The combined effects of the pandemic and the lockdown have never been assessed on the quality of life of students. Our study showed that an impaired mental health associated with female sex, reduced learning time, reduced access to the outside, and other difficulties with the living situation. Other risk factors were tobacco consumption, ineffectiveness of media entertainment or reading, and effectiveness of snacking to calm oneself, while physical activity and getting outside were protective.
The COVID-19 pandemic has prompted most countries to opt for population containment and social distancing measures to control the spread of the virus. However, significant psychological effects have been reported in previous containment experiments (24). This pandemic has already shown significant psychological symptoms related to anxiety, stress and depression (18, 25). The development of new guidelines to establish appropriate counseling, preventive and curative psychological actions online or for specific groups such as healthcare workers or older people have been identified as necessary measures in this situation (26). However, none of these measures currently address the particularly vulnerable student population. Studies have demonstrated the importance of assessing the health-related quality of life of the student community (27, 28), a population group passing through an important phase of life. The epidemics SARS, Ebola, H1N1 and now COVID-19 have had a significant impact on the activity, behavior, morale and health of our fellow citizens. The first studies conducted in China on the impact of the current epidemic reported a significant amount of anxiety and depressive disorders as well as sleep disorders. Other studies have suggested a risk of increased suicidal behavior, psychotic symptoms, psychosomatic symptoms, symptoms of post-traumatic stress and consumption of psychoactive substances (alcohol, tobacco, etc.). The situation of the lockdown and its psychosocial and economic consequences but also the fear, for oneself and one's loved ones, of contamination, the virus, the illness and its consequences (serious somatic disorders and death) act on the mental health of students. Moreover, long periods of social isolation are well known to be associated with mental health problems, post-traumatic stress symptoms, avoidance behaviors and family conflicts (29). In our study, mental health status of post-secondary students was closer to that of chronically ill young adults than the general population (30) and higher than that of Mexican students; the MCS was close to 23.7 with the presence of moderate depressive symptoms versus 39 with severe anxiety (31). However, this comparison is cautioned because of the different culture and educational system between the two populations.
In the current study, among socio-demographic characteristics, only female sex was associated with increased likelihood of impaired perceived mental health. This result differed from a previous study finding no significant effect of sex on quality of life among undergraduate dentistry students in social isolation due to the COVID-19 pandemic (29) but agree with those of a recent study finding lower quality of life reported by female than male students (31). This result is not surprising because women are known to appreciate their quality of life more seriously because they are considered more emotional than men, either in the general population or those with various chronic diseases (32, 33, 34).
As a direct consequence of the closure of universities, some students experienced a decrease in learning time, with a negative effect on their mental health. The reasons for this decrease could be inherent to the university system, some students having more difficulty than others in organizing distance learning. Previous work has effectively shown that performing distance education was significantly associated with good quality of life among students in isolation for COVID-19 (29). The observation could also be due to factors intrinsic to students such as decreased motivation in this uncertain period. When students are not motivated, their level of engagement is reduced (35). This phenomenon should be the subject of in-depth reflection by university officials to limit disparities between courses and ensure that students’ learning is properly monitored.
The type of housing and its effect on students’ mental health was a much-anticipated outcome of this study. Not having direct access to the outdoors with a garden, terrace or balcony had a significant impact on their mental health during the lockdown. This outcome was also predictable, but the study was able to quantify it. The finding reflects a well-known phenomenon: the impact of social inequalities on the health of individuals. In line with a previous review that highlighted more frequent housing in small apartments without habitable balconies, with poor housing quality such as a little natural lighting and acoustic comfort, and with the absence of soft qualities in living quarters among individuals with than without moderate-severe depressive symptoms (36). Indeed, students living in university rooms may have had more mental health problems during the lockdown than those living in parental housing or another place with access to a private outdoor space. More surprisingly, the situation of some students who may have been confined to the family home also exposed them to risk. Indeed, difficulties isolating within the home, noise pollution in the home, proximity to an infected relative and conflicts with a family member were associated with increased likelihood of impaired mental health. The development of resilience may offer a feasible intervention and the benefits of such preparation will likely extend further, with strengthened resilience aiding in the transition from a student to an adult earning a living (37). These observations support the need to develop interventions to support students who are isolated and potentially at risk. This support could include digital forms of study groups, peer group sessions and psychological interventions.
Increased tobacco use was associated with impaired mental health. The factors underlying this association are still being discussed, and given the cross-sectional design, we caution the interpretation of the findings. However, some students used psychoactive substances to help cope with stress during the pandemic. People relying on negative coping methods such as drinking and smoking and others using self-management relaxing hobbies including physical exercise or reading were previously described (38).
The study has a number of limitations. First, the representativeness of the sample is limited, as it is a sample of voluntary participants, with an over-representation of women, which may have led to an under-evaluation of impaired mental health. Second, this cross-sectional study is useful in understanding the immediate or short-term impact apparent at a certain time point. However, the limitation of a cross-sectional design is that it cannot conclude on the long-term impact of COVID- 19, given that certain pre-existing vulnerabilities and high-risk factors could be multiple, ongoing or recurrent, and also the manner by which they work may vary. Consequently, there is a pressing need for longitudinal and developmental studies to be able to reveal the multiple layers of dynamic determinants playing a role during this time of global crisis (39). Third, the students were recruited from one of the French areas that was the most substantially affected by COVID-19, which limits the generalizability of these results to all students. Finally, despite the large number of determinants included in the analyses, the multivariable model explained 19% of the explained variance; thus, other factors, such as anxiety due to media coverage and daily accurate information regarding the infection rates and number of deaths, were not accounted for in our study and should be included in future studies.
However, this study also has strengths. First, the large sample size (4018 respondents) allowed for a robust analysis and extracting solid tendencies and associations. Also, this is an early study that offers a unique opportunity to investigate the mental impact of the COVID-19 pandemic in a French student environment. Second, it provides valuable information about the current situation useful to gain some insights into the situation in other universities or in possible future global crises. Third, this study provides invaluable information on the self-perceived mental health of students in a French area particularly affected by COVID-19. Finally, our results bring attention to the findings that health initiatives for students should include improvements in learning and living environments. Simply developing resources to facilitate online guidance and lectures to offer strategies for managing anxiety and building a campus environment that offers access to a private outside space for students are essential, as these actions might have benefits for mental health.