key: cord-0867008-1v54f27r
authors: Faisal, Rajib Ahmed; Jobe, Mary C.; Ahmed, Oli; Sharker, Tanima
title: Mental Health Status, Anxiety, and Depression Levels of Bangladeshi University Students During the COVID-19 Pandemic
date: 2021-01-04
journal: Int J Ment Health Addict
DOI: 10.1007/s11469-020-00458-y
sha: a34f6f1ba8ccd9398017ffbc1ef2a6b089bb7d60
doc_id: 867008
cord_uid: 1v54f27r

The current COVID-19 pandemic has affected people of all ages across the world both physically and psychologically. Understanding COVID-19’s impact on university students’ mental health status in Bangladesh has been limited, yet is a necessary population to study, since they are particularly vulnerable to stress and mental health issues. This study assessed anxiety, depressive symptoms, and mental health status among university students in Bangladesh. The Generalized Anxiety Disorder-7, Center for Epidemiological Studies Depression Revised Scale, and Mental Health Inventory-5 were translated into Bangla and administered to university students (N = 874) online. In total, 40% of the participants had moderate to severe anxiety, 72% had depressive symptoms and 53% had moderate to poor mental health status. Moreover, path analysis showed worrying about COVID-19 and knowledge about the virus predicted anxiety and moderate to poor mental health status; knowledge and belief about COVID-19’s severity in Bangladesh predicted depressive symptoms. Thus, revealing that mental health issues were high and COVID-19 worry predicted psychopathology symptoms among Bangladeshi university students. Overall, these results, examining students’ mental health during COVID-19, in April 2020, can be helpful to compare how students have adjusted over the pandemic’s progression.

and in general have been prone to experience high levels of stress, anxiety, and depression (APA 2013; Craven 2020; Zivin et al. 2009 ). These general mental health impacts for college students have also been found among Bangladeshi students-showing that they experience high levels of anxiety and depression than adults (Mamun et al. 2019) . Within the pandemic context, Khan et al. (2020b) noted that Bangladeshi college students would specifically be an impacted group, due to these norm disruptions brought about by COVID-19.

As a part of curbing the spread of COVID-19 in its beginning months, educational institutions in Bangladesh closed, so students no longer had the sense of stability and stimulation offered by that community, and had less opportunity to be with their friends and have the social support that is necessary for good mental health (WHO 2020). On March 18, 2020, when there were only eight reported cases in Bangladesh, all the educational institutions were closed by the government for the remainder of the month, until further notice (UNICEF 2020) . Dormitories of public universities in which spatial distancing could not be preserved have remained closed for the safety of their residents. Overall, this interruption, brought on by the pandemic, of normal daily operations had already been found to cause tension and anxiety (Ansari and Yousefabad 2020) and college students are no exception to these impacts (Khan et al. 2020b) .

For example, previous studies show that outbreaks of infectious diseases have adverse effects on mental health among students, like in the last SARS outbreak (Akan et al. 2010; Petrosillo et al. 2020) ; such impacts have also been found between the COVID-19 and SARS outbreaks demonstrating similar significant associations (Petrosillo et al. 2020; Wang et al. 2020) . One sample in China found that, due to 24 .9% of university students experienced anxiety (Cao et al. 2020) . For COVID-19 experiences among Bangladeshi college students, one study found a high prevalence of mild to severe depressive symptoms, especially for those living with their families or in urban areas ). In addition, nearly 88% of students experienced mild to severe anxiety symptoms . Another crosssectional study among Bangladeshi university students, during COVID-19, found that about 47% of students reported mild to extremely severe depression levels and 69.3% reported mild to severe levels of psychological impact due to the pandemic (Khan et al. 2020a) . Although early literature for this demographic is limited, these studies do demonstrate that Bangladeshi college students experienced mental health impacts as a result of COVID-19.

This study intends to add to the early conducted COVID-19 research-and is among the first few to explore Bangladeshi tertiary level students' psychological impact and mental well-being during the first month of the COVID-19 pandemic Khan et al. 2020a) . The present study aims to assess the prevalence of psychiatric symptoms and identify psychological stress causing vulnerability and protective factors. Ultimately, these findings can help enable university administrations, government agencies and healthcare professionals to secure students' mental well-being in the face of Bangladesh's COVID-19 outbreak. In addition, these findings can be used to compare how students are currently adjusting to the pandemic; they may also be useful in understanding university students in other areas of the world.

