key: cord-0922613-1yjbls0j authors: Martínez Arriaga, Reyna J.; González Ramírez, Leivy P.; de la Roca‐Chiapas, José M.; Hernández‐González, Martha title: Psychological distress of COVID‐19 pandemic and associated psychosocial factors among Mexican students: An exploratory study date: 2021-07-02 journal: Psychol Sch DOI: 10.1002/pits.22570 sha: 1ec6feb363c1be7bb3dce9579aefb18bf0c4efcf doc_id: 922613 cord_uid: 1yjbls0j COVID‐19 related social isolation measures and school closures have likely increased students' stress levels. In our study, we assess the level of psychological distress and psychosocial factors among students in Mexico at the beginning of the pandemic. We conducted a cross‐sectional exploratory study with 848 participants, the majority undergraduate or postgraduate (79.7%). Participants completed the Impact of Event Scale‐Revised to measure emotions, and a COVID‐19 questionnaire. We conducted a logistic regression analysis to find variables associated with stress: 36% (n = 309) had elevated stress, 31.4% (n = 266) anxiety, and 18.2% (n = 154) sadness often or all the time. Those who identified as women and reported a reduction in their incomes also reported a higher stress level. Stress was positively correlated with anxiety, anger, sadness, days in isolation, and hours watching TV daily; and negatively correlated with relaxation and happiness. The variable most strongly correlated with stress was a high perception of infection risk. Our findings will inform mental health strategies for students who are at higher risk of stress due to the COVID‐19 pandemic response. Although various studies on the impact of COVID-19 have been conducted on the general population (Chew et al., 2020) , among health workers and patients (Duan & Zhu, 2020) , few studies provide evidence of the psychological impacts that students are experiencing in response to the current COVID-19 pandemic. In response to this crisis, this study aimed to study the prevalence of psychological distress among Mexican students at the beginning of the COVID-19 pandemic. Moreover, we aimed to investigate the association of psychological distress with sociodemographic issues: (1) sex, (2) age, (3) marital status, and (4) education; and with COVID-19 related variables: (1) reduction in activities, (2) related to isolation, (3) economic income reduction, (4) perception of infection risk, (5) hours watching TV daily, and (6) hours spent online daily. We employed a cross-sectional exploratory study due to the lack of information in Mexico on the emotional distress of the COVID-19 pandemic. The sampling was nonprobabilistic. The volunteer participants were high school, undergraduate, or postgraduate students from private or public schools that agreed to participate. Inclusion criteria were students from the abovementioned educational levels who gave their informed consent to participate in the study. The number of cases during the study period determined the sample size. In total, we received 848 responses. The mean age was 22.03 (SD = 5) years, 643 (75.8%) were women, 793 (93%) single, 676 (79.7%) were undergraduate or postgraduate (Table 1) . We created an online survey through a google form. Recruitment was implemented with the snowball technique with volunteer students, sending the form to key persons belonging to some educational institution, particularly high schools and colleges. The duration of the survey was approximately 10-15 min. The survey was open from the 27th of March to the 2nd of April, 2020. Later, we deleted the data of participants who did not meet the inclusion criteria. To evaluate the psychological distress, we applied the Impact of Event Scale-Revised (IES-R) to find the stress experienced since COVID-19. The revised scale version was developed by Weiss and Marmar (1997) Horowitz's posttraumatic stress model (Horowitz et al., 1979) . It considers three subscales of stress: intrusion (nightmares, intrusive feelings, and imagery, dissociative-like re-experiencing), avoidance (numbing of responsiveness, avoidance of feelings, situations, and ideas), and hyperarousal (anger, irritability, hypervigilance, difficulty concentrating, heightened startle). The scale is measured on a likert scale (0 = Nothing to 4 = Very much). Cut-off points were determined to suggest clinical stress, by obtaining a total score of 35 or more. For the subscales, a score equal to or <14 was T A B L E 1 Descriptive analysis of sociodemographic characteristics, stress, and COVID-19 variables It was evaluated in a scale ranging from 1 to 10, where 0 was no risk and 10 was high risk. considered "normal," from 15 to 20 "moderate" stress, and above 20 points as "severe" The scale has been validated in a Mexican population, finding a cronbach alpha of 0.88 of the total scale (Hernández Moreno & Landero Hernández, 2015) . The subscales have shown high levels of reliability: intrusion α = .89, avoidance α = .84, and hyperarousal α = .82 (Caamaño et al., 2011) . In addition to the IES-R, we created an emotions-related scale of 0-Never to 4-All the Time, where we asked, "In the last three days, how have you felt?," with the following emotions as options: anxiety, relaxation, anger, happiness, and sadness. These emotions were considered based on previous studies that report the emotional state of students during the COVID-19 pandemic (Cao et al., 2020) . The psychosocial factors included sociodemographic characteristics and COVID-19-related variables. To assess the sociodemographic variables, a survey to collect sociodemographic data was generated and included: age, sex, marital status, and education level. Furthermore, the questions related to the COVID-19 were: (1) Have you reduced your activities