This study is the largest conducted in Greece for measuring the mental health conditions of university students during the COVID-19 pandemic. An internet survey was widely distributed, in which 1266 students from public universities nationwide in Greece participated, to better understand the psychosocial outcomes of the COVID-19 pandemic, and the effects on their quality of life, mental health, and well-being.
Ιn our study, we found that age has a positive but not strong correlation with the physical, social and psychological domains of the WHOQOL-BREF questionnaire. The age variable has a statistically significant dependence with all domains as in all cases p < 0.05 as shown in the following tables. Literature reports mixed results for this variable, indicating a greater psychological impact for both young adults and the elderly. It has been observed that young adults are at a greater risk for depression, anxiety, and psychological distress during the pandemic, according to multiple studies [6, 15, 22–24, 27, 42]. One study conducted on Greek university students reports a non-significant trend for greater sleep difficulties in younger ages (18–30) [25]. Weight was found to have a positive correlation with the physical and negative related to the social domain, while height has a positive correlation with the physical, psychological, and environmental domain. The above correlations are not statistically significant. According to a systematic review [15], one study found that neither age nor BMI is correlated with the IES-scores. Another study indicated that age did not predict either depression or PTSD [36].
In our study, the participants were female in the majority (73.1%), and as expected it was the female gender that reached the higher levels of anxiety in the COVID-19 pandemic period. As observed in similar studies during the pandemic [4, 6, 10–27, 35, 38, 39, 41–43] that show a high prevalence of depression, anxiety, and distress in women, in our study, we found that gender has a statistically significant correlation with the categories physical, social, and environmental domain of the WHOQOL-BREF questionnaire as p < 0.05, as shown in Table 7. In addition, it has been observed that the female gender is more susceptible to developing PTSD symptoms during the pandemic [15, 18] and a Greek study found that women’s insomnia during the pandemic is worse than the men’s [25]. However, there are a small number of studies that did not find a statistically significant difference in the prevalence of anxiety, depression, [23] sleep quality [30], and IES scores by gender [15].
The World Health Organization states that adult women, in general, tend to report higher levels of depression and anxiety [52] so the higher prevalence in women during this particular period of our study is more than expected. That would also be consistent with evidence from the prior epidemic of the Middle East Respiratory Syndrome-CoronaVirus (MERS-CoV) [4]. One study [9] has attributed the higher prevalence of negative feelings in women to the fact that during the pandemic period women are more likely to be tasked with additional caretaking duties, accounting for increased levels of symptoms of depression, stress, and anxiety.
Regarding the students’ demographic variabilities, the literature agrees about the importance of this characteristic, however, mixed results are reported. Studies report that the place of residence (hit hardest or not by the pandemic) is significantly related to depression and anxiety symptoms [6, 27] as well as PTSD symptoms [36].
In our study, we found that the location where the students attend university has a statistically significant dependence on the psychological and environment domain as p = 0.010 < 0.05 and p = 0.013 < 0.05 respectively, and that the place of permanent residence has a statistically significant dependence on the psychological domain as p = 0.000 < 0.05.
The literature reports mixed results. By some studies, living in an urban area was identified as a risk factor for developing psychological distress during the pandemic [15, 21, 25, 33]. One study reports that odds of anxiety were 64% times less likely to occur among students who live in a rural area than in an urban area [33]. A Greek study reports that urban citizens suffer from insomnia more than rural residents, and attributes this to the fact that rural residence may act protectively as it provides more opportunities for physical activity and exposure to nature, as well as less strict application of restrictive measures [25]. Since reduced physical fatigue and exposure to the sun, as well as increased use of electronic devices which is often observed in urban areas, may negatively affect sleep homeostasis, living in an urban area acts as a risk factor for lower sleep quality [25].
On the other hand, several studies identify living in a rural area as a factor positively related to increased feelings of depression, anxiety, and psychological distress, and imply that living in an urban area may act protectively against negative psychological outcomes during the COVID-19 pandemic [4, 9, 26, 30, 42]. We could attribute these results to poorer economic conditions and less sanitary resources in rural areas [4], or to the less preventive strategies taken by the politicians of this area. The sanitary conditions in cities are usually better than in towns and villages. Moreover, cities tend to make larger efforts to sensitize the public and spread knowledge on how to prevent the pandemic. [30, 36]
The economic status of university students is considered an important factor for mental well-being in several studies. It has been shown that low socioeconomic status and low or unstable household income contribute significantly to feelings of fear, anxiety, and depression during the COVID-19 pandemic [11, 12, 15, 16, 26, 27, 30, 38, 40–43], a problematic period for a lot of families who go through economic distress. A Chinese study reports that the high average household income group had a significantly lower level of depression than the low average household income groups [27]. The stability of students’ family income as well as living with parents were found to be protective factors against anxiety [30].
In our study, we found that the variable concerning the annual family income has a statistically significant dependence on the psychological and environmental domain as in both cases p = 0.00 < 0.05.
The variables related to chronic physical or mental illness have statistically significant dependence on all domains of WHOQOL-BREF as p < 0.05. Additionally, we observe that the score of the IES-R questionnaire has a statistically significant dependence on chronic mental illness as p = 0.00 < 0.05.
That result is consistent with multiple studies that demonstrated a significant correlation between pre-existing psychiatric or physical illness and increased feelings of health anxiety, depression, and distress during the COVID-19 pandemic [10, 15, 16, 21, 24, 34, 39, 41].
