Impact of Attending Online Classes on Mental Health Among University Students During COVID-19 Pandemic in Lahore

Background: There are many challenges that people face in their lives. Recently, the whole world was affecting because of a unique virus known as COVID-19 or coronavirus. Objective: To determine the impact of attending online classes on mental health among university students during the COVID-19 pandemic in Lahore. Methods: This cross-sectional study was conducted on 215 undergraduate students who were locked down in their homes during the COVID-19 pandemic and took online classes using the depression, anxiety, stress scale and online learning scale through convenient sampling. The demographics were reduced to numbers, percentages, and frequencies for analysis. The frequency and percentage of occurrence were selected as the presentation formats for qualitative variables. Cross-tabulation was used to see whether online learning was related to depression, anxiety, or stress levels. Results: Among 215 Undergraduate students, 53 (24.7%) were males and 162 (75.3%) were females. While 15 (7.0%) presented with symptoms, the level of depression was moderate among 65 (30.2%), severe 69 (32.1%) and extremely severe 81 (37.7%). Level of anxiety was moderate among 23 (10.7%), severe at 32 (14.9%) and extremely severe at 160 (74.4%) while the level of stress was normal 15 (7.0%), mild at 25 (11.6%), moderate 59(27.4%), severe 71 (33.0%) and extremely severe 45 (20.9%). There was a significant association between online classes and mental health including depression, anxiety and stress as the p-value was 0.029, 0.045 and 0.043 respectively. Conclusion: The level of depression, anxiety and stress was high among undergraduate university students during the COVID-19 pandemic. There was a significant impact of online classes on mental health symptoms including the level of depression, anxiety, and stress. Students taking online classes suffer from poor mental health.


Introduction
There are many challenges that people face in their lives. Recently, the whole world was affected by this unique virus known as COVID-19 or coronavirus. (1) There is no cure for the virus, and no vaccine has been developed to prevent the spread of the virus. (2) Protection is the only solution to prevent the spread of the virus. (3,4) On December 31, 2019, China reported a cluster of pneumonia cases with an unknown origin. These patients were eventually identified as having coronavirus 2 infections (SARS-CoV-2) The COVID-19 issue first arose in the Chinese regions of Wuhan and Hubei at the end of December 2019. (5) The World Health Organization (WHO) formally classified the illness as COVID-19 in February 2020, which stands for "coronavirus disease in 2019." The virus responsible for COVID-19 was formerly known as 2019-nCoV before being identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Symptoms include sore throat, cough, and possibly pneumonia, in addition to fever and shortness of breath. Aside from having terrifying impacts on human life, the recently detected coronavirus strain known as COVID-19 has the potential to greatly impede economic growth not just in China but around the globe. (6) WHO has declared COVID-19 to be a public health emergency of international concern (PHEIC), putting public health at risk. PHEIC, according to the WHO, is either an infectious disease that spreads globally or an unexpected, unusual, and severe public health crisis that exceeds the capacity of the local healthcare system. (7) Humans have always been gregarious beings, and although many are indeed terrified at this moment and many people feel threatened and are hiding inside their homes. During the COVID-19 disease epidemic, it is critical to understand how the community has responded to such a significant disaster, especially in nations such as China that have been severely impacted. The damage caused by COVID-19 is likely to be comparable to the devastation caused by SARS in 2003. The SARS epidemic has resulted in over 8,000 cases of illness and over 800 fatalities worldwide in 26 countries. (8,9) There have been reports of moderate to severe occurrences of stressful life events in places severely impacted by the SARS pandemic.
Within eight months, the SARS pandemic had been controlled. SARS-CoV-2 and COVID-19, like other viral respiratory diseases, may be spread via the respiratory system. (10) Infected people often suffer severe pneumonia and other respiratory tract infections, with some requiring critical care unit hospitalization. (11) One of the most likely reasons people die from serious diseases is that they can no longer breathe. This virus may infect anybody, but those who are already sick or old are more likely to develop serious complications because of infection. (12) According to the most recent findings, people with several chronic underlying conditions have a significantly increased mortality risk. As a result, aged people and patients with impaired immune systems should be given special consideration.
In these populations, infections may spread quickly, necessitating quick treatment choices. (13) In the absence of a vaccine, social isolation has become the most preferred method of mitigating and controlling the disease's effects. The basic purpose of public health interventions is to prevent disease transmission from person to person by separating groups of people to break the chain of transmission. As methods, we have accessible isolation and quarantine, social separation, and community control or lockdown.
The terms "community confinement" or "lockdown" refer to an intervention that is implemented over a whole town, city, or area to limit the amount of individual contact and mobility. These methods vary from social isolation (such as canceling public events, closing schools, and working from home) to communal usage of face masks to the closure of whole towns or districts. The goal of "social distance" is to limit contact among members of a larger group in which some people may be infectious but have not yet been recognized and hence are not segregated from the rest of the community. (14,15) The administration had no option but to establish nationwide lockdown rules. The government's initial response was to move and clean out hostels located near schools and other institutions around the nation. (16) As a result, each student is required to return to their respective hometowns and home states in a very short period, raising concern not only among the students but also among their parents about their children's safety while traveling. Because a statewide lockdown was about to happen, the school board decided to hold classes online to protect the educational system of the country. (17) Research undertaken by the Institute of Medical Education and the National Center for Health Professions Education Development at Peking University in Beijing, China, found that when the right materials and arrangements were used, the online study would be just as successful as a conventional study. Because of the lockout, no school had enough time to manage the online classroom system, and students weren't ready to take online classes, which made them even more nervous. (6) In response to the growing concern over the ongoing COVID-19 outbreak, an increasing number of educational institutions throughout the world have either postponed or canceled all campus events and activities.
Seminars, conferences, intra-and interuniversity sports events, and other activities are examples. (18) The distribution method for a variety of university courses and programs has swiftly transitioned from in-person to online delivery at various educational institutions. The COVID-19 epidemic has drastically disturbed the daily lives of many individuals throughout the globe. Because of the fast growth in the number of infected people throughout the globe, there is growing concern about the future. It has also caused a lot of tension between students and the rest of the academic community. (19) Students' ability to study as well as their mental health may suffer because of this stress. In addition to their health, safety, and education, international students studying in a foreign country are often worried about the well-being of their families. The COVID-19 epidemic has the potential to have a substantial influence on the professional lives of this year's college graduates. (20) They are nearing the end of their studies, which is distinguished by significant disruptions in both teaching and assessment. Because of the postponement of the final examination, students were likely to graduate later than expected. Furthermore, the graduates had confronted considerable challenges as a consequence of the current global recession caused by the COVID-19 pandemic. (21) Extreme weather conditions had caused mental health issues such as stress, anxiety, depressive symptoms, sleeplessness, denial, wrath, and panic, as well as decreased the capacity to pay attention, comprehend, and make decisions, which may make combating COVID-19 more difficult. (22) The purpose of the study was to determine the impact of attending online classes on mental health among university students during the COVID-19 pandemic in Lahore.

