Impact of COVID-19 Pandemic on Mental Health of University Students in Pakistan

Purpose: A novel coronavirus, SARS-CoV-2 was identified as the cause of COVID-19 eventually led to the declaration of Public health emergency of international concern and a pandemic by WHO due to its exponential global spread. Present study was conducted to investigate the impact of second wave of pandemic on mental wellbeing and social behaviors among university students of Pakistan during this crucial period of COVID-19 infection. Methods: A cross-sectional analytical study was designed to evaluate the psychosocial impact during the current COVID-19 outbreak among the students of The Islamia University of Bahawalpur, Pakistan. Snowball sampling or chain referral sampling procedure was adopted to recruit the participants in the study. Verbal informed consent was taken from all participants before recruitment in the study irrespective of their gender, age and socioeconomic status. Results: Mental health of university students during COVID-19 epidemic was affected to a varying degree revealing that 26.66% were recorded to have mild, 27.15% moderate and 17.04% suffering from severe anxiety out of total 1029 students. Students who were residing in urban areas with parents and having a steady family income were negatively associated and found protective factors against anxiety. However, having a relative or an acquaintance infected with COVID-19 was an independent risk factor for experienced anxiety. Positively associated factors with the level of anxiety symptoms included economic stressors, effects on daily-life, and academic delays whereas social support was negatively correlated with anxiety in COVID-19 related stressors. Conclusion: Public health emergencies and such pandemic are exerting serious psychological impacts on university students. It is recommended that the higher authorities should plan better policies to reduce this impact for the provision of high quality and timely crisis-oriented psychological services to university students.

most of the patients was dry cough, dyspnea, and fever. Zoonotic to human and then human to human transmissions of pathogens were reported in all thrice outbreaks. Since then, the quantity of cases increased rapidly inside and outside Wuhan, occupying to 34 cities of China by 30 January 2020. 3 It was named as coronavirus disease 2019  after the identification of a novel coronavirus, SARS-CoV-2 as the cause of this pandemic in China and other parts of the world.
Eventually, WHO declare Public health emergency of international concern on January 30, 2020 and a pandemic on March 11, 2020 due to its exponential global spread. 4 The COVID-19 appeared to be more contagious due to its diverse epidemiological and biological characteristics than earlier pandemics such as SARS-2003, MERS-2012. 5 It has affected more than 200 countries globally with 70,461,926 total cases and 1,599,704 deaths as of December 14, 2020. 6 Case-fatality rate (CFR) among confirmed cases of COVID-19 is estimated at 6.80%, despite its significant infectivity rate. Majority of the deaths are typically occurring among the patients above 80 years of age, having multiple comorbidities and the immunocompromised population. 7 In Pakistan, after a brief hiatus of following the first case which was reported on February 26, 2020, Covid-19 cases spiked as more pilgrims returned from Iran and a large number of members of Tableeghi Jamaat, a religious congregation were also tested covid-19 positive, affected more than 438,425 persons and 8,796 deaths till December 14, 2020.Covid-19 epidemic in Pakistan posed a serious challenge to counter it with limited resources of country. 8,9 Covid-19 pandemic led to closure of all educational institutions globally and thus giving rise to multiple challenges at all stages and levels of education in particular for students. 10 Higher education commission (HEC), Pakistan, institutional administrators, teachers, students, and other stakeholders are making considerable efforts and planning to optimally utilize the available technology for continuing the process of education and minimizing the gaps that are ongoing in consequent of the current pandemic of  Psychological distress is strongly associated with widespread outbreaks of infectious disease, such as COVID-19 and symptoms of mental illness appeared in general population. 12 The current global pandemic also has consequences for mental health, as happened in some previous health emergencies. 13 These manifestations should be addressed by psychiatrists across the world, their correlates, and strategies to manage them that counter both the needs of specific populations and the precautionary measures essential to limit the spread of COVID- 19. 14 There are several studies on the psychological impact of the Covid-19 epidemic on the patients, medical professionals, general public, children,and older adults in Pakistan as well as all over the world. 15,16 However, no detailed investigation on the psychological impact and mental health status of university students bearing the epidemic has been conducted till now. The aim of the present study was to investigate the impact of current pandemic on mental wellbeing and social behaviors among university students during this crucial period of COVID-19 infection.

Participants and Setting
A cross-sectional analytical study was designed to evaluate the psychosocial impact during the current COVID-19 outbreak among the students of The Islamia University of Bahawalpur, Pakistan. A snowball sampling or chain referral sampling procedure was adopted to recruit the participants in the study. Students who gave verbal informed consent were recruited in the study irrespective of their Bahawalpur, Pakistan were recruited initially and they were encouraged to disseminate the information to others for the collection of data. Mental health status was assessed by structuring an anonymous online questionnaire ensuring the confidentiality and reliability of the data of all respondents. All the respondents were considered eligible who provided consent, complete information, and followed the directions to a validity item.

