Mental Health Disorders among Students from Rural Areas Three Months after Returning to School: A Cross-Sectional Study among Polish Students

: Background: All over the world, the negative impact of the COVID-19 pandemic on children’s and adolescents’ mental health has been observed. The conducted research aims to verify whether returning to school, to education inside the classroom in the company of their peers, improved or undermined the students’ mental health. Methods: The study was carried out on a sample of students inhabiting rural areas in a borderland region. The research sample was collected using purposive sampling and consisted of 552 respondents from the seventh and eighth grades of primary school. An auditorium questionnaire was used to gather the research material. Results: Three months after returning to school, the students were in a poor mental state; 61% of the respondents were satisﬁed with their lives, while 52% showed symptoms of depression as measured with the WHO-5 index, whereas 85% of the respondents have average and high stress levels as measured with the PSSC scale. Higher levels of mental disorders were observed among female respondents and in those students living in villages and evaluating their ﬁnancial status as worse. Conclusions: Returning to school failed to have a positive impact on the students’ mental health. Disorders occurring on a large scale will have a negative inﬂuence on the students’ performance and hinder their re-adaptation to the school environment. Educational authorities should immediately provide the students with support and monitor the situation over the coming months.


Introduction
Numerous studies carried out on children and adolescents indicate frequent occurrences of anxiety disorders, depression, conduct disorders and hyperkinetic disorders [1][2][3][4]. The question of emotional disorders is an issue connected with the adolescents' stage of life; such problems occur frequently during adolescence [5,6]. Nonetheless, the COVID-19 pandemic and the problems it has caused, such as extended screen time, isolation from peers, limited freedom and lack of privacy have increased the level of mental disorders in this age group [7][8][9][10][11].
The return to school at the end of May 2021 after eight months of distance education was long-awaited, both by the students and their parents. It was expected that returning to school and meeting their teachers and peers would have a positive impact on the students' mental health, as was indicated by research conducted not long before the beginning of the school year in September 2021 [12].
Nevertheless, when the pandemic and the need for distance education began, the occurrence of trauma among students was predicted. This trauma was expected to make re-adapting to the school environment more difficult for the students [13,14]. It was claimed that after returning to school, the levels of depression, suicide, post-traumatic stress disorders and the consumption of psychoactive substances would increase [14]. Research conducted after the students' return to school partially confirms the above theory [15]. Research into the long-term effects of distance education has only just begun. It is possible to measure the effects of a long period of isolation and distance education after three months of the students' stay in school. The main aim of the study was to estimate the levels of mental health disorders among primary-school seventh-and eighth-graders. Yet another research goal was to evaluate the mental health of adolescents inhabiting rural areas in the borderland region. It is a crucial context since the majority of studies have been conducted using online surveys, in which middle-class students inhabiting metropolises are those who participate most often. What is more, the pandemic and distance education were experienced differently in rural areas. The children there were less exposed to social isolation and the lack of contact with peers. Nonetheless, different difficulties related to the pandemic, such as a deterioration in their financial condition or the occurrence of domestic violence, might be worse in rural areas.
In the study, the following hypotheses were verified. The first hypothesis predicts that the students' mental well-being three months after returning to school is good. The second hypothesis indicates that the higher the level of financial deprivation in the students' families, the higher the level of mental health disorders. The disorders are more often observed among girls.

Procedure
The research was conducted using the survey method. During their lessons, the students were given paper questionnaires in which they marked their answers, as most of the questions were of the multiple-choice type. In order to conduct research among the students, the consent of the Ethics Committee, as well as that of school principals and parents, was obtained.
The research sample was selected using purposive sampling. All the students who were present at school on the day of the research in the area of the Strzyżów poviat, which is classified as a borderland region, were surveyed. Due to this procedure, it was possible to gain knowledge about the situation of the students inhabiting this area. It is the first study of this kind carried out in Poland since the vast majority of research in this field is conducted with the use of an online survey; results obtained in this way are burdened with errors. The current research covers the students in senior grades in primary school (seventh-and eighth-graders). The research was carried out between 25 November 2021 and 30 November 2021. In total, 572 questionnaires were filled out at the schools. Ten questionnaires were rejected due to numerous missing answers or illegible handwriting. Eventually, 552 questionnaires were subjected to analysis.
In 2021, there were 1,618,372 students aged 12-15 in Poland. In the researched poviat, there were 2534 young people from this age group [16].
The study was carried out at schools that had more than 10 students in one class. There were 9 such schools in the area of the poviat. Two schools were located in cities with approximately 8000 inhabitants. The other schools were located in rural areas.

