Assessment of Mental Health and Quality of Life Status of Undergraduate Students in Indonesia during COVID-19 Outbreak: A Cross-Sectional Study

The COVID-19 pandemic globally impacted physical, spiritual, and mental health (MH). The consequences significantly affected students’ quality of life (QoL) too. This cross-sectional study assessed MH status and its relationship to the QoL of college students in Indonesia. This study collected data (September 2021–April 2022) online using the depression, anxiety, and stress scale-21 (DASS-21) to measure MH and the world health organization quality-of-life scale (WHOQoL-BREF) to measure the QoL. The data were analysed using SPSS with a bivariate and multivariate linear regression test. A total of 606 respondents participated in this study, with the majority being women (81.0%), aged 21–27 years (44.3%), and unmarried (98.5%) respondents. We observed 24.4% (n = 148) moderate depression, 18.3% (n = 111) very severe anxiety, and 21.1% (n = 128) moderate stress status. The QoL measurement determined that a moderate QoL in the physical and environmental health domains (>70%) and poor QoL in the psychological health domain (58.3%) were found. Gender, age, family support, history of COVID-19 diagnosis, family with COVID-19 diagnosis, vaccination status, and physical symptoms are significantly associated with MH status and QoL (p-value < 0.05). This study demonstrated that COVID-19 was negatively related to college students’ MH and QoL. Targeted interventions may be needed to ameliorate both MH and QoL.


Introduction
Since the announcement of the outbreak of COVID-19 worldwide caused by a virus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the World Health Organization (WHO) on 12 March 2020, Indonesia has become one of the countries that have been severely affected by COVID-19 and it has impacted on physical, spiritual, and mental health (MH) [1]. In the two years since the beginning of the pandemic, the number of positive cases of COVID-19 in Indonesia has reached 6,216,621 million, with a death toll of 157,028 (as of 7 August 2022) [2,3]. With the rapid spread of COVID-19 and the increasing number of cases from day to day globally, the Government of Indonesia has made policies to limit population movement and social activities to reduce the spread of the virus. One of the steps taken by the Indonesian government to prevent the spread Indonesia is the 14th largest country and the largest archipelagic country in the world, with an area of 1,904,569 km 2 , and the 6th largest island country, with 17,504 islands. Indonesia is also the 4th most populous country in the world, with a population of 270,203,917 in 2020 [18]. Indonesia is bordered by several neighbouring countries in Southeast Asia, the Australian continent, and Oceania. Indonesia borders on land with Malaysia on the islands of Borneo and Sebatik, Papua New Guinea on the island of Papua, and Timor Leste on the island of Timor. Indonesia has the five largest islands, including Java, Kalimantan, Sumatra, Sulawesi, and Irian Jaya. Indonesia is an agricultural country where the livelihood of the majority of the population is farming [18,19].
Indonesia is one of the largest populated countries affected by the COVID-19 pandemic, in all aspects of life, including national health status and slowing economic growth. In Indonesia, cases have increased since June 2021, with the highest peak in July 2021, with 49,509 new cases and 1893 deaths, with an average of 1646 every seven days [3]. Then, it decreased from October 2021 to January 2022. However, cases increased again in January to reach the highest number of new cases in February 2022 with 59,384 new cases at an average of 7 days, as many as 55,110 new cases, and the highest death in March 2022 with the number of deaths of 401 cases with an average of 310 cases of death per week [3].

