Front. Public Health Frontiers in Public Health Front. Public Health 2296-2565 Frontiers Media S.A. 10.3389/fpubh.2023.1252849 Public Health Original Research Psychological impact of COVID-19 and determinants among Spanish university students Cebrino Jesús 1 Portero de la Cruz Silvia 2 3 * 1Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain 2Department of Nursing, Pharmacology and Physiotherapy, University of Córdoba, Córdoba, Spain 3Research Group GE10 Clinical and Epidemiological Research in Primary Care, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Córdoba, Spain

Edited by: Wulf Rössler, Charité University Medicine Berlin, Germany

Reviewed by: Kunhua Lee, National Tsing Hua University, Taiwan; Sardar Imran, Independent Researcher, Khulna, Bangladesh; Yifan Zhang, South China Normal University, China; Nor Azlili Hassan, Universiti Tunku Abdul Rahman, Malaysia; Martin Noe-Grijalva, Cesar Vallejo University, Peru

 *Correspondence: Silvia Portero de la Cruz, n92pocrs@uco.es 18 10 2023 2023 11 1252849 04 07 2023 02 10 2023 Copyright © 2023 Cebrino and Portero de la Cruz. 2023 Cebrino and Portero de la Cruz

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

 Background

University students are a vulnerable population and faced a significant psychological impact from the COVID-19 pandemic. Therefore, this study aimed to determine the level of fear of COVID-19 among university students and to evaluate the possible relationship between fear of COVID-19 and socio-demographic, health-related determinants, variables related to the COVID-19 and variables related to the psychological impact of the COVID-19 pandemic.

 Methods

We conducted a cross-sectional study between December 2020 and December 2021 on a sample of 950 university students from two universities in southern Spain. Participants completed a form that collected socio-demographic, health-related and COVID-related variables, a validated questionnaire related to the psychological impact of the COVID-19 pandemic and the fear of COVID Scale (FCV-19S). Descriptive, inferential, and multivariable linear regression analyzes were conducted.

 Results

The mean FCV-19S score was 14.86 ± 5.16 points. The factors identified as predictors of FCV-19S were being female (p < 0.001), holding religious beliefs (p = 0.04), living in towns with over 10,000 inhabitants (p < 0.01), living with someone vulnerable to COVID-19 (p = 0.02), watching TV to keep informed about COVID-19 (p < 0.01), believing in a low probability of surviving if infected with COVID-19 (p < 0.001), having a higher level of death anxiety (p < 0.001) and suffering from insomnia (p < 0.001).

 Conclusion

An average fear of COVID-19 score of 14.86 ± 5.16 points has been found among university students in Spain. These findings can aid in identifying specific factors contributing to fear of COVID-19 and in developing coping strategies to alleviate the stress of the pandemic.

 COVID-19 fear public health Spain students section-at-acceptance Public Mental Health Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the cause of coronavirus disease 19 (COVID-19) in December 2019 (1). The rapid person-to-person transmission, as well as the severity of the virus across the globe (2), led to the implementation of several measures in Spain, including a general lockdown that started on March 15, 2020, and concluded on June 21, 2020. During this period of confinement, comprehensive measures were implemented, including the closure of restaurants, schools, universities, and workplaces which involved close physical contact. Governments also enforced physical distancing through quarantines, travel restrictions, and closures of various establishments such as theaters, cinemas, museums, and stadia. Remote work and online education became widespread, while the limited number of activities permitted included essential work, grocery shopping, caregiving, and medical visits (3). Nevertheless, during those 100 days of lockdown, there were 245,938 total confirmed cases of infection and 28,322 total deaths in Spain (4).

The lockdown period led not only a radical change in the population’s lifestyle (5), but also fear of COVID-19 (6) and a negative effect on mental health (7, 8) with reports of symptoms of common mental disorders in 35–50% of the population (9, 10). Fear, defined as an adaptive response to real or abstract threats which is crucial for survival (11), stands out as one of the most prevalent psychological reactions to pandemic diseases, and differs in responses to other disasters (12).

A multitude of adverse conditions, such as social isolation, uncertainty, chronic illness, financial hardships, disruptions to daily routines, and the loss of family members to COVID-19, particularly among the older adult, contributed to heightened levels of fear during the pandemic (13–16). This pervasive fear has had a profound and widespread impact on the mental health of millions of individuals worldwide (17). Several studies have investigated this impact on different groups (18–22), including university students, who were at risk due to the continued spread of the pandemic, strict isolation measures, and the restrictions on interpersonal relationships (23, 24).

In Spain, the level of fear of COVID-19 among university students (25) is higher than in other countries such as Turkey (26), China (27), Pakistan (28) or Russia and Belarus (29). Multiple studies worldwide performed in that population (30, 31) have shown the impact that fear of COVID-19 has on several psychological constructs. Thus, on the one hand, fear of COVID-19 plays a pivotal role in the initiation and progression of sleep difficulties, stress, panic and common mental disorders (32–37). On the other hand, death anxiety appears as an abnormal response when individuals experience fear regarding COVID-19 (38, 39). Additionally, previous studies reveal that other constructs such as social support, optimism, subjective happiness and resilience mitigates the fear of COVID-19, fostering better mental health in the battle against the virus (40–42).

Additionally, it is important to consider that the fear of COVID-19 has had an impact on the lifestyle habits of university students, such as resorting to increased alcohol or tobacco consumption as coping responses to the stressors associated with the COVID-19 pandemic (43), adopting less healthy dietary practices (44), and exhibiting a low level of physical activity (45).

The COVID-19 pandemic continues to pose significant health challenges (46, 47) and exerts an ongoing impact on a wide range of psychological responses in individuals (48), including university students (49). Despite the growing number of studies on the fear of COVID-19 worldwide, there is a noticeable gap in the scientific literature, to the best of our knowledge, particularly in terms of concurrently evaluating a variety of psychological constructs and assessing their influence in relation to the fear of COVID-19 among university students in Spain. Therefore, the present study aims to determine the level of fear of COVID-19 among university students and to evaluate the possible relationship between fear of COVID-19 and socio-demographic/health-related determinants, variables related to the COVID-19 and variables related to the psychological impact of the COVID-19 pandemic.

 Materials and methods Participants and procedure

We conducted a cross-sectional study among Spanish university students from December 2020 to December 2021.

The study was carried out in 12 different bachelor’s degree courses at two public universities located in the southern region of Spain, Andalusia. The majority of the students were taking degree courses in Health Sciences. Public university 1 had a total of 6,965 university students taking nine different bachelor’s degrees, while public university 2 contained a total of 1,417 university students studying for three different bachelor’s degrees. The exclusion criteria included students who did not fill out the questionnaires correctly, did not understand Spanish, were positive for COVID-19, and were on pharmacological and/or non-pharmacological therapy for anxiety.

The study population was assessed for suitability using Epidat version 4.2. (Ministry of Health, Xunta de Galicia, Galicia, Spain), which estimated a minimum sample size of 138 university students at a 95% confidence level, with an absolute precision of 1%, and a standard deviation of fear of COVID-19 of 6.04 points (50). The study subjects were selected by a non-probabilistic convenience sampling method and participated voluntarily in the study.

At both universities, the data collection was conducted during class hours. Before that, we had contacted the teachers responsible for the subjects involved so as to minimize the interferences in the correct development of the teaching methodology. The planned place, dates, and times to proceed with the data collection were agreed with the teachers. To maximize the response rate, the study was publicized during breaks between classes and on notice boards in common areas of various university faculties.

The students could complete the questionnaires easily by scanning a QR code of the URL of the Google Form with their smartphones. The questionnaires were created in Google Forms due to the advantages of being flexible, unlimited and free of charge (51). The form contained an informative letter emphasizing the voluntary and anonymous nature of the study, as well as an explicit consent form in which the university students agreed to cooperate and participate in the study.

Finally, data were collected from 1,162 students, and 950 completed all the questionnaire surveys, which satisfied the minimum sample size.

 Measurements Dependent variable: fear of COVID-19 scale (FCV-19S)

The level of emotional reactions of fear toward COVID-19 in individuals was assessed using the COVID-19 Fear Scale (FCV-19S) (30), validated in Spain (50). The scale involves responding to items on a 7-point Likert scale, ranging from ‘strongly disagree’ to ‘totally agree’, with scores ranging from 1 for ‘strongly disagree’ to 5 for ‘totally agree’. The total possible score ranges from 7 to 35, with a higher score indicating a higher level of fear toward COVID-19. The measure showed appropriate internal validity (Cronbach’s alpha: 0.83).

 Independent variables

A self-administered survey containing questions concerning the following variables was used to collect the data:

Socio-demographic characteristics of Spanish university students

The socio-demographic data collected included the following: gender (women, men), age (18–24 years, 25–35 years, > 35 years), religious belief (yes, no), spiritual practice (yes, no), belief in life after death (yes, no), population of town/city (< 10,000 inhabitants, 10,000–100,000 inhabitants, > 100,000 inhabitants), type of housing (flat without balcony, terrace or courtyard; house without garden or courtyard; flat with balcony, terrace or courtyard; house with garden or courtyard) and number of people sharing the accommodation (not including the participant who answered).

 Health-related determinants in Spanish university students

The health-related determinants collected included the following: leisure-time physical activity (I do no exercise - I spend my free time almost exclusively sitting down; I occasionally do sports or physical exercise; I do physical exercise several times a month; I do sports or physical exercise several times a week), current smoker (yes, no), frequency of alcohol consumption in the past 12 months (never, less than once a month, monthly, weekly, daily or almost daily) and self-assessed state of health in the past 12 months (very good, good, average, bad, very bad).

