Exploring the quality of life and psychological symptoms of university students in Cyprus during the Covid-19 pandemic

: The onset of the infectious disease Covid19 originating in Wuhan, China, took over the world in December 2019 and was declared a pandemic in January 2020. Empirical evidence resulting from relevant research illustrated that the effects of the pandemic itself but also of the strict measures to contain the spread of the virus on the mental health and well-being of affected populations were just as unanticipated as the pandemic itself. Data led to the identification of six idioms of distress: (1) Demoralization and pessimism towards the future, (2) anguish and stress, (3) self-depreciation, (4) social withdrawal and isolation, (5) somatization, (6) withdrawal into oneself. Our research explores the psychological impact of the Covid19 pandemic on college students and their quality of life. The study took place in Cyprus with 356 young participants, whereas 256 were female (72%) and 100 were male (28%). They all completed the General Health Questionnaire-28 and the Life Satisfaction Inventory (LSI). The present study's findings revealed that six factors, including residence without family, the deterioration of the financial situation of the family, the loss of employment, the deterioration of social relationships, young age, and gender, have significantly affected in a negative way the mental health and quality of life of young people. Research findings revealed that the strict lockdown and physical/social isolation measures had a significant adverse effect on our sample, whereas participants showed increased symptoms of anxiety and insomnia, social dysfunction, and somatization. Young adults who lost their jobs during the pandemic or had a significant decrease in their family income, and students who stayed away from their families, experienced a negative impact on their quality of life and had to cope with more mental health problems.


General psychological impact of the Covid19 pandemic on affected populations
The Covid19 outbreak rapidly emerged as a worldwide pandemic and caused significant disruptions in the social, economic, educational, and other essential areas of life in the populations of the affected countries. In their efforts to contain the spread of the virus, most governments imposed strict measures, such as lockdowns, quarantines, and isolation, social and physical distancing, as significant prevention policies for the broader spread of the virus ( Brooks et al., 2020). Social distancing refers to a measure implemented in all affected countries, which consists of avoiding close contact with other people, maintaining a safe physical distance (usually two meters) from other people, and limiting gatherings of large numbers of people in places such as schools, restaurants, shops, churches. Social distance from family, friends, and relatives presents an aggravating factor in people's mental health and quality of life as it could severe personal freedoms, social life, recreation, and entertainment, cause a disruption of communication, and serious rifts in social bonds and networks.
Given the incidence and mortality rates of the Covid19 virus worldwide, and its negative impact on both social and economic aspects, relevant studies illustrated increasingly adverse effects on peoples' mental health due to physical distancing, quarantining processes, and social isolation (Tanhan et al., 2020), inducing psychological mediators, such as sadness, worry, fear, anger, annoyance, frustration, guilt, helplessness, loneliness and nervousness . These are grave indicators of psychological distress and suffering which individuals may experience during and after pandemics. Emotions such as fear, sadness, depression, and symptoms such as panic attacks, somatization, and social dysfunction have prevailed since March 2020 in the populations of all affected countries across the globe. These emotions can be overwhelming, especially for people who have already faced anxiety, severe depression, and other mental health problems, and may have detrimental effects on their mental health and quality of life.
According to the World Health Organization (2002), mental health is the emotional well-being, where the individual can live and work comfortably in the community and be satisfied with his personal characteristics and achievements. Quality of life refers to the individual's living conditions that, together with material goods, compose the daily well-being of people (Møller & Roberts, 2021). Well-being requires the provision of tangible and intangible resources such as health, harmonious coexistence of individuals, respect for dignity, optimism, perspective, and the social environment. Factors that may negatively impact the quality of life are any stressful experiences or negative situations that significantly increase the possibility of a person experiencing adversities in his/her psychosocial adjustment or even psychological problems. Financial difficulties of the family, parent's mental health, school or community with high rates of delinquency, death of a family member and, parent's divorce (McGregor, 2020) can be considered aggravating factors in a person's overall well-being (Masseé, 2000).

