Mental State of Students During the Pandemic and Affecting Factors: A Cross-Sectional Study.

Evaluation of the psychological symptoms in healthcare students and the development of new strategies to improve their mental health are of great importance. The study was aimed at determining the mental state of students, prospective healthcare workers, during the pandemic, and the influencing factors. The descriptive cross-sectional study was conducted at a Manisa Celal Bayar University Faculty of Health in Turkey. The sociodemographic characteristics questionnaire, Fear of COVID-19 Scale, and Brief Symptom Inventory were used to collect data. The study was conducted with 828 students. In study, variables such as sleep, negative news about COVID-19, sex, income status, presence of social support, department students attend, choosing the profession willingly, and having a physical/mental illness were determined to have an effect on the mental state. The results of this study suggest that there is a relationship between the fear of COVID-19 and mental health state of the students.

What do we already know about this topic?

The Covid-19 pandemic is at risk of adversely affecting the education and mental health of university students.

How does your research contribute to the field?

This study was able to identify the level of mental health state students’ in pandemic.

What are your research’s implications toward theory, practice, or policy?

The results of this study suggest that there is a relationship between the fear of COVID-19 and mental health state of the students.

Introduction

Outbreaks affect not only human life but also mental health negatively. An epidemic is known to cause many psychological problems such as anxiety, depression, and sleep disorders.[1-3] The COVID-19 pandemic and developments subsequent to it have affected the world in many aspects, especially health. It is thought that the ongoing COVID-19 pandemic may have serious effects both on mental health and on economic and political areas.

The coronavirus targets everyone regardless of their ideological, religious, economic, or social status. Therefore, its negative effects are witnessed in all areas of life. The more unprepared for a pandemic a country is, the greater its negative effect is, and thus, it can manifest itself as a crisis, especially in economy, health, and social life. Established orders are being forced to reorganize and to perform radical changes.

Many areas of life such as the suspension of educational activities, postponement or cancellation of sports competitions, physical limitations on social communication, economic activities’ having to come to a standstill or to slow down, unemployment, having to work despite isolation measures, and the postponement of courts have been affected by the pandemic. In order to alleviate the risks and effects of the disease, education was suspended in schools and non-essential social services were stopped. While administrative officials took measures to prevent the spread of the virus, storeowners and supplier companies around the world have sometimes had difficulties in ensuring the availability of products on their shelves. People stored surgical masks, rushed to markets to stock rice, toilet paper, and food. Such sudden changes in daily life are thought to be risk factors that can significantly affect mental health.

Fear of being infected, boredom, lack of knowledge, being away from classmates and teachers, lack of personal space at home, and financial losses in the family cause stress in young people during the pandemic period.[9-11] All these lifestyle changes can worsen young people’s mental health. Healthcare workers are exposed to longer work shifts to meet the increasing demand for health care. Meanwhile, lack of social support, poor sleep quality, isolation from family and friends, fear of infecting family and coworkers, and direct contact with patients are a few triggers leading to further psychological problems among healthcare workers.[12-14] In the literature, although considerable research has been devoted to COVID-19 disease, rather less attention has been paid to pandemic-related research, scales, and how the COVID-19 pandemic process affects students in the field of health. Therefore, more publications and reports on these issues should be published. Evaluation of the psychological symptoms in healthcare students and the development of new strategies to improve their mental health are of great importance. Therefore, in the present study, we aimed to determine the psychological state of prospective health professionals during the pandemic and the affecting factors.

By conducting the present study, we aimed to provide guidance on how to take measures to protect the mental health of students who would be healthcare professionals of the future and how to implement necessary therapeutic strategies, and to contribute to the process academically. The study was aimed at determining the mental state of students, prospective healthcare workers, during the pandemic, and the influencing factors.

Material and Methods

Study Design and Participants

This cross-sectional study was carried out in Manisa Celal Bayar University Faculty of Health Sciences from October 2020 to December 2020.

Ethical Consideration

Permissions to conduct the study and collect the data were obtained from the Scientific Research Platform of the Ministry of Health (October 5, 2020, T22_16_35), Manisa Celal Bayar University Faculty of Health Sciences (October 13, 2020, E.77774, 64031256-300), and Manisa Celal Bayar University Faculty of Medicine Health Sciences Ethics Committee (October 22, 2020, E.80434, 20478486-050.04.04).

