Has COVID-19 really affected the physical and mental health of university students? One-year follow-up results after the pandemic declaration

Abstract

BACKGROUND:

The COVID-19 pandemic affected the whole world and various isolation measures were applied during this period. One of the groups that were physically and mentally affected by this period was students.

OBJECTIVE:

To investigate the effects of the COVID-19 pandemic on the physical activity (PA) level, attitudes and behaviors related to PA, smoking, perceived stress, and fatigue of university students one-year after the declaration of the pandemic.

METHODS:

A total of 102 students (79F/23M, 20.68±1.81 years) who were evaluated face to face with International Physical Activity Questionnaire-Short Form (IPAQ-SF), Cognitive Behavioral Physical Activity Questionnaire (CBPAQ), Perceived Stress Scale (PSS), and Turkish Checklist Individual Strength (CIS-T) Questionnaire before the declaration of the pandemic, were evaluated online with the same questionnaires one-year after the declaration of the pandemic.

RESULTS:

Although there was no difference in terms of other variables, there was a statistically significant difference in the CBPAQ outcome expectation subscale (p = 0.04). The ΔPSS and ΔCIS-T total had a statistically significant effect on the ΔCBPAQ total (p = 0.003 and p = 0.007), ΔPSS and ΔCIS-T total were independent predictors of ΔCBPAQ total (Δ: before-one year after the declaration of the pandemic)

CONCLUSION:

University students had positive attitudes and behaviors related to PA and they increased their PA levels, although not significantly, compared to before the declaration of the pandemic. Perceived stress and fatigue may have an effect on attitudes and behaviors related to PA and PA levels. It is thought that university students continue their routines despite the many limitations of the pandemic.

Keywords

COVID-19 mental health pandemic physical activity smoking student

1 Introduction

On March 11, 2020, the same day the first case was seen in Turkey, the novel coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization (WHO) [1, 2] With the devastating outbreak throughout the world, COVID-19 led to a new lifestyle and threatened physical and mental health at the global level [3, 4]. During prolonged lockdowns for COVID-19, there were risk factors such as physical inactivity, social isolation, and behavioral addiction disorders and these caused many health consequences [5].

One of the groups most affected physically and mentally by the COVID-19 pandemic is the young. It was previously reported that being in the younger age group (≤40 years old) and being a student were among the risk factors associated with distress [6]. It was also reported that the level of physical activity (PA) of young adults decreased during this period, while sedentary behavior and sleep duration increased [7]. Moreover, a study conducted with university students in May 2020 in Turkey [8], during a period of intense measures, showed that anxiety and physical inactivity were significant predictors of high perceived stress, and the students’ mental health was at high risk during the pandemic. It has also been periodically reiterated by the WHO that staying active and maintaining exercise patterns are important for maintaining physical and mental health during COVID-19 restrictions [5, 9]. In addition, smoking is used as a tool for coping with stress among university students [10] and, despite the fear of COVID-19, university students continued to smoke or increased the number of cigarettes smoked per day during the pandemic [11].

In many countries, various isolation measures such as home isolation, social distance, and travel restriction were imposed to prevent the spread of the outbreak. Early preventive measures were also applied in Turkey. Along with cleaning, mask, and distance rules, the rules and measures to be followed in all areas of life were announced within the scope of the fight against COVID-19 [12]. One of the areas where measures were taken was the closure of schools/universities and education was conducted digitally [13]. Until the fall semester of 2021 most universities continued digital education in Turkey.

According to the number of COVID-19 cases, the measures were increased occasionally, full lockdown was applied, or the measures were reduced; however, there was no full normalization until one-year after the declaration of the pandemic. Therefore, the aim of the present study was to longitudinally investigate the COVID-19 pandemic’s effect on university students’ physical and mental health.

