The COVID-19 pandemic has had a profound impact on global health, with, as of September 2020, more than 27 million confirmed cases and almost 900,000 deaths.(1) Belgium was hit hard by the pandemic: by September 2020, authorities reported more than 88,000 confirmed cases and almost 10,000 deaths. Transmission of COVID-19 within the country was confirmed in early March 2020 and increased rapidly during March and April 2020. Belgium was among the world's worst-affected countries in terms of the number of deaths per capita attributed to COVID-19, although this was likely due to using a different method of reporting compared to other countries.(2)
The rapid spread of the virus spurred a series of unprecedented policy measures, including a stay-at-home order. On 18 March, strict physical distancing measures were imposed, with non-essential travel prohibited.(3) People were only allowed to leave their house to buy food or go to work if considered essential (e.g., people working in healthcare, transportation, food distribution, etc.). All bars, restaurants and shops providing non-essential services were closed, but individual physical exercising was still allowed. Gatherings were banned, and students were prohibited to attend classes physically and higher education institutions (HEI) were forced to move to online teaching methods. Penalties were imposed for individuals who failed to comply.(3)
The implementation of such radical measures comes with multiple side-effects, and experts expressed their concern about a profound impact on mental health.(4) However, direct physical consequences (i.e., morbidity and mortality directly caused by COVID-19) have typically been given more weight in decision-making and public health interventions. An example of this was the suspension of schools in 188 countries, affecting over 90% of enrolled students globally (1·5 billion young people)(5), despite conflicting evidence of a substantial contribution to COVID-19's transmission control.(6) To obtain a more balanced image, mental health experts have been calling for immediate and high-quality evidence on the mental health impact of the COVID-19 pandemic and related containment measures from novel population-based studies.(4) In addition, experts reached a consensus on the urgent need to identify the mechanisms that are affecting mental health during the pandemic in order to provide evidence-based and mechanistically informed psychological treatment and public health interventions.(4)
College and university students have been shown a vulnerable group regarding mental health. Mental disorders have been shown common in this population and are typically untreated.(7) A German study reported a higher prevalence of depressive symptoms in university students compared to the general population, which the authors attributed to an increase in academic demand and a decrease in peer support.(8) During the COVID-19 pandemic, students have been confronted with a combination of government and institutional specific measures – potentially adding to their mental health vulnerability(5): 1) a radical transformation from in-person to online teaching and evaluation; 2) cancellations of anticipated events such as exchange studies, internships, graduation ceremonies, etc.; 3) the loss of part-time jobs; and 4) a shrinking job market enhancing uncertainty among students in their final year.
Preliminary evidence from studies conducted during the current pandemic indeed seems to suggest their age group to be among the most affected.(9–12) Moreover, a study in 1000 university students in Greece reported an alarming increase in suicidal thoughts and symptoms severity scores of depression and anxiety during the first phase of a national stay-at-home order.(13) A study in 7143 medical students in China reported a high level of anxiety and found an association with COVID-19-related stressors such as economic stressors, effects on daily-life, and academic delays.(14) A study with university students in Spain also reported a negative effect on their mental health.(15) However, it remains unclear why and how this subgroups' mental health has been affected, and several potential stressors remain unexplored.
A recent review identified a comprehensive set of mental health stressors that were shown to play a role in specific populations of infected people who were quarantined to limit the transmission of pathogens similar to COVID-19.(16) These stressors included: frustration and boredom, inadequate supplies of resources, inadequate information from public health authorities, insufficient financial resources, perceived stigma, and fears of infection. Duration of the exposure to quarantine was also found to play a role, but it was unclear through which mechanism.
We hypothesize that the same type of mental health stressors, after contextualization, could play a role among students attending higher education exposed to a stay-at-home order during the COVID-19 pandemic. Contextualization of these stressors relates to the study population (i.e., higher education students) and to the exposure (i.e., a stay-at-home order vs. quarantine). For example, tailored to this study population of students, we propose to examine the mental health effect of COVID-19 related repercussions on their academic work (i.e., academic stress) and their institutions' response to the COVID-19 pandemic (i.e., institutional dissatisfaction). Of this compilation of stressors, we further hypothesize that the level of boredom and academic stress may typically worsen over a relatively short time period (i.e., two weeks). As such, we think that these two stressors may explain the assumed association between duration of exposure to the stay-at-home and mental health outcomes.
This study aims to investigate the mental health impact of the COVID-19 pandemic and related containment measures on students attending higher education in Belgium. In particular, we will examine the association between depressive severity scores and a set of mental health stressors identified by Brooks et al. during quarantine, after tailoring them to our study population. Finally, we will test if the stressors' perceived boredom' and 'perceived academic stress' mediate the effect of the duration of the stay-at-home order on students' mental health.