The survey received 874 respondents from current Bangladeshi students attending universities either in Bangladesh or abroad, using the snowball sampling technique. The sample is significant based on the sample size calculation: x = Z( c / 100 ) 2 r(100-r). Bangladesh has roughly 1.3 million students currently pursuing higher education (Light Castle Analytics Wing 2019). Considering this population, we had 874 respondents as a sample where margin of error was 4.35%, confidence level was 99%, and response distribution was 50%. The minimum sample needed for 95% confidence would be 384, adding about 10 to 15% non-respondent error that becomes 423 to 442. Thus, our sample is significant, since 874 > 442. Table 1 shows the demographic characteristics of the respondents. Respondents' ages ranged from 17 years to 38 years (M = 22.83, SD = 2.79). The difference between the response of residential (those attending a Bangladesh university) and nonresidential students (who are pursuing their higher education in a university located out of the country) is very high (96.90% and 3.10%, respectively). Roughly three-quarters (76.50%) of the respondents were from an undergraduate level of education, followed by graduate (20.4%), and then doctoral (3.1%). Participants from the Arts and Humanities discipline were higher in frequency (25.20%) than other subjects, while the rate of respondents from the Education discipline was similar (23.30%).

The survey was distributed using Google Forms from April 10, 2020 through April 24, 2020. The inclusion criteria were that participants had to be a current student in higher education (undergraduate, graduate, doctoral student), from Bangladesh, and be able to read Bangla. The Google Form link, containing the survey questionnaire, was shared in different student groups on Facebook. In these groups, students were requested to participate in the survey. The survey link was also distributed to students over Facebook Messenger and email, requesting their participation and for them to share in their corresponding online student Facebook groups. 

The online questionnaire included the Generalized Anxiety Disorder 7 (GAD-7; Spitzer et al. 2006) , the Center for Epidemiologic Studies Depression Scale Revised (CESD-R-10; Andresen et al. 1994) , the Mental Health Inventory-5 (MHI-5; Berwick et al. 1991) , questions about beliefs, awareness, worry and knowledge about COVID-19, and demographic information-which asked gender, age, residential status (i.e., attending university in Bangladesh or not), level of education (i.e., undergraduate, postgraduate, doctoral), and educational discipline (i.e., Social Sciences, Arts and Humanities, Business Administration, etc.).

The GAD-7 is a 7-item valid and efficient tool for screening generalized anxiety symptoms (Spitzer et al. 2006) . In this scale, participants rated their feelings in response to seven general statements on how often they have been bothered by the given problems over the last 2 weeks (e.g., "Feeling nervous, anxious, or on edge") using a 4-point Likert-type scale [from 0 (not at all sure) to 3 (nearly every day)]. Total scores could range from 0 to 21, higher scores indicated high anxiety. Spitzer et al. (2006) reported good reliabilities and criterion, construct, factorial, and procedural validities for this scale. To use this assessment, the GAD-7 was translated into the Bangla language following the International Test Commission's guideline (ITC; International Test Committee 2018). At first, this scale was translated into Bangla by two independent bilingual experts; then, these translations were synthesized into one. Next, this translated Bangla version was back-translated into English by two other bilingual experts and were similarly incorporated into one. Following that, the contents of the original and backtranslated versions were compared to assess the discrepancy in meaning. Both had a minimal difference in meaning. Finally, this scale was placed in a pilot test where a cognitive interview was taken (n = 10). Results suggested that the items were evident in meaning to the participants. The analysis regarding the psychometric properties (see Tables 2 and 3) show that the GAD-7 Bangla version has good item discrimination (corrected item-total correlation ranged from .601 to .689), reliabilities (Cronbach's alpha = .869 and McDonald's omega = .872), and construct validity (the confirmatory factor analysis model fits: χ 2 /df = 3.875, goodness-of-fit index (GFI) = .985, comparative fit index (CFI) = .987, Tucker-Lewis index (TLI) = .976, root mean square error of approximation (RMSEA) = .057, and standardized root mean square residual (sRMR) = .024). In the present study, the following cut-offs were used: scores 5 to 9 (mild anxiety), 10 to 14 (moderate anxiety), and 15 and above (severe anxiety) (Spitzer et al. 2006) .

