Abstract
The COVID-19 pandemic has disrupted the lives of all including university students. With the preventive measures to reduce the transmission of COVID-19, all face-to-face teaching and learning are converted to e-learning. The COVID-19 pandemic and the implementation of e-learning may influence these students’ mental conditions. This study aimed to determine the association of factors with mental health status (depression, anxiety and stress) among university students in Malaysia. Study participants were tertiary education students from both the private and public universities in Malaysia. Participants were recruited via university emails and social media. The survey was administered via the online REDCap platform, from April to June 2020, during the movement control order period in the country. The questionnaire captured data on socio-demographic characteristics, academic information, implementation of e-learning, perception towards e-learning and COVID-19; as well as DASS 21 to screen for depression, anxiety and stress. The levels of stress, anxiety and depression were 56.5% (95% CI: 50.7%, 62.1%), 51.3% (95% CI: 45.6%, 57.0%) and 29.4% (95% CI: 24.3%, 34.8%) respectively. Most participants had good perception towards e-learning but negative perception on COVID-19. From the multivariate analysis, participants with positive perception on COVID-19 were protective towards stress (aOR: 0.96; 95% CI: 0.92, 0.99), anxiety (aOR: 0.94, 95% CI: 0.90, 0.98) and depression (aOR: 0.95; 95% CI: 0.91, 0.99). Older students were 14% (aOR: 0.86, 95% CI: 0.79, 0.94) and 11% (aOR: 0.89: 95% CI: 0.80, 0.99) less likely for anxiety and depression, respectively. Students originated from the Malay ethnicity had higher odds (aOR: 1.93; 95% CI: 1.05, 3.56) for depression. These findings demonstrated that the mental status of university students was greatly affected during the COVID-19 pandemic. Timely and credible information should be disseminated to alleviate their negative perception towards COVID-19.
Introduction
The novel coronavirus disease 2019 (COVID-19) has swept across the world, causing a global pandemic. Countries all over the world, including Malaysia, are greatly affected. There is no doubt that the COVID-19 pandemic has affected the public’s mental health status globally, with an increase in the individuals’ depression, anxiety and stress levels.1–6 In Malaysia, the adults were also affected with a high percentage of anxiety and depression, but not in terms of stress. 7 To control the transmission of COVID-19 among the community, the Malaysian government enforced movement control nationwide from 18 March to 9 June 2020. 8 Mass movements and gatherings across the country including religious, sports, social and cultural activities were prohibited. All kindergartens, government and private schools, as well as all public and private higher education institutions and skills training institutes nationwide, were also closed during that period. In addition, most tertiary education institutions converted all face-to-face learning and teaching activities to e-learning for the semester. The rationale was to reduce transmission of COVID-19 even though the movement control was lifted. In the current situation, the online mode of teaching and learning has become a viable academic alternative to conventional teaching techniques.
E-learning is not new and many universities around the world implementede-learning even before the COVID-19 pandemic. Fast wireless Internet access enabled e-learning to be conducted on mobile devices such as laptops, smartphones, tablets, making e-learning implementable just about anywhere with a good Internet connection. Almost all learning can be conducted through e-learning except for hands-on teaching involving mechanical manipulation, chemical and biological specimens. Even clinical teaching can be conducted through e-learning to a certain extent although clinical examination and treatment might be challenging to perform via e-learning.
Most university students are familiar with face-to-face teaching as this is the conventional teaching method implemented since primary and secondary education. When they enter the universities, they may experience multifaceted pressures such as academic workload, economic difficulties and interpersonal relationships. These stressful experiences may put them at high risk of mental health problems such as stress, anxiety and depression. The rapid spread of COVID-19 and measures imposed to slow down the transmission and relieve the public health systems may further affect their mental health status. During the COVID-19 pandemic, university students were reported to experience higher levels of stress and anxiety.9,10 with concerns related to academic, health and lifestyle issues. 11 However, there are limited studies examining the impact of COVID-19 epidemic and the implementation of e-learning on the psychological health of university students. Little is known if e-learning contributes to psychological distress among university students. There is also a scarcity of such studies in Malaysia. To date, only 1 published study reported the levels of anxiety among university students during the COVID-19 pandemic. Remote online learning was reported as one of the stressors for anxiety among these students. 12 Therefore, we aimed to study the university students’ perception towards e-learning and COVID-19 on mental health status during the movement control period in Malaysia.
Methods
Participants
Study participants were tertiary education students from both the private and public universities in Malaysia. Participants were recruited via university emails and social media. Inclusion criteria were all undergraduates and postgraduates studying in the private or public universities in Malaysia. Participation was voluntary and all data were kept confidential. Ethics clearance was obtained from the University of Malaya Ethics Committee (Reference number: UM.TNC2/UMREC – 952).
