THE SUBJECTIVE WELL-BEING OF INTERNATIONAL STUDENTS DURING THE QUARANTINE PERIOD OF COVID-19

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THE SUBJECTIVE WELL-BEING OF INTERNATIONAL STUDENTS

DURING THE QUARANTINE PERIOD OF COVID-19

Agneta Musu Eklöf

Medicine, Faculty of Medicine, Department of Psychiatry

Lithuanian University of Health Sciences

Final Master Thesis

Kaunas, Lithuania, 2021

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1.SUMMARY

Author: Agneta Musu Eklöf.

Title: The subjective well-being of international students during the quarantine period of COVID-19. Aim: To evaluate the impact of quarantine on the international students of LUHS subjective well-being.

Objectives:

1. To evaluate sample characteristics (sociodemographic, statements regarding the Quarantine, Health Status, Lifestyle Habits, Academics) of international students of LUHS.

2. To measure symptoms of depression, stress and anxiety severity among international students of LUHS.

3. To measure psychological impact of the Coronavirus disease 2019 (COVID-19) outbreak and lockdown among international students of LUHS.

4. To measure correlations between DASS-21 and IES-R

5. To find relationships between international student’s sample characteristics and the psychological impact/consequences of COVID-19.

Study participants: The international students of LUHS.

Methodology: 102 international students participated in an online-survey that evaluated their

intrusion, avoidance and hyperarousal symptoms using the IES-R (Impact of Event Scale-Revised) and depression, stress and anxiety symptoms by using the DASS-21 (Depressive, Anxiety, Stress scale) instruments. The students also answered a set of questions about sociodemographic characteristics. Results: The average student reported mild depressive symptoms (mean [SD]=12,49 [12,36]), mild anxiety symptoms (mean [SD]=9,06 [11,15]) and normal stress symptoms (mean [SD]=12,25 [11,63]). 24,5% of students reported severe depressive symptoms. 26,5% of students had severe anxiety

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4 anxiety symptoms compared to those without family history (p<0,05). Higher depressive symptoms were reported in students who were aware of the infection control directives compared to those who were not aware (p<0.05). Lower stress and anxiety symptoms were reported by those who had readily available information regarding the pandemic compared to those without the information p<0.05). Higher depressive and anxiety symptoms were reported by those who experienced a drop in their academic grades compared to those without the experience (p<0,05). Higher levels of depression, stress and anxiety symptoms were reported by those who wished for taking an academic leave

compared to those who did not want to leave (p<0,05). Higher levels of depression, stress and anxiety was reported by students who wanted to drop out compared to those who did not want to leave LUHS (p<0,05). Majority of students reported lower levels of stress and did not have a family history of depression/anxiety (p<0,05), neither did they experience a drop in their grades (p<0,05). Most students had trouble sleeping but reported lower levels of depression, stress and anxiety (p<0,05).

Conclusion:

1. Majority of the international students of LUHS are single, live in an apartment and typically not alone, have poor Lithuanian language skills, good health, typically no family history of depression or anxiety, exercise regularly, consume alcohol, but tend not to be a smoker and have sleep disturbances during the quarantine. The students are aware of the reason for quarantine, know and follow the infection control directives established in Lithuania, receive proper information about the pandemic, have kept a social distancing and feel difficulties being away from family and friends during the quarantine. Most students do not experience academic failures, do not wish for an academic leave, and do not want to drop out LUHS due to the pandemic.

2. The average international student of LUHS has mild depressive and anxiety symptoms, but normal stress symptoms. Higher depressive and anxiety symptoms were reported by one fourth of the students. Higher stress symptoms were reported by one fifth of the students.

3. The average international student demonstrates ´a little bit’ of intrusive, avoidance, and hyperarousal behavior as a psychological response to the COVID-19 pandemic. Higher intrusive, avoidance, and hyperarousal symptoms was reported by a third of the international students of LUHS.

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5 5. Relationships between the student’s sample characteristics and severity levels of intrusion,

avoidance, hyperarousal, depression, stress, and anxiety symptoms tells of:

•_{Most students with a past diagnosis of depression or anxiety disorder reported higher} symptom severities of intrusion, avoidance, hyperarousal, depression, stress, and anxiety. The students with a family history of depression or anxiety reported higher levels of depression and anxiety symptoms

• Students who reported of being aware of the infection control directives had higher levels of depression and those who felt that information was readily available to them in English about the pandemic in Lithuania reported lower stress and anxiety symptom severities.

• Most students who experienced a decline in their academic grades reported higher depressive and anxiety symptom severities compared to those who did not have a negative impact to their grades. Most students who wished for taking an academic leave or wanted to drop out reported higher levels of depression, stress and anxiety

symptoms severity.

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2.ACKNOWLEDGMENTS

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3.CONFLICTS OF INTERESTS

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4.PERMISSION ISSUED BY THE ETHICS COMMUNITY

Title: The subjective well-being of international students during the quarantine period of COVID-19. Number: BEC-MF-171

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5.ABBREVIATIONS

LUHS – Lithuanian University of Health Sciences COVID-19 – Coronavirus disease 2019

WHO – World Health Organization

DASS-21 – Depression, Stress, and Anxiety Scale-21 IES-R – Impact of Event Scale-Revised

PTSD – Posttraumatic stress disorder SD – Standard Deviation

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6.INTRODUCTION

In the end of year 2019, media statements about an atypical pneumonia of unknown cause were circulating around in the city of Wuhan, People’s Republic of China. As time went into the year of 2020, the World Health Organization (WHO) made reports that Chinese authorities had determined the cause of the outbreak being due to a novel coronavirus [1]. All around the globe, measures had to be taken in order to control the outbreak of this new disease. Enforcing world-wide quarantines was one of these measures. The consequences of these quarantines have been vast, ranging all the way from financial losses, deteriorating physical health, and not the least negative impacts to psychological well-being.