After the students to participate in the study were informed about the purpose and procedure of the study, and survey forms via the online link, their written informed consent was obtained. They were told that participation was voluntary. The study was conducted in accordance with the Declaration of Helsinki.

Sample Size

The population of the study consisted of 1st, 2nd, 3rd, and 4th year students attending the Nursing, Midwifery, Physiotherapy and Rehabilitation, Social Work Departments of Faculty of Health Sciences, Manisa Celal Bayar University (N = 2347). The sample size of the study was calculated as a minimum of 330 students by using the Epi Info statistical package program, with a 5% margin of error, a 95% confidence level and a design effect of 1.0. Eight hundred and twenty eight students participated in the study.

Data Collection Procedure

The Sociodemographic Characteristics Questionnaire, The Fear of COVID-19 Scale (FCV-19S), and Brief Symptom Inventory (BSI) were used to collect data.

Sociodemographic Characteristics Questionnaire: The questionnaire includes items questioning the Sociodemographic Characteristics of the participants.

Fear of COVID-19 Scale: The scale developed by Ahorsu in 2020 was adapted into Turkish by Bakioglu in 2020.[15,16]

The number of sub-dimensions and items: The scale consists of one dimension and 7 items.

Scoring of the scale: The scale has no reverse scored items. The total score obtained from all the items of the scale indicates the individual’s level of FCV-19S. The minimum and maximum possible scores to be obtained from the scale are 7 and 35, respectively. The higher the score is, the higher the level of FCV-19S is.

Brief Symptom Inventory: The inventory was developed by L. R. Derogatis in 1983. Sahin and Durak (1994) conducted three studies to adapt it into Turkish. The 53-item inventory consists of nine subscales, additional items and three global indexes.

The subscales are as follows: Somatization, obsessive compulsive symptom, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid thoughts, and psychoticism. The three global indices are as follows: Global Severity Index (GSI), Positive Symptom Total Index (PSTI), and Positive Symptom Distress Index (PSDI).

Statistical Analysis

The data were analyzed using the SPSS for Windows 21.0 (Statistical Package for Social Sciences for Windows). Numbers, percentages, arithmetic mean, standard deviation, minimum and maximum values were used in the analysis of the descriptive data. The relationship between the different independent groups with normal distribution was analyzed using the independent sample t-test and correlation tests. The relationship between different independent variable groups without normal distribution was tested using the Kruskal–Wallis test, one of the non-parametric tests. The cause and effect relationship between variables with significant relationships in the independent groups was analyzed by using the Multiple Linear Regression test. The significance level for statistical analysis was accepted as P <.05.

Results

The mean age of the participating students was 20.36 ± 1.82 (min: 17, max: 28) years.

Of them, 84.2% were women, 39.0% were students in nursing, 16.3% were students in midwifery, 28.1% were students in physiotherapy and rehabilitation, 16.5% were students in social services, 99.3% were single, 52.5% lived in a city, 95.2% lived with their family, 58.2% had an income equal to their expenses, 93.0% were unemployed, 78.9% preferred the profession of their own free will, 88.2% did not have a physical/mental illness, and 61.7% had social support (Table 1).

Table 1.

Distribution of the Participating Students’ Sociodemographic Characteristics.

Sociodemographic Characteristics	n (%)
<20 years	419 (59.3)
≥21 years	337 (40.7)
Sex	Woman	697 (84.2)
	Men	131 (15.8)
Department	Nursing	323 (39.0)
	Midwifery	135 (16.3)
	Physical therapy and rehabilitation	233 (28.1)
	Social service	137 (16.5)
Family type	Extended family	42 (35.0)
	Nuclear family	75 (62.5)
	Broken family	3 (2.5)
Year at school	1st grade	158 (19.1)
	2nd grade	290 (35.0)
	3rd grade	217 (26.2)
	4th grade	163 (19.7)
Marital status	Single	822 (99.3)
	Married	6 (.7)
Place of residence	City	435 (52.5)
	District	284 (34.3)
	Village	109 (13.2)
Person(s) lived together	Family	788 (95.2)
	Friend	18 (2.2)
	Alone	11 (1.3)
	Other	11 (1.3)
Income status	Income less than expenses	253 (30.6)
	Income equal to expenses	482 (58.2)
	Income more than expenses	93 (11.2)
Employment status	Employed	58 (7.0)
	Not employed	770 (93.0)
Choosing the profession of one’s own free will	Yes	653 (78.9)
	No	175 (21.2)
Having a physical/mental illness	Yes	93 (11.2)
	No	735 (88.2)
Having social support	Yes	511 (61.7)
	No	317 (83.7)
TOTAL		828 (100.0)