Data collection
The study was conducted from April to June 2020, during the movement control order period. Study data were collected and managed using REDCap electronic data capture tools hosted at our university (University of Malaya). REDCap (Research Electronic Data Capture)13,14 is a secure, web-based software platform designed to support data capture for research studies, providing a) an intuitive interface for validated data capture; b) audit trails for tracking data manipulation and export procedures; c) automated export procedures for seamless data downloads to common statistical packages; and d) procedures for data integration and interoperability with external sources.
The questionnaire was constructed in the English language. It captured data on socio-demographic characteristics (age = scaled, sex = female versus male, marital status = married versus single, current residence = university hostel, own/rented accommodation, hometown, or home country), academic information (field and levels of study = medicine, allied health, engineering, science, or others (Law, social sciences, arts), on scholarship = yes versus no, implementation of e-learning including mode and frequency ), internet connectivity = good, moderate, or poor, perception towards e-learning as well as COVID-19; and DASS 21. Questions on perceptions towards e-learning were adapted from Keller and Cernerud 15 while the perceptions on COVID-19 were adapted from the study by Wong et al. 16 The minimum and maximum scores for perception towards e-learning were 5–40 while for the perception on COVID-19 were 12–60. The Depression, Anxiety and Stress Scale-21 Items (DASS-21) is a set of three self-reported scales designed to measure the emotional states of depression, anxiety and stress. The total scores for each scale were cut-off using the recommended scores for levels as normal, moderate, severe and extremely severe. 17 In the multivariate logistic regression, the levels were merged as binary outcomes with categories of normal and abnormal (moderate, severe and extremely severe) categories.
Data analysis
Mean with standard deviation (SD) or median with inter-quartile range (IQR) was used to represent the normally distributed or skewed data respectively. Frequency with percentage was used to present categorical variables. Prior to inferential statistical analysis, some variables were transformed. These variables including race (Malay, Chinese, Indian, Others), residency (away from home, home/home country) and faculty (Allied Health Sciences, Others). Under univariate analyses, parametric tests (t-test, ANOVA, Pearson correlation) and nonparametric tests (Mann-Whitney, Kruskal-Wallis, Spearman ranked correlation) were used to investigate factors associated with the scaled outcome variables. A Chi-square test was applied to determine the potential factors associated with the binary outcome variables. Multivariable logistic regression analysis was carried out. All variables with p values < 0.25 were included in the models. 18 A significant level was preset at p < 0.05. All statistical analyses were conducted using SPSS version 23 software.
Results
Sociodemographic characteristics
A total of 367 students participated, but some participants did not complete the survey. The majority of the participants were Malaysians, with only 7.7% international students (Table 1). Malays and Chinese ethnicities made up more than 70% of the participants. Approximately 80% of them were females and single. The median age of participants was 23 years old. More than half of them resided in their hometowns during this movement control order (MCO) period, and about 30% of them stayed either on campus or nearby their tertiary institutes. Approximately half of the participants reported having a good internet connection.
Sociodemographic characteristics of students in tertiary institute.
IQR: Interquartile range.
Academic profiles
Table 2 shows that two-thirds of the participants were from public universities. Only one-third of them had study scholarships and about half of them were from the faculty of Medicine, followed by Allied Health-related fields (18.3%). A total of 36% of the participants were postgraduate students and most of them were full-time students.
Students’ academic profile.
Before the COVID-19 outbreak, 45% of the participants’ universities utilized e-learning as part of their teaching methods. Zoom, Microsoft Teams and Skype (Application) platforms were the preferred choices (38.2%) compared to other methods. During the MCO period, the usage of e-learning doubled to approximately 94%. During this period, the application platform (Zoom, Microsoft Teams and Skype) remained popular (53.3%). Besides, the frequency of e-learning also doubled during the MCO period.
Students’ perception on e-learning
About 80% of the participants agreed that their academic study was affected by the COVID-19 outbreak and e-learning may not be as effective as face-to-face teaching (Table 3). More than half of them agreed that e-learning was affected by internet connection at where they stayed. Only one-third felt that e-learning was easy to understand and use. Almost half of them felt that e-learning had facilitated their studies during this COVID-19 outbreak and allowed communication with lecturers and other students. About two-thirds agreed that e-learning was flexible in time and place. The overall median (IQR) score was 30.0 (7.0).
Perception on E-learning during Covid-19 outbreak.
