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The research on the impact of distance learning on students’ mental health

Yinghua wang.

School of Basic Science, Zhengzhou University of Technology, Zhengzhou, China

Associated Data

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

The mental health of students learning online is a critical task for many countries around the globe. The research purpose was to analyse the factors affecting the quality of mental health of young individuals who learnt under conditions of not total lockdowns but adaptive quarantine restrictions. The research involved 186 volunteers from Zhengzhou University of Technology, 94 were first-year students, and 92 were fourth-year students. The experimental group involved first-year students, and the control group involved fourth-year students. An average age of the participants in the experimental group was 18.3 years, and in the control group, the average age was 22.4 years. The scholars conducted the research after four months of distance learning under the adaptive quarantine. The students could be involved in their usual entertainment activities and interpersonal communication outside the home. The Behavioural Health Measure, better known as BHM-20, was the core psychometric tool. The research finds that distance learning is less effective for first-year students than for fourth-year students because the former cannot effectively adapt and communicate in a new social environment, and develop trusting interpersonal relationships with fellow students and teachers. The research results coincide with other research on this issue and demonstrate a low degree of mental resilience during and after the pandemic. Previous research is not suitable for the analysis of the mental health of students under adaptive quarantine, including the freshmen, considered the most vulnerable group. The article will be useful for professionals interested in distance education in higher educational institutions, workers of socio-psychological services at universities or individuals involved in adapting curriculum materials for distance learning.

Introduction

The COVID-19 pandemic has had a great impact on the mental health and well-being of individuals around the world. While some citizens successfully adapted to the reality of the pandemic and societal lockdowns, others have suffered from mental health disorders caused by a new infection (Serdakova et al., 2023 ).

Moreover, access to mental health services has been severely impeded which had an impact on the mental health of individuals and significantly increased the risk of suicide (Gunnell et al., 2020 ). Most countries on different continents have introduced immediate and drastic protective measures in the fight against the spread of infection, such as closed borders, forced isolation, quarantine restrictions, and distance learning. On the one hand, the virtualization of the educational environment and distance education have reduced inequalities in poor rural regions and ensured equitable access to the education of the population. On the other hand, social isolation in the midst of the COVID-19 pandemic required a unique educational environment but it has caused an increased number of psychological disorders around the world and mental illnesses, including depression, obsessive-compulsive disorder, long-term episodes of counterproductive anxiety, and others (Clemente-Suárez et al., 2021 ). The unexpected shift from in-person to online learning has created a lot of problems for students, teachers, and administrators because many years distance learning has not been very popular in schools and universities (Brown & Carreno-Davidson, 2020 ). At the same time, protecting the mental health of students is vital for higher education because cognitive abilities directly depend on the psychological state of the student, which affects academic motivation, the level of aspirations, involvement in learning, and the emotional and volitional spheres.

As a stage of ontogenesis (human development), higher education may cause exacerbate mental health problems. Before the pandemic, research has primarily focused on student group relationships and campus living as the most common stress factors among students (Davis et al., 2021 ). The research finds that distance learning students report psychological problems more frequently than face-to-face learners, and it is important to analyse the factors that influence mental well-being in distance learning and help to focus on the problem identification related to the transformation of the face-to-face classroom to a virtual environment. The research is important for educators because the COVID-19 infection has not yet been completely defeated, and distance learning is already seen not only as a necessary measure but also as a way to simplify access to education around the world and in China in particular.

Literature review

Since the first cases of COVID-19 were detected, countries’ authorities have tried to find possible measures and ways to fight the pandemic around the world. Face-to-face and autonomous learning systems were replaced by distance learning platforms, and it became a significant factor of mental tension while adapting to new conditions in all areas of life and influenced by inadequate communication at the interpersonal level.

Distance or online learning is the method which helps to prevent the spread of COVID-19, but it has a negative impact on the mental health of higher education students. The main problems experienced by students include anxiety, mild and severe stress, social media fatigue, and depression. At the same time, the symptoms are not always caused by mental health problems (Grigorkevich et al., 2022 ).

The literature analysis revealed the impact of distance learning on the mental health of students and showed that the most sensitive aspects included inadequate time management, the lack of a full-fledged adaptation strategy, the development of digital technologies in a new way, the burden to ensure the quality of new material learning, as well as concerns about the impossibility of funding educational activities under the COVID-19 conditions (Aditya & Ulya, 2021 ).

Some scholars have focused on fear as an emotional response of teachers and students to the distance learning model. The research confirmed that COVID-19 as a global social phenomenon increased the feeling of fear in different areas of life. First of all, it is the fear of being isolated from the family, the fear of academic failure, and the fear of losing social relationships (Al-Maroof et al., 2020 ). At the same time, modern online learning differs significantly from emergency distance learning, influenced by the mental tension decrease, in which addiction as a form of adaptation plays an important role. Under the pandemic restrictions and conditions, universities will adopt mixed or blended formats, since the problems of distance education are turned into educational opportunities. Distance learning allows easy access to education, development of different forms and methods of control, and adaptation and revision of inadequate university programmes (Adedoyin & Soykan, 2020 ).

The mental health of teachers is a part of the discussion devoted to the ecological environment of distance education. A sample of Pakistani and Malaysian teachers was used to analyse the parameters such as teacher self-efficacy and the quality of distance education. The research found that the mental well-being of teachers was a significant factor in ensuring academic success (Guoyan et al., 2021 ).

In Germany, scholars discuss the importance of psychological assistance provided by educational institutions during the crisis at the initial and final stages of distance learning. The attention of the German sociological and psychological services is on the well-being of students and burnout caused by nervous breakdown or inability to continue effective training under the COVID-19 restrictions.

In Germany, mental illness prevention strategies are introduced for first-year students who find it difficult to move into a new social environment despite the distance format. The transition to a new environment causes a high-stress level due to psychological tension, anxiety and increased learning requirements compared to previous school years.

An academic overload and a low level of knowledge among first-year students lead to learning problems, especially in specialised disciplines. Moreover, social and psychological aspects are important, such as mental exhaustion at the stage of admission, the development of new interpersonal relationships, and getting used to the university system of education and assessment (Schindler et al., 2021 ).

The factors mentioned above suggest that education during the first year of study based on the distance learning system can be more difficult for students in a situation when one problem is replaced by another. Cross-sectional research on the mental well-being of European students during the first wave of COVID-19 in May 2020 found that all university students (regardless of the year of study) had poorer mental health than before the pandemic. However, the mental health variable correlated with the belief (irrational belief) that the national government ensured effective management of the epidemic at the municipal level and reduced the risks of infection and negative macroeconomic outcomes (Allen et al., 2022 ).

The spread of the virus, long-term preventive measures and changes in daily routine have led to psychological problems such as anxiety, confusion, social deprivation, and depression. The chronic stress caused by the ongoing pandemic has a profound impact on a sharp and sustained decline of the psychological support that helped individuals cope with failure, emotional problems, disappointment, frustration, and preventing negative emotional experiences, namely resilience, optimism, psychological flexibility, and social relationships (Moroń et al., 2021 ). In China, the effectiveness of psychosocial support and the impact of COVID-19-related stressors on mental health have been investigated.

In Chinese realities, the concept of Psychosocial Support means family and social support in construct to Europe where it involves socio-psychological services.

Moreover, the assessment of the mental health of the respondents was based on the symptoms of depression and loneliness.

The scholars considered that the authorities should focus on the stress that followed the pandemic, as a serious threat to life and well-being, and the risk of infection with new and poorly researched diseases. However, the fear of infection as an independent variable was not correlated with either loneliness or depression, leading to heated debates about the impact of the pandemic on human mental health and well-being (Wang et al., 2022 ).

The COVID-19 pandemic has led to higher rates of mental disorders among the Chinese population. Many individuals have experienced increased resilience during the pandemic as a post-crisis change which had a positive impact not only on the population but on the healthcare system in the country (Zhang, 2022 ).

Restrictive measures under the quarantine have no impact on the cognitive performance of the population on different continents. However, complaints about cognitive decline increased significantly during the pandemic. High quality of life before the period of social isolation is the main factor that influences psychological disability, such as depression, anxiety, low-stress tolerance, ineffective self-regulation, and cognitive complaints (Nogueira et al., 2022 ). Reducing the negative consequences is important for young people in higher education during distance learning.

Problem identification

Only a limited number of publications covered the mental health of students during distance learning and discussed the problems faced by the post-COVID societies. This issue is of particular importance if the governments do not consider distance learning as a vital point and the only possible preventive measure against the spread of a deadly disease. The research purpose is to assess the psychological health of students learning online and investigate the factors that affect the mental health of students. Many scholars analyse the behaviour and psychological problems of schoolchildren, their parents and schoolteachers, paying less attention to the university environment.

This article considers age as the main factor to assess the opportunities and effectiveness of distance education for promoting the mental health of Chinese students in higher education. New experimental data will strengthen the debates about the opportunities promised by online education. After the weakening of quarantine measures, distance learning was no longer mandatory. This fact allowed the scholars to consider distance learning as an alternative form of education for the adult Chinese population who have already mastered social skills at earlier stages of ontogenesis and have maintained working, friendly, and romantic relationships with other people.

The scholars will complete the following tasks, such as identify the most appropriate psychometric tools to assess the quality of the student’s mental health learning remotely under weak isolation conditions; identify a sample size of first-year and fourth-year students to compare the mental health of those who entered the university and those who had experience learning online in a higher educational institution. Moreover, the research will compare the statistical data of two groups and test the null hypothesis. In this article, mental health is evaluated under conditions of adaptive quarantine, during which students have access to mobility, interpersonal communication outside their home, and quality leisure activities, which become possible due to mass vaccination and economic feasibility.

Methods and materials

The BHM-20 methodology can help to assess mental health and the psychotherapy progress used as the main diagnostic tool (Kopta et al., 2015 ). This technique is a 20-item questionnaire that evaluates three components of healthy behaviour: well-being (stress, life satisfaction, and motivation); psychological symptoms (depression, anxiety, panic disorder, mood changes caused by bipolar disorder, eating disorder, substance abuse, suicide intentions, and risk of violence); life activities (work and study, intimate relationships, social relationships, and enjoyment of life).

The full technique name is Behavioural Health Measure often used in a short form BHM. This technique can be used remotely without the direct participation of a psychologist because the respondent can insert answers using a computer or gadget, and the average time to complete the questionnaire is about three minutes. This tool is used in behavioural health clinics of primary health care (Bryan et al., 2014 ). The test consists of 20 statements rated by respondents where 0 points mean Strongly Disagree and 4 points represent Strong Agree .

The maximum total score of psychological well-being, without the suicidal scale, is 80 points, and the minimum score is 0 points, which means deep mental exhaustion. The scales do not have a separate gradation, and it means that the scale showed the overall score of mental health. Moreover, BHM-20 allows additional screening of suicidal thoughts and impulses, and it is considered six times better to identify suicidal intentions in primary care than the standard interview method. However, the research does not make use of this method, because it is secondary in importance to clinical psychological care.

In many cases, BHM-20 is used for primary psychological counselling at a certain number of higher education institutions, including Harvard University, the University of Minnesota, Indiana University, the University of Florida, and others, making this psychometric tool effective for data analysis. The tool is appropriate for adults aged 18 + with normal or high intelligence (Bryan et al., 2014 ). Express methods with a high level of reliability exist in modern methodology including BHQ-20 (Behavioural Health Questionnaire) with similar scales. The technique’s reliability was evaluated using four samples of different age groups, showing high results during the initial testing. Moreover, the high correlation between the scales in the BHQ-20 method indicated the presence of 1 key parameter of mental health. The analysis finds that the BHQ-20 is a reliable and valid mental health questionnaire, even though the number of questions is small (Kopta & Lowry, 2002 ).

Participants

The experimental group of first-year students included 94 individuals (38 females and 56 males) aged 18 to 19 years interested in this research. The control group of fourth-year students consisted of 92 individuals (48 females and 44 males) aged 21 to 23 years. All respondents had prior distance learning experience because the experiment was conducted during the second half of the academic year when both groups learnt for four months under adaptive quarantine. The distance learning experience differed across groups because for first-year students it was similar to their school experience while the control group actually continued professionalization, first under conditions of total quarantine, and then under conditions of adaptive quarantine.

Study design

This research was easy to organise and manage because it was conducted remotely and involved first-year and fourth-year volunteers of Zhengzhou University of Technology. The respondents received instructions in real time and proceeded to complete the electronic questionnaires on the Google platform at the agreed time on their personal computers. The preliminary briefing was conducted in the format of an online conference on ZOOM. The results were sent directly to the experimenter’s computer, entered into a common table, processed, and also remained anonymous. Although the participants logged in via e-mail in a Google form. In fact, the Google form presented to the respondents repeated the questions from BHM-20, greatly simplified the collection and processing of data. The well-structured methodology supported the high motivation level among the participants, immersed in the psycho-diagnostic process. The students were not informed about the research objective, which was the impact of distance learning on the mental health of young individuals. It helped the scholars to ensure the experiment’s purity and avoid bias. Moreover, all respondents could review the methodology results. The primary data processing did not take much time and the experimenter move quickly to statistical analysis.

Data analysis

Data processing was carried out using the SPSS Statistics 22 programme. To test the research hypothesis, the popular nonparametric Mann-Whitney U-test for independent samples was used. It helped to assess the statistical homogeneity of the two samples and ensured the significant differences.

Research limitations

The research had several limitations. First, the BHM-20 is a fast test without subscales. Second, the single-item suicide risk scale was not used in this experiment because this factor is usually used for the pre-responses analysis only. Third, the mental development of first-year and fourth-year students differs due to age differences and life experience, which can affect the level of mental health. Fourth, the BHM-20 method, considered an individualised one, does not have any gradations of Mental Health Normality , which limits the possibility of using this psychometric tool for large-scale research. Fifth, both samples involved volunteers only. The research did not capture the required social section of the population. Sixth, the BHM-20 was originally developed to assess the progress of individual psychotherapeutic performance. It heats the debates about the lack of standardised tests to assess the overall mental health of an individual. Tests without subscales would simplify the assessment of the impact of distance education on the mental health of Chinese youth.

The unprecedented nature of this pandemic has caused several risk factors and events not explored in this research. The overall physical health, physical training, domestic abuse, violence, and mental health problems experienced by individuals caused by the pandemic were not examined. All indicators used in this research are self-reported, so the scholars consider that some respondents may be apt to provide truthful or false answers, which therefore could influence negatively the results.

Ethical issues

This experiment was based on high ethical standards because both samples involved volunteers and their identity was kept anonymous. Some students received feedback from the researcher on an individual basis. The experiment goals were not disclosed to the participants. The students were informed about some goals without going into detail including information about voluntary mental health monitoring. The experimenter did not benefit from the research and all the financial expenses were covered by Zhengzhou University of Technology.

The research usefulness function was realised in full because distance learning under adaptive quarantine was introduced not only in China but in Europe. This is an important factor because the pandemic has not yet been completely defeated despite the mass vaccination programmes. The use of distance learning in higher education institutions, considering mental health, has been still questioned. The research finds drawbacks in policy development especially when distance learning is proposed for first-year students who integrate into a new social environment and acquire new skills and master knowledge.

This scientific discussion is of exceptional social significance, allowing academic institutions to balance live communication in the classroom and the mental health of students who experienced an academic overload. There was no risk to the physical and mental health of freshmen. Moreover, monitoring was used as a self-report measure and forced respondents to pay attention to their mental health and analyse their overall mental conditions over the past two weeks.

The results processing started with the analysis of the mean values for groups, which made it possible to produce high-quality primary research. At this stage, significant differences between the groups were manifested. Significant differences were found in the median of grouped data, and minimum and maximum values. So, the average value in the experimental group of first-year students was 35.14 points out of 80 possible points, while in the control group of fourth-year students this indicator was higher and reached 52.66 points. The data is available in Table  1 .

Primary Data Analysis

If the minimum value of the BHM index in the group of first-year students is 10 points, then in the control group it is already 33 points. The difference illustrates the high vulnerability level of former school students and a need for adaptation and effective use of psychological resources during the transition period, from one social environment to another. At the same time, the maximum intragroup values are similar. In the experimental group, the BHM score did not exceed 61 points, while in the control group, the highest value was 74 points out of 80 points. The standard deviation is lower in the group of fourth-year students, which suggests a higher homogeneity in the assessment of psychological well-being.

It proves the significance of the socio-psychological services at the stage of adaptation of first-year students so that the students can receive professional support and focus on the educational process. These strategies should be introduced into practice under adaptive quarantine. For example, one of the possible interventions is support groups organised once a week and conducted by a professional psychologist online.

The second stage of data processing involved a comparison of samples to identify the statistical differences. The classical Mann-Whitney U-test for independent samples was used. The analysis revealed that there were statistically significant differences between the groups. The data are available in Table  2 .

Secondary Statistical Analysis

The results reveal that the integrated value of BHM in the groups of first-year and fourth-year students is significantly different because an extremely low level of statistical error was detected, namely - p = 0.000 with admissible p = 0.05. This result suggests that the psychological well-being of fourth-year students is more stable compared to first-year students. The research considers that distance learning is not the only factor affecting the mental health of the respondents from the experimental group. The scholars assumed that psychological problems experienced by students were caused by many factors including adaptation processes to distance learning, personality crises and academic overload. The results showed that distance learning for first-year students was less desirable than for the fourth-year respondents. It is difficult for the socio-psychological service workers to support students and provide psychological help online, detect emotional burnout, apathy, and depressive episodes in a distance learning format. This research showed that age and the year of study significantly affected the mental health of students learning online.

Empirical research in South Africa illustrated that university professors failed to deliver adequate psychological support to isolated students. Students relied heavily on the support of both the administrative and academic staff when it came to the learning process. As a result, the high work stress felt by teachers was added to the high academic stress of students, which increased the risk of emotional burnout and nervous exhaustion in both groups (Poalses & Bezuidenhout, 2018 ).

Distance learning sabotage denial to accept a new academic environment increases the likelihood of mental disorders and reduces the cognitive abilities of schoolchildren whose parents are against this form of teaching (Davis et al., 2021 ). Distance learning under total lockdowns can cause a sense of learned helplessness with online learning technology, and worsen the quality of mental health of students of different age groups. The factors that may eliminate the negative consequences are academic motivation, reduced fatigue and a loss of interaction that cannot be restored with any online conferences (Garcia et al., 2021 ).

