Medicine®

Observational Study

Factors affecting the mental health of medical
students during the COVID-19 pandemic
A cross-sectional study
Moemi Matsuo, PhDa,* , Sayaka Sesoko, BAa, Ayumu Kosa, BAa, Sakuya Noda, BAa, Seigo Koura, PhDa,
Hiroya Miyabara, PhDb, Takashi Higuchi, PhDc

Abstract

The coronavirus disease 2019 outbreak has impacted many educational institutions by imposing restrictions on offline or in-person
lessons. Many students were stressed by “the loss of everyday life” due to the pandemic, and it is important to examine theimpact of this loss on adolescents’ mental health. This study aimed to investigate the factors that affect students’ mental healthduring the pandemic from various perspectives. A total of 166 medical students participated in this study. Participants completed
questionnaires about their demographics, life stress, mental health, and stress factors during in-person and online lecture days.
Participants were divided into 2 groups, those with low and high mental health. The researchers compared independent variables
between the groups using the χ2 test or Fisher’s exact test. Multiple logistic regression analysis was performed, with mental healthas the dependent variable. The multiple logistic regression analysis indicated that increased time spent online was significantly
associated with mental health (P < .05). Human relations and the inability to meet/talk with friends trended toward a significant
association with mental health (P < .1). The students who were not stressed about the increased time spent online were at a riskof low mental health. The students who appreciated interacting with others experienced more stress during the lockdown. To
reduce students’ stress on online days, teachers should devise a lecture style with frequent breaks and introduce active learning.
The findings of this study will contribute to addressing students’ low mental health and reducing their stress during the coronavirus
disease 2019 pandemic.
Abbreviations: COVID-19 = coronavirus disease 2019, K6 = Kessler screening scale for psychological distress, OR = odds

ratio, WHO = world health organization.
Keywords: COVID-19, interpersonal exchange, mental health, online learning

contact with faculty and other students. Specifically, medical
students could no longer directly receive practical instruction that was supposed to be provided in person, and issues
regarding the ideal form of medical education have beenhighlighted.[13,14] As such, students’ lives drastically changed.
Their time on the Internet increased as they adapted to online
learning and experienced a student life without sports, interaction with friends, and campus life.[15] A systematic review
reported that these measures reduced the spread of the virus,
while increasing depression and reducing well-being in people. This review found lower psychological well-being andhigher anxiety and depression than before COVID-19.[16]Many students were stressed by “the loss of everyday life”
due to the pandemic. Therefore, it is important to examine thepandemic’s impact on adolescents’ mental health,[17] as developmental theorists labeled this stage as a period of storm andstress.[18] Factors including social restrictions, low-self rated

1. Introduction
The coronavirus disease 2019 (COVID-19) outbreak has
impacted the lives of millions of people worldwide since2019, causing extraordinary disruptions to healthcare delivery, economic activities, and social interactions.[1] A COVID19 outbreak occurred in Wuhan, Hubei Province, China.[2–4]
The world health organization (WHO) declared the coronavirus outbreak a public health emergency of international concern,[5,6] and declared the new COVID-19 as a pandemic.[7–10]
In Japan, schools were temporarily closed nationwide,[11]and a state of emergency was declared for the metropolitan
areas.[11,12]
Consequently, many educational institutions, including
universities, imposed restrictions on in-person lessons, forcing
them to shift to remote learning. In remote lectures, students
attended lectures online, reducing the chances of in-person
The authors have no funding and conflicts of interest to disclose.

Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it ispermissible to download, share, remix, transform, and buildup the work provided
it is properly cited. The work cannot be used commercially without permission
from the journal.

The datasets generated during and/or analyzed during the current study areavailable from the corresponding author on reasonable request.
a
Major of Occupational Therapy, Faculty of Rehabilitation Sciences, Nishi
Kyushu University, Kanzaki, Saga, Japan, b Major of Physical Therapy, Facultyof Rehabilitation Sciences, Nishi Kyushu University, Kanzaki, Saga, Japan, cDepartment of Physical Therapy, Osaka University of Human Sciences, Settsu,
Osaka, Japan.

