Psychological Impacts of COVID-19 among College Students in Dessie Town, Amhara Region, Ethiopia; Cross-sectional Study

s Background: The COVID-19 pandemic is a catastrophic health crisis that affects several nations across the world. Hence, such widespread outbreaks are associated with adverse mental health consequences. However, there is scarce information regarding the psychological impacts of COVID 19 on college students in Ethiopia. Thus, this study investigated the psychological impact of COVID-19 upon students. Methods: A cross-sectional study was conducted among 422 college students who were learning at randomly selected public and private colleges and universities in Dessie town. The sample was proportionally allocated into the four randomly selected colleges and the students were recruited using a systematic random sampling technique with every 6 th interval that was obtained from each college’s registrar office. The data analysis was done using SPSS version 23.0. Variables with p-value < 0.25 in the bivariate analysis were entered into the multivariable logistic regression model. Model fitness was checked using the Hosmer-Lemeshow model fit-ness-test. Statistical significant level was declared at a p-value < 0.05. Results: This study involved 408 students with a response rate of 96.6%. In this study, the overall psychological impact of COVID-19 among college students was 16.2% [95% CI: 12.7%, 19.9%]. Moreover, 77.2% of the students had experienced depression disorder. Similarly, 71.8% and 48.5% of students had experienced anxiety and stress disorders respectively. The multivariable logistic regression showed that being female [AOR=1.68, 95% CI 1.09, 2.91], having inadequate practice of prevention measures [AOR=1.74 : 95% CI 1.01, 3.02] and living urban residency [AOR=0.76: 95% CI 0.48, 0.94] were the independent predictors of psychological problems among students. Conclusions: The study revealed the level of anxiety, stress, and depression disorders are optimally high among students. Therefore, local governments should develop effective psychological interventions for students. Moreover, it is important to consider the educational enrollment types and academic years of the students during the interventions.


Introduction
Severe acute respiratory infection (SARS) is a group of respiratory tract infections caused by a beta coronavirus (SARS-COV2) [1][2][3]. Corona Virus Disease-2019 ("COVID-19") is a family of SARS caused by Novel Coronavirus and was first detected in December 2019 in Wuhan, China.
Since it has been declared a global pandemic by the World Health Organization (WHO), it has made the rapid spread across the world and causes high mortality and morbidity [2][3][4][5]. Globally, there is an estimated number of 7 million cases and nearly half a million deaths [6][7][8]. Following this pandemic, nations across the globe have taken different preventive measures. These include movement restriction, confinement to home and closure of the school, and other social services that lead to increased psychosocial stress among the community, especially students [9][10][11][12][13][14][15][16][17].
A study conducted in china revealed that 53.8% of respondents had experienced moderate to severe psychological crises, in which students were found to contribute a greater number than the larger communities [18]. Another study in China revealed that around 25% of college students experienced anxiety due to the pandemic [19]. A study conducted in Singapore revealed that 14.5%, 8.9%, and 7.7% of participants screened positive for anxiety, depression and stress respectively [20]. Pieces of evidence had suggested that the pandemic resulted in loneliness, anxiety, depression, insomnia, suicide. societal rejection, discrimination, and stigmatization among people [21,22]. Ethiopia has taken different prevention and control measures to halt the spread of COVID-19.
These include school closure, stay at home, keep social and physical distances, putting hand washing basin in places where people use in common (banks, Churches/mosques, markets), preparation of isolation centers, and establishment of state emergency at the national level [23][24][25].
However, still, there is no specific intervention to address the psychological impact of COVID 19 in the country.
Moreover, the studies conducted across the globe have been investigated the psychological impacts of COVID-19 pandemic predominantly focused on health care workers and patients [26][27][28].
Therefore, this study was intended to generate evidence regarding the prevalence of psychological problems due to COVID-19 and its determinants among college students.