The U.S.-based University conducted a multi-thousand online survey involving undergraduate and graduate students based on standardised scales for assessing physical health and anxiety, as well as additional multiple-choice questions and open-ended questions about stressors and coping mechanisms under the pandemic restrictions. The results showed that half of the respondents experienced an increased level of depression and anxiety. At the same time, less than half of the participants indicated that they coped effectively with the stress factors caused by online learning and the threat of infection (Wang et al., 2020 ).

In Malaysia, the mental health of students during distance learning was evaluated using the DASS-21 methodology, designed to assess the depressive-anxiety stress factors. The questionnaire analysis showed that 30% of students in vocational schools experienced severe or extremely severe depression, 41% had anxiety, and 20% had chronic stress. At the same time, the biological sex of the respondent had a significant impact on anxiety. The research suggests investigating and combining distance learning with face-to-face education and practical work experience within the curriculum (Ahmad et al., 2022 ).

The results comparison of the mental state of students in full-time and distance learning was performed in Eurasia. This research assessed satisfaction with academic performance and the severity of depression and anxiety symptoms. The results showed that the prevalence of depressive symptoms and anxiety among students was higher during distance learning, compared with similar results obtained during full-time education. Moreover, the research results showed that the sudden transition from one learning environment to another was a major cause of chronic stress, which led to a high prevalence of depressive symptoms and anxiety among students (Lyubetsky et al., 2021 ).

In Italy, the impact of long-term online learning on the mental health of students was also researched. The second (control) experiment used the same sample and conducted the research over six months. The results reveal significant differences on scales such as students’ connection with other students and teachers, workspace organisation, and boredom between lessons. Moreover, the results show significant correlations between student academic development and the quality of distance learning, course adaptation, workspace arrangements and communication with other students and teachers, and between students’ emotions and communication with other students and teachers (Baltà-Salvador et al., 2021 ). The research finds that the social relations in distance learning can be an additional psychological resource for students that should not be underestimated.

Cross-cultural research based on a sample of thousands of students showed higher rates of depression, suicidal intentions and post-traumatic stress disorder compared to pre-pandemic levels and current rates in individuals belonging to ethnic minorities, which could also be considered as one of the factors of influence. Though the most common pandemic outcome is PTSD (Post-traumatic stress disorder ) , recorded in 62% of the respondents. However, neither age, nor personal history of mental illness, nor perceived social support was a significant risk factor of mental health (Torres et al., 2022 ).

The UK has developed a large-scale online questionnaire designed to assess mental health under the pandemic restrictions. The authors of the questionnaire considered socio-demographic variables, previous physical or mental illness, personal experience with COVID-19, information in the media, pandemic concerns, degree of personal traumatic experiences, PTSD caused by a pandemic outbreak, generalised anxiety disorder, depressive disorder, sleep quality, emotional deregulation, loneliness, social support, and the meaning of life (Armour et al., 2021 ). This questionnaire has not yet been standardised and adapted in other countries. However, all of the above factors affect the quality of mental health during and after the pandemic. There were no publications devoted to mental health under adaptive quarantine, which proved the need to start a debate on the key theoretical and empirical questions.

This article investigated the main factors that affected the mental health of students. The theory of intelligence helps to illustrate that the pandemic and distance education increase the risk of clinical depression, generalised anxiety disorder, PTSD, apathy, learned helplessness, burnout, nervous breakdown, and so on. Furthermore, non-university students more often report mental health problems than those who learn academic disciplines in a traditional format. The results prove that therapeutic and individualistic approaches to mental health cannot be the only methods used to improve students’ mental well-being.

The scholars have to investigate inclusive curriculum design and assessment methods. Moreover, educational institutions should introduce and teach advanced telecommuting skills, implement educational systems and processes that do not cause stress, and design learning environments based on professional feedback to maintain a balance between quality education and the student’s mental health. The research proposed the holistic approach to introduce mental health practices during distance learning that can influence positively the mental well-being of students. At an empirical level, the present research investigates distance learning opportunities during adaptive quarantine and finds that it is less effective for first-year students who have just entered the university. The problems that may arise are caused by the complicated adaptation process which requires a significant amount of effort, the difficulties in developing new social relations with teachers and fellow students, and academic overload, especially in learning specialised disciplines.

The experiment shows that first-year students are a more vulnerable group than fourth-year students who have learnt online at the university and feel much more competent when it comes to university education. In addition, the research finds that first-year students need high-quality psychological support being at risk with a reduced tolerance for uncertainty. The empirical research finds that age and the year of study affect the mental well-being of students. The scholars suggest that under conditions of adaptive quarantine, it is necessary to pay attention to psychological screening and psychological interventions to prevent depressive episodes, apathy, low academic motivation, low-stress resistance, ineffective self-regulation, and so on. The scientific value of the research is that it causes a worldwide discussion about the safety of distance education and its impact on the mental health of university students.

Moreover, some risks for mental health may occur when young individuals learn remotely. However, the research proves that the psychological states of undergraduate students are more stable and the students are better prepared for distance learning. This is the main practical value of the article to the university administration and teachers. This research manifests that the quality of socio-psychological services in universities is a priority for the administration, and special strategies should be developed to prevent mental disorders among students and maintain an effective and advantageous learning environment for all parties involved in the education process.

No funding was received to assist with the preparation of this manuscript.

Data availability

Declarations.

There are no competing interests to declare that are relevant to the content of this article.

The study was conducted in accordance with the ethical principles approved by the Ethics Committee of Zhengzhou University of Technology.

All participants gave their written informed consent.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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  • Published: 14 July 2022

The impact of virtual learning on students’ educational behavior and pervasiveness of depression among university students due to the COVID-19 pandemic

  • Fatima M. Azmi   ORCID: orcid.org/0000-0001-9275-0965 1 ,
  • Habib Nawaz Khan   ORCID: orcid.org/0000-0003-3519-264X 2 &
  • Aqil M. Azmi   ORCID: orcid.org/0000-0002-0983-2861 3  

Globalization and Health volume  18 , Article number:  70 ( 2022 ) Cite this article

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One of the worst pandemics of recent memory, COVID-19, severely impacted the public. In particular, students were physically and mentally affected by the lockdown and the shift from physical person-to-person classrooms to virtual learning (online classes). This increased the prevalence of psychological stress, anxiety, and depression among university students. In this study, we investigated the depression levels in Saudi Arabian university students who were learning virtually because of the COVID-19 pandemic and examined its impact on their educational proficiency.

The study focused on two points: first, examining the depression levels among undergraduate students in Saudi Arabia, by adapting the Zung (Self-Rating Depression Scale) questionnaire. Second, whether there is an association between the levels of depression and various distress factors associated with virtual (online) learning resulting from the COVID-19 pandemic and its impact on students’ educational behaviors. The questionnaire was prepared using a monkey survey and shared online, via email, and on WhatsApp groups, with participants in two universities, a public and private university in the largest city of Saudi Arabia. A total of 157 complete responses were received. Data were analyzed using SPSS-24, the chi-square test, descriptive statistics, and multilinear regression.

The results indicated that three-fourths of the university students suffered from different depressive symptoms, half of which had moderate to extreme levels of depression. Our study confirmed that a boring virtual (online) learning method, stress, fear of examinations, and decreased productivity were significantly associated with increased depression. In addition, 75% and 79% of the students suffered from stress and fear of examinations, respectively. About half of the students were associated with increased depression. The outcome also indicated that female students experienced extreme depression, stress, and fear of examinations more than males.

These findings can inform government agencies and representatives of the importance of making swift, effective decisions to address students’ depression levels. It is essential to provide training for students to change their educational experience mindset, which might help decrease "depression and stress-related growth." There is also a need to search for a better virtual teaching delivery method to lessen students' stress and fear of examinations.

On March 11, 2020, the World Health Organization (WHO) declared the highly contagious coronavirus (COVID-19) a global pandemic [ 1 ]. As the cases of COVID-19 increased, China, and many other countries practiced partial or complete lockdowns. It is estimated that this drastic measure helped save 3 million lives across 11 European nations [ 2 ]. Toward the end of January 2022, the total number of confirmed COVID-19 cases worldwide was 360,578,392, and 5,620,865 confirmed deaths. The number of people who received vaccination doses globally was 9,679,721,754 [ 3 ].

To contain the virus, the lockdown caused academic disruptions. This resulted in the indeterminate closure of schools, universities, various institutes, shopping malls, and centers of economic activities [ 4 , 5 ]. Repetitive activities, transfer of educational mode to distance (virtual) learning, and change in social life amplified the prevalence of psychological stress, anxiety, depression, and acute stress reactions among university students [ 6 ]. Sociodemographic factors associated with low mental health include financial constraints, old age, infection risk, and fear of losing a relative or friend. In addition, COVID-19 pandemic-related educational stress may be attributed to (in no particular order): (a) transformed teaching and assessment methods; (b) skepticism about university education; (c) technological worries about online courses [ 7 , 8 ]; (d) uncertainty about the future because of academic disruptions; (e) fear of failing examinations; (f) inability to concentrate during lectures, and many more factors. All these factors have been detected in universities across the world [ 9 , 10 ]. A global study that inspected students’ experiences in about 62 different countries, including a university in the United States, found that students expressed worries about their academic achievements and professional careers and feelings of dullness, anxiety, and frustration [ 9 ]. Students in China also reported increased sadness, anger, anxiety, and fear [ 11 ]. The occurrence of depression, psychological distress, and anxiety from pandemics differed from country to country. A study in Italy reported that 15.4% of Italians suffered from extremely high levels of depression, 12.6% were highly stressed, and 11.5% were highly anxious [ 12 ]. In Malaysia, it was reported that severe to extremely severe levels of depression and anxiety were found in 9.2% and 13.2% of the subjects, respectively. Moderate stress was found in 9.5% of subjects, and severe to highly severe stress was found in 6.6% of subjects [ 13 ]. Furthermore, students in Switzerland manifested a decrease in social interface and higher levels of stress, anxiety, and loneliness [ 14 ]. Adults have also reported declining physical activity, while food eating increased during pandemic quarantine periods compared to previous times [ 15 ].

The first COVID-19 case appeared in the Kingdom of Saudi Arabia (KSA) on March 2, 2020 [ 16 ], while the lockdown was imposed on March 8, 2020. To keep students on track due to the pandemic, the education delivery mode was switched to virtual learning. It has been over one year since teaching was transferred online, and many countries worldwide have tried to revert to the standard path of education by opening schools and universities. Although the COVID-19 vaccine is available worldwide, some countries are still practicing lockdown because of the appearance of several more contiguous variants of the coronavirus, such as Delta, a SARS-CoV-2 strain that was first spotted in India [ 17 ]. The spread of COVID-19 presents a serious risk; in mid-April 2022, the confirmed cases in KSA were 751,717, out of which 736,910 had recovered, and 9,055 deaths were recorded [ 18 ].

The psychological consequences of COVID-19 have been observed and described in KSA. Al-Hanawi et al. [ 19 ] reported different levels of distress in 40% of the general Saudi population because of COVID-19. Moreover, Alkhamees et al. [ 20 ] reported moderate to severe psychological effects in 23.6% of the general Saudi population. In another study of the influence of the COVID-19 pandemic on Saudi Arabian residents, Alyami et al. [ 21 ] stated that the percentages of mild, moderate, moderately severe, and severe levels of depression were 41%, 20%, 6.2%, and 3.2%, respectively. Furthermore, Khoshaim et al. [ 22 ] reported that about 35% of students experienced moderate to extreme anxiety levels. Azmi et al. [ 23 ] observed that 75% of students suffered from various levels of depression, while 41% suffered from low levels of self-esteem.

Likewise, another study found that 35% of students in the western and northern regions of KSA had high rates of distress [ 24 ]. Following the observed rise of psychological disorders, the authorities posted health messages and distributed procedures to the public. For example, during the pandemic, the Saudi Center for Disease Control and Prevention (CDC) [ 25 ] supplied a precautionary manual for mental and social health focused on prevention, pressure, and fear control. From the foregoing, the COVID-19 pandemic has had a severe impact on the physical and mental health of the public in general and students in particular, as university students are among those most severely affected by the COVID-19 pandemic.

In this study, we investigated the depression levels of university students in Riyadh, the capital and largest city in KSA, who were learning virtually because of the COVID-19 pandemic. We also assessed the impact of virtual learning on their educational behaviors. The following questions were explored during the investigation:

What are the levels of depression among university students?

What is the impact of virtual learning on students’ educational behaviors and what are the relationship between depressive symptoms they exhibited and virtual learning?

To answer the second question, we explored the relationship between the levels of depression and various distress factors associated with virtual learning because of the COVID-19 pandemic and its impact on students’ educational behaviors. These factors were divided into two main categories: Category 1 dealt with factors relating to how virtual learning has affected students’ feelings from an educational perspective. Category 2: dealt with factors relating to how virtual learning affected students’ understanding of subjects/learning materials.

Once we ascertain the current levels of depression and their impact on students’ educational behavior, we may embark on helping them cope with the extraordinary situation. Hopefully, this will help lower their elevated depression levels. Furthermore, we hope our study will guide policymakers in searching for innovative ways of online teaching to make learning less stressful and more productive.

Design and sampling procedure

This study examines depression levels and investigates virtual learning-related distress factors, which might predict the increased level of depressive symptoms among university students in Riyadh City during the COVID-19 pandemic.

Research design

We conducted a descriptive survey-based study to obtain responses from students at large universities in Riyadh, the capital of KSA. The total size of the target population of the city of Riyadh is about 7 million [ 26 ]. The sampled population of both universities’ undergraduate students was approximately 0.027 million (27,000). The male-to-female ratio of undergraduate students at King Saud University (KSU) is about 67%: 33%; the male-to-female ratio of undergraduate students at Prince Sultan University (PSU) is about 28%: 72%, as this is a female-dominated university. Since the sampled population was largely heterogeneous, we minimized the heterogeneity by dividing the given population into sub-populations to obtain sampling units that are homogeneous internally and heterogeneous externally. Hence, we used a stratified random sampling technique, which is more appropriate than other sampling techniques for obtaining better estimates of the parameters of interest. To ensure the efficiency of the estimates, we used the proportional allocation technique to determine the sample size.

A Monkey survey was used to prepare the questionnaire, following the approval of PSU’s Institutional Review Board. The questionnaire included demographic questions, such as gender, age, and college. Zung’s Self-Rating Depression Scale (ZSDS), with 20 items on a 4-point Likert scale, was used to measure depression. The questionnaire also had questions to address distress factors associated with virtual learning because of the COVID-19 pandemic. The students were asked to read all the questions carefully and answer them.

The survey was written in English and Arabic side by side. A subject expert translated the questionnaire from Arabic to English. Thereafter, five more experts checked the same questions for more corrections and authenticity. The actual online survey took place from March to April 2021. The survey was voluntary, and the informed consent of the students was sought. We received reasonable responses from the students; however, we also received some incomplete responses. The missing/incomplete responses were discarded from the study so that the estimated results were not compromised. The valid responses received from males and females were 49.7% and 50.3%, respectively.

Measuring instruments

Demographic data and personal characteristics, such as age, gender, and area of study, were recorded.

Depression measure

The ZSDS was used to measure the levels of depression. The tool is a 20-item self-reporting assessment device used for measuring depression levels [ 27 , 28 ]. This is divided into 10 positively worded and 10 negatively worded items. The latter items were reversely scored. Each item was scored on a Likert-type scale as follows: 1 =  Never , 2 =  Sometimes , 3 =  Often/most of the time , and 4 =  Always . The total raw scores ranged from 20–80, and when converted into the depression index (termed "ZSDS index"), the range becomes 25–100. To determine the level of depression, we classified the ZSDS index into four classes (levels). Therefore, ZSDS index scores were considered "normal" from 25–49, "Mildly Depressed,” from 50–59, “Moderately Depressed” from 60–69, and “Severely Depressed” from 70 and above [ 27 ]. In [ 29 ], the author translated the ZSDS measure into Arabic and further validated it. Question 6, “I still enjoy sex,” was deemed offensive religiously and culturally. Therefore, it was rephrased to “I enjoy looking at, talking to, and being with attractive women/men,” which is culturally more appropriate. The accuracy of the new version was verified in [ 29 ]. The Arabic and English languages were used side by side to prepare the questionnaire. The Cronbach’s alpha coefficient of this study was 0.87, showing high internal consistency.

Data on distress factors associated with virtual learning

Data on distress factors associated with virtual learning due to the COVID-19 pandemic were divided into two categories. The first category dealt with questions on how virtual learning due to the pandemic affected students’ feelings from an educational perspective and caused a) lack of motivation/boredom, b) stress, c) worry and fear of exams, and d) decreased productivity. The second category dealt with questions on virtual learning and its effect on students’ understanding of subjects/materials, such as a) It needs more self-effort to understand, b) It made learning and understanding harder for them, c) They need more time to understand the subject, i.e., the understanding pace became slower, d) Virtual learning is boring, and e) they had difficulty solving problems in academic subjects and writing down the solutions correctly. The answer to each question was either “Yes” or “No.”

Finally, the questionnaire had an open-ended question that offered students a chance to express in their own words how the lockdown and virtual teaching had affected their educational advancement.

Data analysis

Data were analyzed using IBM SPSS version 24 software. The categorical variable demographic data were analyzed descriptively to determine the essential characteristics of the sample and were presented as counts and percentages. The level of depression index among university students in Riyadh, and its association with gender, age, and their field of education, was analyzed using the chi-square test and descriptive statistics. Multilinear regression analysis was performed to investigate the connection between depression levels and various factors associated with virtual learning due to the COVID-19 pandemic. The statistically significant level was set at \(p \le 0.05.\)

Demographic characteristics

The total number of participants was 157 university students. Table 1 shows the demographic characteristics of the participants.

