Prevalence of stress, anxiety, and depressive symptoms
This research examined the prevalence of stress, anxiety, and depressive symptoms experienced among university undergraduates at the selected faculties of the UoR, Sri Lanka, during the Covid-19 pandemic, its associated factors, and the correlations of those psychological disturbances. The prevalence of stress, anxiety, and depressive symptoms was 53%, 42%, and 64%, respectively in this study. Therefore, a higher percentage of undergraduates encountered stress, anxiety, and depressive symptoms in the current study.
The Covid-19 pandemic has significantly affected different types of university undergraduates worldwide, making them more susceptible to the emergence of several mental diseases like stress, anxiety, depression, etc., which are in line with some studies that reported higher prevalence33,34,47,48,49,50 and slightly lower prevalence1,2,29,51,52,53. Covid-19 and the lock-down caused different types of psychological problems among the Chinese population10; Arabian, Chinese, and Polish researchers found that undergraduates displayed mild to moderate anxiety symptoms (1–22%) but very low levels of severe anxiety symptoms (0–1%)29,31,51,52,54 compared to the current findings. According to another study from Malaysia, respondents suffered from mild to moderate anxiety levels (6%-20%) and 2.8% had severe anxiety levels15 but lower than the anxiety levels in the current study. However, some undergraduates had higher levels of anxiety (50–60%)48,50, and 18.1% of severe levels of anxiety in line with the current findings50.
In India, levels of anxiety and stress were higher during the Covid-19 pandemic than before55; 269 Indian medical undergraduates were evaluated for levels of anxiety and stress and reported 21.2% anxiety and 20.7% stress which was lower than this study findings55. A higher level of stress was found among Jordan undergraduates which was around 60% during the home-quarantine period and reported mild (15.5%), moderate (19.6%), severe (13.6%), extremely severe (10.0%) levels of stress49 and around 56% of stress was reported among Polish undergraduates54. Some undergraduates in the United States of America perceived an increased level of study‐related stress (e.g., due to related campus closure and shift to virtual classes) after the outbreak of the Covid‐19 pandemic35. A lower level of stress was found among undergraduates in France than among non-students who scored 33.1%16.
Depressive symptoms are a very common and widespread problem among undergraduates. In response to this stress, some undergraduates become depressed19. The past ten years have seen a rise in interest in researching undergraduates’ mental health; a 24–34% incidence of depressive symptoms was reported in the very early period23. Another study conducted in one of the large universities in Saudi Arabia during 2012–2013, reported prevalence of depressive symptoms was 46% before the pandemic56 and was not much different from the current depression levels although studies were done with or without Covid-19. However, above 80% of depressive symptoms were evidenced in the Bangladesh undergraduates50 than the current findings and 78.7% had depressive symptoms in the Jordan study49. Severe levels of depression symptoms were in the range of 10–12%50. Not only the higher values, a considerable level of depressive symptoms was found among France and Arabic undergraduates (32% and 49%) due to Covid-1916,33 and lower depressive symptoms (10–20%)31,52. In 2020, 61.4% of undergraduates in Jordan (N = 1165) were diagnosed with moderate-to-severe depression57 and this was consistent with the current findings. As mentioned by Saraswathi et al.55 depressive symptoms had not changed during the pandemic whereas anxiety and stress increased due to the pandemic. Wang et al.52 also reported 12.2% of depressive symptoms which was very lower than the current depressive symptom levels. Among studied 3044 undergraduates in Saudi Arabia, 47.7% of individuals reported having severe depressive symptoms34.
Similar impacts were stated in Sri Lanka as well. Therefore, it is necessary to effectively report the psychological disturbances of Sri Lankan undergraduates due to Covid-19—how it could affect their academic performances; how this type of unexpected circumstances affect the very gentle personalities the young population have; and how their normal education which is not normal to them as previous is impacted. However, studies related to other undergraduates are scarce40,58,59,60 compared to the studies done among medical undergraduates in Sri Lanka12,61,62,63,64. Several research findings about the prevalence of psychological issues and factors associated with the Covid-19 disease among undergraduates in Sri Lanka were reported7,40,58,59,62,63. It was evidenced by a study conducted among children, adolescents, and youth in Sri Lanka12, that there were significant psychosocial stressors, and it may tend to develop more psychological morbidity among that population.