Effects of Covid19 restrictive measures on university student populations
Recent studies conducted worldwide, show clearly that the Covid19 pandemic has severely affected young adults' mental health and subsequent quality of life (Cao et  College students are a particular population, going through a critical period of life and often experiencing stressful events (Buchanan, 2012). In Cyprus all tertiary education institutions have been closed to students and face-to-face teaching was suspended for an out of the ordinary timeframe (March to June 2020, September, mid-October to May 2020, September 2020 to May 2021), with short intervals of onsite, conventional operations. Hossein et al. (2019) illustrated that such closures trigger uncertainty amongst students regarding academic matters and intensify persistent mental health challenges in the student population.
University students' lives changed drastically due to the physical distancing and social isolation measures that led to switching from conventional learning to distance learning. Students were confined at home, and all teaching, learning, and evaluation took place online . At the same time, insecurities regarding employment and the financial future were accentuated. Negative emotions such as the fear of death and the fear of an "unknown enemy" (as this was depicted in the media) created a generalized fear in the people, as they did not know exactly where the threats were coming from ( Research conducted with students in Cyprus earlier this year  showed that more than 70% of the participating students experienced high to medium stress during the lockdowns. In this framework, working students experienced significantly more anxiety and stress than those who did not have to juggle studies with work, and it manifested in somatic symptoms, such as difficulty breathing and general nervousness. Asif and her associates (2020) also determined higher stress levels in students, who found that anxiety was the most prevalent issue, followed by stress as the second most prevalent problem among her sample's college students. Students reported a more frequent appearance of fear, dizziness, and numbness than those that were not employed or worked part-time during the lockdown. Islam et al. (2020) have pointed to the disruption of regular income and employment as a critical factor in understanding the increased frequency of anxiety and depression in university students. It seems that student adaptation to online classes contributed to the increase in their stress levels.

Purpose and Research Questions of the study
The purpose of this study was to investigate the psychological impact of the measures of social distancing of the Covid-19 pandemic on the mental health and quality of life of college and university students in Cyprus. In this framework, we placed the following two research questions: (a) What is the impact of the lockdown and social distancing measures on university students' mental health and quality of life during the Covid19 pandemic?
(b) Which factors may be considered either aggravating or protective to tertiary education students' mental health and quality of life?

Procedure -Data collection
We surveyed a sample of university students in Cyprus. Participants completed two questionnaires in the Greek language: The General Health Questionnaire (GHQ-28) and the Life Satisfaction Inventory (LSI). In addition, we collected demographic information, including age, gender, place of residence, and information relating to the COVID-19 pandemic, such as parents working status and quality and frequency of interpersonal, social relationships during the pandemic. Authors used a web-based survey design and obtained the approval from the Psychology and Social Sciences Department at Frederick University. All participants gave their consent online before responding to the survey questions. The participants answered the questionnaires anonymously on the Internet platform Enklikanketa, from May to June 2021, and they were allowed to terminate the survey at any time they wished.

Sample
The survey took place in May 2021 and focused on a sample of 356 Cypriot participants. The sample included 256 young women (72%) and 100 young men (28%). The mean age for our participants was 23+5 years old. The majority of the participants (75%) resided in urban areas, and 25% resided in rural areas. 50% of participants were employed before the pandemic outbreak, whereas 25% of the subjects remained employed during the pandemic. More than half of the participants (52%) experienced a decrease in their family income. Regarding their residential situation, 38% resided without their family during the lockdown measures (Table 1).

General Health Questionnaire -28 (Goldberg and Hillier 1979)
The General Health Questionnaire is a self-report tool used to compare the current psychological state of the participants with their usual state of psychological health. We applied the 28-item version, whereas factor analysis of the GHQ-28 identified four 7-item subscales (https://strokengine.ca/en/assessments/general-healthquestionnaire-28-ghq-28/): Somatic symptoms (items 1-7); Anxiety/insomnia (items [8][9][10][11][12][13][14]; Social dysfunction (items 15-21); Severe depression (items 22-28). The possible score ranges from 28 being the lowest to 112 being the highest. The higher score shows the participants' more deficient psychological state. There is a high correlation between the anxiety subscale and the total score, illustrating that anxiety is a common indicator of psychiatric disorders (Goldberg & Hillier, 1979). The Cronbach's alpha coefficients of reliability of the subscales are 0.84 to 0.94, and the internal consistency of the total scale is 0.93 (ibid).

