Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 32 (4) July 2022
www.eubios.info

ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)

Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2022 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Putting an end to this virus:
Practical and ethical issues in
stopping COVID-19 in Africa- Saheed Akinmayowa Lawal
Medical/Health Sociology and Bioethics Unit,
Department of Sociology, Olabisi Onabanjo University,
Ago-Iwoye, Nigeria
Email: sakinlawal@gmail.com- Isaac A. Adedeji
Medical/Health Sociology and Bioethics Unit,
Department of Sociology, Olabisi Onabanjo University,
Ago-Iwoye, Nigeria- Isabel Kazanga Chiumia
Department of Health Systems and Policy, College ofMedicine, University of Malawi- Simon Nantamu
Department of Psychology, Makarere University,
Kampla, Uganda- Onyeunoneme Alexandra OdiariCommunity Medicine Department, Babcock University
Teaching Hospital, Ilishan-Remo, Nigeria- Ayodele S. Jegede
Department of Sociology, Faculty of the Social Sciences,
University of Ibadan, Ibadan, Nigeria

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Abstract
As Coronavirus disease (COVID-19) continues to rise
globally mutating into new variants, concerns are
growing on how to put an end to the virus. Ongoingclinical trials are showing some hopeful results, yetother non-clinical factors such as people’s
perception of the virus and their attitudes towards
COVID -19 guidelines for prevention are important.
Most countries in Africa have adopted various
preventive measures to slow down the rapid spreadof COVID-19. Some of these measures include
patient screening, contact tracing, regular hand washwith soap and water, social distancing, use of handsanitizer lock down and quarantine. However, someof these measures have raised concerns regarding
ethical issues in Africa
and other countries
worldwide. To stop the spread of the virus in Africa,

there is a need to address certain practical andethical issues. This paper presents a re lections onpractical and ethical issues on mitigation of
COVID-19 pandemic in Africa
We conducted a literature search online ofvarious journals and databases including Medline,
PubMed, Google Scholar, policy documents andnewspaper reports on COVID-19 published from
December 2019-September 2020. In our search, we
identi ied keywords "practical", “ethical”, “ethics”“COVID-19”, ”pandemic” “EndCOVID” and “Africa”. We
included only articles in English.
Centred on practical and ethical issues drawn
from a Kantian ideology, irstly we discuss how the
implementation of pandemic control measures
promotes public trust in public health emergency
leadership and governance structure. Secondly, weraise the question of what pandemic control policies
best promote the greatest bene its to the greatest
number of the public.

Contents of this Issue

page

Putting an end to this virus: Practical and ethicalissues in stopping COVID-19 in Africa
97
Saheed Akinmayowa Lawal, Isaac A. Adedeji, Isabel
Kazanga Chiumia and Simon Nantamu
The Early Hours of the COVID-19 Pandemic: Issues
encountered by Students at Malaysian Higher
Education Institution
103
Randy A. Tudy, Rozinah Jamaludin and Ida G. Tudy
The Impact of COVID-19 Pandemic on Mental Well-beingof African Students in Chinese Universities
112
Uwimana Alexandre and Darryl R.J. Macer
Factors affecting posttraumatic growth of childhood
cancer survivors
120
Naoki Mashiko and Tomoko Sumiyoshi
EJAIB Editorial Board
124
Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign Nations (AUSN),
https://www.ausovereignnations.org
Email: darryl@eubios.info

98

Eubios Journal of Asian and International Bioethics 32(4) (July 2022)

Thirdly, we re lect on the extent to which thepolicies are just and fair to the public. Fourthly, weinterrogate the potential consequences of thepandemic control measures on the public. Fifthly, we
discuss the risks involved in the pandemic control
measures and management style. Finally, we present
an analysis of how these processes re lect on theextent to which the individual citizen is/has beenable to make an informed decision about the
pandemic control measures.
We concluded that country and context-speci ic
ethical frameworks are required to effectively
combat the COVID-19 pandemic in Africa.

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Introduction
In some African countries like Nigeria, Ghana, Kenya
and Malawi [1-4], the social organisation of the
public health apparatus is weak due to poor
governance and leadership system, social structure,
stakeholder engagement, and information sharingthat could have enhanced effective control of
diseases of public health emergencies. The socialorganisation is the pattern of social relationshipsthat are formed between and amongst the people asa social group within the entire social structure. Thispattern of social relationships de ines the nature ofsocial relations in the public health systems fromone country to another. As such the failure of thesocial organisation of healthcare continues to affectthe planning and organisation of the public healthsystem to contain the spread of diseases andinfections such as the Coronavirus diseases(COVID-19), which continues to increase daily in
Africa [5]. The political economy of African societies
rooted in culture in luences the social organisationof health systems leadership and governance, asinterest in who gets what, why, when, and how
hinders the way resources are deployed in the healthsystems, even in the management of the COVID-19
pandemic control. At present, COVID-19 adds to theexisting burden of diseases (infectious and noncommunicable diseases that include HIV/AIDS,
mental illness, stroke, cardiovascular diseases, andmalaria) on the health system. More so, because
there is insiffcient stakeholder engagement, decision
making is taken solely by the government with little
community consultation on ways to tackle COVID-19
despite their relevance in public health management.
Similarly, the social organisation of the healthsystems is being affected by the imbalance ininformation and data sharing which is a result of theskewed pattern of social relationships that exists. An
improvement in the social organisation of publichealth systems to strengthen governance andl e a d e r s h i p , s o c i a l s t r u c t u re , s t a ke h o l d e r
engagement, and networking is imperative as ways
to addresses public health-related challenges in thepresent and the future.
The public health system in some Africancountries do not possess the capabilities required incontrolling the COVID-19 pandemic. For instance,the 2019 Global Health Security Index showed thatthe preparedness of Nigeria for an outbreak was
generally weak [6]. In addition to this, Nigeria’s 2019
proposed health budget was only 2% of the national
budget and a signi icant proportion of the budget
was allocated to vaccination programs [7]. Thus, theproblems of resource-allocation, double-burden of
disease, and a poor workforce ratio put adisproportionate burden on the health system. Most
isolation centres and testing facilities have not beenin use after the 2014 Ebola outbreak. Most facilities
were dilapidated, obsolete, or unavailable. There
were only seven (8) testing laboratories acrossNigeria in the wake of COVID-19 outbreak [8]. Hencethe need for more structures as well as rapid testing.
These issues were prominent among other systemic
challenges which the Nigerian health systemgrappled with before the outbreak.
In this article, we offer practical and ethicalapproaches to improve the social organisation of
public health systems in Africa for mitigating
COVID-19. We begin with an analysis of how ethics
relate to these issues.
Ethical framework
Kantian deontology emphasizes the importance ofstaying bound to the cause of duty regardless of theoutcomes. Deontological ethics is bound by the'categorical imperatives' to produce actions that arecapable of becoming universal principles, respect forhumanity by not seeing people as means to an end,
but as ends in themselves, and acknowledging thehuman will as a universal law. Because duty is acorollary of roles and expectations, duty is not freefrom moral con licts. Hence, a re lection on the needfor decisional equilibrium and common morality
necessitates an appeal to principles. According to[9], there are certain ethical and moral principles
which should guide individuals as rational agents intheir decision making. As such encouraging the
pursuit of actions that respect individuals'
autonomy, produce bene icial outcomes, does not
induce any form of harm, and are fair to allconcerned. In extending the ideals of principlism tobenchmarks, [10] advanced the benchmarks whichshould guide against exploitative relationships when
duty is to be dispensed. In practice,consequentialism analyses the potential (positive/
negative) outcome of policies and frameworks [11].
The outcome of an action in comparison with nottaking such action is considered important. This
notion gives expression to the utilitarian principle
which considers the goodness of actions in terms ofthe number of people who bene it from them. Hence,
consequentialism lies at the intersection of duty andutilitarianism (consequentialist moral action). It
evaluates the extent of bene it in an action. Virtue
ethics, however, differs. Virtue ethics justi ies actions
not simply based on duty, or to measure theconsequence of neither action/inaction nor thenumber of people who bene it from a course ofaction. Virtue ethics highlights the cause of good or
bad actions, as proceeding from the dominant virtue.

Virtue ethics apply relativism as an important ethos.
This situates the transcendental nature of virtue as
being cross-cultural.
The preceding ethical foundations andorientations provide us with the framework for theensuing ethical analysis of COVID-19 response in
Nigeria. First, we examine how the implementationof pandemic control measures promotes public trustin public health emergency leadership andgovernance structure. Second, is the question ofwhat pandemic control policies best promote thegreatest bene its to the greatest number of the
public? Third, is a re lection on the extent to which
the policies are just and fair to the public. Four is aninterrogation of the potential consequences of thepandemic control measures on the public. Five, we
discuss the risks involved in the pandemic control
measures and management style. Six presents ananalysis of how these processes re lect on the extent
to which the individual citizen is/has been able to
make an informed decision about the pandemic
control measures.

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Governance and leadership
Public Health emergency leadership and governancestructure are vital for community resilience inoutbreak containment, treatment, and public
perception.
Outbreak containment: COVID-19 outbreakcontainment has been challenging for many Africancountries. Africa’s irst case of COVID-19 emerged 45
days after on 14th February 2020 [12] sequel towhen China reported the Wuhan outbreak to theWHO. The time-lag of spread notwithstanding, thegovernance structures in most African countries
were unable to translate these windows into
opportunities for COVID-19 containment. Most
African countries relied on the WHO guidelines toprovide some direction for a response. However, theideals were not situated within the social, economic,
and cultural peculiarities of Africa [13]. It is a factthat about 65% of Nigeria's GDP economy thrives in
the informal sector [14]. Hence, the transplant ofWestern disease control approaches created a gap
between the machinery of disease control leadershipand governance and the citizens. This fuelledinsinuation of Western conspiracy, as well as
connivance and complicity on the part of Africa
leaders. This quickly eroded the trust that people
should have had in the process.
Treatment: Search for effective treatment is still achallenge and more complicated in Africa due to theweak health care system. The weak healthgovernance structure compounds the quest for an
inward-looking approach for effective treatment.
Aside from the politics of science in African states
are still constrained by the strings attached to theirformer colonial masters. Even internally, the neocolonial agenda being implemented in the continent
does not allow freedom of utilising home-grown
innovation for development. While there is noperfect system in the world, lack of support forff

Eubios Journal of Asian and International Bioethics 32(4) (July 2022)

99

Madagascar's treatment by African governments is ademonstration of the insincerity of the continent's
lack of preparedness for the industrial revolution. It
is easily apparent that tropical medicine requires
tailored tropical solutions demanding effective
health governance and leadership structure taking
proactive actions, especially during public healthemergencies. While the government can save fromforeign exchange needed for importing drugs so that
individuals to have access to effective and cheap
treatment. However, this is not the situation. Most
African countries rely on donations and loans
currently to address the problem. The risk isenormous for the public due to exposure to vaccine
trials that might not have considered gene variation
which may lead to unnecessary harm. The choice isstill a problem for Africa countries due to the burdenof debt and string attached to the aprons of theircolonial master including China leading the newagenda for scrambling for Africa.
Public perception: Trust is a vital element ofpandemic control. Public trust emerges from theapproach to disease control policies and activities.
The transparency and the availability of
stakeholder engagement platforms provide
important dimensions of ownership andinvolvement. In Sweden, the herd immunity orcommunity immunity approach to addressing
COVID-19 was based on the principle of trust which
was an outcome of the moral obligation/contract ofleadership [15].
In Nigeria and Malawi [16] for example, theurgency of the situation moved the government toimplement the recommendations of the WHO
without recourse to local realities and with minimal
stakeholder engagement. This was a major cause of
the failure of the initial containment/mitigation
measures [17,…]. Governments can draw from thelessons learned from the HIV/AIDS programme
implementation or the 2014 Ebola crisis and theongoing H3 Africa project. Although these exist in
Africa they may not be exactly what is needed in theight against COVID-19. However, lessons can belearned from these for better stakeholders'engagement.
Preparedness for COVID-19 control and theutilitarian effect
For policies [18] that improve basic health provision,disease/epidemiologic surveillance andpreparedness systems cannot be overemphasized as
potential approaches to promoting health bene its
among a large proportion of the population. In
addition, [19] identi ied the value of risk
communication policies that has the potential ofbringing the greatest health bene its to the country.
These have the capacity to enhance the ability forearly recognition and containment activities needed
to curb the spread of the disease. Local contexts, theextent of disease severity/infectiousness, and thecategory of public health emergencies are importantconsiderations in disease control activities. This isEubios Journal of Asian and International Bioethics 32(4) (July 2022)

