Assessing the Psychological Impact of COVID-19 among College Students: An Evidence of 15 Countries

Mental health issues among college students is a leading public health concern, which seems to have been exacerbating during the COVID-19 pandemic. While previous estimates related to psychological burden among college students are available, quantitative synthesis of available data still needs to be performed. Therefore, this meta-analysis endeavors to present collective evidence discussing the psychological impact of COVID-19 among college students. Bibliographical library databases, including Embase, Medline, CINAHL, Scopus, and PsycINFO, were systematically searched for relevant studies. Titles, abstracts, and full articles were screened, and two reviewers extracted data. Heterogeneity was assessed by I2 statistic. The random-effects model was utilized to obtain the pooled estimates of psychological indicators among college students. Location, gender, level of severity, and quality scores were used as moderator variables for subgroup analyses. Funnel plot and Egger linear regression test was used to assess publication bias. Twenty-seven studies constituting 90,879 college students met the inclusion criteria. The results indicated 39.4% anxiety (95% CI: 28.6, 51.3; I2 = 99.8%; p-value < 0.0001) and 31.2% depression (95% CI: 19.7, 45.6; I2= 99.8%, p < 0.0001) among college students. The pooled prevalence of stress (26.0%), post-traumatic stress disorder (29.8%), and impaired sleep quality (50.5%) were also reported. College students bear a disproportionate burden of mental health problems worldwide, with females having higher anxiety and depression levels than males. This study‘’s findings underscore the need to develop appropriate public health interventions to address college students’ emotional and psychosocial needs. The policies should be reflective of demographic and socioeconomic differentials.


Introduction
By and large, college students generally experience several challenges, including starting new relationships, new life experiences, often new living situations, often an exploration of their sexual identities, usually academic pressures, need for time management, and sometimes balancing study, work, and personal life [1]. A study of college students investigating the psychological correlates found that the top concerns among this subgroup include pressure to succeed, educational performance, and post-college graduation plans [2,3]. These challenges make these students vulnerable to distress and associated negative sequelae such as depression, anxiety, insomnia, suicidal ideation, and adoption of maladaptive behaviors [1][2][3].
Mental health issues are alarmingly high among college students, particularly in the United States, with every eight in ten students experiencing frequent stress episodes in

Protocol Registration
The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed for this study [31]. This study's protocol was registered with the National Institute for Health Research (CRD42020203560), which serves as a prospective systematic review register. A detailed protocol can be found at https://www.crd.york.ac. uk/PROSPERO/display_record.php?RecordID=203560 (accessed on 16 February 2021).

Eligibility Criteria
We adapted the eligibility criteria used in the previous reports [27] to identify noninterventional and quantitative studies assessing the psychological impact of COVID-19 among college students. Studies were grouped according to the type of psychological morbidity observed, location (continent/country), quality score, and assessment method. Studies were included which met the following criteria: (1) use of the English language; (2) published from the inception of the pandemic to 27 July 2020; (3) utilized survey tools with good psychometric properties, and (4) full texts of the studies were available. Studies with the following characteristics were excluded: (1) Studies performed on populations other than students; (2) study designs utilizing descriptive, mixed-methods, qualitative approaches; (3) studies with unclear methodology or unvalidated survey tools; (4) studies using a language other than English; (5) studies conducted after 27 July 2020; (6) studies conducted among adolescents/students with pre-existing mental conditions, such as Attention Deficit Hyperactivity Disorder (ADHD); and (7) studies lacking the individual estimates for students.

Search Strategy
An experienced medical librarian (NS) designed the Medline search and then translated that search for use in the other databases [27]. When available, a search limit to the English language was applied, as was a publication date limit of 1 December 2019 to 27 July 2020. The search strings consisted of natural language terms and (when available) controlled vocabulary representing the concepts of "COVID-19" and "psychological outcomes." A detailed search strategy can be found in Appendix A, Box A1.