 Variables related to COVID-19 in Spanish university students

The variables related to COVID-19 were collected from a previous study (52) and included the following: living with someone considered to be in a vulnerable group to COVID-19 (yes, no), watching television to stay informed about COVID-19 (little or not at all, only at specific times, most of the day), time spent using the Internet to stay informed about COVID-19 (little or not at all, only at specific times, most of the day), time spent using social networks to stay informed about COVID-19 (little or not at all, only at specific times, most of the day), time spent reading the press (newspapers) to stay informed about COVID-19 (little or not at all, only at specific times, most of the day) (Cronbach’s alpha of 0.62), the probability you think you have of surviving if you become infected with SARS-CoV-2 [5-point Likert scale ranging from 1 (no probability) to 5 (very high probability)], how effective you think preventive measures are to avoid infection with COVID-19 [5-point Likert scale ranging from 1 (not effective at all) to 5 (very effective)], and how satisfied you are with the measures adopted to control the COVID-19 pandemic [5-point Likert scale ranging from 1 (not satisfied at all) to 5 (very satisfied)]. Finally, to prevent the spread of COVID-19, the following items were used (never, rarely, sometimes, nearly always, always): (i) ‘I do not leave the house except to do the shopping or some other essential activity’, (ii) ‘If I have respiratory symptoms, I avoid close contact with other people by staying home’, (iii) ‘I keep a distance of at least 1.5 m from other people’, (iv) ‘When I sneeze or cough, I cover my mouth and nose with my elbow’, (v) ‘I avoid touching my eyes, nose and mouth with my hands’, (vi) ‘I use disposable tissues when sneezing or wiping my nose and throw them away after use’, (vii) ‘I wash my hands frequently’, (viii) ‘I use a mask’, (ix) ‘When I go outside, I mainly stay in outdoor spaces’ and (x) ‘I ventilate closed spaces frequently’ (Cronbach’s alpha of 0.83).

 General health questionnaire (GHQ-12)

The assessment of common mental disorders was conducted using the 12-item General Health Questionnaire (GHQ-12) (53), which was validated for the Spanish population (54, 55). The GHQ-12 utilizes a Likert-like scale with response options ranging from 0 (‘more than usual’) to 3 (‘much less than usual’). The scoring in the response categories followed the original GHQ method (56), where the first two response options were scored 0 and the last two received a score of 1, resulting in a bimodal score (0–0–1-1). The total score ranged from 0 to 12, with higher scores indicating a greater degree of psychological distress. The measure demonstrated adequate internal validity (Cronbach’s alpha of 0.90).

 Duke-UNC functional social support questionnaire (DUKE-UNC-11)

The Duke-UNC-11 questionnaire (57), which was validated for use in Spanish populations (58), was utilized to collect information regarding perceived personal social support. The questionnaire comprises 11 items, each scored on a Likert-like scale ranging from 1 (‘much less than I would like’) to 5 (‘as much as I would like’). The total perceived social support score is obtained by adding together the scores of all 11 items, which range from 11 to 55, with higher scores indicating a greater level of perceived social support. Internal validity was adequate (Cronbach’s alpha of 0.90).

 Death anxiety inventory (DAI)

The level of death anxiety was assessed using the Death Anxiety Inventory (DAI), which was initially developed in Spanish (59). The DAI consists of 20 items, and respondents rated their agreement with each item on a 5-point Likert scale ranging from 1 (‘totally disagree’) to 5 (‘totally agree’). The total possible score ranges from 20 to 100, with higher scores indicating a higher level of death anxiety. The DAI had excellent internal consistency in this sample (Cronbach’s alpha of 0.92).

 Subjective happiness scale (SHS)

Subjective happiness was assessed using the Subjective Happiness Scale (SHS) (60), which has been validated for use in Spain (61). The scale comprises 4 items presented in a Likert format that measure global subjective happiness through self-rated statements or by comparing oneself to others. The Likert-type scale ranges from 1 (‘not at all’) to 7 (‘to a great extent’), and the total score ranges from 4 to 28 points. Higher scores on the SHS indicate greater levels of global subjective happiness. The scale has an adequate unitary structure and temporal stability, as confirmed in these samples (Cronbach’s alpha of 0.81).

 Life orientation test-revised (LOT-R)

The Life Orientation Test-Revised (LOT-R) (62, 63), which has been adapted for use in Spanish (64, 65), was used to quantitatively assess the participants’ levels of optimism. The LOT-R comprises ten items, with three items measuring optimism (items 1, 4, and 10), three items measuring pessimism (items 3, 7, and 9), and four neutral filler items (items 2, 5, 6, and 8). Response options are on a Likert scale ranging from 0 (‘strongly disagree’) to 4 (‘strongly agree’), resulting in a total scale range of 0 to 24, which contains both the optimism scale and the inverted pessimism scale. Higher scores on the LOT-R indicate higher levels of optimism. The measure showed appropriate internal validity (Cronbach’s alpha of 0.68).

 Connor-Davidson resilience scale (CD-RISC)

The level of resilience was measured using the Connor-Davidson Resilience Scale (CD-RISC), a 10-item scale developed by Campbell and Stein (66) and validated in Spain by Notario et al. (67). Each item is rated on a 5-point Likert scale ranging from 0 (‘not true at all’) to 4 (‘true nearly all the time’). The total score ranges from 0 to 40, with higher scores indicating higher levels of resilience. Cronbach’s alpha displayed a good internal consistency (Cronbach’s alpha of 0.84).

 Athens insomnia scale (AIS-8)

The Athens Insomnia Scale (AIS-8) (68), validated in Spain (69), was used to measure insomnia. The scale consists of 8 items that assess various aspects of sleep difficulty, including sleep induction, night wakings, early morning waking, total sleep time, sleep quality, and the consequences of insomnia the following day, including its effects on functional capacity, well-being, and sleepiness. Responses are rated on a Likert scale from 0 (‘no problem’) to 3 (‘serious problem’). The total score ranges from 0 to 24 points, with higher scores indicating more severe insomnia. The measure showed appropriate internal validity (Cronbach’s alpha of 0.82).

 Ethics statement

The study received approval from the clinical research ethics committee (approval number 316, reference 4845).

The study adhered to the principles of good clinical practice and followed the ethical guidelines outlined in the latest version of the Declaration of Helsinki, including the Oviedo agreement, as well as Law 14/2007, dated July 3, concerning Biomedical Research. The confidentiality of the data was strictly maintained at all times by ensuring the anonymity of the data on the database, in compliance with Organic Law 3/2018, dated December 5, on the Protection of Personal Data and guaranteeing digital rights.

 Statistical analysis

Descriptive statistics were used to analyze both the categorical variables, including frequencies and percentages, and the quantitative variables, including means and standard deviations. The Kolmogorov–Smirnov test was also used to assess the normality of the variables. Student’s t and ANOVA tests were used to investigate the relationship between FCV-19S scores and the socio-demographic/health-related determinants, variables related to COVID-19 and variables related to the psychological impact of the COVID-19 pandemic, and Pearson’s correlation test was used for correlations between quantitative variables. The variables that demonstrated a statistically significant association with Fear of COVID-19 scores (p < 0.05) were later integrated into a multivariable linear regression model. The goodness of fit of the final model was assessed using the adjusted coefficient of determination R2. Validation of the collinearity conditions (through analysis of the variance inflation factor), normality, and independence of residuals was confirmed using the normality test and Durbin-Watson test, respectively. The IBM SPSS Statistical package version 26.0.0 (IBM Corp, Armonk, NY, United States), licensed to the University of Seville (Spain), was used to carried out the statistical analysis.

 Results Descriptive analysis of socio-demographic characteristics and health-related determinants in Spanish university students

We evaluated the data from 950 Spanish university students, mostly aged 18 to 24 years old (92.74%). Most of these students were women (74.11%), did not engage in spiritual practice (70.53%), lived in a town with over 100,000 inhabitants (44.00%), and their self-assessed state of health in the past 12 months was good (55.37%) (Table 1).

Socio-demographic characteristics and health-related determinants of Spanish university students (n = 950).

Variables Frequency Percentage
Gender
Female 704 74.11
Male 246 25.89
Age
18−24 years 881 92.74
25−35 years 47 4.95
> 35 years 22 2.32
Religious belief
No 361 38.00
Yes 589 62.00
Spiritual practice
No 670 70.53
Yes 280 29.47
Believe in life after death
No 416 43.79
Yes 534 56.21
Population of town/city
< 10,000 inhabitants 178 18.74
10,000−100,000 inhabitants 354 37.26
> 100,000 inhabitants 418 44.00
Type of housing
Flat without balcony, terrace or courtyard 122 12.84
House without garden or courtyard 26 2.74
Flat with balcony, terrace or courtyard 427 44.95
House with garden or courtyard 375 39.47
Leisure-time physical activity
I do no exercise - I spend my free time almost exclusively sitting down 165 17.37
I occasionally do sports or physical exercise 278 29.26
I do physical exercise several times a month 161 16.95
I do sports or physical exercise several times a week 346 36.42
Current smoker
No 840 88.42
Yes 110 11.58
Frequency of alcohol consumption in the past 12 months
Never 166 17.47
Less than once a month 300 31.58
Monthly 243 25.58
Weekly 221 23.26
Daily or almost daily 20 2.11
Self-assessed state of health in the past 12 months
Very good 156 16.42
Good 526 55.37
Average 225 23.68
Bad 38 4.00
Very bad 5 0.53
Variables Mean Standard deviation
Number of people sharing the accommodation 2.88 0.98
Descriptive analysis of variables related to COVID-19 in Spanish university students

The majority of participants reported not living with someone considered to be in a group vulnerable to COVID-19 (56.11%), watching television only at specific times to stay informed about COVID-19 (64.95%), using the Internet only at specific times to stay informed about COVID-19 (58.95%), using social networks to stay informed about COVID-19 only at specific times (51.16%), and spending little or no time reading the press (newspapers) to stay informed about COVID-19 (67.58%). In addition to this, the participants felt that the probability of surviving if they became infected with COVID-19 were high (4.49 ± 0.72 points). Moreover, they considered the preventive measures to be moderately effective (3.06 ± 0.88 points) and were moderately satisfied (2.81 ± 0.99 points) with the measures adopted to control the COVID-19 pandemic in Spain.

