JMIR FORMATIVE RESEARCH

Drissi et al

Original Paper

Investigating the Impact of COVID-19 Lockdown on thePsychological Health of University Students and Their Attitudes
Toward Mobile Mental Health Solutions: Two-Part Questionnaire
Study
Nidal Drissi, MSc; Ayat Alhmoudi, BSc; Hana Al Nuaimi, BSc; Mahra Alkhyeli, BSc; Shaikha Alsalami, BSc; Sofia
Ouhbi, PhD
United Arab Emirates University, Al Ain, United Arab Emirates

Corresponding Author:
Sofia Ouhbi, PhD
United Arab Emirates University
Al AinUnited Arab Emirates
Phone: 971 37135568
Email: sofia.ouhbi@uaeu.ac.ae

Abstract
Background: The COVID-19 outbreak was first reported to the World Health Organization on December 31, 2019, and it was
officially declared a public health emergency of international concern on January 30, 2020. The COVID-19 outbreak and thesafety measures taken to control it caused many psychological issues in populations worldwide, such as depression, anxiety, andstress.
Objective: The objectives of this study were to assess the psychological effects of the lockdown due to the COVID-19 outbreakon university students in the United Arab Emirates (UAE) and to investigate the students’ awareness of mobile mental healthcare apps as well as their attitudes toward the use of these apps.
Methods: A two-part self-administered web-based questionnaire was delivered to students at United Arab Emirates University.
The first part of the questionnaire assessed the mental state of the participants using the 12-item General Health Questionnaire(GHQ-12), while the second part contained questions investigating the participants’ awareness of and attitudes toward mental
health care apps. Students were invited to fill out the web-based questionnaire via social media and mailing lists.
Results: A total of 154 students participated in the survey, and the majority were female. The results of the GHQ-12 analysis
showed that the students were experiencing psychological issues related to depression and anxiety as well as social dysfunction.
The results also revealed a lack of awareness of mental health care apps and uncertainty regarding the use of such apps.
Approximately one-third of the participants (44/154, 28.6%) suggested preferred functionalities and characteristics of mobile
mental health care apps, such as affordable price, simple design, ease of use, web-based therapy, communication with others
experiencing the same issues, and tracking of mental status.
Conclusions: Like many groups of people worldwide, university students in the UAE were psychologically affected by the
lockdown due to the COVID-19 outbreak. Although apps can be useful tools for mental health care delivery, especially incircumstances such as those produced by the outbreak, the students in this study showed a lack of awareness of these apps andmixed attitudes toward them. Improving the digital health literacy of university students in the UAE by increasing their awarenessof mental health care apps and the treatment methods and benefits of the apps, as well as involving students in the app creation
process, may encourage students to use these tools for mental health care.
(JMIR Form Res 2020;4(10):e19876) doi: 10.2196/19876
KEYWORDS
COVID-19; GHQ-12; mobile; apps; m-health; m-mental health; UAE; attitudes; university students; questionnaire

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Introduction

28-item General Health Questionnaire (GHQ-28) was comparedto the GHQ-12 [14].

On December 31, 2019, the World Health Organization (WHO)was informed of several cases of pneumonia of unknown cause
detected in Wuhan City, China [1]. On January 7, 2020, thecause was reported to be a new coronavirus, which was thenreferred to as “2019-nCoV” [1]. By January 20, 2020, the virus
had spread, and multiple cases were reported in four countries[1]. On January 30, 2020, the WHO declared the outbreak to
be a public health emergency of international concern [2]. By
February 11, 2020, the virus had spread to more than 24
countries in addition to China, and the coronavirus disease wasofficially named COVID-19 [3]. By May 2020, the virus had
spread to all regions of the world [4]. More than 3 million casesand 248,847 deaths were reported worldwide as of May 4, 2020.
To limit the spread and risk of the virus, the WHO advised
people to practice social distancing and to stay at home [5].
Countries took different safety measures and precautions toprevent the spread of the disease. Several countries declaredobligatory lockdowns, travel was halted and airports were shut
down, and many work spaces, schools and universities wereclosed.