Students’ levels of depression and demographic variables

In the univariate analysis, chi-square tests were used to determine the associations between students’ demographic variables and the ZSDS level. Table 2 displays the association between depression levels with gender, age, and college. Among the demographic variables, only the association with gender was statistically significant at \({\chi }^{2}\) = 20.229, and p  < 0.001, while the association with age and college was not significant. A total of 74.4% of the students had various levels of depression. Of these, 37%, 21.7%, and 16% had mild, moderate, and severe depression levels, respectively. In addition, females (28%) had more depressive symptoms than males (4%).

Educational distress factors associated with virtual learning and descriptive statistics

The factors related to virtual learning sequel to the COVID-19 pandemic, and its impact on students’ educational behaviors were divided into two categories. Questions on virtual learning's effect on students' feelings from an educational perspective (Category 1) had four items, each with a "Yes" or "No" answer. Likewise, questions on virtual learning and its effect on students’ understanding of the subjects/materials (Category 2) had five items, each with a “Yes” or “No” answer. Table 3 demonstrates the descriptive statistics. In the first category, the highest percentage was feeling worried and having a fear of exams (79%), followed by stress (75.2%), lack of motivation, and decreased productivity (70%, each). In the second category, the highest percentage was 78%, who felt they had to put extra self-effort into understanding and studying.

Furthermore, 74.5% felt that virtual learning was more challenging for them to understand than physical learning. In addition, 73% said virtual learning was slow and extra time was needed to understand and learn the concepts, while 64% found it boring. Finally, 58.6% had difficulty solving problems and submitting properly written answers (for math and computer science subjects).

Distress factors related to virtual learning and depressive symptoms

Multilinear regression analysis was used to study whether various distress factors related to virtual learning can influence depressive symptoms among students.

The first category, which dealt with students’ feelings from the educational point of view, hypothesized that lack of motivation, stress, worry/fear of examinations, and decreased productivity would significantly impact the development of depressive symptoms among students.

Multi-regression analysis was used to test the hypotheses, with the Zung depression index as a dependent variable. The results show that 24.6% of the variance in Zung’s depression index can be accounted for by four predictors, collectively \(, F(4, 152) = 12.414, p < 0.001\) . Looking at the unique individual contribution of the predictors, the result shows that worry and fear of exams ( \(\beta =0.290, t=3.589, p<0.001)\) , stress ( \(\beta =0.202, t=2.566, p=0.011<0.05)\) , and decreased learning amount and not being productive ( \(\beta =0.211, t=2.783, p=0.006<0.05)\) , statistically significantly contributed to worsening depressive symptoms. The predictor, feeling lack of motivation, did not significantly impact developing depressive symptoms.

The second category dealt with virtual learning and its effect on students’ understanding of the subjects/materials. It was hypothesized that the need for extra self-effort to understand the subject, learning became harder, learning became slower, learning was boring, and difficulty in solving problems and writing answers properly would have a statistically significant impact on developing depressive symptoms among students.

Multi-regression analysis was used to test the hypotheses, with Zung’s depression index as a dependent variable. The test showed that 13% of the variance in Zung's depression index can be accounted for by the five predictors, collectively \(, F(5, 151) = 4.505, p < 0.001\) . Looking at the unique individual contribution of the predictors, the result shows that learning is not much fun or exciting ( \(\beta =0.250, t=3.060, p=0.003<0.05)\) , and facing difficulty in solving questions and writing answers properly ( \(\beta =0.176, t=2.067, p=0.05<0.05)\) , were statistically significantly associated with worsening depressive symptoms. While the other three predictors, learning became harder, learning became slower, and the need to put extra self-effort did not contribute significantly to depressive symptoms, as shown in Table 4 .

Furthermore, we explored two distress factors, stress, and worry/fear of exams, which contributed statistically significantly to worsening depressive symptoms. Using the chi-square test, we examined the association of the distress factors with depression levels; that is, what extent does stress or worry/fear of exams contribute to moderate or severe depression. The results showed a statistically significant association between stress and moderate to severe levels of depression ( \({\chi }^{2}\) = 17.179, and p  < 0.001). Likewise, there was a statistically significant association between worry/fear of exams and moderate to severe levels of depression ( \({\chi }^{2}\) = 30.236, and p  < 0.001), Table 5 .

The association between stress or worry/fear of exams and gender was examined using the chi-square test. There was a statistically significant association between these two factors and gender, with more females having higher stress levels (54%) than males (41%). Also, worry/fear of exams manifested in 60% of females and 40% of males during virtual learning, sequel to the COVID-19 pandemic. The results are presented in Table 6 .

Open-ended questions

The questionnaire ended with an open-ended question, in which students were asked to write in their own words how the lockdown has affected their educational advancement. Excerpts of the negative comments from students are outlined below:

“Virtual teaching and exam resulted in increased cheating." “Virtual teaching caused difficulty in understanding the subject, which resulted in lowering my grades.” "I have to sit in the same room with my siblings while learning online, as my home is small. So, I cannot concentrate at all; it just makes me very frustrated.”

From their comments, it is clear that a virtual learning environment is entirely different from a physical classroom teaching environment where exams are conducted with invigilators proctoring.

Significantly few students provided positive comments.

"Virtual teaching made me understand better and increased productivity and my grades."

In this study, we investigated the severity of depressive symptoms among university students while learning virtually because of the COVID-19 pandemic and its impact on educational behaviors in KSA We collected samples from different universities in Riyadh. The total number of complete responses was 157. The Zung Self-Rating Depression measure was used to measure depression levels. Our results indicate that 75% of the students suffer from different levels of depression (37%, 22%, and 16% of the students reported mild, moderate, and extremely severe levels of depression, respectively). This result is consistent with an American study, which reported that 44% of students in the USA experienced an augmented level of depressive thoughts [ 30 ].

The association between the levels of depression and various distress factors associated with virtual learning due to the pandemic and its impact on students’ educational behaviors was explored using multilinear regression. These factors are divided into two main categories: Category 1: These factors relate to how virtual learning has affected students’ feelings from an educational perspective. This consists of four items: lack of motivation, stress, worry/fear of exam, and decreased productivity. Category 2 factors relate to how virtual learning has affected students’ understanding of the subjects/materials. This category has five items, including need of extra self-effort, need to study harder, learning is slower, virtually learning is boring, difficulty in solving problems, and writing properly.

Consistent with our hypotheses, we confirmed that stress, worry/fear of examinations, and decreased productivity were significantly associated with an increased level of depression. Another recognized factor that contributes significantly to a higher risk of developing depressive symptoms among university students is that virtual teaching and learning becomes boring. Furthermore, students faced difficulty in solving mathematics and science problems and writing the answers properly due to online teaching. A few other factors, such as lack of motivation, learning became more complex and slower, and the need to put extra self-effort contributed to developing depressive symptoms.

Our results indicate that 75% of the students suffer from stress, and about half (47%) have high levels of depression. This is consistent with the results in [ 13 ]. Our findings also indicate that 79% of the students suffer from fear of exams, and about half of them (47%) experience moderate to severe levels of depression. It is usual for some students to have worries and fear for exams; however, it is highly unusual for more than three-fourths of the students to experience fear and worry. This is a clear indication that the changed mode of lecture delivery and exam administration because of COVID-19 has a significant role in raising depression levels among university students. Our findings indicate that a higher percentage of females experience extreme levels of depression than males (28% of females compared to only 4% of males), stress (59% females, vs. 41% males), and worry/fear of exams (60% females, vs. 40% males). This finding is consistent with many studies concerning college students, in which females were at a higher risk of suffering psychologically during virtual learning because of the COVID-19 pandemic [ 9 , 31 , 32 , 33 ]. Another study showed that Vietnamese female students had a higher percentage of depression compared to male students [ 34 ]. Furthermore, Huange et al. [ 35 ] reasoned that Chinese females experienced more anxiety than males during the COVID-19 pandemic. Thus, we assert that feamles are more commonly inclined toward depression and anxiety disorders than males [ 36 ].

The results of the open-ended responses demonstrated the students’ frustration and stress relating to online learning. In contrast, very few students positively indicated that online learning and studying from home felt relaxing.

COVID-19 has been a catastrophic experience. Although it has largely subsided, new variants are causing apprehension among health officials. Our research found that 75% of university students in Saudi Arabia suffer from some degree of depression. Half of these students showed moderate to extreme levels of depression. This is greater than the expected depression level in the overall population. Our study confirms that stress, worry, and fear of examinations, decreased productivity, and the fact that virtual learning is boring are significantly associated with increased depression. Our findings also indicate that 75% (79%) of the students suffer from stress (fear of exams), and that about half of them have increased levels of depression. It should be noted that the students are 18–24 year olds. This is consistent with the study [ 22 ], which found that psychological distress, stress, and anxiety were higher in the younger age group during the COVID-19 pandemic.

Remarkably, more female students experienced extreme depression, stress, and fear of exams than male students. This result supports previous reports that females were at higher risk of psychological distress during the COVID-19 pandemic [ 9 , 31 , 32 , 33 ].

Our observation calls for instant attention and sustenance for students. There is a requirement to explore potential coping policies that have been shown to be effective during pandemics [ 37 ]. The results of our research might direct policymakers to develop distress management protocols as part of their policy for dealing with future pandemics [ 38 ]. It is essential to provide training for students to redirect their educational experience mindset to focus on the “bright side” and expand instances that may guide "depression and stress-related growth.” A flexible mindset can also help students adapt to new ways of learning and developing tremendous gratitude for life. In addition, there is a need to explore better online teaching delivery methods to lower students’ stress and fear of exams.

Study strengths and limitations

The strength of this study is that it was conducted after students had received virtual teaching for more than one year because of the Pandemic. Therefore, this study accurately reflects students’ depression levels and how these impact their educational behaviors in KSA.

Furthermore, the study was conducted in Riyadh, the capital of KSA, hence our study sample is more reflective of the Saudi student population. Moreover, the depression assessment tool for the study, the Zung Self-Rating Depression Scale, is a reliable, universally acceptable scale.

The limitation of our study is that the sample was not randomly selected from all university students, as a convenience sampling method was used.

Availability of data and materials

The raw data supporting the results of this study will be made available by the corresponding author without undue reservation.

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Acknowledgements

Fatima Azmi would like to thank Prince Sultan University for funding the project and covering the publication fees.

This work was supported by a research project grant [Grant number: COVID-19-DES-2020–43] from Prince Sultan University, KSA.

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Azmi, F.M., Khan, H.N. & Azmi, A.M. The impact of virtual learning on students’ educational behavior and pervasiveness of depression among university students due to the COVID-19 pandemic. Global Health 18 , 70 (2022). https://doi.org/10.1186/s12992-022-00863-z

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effect of online learning on mental health research paper

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Mental health, learning behaviour and perceived fatigue among university students during the COVID-19 outbreak: a cross-sectional multicentric study in the UAE

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The rapid shift to online education due to COVID-19 quarantine challenged students’ ability to accept pure online learning without negative consequences for their physical, emotional and mental health. Some educational institutions introduced new strategies to reduce the psychosocial burden associated with online learning during home confinement. Thus, the primary aims were to determine the consequences of COVID-19 for the psychological well-being and fatigue levels of higher education students and to explore the effects of a new academic assessment approach in reducing home confinement stress.

A cross-sectional online survey was conducted among students, from 30 August to 30 September 2020, of 7 disciplines in all 16 higher colleges of technology in the United Arab Emirates (UAE). The Mental Well-being and Learning Behaviours Scale and the modified Copenhagen Burnout Inventory were used to evaluate students’ psychological well-being and fatigue levels. A Welch t-test and Welch ANOVA were performed to determine the differences in perceived psychological well-being associated with students’ characteristics. Second, Kruskal_Wallis and Mann_Whitney were performed to determine the differences in fatigue level based on students’ characteristics.

One thousand four hundred students participated. The majority were female (78.5%) and aged from 21–25 years (58.1%). Around 14% of respondents were married with children. Nearly 40% were satisfied with the new assessment approach introduced during the COVID pandemic and 45.5% perceived it as having reduced their home confinement stress. The mean psychological distress score of 3.00 (SD ± 0.71) indicates a moderate impact of COVID-19 on psychological well-being. Students’ psychological distress was positively correlated with fatigue level (0.256, p  < 0.001) and negatively correlated with the perceived impact of the new assessment approach on student lifestyle (− 0.133, p  < 0.001), physical health (− 0.149, p  < 0.001) and coping with stress (− 0.125, p  < 0.001). Male students experienced significantly lower fatigue and better psychological well-being than female students.

The study reveals that new assessment approaches which emerged during home confinement reduced students’ perception of stress and of impaired lifestyle. However, students still had a considerable burden of psychological distress, requiring further preventive measures to maintain their psychological well-being during future outbreak events. Educational institutions should consider additional strategies to improve students’ preparedness for online teaching, which could help maintain their psychological well-being.

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Since the emergence of Coronavrus Disease 2019 (COVID-19) in Wuhan in December 2019, major extraordinary measures have been implemented globally to reduce transmission of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2 virus) [ 1 , 2 ]. Despite these, within weeks the ensuing pandemic caused significant changes to the educational landscape worldwide. In the United Arab of Emirates (UAE), the first case of COVID-19 was identified on 29 January 2020. In response, the government has taken stringent steps to control the spread of the virus, including stay-home orders of two to three months duration [ 1 , 3 ] . On 3 March 2020, the UAE Ministry of Education announced that all schools, colleges and universities across the country would close for a month starting Sunday 8 March as part of efforts to contain the spread of the virus [ 4 ].

In response to the spread of COVID-19, higher education institutions (HEIs) around the globe closed their physical campuses and moved rapidly from traditional face-to-face courses to remote or online courses [ 5 , 6 ]. According to the United Nations Educational, Scientific and Cultural Organization [ 7 ], the pandemic has interrupted the learning of more than one billion students in 129 countries worldwide. In the UAE, many HEIs have been forced to make timely adjustments to ensure the provision of education and sustain students’ academic progress.

Consequently, students are liable to have experienced stressors subsequent to the academic burden, lack of relaxation time and repeated examinations in a competitive environment [ 8 , 9 ]. The pandemic disrupted student life; normal classes were suspended and students could not participate in social activities, affecting their academic performance and aggravating stress levels [ 1 , 10 , 11 ]. Previous studies have found significantly high stress and anxiety levels among university and college students during the pandemic, negatively impacting their perception of online courses [ 10 , 12 , 13 , 14 ].

Previous research has established that students’ ability to use learning technology tools, lack of IT knowledge, lack of technical support during virtual classes and the inappropriateness of online course content were causes of students’ distress and burden during home quarantine [ 10 ]. Hasan and Bao [ 1 ] examined the effects on students’ psychological distress of ‘e-learning crack-up’ during COVID-19 lockdown; their survey of 400 students identified perception of e-learning crack-up as a significant independent predictor of psychological distress.

The prevalence of emotional distress varies among recent studies but demonstrates that a considerable percentage of students risk psychological distress. For example, Li et al. [ 15 ] found that 139 (13.63%) had anxiety related to the COVID-19 pandemic and 406 (39.80%) of them had high stress levels. In a Spanish study, 34.19% of respondents showed moderate to extremely severe depression symptoms, 21.34% showed extremely severe anxiety symptoms and 28.14% exhibited moderate to severe stress symptoms subsequent to the COVID-19 pandemic [ 16 ]. The literature also identifies various factors influencing students’ mental health. A recent study among 7143 college students revealed that COVID-19-related factors such economic stressors, effects on daily life and academic delays were positively associated with the level of anxiety symptoms [ 10 ], while supportive family, living with parents and having a steady income were protective against high levels of anxiety. Moreover, the findings of Meo et al. [ 17 ] show that a sense of emotional detachment from family, friends and fellow students was significantly associated with emotional distress and had negatively impacted students’ academic performance and total daily studying hours. Despite the extensive research conducted over the last year, however, no attention appears to have been paid to changes in assessment methods during the crisis, students’ GPA before and after the outbreak and marital status. This study therefore explores the association of these factors with students’ fatigue levels and psychological well-being.

Significance of the study

Before 2020, a major transition to online education was already underway. Over the past decades, online teaching had become a strategic objective for many HEIs, including those in the UAE. Then, when the pandemic nature of the COVID-19 outbreak became evident in the spring of 2020, universities abruptly went online with very few days of planning [ 18 ]. A growing body of literature recognises the importance of exploring the impact of the pandemic and the sudden shift to online learning on students’ psychological well-being. To our knowledge, no studies within Arab culture and the Gulf countries have examined this impact. The study also aims to determine the association of students’ characteristics with perceived psychological well-being and the fatigue associated with confinement due to the COVID-19 outbreak.

The Higher Colleges of Technology (HCT) is a federal educational institution comprising the largest student body in the UAE, with more than 20,000 students in 16 campuses across the country. Since March 2020, various strategies have been actioned to ensure a smooth transmission to online learning and teaching experience [ 3 ]. One of strategies was to modify the academic assessment approach after extensive consultation with faculty and the endorsement of the HCT’s Academic Council. Examples of changes to traditional exams include splitting them into multiple online quizzes and assignments; replacing them with projects or case studies, reducing the weight to 15% and distributing the remaining weight over other formative assessments; replacing them with e-portfolios; using questions with an increased level of cognitive complexity; and setting online, open-book practical exams (timed and scheduled during online class sessions).

This study examines three main hypotheses: (1) The abrupt transition to pure online learning increased students’ psychological distress and fatigue; (2) The modified assessment strategy during home confinement moderated the effect on students’ family lifestyles, physical health, mental health and stress; and (3) Students’ perception of psychological well-being moderated fatigue levels and academic performance.

The results could assist colleges, administrators and policymakers in the UAE by providing a theoretical basis for assessing psychological well-being and identifying the appropriate actions to help students during future pandemics. It should also provide guidelines for policymakers on possible mechanisms to moderate the impacts of anxiety on students during such health crises.

Design and setting

The study had a descriptive cross-sectional quantitative design. Data were collected at one point in time via an online survey sent to potential participants by email, to be completed at their convenience. The email was sent from 30 August 2020 to 30 September 2020, and up to three reminders were sent weekly to enhance the response rate. The target population was all 20,000 students on 16 HCT campuses across the UAE.

