The Impact of Peers with Severe Sickness Experience on Students’ Mental Health

Liping Chen; Jiada Lin; Zhihan Zhou

doi:10.1515/bejeap-2024-0334

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The Impact of Peers with Severe Sickness Experience on Students’ Mental Health

Liping Chen , Jiada Lin and Zhihan Zhou

Published/Copyright: November 18, 2025

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From the journal The B.E. Journal of Economic Analysis & Policy

Abstract

This study, using data from the China Education Panel Survey, examines the impact of peers with severe sickness experience within the classroom on the mental health of middle school students. To address endogeneity issues and establish causal inference, we focus on a sample of schools where students are randomly assigned to classes. Our results indicate that a one standard deviation increase in the share of peers with severe sickness experience in the classroom reduces students’ standardized indexes of mental health by 0.07 standard deviations. To explore potential mechanisms, we examine the classroom environment and teachers’ teaching behavior. Our findings indicate that exposure to peers with severe sickness experience deteriorates the classroom environment, but no significant effect is found on teachers’ teaching behavior.

Keywords: mental health; peer effect; severe sickness experience; random class assignment

JEL Classifications: I15; I25; J13

Corresponding author: Jiada Lin, International School of Business and Finance, Sun Yat-Sen University, Zhuhai, Guangdong, China, E-mail: jiada.lin0@gmail.com

All authors are in alphabetical order and contributed equally to the paper and could be treated as the joint first author.

Funding source: National Social Science Fund of China

Award Identifier / Grant number: No. 23 & ZD183

Conflict of interest: The authors have no relevant financial or non-financial interests to disclose.
Research funding: This work is funded by the Major Program of the National Social Science Fund of China (Grant No. 23 & ZD183).

Appendix A: Additional Figures and Tables

see Figures A1 and A2, Tables A1–A12.

Figure A1:

Distribution of the number and share of students with severe sickness experience. Note. Data are from the 2013–2014 CEPS. The figures plot the distributions of the number and share of students with severe sickness experience.

Figure A2:

Placebo test. Note. Data are from the 2013–2014 CEPS. The figure plots the distribution of mental health index coefficients and corresponding p-values from 1,000 regressions, each conducted after randomly reassigning the share of peers with severe sickness experience across classes within each school. The vertical dashed lines represent the baseline estimates for the corresponding outcomes (Columns 3 and 7 of Table 3).

Table A1:

Comparison of average health and academic outcomes between students with severe sickness experience and students who repeated a grade in primary school.

	Students with severe sickness experience(1)	Students who repeated a grade in primary school(2)
*Panel A. Mental health*
Average index	−0.337	−0.127
PCA index	−0.338	−0.126
*Panel B. Physical health*
Physical health (self-report)	0.576	0.685
Physical health (parents’ assessments)	0.547	0.673
Height-for-age	−0.247	−0.242
*Panel C. Test scores*
Chinese	−0.083	−0.219
Mathematics	−0.134	−0.179
English	−0.083	−0.267

Data are from the 2013–2014 CEPS. The sample used here is identical to that in the main analysis. Variable definitions and construction details are provided in Section 3.

Table A2:

Characteristics of random sample and full CEPS sample.

	Random sample	Full CEPS sample
	(1)	(2)
Panel A. School characteristics
# of schools	63	112
Type of schools
Public school	92.06 %	92.86 %
Private school	7.94 %	7.14 %
Rank of schools
Medium and below	19.05 %	21.43 %
Top middle ranking	57.14 %	59.82 %
Top	23.81 %	18.75 %
School principal
Gender (Male = 1)	79.37 %	82.57 %
Education	5.52	5.41
Working experience	24.76	24.56
Whether school principal graduated from a normal college (Yes = 1)	100 %	99.07 %
Panel B. Class characteristics
# of classes	194	438
Head teacher characteristics
Age	37.53	37.16
Gender (Male = 1)	31.96 %	34.02 %
Education	5.44	5.39
Working experience	15.85	15.87
Marital status (Married = 1)	90.72 %	89.24 %
Student characteristics
Age	13.91	13.90
Gender (Male = 1)	49.73 %	51.53 %
Minority (Yes = 1)	10.90 %	8.73 %
Local student (Yes = 1)	81.27 %	82.04 %
Whether fathers have a college education or above (Yes = 1)	21.30 %	15.39 %
Whether mothers have a college education or above (Yes = 1)	18.49 %	12.91 %
Low-income family (Yes = 1)	15.32 %	21.31 %

Data are from the 2013–2014 CEPS.