Study Design, Data Collection, and Sample Size
This research is a cross-sectional study with a purposive sampling technique. Data collection was done online using a validated questionnaire consisting of the DASS-21 and WHOQoL-BREF questionnaires [20,21]. The DASS-21 questionnaire was translated using the forward-backward translation method. It was translated from English to Indonesian by an English-Indonesian sworn translator and then re-translated into English by another certified English-Indonesian translator to ensure validity and accuracy [22]. Furthermore, the translation process was not carried out on the WHOQoL-BREF questionnaire because WHO provided it in Indonesian [23]. The questionnaire was presented in the form of a google form in the Indonesian language and then distributed online via social networking apps, such as WhatsApp, Instagram, and Line. Data were collected from September 2021 and April 2022. The inclusion criteria in this study were active undergraduate students aged ≥17 years who could fill out a questionnaire via a google form and were willing to participate. Several efforts were made to get the appropriate respondents. Inclusion and exclusion criteria for respondents were written at the beginning of the questionnaire, and information about rewards for lucky participants was also stated. In addition to sharing the questionnaire link on social media groups consisting of students, group members were also asked to share the link with other friends. Involving students in the research team helps maximize the recruitment of respondents. Raosoft's sample size calculator was used to determine the sample size for this study [21,24]. For more than 270 million people in Indonesia, the minimum estimated sample size was 385.
Total score (%) = Obtained score − least possible score Maximum score − Least possible score × 100 The questionnaire's validity and reliability were evaluated on 30 respondents. The Pearson bivariate method was used to assess the data validity, while Cronbach's alpha was used to assess the data reliability. Results obtained a value of sig two-tailed 0.05 or R count >0.361 from the DASS 21 questionnaire, indicating that the questionnaire is valid, and a score of 0.918 for Cronbach Alpha, indicating that the DASS 21 questionnaire is reliable. In addition, the results of the validity and reliability test of the WHOQoL-BREF questionnaire are also valid and reliable. An R count is more than the R table with an R count range of 0.425-0.749. At the same time, Cronbach's Alpha test result is 0.931 [26,27].

Ethical Clearance
The Medical and Health Research Ethics Committee of the Faculty of Medicine at Universitas Muhammadiyah Surakarta approved the study protocol before the study's execution (Reference No. 3725/B.1/KEPK-FKUMS/IX/2021). The nature of the study was explained to the respondents in writing, who were asked to sign an informed consent form by clicking "agree to participation" to confirm their participation.

Data Analysis
Online-based questionnaires were collected, and data were analysed using the Statistical Package for the Social Sciences (SPSS) version 25 (International Business Machines Corporation, New York, NY, USA). Descriptive statistics are used to analyse respondents' demographic data. First, the normality of the data was tested with Kolmogorov Smirnov. A bivariate correlation test (Mann-Whitney and Kruskal-Wallis) determined the relationship between demographic characteristics with MH status and the QoL of respondents. Mann-Whitney determined the relationship of the two groups' independent variables (e.g., gender, marital status, faculty, and perceived physical symptoms) to the dependent variable. At the same time, Kruskal-Wallis was used to evaluate the relationship between independent variables of more than two groups, such as age and the dependent variable. Variable results of the bivariate analysis with a p-value <0.25 were followed by a multivariate analysis tests with a linear regression method [28]. The correlation between MH and QoL was tested with the Spearman test correlation and Bonferroni correction. A statistically significant difference between groups was determined at the 95% confidence level (p-value < 0.05).