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especially so because there is not one single
suf icient that can provide an optimal response to
public health emergencies of the magnitude of
COVID-19.
Africa had the advantage that COVID-19 did notenter the continent until mid February [12] when
the irst case was announced in Egypt; yet some
African governments like Tanzania refused to accept
and properly prepare to combat the spread of thevirus. Presently, the number of con irmed cases on
the continent is estimated at 335,791. This
inadequate preparedness shows that the leadershipand governance structure for health on the continent
are weak. Due to governance inadequacies at thelarger state level, the spread of COVID-19 continues
to rise across Africa. The governance structures failin their duty to protect the lives and properties ofcitizens. Preparedness strategies used by African
governments ve been lopsided as issues of equity
and fairness have not been guaranteed in the various
containment and mitigation measures employedagainst COVID-19. For example, in Nigeria andMalawi, as the con irmed cases of COVID-19
continued to rise many states lacked testing centres
for a country of over 200 million people. Only Lagos
state and Abuja as of March 2020 had a functional
COVID-19 facility. In Nigeria, like in most Africancountries, the adoption of isolation, lockdowns, andother restrictive measures have been mostly
unsuccessful since they lasted longer than necessary.
The restrictive approaches were not supposed to last
for long [19]. They were to be imposed to allow
governments to assess the situation and implement
disease control responses. One positive consequenceof the restrictions (lockdown and other approaches)
was the increase in terms of testing capacity in
Nigeria. The number of laboratories grew from iveto thirty-three [19-20]. However, in economic terms,
the restrictions generated disaffection among themasses in Nigeria. This led to the breakdown of law
and order the beginning of protests. Immediate
underlying explanations include the fact that Nigeria
thrives on a highly informal economy, coupled with
the indirect problems of depleted foreign reserve,
global oil price crash [21], and decreased purchasing
power of the Naira against the dollar. Also, there
were marked inequalities in the administration of
the restrictive measures [22]. There were complaints
about the quality of care in the isolation centers,
consistent with the history of poor service delivery
in the Nigerian health system [23], and in somecases, infected persons broke out of isolation centres[24].
In Malawi, a state of disaster to prevent
COVID-19 was declared on 20th March 2020 and theirst Covid-19 cases were reported on 2nd April 2020.
A national COVID-19 Preparedness and Response
Plan was developed in June 2020 to ensure
prevention of COVID-19 spread into the country,
preparedness and readiness for a timely, consistentand coordinated response to COVID-19 pandemic[25]. Malawi, like other countries around the world

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adopted the various measures recommended by the
WHO to slow down the spread of COVID 19. The
measures include but are not limited to: social
distancing, regular hand washing with soap andwater, use of hand sanitizer, practising respiratory
hygiene, putting on masks, restriction of gatherings,
use of personal protective equipment (PPE),
screening, contact tracing, self-isolation andquarantine of suspected or con irmed cases.
However, implementation of some of these measures
has been a challenge due to resistance by the public
especially due to the socio-economic and ethicalconcerns. For instance, issue about disclosure of
information and mandatory testing in contact
tracing has been one of the key issues of ethicalconcern in the country due to its potentiality to
infringe on individuals’ privacy and con identiality.
These germane issues have made preparedness
strategies for COVID-19 lopsided and an ethicalissue, as the implementation of already existing
strategies to combat the continued spread of
COVID-19. More so, the isolation strategies infringeon the rights of the infected persons. While theethics of treatment on who gets tested and who does
not has led to the underreporting of cases of
COVID-19 pandemic in Africa.
Restrictions
Restrictions were set up to reduce the spread of thevirus and to provide government time to be able to
make provision for mitigation and treatment.
However, two major risks emerged from therestrictions that were imposed. First, was increased
poverty and second, was the spike in the rate of
infections. Poverty rates increased [21] putting more
people into the poverty class. The effect of therestrictions increased the burden on the informal
sector as the largest employer of labour, even as
lockdowns are being partially lifted. The noninclusion of Nigeria’s informal economic sector in
the social protection programmes of the government
further made the sector more vulnerable [21](ACAPS, 2020). The rate of infection has been on asteady rise and the implication of this is anotherwave of lockdown if the number of infections keeps
rising. In most African coutries, the restriction
measures faced a resistance making enforcement
dif icult. For example in Malawi, the Covid-19
response policies restricted gatherings likeweddings and funerals, whilst political rallies
occurred without adhering to Covid- 19 measures[26]. This resulted in loss of public trust in thegovernment and affected compliance of the public to
Covid 19 prevention measures.
Self-Isolation: The adoption of self-isolation as ameans of disease control was not properly managed
in the Nigerian context. The self-isolation rule was
not observed and, in some situations, people who
were of the elite class louted the directives [27].
There were social class-based disparities in terms ofthe management of self-isolation. The government
also recognized the failure of this measure of diseaseEubios Journal of Asian and International Bioethics 32(4) (July 2022)
control as most travellers did not stay true to theguidance to stay in self-isolation for 14 days
following their arrival from international travels.
This non-compliance was a key factor in the
proliferation of cases across the country [27].
Social distancing: Social distancing is alien concept
to Africa. Africans live by the principle of being theirbrothers' keeper. The implementation of social
distancing is unpopular and dif icult for people toadapt into practice. The practice is a major concern
as it hinders persons from rendering the necessary
care to loved ones which is critical on a continent
with a very weak health system. Hence, this may
cause more harm than bene it.
Quarantine: The structure of quarantine on
standards of care, proper management ofgatekeepers, scope [28] and contact tracing,monitoring, and ensuring compliance is based on
coercion and force [29] which has infringed upon therights of persons. The structure of quarantine for
COVID-19 in Africa has not been effective in a time of
COVID-19 pandemic. Both self and forcefulquarantine measures have been used to combat the
spread of COVID-19 [19]. For example, in Kenya
people that violate curfew are subjected to forcefulquarantine [30]. These reports of forceful quarantine
have been one of the ways the government has
infringed on the rights of the citizen. This is deemed
unethical as it erodes the right to justice for thoseconcerned and affected.

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Lockdown: Based on the recommendation of theWHO, the lockdown was the irst level of response toaddressing the outbreak.
The situation was an evolving one, governments
were bound to carry out a situational analysis andgenerate informed decisions to guide disease control
activities. However, in Nigeria like in Uganda, Kenya,
Malawi and Zimbabwe, the lockdown wasannounced without viable structures for providing
palliatives. It was still extended without feasible next
steps [31]. In Malawi, immediately after the
President announced a national lockdown an
injunction was obtained against the lockdown. The
Malawi High Court overruled the lock down policy
arguing that it would be unconstitutional because its
negative consequences on the socio-economic stateof the majority of Malawians [32]. The ‘conditional
cash transfer’ [33, 34…], school feeding program at‘home’ [35], and use of TV/Radio platforms for theteaching of school children were major points ofcontroversy [36]in most African countries. The
governments did not provide clear directions/guidelines regarding the management of theseprocesses. The provision of palliatives in mostAfrican countries was plagued with party politics,
partisanship, and political clientelism [37-40]. Thisapproach made it very impossible for non-politicalgroups and unaligned persons to access support
from the government. Also, varied dimensions of101

inequity were identi ied in the use of lockdown. This
lower social class in the society interpreted the
lockdown not just as a 'protective' measure, but as apart of the government's 'historical’ conspiracy
against the ‘poor’. There were social class differencesin the implementation of the restrictions [41-42].
Capacity to make informed consent for prevention
The capacity to make informed consent is dependent
on access to the right information. The reportage of
COVID-19 has been fraught with hoaxes andrumours. The ideological state apparatus is thepress/media and it is through the media that thecitizens can rightly access the information required
to make informed safety decisions.
The misinformation has led some citizens suchas in Nigeria to consider the outbreak as being
politically motived or manipulated. There have beenconspiracy ideas about the global political structureof COVID-19 origin and spread. Hence, in some cases,
people have explored the use of natural remedies as
preventative and curative measures. These havemade the use of personal protective equipment torequire signi icant enforcement. Although there are
mass-media advertisements to provide information
regarding the virus, the aetiology (controversial) andepidemiological reports have been scanty. For
example, the government of Tanzania has restrictedpress freedom, provided sporadic COVID-19 data,and communicated COVID-19 health informationthat may potentially compromise the health securityof the East African region. In another dimension, theavailable information about the patterns of
COVID-19 in Nigeria has been limited to simple disaggregations like gender and local government
areas. With better-disaggregated data, Nigerians
would have been better able to make informed
choices about control and preventive decisions.
These and other possible reasons demonstrate that
individual citizens have been rendered less capableof informed decisions.
The way forward
In low-and-middle-income countries, the inancial
inability of the government to readily respond tohealth emergencies requires a re lection. While it isestablished that there is no one-size- its-all
approach to disease control efforts, we suggest two
valuable ways to develop ethical contexts for better
outcomes. First, the government must leverage therole of stakeholders, and second, is the need forcountry-speci ic ethical framework to guide theallocation of resources, priority setting, andcommunity-ownership.
In Nigeria, the Coalition Against COVID-19 (CACOVID) was set up by leaders in the private sector to
support the government in her activities regarding
COVID-19. This provided ownership to the private
sector and has signi icantly helped the process.
Stakeholder engagement at all levels is a useful
resource in countries with limited resources. In
Kenya, Ethiopia, and Tanzania [43], the governments

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Eubios Journal of Asian and International Bioethics 32(4) (July 2022)

are leveraging extensively on the willingness of theC o m m u n i t y H e a l t h wo r k fo rc e . T h ey h ave
signi icantly helped to accelerate contact-tracing,reaching hardest-to-reach communities with
supplies, and providing health education about
COVID-19. Stakeholders are vital for ensuring theimplementation of disease control strategies as they
have a grasp and understanding of approaches forreaching their constituents.
Another approach that is potentially viable forpandemic mitigation and control activities is an
ethical framework. Most African countries require
ethical frameworks to guide community
engagement, resource allocation, priority setting,and clinical care among other important areas ofcontrol activities. The development of an ethicalframework will help governments to provide
healthcare for all. Although the WHO has developed
a related guidance document, this may not be
suf icient to address the governance and resource
peculiarities of the African continent. Hence,
country-speci ic ethical frameworks will focus onaddressing the local realities and providing
directions for resource allocation and otherengagements in a pandemic. Indigenized strategies
potentially bene it from inputs from the local
communities. This approach is ethically sound,respects the autonomy of locals, and drives
ownership and the possibilities of achieving higher
levels of compliance in their implementation.
Conclusion
Governance and leadership are central to stopping
COVID-19 in Africa. At the centre of strengthening
the social organisation of public health systems in
Africa, there is a need for better governance andleadership for health. The need for country-speci ic
e t h i c a l f ra m e wo r ks t h a t a re p ra c t i c a l i n
implementation across Africa is needful, as the social
construction of COVID-19 differs across thecontinent.
Competing Interest
The authors declare no competing interest.
Acknowledgements
The research reported in this publication was supportedby the Fogarty International Center and National Instituteof Mental Health, and the National Institute on Aging(NIA) of the National Institutes of Health under Award
Number D43 TW010543. The content is solely the
responsibility of the author and does not necessarily
represent the of icial views of the National Institutes of
Health.