The Center for Epidemiologic Studies Depression Scale is a 20-item scale for screening depression symptoms developed by Radloff (1977) . This scale has good reliabilities, construct, and concurrent validity to assess depression (Miller et al. 2008 ). There are several shorter versions of this scale; the revised version, the CESD-R-10, was used in this study as it has almost the same psychometric properties compared to a full-length scale (Andresen et al. 1994) . The CESD-R-10 consists of 10-items (e.g., "I felt fearful," "I felt lonely"). Respondents rated their feelings over the past week on a 4-point Likert-type scale [from 0 (Rarely or none of the time) to 3 (All of the time)]. Total scores could range from 0 to 30, with higher scores indicating depression. In the current study, CESD-R-10 was translated into the Bangla language following the same procedure as the GAD-7. The CESD-R-10 Bangla version was found to have good psychometric properties (see Tables 2 and 3) to use for assessing depressive symptoms among Bangladeshi people. This scale also has good item discrimination (corrected item-total correlation ranged from .388 to .771), reliabilities (Cronbach's alpha = .845 and McDonald's omega = .848), and construct validity (Confirmatory factor analysis model fits: χ 2 /df = 2.956, GFI = .978, CFI = .974, TLI = .966, RMSEA = .047, and sRMR = .029). In the present study, the cut-off score for this scale that indicated depression was 10 (Radloff 1977) . The Mental Health Inventory (MHI; Veit and Ware 1983 ) is a 38-item valid tool for assessing the mental health of general people that include both psychological well-being and distress. The MHI-5 (Berwick et al. 1991 ) is the shorter version of the MHI, containing only five items. MHI-5 is a reliable and valid tool for assessing mental health and provides a quick assessment of it (Berwick et al. 1991; Ware and Sherbourne 1992) . Participants rated items based on the last month (e.g., "how much of the time, during the past month, have you been a very nervous person?") on a 6-point Likert-type scale [from 0 (none of the time) to 5 (all of the time)], with higher scores indicating poorer mental health. Raw scores on this scale (ranging from 5 to 25) are transformed to a 0 to 100 scale using the following formula: [(sum of the raw score of the 5 items/25) × 100]. The MHI-5 was translated into the Bangla language for the present study following the same procedures as the aforementioned scales. This scale also was found to have good psychometric properties to assess the mental health of the Bangladeshi people. Moreover, this scale has good item discrimination (corrected item-total correlation ranged from .404 to .722), reliabilities (Cronbach's alpha = .839 and McDonald's omega = .850), and construct validity (the confirmatory factor analysis model fits: χ 2 /df = 3.913, GFI = .994, CFI = .993, TLI = .985, RMSEA = .058, and sRMR = .013). The cut-off score for this scale was 60 to define moderate to poor mental health (Theunissen et al. 2011 ).

To assess the beliefs about the severity of the COVID-19 outbreak, participants were asked two questions ("There is nothing to worry about with COVID-19" and "COVID-19 could not become a pandemic here"), rating their answers on a 5-point scale (from strongly disagree to strongly agree). These items were found to be significantly correlated (r = .309, p < .001). There were also two questions regarding worry about the effect of COVID-19 ("I feel tense when I think about the effects of COVID-19" and "Considering the impact of COVID-19, I am afraid of the days to come") rated on a 5-point scale, similar to the belief items. To assess awareness, two other questions ("I am aware of how to deal with COVID-19" and "I have changed my hygiene behaviors as a result of COVID-19") were asked on a 5-point scale (from not at all to absolutely). There were significant correlations between items for worry (r = .528, p < .001) and awareness (r = .185, p < .001). Lastly, a single question was asked regarding participants' knowledge about COVID-19 ("I have sufficient knowledge of COVID-19") on a 5-point scale (from absolutely not to absolutely).

The collected data of the present study were maintained and analyzed using IBM SPSS version 26, IBM AMOS version 24, JASP 0.12.1.0, and Microsoft Excel 2013. At the first stage, psychometric properties of the translated scales were assessed via reliability analysis (corrected item-total correlation, Cronbach's alpha, and McDonald's omega), confirmatory factor analysis (the factor structure of the translated scales), Ferguson's delta, and the standard error of measurement (SEM). At the next stage, descriptive statistics (frequency and percentages), χ 2 test, and path analysis were run. In both the χ 2 test and path analysis, Bonferroni corrected p value was used to assess the level of significance. As there were 15 χ 2 tests, the corrected p value in the χ 2 test was .003. There were 12 tests in the path analysis; therefore, the Bonferroni corrected p value in the path analysis was .004.

This research was carried out in compliance with the Helsinki Declaration and its corresponding modifications or similar ethical principles (World Medical Association 2001). The data was collected using an online survey where participants were informed about the study purposes, its costs and benefits, and conditions of confidentiality before starting the survey. Participants then expressed their consent, after reading the aforementioned, to participate in the study by clicking either "Yes" or "No." Those who did not consent, by clicking "No" were not given the survey. This study's protocol was approved by the ethical research committee at the Noakhali Science and Technology University (reference number: 19/2020).

