Well-Being and General Health of University Students during the Severe Acute Respiratory Syndrome-Coronavirus-2 Process

Introduction

To this date, a significant number of epidemics have occurred all around the world. Herpes and Legionnaires’ disease (in the 1970s), AIDS, Ebola, Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome, and the current novel coronavirus (SARS coronavirus [SARS-COV-2]) are among such epidemics, continuing to pose a threat to the human population while increasing the rates of morbidity and mortality¹. SARSCOV-2 was initially diagnosed in December 2019 in a group of individuals with a history of visits to the Huanan market of sea products, located in Wuhan’s city in China^2,3. Transmitted through respiration, droplets, and contact, the novel Coronavirus became a global health problem in a short period, affecting all the world countries. Within this scope, the World Health Organization declared SARS-COV-2 “A Public Health Problem of International Importance” on December 30, 2020, and a “Pandemic”” as of March 11, 2020^2,4.

China, ground zero of SARS-COV-2 cases, and other countries where patients were being observed focused on traditional public health techniques of the fight against pandemics to prevent the disease’s spread. In particular, the quarantine practice was successfully implemented as a useful measure throughout the SARS pandemic of 2003. In studies on this matter that analyzed the psychological effects of quarantine practices, which were implemented in previous endemics and the recent SARS-COV-2 pandemic, it was reported that individuals experienced fear, anger, bad temper, sadness, guilt, confusion/ perplexity, grief, and anxiety-induced sleep deprivation problems^5,6.

The SARS-COV-2 virus also affects students in many ways. To slow down the spread of the virus among young and adult populations, several countries are suspending educational activities at all levels^7,8. As per the The United Nations Educational, Scientific and Cultural Organization data, schools were closed in 191 countries as of April 8, 2020, and more than 90% of the students enrolled almost all around the world (1.5 billion youths) ceased face-to-face education⁹.

The transition to online education requires both educational institutions and students to adapt to the current technology and be in various equipments. On increasing online activities, the entire household has started to heavily demand computers, tablets, and similar equipment available at home. On the other hand, some students do not have any access to such resources. The doubts on how it would be possible to conduct effectively the educational activities, such as theoretical and applied courses, or laboratory, music, or art courses taught online using such technological equipment, are causing students to become concerned and stressed^8,10,11. In particular, senior students and many students who have completed their graduate programs are concerned about their seminars and dissertation defenses due to the uncertainty caused by the risk of unemployment¹⁰.

In a study, which determined the prevalence of anxiety during the SARS-COV-2 pandemic among the general population, the rate of the anxiety of the students was found to be 21.5%, with a rate of depression of 38.6%, which was considered to be at high levels¹². In a longitudinal study conducted on 66 university students in China, it was found that university students experienced cognitive problems, negative emotions, and aggressiveness and that they had issues, such as low quality of sleep, a sense of tiredness, and loss of motivation, due to the fears regarding SARS-COV-2¹³.

The SARS-COV-2 pandemic process affects general and physical health and its effects on the mental health and state of well-being. A decrease in physical activity (PA) and an increase in sedentary behaviors occur as the unwanted consequences of the traditional pandemic interventions being implemented^14,15.

In addition to those who experience the SARSCOV-2 pandemic during their studentship period, some students are going through this process under quarantine, away from their homelands and families^16,17. As per the International Federation of Medical Students’ Associations, managing the student exchange programs of medical students, thousands of students were affected on a global scale upon the cessation of student mobility programs unexpectedly¹⁶.

Emergency public health situations may cause numerous psychological effects on university students, such as anxiety, fear, and apprehension, while affecting their well-being¹⁸. Although the state of well-being does not have a single definition, the literature harbors some definitions made by several researchers^19,20. These definitions are associated with the absence of negative emotions connected to mental health problems, such as depression, as well as with the state of being pleased with life, happiness, satisfaction with life, a positive psychological functioning, establishing positive relations with others, having a purpose of living, the ability to achieve one’s objectives, and the completion of self-acceptance²¹.