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43. Nduta J. Ouma G. In their words: Community healthworkers ight COVID-19. 1 June 2020. Retrieved fromhttps://www.actionagainsthunger.org/story/theirwords-community-health-workers- ight-covid-19

The Early Hours of the COVID-19
Pandemic: Issues encountered byStudents at Malaysian Higher
Education Institution- Randy A. Tudy
Commission on Higher Education, the Philippines
Email: rtudy@ched.gov.ph- Rozinah Jamaludin
Universiti Sains Malaysia, Malaysia
Email: rozinah@usm.my- Ida G. Tudy
City College of Davao, the Philippines
Email: tudyida@gmail.com
Abstract
With COVID-19’s exponential spread threatening theentire population, lockdown was imposed where alluniversities, schools, restaurants, and other publicareas come to a standstill and closure. No more faceto-face teaching at the universities, as everybody was
asked to work from home (WFH). From here, allteaching and learning turned to virtual or remotelearning. Everything goes online as both teachersand students are at risk. This study explored theissues encountered by Malaysian students in higher
education during the early months of the COVID-19
pandemic.
It employed a phenomenologicalapproach to qualitative design. The qualitative data
came from an online survey with 617 student
respondents. Results revealed the following issues:dealing with limitations due to the pandemic,
personal-related struggles, keeping oneself healthy,boredom, and changes in school dynamics. When
asked for their suggestions, the following top themes
emerged: upgrade internet speed, apply practicalteaching methods, stay safe, abide by laws andguidelines, and improve government support. Basedon the results, it can be argued that the students'
challenges brought about by the pandemic is not
purely academics, more to social presence. They had
to deal with other issues, just like any ordinary
person affected by the pandemic's adverse impact.

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Introduction
The COVID-19 pandemic caught everyone bysurprise in one way or another. Many people lost

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their jobs (Baert et al., 2020; Wilson et al., 2020),
and the lockdowns imposed by governments had
severe economic repercussions (Ozili & Arun, 2020).
In the educational sector, teachers and students had
to ind ways that education can continue. As thegovernment implemented lockdowns and othermovement restrictions, schools were forced to stop
doing face-to-face classes. As a result, online courses
or online platforms were used to continue theirstudies and for the schools to continue operating.
However, students were not used to the platform.
Some were having dif iculty adapting to the newsetup (Alharthi, 2020). Although students werequick to point out the advantages of having online
classes (Shim & Lee, 2020; Naji et al., 2020), likeallowing them to listen to their teachers at the
comfort of their homes or anywhere they want (Najiet al., 2020), there were disadvantages that theyencountered. Some complained of having so muchwork to do, causing them fatigue in the end (Niemi &Kousa, 2020). Others reported having been stressedout (Elmer et al., 2020; Salari et al., 2020; Simamora,2020). Hence, the COVID-19 pandemic has broughtso much inconvenience for both students andteachers.
The pandemic brought another dimension toeducation. Unprecedented in history as regards
education during a pandemic, educators need toknow the situation of their students. In this paper,
we look into how this pandemic affected thestudents. We dig deeper into their lived experiencesby raising their voices through a qualitative inquiry.
This study explores the issues based on theexperience of the higher institution students in
Malaysia during the COVID-19 pandemic. This paper
addresses the gap in understanding the real score on
the ground, meaning the students' situation. The
indings contribute to the literature on the debate
about the effectiveness of implementing distanceeducation amidst a pandemic.
Online Education during COVID-19 Pandemic
Schools shifted to an online platform to cater to thestudents' needs during a pandemic. While online
education is nothing new and is bene icial during apandemic (Basilaia & Kvavadze, 2020; Muthuprasad
et al., 2021; Paudel, 2021), it also has its
disadvantages. During the COVID-19 pandemic,
several challenges emerged, such as lack oftechnological resources or internet problems(Doyumgaç et al., 2021; Muthuprasad et al., 2021;
Paudel, 2021), stress (Chandra, 2020; Husky, 2020;
Rajab et al., 2020), communication dif iculties(Alawamleh et al., 2020; Dhawan, 2020; Rajab et al.,2020), and student assessment (García-Peñalvo etal., 2021). Despite these challenges, both students
and teachers work hard to attain the goals in
education. Aside from online classes, other forms oflearning are through modules or a combination of
both. Hence, the terms blended learning or lexible
learning became more popular during the pandemic.

Eubios Journal of Asian and International Bioethics 32(4) (July 2022)
There were also concerns among teachers as
regards themselves concerning online education.
Some of these included low motivation in using
technology (Aytaç, 2021), unpreparedness (Atiles etal., 2020; Carver & Shanks, 2021), communicatingwith students (Primdahl et al., 2020), academic
dishonesty among students (Moralista & Oducado,2020), and most especially their concern about thequality of teaching (Cheng & Lam, 2021). Teachers
knew how the pandemic impacted their role in theteaching-learning process. They also were verymuch aware of the dif iculties their students went
through. Thus, they needed to be innovative andexerted more effort to reach out to them.
Both students and teachers have their share of
dif iculties because of the pandemic while online
education is implemented. Nevertheless, there arealso positive developments in doing online classes
during the pandemic. For example, the interactive
communication tool used by teachers, in somedegrees, compensated their actual classroom
presence (Roque-Hernández et al., 2021). Students
found lexibility and convenience as positive featuresof online education (Bdair, 2021; Muthuprasad et al.,2021). In one study, both teachers and students
agreed that online education promotes online
research (Paudel, 2021), a skill that is very
important for learning. Moreover, the pandemic andonline education help promote internalization. For
example, exchanging online modules became
possible and even broadened the scope into globalclassrooms (Shahrill et al., 2021).

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The Chronology of Covid-19 Pandemic in Malaysia
On January 31, 2020, the World Health Organisation(WHO) announced that globally, COVID-19 is at apandemic level. Authorities reported that the virus
was discovered on December 8, 2019, from Wuhan
City in Hubei Province in central China where many
patients worked at or lived around the local Huanan
Seafood Wholesale Market, although other earlycases had no exposure to this market (Lu, Stratton, &Tang, 2020). On January 25, 2020, Malaysia was irst
hit by this COVID-19 by contacting three Chinesethat came in through Singapore in Johor Baharu(Malaysian Health Ministry, 2020). However, thenumbers kept increasing until early March 2020.
Then, the government imposed the irst national
lockdown called Conditional Movement Control
Order (CMCO) or Targeted Enhanced Movement
Control Order (TEMCO) from March 18, 202, toMarch 31, 2020. As the cases became more serious,
the government imposed a second lockdown fromMarch 31 to April 14, 2020 and continued the third
lockdown extended to April 28. The government
extended again until the end of December 2020.
During this lockdown, the term "new normal"
emerged, replacing the old normal routine thatpeople usually do before the pandemic. Under thisnew normal situation, all higher education
institutions (HEIs) in Malaysia implemented virtual
learning for the foreseeable future and complied105

with standard operating procedures (SOP) anddirectives set by the authorities to keep the virus atbay and break the infection chain (Lee, 2020).
Students continued their schooling without
going to school campuses.
Using technology,
teachers and students made it possible to engage inthe teaching-learning process.
However, as the
weeks and months passed, both students andteachers noticed and experienced several problems.
In this paper, we present the issues as identi ied by
the students and at the same time discuss theirsuggestions to help them in their situation during
this new normal situation.
Research Questions
1. What are the issues the Malaysian Higher
Education Institutions (HEIs) face during theearly hours of the COVID-19 pandemic?
2. What are their suggestions to help them continue
their studies during the pandemic?
Methods
The study employed a qualitative design using aphenomenological approach. The phenomenon we
investigated was the lived experience of Malaysian
higher education students affected by the changes
brought about by the COVID-19 pandemic. According
to Creswell (2007), the phenomenological approachin qualitative research focuses on the lived
experiences of people who are directly or indirectly
involved in the phenomenon being investigated.
S p e c i i c a l l y, w e e m p l o y e d d e s c r i p t i v ephenomenology.
As cited by Giorgi (2007),
descriptive phenomenology, from the perspective ofHusserl, is "designed to deal with any type of object
and its manner of appearance is the basis uponwhich investigative procedures should proceed" (pp.
73-73). Descriptive phenomenology is more on
knowing the phenomenon per se rather than giving
an interpretation of it. In this study, we focused on
the actual experience of the students.
Study Participants: The study participants were the617 students of a university in Malaysia who
participated in the online survey. They werestudents enrolled in different programs during the
COVID-19 pandemic.
Data Sources and Data Collection: The main sourceof the data was from the students' responses in thesurvey questionnaires of an online survey. Hence, weonly analyzed the qualitative data from the openended questions included in the online survey.
Analysis & Interpretation of the Data: We followed
the six phases of thematic analysis, as suggested byBraun and Clarke (2006). First, we familiarize
ourselves with the data. We read and re-read thestudents' responses for us to have a better grasp of
their experiences.
Second, we generated initialcodes. It was the irst step in organizing the data.
Third, after generating initial codes, we searched for106

Eubios Journal of Asian and International Bioethics 32(4) (July 2022)

themes. We did this phase by sorting out thedifferent codes by analyzing which codes are similar
or combined. We then started to see the possible
relationship between codes or between themes.
Fourth, when we identi ied themes, we reviewed
these themes to come up with some re ined ones. We
narrowed down our themes in this phase after
eliminating those with not much data to support or
combine two themes into one. Fifth, we de ined andnamed the themes. Here, we explained the essenceof each theme and narrated a story-like discussion.
Sixth, we produced the result. Here, we wrote theresults by explaining each theme. We further
explained each theme by providing actual responses
from the participants.
Trustworthiness: We ensured that we followed theprotocols in conducting qualitative research byobserving the trustworthiness. According to Guba
(1981), the following must be observed to achieve
trustworthiness:credibility, transferability,
dependability, and con irmability. Our longexperience as educators and researchers gave us thecon idence and credibility to conduct this study on
credibility. We carefully crafted the online survey's
qualitative questions to ensure the students' rightand appropriate responses. We also asked forcomments from our colleagues, who are qualitative
research practitioners, to ensure that we followed
acceptable standards. For transferability, we
believed this study is worth emulating or replicatedin other contexts since the phenomenon we were
investigating was true in Malaysia and othercountries. Hence, we desired wider dissemination of
the study's indings. As to the dependability, we
provided here a detailed account of how we
conducted the study. We also supported our indings
with related literature. For con irmability, we
created an audit trail in our analysis of the data.
Also, we observed and conformed to the descriptive
phenomenological theory of focusing on the reale x p e r i e n c e w i t h o u t g iv i n g o u r b i a s a n dinterpretation.
Ethical considerations
Since the data came from the online survey, there
was no problem with identi iers like theparticipants' names. The data only contained
students’ numbers. We got permission to use andanalyze the qualitative data, which already had priorconsent from the survey respondents. Furthermore,
we did not use any name or even Pseudonyms but
only numbers of students' entry in our database andthe result section. We also hid the name of theuniversity.

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Results
The presentation of this study's indings is clusteredinto two. These are issues experienced by students
and their suggestions to help them continue theirstudies during a pandemic.