The findings show that the majority of this university student sample scored highly for anxiety and depression symptoms determined by the cut offs of those respective measures. Table 4 shows that 40.2% of students had moderate to severe anxiety symptoms (modest at 23.6% and critical at 16.6%) and 72.1% had depression symptoms. Besides these, Table 4 also shows that more than half of the participants' mental health statuses were in the moderate to poor range (53.9%). Regarding beliefs, 34.3% disagreed on "nothing to worry about," and approximately two-thirds (62.5%) strongly disagreed with the possibility of COVID-19 pandemic's presence in Bangladesh. Regarding worry, 77.1% felt tense when they thought about the effects of COVID-19, and 88.1% were afraid about the upcoming days. For knowledge, only 9.5% thought that they had an absolute understanding about COVID-19. Among the participants, 95.1% were aware of COVID-19, and about three-quarters (77.1%) changed their hygiene behaviors because of it. Table 5 shows the non-significant interactions of having anxiety and depressive symptoms, and mental health status by gender, age group, residential status, level of education, and educational discipline. Figure 1 shows that worrying about the effects of COVID-19 (β = .40, p < .004) was a significant predictor of anxiety symptoms. Figure 1 also shows that COVID-19 related knowledge (β = − .09, p = .004) was negative and worrying about the effects of COVID-19 (β = .32, p < .004) were positive contributors for the depression symptoms. Furthermore, worry (β = − .31, p < .004) also significantly predicted mental health status. All of these predictors explained 18% of anxiety's variability, 14% of depression's variability, and 12% of mental health's variability.

The COVID-19 pandemic affects all aspects of life, including the education sector. This is evident as all educational institutions during the early months of the pandemic closed or began meeting online since the outbreak started, in most countries. This study was undertaken to understand how Bangladeshi university students' mental health and well-being were doing, during this ongoing pandemic in April 2020. The results showed that university students have high rates of having anxiety and depression symptoms as well as moderate to poor mental health scores per their respective measures' cut scores. These high anxiety and depression frequencies are comparable to Bangladesh university student samples Jamilah et al. 2020) and are higher than when studied in Bangladesh adult samples (Ahmed et al. 2020c; Mamun et al. 2020) . Additionally, in terms of our study's sample experiencing these high anxiety and depression symptoms, studies have similarly found that college students generally have had higher levels of stress, anxiety, and depression during the COVID-19 pandemic (Ahmed et al. 2020b; Cao et al. 2020; Wang et al. 2020) . Ahmed et al. (2020b) also found that higher anxiety and depression symptom levels among students were comparable to those who are full-time employees, have a business, or are unemployed. These findings relating to high depression, anxiety, and mental health statues due to the pandemic were also found to be consistent with COVID-19 literature among Bangladesh university student samples Khan et al. 2020a ) as well as a large Bangladeshi sample Numbers 4 through 5 reference the belief measure; 6 to 7 reference worry; 8 to 9 reference awareness; and 10 references knowledge ). These findings also are supported in the notion that college students in particular are vulnerable population for these psychological pandemic-related impacts (Khan et al. 2020b) . Overall, the anxiety, depression, and mental health dispositions for college students, as surveyed in April, may have been stemming from a more central fear constructwhich was found to be high during the beginning months of the pandemic for Bangladeshis ).

Moreover, this study's results found that anxiety and depression symptoms as well as mental health status did not differ significantly by gender, age, residential status, education level, and educational discipline. In terms of age, residential status, education level, and educational discipline, literature on college students have also found insignificant differences across these groups (Ickes et al. 2015; Liu et al. 2019; Saleh et al. 2017) . In terms of gender, there has been some inconsistency in the literature. For one Bangladeshi student population, Islam et al. (2020) found males experienced higher levels of psychopathology. However, Wang et al. (2020) found that females and students show significant associations with anxiety, depression, and stress during the COVID-19 outbreak, in China. Although there are contradictions with gender, Andrade et al. (2020) emphasized for a Brazilian sample, females in comparison to males may be more vulnerable to psychopathology as a result of COVID-19, due to biological and social factors. Conclusiveness regarding our study's result with gender may be worth replicating in a subsequent study.