Identifying existing psychological issues is an important step;
however, it is more important to deliver mental health care when
it is needed. This delivery is currently challenging because of
the safety measures being applied to prevent the spread of
COVID-19. Telehealth is a health care delivery method that,like tele-education and telework, currently seems to be the safest
approach. Telehealth can be applied to mental health care via
several methods, one of which is mobile apps. Apps are highly
suitable to provide services while safety measures are being
applied during the pandemic. They can be used to provide
mental health care without need for human contact, and the user
can benefit from care delivered via the app without needing toleave their home and risk exposure to the virus. Apps can also
help overcome several pre-existing barriers to mental healthcare delivery in addition to those created by the COVID-19
outbreak, such as cost problems, stigma, and distance or shortageof mental health professionals. Apps have also shown promising
results in the management of many mental issues, such as
anxiety, depression, and stress [15,16].

Lockdown-related stressors such as concern about the durationof lockdown, fear of infection, boredom, inadequate information[6], and fear of the unknown [7] had significant psychologicaleffects on people, including posttraumatic stress disorder
symptoms, anger, confusion, fear, worry, sadness, and elevatedanxiety and stress [6,8]. As part of its application of precautions
and safety measures to address the outbreak, the United ArabEmirates (UAE) closed its universities and stopped all related
activities. To investigate the impact of the lockdown on
university students in the UAE, we conducted a mental healthassessment based on the 12-item General Health Questionnaire(GHQ-12). The GHQ-12 has been used in previous studies toassess the mental health of students and has shown positive
reliability results. A study using the GHQ-12 to assess thepsychological state of Malaysian college students affirmed that
the GHQ-12 is a good tool for assessing the overall
psychological well-being of students [9]. In another study, thequestionnaire was used with Australian college students; theresults suggested that the GHQ-12 is a viable tool with goodclinical utility and that it can be implemented as part of routine
school screening procedures to help identify young people atrisk of depressive and anxiety disorders [10]. Another study
used the GHQ-12 with Tehrani university students, and it was
concluded that the questionnaire is suitable for screening
psychopathology in university students [11].
Moreover, the validity of the psychometric properties of theGHQ-12 was asserted in several studies. The GHQ-12 wasassessed against the Clinical Interview Schedule (CIS) in three
primary care settings in Brazil and was found to be acceptableand valid [12]. The GHQ-12 was also assessed in a sample ofdermatological patients against the Skindex-29, which is a tool
to evaluate the impact of skin conditions on the quality of lifeof patients. The results showed that the GHQ-12 is a reliable
and valid instrument [13]. Furthermore, the GHQ-12 wasreported to be robust and suitable for use as a screening
instrument in a study conducted by the WHO in which the
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This study had two main goals. The first goal was to assess themental state of university students during the first period of the
lockdown caused by the COVID-19 outbreak. The second goalof the study was to investigate the students’ awareness of mobile
apps for mental health care and their willingness to use themas well as to discover the features they would like a mental
health care app to have and the factors that would encouragethem to use such apps. A two-part web-based questionnaire wasdelivered to United Arab Emirates University (UAEU) students
via social media and email during the first two weeks of the
lockdown imposed in the UAE. The first part of the form
consisted of the GHQ-12 questionnaire, and the second part of
the form included questions investigating the students’ attitudes
toward mobile apps for mental health care. The study verified
the following hypotheses: (h1) the lockdown has an impact on
the psychological state of the university students in the UAE;(h2) university students are aware of the existence of mobile
apps for mental health care; and (h3) university students havepositive attitudes toward mobile mental health care apps andare open to the use of such solutions.

Methods
Research Design
This study constitutes two main parts. The objective of the firstpart was to assess the psychological health of university
students. The objective of the second part was to investigate
the students’ awareness of and attitudes toward mHealth apps
for mental health care.