The studies conducted report that students must be provided with social support by having their overall levels of health, their psychological states, and their states of well-being monitored throughout communicable diseases, such as the SARS epidemic and the SARS-COV-2 pandemic^17,22. There are reports on the psychological effects of the SARS-COV-2 pandemic over the general public, patients, healthcare personnel, children, and elderly^14,23. Nevertheless, universities and educational institutions across the world are not sure of how long the SARS-COV-2 pandemic would last or how it could affect their students’ overall, emotional, and psychological health¹⁰. Since the measurement and precautionary and the declaration of the SARS-COV-2 outbreak, there is growing anxiety and panic worldwide, especially for people who stay away from their hometown. In this context, this study aims to determine the levels of the overall state of health and the well-being of university students, who were abroad when the SARS-COV-2 pandemic broke out and who had to go through this process quarantine in the country where they were present. This study will seek answers to the following research questions:

1. How are the psychosocial states and levels of international students’ general health during the SARS-COV-2 pandemic?

2. Are the states of psychosocial well-being and levels of health of the students correlated with their sociodemographic characteristics within the scope of the precautions taken during the SARS-COV-2 pandemic?

Materials and Methods

This cross-sectional study was conducted between April 16 and May 29, 2020, within a month after the SARSCOV-2 lockdown and travel bands were announced in all countries. As the specific prevention recommended during the pandemic, including prevention in close contacts and following precaution measurements, the authors designed an online electronic form and reached the participant through social media such as Facebook, Instagram, and WhatsApp links. The sample of the study was included 167 international students. In the study, the authors aimed to reach Turkish students and international students from other nationalities. Although there had not been assigned specific inclusion criteria for sample characteristics, the target population comprised the students who were having difficulties returning to their home country or visiting families due to the travel bands. The authors enrolled in many student groups allowed by the group manager-especially on Facebook, to share the link of the form designed as electronic-based. To present and evaluate the data in the first rite month of the pandemic and lockdown process, the data collection time duration was restricted to a short-time. Data were collected with electronic Google-Form consists of the Personal Information Form, WHO-5 Well-Being Index (WBI), and General Health Questionnaire (GHQ-28 -28). All three measurement tools were combined to easily access to the students and created in both English and Turkish languages as an electronic google form.

Results

The participating students’ mean age, 69% of whom were Turkish citizens, and 31% foreign nationals (Europe, the USA, Turkey, Asia, and the UK), were 26.38 ± 4.5 (min. 19, max. 45). Of the participants, 61% were female, 92% single. Undergraduate studies constituted the fundamental reason why students were abroad (38.7%), while those individuals lived mainly in cities (46%). The rate of quarantining was 85% in the countries they lived in. Of these individuals, 25% stated that they lived in flats or studio flats with their friends/families/relatives, while 23.9% reported that they lived in the same house with their friends, families, or relatives (Table 1). Of the students who lived in dormitories, 58.69% reported that the dormitories’ precautions were sufficient, and 56.69% that hygiene rules were followed. Of these individuals, 58.1% said that the country allowed a limited time for shopping purposes, 20% that they had difficulties in providing their food requirements; only a small rate of students (23.9%) stated that they could not continue their education during the pandemic, and 73.5% that they were satisfied with the practices of the countries they lived in during the pandemic. Of the students, 23.9% stated that they couldn’t sustain their education lives. When asked about their respective reasons for not continuing their education, undergraduate students, exchange students, and students enrolled in certificate programs, such as language courses, reported that they were facing hardware problems, such as internet issues. However, many graduate students said that they could not sustain their education due to problems, such as provisional suspension or closure of laboratory studies, suspension of studies requiring contact with living individuals, and being unable to gather with research teams, etc. Of the students, 44.5% reported that they had financial problems due to the pandemic, while some of these students stated that this was caused by some setbacks in the payment of their stipends (Table 2).

A great majority of the students (72.3%) reported that their overall concerns increased during the pandemic. Of the students, 43.2% did not want to go back to their homelands or could not return to their families due to travel restrictions during the pandemic. Of those individuals, 70.3% stated that they consumed alcohol, 33.5% that their alcohol consumption decreased throughout this process, and 31.6% started to consume alcohol in recent months. Of the individuals, 29% reported that they smoked, 39.2% that they reduced the amount they smoked during this process, 31.4% continued to smoke the same amounts of cigarettes. Of the individuals, 60% stated that they had regularly exercised before the recent month, 25% that they did not exercise at all during this process, and 22.6% that they started to exercise less (Tables 1 and 2).

The average score obtained in the total of the GHQ-28 points scale was 9.16 (SD = 7.06). Establishing a cut-off point of 3 or more points, the results showed that the participants presented psychological distress. When the subscales of the scale subscale scores for GHQ-28 were as follow somatic symptoms 1.51 (SD = 1.75), anxiety and insomnia 2.78 (SD = 2.73), social dysfunction 3.38 (SD = 2.44), and severe depression 1.50 (SD = 1.90). The social dysfunction subscale score was found to be higher. No statistical difference was found between the mean scores of the GHQ-28 scale and the sociodemographic characteristics of the participants.