Issues Experienced by Students in MalaysianHigher Educational Institutions
For the students' answers to the qualitative question
about the issues they experienced during the earlymonths of the COVID-19 pandemic, we analyzed
using Colaizzi’s (1978) method. The analysis of data
yielded ive themes, namely, (1) dealing withlimitations due to the pandemic, (2) personalrelated struggles, (3) keeping oneself healthy, (4)boredom, and (5) changes in school dynamics.
Dealing with Limitations Due to the Pandemic.
The students recognized the limitation theyexperienced because of the lockdowns imposed by
the Malaysian government. As classes were nolonger allowed in an actual classroom setting, thestudents were forced to go online. Their number one
limitation is the problem with an internet
connection or the limited connection to it. For
example, student number 110 shared how thisinternet problem affected him, saying, “It's really
dif icult to access e-learning due to slow internet
connection.”
The other limitation they commonly experienced
was the dif iculty of online classes and the lack ofresources. These limitations pushed them to lose
focus on their studies. They also expressed having
problems with online classes, particularly with doing
their assignments. They said this format, referring
to an online class, is not ef icient. One student
expressed her sentiments, saying:“It's a challenge to be at home and to study/
doing assignments. Hearing that the wholesemester will be done online tear me apart. I
don’t ever think I can. I hope the university thinksof people who live in rural areas and do not haveinternet privilege. Please, think of those in need”(Student # 562).
The other common limitation they identi ied was theavailability of facilities such as food andtransportation.
For example, student #608
enumerated several limitations she experienced,
such as “restrictions in studying, lack socializing, lessphysical activities, and restricted food supply.”
Transportation is also identi ied as anotherlimitation. Student # 47 shared, “I have dif iculties togo outside and so little access for transportation.”
Personal Related Struggles
Aside from the aforementioned school-related issues
and challenges identi ied by the student
respondents, they also had to deal with personal
struggles. For example, their usual daily routine
before, which included part-time work, was in peril.
One student, living away from home, described hersituation this way:
"It is dif icult to survive as a student, staying
away from my parents, reconsidering that theyneed to save and had to spend too. So here I am.
I did a part-time job. I hope this outbreak willcease" (Student #148).

The other personal related struggles they had wereinancial. They said they did not have enough money
to save. They were worried about what happens if
the pandemic would drag for long. Undoubtedly, it
would have affected their inances. One student
expressed her fears, saying:“I have many challenges that I face. We will neverknow what will happen in the future. If we lookthrough the broadcast news, this makes meworry. In addition to the dif iculty of buying
personal protection equipment, I must haveinancial reserves for the next few weeks”(Student #400).
Based on the responses from the students, thepandemic did not only affect their studies. It had atrickling down effect on all the aspects of their lives,
including their personal lives.
Keeping Oneself Healthy
The students were afraid. They had fears about thevirus. Since they could not do anything much, theyshared that they had to be healthy not to contract theunseen enemy. They also recognized that pandemic
had caused the lack of food supply, access tonecessities, and other health problems. One student
had this advice to fellow students:“I hope we still in healthy condition, and for the
students, we need to keep studying at home”(Student #326)
With the limited or lack of food supplies, students
also expressed the need for health care protections.
For example, another student enumerated her
problem, such as:“Low stock of foods, a load of assignments andpresentations, non-healthy lifestyle, and being
homesick” (Student #462).
Boredom
Although closely related to the number three theme,
the other issue that the students faced was boredom.
Again, students were glued in their apartments orhouses because of movement restriction, withobviously not much to do. The lockdown prevented
people from going out. Social distancing was strictly
observed; hence, the students were forced to staywhere they were. However, the lack of social
interaction affects the students, especially that they
are sociable, meaning they want to be with theirfriends. Another student explains this scenario.
“Social distancing might be challenging because I
cannot simply interact with other peers”(Student #148).
Staying at home for a more extended period madethe students bored, distracted, and even emotional.
They were constricted to interacting with people
online. They wanted to go outside and resume
regular classes. One student expressed it this way:

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“I am too bored at home! I want to go to a classsoon. I still study though, but yeah, I need to

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107

communicate with others as well. My Wi-Fi...
damn! it’s a problem” (Student #396).
Indeed, the longer the pandemic drag on, the more
the students felt isolated and did limited activities
causing them boredom. They were used to movingaround freely, but the pandemic constrained such
movements, and they had to deal with thepsychological impact.
Changes in School Dynamics
When the government employed lockdowns andother movement restrictions, schools have to adapt
and implement appropriate measures. However, thestudent participants had to deal with the changes
with so much dif iculty on their part. Top on the list
for the changes in school dynamics was limited
guidance from teachers. They felt that the lessons
were not imparted to them due to the limitations of
the new setup. In short, compared to the actualclassroom setting, they had less help from theirteachers. In fact, some expressed the dif iculty ofreaching out to their teachers for consultation. In
particular, Student #32 shared this experience,saying:“Lesson prepared for the school were not
imparted to the students; thus, these may affectthe learning of the students.”
As schools' main response to continuing classes, thetransfer to online classes had its own disadvantages,
like lessons not received by the students.
For
instance, an observation of one student explained
the issue.
“There are problems associated with the learning
process for lecturers and students. The lecturers'
input does not reach 100% to the students”(Student # 531).
The other school changes they noticed were thepostponement of school activities such as researchpresentations, examinations, classes, and on-thejob training. All these have affected the routine ofstudents' lives, although they have to deal withthese changes due to the pandemic's adverse effect.
Suggestions of Students to help them continue
their Studies during the Pandemic
Besides asking them about the issues and problems
they encountered during the pandemic, they werealso asked about their suggestions. The top ive
common suggestions were (1) upgrade internet
speed, (2) apply practical teaching method, (3) staysafe, (4) abide by laws and guidelines, and (5)improve government support.
Upgrade Internet Speed
Because schools use online platforms for thecontinuity of classes, students have no recourse but
are dependent on the internet in the irst place.
However, as already shared in the issues theyencountered, internet speed was a big problem. A
student who had a poor internet connection had thisto say:108

Eubios Journal of Asian and International Bioethics 32(4) (July 2022)“Before turning to an online platform, please domake sure that students have good internet
access and reachable” (Student #615).
Apply Practical Teaching Method
Students felt dif iculties in how the teaching-learning
process was conducted as online classes replaced
the usual face-to-face interaction. It started with thechecking of attendance. Depending on how teachers
check the attendance, it was varied, but one student
suggested an easier way of doing it. She said:“I hope the online teaching more lexible as some
lecturers would like to take attendance on thatspeci ic period by using face to face online
teaching, but I think there is another method toprove the attendance” (Student #686).
As to the teacher's best learning method, studentssuggested that teachers take a video of themselves
discussing the lesson.
One of the speci ic
suggestions from the students was:“I hope that our lecturers upload a video of themteaching us as if we are in class” (Student #407).
The above suggestion was echoed by one student,
saying:“It is better having the video teaching. This also
can let us repeat if we miss some importantnotes” (Student #237).
Stay Safe
Students knew there was no much to do on theirpart aside from studying. But, in terms of ighting or
escaping from the virus, they suggested staying
better safe. A good number of the participants
mentioned this advice of keeping themselves safe.
Moreover, one student put his suggestion in this way:
“Although self-quarantine may be boring, it is forthe safety of everyone. I think it is important toeducate people on how telecommunicating sothey can do physical distancing and still socialize
with others” (Student #57).
Abide with Laws and Regulations
Besides keeping themselves healthy, students also
agreed to follow the government's protocols toensure everyone's safety. There are rules andguidelines that they believed must be followed. For
example, one student suggested:“Keep yourself healthy and stay at home during
this pandemic and follow government rules”(Student #534).
However, students would like to be clear on thestudents' guidelines when it comes to school. For
example, one student commented:“We need clear and immediate instructions onwhat to do. At least, a guideline for us to follow.
How do school assess our progress? What are thetasks?” (Student #137).

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Improve governmental support

In times of pandemic, the people relied heavily on
the government. The students felt this way too.
First, the students wanted the government tosupport their schooling, especially with the internet.
A particular student even suggested for thegovernment to lower the charges for data usage.
Another student told the government:"Government need to upgrade the wirelesscoverage to all slow coverage regions" (Student#155).
Some students wanted the government to provide
them with other non-school support. For instance,
one student expressed her desire for the government
to give them money and food, saying:“The government should give the people
incentive so that we have enough food andmoney” (Student #204).
Moreover, students would like their government to
do the right and effective ways to address the
pandemic problem. They wanted to end the crisis
with the government's bold move. For example, asuggestion about what the government should do
was shared by another student:“My advice regarding this case, hopefully, thisoutbreak is completed quickly. The government
must learn a lot from countries that can solve
problems quickly and solve us as a society andcare about cleanliness and health. For humanresources in the health sector, they must also
learn a lot from developed countries” (Student#400).
Discussion
The COVID-19 pandemic has affected the lives of all
people around the world. In the education sector,
the students suffered a lot. They lost the luxury oflearning face-to-face with their respective
professors. Schools turned into online classrooms tocontinue operating and providing access to
education. However, the students faced the most
dif icult hurdle- the internet problem. The Malaysian
students were not alone as students from othercountries also had to deal with no or slow internet
connection (Adnan & Anwar, 2020; Lokanath Mishra& Gupta, 2020). Also, in Malaysia, students had todeal with the same problem (Ahmad et al., 2020;
Chung et al., 2020). The internet connection was
highlighted as the main concern, particularly for
those living in rural areas. The absence of face-toface classes forced students to venture into
unfamiliar territories, like having less guidance fromthe professors (Adnan & Anwar, 2020).
The
participants of this study pointed out the hurdles ofdoing their assignments and the lack of resources.
Food was also mentioned as one issue. All theseissues were summed up into the limitations thatstudents had to deal with as the government
restricted school campuses' opening, thereby
alienating them in their respective homes orapartments.

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The COVID-19 pandemic disrupted almost all
facets of the daily lives of people. Besides dealing
with the limitations of slow internet connection andthe lack of food and other resources, they had to deal
with school dynamics changes. For example, the lackof guidance from their professors added to the
problem of slow internet connection. They relied on
online classes where professors can either use videoconferencing or gave materials online. In one study,
students demanded their professors to change theirteaching style to conform to an online platform(Akyıldız, 2020). Other studies also identi ied thenegative effects of online classes, such as theinability to perform practical applications (Radu etal., 2020). A survey of higher education students inPakistan revealed that online learning is not effective(Adnan & Anwar, 2020).
Indeed, the school
dynamics changes added to the dif iculty students
were already experiencing during the COVID-19
pandemic. The new normal in the education sector
is a rich area for research. Teachers andadministrators are interested in seeing if the online
platform is effective or not and how to improve it.
The students in this study also share theirpersonal-related struggles, speci ically the
disruption of their part-time work and inancial
problem. The loss of jobs during a pandemic wasalready expected to cause many inancial and otherrelated problems (Baert et al., 2020; Wilson et al.,2020). Losing a part-time job was dif icult because
they needed to support themselves. They also, likeregular employees, could not avail of any assistancefrom the government. However, losing one's job canalso lead to mental health problems like depression
and anxiety (Wilson et al., 2020). It is another issue
that the students faced- boredom. There werealready earlier reports that students areexperiencing depression because of the effect of thepandemic (Akyıldız, 2020; Islam et al., 2020; Kapasia
et al., 2020; Mechili et al., 2020; Son et al., 2020),
while some lost the motivation to learn (Niemi &Kousa, 2020). The lack of interaction (Akyıldız,
2020) among students and between them and theteacher changed the teaching-learning process,which also affected the students' emotional andpsychological status.
Amidst the numerous challenges of thepandemic, the student participants highlighted theirconcern about making themselves healthy. Thisissue emerged because of the problem of the foodsupply. Understandably, the lockdowns had limited
movements both for people and transportation
services, including transportation for food supplies.
However, the government made sure that these
services continue to low as a priority. However,food supply remained a big concern. Even in the
United States, a study reported food insecurity
among college students during the pandemic(Owens et al., 2020). Overall, students were worried
about their health. Globally, several studies had
already reported the adverse effects of the pandemic
on people's health (Xiong et al., 2020). The same109

