A longitudinal study of the impact of COVID-19 restrictions on students’ health behavior, mental health and emotional well-being

Introduction

The COVID-19 pandemic started slowly and inconspicuously when the Wuhan Municipal Health Commission in China reported a cluster of pneumonia cases on December 31, 2019 (World Health Organization, 2020). Within one month, the case number had climbed to more than 9,800 worldwide and the death toll exceeded 200, prompting the World Health Organization (WHO) to declare a global health emergency. On March 11, 2020 the WHO declared COVID-19 a pandemic (World Health Organization, 2021). Within a few days, many countries went into some form of lockdown, and most public and private colleges and universities were forced to either shut down temporarily or to transition to online (remote) learning. These sudden and unexpected changes impacted millions of college and university students around the world. Many were forced to move back home or find other alternative living arrangements when campuses and dorms closed. The shift to online teaching also created challenges and struggles for many students as it required a level of hardware, software, and internet connectivity for which many students were not prepared (Aucejo et al., 2020; Gillis & Krull, 2020).

Although the situation differed for students across different countries, studies looking at the impact in the early part of the pandemic (Spring and Summer 2020) equally reported that students experienced high levels of stress that negatively impacted their mental health leading to increased levels of anxiety and depression (Essadek & Rabeyron, 2020; Kaparounaki et al., 2020; Saddik et al., 2020; Wathelet et al., 2020; Zandifar & Badrfam, 2020; Zhang et al., 2020; Baloch et al., 2021; Ochnik et al., 2021). Longitudinal studies that compared data collected from before the pandemic (pre-COVID) with data collected during the pandemic reported similar results. For example, data collected at a university in the United Kingdom in Fall 2019 and Spring 2020 by Evans et al. (2021) showed that students experienced a decrease in well-being and increase in depression. Savage et al. (2020) also collected data from students at a university in the United Kingdom in Fall 2019 and Spring 2020; they too found increased stress levels and a decrease in mental well-being of participating students.

Studies involving college and university students in the US also reported increases in anxiety and depression during this period (Holingue et al., 2020; Jeffery & Bauer, 2020; Kecojevic et al., 2020; Wang et al., 2020; Hawes et al., 2021). Again, the results of cross-sectional studies were confirmed by longitudinal studies such as the studies by Fruehwirth, Biswas & Perreira (2021), Giuntella et al. (2021), and Wilson et al. (2021). The study with the largest number of participants in the US was conducted by the Healthy Minds Network (HMN) in association with the American College Health Association (ACHA); more than 18,000 students on 14 campuses participated from late March through May 2020 (Martinez & Nguyen, 2020). Two-thirds of participants reported experiencing more stress, and one-third had gone through a change in living arrangements. The participants also reported an increase in depression, and 60% indicated that the pandemic had made it more difficult to access mental health care providers.

There are, however, only a few studies exploring how the sudden changes and restrictions impacted students’ health behaviors and habits. Bertrand et al. (2021) collected data from students at two universities in Canada in April/May 2020. They found increased sedentary behavior and alcohol consumption, a reduction in physical activity, and a drop in the quality of the students’ diet. A study from the UK comparing pre-COVID (Fall 2019) and COVID (April/May 2020) data reported a decrease in alcohol consumption and a shift in sleep behavior; participants reported staying up later but not sleeping longer (Savage et al., 2020). In the US, Moriarty et al. (2021) found that while some students exercised more and slept longer, other students did just the opposite, while Maher et al. (2021) reported a loss of sleep quality.

Studies from different countries described a decline in physical activity of students during this first part of the pandemic (Savage et al., 2020; Fruehwirth, Biswas & Perreira, 2021; Giuntella et al., 2021; López-Valenciano et al., 2021; Maher et al., 2021). However, two studies from Spain reported opposite results; in the study by Romero-Blanco et al. (2020), physical activity increased during the early lockdown, whereas Castañeda Babarro et al. (2020) found a decrease in physical activity during the same period. Du et al. (2021) conducted a multinational study involving students in Asia, Europe, and North America that investigated the impact of the pandemic on sleep quality, dietary behavior, and alcohol consumption. They showed a negative impact on the diet of participants and sleep quality; nonetheless, there was no increase in alcohol consumption. Participants in Firkey, Sheinfil & Woolf-King’s (2021) study reported an increase in anxiety and a decrease in quality of life and sleep quality; nonetheless, there was no increase in alcohol or marijuana consumption associated with the change in mental health. Sokolovsky et al. (2021) reported a decrease in the frequency of smoking and vaping among students in early Spring 2020.