Data collection

Data were collected over one month. The survey, which took the participants about 10–14 min to complete, contained questions on demographics, academic performance, psychological well-being and fatigue. The first section elicited information about students’ age, gender, marital status, academic level and Grade Point Average (GPA) before and after the pandemic semester. Participants also reported their perceptions of the impact of learning from home on their daily family lifestyle, physical health, mental health and ability to cope with stress. These four items were assessed on a scale from 1 (very negatively) to 5 (very positively). A single-item measure was used to reduce the demand on participants and make it easier to complete the entire survey.

Psychological well-being was evaluated using the Mental Well-being and Learning Behaviors scale [ 17 ], a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). This instrument had two parts, the first comprising twelve questions to assess psychological well-being and stressors resulting from COVID-19, with a higher score indicating a greater negative impact on students’ well-being. The second part comprised eight items on learning behaviours during the COVID outbreak, with a higher score representing a more positive attitude to e-learning. In this study, the Cronbach’s alpha values for psychological well-being and learning behaviours were α = 0.90 (95%CI: 0.888 to 0.904) and α = 0.84 (95%CI: 0.833 to 0.856) respectively.

Student fatigue level related to learning online from home subsequent to the COVID-19 pandemic was evaluated by a modified version of the Copenhagen Burnout Inventory [ 19 ]. The modified scale comprised 16 items in three subscales, measuring personal burnout attributed by the participant to factors unrelated to work (5 items), to working online (5 items) and to learning from home (6 items). Total score range from 13 to 65, all items were scored on a four‐point Likert scale. The internal consistency of the three subscales was α = 0.93; (95%CI: 0.924 to 0.936), α = 0.81 (95%CI: 0.0.799 to 0.829) and α = 0.94; (95%CI: 0.941 to 0.950) respectively.

The instrument was piloted among 25 students to determine whether the items were clear and concise, before being administered to the full sample.

Data analysis

The data were analysed quantitatively. All collected data were organized and summarized by descriptive statistics (measures of central tendency, dispersion and percentages) and the chi-square test was applied to determine how some demographic variables varied with the students’ knowledge and health outcomes. Mean and standard deviation were reported to represent the average score for each scale item. In all statistical tests, two-tailed tests of significance and confidence intervals were based on the unadjusted P-value less than 0.05 level. First, Psychological well-being mean score was normally distributed (skewness = − 0.050; kurtosis = 0.133). Equal variance was not assumed in all performed test due to the variation in sample size between the comparisons groups, therefore the Welch t-test and Welch ANOVA were performed to determine the differences in perceived psychological well-being based on students’ characteristics. The fatigue mean score was slightly skewed, Kruskal_Wallis and Mann_Whitney tests were performed to determine the differences in fatigue level based on students’ characteristics. The software used for data analysis was SPSS version 23 [ 19 ].

Ethical considerations

This study was conducted with the approval of the Research and Ethical Committee of the Higher Colleges of Technology. Students signed an informed consent and informed that their participation was voluntary, and that they could withdraw from the study at any time. Data collection process was carried out in accordance with relevant guidelines and regulations.

One thousand four hundred students participated in the study. Most were female (78.5%) and aged 21–25 years (58.1%), while around 14% were married with children (Table 1 ).

Impact of the COVID outbreak on academic performance

During COVID-19 quarantine, major coursework assessments were split into short quizzes and open-book exams. Almost 40% of participants reported being satisfied with the changes in assessment delivery method during home confinement and 45.5% perceived it as having reduced their stress. Three quarters of participants (76%) reported an improvement in their GPA during the pandemic semester and a similar percentage believed that online assessment had succeeded in reducing their stress levels. Projects and open-book exams (instead of the final written exam) were the assessment methods perceived as having contributed most to GPA improvement and stress reduction during COVID-19 quarantine (Table 2 ).

Impact of new assessment approach on student stress level

Students reported diverse perceptions of the impact of modified assessment during the COVID-19 pandemic. A fifth (22%) of students reported a negative effect on family lifestyle, while more than half (53%) said this impact was positive (Table 3 ). Over a quarter (27.8%) reported a negative effect on physical health, while almost as many (27.1%) perceived negative mental health effects. As to stress, 28.8% of students felt that online assessment had increased their stress levels, whereas 45.5% felt that the modified assessment had reduced their stress.

Student fatigue during e-learning

The median fatigue score was with a interquartile range of 22 to 46, indicating moderate fatigue. On the personal, online learning and learning from home burnout subscales respectively, the median score were 2.20 (IQR 1.20 to 3.0), 2.20 (IQR 1.40 to 3.0), and 2.0 [1 to 3]. Results on all subscales indicate low fatigue levels associated with e-learning. However, a significant percentage of students reported always having fatigue more than five days per week.

Students’ psychological well-being during the COVID pandemic and quarantine

Participants’ mean score on psychological well-being was 3.0/5 (SD = 0.71), with a range from 1 to 5, indicating a moderate impact. The mean score on the mental health subscale was 3.00 (SD = 0.87), with a range from 1 to 5, and approximately a third of students agreed that they were always thinking about being infected with the virus, with a mean of 3.07. Thirty-seven percent of students perceived themselves as depressed, while 31.1% agreed that they felt detached from social life, were anxious and suffered from insomnia, with a mean of 2.99.

On the learning behaviour subscale, the mean score was 3.01 (SD = 0.68), indicating a moderate impact of COVID-19 on learning behaviour. Lack of motivation was reported by 22.6% of students, while 18% said they suffered from poor concentration and 23.3% had difficulty remembering recent information. Almost 40% reported an increase in time spent studying, while 25% stated that this time had decreased.

Univariate coefficients for the association between the main study outcomes are presented in Table 4 . A positive relationship emerges between fatigue and psychological distress, indicating that students who perceived a higher level of psychological distress also perceived higher fatigue levels. In addition, a higher impact on psychological well-being (mental health and learning behaviour) was observed among students who reported a low negative impact of the new assessment approach on their lifestyle, physical health and coping with stress.

Differences based on students’ demographical characteristics

Various sociodemographic variables significantly associated with study outcomes (Table 5 ). Male students experienced more significant psychological well-being than females. The student who was satisfied with the number of online assessments and had improved GPA at the end of the spring semester had more significant psychological well-being. The Welch ANOVA test revealed more significant psychological well-being among students with a GPA above two and are very satisfied with the number of online assessments. Health science students experienced better psychological well-being, but the result is less statistically significant.

Results shown in Table 6 suggest significant differences in fatigue level based on student’s characteristics. Kruskal_Wallis test result showed that students were more significantly had less fatigue level if they were between 26 and 30 years old, single, employed in a full-time job, and were very satisfied with the number of assessments in the spring semester.

The COVID-19 pandemic has caused an unpredictable and unprecedented wave of closures of academic facilities, affecting millions of HEI students worldwide. Many academic institutions have been forced to take difficult decisions and implement modifications to their teaching and learning activities in order to continue delivering courses while avoiding the risk of virus transmission associated with students attending campuses.

The present study documents perceptions of student-centred active learning delivered through full distance learning during the pandemic period among a group of undergraduate students enrolled in various programmes at HCT campuses across the UAE. The HCT was already providing many online learning methods and tools for both teachers and students, but most of these were not fully utilized before the COVID-19 pandemic. During the pandemic, full distance learning was adopted, whereby online group discussions and new online assessments were carried out synchronously through the online communication platform known as BBL-Ultra. This study is the first to report on students’ perceptions of the effectiveness of the fully online learning methods and their learning satisfaction during the COVID-related restrictions.

Participating students reported moderate fatigue levels when engaged in e-learning during the COVID-19 quarantine period. All subscales indicated low fatigue levels associated with e-learning. However, a significant percentage of students stated that they always felt fatigued more than five days per week. Possible reasons for these results, which are congruent with previous studies [ 10 , 14 , 15 , 20 ], are the cumulative psychological and physiological burden experienced due to the unprecedented experiences associated with COVID-19 in the personal, social and academic domains. Results for the different items of the three scales indicate that students perceived the e-learning process to engender a burden that could negatively impact their psychological status and academic achievements.

Quality of course design to fit online learning and course instructor’s redness to provide quality feedback are factors found to increase student satisfaction and academic performance during the pandemic [ 21 ]. Our study revealed that students experienced lower fatigue levels if they were more satisfied with online assessment and had improved academic performance. Future studies should investigate factors escalating these burdens in more depth and seek solutions to minimize or prevent fatigue.

Participants in this study reported poor psychological well-being due to quarantine. This result was expected, as students were required to fully accept unpredictable changes and adapt to them immediately. Similar findings are reported by Cao and colleagues [ 1 ], who state that college students in China reported moderate to high anxiety levels and suffered many psychological effects of COVID-19 and the subsequent quarantine. One explanation for this might be the extended time spent working alone on computer screens, accompanied by the anxiety of being quarantined, adapting to an unprecedented situation and absorbing news about the numbers of confirmed COVID-19 cases or resultant deaths. Lack of necessary infrastructure, limited communication with the teacher, lack of face to face communication with colleagues, and low students’ motivation to engage with online learning were potential factors that affected students’ physical and mental well-being during the pandemic [ 22 , 23 ].

Students taking part in this study were preoccupied with the fear of COVID infection, resulting in feelings of depression or anxiety which could be related to their reports of insomnia and lack of motivation. Similar results have recently been reported, where students in various programmes and at several academic levels reported moderate to severe levels of anxiety or mental health concerns [ 10 , 24 , 25 ]. Further, various factors were reported in the literature as stressors contributing to feelings of anxiety or depression during the pandemic, such as poor economic status [ 14 ]. Although exploring the factors/stressors contributing to anxiety goes beyond the purpose of this study, it is worth noting that students pursuing their studies online while being quarantined at home are likely to face many risks that would negatively impact their psychological status and mental well-being. Possible stressors are having a family member with a confirmed COVID-19 infection at home, changes imposed on their daily routines and fear of academic delays. Indeed, it is strongly recommended that educational institutions and authorities provide students with continuous support, ensuring the availability of the necessary emotional support mechanisms and counselling services, which should be available and accessible per each institution’s guidelines. Redesigning curricula with a more focused student-centred approach for online delivery, online academic support sessions, and implementing counselling and mental health programs are possible suggestions to care for at-risk students because of the pandemic.

This study has revealed a significant psychological effect of the COVID-19 pandemic on the teaching and learning of HCT students. While the crisis has been stressful for students, they are hoping, in common with other community members, that it will eventually end, that restrictions will be eased and that their lives will return, albeit gradually, to a pre-COVID normality. Therefore, in addition to sustaining students’ emotional and psychological well-being, offering stress counselling and applying the hybrid model of teaching which the HCT has announced, it is essential to continue to provide a reliable educational environment and to prepare a safe future for students. HCT students are familiar with e-learning but did not experience fully online delivery until the restrictive quarantine measures came into force. Any class of students will have diverse learning styles and it will thus be very challenging for the teacher to adapt and accommodate e-learning methods and tools to best meet their collective needs.

One of the main limitations of this study is its cross-sectional design; while this suited the present purpose, a future longitudinal study would be highly recommended to determine the long-term impacts on students’ health of the COVID-19 crisis. On the other hand, the large sample size among multiple colleges involved in the study is considered a strong point, upholding the generalizability of the findings and enabling the drawing of solid conclusions about the current situation in UAE universities on which to ground a possible national crisis strategy.

Fatigue levels were measured using a version of the Copenhagen Burnout Inventory, modified to fit the purpose of investigating online learning during COVID-19 quarantine. Although the three subscales as modified were found to have good internal consistency, further research could be conducted to confirm the internal validity of the scale. Finally, a further study could employ a more complex analytical approach to determine the confounding variables for students’ psychological well-being and the mediating effect of fatigue level.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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• Christina Muñoz  • IDRA Newsletter • March 2021 •

effect of online learning on mental health research paper

If you put faces and voices to the numbers, each will echo similar sentiments in their experiences with virtual, remote and distance-learning during the pandemic. Among high school students, stress is a loud theme that reverberates in dialogues about the many challenges students faced this past year.

With the abrupt mass transition to an online distance-learning model in schools, students’ home and school environments merged; residual stress from the school day knows no boundaries. They face at-home stressors, like the care and support of younger siblings engaging in their own learning, Internet connectivity issues, learning distractions, restricted privacy for completing classwork, inadequate space to study, and work obligations to help support their families during this period. These apply pressure from yet another angle to students’ normal school-related stressors and healthcare concerns heightened by the pandemic.

Preliminary findings from a ground-breaking participatory action-based research conducted by San Antonio students show that more than 71% of survey respondents consider virtual remote learning as contributing more stress than traditional in-person school. Through an IDRA project funded by Seek Common Ground, a team of teens surveyed high school upperclassmen and university undergraduate lowerclassmen finding that 75% of respondents report having struggled with mental health issues during the pandemic. (See Page 2.)

“There is often no separation from my school life and my home life. I’m always mentally thinking about the next assignment I have due, and it keeps me up at night and increases my anxiety.” – student survey respondent

Many students report experiencing a back-and-forth battle between “I’m doing too much, and I’m not doing enough” while engaging in their large amount of online classwork, during and after the school day, as they manage their interaction across several online programs and sites. That emotional stress manifests into physical strain, such as anxiety-induced headaches, stomachaches and back pain.

Virtual remote learning for most students has also meant a disruption to their social lives with friends and peers in the school setting. Little to no socialization with friends and peers during the school day has increased feelings of isolation for students. It has the added layer of limited social interaction due to the fear of contracting the COVID-19 virus and has drastically increased depression rates among young adults.

A national survey by America’s Promise Alliance conducted in spring 2020 found almost one third of high school students reported feelings of unhappiness and depression outside their normal ranges during the first months of the pandemic.

Limited social interaction impacts students’ attention and interest in school in general, so the reduced interaction through online learning platforms between students and their peers and teachers has greatly affected students’ relationship with their learning (Wentzel & Wigfield, 1998).

Students also struggle to maintain authentic engagement with their peers and instructors during the school day. A Texas Education Agency (TEA) report found that 11% of the state student population (more than 600,000 public school students) were disengaged from their classwork or unresponsive to teacher and school outreach (2020).

While defined by TEA in this case as the completion of assignment and response to teacher and school outreach, student engagement usually is more broadly characterized as a student’s sense of connection to, safety and involvement in their learning environment that leads to positive outcomes in motivation, academic achievement, regular school attendance and graduation. Engagement is a nuanced construct and is comprised of various facets of the student’s experience at school, including academic self-efficacy, motivation and connectedness to or feelings of belonging in their school and classroom environment.

It is important to examine these facets of student engagement deeper through the lens of student mental health and wellness. State leaders, school leaders, advocates and other community leaders need to understand the nuances of the student experience during the pandemic and work to create a safe, nurturing space in which students can equitably receive a quality education, through both traditional and virtual options.

Schools and communities need viable solutions to address student mental health and wellness concerns and their impact on academic engagement. IDRA advocates for legislation that directly addresses student mental health concerns. For example, a proposal in the Texas Senate (Senate Bill 179) responds to the growing need for accessible and effective counseling support in schools, particularly in response to the impact of the COVID-19 pandemic on student’s mental health and wellness. Another measure (SB 178) would work to incrementally reduce student to counselor ratios in Texas public schools over the course of nine academic school years to reflect one school counselor for every 300 students by the 2029-30 academic school year. The average in Texas is currently one counselor for every 442 students.

Other strategies include teaching students self-care techniques and effective tools in promoting strong, resilient mental and emotional wellness for themselves, their peers and their families.

Additionally, IDRA advocates for training school board leadership, school leaders and teachers in trauma-informed school care to better equip them to respond to the mental health crisis pervasive among young students.

Conversations surrounding mental health concerns must continue for promoting authentic, transparent and accepting culture around strong student mental health and wellness. Schools should continue to connect students in need of support and guidance with counselors and other mental health professionals to whom they can entrust their challenges and struggles.

America’s Promise Alliance. (June 9, 2020). Appendix: The State of Young People During COVID-19 . Washington, D.C.

Czeisler M.É., Lane, R.I., Petrosky, E., Wiley, J.F., Christensen, A., Rashid Njai, R., Weaver, M.D., Robbins, R., Facer-Childs, E.R., Barger, L.K., Czeisler, C.A., Howard, M.E., & Rajaratnam, S.M.W. (August 14, 2020). Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic – United States . Centers for Disease Control and Prevention.

Klass, P. (August 24, 2020). Young Adults’ Pandemic Mental Health Risks . New York Times.

McClurg, L. (November 28, 2020). Pandemic Takes Toll on Children’s Mental Health . NPR.

Swaby, A. (June 30, 2020). Warning of “COVID slide,” Texas Education Agency reports 1 in 10 students have disengaged during the pandemic . Texas Tribune.

Wentzel, K.R., & Wigfield, A. (June 1998). Academic and Social Motivational Influences on Students’ Academic Performance . Educational Psychology Review, Vol. 10, No. 2, pp. 155-175.

Christina Muñoz is an IDRA Education Policy Fellow. Comments and questions may be directed to her via email at [email protected].

[©2021, IDRA. This article originally appeared in the March 2021 IDRA Newsletter by the Intercultural Development Research Association. Permission to reproduce this article is granted provided the article is reprinted in its entirety and proper credit is given to IDRA and the author.]

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English Department: Research for Change - Wicked Problems in Our World

Online Learning's Impact on Mental Health

Alexandria Palmieri Follow

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Due to the global pandemic education has evolved and started online learning. While online learning is helping it brings its own set of problems and impacts. This paper will talk about 3 aspects of online learning, social interaction, motivation, and participation and how students’ mental health is being impacted. The paper includes a research study done by giving a number of college aged students a survey. The survey asked questions about the 3 aspects of online learning and how each of them impact students’ mental health as well as ways to relieve the stress and lessen the impact of online learning.