The mean score the participants obtained from the FCV-19S was 19.35 ± 5.90 (Table 2). The mean scores they obtained from the nine subscales of the BSI were as follows: 4.76 ± 5.03 (somatization), 8.96 ± 5.56 (obsessive compulsive symptoms, interpersonal sensitivity (5.42 ± 4 09), 8.69 ± 5.96 (depression), 6.63 ± 5.46 (anxiety), 5.97 ± 4.82 (hostility), 5.76 ± 4.64 (phobic anxiety), 7.37 ± 4.64 (paranoid thoughts), (psychoticism) 4.15 ± 3.99, and 4.25 ± 3.58 (additional items) (Table 2). The mean scores for the three global indices of the scale are as follows: 1.76 ± .76 (Global Severity Index), 9.06 ± 1.86 (Positive Symptom Total Index), and 6.48 ± 3.88 (Positive Symptom Distress Index) (Table 2).

Table 2.

Distribution of the Mean Scores the Participants Obtained From the FCS-19 and BSI.

FCS-19	Mean	SD	Min	Max
Mean score for the Fear of COVID-19 Scale	19.35	5.90	7	35
BSI sub-dimensions	Mean	SD	Min	Max
Somatization	4.76	5.03	0	28
Obsessive compulsive symptoms	8.96	5.56	0	24
Interpersonal sensitivity	5.42	4.09	0	16
Anxiety	6.63	5.46	0	24
Hostility	5.97	4.82	0	20
Phobic anxiety	5.76	4.64	0	20
Depression	8.69	5.96	0	24
Paranoid thoughts	7.37	4.64	0	20
Psychoticism	4.15	3.99	0	20
Additional items	4.25	3.58	0	20
Global Severity Index	1.76	.76	0	4
Positive Symptom Total Index	9.06	1.86	0	10
Positive Symptom Distress Index	6.48	3.88	0	20

Of the variables, sex (P <.001) and social support (P <.05) were determined to affect the FCV-19S scores (Table 3). On the other hand, of the variables, sex, choosing the profession willingly, monthly income, having a mental/physical illness, social support affected the mean scores obtained from the Somatization, Obsessive compulsive symptom, Personal Sensitivity and Depression subscales of the BSI (P <.05) (Table 3). Of the variables, sex, choosing the profession willingly, having a mental/physical illness, and social support affected the mean scores obtained from the Anxiety and Phobic anxiety subscales of the BSI (P <.05) (Table 3). Of the variables, department attended, choosing the profession willingly, having a mental/physical illness and social support affected the mean scores obtained from the Hostility, Psychoticism and Additional Items subscales of the BSI (P <.05) (Table 3). Of the variables, sex, monthly income, choosing the profession willingly, having a mental/physical illness, and social support affected the mean scores obtained from the Global Severity Index (GSI), and Positive Symptom Distress Index of the BSI (P <.05) (Table 3). Of the variables, choosing the profession willingly and social support affected the mean scores obtained from the Positive Symptom Total Index of the BSI (P <.05) (Table 3).

Table 3.

Relationship Between Sociodemographic Characteristics of the Participating Students and the Mean Scores They Obtained From the FCS-19 and BSI (Multiple Linear Regression Analysis).