Results
The number of respondents who were willing to fill out the questionnaire in this study was 606, with the majority being female respondents amounting to 81.0% (n = 491) respondents, 44.3% (n = 268) 21-27 years old, and 98.5% unmarried. The demographic data of the respondents are presented in Table 1.  Tables 2 and 3, although the majority of respondents (42.1%) were categorized as normal depression with a score between 0 and 9, almost a quarter of respondents experienced moderate depression (24.4%) with a score of 14-20 and 6.8% experienced a very severe depression with score 28-42. More than half of the respondents sometimes experienced that they could not seem to experience any positive feeling at all, had difficulty working up the initiative to do things, felt downhearted and blue, or were unable to become enthusiastic about anything. More than 10% of respondents often experienced difficulty working up the initiative to do things, felt that they had nothing to look forward to, felt downhearted and blue, or were unable to become enthusiastic about anything. For the anxiety domain, 34.3% (n = 208) of participants reported moderate depression with a score of 10-14, and almost a fifth of respondents reported a very severe level of anxiety with a score of 20-42. More than a third of respondents experienced dryness of their mouth, trembling, worry about situations, panic, a sense of heart rate increase, and feeling scared without any good reason. The stress domain result revealed that most respondents experienced mild stress (40.8%), and more than a fifth suffered moderate stress (21.1%). About 20% of respondents often experienced difficulty winding down, tended to overreact to situations, used much nervous energy, got agitated, and were intolerant of anything.  1.0 0 = did not apply to me at all, 1 = applied to me to some degree or some of the time, 2 = applied to me a considerable degree or a good part of the time, 3 = applied to me very much or most of the time.
The QoL of more than 70% of respondents was at a moderate level in the domain of physical health and environmental health. A total of 35.6% of respondents said they do not have enough energy to carry out daily activities. More than 30% of respondents also stated that they feel insecure in their daily lives, feel that the physical environment is unhealthy, do not have enough money to meet their needs, lack opportunities in recreational activities, and lack availability of required information. Although 42.4% of respondents' QoL in the social relationship domain were in a moderate category, more than half of the respondents (58.3%; n = 353) stated that they were poor in the psychological health domain. Respondents stated that they do not enjoy life, feel that life is less meaningful, have difficulty concentrating, and are not satisfied with their bodily appearance (Tables 4 and 5).
In general, the levels of depression, anxiety, and stress in women are higher, and their QoL is lower than in men (Table 6). Faculty and marital status are unrelated to students' mental status and QoL. The variables that significantly affect students' mental status (depression, anxiety, and stress) are gender, family support, history of COVID-19 diagnosis, and physical symptoms, such as headache, myalgia, and sore throat. Age, family support, family with COVID-19 diagnosis, vaccination status, and experience of suffering physical symptoms, such as sore throat and cough, influenced the QoL significantly (Tables 7 and 8).    A spearman test was conducted to determine the correlation between MH status and students' QoL. Based on the results of the spearman test for the correlation between MH status and QoL, it was found that MH status was significantly correlated with the QoL in the domains of physical health, psychology, and social relationships (p < 0.05). In contrast, MH was not significantly correlated to the QoL in the environmental health domain (p > 0.05) ( Table 9).