Data Analysis
We analyzed the data using the Statistical Package for Social Sciences (SPSS) version 25.0. Data analysis included descriptive statistics, such as mean, standard deviation, frequencies, and percentages, to describe the participants' demographic characteristics. The level of significance (p-value) in questionnaires was set at p< 0.05. In order to examine our research questions applied the following data analysis methods: t-test, two-way ANOVA, and the multivariate ANOVA (MANOVA) to compare the means between participants' demographic characteristics (gender, age, family income, occupation) and their impact on their overall quality of life and mental health dimensions. Furthermore, we applied Pearson's correlation coefficient to examine whether correlations (positive or negative) could be found between mental health dimensions and quality of life.

Impact of the lockdown and social distancing measures on university students' mental health and quality of life during the Covid19 pandemic
The findings of the present study underlined that the measures taken during the pandemic have significantly affected the mental health (p <0.001) and quality of life of young people (p <0.05). About half of our sample population (51%) experienced symptoms of anxiety and insomnia (p <0.05), and 48% experienced physical symptoms (p <0.01). More than half of the participants (55%) reported social dysfunction (p<0.001), 10% experienced severe depression (p <0.05), and 34% felt that during the pandemic, their quality of life had been impacted negatively (p <0.05) ( Table 2).

Aggravating or protective factors to tertiary education students' mental health and quality of life
Αs aggravating factors which contributed to the increase of student stress levels our results record the following: (f) Gender: The analysis of the results of the present study showed that there is a statistically significant difference between men and women in the dependent variable severe depression [F (1,355) = 2,220 p <0.05], whereas women reported a higher frequency of symptoms of severe depression than men.

The relationship between the Quality of Life and Mental Health Dimensions
Our findings suggest a significant negative correlation between the Quality of Life and the following Mental  Table 3).

Discussion
The present study aimed at exploring the extent of the impact of the lockdown and social distancing measures on university students' mental health and quality of life and researching the factors that either aggravate or protect students' mental health and quality of life in the duration of the pandemic. Our findings answered both questions. Our results showed that the pandemic had significantly affected the mental health and quality of life of young people. Participating students reported symptoms of anxiety and insomnia (51%), physical symptoms (48%), social dysfunction (55%), and 10% severe depression symptoms. One-third of the participants (34%) reported a significant decrease in their quality of life. Research by Cao et al. (2020) showed that similar highly restrictive measures to contain the pandemic lead 24.9% of students to experience intense stress and anxiety.
Additional findings posed that the pandemic as a stress factor is positively related to anxiety, stress, family income, and the academic life of students. Aslan, Ochnik, & Çınar (2020) revealed that students' mental health has been at high risk during the pandemic. More than half of the students met the diagnostic criteria of a generalized anxiety disorder (52%) and depression (63%). Kecojevic et al., (2020) stated that the pandemic revealed widespread concerns about the impact of social isolation, social distance, increased stress, depression, anxiety, and other negative emotions and has generated financial difficulties.
Regarding the factors that play an aggravating role in students' mental health, our findings showed that six factors seem to have a detrimental effect on students' mental and psychological states, namely: Residence without family during the lockdowns, the deterioration of the financial situation of the family, the loss of employment of the students themselves, their lack of close contact with friends, young age and gender.
A significant factor contributing to increased stress in young people is related to residing with or without their family during the measures to contain the spread of the virus. Our findings agree with similar research, confirming that the quality of the relationships with family members can be a  2021) revealed that students who resided with their families during the lockdown had significantly lower stress levels than those who did not; in fact, the students who were surrounded by family reported less frequent terror symptoms than the students who were living alone during that time.
Our data analysis showed that the deterioration of the family's financial situation during the consecutive lockdowns significantly impacted our subjects' well-being. The mental health of our participants who became bystanders as their family income kept shrinking reported more insomnia and anxiety symptoms than participants whose family income remained stable during the time. Similar research in Cyprus  showed that the mental health of participants whose family income was negatively affected presented more depression, anxiety, and insomnia symptoms than those whose family income was not affected by the quarantine and lockdown measures. In fact, participants whose family income had remained stable also reported a better quality of life than those whose family income has been affected. In the months of the pandemic's peak and while the restraining measures were at their strictest (lockdowns and physical/social distancing), over half of our participants (58%) stated their social relations with their network of friends were negatively affected or disrupted. Similar findings regarding Cypriot university students were recorded by Demetriou (2021), who underlined that students exhibited many adverse psychosocial effects from the strict implementation of lockdown measures, experienced a deterioration of their social and sexual relations, and felt that they received less support from their immediate social network.
The younger population of our sample, namely students in the age group 18-20 years, reported more symptoms of anxiety, social dysfunction, and a lower quality of life than their older colleagues. , whereas young participants experienced higher anxiety and depression levels and reported more frequent incidents of depression and somatic symptoms than the older ones. Similar results by  showed that young participants were more affected psychologically than older ones during the Covid19 pandemic crisis. Demetriou et al. (2020) suggested that older people showed higher levels of psychological resiliency and adaptation than the younger participants.
Lastly, our findings revealed a significant difference between the genders regarding symptoms of severe depression; women reported a higher frequency of such symptoms than men in our sample. Similar results related to our research are presented by Guo et al., (2016), stating that women are more likely to experience increased anxiety and depression compared to men. Aslan, Ochnik, & Çınar, (2020), illustrated that female students had higher perceived stress levels. In relation to other studies, female students reported significantly higher stress levels compared to male students (Wang, et. al Cypriot students confirm our findings. She reported that young women exhibited significantly higher levels of stress compared to the men of their sample. Of the 33,8% of the participants with acute anxiety, 76% were women, and 23,8% were men, and out of the 56,8% of the students with moderate stress, 76,2% were women, and 23% were men.