Study Setting and Participants
The community-based cross-sectional study design was conducted from April 15-May 15, 2020 to assess the psychological impacts of COVID-19 on students who were learning in the four randomly selected private and public colleges and Universities, Namely; Dream Science and Technology College, Dandi Boru College, Unity University, and Dessie Health Science College.
These higher institutions are found in South Wollo Zone, Dessie city administration. Dessie city administration is located 401Km away from the capital city of Ethiopia, Addis Ababa. The city has eight private colleges, one private University, and three public colleges which accommodate a total of 20,907 students in different fields of study.
All active students, registered for second-semester academic year, and those 16 and above years of age were included in this study. However, students who were seriously ill during the data collection period were not included in this study.
The sample size was calculated for both determinants and prevalence of psychological problems due to COVID 19 and the maximum sample size was considered for this study. Thus, the final sample size was determined using a single population proportion formula with assumptions: 5% type I error, 95% Confidence Intervals, 50% proportion since no study in Ethiopia on this problem. Finally, the researchers added 10% to compensate for the non-response of participants and the final sample size became From a total of twelve colleges and universities found in Dessie city administration, four higher institutions (three colleges and one university) were randomly selected. The calculated sample size was proportionally allocated in each college based on the second-semester academic student number reports. To calculate the required number of participants from each college, we multiplied the total number of students actively learning in each college by the sampling fraction (n/N). The sampling fraction is approximately equal to six for all colleges. Accordingly, every 6th participants were selected using a systematic random sampling technique from each college registrar office log-book.

Study variables:
Dependent variable: the psychological impact of COVID 19 (Yes/No) that was assessed using all of Depression, Anxiety, and Stress Scales (DASS-21).
Independent variables: sociodemographic characteristics (age, residence, sex, marital status, educational level, the field of study, income, family size, religion), knowledge, attitude and practice towards the preventive measures of COVID-19.

Data Collection Tools and Procedures
The questionnaire was adopted from studies conducted before this study [19,[29][30][31] and modified into context. The questionnaire was developed in the English language and it consists of sociodemographic characteristics, 20-items for knowledge, eight items for attitude, and 12-items for the practice of preventive measures against COVID-19. The psychological impact was assessed by using mental health status assessment tool, DASS-21 (i.e. the Depression, Anxiety, and Stress Scales) [29]. The tools were translated into the local language (Amharic) and back to English to keep its consistency. The tool was pretested on 5% (21 participants) of samples other than selected colleges those found in Woldia town and some amendments were made based on the pretest findings. The data was collected using both phone-call and personal interviews. Phone-call was used for students who are out of Dessie town. The study participants were approached by trained health professionals who were working out of the selected colleges.

Data management and analysis
The data were cleaned, coded, and entered into Epi data version 3.1 software and exported to SPSS version 23.0 for analysis. The descriptive statistics was done and the results were presented using texts, frequency tables, figures, and median with Interquartile range (IQR).
Bivariate logistic regression analysis was done to assess the association between the dependent variable with each independent variable. The socio-demographic factors, knowledge, attitude, and practice of preventive measures against COVID-19 were the factors included in the bivariate logistic regression analysis. Thus, independent variables with a p-value of less than 0.25 were considered in the final model. Correlation between independent variables was assessed but we did not find any correlation between independent variables. The model fitness was also checked using the Hosmer-Lemeshow model fit-ness test. Finally, multivariable logistic regression analysis was done to control potential confounders and to identify the factors associated with the psychological impact of COVID-19 among students. The statistical significance level was declared at a P-value <0.05.

Operational Definitions
Psychological problem: students who were experienced all of Depression, Anxiety, and Stress Scale (DASS-21) [29] were considered as students affected by the psychological impacts of COVID-19.
Knowledge level: students who were correctly answered 70% or more (14/20) of the knowledge questions were considered as students with a good knowledge level while students who answered correctly below 70% of the knowledge questions were considered as having poor knowledge.
Attitude level: students who were correctly answered 70% or more (5.6/8) of the attitude questions were considered as students with a positive attitude while students who correctly answered below 70% of the attitude questions were considered as students with a negative attitude.
Practice level: students who were correctly answered 70% or more (8.5/12) of the practice questions were considered as students with a good practice e level while students who correctly answered below 70% of the practice questions were considered as students with a poor practice.

Sociodemographic characteristics of Participants
In this study, 422 participants were involved with a response rate of 96.6%. The median age of the participants was 21 years with three Interquartile Range (IQR). Of the total students; 155 (38.0%) were lived in the rural residence, 194 (47.5%) were females, 215 (52.7%) were learning TVET or diploma level training, and 340 (83.3%) were living with their families during the COVID-19 lockdown. In this study, the participants had a median of 5 total family size with 3 IQR ( Table 1).