FCS-19	Unstandardized Coefficient
	B	SE	β	t	P	R 2
Sex	−3.371	.589	−.208	−6.065	.000	.358
Perceived social support	.823	.421	.069	1.990	.047
Unstandardized coefficient
Somatization	B	SE	β	t	p	R 2
Sex	−1.318	.483	−.006	−2.291	.022	.595
Choosing the profession willingly	1.054	.406	.088	2.678	.008
Monthly income	−.652	.271	−.088	−2.668	.008
Having a mental/physical illness	−2.757	.531	−.1770	−5.336	.000
Social support	2.349	.346	.234	7.014	.000
Unstandardized coefficient
Obsessive compulsive symptom	B	SE	β	t	p	R 2
Sex	−1.362	.524	−.079	−2.424	.016	.558
Choosing the profession willingly	1.547	.441	1.556	.114	.000
Monthly income	−.591	.295	−.062	−1.931	.054
Having a mental/physical illness	−1.657	.576	−.095	−2.931	.003
Social support	3.809	.375	.332	10.190	.000
Unstandardized coefficient
Interpersonal sensitivity	B	SE	β	t	p	R 2
Sex	−1.187	.385	−.090	−2.790	.005	.642
Choosing the profession willingly	1.019	.324	.105	3.248	.001
Monthly income	−.638	.216	−.098	−3.052	.002
Having a mental/physical illness	−1.933	.423	−.148	−4.569	.000
Social support	2.651	.275	.317	9.744	.000
Unstandardized coefficient
Depression	B	SE	β	t	p	R 2
Sex	.508	.164	.098	3.148	.002	.564
Choosing the profession willingly	1.789	.451	.124	4.033	.000
Monthly income	−.949	.301	−.093	−3.001	.003
Having a mental/physical illness	−1.982	.589	−.102	−3.299	.001
Social support	4.999	.384	.406	13.005	.000
Unstandardized coefficient
Anxiety	B	SE	β	t	p	R 2
Sex	−1.772	.513	−.113	−3.497	.000	.644
Choosing the profession willingly	1.537	.432	.116	3.599	.000
Having a mental/physical illness	−3.232	.564	−.187	−5.774	.000
Social support	3.357	.368	.299	9.185	.000
Unstandardized coefficient
Hostility	B	SE	β	t	p	R 2
Department	.294	.141	.068	2.082	.038	.590
Choosing the profession willingly	1.454	.388	.124	3.784	.000
Having a mental/physical illness	−1.819	.507	−.120	−3.637	.000
Social support	2.823	.330	.285	8.618	.000
Unstandardized coefficient
Phobic anxiety	B	SE	β	t	p	R 2
Sex	−1.411	.454	−.102	−3.027	.003	.598
Choosing the profession willingly	1.227	.382	.109	3.265	.001
Having a mental/physical illness	−1.358	.500	−.904	−2.778	.006
Social support	2.195	.325	.230	6.798	.000
Unstandardized coefficient
Paranoid thoughts	B	SE	β	t	p	R 2
Choosing the profession willingly	1.274	.371	.113	3.484	.001	.644
Having a mental/physical illness	−1.909	.484	−.075	−2.316	.021
Monthly income	−.580	.248	−.127	−3.707	.000
Social support	2.943	.315	.307	9.363	.000
Unstandardized coefficient
Psychoticism	B	SE	β	t	p	R 2
Department	.332	.113	.093	2.909	.004	.638
Monthly income	−.567	.209	−.092	−2.899	.004
Choosing the profession willingly	1.273	.312	.132	4.155	.000
Having a mental/physical illness	−1.801	.408	−.142	−4.435	.000
Social support	2.636	.266	.324	10.088	.000
Unstandardized coefficient
Additional items	B	SE	β	t	p	R 2
Department	.213	.105	.069	2.103	.036	.588
Monthly income	−.514	.193	.109	3.329	.001
Choosing the profession willingly	.945	.289	−.084	−2.554	.011
Having a mental/physical illness	−1.389	.377	−.126	−3.820	.000
Social support	2.014	.246	.273	8.217	.000
Unstandardized coefficient
Global severity index	B	SE	β	t	p	R 2
Sex	−.164	.071	−.078	−2.314	.021	.191
Monthly income	.250	.060	.133	4.197	.000
Choosing the profession willingly	−.112	.040	−.090	−2.803	.005
Having a mental/physical illness	−.379	.078	−.155	−4.862	.000
Social support	5.740	.050	.363	11.405	.000
Unstandardized coefficient
Positive Symptom Total Index	B	SE	β	t	p	R 2
Choosing the profession willingly	.440	.155	.096	2.832	.005	.064
Social support	.787	.131	.205	5.991	.000
Positive Symptom Distress Index	B	SE	β	t	p	R 2
Sex	−.729	.359	−.068	−2.030	.043	.187
Monthly income	−.542	.202	−.086	−2.685	.007
Choosing the profession willingly	1.268	.302	.134	4.206	.000
Having a mental/physical illness	−1.929	.394	−.157	−4.897	.000
Social support	2.873	.255	.360	11.270	.000

Multiple Linear Regression Analysis.

