Impact of Three Waves of the COVID-19 on Students of Higher Education Institutions—Challenges and Way Forward

Study Selection and Eligibility Criteria

Each publication was screened based on titles and abstracts. Then, the full-text articles were reviewed to check whether they were eligible for inclusion. The inclusion criteria for the study were that (1) the study should be a cross-sectional study, (2) it should address the psychological impact of COVID-19 among university/college students and its associated risk factors, (3) it should use standardized scales for measurement, (4) it should be published in peer-review journals, and (5) it should be published during the period of January 2020 to September 2022. The exclusion criteria were (1) studies not in English, (2) non-peer-reviewed journals, (3) literature not related to search/keywords, and (4) papers published before and after the specific period of the study.

Data Extraction and Synthesis

The authors extracted the following information from the full text: authors and year of publication, the country in which the study was done, study design, sample size, instruments used, number of participants, the prevalence of symptoms of stress/anxiety/depression, and associated risk factors.

Study Characteristics

A total of 122 pieces of literature were identified for this analytical review. Of those, 20 studies were excluded due to duplication. Sixty articles were removed based on the screening of titles and abstracts. Forty-two articles were accessed for eligibility and out of it 22 full-text articles were excluded (10 reviews, 7 qualitative studies, and 5 mixed-method studies). Hence, 20 studies met the inclusion criteria and were included in the review. Twenty cross-sectional studies were conducted in 12 countries, including the United States of America (n = 2), China (n = 1), Ethiopia (n = 1), Bangladesh (n = 3), Malaysia (n = 2), Greece (n = 1), Kosovo (n = 1), Egypt (n = 1), Jordan (n = 1), Pakistan (n = 1), Indonesia (n = 1), and India (n = 4). A variety of scales were used for measuring the psychiatric outcome of the studies (n = 20). The Depression, Anxiety and Stress Scale- 21 items (DASS-21), Perceived Stress Scale (PSS), Generalized Anxiety Disorder Scale- 7 (GAD-7), Positive and Negative Affect Schedule (PANS), Penn State Worry Questionnaire (PSWQ), Patient Health Questionnaire (PHQ), Zung’s self-rating anxiety scale (SAS), Subclinical Stress Symptom Questionnaire- 25 (SSQ-25), Beck Depression Inventory (BDI), Hospital Anxiety and Depression Scale (HADS), and Hamilton Anxiety Rating Scale (HAM-A) were used to assess the depression, anxiety, and stress symptoms. Impact of Event Scale-Revised (IES- R) was used to evaluate the degree of distress among students in response to the COVID-19 crisis, and the Multidimensional Scale of Perceived Social Support (MSPSS) was used to measure the social support received during the pandemic.

The Psychological Impact of COVID-19 on HEI Students

The COVID-19 pandemic and its subsequent lockdown caused unique mental health issues among HEI students. Health experts say that a healthcare crisis posed a dual challenge for both the mind and body. The worldwide closure of schools and educational institutions impacted 80% of the student population (Sahu, 2020). Fear of contracting the infection is one of the sources of stress among college students. The HEI students also experienced pandemic-related problems like disrupted social rhythms and daily routines. During the COVID-19 lockdown, the student community reported a high prevalence of anxiety, depression, and insomnia (Alfawaz et al., 2021). University students are considered vulnerable to various mental health problems (Pushparaj & Vinnarasi, 2019), such as higher levels of anxiety, depression, substance misuse, and eating disorders, as compared to the general population. The burden caused during the COVID-19 pandemic has amplified these mental health problems (Browning et al., 2021). A study from the United States of America directly reported the psychological impact of COVID-19 among university students. The findings showed that the psychological impact was high among female students. Besides, higher levels of psychological impact were found among the students who were non-Hispanic Asians, with fair/poor health status, between 18 and 24 years of age, spending more than 8 hours on screens every day, and knowing someone infected with the virus (Browning et al., 2021).

While analyzing some of the high-income economies, Table 1 exposes that the students’ mental health has been affected by COVID-19 experiences. These experiences are basically based on the effects of quarantine, social distance, academic delays, fear of infection, disruption of sleep, decreased social interaction, and increased time on screens.

