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Table of Contents
Year : 2022  |  Volume : 19  |  Issue : 1  |  Page : 1-6

Mental health and sleep quality among health-care students during the second wave of COVID-19 pandemics in Erode District: A cross-sectional study

1 Department of Physiology, Vinayaka Mission's Kirupananda Variyar Medical College and Hospital, Salem, Tamil Nadu, India
2 Department of Physiology, Government Erode Medical College, Erode, Tamil Nadu, India
3 Department of Psychiatric Nursing, Nursing Research Scholar, Vinayaka Mission's Research Foundation - Deemed to be University, Salem, Tamil Nadu, India
4 Department of Microbiology, Palanisamy College of Arts, Erode, Tamil Nadu, India

Date of Submission11-Jun-2021
Date of Decision04-Sep-2021
Date of Acceptance10-Sep-2021
Date of Web Publication24-Jan-2022

Correspondence Address:
Panneerselvam Periasamy
Department of Physiology, Government Erode Medical College, Perundurai, Erode, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_55_21

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Background: The mental health of medical and paramedical college students is likely to be severely affected by the second wave of COVID-19 pandemics, affecting their learning process. Aim and Objectives: The aim of the study was to assess the prevalence and level of stress, anxiety, and depression of health-care students living in Erode district, and their sleep quality during the second wave of COVID-19 pandemic. Methodology: This is a cross-sectional study and it was conducted via Google Form survey completed by students studying health-care-oriented courses such as MBBS and nursing students in Erode district. Results: A total of 318 students had completed data on demography details, sleep quality by Pittsburgh Sleep Quality Index, and mental health by Depression Anxiety Stress Scales questionnaires. The prevalence of borderline abnormal depression, anxiety, and stress was 25.5%, 25.2%, and 16%, respectively. The prevalence of poor sleep was 45% and overweight and obese students (P = 0.03) had more poor sleep scores than others. Nursing students had significant depression (P = 0. 03), anxiety (P = 0.04), and stress (P = 0.03) score than others. Conclusion: During the second wave of the COVID-19 epidemic, there was a significant rise in the incidence of unpleasant feelings and attitudes among health-care students stationed in COVID treatment hospitals, as well as poor overall sleep quality. We hope that this research will lead to an additional investigation into the mental condition of health-care students during public health emergencies. Furthermore, special emphasis must be devoted to improving the sleep quality of health-care students who are constantly exposed to the current viral pandemic due to their profession.

Keywords: Anxiety, COVID-19, depression, mental health, second wave, sleep quality, stress

How to cite this article:
Suganthi V, Subha K C, Periasamy P, Sasikala G, Senthamil Selvi C S, Seralathan G. Mental health and sleep quality among health-care students during the second wave of COVID-19 pandemics in Erode District: A cross-sectional study. Apollo Med 2022;19:1-6

How to cite this URL:
Suganthi V, Subha K C, Periasamy P, Sasikala G, Senthamil Selvi C S, Seralathan G. Mental health and sleep quality among health-care students during the second wave of COVID-19 pandemics in Erode District: A cross-sectional study. Apollo Med [serial online] 2022 [cited 2022 May 21];19:1-6. Available from: https://www.apollomedicine.org/text.asp?2022/19/1/1/336569

  Introduction Top

The novel coronavirus disease in December 2019 (COVID-19), which originated in Wuhan, China, spread around the world, forcing the World Health Organization to recognize this unanticipated health emergency as a global pandemic on March 11, 2020.[1] The difference between current COVID-19 with that of previous coronavirus rarely produces runny noses or GIT problems in those infected, which are unexceptional in severe acute respiratory syndrome (SARS).[2] SARS-CoV-2 is causative of severe viral pneumonia, affecting more than 120 million people in 220 countries and 2.66 million deaths as of March 16, 2021.[3]

Hospitals, as the epicenter of epidemic prevention and control, are the primary locations of confirmed or suspected COVID-19 cases, making them the most vulnerable sites for new infections. Frontline medical staff (FMS) have unquestionably been the most impacted groups in the aftermath of the current viral pandemic, with increased workload involving diagnosis and treatment of new infections, elevated stress levels, reduced or overwhelmed health system capacity, and increased infection risk.[4] These continuous stresses may have a negative influence on FMS patients' sleep quality and mental health. During the COVID-19 pandemic, anxiety was measured in 12 investigations, with a pooled prevalence of 23.2%, and depression was assessed in 10 studies, with a prevalence rate of 22.8%.[5]