Recruitment and Data Collection
A self-administered web-based questionnaire was created using
Google Forms and sent to UAEU students via social media andmailing lists. Recruiting participants through social media has
been found to be effective and time-efficient [17]. The included
participants were a self-selecting sample, as participation in thesurvey was voluntary and participants were not offered any
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incentives. The questionnaire consisted of 20 questions and wasmade available on the internet for two weeks, from March 15,
2020, to March 29, 2020. The questions included 13 predefined
multiple-choice questions, 4 yes/no questions, and 3 open
questions. None of the questions were personal questions that
could reveal the participants’ identity. The questionnaire wastested by the authors before it was sent to students. The
estimated time to complete the questionnaire was 4 minutes,
which was stated in the questionnaire. The questionnaire also
stated that the responses would be anonymous. Prior to datacollection, permission was obtained from the relevant authorities
at UAEU, and a psychologist was consulted to determine theappropriateness of the questionnaire for the target respondents.
The information provided about the questionnaire was basedon the Checklist for Reporting Results of Internet E-Surveys(CHERRIES) [18].

Survey Questions
The web-based questionnaire contained 20 questions. The first
three questions aimed to obtain basic information andcharacteristics of the participants (age, gender, and academic
major). The remaining questions were divided into two parts.

Part 1: GHQ-12
In this part, we used the GHQ-12 [19] to measure thepsychological health of the survey participants. The GHQ-12
can be analyzed as a single dimension psychological health test[20]. However, many researchers have suggested that it can bedivided into two or three specific and meaningful factors, inwhich each factor is composed of several items from thequestionnaire. Gribbin and Worsley [21] proposed a three-factor
approach: anxiety/depression, social dysfunction, and loss ofconfidence. Andrich and van Schoubroeck [22] suggested that
positively worded items or questions constitute one factor andnegatively worded ones constitute another. Politi et al [23]identified two factors: general dysphoria and social dysfunction.

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Drissi et al
Martin [24] proposed three factors: self-esteem, stress, andsuccessful coping. When compared to other methods and applied
to different samples, the three-factor model proposed by Gribbin
and Worsley [21], including anxiety and depression (4 items),social dysfunction (6 items), and loss of confidence (2 items),
was found to give the best fit [25,26]. Therefore, we used thismodel in this study.
Table 1 presents the 12 items of the GHQ-12. Table 2 presents
the association between the GHQ-12 items and the threepsychological factors. A study by Gao et al [27] showed thatthe loadings of the items on their associated factors are very
close, ranging from 0.72 to 0.9. The correlation between thethree factors was also found to be very high, ranging from 0.83
to 0.9 [27]. Based on these results, and to simplify theassessment, we assumed that all items had the same loadingson their associated factors.
The potential answers to the GHQ-12 items range from“better/healthier than normal” through “same as usual” and“worse/more than usual” to “much worse/more than usual.” Theanswers reflect the difference between the psychological healthstates of the participants when they responded to thequestionnaire and when they considered their health states tobe normal. The answers can be scored in four different ways:
GHQ scoring (0-0-1-1), C-GHQ scoring ((0-1-1-1) for negative
items and (0-0-1-1) for positive items), Likert scoring (0-1-2-3),
and modified Likert scoring (0-0-1-2).
This study investigates the severity of the identified
psychological issues in addition to their prevalence; therefore,
we used the Likert scoring method to score the answers because
it produces a wider and smoother score distribution, which helps
to assess severity [28]. Each item of the GHQ-12 had 4 possible
answers that were scored from 0 to 3. A higher score indicateda more severe condition. The scores for each answer of the 12
items are presented in Table 1.

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Table 1. Questions, answers, and scores of the 12-item General Health Questionnaire.
Item ID

Question

Answers

Score

1

Have you recently been able to concentrate on what you are doing?

Better than usual0Same as usual1

Less than usual2

Much less than usual3

Not at all0

No more than usual

1

Rather more than usual2

Much more than usual

3

More so than usual0Same as usual1

Less than usual2

Much less than usual

3

More so than usual0Same as usual1

Less than usual2

Much less than usual3

Not at all0

No more than usual

1

Rather more than usual2

Much more than usual3

Not at all0

No more than usual

1

Rather more than usual2

Much more than usual

3

More so than usual0Same as usual1

Less so than usual2

Much less than usual

3

More so than usual0Same as usual1

Less so than usual2

Much less than usual3

Not at all0

No more than usual

1

Rather more than usual2

Much more than usual3

Not at all0

No more than usual

1

Rather more than usual2

Much more than usual3

Not at all0

No more than usual

1

2

3

4

5

6

7

8

9

10

11

Have you recently lost much sleep over worry?