In terms of actions taken to prevent the spread of COVID-19, the majority of Spanish university students reported always wearing a mask (85.69%), covering their mouth and nose with their elbow when coughing or sneezing (74.10%), and prioritizing outdoor spaces when going outside (71.58%) (Figure 1).

Actions to help preventing the spread of COVID-19 by Spanish university students (n = 950).

 Descriptive and correlational analysis of fear of COVID-19 and variables related to the psychological impact of the COVID-19 pandemic

As shown in Table 2, the average fear of COVID-19 score among Spanish university students was found to be 14.86 ± 5.16 points and was positively correlated with common mental disorders (r = 0.680, p = 0.036) and death anxiety (r = 0.472, p < 0.001). On the contrary, fear of COVID-19 was negatively correlated with social support (r = −0.081, p = 0.012), optimism (r = −0.142, p < 0.001), resilience (r = −0.156, p < 0.001) and insomnia (r = −0.157, p < 0.001).

Description and correlation between fear of COVID-19 and variables related to the psychological impact of the COVID-19 pandemic in Spanish university students (n = 950).

Variables M (SD) (scores) FCV-19S r (value of p) GHQ-12 r (value of p) Duke-UNC-11 r (value of p) DAI r (value of p) SHS r (value of p) LOT-R r (value of p) CD-RISC r (value of p) AIS-8 r (value of p)
FCV-19S 14.86 (5.16) 1
GHQ-12 6.14 (1.56) 0.68 (0.036) 1
Duke-UNC-11 43.00 (9.06) −0.081 (0.012) 0.053 (0.101) 1
DAI 52.86 (16.51) 0.472 (<0.001) 0.071 (0.029) 0.006 (0.857) 1
SHS 18.18 (2.73) −0.061 (0.060) −0.002 (0.962) 0.172 (<0.001) −0.023 (0.488) 1
LOT-R 14.14 (3.92) −0.142 (<0.001) −0.162 (< 0.001) 0.196 (<0.001) −0.122 (<0.001) 0.349 (<0.001) 1
CD-RISC 27.50 (6.46) −0.156 (<0.001) −0.083 (0.010) 0.183 (<0.001) −0.162 (<0.001) 0.364 (<0.001) 0.435 (<0.001) 1
AIS-8 5.91 (3.98) −0.157 (<0.001) 0.097 (0.003) −0.256 (<0.001) 0.077 (0.018) −0.253 (<0.001) −0.309 (<0.001) −0.189 (<0.001) 1

FCV-19S, COVID-19 Fear Scale; GHQ-12, General Health Questionnaire; Duke-UNC-11, Functional Social Support Questionnaire; DAI, Death Anxiety Inventory; SHS, Subjective Happiness Scale; LOT-R, Life Orientation Test-Revised; CD-RISC, Connor-Davidson Resilience Scale; AIS-8, Athens Insomnia Scale; M, Mean; SD, Standard deviation; r, Pearson’s r.

 Relationship of the fear of COVID-19 with socio-demographic characteristics and health-related determinants in Spanish university students

Statistically significant differences in socio-demographic characteristics and health-related determinants among Spanish university students were observed (Table 3). A higher score of fear of COVID-19 was reported among females (t = −6.11, p < 0.0001), those who lived in a town with less than 10,000 inhabitants (F = 1.82, p = 0.009), those who practiced a religion (t = 0.24, p < 0.0001) and believed in life after death (t = −1.09, p = 0.018), and participants who reported a bad self-assessed state of health in the past 12 months (F = 2.07, p < 0.0001).

Comparative analysis of participants’ Fear of COVID-19 scores and socio-demographic characteristics and health-related determinants in Spanish university students (n = 950).

Variables Fear of COVID-19 Scale (score)
M (SD) t value F Value of p
Gender −6.11 < 0.001
Female 15.45 (5.09)
Male 13.16 (5.01)
Age 1.02 0.518
18−24 years 14.88 (5.17)
25−35 years 14.91 (4.87)
> 35 years 13.91 (5.75)
Religious belief −2.68 < 0.001
No 14.05 (4.97)
Yes 15.35 (5.22)
Spiritual practice 0.24 0.462
No 14.79 (5.21)
Yes 15.02 (5.06)
Believe in life after death −1.09 0.018
No 14.40 (5.05)
Yes 15.22 (5.22)
Population of town/city 1.82 0.009
< 10,000 inhabitants 16.06 (5.74)
10,000−100,000 inhabitants 14.58 (4.91)
> 100,000 inhabitants 14.58 (5.05)
Type of housing 1.65 0.859
Flat without balcony, terrace or courtyard 14.64 (5.26)
House without garden or courtyard 15.58 (6.31)
Flat with balcony, terrace or courtyard 14.87 (4.96)
House with garden or courtyard 14.87 (5.28)
Leisure-time physical activity 0.96 0.524
I do no exercise - I spend my free time almost exclusively sitting down 15.05 (5.25)
I occasionally do sports or physical exercise 14.92 (5.29)
I do physical exercise several times a month 15.20 (5.09)
I do sports or physical exercise several times a week 14.56 (5.05)
Current smoker 1.28 0.854
No 14.87 (5.22)
Yes 14.79 (4.68)
Frequency of alcohol consumption in the past 12 months 1.27 0.099
Never 15.20 (5.60)
Less than once a month 15.43 (5.54)
Monthly 14.65 (4.86)
Weekly 14.03 (4.50)
Daily or almost daily 15.15 (5.10)
Self-assessed state of health in the past 12 months 2.07 <0.001
Very good 13.41 (4.95)
Good 14.62 (4.93)
Average 16.02 (5.37)
Bad 17.13 (5.90)
Very bad 16.00 (5.15)
Variables Pearson’s r Value of p
Number of people sharing the accommodation −0.070 0.777

M, Mean; SD, Standard deviation.

 Comparison of the fear of COVID-19 and variables related to COVID-19 in Spanish university students

Fear of COVID-19 was higher in university students who lived with someone considered to be in a group vulnerable to COVID-19 (t = −2.24, p = 0.022), watched television, used the Internet and social networks most of the day to stay informed about COVID-19 (F = 3.41, p < 0.0001; F = 2.11, p = 0.010; F = 2.03, p < 0.0001, respectively), and spent only a short time reading the press (newspapers) to stay informed about COVID-19 (F = 2.03, p = 0.040). Lastly, a negative correlation was found between fear of COVID-19 and the probability of the participants believing they could survive if they became infected with COVID-19 (r = −0.580, p = 0.009; Table 4).

Comparative analysis of participants’ fear of COVID-19 Scale scores and variables related to COVID-19 in Spanish university students (n = 950).

Variables Fear of COVID-19 Scale (score)
M (SD) t value F Value of p
Living with someone considered to be in a vulnerable group to COVID-19 −2.24 0.022
No 14.49 (5.00)
Yes 15.33 (5.33)
Time spent watching television to stay informed about COVID-19 3.41 < 0.001
Little or not at all 13.30 (4.95)
Only at specific times 15.48 (5.05)
Most of the day 16.60 (5.87)
Time spent using the Internet to stay informed about COVID-19 2.11 0.010
Little or not at all 14.08 (5.24)
Only at specific times 15.21 (5.04)
Most of the day 15.26 (5.44)
Time spent using social networks to stay informed about COVID-19 2.03 < 0.001
Little or not at all 13.84 (5.01)
Only at specific times 15.44 (5.13)
Most of the day 15.53 (5.33)
Time spent reading the press (newspapers) to stay informed about COVID-19 1.16 0.040
Little or not at all 14.53 (5.00)
Only at specific times 15.55 (5.45)
Most of the day 15.47 (5.10)
Variables Pearson’s r Value of p
The probability you think you have of surviving if you become infected with SARS-CoV-2 −0.580 0.009
How effective you think preventive measures are to avoid infection with COVID-19 0.158 0.518
How satisfied you are with the measures adopted to control the COVID-19 pandemic 0.281 0.243

M, Mean; SD, Standard deviation.

 Multivariate linear regression model between fear of COVID-19 and independent variables in Spanish university students

The results of the multiple linear regression analyzes are shown in Tables 5, 6 (Adjusted R2 = 0.35). Fear of COVID-19 was determined by gender (t = 3.54, p < 0.001), religious beliefs (t = 2.00, p = 0.04), population of town/city (t = −3.33, t = −3.41, p < 0.01), living with someone considered to belong to a group vulnerable to COVID-19 (t = 2.26, p = 0.02), watching TV only at specific times (t = 5.38, p < 0.001) or most of the day (t = 3.27, p < 0.01) to stay informed about COVID-19, perceived probability of surviving a COVID-19 infection (t = −7.62, p < 0.001; Table 5), level of death anxiety (t = 14.88, p < 0.001) and level of insomnia (t = 4.43, p < 0.001; Table 6).