Travelling to a foreign country to pursue medical studies can be an invigorating and life-fulfilling experience for a student. However, to get acquainted and accustomed to a new culture, being away from family and friends, and while having to handle an increased academic workload can be very difficult and have various effects on student’s mental health [2]. Symptoms of stress, depression and anxiety may increase during the study period of various reasons as the student tries to adapt to his new environment.

Not much research has been carried out on how severe these symptoms are during confinement in the international students of LUHS, neither has there been sufficient reports on how the COVID-19 quarantine impacts the psychological subjective well-being of LUHS students. Therefore, the purpose of this study is to investigate for relationships between the psychological impact of the COVID-19 lockdown with the sociodemographic characteristics in the population of LUHS international students.

7.AIMS AND OBJECTIVES

The aim of the study: To evaluate the impact of quarantine on the international students of LUHS subjective well-being.

The objectives of the study:

1. To evaluate sample characteristics (sociodemographic, statements regarding the

Quarantine, Health Status, Lifestyle Habits, academics) of international students of LUHS. 2. To measure symptoms of depression, stress and anxiety severity among international

students of LUHS.

3. To measure psychological impact of the Coronavirus disease 2019 (COVID-19) outbreak and lockdown among international students of LUHS.

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11 5. To find relationships between international student’s sample characteristics and the

psychological impact/consequences of COVID-19.

8.LITERATURE REVIEW

8.1 A definition of emotions

Donald Hebb wrote that man is the most emotional of all animals, implicating that the degree of emotional intensity increases across species with the development of a more sophisticated nervous system [3]. From this observation, it was suggested that emotions may perform an adaptive function that requires a degree of processing complexity. Emotional responses create a latency time during which psychological responses can be initiated and several appropriate actions can be prepared while the situation is further analyzed [3]. From this, the organism will benefit from a more thorough appraisal of the situation and will not loose time as potential responses are already prepared and executed rapidly.

Emotions can be defined as an event-focused process that consists of (a) specific elicitation mechanisms that are based on the relevance of a stimulus, which b) shape an emotional response instantly across several subsystems of the organism that includes motivational changes (changes in action tendency, such as approach vs withdrawal), physiological changes (e.g. heart rate, skin conductance), changes in motor expression (face, voice, body tone) and the changes in subjective feeling [1]. People are experiencing emotions continuously while evaluating objects, events and situations with respect to their relevance for his/her needs, goals, values and general well-being (appraisal). Events elicits adaptive emotional responses in people, which helps to mobilize resources that allows an individual to cope with the situation.

8.3 The appraisal theories of emotion

What underlies the elicitation of an emotion is the evaluation process which can be described with psychological appraisal theories of emotion. The Component Process Model of Emotion categorizes appraisal into four objectives that concerns the major types of information that is required to react adaptively to an event: (1) Relevance: How relevant is this for me? Does it directly affect me or my social group? (2) Implications: What are the implications or consequences of this event and how do these affect my well-being and my immediate or long-term goals? (3) Coping potential: How well can I cope with or adjust to these consequences? (4) Normative significance: What is the significance of this event with respect to my self-concept and to social norms and values? It is thought that the

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12 individual characteristics and the specific situation. This in turn explains why different people may react to the same situation with different emotions, and the same person may react with a different emotion each time when exposed to similar situations [4,5].

8.3 The COVID-19 impact on students psycho-emotional state

The psycho-emotional state of a person can be defined as a form of a mental state with predominance of emotional reaction modeled on dominants. A person needs to act out on his emotions in response to the reality so he can balance his overall state of health, wellness and functional state. When there is optimal emotional arousal, the person is prepared for efficient activity that will not be a danger for health. However, when there is a state of excessive influence of emotional factors, our neuro-mental processes get stressed and the higher neuronal centers are disrupted [6]. To further define this concept, a negative psycho-emotional state is a complex emotional state characterized by negative emotions (depressed mood, sadness, anxiety, etc.), cognitive disorder (a decrease in intellectual efficiency), and somatovegetative disorders (all forms of pain, malaise with no obvious reasons, sleep disturbances, decreased work availability).

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13 academic performance had higher levels of depressive and anxiety symptoms [22]. It is known that medical students are a vulnerable population globally, not only do they have a great probability to develop a negative emotional state, they also tend to have a stigmatization towards mood disorders and are less likely to seek support [23]. It is therefore important to evaluate student’s emotional states and determine if proper interventions are needed or not.

To conclude, the evaluation for negative psycho-emotional states in students is important because it affects different and many sectors of a person’s life. From a psychophysiological perspective, a person overall state may deteriorate or develop into any kind of psychosomatic and psychoneurological disease by having a negative pscyho-emotional state [6]. Our emotions affect our perception, attention, memory and decision-making [3] meaning that these spheres can also be affected by

negative psycho-emotional states. Finally, it is known that a positive psycho-emotional state leads to a good physical health [24], which is what all people should strive for.

9.RESEARCH METHODOLOGY AND METHODS

The research methodology consisted of a cross-sectional survey carried out in Lithuanian university of health sciences (LUHS). The questionnaire was distributed to international students during the month of January year 2021. The informed consent of the research participants was given in the preamble of the questionnaire. Participants of the survey were anonymous, and the study population consisted of 1295 students. Of those students, 102 delivered a response to the questionnaire, therefore the sample size of the research was 102.

Research methods consisted of creating the questionnaire online using Microsoft Forms. By using

Microsoft outlook, an invitation for the questionnaire was sent by email to the research participants

LUHS emails. The research participants were allowed as much time as needed for answering all questions or statements.

The questionnaire consisted of three parts: a sociodemographic questionnaire, the Impact of Event-Scale Revised (IES-R), and Depression, Anxiety, Stress, Event-Scale – 21 (DASS-21).

The part regarding the students sociodemographic consisted of questions about social status, health and lifestyle habits, academics and general questions regarding quarantine.

