group and low-score group of IES-R on SRF-S and SCS. All tests were two-tailed, with a signi cance level of p < 0.05. It was performed by SPSS Statistic 20.0 (IBM SPSS Statistics, The English Version).

Results
The differences in sociodemographic variables on IES-R,SRF-S, SCS Firstly, there was no difference between male and female on SRF-S(t=-0.53,p=0.59) and SCS(t=-1.71,p=0.09) except the total score of IES-R(t=2.09,p=0.04).
Secondly, we divided the participants into four groups by age ,and listed 16~25 as team 1(N=130), 25~35 as team 2(N=85), 35~50 as team 3(N=99), >50 as team 4(N=51). The result of One-Way ANOVA showed that there were signi cant differences on the total score of SCS(F=12.86 p=0.00) and SRF-S(F=5.86 p=0.00), while there were no difference on IES-R(F=1.92 p=0.13). Meanwhile, we found the participants in the team 4(>50) was signi cantly lower than the other teams on the total scores and all the subscales of SCS and SRF-S except the focusing-on-work subscale.
Thirdly, we divided the participants into three groups by educational attainment, and listed Master's and Doctoral degree as team 1(N=44), Bachelor's degree as team 2(N=249), secondary school, primary school and none as team 3(N=81). The result of One-Way ANOVA showed that the there were no signi cant difference on SCS(F=0.1 p=0.91) and SRF-S(F=2.19 p=0.11), and signi cant differences on the total scores of IES-R.
Fourthly, there were many differences between different regions on IES-R,SRF-S and SCS: There were signi cant differences between the provinces adjacent to Hubei province (N=236) and the other ones(N=164) in China on IES-R(t=-2.76 p=0.01), SRF-S(t=-2.04 p=0.04) and SCS(t=3.40 p=0.00).
We divided the participants into two groups by GDP in different provinces ,and listed the top-8 provinces in 2019 , Shanghai and Beijing as economically developed areas(N=95) with the rest ones as developing areas(N=305).And then we found that people in economically developed areas got signi cantly higher scores on the total score of SCS(t=2.34 p=0.02) and IES-R(t=3.54 p=0.00), while there was no signi cant difference on SRF-S(t=1.08 p=0.28). We divided the participants into ve groups by the accumulative number of con rmed cases in different province during the survey, and listed <100 as team 1(N=69), 100~200 as team 2(N=53), 200~300 as team 3(N=183), 300~400 as team 4(N=71), >400 as team 5(N=24). The result of One-Way ANOVA showed that there were signi cant differences on the total score of SCS(F=3.09 p=0.02), SRF-S(F=2.57 p=0.02) and IES-R(F=9.00 p=0.00). We divided the participants into four groups by the size of the city ,and listed the big-sized cities as team 1(N=70) such as provincial capital cities, small and medium-sized cities as team 2(N=184), towns as team 3(N=37), rural areas as team 4(N=83

The comparison of current study and previous research on SRF-S and SCS
We put the means, SDs and the number of participants(N) in the mathematical formula of two independent sample T-test rst, and then we found that the IES-R scores of current study was signi cantly lower than the previous research which included residents in Hubei province (t=14.99,p<0.01) .The total score and subscale scores of SRF-S are signi cantly higher than the previous study(t=3.43 12.83 p<0.05).
The total score of SCS and the scores of focusing-on-work, Healthy-habits, refraining-from-entertainment, Resisting-temptation were signi cantly lower than the last one(t=3.64 12.68,p<0.01), while the scores of impulse-control were signi cantly higher than the previous research(t=3.07,p<0.01). All were listed in Table   3. The comparison of high-score group and low-score group of IES-R on SRF-S and SCS We rst sorted the total score of SCS in descending order, and then de ned the top 202 participants as high-score group and the rest ones as low-score group. The result of independent sample T-test revealed that the high-score group had got signi cantly higher scores on the total score of SRF-S, emotional components, behavioral components, the total score of IES-R than low-score group. All were listed in Table   4. The mediating effect of Self-Regulatory Fatigue Scale(SRF-S) between Self Control Scale(SCS) and Impact of Event Scale-Revised(IES-R) According to the testing procedure of The mediating effect which was formulated by Wen Zhonglin et al.