Multivariate linear regression model between fear of COVID-19 scores and socio-demographic, health-related determinants and variables related to COVID-19 (n = 950).

Variables Crude analysis Adjusted analysis†
B β t statistic Value of p B β t statistic Value of p
Gender
Female 2.29 0.19 6.11 <0.001 1.12 0.10 3.54 < 0.001
Male Ref. Ref. Ref. Ref.
Age
18−24 years 0.97 0.05 0.87 0.38
25−35 years 1.01 0.04 0.75 0.45
> 35 years Ref. Ref.
Religious belief
No Ref. Ref. < 0.001 Ref. Ref. 0.04
Yes 1.30 0.12 3.80 0.57 0.05 2.00
Spiritual practice
No Ref. Ref. 0.54
Yes 0.22 0.02 0.61
Believe in life after death
No Ref. Ref. 0.02
Yes 0.81 0.08 2.41
Population of town/city
< 10,000 inhabitants Ref. Ref. Ref. Ref.
10,000−100,000 inhabitants –1.48 –0.14 −3.14 <0.01 –1.29 –0.12 −3.33 <0.01
> 100,000 inhabitants –1.47 –0.13 −3.22 <0.01 –1.28 –0.11 −3.41 <0.01
Type of housing
Flat without balcony, terrace or courtyard Ref. Ref.
House without garden or courtyard 0.94 0.03 0.84 0.40
Flat with balcony, terrace or courtyard 0.23 0.02 0.43 0.67
House with garden or courtyard 0.24 0.02 0.44 0.66
Leisure-time physical activity
I do no exercise - I spend my free time almost exclusively sitting down Ref. Ref.
I occasionally do sports or physical exercise –0.31 –0.01 −0.26 0.80
I do physical exercise several times a month –0.16 0.01 −0.27 0.78
I do sports or physical exercise several times a week –0.49 –0.05 −0.99 0.32
Current smoker
No Ref. Ref. 0.88
Yes –0.08 –0.005 −0.15
Frequency of alcohol consumption in the past 12 months
Never Ref. Ref.
Less than once a month 0.23 0.02 0.65
Monthly –0.55 –0.05 0.29
Weekly –1.17 –0.10 0.03
Daily or almost daily –0.06 –0.002 0.96
Self-assessed state of health in the past 12 months
Very good Ref. Ref.
Good 1.21 0.12 2.61 <0.01
Average 2.61 0.22 4.93 <0.001
Bad 3.72 0.14 4.05 <0.001
Very bad 2.59 0.04 1.12 0.26
Number of people sharing the accommodation –0.36 –0.07 −2.12 0.03
Living with someone considered to be in a vulnerable group to COVID-19
No Ref. Ref. 0.01 Ref. Ref. 0.02
Yes 0.84 0.08 2.49 0.63 0.06 2.26
Time spent watching television to stay informed about COVID-19
Little or not at all Ref. Ref. Ref. Ref.
Only at specific times 2.18 0.20 6.06 <0.001 1.63 0.15 5.38 <0.001
Most of the day 3.30 0.13 3.95 <0.001 2.28 0.09 3.27 <0.01
Time spent using the Internet to stay informed about COVID-19
Little or not at all Ref. Ref.
Only at specific times 1.13 0.11 3.06 <0.01
Most of the day 1.18 0.07 1.92 0.06
Time spent using social networks to stay informed about COVID-19
Little or not at all Ref. Ref.
Only at specific times 1.60 0.16 4.46 <0.001
Most of the day 1.69 0.11 3.08 <0.01
Time spent reading the press (newspapers) to stay informed about COVID-19
Little or not at all Ref. Ref.
Only at specific times 1.02 0.09 2.81 <0.01
Most of the day 0.94 0.03 0.79 0.43
The probability you think you have of surviving if you become infected with SARS-CoV-2 –2.32 –0.32 −10.48 <0.001 –1.49 –0.21 −7.62 <0.001
How effective you think preventive measures are to avoid infection with COVID-19 –0.25 –0.04 −1.31 0.19
How satisfied you are with the measures adopted to control the COVID-19 pandemic –0.25 –0.05 −1.45 0.15

†Adjusted for variables related to the psychological impact of the COVID-19 pandemic; B = Estimated parameter; Ref.: Reference; Adjusted R-Squared = 0.35; F = 51.24; p < 0.001.

Multivariate linear regression model between fear of COVID-19 scores and variables related to the psychological impact of the COVID-19 pandemic of Spanish university students (n = 950).

Variables Crude analysis Adjusted analysis†
B β t statistic value of p B β t statistic value of p
Common mental disorders 0.19 0.06 1.73 0.08
Perceived social support –0.04 –0.08 −2.39 0.02
Death anxiety 0.15 0.48 16.75 <0.001 0.13 0.40 14.88 < 0.001
Subjective happiness –0.11 –0.06 −1.78 0.08
Optimism –0.19 –0.14 −4.43 <0.001
Resilience –0.10 –0.15 −4.68 <0.001
Insomnia 0.23 0.18 5.54 <0.001 0.16 0.12 4.43 <0.001

†Adjusted for socio-demographic, health-related determinants and variables related to COVID-19; B = Estimated parameter; Ref.: Reference; Adjusted R-Squared = 0.35; F = 51.24; p < 0.001.

 Discussion Main findings

The present study presents a multidisciplinary approach to examine the relationship between fear of COVID-19 and multiple factors that may influence the psychological impact of the COVID-19 pandemic on Spanish university students. Overall, the study found that the average fear of COVID-19 score was 14.86 ± 5.16 points. Several factors were identified as predictors of fear of COVID-19, including being female, holding religious beliefs, residing in towns/cities with over 10,000 inhabitants, living with someone vulnerable to COVID-19, and watching TV to stay informed about COVID-19 either at specific times or for most of the day. Additionally, the higher the participants’ perceived probability of surviving a COVID-19 infection, the lower their fear of COVID-19 score. However, the fear of COVID-19 score increased with every one-point increase in the level of death anxiety and insomnia.

According to our results, the level of fear of COVID-19 among Spanish university students was found to be lower than that reported in other studies conducted in the same context in Spain (25, 70, 71). In contrast, other countries have reported higher average scores of fear of COVID-19, including China (27), Pakistan (28), Russia and Belarus (29) and Turkey (26). Spain was one of the countries in the world most affected by the first wave of the COVID-19 pandemic (72–74). The measures implemented by the Spanish government, autonomous communities and Spanish universities to ensure the safety and well-being of students during the COVID-19 pandemic (75, 76) may have contributed to reducing fear of COVID-19 in this population group. In fact, our study also found that the majority of participants reported engaging in preventive practices such as wearing masks, covering their mouth and nose with their elbow when coughing or sneezing, and always prioritizing outdoor spaces when going outside. In that context, measures such as limiting face-to-face attendance at universities (77), promoting online classes (78), and implementing health safety protocols (79) may have contributed to creating a sense of safety and confidence among students (80).

Fear of COVID-19 may have affected women and men differently (81), with women having a higher perceived risk of infection (82). Various studies have shown that women experienced higher levels of stress, anxiety, and depression related to the COVID-19 pandemic compared to men (83–85). It is also important to note that women often take on caregiving roles (86, 87) and work as front-line health-care workers (88), which put them at greater risk and vulnerability during COVID-19 pandemic (89).

One of the best-known coping strategies to deal with the negative effects that the COVID-19 pandemic had on the mental health of the population was having religious beliefs, attitudes, or practices (90–94). Nevertheless, our study participants who believed in a religion showed a higher score for fear of COVID-19, in line with other studies (95–97). According to Krok et al. (98), the fear of COVID-19 also intensified the effect of religiosity on meaning-making, leading individuals to seek religious activities for emotional support and coping strategies.

According to our results, university students who lived in a town/city with over 10,000 inhabitants had higher fear of COVID-19 scores, in agreement with other studies (99, 100). This may be because people living in urban areas may be more exposed to the virus due to the higher population density and more frequent social interactions (101).

We also found that university students who lived with someone considered to be in a high-risk group for COVID-19 experienced a significantly greater fear of COVID-19, in line with other studies (102, 103). It is likely that people experienced higher levels of anxiety due to the fear of infecting their sick relatives as well as from the fear of contracting SARS-CoV-2 coronavirus themselves (104). Watching TV to stay informed about COVID-19 was identified as another factor that contributed to the greater fear of COVID-19 among study participants. This finding is consistent with the idea that the coverage of COVID-19 in the mainstream media focused predominantly on negative issues (105), disseminating uncertainties about the virus, the global spread of the pandemic (106), the increasing number of cases and fatalities (107), government policies (108), and the rising demand for healthcare (109), all of which had psychological implications.