Generalized Anxiety Disorder Scale (GAD-7)
The online questionnaire (Google online doc/form) was designed comprising of basic demographic characteristics such as name, gender, age, parental occupation and economic status/monthly income, religion, and contact information. Personal information of the entire participants including names and contact details were anonymized to maintain and protect confidentiality. Cognitions and preventive behavior towards COVID-19 and the availability of social support was also inquired.
The participants responded to the 7-item Generalized Anxiety Disorder Scale (GAD-7) which includes seven core symptoms, i. Respondents report their symptoms using a 4-item Likert rating scale ranging from 0 (not at all sure), 1 (Several days), 2 (Over half the days), 3 (Nearly every day). The GAD-7 is a valid and reliable tools for the assessment of psychological impact and mental health among society during these circumstances (Cronbach's ɑ = 0.911). 17

Data analysis
Demographic and other selected characteristics of the respondents were analyzed by descriptive statistics. A univariate analysis (Nonparametric test) was used to reveal the significant associations between anxiety level and characteristics of sample. 18

COVID-19 outbreak
Mental health of university students during COVID-19 epidemic was affected to a varying degree.
No symptoms of anxiety was recorded in 27.45%, while 26.66% were recorded to have mild, 27.15% moderate and 17.04% severe anxiety out of total 1029 students as shown in Figure 1. The ratio of anxiety and the discipline wise details of students are given in Table 1.

Association of Anxiety with Demographic variables of students
The demographic and selected characteristics of the study population are shown in Table 2.
Among the sample of 1029 university students, male were 544 (52.86%) and female were 485 (47.13%).  Table 2 shows the detailed relationship between the demographic variables of students and level of anxiety.

Factors associated with anxiety during the COVID-19 epidemic
Results of factors associated with anxiety during the COVID-19 crisis are presented in Table 3 by ordinal multivariate analysis. Significance factors from the univariate analysis were included in the ordered logistic regression analysis.

COVID-19-related stress factors and level of anxiety
Worry about interruption or delay in academic activities (r = 0.217, P < 0.001), economic influences (r = 0.321, P < 0.001) and the influence of the epidemic on daily life (r = 0.226, P < 0.001) were also moderately and positively correlated with the level of anxiety while a negative association between social support and anxiety symptoms during the COVID-19 outbreak was revealed (r = −0.121, P < 0.001) as shown in Table 4. inevitably disrupted routine life and resulted in anxiety. 19 Some previous reports have also revealed that public health crises can have numerous mental consequences among general population as well as among the college and university students, which can be expressed as anxiety, stress and fear. 20 We investigated that 26.66% have mild, 27.15 % moderate and 17.04% severe anxiety on account of the COVID-19 flare-up. Anxiety in students might be due to the impact of the epidemic on their studies and future work. 21 Place of residence, source of parental income, whether living with parents and whether a relative or an acquaintance was infected with COVID-19 is strongly associated with level of anxiety. High level of anxiety was recorded among the students residing in rural areas as compared to urban areas which might be due to better health and education resources in cities. Living with parents was another favorable factor against feeling anxious. Previous studies have indicated that the risk factors associated with emotional and anxiety disorders in adults include the death of parents in childhood, not living with parents, and parents' psychological problems and mental illnesses, which are consistent with the results of this study. 22,23 The COVID-19-related stressors, which include economic stressors, effects on daily life, and academic delays, were positively associated with anxiety symptoms during the epidemic. E-learning methods of teaching are being recommended by higher authorities in Pakistan to reduce the academic loss of students. Despite the world wide adoption of e-learning, it was never considered as a part of formal education in Pakistan by many institutions until the spread of Covid-19. However, in spite of its multiple advantages there are quite a few limitations of e-learning such as social isolation, lack of student teacher interaction and connectivity issues etc. 24,25 This sudden interruption of academic activities might have led to stress and anxiety and negative psychological impact among students. government. One of the biggest reliefs was Ehsaas Emergency Cash programme offering one-time cash assistance of Rs. 12,000 each to support 12 million families. 10 Specific strategies providing mental health services in an easily accessible manner should be developed to minimize the impact of these health emergencies. These includes online surveys to assess the scope of mental health problems; mental health education by developing online materials; online counselling and self-help services material; telepsychiatry consultation by developing structured letters; telemedicine services for diagnostic and counselling purposes; online mental health services are needed which should be easily accessible to lower socioeconomic society. 29,30

Limitations and Strengths
Our study has several limitations. We adopted snowball sampling or chain referral sampling procedure due to current conditions, limited resources and time-sensitivity of the COVID-19 epidemic rather random selection of the sample. Furthermore, this study is limited to the students who had internet resources, smartphones, whatsapp and e-mail IDs. This study conducted among university students those

Conclusion
Mental health of university students during COVID-19 epidemic was affected to a varying degree revealing that 26.66% were recorded to have mild, 27.15 % moderate and 17.04% severe anxiety out of total 1029 students. Students who were residing in urban areas with parents and having a steady family income were negatively associated and found protective factors against anxiety. However, having a relative or an acquaintance infected with COVID-19 was an independent risk factor for experienced anxiety. Positively associated factors with the level of anxiety symptoms included economic stressors, effects on daily-life, and academic delays whereas social support was negatively correlated with anxiety