Discussion
This study was rstly conducted to evaluate the psychological impact of COVID-19 on Chinese residents who lived outside the Hubei province from 30 January to 2 February 2020, just several days after the blockade of Wuhan city and when WHO determined it as public health emergency events of international concern. Secondly, another aims was to examine the relationship between self-control, self-regulatory fatigue and psychological in uence.
From detection rate of IES-R which was mentioned above, 18.75% of Chinese residents who lived outside the Hubei province had been suffering a moderate or severe psychological impact from COVID-19 Epidemic, which was quite different with 53.8% of another Chinese research conducted. We had compared the composition of the participants and found that there were differences that we had collected 46% participants under the age of 30 comparing with 81.5% in previous research. Another difference was that we had removed the questionnaires from Hubei province while they included ). In addition, we also found there was nearly 15% of the residents suffering a severe impact comparing with 24.1% in the study which conducted in a month after a disastrous hydrogen uoride spillage (Yoo et al. 2017) which seemed to be more terrible than COVID-19. However, IES-R was ever used as a tool of examining PTSD in the previous research (Kerai et al. 2017;Hong et al. 2009) and it had been proved that traumatic symptoms and the rebuilding of mental health would last from several months to several years.
A previous research reveal that there was signi cant difference on IES-R in the patients of PTSD between 2 months, 7 months, 10 months, 20 months, 46 months(Estimate=-2.8, S.E.=0.9,p=0.03) after discharging from medical hospitalization for treatment of SARS. There were also signi cant differences on IES-R between in the patients of PTSD and no PTSD in 2 months , 7 months, 10 months, 20 months, 46 months (Hong et al.,2009).Thus, the residents of moderate to extremely severe impact still deserved to be better treated specially when there were intrusive symptoms (Feinstein et al. 2018).
The studies should not only have quantitative results, but also took the in uence of culture into consideration. The study was conducted on the seventh or eighth day of the new year when the workers would usually go back to work in succession. Thus it made the workers being anxious because they could not go back to work immediately. The residents generally more or less suffered a psychological impact during 7-10 days of isolating themselves at home. T We had had one-on-one interviews with 5 residents about their living conditions and feelings through Wechat during the survey. It is known that one of traditional customs in Spring Festival was to meet with the relatives and friends to wish them all Happy New Year. However, nearly all the residents decided to send their wishes on Wechat or by mobile phones this year instead of visit, which made some people have a strong sense of loss. Therefore, all of them reported changes of behaviors, such as eating more, asleep later, waking up later, exercising less or spending more time sur ng on internet than usual.
We noticed that the female suffered severer psychological impact and were easier to evade the event than the male, which was consistent with another Chinese research ). In addition, It's to be unexpected that the residents over 50 didn't suffered severer impact which was consistent with another Chinese research conducted by Wang et.al(2020) despite of too much reports on that the old infected with COVID-19 were more likely to die. We guess that the old were in uenced less because they were used to stay at home and got less information from internet. The residents of Master's and Doctoral degree suffered severer impact than the others, while Wang Cuiyan didn't nd signi cant difference between them .In addition, it was interesting that the residents in different regions were differently affected from the disease. The residents from the provinces adjacent to Hubei province or in economically developed areas or in the province of the accumulative number of >400 con rmed cases or living in towns and rural areas suffered severer impact. It was similar to another research that divided the participants along the dimensions of location into high SARS-prevalent and low SARS-prevalent regions and found there were signi cant differences on between the regions (IES-R, Intrusion, Avoidance, Hyperarousal) (Lee et al. 2006). And only the residents from the provinces adjacent to Hubei province felt more self-regulated fatigued, and the residents in economically developed areas or from big-sized cities showed more self- control.
From what was mentioned above, it revealed that people felt more intruded after the blockade of Wuhan city  and was cognitively, emotionally, and behaviorally more tired than usual (Wang et al.,2015), and they were in a less favorable position of self-control including being more impulsive, less healthy habits, being vulnerable to temptation, less commitment to work, and more entertainment (Zhang et al.,2019). It was known to all that we had got little knowledge about how to treat COVID-19 effectively, thus many things got out of control in the situation, which forced someone to regulate physical and mental resources to keep the balance of a normal life. We had found that the higher level of self-control they were the more self-regulated fatigue and psychological impact they felt. And self-control could not only had an direct in uence on impact of event but also had an indirect in uence on it through selfregulatory fatigue. One of high level of self-control would produce more ego depletion and then resulted in more psychological impact.A previous research had con rmed that people of high level of self control group made poorer performance in the ego depletion task(Wei 2013). Combined with the strength model of self -control (Baumeister and Bratslavsky, 1998;Baumeister, 2002), when people were experiencing a public health event and spent their self-control resources to deal with the emotional and behavioral problems, people of higher level of self-control would led to more self-regulated fatigue, which thus would gave rise to more psychological effects. A previous research thought that providing accurate and transparent information about the epidemic would contribute to the public's mental health during the outbreak (Xie et al. 2020 ).It was known to all that we had got little knowledge about how to treat COVID-19 effectively then, so people felt disturbed seriously and many things got out of control in the situation. Home quarantine forced someone to use physical and mental resources to keep the balance of a normal life.
Fatigue might be a warning of worse mental health conditions to the residents. Some residents with mild impact might adapt to working and studying at home and also might become severe mental impact because of more ego depletion, while the residents with severe mental impact might recover from the terrible feelings and also might develop into worser condition later.Thus psychological support and selfawareness is extremely necessary.

Conclusions
We found that the residents suffered a psychological impact during the outbreak of COVID-19 .The more self-control they were, the more self-regulated fatigue and psychological impact they suffered, and selfcontrol could not only had an direct in uence on psychological impact but also had affected it indirectly through self-regulated fatigue.

Declarations
Con ict of interest statement:The authors declare that they have no competing interests.

Figure 1
The cumulative con rmed cases and cumulative suspect of COVID-19 in China during the investigation(China, Jan 30 to Feb 2, 2020)