INTRODUCTION

The mental health of the pediatric population is greatly affected during public health crisis. The family members together with the academe and local government should collaborate to provide a crisis oriented psychological service.¹

The coronavirus disease 2019 (COVID-19) affected the world negatively. There are many factors that brought change in the psychosocial environment like prolong isolation, absence of social interactions and fear of being infected were some of the measures   that threatened the mental health of children and adolescents significantly. It has been a major challenge to maintain an accessible emergency child and adolescent psychiatric treatment during this pandemic.³

The World Health Organization stated that adolescence is a unique and formative time wherein physical, emotional, intellectual and social changes occur. These changes and struggles make them vulnerable to mental health problems.⁴ 

During adolescence, friends or peer groups provide an important context for social and emotional support but during health crisis social interactions are restricted. Concerns about maintaining close relationship with peers and the consequences of isolation for social status and peer belonging may be strikingly observed in adolescents. Due to absence of social interactions and different factors teenagers are likely to experience the same stressors as adults during the pandemic.⁴

Lockdowns and school closures disrupted the lives of children and adolescents leading to limited and restricted freedom of movement, online learning and sudden absence of physical and social interactions with peer groups. This pandemic had a huge impact, not only on the mental health of children and adolescents, but also on their caregivers, families and communities. ⁵

Schools for more than 168 million children globally have been completely closed for almost an entire year due to COVID-19 lockdown. School closures have devastating consequences for children’s learning and wellbeing. The most vulnerable children and those unable to access remote learning are at an increased risk of never returning to the classroom, and even being forced into child marriage or child labor. According to latest data by UNESCO, more than 888 million children worldwide continue to face disruptions to their education due to full and partial school closures.² The impact of school closures to the mental health of the students during the pandemic lacks empirical evidences and is yet to be identify.

School closure is one of the community interventions made by the government to mitigate the transmission of the virus in the school, community and to the household hence the government and the academes were forced to shift the traditional curriculum to online learning.

Online Distance Education” or ‘E-learning” utilizes the advent of virtual technology to maintain interactive learning among students. E-learning during the COVID-19 pandemic was the most sustainable and feasible way to continue studies as per the academic calendar. Thus, almost all countries implemented this type of learning at all levels to prevent the spread of Covifd-19 in the community and household.   However, the academes, teachers and students faced multiple challenges in terms of execution and quick adaptation to e-learning during the early phase of the pandemic.⁷ Moreover, in a cross-sectional survey of university students of Saudi Arabia reported academic stress, anxiety and depression, insomnia and low levels of resilience during the pandemic.⁷ Currently, there are only limited studies regarding the immediate and long-term effects of online learning to the physical, mental, social and emotional health of the students brought about by the Covid-19 pandemic.

During the Covid-19 pandemic, the sudden shift of the academic curriculum affected the lives of the students and the academes as well. Also, we need to assess parental beliefs and attitudes concerning online learning.

METHODOLOGY:

Study Design and Participants

This descriptive analytical study registered senior high school students in grades 11 and 12, aged 15-18 years old who are enrolled on online learning in a public school in Ermita, Manila for Academic Year 2021-2022. The survey was conducted from November 6, 2021 until January 31, 2022.

ETHICAL CONSIDERATION

Prior to initiation, the study was reviewed and approved by the ManilaMed Ethical Review Committee.

A permit was secured from school administrators prior to the implementation of the study. Upon approval, a google form link containing the informed consent and assent form was then given to the teachers and they randomly distributed it to the participants. Those who voluntarily agreed to join the study were oriented virtually via google meet. During the orientation, the purpose and procedure of the study were discussed to the participants, together with their parents.  After the orientation, the participants were surveyed online using the 22-item general data collection tool, PHQ-9 and GAD-7. To be considered an eligible participant, the student should meet the following criteria: Currently a senior high school student aged 15-18 years old on online learning, currently enrolled in a public school in Ermita, Manila; signed parental consent and assent form for those age 15-17 years old and lastly signed informed consent form to those 18 years old.  Those who were > 18 years old; with pre-existing psychological disorders; >18 years old with concomitant pre-existing psychological disorder were excluded in the study. The school medical records of those who answered with pre-existing psychological disorders on the general screening tool were verified and found out that they don’t have any record that they were diagnosed with pre-existing psychological disorder hence were excluded to avoid bias and confounder (see flow study diagram).   Those who were screened with PHQ-9 score > 11 or GAD score >10 were referred to adolescent medicine specialist for further evaluation and management. 