Have you recently felt you were playing a useful part in things?

Have you recently felt capable of making decisions about things?

Have you recently felt constantly under strain?

Have you recently felt you couldn’t overcome your difficulties?

Have you recently been able to enjoy your normal day-to-day activities?

Have you recently been able to face up to your problems?

Have you recently been feeling unhappy and depressed?

Have you recently been losing confidence in yourself?

Have you recently been thinking of yourself as a worthless person?

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Item ID

12

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Question

Have you recently been feeling reasonably happy, all things considered?

Answers

Score

Rather more than usual2

Much more than usual

3

More so than usual0

About same as usual1

Less so than usual2

Much less than usual

3

Table 2. Associations between items and psychological factors of the 12-item General Health Questionnaire.
Psychological factor

Associated item IDs

Anxiety and depression

2, 5, 6, and 9

Social dysfunction

1, 3, 4, 7, 8, and 12

Loss of confidence

10 and 11

The answers of the participants were collected and scored. Basedon the maximum score of each psychological factor and thetotal score, the answers were categorized to represent threeseverity categories: normal, high, and severe.
For the total score of the GHQ-12, the normal state scorecategory ranged from 0 to 12, the high-risk score category
ranged from 13 to 24, and the severe case score category ranged
from 25 to 36. For the anxiety and depression factor, the normal
state scores ranged from 0 to 4, the high-risk category scores
ranged from 5 to 8, and the severe case scores ranged from 9
to 12. For the social dysfunction factor, the normal state scores
ranged from 0 to 6, the high-risk scores ranged from 7 to 12,
and the severe case scores ranged from 13 to 18. For the “lossof confidence” factor, the normal state scores ranged from 0 to
2, the high risk state included scores of 3 and 4, and the severecase state included scores of 5 and 6.

Part 2: Awareness of and Attitudes Toward Mobile
Mental Health Apps

opinions about the use of these apps for mental health care. The
questions were formulated based on questions retrieved from
related literature investigating similar topics [29-32]. As shownin Table 3, the questions were formulated mainly to determine
if the students had any previous knowledge or experience withmental health apps; understand their willingness to consider
using a mental health app; and understand the preferences andfactors that could encourage them to use apps for mental healthcare.
Questions Q1 and Q2 were yes/no questions. Questions Q3 andQ4 had possible answers of “Yes,” “No,” or “I don’t know.” If
a participant answered “Yes” to Q4, they were asked to provide
the reason for their choice in Q4.1, in which the participant
could choose from a predefined list of reasons, including costproblems, stigma related to mental problems, distance frommental health care professionals, shortage of mental health care
professionals, and lack of knowledge (information) on mental
health; they could also choose the “Other” option and express
their own reasons. Q5 was an open question.

The second part of the questionnaire served to investigate theuniversity students’ knowledge of mental health apps and their
Table 3. Questions in Part 2 of the questionnaire related to mental health care apps.
Item ID

Question1

Have you ever heard of mobile mental health apps?

2

Have you ever used a mobile app for your mental well-being?

3

Would you be open to using a mobile app for your mental well-being in the future?

4

Would you prefer using a mobile app over consulting with a mental health care specialist?

4.1

If yes, why?

5

What would you like to see in an app for mental health care?

Correlations
The correlations between the age and the total GHQ-12 score
as well as between the gender and the total GHQ-12 score were
calculated using the Pearson correlation coefficient, which has
a value between +1 and –1. A value of +1 indicates a perfect
positive correlation between the sets of data, while a value of
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is to 0, the weaker the correlation is.