Of the variables, choosing the profession willingly, having a mental/physical illness and social support affected the mean scores obtained from the paranoid thoughts subscale of the BSI (P <.05) (Table 3).

There was a statistically significant correlation between the mean scores obtained from the somatization, obsessive compulsive symptom, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid thoughts, psychoticism, additional items and the three global indices (Global Severity Index (GSI), Positive Symptom Total Index (PSTI), and Positive Symptom Distress Index) of the Brief Symptom Inventory and the mean scores obtained from the overall the FCV-19S (P ≤ .001) (Table 4).

Table 4.

Correlation Between the Mean Scores the Participating Students Obtained From the Fear of COVID-19 Scale and Brief Symptom Inventory (BSI).

		Fear of COVID-19 Scale Total Score
Somatization	r	.264 **
	p	.000
Obsessive compulsive symptom	r	.237 **
	p	.000
Interpersonal sensitivity	r	.266 **
	p	.000
Depression	r	.227 **
	p	.000
Anxiety	r	.339 **
	p	.000
Hostility	r	.154 **
	p	.000
Phobic anxiety	r	.407 **
	p	.000
Paranoid thoughts	r	.239 **
	p	.000
Psychoticism	r	.167 **
	p	.000
Additional items	r	.253 **
	p	.000
Global severity index	r	.301 **
	p	.000
Positive Symptom Total index	r	.246 **
	p	.000
Positive Symptom Distress Index	r	.288 **
	p	.000

**The correlation is significant at the P ≤ .001 level.

Discussion

It is considered that university students constitute a population particularly vulnerable to mental health problems. The present study focuses on the effects of pandemic on this specific population’s, in other words, university students’ mental health. The findings indicated that the COVID-19 pandemic had a negative impact on mental health and lifestyle outcomes of the participating students. In a systematic review, healthcare workers were observed to experience psychological problems such as depression, anxiety, and insomnia during the COVID-19 pandemic. The increasing burden of disease worldwide and the increasing mortality rate of COVID-19 have caused widespread fear, and posed a major threat to the current workforce and future workforce. Imposing restrictions to reduce the transmission of COVID-19 has changed the education pattern, leading to workforce reductions in many economic sectors. Due to the effects of COVID-19, healthcare workers are likely to develop mental health and sleep problems because a significant change in lifestyle is a major source of stress. For example, individuals may have to adhere to new policies strictly (eg, wearing masks in public places) in order to isolate and quarantine themselves at home, to avoid leisure and recreational social activities they previously participated in, and to minimize the spread of the virus. While we carried out the study, the government imposed a curfew and travel bans in Turkey. Students switched to online education and were isolated at home. We can say that these changes, new applications may have affected the mental health of students.

Of the effects of the pandemic on the students, concerns about one’s own health, fear of losing one’s life, stories and news about coronavirus on social media were determined to cause tension, anxiety, insomnia and heart palpitations. Findings on the effects of pandemic on sleeping habits indicate that such effects are the source of fear, heart palpitations and concern because these variables are correlated with depressive symptoms and anxiety.

This suggests that the measures such as staying at home and social distancing taken against COVID-19 may have led to significant changes in the lives of university students. For instance, changes in social relationships were observed in the majority of the participants, largely due to their limited physical interactions with their friends. These findings are consistent with those of recent studies conducted in China, which also reflect concerns that are quite common in the general population during the pandemic regarding the health of individuals and their family members. In another study, students stated that they first experienced anxiety about their own health and the health of their loved ones during the pandemic process, and then difficulty in concentration.