Students’ perception on COVID-19
More than 80% of participants felt that COVID-19 would spread quickly, persist in the community and their family and friends would be affected (Table 4). About half and 65% of participants felt it was difficult to prevent or control COVID-19 respectively. Although more than 70% felt that COVID-19 restricted social meetings with their friends, as well as shopping, sporting and religious activities, only 42.3% worried about poor relationships between family members, course mates, friends and themselves induced by COVID-19. Less than half felt uneasy with the news on COVID-19 from social media, while less than 20% felt they were not getting adequate and timely information regarding COVID-19. Only 20.7% were affected financially by the COVID-19 outbreak. The overall median (IQR) score was 23 (6).
Perception on COVID-19.
Stress, anxiety and depression and the associated factors
Proportions of students with abnormal scores for stress, anxiety and depression were 56.5% (95% CI: 50.7%, 62.1%), 51.3% (95% CI: 45.6%, 57.0%) and 29.4% (95% CI: 24.3%, 34.8%) respectively (Table 5). Univariately, having a scholarship and a higher mean score on perception for COVID-19 were significantly associated with a lower proportion of stress. Younger age, being single, studying in a private university and having a lower mean score in COVID-19 perception were associated with anxiety while younger age, being single and an undergraduate, having negative perception on COVID-19 and e-learning were associated with depression (Table 6).
Scores of students’ perceptions on COVID-19 and E-learning and their mental health status during the COVID-19 pandemic.
Risk factors associated with stress, anxiety and depression among students in tertiary institute during COVID-19 pandemic.
A total of 57 participants did not answer the DASS instrument were removed from the inferential analyses.
All variables with p Values < 0.25 were included in multivariate analyses.
The authors identified no multicollinearity issues on all variables included in all multivariate models (variance inflation factor < 5.0). However, in the multivariate analyses where variables with p < 0.25 were entered in the models (Table 7), only the perception on COVID-19 was significantly associated with stress; while levels of study, perception on COVID-19 and age were associated with anxiety; Malay ethnicity, perception on COVID-19 and age were associated with depression. Students having positive perception on COVID-19 had 4% lower odds for stress (aOR: 0.96; 95% CI: 0.92, 0.99). Being a post-graduate student had a higher odds (aOR: 2.99; 95% CI: 1.27, 7.06) for anxiety while for every unit increase in the score of perception in COVID-19 and every one year increase in age reduced the odds of anxiety by 6% (aOR: 0.94, 95% CI: 0.90, 0.98) and 14% (aOR: 0.86, 95% CI: 0.79, 0.94) respectively. Originated from the Malay ethnicity had higher odds (aOR: 1.93; 95% CI: 1.05, 3.56) for depression, while for every unit increase in the score of perception in COVID-19 and every one-year increase in age reduced the odds of depression by 5% (aOR: 0.95; 95% CI: 0.91, 0.99) and 11% (aOR: 0.89: 95% CI: 0.80, 0.99) respectively.
Multivariate analysis on factors associated with stress, anxiety and depression.
aOR: adjusted odds ratio; CI: confidence interval; (R): reference group.
Discussion
The participants consisted of a good mix of public and private university students but predominated by females, which is commonly found in surveys. 19 E-learning was not frequently used as the mode of teaching and learning pre-COVID. However, the Ministry of Higher Education has strongly encouraged the universities to implement online teaching during the closure of universities. To reduce the transmission of COVID-19, all universities were instructed to continue with online teaching for an additional semester even when MCO was lifted. As most students had moderate to good internet connections, their perception towards e-learning was quite positive (median score of 30 out of total 40, approximately 75%).
Although e-learning offers a cost-effective, easily accessible and more flexible study environment, 20 this platform has some disadvantages. The current rapid shift from face-to-face to e-platform required a major modality to support internet connectivity. 21 Besides, unfamiliarity with information technology also impedes students from adapting well to the e-learning environment, resulting in high academic distress. 22 Consequently, prolonged high academic distress via e-learning may prevent students to revert to normal life even after the relaxation of the movement control order. 23 In addition, frustration from loss of daily routine and disruption of study during the COVID-19 pandemic may be other reasons that the levels of depression, anxiety and stress remained high even after the movement control order was lifted. 24 Therefore, online mindfulness and relaxation therapy can be offered to assist students in coping with their depression, anxiety and stress. 25
On the other hand, the participants had a negative perception towards COVID-19 probably because this is a new disease that is yet to have a cure with lots of precautionary measures (such as mask-wearing, hand hygiene and social distancing) being implemented. Social distancing has resulted in the closing of universities and movement control orders restricted mobility that these young adults used to enjoy. Low levels of social activities could bring psychological stress and negative affect on the life of these young adults.26,27 About half of the participants felt uneasy with the news on COVID-19 from social media. It is important to ensure exposure to accurate content of health information is in place. Social media are useful means of disseminating credible health messages and contribute to the betterment of psycho-behavioural responses to COVID-19. 28
The levels of depression, anxiety and stress among our participants were 29.4%, 51.3% and 56.5% respectively. The findings for depression and anxiety were comparable with those reported before the COVID-19 pandemic, however, the stress level was higher in our study which was conducted during the COVID-19 pandemic. The prevalence of depression, anxiety and stress reported before COVID-19 among the Malaysian undergraduate students ranged from 13.9% to 29.3%, 51.5% to 55.0% and 12.9% to 21.6% respectively.29–31 Another study among only medical undergraduates reported that the prevalence of depression, anxiety and stress, were 30.7%, 55.5% and 16.6%, respectively. 32 Studies from other countries also found significant proportions of university students to experience mental health problems during the COVID-19 pandemic.11,33–36 However, the proportions were not comparable as different tools were used in different studies.