While investigating the impact of COVID-19 on the mental health of the students in some of the upper-middle-income economies, Table 2 reveals that the impact had been severe and the experiences of anxiety, depression, and stress were from mild to severe. They were induced by academic delays, economic stressors, frustration from loss of daily routine, disruption of study, quarantine, staying alone, remote learning, loneliness, and uncertainty related to academic performance, graduation, and future career prospects.

While investigating the impact of COVID-19 on the mental health of the students in some of the lower-middle-income economies, Table 3 reveals that in the high-income and upper-income economies, the impact had been the same, and the experiences of stress, anxiety, and depression were from mild to severe. They were caused by prolonged unemployment, financial insecurity, fear of infection, inadequate food supply, lack of social support, academic delays, lack of social interaction, worsening financial conditions, spending more time on mobiles, and concerns about future career prospects.

Risk factors of psychological problems

Discussion

The current review explored the psychological impact of COVID-19 on university/college students and its predictive factors. In general, there is an increased prevalence of psychiatric symptoms among students compared to their prevalence before the pandemic (Huang et al., 2019). The prevalence rate of depression, anxiety, and stress ranges from 21.2 to 82.4%, 3.82 to 87.7%, and 11 to 81.2%, respectively. Variations in the prevalence rate were found in the studies, which could be due to various tools used for measurement, cutoff scores of the instruments, reporting patterns, cultural differences, social support systems, the infection rate in the study area, etc. The regional difference was observed in the prevalence of mental health problems among the students during the outbreak of COVID-19, which could have resulted from the availability of health infrastructure, quality of governance, economy, policy response, and dissemination of information during the COVID-19 crisis. However, the issues mentioned above were not identified in the studies during the review, limiting the findings’ generalizability. Several contributing factors were also identified in the review. For example, the female students reported a significant increase in the level of depression, anxiety, and stress symptoms during the pandemic compared to their male counterparts (Arënliu et al., 2021; Aylie et al., 2020; Biswas & Biswas, 2021; Browning et al., 2021; Ghazawy et al., 2021; Salman et al., 2022; Wathelet et al., 2020). A higher level of psychological impact was predicted in the age group of 18–24 years (Browning et al., 2021; Wathelet et al., 2020). Further, students in their early 20s reported a higher level of depressive symptoms (Islam et al., 2020), and anxiety (Biswas & Biswas, 2021; Sundarasen et al., 2020), due to the closure of educational institutions.

Students with a history of medical illness have reported a higher level of depression, anxiety, and stress symptoms during the COVID-19 pandemic due to compromised immunity caused by pre-existing conditions (Aylie et al., 2020; Corse et al., 2020; Ghazawy et al., 2021). Having a poor/fair general health status was found to be associated with higher levels of psychological impact (Browning et al., 2021). This could be due to the postponement of treatment and lack of access to medical services during the COVID-19 pandemic. Additionally, during the pandemic, external stress factors like social isolation lead to loneliness and boredom have a significant effect on the physical and mental health of the students. Many studies have identified a strong link between excessive social media exposure and psychological problems (Arënliu et al., 2021; Browning et al., 2021; Khan et al., 2020). Seeking more COVID-19-related information through social and mass media has amplified anxiety and stress levels among students (Khan et al., 2020). Further, fake news reported on social media is one of the causative factors for stress and anxiety. Studies have reported that learning through online platforms has given rise to the prevalence of anxiety, stress, and depressive symptoms (Arënliu et al., 2021; Sundarasen et al., 2020). In addition, the abrupt switch from traditional face-to-face to online learning likely diminishes students’ academic motivation as they face additional self-regulated learning challenges (Sukhawathanakul, Hadwin, Rostampour, Bahena Olivares, & Shostak, 2022). Online learning has disrupted the students’ social lives with their peers in university/college and has led to social isolation. Further, excessive use of mobile phones than usual during the lockdown was associated with negative emotions (Browning et al., 2021; Ravichandran et al., 2020). Closure of colleges/universities has reduced students’ contact with their friends, and induced psychological distress reported in many countries (Ravichandran et al., 2020; Son et al., 2020). Studies have suggested that lower family income, academic delays, and increased concerns about academic performance and career prospects were found to be associated with a higher level of anxiety, perceived stress, and psychological distress during the pandemic (Aylie et al., 2020; Browning et al., 2021; Cao et al., 2020; Dhar et al., 2020; Khan et al., 2020; Ravichandran et al., 2020; Satpathy & Ali, 2020; Sundarasen et al., 2020). Studies also identified that poor social support from families, society, and educational institutions; having relatives and friends being infected with the pandemic; fear of contracting the COVID-19 virus; losing part-time jobs, prolonged unemployment, financial uncertainty, inadequate food supply, and lack of physical exercise are the significant predictors for developing psychological symptoms (Islam et al., 2020; Khan et al., 2020).