Finally, university students reported feeling less fear of COVID-19 if they believed they could survive the disease, whether they were already infected or might become infected in the future, in agreement with Tusey et al. (110). In fact, participants in the study by Mousavi et al. (111), who believed they had a low probability of surviving if infected with COVID-19 were more likely to practice preventive behavior. Considering that a significant majority of the participants in the present study were under 25 years of age, this is likely to be due to the scientific literature reporting high SARS-CoV-2 transmissibility but relatively low mortality rates in this age range (112–114). Nevertheless, survivors who had COVID-19 perceived the disease as a factor affecting their existence and reported having a fear of death (115–118). In fact, it is not surprising that death anxiety arises when individuals face the threat of death due to either experiencing or fearing COVID-19 (119). In this case, the effective utilization of mindfulness and coping strategies can assist individuals in managing stressful situations, decreasing negative emotions (120) and improving sleep quality (121). Fear plays a determinant factor in modifying normal sleep patterns (122, 123), and so the connection between the fear of COVID-19 and sleep problems could be linked to concerns about the contagious nature of the disease (124), as supported by other studies (125, 126). Nevertheless, when Cerqueira et al. (127) asked university students about the quality of their sleep in the COVID-19 pandemic, 55.7% described it as either ‘very good’ or ‘good in general’. In addition, Wright et al. (128) reported that during the lockdown period, time in bed increased by around 30 min on weekdays and 24 min at weekends, sleep timing regularity improved by approximately 12 min, and university students extended the duration of their sleep by about 50 min on weekdays and approximately 25 min at weekends, thereby reducing social jetlag. Leone et al. (129) attributed the improvement in weekday sleep duration and the reduction in social jetlag to a plausible explanation based on lifestyle changes associated with weaker social cues, such as work and class schedules becoming more flexible, delayed, or even absent. t.

 Strengths and limitations

One of the major strengths of this study was its multidisciplinary approach, which explored the relationship between fear of COVID-19 and various factors that may have affected the psychological impact of the pandemic on Spanish university students, using a considerable number of validated questionnaires. Nevertheless, the study has several limitations. Firstly, its cross-sectional design means that no causal relationships can be established. Secondly, the study was conducted from December 2020 to December 2021, and therefore further research is needed to investigate how levels of fear of COVID-19 may have changed over time. Thirdly, the use of questionnaires as a data collection method is subject to the participants’ truthfulness in responding. For example, using self-report measures may not reflect people’s real opinions and feelings due to the demands of social desirability (130). Lastly, the study’s non-probabilistic convenience sample of university students from the southern region of Spain limits the generalizability of its findings.

 Implications for research and practice

This study highlights the significance of fear of COVID-19 and its impact on the mental health of university students. Previous research has demonstrated that a significant proportion of Spanish university students suffer from mental health disorders (131), and that the COVID-19 pandemic exacerbated negative mental health outcomes (132). These findings can help to identify specific factors that contribute to the fear of COVID-19 and enable us to develop coping strategies to alleviate the stress caused by the pandemic. They may also help policymakers and health professionals in devising suitable strategies to address the pandemic’s long-term effects on mental health, for example, by emphasizing the need to enable universities to make decisions regarding changes to the curriculum and assessment methods that align with students’ well-being and mental health expectations (133). This could include flexible academic schedules, reduced workloads during future pandemics, and the option of distance-learning to accommodate students’ needs during a pandemic (134). Furthermore, the study suggests that universities may be an ideal environment for implementing health promotion programs focusing on mental health and well-being (135), as they allow students to develop coping skills and better understand how to manage fear during a pandemic.

 Conclusion

A score of 14.86 ± 5.16 points was identified as the average level of fear of COVID-19 among university students in Spain. The main predictors of fear of COVID-19 are being female, having religious beliefs, living in towns/cities with over 10,000 inhabitants, living with someone vulnerable to COVID-19, watching TV to stay informed about COVID-19, believing in a low probability of survival if infected with COVID-19, and having a higher level of death anxiety and insomnia. The findings of this study, which identify numerous factors related to fear of COVID-19, can aid policymakers and health professionals in developing appropriate strategies to address the pandemic’s long-term effects on mental health. In addition, these findings can facilitate future research on coping strategies for university students facing the stress caused by a pandemic.

 Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

 Ethics statement

The studies involving humans were approved by Ethical Committee for Clinical Research of Cordoba (Spain) (approval number 316, reference 4845). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

 Author contributions

JC: conceptualization, methodology, and writing–original draft. JC and SP: data curation, data analysis, resources, visualization, project administration, methodology, and writing–reviewing and editing. SP: supervision. All authors contributed to the article and approved the submitted version.

Our gratitude goes to all the students who participated in the current study.

 Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

 Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

 References Zhu N Zhang D Wang W Li X Yang B Song J . A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. (2020) 382:727–33. doi: 10.1056/nejmoa2001017, PMID: 31978945 World Health Organization. Coronavirus disease (COVID-19) pandemic. Geneva: World Health Organization. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019 (Accessed September 1, 2023). Agencia Estatal Boletín Oficial del Estado. (2020). Real Decreto 463/2020, de 14 de marzo, por el que se declara el estado de alarma para la gestión de la situación de crisis sanitaria ocasionada por el COVID-19. Available at: https://www.boe.es/buscar/doc.php?id=BOE-A-2020-3692 (Accessed September 1, 2023). World Health Organization. Coronavirus disease 2019 (COVID-19) situation report–153. (2023). Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200621-covid-19-sitrep-153.pdf?sfvrsn=c896464d_2 (Accessed September 1, 2023). Jiménez-Pavón D Carbonell-Baeza A Lavie CJ. Physical exercise as therapy to fight against the mental and physical consequences of COVID-19 quarantine: special focus in older people. Prog Cardiovasc Dis. (2020) 63:386–8. doi: 10.1016/j.pcad.2020.03.009, PMID: 32220590 Saraf A Sathe H Mishra K John S. A cross-sectional study of psychological distress and fear of COVID-19 in the general population of India during lockdown. Ann Ind Psychiatr. (2020) 4:181. doi: 10.4103/aip.aip_54_20 Chen P Mao L Nassis GP Harmer P Ainsworth BE Li F. Coronavirus disease (COVID-19): the need to maintain regular physical activity while taking precautions. J Sport Health Sci. (2020) 9:103–4. doi: 10.1016/j.jshs.2020.02.001, PMID: 32099716 Wang C Pan R Wan X Tan Y Xu L Ho CS . Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. (2020) 17:1729. doi: 10.3390/ijerph17051729, PMID: 32155789 Planchuelo Á Odriozola P Irurtia MJ de Luis R. Longitudinal evaluation of the psychological impact of the COVID-19 crisis in Spain. J Affect Disord. (2020) 277:842–9. doi: 10.1016/j.jad.2020.09.018, PMID: 33065825 Odriozola P Planchuelo Á Irurtia MJ De Luis R. Psychological effects of the COVID-19 outbreak and lockdown among students and workers of a Spanish university. Psychiatry Res. (2020) 290:113108. doi: 10.1016/j.psychres.2020.113108, PMID: 32450409 Gullone E. The development of normal fear. Clin Psychol Rev. (2000) 20:429–51. doi: 10.1016/s0272-7358(99)00034-3 Ahorsu DK Lin C-Y Pakpour AH. The association between health status and insomnia, mental health, and preventive behaviors: the mediating role of fear of COVID-19. Gerontol Geriatr Med. (2020) 6:233372142096608. doi: 10.1177/2333721420966081, PMID: 33195740 Tzur Bitan D Grossman-Giron A Bloch Y Mayer Y Shiffman N Mendlovic S. Fear of COVID-19 scale: psychometric characteristics, reliability and validity in the Israeli population. Psychiatry Res. (2020) 289:113100. doi: 10.1016/j.psychres.2020.113100, PMID: 32425276 Coelho CM Suttiwan P Arato N Zsido AN. On the nature of fear and anxiety triggered by COVID-19. Front Psychol. (2020) 11:581314. doi: 10.3389/fpsyg.2020.581314, PMID: 33240172 Satici B Gocet-Tekin E Deniz ME Satici SA. Adaptation of the fear of COVID-19 scale: its association with psychological distress and life satisfaction in Turkey. Int J Ment Health Addict. (2021) 19:1980–8. doi: 10.1007/s11469-020-00294-0, PMID: 32395095 Smith BM Twohy AJ Smith GS. Psychological inflexibility and intolerance of uncertainty moderate the relationship between social isolation and mental health outcomes during COVID-19. J Contextual Behav Sci. (2020) 18:162–74. doi: 10.1016/j.jcbs.2020.09.005, PMID: 32953435 Mahmud MS Talukder MU Rahman SM. Does ‘fear of COVID-19’ trigger future career anxiety? An empirical investigation considering depression from COVID-19 as a mediator. Int J Soc Psychiatry. (2021) 67:35–45. doi: 10.1177/0020764020935488, PMID: 32615833 Barello S Palamenghi L Graffigna G. Burnout and somatic symptoms among frontline healthcare professionals at the peak of the Italian COVID-19 pandemic. Psychiatry Res. (2020) 290:113129. doi: 10.1016/j.psychres.2020.113129, PMID: 32485487 Dubey S Biswas P Ghosh R Chatterjee S Dubey MJ Chatterjee S . Psychosocial impact of COVID-19. Diabetes Metab Syndr. (2020) 14:779–88. doi: 10.1016/j.dsx.2020.05.035, PMID: 32526627 Garnier-Crussard A Forestier E Gilbert T Krolak-Salmon P. Novel coronavirus (COVID-19) epidemic: what are the risks for older patients? J Am Geriatr Soc. (2020) 68:939–40. doi: 10.1111/jgs.16407, PMID: 32162679 Li S Wang Y Xue J Zhao N Zhu T. The impact of COVID-19 epidemic declaration on psychological consequences: a study on active Weibo users. Int J Environ Res Public Health. (2020) 17:2032. doi: 10.3390/ijerph17062032, PMID: 32204411 Lima CKT Carvalho PMM Lima IAAS Nunes JVAO Saraiva JS de Souza RI . The emotional impact of coronavirus 2019-nCoV (new coronavirus disease). Psychiatry Res. (2020) 287:112915. doi: 10.1016/j.psychres.2020.112915, PMID: 32199182 Son C Hegde S Smith A Wang X Sasangohar F. Effects of COVID-19 on college students’ mental health in the United States: interview survey study. J Med Internet Res. (2020) 22:e21279. doi: 10.2196/21279, PMID: 32805704 Nania T Dellafiore F Caruso R Barello S. Risk and protective factors for psychological distress among Italian university students during the COVID-19 pandemic: the beneficial role of health engagement. Int J Soc Psychiatry. (2021) 67:102–3. doi: 10.1177/0020764020945729, PMID: 32721256 Muyor J Caravaca F Fernández JS. COVID-19 fear, resilience, social support, anxiety, and suicide among college students in Spain. Int J Environ Res Public Health. (2021) 18:8156. doi: 10.3390/ijerph18158156, PMID: 34360447 Yeni Elbay R Yılmaz H Çifteci K Karadere E. The psychological effects of COVID 19 on medical and non-medical university students. Psychiatr Danub. (2021) 33:126–31. PMID: 34672285 Yang W Li P Huang Y Yang X Mu W Jing W . Cross-cultural adaptation and validation of the fear of COVID-19 scale for Chinese university students: a cross-sectional study. Int J Environ Res Public Health. (2022) 19:8624. doi: 10.3390/ijerph19148624, PMID: 35886480 Green ZA Noor U Ahmed F Himayat L. Validation of the fear of COVID-19 scale in a sample of Pakistan’s university students and future directions. Psychol Rep. (2022) 125:2709–32. doi: 10.1177/00332941211016754, PMID: 34047221 Reznik A Gritsenko V Konstantinov V Khamenka N Isralowitz R. COVID-19 fear in eastern Europe: validation of the fear of COVID-19 scale. Int J Ment Health Addict. (2021) 19:1903–8. doi: 10.1007/s11469-020-00283-3, PMID: 32406404 Ahorsu DK Lin C-Y Imani V Saffari M Griffiths MD Pakpour AH. The fear of COVID-19 scale: development and initial validation. Int J Ment Health Addict. (2022) 20:1537–45. doi: 10.1007/s11469-020-00270-8, PMID: 32226353 Sakib N Bhuiyan AKMI Hossain S Al Mamun F Hosen I Abdullah AH . Psychometric validation of the Bangla fear of COVID-19 scale: confirmatory factor analysis and Rasch analysis. Int J Ment Health Addict. (2022) 20:2623–34. doi: 10.1007/s11469-020-00289-x, PMID: 32395096 Fang H Tu S Sheng J Shao A. Depression in sleep disturbance: a review on a bidirectional relationship, mechanisms and treatment. J Cell Mol Med. (2019) 23:2324–32. doi: 10.1111/jcmm.14170, PMID: 30734486 Ahmed MZ Ahmed O Aibao Z Hanbin S Siyu L Ahmad A. Epidemic of COVID-19 in China and associated psychological problems. Asian J Psychiatr. (2020) 51:102092. doi: 10.1016/j.ajp.2020.102092, PMID: 32315963 Redeker NS Conley S Anderson G Cline J Andrews L Mohsenin V . Effects of cognitive behavioral therapy for insomnia on sleep, symptoms, stress, and autonomic function among patients with heart failure. Behav Sleep Med. (2020) 18:190–202. doi: 10.1080/15402002.2018.1546709, PMID: 30461315 Rubin GJ Wessely S. The psychological effects of quarantining a city. BMJ. (2020) 368:m313. doi: 10.1136/bmj.m313 Siddique RF Ahmed O Hossain KN. Relationship between the fear of COVID-19 disease and sleep quality: the mediating role of stress. Heliyon. (2021) 7:e07033. doi: 10.1016/j.heliyon.2021.e07033, PMID: 34027200 Han B Ma C Liu Z Jiang R Zhang T Wang Y . Perceived psychological feelings make important contributions to the symptoms of common mental disorders of medical staff during the COVID-19. Front Psych. (2022) 12:8610. doi: 10.3389/fpsyt.2021.738610, PMID: 35153846 Menzies RE Menzies RG. Death anxiety in the time of COVID-19: theoretical explanations and clinical implications. Cogn Behav Therap. (2020) 13:e19. doi: 10.1017/s1754470x20000215, PMID: 34191938 Menzies RE Neimeyer RA Menzies RG. Death anxiety, loss, and grief in the time of COVID-19. Behav Change. (2020) 37:111–5. doi: 10.1017/bec.2020.10 Alnazly E Khraisat OM Al-Bashaireh AM Bryant CL. Anxiety, depression, stress, fear and social support during COVID-19 pandemic among Jordanian healthcare workers. PLoS One. (2021) 16:e0247679. doi: 10.1371/journal.pone.0247679, PMID: 33711026 Alves MP Costa V Cunha AI Carvalho P Loureiro MJ. Optimism and fear of COVID-19 in higher education students: the mediating role of general anxiety. Psychol Health Med. (2023) 28:241–52. doi: 10.1080/13548506.2022.2073376, PMID: 35510891 Satici SA Kayis AR Satici B Griffiths MD Can G. Resilience, hope, and subjective happiness among the Turkish population: fear of COVID-19 as a mediator. Int J Ment Health Addict. (2023) 21:803–18. doi: 10.1007/s11469-020-00443-5, PMID: 33293904 Gritsenko V Skugarevsky O Konstantinov V Khamenka N Marinova T Reznik A . COVID 19 fear, stress, anxiety, and substance use among Russian and Belarusian university students. Int J Ment Health Addict. (2021) 19:2362–8. doi: 10.1007/s11469-020-00330-z, PMID: 32837418 Grande M Doyle-Baker P. Fear of COVID-19 effects