2 Methods

2.1 Study design and participants

This cross-sectional study was conducted at a public university (Bandırma Onyedi Eylul University) between February 2020 and April 2021. A total of 117 of 189 university students in the Division of Physiotherapy and Rehabilitation whose PA levels, attitudes and behaviors related to PA, smoking, perceived stress, and fatigue were evaluated using face-to-face questionnaires before the declaration of the pandemic (February 24th–28th, 2020), and the results were presented at a national congress [14]. Students who participated in the study mentioned above [14], had been receiving online education for one year, and volunteered to participate in the study were included in the study. The exclusion criteria were as follows: refusal to participate in the study; undergoing any surgical operation involving the lower or upper extremities, thorax, lungs, or heart within the previous six months; having any psychological disorders; and having a change in physical or psychological health status compared to before the declaration of the pandemic. Six students who refused to participate in the study and nine students who could not be contacted were excluded from the study. In the end, a total of 102 university students were included in this study. The study flowchart is shown in Fig. 1. Prior to the study, all participants were informed about the study and the Informed Consent Form was obtained from the participants.

Fig. 1

Flowchart of the study.

Online questionnaires were prepared and sent to the students via Google Forms. At the beginning of the online questionnaires, the students filled out the Demographic Information Form and then completed the study by filling out the International Physical Activity Questionnaire-Short Form (IPAQ-SF), Cognitive Behavioral Physical Activity Questionnaire (CBPAQ), Perceived Stress Scale (PSS), Turkish Checklist Individual Strength (CIS-T) Questionnaire, and Fear of COVID-19 Scale (FCV-19S), consecutively.

The study protocol was approved by the Bandırma Onyedi Eylul University Health Sciences Non-Interventional Research Ethics Committee (No: 2021-21). The study was conducted in accordance with the principles of the Declaration of Helsinki.

2.2 Data collection

2.2.1 Demographic information form

This form contains information regarding the student’s e-mail address, age, gender, Body Mass Index (BMI) and smoking status.

2.2.2 IPAQ-SF

Using this questionnaire, the time spent on vigorous and moderate PA, walking, and sitting within the previous seven days is evaluated. The score for the time spent sitting is not included in the scoring of the test and is expressed separately [15]. The score is calculated by multiplying the number of days per week and the number of minutes per day. Vigorous PA is 8 METs, moderate-intensity PA is 4 METs, walking is 3.3 METs, and sitting is 1 MET [15, 16]. According to the results of the scoring, <600 MET-min/week indicates low, 600–3000 MET-min/week indicates moderate, and > 3000 MET-min/week indicates high PA [16]. The validity and reliability of the Turkish version were confirmed by Saglam et al. The test–retest reliability coefficient of the questionnaire is 0.69 [17].

2.2.3 CBPAQ

There are 15 items in the test and a 5-point Likert-type scale is used for scoring each item. The test has three main subscales: outcome expectation, self-regulation, and personal barriers. The score for each subscale is calculated by grouping specific test items separately. The total score is “outcome expectation + self-regulation – personal barriers” [18]. The validity and reliability of the Turkish version were confirmed by Eskiler et al. The internal consistency coefficient of the scale is 0.84 [19].

2.2.4 PSS

This scale is composed of 14 items in total and each item is scored between 0 (Never) and 4 (Very often). Seven items are reverse scored. Higher scores indicate a greater level of perceived stress [20]. The validity and reliability of the Turkish version were confirmed by Eskin et al. The internal consistency coefficient of the scale is 0.84 [21].

2.2.5 CIS-T Questionnaire

This consists of 20 items in total with a score between 1 (Yes, true) and 7 (No, not true). Eleven items are reverse scored. A total of four main subscales, namely subjective fatigue, concentration, motivation, and PA, are scored separately to assess fatigue in the questionnaire. The sum of the scores of the items included in each subscale gives the score for that subscale. The total score for the questionnaire is obtained by summing the scores of all items [22]. The validity and reliability of the Turkish version were confirmed by Ergin and Yıldırım. The interclass correlation coefficient reliability of the scale is 0.92 [23].

2.2.6 FCV-19S

This scale includes a total of seven items on a 5-point Likert-type scale (1: Strongly disagree –5: Strongly agree). The total score of the scale varies between 7 and 35 and higher scores indicate a greater level of fear of COVID-19 [24]. The validity and reliability of the Turkish version were confirmed by Artan et al. The internal consistency coefficient of the scale is 0.867 [25].