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Palmieri, Alexandria, "Online Learning's Impact on Mental Health" (2020). English Department: Research for Change - Wicked Problems in Our World . 32. https://research.library.kutztown.edu/wickedproblems/32

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The research on the impact of distance learning on students’ mental health

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The mental health of students learning online is a critical task for many countries around the globe. The research purpose was to analyse the factors affecting the quality of mental health of young individuals who learnt under conditions of not total lockdowns but adaptive quarantine restrictions. The research involved 186 volunteers from Zhengzhou University of Technology, 94 were first-year students, and 92 were fourth-year students. The experimental group involved first-year students, and the control group involved fourth-year students. An average age of the participants in the experimental group was 18.3 years, and in the control group, the average age was 22.4 years. The scholars conducted the research after four months of distance learning under the adaptive quarantine. The students could be involved in their usual entertainment activities and interpersonal communication outside the home. The Behavioural Health Measure, better known as BHM-20, was the core psychometric tool. The research finds that distance learning is less effective for first-year students than for fourth-year students because the former cannot effectively adapt and communicate in a new social environment, and develop trusting interpersonal relationships with fellow students and teachers. The research results coincide with other research on this issue and demonstrate a low degree of mental resilience during and after the pandemic. Previous research is not suitable for the analysis of the mental health of students under adaptive quarantine, including the freshmen, considered the most vulnerable group. The article will be useful for professionals interested in distance education in higher educational institutions, workers of socio-psychological services at universities or individuals involved in adapting curriculum materials for distance learning.

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1 Introduction

The COVID-19 pandemic has had a great impact on the mental health and well-being of individuals around the world. While some citizens successfully adapted to the reality of the pandemic and societal lockdowns, others have suffered from mental health disorders caused by a new infection (Serdakova et al., 2023 ).

Moreover, access to mental health services has been severely impeded which had an impact on the mental health of individuals and significantly increased the risk of suicide (Gunnell et al., 2020 ). Most countries on different continents have introduced immediate and drastic protective measures in the fight against the spread of infection, such as closed borders, forced isolation, quarantine restrictions, and distance learning. On the one hand, the virtualization of the educational environment and distance education have reduced inequalities in poor rural regions and ensured equitable access to the education of the population. On the other hand, social isolation in the midst of the COVID-19 pandemic required a unique educational environment but it has caused an increased number of psychological disorders around the world and mental illnesses, including depression, obsessive-compulsive disorder, long-term episodes of counterproductive anxiety, and others (Clemente-Suárez et al., 2021 ). The unexpected shift from in-person to online learning has created a lot of problems for students, teachers, and administrators because many years distance learning has not been very popular in schools and universities (Brown & Carreno-Davidson, 2020 ). At the same time, protecting the mental health of students is vital for higher education because cognitive abilities directly depend on the psychological state of the student, which affects academic motivation, the level of aspirations, involvement in learning, and the emotional and volitional spheres.

As a stage of ontogenesis (human development), higher education may cause exacerbate mental health problems. Before the pandemic, research has primarily focused on student group relationships and campus living as the most common stress factors among students (Davis et al., 2021 ). The research finds that distance learning students report psychological problems more frequently than face-to-face learners, and it is important to analyse the factors that influence mental well-being in distance learning and help to focus on the problem identification related to the transformation of the face-to-face classroom to a virtual environment. The research is important for educators because the COVID-19 infection has not yet been completely defeated, and distance learning is already seen not only as a necessary measure but also as a way to simplify access to education around the world and in China in particular.

1.1 Literature review

Since the first cases of COVID-19 were detected, countries’ authorities have tried to find possible measures and ways to fight the pandemic around the world. Face-to-face and autonomous learning systems were replaced by distance learning platforms, and it became a significant factor of mental tension while adapting to new conditions in all areas of life and influenced by inadequate communication at the interpersonal level.

Distance or online learning is the method which helps to prevent the spread of COVID-19, but it has a negative impact on the mental health of higher education students. The main problems experienced by students include anxiety, mild and severe stress, social media fatigue, and depression. At the same time, the symptoms are not always caused by mental health problems (Grigorkevich et al., 2022 ).

The literature analysis revealed the impact of distance learning on the mental health of students and showed that the most sensitive aspects included inadequate time management, the lack of a full-fledged adaptation strategy, the development of digital technologies in a new way, the burden to ensure the quality of new material learning, as well as concerns about the impossibility of funding educational activities under the COVID-19 conditions (Aditya & Ulya, 2021 ).

Some scholars have focused on fear as an emotional response of teachers and students to the distance learning model. The research confirmed that COVID-19 as a global social phenomenon increased the feeling of fear in different areas of life. First of all, it is the fear of being isolated from the family, the fear of academic failure, and the fear of losing social relationships (Al-Maroof et al., 2020 ). At the same time, modern online learning differs significantly from emergency distance learning, influenced by the mental tension decrease, in which addiction as a form of adaptation plays an important role. Under the pandemic restrictions and conditions, universities will adopt mixed or blended formats, since the problems of distance education are turned into educational opportunities. Distance learning allows easy access to education, development of different forms and methods of control, and adaptation and revision of inadequate university programmes (Adedoyin & Soykan, 2020 ).

The mental health of teachers is a part of the discussion devoted to the ecological environment of distance education. A sample of Pakistani and Malaysian teachers was used to analyse the parameters such as teacher self-efficacy and the quality of distance education. The research found that the mental well-being of teachers was a significant factor in ensuring academic success (Guoyan et al., 2021 ).

In Germany, scholars discuss the importance of psychological assistance provided by educational institutions during the crisis at the initial and final stages of distance learning. The attention of the German sociological and psychological services is on the well-being of students and burnout caused by nervous breakdown or inability to continue effective training under the COVID-19 restrictions.

In Germany, mental illness prevention strategies are introduced for first-year students who find it difficult to move into a new social environment despite the distance format. The transition to a new environment causes a high-stress level due to psychological tension, anxiety and increased learning requirements compared to previous school years.

An academic overload and a low level of knowledge among first-year students lead to learning problems, especially in specialised disciplines. Moreover, social and psychological aspects are important, such as mental exhaustion at the stage of admission, the development of new interpersonal relationships, and getting used to the university system of education and assessment (Schindler et al., 2021 ).

The factors mentioned above suggest that education during the first year of study based on the distance learning system can be more difficult for students in a situation when one problem is replaced by another. Cross-sectional research on the mental well-being of European students during the first wave of COVID-19 in May 2020 found that all university students (regardless of the year of study) had poorer mental health than before the pandemic. However, the mental health variable correlated with the belief (irrational belief) that the national government ensured effective management of the epidemic at the municipal level and reduced the risks of infection and negative macroeconomic outcomes (Allen et al., 2022 ).

The spread of the virus, long-term preventive measures and changes in daily routine have led to psychological problems such as anxiety, confusion, social deprivation, and depression. The chronic stress caused by the ongoing pandemic has a profound impact on a sharp and sustained decline of the psychological support that helped individuals cope with failure, emotional problems, disappointment, frustration, and preventing negative emotional experiences, namely resilience, optimism, psychological flexibility, and social relationships (Moroń et al., 2021 ). In China, the effectiveness of psychosocial support and the impact of COVID-19-related stressors on mental health have been investigated.

In Chinese realities, the concept of Psychosocial Support means family and social support in construct to Europe where it involves socio-psychological services.

Moreover, the assessment of the mental health of the respondents was based on the symptoms of depression and loneliness.

The scholars considered that the authorities should focus on the stress that followed the pandemic, as a serious threat to life and well-being, and the risk of infection with new and poorly researched diseases. However, the fear of infection as an independent variable was not correlated with either loneliness or depression, leading to heated debates about the impact of the pandemic on human mental health and well-being (Wang et al., 2022 ).

The COVID-19 pandemic has led to higher rates of mental disorders among the Chinese population. Many individuals have experienced increased resilience during the pandemic as a post-crisis change which had a positive impact not only on the population but on the healthcare system in the country (Zhang, 2022 ).

Restrictive measures under the quarantine have no impact on the cognitive performance of the population on different continents. However, complaints about cognitive decline increased significantly during the pandemic. High quality of life before the period of social isolation is the main factor that influences psychological disability, such as depression, anxiety, low-stress tolerance, ineffective self-regulation, and cognitive complaints (Nogueira et al., 2022 ). Reducing the negative consequences is important for young people in higher education during distance learning.

1.2 Problem identification

Only a limited number of publications covered the mental health of students during distance learning and discussed the problems faced by the post-COVID societies. This issue is of particular importance if the governments do not consider distance learning as a vital point and the only possible preventive measure against the spread of a deadly disease. The research purpose is to assess the psychological health of students learning online and investigate the factors that affect the mental health of students. Many scholars analyse the behaviour and psychological problems of schoolchildren, their parents and schoolteachers, paying less attention to the university environment.

This article considers age as the main factor to assess the opportunities and effectiveness of distance education for promoting the mental health of Chinese students in higher education. New experimental data will strengthen the debates about the opportunities promised by online education. After the weakening of quarantine measures, distance learning was no longer mandatory. This fact allowed the scholars to consider distance learning as an alternative form of education for the adult Chinese population who have already mastered social skills at earlier stages of ontogenesis and have maintained working, friendly, and romantic relationships with other people.

The scholars will complete the following tasks, such as identify the most appropriate psychometric tools to assess the quality of the student’s mental health learning remotely under weak isolation conditions; identify a sample size of first-year and fourth-year students to compare the mental health of those who entered the university and those who had experience learning online in a higher educational institution. Moreover, the research will compare the statistical data of two groups and test the null hypothesis. In this article, mental health is evaluated under conditions of adaptive quarantine, during which students have access to mobility, interpersonal communication outside their home, and quality leisure activities, which become possible due to mass vaccination and economic feasibility.

2 Methods and materials

The BHM-20 methodology can help to assess mental health and the psychotherapy progress used as the main diagnostic tool (Kopta et al., 2015 ). This technique is a 20-item questionnaire that evaluates three components of healthy behaviour: well-being (stress, life satisfaction, and motivation); psychological symptoms (depression, anxiety, panic disorder, mood changes caused by bipolar disorder, eating disorder, substance abuse, suicide intentions, and risk of violence); life activities (work and study, intimate relationships, social relationships, and enjoyment of life).

The full technique name is Behavioural Health Measure often used in a short form BHM. This technique can be used remotely without the direct participation of a psychologist because the respondent can insert answers using a computer or gadget, and the average time to complete the questionnaire is about three minutes. This tool is used in behavioural health clinics of primary health care (Bryan et al., 2014 ). The test consists of 20 statements rated by respondents where 0 points mean Strongly Disagree and 4 points represent Strong Agree .

The maximum total score of psychological well-being, without the suicidal scale, is 80 points, and the minimum score is 0 points, which means deep mental exhaustion. The scales do not have a separate gradation, and it means that the scale showed the overall score of mental health. Moreover, BHM-20 allows additional screening of suicidal thoughts and impulses, and it is considered six times better to identify suicidal intentions in primary care than the standard interview method. However, the research does not make use of this method, because it is secondary in importance to clinical psychological care.

In many cases, BHM-20 is used for primary psychological counselling at a certain number of higher education institutions, including Harvard University, the University of Minnesota, Indiana University, the University of Florida, and others, making this psychometric tool effective for data analysis. The tool is appropriate for adults aged 18 + with normal or high intelligence (Bryan et al., 2014 ). Express methods with a high level of reliability exist in modern methodology including BHQ-20 (Behavioural Health Questionnaire) with similar scales. The technique’s reliability was evaluated using four samples of different age groups, showing high results during the initial testing. Moreover, the high correlation between the scales in the BHQ-20 method indicated the presence of 1 key parameter of mental health. The analysis finds that the BHQ-20 is a reliable and valid mental health questionnaire, even though the number of questions is small (Kopta & Lowry, 2002 ).

2.1 Participants

The experimental group of first-year students included 94 individuals (38 females and 56 males) aged 18 to 19 years interested in this research. The control group of fourth-year students consisted of 92 individuals (48 females and 44 males) aged 21 to 23 years. All respondents had prior distance learning experience because the experiment was conducted during the second half of the academic year when both groups learnt for four months under adaptive quarantine. The distance learning experience differed across groups because for first-year students it was similar to their school experience while the control group actually continued professionalization, first under conditions of total quarantine, and then under conditions of adaptive quarantine.

2.2 Study design

This research was easy to organise and manage because it was conducted remotely and involved first-year and fourth-year volunteers of Zhengzhou University of Technology. The respondents received instructions in real time and proceeded to complete the electronic questionnaires on the Google platform at the agreed time on their personal computers. The preliminary briefing was conducted in the format of an online conference on ZOOM. The results were sent directly to the experimenter’s computer, entered into a common table, processed, and also remained anonymous. Although the participants logged in via e-mail in a Google form. In fact, the Google form presented to the respondents repeated the questions from BHM-20, greatly simplified the collection and processing of data. The well-structured methodology supported the high motivation level among the participants, immersed in the psycho-diagnostic process. The students were not informed about the research objective, which was the impact of distance learning on the mental health of young individuals. It helped the scholars to ensure the experiment’s purity and avoid bias. Moreover, all respondents could review the methodology results. The primary data processing did not take much time and the experimenter move quickly to statistical analysis.

2.3 Data analysis

Data processing was carried out using the SPSS Statistics 22 programme. To test the research hypothesis, the popular nonparametric Mann-Whitney U-test for independent samples was used. It helped to assess the statistical homogeneity of the two samples and ensured the significant differences.

2.4 Research limitations

The research had several limitations. First, the BHM-20 is a fast test without subscales. Second, the single-item suicide risk scale was not used in this experiment because this factor is usually used for the pre-responses analysis only. Third, the mental development of first-year and fourth-year students differs due to age differences and life experience, which can affect the level of mental health. Fourth, the BHM-20 method, considered an individualised one, does not have any gradations of Mental Health Normality , which limits the possibility of using this psychometric tool for large-scale research. Fifth, both samples involved volunteers only. The research did not capture the required social section of the population. Sixth, the BHM-20 was originally developed to assess the progress of individual psychotherapeutic performance. It heats the debates about the lack of standardised tests to assess the overall mental health of an individual. Tests without subscales would simplify the assessment of the impact of distance education on the mental health of Chinese youth.

The unprecedented nature of this pandemic has caused several risk factors and events not explored in this research. The overall physical health, physical training, domestic abuse, violence, and mental health problems experienced by individuals caused by the pandemic were not examined. All indicators used in this research are self-reported, so the scholars consider that some respondents may be apt to provide truthful or false answers, which therefore could influence negatively the results.

2.5 Ethical issues

This experiment was based on high ethical standards because both samples involved volunteers and their identity was kept anonymous. Some students received feedback from the researcher on an individual basis. The experiment goals were not disclosed to the participants. The students were informed about some goals without going into detail including information about voluntary mental health monitoring. The experimenter did not benefit from the research and all the financial expenses were covered by Zhengzhou University of Technology.

The research usefulness function was realised in full because distance learning under adaptive quarantine was introduced not only in China but in Europe. This is an important factor because the pandemic has not yet been completely defeated despite the mass vaccination programmes. The use of distance learning in higher education institutions, considering mental health, has been still questioned. The research finds drawbacks in policy development especially when distance learning is proposed for first-year students who integrate into a new social environment and acquire new skills and master knowledge.

This scientific discussion is of exceptional social significance, allowing academic institutions to balance live communication in the classroom and the mental health of students who experienced an academic overload. There was no risk to the physical and mental health of freshmen. Moreover, monitoring was used as a self-report measure and forced respondents to pay attention to their mental health and analyse their overall mental conditions over the past two weeks.

The results processing started with the analysis of the mean values for groups, which made it possible to produce high-quality primary research. At this stage, significant differences between the groups were manifested. Significant differences were found in the median of grouped data, and minimum and maximum values. So, the average value in the experimental group of first-year students was 35.14 points out of 80 possible points, while in the control group of fourth-year students this indicator was higher and reached 52.66 points. The data is available in Table  1 .

If the minimum value of the BHM index in the group of first-year students is 10 points, then in the control group it is already 33 points. The difference illustrates the high vulnerability level of former school students and a need for adaptation and effective use of psychological resources during the transition period, from one social environment to another. At the same time, the maximum intragroup values are similar. In the experimental group, the BHM score did not exceed 61 points, while in the control group, the highest value was 74 points out of 80 points. The standard deviation is lower in the group of fourth-year students, which suggests a higher homogeneity in the assessment of psychological well-being.

It proves the significance of the socio-psychological services at the stage of adaptation of first-year students so that the students can receive professional support and focus on the educational process. These strategies should be introduced into practice under adaptive quarantine. For example, one of the possible interventions is support groups organised once a week and conducted by a professional psychologist online.

The second stage of data processing involved a comparison of samples to identify the statistical differences. The classical Mann-Whitney U-test for independent samples was used. The analysis revealed that there were statistically significant differences between the groups. The data are available in Table  2 .

The results reveal that the integrated value of BHM in the groups of first-year and fourth-year students is significantly different because an extremely low level of statistical error was detected, namely - p = 0.000 with admissible p = 0.05. This result suggests that the psychological well-being of fourth-year students is more stable compared to first-year students. The research considers that distance learning is not the only factor affecting the mental health of the respondents from the experimental group. The scholars assumed that psychological problems experienced by students were caused by many factors including adaptation processes to distance learning, personality crises and academic overload. The results showed that distance learning for first-year students was less desirable than for the fourth-year respondents. It is difficult for the socio-psychological service workers to support students and provide psychological help online, detect emotional burnout, apathy, and depressive episodes in a distance learning format. This research showed that age and the year of study significantly affected the mental health of students learning online.

4 Discussion

Empirical research in South Africa illustrated that university professors failed to deliver adequate psychological support to isolated students. Students relied heavily on the support of both the administrative and academic staff when it came to the learning process. As a result, the high work stress felt by teachers was added to the high academic stress of students, which increased the risk of emotional burnout and nervous exhaustion in both groups (Poalses & Bezuidenhout, 2018 ).

Distance learning sabotage denial to accept a new academic environment increases the likelihood of mental disorders and reduces the cognitive abilities of schoolchildren whose parents are against this form of teaching (Davis et al., 2021 ). Distance learning under total lockdowns can cause a sense of learned helplessness with online learning technology, and worsen the quality of mental health of students of different age groups. The factors that may eliminate the negative consequences are academic motivation, reduced fatigue and a loss of interaction that cannot be restored with any online conferences (Garcia et al., 2021 ).