In some literature, lower levels of stress and anxiety were found. Covid-19 epidemic had a significant impact on medical students’ psychological health (25.1%) and (1.6%) of students reported having anxiety and stress levels that were over the recommended levels61. One study done in Sri Lanka in 2020, including Indian and Russian undergraduates, reported that 3.16% of undergraduates experienced stress and 11.58% of undergraduates had anxiety due to Covid-19 which was remarkably lower than the current study7. Another finding of nursing undergraduates of KAATSU International University (KIU) reported the prevalence of anxiety and stress as 13% and 3%65 which were also much lower. In the first phase of the Covid-19 epidemic, 22% of students at the Sri Lanka Institute of Advanced Technological Education (SLIATE) showed mild anxiety, 7% showed significant anxiety, and just 2% showed severe anxiety. Thirty undergraduates were used in the study by Athukorala and Joniton58 which revealed that they were under stress throughout Covid-19. According to the findings of the DASS-21, 3 (10%), 18 (60%), 4 (13%), 3 (10%), and 2 (6%) of the undergraduates displayed signs of normal, mild, moderate, severe, and extremely severe stress status, respectively58.
Another study of 384 undergraduates of both state and non-state universities/higher educational institutes reported 41% severe and 36% moderate stress levels due to the pandemic (during the year 2020) similar to the current evidence40 and another study of medical students64. It was also found that online learning experience and university workload affected many undergraduates during the Covid-19, and experienced more challenges with the information technology capabilities/infrastructure (50%) and increased workload (75%) which was a novel experience for the new entrants and majority of students who had economic hardships40. They did not discuss the influence of any socio-demographic characteristics on stress and found that new challenges and difficulties in carrying out day-to-day activities affected their stress. Further, they were more distressed about semester grades and how the class would impact their future40 and career opportunities. The start and end dates of degree programmes and postponements of planned examinations in educational settings may be influenced by the prevalence of certain stresses due to unexpected delays in educational activities.
According to a study by Galhenage et al.62, 78.2% of medical students were worried and had stress levels higher than those of working doctors, which was higher than the findings at the time of Covid-19. Distressed medical students were concerned about their own and their loved ones’ health. Like doctors, those undergraduates believed that stress interfered with their everyday activities and that they had a high risk of getting Covid-19 (63.5%). Additionally, half of the students stated that while learning about Covid-19 was generally beneficial, it also led to more distress (24%)62. Before the pandemic, Sri Lankan research (N = 327) indicated that 40.4% of medical undergraduates had serious psychological distress46 while a much higher level of distress (78.2%) occurred due to the Covid 19. Among 527 medical undergraduates, the reported prevalence of anxiety and stress was 34% and 24.7%63. Possible explanations for these findings include that medical undergraduates being directly exposed to the clinical settings than other undergraduates would be a cause of having higher stress scores than our findings although we had not discussed about exposure status of studied undergraduates.
As evidenced, medical students had 9.6% depressive symptoms due to Covid-19 according to the DASS-2161. According to another study (N = 208), 40% of undergraduates reported mild to severe depressive symptoms and only 3% had severe symptoms59, and 40.8% of medical students reported depressive symptoms in a study of 527 undergraduates63. Slightly similar findings were reported in a previous study done among undergraduates from Sri Lanka, India, and Russia; 11.58% of students had elevated depressive symptoms due to Covid-197. A low level of depression was reported during the study period among nursing undergraduates who studied at KIU, Sri Lanka; the revealed prevalence of depression was 7%65. When considering previous studies done in Western countries, undergraduates of the current study and other studies reported a considerably higher level of stress, anxiety, and depressive symptoms which may be due to new experiences with the pandemic (e.g., some countries have been exposed to H1N1, SARS, Bird’s flu, etc.) such as lock-down, quarantine, precautionary measures, and rising of cases and deaths globally. It has caused disruptions of ongoing physical education which had not been experienced by Sri Lankans due to a disease condition. Thus, adolescents and youth in Sri Lanka have experienced significant psychosocial stressors, making them more vulnerable to developing psychological morbidity due to the current crisis as reported in studies12,66.
A recent study conducted among 100 undergraduates of the same university, the UoR in Sri Lanka from December 2021-January 2022 revealed environmental factors and other associated factors of stress and psychiatric illnesses; 68% of undergraduates were psychologically distressed and 50% of the students were moderate to severely distressed67 similar to the current results. Reported main environmental factors that caused high stress were lack of time for leisure/sports activities (40–50%), following Covid-19 (30–40%), and issues related to online learning and evaluation (30%)67. However, they had studied many more reasons than the current study which focused on Covid-19 disease itself. Before Covid-19, 51.1% of nursing undergraduates at the University of Peradeniya, Sri Lanka had mild to extremely severe depressive symptoms same as our findings although not done during the Covid-19 period68. This argument was proved by the authors in Sri Lanka12 who stated that Sri Lankan adolescents usually have experienced higher levels of psychosocial stressors. As previously reported, student’s age, academic year, satisfaction with the nursing program, physical well-being elements, potential stresses, self-rated physical health, and self-rated mental health were all related to depressive symptoms68. Therefore, differences among psychological disturbances could occur due to socio-cultural, religious, and ethnic differences, and due to the usage of various scales/tools (e.g., 21-DASS, PHQ-9, GAD, SAS, CES-D scale, etc.) to measure stress, anxiety, and depressive symptoms, which might affect the outcome.