How to cite this article: Matsuo M, Sesoko S, Kosa A, Noda S, Koura S, Miyabara
H, Higuchi T. Factors affecting the mental health of medical students during the
COVID-19 pandemic: A cross-sectional study. Medicine 2022;101:47(e31897).
Received: 13 September 2022 / Received in final form: 26 October 2022 /Accepted: 27 October 2022

* Correspondence: Moemi Matsuo, Major of Occupational Therapy, Faculty of
Rehabilitation Sciences, Nishi Kyushu University, 4490-9 Ozaki, Kanzaki, Saga
842-8585, Japan (e-mail: matsuomo@nisikyu-u.ac.jp).

http://dx.doi.org/10.1097/MD.0000000000031897

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Matsuo et al. • Medicine (2022) 101:47Medicine

health, poor sleep quality, higher perceived stress load, lessfamily support, and unsteady family income are associatedwith decreasing mental health.[16,19,20] Additionally, some studies suggested that remote learning also affects students’ mental health. However, the participants of these studies were not
medical students; they were students in fields such as businessand music.[21–23]
The authors hypothesized that the decrease in opportunities
for students to meet in person due to changes in the lecture format may be 1 of the contributing factors to the decline in students’ mental health during the pandemic. Specifically, mental
health of medical students may be affected to a similar or evengreater degree than that reported in previous studies due tothe remote learning system. This may be because even though
medical students are required to attend practical lectures,
they do not get the opportunity for in-person learning due to
COVID-19, which may increase their anxiety. Therefore, it isnecessary to clarify what affects the mental health of medical
students. This study investigates the factors that affect students’mental health during the COVID-19 pandemic from various
perspectives.

and the second group included those with high mental health(Fig. 1).

2. Methods

2.3.2. Questions about life stress. The authors devised 12
items regarding subjective life stress. Items included humanrelations, academics, behavioral restrictions, health, income,inability to meet/talk with friends, home environment, job/career
options, cultural activities such as club activities, increased timespent online, in-person lectures, and online lectures (Table 1).
We asked about the category relating to life stress based onwhether the participants thought the item related to their stress;
this was not a rated scale.

2.2. Procedures
The study’s participants completed and returned the questionnaires, and the collected data were aggregated and analyzed.
The study questionnaires were self-reported and took approximately 5 minutes to complete. Participants completed questionnaires about their demographics, life stress, and mental healthand questions about stress factors during in-person lecture days
and online lecture days. All the questionnaire responses werereceived anonymously.
2.3. Measures
2.3.1. Demographics. The questionnaire comprised 5
questions: gender, grades, major, part-time job, and family
environment. Table 1 reports the comparative data from thisquestionnaire between participants with low mental health andhigh mental health.

2.1. Participants
A total of 177 medical students in their first to third years in
the Faculty of Rehabilitation, Nishi Kyushu University, wererecruited for this study. Informed consent was obtained fromall the participants before the study. From the potential participants, 166 completed responses (collection rate: 93.8%) werereceived. None of the responding participants were excluded, andthe final sample consisted of 166 participants: 70 female and 96
male students; 65, 63, and 38 were in their first, second, and thirdyears, respectively (Fig. 1). The study was conducted in January2022 with the approval of the Ethics Committee of Nishi Kyushu
University (approval number: 21TKQ21) and in compliance with
the Declaration of Helsinki.[24]The 166 participants who met the research criteria (the students who completed responses) were divided into 2 groups.
The first group included students with low mental health,2.3.3. Mental health. The Kessler screening scale forpsychological distress (K6) was used to measure students’mental health. The scale has been employed in annual
government health surveys in the United States, Canada, and
the WHO World Mental Health Surveys.[25] The scale assesses
the frequency of experiencing psychological distress over 30days through 6 items. Participants responded to the items on
a 5-point Likert scale (0 = not at all, 1 = little, 2 = sometimes,

Figure 1. Flow chart of the study.