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14 The symptom intrusion is assessed with eight items on the scale, and evaluates intrusive thoughts, nightmares, intrusive feelings and imagery, and dissociative-like re-experiencing. Avoidance is as well assessed with eight items which evaluates numbing of responsiveness, avoidance of feelings,

situations, and ideas. Lastly, hyperarousal is assessed with six items, evaluating feelings of anger irritability, hypervigilance, difficulty concentrating, and heightened startle.

The participants of the study were asked to state the degree of their distress for each of 22 symptoms according to a five-point Likert scale: 0 indicated that symptom occurs “not at all”; 1, “a little bit”; 2 “moderately”; 3 “quite a bit”; and 4 “extremely”. Each IES-R subscale’s total score is calculated by using the mean of the scored responses. The amount of distress the individual is experiencing

corresponds, therefore, to the categories on the scale; for example, an individual with a mean score of 3 in avoidance displays “quite a bit of avoidance behavior”. The mean rating for each subscale and the total score is presented. The mean values give an indication of the level of impairment of

posttraumatic stress.

DASS-21 is a set of three self-report scales that was created to measure the negative emotional states of depression, anxiety and stress. It is a shorter version of the basic 42-item questionnaire, and is available with 7 items per scale. The Depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia and inertia. The Anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. Finally, the Stress Scale is sensitive to levels of chronic non-specific arousal. It assesses difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient.

The subjects were asked to use a 4-point severity scale to rate each statement to an extent of which they have experienced each state over the past week. The answers to each statement of each subscale are summed up, in which the result will assess the severity of symptoms depression, anxiety and stress by a mild, moderate or severe scale.

To find relationships between categorial data, the subscales of IES-R were categorized into groups of

no, mild, and moderate-severe symptom severity according to the mean scores of the IES-R scoring

template. A mean score of <1 belonged to the no category, ≥1 and <1.5 to mild, and more than >1.5 to

moderate-severe. The subscales of DASS-21 were categorized into normal, mild, moderate, and severe symptom severity according to the DASS scoring template. The following score system was

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Severity/subscale Depression Stress Anxiety

Normal 0-9 0-7 0-14

Mild 10-13 8-9 15-18

Moderate 14-20 10-14 19-25

Severe +21 +15 +26

A statistical analysis was executed by using IBM SPPS Statistics Version 27. Descriptive statistics was made by calculating frequencies of the statements regarding sociodemographic and the severity levels of the subscales of DASS-21 and IES-R. Shapiro-Wilk test was used to discover if values were normally distributed. Chi square tests were performed to investigate for relationships between categorical data. If one value of a cell was less than 5 and there was a statistically significant difference detected while performing the Chi square test, the null hypothesis was retested and regrouping of the symptom severity into normal-mild and moderate-severe groups of the DASS-21 scores was performed. Cramer’s V was used to measure the strength of relationships between categorical data. Spearman’s rank of correlation was used to measure the degree of association between quantitative data. One score from the age scale had to be omitted from the study since one participant added a score of 0. Statistically significant differences were established when p-value was <0.05.

10. RESULTS

10.1 Sample characteristics

Sociodemographic parameters (Table 1)

The total number of students that replied to the questionnaire were 102, in which 33 were males and 69 were female. The average age of the participants was 23,01 (SD=2,89), whereas the average of males was 23,3 (SD=2,89) and females 22,87 (SD=2,676).

The international students of LUHS relationship status consisted of 63,7% of them being single, 29,4% of them being in a relationship, and 6,9% were married.

About two thirds of the students considered that their Lithuanian language skills were poor (70,76%) whereas one fifth thought that their skills were moderate (21,26%) and the remainder considered it to be good (7,8%).

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16 Reported Frequencies of Statements Regarding the Quarantine (Table 1)

91,2% of students knew the reason for the quarantine of COVID-19 in Lithuania. 81,4% thought that the source of information regarding the pandemic in Lithuania was readily available in English. Three fourths (75.5%) of the participants were aware of the infection control directives established by the National Public Health Center under the Ministry of Health in Lithuania, but only 68,6% were following the infection control directives. Out of the 102 participants, 68,6% of the students had kept social distancing during the quarantine, 29,4% had kept themselves partly from social distancing, and 2% did not maintain a social distancing.

90 students (88,2%) do not have family members living in Lithuania. Regarding the statement of being apart from family members and friends, more than half (54,9%) of the participants thought that it was ‘somewhat difficult’, 27% thought it was ‘difficult’, and 17,6 stated it was ‘not difficult’. See Table 1.

Reported Frequencies of Statements Regarding Health Status (Table 1)

21.6% of students subjectively considered their health to be very good and 36,3% thought of it to be just good. 35,3% stated it was normal, 4,9% responded with it being bad and 2% very bad. 26,5% stated that they had family history of depression or anxiety disorder. 36,3% of students were themselves once diagnosed with depression or anxiety disorder. See Table 1.

Reported Frequencies of Statements Regarding Lifestyle Habits (Table 1)

More than half of the students had trouble sleeping during the quarantine (54,9%). The majority of students do not smoke (82.4%). However, 8,8% smoke several times per day, 2,0% several times per week, and 8,8% several times per month. A total of 17,7% of the student’s smoke, and 3,9% of the sample had started to smoke during the quarantine.

A half of the respondents (52%) consume alcohol regularly, while during the quarantine 2,9% of the students started to drink alcohol. The majority of students (91,2%) do not use any recreational drugs, and neither did they start to do so during the quarantine in which 82 (80,4%) of the students replied

‘No’ to the statement and 18 (17,6%) students responded with ‘Not applicable’. 2% of students stated

‘Yes’ if they had started to do drugs during the quarantine.