Factors that influence stress, anxiety, and depressive symptoms and correlations between stress, anxiety, and depressive symptoms
Several factors associated with stress, anxiety, and depressive symptoms were found in the current study. Age and type of faculty were significantly associated with three types of psychological disturbances. Gender was significantly influenced by anxiety and depressive symptoms while depressive symptoms were significantly influenced by academic year. As reported in the current study, each psychological problem caused increased stress, anxiety, and depressive symptoms among undergraduates of the UoR.
As mentioned earlier in a study by Galhenage et al.62, medical students had higher levels of stress, and getting more information about the disease also increased their stress. When considering the medical undergraduates of the current study, they did not study about such a risk. However, the type of faculty or type of undergraduates had some influence on stress, anxiety, and depression in the current findings, respectively (p < 0.001; p < 0.05; p < 0.001). Medical undergraduates/FoM showed an impact on depressive symptoms while a higher number of humanities undergraduates/FoHSS had shown an impact on stress, anxiety, and depressive symptoms which may be due to low exposure to contagious disease or less awareness about the disease compared to the medical undergraduates. As another study of medical students in Sri Lanka in that period revealed, some factors of depression were the presence of economic difficulties (p < 0.05); previous contact with psychiatric services (p < 0.01); the presence of medical/surgical impairment); anxiety [e.g., previous contact with psychiatric services (p < 0.001)]; and stress, e.g., perceived lack of support from the university administration and difficulty accessing internet facilities, previous contact with psychiatric services (p < 0.001); presence of medical/surgical impairment]61. Another study’s findings were also similar showing depression (p < 0.01), anxiety (p < 0.05), and stress (p < 0.01) were significantly higher in medical students with a history of psychiatric disorders63 which was not studied in the current study. A working experience of nursing undergraduates who studied at KIU, Sri Lanka had a significant association with depression (p < 0.001), anxiety (p = 0.006), and stress (p = 0.011) and was further evidence for the type of undergraduates65 who were exposed to the clinical settings as medical students during their training period.
Female undergraduates in the current study had a significant impact on stress, anxiety, and depressive symptoms than their male counterparts similar to the previous medical students’ study61,64 and are similar in most Western studies33,34. However, gender significantly had an impact on depression (p < 0.05) and anxiety (p < 0.05). The Covid-19 epidemic caused psychological disturbances in 59% of female students compared to 49% of male students and stress, anxiety, and depressive symptoms were more common in female students5. A possible explanation for female undergraduates being more susceptible to psychological stressors compared with male undergraduates is that extra responsibility relates to caregiving activities and engaging with family members during the pandemic33,34. Our female undergraduates are largely socialized and capable of doing many duties and home activities simultaneously as explained by another study which states that girls played different roles within the family53. Also, their self-confidence about the disease condition being impacted by their low nutrition levels, low income, etc., during that period, may have contributed to higher distress, anxiety, and depression levels. Although women had more depression, men had a significant risk of severe depression symptoms (p < 0.05)33. A study by Rohanachandra et al.63 did not report any gender differences in anxiety, depression, or stress; these inconsistencies may be related to cross-cultural differences and unique traditions as suggested by Rogowska et al.54.
Further, older/senior undergraduates showed a significant influence on stress, anxiety, and depressive symptoms than younger participants as found in the current study (p < 0.001) while age was associated with the level of depression among nursing undergraduates at KIU (p = 0.016)65. It was discovered that being younger was a protective factor against experiencing depression symptoms33. A study of medical students reported the reason for having higher stress among senior students might be due to the difficulty in making career choices, and opinions, and a lack of self-confidence in fitness for future clinical practice69. In contrast to the current findings, younger and distance learners in OUSL (e.g., Humanities and social sciences, Natural science, Engineering, Education and Health sciences faculties) had reported significantly higher levels of stress, anxiety, and depressive symptoms although they used 21-DASS scale like the current study39. However, only depressive symptoms had a significant impact by the academic year in the current study (p < 0.05). As in other findings, first-and second-year medical students had higher depressive symptoms compared to the fourth year (p < 0.05)63; the final years reported additional psychological distress and burnout than first -fourth, and fifth-year students evidenced lower positive mental health than first year students64 which could be a reason of increased responsibilities in the final clinical years of training.
