ABSTRACT
Background This study primarily aimed to evaluate the associations between mental distress and COVID-19-related changes in behavioral outcomes, and potential modifiers (age, gender, and educational attainment) of such associations.Methods An online survey using anonymous network sampling was conducted in China during April-May, 2020 using a 74-item questionnaire distributed through social media. A national sample of 10,545 adults in 31 provinces provided data on socio-demographic characteristics, COVID-19-related mental distress, and changes in behavioral outcomes. Structural equation models were used for data analyses.Results About 13% of adults reported experiencing at least one symptom of mental distress. After adjusting for covariates, greater mental distress was associated with increased smoking and alcohol consumption (among current smokers and drinkers) and with both increased and decreased physical activity. Underweight adults were more likely to lose body weight (≥ 1 kg) whereas overweight adults were more likely to gain weight by the same amount. Association between mental distress and change in physical activity was stronger in adults aged 40 and above and those with high education.Conclusions Mental distress was associated with increased smoking in males but not females. These findings inform the design of tailored public health interventions aimed to mitigate long-term negative consequences of mental distress on outcomes.