2.3 Statistical analysis

Statistical analysis was performed using SPSS for Windows version 23.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were expressed as mean±standard deviation (SD) if numerical variables provided the parametric assumption or as median (min-max) if they did not. Categorical variables were expressed as number (n) and frequency (%). For all continuous measurements, the normality of distribution was checked using the Kolmogorov–Smirnov Test. For the comparison of two dependent groups, the Paired Samples t-Test was used for normally distributed variables, while the Wilcoxon Signed-rank Test was used for the non-normally distributed variables. McNemar Test and McNemar-Bowker Test were used to compare two dependent groups in terms of categorical variables. Pearson Correlation Analysis was performed to identify the correlation between numerical variables. The effects of ΔPSS, ΔCIS-T total, and FCV-19S on ΔCBPAQ total and ΔIPAQ-SF total were calculated according to the Enter method using Multiple Linear Regression Analysis. A p value of < 0.05 was considered statistically significant.

3 Results

A total of 102 university students who received online education during the one-year pandemic period completed the study (Fig. 1). Seventy-nine were female and 23 were male and their mean age was 20.68 ±1.81 (range 18 to 33) years. The demographic characteristics of the 102 university students who completed the study before and after the declaration of the pandemic are given in Table 1.

Table 1
Demographic characteristics of the participants

Variables Before the declaration of the pandemic One-year after the declaration of the pandemic p

Age (years) (Mean±SD) 19.71±1.83 20.68±1.81 <0.001^a^*

BMI (kg/m²) (Mean±SD) 22.09±3.28 22.15±3.47 0.605^a

FCV-19S score (Mean±SD) – 16.54±5.67 –

Smoking status

Yes n (%) 22 (21.6%) 15 (14.7%) 0.092^b

No n (%) 80 (78.4%) 87 (85.3%)

Physical Activity Levels

Low PA n (%) 21 (20.6%) 19 (18.6%) 0.679^c

Moderate PA n (%) 57 (55.9%) 60 (58.8%)

High PA n (%) 24 (23.5%) 23 (22.5%)

Variables	Before the declaration of the pandemic	One-year after the declaration of the pandemic	p
Age (years) (Mean±SD)	19.71±1.83	20.68±1.81	<0.001^a^*
BMI (kg/m²) (Mean±SD)	22.09±3.28	22.15±3.47	0.605^a
FCV-19S score (Mean±SD)	–	16.54±5.67	–
Smoking status
Yes n (%)	22 (21.6%)	15 (14.7%)	0.092^b
No n (%)	80 (78.4%)	87 (85.3%)
Physical Activity Levels
Low PA n (%)	21 (20.6%)	19 (18.6%)	0.679^c
Moderate PA n (%)	57 (55.9%)	60 (58.8%)
High PA n (%)	24 (23.5%)	23 (22.5%)

SD, Standard Deviation; BMI, Body Mass Index; FCV-19S, Fear of COVID-19 Scale; PA, Physical Activity; ^a:Wilcoxon Signed-rank Test; ^b: McNemar Test; ^c: McNemar-Bowker Test; ^*: There is a statistically significant difference.

There was no significant difference in the IPAQ-SF, PSS, and CIS-T scores of the students between before and after the declaration of the pandemic (p > 0.05). There was also no significant difference between before and after the declaration of the pandemic in the self-regulation and personal barriers subscales of the CBPAQ and CBPAQ total (p > 0.05); however, there was a significant difference in the outcome expectation subscale (p = 0.04) (Table 2).

Table 2

Effect of the pandemic on the level of physical activity, perceived stress, attitudes and behaviors related to physical activity, and fatigue