Upon the analysis of the results of the comparison of the GHQ-28 scale based on the sociodemographic characteristics, it was found out that the points scored in the GHQ-28 scale differed, depending on whether the individuals had any difficulties in providing their individual and fundamental food requirements throughout the pandemic (P < 0.05). It was found that those who had challenges scored higher points in the GHQ-28, compared to those who did not have any difficulties. It was determined that the points scored in the GHQ-28 differed between those who did and did not feel safe throughout the pandemic and that those who did not feel safe within the scope of the SARS-COV-2 precautions scored higher points (P < 0.05). It was found that the points scored in the GHQ-28 differed in regards to the changes in the levels of overall anxiety throughout the SARS-COV-2 pandemic (P < 0.05). A multiple comparison test was administered to determine the groups that differed. Accordingly, it was found that the differing group was between those whose level of anxiety increased and those who had experienced no changes at all. It was determined that the points scored in the GHQ-28 scale did not differ at all, based on other demographic characteristics. Unlike these data, it was determined that the students’ WBI scores did not yield any differences compared to sociodemographic characteristics (P > 0.05). It was determined that the students, who reported an increase in their levels of anxiety, had higher mean WBI scores, although their GHQ-28 levels were found to be worse (P < 0.05) (Table 3).

The students of Turkish origin were asked about their opinions in regards to the 14-day quarantine process, which mandated a stay at the dormitories or hotels provided by the offices of governors, instead of a self-quarantine applied upon their return to the country, and it was analyzed whether there were any differences between their GHQ-29 and WHO scores. Of the Turkish students, those who said “I avoided going back to my country due to this practice” were found to have higher mean total GHQ-28 scores for all sub-scales (Table 4).

A simple linear regression analysis was conducted to determine whether the GHQ-28 and WHO-5 WBI points scored by the students had any impact on their nationality. The regression model established on the analysis of the results was statistically significant (F: 37. 517; P < 0.05). It was found that there was a statistically significant, negative, and moderate correlation between the students’ mean scores of WBI and GHQ-28 (P < 0.01; r = −0.570) (Table 5). The change in the overall state of health of the students was explained through a 32% state of well-being. Furthermore, one unit of decrease in the state of well-being of the students increases the overall level of health by 0.77 units. It was found that the nationalities of the students were not statistically significant (P > 0.05).

Discussion

As of the beginning of the pandemic, potent precautions have been implemented to effectively alleviate the disease, including the shutdown of Wuhan and the collective quarantine practices imposed by local governments. Throughout the process after SARS-COV-2 was declared a pandemic, mandatory lockdown and quarantine practices were initiated by the leaders of almost all countries across the globe, to alleviate its effects on a global scale and its rate of infection. Moreover, in addition to these comprehensive precautions taken, each country published circulars, consisting of the Universal rules and sanctions to be followed domestically. Citizens, vulnerable groups in the community, and international students were reported to have been affected by a number of measures implemented with all these global precautions such as the closure of borders between the world countries, limited shopping practices, curfews, educational activities having been taken to online platforms, and cancellation of specific education and certificate programs, excluding education programs providing diplomas^11,30,31.

According to the related literature, it can be seen that quite a limited number of studies that focus on the student samples throughout the SARS-COV-2 pandemic. Therefore, this study aimed to determine the states of psychosocial well-being and levels of general health of the students who could not return to their own countries because of the travel and flight restrictions, imposed within the scope of the lockdown and emergency measurements throughout the pandemic. In this context, it is believed that this study functions as the first research example, which presents the problems faced by international students during the SARS-COV-2 period, despite the limitations of research.

Even though the study did not find any statistically significant correlation between the sociodemographic characteristics of the students during the SARS-COV-2 and the mean scores in the GHQ-28 and WHO-5 WBI was found higher during the pandemic (Table 3). Likewise, in previous studies, it was found that it had effects over the time spent by individuals throughout the pandemic, as well as over their levels of psychosocial health^{11,30,32,33,34}.

To the best of our knowledge, it can be easily mentioned that the countries of the participating students have been implementing quarantines and lockdown practices. It is a significant finding that the students living in dormitories stated that their dormitory of residence took the necessary precautions in regards to SARS-COV-2 and that their fundamental requirements of food and hygiene were met, despite the obligation of using common areas, such as lavatories, bathrooms, or kitchens (Table 3)³⁵.