Instruments
The questions in the questionnaire were divided into three sections. The first section contained questions regarding the identification of problems occurring during distance education. The second section includes indices and scales used to measure mental health disorders. The third section covers the sociodemographic characteristics of the respondents.
The WHO-5 Well-Being Index, which consists of five items, was used to measure the levels of depression. The respondent is asked to rate how well each of the 5 statements applies to him or her when considering the previous 14 days. Each of the 5 items is scored from 5 (all the time) to 0 (none of the time). Therefore, the raw scores theoretically range from 0 (the absence of well-being) to 25 (maximum well-being). For ease of data analysis, the overall score of 25 is multiplied by 4, which gives a maximum score of 100. A cut-off score of ≤50 on the WHO-5 index is used to assign a "screening diagnosis" of depression [18]. The index in the conducted research scored highly for reliability; the alpha coefficient was 0.882.
Yet another scale used in the research was the Perceived Stress Scale for Children [19,20]. The scale was slightly modified and, thus, consists of 8 items. Each of the 8 items is scored from 5 (very often) to 0 (never). A higher value in the total of all 8 scored questions equated to higher stress perception (Questions 2, 6, and 7 have reversed scores). The index of the conducted research scored highly for reliability; the alpha coefficient was 0.806.

Sample
The sociodemographic characteristics of the surveyed students are presented in Table 1.
Half of the research sample were females and the other half were males. The average age of the surveyed students was 13. Most of the students inhabited villages and came from small families. Most of the respondents evaluated their financial status as good. They came from families with an average social status. The students also had an average cultural capital, which is indicated by the average number of books they possessed. The majority of respondents declared that they had average and high school achievements.

Results
The evaluation of the mental health of the students inhabiting the borderland region was carried out on the basis of three indices. The first general index of well-being indicates that 8% of respondents were definitely dissatisfied with their lives (n = 46), while 12% of the respondents claim to be rather dissatisfied (n = 67). In addition, 39% of the respondents declared that they were rather satisfied with their lives (n = 213), whereas 22% of the respondents maintained that they were definitely satisfied (n = 120). Finally, 19% of the surveyed students (103) could not evaluate their well-being.
The obtained results indicate that 61% of the respondents have good levels of wellbeing. Even worse results were obtained in the measurement of mental health with the use of the WHO-5 index. The overall score for the researched sample was M = 48.6; SD = 26.8. According to the acceptance criteria, the cut-off score was ≤50 [18]. In the research sample, such a score was achieved by 52% of the respondents (n = 275). The distribution of answers is presented in detail in Table 2. The answers show that the students are coping with a lack of energy, boredom, anxiety and stress.   (15) 147 (27) 124 (23) 64 (12) 100 (18) 30 (6) 2. I have felt calm and relaxed 69 (13) 95 (17) 109 (20) 86 (16) 113 (21) 77 (14) 3. I have felt active and vigorous 76 (14) 97 (18) 113 (21) 96 (18) 104 (19) 61 (11) 4. I woke up feeling fresh and rested 67 (12) 68 (12) 78 (14) 66 (12) 112 (20) 157 (29) 5. My daily life has been filled with things that interest me 70 (13) 91 (17) 81 (15) 72 (13) 140 (26) 93 (17) The next mental health index is the Stress Scale for Children. Thanks to the scale, it was possible to determine the range of stress among the surveyed students. The PSS-C may be helpful for the early identification of children at risk of chronic anxiety/stress [19]. The overall score for the researched sample was M = 16.1; SD = 5.92. According to the modified criteria for 8 items (see Table 3), low stress levels (scores 0-10) were indicated by 17% of the respondents (n = 88). Moderate stress (scores 11-21) was indicated by 64% of the surveyed students (n = 335), whereas high stress (scores 22-32) was indicated by 19% of the respondents (n = 100). The results in Table 3 show that the students were under the influence of stress, which occurred when they attended school.
The final part of the analysis is an attempt to determine the mental health risk factors among students, while taking their sociodemographic characteristics into account (Table 4). The results of the correlation analysis indicate that life satisfaction is higher among students from cities and among those who evaluate their financial status as being better. Depression, which was measured using the WHO-5 index, occurs more often among girls than among boys. It is more frequent among students who evaluate their family financial status as being average. Higher depression scores were achieved by those students with low school performance. The PSS-C stress index was more frequent among girls; higher scores were achieved by the students from villages and the students who evaluate their financial status as worse. This is confirmed by the results of variance analysis, which shows a detailed division of average values in the categories of independent variables (Table 5). The analyses have shown that the main risk factor for a mental health disorder at this age is being female. Living in a village and having a negative evaluation of one s financial situation also have detrimental effects on one's mental well-being.

