The Impact of the COVID-19 Pandemic on Students' Mental
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International Journal of Environmental Research and Public Health Article The Impact of the COVID-19 Pandemic on Students’ Mental Health and Sleep in Saudi Arabia Azizah Alyoubi 1, Elizabeth J. Halstead 1 , Zoe Zambelli 1 and Dagmara Dimitriou 1,2,* 1 Sleep Education and Research Laboratory (SERL), Department of Psychology and Human Development, University College London-Institute of Education, 25 Woburn Square, London WC1H 0AA, UK; [email protected] (A.A.); [email protected] (E.J.H.); [email protected] (Z.Z.) 2 The National Institute for Stress, Anxiety, Depression and Behavioural Change (NISAD), 252 21 Helsingborg, Sweden * Correspondence: [email protected] Abstract: Background: Mental health problems are prevalent among university students in Saudi Arabia. This study aimed to investigate the impact of the COVID-19 pandemic on university students’ mental health and sleep in Saudi Arabia. Method: A total of 582 undergraduate students from Saudi Arabia aged between 18 and 45 years old (M = 20.91, SD = 3.17) completed a cross-sectional online questionnaire measuring depression, anxiety, stress, resilience, and insomnia during the COVID-19 pandemic (2020). Analysis included an independent samples t-test, one-way ANOVA, and Hierarchical regression analysis. Results: Undergraduate students reported high levels of depression, anxiety, and perceived stress and low levels of resilience (p < 0.001) during the pandemic. In addition, students reported experiencing insomnia. A hierarchical regression analysis indicated that lower resilience, high levels of insomnia, having a pre-existing mental health condition, and Citation: Alyoubi, A.; Halstead, E.J.; learning difficulties (such as dyslexia, dyspraxia, or dyscalculia) were significantly associated with Zambelli, Z.; Dimitriou, D. The high levels of depression and stress. In addition, lower resilience, a high level of insomnia, and pre- Impact of the COVID-19 Pandemic on Students’ Mental Health and Sleep in existing mental health conditions were significantly associated with high levels of anxiety. Finally, a Saudi Arabia. Int. J. Environ. Res. lower level of psychological resilience and a high level of insomnia were significantly associated with Public Health 2021, 18, 9344. https:// increased levels of depression, anxiety and stress within university students. Conclusion: This study doi.org/10.3390/ijerph18179344 has provided evidence that a lower level of psychological resilience and insomnia were associated with mental health problems among undergraduate students in Saudi Arabia, thus enhancing Academic Editors: Andrea Fiorillo, psychological resilience and interventions to support sleep and mental health are vital to support Maurizio Pompili and student well-being outcomes throughout the pandemic. Gaia Sampogna Keywords: university students; pandemic; depression; stress; anxiety; resilience; sleep Received: 11 July 2021 Accepted: 29 August 2021 Published: 4 September 2021 1. Introduction Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in In December 2019, Wuhan, a city in China, became the center of an outbreak of the published maps and institutional affil- coronavirus disease 2019 (COVID-19) [1], which is caused by severe acute respiratory iations. syndrome coronavirus 2 (SARS-CoV-2) [2]. The World Health Organization (WHO) de- clared this disease a Public Health Emergency of International Concern (PHEIC) at the end of January 2020 [3]. Recommendations by WHO included taking simple precautions such as physical distancing, wearing a mask, keeping rooms well ventilated, avoiding crowds, and cleaning hands [3]. The first case of COVID-19 was reported in Saudi Arabia in Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. March 2020 [4]. On 8 March 2020, the Saudi Government declared temporary closure of all This article is an open access article educational, religious, and social settings and venues (except for essential services such as distributed under the terms and pharmacies, supermarkets, and hospitals). Further restrictions were imposed on 23 March conditions of the Creative Commons 2020 that included a curfew starting from 7 pm to 6 am for 21 days and to observe new rules Attribution (CC BY) license (https:// of recommendations by the WHO. Efforts were made to switch teaching among higher creativecommons.org/licenses/by/ education from face to face to online teaching. To aid this, academic staff received training 4.0/). workshops to support students in successful online learning [5]. However, university and Int. J. Environ. Res. Public Health 2021, 18, 9344. https://doi.org/10.3390/ijerph18179344 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021, 18, 9344 2 of 16 