Individuals with known obsessive-compulsive disorders (OCD) and ‘high health anxiety’ (likely patients of generalized anxiety disorders, somatization disorder) may experience an exacerbation of anxiety and distress by misinterpreting harmless bodily symptoms as the evidence of acquiring dangerous illness as well as by practicing frequent self-monitoring such as temperature checks and practicing extreme hygiene measures like very frequent hand-washing [10].
Psychiatric patients have been identified as of high risk for contracting pneumonia and COVID-19 but even non-infected individuals with pre-existing depression, anxiety, and other mental health issues are expected to experience elevated worry and anxiety symptomatology due to exacerbation of their symptoms by pandemic-related stress [16]. History of self-injury and suicide attempts have also been identified as risk factors [39].
One study examined the psychological well-being of eating disorder patients during the pandemic and found 37.5% to report worsening in their symptomatology and 56.2% to report additional anxiety symptoms, while another study reported that 20.9% of patients with preexisting psychiatric disorders reported worsening of their symptoms [14]. A systematic review found the prevalence of anxiety and depression was the highest among patients with pre-existing conditions [26].
While similar studies in other countries like Bangladesh showed no dissatisfactory sleep during the pandemic [9], in our study 27.9% of the participants were not satisfied with their sleep, whereas 35.2% were neither satisfied nor dissatisfied with their sleep.
Moreover, only 38.2% of the participants in our study experienced not at all trouble falling asleep.
We attribute this result to the fact that sleep helps maintain the biological rhythm of an individual and since it is strictly connected to one’s mental health, sleep disorder during the pandemic reflects the negative impacts on students’ mental health. Studies report low sleep quality [15] as well as short sleep duration (< 6 h/night) [36] to be a risk factor for PTSD and depression symptoms. Another Greek study on university students reports increased quantity in 66.3% but lower quality of sleep in 43.0% of the sample during the first days of the lockdown in Greece [37].
Social support has also been studied for its correlation with anxiety and depression of students during the COVID-19 crisis. Lack of social support and loneliness have been identified as risk factors for worse mental health by several studies [11, 12, 15, 17, 18, 26, 30, 35, 42].
One study [34] reports that individuals with low perceived social support were 4.92–5.97 times more likely to experience anxiety or depressive symptoms, compared to individuals with high perceived social support, and one study claims that the largest protective factor against stress was social support [12]. A decrease in going out for drinks or food with friends is a predictor for stress [35] and impacted social life [40] is one of the factors of concern by students during the pandemic. Interestingly, a small number of students reported that they were experiencing reduced social anxiety from not having to interact with other students [40].
Even being divorced or widowed, being single [15, 27], and living alone [30, 43] have been identified as risk factors for worsening mental health, especially during quarantine. Loneliness also showed a positive correlation with insomnia in Greece [25].
On the other hand, it has been reported that married participants had higher anxiety levels than those who were unmarried [15] and another story reports that students who live with their parents have higher stress and depression, possibly due to the fear of infecting their family [33].
Another aspect of social support includes spiritual and religious activities, as spiritual well-being was identified as a protective factor against stress [18]. Social distancing and stay-at-home oreders limit involvement in religious communities and services, reducing the protective effects these practices typically have on suicide risk on those who practice religion [16].
The results of our study show that even though the majority of the participants (60%) are satisfied with their friends and social support, for 82.4% of them the frequency of exhibiting negative feelings, such as anxiety or depression is not uncommon. This result raises the question if social and friend support actually reduces the psychological pressure during the epidemic. Nevertheless, it is a common opinion that effective social support is necessary during public health emergencies.
Multiple studies globally have been conducted in order to evaluate the university students’ mental health during the COVID-19 pandemic. Student status has been identified as a risk factor for problematic mental health in studies conducted on the general population [6, 10, 15, 27]. For university students heightened levels of psychological distress and downstream negative academic consequences are prevalent under normal circumstances [29], let alone during a pandemic that disrupts their routines and jeopardizes the quality of their education.
Regarding the education level, both high [6, 10, 15, 22] and low [12, 15, 24, 26, 38] education levels were found as risk factors for negative psychological outcomes. Students studying in non-health-related departments were found to have higher depression levels [33] and students following theoretical studies in Greece were found to accept conspiracy theories by 20–68% [39]. Additionally, being a graduating/final year student is related to higher levels of anxiety, depression, and PTSD [31, 34, 36], an expected reaction to anxiety about the job market after graduation. The biggest contributor to the declining mental health of students was found to be academic-related stress, regarding the transition to online classes, declining grades, and delayed graduation [40]. School routines are important coping mechanisms especially for young people with mental health issues. When in-person education is prohibited, their routine is disrupted, not to mention stress about dormitory evacuation and cancellation of anticipated events such as exchange studies and graduation ceremonies [31]. Lastly, a large number of students are international students studying away from home, who are not only worried about their health and safety but also face a big amount of stress concerning the well-being of their families [32].
Having accurate and high-quality information available during a time of crisis such as a global pandemic can help prevent mass panic and overreactions. However, excess time spent reading or watching news about COVID-19 was found to be a factor contributing to feelings of anxiety and panic [10, 11, 15, 22, 26, 28, 34, 41]. Poor-quality media and news can not only increase stress and panic but also spread misinformation and lead to wrong decisions by the public.
Additionally, the increased use of social media by students during the quarantine was related to worse mental health outcomes [11, 15, 34, 35]. A study showed that students with exposure to mediacoverage of the COVID-19 ≥ 3 h/day were 2.13 times more likely than students with media exposure < 1 h/day to have acute stress symptoms.