COVID-19 and its Psychological Impact on Students
In this study, the overall psychological effect of COVID-19 among college students was 16.2% (95% CI: 12.7%, 19.9%) which was measured using the students' experience of all anxiety, depression, and stress disorders. Moreover, 315 (77.2%) of the students had reported that they are experienced depression disorder. Similarly, 293 (71.8%) and 198 (48.5%) of students had experienced anxiety and stress disorders respectively (Fig. 1).

Figure 1:
Types of psychological problems students experienced during the lockdown of COVID-19, June 2020, Ethiopia.

Determinants of Psychological Problems among Students during COVID-19
The selection of variables to be entered into a multivariable logistic regression model was based

Discussion
In this study, the overall psychological effect of COVID-19 among college students was low that was measured using the experience of all of anxiety, depression, and stress disorders. The multivariable logistic regression model showed that residence, poor practice, and sex of the participants were the independent predictors of the psychological impact of COVID 19 among students.
In this study, the overall psychological impact of COVID-19 among college students was 16.2%.
This finding is lower than studies conducted in northern Ethiopia (85.3%) [27], University of Dhaka (43.4%) [32], Jilin Province, China (40.4%) [33], 194 cities in China (53.8%) [34]. The outbreak of COVID-19 has shown many psychological problems [35] that need provision of improved psychological interventions at national, regional, and district levels. The discrepancy might be due to differences in the measurement of the psychological problems. In the current study, psychological problem among students was measured using the co-existence of all of anxiety, stress and depression. However, the psychological problem in the previous study was measured using either stress or anxiety or depression.
In our study, more than three-fourth (77.2%) of the students had experienced depression disorder.
This finding is higher than studies conducted in Hubei Province, China (37.1%) [36], and 194 cities in China (16.5%) [34]. Furthermore, our study showed that nearly three-fourth (71.8%) of students had experienced anxiety disorders during the lockdown. This finding is higher than a study conducted in China that found only one-fourth (25%) of college students presented anxiety disorder [19]. This finding is also higher than studies conducted in Hubei Province, China (29%) [36], and 194 cities in China (28.8%) [34]. Moreover, in this study, nearly fifty percent (48.5%) of students had experienced stress disorders during the lockdown. This finding is higher than studies conducted in Samara University, Northeast Ethiopia (53.2%) [37] and 194 cities in China (8.1%) [34]. In Ethiopia, the widespread outbreak of COVID 19 is directly associated with these adverse mental health consequences among students who are out of school.
In this study, the odds of psychological impact of COVID among female students was twice higher compared to male students. This finding is similar to studies conducted in Hubei Province, China [36], and Jilin Province, China [33]. In Ethiopia, female students prone to gender-based violence, poor social and economic support [37,38]. Consequently, these conditions can easily lead them into loose of self-confidence and many stressors in life. Hence, they are victims of stress disorders compared to their counterparts, male students.
This study revealed that students who were living in urban residency had 24% less likely to experience psychological problems compared to students currently living in rural areas. This finding is similar to a study conducted in China [19]. Moreover, students with poor preventive practice had experienced twice greater odds of psychological impacts of COVID 19 compared to students having adequate practices. Many studies revealed that students out of school and in the final stage of graduation are more prone to many psychological crises [17,33] which is due to poor adherence to the preventive measure of COVID 19 pandemic.
Limitation of the study: the study was done using a phone call interviews which may be prone to social desirability bias. Besides, the study was not involved adolescents in high schools and precollege schools. Thus, it may not represent all of the adolescents in Dessie town. Moreover, the study also share the limitations of a cross-sectional study design.

Conclusions
In this study, the overall psychological impact of COVID 19 among students was low. The multivariable logistic regression analysis showed residence, sex, and level of preventive practice were the independent predictors of psychological problems among students.
However, the level of anxiety, stress, and depression disorders are optimally high among students.
Therefore, the Ministry of Sciences and Higher Education [MOSHE] and local governments should develop effective strategies and interventions to address students with psychological problems. Moreover, it is important to consider the educational enrollment types and academic years of the students during the interventions.