scenario with the students who had to deal withmaintaining their good health condition whilehandling the new normal set up in school.
Students provided valuable suggestions for theschools and the government with all the identi ied
struggles they were facing. One of these is the
speeding up of internet connection. This problem
had existed even before the pandemic. Without thistechnology, education is in peril. Students will suffer
because the quality of education is sacri iced. Theinternet is the lifeline between students andprofessors or school, for that matter. Added to thiswere reports of students' dissatisfaction with online
classes (Sarwar et al., 2020). For teachers, quality
and timely exchanges in online classes could help thestudents (Nambiar, 2020), but this cannot be madepossible without a stable internet connection. The
students also demanded teachers to adapt to a more
effective teaching method. Teachers asked fortechnical support (Nambiar, 2020), while thestudents suggested objective assessment (Kaliyadan
et al., 2000; Radu et al., 2020). Moreover, students
would like the teachers to change their teachingstyle to conform to an online platform (Akyıldız,
2020).
The students' other suggestions were to keep
themselves safe and healthy and follow the rules andguidelines. Governments worldwide are working so
hard to address the pandemic's problems and ensurethat the people are safe from the virus (Ha et al.,2020; Weible et al., 2020). Many of the protocols
implemented by governments are on social
distancing, wearing masks, and handwashing. These
were considered the minimum health standards.
Just like the rest of the population, students need toobserve these protocols. Moreover, the studentparticipants demanded clear instructions from theschool on what to do for them to follow.
Lastly, students suggested that the government
increase support, particularly on increasing theinternet speed, non-school support, and measures toaddress the pandemic. The internet problem seems
to be the most mentioned issue among students.
This is something that the government on themacro-level and schools on the micro-level have toaddress seriously. The new normal setup will notprosper without technological support, particularly
the availability of the internet.
Implication of the Study
The indings have implications for the government,
particularly in ensuring faster internet speed by theproviders. Similarly, governments can look into
additional support to students, particularly on foodand even transportation, to make sure they cancontinue their studies while at the same timeensuring their safety. The students had valuable
insights on appropriate teaching methods, reliable
assessment, and an internet connection to theschools.

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Concluding remarks
The COVID-19 pandemic has revolutionized theeducational setting due to the stoppage of actualclassroom classes.
However, online classes arenothing new to schools as there are alreadymechanisms wherein blended learning is applied.
H o w e v e r, t h e p a n d e m i c c a u s e d a l o t o finconvenience among students. They had to deal
with limitations due to the pandemic, school
dynamics changes, personal related struggles,boredom, and keeping oneself healthy. With theseissues, they suggested upgrading internet speed,
applying practical teaching methods, staying safe,
abiding by laws and guidelines, and improving
government support. In other words, while there areissues attributed to the pandemic, there are ways toaddress or limit the adverse effects to the students
and the school in general. The suggestions of thestudents are just a few of these. Hence, more can bedone, and research could play an important role inproviding information and recommendations.

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j.jad.2020.08.001

The Impact of COVID-19
Pandemic on Mental Wellbeing of African Students in
Chinese Universities- Uwimana Alexandre, M.D., MNGPH, Ph.D.,
American University of Sovereign Nations, Rwanda
Email: alexukimumu@gmail.com- Darryl R.J. Macer, Ph.D., Hon.D., MPH.
American University of Sovereign Nations, Sacaton,
Arizona 85147, USA
Email: provost@ausn.info
Abstract
Background: The COVID-19 Pandemic is associatedwith various stressors that deteriorate the general
population's mental well-being (MWB). Students areamong the most mentally-affected people by thecurrent Pandemic, and it is known that college
students are usually associated with the low MWB.
However, compared to local students, international
students face additional challenges related to living
in a foreign country, making them more prone tomental instability than their local peers.
Objectives: This study aimed to investigate thestatus of MWB of African students in Chinese
universities after two years of challenges related to
the COVID-19 Pandemic and explore the different
stressors deteriorating their MWB.
Methods: This was a cross-sectional study. The
questionnaire was built using a WeChat-based online
survey. The Warwick-Edinburgh Mental Well-Being
Scale (WEMWBS-14) questionnaire was used toassess the MWB of our participants. The higherscores represent the higher levels of MWB.
Respectively, 14-32, 32-40, 40-59, and 59-70 scoresindicate very low, below the average, average, andabove the average level of MWB. Therefore, thecutoff of ≤ 40 scores designated the low level of
MWB, and scores of > 40 were considered good
MWB.
Results: 134 students from 31 cities and 54
universities completed the survey. The mean
WEMWBS-14 was 47.84 ± 9.416, and the lowest
level of MWB was observed among the tested
positive students for COVID-19 (35.50 ± 7.778; P =0.033). Of all, 6.72%, 13.43%, 67.16%, and 12.69%
of students had very low, below the average, average,
and above the average level of MWB, respectively.
Conclusion: The COVID-19 Pandemic has worsened
the preexisted poverty and unemployment rate in
African countries, deteriorating the MWB of African
people, especially African students. Universities
should make a lexible teaching environment,
consider inancial support, and provide stressmanagement guidelines.
Keywords: COVID-19 Pandemic, International
students, Mental well-being, University students,
WEMWBS-14

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Introduction
The COVID-19 Pandemic is associated with thegeneral population's poor mental well-being (MWB).
Complete mental health comprises mental wellbeing and mental ill-being. MWB is characterized by
the optimal psychological functioning andexperience, without any psychopathologicalsymptoms, and with the satisfaction of theindividual’s emotional, social and psychological life,
including optimism, coping, feeling of control, selfesteem, resilience, functioning, psychologicallexibility, and adjustment. On the other hand,mental ill-being is a wide range of hard experiences
which decrease optimal psychological functioning
and lead to worries, stress, loneliness, andpsychological disorders [1].
Healthy mental life in this pandemic era is linked
with MWB and strengths such as resilience, hope,and meaningful living. Looking for a meaningful life
is the fundamental MWB of human beings. A
meaningful life is a subjective concept with different
essential factors such as love, success, and not
suffering. Subjective well-being (SWB) is related to
the grati ication of life and positive and negative
feelings. In contrast, psychological well-being (PWB)
is related to the positive ability to contribute tovirtue life to achieve excellence. PWB has six
dimensions of optimal psychological functioning:
autonomy, self-credence, life’s aims, positive
relations, environmental mastery, and personal
growth [1,2].
Being a college student is usually associated withlow MWB, which deteriorated more due to various
stressors related to the COVID-19 Pandemic.
Compared to local students, international students
face additional challenges such as living away fromtheir families, homesick feelings, continuous worry
about their family during the Pandemic, culturaldifferences, language barriers, inability to accesspublic resources, and lack of access to reliable
information. Consequently, international students
are more exposed to psychological disorders thantheir domestic peers [3]. Moreover, on-campus
international students are usually the minority andcan be neglected in some universities [4]. The
COVID-19 Pandemic has worsened Africancountries' preexisted poverty and unemployment
rate. Therefore, African students in different
universities face inancial crises, thus deteriorating
their MWB and psychological health.
Furthermore, due to tough measures taken by the
Chinese Center for Disease Control and Prevention(CDC), students in many cities are still under
lockdown inside their campus. Due to the borders'closure policy, international students cannot travelto their countries and return. This study investigatesthe status of MWB of African students in Chinese
universities after two years of challenges related to
the COVID-19 Pandemic. Additionally, we explore thedifferent stressors and factors in luencing thedeterioration of their mental health.

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Methods
DesignThis cross-sectional study surveyed African students
currently enrolled in Chinese universities using
WeChat-based online survey questionnaires. The
survey link was posted on WeChat groups of African
students for one month and took approximately 15
minutes to complete. The aims and purposes of thestudy were explained, and the participants wereasked to read the consent form carefully andvoluntarily choose to participate or not, with an
option to withdraw their participation at any time.
Pa r t i c i p a n t s d i d n’ t re c e ive a ny i n a n c i a lcompensation for participating in this study. This
study was conducted online in full compliance withthe provisions of the Declaration of Helsinki
regarding research on human participants. The
study was reviewed and approved by theInstitutional Review Board of the American
University of Sovereign Nations.
Measures
The Warwick-Edinburgh Mental Well-Being Scale(WEMWBS-14) questionnaire was used to assess the
MWB of our participants. WEMWBS-14 is a 14-item
tool assessing SWB and mental functioning. The total
score is obtained by the sum of scores for every 14
items and ranges from 14-70. 14-32 score indicates avery low level of MWB, 32-40 score indicates below
the average level of MWB, 40-59 score indicates theaverage level of MWB, and 59-70 score indicates
above the average level of MWB. The National HealthService (NHS) and other studies set the cutoff of ≤ 40
as the cut score for a low level of mental well-being[5-7].
Socio-demographic information was obtained byasking participants questions involving their name,age, gender, home country, marital status, university,
major, level of education, academic year, andresidence. In addition, close questions were asked to
explore how this Pandemic has affected ourparticipant’s physical, emotional and mental health.
Moreover, we investigated the related inancial
issues raised by this Pandemic. Finally, we assessed
the participants’ own experience during the
COVID-19 pandemic era by asking them thefollowing open questions: describe in your own
words anything positive and negative you felt about
your COVID-19 Pandemic experience?
Statistical Analyses
Descriptive statistics were utilized to describe
demographic characteristics. Pearson Chi-Square(χ2) test was conducted to analyze the distributionof survey items and ind whether there was asigni icant association between variables and
WEMWBS-14. Pearson correlation was conducted to
ind an association between WEMWBS-14 andvariables. Ordinal logistic regression was performed
to determine the independent predictors of low
MWB. Finally, Cronbach’s alpha was examined to test
the internal consistency. P ≤ 0.05 was consideredEubios Journal of Asian and International Bioethics 32(4) (July 2022)

statistically signi icant. All analyses were performedby IBM SPSS version 25.0 (IBM Corporation,
Armonk, New York, United States).

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Results
A total of 134 students in 31 cities in China
completed the survey. All participants wereoriginally from 29 African countries (Table 1). The
demographic characteristics of our study sample aredetailed in Table 2. The internal consistency of items
and scale was good, with a high level of reliability
and the Cronbach’s alpha of 0.892. The range scoreof the WEMWBS-14 was between 20 and 70, with amean of 47.84 ± 9.416 and a median of 48.00. Low
MWB was associated with being tested positive for
COVID-19 (35.50 ± 7.778; P = 0.033). According to
WEMWBS-14 scoring, 9 participants were in therange of 0-32 (low level of MWB), 18 participants
were in the range of 32-40 (below the average levelof MWB), 90 participants were in the range of 42-59(average level of MWB), and 17 participants were in
the range of 59-70 (above the average level of MWB).
The higher scores represent the higher levels of
MWB.
The Pearson correlation analysis was performed
to determine a signi icant relationship between
measure scores and gender. It was hypothesized thatfemale students had a lower level of MWB. The result
revealed a very low correlation of gender withWEMWBS-14 (r (134) = -0.057, P = 0.511). However,ordinal logistic regression showed that female
students predicted low MWB (Table 3). The mean
was 47.07 ± 9.148 and 48.21 ± 9.572 for females andmales. Furthermore, we found a very low correlation
between age and WEMWBS-14 (r (134) = 0.154, P =0.076).
WEMWBS-14 wasn’t statistically signi icant withmarital status (P = 0.115). The mean was 51.83 ±
8.750, 51.61 ± 9.894, and 47.00 ± 9.245 for marriedliving with partners, married living alone, and single,
respectively. The results found no association
between education level and WEMWBS-14 (P =0.411). The mean was 45.80 ± 8.581, 49.12 ± 9.384,
and 49.31 ± 10.24 for undergraduate, master, andPh.D. students, respectively. There was no statisticaldifference between students living on campus or
outside (P = 0.290), with a mean of 47.92 ± 9.937
and 47.63 ± 8.069 for those living on-campus or offcampus, respectively.
Comparing WEMWBS-14 and the factor of testing
positive, the results showed a statistical signi icance(P = 0.033), with the mean of 47.75 ± 11.99 for those
who had close friends or classmates who tested
positive, 44.33 ± 7.154 for those who had a tested
positive family member, 48.63 ± 9.424 for who didn’t
have anyone tested positive, and 35.50 ± 7.778 for
who themselves tested positive. The results failed to
ind a statistical signi icance between WEMWBS-14
and the factor of having someone who died due tothe COVID-19 (P = 0.361).
The mean was 43.62 ± 10.92, 42.00 ± 11.32, and48.57 ± 9.011 for those who had a died close friend