Methods
It was a cross-sectional survey conducted on 215 undergraduate students taking online classes selected for data collection. The data for this research was gathered from the University of Lahore and students aged between 20-30 years attending the online classes using standardized questionnaires like Depression, Anxiety Stress scale (DASS-21) and online learning/distance education questionnaire by convenient sampling from undergraduate students during COVID-19. The first part contained demographic information; the second part assessed online learning/distance education questionnaire; the third part assessment of the level of depression anxiety and stress.
The participants were questioned to see whether or not they fit the study's inclusion criteria. After gaining permission to publish from the University of Lahore's ethical committee and authorization from all departments involved. Participants were given a thorough description of the testing technique. The survey questionnaire was distributed following the established inclusion criteria for the study. The survey was conducted after gaining consent from the proper authorities at the institution and the university's committee.
The research was completed six months after the executive summary was approved. The data were analyzed using IBM SPSS Statistics 25.0. The data was put into the SPSS file once the participants' replies were collected. The information was then analyzed. The demographics were reduced to numbers, percentages, and frequencies for analysis. The frequency and percentage of occurrence were selected as the presentation formats for qualitative variables (frequency tables and bar charts). After calculating the descriptive measure for each variable, cross-tabulation was used to see whether online learning was related to depression, anxiety, or stress levels. Almost 15 (7.0%) were currently ill, 188 (87.4%) were not currently ill and 12 (5.6%) may or may not be ill. While 15 (7.0%) presented with symptoms, the level of depression was moderate among 65 (30.2%), severe 69 (32.1%) and extremely severe 81 (37.7%). Level of anxiety was moderate among 23 (10.7%), severe at 32 (14.9%) and extremely severe at 160 (74.4%) while the level of stress was normal 15 (7.0%), mild at 25 (11.6%), moderate 59(27.4%), severe 71 (33.0%) and extremely severe 45 (20.9%) shown in Table I. Among 215 undergraduate students, crosstabulation has been done among students attending online classes and depression according to which there is a significant association between them as the p-value was found to be 0.029 which is <0.05. (Table II) Cross-tabulation between students attending online classes and anxiety also showed a significant association with a p-value of 0.045. (Table III)  among students attending online classes and stress displayed a significant association, p=0.043. (Table IV) (2020) in China 1210 participants included 67.3% were women out of which 53.1% with 21-30 years of age and 76.4% were married, 52.8% were students and 87.9% were well-educated. (23) A study conducted in 2020 by Sijia Li et al included 25% males and 75% females. This study concluded that psychological problems including depression, anxiety and stress are negative emotions and the score for these emotions has been increased and the score for positive emotions including happiness and leisure activities has been decreased. People are worried and are more concerned about their family and health than their friends and leisure activities. (24) According to our study, there was a significant association between students attending online classes and depression. Students taking online classes had poor mental health. Yingfei Zhang et al conducted a study in China (2020) comprised of 263 individuals out of which 157 were males and 106 females with age 14-37 years and 74.9% had high education levels. According to this study, a mild impact was found between quality of life and mental health and most of the individuals about 53.3% did not feel helpless but about 52.1% of the participants were terrified and 57-77% population received support from their friends and family to overcome this stressful condition. (25) In the current study, psychological symptoms including depression, anxiety and stress have a strong impact on the quality of life and the performance of students was also impaired due to increased levels of depression, anxiety and stress.

Among
Paula Odriozola-González et al in 2020 found that score for depression was 44.1%, the score for anxiety was 32.4% and for stress was 37.0%. Psychological stress indicated by the symptomatic score was 88.6% of participants. The frequency of depression anxiety and stress was more among young females and among those who reported COVID-19 symptoms by themselves. According to the present study, about 37.7% of the students were affected with extremely severe depression and 74.4% have extremely severe anxiety and 20.9% with extremely severe stress.

Conclusion
Level of depression, anxiety and stress was high among undergraduate university students during the COVID-19 pandemic. There was a significant impact of online classes on mental health symptoms including the level of depression, anxiety and stress. Students taking online classes had poor mental health.

Declarations
Consent to participate: Written consent had been taken from patients. All methods were performed following the relevant guidelines and regulations.
Availability of data and materials: Data will be available on request. The corresponding author will submit all dataset files.