Conclusion
Research shows that populations affected by Covid19 have been experiencing multiple threats to their mental health and well-being. The psychological strain across these populations owes to factors such as quarantine and the constant changes in one's perceived reality, being in contact with possibly infected patients, and the constant looming existential anxiety. All these factors, plus many more, have a detrimental impact on the wellbeing of an individual. This impact is well documented among general populations and among university students (Andrews and Wilding 2004). Understanding the factors affecting peoples' psychological well-being during the Covid19 pandemic crisis is, therefore, of paramount importance.
Increasing reports and studies inform of higher frequencies of depression, anxiety, psychological distress and suicidal behaviors during COVID-19 which necessitates an in-depth understanding of the mental health epidemiology during this pandemic .
It seems that younger adults are more vulnerable to higher levels of distress due to more exposure to a large amount of information from social media that can easily trigger stress (Cheng et al., 2014). Moreover, the younger adult group is prone to more unstable relationships, lack of economic independence, and less adaptive coping strategies (Jackson, 2002) compared to those who have had years of experience behind them (Demetriou, 2020). These factors may also contribute to the higher level of distress young adults face when confronted with harsh life situations.
We believe that individuals and society, in general, will require extensive and systematic interventions to heal the wounds in the aftermath of the Covid19 pandemic crisis. In this framework, governments must give vital importance and attention to the mental health of their citizens and especially to the well-being of their young citizens. Research results showed no magic formulas or characteristics that enable young people to adapt and cope with the difficulties in this situation. Young adults showed psychological resilience in some circumstances but not in others; the power of protective factors as a shield against difficulties and obstacles can change at different times in their lives. Therefore, it is crucial to design preventive programs to empower and support young people to successfully manage and adapt to the environment, despite the challenges, difficulties, and obstacles that will arise in their lives.
Given the Covid19 pandemic, crisis research has shown that the networks of family and friends, the community, and the individual characteristics of young adults play an essential role in the coping strategies they will implement to develop and maintain ongoing mental health and a high quality of life. Adaptation to the crisis requires, amongst other things, maintaining high activity levels, self-care, and keeping friends and family close. Learning to focus more on the positives rather than prioritizing the negatives is also essential for well-being in these times of adversity.