The U.S.-based University conducted a multi-thousand online survey involving undergraduate and graduate students based on standardised scales for assessing physical health and anxiety, as well as additional multiple-choice questions and open-ended questions about stressors and coping mechanisms under the pandemic restrictions. The results showed that half of the respondents experienced an increased level of depression and anxiety. At the same time, less than half of the participants indicated that they coped effectively with the stress factors caused by online learning and the threat of infection (Wang et al., 2020 ).

In Malaysia, the mental health of students during distance learning was evaluated using the DASS-21 methodology, designed to assess the depressive-anxiety stress factors. The questionnaire analysis showed that 30% of students in vocational schools experienced severe or extremely severe depression, 41% had anxiety, and 20% had chronic stress. At the same time, the biological sex of the respondent had a significant impact on anxiety. The research suggests investigating and combining distance learning with face-to-face education and practical work experience within the curriculum (Ahmad et al., 2022 ).

The results comparison of the mental state of students in full-time and distance learning was performed in Eurasia. This research assessed satisfaction with academic performance and the severity of depression and anxiety symptoms. The results showed that the prevalence of depressive symptoms and anxiety among students was higher during distance learning, compared with similar results obtained during full-time education. Moreover, the research results showed that the sudden transition from one learning environment to another was a major cause of chronic stress, which led to a high prevalence of depressive symptoms and anxiety among students (Lyubetsky et al., 2021 ).

In Italy, the impact of long-term online learning on the mental health of students was also researched. The second (control) experiment used the same sample and conducted the research over six months. The results reveal significant differences on scales such as students’ connection with other students and teachers, workspace organisation, and boredom between lessons. Moreover, the results show significant correlations between student academic development and the quality of distance learning, course adaptation, workspace arrangements and communication with other students and teachers, and between students’ emotions and communication with other students and teachers (Baltà-Salvador et al., 2021 ). The research finds that the social relations in distance learning can be an additional psychological resource for students that should not be underestimated.

Cross-cultural research based on a sample of thousands of students showed higher rates of depression, suicidal intentions and post-traumatic stress disorder compared to pre-pandemic levels and current rates in individuals belonging to ethnic minorities, which could also be considered as one of the factors of influence. Though the most common pandemic outcome is PTSD (Post-traumatic stress disorder ) , recorded in 62% of the respondents. However, neither age, nor personal history of mental illness, nor perceived social support was a significant risk factor of mental health (Torres et al., 2022 ).

The UK has developed a large-scale online questionnaire designed to assess mental health under the pandemic restrictions. The authors of the questionnaire considered socio-demographic variables, previous physical or mental illness, personal experience with COVID-19, information in the media, pandemic concerns, degree of personal traumatic experiences, PTSD caused by a pandemic outbreak, generalised anxiety disorder, depressive disorder, sleep quality, emotional deregulation, loneliness, social support, and the meaning of life (Armour et al., 2021 ). This questionnaire has not yet been standardised and adapted in other countries. However, all of the above factors affect the quality of mental health during and after the pandemic. There were no publications devoted to mental health under adaptive quarantine, which proved the need to start a debate on the key theoretical and empirical questions.

5 Conclusion

This article investigated the main factors that affected the mental health of students. The theory of intelligence helps to illustrate that the pandemic and distance education increase the risk of clinical depression, generalised anxiety disorder, PTSD, apathy, learned helplessness, burnout, nervous breakdown, and so on. Furthermore, non-university students more often report mental health problems than those who learn academic disciplines in a traditional format. The results prove that therapeutic and individualistic approaches to mental health cannot be the only methods used to improve students’ mental well-being.

The scholars have to investigate inclusive curriculum design and assessment methods. Moreover, educational institutions should introduce and teach advanced telecommuting skills, implement educational systems and processes that do not cause stress, and design learning environments based on professional feedback to maintain a balance between quality education and the student’s mental health. The research proposed the holistic approach to introduce mental health practices during distance learning that can influence positively the mental well-being of students. At an empirical level, the present research investigates distance learning opportunities during adaptive quarantine and finds that it is less effective for first-year students who have just entered the university. The problems that may arise are caused by the complicated adaptation process which requires a significant amount of effort, the difficulties in developing new social relations with teachers and fellow students, and academic overload, especially in learning specialised disciplines.

The experiment shows that first-year students are a more vulnerable group than fourth-year students who have learnt online at the university and feel much more competent when it comes to university education. In addition, the research finds that first-year students need high-quality psychological support being at risk with a reduced tolerance for uncertainty. The empirical research finds that age and the year of study affect the mental well-being of students. The scholars suggest that under conditions of adaptive quarantine, it is necessary to pay attention to psychological screening and psychological interventions to prevent depressive episodes, apathy, low academic motivation, low-stress resistance, ineffective self-regulation, and so on. The scientific value of the research is that it causes a worldwide discussion about the safety of distance education and its impact on the mental health of university students.

Moreover, some risks for mental health may occur when young individuals learn remotely. However, the research proves that the psychological states of undergraduate students are more stable and the students are better prepared for distance learning. This is the main practical value of the article to the university administration and teachers. This research manifests that the quality of socio-psychological services in universities is a priority for the administration, and special strategies should be developed to prevent mental disorders among students and maintain an effective and advantageous learning environment for all parties involved in the education process.

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

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  • Published: 21 February 2024

Making cities mental health friendly for adolescents and young adults

  • Pamela Y. Collins   ORCID: orcid.org/0000-0003-3956-448X 1 ,
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Urban life shapes the mental health of city dwellers, and although cities provide access to health, education and economic gain, urban environments are often detrimental to mental health 1 , 2 . Increasing urbanization over the next three decades will be accompanied by a growing population of children and adolescents living in cities 3 . Shaping the aspects of urban life that influence youth mental health could have an enormous impact on adolescent well-being and adult trajectories 4 . We invited a multidisciplinary, global group of researchers, practitioners, advocates and young people to complete sequential surveys to identify and prioritize the characteristics of a mental health-friendly city for young people. Here we show a set of ranked characteristic statements, grouped by personal, interpersonal, community, organizational, policy and environmental domains of intervention. Life skills for personal development, valuing and accepting young people’s ideas and choices, providing safe public space for social connection, employment and job security, centring youth input in urban planning and design, and addressing adverse social determinants were priorities by domain. We report the adversities that COVID-19 generated and link relevant actions to these data. Our findings highlight the need for intersectoral, multilevel intervention and for inclusive, equitable, participatory design of cities that support youth mental health.

More than a decade ago, Galea posed the question “Can we improve mental health if we improve cities?” 4 . In the past two centuries, urbanization has shaped landscapes and lives, making it the “sentinel demographic shift” of our times 4 . The relationships between mental health status and the social, cultural and physical environment have been explored for at least as long; nineteenth-century researchers proposed environmental exposures as possible explanations of ‘insanity’ 5 . Faris and Dunham’s classic 1930s study 6 linked social disorganization and unstable communities to mental disorders. Two decades later, Leonard Duhl sought to create healthy societies through liveable cities, informing the World Health Organization’s Healthy Cities initiative 7 , 8 . The question remains pertinent today even as we recognize the multiple and complex forces that shape mental health 9 . Today we understand that urban environments influence a broad range of health outcomes for their populations, positively and negatively, and this impact is manifested unequally 10 . Opportunities for education and connection exist for some, whereas rising levels of urban inequality, violence, stressful racial or ethnic dynamics in urban neighbourhoods, exposure to environmental toxins, lack of green space, inadequate infrastructure and fear of displacement increase risk for poor mental health and disproportionately affect marginalized groups 11 . Disparate outcomes also pertain to distinct developmental stages, and the mental health of adolescents and young adults is particularly vulnerable to urban exposures.

Adolescents, youth and urban mental health

Young people under the age of 25 are the demographic group most likely to move to cities for educational and employment opportunities, and by 2050 cities will be home to 70% of the world’s children 3 . Cities concentrate innovation 3 and have long been considered the consummate source of skills, resources and talent 12 . They offer greater opportunities for health and economic development, education, employment, entertainment and social freedoms (that is, the ‘urban advantage’), but rapid urbanization also deepens disparities and exposes individuals to considerable adversity, placing their mental health at risk 13 . In fact, most evidence points to urban living as a risk factor for poorer mental health, yielding increased risk for psychosis, anxiety disorders and depression 1 , 2 . Adolescence and young adulthood, specifically, encompass a critical period of risk for the incidence of mental disorders: an estimated half of mental disorders evident before age 65 begin in adolescence and 75% begin by age 24 (ref.  14 ). Mental disorders are the leading causes of disease burden among 10–24-year-olds worldwide 15 , responsible for an estimated 28.2 million disability-adjusted life years globally, with 1 disability-adjusted life year being equivalent to a healthy year of life lost to the disability caused by mental disorders. Public awareness of these issues rose as the incidence of mental disorders and suicide increased in some countries among adolescents and young adults during the coronavirus pandemic 16 , 17 . Urban environments probably have a role in these processes.

Fundamental to adolescents’ growth and development are their interactions with the complex urban environment: physical, political, economic, social and cultural 18 . Adolescents have a heightened sensitivity to context and social evaluation, and a stronger neural response to social exclusion, as well as to threat and reward stimuli 19 , and it is plausible that they may be particularly sensitive to social and environmental cues in the urban context, such as discrimination or violence. Discriminatory policies and norms are entrenched in many of the institutions with which young people interact (for example, schools, housing, justice and policing), and minoritized youth may experience the emotional and mental health consequences 20 . In fact, in settings of structural inequality (for example, high neighbourhood poverty and unemployment), young people are at greater risk for low self-efficacy and feelings of powerlessness and depression 21 . Social cohesion and collective efficacy can reduce the effects of concentrated disadvantage and nurture social and emotional assets among young people, families and their networks 21 .

At present, the world’s largest population of adolescents and young adults so far is growing up amid the sequelae of a tenacious pandemic, rapid population growth in urban centres and increasing urbanization, demanding an urgent response to support youth mental health 22 . Investing in adolescent well-being is said to yield a triple dividend through actions that reduce mortality and disability in adolescence, prolong healthy life in adulthood, and protect the health of the next generation by educating and strengthening the health of young parents 23 . Interventions in urban settings that align with developmental needs of adolescents and young adults could remediate insults from early life and establish healthy behaviours and trajectories for adult life 19 , 24 , potentially averting chronic conditions such as human immunodeficiency virus (HIV) and the associated mental health, social and physical sequelae 25 . In fact, investment in a package of adolescent mental health interventions can yield a 24-fold return in health and economic benefits 26 . At the societal level, shaping the aspects of urban life that influence youth mental health—through services, social policies and intentional design—could have an enormous impact 4 . Proposals for ‘restorative urbanism’ that centre mental health, wellness and quality of life in urban design may move cities in the direction of moulding urban environments for better adolescent health 27 , 28 . Young people, who contribute to the creativity of urban environments and drive movements for social change 29 , have a central part to play in this transformation.

Mental Health Friendly Cities, a global multi-stakeholder initiative led by citiesRISE, mobilizes youth-driven action and systems reform to promote and sustain the mental health and well-being of young people in cities around the world 30 , 31 ( Supplementary Information ). To guide transformative actions that will enable cities to promote and sustain adolescent and youth mental health, we studied global priorities for urban adolescent mental health. One aim of this study is to contribute data-driven insights that can be used to unite several sectors in cities to act within and across their domains in favour of mental health promotion and care that is responsive to the needs of young people. To that end, we administered a series of linked surveys that permitted the influence of ideas from young people and multidisciplinary domain experts through an anonymous sequential process, following established methods for research priority setting 32 .

Framework and top-ranked recommendations

To determine the elements of an urban landscape that would support mental health for adolescents and youth and would amplify their voices, we recruited a panel of 518 individuals from 53 countries to participate in a series of three digitally administered surveys that began in April 2020 (Table 1 ). Figure 1 shows the panel participation at each round. In survey 1, panellists responded to the open-ended question: “What are the characteristics of a mental health-friendly city for young people?”. Analysis of survey 1 data produced 134 statements about mental health-friendly cities for young people ( Methods ). In survey 2, participants selected their preferred 40 of the 134 statements. They were also presented with a second question related to the influence of the COVID-19 pandemic on their ideas about youth well-being in cities. In survey 3, we categorized survey 2 statements by socioecological domains (Fig. 2 ) and asked panellists to rank-list their preferred statements in each domain. Before ranking, panellists were required to choose one of three framings that informed their selected ranking: immediacy of impact on youth mental health; ability to help youth thrive in cities; and ease or feasibility of implementation.

figure 1

The composition of the project leadership structures, sample recruitment and participation by each survey round are shown below. We invited 801 individuals to participate in the survey panel through recommendations and direct invitations from advisory board members. Participants recruited through snowball sampling received the Research Electronic Data Capture (REDCap) link ( n  = 24). Individuals who gave informed consent in REDCap were deemed to have accepted the survey panel invitation. S1, survey 1; S2, survey 2; S3, survey 3.

figure 2

The socioecological model with six levels (personal, interpersonal, community, organization, policy and environment) that are used to categorize the characteristics of a mental health friendly city.

We present the findings of the third survey within a socioecological model (Figs. 3 – 5 ) because of this model’s relevance to the combination of social and environmental exposures in an urban setting and their interaction with the developing adolescent 33 . Bronfenbrenner’s model begins by recognizing that young people’s personal experiences and development are shaped by their interactions with the people around them 34 ; that is, they react to and act on their immediate environment of familial and peer relationships (microlevel). These interpersonal relationships are also influenced by neighbourhood and community dynamics and exposure to institutions and policies (mesolevel). These, in turn, are nested within the organizational, political, historical, cultural (for example, values, norms and beliefs) and physical environments (macrolevel) whose interplay directly or indirectly affects the adolescent’s mental health and well-being. A high court ruling (policy environment) could have direct or indirect effects on the community, household and personal well-being of a young person seeking asylum. The socioecological framework encompasses the dynamic relationships of an individual with the social environment.

figure 3

Mean ranks and standard deviations (s.d.) values for each mental health-friendly city (MHFC) characteristic are reported grouped by socioecological level and three framings described in the Analysis: immediacy of impact; ability to help youth thrive in cities; and ease or feasibility of implementation. Overall ranks (along with mean and s.d. values) for the total sample are reported. n values in bold represent the number of participants responding for each domain; the percentages in bold represent the percentage of respondents per domain. The number and percentage of the sample that assigned the highest rank for each characteristic are also reported (column 2). The colour continuum from light blue to dark blue shows the highest ranked means in the lightest shades and the lower ranks in darker blue.

figure 4

See the caption of Fig. 3 for details.

figure 5

See the caption of Fig. 3 for details. LGBT+, people from sexual and gender minorities.

The characteristics

We grouped 37 city characteristics across 6 socioecological domains: personal, interpersonal, community, organizational, policy and environmental. Figures 3 – 5 show the mean ranking for each framing and the total mean ranking averaged across frames. We show, for each characteristic statement, the number and percentage of panellists who ranked it highest. The five characteristics in the personal domain centre on factors that enable healthy emotional maturation for young people, future orientation and self-reflexivity. Most panellists (53%) ranked these characteristics according to immediacy of impact on youth mental health in cities, and mean rankings were identical to those linked to ability to help youth thrive in cities. The characteristic that describes prioritizing teaching life skills, providing opportunities for personal development and providing resources that allow young people to flourish rose to the top mean rank for each frame and was also ranked first in this domain by the largest number of panellists ( n  = 93). Notably, the characteristic that describes preparing youth to handle their emotions and overcome challenges was ranked first by 62 panellists, although its mean rank was much lower.

Characteristics in the interpersonal domain refer to young people’s interactions with others in the environment. Prioritized characteristics in this domain centred on relationships marked by acceptance and respect for young people and noted the value of intergenerational relationships. The top-ranked characteristic emphasized age friendliness and interactions that value the feelings and opinions of young people as well as safe and healthy relationships. In this domain, ranked means for characteristics framed according to immediacy of impact on youth mental health and ability to help youth thrive were the same for the top two characteristics. Notably, the two highest-ranked means for ease of implementation focused on opportunities for safe and healthy relationships and strengthening intergenerational relationships.

Young people’s intrapersonal experiences and interpersonal relationships are nested within a system of community and organizational relationships. Study participants prioritized access to safe spaces for youth to gather and connect among the three characteristics in the domain of community, and rankings were identical for each framing. At the organizational domain, two characteristics shared high mean rankings: employment opportunities that allow job security and satisfaction and a responsive and supportive educational system. Health-care services and educational services were the organizations most frequently referenced in relation to youth mental health. Whereas employment opportunities ranked first in terms of feasibility of implementation, provision of youth-friendly health services ranked first for immediacy of impact on youth mental health. With the exception of the community and organizational domains, more panellists chose to frame their responses in terms of immediacy of impact on youth mental health.

Of the four statements in the policy domain, the design and planning of cities with youth input and gender sensitivity ranked highest overall and was most frequently ranked first by panellists (30.68%). Promoting democratic cooperation and equal opportunity and anti-discrimination in all institutions received the highest mean rank for feasibility of implementation.

The sixth socioecological domain lists 13 characteristics related to the social, cultural and physical environments. Addressing adverse social determinants of health for young people had the highest overall ranked mean; however, normalizing youth seeking mental health care and addressing service gaps ranked first when framed by feasibility of implementation and immediacy of impact. Having access to affordable basic amenities was most frequently ranked first in this domain by panellists, but panellist preferences were distributed across the list.

COVID-19 and urban youth well-being

Our data collection began in April 2020 during the COVID-19 pandemic, and by survey 2 (August 2020), most countries were experiencing the pandemic’s public health, social and economic effects. In light of this, we added an open-ended survey question to which 255 participants responded “How has the COVID-19 pandemic changed your ideas about the wellbeing of young people in cities?” ( Methods ). Most respondents reported changes in perspective or new emphases on inequities as determinants of youth well-being and mental health, whereas nine reported that COVID-19 did not change their ideas. For one such respondent (in the >35 years age category), the pandemic merely confirmed the powerful effect of social vulnerabilities on risk and outcomes during an emergency: “COVID-19 has not changed my ideas about the wellbeing of young people in cities. I found that the young people in cities who did well during the lockdown period and the difficult period of the pandemic were those who were already doing well in terms of a rich social network, good interpersonal relations with family and friends, enjoyable work life, a close religious network, membership [in] a young people’s club so that they were able to stay connected via social media. Those who had access to food and essential commodities and those who knew they would return to school or work after the pandemic. Those who had access to good living conditions and some space for recreation also did well. ... The impact of COVID19 was felt much more by those with existing mental health conditions, living in crowded slums, poverty, unemployment, who were uncertain about the next step”.