Summary of the Analytical Strategy
For the GHQ-12 items, the participants answered each GHQ-12
item with “better/healthier than normal,” “same as usual,”
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JMIR FORMATIVE RESEARCH“worse/more than usual,” or “much worse/more than usual.”
The collected answers were converted to numerical scores basedon the Likert scoring (0-1-2-3) method. The scores wereregrouped to investigate the psychosocial factors presented inTable 2 (anxiety and depression, social dysfunction, and lossof confidence). A total GHQ-12 score was calculated based on
the scores of all the items. The total score and scores of thepsychological factors were categorized into three categories:
normal state, high-risk state, and severe state. The higher thescore, the more severe the participant’s condition.
For the questions related to mental health care apps, theparticipants answered questions Q1 to Q4 using predefined
options. The answers to questions Q1 to Q4 were then quantified

Drissi et al
and analyzed. For the open questions (Q5 and the “Other “option
in Q4.1), the participants provided short answers. The answersof these open questions were then categorized based on their
meanings and presented in a list.

Results
Sample Characteristics
A total of 154 university students participated in the survey; themajority of the participants were female (113, 73.4%). The
academic majors of the majority of the respondents fell into thecategories of science, mathematics, and technology (89/154,
57.8%). Table 4 summarizes the main characteristics of theparticipants.

Table 4. Characteristics of the study participants (N=154).
Variable

Value

Gender, n (%)
Female113 (73.4)

Male

41 (26.6)

Age (years)
15-22, n (%)

118 (76.6)≥23, n (%)

36 (23.4)

Mean (SD)22.45 (5.87)

Academic major, n (%)
Science, mathematics, and technology

89 (57.8)

Business

24 (15.6)

Health and medicine

10 (6.5)

Social sciences

5 (3.2)Public and social services

5 (3.2)

Other

21 (13.6)

Part 1 Results
Results by Item
The results of the analysis of the items identified specific issues
that the students suffered from more during the period of thesurvey. If the participant’s answer to an item indicated abetter/healthier state than usual or the same state as usual, theissue investigated by the item was not considered to be morepresent than usual for the participant; however, if the answer
indicated a worse or much worse state than usual, it reflected
an abnormal presence of the issue during the survey period.
Figure 1 presents the answers to the GHQ-12 items.

(11.7%) reported much worse sleep than usual. The same
number of participants (50/154, 32.5%) showed elevated statesof unhappiness and depression (Item 9), with 31/154 (20.1%)
answering worse than usual and 19/154 (12.3%) answeringmuch worse than usual. One-third of the participants (47/154,
30.5%) reported feeling constantly under strain (Item 5), with
34/154 (22.1%) answering worse than usual and 8.4% (13/154)
answering much worse than usual. The issues for which
participants showed the least elevated states were the capabilities
of making decisions and facing problems (Items 4 and 8,
respectively); 19/154 participants (12.3%) reported worse
capability of making decisions, and 21/154 (13.6%) reported
worse ability to face problems.

One third of the 154 participants (50, 32.5%) had sleep issues(Item 2): 32 (20.8%) reported worse sleep than usual and 18

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Figure 1. Proportions of participants’ answers to the 12-item General Health Questionnaire.

Total Score and Psychological Factors
Analysis of the total scores and the scores of each psychologicalfactor gave a general idea of the students’ mental states and themental issues they were more susceptible to. Figure 2 presents
the severity categories of each psychological factor as well as
the total score of the GHQ-12. The figure also presents aclassification by gender for each category.

More than one-third of the participants (66/154, 42.9%) had
high scores indicating high risk of having mental issues, and asmall number of participants (2/154, 1.3%) had very high scoresand were classified as severe cases. The issues of the participants
mainly seemed to relate to depression and anxiety.
Weak correlations were found between the age of theparticipants and the total score of the GHQ-12 (–0.101) andbetween the gender of the participants and the total score of theGHQ-12 (–0.128).

Figure 2. Classification of GHQ-12 answers by severity category and gender. GHQ-12: 12-item General Health Questionnaire.