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or classmate, a dead family member, and no one who
died, respectively.
Table 2: Socio-demographic information ofparticipants
Characteristics

N (%)

Age
GenderMale
Female27.25 ± 6.60
90 (67.16)
44 (32.84)

Marital Status
SingleMarried/Cohabitation
Living with partner
Living alone

113 (84.33)
21 (15.67)
8 (5.97)
13 (9.70)

Level of education
Undergraduate
Masters
PhD

54 (40.30)
41 (30.60)
39 (29.10)

Parent lost job
YesNo

60 (44.78)
74 (55.22)

Decreased inancial
incomeYes
No
Unable to pay tuition fee
YesNo
Problem paying basic
needs
Yes
No
Worry about theacademic delay
Yes
No
Worry about getting a
job
Yes
No
Currently in university
lockdown
YesNo

82 (61.19)
52 (38.81)
38 (28.36)
96 (71.64)
60 (44.78)
74 (55.22)
80 (59.70)
54 (40.30)
93 (69.40)
41 (30.60)
35 (26.12)
99 (73.88)

Eubios Journal of Asian and International Bioethics 32(4) (July 2022)

115

Table 1: Participants’ Origin Country by Region.
NORTHERN AFRICA

Algeria, Egypt, and Sudan.

SUB-SAHARAN AFRICA
Eastern Africa

Burundi, Eritrea, Ethiopia, Kenya, Malawi, Mauritius,
Mozambique, Rwanda, Somalia, South Sudan, Tanzania,
Uganda, Zambia, and Zimbabwe.
Angola, Cameroon, and the Republic of Congo.
Namibia and South Africa.
Cape Verde, Ghana, Guinea-Bissau, Liberia, Nigeria, Senegal,
and Sierra Leone.

Middle Africa
Southern Africa
Western Africa

Table 3: Predictors of low mental well-being
Variables

SEOR

95% CIP

Female

0.796

1.834

0.274 – 3.394

0.021

Died family member

1.388

3.353

0.633 – 6.073

0.016

Increased alcohol consumption

0.954-2.501-4.371 – (-0.632)

0.009

Increased sexual activity

1.145-3.733-5.977 – (-1.490)

0.001

50.00%

37.50%

25.00%

12.50%

0.00%
NONE OF THE TIMERARELYSOME OF THE TIME

OFTEN

1.I’ve been feeling op mis c about the future
2.I’ve been feeling useful
3.I’ve been feeling relaxed
4.I’ve been feeling interested in other people
5.I’ve had energy to spare
6.I’ve been dealing with problems well
7.I’ve been thinking clearly
8.I’ve been feeling good about myself
9.I’ve been feeling close to other people
10.I’ve been feeling con dent
11.I’ve been able to make up my own mind about things
12.I’ve been feeling loved
13.I’ve been interested in new things
14.I’ve been feeling cheerful

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Figure 1: The WEMWBS-14 scoring of participants

ALL OF THE TIME

Eubios Journal of Asian and International Bioethics 32(4) (July 2022)

The results showed a signi icant association
between WEMWBS-14 and behavioral changes (P =0.010). The mean was 43.29 ± 10.41, 40.00 ± 8.435,
and 41.00 for those with changes in increased
alcohol consumption, increased sexual activity, andi n c re a s e d t o b a c c o s m o k i n g , re s p e c t ive ly.
WEMWBS-14 was compared with the factor of losing
a job for parents, and no statistical signi icance (P =0.741) was found. The mean was 49.09 ± 9.268 and46.28 ± 9.442, respectively, for those who had
parents who didn’t lose their job and who lost theirjob. No statistical signi icance was observed between
WEMWBS-14 and the factor of decreasing income (P= 0.864). The mean was 50.52 ± 9.587 and 46.13 ±8.954 for those who didn’t experience decreased
income and experienced decreased income,respectively.
The results do not reveal any association between
WEMWBS-14 and the factor of dif iculty in paying
tuition fees (P = 0.945), with the mean of 48.49 ±9.517 and 46.18 ± 9.070, for those who didn’t have
dif iculty paying tuition fees and those who said thatthey had dif iculty paying tuition fee, respectively.
WEMWBS-14 didn’t have a signi icant association
with the factor of dif iculty in paying for basic needs
such as food and housing (P = 0.282). The mean was
49.88 ± 8.620 and 45.32 ± 9.811 for those who didn’t
have dif iculty paying for basic needs and who had
dif iculty paying for basic needs, respectively. We
failed to ind a statistical signi icance in theassociation between WEMWBS-14 and the online
studying factor (P = 0.284). The mean was 49.81 ±8.758 and 45.32 ± 9.694 for those who weren’t
studying online and who were studying online,
respectively. Our results didn’t ind a signi icant
association between WEMWBS-14 and the factor ofbeing in lockdown (P = 0.547). The mean was 48.33± 9.800 and 46.43 ± 8.201 for those who were not in
lockdown and those in lockdown, respectively.

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Discussion
The WEMWBS-14 is the most popular assessment
scale of MWB for population and individuals, createdby a research team at the University of Warwick andthe University of Edinburgh. It was irst used in the
United Kingdom as a psychometric assessment of the
MWB of adults over 16 years old and then validated
for teenagers and adolescents (13 to 16 years old) in
England and Scotland [8]. The dominant feelings
self-reported by participants were “I have had theenergy to spare” and “I have been feeling cheerful,”
and the least reported feeling was “I have been able
to make up my own mind about things” (Figure 1).
Maheswaran et al. [9] summarized twelve surveys
of MWB in different nations and found the baselinemean WEMWBS-14 score of the general population
to be 50.7. Most studies reported the mean
WEMWBS-14 higher than 50 [10-14]. Our study
population showed a lower level of MWB comparedto the general population (mean WEMWBS-14 of
47.84 ± 9.416), which was surprisingly the same as
the recent study among Chinese university students

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( 4 7 . 4 1 ± 8 . 9 3 ) [ 1 5 ] . C o nve n t i o n a l ly, t h e
WEMWBS-14 cutoff score ≤ 40 refers to low MWB[5-7]. Therefore, 20.15% (including very low: 6.72%
plus below the average: 13.43%) of our participants
had low MWB (Figure 2).

0.13430.6716

0.06720.1269Very low
Average

Below the average
Above the average

Figure 2: Prevalence of mental well-being among
our participants
We didn’t observe a signi icant correlation of
MWB with age. However, one study showed that the
MWB of the Danish population rose with age [12].
The same study reported a signi icantly higher MWB
of males than females (P = 0.047). Moreover, Gray etal. [16] reported an important effect of COVID-19 on
the psychological well-being of female and younger
adults, yet, they didn’t ascertain any reason for this.
Inconsistently, our results failed to ind a signi icant
relationship between males and females, but themean WEMWBS-14 was slightly lower in female
students than in males. This was probably due to thelow prevalence of females in our sample (32.84%). It
is known that younger adults are hard to tolerate theprohibition of social interactions and interdiction tomeet up with friends, which are vital for maintaining
good well-being at their age [17]. Furthermore, it has
been reported that the good MWB of older adults
can be attributed to their employment security andinancial stability [18]. Also, pre-COVID-19 studies,
as well as COVID-19 era studies, announced lower
MWB in females. Although the reasons are unclear,some studies associated this with the lack of socialcultural support, coping styles, and biologicalmechanisms for gender well-being differences[19-21].
Our study revealed a very low level of well-being
in single students and greater well-being in married
students who live together with their partners.
However, no signi icant difference was observed (P =0.115). The insigni icance might be due to a small
number of married students among our participants(15.67%); of them, only 5.97% were living with theirpartners at the time of the study. Several studies
have reported lower MWB among single individuals
and showed that they are prone to mental distresses.
In comparison, married individuals are linked tosatisfying well-being and are unlikely to experiencemental disorders [22-24]. On the contrary, theCatalan population showed higher MWB among

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single people than married people [11]. The same
study found that any dif iculty or limitation to secure
daily living expenses in luences well-being.
Approvingly, a study of the Northern Irish
population revealed a very low MWB among
unemployed people [25]. Similarly, we found thatstudents who had dif iculties paying their tuition
fees or basic needs such as food and housingpresented with lower MWB. Same, the students who
experienced decreased income and those withparents who lost their jobs had low MWB.
The MWB of undergraduate students was very low
compared to postgraduate students (masters andPh.D.). Unlikely, a study among French students
didn’t ind any difference in WEMWBS-14 score byeducation level [14]. Also, we observed a low MWB
among students whose family members, friends, orclassmates were affected or died due to COVID-19,
with the lowest mean WEMWBS-14 (35.50 ± 7.778)
among students infected with the COVID-19.
Consistently, Gül and Yeşiltaş [26] highlighted
increased psychological problems and mental
unwell-being among Turkish people who had
infected or died friends or family members due to
COVID-19. Moreover, the latter was stressed by
Asghar et al. [27] when discussing coronaphobia.
This pandemic period is associated with different
challenges and stressors that negatively affect the
MWB of people. China implemented the strongest
prevention measures to control the Pandemic. In
general, students are among the most affected bythese regulations. They must stay locked inside thecampus and compel to study through online
platforms. Some international students had toextend their stay because they couldn’t complete
their internship on time, which resulted in a
inancial crisis. Moreover, medical students can not
only rely on online platforms to study because theyneed to do rotations in hospitals for clinical andsurgical training. In addition, many international
students miss their families and friends because
China’s borders have been closed since the beginningof the Pandemic. Unfortunately, they are facing an
ambiguous dilemma of choice. Either they stay in
China and somehow cope with the dif iculties ofisolation, or they go home near their families, yet
knowing that they will not be able to return tocontinue their studies. Also, once students leave for
their home country, the scholarship is temporarilysuspended and will be resumed when they areenabled to come back to pursue studies. However,some students need and use these scholarship feesto support their families. Additionally, as the
COVID-19 outbreak surges, people worldwide face
inancial crises, and others have become jobless. It isworse in African countries with preexisted economic
instability, extreme poverty, lack of savings, and ahigh unemployment rate. Furthermore, until now,
several international students in China are still in
con inement inside their campuses. They need to ask
for a special authorization to be allowed to leave thecampus for a very limited time and limited approved

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Eubios Journal of Asian and International Bioethics 32(4) (July 2022)

