Suboptimal Health Status of High School Students in 2 Guangzhou , Shanxi , and Tibet , China : A Cross-Sectional 3 Study 4

* Correspondence: zhjinx@mail.sysu.edu.cn; Tel.: +86-20-87332453. 13 † Gehendra Mahara and Jianzhi Liang both are equally contributed for this work. 14 15 Abstract: Suboptimal health status (SHS) is a state between health and disease, has 16 several associated factors, although, its underlying mechanism is still unclear. This 17 study aimed to investigate the status of SHS and its associated factors of high school 18 students in three areas of China (Shanxi, Guangzhou, and Tibet). A 19 multidimensional sub-health questionnaire of adolescent (MSQA) is used to 20 evaluate SHS. Among 1461 respondents, females proportion 56.47% was higher than 21 males 43.53% where SHS was higher in Shanxi, followed by Tibet and then 22 Guangzhou. The rural area, grade, lack of sleep, home visit in a week, lack of 23 exercise, a heavy burden of study, smoking, drinking, and fewer friends were the 24 risk factors of SHS, while, families living status, seeking help, and extroversion were 25 the protective factors. SHS is significantly associated with different influencing 26 factors. For comprehensive prevention and control measures, reduce the risk factors, 27 and enhance the protective factors. 28 29


33
Health is the functional phenomenon of human-being. The condition of being 34 sound in body, mind, spirit, and free from disease or pain is the meaning of health 35 [1]. In 1946s, The World Health Organization (WHO) defined that "health is a state 36 of complete physical, mental, and social well-being and, not merely the absence of 37 disease or infirmity" [2]. Likewise, the suboptimal health or sub-health status, also 38 known as suboptimal health status (SHS) [3] is the physical state of people which is 39 generally undiagnosed [4], however, some changes in psychological behavior or 40 physical characteristics can observe [5], In fact, SHS is an intermediate state between 41 health and disease condition [6]. In this state, there are no organic lesions in the body, 42 only characterized by persistent and recurrent fatigue, headaches, dizziness, 43 anxiety, depression, as well as a series of symptoms including non-specific pain and 44 sleep disorders [6][7][8]. 45 Several studies suggested that SHS is as an intermediate state between health  46 and disease, which is due to the physical, psychological, and social stress of an 47 individual [4,[9][10][11][12]. Due to the physical and psychological behavior, the overall 48 coordination of the body system become imbalance and dysfunction e.g. the nervous 49 system, endocrine system, and immune system that lead to the decline of 50 physiological, psychological, and social functions; however, the body has not yet 51 reached the disease stage [6,8]. Therefore, it is also regarded as a subclinical, 52 reversible stage of chronic diseases [3,6]. Because and other factors (student source, interpersonal relationship) etc (S. Table 1). 120

Data collection 121
The pre-test is conducted prior to the formal investigation. The first grade of an 122 ordinary high school in Guangzhou was selected by means of convenient sampling 123 for the pre-test. The information associated with survey questions and calculated 124 scales were revised after getting feedback from the pre-test and then finalized the 125 questionnaire for the final study. 126 Students are filled with information anonymously by means of centralized filling, 127 independent answering, on-the-spot recycling, and on-the-spot investigation. At the 128 spot, the local education authorities and their subordinate schools co-operated 129 closely. Investigators collect all filled questionnaires after the survey is completed. 130 The interview/survey was excluded from those participants who declined to 131 participate in the survey. The questionnaire was finished by each respondent within 132 20 min. All information of the respondents was kept strictly confidential. 133

Ethical Approval 134
Ethical approval had been approved by the Ethics Committee of the School of Public 135 Health, Sun Yat-Sen University, Guangzhou, China. The ethical approval number is 136 2018 (050). The written and verbal sign was taken with each respondent in an 137 informed consent form at the beginning of each survey. 138

Statistical analysis 139
Epidata-3.1 software is used to record the database. Normality distributed 140 quantitative data were displayed as mean and standard deviations, where non-141 normally distributed data were represented as medians and quartiles (P25⁓P75).

142
Qualitative data were presented as a rate or percentage. A Pearson chi-square (ꭓ2) 143 test was applied to compare between groups. The influencing factor of SHS was 144 estimated using logistic regression analysis for multivariate analysis, by adjusted 145 Odds ratios (AOR) and 95% confidence interval (CI). All statistical analyses carried 146 out using SPSS 23.0 software. All reported P values were two-sided, and P<0.05 was 147 considered statistically significant. 148

Basic characteristics of respondents 150
A total of 1472 respondent, 11 participants were excluded due to missing items or 151 information in the questionnaire.