Variables	Before the declaration of the pandemic	One-year after the declaration of the pandemic	Δ (Before and after declaration of the pandemic)	p
IPAQ-SF (MET-min./week) (Median, range)	1201.50 (99–12870)	1481.00 (0–12384)	44.50 (–9702–11487)	0.61^a
PSS (Mean±SD)	27.24±7.54	27.00±7.32	–0.24±7.73	0.76^b
CBPAQ
CBPAQ outcome expectation (Median, range)	4.20 (1.80–5.00)	4.40 (2.60–5.00)	0.20 (–2.00–3.20)	0.04^a^*
CBPAQ self-regulation (Median, range)	3.00 (1.00–5.00)	3.10 (1.00–5.00)	0.00 (–2.20–3.00)	0.66^a
CBPAQ personal barriers (Mean±SD)	2.98±0.76	3.00±0.79	0.02±0.86	0.80^b
CBPAQ total (Median, range)	4.10 (1.40–9.00)	4.40 (–0.80–8.20)	0.20 (–5.40–4.40)	0.31^a
CIS-T
CIS-T subjective fatigue (Mean±SD)	31.79±10.41	31.33±10.62	–0.46±10.88	0.67^b
CIS-T concentration (Median, range)	19.00 (6.00–35.00)	20.00 (10.00–35.00)	1.00 (–14.00–15.00)	0.07^a
CIS-T motivation (Median, range)	14.00 (4.00–25.00)	11.00 (4.00–28.00)	–1.00 (–15.00–17.00)	0.07^a
CIS-T physical activity (Median, range)	12.00 (3.00–19.00)	12.00 (3.00–21.00)	0.00 (–13.00–12.00)	0.59^a
CIS-T total (Median, range)	78.00 (24.00–128.00)	74.00 (27.00–130.00)	–1.00 (–60.00–49.00)	0.95^a

SD, Standard Deviation; IPAQ-SF, International Physical Activity Questionnaire-Short Form; PSS, Perceived Stress Scale; CBPAQ, Cognitive Behavioral Physical Activity Questionnaire; CIS-T, Turkish Checklist Individual Strength; ^a:Wilcoxon Signed-rank Test; ^b:Paired Samples t-Test; ^*: There is a statistically significant difference.

The correlations of the before and after the declaration of the pandemic changes in the variables (Δ before-one year after the declaration of the pandemic) are analyzed in Table 3. The effects of ΔPSS, ΔCIS-T total, and ΔFCV-19S score on ΔCBPAQ total and ΔIPAQ-SF were analyzed by Multiple Linear Regression Analysis (Table 4). The explanatory power of these variables for the ΔCBPAQ total was 21%. The ΔPSS and ΔCIS-T total had a significant effect on the ΔCBPAQ total (p = 0.003 and p = 0.007). There was no significant effect of the variables on the ΔIPAQ-SF (p > 0.05).

Table 3

The correlations between changes in levels of physical activity, changes in attitudes and behaviors related to physical activity, and changes in levels of perceived stress, fatigue, and fear of COVID-19 before/after the declaration of the pandemic (one-year pandemic period)

	ΔIPAQ-SF	ΔCBPAQ outcome expectation	ΔCBPAQ self-regulation	ΔCBPAQ personal barriers	ΔCBPAQ total
ΔPSS
r	–0.033	–0.325^^	–0.204^*	0.307^^	–0.389^^
p	0.741	0.001	0.040	0.002	< 0.001
ΔCIS-T subjective fatigue
r	0.015	–0.228^*	–0.212^*	0.351^^	–0.373^^
p	0.879	0.021	0.032	< 0.001	< 0.001
ΔCIS-T concentration
r	–0.040	0.030	–0.069	0.189	–0.113
p	0.692	0.768	0.488	0.057	0.259
ΔCIS-T motivation
r	–0.093	–0.276^^	–0.189	0.301^^	–0.358^^
p	0.354	0.005	0.057	0.002	< 0.001
ΔCIS-T
physical activity
r	–0.327^^	–0.163	–0.138	0.211^*	–0.240^*
p	0.001	0.103	0.168	0.033	0.015
ΔCIS-T
total
r	–0.104	–0.217^*	–0.209^*	0.359^^	–0.370^^
p	0.300	0.028	0.035	< 0.001	< 0.001
FCV-19S score
r	–0.163	–0.045	0.026	–0.077	0.031
p	0.102	0.651	0.796	0.443	0.761

IPAQ-SF, International Physical Activity Questionnaire-Short Form; CBPAQ, Cognitive Behavioral Physical Activity Questionnaire; PSS, Perceived Stress Scale; CIS-T, Turkish Checklist Individual Strength; FCV-19S, Fear of COVID-19 Scale; ^*: Correlation at 0.05 level is significant, ^*^*: Correlation at 0.01 level is significant; Bold values indicated statistically significant difference.