Once the early stage of the pandemic had passed, different countries adopted diverging approaches depending on the number of COVID cases as well as economic and political considerations (Ibrahim, Binofai & Alshamsi, 2020; OECD, 2020). Some countries went through extended lockdowns while others decided against further restrictions or used shorter complete or partial lockdowns only. The United States was a mirror image of what happened around the world; some states imposed extended lockdowns that included closure of schools and universities, others decided to open up everything as soon as possible (Treisman, 2020). The differences in when and to what extent countries were affected by the second and third wave of the pandemic and which approach they adopted are the main reasons why there are only a few longitudinal studies on the impact on students’ mental health and health behavior beyond the initial stage so far. Savage et al. (2021) investigated the impact on mental health and physical activity of university students in the UK nine months into the pandemic. Study participants still reported reduced mental well-being and physical activity, and increased perceived stress and sedentary behavior in October 2020. Collecting data from graduating students at a university in Ethiopia in November 2020, Mekonen et al. (2021) found that one-fifth of students reported stress, and two-fifths anxiety and depression.

Our research project on student health behaviors and habits started in Spring 2018 and, therefore, adding survey data from Fall 2020 and Spring 2021 enabled us to assess the impact COVID-related restrictions had on our students beyond the initial phase. Although the situation in Florida and at our university was different from what students in other countries and at other institutions of higher education experienced, the results are an important contribution to our understanding of how prolonged extreme events can impact students’ behaviors, habits, and mental and emotional health.

Methods

Data for this article were collected between April 2018 and April 2021 using two anonymous online surveys. Each Summer and Fall semester, emails were sent to students enrolled in courses that are taken by students from different colleges and majors, such as ‘Statistical methods’ or ‘Introduction into Psychology’, inviting them to participate in our survey. The total number of students invited per semester was approximately 2,000–2,500. The number of students participating in the survey per semester usually ranged from 150–250, i.e., the response rate was in the range of 6–10%.

The first survey, used from April 2018 to February 2020, consisted of five groups of questions around health and wellness (see Appendix 1); the survey was described previously (Reuter & Forster, 2021). Some of the data collected, but unrelated to the current research, has been published elsewhere (Reuter, Forster & Brister, 2020; Reuter & Forster, 2021).

After the onset of the COVID-19 pandemic and the introduction of pandemic-related restrictions nationally, locally, and at Florida Gulf Coast University (FGCU), the survey was modified in order to capture the impact these restrictions had on students’ health behaviors, and habits as well as their mental and emotional health (see Appendix 2).

Although the study used a repeated cross-sectional survey design, the data collected did not consists of independent data sets as students may have participated more than once during different semesters. Thus, our study contained repeated cross-sectional and panel elements.

Both surveys were approved by the Institutional Review Board (IRB) at FGCU prior to sending email invitations to students (IRB 2018-17). The first page of the survey consisted of an approved online survey consent form; in other words, consent was obtained. Participation was voluntary and participants did not receive any compensation or any other direct or indirect benefit from the university or us.

Results

Discussion

The purpose of this research project was to study the impact prolonged restrictions related to COVID had on students’ health behavior as well as their mental and emotional health. Because the situation was unique in recent history, the results add to our general understanding of how extreme events impact people’s physical and mental health. The longitudinal data of our study show a significant difference for some student behaviors and habits, such as sleeping habits, physical activity, breakfast consumption, time spent online or playing video games, vaping, and marijuana use, during the COVID pandemic compared with pre-COVID data. While study respondents also reported a significant increase in difficulty concentrating, remembering, or making decisions, as well as being impacted by feeling sad or hopeless, there was no increase in the proportion of respondents considering, planning or attempting suicide during COVID.