on university student’s health behaviours: the FRESH study. Int J Kinesiol Sports Sci. (2021) 9:52. doi: 10.7575/aiac.ijkss.v.9n.3p52 Cardoso JPP Afonso MVR Mendes BF Vieira ER Pereira WF Dias-Peixoto MF . Fear of COVID-19 influences physical activity practice: a study in a Brazilian sample. Psychol Health Med. (2023) 28:232–40. doi: 10.1080/13548506.2022.2072916, PMID: 35505523 Basseal JM Bennett CM Collignon P Currie BJ Durrheim DN Leask J . Key lessons from the COVID-19 public health response in Australia. Lancet Reg Health West Pac. (2023) 30:100616. doi: 10.1016/j.lanwpc.2022.100616, PMID: 36248767 Yeboah H Yaya S. Health and economic implications of the ongoing coronavirus disease (COVID-19) pandemic on women and children in Africa. Reprod Health. (2023) 20:70. doi: 10.1186/s12978-023-01616-w, PMID: 37158924 Mauz E Walther L Junker S Kersjes C Damerow S Eicher S . Time trends in mental health indicators in Germany’s adult population before and during the COVID-19 pandemic. Front Public Health. (2023) 11:1065938. doi: 10.3389/fpubh.2023.1065938, PMID: 36908429 Kohls E Guenthner L Baldofski S Brock T Schuhr J Rummel-Kluge C. Two years COVID-19 pandemic: development of university students’ mental health 2020–2022. Front Psych. (2023) 14:1122256. doi: 10.3389/fpsyt.2023.1122256, PMID: 37091715 Martínez-Lorca M Martínez-Lorca A Criado-Álvarez JJ Armesilla MDC Latorre JM. The fear of COVID-19 scale: validation in spanish university students. Psychiatry Res. (2020) 293:113350. doi: 10.1016/j.psychres.2020.113350, PMID: 32777619 Abundis-Espinosa VM. Beneficios de las encuestas electrónicas como apoyo para la investigación. Tlatemoani. (2016) 7:168–86. Parrado A León J. COVID-19: Factores asociados al malestar emocional y morbilidad psíquica en población española. Rev Esp Salud Pública. (2020) 4:e1–e16. Goldberg DP Hillier VF. A scaled version of the general health questionnaire. Psychol Med. (1979) 9:139–45. doi: 10.1017/s0033291700021644 Goldberg DP Williams P. Cuestionario de Salud General GHQ (General Health Questionnaire): Guía para el usuario de las distintas versiones. Barcelona: Masson (1996). 163 p. Sánchez-López MP Dresch V. The 12-item general health questionnaire (GHQ-12): reliability, external validity and factor structure in the Spanish population. Psicothema. (2008) 20:839–43. PMID: 18940092 Goldberg DP Gater R Sartorius N Ustun TB Piccinelli M Gureje O . The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med. (1997) 27:191–7. doi: 10.1017/s0033291796004242, PMID: 9122299 Broadhead WE Gehlbach SH De Gruy FV Kaplan BH. The Duke-UNC functional social support questionnaire: measurement of social support in family medicine patients. Med Care. (1988) 26:709–23. doi: 10.1097/00005650-198807000-00006 Bellón JA Delgado A Luna del Castillo JD Lardelli P. Validez y fiabilidad del cuestionario de apoyo social funcional Duke-UNC-11. Aten Primaria. (1996) 18:153–63. Tomás-Sábado J Gómez-Benito J. Construction and validation of the death anxiety inventory (DAI). Eur J Psychol Assess. (2005) 21:108–14. doi: 10.1027/1015-5759.21.2.108 Lyubomirsky S Lepper HS. A measure of subjective happiness: preliminary reliability and construct validation. Soc Indic Res. (1999) 46:137–55. doi: 10.1023/a:1006824100041 Extremera N Fernández-Berrocal P. The subjective happiness scale: translation and preliminary psychometric evaluation of a Spanish version. Soc Indic Res. (2014) 119:473–81. doi: 10.1007/s11205-013-0497-2 Scheier MF Carver CS Bridges MW. Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a reevaluation of the life orientation test. J Pers Soc Psychol. (1994) 67:1063–78. doi: 10.1037/0022-3514.67.6.1063, PMID: 7815302 Glaesmer H Rief W Martin A Mewes R Brähler E Zenger M . Psychometric properties and population-based norms of the life orientation test revised (LOT-R): psychometric properties of the LOT-R. Br J Health Psychol. (2012) 17:432–45. doi: 10.1111/j.2044-8287.2011.02046.x, PMID: 22106985 Ferrando PJ Chico E Tous JM. Propiedades psicométricas del test de optimismo Life Orientation Test. Psicothema. (2002) 14:673–80. Cano FJ Sanduvete S Chacón S Rodríguez L García J Antuña MA . Factor structure of the Spanish version of the life orientation test-revised (LOT-R): testing several models. Int J Clin Health Psychol. (2015) 15:139–48. doi: 10.1016/j.ijchp.2015.01.003, PMID: 30487831 Campbell L Stein MB. Psychometric analysis and refinement of the Connor-davidson resilience scale (CD-RISC): validation of a 10-item measure of resilience. J Trauma Stress. (2007) 20:1019–28. doi: 10.1002/jts.20271, PMID: 18157881 Notario B Solera M Serrano MD Bartolomé R García J Martínez V. Reliability and validity of the Spanish version of the 10-item Connor-Davidson resilience scale (10-item CD-RISC) in young adults. Health Qual Life Outcomes. (2011) 9:63. doi: 10.1186/1477-7525-9-63, PMID: 21819555 Soldatos CR Dikeos DG Paparrigopoulos TJ. Athens insomnia scale: validation of an instrument based on ICD-10 criteria. J Psychosom Res. (2000) 48:555–60. doi: 10.1016/s0022-3999(00)00095-7, PMID: 11033374 Gómez-Benito J Ruiz C Guilera G. A Spanish version of the Athens insomnia scale. Qual Life Res. (2011) 20:931–7. doi: 10.1007/s11136-010-9827-x, PMID: 21210225 Morales-Rodríguez FM. Fear, stress, resilience and coping strategies during COVID-19 in Spanish university students. Sustainability. (2021) 13:5824. doi: 10.3390/su13115824 Cantero PA Rodríguez M Moraleda E Polonio B Marcos F. Analysis of fear post COVID in first-year students after the incorporation to the classroom: descriptive study in university students of health sciences. Healthcare (Basel). (2021) 9:1621. doi: 10.3390/healthcare9121621, PMID: 34946348 Khafaie MA Rahim F. Cross-country comparison of case fatality rates of COVID-19/SARS-COV-2. Osong Public Health Res Perspect. (2020) 11:74–80. doi: 10.24171/j.phrp.2020.11.2.03, PMID: 32257772 Verelst F Kuylen E Beutels P. Indications for healthcare surge capacity in European countries facing an exponential increase in coronavirus disease (COVID-19) cases, march 2020. Euro Surveill. (2020) 25:2000323. doi: 10.2807/1560-7917.ES.2020.25.13.2000323, PMID: 32265003 Rodríguez M Rivas L Quiles JL Redondo D Aranda P Llopis J . The spread of SARS-CoV-2 in Spain: hygiene habits, sociodemographic profile, mobility patterns and comorbidities. Environ Res. (2021) 192:110223. doi: 10.1016/j.envres.2020.110223, PMID: 32971081 Legido H Mateos JT Campos VR Gea M Muntaner C McKee M. The resilience of the Spanish health system against the COVID-19 pandemic. Lancet Public Health. (2020) 5:e251–2. doi: 10.1016/S2468-2667(20)30060-8, PMID: 32199083 Government of Spain. Royal decree, of march 14, declaring the state of alarm for the management of the health crisis situation caused by COVID-19. Madrid: Spain (2020). Díaz RM Caravaca F Martín MC De la Fuente YM. Anxiety levels among social work students during the COVID-19 lockdown in Spain. Soc Work Health Care. (2020) 59:681–93. doi: 10.1080/00981389.2020.1859044, PMID: 33297878 Verde A Valero JM. Teaching and learning modalities in higher education during the pandemic: responses to coronavirus disease 2019 from Spain. Front Psychol. (2021) 12:648592. doi: 10.3389/fpsyg.2021.648592, PMID: 34504455 Aguilar AJ de la Hoz ML Oltra L Ruiz DP Martínez MD. Impact of COVID-19 protocols on IEQ and students’ perception within educational buildings in southern Spain. Build Res Inf. (2022) 50:755–70. doi: 10.1080/09613218.2022.2082356 Tuells J Egoavil CM Pena MA Montagud AC Montagud E Caballero P . Seroprevalence study and cross-sectional survey on COVID-19 for a plan to reopen the university of Alicante (Spain). Int J Environ Res Public Health. (2021) 18:1908. doi: 10.3390/ijerph18041908, PMID: 33669412 Abdelghani M Hassan MS Elgohary HM Fouad E. Exploring the factors associated with coronaphobia among physicians during the COVID-19 outbreak in Egypt. Egypt J Neurol Psychiatr Neurosurg. (2021) 57:105. doi: 10.1186/s41983-021-00357-6, PMID: 34341653 Ding Y Du X Li Q Zhang M Zhang Q Tan X . Risk perception of coronavirus disease 2019 (COVID-19) and its related factors among college students in China during quarantine. PLoS One. (2020) 15:e0237626. doi: 10.1371/journal.pone.0237626, PMID: 32790791 Moghanibashi-Mansourieh A. Assessing the anxiety level of Iranian general population during COVID-19 outbreak. Asian J Psychiatr. (2020) 51:102076. doi: 10.1016/j.ajp.2020.102076, PMID: 32334409 Zhou SJ Zhang LG Wang LL Guo ZC Wang JQ Chen JC . Prevalence and socio-demographic correlates of psychological health problems in Chinese adolescents during the outbreak of COVID-19. Eur Child Adolesc Psychiatry. (2020) 29:749–58. doi: 10.1007/s00787-020-01541-4, PMID: 32363492 Wang Y Di Y Ye J Wei W. Study on the public psychological states and its related factors during the outbreak of coronavirus disease 2019 (COVID-19) in some regions of China. Psychol Health Med. (2021) 26:13–22. doi: 10.1080/13548506.2020.1746817, PMID: 32223317 Bauer JM Sousa-Poza A. Impacts of informal caregiving on caregiver employment, health, and family. J Popul Ageing. (2015) 8:113–45. doi: 10.1007/s12062-015-9116-0 Cohen SA Sabik NJ Cook SK Azzoli AB Mendez-Luck CA. Differences within differences: gender inequalities in caregiving intensity vary by race and ethnicity in informal caregivers. J Cross Cult Gerontol. (2019) 34:245–63. doi: 10.1007/s10823-019-09381-9, PMID: 31407137 Boniol M McIsaac M Xu L Wulijiç T Diallo K Campbell J. Gender equity in the health workforce: Analysis of 104 countries. Geneva: World Health Organization (2019). Almeida M Shrestha AD Stojanac D Miller LJ. The impact of the COVID-19 pandemic on women’s mental health. Arch Womens Ment Health. (2020) 23:741–8. doi: 10.1007/s00737-020-01092-2, PMID: 33263142 Koenig HG. Spirituality in patient care: Why, how, when, and what. Radnor: Templeton Foundation Press (2007). 