The findings indicate that educational institutions should consider providing psychological support to the most vulnerable students by embarking on structured programs like life-skills training and mindfulness therapy to reduce anxiety levels; providing psychological-oriented services to mitigate the emotional impact of the outbreak; staying connected with students using social media platform and motivating them to move forward during the crisis; training the educators in basic aspects of students mental health care; educating the students about the psychological effects of COVID-19 pandemic along with multidimensional psychological interventions like Cognitive Behavioural Therapy (CBT), psycho-education, behavioral activation; (Arënliu et al., 2021; Aylie et al., 2020; Chakraborty et al., 2020; Ghazawy et al., 2021; Sundarasen et al., 2020). Individuals’ efforts like regular physical activity, maintaining healthy dietary habits, interacting with family members, focusing on healthy lifestyle changes, relying on trusted sources of information related to the COVID-19 pandemic, using Internet sites effectively and avoiding excessive exposure to media coverage can help students to deal with the negative psychological impact of the COVID-19 pandemic (Adefris & Moges, 2021; Biswas & Biswas, 2021; Carek, Laibstain, & Carek, 2011; Dhar et al., 2020; Pushparaj et al., 2022). Further, academic institutions must re-evaluate curriculums, learning outcomes, and evaluation strategies to provide effective online courses.

Universities must prioritize mental health awareness to empower students during such disasters. Higher education should continue providing counseling to their students (tele-mental health counseling). Since tele-mental health counseling has been shown to be effective in treating anxiety and depressive symptoms (Brenes, Danhauer, Lyles, Hogan, & Miller, 2015), implementing it will facilitate counseling services to address students’ pressing mental health concerns. Students can also join online support groups to share their concerns and seek social support through counseling centers (Rollman et al., 2018). Furthermore, university counseling centers and other departments should disseminate public health messages to students and provide them with the necessary skills to preserve their mental health.

Interventions and Strategies

The interventions and strategies to help HEI students to overcome the psychological impacts during the multiple waves of COVID-19 need to be addressed at three levels: at the individual level, family level, and educational institutional level (Figure 1).

Figure 1 Interventions and strategies at various levels.

Interventions at Individual Level

At the individual level, the students can adopt to any one or two strategies proposed in Table 4.

Most of the strategies suggested here are very easy to adopt and practice even in the worst situations like COVID-19. Yoga and meditation (Nagendra, 2020; Pushparaj et al., 2022) are the most important and effective strategies to follow. This can be learned even through social media platforms if someone is a beginner. Learning and doing mindfulness activities (Koner & Weaver, 2021) and self-care practices (Brouwer et al., 2021) help one to overcome the challenges of mental health.

Building resilience in oneself helps to improve one’s well-being (Giordano, Cipolla, & Ungar, 2022). Optimism is one of the important virtues required for everyone. It helps in overcoming psychological stress in life and to find meaning in life (Arslan & Yıldırım, 2021). It is very important to keep oneself cheerful and to develop a sense of humor to enhance one’s well-being (Saricali, Satici, Satici, Gocet-Tekin, & Griffiths, 2022). Maintaining positive thoughts (Bakioğlu, Korkmaz, & Ercan, 2021) and practicing self-compassion helps one to improve his/her well-being (Gutiérrez-Hernández et al., 2021).

Interventions at the Family Level

Family plays an important role in enhancing the overall well-being of students. During the COVID-19 lockdown, the family members got the chance to spend more time with each other (Table 5).

Family bonding is identified as one of the coping mechanisms to preserve mental well-being (Alfawaz et al., 2021). Family bonding plays a vital role in overcoming psychological distress (Avasthi, 2010). Helping the students to forgive people who have hurt them in one way or the other helps them to overcome bitter feelings and to improve their overall well-being (Ciencia, Barry, & Toussaint; Pushparaj et al., 2022).