school closures have affected young individuals‘ mental health in numerous countries and led to increased levels of anxiety and loneliness [6]. Based on findings from previous studies during pandemics, the WHO recognized that imposing measures such as social distancing might increase anxiety, stress, and anger among individuals [7]. For example, increased levels of anxiety were significantly associated with several avoidance behaviors, such as international travel and visiting public places, during the outbreak in Jeddah, western Saudi Arabia [8]. To date, the impact of COVID-19 on university students’ mental health and sleep has been investigated in several countries including Bangladesh, China, U.S., Australia, and Canada. One study, which collected data using the event-specific distress scale, reported that 69.31% of university students in Bangladesh had a mild to severe level of psychological impact caused by the pandemic [9]. Specifically, home quarantine, the absence of physical exercise, uncertainty about the pandemic trajectory, lack of information, and fear of becoming infected with COVID-19 were determined as risk factors for mental health status among university students in Bangladesh [9]. Additionally, fear of the possibility to be infected and the perceived high risk of becoming infected were also identified to impact university students’ mental health in China [10]. Previous research has shown students who enrolled in the final year at university who had short sleep durations (<6 h per night) were more likely to experience Post-Traumatic Stress Disorder (PTSD) and symptoms of depression among undergraduate students in China [11]. In France, the level of anxiety had increased among university students who did not relocate or move house to a rural area since the beginning of the quarantine period [12]. A study by Goodman, Wang, Guadrrama, and Santana (2020) [13] demonstrated that 60% of students living in the U.S. reported a negative impact of the pandemic on their mental health, while 90% of students were more anxious about finances. Sixty-two percent of students living in the U.S. met the clinical cut-off for depression, while (47%) students met the clinical for generalized anxiety [13]. Additionally, the risk of depression symptoms was three times higher between students who had confirmed and suspected COVID-19 cases among relatives [14]. Australian university students reported 66.3% poorer well-being overall during the pandemic [15]. Age and gender have been identified as risk factors for poorer mental health outcomes during the pandemic. For example, the prevalence of generalized anxiety disorder, symp- toms of depression and stress were significantly higher in younger adults than adults over 60 years old in Canada during the SARS-CoV-2 pandemic [16]. In addition, previous stud- ies in numerous countries have revealed that females were at a high of risk having mental health conditions and sleep problems more than males. For instance, female Brazilian students aged between 11 and 19 years old have been reported to have more difficulties falling asleep due to worrying (45.1%) than their male student peers [17,18]. Analysis of focus group data conducted in Germany found that adolescent and young adult females (mean age 22.5 years old) have reported a higher prevalence of depression, and severity of symptoms of depression, than their male peers [19]. Similarly, female graduates (aged between 21 and 40 years old) in Japan reported higher levels of psychological distress, including anxiety, as measured by the General Health Questionnaire-12 (GHQ-12) when compared with male peers during the pandemic [20]. Learning difficulties such as dyslexia, dyspraxia, and dyscalculia have been identified as risk factors for mental health conditions within university students. Prior to the pan- demic, Italian university students with learning difficulties such as dyslexia reported high depression scores and lower self-esteem and resilience [21]. Likewise, university students in Georgia aged between 18 and 25 years old who were diagnosed with dyslexia had higher anxiety and depressive symptoms than students who did not have learning difficulties [22]. Several studies have suggested that the prevalence of mental health problems in university students in Saudi Arabia was high prior to the SARS-CoV-2 pandemic. Al Bahhawi et al. (2018) [23] found that 34.3% of university students at Jazan University in Saudi Arabia have experienced stress, 65.7% anxiety, and 53.6% have experienced moderate Int. J. Environ. Res. Public Health 2021, 18, 9344 3 of 16 depression. However, in general, there is limited evidence available on the mental health of university students in Saudi Arabia with only a few studies available that focus on medical students, reporting