Respondents highlighted losses young people experienced as a result of the pandemic. These included loss of the city as a place of opportunity; loss of jobs, familial and individual income, and economic stability; loss of a planned future and loss of certainty; loss of rites of passage of youth; loss of access to friends, social networks and social support; loss of access to quality education and to health care, especially mental health care and sexual and reproductive health services; loss of opportunities for psychological and social development; and loss of loved ones who died from COVID-19. We summarize the qualitative findings according to the socioecological framework. We present sample quotes in Table 2 , along with the age category of the respondents (18–24, 25–35 and >35) and actions for cities to take.

Policy and environment

Governance and equity.

Freedom from discrimination and the value of equity were listed among the mental health-friendly city characteristics; however, respondents pointed out the dearth of equity that COVID-19 unveiled (see the first quote in Table 2 ).

Respondents observed that policy responses to COVID-19, including mandated curfews and quarantines, shifted the social and economic environment of cities. Young people and their families lost economic opportunities, and cities also became less affordable during the pandemic. Participants explained that poverty and job loss worsened young people’s mental health and well-being and exposed youth to more risk factors because they needed to “hustle or work to place food on the table”. The loss of jobs also deprived youth of hope and underlined the economic inequities that some felt marked their generation more than previous ones. One participant (18–24) reported “Before, I used to think youths need someone who can understand them, empathize with them, but looking at the current scenario, I feel youths need security and a hopeful future too”. In some settings, these economic shifts resulted in an exodus from cities. A respondent (18–24) observed “Cities have always attracted young people but since the pandemic started the cost of living has gone from being a barrier to being another factor in encouraging young people to leave”.

Urban built environment

For those who remained in the city, the urban built environment could also offer respite from pandemic-related restrictions in mobility when green spaces and other open spaces were accessible. Participants alluded to cramped urban housing, crowded slums and poor housing infrastructure as stressors that the availability of safe public spaces alleviated. Green space in particular provided solace for young people. A participant (18–24) responded “It’s difficult when you’re confined to the limited space especially when you’re not closer to nature. Negative thoughts get you one way or another even if you try your best. Pandemic has caused more depression I reckon among the youths”. Accessible green space was highlighted as a need and an area for investing effort and policy change (Table 2 ). A desire for clean, youth-friendly green space for safe gathering and recreation was contrasted with unplanned land use and confined spaces, the latter of which some participants linked to greater risks for young people.

Community and organizations

Respondents reported diminished access to education and health care, and a disregard of young people’s needs by decision-makers (Table 2 ). Some responses criticized the lack of forethought before the pandemic to budget for and provide supportive learning environments for youth of all socioeconomic strata. The closure of schools generated stress for young people with the disruption of routines and opportunities to socialize. The pandemic generated greater uncertainty about job opportunities and future trajectories. At the same time, the pandemic brought opportunities to position youth as either contributors and leaders or detractors from community life. Young people reflected on how they experienced inclusion, empathy and exclusion, as well as opportunity for leadership. One respondent (25–35) commented “Our worlds are changing and with it many of our expectations about our education, work, personal interactions and relationships. Instead of being met with understanding, we are collectively positioned as transgressors of social distancing in a way that fails to understand that we are often incredibly vulnerable in this new world and left exposed by lack of infrastructure, service provision and support”.

A respondent (18–24) noticed possibilities for involving young people in responses that could mitigate their numerous losses: “Given the opportunities and resources, young people can be a carrier of change and wellbeing if adults trust them enough to be”.

Interpersonal domain

Getting through difficult times required interpersonal supports: connectedness through in-person encounters in safe spaces, complemented by digital interactions. Multiple respondents emphasized the relationship between social isolation and poor mental health among city youth during the pandemic, noting the difficulty of making meaningful connection during a time of physical isolation. Two young respondents (18–24) said the well-being of young people was linked to being “in a group of people”, which provides “safety and unity”, and to “inclusion, activity, and interpersonal relationships”. Space repeatedly emerged as a theme, as a conduit to facilitate social connection for young people without risk of COVID-19 transmission, violence, sexual abuse or exposure to drug use. Some participants called for greater investment in creating strong, safe virtual communities for young people; however, although participants identified virtual spaces as a resource for mental health support, a young panellist (18–24) remarked of social media and technology that “It isolated people, even though we have … ways of staying connected 24/7, we still feel lonely.”

Consistent with the lead mental health-friendly city characteristic in the personal domain (Figs. 3 – 5 ), the pandemic prompted realization of the need for personal skills development to support youth mental well-being. Some respondents expressed concern about the loss of social skills among young people as a result of confinement and an 18–24-year-old commented “… Youths are in that stage where they need to be equipped with skills to promote positive mental wellbeing”. Another young person (18–24) remarked “Most of us do not really have the capacity and necessary skills to support each other when it comes to mental health”. Participants described the importance of being prepared for unpredictable circumstances and enabling youth to “manage themselves, their emotions, and wellbeing”.

Pandemic-related gains

In some cases, the pandemic brought positive experiences for young people, including more time for self-reflection and discovery, engaging in healing practices, more opportunities to connect with friends, and overall, a greater societal and individual focus on strengthening mental health. A participant (25–35) referred to young people: “They are more conscious about health and their wellbeing by reducing workload and connecting with nature”. Others believed the pandemic revealed young people’s capacity to adapt and to consider the needs of their elders. Some viewed the social justice uprisings that occurred in many countries as a positive vehicle for change and cooperation with others. Changing these conditions would require longer-term solutions: strengthening urban infrastructure and addressing the underlying drivers of inequity. Another participant (>35) lauded the power of youth activism: “… the pandemic has shown us that the resilience of youth is great, as well as the commitment and solidarity with their communities through volunteering, advocacy and youth mobilization”.

Our study convened a multinational and multidisciplinary panel of researchers, practitioners, advocates and young people to identify the characteristics of a mental health-friendly city for youths. The characteristics are distributed among six socioecological domains (Figs. 3 – 5 ) that encompass the personal development of young people, supportive educational systems, people-centred health care, a built environment responsive to the needs of young people, and equity-focused policy-making and governance. Within each of these domains, the characteristics we identified are associated with an evolving evidence base linked to youth mental health outcomes and to potential policy intervention.

Intrapersonal characteristics in our list underline the centrality of enabling young people to cultivate skills to manage their interior lives. The targets of such skills-building activities align with proposed ‘active ingredients’ of mental health interventions, such as intervention components related to mechanisms of action or clinical effects on depressive or anxiety symptoms 35 . Examples include affective awareness skills that enable young people to differentiate and describe emotions 36 and emotion regulation skills to increase and maintain positive emotions 37 . Youth-friendly mental health and educational services, a priority theme at the community level of the framework, could support the intrapersonal realm by deploying a variety of interventions for self-control that benefit adolescent and young adult academic, behavioural and social functioning 38 . Such interventions can also be implemented in earlier childhood educational settings through integration into the curriculum or through other community-based medical or social service organizations 39 . Interventions implemented in selected high-income settings include Promoting Alternative Thinking Strategies 40 , the Incredible Years 41 and Family Check-up 42 . For young adults, interventions that convey skills to alleviate common psychological problems such as procrastination, perfectionism, low self-esteem, test anxiety and stress could potentially reduce the prevalence of specific mental health conditions while possibly providing acceptable and non-stigmatizing options for care 43 , 44 .

Our data suggest that a defining theme of any mental health-friendly city for youth is the quality of young people’s social fabric and the city’s ability to provide young people with the skills, opportunities and places required to build and maintain healthy social relationships with their peers, across generations, and as members of a community. The relationships of concern in the interpersonal realm have intrinsic value for healthy adolescent and youth development, promoting well-being 45 and prevention of depression 46 , 47 . Panellists also linked opportunities to socialize and build social networks to the availability of safe spaces, the top-ranked priority in the community domain. Achieving safety necessitates equitable and violence-free institutions and cities 48 , a priority that panellists ranked first for ease of implementation in the policy domain. Thus, policies and legislation are required that reduce neglect, bullying, harassment, abuse, censorship, exposure to violence and a wide range of threats towards young people, from homelessness to crime to intimidation by officials 48 , 49 .

Exposure to community violence and household violence consistently worsens mental health outcomes for youth 50 , 51 , 52 , 53 ; successful reduction of urban violence should be prioritized. Equity-focused responses to safety needs should include reducing discriminatory physical and structural violence against young people based on race, ethnicity, gender, sexuality or mental health status, which place youth at risk of harmful exposures: rape or trafficking of adolescent girls or police killings of North American Black youth. To create urban spaces in which young people can experience safety, freedom and belongingness requires approaches that actively prevent discrimination 54 and that consider young people’s multiple identities in the design of institutional as well as outdoor spaces. Women-only parks create greater security for girls and young women and potentially more positive social interaction in some settings 55 .

The benefits of green space, measured as self-satisfaction for adolescents, are linked to greater social contact (for example, more close friends), underscoring space as a conduit for social connection 55 . The advantages of healthy urban spaces for adolescents have emerged not only in health sciences research but also in allied fields such as urban design and sociology 27 , 56 , 57 . Urban spaces with opportunities for active commute options to and from school are associated with increased physical activity and environmental supportiveness 58 . Similarly, the presence of community spaces, such as town centres, is associated with improved social connectedness and sense of belonging 59 .

The critical importance of social connectedness was reinforced in the COVID-19 responses. Yet, in many cities the pandemic eliminated spaces that foster urban conviviality, often with lasting effects 60 . Restricted movement and COVID-19 transmission risk associated with public transport may have contributed to greater stress for urban dwellers and ongoing reluctance to use these services 61 . Such factors contribute to social isolation, which may persist in the near term. Consistent with our COVID-19 data, responses from a sample of Australian youth identified social isolation, interrupted education and work, and uncertainty about the future among the primary negative effects of COVID-19 pandemic 62 . In several studies, loneliness increased the risk of mental health conditions among young people during prior epidemics; of relevance to the COVID-19 pandemic, the duration of loneliness predicted future mental health problems 63 .

Analysis of our survey 2 data revealed differences in the priorities of young participants (18–24 and 25–35) compared with panellists over age 35. This discrepancy could have implications for urban decision-makers whose plans to implement positive actions on behalf of young people may not align with what is most salient for youth. Thus, youth involvement in policy development is even more crucial. Soliciting youth perspectives about what supports their mental health based on their personal experiences could simplify and improve interventions intended for them 64 . Several actions could facilitate meaningful youth engagement in governance: encourage collaboration between governments and youth organizations to co-create and co-lead national action plans; implement mechanisms within global governance organizations for youth consultation at local, national and international levels; require inclusion of young people on relevant conference agendas; and improve access to funding for youth-led organizations 65 , 66 .

Notably, the themes of equity and elimination of discrimination due to race, gender, sexual orientation and neurodiversity arose frequently in the responses to the survey and the COVID-19 question, as did the adversities to which minoritized groups are vulnerable (for example, community violence, police violence and bullying; Figs. 4 and 5 ). A city that is free of discrimination and racism ranked first among policy responses with immediacy of impact on the mental health of youth—even though no statements proposed dismantling systems of oppression that underlie racism and discrimination, as one respondent noted (Fig. 4 ). Globally, racism, xenophobia and other forms of discrimination increase mortality and harm the mental health of affected groups through stress-related physiological responses, harmful environmental exposures and limited access to opportunities and health services 20 , 67 , 68 , 69 . Embedded racist and xenophobic norms, policies and practices of institutions—including those that govern educational, labour and health care systems—yield racialized outcomes for young people around the world (for example, high incidence of HIV infection among adolescent girls in southern sub-Saharan Africa) 20 . To disrupt these forces requires multiple approaches, including recognition and remedy of historical injustices, the activism of social movements committed to change, and implementation of legal frameworks based in human rights norms 70 .

When participants ranked characteristics for ease of implementation (Figs. 3 – 5 ), they coalesced around a broad set of factors demonstrating the need for collaboration across urban sectors (for example, normalizing seeking mental health care, promoting democratic cooperation and equal opportunity, and creating employment opportunities and progressive educational systems). This need for cooperation is perhaps most apparent for actions that increase equity. Successful cooperation requires a clear, shared vision and mission, allocation of funding in each sector, diversity of funding sources, distributed decision-making and authority across sectors, and policies that facilitate collaboration 71 . However, well-intentioned cross-sectoral responses to urban needs may inadvertently increase inequities by designing programmes influenced by market forces that magnify environmental privilege (that is, unequal exposure to environmental problems according to social privilege) 54 . Examples include gentrification and development that use land to create green spaces but further dislocate and marginalize communities in need of affordable housing 54 . Implementing community- and youth-partnered processes for urban health equity policy co-creation could yield unified agendas and help to circumvent inequitable outcomes 54 , 72 . A mental health-friendly city must be positioned to support, integrate and enable the thriving of marginalized and vulnerable young people of the society, who should be involved in its governance.

Strengths and limitations

Our study has several strengths. First, this priority-setting study yielded a rich dataset of recommended characteristics of a mental health-friendly city for young people from a globally diverse panel of more than 480 individuals from 53 countries. Second, we welcomed expertise from participants with roles relevant to urban sectors: researchers, policymakers and practice-based participants, and we engaged young people in the study advisory board and as study participants, capitalizing on their lived experience. Third, we captured information about how the COVID-19 pandemic influenced participants’ ideas about urban adolescent mental health. Fourth, to our knowledge, this is the first study that brings together a large and multidisciplinary set of stakeholders concerned for cities (for example, urban designers) and for youth mental health (for example, teachers and health professionals) to identify priorities for intersectoral action.

Our study also has several limitations. First, the participants recruited do not reflect the full social and economic diversity of urban populations whom city governments and decision-makers must serve. Our decision to use a web-based format following standard health research priority-setting methods required tradeoffs. We sought disciplinary, age and geographic diversity; however, our sample does not represent the most marginalized groups of adolescents or adults. Rather, the recruitment of academics, educators, leaders and well-networked young people through an online study probably minimizes the number of participants living in adversity. Although we also recruited young people who were not necessarily established experts, many were students or members of advocacy or international leadership networks and were not likely to exemplify the most disadvantaged groups. We risk masking the specific viewpoints or needs of marginalized and at-risk young people. However, we are reassured by the prominence of equity as a theme and the call to address social determinants of health. Second, it is possible that participants recruited through the authors’ professional networks may be more likely to reflect the viewpoints of the advisory committee members who selected them, given collaborative or other professional relationships. This may have shaped the range of responses and their prioritization. Third, the aspirational calls for an end to discrimination and inequalities highlighted in our results require confronting long-standing structural inequities both within and between countries. Structural violence frequently maintains these power imbalances. Although we do not view their aspirational nature as a limitation, we note that our study data do not outline the complexity of responses required to address these determinants of mental health or to dismantle discriminatory structures. Fourth, our data present several aggregated characteristics that may require disaggregation as cities contextualize the findings for their settings. Fifth, our network recruitment strategy led to skewed recruitment from some geographic regions (for example, North America and Nepal), which may have biased responses (Extended Data Figs. 1 – 3 ). Extended Data Table 1 shows the similarities and differences in the rankings for Nepal, USA and the remaining countries in survey 3. Additionally, we recruited few 14–17-year-olds. We experienced attrition over the three rounds of surveying, ending with complete responses from 261 individuals from 48 countries, with the greatest loss in participants between surveys 1 and 2 (Table 1 ), among the 14–17-, 18–24- and 25–35-year-old age groups, and among participants from Nepal (Extended Data Fig. 2 ).

Conclusions

We identified a set of priorities for cities that require intervention at multiple levels and across urban sectors. A clear next step could involve convenings to build national or regional consensus around local priorities and plans to engage stakeholders to co-design implementation of the most salient characteristics of a mental health-friendly city for youth in specific cities (Box 1 ). It is likely that many variables (for example, geography, politics, culture, race, ethnicity and sexual identity) will shape priorities in each city. Therefore, essential to equitable action is ensuring that an inclusive community of actors is at the table formulating and making decisions, and that pathways for generating knowledge of mental health-friendly city characteristics remain open. This includes representation of sectors beyond mental health that operate at the intersection of areas prioritized by young people. Preparing for implementation will require avenues for youth participation and influence through collective action, social entrepreneurship and representation in national, regional and community decision-making. Enlisting the participation of youth networks that bring young people marginalized owing to sex, gender, sexual orientation, race, economic status, ethnicity or caste; young people with disabilities; and youth and adults with lived experience of mental health conditions in the design of mental health-friendly cities will help to level power imbalances and increase the likelihood that cities meet their needs.

Action for adolescent mental health aligns well with actions nations should take to achieve development targets, and collective action to draw attention to these areas of synergy could benefit youth and cities. Specifically, supporting the mental health of young people aligns with Sustainable Development Goal 11 (sustainable cities and communities) and the New Urban Agenda that aims to “ensure sustainable and inclusive urban economies, to end poverty and to ensure equal rights and opportunities … and integration into the urban space” 73 , 74 , 75 .

Additionally, the list of mental health-friendly city characteristics presents a starting point for strengthening the evidence base on intervening at multiple levels (for example, individual, family, community, organizations and environment) to better understand what works for which youth in which settings. Cities function as complex systems, and systems-centred research can best enable us to understand how individuals’ interactions with one another and with their environments influence good or poor mental health 76 . Similarly, interdisciplinary inquiry is needed that investigates urban precarity and sheds light on social interventions for youth mental health 77 . New research that tests implementation strategies and measures mental health outcomes of coordinated cross-sectoral interventions in cities could be integrated with planned actions. Innovative uses of data that measure the ‘racial opportunity gap’ can help cities to understand how race and place interact to reduce economic well-being for minoritized young people on their trajectory to adulthood 78 . Even heavily studied relationships, such as mental health and green space, can benefit from new methodologies for measuring exposures, including application of mixed methods, and refined characterization of outcomes by gender and age with a focus on adolescents and youth 79 . Globally, mental health-supporting actions for young people in urban areas have an incomplete evidence base, with more peer-reviewed publications skewed towards North American research 73 .