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17 Reported Frequencies of Statements Regarding Academics (Table 1)

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18 Table 1. Sample characteristics of study population

Statements N (%), n=102 Gender Male Female 33 (32,4%) 69 (67,6%) Age years (Mean ± SD)

Male Female 23,01 ± 2,897 23,30 ± 3,331 22,87 ± 2,676 Relationship status In a relationship Married Single 30 (29,4%) 7 (6,9%) 65 (63,7%) Lithuanian language skills

Good Moderate Poor 8 (7,8%) 22 (21,26%) 72 (70,76%) Living condition in Lithuania

Apartment Dormitory

79 (77,5%) 23 (22,5%) Living alone in Lithuania

Yes No

46 (54,9%) 56 (45,1%) Do you know the reason for the quarantine

of COVID-19 in Lithuania? Yes

No

93 (91,2%) 9 (8.8%) Is the source of information regarding the

COVID-19 pandemic in Lithuania readily available in English?

Yes

No 83 (81,4%)

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19 Table 1 (continued).

Infection control directives awareness Yes

No

77 (75.5%) 25 (24,5%) Infection control directives adherence

Yes No Not applicable 70 (68,6%) 13 (12,7%) 19 (18,6%) Social distancing during quarantine

Yes No Partly 70 (68,6%) 2,0 (2.0%) 30 (29,4%) Family members living in Lithuania

Yes No

12 (11,8) 90 (88,2%) Being apart from family and friends and

away from home country Difficult Somewhat difficult Not difficult 28 (27,5%) 56 (54,9%) 18 (17,6) General health status

Very bad Bad Normal Good Very good 2 (2,0%) 5 (4,9%) 36 (35,3%) 37 (36.3%) 22 (21,6%) Family history of depression or anxiety

disorder Yes

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Past diagnosed depression or anxiety disorder

Yes

No 37 (36,3%) _{65 (63,7%)}

Trouble sleeping during quarantine Yes

No

56 (54,9%) 46 (45,1%) Do you smoke?

Yes, several times per day Yes, several times per week Yes, several times per month No

7 (6,9%) 2 (2,0%) 9 (8,8%) 84 (82,4%) Did you start to smoke during the

quarantine (in case you did not smoke before?) Yes No Not applicable 4 (3,9%) 79 (77,5%) 19 (18,6%) Do you consume alcohol?

Yes, several times per week Yes, several times per month No

11 (10,8%) 42 (41,2%) 49 (48,0%) Did you start to consume alcohol during the

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Do you use any recreational drugs? Yes, several times per day

Yes, several times per week Yes, several times per month No

1 (1,0%) 2 (2,0%) 6 (5,9%) 93 (91,2%) Did you start to use recreational drugs

during the quarantine? Yes No Not applicable 2 (2,0%) 82 (80,4%) 18 (17,6%) How often do you exercise?

Daily Weekly Monthly Never 26 (26,5%) 36 (35,3%) 26 (25.5%) 14 (13,7%) Did you start to exercise during the

quarantine? Yes No Not applicable 38 (37,3%) 58 (56,9%) 6 (5,9%) Have you ever wished for taking an

academic leave due to COVID-19? Yes

No 25 (24,5%) _{77 (75,5%)}

Have you ever wanted to leave (drop out) of LUHS due to COVID-19?

Yes No

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10.2 The IES-R Scale

Table 2 illustrates the mean values of IES-R subscales. In the intrusion subscale, the mean statistic is 1,16 (SD=0,95). The avoidance subscale and the hyperarousal subscale had mean values of 1,21 (SD=0,86) and 1,21 (SD=1,01), respectively. All three subscales p-value was less than the alpha coefficient (0.05). To summarize, the mean scores are interpreted as the average student having ‘a little bit’ of intrusive, avoidance, and hyperarousal behavioral symptoms. The mean scores are not

distributed normally in the study sample. Have you experienced a decline in your academic grades during the past year (2020)?

Yes No

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23 Table 2. Intrusion, avoidance, and hyperarousal mean score symptom severity among international

students of LUHS

*Shapiro-Wilk Test of Normality

Table 3 demonstrates the frequencies of different severity levels of the IES-R subscales. The severity levels are categorized in to no (normal), mild, and moderate-severe symptoms. In the intrusion subscale, the majority of the respondents expressed no intrusive symptoms (50%), as well in the avoidance and hyperarousal categories, with 41,2% and 44,1% respectively in the no category. However, over one third of students expressed moderate- to-severe symptom severity in all subscales (intrusion – 32,4%; avoidance – 37,3%; hyperarousal – 34,3%). 17,6% of students expressed mild intrusive symptom severity and 21,6% of students had mild symptoms in categories of avoidance and hyperarousal, respectively. To summarize, in the context of COVID-19 quarantine the majority of students expressed no psychological response, however a third of students expressed a moderate-to severe symptom severity in intrusion, avoidance and hyperarousal subscales.

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24 Table 3. Frequencies of intrusion, avoidance, and hyperarousal score severity levels among

international students of LUHS

10.3 The DASS-21 scale

Table 4 illustrates the mean values of the depression, anxiety and stress scores of the DASS-21 scale. In the depression scale, the mean score is 12,49 (SD=12,36. 9,06 (SD=11.15) was the score for the anxiety scale. The mean for the stress severity scale was measured to be 12,25 (SD = 11,63. All p-values of the scales were <0.05. To summarize, the mean scores are interpreted as the average student has mild depressive and anxiety symptoms, and normal stress symptoms. The mean scores are not distributed normally in the study sample.

Scale Frequency (n) Percentage (%)

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25 Table 4. Depression, anxiety and stress mean score symptom severity among international students

of LUHS

*Shapiro-Wilks Test of Normality

Table 5 describes the frequencies of depression, stress and anxiety symptoms severity levels among the students of LUHS. Around one fourth of the students indicated severe depressive and anxiety symptoms with 24,5% and 26,5% in each category, respectively. More than half of the students exhibited normal symptom severity levels in each subscale; 53,9% of students had normal depressive symptoms, 60,8% had normal anxiety symptoms, and 59,8% had normal stress symptoms. To summarize, the majority of students expressed normal depressive, anxiety and stress symptoms. One fourth of students reported severe depressive and anxiety symptoms. One fifth of students reported severe stress symptoms.