According to a systematic review and meta-analysis of reports on anxiety and depression during the first wave of the COVID-19 pandemic, the incidence of mental health issues rose, as well as a substantial rise in suicidal ideation and panic attacks among COVID-19 patients.[6] The outcomes manifested as mental health changes are already being referred to as “the inevitable next pandemic” or “the pandemic of severe mental disorders.”[4],[5],[6],[7],[8] Therefore, it is of great importance to address long- and short-term aftermaths of the pandemic, both on the individual and population levels, which is also underlined by the United Nations, among others.[9] However, we are still unaware of the extent of the pandemic's impact on mental health and we do not know the dynamics of these changes, whether they intensify or weaken as we adapt to specific pandemic-related restrictions. We also do not have enough information on psychological resources (adaptive stress-coping methods), which might be crucial in bolstering and enhancing mental health. Therefore, it is critical to establish sociodemographic factors and psychometric profiles in students, which will help us better understand psychological causes of anxiety and depression in the COVID-19 epidemic period, as well as define treatment suggestions. It has been found that during the initial wave of the pandemic, more than 25% of the population had substantial mental health impairment.[10] Therefore, it is interesting and valuable to analyze mental health status of the health-care students during the second wave of the COVID-19 pandemic.

Huang and Zhao[11] found that during the COVID-19 outbreak, the prevalence of insomnia rose considerably (in some cases, new onsets of insomnia), that time in bed (TIB) and total sleep time (TST) increased, and that sleep efficiency dropped significantly.


  1. To study the prevalence of the second wave of COVID-19 on students' mental health state
  2. To study the effects of the second wave of COVID-19 on students' sleep quality
  3. To identify the variables to cause stress, anxiety, and depression in students.

  Methodology Top

Study design and participants

This cross-sectional study was conducted via online survey among 318 health-care (152 of MBBS and 166 of nursing) students aged between 18 and 22 years during the period April–May 2021. After obtaining online consent, we collected data assessing students' sociodemographic details, Pittsburgh Sleep Quality Index (PSQI), and DASS scales of self-explained questionnaires. The link to the online survey was shared to health-care students (MBBS and nursing) in medical colleges in the Erode district of Tamil Nadu. Those who are willing to give online consent and students studying MBBS, nursing, and paramedical within Erode district were included in this study, whereas other districts of Tamil Nadu students, not willing to take part in this study, and other nonhealth-care students (like Arts and Science, Engineering, etc.) were excluded from this study. The Google Form online questionnaire was sent to the students via an online platform. Students pursuing MBBS and nursing in the Erode region of Tamilnadu were contacted via WhatsApp and E-mail and interviewed after receiving permission from their respective college.

Study tool

Based on a review of the literature, the questionnaire applied in this study was designed. The participants were informed that their responses would be kept private and confidential. The questionnaire was created to decrease survey fatigue and was reviewed by the experts in survey research for face validity. The final version of the questionnaire required 5–10 min of time approximately to complete. Sociodemographic information includes age, sex, religion, marital status, type of family, place of living, district currently living, educational qualification, employment status, and monthly family income. The first part of the online Google Form survey contained the information regarding participants' demographic details, course, college, year of study, and socioeconomic status.

PSQI is a self-administered questionnaire[12] that may be used in both nonclinical and clinical settings to measure subjective sleep quality. Scores higher than 5 indicate poor sleep. We gathered data from the PSQI on how many hours participants spent in bed (TIB; min) and sleeping (TST; min) when they went to bed to sleep (BT; hr), and when they woke up in the morning (WU; hr) throughout the second wave of COVID-19, as well as changes in sleep pattern.

The Depression, Anxiety, and Stress Scale (DASS-21) was used in the second portion to measure the degree of stress, anxiety, and depression among participants. The DASS-21 is a 21-item self-report questionnaire that is used to assess the severity of a variety of symptoms that are typical in both depression and anxiety. The participant must identify the presence of a symptom during the preceding week when completing the DASS. Each item is given a score ranging from 0 (did not apply to me at all in the previous week) to 3 (applied to me a lot or the majority of the time in the previous week).[13]

The DASS is used to determine the degree of depression, anxiety, and stress symptoms. The letters D (Depression), A (Anxiety), and S (Stress) indicate which scale each item belongs to. Add the scores for recognized items on each scale (D, A, and S). The final score of each item group (Depression, Anxiety, and Stress) needs to be multiplied by two since the DASS-21 is a short-form version of the DASS 42 (the long form includes 42 items) (×2). The lowest possible score is 0, and the highest possible score is 42. [Table 1] shows how the DASS final score might be classified. According to studies, the DASS-21 score is accurate in determining a person's level of depression, anxiety, and stress. It also has a high level of dependability in both clinical and nonclinical settings.[14],[15] The information was input into Microsoft Excel, and descriptive statistics were calculated.
Table 1: Association between the level of Pittsburgh Sleep Quality Index score and demographic variables