Designing mental health-friendly cities for young people is possible. It requires policy approaches that facilitate systemic, sustained intersectoral commitments at the global as well as local levels 80 . It also requires creative collaboration across multiple sectors because the characteristics identified range from transport to housing to employment to health, with a central focus on social and economic equity. Acting on these characteristics demands coordinated investment, joint planning and decision-making among urban sectoral leaders, and strategic deployment of human and financial resources across local government departments that shape city life and resources 75 , 81 . This process will be more successful when cities intentionally and accountably implement plans to dismantle structural racism and other forms of discrimination to provide equitable access to economic and educational opportunities for young people, with the goal of eliminating disparate health and social outcomes. The process is made easier when diverse stakeholders identify converging interests and interventions that allow them each to achieve their goals.

Box 1 Considerations for implementing a mental health-friendly city for youth

Considerations for implementing a mental health-friendly city for youth using a structure adapted from UNICEF’s strategic framework for the second decade of life 82 and integrating selected characteristics identified in the study with examples distilled from scientific literature and from project advisory group members. Objectives for implementation along with corresponding examples and selected initiatives are shown.

Youth are equipped with resources and skills for personal and emotional development, compassion, self-acceptance, and flourishing.

Youth develop and sustain safe, healthy relationships and strong intergenerational bonds in age-friendly settings that respect, value and validate them.

Communities promote youth integration and participation in all areas of community life.

Communities establish and maintain safe, free public spaces for youth socializing, learning and connection.

Institutions facilitate satisfying, secure employment; progressive, inclusive, violence-free education; skills for mental health advocacy and peer support.

Policies support antiracist, gender equitable, non-discriminatory cities that promote democratic cooperation and non-violence.

Urban environments provide safe, reliable infrastructure for basic amenities and transportation; affordable housing; access to green and blues space; and access to recreation and art.

Cities minimize adverse social determinants of health; design for safety and security for vulnerable groups; and orient social and built environments to mental health promotion, belonging and purpose.

Use rights-based approaches

Prioritize equity for racially, ethnically, gender, sexually and neurologically diverse young people

Ensure sustained and authentic participation of youth

Schools and other educational settings

Health and social services

Families and communities

Religious and spiritual institutions

Child protection and justice systems

Peer groups

Civil society

Digital and non-digital media

Implementation objectives

Build consensus and contextualize the mental health-friendly city approach at local, regional, national levels

Engage diverse youth in co-design of mental health-friendly city plans

Expand opportunities for youth governance

Enable collaboration among sectors for policy alignment

Engage communities, schools, health services, media for intervention delivery

Legislate social protection policies

Scale interventions to improve economic and behavioral outcomes

Link implementation to achievement of national or international objectives

Selected implementation strategies

Youth co-design and participation: Growing Up Boulder is an initiative to create more equitable and sustainable communities in which young people participate and influence issues that affect them. It is a partnership between local schools, universities, local government, businesses and local non-profit organizations in the USA that has enabled young people to formally participate in visioning processes such as community assessments, mapping, photo documentation and presentations to city representatives 83 .

Engaging schools for interventions: universal school-based interventions for mental health promotion 84 ; linkage to mental health care for school-based programs 85 ; “Whole-school approaches” that engage students and families, communities, and other agencies to support mental health and improve academic outcomes 84 , 86 .

Digital platforms for youth mental health: Chile’s HealthyMind Initiative digital platform launched during the COVID-19 pandemic and provided a one-stop resource for information and digital mental health services. The platform included targeted evidence-based resources for children and adolescents 87 .

Interventions to test at scale: Stepping Stones and Creating Futures is a community-based intervention for intimate partner violence reduction and strengthening livelihoods in urban informal settlements in South Africa that reduced young men’s perpetration of intimate partner violence and increased women’s earning power 88 .

Shared international objectives: support Sustainable Development Goal 11 and New Urban Agenda targets and Sustainable Development Goals 1–6, 8, 10 and 16.

Project structure and launch

This study aimed to identify priorities for creating cities that promote and sustain adolescent and youth mental health. Central to achieving this aim was our goal of engaging a multidisciplinary, global, age-diverse group of stakeholders. As we began and throughout the study, we were cognizant of the risk of attrition, the importance of maintaining multidisciplinary participation throughout the study and the value of preserving the voices of young people. We used a priority-setting methodology explicitly aimed to be inclusive while simultaneously limiting study attrition. To ensure that we were inclusive of the voices of young people and our large and diverse sample, we limited our study to three surveys, which we determined a priori. Our approach was informed by standard methodologies for health research priority setting 32 .

The project was led by a collaborative team from the University of Washington Consortium for Global Mental Health, Urban@UW, the University of Melbourne and citiesRISE. We assembled three committees representing geographic, national, disciplinary, gender and age diversity to guide the work. First, a core team of P.Y.C., T.W., G.P., M.S. and T.C., generated an initial list of recommended members of the scientific advisory board on the basis of their research and practice activities related to adolescent mental health or the urban setting. We sought a multidisciplinary group representing relevant disciplines. The 18-member scientific advisory board, comprising global leaders in urban design and architecture, social entrepreneurship, education, mental health and adolescent development, provided scientific guidance. We invited members of an executive committee, who represented funding agencies as well as academic and non-governmental organizational leadership, to provide a second level of feedback. A youth advisory board, recruited through citiesRISE youth leaders and other global mental health youth networks, comprised global youth leaders in mental health advocacy. A research team from the University of Washington (Urban@UW, the University of Washington Population Health Initiative and the University of Washington Consortium for Global Mental Health) provided study coordination. The study received institutional review board approval at the University of Washington (STUDY00008502). Invitations to advisory groups were sent in December 2019, along with a concept note describing the aims of the project, and committee memberships were confirmed in January 2020. In February 2020, the committees formulated the question for survey 1: “What are the characteristics of a mental health friendly city for young people?”.

Study recruitment

The members of the scientific advisory board, youth advisory board and executive committee were invited to nominate individuals with expertise across domains relevant to urban life and adolescent well-being. The group recommended 763 individuals to join the priority-setting panel; individuals invited to serve on the scientific advisory board, youth advisory board and executive committee were included in panel invitations ( n  = 38). Our goal was to establish a geographically diverse panel of participants with scientific, policy and practice-based expertise corresponding to major urban sectors and related challenges (for example, health, education, urban planning and design, youth and criminal justice, housing and homelessness, and violence). Many of the nominees were experts with whom the core group and scientific advisory board members had collaborated, as well as individuals recruited on the basis of their participation in professional and scientific associations and committees (for example, Lancet Commissions and Series) or global practice networks (for example, Teach for All). Nominees’ names, the advisory member who nominated them, gender, country and discipline were tracked by T.C. We used snowball sampling to recruit participants from geographic regions that were under-represented: an additional 24 people were recruited through referrals. The scientific advisory board and youth advisory board sought to maximize the number of young people participating in the study, and invitations were extended to adolescents and young adults through educational, professional, advocacy and advisory networks. Nominees received an invitation letter by e-mail, accompanied by a concept note that introduced the study, defined key constructs, described the roles of the study advisory groups and provided an estimated study timeline. Youth participants (14–24) received a more abbreviated introductory letter. A link to a REDCap survey with an informed consent form and round 1 question was embedded in the invitation e-mail, which was offered in English and Spanish. Of the 824 individuals invited, 518 individuals from 53 countries provided informed consent and agreed to participate, resulting in a nomination acceptance rate of 62.8%.

Data collection

We administered a series of three sequential surveys using REDCap version 9.8.2. Panellists were asked to respond to the survey 1 question “What are the characteristics of a mental health friendly city for young people?” by providing up to five characteristics and were invited to use as much space as needed. In survey 2, panellists received 134 characteristic statements derived from survey 1 data and were asked to select their 40 most important statements. From these data, we selected 40 most frequently ranked statements. These were presented in the round 3 survey with three redundant statements removed. The remaining 37 characteristic statements were categorized across 6 socioecological domains and panellists were asked to select 1 of 3 framings by which to rank the statements in each domain: immediacy of impact on youth mental health in cities, ability to help youth thrive in cities, and ease or feasibility of implementation. Of individuals who consented to participate, 93.4% completed round 1, 58.5% completed round 2 and 56.2% completed round 3 (Table 1 ).

We added a new open-ended question to survey 2: “How has the COVID-19 pandemic changed your ideas about the wellbeing of young people in cities?”. Panellists were invited to respond using as many characters (that is, as much space) as needed.

Data analysis

Three-survey series.

We managed the survey 1 data using ATLAS.ti 8 software for qualitative data analysis and conducted a conventional content analysis of survey 1 data 89 . Given the multidisciplinarity of the topic and our multidisciplinary group of respondents, we selected an inductive method of analysis to reflect, as simply as possible, the priorities reported by the study sample without imposing disciplinary frameworks. In brief, responses were read multiple times, and characteristics were highlighted in the text. A list of characteristics (words and phrases) was constructed, and we coded the data according to emerging categories (for example, accessibility, basic amenities, career, built environment, mental health services and so on). The analysis yielded 19 broad categories with 423 characteristics. Within each category, characteristics were grouped into statements that preserved meaning while streamlining the list, which yielded 134 characteristic statements. The University of Washington research team convened a 1-week series of data discussions with youth advisers to review the wording of the characteristics and ensure their comprehensibility among readers from different countries. The survey 1 categorized data were reviewed by members of the scientific advisory board, who recommended that using relevant domains to group characteristics would provide meaningful context to the final list. We used IBM SPSS 28.0 for quantitative analyses of data from surveys 2 and 3. In survey 2, we analysed the frequency of endorsement of the 40 characteristics selected by panellists and generated a ranked list of all responses, with the most frequently endorsed at the top. The decision to select 40 characteristics aligned with methods applied in a previous priority-setting exercise 90 and permitted a list of preferred characteristics that could subsequently be categorized according to a known framework, allowing city stakeholders a broad list from which to select actions. We also analysed frequency of endorsement by age categories (18–24, 25–35 and >35). To amplify the viewpoints of younger participants (under age 35), we combined the top 25 characteristic statements of panellists over 35 with the top 26 characteristic statements of participants under 35 to generate a list of 40 statements, including 11 shared ranked characteristics. As noted, we removed three of these statements because of their redundancy. In survey 3, we analysed data consisting of 37 characteristic statements divided across 6 socioecological domains. Characteristics in each domain were ranked according to one of three framings. We calculated mean ranking and standard deviation for characteristics in each framing category per socioecological domain. Mean rankings (with standard deviation) were calculated across framing categories to arrive at the total mean rank per characteristic and they reflect the proportional contribution of each domain. We also calculated the frequency with which panellists ranked each characteristic statement number 1.

Our study methods align with good practices for health research priority setting as follows 32 .

Context: we defined a clear focus of the study.

Use of a comprehensive approach: we outlined methods, time frame and intentions for the results before beginning the study; however, we modified (that is, simplified) the methods for survey 3 to minimize study attrition.

Inclusiveness: we prioritized recruiting for broad representation and maintaining engagement of an inclusive participant group, and methodological decisions were made in service of this priority.

Information gathering: our reviews of the literature showed that a study bringing together these key stakeholders had not been conducted, despite the need.

Planning for implementation: we recognized from the outset that additional convening at regional levels would be required to implement action, and our network members are able to move the agenda forwards.

Criteria: we determined criteria for the priorities (framing: feasibility of implementation, immediacy of impact and ability to help youth thrive) that study participants used and which we believe will be useful for practical implementation.

Methods for deciding on priorities: we determined that rank order would be used to determine priorities.

Evaluation: not applicable; we have not planned an evaluation of the impact of priority setting in this phase of work.

Transparency: the manuscript preparation, review and revisions enable us to present findings with transparency.

COVID-19 qualitative data

We managed the COVID-19 qualitative data using Microsoft Excel and Microsoft Word. We carried out a rapid qualitative analysis 91 . First, the text responses were read and re-read multiple times. We coded the data for content related to expressions of change, no change or areas of emphasis in participants’ perceptions of youth mental health in cities during the pandemic. We focused our attention on data that highlighted changes. We further segmented the data by participant age categories, domains of change and suggested actions, and we assigned socioecological level of changes. We created a matrix using excerpted or highlighted text categorized according to these categories. Three data analysts (P.Y.C., T.C. and A.M.-K.) reviewed the domains of change and identified emerging themes, which were added to the matrix and linked to quotes. The team discussed the themes and came to consensus on assignment to a socioecological level. We prioritized reporting recurring concepts (for example, themes of loss, inequity, green space, isolation and mental illnesses) and contrasting concepts (for example, gains associated with COVID-19) and associated actions 92 .

Reporting summary

Further information on research design is available in the  Nature Portfolio Reporting Summary linked to this article.

Data availability

Survey data that support the findings of this study are available from the corresponding author, P.Y.C., on reasonable request. The sharing of data must comply with institutional policies that require a formal agreement (between the corresponding author and the requester) for sharing and release of data under limits permissible by the institutional review board.

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Acknowledgements

We thank M. Antia, S. Talam and J. Vollendroft for contributions to this project; H. Jack for contributions to the manuscript revision; and the survey panellists without whom this work would not have been possible. M.K. was supported in part by funding from the Fogarty International Center (K43 TW010716) and the National Institute of Mental Health (R21 MH124149) of the National Institutes of Health. This study was supported in part by funding to citiesRISE (M.M. and M.H.) from the Rural India Supporting Trust and from Pivotal Ventures. This study was conducted while P.Y.C. was on the faculty at the University of Washington, Seattle. The University of Washington (P.Y.C. and T.C.) received funding from citiesRISE by subcontract. T.D. is a staff member of the World Health Organization (WHO). The content and views expressed in this manuscript are solely the responsibility of the authors and do not necessarily represent the official views, decisions or policies of the institutions with which they are affiliated, including WHO, the US Department of Health and Human Services and the National Institutes of Health.

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Pamela Y. Collins, Augustina Mensa-Kwao & Emily Queen

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This study was led by a core group, P.Y.C., G.P., M.S. and T.W., who were members of the project’s scientific advisory board and executive committee and part of the group of 32 co-authors (P.Y.C., M.S., T.C., G.P., T.W., L.M., A.M.-K., L.A., N.B., I.B., Y.C., T.D., E.d.L., N.F., H.H., S.K., M.K., B.L., O.O., J.M.U.-R., C.B., K.D., M.H., D.J., M.M., E.Q., Y.O., L.Z., N.A., P.M., J.U. and M.W.). P.Y.C. and T.C. regularly updated the core group members by e-mail, and P.Y.C. led online meetings with updates on study progress and data collection and study outcomes with members of the scientific advisory board (N.B., I.B., Y.C., T.D., E.d.L., N.F., H.H., S.K., M.K., B.L., O.O., J.M.U.-R. and K.D.), youth advisory board (K.D., C.B., D.J., Y.O., E.Q. and L.Z.) and executive committee (N.A., J.U. and M.W.). P.Y.C. (the core group lead) and members of the scientific advisory board and executive committee were involved with conceptualization, study design and methodology. Youth advisers assisted with qualitative data analysis. P.Y.C., T.C. and A.M.-K. were also responsible for data curation and formal analysis; P.Y.C. and T.C. wrote the original draft, with contribution from G.P., M.S., T.W., H.H. and L.M. P.Y.C., T.C., A.M.-K., M.M., H.H. and E.d.L. reviewed and organized responses to reviewers. All co-authors reviewed responses to the reviewers. P.Y.C. led the manuscript revision with A.M.-K., M.M. and T.C. All co-authors had the opportunity to discuss the results, review full drafts of the manuscript and provide comments on the manuscript at all stages.

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Correspondence to Pamela Y. Collins .

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Extended data figures and tables

Extended data fig. 1 distribution of participants by nationality (n = 518) a,b,c ..

a Countries Participating: Argentina, Australia, Bangladesh, Cameroon, Canada, China, Colombia, Croatia, Czech Republic, Ecuador, Egypt, Ethiopia, France, Germany, Ghana, Haiti, Hong Kong, India, Iran, Italy, Kenya, Malawi, Mauritius, Mexico, Nepal, Netherlands, New Zealand, Nigeria, Norway, Pakistan, Papua New Guinea, Peru, Philippines, Poland, Rwanda, Samoa, Sierra Leone, Slovenia, South Africa, South Korea, Sweden, Switzerland, Taiwan, Tanzania, The Gambia, Tunisia, Turkey, Uganda, UK, USA, Venezuela, Zambia, Zimbabwe (53 total); b Two responses (“Asian” and “Indigenous and European”) do not list a nation but capture verbatim open-text responses; c Countries with one participant removed from graph and include: Argentina, Bangladesh, Cameroon, Croatia, Czech Republic, Ecuador, Egypt, Ethiopia, France, Haiti, Hong Kong, Indigenous and European, Mauritius, New Zealand, Norway, Papua New Guinea, Samoa, Slovenia, South Africa, South Korea, Switzerland, Taiwan, Tanzania, The Gambia, Tunisia, Turkey, Uganda, Venezuela.

Extended Data Fig. 2 Participant Nationality by Survey Round.

a SEA = South-East Asia, NA = North America*, AF = Africa, LSA = Latin & South America*, EU = Europe, WP = Western Pacific, EM = Eastern Mediterranean.

Extended Data Fig. 3 Distribution of Participants by WHO Region * and Survey Round.

a SEA = South-East Asia, NA = North America*, AF = Africa, LSA = Latin & South America*, EU = Europe, WP = Western Pacific, EM = Eastern Mediterranean; *We separated North America from Latin & South America for more transparent display of participant distribution.

Supplementary information

Supplementary information.

Supplementary Note which describes citiesRISE and lists the project team members of Making cities mental health-friendly for adolescents and young adults.

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Collins, P.Y., Sinha, M., Concepcion, T. et al. Making cities mental health friendly for adolescents and young adults. Nature (2024). https://doi.org/10.1038/s41586-023-07005-4

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Received : 15 June 2022

Accepted : 15 December 2023

Published : 21 February 2024

DOI : https://doi.org/10.1038/s41586-023-07005-4

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