Discussion
This study aims to identify and determine the relationship between MH status and the QoL of students in Indonesia during the COVID-19 pandemic and its associated factors. This study found that the majority of the respondents (42.1%) suffered normal levels of depression, which is a good sign of community MH. For the anxiety domain, almost onefifth of respondents reported a very severe level of anxiety, which is alarming. The stress domain result revealed that more than one-fifth suffered moderate stress (21.1%). In general, depression, anxiety, and stress levels in women are higher than in men. Compared to men, women's QoL is lower. This is in line with a study conducted in the United Kingdom and Saudi Arabia, where there were high levels of anxiety and depression in university students, with more than 50% experiencing levels above the clinical cut-offs and females scoring significantly higher than males [10,29]. Several other studies conducted in Pakistan, China, Hungary, the United States, and Indonesia also reported a significant impact on university students' MH due to the COVID-19 outbreak. College students reported feeling more anxious, tired, and depressed than before the pandemic [12,16,[30][31][32][33].
This study also revealed that most college students report a moderate QoL in the domain of physical health and environmental health. The existence of social distancing implemented to prevent the spread of the COVID-19 virus causes limitations in physical and social activities, including leisure activities and the sufficiency of the family's financial needs. This is consistent with a study conducted in the UK, which stated that low resilience was associated with restriction and isolation, reducing the chances of engaging in beneficial coping strategies and activities rather than enduring personality characteristics. Higher levels of distress are associated with lower levels of exercise, higher rates of tobacco use, and several life events associated with the pandemic and lockdown, such as cancelled events, worsening personal relationships, and financial problems [14]. Furthermore, the lockdown and university closures have forced students to study at home. In a study conducted in Indonesia, 34.38% of students felt depressed while studying at home. Other emotions were anger (0.39%), surprise (7.91%), and fear (15.81%) [30].
The QoL of more than 50% of respondents in the psychological health domain is in the poor category, where pleasure in life, the meaning of life, concentration, and self-acceptance begin to decrease. A qualitative study in the USA showed that out of 195 students, 138 (71%) showed increased stress and anxiety due to the COVID-19 outbreak. In addition, several stressors were identified that contributed to increased stress, anxiety, and depressive thoughts among students. These included fears and concerns about their health and those of their loved ones (91% reported a negative impact of the pandemic), difficulty concentrating (89%), disturbed sleep patterns (86%), decreased social interaction due to physical distance (86 %), and increased concern about academic performance (82%) [33].
The study results show that MH status is related to students' QoL. Student MH status scores significantly negatively correlate with each dimension of QoL, as measured using WHOQOL-BREF. Depression has a negative and significant correlation with physical health domains r = −0.393 (p < 0.001), psychology r = −0.161 (p < 0.001), and social relations r = −0.400 (p < 0.001) but has no significant impact on environmental health r = −0.040 (p = 0.325). This means a significant relationship exists between depression and students' physical, psychological, and social health. The higher the student's depression score, the lower the student's QoL [11]. These results are consistent with a study conducted in Macau, Hong Kong, and mainland China which stated that, compared to the "No depression" group, students with depression had significantly lower QoL scores in the physical, psychological, social, and environmental domains [34]. Depressed people tend to isolate themselves from their surroundings. They get tired quickly, struggle to go asleep, have trouble staying awake, experience uncontrollable and unpleasant emotions, and lack interest in learning in students due to impaired concentration [35]. For students with low levels of depression, the strategy used is to divide time between studying and exercising, even though most activities are carried out at home, in line with research conducted by Abdullah et al. [11]. During the lockdown in Malaysia, it was found that there were changes in the daily lives of students in terms of activities that affect physical activities, such as exercising with family, which became a new routine for students to overcome boredom and maintain their physical health during the pandemic [11].
Anxiety and stress are also significantly negatively correlated with physical, psychological, and social domains. This indicates that the higher the level of anxiety and stress of students, the lower their QoL, especially in the physical, psychological, and social domains. Stress is a condition that often occurs in everyday life, especially with the pandemic as a stressor that increasingly triggers the emergence of psychological pressures. The forms of stress experienced by students during the pandemic are difficulty concentrating because they have to be isolated at home, difficulty studying lecture material, and worries about their future [36]. Another study in a public university in North Carolina showed that the problem with distanced learning and social isolation contributed to the increases in depression and anxiety [37].
In this study, MH and QoL were influenced by age, gender, family support, history of COVID-19 diagnosis, family with COVID-19 diagnosis, vaccination status, and physical symptoms, such as headache, myalgia, sore throat, and cough. A study in the United States revealed that being a woman and knowing someone infected with COVID-19 predicted higher levels of psychological impact among university students [38]. The possible symptoms of COVID-19 infection include fever or chills, cough, shortness of breath, muscle or body aches, headache, loss of taste or smell, diarrhoea, and sore throat [39,40]. The COVID-19 symptoms may persist and continue for weeks or months [41,42]. A multicentre prospective cohort study reported that the burden of persistent symptoms was strongly correlated with poorer long-term health status, lower QoL, and psychological distress in patients with moderate acute COVID-19 [43]. Support from family, neighbours, and colleagues plays an important role in helping strengthen people or families who are positive for COVID-19 in living their daily lives. The support is in the form of moral and material support, including emotional support (asking for news, encouraging), instrumental support (meeting basic needs, household needs, and medicine), information support, and logistical and financial assistance [44].
Universities, the institutions closest to and associated with students, can take roles related to MH and improving students' QoL, especially during the COVID-19 outbreak. Universities can carry out several strategies for promotion and prevention and the therapeutic process related to students' MH disorders. Psychoeducation is one of the promotions of individual action for good MH, which can be broken down into recommendations for general well-being, dealing with stress and crises, providing tips for healthy lifestyles, explaining general emotional reactions to epidemics, advising on how to cope with isolation and quarantine periods, and describing warning signs that require personal assessment or even emergency treatment [45]. Screening can also be done, especially in high-risk populations, for example having a history of mental disorders, students with poor economic conditions, and students with divorced parents. Screening should include symptoms of depression, anxiety, stress, suicidal ideation and behaviour, and insomnia, which can be early markers of mental disorders. Counselling is carried out with the aim of providing psychological support and even clinical psychology and psychiatric care. Referral assistance and funding can be applied if students require continued therapy and medication [45,46].
Teaching-related changes emphasizing MH can also be applied by implementing a fun online learning process. Features described for this learning environment include active, interactive learning, with discussion panels and group work, and inclusive learning, in the sense that the student leads and participates in teaching-related decisions [46]. Explicit instruction about academic activities can reduce uncertainty and anxiety and help students manage their time. Remedial programs and temporary suspension of payments can be included to offset possible disruptions caused by the pandemic [47,48]. Furthermore, students are encouraged to apply good time management to help balance study, rest, exercise, fun, and leisure activities [46].