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26 Table 5. Frequencies of depression, anxiety and stress score severity levels among international

students of LUHS

10.4 Correlations between DASS-21 and IES-R

Table 6 presents correlations between the variables stress, anxiety, depression, and posttraumatic stress levels (IES-R). There is a statistically significant dependence between stress and anxiety levels in the students with a correlation coefficient of 0,834 (p<0.001); between depression and anxiety having a correlation of 0,781 (p<,001); among the IES-R scale and stress with a correlation of 0,744 (p<0.001), and between IES-R and anxiety in which the correlation coefficient was 0,731 (p<0.001). All

discovered correlations between the variables were positive. Strong correlations were found between

stress vs. anxiety and depression vs. anxiety. Moderate correlations were found between stress vs. IES-R and anxiety vs. IES-IES-R.

Scale Frequency (n) Percentage (%)

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27 Table 6. Correlations between DASS-21 subscales stress, anxiety and depression and IES-R among

international students of LUHS

10.5 Relationships between sociodemographic characteristics and psychological impact of COVID-19

Table 7 demonstrates relationships between the following sample characteristics of ‘age’, ‘gender’, ‘relationship status’, ‘diagnosed past depressive/anxiety disorder’, ‘family history of anxiety or depressive disorder’ and ‘have you maintained social distancing during the quarantine?’ with degrees of intrusion symptom severity levels among the international students of LUHS. One statistically significant difference was discovered between the variables of ‘’did you have any past depressive anxiety disorder?’’ and intrusion groups (p<0,05). Majority of the students (n=40) stated that they had no intrusive symptoms and were neither diagnosed with a depressive or anxiety disorder. However, the majority of students who were diagnosed with depression or anxiety disorder in the past belonged to the category of having moderate-severe intrusion symptoms (n=19), (Χ2_{(1) =11,302, p=0,004). The} degree of association between the intrusion score and a diagnosed depression/anxiety disorder was 0,333 and is interpreted as moderate (φc = 0,3-0,5). No other statistically significant differences were found.

Stress vs Anxiety Depression vs Anxiety

IES-R vs Stress IES-R vs Anxiety

Rs 0,834 0,781 0,744 0,731

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28 Table 7. Relationships between sociodemographic characteristics and intrusive symptoms severity

among international students of LUHS No

intrusion Mild intrusion Moderate severe intrusion Total (n) Pearson-Chi square Χ2₍₁₎ p-value Cramer’s’ V (φc)

Did you have any past depressive/ anxiety disorder 11,302 0.004 0.333 No 40 11 14 65 Yes 11 7 19 37 Total (n) 51 18 33 102

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29 Table 8. Relationships between sociodemographic characteristics and avoidance symptoms severity

among international students of LUHS. No

avoidance Mild avoidance Moderate-severe avoidance Total (n) Pearson-Chi square Χ2₍₁₎ p-value Cramer’s V (φc)

Did you have any past depressive/ anxiety disorder? 8.403 0,015 0,287 No 33 14 18 65 Yes 9 8 20 37 Total (n) 42 22 38 102

Table 9 illustrates as well relationships between the sample characteristics of ‘age’, ‘gender’,

‘relationship status’, ‘diagnosed past depressive/anxiety disorder’, having a ‘family history of anxiety or depressive disorder’ and ‘have you maintained social distancing during the quarantine?’ with

degrees of hyperarousal symptom severity levels among the international students of LUHS. There is a statistically significant difference between the categories of having a diagnosed past anxiety and depressive disorder with hyperarousal symptoms associated with the COVID-19 psychological impact (p<0.05). 65 students had no depressive or anxiety disorder diagnosed in the past, in which 35 of those demonstrated no symptoms of hyperarousal. The remaining 30 students in this category were divided equally, in which 15 students had stated mild severity of hyperarousal symptoms and the other 15 students had moderate-severe hyperarousal symptoms. 37 students were diagnosed with depression or anxiety in the past, and the majority of them (n=20) expressed moderate-severe hyperarousal

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30 Table 9. Relationships between sociodemographic characteristics and hyperarousal symptoms

severity among international students of LUHS. No hyperarousa l Mild hyperarousa l Moderate-severe hyperarousal Total (n) Pearson-Chi square Χ2₍₁₎ p-value Cramer’s V (φc) Did you have any past depressive/ anxiety disorder? 10,627 0.005 0.323 No 35 15 15 65 Yes 10 7 20 37 Total (n) 45 22 35 102

Relationships among depressive symptoms severity (normal, mild, moderate, and severe) and the sample characteristics of ‘age’, ‘gender’, ‘living condition in Lithuania, including whether living alone or having family members in Lithuania’, ‘relationship status’, ‘Lithuanian language proficiency’, ‘alcohol consumption’, ‘exercise frequency’, usage of ‘recreational drugs’ and ‘maintenance of social distancing’ had no statistically significant differences between each other.

Table 10 represents relationships between sample characteristics of having ‘family history of

depression or anxiety disorder, being ‘diagnosed with a past depressive or anxiety disorder’, ‘academic performance’, having an ‘awareness of the infection control directives’, the availability and ‘source of information regarding the pandemic in English’ during quarantine in Lithuania, and ‘sleep disturbance’ with depression.

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31 In terms of having a diagnosed past depressive or anxiety disorder, 37 students stated that they had been diagnosed. Of those 37 respondents, 23 had moderate-severe depression symptoms and 14 had normal-to-mild. 65 students did not have a diagnosis, in which 51 demonstrated mild-normal

symptoms and the remaining 14 moderate-severe symptoms (Χ2_{(1) = 16,833, p = <0,001). Cramer’s} coefficient was 0,406, interpretated as a moderate degree of association between the categories. 74 students did not experience a drop in their academic grades during the past year, 52 of them demonstrated normal-mild severity levels of depression and the remaining 22 moderate-severe

symptoms. 28 students did experience a decline, 15 of them had moderate-severe depressive symptoms and remaining 13 normal-to-mild severity of symptoms (Χ2_{(1) = 4,995, p = <0.05). Cramer’s}

coefficient was 0,221, meaning a low degree of association between categories.