Table A3:

Principal components of the mental health index.

Component	Eigenvalue	Difference	Proportion	Cumulative
Factor1	3.27	2.70	0.65	0.65
Factor2	0.57	0.11	0.11	0.77
Factor3	0.45	0.09	0.09	0.86
Factor4	0.36	0.02	0.07	0.93
Factor5	0.35		0.07	1.00

Data are from the 2013–2014 CEPS.

Table A4:

Contribution of each variable and Kaiser-Meyer-Olkin measure of sampling adequacy.

Variable	Factor1	Uniqueness	KMO
Blue	0.83	0.32	0.86
Depressed	0.82	0.33	0.85
Unhappy	0.84	0.29	0.86
Perceiving life as meaningless	0.74	0.45	0.89
Sad	0.81	0.34	0.87
Overall			0.86

Data are from the 2013–2014 CEPS.

Table A5:

The correlation between severe sickness experience and student characteristics.

	Severe sickness experience
	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)	(11)	(12)
Age	0.014**											0.010
	(0.006)											(0.006)
Gender		0.003										−0.002
		(0.006)										(0.006)
Minority			−0.002									−0.003
			(0.013)									(0.013)
Local student				0.003								0.006
				(0.009)								(0.009)
Only child					−0.002							0.000
					(0.006)							(0.007)
Owing computer						−0.016*						−0.012
						(0.009)						(0.009)
Suspension in primary school							0.125***					0.122***
							(0.023)					(0.022)
Grade repetition in primary school								0.022*				0.009
								(0.013)				(0.013)
Whether fathers have a college education or above									−0.003			0.002
									(0.008)			(0.008)
Whether mothers have a college education or above										−0.008		−0.006
										(0.008)		(0.009)
Low-income family											0.030***	0.027**
											(0.011)	(0.011)
School-grade fixed effects	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
R ²	0.076	0.075	0.075	0.075	0.075	0.075	0.082	0.075	0.075	0.075	0.076	0.084
Observations	7,348	7,348	7,348	7,348	7,348	7,348	7,348	7,348	7,348	7,348	7,348	7,348

Data are from the 2013–2014 CEPS. The dependent variable is a dummy indicating whether a student experienced severe sickness before primary school. All regressions include school-grade fixed effects. Standard errors in parentheses are clustered at the class level. ***, **, and *denote statistical significance at the 1 %, 5 %, and 10 % level, respectively.

Table A6:

The correlation between severe sickness experience and students’ human capital performance.

	Average index of mental health	PCA index of mental health	Physical health (self-report)	Physical health (parents’ assessments)	Height-for-age	Chinese	Mathematics	English
	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)
Severe sickness experience	−0.397***	−0.397***	−0.154***	−0.179***	−0.154***	−0.097**	−0.158***	−0.098**
	(0.045)	(0.044)	(0.022)	(0.020)	(0.058)	(0.046)	(0.046)	(0.043)
School-grade fixed effects	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
R ²	0.011	0.011	0.061	0.102	0.064	0.001	0.002	0.001
Observations	7,348	7,348	7,291	7,229	7,116	7,154	7,157	7,157

Data are from the 2013–2014 CEPS. Each column presents the results from a separate regression. All regressions include school-grade fixed effects. Standard errors in parentheses are clustered at the class level. ***, **, and *denote statistical significance at the 1 %, 5 %, and 10 % level, respectively.

Table A7:

Permutation test.