161
The survey results showed that there were significant differences in the physical SHS 162 and psychological SHS along with different detection rates among the high school 163 students in the three regions. Psychological SHS was higher in Shanxi (20.69%) 164 followed by Tibet (18.77%) and Guangzhou (13.03%) among surveyed populations 165 (S. Table 3). 166 167

SHS detection Score and rate by gender 168
The results of this study showed that the detection rate of physical SHS symptoms 169 and the Psychological SHS of females was higher than that of males, which is the 170 statistically significant (STable 3,4,5). 171

Multiple logistic regression analysis of influencing factors with SHS and 172
Psychological SHS 173 In order to know the comprehensive effect of the factors affecting the SHS, a stepwise 174 multi-factor unconditional logistic regression analysis was carried out. The result of 175 this analysis showed that the region, lack of sleep time, heavy learning burden, lack 176 of exercise, drinking alcohol, lack of frequent home visit, and eating habit were the 177 statistically significant associated risk factors of SHS, while an hour of daily internet 178 access was found to be a protective factor for the SHS (

183
Similarly, the results of logistic regression analysis exhibited that the region (rural), 184 grade of class, lack of sleep time, heavy learning burden, less than one time per week 185 home visit, lack of exercise, smoking, drinking, and fewer friends were the risk 186 factors for psychological SHS, while females (gender), family, township, seeking 187 help, and extroversion were the protective factors for the occurrence of 188 psychological SHS (Table 3-4). 189 Questionnaire (SHSQ-25) [3], predominantly targeted at the Physiological and 212 Psychological status of people, has been widely applying at the national or 213 international level in different ethnic groups (Asian, African, and Caucasians), 214 which is also a new mechanism to enables people for early intervention in terms of 215 Predictive Chao confirmed that MSQA is a credible, effective, and sensitive SHS tool for 221 adolescents. Therefore, to assess the SHS of adolescents, MSQA is a suitable 222 measuring scale; thus, we applied in our study. 223 The study result showed that the geographical region, rural area, lack of sleep 224 time, heavy learning burden, drinking alcohol, lack of frequent home visit, and 225 eating habit were significant risk factors for SHS, similarly the region (rural), the 226 grade of class, lack of sleep time, heavy learning burden, personal behaviour, less 227 than one time per week home visit, lack of exercise, smoking, and drinking, were 228 risk factors for psychological SHS. Interestingly, only an hour of daily internet access 229 was found to be a protective factor for physical SHS, whereas, seeking help, and 230 extroversion were the protective factors for the psychological SHS. Consisting, Zhao 231 [29] and Hou et, al [12], reported that the main physiological problems of middle 232 school students are fatigue, dizziness, gastrointestinal discomfort, and poor sleep 233 tendency. Proper and active exercise, a balanced diet, avoid alcohol, and tobacco 234 habit is the best way to overcome from SHS. 235 Notably, this study found that surfing the internet for no more than an hour in 236 a day was a protecting factor for SHS for high school students. This finding is 237 supported by a study that long-term internet access, high frequency of internet 238 access, and internet addiction are the significant risk factors for SHS [30], which is 239 consistent with our study. The short-term internet access can alleviate the student's 240 stressful learning pressure to a certain extent so that their life rhythm can be slowed 241 down. 242 An earlier study [30] suggested that, in terms of gender, females have their own 243 physiological characteristics, those are more sensitive, delicate as well as the more 244 complex during the physical and psychological changes of adolescence period, thus 245 difficult to guide them at this period, which makes females more likely to have SHS. 246 Our study also found that SHS was high among female students, which is also is the holistic approach in terms of PPPM. 277 However, some limitations must be considered when interpreting the findings 278 of this study. This study used a prospective questionnaire survey method, which is 279 difficult to avoid bias and errors caused by differences in understanding an ability 280 among students from different regions or ethnic groups. This was a cross-sectional 281 survey, which did not allow us to assess accurate causality between psychological 282 symptoms and physical SHS. And data was obtained by the self-rating 283 questionnaire, which might have led to information bias. The participants were 284 selected by a convenient sampling method, which leaves the potential for selection 285 bias, and limited generalizability, the relevancy of results to other populations. 286

Conclusions 287
This study evaluated the SHS of high school students in three regions in 288 China, where SHS was found high in Shanxi, followed by Tibet and Guangzhou. 289 The SHS among females was high than that of males. Rural areas, grades of class, 290 lack of sleep time, heavy study burden, low number of home visits per week, lack of 291 exercise, smoking, drinking, and fewer friends were risk factors for SHS, while, 292 family in townships, seeking help, extroversion person were a protective factor for 293 the occurrence of SHS. Through the comprehensive prevention and control 294 measures of the school and family of the student, promote students to develop good 295 habits, promptly guide various psychological problems and adjust social 296 adaptability, timely detect and treat the sub-health symptoms that have emerged, 297 and effectively prevent and control the student's health.  Supplemantary-2 (Table S1: Indicators of SHS used in questionnaire,