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Table 1
Variable comparison between the 2 groups.

Variables

Low mental health group n = 83

High mental health group n = 83

P-value

44 (53)39 (47)52 (62)31 (37).21

28 (34)33 (40)22(27)

37 (45)30 (36)16 (19).31

45(54)
38(46)

61 (73)22 (27)<.01*

63 (76)20 (24)65 (78)18 (22).71

29(35)
50 (60)36(43)8(10)34 (41)46 (55)29 (35)9 (11)

.42
.53
.27
.58

16 (19)28 (34)48 (58)11(27)
23 (28)19 (23)1 (1)7(8)
11 (13)13(16)
58 (70)44 (53)6 (7)19 (23)49 (59)10 (12)20 (24)21 (25)
0 (0)
4 (5)
5 (6)
3 (4)
38 (48)46 (55)

<.05*
.12
.59
.82
.60
.72
.32
.35
.12
<.01*
<.01*
.59

Gender, n (%) Male Female
Grades, n (%)
 1st
 2nd
 3rd
Major, n (%) Physical therapy Occupational therapy
Part-time job, n (%) Have NoneFamily environment, n (%) Living alone/living in the dormitory Living with parent Living with brother/sister Living with others
Subjective life stress during the COVID-19 pandemic, n (%) Human relations Academics Behavioral restrictions Health Income Inability to meet/ talk with friends Home Finding a job/ career options Cultural activities such as club activities Increased time spent online In-person lectures Online lectures* P < .05, χ2 test or Fisher’s exact test.
COVID-19 = the coronavirus disease 2019.
Data are expressed as number (%).

2.3.4. Questions about stress factors during in-person
lecture days. The authors developed 13 items that could beconsidered as stress factors during in-person lecture days. Items
included waking up early, taking a long time to leave for school,lack of sleep, returning home late, carrying heavy teachingmaterials, grooming, school expenses, interacting with people,
inability to learn at own pace, obligation to wear a mask,
preparation of lunch, high risk of spreading COVID-19, andOthers.

3 = often, 4 = always). High K6 scores indicate a high level ofpsychological distress. The participants were categorized into
2 groups based on their scores: K6 < 13 or K6 ≥ 13. Scores in
the K6 ≥ 13 categories indicated that the participants had low
mental health.
Furthermore, the Japanese version of the burnout scale wasused as another measure of mental health. Burnout has been
defined as “a state of exhaustion in which 1 is cynical about
the value of 1’s occupation and doubtful of 1’s capacity to perform.”[26] WHO includes burnout in the recent 11th revision of
the International Classification of Diseases as a global occupational phenomenon that influences health.[27] The Japanese version of the burnout scale consists of 17 items across 3 subscalesof emotional exhaustion, depersonalization, and decreased personal achievement. The reliability and validity of the scale havealso been reported.[28] This study used a burnout scale created for
medical students with certain modifications. As for the scale, all
the 17 items were rated on a 5-point Likert scale (1 = not applicable to 5 = most applicable). The higher the score on the modified version burnout scale, the higher the burnout risk. However,as this scale did not have a cutoff value, the median was set basedon the data obtained from this survey. Those with a higher scorethan the median were considered to have low mental health,whereas those with a lower score had high mental health.
In this study, these 2 scales were used to identify stress factorsthat affect participants’ mental health from various angles, as
previous research has suggested that both psychological distressand burnout affect mental health,[25,27] and if either scale indicated low mental health, the participants were assigned to thelow mental health group.