The cross-sectional data from the survey administered during the COVID pandemic illuminate the negative effect of the overall situation and the restrictions on students’ mental and emotional well-being. While we have no pre-COVID data to compare with, it is doubtful that three-quarters of respondents would have craved human interaction during normal times. It is also telling that the six words describing emotions selected by half of respondents or more describe negative emotional states. On the other hand, respondents in our survey were not more worried about their safety on campus during COVID. Data from the American College Health Association (2020) show that prior to COVID one in seven male students and one in four female students did not feel safe on campus during daytime hours, and one in two male and four in five female students did not feel safe on campus at night.

The change in the proportion of students living at home can be attributed to a number of factors. Although more than half of respondents (51.3%) were enrolled in at least one in-person face-2-face class, most of them took mainly online classes. Living at home and commuting once or twice per week to campus was preferable at a time where many families experienced economic hardship. Plus, students living at home faced fewer restrictions on social interactions and outside activities than students living on campus, making living at home more attractive.

The fact that there is no difference in the proportion of students working and in the number of hours worked is a reflection of the overall approach to handling the pandemic by the state of Florida. The difference in sleeping patterns found in our study with students sleeping longer and staying up later during the COVID pandemic do not point at a loss of sleep quality. With fewer students having to get up in the morning to go to campus or to get to class, one can understand that there is a tendency to stay up late and sleep longer. Thus, our findings do not confirm the loss of sleep quality reported by Deng et al. (2021), Du et al. (2021), Firkey, Sheinfil & Woolf-King (2021), Giuntella et al. (2021), and Maher et al. (2021) during the early (lockdown) stage in different countries. The study by Moriarty et al. (2021) was conducted in the US in June/July 2020 and its results are similar to ours. Evans et al. (2021) also found a shift to staying up late in their study of undergraduate psychology students at a UK university.

The same reasons, i.e., not having to get up in the morning, as well as the limitations on social activities, may explain shifts in sleeping patterns and why respondents reported more screen time during the COVID pandemic (i.e., spending more time online reading or watching TV or movies, and playing video or computer games). Giuntella et al. (2021) also reported an increase in screen time. This increase can also be considered increased sedentary behavior and confirms similar findings reported by Savage et al. (2020) and Bertrand et al. (2021) in the early pandemic stage as well as in the longitudinal study by Savage et al. (2021).

The decline in physical activity reported by our study respondents from pre-COVID to COVID is in line with results for the early pandemic published by Savage et al. (2020), Bertrand et al. (2021), Giuntella et al. (2021), López-Valenciano et al., (2021), and Wilson et al. (2021). The longitudinal study by Savage et al. (2021) also reported a decrease in physical activity among university students in the UK nine months into the pandemic.

While we found a negative impact on breakfast and fast-food consumption, this should not be understood as a reduction in the quality of the diet along the line of results reported by Bertrand et al. (2021) and Du et al. (2021). These changes may be due to students’ changed living arrangements and sleeping habits. For example, they may skip breakfast because they sleep longer or may consider the first meal of the day to be lunch if they sleep in. Likewise, because more of them live at home without a meal plan, they may be prone to picking up fast food on the way to or from work and campus.

The increase in vaping, alcohol consumption, and marijuana use from the pre-COVID to the COVID period aligns with the increases found in studies during the early pandemic (Bertrand et al., 2021; Du et al., 2021; Evans et al., 2021; Firkey, Sheinfil & Woolf-King, 2021). Contrary to these studies and ours, the retrospective study by Sokolovsky et al. (2021) found that the frequency of smoking and vaping decreased after students went into lockdown.

The longitudinal as well as the cross-sectional survey data in our study show an increase in stress levels, anxiety, and depression during the COVID period, and thus, broadly confirm studies from the early pandemic involving college and university students in the US (Holingue et al., 2020; Jeffery & Bauer, 2020; Kecojevic et al., 2020; Wang et al., 2020; Hawes et al., 2021) and other countries (Essadek & Rabeyron, 2020; Kaparounaki et al., 2020; Wathelet et al., 2020; Baloch et al., 2021). Fortunately, our data show that the proportion of students considering, planning, and attempting suicide did not increase during the pandemic. This was also reported by Pirkis et al. (2021), who analyzed data from 21 countries around the world in Fall 2020 and found no evidence for an increase in suicide rates compared with pre-pandemic levels.