Majority of the students (n=77) in the sample did not wish for taking an academic leave due to the quarantine, and 57 of them had normal-mild depressive symptoms and 20 moderate-severe. One fourth (n=25) of the respondents wished for an academic leave, in which 17 of them demonstrated moderate-severe symptoms and the remaining 8 normal-to-mild levels symptoms (Χ2_{(1) = 14,420, p = <0,001).} The degree of association was 0,376, interpreted as a moderate degree of association was found. Around 80 % (n=84) of the students did not want to terminate their studies at LUHS due to the COVID-19. 62 of these 84 respondents had mild-moderate severity symptoms of depression. Around one-fifth (n=18) of the respondents wanted to terminate the studies, and the majority of them (n=15) expressed moderate-severe symptoms. (Χ2_{(1) = 20,939, p = <0,001). The degree of association} between the categories was moderate (0,453).

A little more than three-quarters (n=77) of the respondents were aware of the infection control

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32 Table 10. Relationships between sociodemographic characteristics and depressive symptom severity

in normal-mild and moderate-severe categories among international students of LUHS. Normal-mild depression Moderate-severe depression Total (n) Pearson chi square Χ2₍₁₎ p-value Cramer’s V (φc)

Do you have any family history of depression or anxiety disorder? 8,392 0,004 0,287 Yes 11 16 27 No 54 21 75 Total (n) 65 37 102

Did you have any past depressive/anxiety disorder? 16,833 <0,001 0,406 Yes 14 23 37 No 51 14 65 Total (n) 65 37 102 Have you experienced a decline in your academic grades during the past year (2020)?

4,995 0,025 0,221

Yes 13 15 28

No 52 22 74

Total (n) 65 37 102

Have you ever wished for taking an academic leave due to covid-19? 14,420 <0,001 0,376 Yes 8 17 25 No 57 20 77 Total (n) 65 37 102

Have you ever wanted to leave (drop out) of LUHS due to COVID-19? 20,939 <0,001 0,453 Yes 3 15 18 No 62 22 84 Total 65 37 102

Are you aware of the infection control directives established by national health

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33 public center under

ministry of health in Lithuania?

Yes 55 22 77

No 10 15 25

Total (n) 65 37 102

Have you had trouble sleeping during the quarantine? 7,685 0,006 0,274 Yes 29 27 56 No 36 10 46 Total (n) 65 37 102

Relationships between stress symptoms severity (normal, mild, moderate, severe) and sample

characteristics regarding drugs, smoking, living conditions in Lithuania, age, gender, study program, exercise frequency, relationship status, Lithuanian language proficiency, and social distancing demonstrated no statistically significant differences.

Table 11 represents relationships between stress severity levels of normal-to-mild and moderate-to-severe categories and the sample characteristics. The statements related to the sample characteristics revolves around sleep disturbance, alcohol usage, being diagnosed with depression or anxiety in the past, having a family history of depression or anxiety, whether the information regarding the pandemic is readily available in English in Lithuania, health status and academic performance. All statements had a statically significance except for two (alcohol consumption and health status).

More than half of the respondents (n=56) stated that they had difficulty sleeping during the quarantine, in which 33 reported normal-to-mild stress symptoms and remaining 23 moderate-to-severe levels. 46 students reported no sleep disturbances, and the majority of those (n=41) demonstrated normal-to-mild stress. (Χ2_{(1) = 11,567, p= <0,001)). The degree of association between the categories was moderate} (0,337)

37 students had a diagnosed depressive or anxiety disorder, in which 19 stated normal-mild stress symptoms and 18 moderate-to-severe stress. Majority of the respondents did not have a diagnosis (n=65), and the overall group in this category stated mild-moderate severity levels of stress (n=55). 10 students had moderate-severe stress. (Χ2_{(1) = 13,100, p = <0,001). Cramer’s’ coefficient was 0,358,} interpreted as a moderate degree of association between categories.

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34 students with no family history had moderate-severe stress (Χ2_{(1) = 5,234, p = 0,021). Cramer’s}

coefficient was interpreted as low degree of association between the categories. (0,228)

Majority of students stated that information regarding pandemic is readily available (n=83), and 65 of them had normal-to-mild stress symptoms and the other 18 students had moderate-to-severe. 19 students considered that information was not readily available, in which 10 had moderate-to-severe stress and 9 mild-to-moderate. (Χ2_{(1) = 7,434, p=0.006). 0,270 was the degree of association between} the categories, meaning it was low.

Concerning academic performance, 74 students did not experience a drop in their academic grades and 59 of those had normal-to-mild stress symptoms while 15 had moderate-severe. For those that did experience a decline (n=28), 15 experienced normal-to-mild stress and 13 moderate-to-severe levels of stress. (Χ2_{(1) = 6,979, p = 0.008). Cramer’s coefficient was 0.262, also interpreted as a low degree of} association between these categories.

For those who did not wish for taking an academic leave, 62 of them demonstrated normal-to-mild stress and remaining 15 moderate-severe symptoms (total n= 77). The students who wished for taking the leave were categorized as 12 respondents with normal-to-mild symptoms and 13 with moderate-to-severe. (Χ2_{(1) = 10,021, p = 0,002). The degree of association was 0,313 meaning a moderate degree} of association between categories

A minority of the students wanted to drop out of LUHS due to the coronavirus (n=18) in which, 11 had moderate-to-severe stress and 7 normal-to-mild. The remaining majority (n=84) did not want to leave the university, in which 67 had normal-to-mild stress, and 17 moderate-to severe levels of stress. (Χ2_{(1) = 12,435, p= <0,001). The degree of association was 0,349 (moderate).}

Table 11. Relationships between sociodemographic characteristics and stress symptom severity in normal-mild and moderate-severe categories among international students of LUHS.