2.3.5. Questions about stress factors during online lecturedays. The authors devised 16 items that could be consideredstress factors on online lecture days. Items included studying
atmosphere, ability to concentrate, difficulty in making
presentations, face appearances, a considerable amount of
assignments, ability to correctly grasp the way to attend classes
and submit assignments, online communication (group work),no interaction with people, inadequate online environment,
checking emails, fewer opportunities for communication, feelingphysical fatigue, less time for mutual exchange of questions, lackof exercise, cost of environment maintenance, and electricity billincrease.

2.4. Statistical analysis
Independent variables were compared between the 2 groups
using the χ2 test or Fisher’s exact test as appropriate. In addition, multiple logistic regression analysis with backward
stepwise selection was performed with mental health as the3Matsuo et al. • Medicine (2022) 101:47Medicine

dependent variable. Odds ratios (ORs), which is a measure of
the association between an exposure and outcome, and 95%
confidence intervals, which is a range of values that 1 can be
95% confident contains the true mean of the population, were
calculated. While calculating the multivariate OR, human relations, inability to meet/talk with friends, increased time spent
online, and in-person lectures were set as covariates. In theabove analyses, a bilateral P-value < .05 was considered statistically significant. All statistical analyses were performed
using the statistical analysis software SPSS (Version 26.0, IBM,Tokyo, Japan).

use impacts students’ health-promoting and health-threatening
behavior. Potential harmful effects of extensive screen time andtechnology use include lower mental and physical health aswell as lower well-being, including attention-deficit symptoms,
impaired emotional and social intelligence, technology addiction, impaired brain development, disrupted sleep, digital eye
strain, and social isolation.[31–33] Therefore, it can be inferredthat students who report “not stressed with increased time spent
online” are at risk of low mental health during the COVID-19
pandemic.
Second, students who are not stressed with human relations
and students who are stressed by the inability to meet/talk withfriends may appreciate interacting with others or want to interact with others. As it has been reported that less communication
with friends was the main risk factor for mental health problems during the COVID-19 pandemic,[34] those who appreciateinteracting with others can easily feel more stressed because
they are restricted from doing so. The communication between
students is mostly text-based exchanges through smartphones.
Therefore, non-verbal communication such as facial expressions
and speaking styles are unavailable, making it challenging tocompletely understand each other’s intentions, which may also
be stressful.
Third, regarding stress factors during in-person and online
lecture days, the main stress factors were waking up early, taking a long time to leave for school, and lack of sleep duringin-person lecture days. Alternatively, the main stress factors foronline lecture days were a lack of appropriate atmosphere forstudying, ability to concentrate, and difficulty in making presentations. These results indicate that teachers should develop
a lecture style that includes frequent breaks. They should also
introduce active learning, which maximizes information processing and requires critical thinking, and other strategies tobest support student learning[33] to make students feel as if they

3. Results
The results indicated that the dependent variable (mental
health) was significantly affected by the independent variables:
major (P < .01), human relations (P < .05), increased time spent
online (P < .01), and in-person lectures (P < .01), using the χ2
test or Fisher’s exact test (Table 1). The multiple logistic regression analysis results using the step-down procedure indicatedthat the increased time spent online was significantly associatedwith mental health (P < .05). Furthermore, human relations andthe inability to meet/talk with friends were significantly associated with mental health (P < .1). The OR of stress caused byincreased time spent online was 0.231 times higher than that ofthose who were not stressed by the same, indicating that students who were not stressed by increased time spent online had
low mental health. The OR of stress with human relations was
0.345 times higher than that of those who were not stressedby human relations. This indicated that students who were notstressed by human relations had low mental health. The ORof stress caused by the inability to meet/talk with friends was
2.033 times higher than that of those who were not stressed by
the same. This indicated that the students who were stressed by
the inability to meet/talk with friends had low mental health(Table 2).
The results of the questions about stress factors during in-person lecture days are shown in Table 3. The main factors reported
were rising early, taking a long time to leave for school, and lackof sleep. The results from questions about stress factors during
online lecture days are shown in Table 4. The main factors thatwere reported are inadequate study atmosphere, required concentration, and difficulty in making presentations.