During a crisis, people in any society want to be aware of what is going on. Excessive fear and uncertainty can determine people’s emotional reactions. When information released by official channels is incomplete or spreads irregularly, people may be exposed to misleading social media information. Fear and distorted risk perceptions can lead to negative social behaviors. It has been stated that fear of the unknown causes high anxiety levels in individuals.[22,23] In the present study, it was determined that pandemic-related news caused FCV-19S, tension and anxiety in students.

The analysis of the effects of sociodemographic data on students’ FCV-19S and mental health demonstrated that sex, income level, presence of social support, department attended, choosing the profession willingly and having a physical/mental illness affected their FCV-19S.

In the present study, the mean scores obtained from the FCV-19S and the Brief Symptom Inventory by the female students were higher than were those obtained by the male students, and the difference between them was statistically significant. The results obtained in the present study were consistent with those obtained in the literature. According to the results of some studies, female nursing students experience more severe anxiety and fear than do male students. In a study conducted with healthcare professionals treating patients with COVID-19 in China, of all the participants, 50.4% suffered from depression, 44.6% from anxiety, 34.0% from stress, and 71.5% from insomnia symptoms. In the same study, it was also determined that the participating female nurses’ anxiety and stress scores were higher than were those of the male students. The results of the present study suggest that women were emotionally more sensitive than were men, that they were affected more quickly, and that students who were the prospective healthcare workers displayed an emotion-oriented approach.

In the present study, the mean scores obtained from all the scales by the participants whose income levels were low were statistically significantly higher. In the literature, financial difficulties due to COVID-19 are mentioned as one of the causes of the pandemic-induced psychological stress.

In the present study, the mean scores obtained from all the scales by the participants who did not have social support were significantly higher than were those obtained by the participants who had social support. In the literature, it is reported that prolonged social isolation may increase the risk of mental illnesses such as anxiety and mood disorders and that isolation is associated with feelings of loneliness and distress. In the literature, it is also reported that living alone is associated with a higher risk of depression. In a study conducted in our country, Turkey, it was stated that closures of schools and isolation at home during the pandemic caused anxiety and loneliness in young people. Our study findings are consistent with those in the literature.

In the present study, the students whose psychological state was affected most during the pandemic were the students studying in the social service, physiotherapy and rehabilitation, nursing and midwifery departments, respectively. As midwifery is a health profession that provides care only for women, midwives, members of this health profession, can be said to be affected psychologically less. During the pandemic, the mental state of the students who chose the profession willingly was less affected than was that of the students who chose the profession unwillingly. Individuals who consider their profession is suitable for them do their jobs willingly in the society, progress in their profession, and continue their lives happily and productively. An individual can become successful in the field if he or she has chosen it as a profession in line with his skills, interests and desires. If he or she has chosen it without considering his or her characteristics, he or she becomes unsuccessful, inefficient, and unhappy. In the present study, the students with a physical or mental illness obtained significantly higher scores from the subscales of the Brief Symptom Inventory than did the students without any illnesses. It was mentioned that people with chronic diseases would have a higher risk of being exposed not only to the physical effects of COVID-19 but also to its negative psychological effects compared to healthy people.[30,31] In this context, it can be said that the level of FCV-19S that the participants with an illness had was consistent with that in the literature.

Limitations

The present study is limited to the sample of Health Sciences students of a university in Turkey and the social isolation period due to COVID-19 pandemic in Turkey. It is assumed that the students participating in the present study answered the survey questions sincerely and gave true information. This study focused on the mental state of students during the social isolation process.

Conclusion

School closures and quarantine at home during the pandemic increase the level of anxiety among young people. Identifying students in at-risk groups and supporting them appropriately by establishing various social contacts including healthcare professionals, families and universities are expected to help students. Neglecting the mental health of students who are the prospective healthcare workers can have long-term harmful effects not only on their quality of life, but also on the overall performance of the healthcare system. Making an effective plan to protect the mental health of prospective healthcare professionals is of great importance. We believe that our findings will help healthcare educators address and reduce the increase in pandemic-induced mental health disorders. More studies should be conducted to analyze changes in the mental health status of.

The healthcare professionals of the future will take part in health services in the protection and improvement of health as an important occupational group in public health. Therefore, it is very important for students to manage their own concerns and anxieties. Determining the mental health and psychological needs of students during the epidemic and teaching effective coping methods will greatly contribute to the pandemic management process.