	(1)
Age	0.472
Gender	0.476
Minority	0.246
Local student	0.461
Only child	0.478
Owning computer	0.456
Suspension in primary school	0.293
Grade repetition in primary school	0.329
Whether fathers have a college education or above	0.347
Whether mothers have a college education or above	0.335
Low-income family	0.417

Data are from the 2013–2014 CEPS.

Table A8:

The correlation between mental health and student characteristics.

	Average index	PCA index
	(1)	(2)
Age	−0.048**	−0.048**
	(0.021)	(0.021)
Gender	0.044*	0.049*
	(0.025)	(0.025)
Minority	−0.036	−0.037
	(0.053)	(0.053)
Local student	0.051	0.052
	(0.039)	(0.039)
Only child	0.003	0.003
	(0.029)	(0.029)
Owing computer	−0.005	−0.005
	(0.034)	(0.034)
Suspension in primary school	−0.091	−0.090
	(0.064)	(0.064)
Grade repetition in primary school	−0.125**	−0.124**
	(0.048)	(0.048)
Whether fathers have a college education or above	0.069*	0.067
	(0.042)	(0.042)
Whether mothers have a college education or above	0.038	0.039
	(0.045)	(0.045)
Low-income family	−0.156***	−0.157***
	(0.036)	(0.036)
School-grade fixed effects	Yes	Yes
R ²	0.010	0.010
Observations	6,758	6,758

Data are from the 2013–2014 CEPS. The dependent variables are average index and PCA index of mental health. All regressions include school-grade fixed effects. Standard errors in parentheses are clustered at the class level. ***, **, and *denote statistical significance at the 1 %, 5 %, and 10 % level, respectively.

Table A9:

The effects of peers without severe sickness experience on the mental health of students with severe sickness experience.

	Average index	PCA index
	(1)	(2)
Share of peers without severe sickness experience	0.092	0.095
	(0.113)	(0.113)
Student controls	Yes	Yes
Class controls	Yes	Yes
School-grade fixed effects	Yes	Yes
R ²	0.160	0.159
Observations	590	590

Data are from the 2013–2014 CEPS. Each column presents the results from a separate regression. Student controls include students’ age and dummy variables indicating gender, minority, local student, only child, whether they own computer, whether they were suspended in primary school, whether they repeated a grade in primary school, whether fathers have a college education or above, whether mothers have a college education or above, and whether they come from a low-income family. Class controls include head teacher’s age, gender, education, working experience, marital status, and whether the class is large. All regressions include school-grade fixed effects. Standard errors in parentheses are clustered at the class level. ***, **, and *denote statistical significance at the 1 %, 5 %, and 10 % level, respectively.

Table A10:

The effects of the number of peers with severe sickness experience on students’ mental health.

	Average index	PCA index
	(1)	(2)
Number of peers with severe sickness experience	−0.019**	−0.019**
	(0.008)	(0.008)
Student controls	Yes	Yes
Class controls	Yes	Yes
School-grade fixed effects	Yes	Yes
R ²	0.012	0.012
Observations	6,758	6,758

Data are from the 2013–2014 CEPS. Each column presents the results from a separate regression. Student controls include students’ age and dummy variables indicating gender, minority, local student, only child, whether they own computer, whether they were suspended in primary school, whether they repeated a grade in primary school, whether fathers have a college education or above, whether mothers have a college education or above, and whether they come from a low-income family. Class controls include head teacher’s age, gender, education, working experience, marital status, and whether the class is large. All regressions include school-grade fixed effects. Standard errors in parentheses are clustered at the class level. ***, **, and *denote statistical significance at the 1 %, 5 %, and 10 % level, respectively.

Table A11:

Tests for sample attrition.

	Attrition dummy
	(1)
Share of peers with severe sickness experience	0.010
	(0.016)
School-grade fixed effects	Yes
R ²	0.092
Observations	7,741

Data are from the 2013–2014 CEPS. Each column presents the results from a separate regression. All regressions include school-grade fixed effects. Standard errors in parentheses are clustered at the class level. ***, **, and *denote statistical significance at the 1 %, 5 %, and 10 % level, respectively.