Table 4

Multiple linear regression analysis of the effects of ΔPSS, ΔCIS-T total, and ΔFCV-19S score on ΔCBPAQ total and ΔIPAQ-SF

Dependent Variables	Independent Variables	R	R ²	Standardized Coefficients Beta	p
ΔCBPAQ total	Model 1				< 0.001^*
	ΔPSS			–0.294	0.003*
	ΔCIS-T total	0.462	0.213	–0.266	0.007*
	Δ FCV-19S score			–0.003	0.975
ΔIPAQ-SF	Model 2				0.231
	ΔPSS			0.015	0.888
	ΔCIS-T total	0.207	0.043	–0.133	0.217
	Δ FCV-19S score			–0.181	0.074

CBPAQ, Cognitive Behavioral Physical Activity Questionnaire; PSS, Perceived Stress Scale; CIS-T, Turkish Checklist Individual Strength; FCV-19S, Fear of COVID-19 Scale; IPAQ-SF, International Physical Activity Questionnaire-Short Form; ^*: There is a statistically significant difference.

Twenty-two of the 102 students were smokers before the declaration of the pandemic, while 15 students were smokers at the time of the evaluation one-year after the declaration of the pandemic. Ten of the 22 students quit smoking during the pandemic (a mean quitting period of 6.7 months) and three students started smoking during this period. The mean FCV-19S scores of the 15 smokers were 18.33±5.65, the mean FCV-19S scores of the 10 smokers who quit smoking were 15.00±6.07, and the mean FCV-19S scores of the 87 non-smokers were 16.23±5.64. There was no significant difference in FCV-19S scores between the smokers and non-smokers (p > 0.05). Similarly, there was no significant difference in FCV-19S scores between the smokers and those who quit smoking (p > 0.05).

4 Discussion

The present study, which investigated PA level, the attitudes and behaviors related to PA, smoking, perceived stress and fatigue for one year during the pandemic, was completed with 102 university students. At the end of the one-year pandemic period, only the attitudes and behaviors related to PA of the students improved according to the subscale of outcome expectation, while the PA levels, perceived stress, and fatigue remained unchanged. The correlation between the changes in the evaluations over the one-year period (Δ before the declaration of the pandemic-one year after the declaration of the pandemic) showed that the attitudes and behaviors related to PA of the students were adversely affected (negative correlation) by the increased perceived stress and fatigue, while the change in the PA level was only affected by fatigue in terms of PA (negative correlation).

In a study conducted at the beginning of the COVID-19 pandemic [26], during the period of intense restrictions, the rate of PA of the students decreased due to the pandemic, and the students who continued to do PA, when it came to a choice of PA type, showed a tendency to perform exercise that could be done at home. However, most of the inactive students (76.08%) during this period were willing to develop regular PA behaviors in the future. At the end of the study, it was seen that the pandemic decreased the PA rate in university students, and those who did regular PA adapted to the process by changing their pattern of activity. In contrast to that study [26], in our study there was an increase in the PA levels of the students, although it was not statistically significant. Before and after the declaration of the pandemic, students who did moderate PA constituted the majority. Videos, brochures, online lessons, and advertisements for PA on platforms such as social media during the pandemic may have contributed to the significant increase in students’ attitudes and behaviors related to PA and PA levels. In fact, it has been stated that social media facilitates the self-management of behaviors related to PA through access to information about exercises and opportunities for social interaction [27]. In a study conducted with university students before the declaration of the pandemic, it was stated that social media may be important in increasing PA [28]. However, in our study, it is difficult to make a clear comment, since no evaluation was made regarding the duration or purposes of social media use.