The participants had the freedom to withdraw anytime from the study and will not be penalized. To secure the participants privacy, any information given by the participants was known to the researchers only.  Details such as participants’ names, addresses were anonymized in the accordance to the guidelines for privacy and confidentiality as per Data Privacy act of 2012 and 2017 National Guidelines for Health-Related Research (NGHRR).

DATA PROTECTION PLAN

No data were used for any purpose other than what was intended for this study. The principal investigator accomplished data collection forms to ensure that only data needed by the study was collected while refraining from collecting confidential data that are unrelated to the study objectives.

The co-investigator and content adviser have reviewed the scientific and ethical soundness of the study and reviewed the interim report and final results. Data were protected by keeping the electronic files in an encrypted password protected external hard drive.  Only the principal investigator had accessed to these records. The participants were randomly coded and that code served as their identity during the duration of the study. A master list was kept thru a separate password protected hard drive which will was only known to the researcher. The google form and the master list will be deleted 1 year after completion of the study and the electronic files will be erased by reformatting the hard drive 5 years after completion of the study.

Figure 1: Flow study diagram

Measurement

1) General Data Collection Tool - includes the general information such as age, gender, educational level, time spent online before and during the pandemic, activities prior and during the pandemic and possible trigger factors of anxiety and depression.

2) Patient Health Questionnaire-9 (PHQ-9) - consist of 9 questions that assess the severity of depression symptoms (DSM- 5).  The individual will rate the severity of his or her symptoms over the past 2 weeks. Response includes “not at all”, “more than half the days”, “nearly every day”. A PHQ-9 score >11 or answered 1,2 or 3 on item 9 is considered significant.

3) Generalized Anxiety Depression Scale 7 (GAD-7) - is a 7-item questionnaire used to assess the severity of generalized anxiety disorder. The individual will rate the severity of his or her symptoms over the past 2 weeks. Similar to PHQ-9, the response includes “not at all”, “several days “,” more than half the days” and “nearly every day”.  A GAD-7 score of >10 is considered significant.

STATISTICAL ANALYSIS

Data were analyzed using Microsoft excel. The socio-demographic characteristics of participants were recorded and summarized using applicable descriptive statistics. Numerical data were summarized as mean, median standard deviation. Minimum and maximum values were also reported. Categorical data were presented as frequencies and percentages.

Anxiety and depression were determined using the patient health questionnaire 9 (PHQ-9) and generalized anxiety disorder 7 (GAD-7), respectively.

For this study, the minimum number of patients is calculated based on the prevalence of anxiety and depression among college students in Metro Manila (Cleofas, 2019) using the formula:

where Zα/2 is the critical value of the Normal distribution at α/2 (e.g. for a confidence level of 95%, α is 0.05 and the critical value is 1.96), E is the margin of error, p is the sample proportion, and N is the population size. Assuming N = 10,000 , p = 55%, α = 0.05 and E = 8%, the recommended minimum sample size is 130.

The above sample size is also sufficient for logistic regression according to the study of Peduzzi et al. (1996) using the formula:

n = 10 k / p

 The groups mean, median, and standard deviation were calculated and compared using analysis of variance and independent t-test. Based on the scoring systems, the participants were classified as normal, minimal, moderate, moderate-to-severe, and severe anxiety and depression. A Multivariate analysis was used to assess the relationship of the identified factors to the level of anxiety and depression. Association of depression and anxiety with socio-demographic factors triggers such as prolonged online used were tested using Chi square or Fisher exact test.