Discussion
The results of the research disprove the first hypothesis, which predicted that the students' mental health would improve after they spent some more time with their friends. The results are consistent with the initial assumptions that the symptoms of trauma will still be observed among students [14]. Half of the respondents were depressed, and threequarters of the respondents had symptoms of average and high stress. The obtained results are alarming, as they indicate an increase in mental health disorders among adolescents. At present, the level of life satisfaction is 61%. Many years before the pandemic, i.e., in 2009, the level of life satisfaction among adolescents was 87% [20]. In research carried out on secondary school students from rural areas, answers to this question scored 77% in 2001 and 77% in 2015 [21].
The serious condition of the students' mental health is also indicated by the scores for depression in the WHO-5 index. In Poland, more than half of the students displayed symptoms of depression three months after returning to school. Mental well-being is a serious issue among adolescents. The study carried out before the pandemic showed that the level of depression measured using the WHO-5 Index in a similar age group was 12% [22]. Furthermore, the study indicates that three months after returning to school, the level of depression among students increased. In the study carried out among this age group before they returned to school in September 2021, the level of depression, as measured using the PHQ-9 assessment, was 20% in Poland and 16% in Ukraine [12].
The increase in mental health disorders among children and adolescents is also indicated by numerous longitudinal studies that indicate a deterioration in mental health during distance education [23][24][25].
The second hypothesis has been confirmed by the study. The conducted research shows that worse mental health was observed among female students, which is also confirmed by many other studies [26,27]. The lower financial status of a household may have a negative impact on the possibility of satisfying one s needs in terms of autonomy, privacy, or access to distance education; therefore, this impact is reflected in worse mental health among children and adolescents from poorer families [28]. The collected data also indicate that students from rural areas display mental health disorders more frequently than students from urban areas, which may constitute a confirmation of the above hypothesis. It is worth mentioning that higher levels of stress among students from rural areas may result from the fact that they need more time to travel to school. This situation is also less advantageous when compared with online learning at home. Together with returning to schools, the necessity of waking up early and the difficulties connected with waiting for the bus in constantly worsening weather conditions (rain, snow, cold winds) arose. The traditional school environment generates more stress among students from rural areas rather than distance education, which is associated with the comforts of learning from home. Therefore, a comparison between the traditional conditions of school functioning and distance education may reveal another factor having a negative impact on the students' mental health.

Conclusions
Research carried out among students after three months of their attendance at school after COVID-19-related distance learning ceased indicates serious mental health problems among them. Returning to school after such a long period of distance functioning became stressful and challenging. Changes to their lifestyle, teachers' expectations and an increased number of duties became a nuisance to them and generated stress.
This alarming situation indicates the necessity for educational authorities to react immediately to the current mental health crisis, which is on the rise in schools.
The fact that the respondents come from rural areas is worth taking into account because this may result in lower willingness in students and their families to report mental health issues, as they might be worried regarding the stigma associated with such problems. The surveyed students have no access to private psychological counseling, due to limited financial resources.
The obtained results also indicate that the negative effects that eventuated due to the pandemic have had further negative repercussions and still hinder effective learning for half of the surveyed students.
The results of this research concern a sample of students who inhabit rural areas. The students who live in a city may display more serious health problems.
The results in this paper, obtained by means of a survey carried out using the auditorium questionnaire technique, are more reliable than the methodology of online surveys; thus, such research should be carried out more often on representative samples of children and adolescents, in order to diagnose the mental health condition of students in these difficult times.
The study population was enrolled by means of convenience sampling from one Polish group; it represents a specific population group and is not representative of the whole population of children and adolescents in Poland.

Funding:
The study was funded within the framework of the project, Visegrad Grants: Preventing post-COVID Social Exclusion Together (22110213).

Institutional Review Board Statement:
The study was conducted according to the guidelines of the Declaration of Helsinki and was approved by the Ethics Committee of the Pedagogical University of Krakow (R/D 0201-19/2020/07.09.2020).

Data Availability Statement:
The data presented in this study are available on request from the corresponding author.