A major strength of our study is having data from before the COVID pandemic through the later part of the pandemic. Even though the data are not truly longitudinal, this enabled us to compare how students’ health behaviors and habits changed or did not change during the course of the pandemic, and how students coped with the extended period of stress and uncertainty. The main limitations of our study were participant selection and reliance on self-reported health behaviors and habits. Even though students from all colleges across the university were invited to participate, the overall response rate was in the range of 6–10% only. We received almost 80% of responses from female students, whereas the FGCU student body has only slightly more than 50% female students (Florida Gulf Coast University, 2021b). Additionally, we cannot rule out that students may have participated more than once during the same semester.

Every survey has to question whether respondents may have intentionally or unintentionally provided incorrect information, especially when behaviors are involved that are not legal or socially acceptable. For example, the legal drinking age in Florida is 21 years and, therefore, students under 21 who report drinking alcohol admit to breaking the law. The same applies to the use of recreational drugs. Also, some of the health behaviors and habits included in the survey were not well defined and respondents may have interpreted them differently. For instance, respondents may have considered walking to class as being physically active. We are also aware that some questions could be considered overlapping; for example, the questions relating to time spent watching TV, movies, or reading news online, and time spent playing video or computer games. We also failed to include a question relating to time spent on social media in general in our survey, leading to responses indicating that students had not spent much time online overall. However, because we looked at a change from pre-COVID to COVID, this mistake did not impact our results negatively.

One also has to point out that Florida had very limited restrictions compared with other states and countries, which led to our respondents being able to continue to work almost as much as before the pandemic, for example. This, in turn, buffered the economic impact on students and their families as well as on students’ emotional and mental health. Likewise, our university is located in an area with an above average median household income, 90% percent or more of household have a computer, and 80% or more broadband internet connection (United States Census Bureau, 2021).

Following how students’ behaviors and their emotional health change during academic year 2021/2022 will be very interesting. At the moment, the plan for Florida and our institution is to go back to pre-pandemic conditions as far as teaching, restrictions on class sizes, meetings, and indoors and outdoors social events (all removed), face masks (not required anymore), and social distancing (not required anymore) are concerned. Unfortunately, because the State of Florida made it illegal to ask students, faculty, or staff to report their vaccination status (although the information can be provided voluntarily) or to require them to get vaccinated, what will or may happen is less certain than one may think. Among our survey respondents, only 64.2% (194 of 302 responses) indicated that the chances of them getting a COVID vaccination was 70% or higher, while more than one-quarter put the chances of them getting vaccinated at 30% or less (26.8%; 81 of 302 responses). These data indicate that our student population may still be vulnerable to COVID for some time, especially now that more contagious virus variants become dominant. By Spring 2022, seniors participating in our survey will have been freshmen or sophomores pre-pandemic and juniors during the pandemic, allowing us to chart their journey longitudinally.

Conclusions

The longitudinal data collected and analyzed indicate that the impact of COVID-related restrictions on students’ behaviors and habits as well as their mental and emotional health was less severe than one would have expected based on studies during the early stage of the pandemic. While some behaviors and habits changed during the COVID pandemic compared with the pre-COVID period, the changes were not substantial overall and most students’ lives outside of studying went on with little change. Likewise, our study did not find an increase in the proportion of respondents considering, planning or attempting suicide during COVID, although study participants reported a significant increase in difficulty concentrating, remembering, or making decisions, as well as being impacted by feelings of sadness or hopelessness. Also, the cross-sectional data from our survey make the negative effect of the overall situation and the restrictions on students’ mental and emotional well-being evident.

The impact of this pandemic will unquestionably be long-lasting and, thus, necessitate future investigations. Even though some countries and states in the US, including Florida, have dropped almost all restrictions and more or less plan on business as usual for schools, colleges, and universities for Fall 2021 and beyond, new waves of high infection rates caused by different SARS-CoV-2 variants may force a change of course. Studying how students react to even more or new restrictions and whether those who were impacted by the first round of restrictions will handle the situation better than those who enter higher education now, will be an interesting focus for further research.

Supplemental Information