Table 2Multiple logistic regression analysis between the 2 groups.
Multivariate OR
Variables
Human relations
Inability to meet/ talk with friends
Increased time spent online
In-person lectures

4. Discussion

OR (95% CI)
0.345(0.117–1.012)
2.033(0.882–4.687)
0.231(0.059–0.900)
1.190 (0.099–4.300)

P-value
.053
.096
.035*
.891

* P < .05, by multiple logistic regression analysis.
OR = odds ratio, CI = confidence interval.
Data are expressed as median (interquartile range) or number (%).
Increasing time spent online was significantly associated with mental health.

This study investigated the factors affecting students’ mental
health during the COVID-19 pandemic from various perspectives. “Not stressed by increased time spent online” was significantly associated with low mental health, and factors such as“not stressed with human relations” and “stressed by the inability to meet/talk with friends” trended toward being significantly
associated with low mental health.
First, it was hypothesized that students stressed by theincreased time spent online had low mental health during the
COVID-19 pandemic. This is because society and the current
educational situation forced them to switch to an online format.
As teachers continue to perform online lectures at the university, it may increase students’ stress levels and cause low mental
health. However, the results of the current study were contrary
and showed that students who answered “not stressed withincreased time spent online” had low mental health, indicatingthat the students who were not stressed about studying online
may themselves increase their daily online time. As a result,they may be affected by Internet use, as previous research hassuggested that online time is negatively associated with mental health.[29] A Chinese cross-sectional self-report survey suggested that psychological disturbances were associated withdaily online time.[30] Review studies have suggested that Internet

Table 3Stress factors on in-person lecture days.
Stress factors on in-person lecture days n = 96n (%)

Getting up early
Taking a long time to leave for school
Lack of sleep
Returning home late
Carrying heavy teaching materials
Grooming
School expenses
Interacting with people
Inability to learn at own pace
Obligation to wear a mask
Preparation of lunch
High risk of spreading COVID-19
Others73 (76)46 (48)36 (38)30 (31)26 (27)26 (27)24 (25)18 (19)17 (18)17 (18)14(15)
8 (8)3 (3)COVID-19 = the coronavirus disease 2019.

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Matsuo et al. • Medicine (2022) 101:47www.md-journal.com

Writing – original draft: Moemi Matsuo, Sayaka Sesoko, Ayumu
Kosa, Sakuya Noda.
Writing – review & editing: Moemi Matsuo, Seigo Koura,
Hiroya Miyabara, Takashi Higuchi.

Table 4Stress factors during online lecture days.
Stress factors on online lecture days n = 90n (%)

No atmosphere for studying
Concentration is required
Difficult to make presentations
Face appearances
Many assignments
Impossible to correctly grasp how to submit assignments
Online communication (group work)
No interactions with people
Inadequate online environment
Checking emails
Less opportunities for communication
Feeling physical fatigue
Less time for mutual exchange of questions
Lack of exercise
Cost of environment maintenance and electricity bill increase
Others59 (66)52 (58)32 (36)32 (36)30 (33)28 (31)27 (30)20 (22)18 (20)17 (19)17 (19)16 (18)14 (16)13 (14)
8 (9)
2 (2)