Normal-mild stress Moderate-severe stress Total (n) Pearson chi square Χ2₍₁₎ p-value Cramer’s V (φc)

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35 Did you have any

past depressive/anxiety disorder? 13.100 <0.001 0,358 Yes 19 18 37 No 55 10 65 Total (n) 74 28 102

Do you have any family history of depression or anxiety disorder? 5,324 0.021 0.228 Yes 15 12 27 No 59 16 75 Total (n) 74 28 102 Is the source of information regarding the COVID-19 pandemic in Lithuania readily available in English? 7,434 0.006 0,270 Yes 65 18 83 No 9 10 19 Total (n) 74 28 102 Have you experienced a decline in your academic grades during the past year (2020)?

6,979 0,008 0,262

Yes 15 13 28

No 59 15 74

Total (n) 74 28 102

Have you ever wished for taking an academic leave due to COVID-19? 10,021 0,002 0,313 Yes 12 13 25 No 62 15 77 Total (n) 74 28 102

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36 Relationships between anxiety severity levels of normal, mild, moderate and severe categories with sample characteristics related to age, gender, drug usage, exercise, relationship status and social distancing demonstrated no statistically significant differences.

Table 12 demonstrates relationships between anxiety severities in normal-mild and moderate-severe ranges with sociodemographic that are related to a diagnosis of depression/anxiety disorder, having a family history of depression or anxiety, alcohol consumption, the availability of information in English regarding the pandemic in Lithuania, health status, academic performance, Lithuanian language

proficiency and sleep disturbance.

Out of the 102 students, 65 were not diagnosed with depression or anxiety and the majority (n=54) of them had normal-to-mild anxiety symptoms with the remaining (n=11) students having moderate-to-severe symptoms. 23 students in the diagnosed group had moderate-moderate-to-severe anxiety levels. 14

respondents with a diagnosis stated normal-mild anxiety levels (Χ2_{(1) =21,715, p= <0,001). The degree} of association between the categories was set to 0,461 (moderate).

27 students with a family history of depression or anxiety disorder were categorized as 16 students having moderate-to-severe levels of anxiety and 11 students with normal-to-mild symptoms. The majority of students with no family history (n = 57) had normal-to-mild severity of symptoms and the remaining 18 moderate-to-severe symptoms. (Χ2_{(1) =11,107, p = <0,001). Cramer’s coefficient was} 0,330, meaning also a moderate degree of association.

59 students with normal-to-mild anxiety stated that the source of information regarding the pandemic was readily available in English, and 24 students with moderate-to-severe levels expressed the same answer to the statement. For the students who did not agree with the information being available, 10 expressed moderate-to-severe anxiety and 9 with normal-mild anxiety (Χ2_{(1) = 3,913, p=0.048).} Cramer’s coefficient was 0,196 (low degree of association).

The majority of students did not wish for taking an academic leave and had normal-to-mild anxiety symptoms (n=59). 18 students had moderate-to-severe levels but did not want to take an academic leave. Those students who wished for taking the leave were proportioned as 16 students expressing moderate-to-severe symptoms and 9 with normal-to-mild symptoms (Χ2_{(1) = 14,015, p= <0,001). The} degree of association between the categories was 0,371 (moderate).

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37 which 18 expressed moderate-to-severe anxiety and 10 with normal-to-mild ranges of anxiety (Χ2_{(1) =} 16,639, p = <0.001). Cramer’s coefficient was 0,404 (moderate degree of association)

Over 80% of respondents did not want to leave (drop out) of LUHS due to the coronavirus. The

majority of students in this category had normal-to-mild anxiety (n=64). For those who wanted to drop out had more moderate-to-severe anxiety symptoms (n=14), (Χ2_{(1) =19,429, p<0,001). Cramer’s} coefficient was 0,436 (moderate)

More than half of the participants of the study had trouble sleeping during the quarantine (n=56). Majority of those with sleep disturbance had normal-to-mild anxiety (n=32). 24 respondents with sleep disturbance had moderate-to severe anxiety. For those with no sleep disturbance, the majority of participants demonstrated normal-to-mild anxiety (n=36) while 10 students having moderate-to-severe anxiety (Χ2_{(1) = 5,068, p =0,024.) the degree of association was 0,223 (low).}

Table 12. Relationships between sociodemographic characterisitcs and anxiety symptom severity in normal-mild and moderate-severe categories among international students of LUHS.

Normal-mild anxiety Moderate-severe anxiety Total (n) Pearson chi square Χ2₍₁ p-value Cramer’s V (φc)

Did you have any past depressive/anxiety disorder? 21,715 <0,001 0,461 Yes 14 23 37 No 54 11 65 Total (n) 68 34 102

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38

Total 68 34 102

Have you ever wished for taking an academic leave due to COVID-19?

14,015 <0,001 0,371

Yes 9 16 25

No 59 18 77

Total (n) 68 34 102

Have you ever wanted to leave (drop out) of LUHS due to COVID-19? 19,429 <0,001 0,436 Yes 4 14 18 No 64 20 84 Total (n) 68 34 102 Have you experienced a decline in your academic grades during the past year (2020)?

16,639 <0,001 0,404

Yes 10 18 28

No 58 16 74

Total (n) 67 34 102

Have you had trouble sleeping during the quarantine? 5,068 0,024 0,223 Yes 32 24 56 No 36 10 46 Total (n) 68 34 102

11.DISCUSSION

Research about stress, anxiety, and depressive symptoms have been performed on international students of LUHS before.