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JMIR FORMATIVE RESEARCHPart 2 Results
Answers to the Questions
Figure 3 presents the responses to questions Q1 to Q4 related
to mental health care apps.
Half of the participants (78/154, 50.6%) had never heard ofmental health care apps (Q1). The majority of the participants

Drissi et al(114/154, 74.0%) had never used an app for mental health care
(Q2). More than half of the participants (82/154, 53.2%) showed
uncertainty regarding their willingness to use mental health careapps in the future (Q3). Of the 154 participants, 83 (53.9%)
justified their answers of “Yes” or “I don’t know” to Q4 by thereasons shown in Figure 4.

Figure 3. Answers to questions Q1, Q2, Q3, and Q4 pertaining to mental health apps.

Figure 4. Answers to Q4.1 indicating the participants’ reasons for preferring the use of a mobile app over consulting with a mental health care specialist(n=83).

To identify the features that the students would need or preferto see in mental health care apps, the participants were asked
an open question (Q5) about what would they like to see in an
app for mental health care. Almost one-third of the participants

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in Textbox 1.

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Textbox 1. Preferred functionality and characteristics of mental health care apps indicated by the survey participants.
Functionality•

Web-based therapy•

Communication with others experiencing same issues•

Tracking mental status•

Advice from specialists•

Motivational statements•

Educational content

•

Games

•

Recommendations of activities and tips•

General health management•

Emergency features•

Tracking of progress•

Stories

Characteristics•

Anonymity•

Simple design and ease of use•

Affordable price•Diversity of features

Associations Between the Answers
Figure 5 shows the associations between the participants’previous use of apps for mental health care (Q2) and their

willingness to use these apps in the future (Q3). Figure 6
presents the answers to questions Q1 to Q4 by the participants
who had high or severe risk scores in Part 1 of the questionnaire.

Figure 5. Associations between the answers to Q2 and Q3.

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Figure 6. Answers to questions Q1 to Q4 by participants whose total GHQ-12 scores indicated high and severe mental health risk (n=68).

Discussion
Main Findings
The results of Part 1 of our questionnaire showed that more than
one-third of the participants (66/154, 42.9%) were experiencing
psychological health issues associated with anxiety anddepression. The most frequently reported issues related toanxiety and depression were sleep problems, feelings ofunhappiness, depression, and being constantly under strain.
Given the period of the survey, those results can be linked tothe measures taken by universities in the UAE due to the
COVID-19 pandemic. The questionnaire was made available
on the internet after universities were officially closed to
students for two weeks and lectures were being given on theinternet. Students were required to adjust to new circumstancesand lifestyles and face ambiguity regarding what would happen
next concerning their education and future. These findings are
consistent with those of other studies conducted in othercountries to analyze the psychological impact of the COVID-19
pandemic. Several studies have shown that anxiety, depression,
sleep issues [33], and stress [34] are the most common
psychological issues caused by the outbreak.
Many students also showed high risk of social dysfunction
issues. Items 4 and 8 of the questionnaire were related to thestudents’ capabilities of making decisions and facing problems,
respectively. The nature of these issues implies that they aremainly linked to critical and problematic cases of social
dysfunction; also, they may be indicators of serious pre-existing
problems that may not necessarily be linked to the COVID-19
lockdown. Social dysfunction issues were mainly related to thelack of enjoyment of daily activities (item 7) and lack of a senseof playing a useful part in things (item 3). This can be linked
to the pausing of many activities and the limitations on what
students could do at and from home due to the safety measurestaken during the outbreak.
We found weak correlations between the age of the participants
and the total score of the GHQ-12 (–0.101) and between thegender of the participants and the total score of the GHQ-12
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COVID-19. The majority of participants that had high or very
high psychological factor scores were female. Women havebeen reported to be more susceptible to anxiety, fear, and stress[35-37], which may explain this result.
The COVID-19 outbreak has caused many psychological issues
among different groups of people, and with the required safetymeasures, it can be difficult to consult with mental health care
professionals even in emergency cases. Alternative remotemental health care solutions are needed during the pandemic,
just as distance learning was required as an alternative toin-school learning. Apps are convenient solutions during thecurrent pandemic, as they provide mental health care via mobile
devices, which are owned by the majority of people in the UAE,
particularly the younger generation [38]. Apps for mental healthcare can also help overcome some pre-existing mental healthcare barriers, such as stigma, cost, and distance from mental
health care professionals and institutions [39,40]. Apps havealso been reported to be effective to alleviate anxiety, stress,and depression [15,16]. The results showed that the majority ofparticipants (78/154, 50.6%), who are university students in the
UAE, had never heard of mobile mental health care apps, and114/154 respondents (74.0%) had never used this type of app.
This was also reflected in their attitudes toward these solutions,as 82/154 participants (53.2%) were unsure about their
willingness to use an app for mental health care in the future.
One-third of the participants (48/154, 31.2%) were not sure if
they would prefer using an app to consulting with a mental
health care professional. These results were also persistent whenanalyzing answers of participants who had high or very highgeneral GHQ-12 scores, as shown in Figure 6. These participants
may be in need of such apps. The lack of knowledge and useof apps may be due to the fact that the younger generation
mainly associates apps with games, communication, or otheractivities not related to health or mental health in particular [41].
A person who is not familiar with the concept of a mental healthcare app may not think to search for one.