Strengths and Limitations of Study
This study has received responses more than 57% higher than the minimum sample size (n = 385). The data were obtained from eighteen different provinces. Since this study collected data by spreading online survey forms using social networking sites, the actual distribution and response rate were not possible to calculate. There is the possibility of sample bias due to the distribution of the survey questionnaire online, as the respondents cannot be described, and biased respondents may re-enrol themselves in the sample.
This study examined psychiatric symptoms using a self-reported questionnaire and did not make a clinical diagnosis. The DASS 21 and WHO QoL questionnaires are initial screening and require further examination by an MH professional to determine a more accurate diagnosis. Despite a few limitations, our study is the first one that has laid a foundation to understand better the students' MH, QoL, the correlation between MH and QoL, and its associated factors. These findings could guide developing policies to address psychological problems brought on by the COVID-19 pandemic. Our results may also be used to create effective psychological and non-psychological interventions to overcome students' MH problems and minimize the negative impact on quality of life.

Conclusions
This study revealed that students reported normal to very severe levels of depression, anxiety, stress, and good-to-poor QoL during the COVID-19 outbreak. Furthermore, gender, age, family support, history of COVID-19 diagnosis, family with COVID-19 diagnosis, vaccination status, and physical symptoms, such as headache, myalgia, sore throat, and cough, are significantly associated with MH and QoL status. The findings of this study are important for improving our understanding of the MH status and QoL of university students.
The level of MH correlates to the QoL status. Urgent efforts by health officials are needed to implement some strategies that may include physical, psychological, and drug treatment to address MH issues among college students and improve their QoL. Here, we suggest some interventions that could be immediately implemented nationwide by the government and universities: (i) implementing a teaching-related process that emphasizes students' MH; (ii) providing explicit instruction about academic activities, remedial programs, and suspension of payments or financial support for students; (iii) promoting and preventing mental disorders through psychoeducation; (iv) screening for early detection; (v) since being a women, being aged 18-20 years old, having a lack of family support, having a history of COVID-19 diagnosis, and having physical symptoms, such as headache, myalgia, sore throat, and cough, are related for the possibility of having a mental disorder, the promotion and prevention programs might be a prioritized for these groups; (vi) for students who should use medicines to treat mental disorders, counselling to medicationrelated adherence and management of medication side effects if they arise is essential so that therapeutic goals can be achieved optimally; (vii) it is important to monitor the MH of students during and after the outbreak and evaluate the success of programs.

Informed Consent Statement:
The nature of the study was explained to the respondents in writing, who were asked to sign an informed consent form by clicking "agree to participation" to confirm their participation. Data Availability Statement: Data are contained within the article.