References[1] Beukes EW, Baguley DM, Jacquemin L, et al. Changes in tinnitus
experiences during the COVID-19 pandemic. Front Public Health.
2020;8:592878.
[2] Berger JR. COVID-19 and the nervous system. J Neurovirol.
2020;26:143–8.
[3] Li X, Xu S, Yu M, et al. Risk factors for severity and mortality inadult COVID-19 inpatients in Wuhan. J Allergy Clin Immunol.
2020;146:110–8.
[4] Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of unknown
etiology in Wuhan, China: the mystery and the miracle. J Med Virol.
2020;92:401–2.
[5] Hui DS, Azhar E I, Madani TA, et al. The continuing 2019-nCoV
epidemic threat of novel coronaviruses to global health – the latest
2019 novel coronavirus outbreak in Wuhan, China. Int J Infect Dis.
2020;91:264–6.
[6] Liu J, Liu S. The management of coronavirus disease 2019 (COVID19). J Med Virol. 2020;92:1484–90.
[7] Bikdeli B, Madhavan MV, Jimenez D, et al. Endorsed by the ISTH,
NATF, ESVM, and the IUA, Supported by the ESC Working Groupon Pulmonary Circulation and Right Ventricular Function. COVID-19
and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art
review. J Am Coll Cardiol. 2020;75:2950–73.
[8] World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. Interim
guidance. Pediatr Med Rodzinna. 2020;16:9–26.
[9] Connors JM, Levy JH. COVID-19 and its implications for thrombosis
and anticoagulation. Blood. 2020;135:2033–40.
[10] Guan WJ, Ni ZY, Hu Y, et al. China Medical Treatment Expert Group
for Covid-19. Clinical characteristics of coronavirus disease 2019 in
China. N Engl J Med. 2020;382:1708–20.
[11] Yabe N, Hanibuchi T, Adachi HM, et al. Relationship between
Internet use and out-of-home activities during the first wave of
the COVID-19 outbreak in Japan. Transp Res Interdiscip Perspect.
2021;10:100343.
[12] Japanese Government. Basic policies for novel coronavirus disease control by the Government of Japan (summary). Available at: https://www.
mhlw.go.jp/content/10900000/000620734.pdf. [access date March 28,
2020].
[13] Alsoufi A, Alsuyihili A, Msherghi A, et al. Impact of the COVID-19 pandemic on medical education: medical students’ knowledge, attitudes,
and practices regarding electronic learning. PLoS One. 2020;15:e0242
905e0242905.
[14] Ross DA; National Neuroscience Curriculum Initiative “Quarantine
Curriculum” Committee. Creating a “quarantine curriculum” toenhance teaching and learning during the COVID-19 pandemic. AcadMed. 2020;95:1125–6.
[15] Guessoum SB, Lachal J, Radjack R, et al. Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown. Psychiatry Res.
2020;291:113264.
[16] Vindegaard N, Benros ME. COVID-19 pandemic and mental healthconsequences: systematic review of the current evidence. Brain Behav
Immun. 2020;89:531–42.
[17] Rapee RM, Oar EL, Johnco CJ, et al. Adolescent development and risk
for the onset of social-emotional disorders: a review and conceptualmodel. Behav Res Ther. 2019;123:103501.
[18] Casey BJ, Jones RM, Levita L, et al. The storm and stress of adolescence:
insights from human imaging and mouse genetics. Dev Psychobiol.
2010;52:225–35.
[19] Kola L, Kohrt BA, Hanlon C, et al. COVID-19 mental health impact
and responses in low-income and middle-income countries: reimagining global mental health. Lancet Psychiatry. 2021;8:535–50.
[20] COVID-19 Mental Disorders Collaborators. Global prevalenceand burden of depressive and anxiety disorders in 204 countries
and territories in 2020 due to the COVID-19 pandemic. Lancet.
2021;398:1700–12.
[21] Ma ZR, Ma WH, Idris S, et al. COVID-19 impact on high school student’s education and mental health: a cohort survey in China. World J
Psychiatry. 2021;11:232–41.

are attending in-person lectures. For online learning to be effective, educators must strive to design courses that incorporate theprinciples of active learning and implement relevant teachingstrategies that focus on practicing scientific skills, critical thinking, and problem-solving.[35]This study also has several limitations. First, the sample sizeof the participants was small. Second, the participants’ selection may have led to bias, as all the participants were recruitedfrom a single university in Japan. Third, data collection for thisresearch did not include the lockdown period due to COVID19; thus, it is still unclear if the students’ mental health was thesame during and after the lockdown period. In future research,
the generalizability of this study’s findings should be assessed forother types of students with a larger sample and other countries
in various situations.