117

permissions such as going to the bank andpurchasing necessities like food and medicine.
Finally, we wished to know whether there wasanything negative or positive that our participants
felt during this COVID-19 Pandemic period. The
majority of participants were very pessimistic about
the COVID-19 Pandemic. Many of them complained
that, according to their experience, there wasnothing positive to mention about the COVID-19
Pandemic. Instead, most students moaned that the
COVID-19 Pandemic brought numerous troubles into
their lives. Each student expressed one or morenegative experiences he/she felt during the
COVID-19 Pandemic. Below we quoted some of theparticipants’ positive and negative feelings.
Positive feelings:• The Pandemic allowed enough time to rest
• I learned how to save money and plan for the
future• I felt like school was useless, so I decided to readbooks based on my interests, which was lifechanging• I have always learned to practice hygiene• The Pandemic allows me to talk with my familyfrequently• Because it is my irst experience being far awayfrom home and unable to travel back, I think thishas made me stronger and more independent• I learned social responsibility• I became closer to God• I could meet more friends online and connect withthose I am locked down with
• I was able to gain weight• This pandemic taught me that anything might
happen on the earth, and we people must always
learn how to be ready for the changes• I got closer to people I never thought I’d be close
with, and now we’re great friends, and some ofthem have become like my own family• I learned about taking good care of myself• I learned how to survive in a hard situation andadapt to living during abnormal conditions• I learned to play guitar
Negative feelings:• My sleeping and eating schedule are terrible, and I
am very unmotivated• I am depressed, unsure, and worried• I had character change, developed bad habits,
emotions and mental exhaustion, sadness, and an
uncertain future• Less physical interaction with people• As foreigners in China, we are discriminatedagainst during this period• My parents lost their jobs, my project failed, and I
felt so lonely because I was far from my family• Dif iculty in studying, such as online classes, and I
can’t do laboratory practices.
• Psychological stress, academic inconvenience,
being hostage on the campus for a long time, being
away from home and friends, being unable toEubios Journal of Asian and International Bioethics 32(4) (July 2022)

travel within China, unable to meet friends eventhough we are in the same city, and unable toparticipate in Church activities• It affected my life, especially my clinical rotation in
the hospital, and it has harmed my life
• An increase in prices for some products• My dad’s job has not been stable since thepandemic's beginning. Due to that, my monthly
stipend has been reduced, and I won’t be able topay school fees for this upcoming academic year,
so my dreams are going to hell for now due to thecovid-19• We will all die. I feel like it is an apocalypse• Man, I have never been depressed before, but now
I suffer severe depression to the point I had to go
to the hospital. I was about to go insane, but I got
some help• I am worried about the future, my family, and myhigh-stress levels• I had planned to travel to all of China’s neighboring
countries while studying. However, now I can’t dothat due to travel restrictions• Lack of inances in different areas of my life, likepaying bills• I always feel so demotivated to attend online
classes• The isolation, the loneliness and feeling desperate,
depression, heavy drinking and smoking• I have not been able to reunite with my family formore than two years. I had to sacri ice myself tostay in China to be able to complete my studies,
which affected me psychologically.
To the best of our knowledge, our study is the irst
to investigate the impact of the COVID-19 Pandemic
on the MWB of African students in Chinese
universities. The primary limitation of the present
study was a small sample size due to a limited
number of African students in China. Anotherlimitation was the language barrier. Many African
students are francophones and study their majors in
the Chinese medium. Therefore, they couldn’t speak
English and could not complete our survey, which
was administered in the English language only. The
inal limitation was the higher rate of maleparticipants (67%).

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Conclusion
It is well known that humanitarian crises anddisasters affect the general population’s mental wellbeing. University students are usually prone to ahigher stress level, so adding extra stressors
exacerbates their exposure. Research studies haveconsidered studying abroad a risk factor for lower
MWB due to several problems international students
confront when staying in a foreign country, awayfrom their families. Moreover, the COVID-19
Pandemic has worsened African countries'
preexisting poverty and unemployment rate.
Universities should ensure lexible teaching andevaluation, consider issues such as inancial support,
and provide stress management services that have to

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be tailored to complement the regulatoryenvironment of local and national government
guidelines, and the complex and evolving
international situation. Future large-scale
exploration of the psychological distresses of thesevulnerable African students in foreign countries ishighly recommended.
Appendix 1: Questionnaire
1、Do you agree to participate?
○ Yes. I have read the consent form, and agree toparticipate.
○ No. I don’t agree to participate.
Section 1: Demographics
2、NAME (Optional): ________________________
3、HOME COUNTRY: ________________________
4、GENDER ○ Male ○ Female
5、AGE:________________________
6、MARITAL STATUS○ Single○ Married/Cohabitation○ Divorced/Widowed
7、Is your partner living together with you in China?
○ Yes
○ No
8、UNIVERITY: ________________________
9、MAJOR:________________________
10、LEVEL OF EDUCATION○ Undergraduate ○ Masters
11、ACADEMIC YEAR
○ First year
○ Second year
○ Third year
○ Fourth year
○ Fifth year
○ Sixth year
12、RESIDENCE○ Campus○ PhD○ Off campus

13、City/Province in China:________________________
Section 2: YOUR EXPERIENCES
Answer the following initial questions by choosing theright answer that describe your experience.
14、Have you or anyone close to you been tested positive
for COVID-19?
□ Yourself□ Family member□ Close friends/Classmates□ No one
15、Has a person close to you died from COVID-19?
□ Family member □ Close friends/Classmates □ No one
16、Have you had any change in the following behaviors
during this COVID-19 period?
□ Alcohol drinking □ Tobacco smoking□ Sexual activity□ Other
17、Have your parents or inancial supporters lost theirjobs or their source of income because of COVID-19? ○ Yes○ NoEubios Journal of Asian and International Bioethics 32(4) (July 2022)
18、Has your inancial income decreased during this
COVID-19 period?
○ Yes
○ No
19、Have you been unable to pay tuition fee during this
COVID-19 period?
○ Yes
○ No
20、Have you experienced any problem about paying
your basic needs like food and housing during this
COVID-19 period?
○ Yes
○ No
21、Are you currently studying remotely from yourdormitory/apartment? ○ Yes○ No
22、Do you think that online studying has a strong
negative effect on your academic performance?○ Yes ○ No
23、Has COVID-19 pandemic in luenced your academic
performance?
○ Yes
○ No
24、Have you experienced or worried about delays incompleting your degree because of COVID-19? ○ Yes ○ No
25、Are you worried about getting a job after graduation?
○ Yes
○ No
26、Do you have students’ psychological support service
in your university? ○ Yes○ No
27、Have you looked for psychological help or counseling
during this COVID-19 period?
○ Yes
○ No
28、Are you currently in university lockdown or city
lockdown？

○ Yes

○ No

29、If yes, how long have you been in lockdown? (Inmonths) ________________________
30、Please describe in your own words anything positive
you felt about YOUR COVID-19 pandemic experience?
(You can answer in any language you are comfortablewith) ________________________
31、Please describe in your own words anything negative
you felt about YOUR COVID-19 pandemic experience?
(You can answer in any language you are comfortablewith) ________________________
Section 3: YOUR FEELINGS AND HEALTH
Below are some statements about feelings and thoughts,
please choose the one that best describes yourexperience.
32、Over the last two weeks, how often have you
experienced any of the following feelings?
SOME OFT
OF
EN
THE

ALL
OF
THE

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

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f

1. I’vebeenfeeling
optimistic
2. I’vebeenfeeling
3. I’vebeenfeeling
4. I’vebeenfeeling
interested

NONE RAR
OF
ELY
THE

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5. I’ve had
○
○
○
○
○
energy tospare
6. I’ve
○
○
○
○
○
been
dealing
7. I’ve
○
○
○
○
○
been
thinking
8. I’ve
○
○
○
○
○
been
feeling
9. I’ve
○
○
○
○
○
been
feeling
10. I’ve
○
○
○
○
○
been
feeling
11. I’ve
been able○○○○○
to make up
my own12. I’ve
○
○
○
○
○
been
feeling
13. I’ve
been
○
○
○
○
○
interested
in new
14. I’ve
○
○
○
○
○
been
feeling
NB: The survey is accessible at the following link:
https://www.wenjuan.com/s/UZBZJv3Eam/#

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Factors affecting posttraumatic
growth of childhood cancer
survivors- Naoki Mashiko1*
1School of Nursing, Gunma Prefectural College of

Health Sciences, Gunma, Japan
Email: mashiko.n.156@gmail.com- Tomoko Sumiyoshi
School of Health Sciences, Niigata University, Niigata,Japan

Abstract
In the long-term follow-up (LTFU) of childhood
cancer, the construction of psychological care to
avoid posttraumatic stress disorder is an important
issue from the perspective of medical ethics.
Theoretical models of posttraumatic growth (PTG)
assume that PTG occurs amid the psychologicalstruggles and tension resulting from an event.
However, scholars have not studied the PTG
experienced according to the type of event
encountered. Focusing on childhood cancer
survivors (CCSs), the present study aimed to obtainbasic data for using PTG in LTFU by examining
survivor factors and to elucidate the factors affecting
PTG in CCSs in adulthood. The study used theJapanese version of the Posttraumatic Growth
Inventory to measure PTG in 13 Japanese CCSs withlong-term survival (aged 20–39 years at survey and
1–14 years at diagnosis). The t-test showed that only

one item, participation in patient groups, exhibited asigni icant difference in the mean PTG value: themean PTG scores were higher for persons who hadparticipated in patient groups. Therefore, thesupport of close people, and talking with them, may
contribute to feelings and cognitive processes
associated with PTG and may possibly contribute to
the mechanism of PTG.
Introduction
Among the psychological complications of childhood
cancer survivors (CCSs), the prevalence rates of
posttraumatic stress disorder (PTSD) andposttraumatic stress symptoms (PTSS) have beenreported to be 2‒20%, linked to reduced healthrelated quality of life and alienation of social
development [1, 2]. In Japan, there are over 50,000
CCSs who have grown to adulthood. Recent stressresearch has, in relation to concerns about PTSD,
focused on posttraumatic growth (PTG), reportingon PTG in CCSs in the US and in various countries in
Europe and Asia [3‒5]. PTG refers to positive
psychological changes due to having contended witha very dif icult life situation; persons who haveexperienced PTG report achieving personal growth[6]. PTG aids in lexible coping and changing one’s
outlook and assists the survivors in overcoming
dif iculties [7]. Although theoretical models of PTG
have assumed that PTG occurs because of thepsychological struggles and tension from an event,scholars have not yet studied, among CCSs who hadcancer a long time ago, the strength of the PTG
experienced by people according to the type of
events encountered, or whether they themselves
could easily perceive it.
The present study aimed to obtain basic data forusing PTG in LTFU by focusing on such survivor
factors and to elucidate the factors affecting PTG in
CCSs in adulthood.

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Methods
Participants: Participants had onset of cancer
during childhood (1‒14 years of age), and ive or
more years had elapsed since the end of treatment.
CCSs belong to the Adolescent & Young Adult (AYA)
age cohort. We made a nationwide request forc o o p e ra t i o n by e m a i l a n d by w r i t i n g t orepresentatives of CCS self-help groups where
associates gather from across Japan, as well as
physicians and nurses collaborating in the treatmentof pediatric and AYA age cohort cancer patients inmajor metropolitan and regional cities in Japan. One
self-help group representative, one physician, andeight nurses cooperated in the recruitment of study
participants. Through their cooperation, 13 CCSs
participated in this study. Data were collected from
October 2017 to November 2018.
Measures: We used the Japanese version (PTGI-J) [8]of the Posttraumatic Growth Inventory (PTGI) [9],which has been broadly used for measuring adult
PTG. In the PTGI, PTG is measured using 21 items inive factors interrogating the degree of psychologicalff

Eubios Journal of Asian and International Bioethics 32(4) (July 2022)

121

growth due to a critical event: Factor 1, Relating to
Others (7 items); Factor 2, New Possibilities (5items); Factor 3, Personal Strength (4 items); Factor
4, Spiritual Change (2 items); and Factor 5,
Appreciation of Life (3 items). These ive factors
have been de ined in studies on American subjects.
In the Japanese version (PTGI-J), for purposes ofmeasuring PTG in Japanese people with theirdifferent cultural background, factors 4 and 5 are notseparated, and PTG is measured with 18 items infour factors: Factor 1, Relating to Others (6 items);
Factor 2, New Possibilities (4 items); Factor 3,
Personal Strength (4 items); and Factor 4, Spiritual
Change and Appreciation of Life (4 items).
The participants were asked “To what degree didhaving childhood cancer change your life? Pleasecircle the item that best matches you.” Each item wasassessed with a six-point Likert scale ranging from 0= did not experience any change to 5 = experienced toa very great degree. The PTGI-J possesses suf icientvalidity and internal consistency. The Cronbach’s αcoef icient of all 18 items was .90. The Cronbach’s αcoef icients of each sub-scale were as follows:
Relating to Others, .86; New Possibilities, .82;
Personal Strength, .79; and Spiritual Change andAppreciation of Life, .66.
Data Analysis: The study investigated the PTG
measurement values with the PTGI-J survey form
and the attributes in the free-entry survey forms
created by the researchers. Eight items related to theattributes from the demographic indicators andsurvivor factors were considered.
For data analysis, descriptive statistics were
calculated for the PTG measurements and attributes.
First, we calculated the mean values and meanscores of each factor in the PTG measurement.
Second, we conducted a comparative analysis of the
PTG values according to the demographic indicatorsand survivor factors using an independent t-test. The
Mann–Whitney U-test was performed when nonormality was con irmed with the Shapiro–Wilk test.
Statistical analysis was carried out using IBM SPSS
Statistics for Windows, Version 22.0; the signi icancelevel was less than 5%. Throughout the analysis, weensured data reliability with the guidance andcon irmation of the quantitative nursing researchleader.
Ethical Considerations
The study participants received written explanationsof the purpose and methods of the study, including
the following: voluntary nature of their participationin the study, protection of their anonymity;
con identiality of their personal information. We
conducted after obtaining participants’ written
informed consent. This study upheld the Guidelines
for Medical Research on Human Subjects of the
Ministry of Health, Labour and Welfare and was
conducted after authorization of the Gunma
Prefectural College of Health Sciences (Approval
number: 2017-19) was obtained.