This study includes relatively quite a low rate of those who could not sustain their education lives due to the pandemic. It is observable that both undergraduate and graduate degree students had some setbacks in terms of continuity of the education, even though unprepared universities and schools put efforts to swiftly create the infrastructure needed within the scope of the pandemic precautions. In particular, it is striking similarly that the scientific activities completely came to a halt for students who were receiving graduate educations and who sustained their scientific activities through dissertation studies (Tables 2 and 3)^8,36,37. Although this study did not find any statistically significant difference between the mean GHQ-28 and WBI scores of the students who had problems sustaining their right of education, it was still relatively high. This result is consistent with many other studies conducted among student populations or academic personnel⁸.

A great majority of the students in this study reported that they had financial problems throughout this process. Furthermore, it can be seen that the students, who had difficulties in providing their individual and fundamental food requirements, had higher mean GHQ-28 scores. It is a fact that the socioeconomic level and levels of mental health were directly proportional, as seen in similar studies in the literature^35,36,38. In this regard, it is believed that it is important to create solutions that would offer economic conveniences in a way that would meet the accommodation, fundamental food and hygiene requirements of international students throughout this pandemic or similar ones.

There are many students in a number of countries, who non-preferred to return to their countries prior to the commencement of travel restrictions because of the anxiety and fear induced by the pandemic. Nonetheless, even though a great majority of the students that stayed following the travel restrictions reported that they felt safe in the countries, the mean GHQ-28 scores of the students who did not feel safe in host country during the pandemic were found high levels (Table 3). In the fact that, it was found that the total mean GHQ-28 scores were higher in those who stated that they avoided going back to their countries because of the 14-day quarantine process imposed on their return to the country, as an answer to the question that was asked only to Turkish students (Table 4). In this context, it can be considered that they preferred staying because of their insecurity in regard to the quarantine and different measurements implemented in their home countries. In the study of Taneri (2020), it was found that Turkish students hardly trust for informative declaration and pandemic management process of the WHO and Turkish Ministry of Health explanation³⁹.

This study assessed the post-pandemic changes in the students’ frequencies of healthy life style behaviors. As is seen, the Tables 2 and 3 show that a small percentage of the students smoked, quite a few of whom stated that their rates of smoking tended to decrease throughout the pandemic. On the analysis of the alcohol consumption habits of the students, while some reported that it decreased by 33.9% compared to the previous month. In a study that conducted in individuals in the community found that the smoking rates remained the same throughout the lockdown period and that individuals smoked even more cigarettes⁴⁰. Students had limited opportunities for socializing, due to strict curfews imposed in many countries on the start of the SARS-COV-2 lockdown process. Therefore, it can be concluded that they tended to sustain their unhealthy behaviors as smoking, for the purpose of stress management. The decrease in the alcohol consumption of the students is among the most important results of this study. Unlike this result, in a study conducted by Chodkiewicz et al. (2020)⁴⁰, it was found that there was a significant increase in the alcohol consumption behaviors of individuals. In a study of Gallè et al.⁴¹, (2020) was found that student who had lower level of satisfaction about control measures were mostly associated and correlated with lower frequency of PA level and higher severity of negative thoughts. As for the examined limited lifestyles behaviors, it was reported that the students smoking habits increased, alcohol consumption and PA level were mostly decreased. In this context, it can be concluded that the outbreak process negatively affects the health behavior of students, but the positive reduction in alcohol consumption behavior is considered as striking and promising. Furthermore, it believed that decrease in the frequency of alcohol consume as a consequence of closure of cafes, restaurants, bars, etc. as well as the limitation of social events inside and outdoors the home due to lockdown measurements. The role of adjustable healthy lifestyle factors in maintaining physical and psychosocial well-being is crucial and fundamental. Likewise, the studies it is mentioned that the perk of encourage and motivate to people in community to stay more active and maintenance healthy lifestyle behaviors during the outbreak^11,41.

To the best of our knowledge, no studies to date have addressed how to new outbreak affect international student’s psychosocial well-being and related factors on student’s general health level who could not return home country due to travel bands after the SARS-COV-2 pandemic. In this context, it provides valuable and crucial insights into community health initiative and raise awareness to prevent measures among international background student during the SARS-COV-2 pandemic.

Conclusion

The international students who had to stay away from their home countries have different well-being and psychosocial health during pandemic and lockdown measures. The factors contributing to varying levels of psychosocial health can be various; universities, colleges, and all educational institutions’ administration and student organization associations should consider these results to plan mental health education for such an unexpected health crisis. They should create health crisis management circulars and economic support funding for students who have accommodation problems or difficulties with fundamental life needs. In addition, mental health counseling and stress management programs should be carried out for students to protect their well-being and physiological health.