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There is a need for digital health literacy, particularly for mental
health care, in the UAE. This can be provided using social
networks such as Instagram and Twitter or via widely usedwebsites such as YouTube, as these platforms reach a large
number of people and can help spread knowledge about
available mental health care apps.
Some participants (12/114, 10.5%) who had never used suchapps expressed unwillingness to use one in the future; this may
be due to a lack of knowledge or trust regarding these apps.
Involving mental health professionals in the design of apps formental health could give the apps more credibility and encourage
university students to be more open toward using them. It isnoteworthy that a group of participants who had used apps formental health care before (7/40, 17.5%) expressed unwillingness
to use them again in the future; this may be due to poor usability
and/or lack of functionality of the used apps. End users should
be involved in the creation of mHealth apps [42] to improve
the adoption of these solutions. Integrating gamification featuresin these apps may also be a solution to make the apps moreenjoyable and engaging and to encourage users to continue
using them.
The majority of participants (109/154, 70.8%) answered “Yes”
or “I don’t know” when asked if they preferred using an app toconsulting with a mental health care professional; theseparticipants justified their choices as being mainly due to theirlack of knowledge of mental health. Apps can be a useful meansfor people to educate themselves about mental issues and toobtain easy access to information. The participants alsosuggested that educational content could be provided in mental
health care apps. It must be noted that mental health care apps
are not a substitute for professional care. These apps can aid
the management of certain mental issues and deliver certain
treatment methods; however, seeking professional help isimperative to treat serious mental health issues.
Stigma was among the expressed reasons for preferring mental
health care apps. Apps can provide anonymity andconfidentiality when only users can access their content, whichhelps overcome stigma barriers. The aforementioned listed
reasons were consistent with the students’ preferred functionality
and characteristics, such as web-based therapy, advice from
specialists, anonymity to help overcome stigma, and affordable
price to overcome cost issues. The results of this study are
consistent with the results of previous studies reporting thatstigma, cost, and distance from mental health care professionals
are the main barriers to mental health care delivery [39,40].
Simple design and ease of use were among the characteristics
suggested by the participants. They felt that the apps should beeasy to use, easy to learn, and provide enjoyable user experience.
The aforementioned functionality and characteristics suggestedby the students could be established as requirements of mental
health apps for university students in the UAE.
Although mental health care apps are a convenient means to
overcome many mental health care barriers, it must be notedthat for an app to be beneficial, it must ensure safety, privacy,
security, and confidentiality of users’ data. Available apps formental health care differ in their quality, effectiveness, andhttp://formative.jmir.org/2020/10/e19876/

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security measures. Psychological health is a sensitive subject;
therefore, the user should check the permissions required bythese apps and the treatment approaches they provide before
using them.