Helping students to practice kindness to themselves and to others is one of the wonderful gifts a family can instill in the lives of young people (Symeonidou, Moraitou, Pezirkianidis, & Stalikas, 2019). As a family, it is important that it builds up their resilience by strengthening the bond among them and enjoy the presence of each other and bases itself on a good value system and builds up strong communication among the family members (De Rosa & Rizzolli, 2021; Gayatri & Irawaty, 2022).

Interventions at HEIs Level

Educational institutions have a greater responsibility of taking care of their students in situations like the COVID-19 pandemic. Most of the institutions found innovative ways to connect to their students and helped them (Table 6).

Six studies from Saudi Arabia have directly addressed the universities’ role in providing psychological support to students (Arënliu et al., 2021; Aylie et al., 2020; Cao et al., 2020; Chakraborty et al., 2020; Ghazawy et al., 2021; Sundarasen et al., 2020). In addition, two studies have examined the crucial role of the government to address the mental health concerns of university/college students during the COVID-19 crisis, such as developing health system strategies to provide crisis-oriented psychological services (Aylie et al., 2020) and working closely with the university to deliver economic psychological support (Islam et al., 2020). Several studies have addressed the following intervention strategies for universities/colleges to support vulnerable students during COVID-19: (1) embarking on structured programs like life skills training and mindfulness therapy to reduce anxiety levels (Sundarasen et al., 2020); (2) providing psychological services to mitigate the emotional impact of the outbreak (Browning et al., 2021; Ghazawy et al., 2021); (3) staying connected with students using social media platform and motivating them to move forward during the crisis (Islam et al., 2020); and (4) educating the students about the psychological effects of COVID-19 pandemic along with multidimensional psychological interventions like CBT, psycho-education, behavioural activation, etc. to cope with the current crisis (Khan et al., 2020). The importance of social support during the COVID-19 crisis was addressed in two studies (Biswas & Biswas, 2021). Further, a study from Ethiopia has discussed the following strategies that can help students to deal with the negative psychological impact of the COVID-19 pandemic: regular physical activity, interacting with family members, focusing on healthy lifestyle changes, relying on trusted sources of information related to the COVID-19 pandemic, using Internet sites effectively and avoiding excessive exposure to media coverage (Adefris & Moges, 2021).

Interventions at Community Level

Interventions at the community level are very important for the students with mental health issues (Table 7).

One of the important interventions at the community level is to provide mental health services to community members. It helps to screen people and to identify early signs and symptoms of mental health issues (Iheanacho et al., 2015).

It also helps in educating the community members about mental health issues and to come out with community-level strategies to promote positive mental health. Wherever it is required, the community can provide a support system to take care of their members’ mental health (Bourns & Holt, 2003).

The community can provide commonplace/gym to do physical exercises and can organize several sports activities to keep the youth active and to promote positive mental health (Appelqvist-Schmidlechner et al., 2018; Wang & Xing, 2022). The community can also organize several creative cultural events to keep the community together and to promote positive mental health (Cohen et al., 2007; Kading et al., 2015).

Interventions at Policy and Governance Level

Interventions at the policy and governance level are very important to promote positive mental health (Table 8).

At the policy and governance level, there is a need to come up with lots of creative programs and initiatives. These initiatives need to be promoted and implemented at all the HEI. In order to give due importance to mental health, a separate center under the health department to promote mental health has to be created. This center should conduct trainings, courses to train mental health professionals and appoint them in every HEI (Palaniswamy, Panneer, Pushparaj, & Rose, 2022).

There should be a resource center at national, state, and district levels to address mental health issues and to promote positive mental health. The government should appreciate and promote digital technology-based applications to promote positive mental health (Johnson, Sanghvi, & Mehrotra, 2022; Teachman, Silverman, & Werntz, 2022).

Suggestions and Way Forward

Every university/college should add to their curriculum a course on positive mental health for all the students. The promotion of positive mental health activities needs to be encouraged both for faculties and students. It would be more appropriate to have a center in every HEI to promote human happiness and positive mental health.