Selection Process
The search results were imported to Rayyan for the screening process. Two investigators (KB and MS) were involved in the screening of titles and abstracts to assess the articles' relevance with the research objective ( Figure 1, Identification step). During the second level of screening, KB and MS independently evaluated all potential full-text articles ( Figure 1, Screening step). In case of disagreements, the consensus among reviewers was built through discussions. The included publications addressed the psychological outcomes of COVID-19 among students. If multiple studies from the same authors were found, only the most recent manuscript was included in the analysis to avoid duplicate data bias. If any data discrepancies were noted in the articles, corresponding authors were contacted for verification.

Data Collection
Full-text articles were obtained for all studies that initially met the inclusion criteria. Two independent reviewers (KB and RB) abstracted all studies for potential inclusion and quality using a customized data abstraction form, resulting in an interrater agreement of 81%. Inconsistencies between reviewers were adjudicated by a third independent reviewer (MS). Information related to study authors, publication year, study location, gender distribution, number of subjects, type of survey tool with the cut-off criteria, and the proportion of subjects with positive psychological outcomes were collected in a spreadsheet. Data were reviewed twice to ensure accuracy. We also attempted to contact corresponding authors of the primary studies to verify the accuracy of data points (if needed).

Assessment of Risk of Bias in Primary Studies
The National Institutes of Health (NIH) quality assessment tool was utilized for the risk of bias assessment. Two reviewers (KB and MS) independently evaluated the risk of bias and assigned the quality scores based on the tool's dictionary and guidelines (Appendix A, Table A1). The overall quality score was assigned according to the tool guidelines. In case of disagreements, the consensus among reviewers was built through discussions.

Measures of Effect and Data Analysis
The Comprehensive Meta-Analysis Package (CMA version 3.0, Englewood, NJ, USA) was utilized to compute the pooled estimates of psychological outcomes, including anxiety, depression, and other psychological indicators. The effect measure was the proportion of anxiety and depression events. The logit transformation of the proportions was used to meta-analyze the data. The Clopper-Pearson method was used to calculate exact confidence intervals for individual studies. Owing to methodologic differences across studies, a random-effects model was used to extract the pooled estimate [32]. Substantial heterogeneity was defined as I 2 > 75% [33]. Subgroup analyses by continent (Asia vs. other), country (China vs. other), survey tool, study quality, gender, and levels of psychological outcomes were performed. Sensitivity analysis or leave-one-out analysis was also conducted to determine the impact of different weights assigned to each study on the final results. Funnel plot and Egger linear regression test statistics were utilized for publication bias [27,34]. p-values less than 0.05 were considered significant.

Assessment of Evidence
We assessed the certainty of the overall evidence based on the quality of individual studies and scientific rigor of the methodology used in each study. Two reviewers assessed the quality of the evidence and did not know each other's decision.

Selection of the Dtudies
A total of 7276 relevant records were identified following systematic and manual search ( Figure 1). The titles of the remaining 3860 records (after removing 3416 duplicates) were screened, of which only 489 articles advanced to the abstract screening step. Only 78 articles were found eligible (51 articles excluded) for the full-text screening, which later reduced to 27 articles for the final review or analysis. Reasons for exclusion are listed in Figure 1.

Characteristics of Included Studies
Twenty-seven studies (Appendix A, Table A2) [19,25, with a sample size of 90,879 students were finally assessed for generating pooled estimates. Eighteen studies were from Asia (14 from China, 1 from India, 1 from Israel, 1 from Jordan, and 1 from Saudi Arabia), seven were from Europe (two from Turkey, one from France, one from Greece, one from Italy, one from Russia and Belarus, and one from Albania), and two were from South and North America (one each). The median number of individuals across studies ranged from 66 to 44,447, with males constituting only 35% (n = 31,536) of the entire population. The remaining 50.4% (n = 45,824) of the sample constituted females. For the remaining 15% of the gender data, individual estimates for students were not provided.