The pandemic and the imminent danger of COVID-19 mean that it is now ubiquitous for people to be alert as well as mindful of their vulnerability to health-related threats, and to take precautionary and preventative steps to decrease them, such as by spatial distancing (Casale and Flett 2020) . Our findings showed that the majority of the participants felt tense about the effects of the disease, and the rate for the respondents who were afraid of their future in the pandemic was even higher. Additionally, a small proportion of the respondents reported that they possessed adequate knowledge about COVID-19; the majority of those same respondents were also found to have positively changed their hygiene behaviors. At this stage of the pandemic, fear, anxiety, and worry were pervasive, anticipated, and present (Ahmed et al. 2020a; Lee 2020; Pakpour and Griffiths 2020; Sakib et al. 2020) . That said, the public understanding of a pandemic is unpredictable, especially when the magnitude and naturally Fig. 1 Path analysis of the effect of belief, worry, awareness, and knowledge on anxiety, depression, and mental health occurring progress of its effects cannot be predicted correctly ( Van et al. 2010) . During April 2020, when participants were surveyed, only one-third of the participants felt worried about the pandemic, whereas two-thirds had confidence that COVID-19 pandemic would not be an issue in Bangladesh.

Even though some participants did not feel that the pandemic would be problematic for Bangladesh, all educational institutions closed beginning March 18, 2020, due to the COVID-19 outbreak in the country (UNICEF 2020). As a result of this first-line emergency response, all students returned to their homes or other private residences unaffiliated with their universities. Since then, students' daily lives became confined and government orders restricted them to remain home over the past 3 months. Such isolation changed the norms of everyday life. Staying home has been found, though, to significantly increase one's anxiety and depression symptoms (Brooks et al. 2020) , especially for college students (Khan et al. 2020b) . In a recent rapid review, Brooks et al. (2020) also found that reduced social contact, the altering of regular activities, norm changes contributed to distress. Moreover, uncertainty about a COVID-19 treatment plan and the lack of a vaccine to help COVID-19 infected patients may have also contributed to a much higher rate of anxiety and depression symptoms, since lack of information can often fuel fears (Taylor and Asmundson 2004) . Zandifar and Badrfam (2020) have found support to this, as misinformation and uncertainty of treatment can often trigger stress, anxiety, depression, etc., in those who feel the pandemic's effects.

Due to confined living, brought on by the pandemic, Bangladeshi people have become more active on social media to pass the time and remain connected (Statista 2020). Gao et al. (2020) suggest that a higher frequency of social media exposure is positively associated with mental health problems. Additionally, one study by Lin et al. (2020) found a mediating effect for COVID-19 fear with social media use and distress; another found that anxiety sensitivity mediates problematic Internet use and fear of COVID-19 among an Iranian sample (Hashemi et al. 2020) . Therefore, we recommend that future researchers examine the potential mediating roles social media, and misinformation can play in the psychological distresses and COVID-19 affectivity relationship among a Bangladeshi sample. Additionally, we recommend that other measures be incorporated into the study, such as an assessment of stress levels-during and after the semester-as well as students' present feelings about the current and upcoming semesters. We also recommend that such research be explored on various populations, not just students, in other areas of the world to determine the applicability of these findings. Finally, we recommend that with these findings governments and higher education institutions create disease regulation interventions and practices that require a thorough and systematic mental health treatment plan and consideration; as it is clear that students-a specific proportion of the population-have been negatively impacted psychologically by the coronavirus' effects so early on in the pandemic.

The present study has some limitations. First, self-report measures were utilized in this study to assess anxiety and depression symptoms and mental health status. The collected self-reported data may have been subjected to social desirability bias, memory recall bias, as well as common methods bias. In addition, the present study's data were collected using snowball sampling on social media-thus, there may be issues with representativeness, since only those on social media and with Internet access would have the ability to take the survey. In addition, this study was conducted early on in the pandemic, therefore, although these findings may serve as useful to compare mental health from this period to how university students are currently impacted, these results should not be taken out of context and applied to how university students are presently feeling about the pandemic.

In brief, the results of this study reveal that Bangladeshi university students, only 1 month into the COVID-19 pandemic, experienced high levels of psychological distress based on the measures' cut scores. University students are an especially vulnerable population since the experience has been shown to be stressful in non-pandemic times. This study does show university students experienced high levels of anxiety, depression symptoms, and low mental health statuses, when transitioning to the coronavirus' new norms in April 2020. Now that students have returned to a virtual or hybrid learning environment, these findings may bring to light how the pandemic's uncertainty is negatively impacting university students in Bangladesh. To address these high levels of symptoms and low statuses, universities should be understanding of and have plans to help those whose mental health may be affected as a result of COVID-19. Finally, these findings can provide insights to university administrations, government agencies, and health professionals to ensure the psychological well-being of students in the face of the ongoing COVID-19 outbreak as well as future infections disease outbreaks in Bangladesh. For further research, we recommend that this study be replicated among a Bangladeshi university student sample to compare whether mental health has changed over the pandemic's progression-especially now with the prospect of a SARS-Cov-2 vaccine.

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Conflict of Interest The authors declare that they have no conflict of interest.