During the COVID-19 pandemic, apart from physical inactivity, risk factors such as social isolation, behavioral addiction disorders, and their relevant health consequences were determined, such as depression, anxiety, and psychological disturbances [5]. In our study, perceived stress and fatigue among the students were low both before and one-year after the declaration of the pandemic, indicating no statistically significant difference. The reason for this may have been the positive psychological effect of PA [29] and since the PA levels of the students were not low in our study, this may have affected the students mentally in a positive way. Several studies from different countries have shown that a decrease in PA and an increase in sedentary behaviors during lockdown are associated with negative changes in mental health such as depression, anxiety, and stress [30 –32]. On the other hand, students may have adapted mentally to the COVID-19 period. The lower risk of health complications caused by COVID-19 in young adults, the effective use of social media, and the lack of care duties may have helped students adapt to the pandemic mentally [32]. However, the factors underlying students’ mental adaptation to the process during the pandemic could have been questioned in more detail.

In our study, we examined the relationship between the one-year changes (Δ scores) in all parameters to investigate the effects of PA, attitudes and behaviors related to PA, perceived stress, and fatigue on each other. The attitudes and behaviors related to PA of the students were negatively affected by the increased perceived stress and fatigue, and the change in PA level was affected by fatigue in terms of PA. The Multiple Linear Regression Analysis showed changes in perceived stress and fatigue to be independent predictors of changes in attitudes and behaviors related to PA. Although fear of COVID-19 affected changes in attitudes and behaviors related to PA, it did not show as much of an effect as changes in perceived stress and fatigue. The results of our study showed that the increase in perceived stress and fatigue reduced attitudes and behaviors related to PA. It is notable that since our results are based on one-year of the pandemic period, this situation made us think that PA, perceived stress, and fatigue could affect each other in the long term and create a vicious circle that needs to be broken.

It is well known that smoking is a risk factor for the progression of COVID-19 [33]. In a comprehensive study [34] including all age groups (mean age: 40.03±13.53 years), smoking habits decreased during the COVID-19 pandemic, and this was attributed to fear of the increased risk of respiratory distress and death from COVID-19 in smokers. In our study, during the one-year study period 10 of the 22 smokers quit for a mean of 6.7 months. Surprisingly, the students who continued to smoke had higher FCV-19S score, although not significantly, than those who quit. Although our sample size is very small, our results are consistent with Nguyen et al.’s large sample size study [11] in which the fear of COVID-19 was greater among students who continued to smoke or increased the number of cigarettes smoked per day during the pandemic. This may have been because students who quit or do not smoke feel healthier and this may have made them less afraid of contracting COVID-19. However, further comprehensive studies are needed on that point.

There were some limitations to our study. The main limitation was the small sample size. Our results regarding smoking were insufficient due to the low number of students who smoked. It was not possible for us to increase the number of participants, as we compared them with the evaluations before the declaration of the pandemic. The second limitation was the absence of data on the duration and purpose of social media use among the participants. The third limitation was that the factors affecting the mental health of the participants were not questioned in detail.

There are studies in the literature that evaluate factors such as PA, stress, and smoking in terms of the pandemic period [31, 35]. However, our study also evaluated factors such as attitudes and behaviors related to PA and fatigue and included a one-year follow-up period. It was also more comprehensive as many parameters of physical and mental health were evaluated. Our study provided clear results since the physical and mental health results of the same participants were evaluated before and one-year after the declaration of the pandemic, and this was the strength of our study.

5 Conclusion

It was found that university students had positive attitudes and behaviors related to PA and they had higher PA levels, although not significantly, compared to before the declaration of the pandemic. Perceived stress and fatigue may have an effect on attitudes and behaviors related to PA and PA levels. However, it is recommended to conduct future studies on the effects of social media on physical and mental health. Additionally, not smoking or quitting smoking may make university students feel healthier and less afraid of contracting COVID-19. In fact, our study showed that university students maintained their routines despite the many restrictions imposed due to the pandemic. There is a need for further studies investigating how the conditions that affect daily life such as smoking, PA, perceived stress, and fatigue are affected during unexpected events, such as pandemics.

Ethical approval

Informed consent

Prior to the study, all participants were informed about the study and the Informed Consent Form was obtained from the participants.

Conflict of interest

The authors declare that they have no conflict of interest.

Footnotes

Acknowledgments

The authors thank all participants who participated in the study.

Funding

The authors report no funding.

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