since the pandemic? (1 = yes, 2 = no); (2) Currently, are you in isolation due to the pandemic? (1 = yes, 2 = no); (3) How many days have you been in isolation?; (4) How many people that you live with are currently in isolation?; (5) Has your economic income been affected? (1 = yes, 2 = no); (6) How at risk do you feel of contracting COVID-19? Where 0 is no risk and 10 is high risk; (7) How many hours a day do you spend watching television?; and, (8) How many hours a day do you spend online? The questions were based on those reported in the literature regarding the psychosocial effects of isolation, such as fear of infection, financial loss, problems with other household members (Brooks et al., 2020) , and the stress generated by hours on the internet . Statistical Package for the Social Sciences (SPSS) v21 was used for data analysis. To describe the sociodemographic variables, frequencies, and percentages, or mean and SD were used, depending on the type of variable. According to the Kolmogorov-Smirnov test, a non-normal distribution in the quantitative variables was found and nonparametric statistics were used. The stress variable was categorized as "Sub-clinical stress" (grouping normal stress) or "Clinical stress" (grouping "moderate and severe stress"). The χ 2 test was calculated to find the differences between subclinical and clinical stress, among the different groups. Then, the Spearman's rho test was calculated to examine the bivariate correlation between the stress (IES), current emotions (anxiety, relaxation, anger, happiness, and sadness), and the COVID-19 variables (days in isolation, perception of infection risk, hours watching TV daily, and hours spent online daily). Finally, a logistic regression analysis was applied to find the predictor variables for the presence of clinical stress and its subscales (intrusion, avoidance, and hyperarousal). The variables included in the models were those significant according to χ 2 test and to the bivariate correlations. We used a method "go: conditional," with a starting point of 0.05 and an endpoint of 0.1, for the probability of the method, and a confidence interval of 95%. The Hosmer-Lemeshow adjustment statistic was calculated to evaluate the goodness of fit of the data. sadness, "often" or "all the time." Moreover, 670 (79%) stated feeling relaxed and 642 (75.7%) happiness, "never" or "sometimes," currently. According to the χ 2 test, there were differences with respect to sex, isolation, and economic income reduction on total stress. Stress was found mainly in women (χ 2 = 14.312, odds ratio [OR] = 1.576, p < 0.001), those in isolation (χ 2 = 7.280, OR = 1.587, p = 0.009), and in those whose economic income was reduced (χ 2 = 21.498, OR = 1.580, p < 0.001). We did not find significant differences in relation to marital status, education, and reduction in activities. In relation to the three subscales, the women presented more intrusion (χ 2 = 9.490, OR = 1.603, p = 0.001), greater avoidance (χ 2 = 8.869, OR = 1.569, p = 0.002), and greater hyperarousal (χ 2 = 10.598, OR = 2.138, p < 0.001). On the other hand, those with a reduction in their economic incomes, had more intrusion (χ 2 = 13, OR = 1.569, p < 0.001), greater avoidance (χ 2 = 20.399, OR = 1.773, p < 0.001) and greater hyperarousal (χ 2 = 12.297, OR = 1.881, p < 0.001). Likewise, among those in isolation, there were higher levels of intrusion (χ 2 = 4.120, OR = 1.547, p = 0.048). With regard to the correlations, the stress was significantly correlated with all emotions-related questions and with COVID-19 variables. All correlations are shown in Table 2 . The variables included in the final logistic regression models were significant. According to the logistic regression models, sex, isolation, perception of infection risk, and economic income reduction were all associated with total stress, intrusion and avoidance. Hyperarousal was associated with sex, perception of infection risk, and economic income reduction (Table 3) . The purpose of the present study was to investigate the psychological distress of the COVID-19 pandemic on students, its associations with sociodemographic issues, and with COVID-19 related variables. The results show the presence of clinical levels of stress in 36% of the students, with high levels of avoidance and intrusion. According to the emotion-related scale, 31.4% presented anxiety often or all the time, 20.3% reported feeling angry often or all the time, and 18.2% stated feeling sad often or all the time. A high perception of infection risk and the number of hours spent online daily, were correlated with negative emotions, such as anxiety, anger, and sadness. Otherwise, being a woman, being in isolation, having a high perception of infection risk, and a reduction of economic income were the main variables associated with stress among the students. The psychological consequences that students may have in the face of a pandemic have been reported elsewhere, including high levels of stress (Main et al., 2011) . The percentage of students with clinical levels of stress in the present study is elevated compared to other studies presented during this pandemic (Cao et al., 2020) . The perception of infection risk by the virus was the factor that was associated with stress in students. This association was more robust in the dimension of intrusion, related to nightmares and intrusive thoughts, and in the dimension of hyperarousal, related to irritability, difficulty concentrating, and other hurdles. Moreover, this perception of infection risk was related to psychological changes such as anxiety, anger, and sadness. Unfortunately, the perception of infection risk is not always accompanied by a real risk in the