One cross-sectional survey was conducted among international students of LUHS during year 2015 [25]. The students were questioned to evaluate their anxiety, depressive and stress symptoms using the DASS-42 scale. the students filled in a sociodemographic questionnaire and another additional

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39 achieving personal goals (30%) [25]. All those stressful situations were statistically significant

(p<0.0001) [25].

In terms of gender, the study above found that females had a little more depressive, anxiety and stress symptom severity than males (p<0,05) [25]. Younger students had significantly more anxiety, stress and depressive symptoms than older students (p<0.001) [25]. Preclinical students expressed greater stress, anxiety and depressive symptoms than clinical students (p<0,05) [25]. Students who were married had less depressive and stress symptoms than single and students who were in a relationship (p<0.05) [25]. Respondents with a family history of depressive/anxiety disorder had less anxiety symptoms severity than respondents without a family history (p<0.05) [25]. Non-smokers had

significantly less stress and depressive symptom severity than smokers (p<0,0001) [25]. Consumers of alcohol had fewer depressive symptoms severity mean score than respondents who did not drink [25]. Those students with poor Lithuanian language skills had more depressive and stress symptoms severity than students who had moderate skills of Lithuanian [25].

In comparison to my study, the findings were that the average student reported mild depressive symptoms (mean [SD]=12,49 [12,36], p<0,001), mild anxiety symptoms (mean [SD]=9,06 [11,15], p<0,001) and no stress symptoms (mean [SD]=12,25 [11,63], p<0,001). 24,5% of students reported severe depressive symptoms. 26,5% of students had severe anxiety symptoms. 20,6% of students reported severe stress symptoms. LUHS students have milder symptom severity in terms of depression and stress but anxiety levels remain the same as compared to five years ago. There were no statistically significant differences found in terms of gender, age, relationship status, alcohol consumption,

smoking, and Lithuanian language proficiency. Having a family history of depressive/anxiety disorder was associated with higher levels of depression and anxiety symptoms compared to those without family history (p<0,05).

Similar studies of measuring depressive, anxiety, and stress symptoms with the emotional impact of the COVID-19 have been conducted throughout the past year.

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40 Students from Arts & Humanities and Social Sciences & Law had higher scores related to depression, stress, anxiety and impact of event with respect to Engineering and Architecture [26]. The study concluded that in order to provide with crisis-oriented psychological services and to take preventive measures in future pandemic situations, mental health in university students should be carefully monitored.

In comparison to my study with Odriozola-González et al [26] , only a third of students reported moderate-severe emotional impact to the pandemic (32,4% moderate-severe intrusion, 37,3%

moderate-severe avoidance, 34,3% moderate-severe hyperarousal). A possible explanation to the lower reported frequencies in my study compared to Odriozola-González et al [26] could be due to the time span between the first initial outbreak of COVID and the point of time conducting this study. It is most likely that the students have adapted themselves psychologically to the current situation and therefore might have reported lesser symptom severities.

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41 measures (e.g., hand hygiene, wearing a mask) had an association with lower psychological impact of the outbreak and lower level of depression, stress and anxiety (p<0.05) [27].

In comparison to my study the results are similar: 26,5% had severe anxiety symptoms. 24,5%

reported severe depressive symptoms. Unfortunately, no statistical significant differences in my study was found in terms of female gender or physical health status of being associated with a greater psychological impact of the outbreak and depressive, stress, and anxiety symptoms. Student status, specific physical symptoms, accurate health information, and precautionary measures are variables that were not investigated during my study and therefore non-comparable.

Another study analyzed Weibo posts from 18000 active Weibo users in China and determined that negative emotions, for example ‘anxiety, depression, and indignation’ have been increased after COVID-19 was declared on January 20, 2020 [29]. Female gender, young age, people with higher educational status, and being students were significantly associated with more negative psychological effects of COVID-19 and higher levels of stress, anxiety, and depression among corresponding individuals [29].

To compare my study with the one above, there were no statistically significant differences in terms of gender or age being associated with more negative psychological effects of COVID-19 and higher levels of stress, anxiety, and depression. Characteristics such as educational status and occupation was not investigated, therefore not comparable with the Weibo study.

12.CONCLUSION

1. Majority of the international students of LUHS are single, live in an apartment and typically not alone, have poor Lithuanian language skills, good health, typically no family history of depression or anxiety, exercise regularly, consume alcohol, but tend not to be a smokers and have sleep disturbances during the quarantine. The students are aware of the reason for quarantine, know and follow the infection control directives established in Lithuania, receive proper information about the pandemic, have kept a social distancing and feel difficulties being away from family and friends during the quarantine. Most students do not experience academic failures, do not wish for an academic leave, and do not want to drop out LUHS due to the pandemic.

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42 3. The average international student demonstrates ´a little bit’ of intrusive, avoidance, and

hyperarousal behavior as a psychological response to the COVID-19 pandemic. Higher intrusive, avoidance, and hyperarousal symptoms was reported by a third of the international students of LUHS.

4. The correlation between DASS-21 and IES-R was established.

5. Relationships between the student’s sample characteristics and severity levels of intrusion, avoidance, hyperarousal, depression, stress, and anxiety symptoms tells of:

•_{Most students with a past diagnosis of depression or anxiety disorder reported higher} symptom severities of intrusion, avoidance, hyperarousal, depression, stress, and anxiety. The students with a family history of depression or anxiety reported higher levels of depression and anxiety symptoms

• Students who reported of being aware of the infection control directives had higher levels of depression and those who felt that information was readily available to them in English about the pandemic in Lithuania reported lower stress and anxiety symptom severities.

•_{Most students who experienced a decline in their academic grades reported higher} depressive and anxiety symptom severities compared to those who did not have a negative impact to their grades. Most students who wished for taking an academic leave or wanted to drop out reported higher levels of depression, stress and anxiety

symptoms severity.

13.PRACTICAL RECOMMENDATIONS

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43

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THE SUBJECTIVE WELL-BEING OF INTERNATIONAL STUDENTS DURING THE QUARANTINE PERIOD OF COVID-19