Certainty of the Evidence
All primary studies were cross-sectional; therefore, the quality of the evidence would be moderate. However, most of the studies included in this analysis were of fair and good quality, which contributes to the certainty of the current meta-analysis evidence.

Discussion
The current metanalysis included 27 studies with a sufficiently large sample of (N = 90,879) college students to explore psychological dimensions during the pandemic. Prior studies and a few systematic review protocols [26] investigated the association between psychological health outcomes and COVID-19, but quantitative synthesis was lacking. To our knowledge, the current meta-analysis provides the first collective evidence of the negative psychological burden of COVID-19 on the mental health of college students. This evidence is critical to inform colleges, universities, and other educational institutions in designing interventions and policies to improve college students' mental health. Previous global evidence indicated that psychological morbidities were long-standing issues among college students even before the pandemic, with nearly 50% of mental issues starting at an early age of 14 years [60][61][62]. Globally, suicide remains among the leading causes of death among adolescents, which warrants the need to develop early interventions to address this population's mental health and emotional needs [62]. The consequences of not addressing these concerns during the early phases of life will be dire. A lack of early intervention may lead to psychological morbidities in later life phases [62]. Regarding the pandemic, it is important to intervene early to promote post-traumatic growth among students in existing and repairing phases of the pandemic. Our findings suggest a higher prevalence of anxiety (39.4%), depression (31.2%), and stress (26.0%) than those reported in the pre-pandemic period with 22.1% anxiety, 19.7% depression, and 13.4% stress [60][61][62]. Corollaries associated with COVID-19, including uncertainty and fear, exert an additional driving force to explain these rising trends [24]. The timeline to graduation, sudden transition to virtual learning, quality and logistics of internships, and post-graduation plans are all in uncertainty, causing significant distress among college students [24,52]. Association of other contributing factors, such as compliance to the new rules, propagation of ambiguous messages through media, and lack of scientific understanding, need to be explored fully to design a holistic public health approach to address mental health challenges among college students [60,62].
Additionally, young people like to socialize and indulge in parties and celebrations, which have been restricted in pandemic times, adding to their frustration levels [52,53,57]. Some students who receive counseling services have not been able to receive such support. Many students who work part-time jobs have lost their employment (voluntarily or employer initiated) during COVID-19, causing financial distress [24,52,53,57]. According to a study of 69,054 French students, nearly 42.8% of students reported having at least one negative mental health outcome; of those, only 12.4% sought assistance from healthcare professionals [24]. The stigma associated with seeking mental health support has been cited as a primary factor of underreported mental health issues among adolescents [62]. Among risk factors, the female gender is associated mainly with psychosocial health [24,53]. Females were twice as likely as males to experience mental health issues [24]. Our study found a significant gender gap in psychological morbidities. Females had significantly higher anxiety levels (34.6% vs. 22.9%) and depression (32.4% vs. 26.0%) than males. This finding was consistent with previous studies [24,63,64]. The gender differences may be attributed to a higher prevalence of pre-existing mental health conditions among females than males, complicated by introversion, higher sensitivity to traumatic events, and other factors, including hormonal imbalances and genetic vulnerability, and a higher mental health stigma among men [64][65][66]. Additional evidence reported that it is likely that mental health issues among men are underreported because of their tendency not to seek help from others [67].
We found a wider variation while making country comparisons. Anxiety and depression reported out of Asian countries were lower compared to other countries. Traditional close-knit family systems in Asia can be a protecting factor overriding one significant risk factor of social isolation, which has shown to contribute to increased risk of mental health issues [66]. Additionally, Asian countries, especially China and India, have traditional medicine with products and services widely available that are acceptable, affordable, and culturally appropriate. Most importantly, these have been adopted by the various Asian countries' health care systems [68]. However, the efficacy of traditional medicine has not been fully proven in counteracting mental health problems.