Limitations
This study may have some limitations. First, the survey was
conducted during the early stages of lockdown in the UAE; thepsychological state of the students may have changed sincethen, and they are likely to be experiencing more psychologicalissues. Second, the difference in the number of participants bygender may have affected the psychological investigation results;
the majority of participants were female, and women have beenreported to more susceptible to certain psychological issues. It
should be noted that female students represent 81% of the entire
UAEU student population [43], which may also have impacted
the results. Third, comparing the results with a prelockdown
investigation of the psychological state of university students
in the UAE using the GHQ-12 would have improved thediscussion of the results. However, to the best of our knowledge,
no such investigation exists. Fourth, a broader number ofparticipants may have been included if the survey had not been
conducted during a pandemic. Fifth, conducting semistructured
interviews could have improved the discussion of the results.
However, as the study was conducted at the beginning of the
lockdown due to the COVID-19 pandemic, delivering thequestions through a web-based form was our best and only
choice. Finally, given that more than half of the respondents
were unfamiliar with mental health apps, the conclusions
regarding the benefits of the use of these apps were not basedon the results of the questionnaire but on results of previous
studies investigating the effectiveness and advantages of mental
health care apps.

Conclusions and Future Work
The COVID-19 outbreak and the applied safety measures tolimit its spread have caused many psychological issues
worldwide. Our psychological assessment test of university
students based on the GHQ-12 showed that more than one-thirdof the participants were experiencing issues related to depression
and anxiety as well as to social dysfunction, which confirmed
our first hypothesis. In contrast, our second hypothesis wasfound to be unsupported, as the majority of students showed alack of awareness of mental health care apps. The students also
showed mixed attitudes and uncertain willingness to use suchapps, which does not support our third hypothesis. The
participants proposed characteristics and functionalities ofmental health care apps that could encourage them to use suchapps. We encourage developers of mental health apps toconsider these suggestions, especially when targeting university
students or the younger generation. We do believe that thefindings of this study may assist researchers and practitioners
investigating the impact of the COVID-19 outbreak on thepsychological health of university students.
In future work, we intend to build on the results of this study
and develop a mobile app to help university students cope withmental health issues.

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Acknowledgments
We would like to thank Dr Leena Amiri for checking the suitability of the survey for university students. This study is part of
the Startup project (#31T131) funded by the UAEU (2019-2021).

Authors' Contributions
All authors contributed to the creation of the manuscript. ND was involved in the study design and conception, acquisition andinterpretation of data, analysis of questionnaire answers, and drafting and revision of the manuscript. SO contributed to the study
design and conception, acquisition and interpretation of data, statistical support, drafting of the manuscript, and critical revisionof the manuscript. MK, AH, HN, and SS were involved in the design and distribution of the questionnaire and the collection ofdata.

Conflicts of Interest
None declared.

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Abbreviations
CHERRIES: Checklist for Reporting Results of Internet E-Surveys
GHQ-12: 12-item General Health Questionnaire
GHQ-28: 28-item General Health QuestionnairemHealth: mobile health
UAE: United Arab Emirates
UAEU: United Arab Emirates University
WHO: World Health Organization

Edited by J Torous, G Eysenbach; submitted 05.05.20; peer-reviewed by N Lau, V Strotbaum, K Reynolds; comments to author
26.06.20; revised version received 09.07.20; accepted 15.09.20; published 20.10.20
Please cite as:
Drissi N, Alhmoudi A, Al Nuaimi H, Alkhyeli M, Alsalami S, Ouhbi S
Investigating the Impact of COVID-19 Lockdown on the Psychological Health of University Students and Their Attitudes Toward
Mobile Mental Health Solutions: Two-Part Questionnaire StudyJMIR Form Res 2020;4(10):e19876
URL: http://formative.jmir.org/2020/10/e19876/
doi: 10.2196/19876
PMID: 32969340©Nidal Drissi, Ayat Alhmoudi, Hana Al Nuaimi, Mahra Alkhyeli, Shaikha Alsalami, Sofia Ouhbi. Originally published in JMIR
Formative Research (http://formative.jmir.org), 20.10.2020. This is an open-access article distributed under the terms of theCreative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution,and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The
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