122

Eubios Journal of Asian and International Bioethics 32(4) (July 2022)

Table 1. Comparison of major attributes with mean PTG value, and factors 1‒4
Participants (n = 13)
CCS
CharacteristicsN(%)

Mean PTG Value

Score by PTGI-J Factor (mean ± SD)
Factor 1
Relating to Others

mea
n

SD

All
Participants

13(100
)

3.65

0.80

Femalea4(30.8)

3.70

1.22

Male

9(69.2)

3.63

0.62

p
Value

.899

mean

SD

3.85

0.74

3.79

1.21

3.87

0.51

3.57

0.71

4.17

0.68

3.97

0.66

3.74

0.83

3.59

1.09

3.96

0.56

3.93

0.63

3.79

0.83

3.67

0.78

4.13

0.62

3.72

0.76

4.13

0.68

4.12

0.66

3.53

0.74

p
Value

.870

Factor 2
New Possibilities
mean

SD

3.79

1.07

3.56

1.57

3.85

0.87

3.63

0.90

3.92

1.31

3.88

0.95

3.67

1.23

4.04

1.04

3.64

1.12

3.70

1.34

3.80

0.96

3.44

1.18

4.28

0.66

3.77

0.94

3.75

1.49

4.32

0.72

3.11

1.08

p
Value

.671

Factor 3
Personal Strength
mean

SD

3.50

1.16

3.75

1.34

3.39

1.15

3.46

1.29

3.54

1.11

3.75

1.35

3.29

1.04

3.81

1.09

3.36

1.23

3.75

0.95

3.34

1.32

3.34

1.27

3.75

1.05

3.28

1.21

4.00

1.02

4.21

0.81

2.67

0.96

p Value.627

Factor 4
Spiritual Change andAppreciation of Life
mean

SD

3.29

1.10

3.63

1.64

3.14

0.85

3.29

0.92

3.29

1.37

3.21

1.03

3.36

1.23

3.88

0.97

3.03

1.10

3.55

1.36

3.13

0.96

3.16

1.17

3.50

1.06

3.06

0.85

3.81

1.55

3.86

1.06

2.63

0.75

p
Value

.486

Type of Childhood Cancera
Solid tumor

7(53.8)

3.54

0.81

Hematologica
l malignancy

6(46.2)

3.78

0.83

.611

.156

.652

.911

.993

Age at Diagnosisa
Up to schoolage (≤12 yrs)

6(46.2)

3.73

0.86

Middle school(13–15 years)

7(53.8)

3.58

0.80

.746

.592

.743

.497

.820

Explicit Noti ication of Cancer at Diagnosisa
Yes4(30.8)

3.87

0.99

No

9(69.2)

3.55

0.74

.521

.418

.553

.542

.213

Experience of Recurrencea
Yes

5(38.5)

3.75

0.74

No

8(61.5)

3.58

0.87

.721

.755

.875

.563

.521

Appearance of ComplicationsaYes

8(61.5)

3.43

0.83

No

5(38.5)

4.00

0.67

.224

.284

.174

.563

.605

Work Experience in Regular EmploymentaYes9(69.2)

3.52

0.74

No

4(30.8)

3.94

0.95

.397

.386

.978

.322

.269

Participation in Patient GroupsabYes7(53.8)

4.13

0.61

No

6(46.2)

3.09

0.62

t-test.011*

t-test.157

t-test.035*

MannWhitneyU.008**

t-test.037*

f

PTG: posttraumatic growth, measured by the Japanese version of the Posttraumatic Growth Inventory (PTGI-J);
CCS: childhood cancer survivor; SD: Standard deviation; aIndependent t-test; bMann–Whitney U test
*p <.05; **p <.01

Eubios Journal of Asian and International Bioethics 32(4) (July 2022)
Results
Consent to participate in the study was obtained
from 13 persons, all of whom cooperated in thesurvey. All 13 participants provided valid responses.
The mean age of the participants at the time of thesurvey was 29.1 years (SD = 5.9, range = 20‒39). The
mean age at the time of childhood cancer diagnosis
was 8.9 years (SD = 5.1, range = 1‒14). Table 1
shows the mean PTG values for all 13 subjects, andthe mean values for each of the factors. In the t-test,
only one item, participation in patient groups,
exhibited a signi icant difference in the mean PTG
value: the mean PTG scores were higher for persons
who had participated in patient groups than for
those who had not. In this group, we observed asigni icant difference (p <0.05) in the mean values offactors 2, 3, and 4.
The results are in Table 1

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Discussion
We investigated the factors affecting PTG from theattributes of Japanese CCSs with long-term survival.
The mean PTG value for the CCSs participating inthis study was 3.65, and the mean values for the four
factors were all 3.0 (experienced to a moderate
degree) or higher. Thus, we surmised that PTG had
occurred in all 13 subjects. At present, the PTG
occurrence rate is unknown for patients in the young
adult period. One report claimed that the longer thetime since the trauma, the greater the PTG [10].
Another report [11] suggested that PTG occurs inyoung adult CCSs, which is similar to our result.
Recent research has indicated that theexperiences of people who have undergone a crisisand the amount of time elapsed must be taken into
account, not merely the PTG score at a single point intime [12-13]. Therefore, among cancer survivors,
their long-term life experiences and their selfcomparison over time have major signi icance.
Scholars have argued that constant high andmoderate levels of PTG even with the passage oftime re lect “stable PTG” [14]. For the participants inour study, a long time had elapsed since they
contracted childhood cancer. They gave replies withregard to life changes after having experienced
childhood cancer, thus indicating that they had
highly stable PTG.
To elucidate the factors affecting the PTG of CCSs,
we investigated eight demographic indicators andsurvivor factors, among which only “participation inpatient groups” had an effect on high PTG. For CCSs
in the AYA age cohort, no reports have shown thatpeer support played a role in promoting PTG.
However, a long-term improvement in psychosocial
function has been reported [15]. In addition, highly
satisfactory social support provided by signi icant
others and close friends has been reported as
promoting PTG [16]. The results of the current
survey supported this report. Thus, the support ofclose people, and talking with them, may contributeto feelings and cognitive processes associated with
PTG and may possibly contribute to the mechanism

123

of PTG. Among the various social supports,
experience of participation in patient groups may
have an effect on PTG. Therefore, research should
investigate whether CCSs who participated in patientgroups perceived positive psychological changes as aresult. Confronting traumatic events, starting withrumination, is important for positive psychologicalchange, and this is theorized to be connected totransformational psychological growth [17]. In
previous research, CCSs have reported an intimate
awareness of the risk of late complications, fear andanxiety from rediscovery of the threat of cancer, andre-experience of trauma through their participationin peer support [18]. In other words, in peer
support, CCSs will experience, for good or for ill, a
deep confrontation with the cancer that traumatized
them, during which psychological growth must be
catalyzed and PTG reinforced.
However, what do CCSs need to be able toparticipate in peer support? As stated previously,
because the effects of peer support are not merely
positive, it is irst necessary that they accept the factthat they are CCSs and take on the challenge of
disclosing that they themselves are cancer survivors
to their associates. Notably, no research has fully
elucidated how CCSs experience self-disclosure.
The developers of PTG theory have also
expressed the importance of experiencing selfdisclosure in the process of psychological change
leading to PTG [6]. A recent report suggested aninteraction between rumination and self-disclosure[19]. In the long-term follow-up (LTFU) of childhood
cancer, the construction of psychological care to
avoid PTSD is an important issue from theperspective of medical ethics. Therefore, for bringing
about PTG in support structures for late
psychological complications in CCSs, we believe that
it will be necessary to investigate how CCSs withlong-term survival experience self-disclosure,including being stricken with childhood cancer, andto search for support to be able to accept thechallenges of self-disclosure.
Conclusions“Participation in patient groups” had an effect onhigh PTG for Japanese CCSs with long-term survival.
For young adult CCSs, the social support enjoyedfrom signi icant others and close friends may
reinforce PTG. Future research should investigate
the challenges in self-disclosure of being a cancer
survivor to make use of PTG in support strategies forlater psychological complications.
Acknowledgments: This work was supported by
JSPS KAKENHI Grant Number JP19K10980.
Con lict of Interest: The authors declare no con lictof interest.
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Chief Editor: Darryl R.J. Macer
Associate Editor: Nader Ghotbi
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Martha Marcela Rodriguez-Alanis (Mexico), Angeles
Tan Alora (Philippines), Atsushi Asai (Japan), Alireza Bagheri(Iran), Gerhold Becker (Germany), Rhyddhi Chakraborty (India/UK), Shamima Lasker (Bangladesh), Minakshi Bhardwaj (UK),
Christian Byk (IALES; France), Ken Daniels (New Zealand), Ole
Doering (Germany), Amarbayasgalan Dorjderem (Mongolia),
Hasan Erbay (Turkey), Soraj Hongladarom (Thailand), Dena
Hsin (Taiwan), Rihito Kimura (Japan), Abby Lippman (Canada),
Umar Jenie (Indonesia), Nobuko Yasuhara Macer (Japan),
Masahiro Morioka (Japan), Anwar Nasim (Pakistan), Jing-Bao
Nie (China, New Zealand), Pinit Ratanakul (Thailand), Qiu Ren
Zong (China), Mariadoss Selvanayagam (India), Sang-yong Song
(Republic of Korea), Yanguang Wang (China), Yanguang Wang
(China), Daniel Wikler (USA), Jeong Ro Yoon (Republic of Korea).
EJAIB adopts and complies with the Committee on Publication
Ethics (COPE) Publication ethics and malpractice policy. Ourpolicy is on the EJAIB website. All potential authors should haveread these guidelines and by submission of an article forpublication you acknowledge that you have complied with thispolicy. Violations will be handled in proportion to the intention
and seriousness of the violation. If there is a con lict of interest
stated by the authors of an article it will be written in the paper.
Registered address of EJAIB: P.O. Box 16 329, Hornby,
Christchurch 8441, New Zealand
For forthcoming conferences see:www.eubios.info or www.ausn.info
International Public Health Ambassadors
https://www.ausovereignnations.org/
international_public_health_ambassadors
Email to: provost@ausn.info

Eubios Journal of Asian and International Bioethics 32(4) (July 2022)

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