Strengths and Limitations
This meta-analysis is the first to assess the psychological impact of COVID-19 among students. It is urgent and essential to know the global scope of the issue. This population group is already facing a disproportionate burden of psychological morbidities even before the pandemic. This study also has some limitations. First, the self-reporting nature of the data collected by the studies in our meta-analysis might not be an accurate representation of the clinical diagnosis of the psychological illness. Second, sampling bias may exist because nearly 66.6% (18 out of 27) of the studies were conducted in Asia and predominantly China (51.8%; 14 out of 27). The larger pool of studies from China may presumably be due to the greater interest of the Chinese researchers in unfolding the epidemiology of COVID-19, as China was the first country to be affected by COVID-19. Other countries might have other research priorities prior to the pandemic inception, which occurred two months following the pandemic emergence in China. Third, all studies included in this metaanalysis were cross-sectional, which only account for prevailing circumstances, thereby lacking a longitudinal aspect to encounter temporality. Fourth, the studies included were only published in the English language, which might have introduced a language bias. Last, most of the studies included in this meta-analysis did not provide the year-wise, program (undergraduate/postgraduate), and type of course (e.g. STEM vs. non-STEM) stratifications of the students, which restricted our ability to determine differences in psychological morbidities among these groups. Future studies can be designed to account for differences in psychological outcomes across different groups of students to design a more targeted interventional approach.

Implications for Practice
This study advocates for designing and implementing appropriate interventions or programs to promote the mental health of students. The new policies and interventions will need to address gender differentials, such as designing tailored interventions for girls to address their specific needs. The use of telehealth has also been expanded in COVID-19, which can be used to offer remote counseling interventions across school or college campuses. Online implementation of mental health programs should be emphasized in lower or middle-income countries, which was reported to be a neglected field despite having good internet use [68]. Regular counseling centers for in-person visits across campuses with limited access to technology can also be beneficial. Besides, efforts should be directed towards increasing the quality of mental health services provided to the students. Mental health services provided by trained staff are improving. However, there are some gaps to be filled. According to the Association for College and College Counseling Center Directors (AUCCCD), comprising counseling directors of educational institutions from the United States, Canada, Europe, the Middle East, Asia, and Australia, one in five centers on their campus were reported to be lacking the optimum quality of mental health services [61,62]. The guided ways of stress management as implemented in certain universities in the US can be tailored towards a more comprehensive virtual delivery during the times of COVID-19. The American Council on Education advisory for the leadership ensures readiness of campuses for handling the increased burden on students' mental health. This involves regularly performing the needs assessment of college students from diverse backgrounds to design prospective policies and interventions. Healthy Minds Study or the American College Health Association-National College Health Assessment are examples that can be launched campus-wide to collect data for assessment and targeted intervention development.

Conclusions
College students bear a disproportionate burden of mental health problems worldwide, with females having higher anxiety and depression levels than males. This study's findings underscore the need to develop appropriate public health interventions to address adolescents' emotional, psychological, and social needs. The policies should be reflective of demographic and socioeconomic differentials. (2019nCoV or 2019-nCoV or coronavirus or coronavirinae or (corona adj3 (virinae or virus)) or "Corona virinae19" or "Corona virinae2019" or "corona virus19" or "corona virus2019" or Coronavirinae19 or Coronavirinae2019 or coronavirus19 or coronavirus2019 or covid19 or COVID-19 or SARS-CoV-2 or "Severe Acute Respiratory Syndrome Corona virus 2" or "Severe Acute Respiratory Syndrome Coronavirus 2" (stress* or "adaptation syndrome" or (caregiver adj4 (burden or fatigue)) or "compassion fatigue" or "reality shock" or "social defeat" (drowsiness or dyssomnia* or hypersomnia* or insomnia* or parasomnia* or sleepless* or sleepwalk* or somnambul* or somnolen* or sopor or (sleep adj5 (disorder* or disturbance* or fragmented or debt or depriv* or walk*))).ti,ab,kw. [   Q14. Measurement of key potential confounding variables and statistical adjustment for their impact on the relationship between exposure(s) and outcome(s); Rating-Good, Fair or Poor: Good = (7-9 yes); fair = (4-6 yes).