In the multivariate analysis, perception on COVID-19 was significantly associated with depression, anxiety and stress respectively. Students having a positive perception on COVID-19 had lower odds for depression, anxiety and stress. Students who had good knowledge on COVID-19 may have better perception 36 and more confidence in handling their daily life during this pandemic. Therefore, credible and reliable information on COVID-19 should be provided to all. The credibility of information shared through mass and social media should be monitored and strategies to counter misinformation should be established. 28 Clear, consistent and constant communications will empower everyone to better manage stressors and maintain their mental health.
Being a post-graduate student had higher odds for anxiety. Post-graduate students working on research projects that require laboratory or mechanical work may not benefit from e-learning. Therefore, they might feel more anxious about not completing their research compared to undergraduate students. There should be plans to allow these post-graduate students to return to their laboratories to continue their research projects in batches.
On the other hand, older age students were less likely to experience anxiety and depression. Being older may be more mature in thinking and more confident or optimistic towards the epidemic. 36 However, contradicting results were reported by Shamsuddin et al. 31 which was conducted pre-COVID-19, where both depression and anxiety scores were significantly higher among older students. Students who originated from the Malay ethnicity were found to have higher odds for depression, similarly, as reported by Shamsuddin et al. 31 However, another local study conducted during the COVID-19 pandemic 12 found no association between ethnicity and mental status. More in-depth studies need to be carried out to further explore the relationship between ethnicities and mental status during the COVID-19 pandemic.
Remote online teaching was reported as one of the stressors during the COVID-19 pandemic. 12 The students may have felt stressed with uncertainties caused by the COVID-19 pandemic and the conversion of all face-to-face teaching and learning to e-learning made it worse. Online or e-learning might be new to many students and they might be worried if their courses could not be carried out or completed on time. However, we did not find perception towards e-learning to be associated with stress, anxiety, or depression. Reasons could be some universities had implemented e-learning before the COVID-19 pandemic. In addition, most of our participants had moderate to good internet connectivity, which may help to alleviate their anxiety. However, there were a small proportion of students having problems with internet connectivity. The university management should take the initiative of providing Wi-Fi data via post-paid cards or to bring these students back to the campus accommodation for them to access the campus Wi-Fi. Training in delivery of e-learning for academic staff should also be provided to ensure the smooth running of online teaching and learning.
Strength and limitations
There are a few limitations that need to be considered while interpreting the results. First, the causal relationship of risk factors with mental status (depression, anxiety and stress) cannot be established as the study is of a cross-sectional design. There may be selection bias as only university students who had access to an internet connection could participate in the study. The DASS-21 instrument used is a screening tool and may not be able to diagnose mental status accurately.
To the best of our knowledge, this may be the first study in the country and of few globally that assessed perception of e-learning and mental status among university students. The findings may be useful for the relevant stakeholders in planning better programs for university’s students.
Conclusions
The university’s students had substantially high levels of depression, anxiety and stress during the COVID-19 pandemic. Perception towards e-learning was not associated with their mental status. However, those with a positive perception towards COVID-19 and being older were associated with better mental health status while being postgraduates and of Malay ethnicity were associated with higher levels of anxiety and depression, respectively. More comprehensive intervention programs should be implemented to address these issues.
Supplemental Material
sj-pdf-1-sci-10.1177_00368504211029812 – Supplemental material for Perception towards E-learning and COVID-19 on the mental health status of university students in Malaysia
Supplemental material, sj-pdf-1-sci-10.1177_00368504211029812 for Perception towards E-learning and COVID-19 on the mental health status of university students in Malaysia by Foong Ming Moy and Yit Han Ng in Science Progress
Footnotes
Acknowledgements
The authors would like to thank the university students who participated in the survey. Dr Abqriyah Yahya’s assistance with setting up the online survey in REDCap is also acknowledged.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Author biographies
References
Supplementary Material
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