264 p. Ano GG Vasconcelles EB. Religious coping and psychological adjustment to stress: a meta-analysis. J Clin Psychol. (2005) 61:461–80. doi: 10.1002/jclp.20049, PMID: 15503316 Lucchetti G Góes LG Amaral SG Ganadjian GT Andrade I Almeida PO . Spirituality, religiosity and the mental health consequences of social isolation during Covid-19 pandemic. Int J Soc Psychiatry. (2021) 67:672–9. doi: 10.1177/0020764020970996, PMID: 33135559 Pirutinsky S Cherniak AD Rosmarin DH. COVID-19, mental health, and religious coping among American orthodox Jews. J Relig Health. (2020) 59:2288–301. doi: 10.1007/s10943-020-01070-z, PMID: 32705481 Yıldırım M Arslan G Alkahtani AM. Do fear of COVID-19 and religious coping predict depression, anxiety, and stress among the Arab population during health crisis? Death Stud. (2022) 46:2070–6. doi: 10.1080/07481187.2021.1882617, PMID: 33555985 Jaspal R Lopes B Lopes P. Fear, social isolation and compulsive buying in response to COVID-19 in a religiously diverse UK sample. Ment Health Relig Cult. (2020) 23:427–42. doi: 10.1080/13674676.2020.1784119 Prazeres F Passos L Simões JA Simões P Martins C Teixeira A. COVID-19-related fear and anxiety: spiritual-religious coping in healthcare workers in Portugal. Int J Environ Res Public Health. (2020) 18:220. doi: 10.3390/ijerph18010220, PMID: 33396750 Rajkumar RP. The relationship between pre-pandemic measures of religiosity and psychological responses to the COVID-19 pandemic: a secondary analysis of data from a multi-country study. Cureus. (2021) 13:e20013. doi: 10.7759/cureus.20013, PMID: 34873550 Krok D Zarzycka B Telka E. Religiosity, meaning-making and the fear of COVID-19 affecting well-being among late adolescents in Poland: a moderated mediation model. J Relig Health. (2021) 60:3265–81. doi: 10.1007/s10943-021-01375-7, PMID: 34417950 Nair D Rajmohan V Tm R. Impact of COVID-19 lockdown on lifestyle and psychosocial stress - an online survey. Kerala J Psychiatry. (2020) 33:194. doi: 10.30834/kjp.33.1.2020.194 Gaur G Sharma M Kundu M Sekhon H Chauhan N. Fear of COVID-19 among the Indian youth: a cross-sectional study. J Educ Health Promot. (2021) 10:340. doi: 10.4103/jehp.jehp_1455_20, PMID: 34761026 Ganasegeran K Jamil MFA Ch’ng ASH Looi I Peariasamy KM. Influence of population density for COVID-19 spread in Malaysia: an ecological study. Int J Environ Res Public Health. (2021) 18:9866. doi: 10.3390/ijerph18189866, PMID: 34574790 Mertens G Gerritsen L Duijndam S Salemink E Engelhard IM. Fear of the coronavirus (COVID-19): predictors in an online study conducted in march 2020. J Anxiety Disord. (2020) 74:102258. doi: 10.1016/j.janxdis.2020.102258, PMID: 32569905 Cerda AA García LY. Factors explaining the fear of being infected with COVID-19. Health Expect. (2022) 25:506–12. doi: 10.1111/hex.13274, PMID: 33974721 Baldi E Savastano S. Fear of contagion: one of the most devious enemies to fight during the COVID-19 pandemic. Disaster Med Public Health Prep. (2021) 15:e8–9. doi: 10.1017/dmp.2020.338, PMID: 32907670 Cowper A. Covid-19: are we getting the communications right? BMJ. (2020) 368:m919. doi: 10.1136/bmj.m919, PMID: 32144115 Wang Y Wang Y Chen Y Qin Q. Unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special control measures. J Med Virol. (2020) 92:568–76. doi: 10.1002/jmv.25748, PMID: 32134116 Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19) in the United States. (2020). Available at: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html (Accessed April 28, 2023). Lazzerini M Putoto G. COVID-19 in Italy: momentous decisions and many uncertainties. Lancet Glob Health. (2020) 8:e641–2. doi: 10.1016/S2214-109X(20)30110-8, PMID: 32199072 Rosenbaum L. Facing covid-19 in Italy - ethics, logistics, and therapeutics on the epidemic’s front line. N Engl J Med. (2020) 382:1873–5. doi: 10.1056/NEJMp2005492, PMID: 32187459 Tusev A Tonon L Capella M. The initial mental health effects of the covid-19 pandemic across some Ecuadorian provinces. Investigatio. (2020) 15:11–24. doi: 10.31095/investigatio.2020.15.2 Mousavi SH Delshad MH Acuti C Bhandari D Ozaki A Pourhaji F . Community behavioral and perceived responses in the COVID-19 outbreak in Afghanistan: a cross-sectional study. Disaster Med Public Health Prep. (2021) 16:1–7. doi: 10.1017/dmp.2021.135, PMID: 33947492 Acuti C Flacco ME Cappadona R Bravi F Mantovani L Manzoli L. SARS-CoV-2 pandemic: an overview. Adv Biol Regul. (2020) 77:100736. doi: 10.1016/j.jbior.2020.100736, PMID: 32773099 Tran HTT Nguyen MH Pham TTM Kim GB Nguyen HT Nguyen N-M . Predictors of eHealth literacy and its associations with preventive behaviors, fear of COVID-19, anxiety, and depression among undergraduate nursing students: a cross-sectional survey. Int J Environ Res Public Health. (2022) 19:3766. doi: 10.3390/ijerph19073766, PMID: 35409448 Perez-Saez J Lauer SA Kaiser L Regard S Delaporte E Guessous I . Serology-informed estimates of SARS-CoV-2 infection fatality risk in Geneva, Switzerland. Lancet Infect Dis. (2021) 21:e69–70. doi: 10.1016/S1473-3099(20)30584-3 Aliakbari M Eisazadeh F Aghajanbigloo S. Psychological consequences of patients with coronavirus (COVID- 19): a qualitative study. Iran J Health Psychol. (2019) 2:9–20. doi: 10.30473/ijohp.2020.52395.1074 Sun N Wei L Shi S Jiao D Song R Ma L . A qualitative study on the psychological experience of caregivers of COVID-19 patients. Am J Infect Control. (2020) 48:592–8. doi: 10.1016/j.ajic.2020.03.018, PMID: 32334904 Son H-M Choi W-H Hwang Y-H Yang H-R. The lived experiences of COVID-19 patients in South Korea: a qualitative study. Int J Environ Res Public Health. (2021) 18:7419. doi: 10.3390/ijerph18147419, PMID: 34299870 Muslu L Kolutek R Fidan G. Experiences of COVID-19 survivors: a qualitative study based on Watson’s theory of human caring. Nurs Health Sci. (2022) 24:774–84. doi: 10.1111/nhs.12979, PMID: 35899855 Özgüç S Kaplan Serin E Tanriverdi D. Death anxiety associated with coronavirus (COVID-19) disease: a systematic review and meta-analysis. Omega (Westport). (2021) 8:503. doi: 10.1177/00302228211050503, PMID: 34622711 Sadri Damirchi E Mojarrad A Pireinaladin S Grjibovski AM. The role of self-talk in predicting death anxiety, obsessive-compulsive disorder, and coping strategies in the face of coronavirus disease (COVID-19). Iran J Psychiatry. (2020) 15:182–8. doi: 10.18502/ijps.v15i3.3810, PMID: 33193766 Zhao Y Liu J-E Lewis FM Nie Z-H Qiu H Han J . Effects of mindfulness-based cognitive therapy on breast cancer survivors with insomnia: a randomised controlled trial. Eur J Cancer Care (Engl). (2020) 29:e13259. doi: 10.1111/ecc.13259, PMID: 32424878 Medina O Sánchez N Conejo J Fraguas D Arango C. Alteraciones del sueño en los trastornos psiquiátricos. Rev Colomb Psiquiatr. (2007) 36:701–17. Krystal AD. Psychiatric disorders and sleep. Neurol Clin. (2012) 30:1389–413. doi: 10.1016/j.ncl.2012.08.018, PMID: 23099143 Jahrami H BaHammam AS AlGahtani H Ebrahim A Faris M AlEid K . The examination of sleep quality for frontline healthcare workers during the outbreak of COVID-19. Sleep Breath. (2021) 25:503–11. doi: 10.1007/s11325-020-02135-9, PMID: 32592021 Xiao H Zhang Y Kong D Li S Yang N. The effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (COVID-19) in January and February 2020 in China. Med Sci Monit. (2020) 26:e923549. doi: 10.12659/MSM.923549, PMID: 32132521 Zhang C Yang L Liu S Ma S Wang Y Cai Z . Survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak. Front Psych. (2020) 11:306. doi: 10.3389/fpsyt.2020.00306, PMID: 32346373 Cerqueira TRDC Batista SG de Mello EB DosSantos MF Tuñas ITC. Impact of the COVID-19 pandemic on stress, sleep, and oral health in university students. Front Pain Res (Lausanne). (2021) 2:264. doi: 10.3389/fpain.2021.744264, PMID: 35295424 WrightKP Jr Linton SK Withrow D Casiraghi L Lanza SM Iglesia H . Sleep in university students prior to and during COVID-19 stay-at-home orders. Curr Biol. (2020) 30:R797–8. doi: 10.1016/j.cub.2020.06.022, PMID: 32693068 Leone MJ Sigman M Golombek DA. Effects of lockdown on human sleep and chronotype during the COVID-19 pandemic. Curr Biol. (2020) 30:R930–1. doi: 10.1016/j.cub.2020.07.015, PMID: 32810450 Smith BJ Lim MH. How the COVID-19 pandemic is focusing attention on loneliness and social isolation. Public Health Res Pract. (2020) 30:8. doi: 10.17061/phrp3022008, PMID: 32601651 Ballester L Alayo I Vilagut G Almenara J Cebrià AI Echeburúa E . Mental disorders in Spanish university students: prevalence, age-of-onset, severe role impairment and mental health treatment. J Affect Disord. (2020) 273:604–13. doi: 10.1016/j.jad.2020.04.050, PMID: 32560960 Boden M Zimmerman L Azevedo KJ Ruzek JI Gala S Abdel Magid HS . Addressing the mental health impact of COVID-19 through population health. Clin Psychol Rev. (2021) 85:102006. doi: 10.1016/j.cpr.2021.102006, PMID: 33714167 Longhurst GJ Stone DM Dulohery K Scully D Campbell T Smith CF. Strength, weakness, opportunity, threat (SWOT) analysis of the adaptations to anatomical education in the United Kingdom and Republic of Ireland in response to the Covid-19 pandemic. Anat Sci Educ. (2020) 13:301–11. doi: 10.1002/ase.1967, PMID: 32306550 Majrashi A Khalil A Nagshabandi EA Majrashi A. Stressors and coping strategies among nursing students during the COVID-19 pandemic: scoping review. Nurs Rep. (2021) 11:444–59. doi: 10.3390/nursrep11020042, PMID: 34968220 Kovess-Masfety V Leray E Denis L Husky M Pitrou I Bodeau-Livinec F. Mental health of college students and their non-college-attending peers: results from a large French cross-sectional survey. BMC Psychol. (2016) 4:20. doi: 10.1186/s40359-016-0124-5, PMID: 27098291