Table A12:

The effects of peers with severe sickness experience on detail items of mental health.

	Blue	Depressed	Unhappy	Perceiving life as meaningless	Sad
	(1)	(2)	(3)	(4)	(5)
Share of peers with severe sickness experience	−0.086**	−0.071*	−0.065	−0.107**	−0.074**
	(0.035)	(0.037)	(0.040)	(0.046)	(0.033)
Student controls	Yes	Yes	Yes	Yes	Yes
Class controls	Yes	Yes	Yes	Yes	Yes
School-grade fixed effects	Yes	Yes	Yes	Yes	Yes
R ²	0.062	0.068	0.065	0.051	0.062
Observations	6,758	6,758	6,758	6,758	6,758

Data are from the 2013–2014 CEPS. Each column presents the results from a separate regression. Student controls include students’ age and dummy variables indicating gender, minority, local student, only child, whether they own computer, whether they were suspended in primary school, whether they repeated a grade in primary school, whether fathers have a college education or above, whether mothers have a college education or above, and whether they come from a low-income family. Class controls include head teacher’s age, gender, education, working experience, marital status, and whether the class is large. All regressions include school-grade fixed effects. Standard errors in parentheses are clustered at the class level. ***, **, and *denote statistical significance at the 1 %, 5 %, and 10 % level, respectively.

Appendix B: Additional Analysis for 9th Grade Sample

The differential effects between the 7th- and 9th-grade samples may reflect potential selection issues. To address this concern, we restrict the analysis to 9th-grade students and conduct two balance tests to assess the randomness of classroom assignment, following the procedures outlined in Section 4.2. First, we re-estimate the balance test based on the student pre-determined characteristics. If non-random selection is present, we would expect a significant correlation between the share of peers with severe sickness experience and students’ pre-determined characteristics. However, as shown in Column 2 of Table B1, and consistent with the results in Column 2 of Table 2, most of the characteristics of 9th-grade students are not significantly correlated with the share of peers with severe sickness experience once school-by-grade fixed effects are included. These findings suggest that student characteristics are balanced across classrooms with varying proportions of peers with severe sickness experience, supporting the assumption of random classroom assignment within the 9th-grade sample.

Second, we follow the methodology of Gong et al. (2021) and Chung and Zou (2023) and conduct a permutation test using a resampling approach to further assess the randomness of student assignment in the 9th-grade sample. As shown in Table B2, all p-values exceed 0.1, providing additional evidence that students in 9th grade are randomly assigned to classrooms. This finding suggests that potential selection or shuffling across classrooms is unlikely to bias the assignment process and does not threaten the validity of our results.

Another potential explanation for the differential effects observed between the 7th- and 9th-grade samples could be related to student transfers across classrooms or schools. However, as outlined in Section 2 on the institutional background, middle school admission in China follows the completion of primary education and is determined by household registration. Upon entering the 7th-grade, students are generally assigned to classes through a random allocation process, aiming for an equitable distribution of students across all classes. Moreover, under the compulsory education system, class transfers are generally prohibited except under special circumstances. Given these institutional features, we believe that school or class transfers are unlikely to occur frequently in our sample, thereby limiting the scope for selection bias.

To further address this concern, we examine the potential for class reassignment, particularly among 9th-grade students. Unfortunately, the available data do not allow us to directly observe class-switching behavior for 9th graders, because information on their class status in 7th and 8th grade is unavailable. However, we conduct a related analysis using data from the 7th-grade sample. CEPS conducted a follow-up survey one year later, when the original 7th-grade students advanced to 8th-grade. We use this follow-up data and calculate the proportion of students who changed either their class or school between 7th- and 8th-grade. The results indicate that such transitions are relatively rare. According to official CEPS data, the 7th-grade sample includes 10,279 students, 830 of whom either transferred to a different school or changed classes within the same school by 8th grade, thereby yielding a transfer rate of 8.1 %. In our estimation sample, which is restricted to students randomly assigned to classrooms, the transfer rate falls further to 5.9 %. These low levels of mobility suggest that class and school changes between 7th- and 8th-grade are limited. On the basis of this evidence, we reasonably assume a similarly limited degree of school and class switching in the 9th-grade.