Some studies found no significant difference in stress, anxiety, and depression among undergraduates regarding age7, gender7,63, and type of degree7. Additionally, some nations mentioned reasons for lesser mental illnesses as developed healthcare systems and the wide range of emergency medical treatments and facilities for Covid-19. As a result, undergraduates in these nations were less concerned about safety precautions and other Covid-19-related resources than others33,53 compared to the condition in our country. Additionally, putting strict health protocols into practice, such as using face masks and hand washing, telling people to “stay at home,” and closing public places, may have increased their sense of security although it increased their psychological problems. However, during that time, longer lockdowns and increased Covid-19 cases/deaths led to higher levels of stress and anxiety because of the closure of religious sites like mosques and fully covered female attire (e.g., Abhaya)34 mostly relevant to Arabic countries/Islamic ethnic groups but related to our nations as well.
Furthermore, our study discovered a significant positive correlation between depression, anxiety, and stress (depressive symptoms-anxiety: r = 0.646, p < 0.001; depressive symptoms-stress: r = 0.868, p < 0.001; and anxiety-stress: r = 0.786, p < 0.001). In 2016, a survey conducted among nursing undergraduates in Sri Lanka evidenced that most similar correlations are in line with the current findings. The reported significant positive relationships were; anxiety and depression (r = 0.689, p < 0.001), anxiety and stress (r = 0.785, p < 0.001), and depression and stress (r = 0.763, p < 0.001)68; this significant relationship also suggests a reduced risk for psychiatric illness in undergraduates. It means that if there is no risk of having a higher level of stress, they are prone to low anxiety and/or depression in other ways68. These negative emotional sensations can lead to poor mental health, which impairs learning and limits academic success. Hence, when the undergraduates are overburdened, it may cause further emotional instabilities and deplete them physically and mentally70. As explained by Rogowska et al.54 it could be summarized that if students worry too much about their health, their level of stress may increase, which may be an additional source of anxiety, and they would end up with severe stress and depression which may need medical assistance.
Considering a very vulnerable population, university undergraduates face a very important transition from high school to university71,72 which is a vital event in late adolescence associated with structural and social changes that influence relationships, routines, assumptions, and individualization in roles such as moving out of home, becoming independent from parents, searching/meeting new friends, facing a new guidelines/responsibility and higher workload of education. Those are some critical events as evidenced during their transition which led to negative consequences such as loneliness, stress, anxiety, depression, etc. in their life71,72 as studied in this study which need more attention by both parents and university academics.
Original contribution and relevance
However, when compared to the Western Province of Sri Lanka, no studies have been published on the psychological problems due to the Covid-19 outbreak in undergraduates in the Southern Province. Therefore, it was better to find out the impact of the disease on the education of undergraduates at the UoR which is the only state university in Southern Sri Lanka. Further, we were able to assess the psychological impact of different five faculties rather than focusing only on medical undergraduates as done by most researchers in Sri Lanka. Universities must develop and implement effective screening procedures to closely monitor undergraduates’ exposure to different stressors and mental health adjustment and to increase the academic performances and student support services of undergraduates in future pandemics. This research will be vital for higher educational sectors and policymakers to create welfare programmes and psychological support services for future undergraduates. Further, this study has important implications for university administration in identifying, treating, and preventing mental health problems among undergraduates during acute, large-scale stressors like infectious disease outbreaks or natural disasters.
Limitations
Due to the institutions being closed at the time of the survey, data were gathered using an online questionnaire, which prevented participants from asking questions regarding the survey or its components. A lack of availability of internet facilities may have predisposed the response rates of students. Additionally, the survey did not allow the contributors to seek explanations about the survey or items in the questionnaire. This study used a cross-sectional design, which makes it impossible to determine the cause and effect/causal relationship among variables. Data were gathered from a single university in Sri Lanka; respondents’ impressions may differ depending on unique aspects of the setting, degree programmes, and the curriculum. Also, some variables such as income, ethnicity, religion, and academic/examination workload were not included in this study and may have some correlations. Because the sample was representative of the population of university undergraduates, the results were rather reliable, but they cannot be generalized to other settings and the whole of Sri Lanka. Yet, the current study incorporated standardized scales to examine the stress, anxiety, and depression symptoms.
Clinical implications
These results of the current study are useful in detecting the need for psychological support programmes to find undergraduates with a high risk of psychological disturbances. Further, it would be better to find reasons for higher levels of psychological disturbances among undergraduates studying in the Southern province than the Western province studies while the Southern province had lower severity than the Western province. Universities must plan short-term and long-term psychological amenities for undergraduates and inspire undergraduates to get support from mental health professionals when essential. Further, examination/investigations and a clinical diagnosis by a psychiatrist may be required for undergraduates who scored extremely severe levels for stress and depressive symptoms. Mental health support strategies specifically need to be focused on undergraduates who are their older ages, females, studying in non-health-related degree programmes, and first-final years. The undergraduates with diagnosed mental problems, such as depression or anxiety disorder, should be under constant monitoring of psychological and psychiatric services73.