population, as during a pandemic, the presence of irrational fears is widespread (Petropoulos & Makridakis, 2020) . It should be highlighted that it is essential to help the population identify when there is a real risk of contamination through health education to increase their knowledge and good practices. This education should be designed for the at-risk population, as well as for someone who has identified as tending to not comply with recommendations, such as people with a lower level of education and young people (Zhing et al., 2020) . Isolation was another factor associated with stress, taking into account that they had already reported some impacts on mental health by finding themselves in quarantine, such as posttraumatic stress, exhaustion, irritability, insomnia, reduction in concentration, and some avoidance behaviors (Brooks et al., 2020) . Furthermore, it is vital to contemplate the educational challenges students face in isolation, such as taking virtual classes, completing the academic year, and having sparse communication with their classmates and friends . T A B L E 2 Bivariate correlation between emotions and COVID-19 variables Communication alternatives, to maintain contact with friends and colleagues, have been recommended to cope with isolation and its adverse effects (Gallegos et al. 2020 ). On the other hand, there were differences according to sex, reporting higher stress levels among women. This finding coincided with other studies that report that women presenting with higher levels of stress, anxiety, and depression in response to crisis (Al-Rabiaah et al., 2020; Wang et al., 2020) . However, despite this difference between the sexes, most women's strategies in times of crisis tend to involve seeking social support, which leads to greater life satisfaction (Main et al., 2011) . Knowing the differences between men and women allows us to generate strategies for further interventions. Other variables related to stress include hours in front of the television and on the internet. Furthermore, hours on the internet was related to anxiety, anger, and sadness. This association may be due to the high content related to COVID-19, discussed daily across all communication media, including social media. Concerning this, Dong & Zheng (2020) present a disorder called "Headline Stress Disorder." This disorder is characterized by a highly emotional response derived from the excessive information of the media. In this sense, if the media can increase knowledge and strategies for COVID-19 prevention, false or exaggerated information could cause panic in the population, including information spread through social networks (Kaufman et al., 2020) . Moreover, the main source of information for adolescents, is social networks (Gallegos et al. 2020 ). In addition, many hours spent online may be due to the online classes. Therefore, this can also provoke high levels of stress and anxiety (Sahu, 2020) . A reduction in economic income was associated with the presence of stress in this study. In a prior study of psychological responses of COVID-19 in students, the levels of anxiety were highest in those without a steady income (Cao et al., 2020) . In addition, is important taking into account that the impact of a COVID-19 could be more devastating in some Latin American countries, due to the socioeconomic conditions (Rodríguez-Morales et al., 2020). Moreover, in Mexico, some students of public universities come from rural areas and/or have limited internet access, nor do they own a computer, which could increase stress levels (Fernández Fassnacht, 2017) . Despite the fact that countries of the Americas are quite diverse; similar physical, biological, psychological, and social dimensions underly the lines of action in health in the face of this pandemic (Gallegos et al. 2020 ). Finally, it is important to highlight that the variables evaluated and included in the logistic regression model, despite obtaining significant results, the models presented explain little of the observed variance. In light of this, we suggest that future studies include further variables that are potentially associated with stress in students. The present study had some limitations. One of these was the nonprobabilistic sampling, through the application of the snowballing technique and the diversity of the sample, as this can result in bias when generalizing the results. Another limitation is the scale created to evaluate the current emotional state (anxiety, relaxation, anger, happiness, and sadness). The scale was created for this study and it does not have validation or confidence values, generating certain difficulties when replicating the study with other populations using the same scale. Moreover, some groups lacked heterogeneity (i.e., sex group), which could influence the finding of greater levels of stress in certain groups (i.e., women). Another possible limitation is the type of study (cross-sectional exploratory study), which is why it is recommended that future studies conduct prospective study designs such as experimental/quasiexperimental study designs oriented toward improving the mental health or well-being of students. However, the findings of the present study allow us to find some of the immediate mental health reactions that students have during confinement. Furthermore, the findings are useful to identify some psychosocial needs and thus generate priority actions to improve the mental health of students. The authors recommend that future studies include variables related to student stress, such as insomnia, drug consumption, personal history of mental disease, and coping strategies for combatting COVID-19. 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