Furthermore, we conduct additional analyses to assess whether exposure to peers with severe sickness experience influences students’ tracking status. We construct a binary variable, “untrackable,” which takes the value 1 if a student cannot be tracked owing to a class or school transfer or for other unspecified reasons, and 0 otherwise. Then, we examine whether the proportion of peers with severe sickness experience in 7th-grade predicts students’ tracking status. The results in Table B3 show no significant relationship, indicating that the presence of such peers does not affect the likelihood of class or school transfers. This result alleviates concerns that our findings for the 9th-grade sample may be driven by selection bias.

In summary, evidence from the transfer rate analysis and regression results suggests that class and school transfers are unlikely to account for the observed effects of peers with severe sickness experience in the 9th-grade sample.

Table B1:

Balance tests for pre-determined characteristics of 9th grade sample.

	Share of peers with severe sickness experience
	(1)	(2)
Age	0.225**	0.013*
	(0.105)	(0.007)
Gender	0.047	−0.011
	(0.044)	(0.009)
Minority	1.166***	−0.015
	(0.360)	(0.012)
Local student	0.106	0.028
	(0.107)	(0.017)
Only child	−0.582***	0.011
	(0.138)	(0.011)
Owning computer	−0.756***	0.024
	(0.182)	(0.017)
Suspension in primary school	0.250***	0.016
	(0.092)	(0.024)
Grade repetition in primary	0.722***	−0.020
school	(0.137)	(0.012)
Whether fathers have a	−0.400***	0.015
college education or above	(0.109)	(0.012)
Whether mothers have a	−0.402***	0.004
college education or above	(0.108)	(0.011)
Low-income family	0.634***	0.032
	(0.170)	(0.031)
School-grade fixed effects	No	Yes
Observations	3,147	3,147

Data are from the 2013–2014 CEPS. In Columns 1 and 2, each cell represents a single regression of the share of peers with severe sickness experience on the corresponding variables. Column 1 presents results without school-grade fixed effects, while Column 2 reports results with school-grade fixed effects included. Standard errors in parentheses are clustered at the class level. ***, **, and *denote statistical significance at the 1 %, 5 %, and 10 % level, respectively.

Table B2:

Permutation test for the 9th grade sample.

	9th grade sample
	(1)
Age	0.461
Gender	0.464
Minority	0.201
Local student	0.454
Only child	0.476
Owning computer	0.484
Suspension in primary school	0.257
Grade repetition in primary school	0.295
Whether fathers have a college education or above	0.330
Whether mothers have a college education or above	0.301
Low-income family	0.396

Data are from the 2013–2014 CEPS.

Table B3:

The effects of peers with severe sickness experience on students’ tracking status.

	Untrackable
	(1)
Share of peers with severe sickness experience	0.012
	(0.014)
Student controls	Yes
Class controls	Yes
School-grade fixed effects	Yes
R ²	0.129
Observations	3,611

Data are from the 2013–2014 and the 2014–2015 CEPS. Each column presents the results from a separate regression. Student controls include students’ age and dummy variables indicating gender, minority, local student, only child, whether they own computer, whether they were suspended in primary school, whether they repeated a grade in primary school, whether fathers have a college education or above, whether mothers have a college education or above, and whether they come from a low-income family. Class controls include head teacher’s age, gender, education, working experience, marital status, and whether the class is large. All regressions include school-grade fixed effects. Standard errors in parentheses are clustered at the class level. ***, **, and *denote statistical significance at the 1 %, 5 %, and 10 % level, respectively.

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Received: 2024-09-25

Accepted: 2025-10-27

Published Online: 2025-11-18

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https://doi.org/10.1515/bejeap-2024-0334

Keywords for this article

mental health; peer effect; severe sickness experience; random class assignment