RESULTS

Out of two hundred twenty students, 171 (77.73%) agreed to join the study, 40 (18.18%) declined and 9 (4.09%) with incomplete data. The responses were validated individually. Of the 171 respondents, 18 (10.52%) were more than 18 years old, 24 (14.03%) answered to have pre-existing psychological disorders and 4 (1.81%) were more than 18 years old and with pre-existing psychological disorder were excluded in the study having a total of 133 (75.14%) responses (minimum target = 130).  A total of 77 (57.8%) of the respondents had a PHQ-9 score of >10, while 56 (42.1%) had a PHQ-9 score <10. Moreover, 72 (54.1%) of the respondents had a GAD-7 score > 11 while 61 (45.86%) garnered a GAD-7 score < 11. (See flow diagram 2).

Flow Diagram- 2

The demographic characteristics of the surveyed participants (n = 133) are shown in Tables 1 and 2. The mean age of the participants is 17.3 years. 79 (59.4%) of the total respondents were female while 54 (40.6%) were male and with a female to male ratio of 3:2. Majority were grade 12 students with 132 (99.2%) participants. Based on GAD-7 scores, minimal, mild, moderate and severe anxiety levels were observed among 22.6%, 23.3%, 24.8% and 29.3% of the students, respectively. PHQ-9 score was 21.1% for minimal depression, 21.1% for mild, 33.8% for moderate, 15.8% moderately-severe and 3.8% for severe (tables 1 and 2). The results demonstrated that there was no association between the age of the student and level of anxiety (p-value 0.127).  There were more male respondents having minimal and mild anxiety (53.3% and 58.1%, respectively) as compared to female (46.7% and 41.9%, respectively). As anxiety level increases to moderate and severe, the percentage of female students also increases (78.8% and 66.7%, respectively). Thus, there is a significant association between sex and anxiety level (p-value = 0.007). Grade level and anxiety level were not significantly associated (p-value = 0.707) (table 1).  In comparison to the anxiety levels of the participants, there were no significant association observed for the age, sex, grade level and depression severity (p-value > 0.05) (table 2).

Table 1: Demographic characteristics versus anxiety (GAD-7)

The results also showed that 53 (39.8%) were very concerned, 59 (44.4%) were concerned, 21 (15.8%) shows average concern during Covid-19 pandemic (table 3). Moreover, 105 (78.9%) of the total participants owned an electronic gadget independently. Also, majority of the participants started to own a gadget between the age of 13-15 years old (53 or 39.6%).

In addition, the following characteristics were also identified to determine the possible contributing factors to anxiety and depression (table 4). Learning of the participants was significantly affected during the pandemic compared to the pre-pandemic period (100 vs 48 or 75.2% vs 36.1%). Prior to pandemic, 4 (3%) of the participants spent 5-30 minutes, 18 (13.5%) spent 30-45 minutes, 28 (21.1%) spent 1 hour, 65 (48.9%) spent 1-5 hours and 18 (13.5%) spent more than 5 hours online. In comparison, 84 (64.3%) of the participants spent more than 5 hours online during the pandemic. Moreover, the results revealed that studying is the primary reason for internet use with 115 (86.5%) pre-pandemic and 126 (94.7%) during the pandemic.

Table 2: Demographic Characteristics versus depression (PHQ-9)

One hundred (87.2%) of the total participants were stressed due to more time spent on online learning. The other reasons for stress were feeling lonely at 52 (39.1%), absence of social interactions at 61 (45.9%) and staying at home during the community quarantine at 85 (63.9%). The study also revealed that 51 (38.3%) believed that they felt more anxious when their parents were around during online learning. The study also shows that lack of social interactions, feeling tired, staying at home, feeling lonely, can’t focus on online learning and disturbed sleep were some reasons for being anxious during the pandemic at 82 (61.7%), 83 (62.4%), 91 (68.4%), 69 (51.9%), 88 (66.2%), 78 (58.6%) respectively (table 6). Prior to the pandemic, 78 (58.6%) of the participants spent their time with friends by going to the mall, 66 (49.6%) watched movies together, 26 (19.5%) played basketball with friends, 30 (22.6%) went shopping, and 95 (71.4%) chatted on their social media account. Their activities were significantly affected by the pandemic and this study has shown that 129 (97%) of the respondents use their social media account for chatting.

Table 3: Degree of concern during COVID-19 Pandemic

Lastly, 125 (95.5%) of the participants did not feel disappointed if they forgot to submit their modules on time. (Table 4-2).