5. Conclusions
The students who are not stressed with increased time spent
online are at a risk of low mental health. Furthermore, students
who appreciate interacting with others may feel more stressed.
Teachers should incorporate frequent breaks and introduce
active learning during lectures to reduce students’ stress during
online lecture days. The findings of this study will contribute toaddressing students’ low mental health and reducing their stressduring the COVID-19 pandemic.

Acknowledgments
The authors would like to express their appreciation to the participants of this study.

Author contributions
Conceptualization: Moemi Matsuo, Sayaka Sesoko, Ayumu
Kosa, Sakuya Noda.
Data curation: Moemi Matsuo, Sayaka Sesoko, Ayumu Kosa,
Sakuya Noda.
Formal analysis: Moemi Matsuo.
Investigation: Moemi Matsuo.
Methodology: Moemi Matsuo.
Project administration: Moemi Matsuo.
Resources: Moemi Matsuo.
Software: Moemi Matsuo.
Supervision: Moemi Matsuo.
Validation: Moemi Matsuo.
Visualization: Moemi Matsuo.
5Matsuo et al. • Medicine (2022) 101:47Medicine[22] Lischer S, Safi N, Dickson C. Remote learning and students’ mental health during the Covid-19 pandemic: a mixed-method enquiry.
Prospects (Paris). 2021;5:1–11.
[23] Badri SKZ, Wan Mohd Yunus WMA, Ramos HM, et al. Remote learning and its implications toward study-life conflicts and the mental
health of university students: does studying at home or campus matter?. High Educ Res Dev. 2021:1–15.
[24] World Medical Association. World medical association declaration of
Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310:2191–4.
[25] Kessler RC, Andrews G, Colpe LJ, et al. Short screening scales to monitor population prevalences and trends in non-specific psychologicaldistress. Psychol Med. 2002;32:959–76.
[26] Maslach C, Jackson SE. Maslach Burnout Inventory. 2nd ed. Palo Alto:
Consulting Psychologists Press. 1986.
[27] World Health Organization. Burn-out an “Occupational Phenomenon”:
International Classification of Diseases. Geneva, Switzerland: World
Health Organization. 2019.
[28] Sakakibara K, Shimazu A, Toyama H, et al. Validation of theJapanese version of the burnout assessment tool. Front Psychol.
2020;11:1819.

[29] Li Z, Yang M. Internet use and depressive symptoms among Chinese
older adults: the mediation and suppression effects of social capital.
Front Psychol. 2021;12:729790.
[30] Ren Z, Zhou Y, Liu Y. The psychological burden experienced by
Chinese citizens during the COVID-19 outbreak: prevalence and determinants. BMC Public Health. 2020;20:1617.
[31] Rouvinen H, Jokiniemi K, Sormunen M, et al. Internet use and healthin higher education students: a scoping review. Health Promot Int.
2021;36:1610–20.
[32] Small GW, Lee J, Kaufman A, et al. Brain health consequences of digitaltechnology use. Dialogues Clin Neurosci. 2020;22:179–87.
[33] Mohan A, Sen P, Shah C, et al. Prevalence and risk factor assessmentof digital eye strain among children using online e-learning during the
COVID-19 pandemic: digital eye strain among kids (DESK study-1).
Indian J Ophthalmol. 2021;69:140–4.
[34] Tahara M, Mashizume Y, Takahashi K. Mental health crisis and stresscoping among healthcare college students momentarily displaced fromtheir campus community because of COVID-19 restrictions in Japan.
Int J Environ Res Public Health. 2021;18:72457245.
[35] Gahl MK, Gale A, Kaestner A, et al. Perspectives on facilitating dynamic
ecology courses online using active learning. Ecol Evol. 2021;11:3473–80.

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