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Statistical analysis

In each category, demographic variables were presented in frequency with percentages. The mean, median, and standard deviation of the PSQI and DASS scores were provided. The Chi-square test was used to examine the relationship between demographic factors and PSQI and DASS scores. Correlation between PSQI and DASS score was assessed using Pearson correlation confidence method. P ≤ 0.05 is considered statistically significant, and two-tailed tests were used for significance testing. The data were analyzed using Statistical Package for Social Sciences for Windows, Version 22 (IBM SPSS Statistics for Windows,Version 22.0. Armonk, NY: IBM Corp. IBM Corp.).


Ethical approval for the study was given by the Government Erode Medical College and Hospital, Perundurai, Erode Institutional Ethical Committee vide Reference number: IEC/001/GEMC& H/2020 Dated: 31.07.2020. Written digital consent was obtained from study participants prior to completing the survey form. Participants gave their consent by ticking the designated box. Personal identifiers such as names were not collected during the study.

  Results Top

There were 318 students were participated in the study. Among them, 71 (22.33%) were male and 247 (77.67%) were female. The mean age of males was 19.56 ± 1.57 years and that of females was 19.66 ± 1.29 years.

[Table 2] depicts that the majority of the students that took part in the study (77.67%) were female. Approximately 66.98% were between the ages of 19 and 20. About 47.80% of students were medical students and 52.20% were nursing students. About 58.17% of the students were 1st and 2nd year students. [Table 3] shows that 63.52% of participants were with normal body mass index.
Table 2: Demographic profile of the participants

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Table 3: Anthropometric measurements of the participants

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[Table 1] shows that nursing students (χ2 = 9.07 P = 0.01) and 3rd to 4th year of studying students (χ2 = 8.25 P = 0.04) had poorer PSQI score. One hundred and forty-one (44.34%) students had poor sleep score. Overweight and obese students (χ2 = 9.13 P = 0.03) had more poor sleep quality score than others. Statistical significance was confirmed using Chi-square test.

[Table 4] shows the prevalence of stress, anxiety, and depression in health-care students. More than 40% of the respondents were affected by depression (40.25%), anxiety (42.14%), and stress (30.82%). However, out of 318 students, 14 students had extremely severe depression.
Table 4: Levels of depression, anxiety, and stress among students

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[Table 5] shows Correlation between sleep quality in PSQI and depression, anxiety, and stress (DASS) by Pearson correlation coefficient was r = 0.19 P ≤ 0.05* (correlation is significant at the 0.05 level [2-tailed]), which means there is a positive, poor correlation between PSQI score and DASS score.
Table 5: Correlation between seven items of sleep quality in Pittsburgh Sleep Quality Index and Depression, Anxiety, and Stress Scale score

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  Discussion Top

This study indicates that COVID-19 pandemic has serious consequences for mental health, which are manifested as intensified psychopathological symptoms in many students. Final-year female nursing students were experiencing high levels of depression, anxiety and stress during the second wave of the COVID-19 pandemic in Erode district, Tamilnadu. In addition, the quality of sleep during the pandemic was poor by nearly half of the students. Our study found that healthcare students had severe depression (15.41%), severe anxiety (18.55%) and severe stress (6.60%), whereas sleep quality has been decreasing as more than 44.97% of students were experiencing poor subjective sleep quality.

The increase of anxiety, depression, and poor subjective sleep quality during the second wave of pandemic is not uncommon. During and after epidemics, previous studies have frequently shown increased mental health issues among persons of various generations[16],[17],[18],[19],[20] and the recent pandemic around the world.[21],[22],[23],[24],[25],[26],[27] Further findings indicate that symptoms of anxiety and depression, along with poor subjective sleep quality, were strongly related to female nursing students in Erode district, Tamil Nadu. The stress in nursing students could be due to the fear of unknown events, working with equipment,[28] staff and professorial rudeness,[29],[30] theoretical and practical differences,[31] the fear of committing an errort[32] and interaction with co-workers, classmates, and patients.[33] It is suggested that medical and nursing students receive the required training in appropriate coping methods. In addition, good time management, social support, positive reappraisal, and participation in leisure hobbies are frequently used to alleviate student stress.

In a similar vein, Yang et al.,[34] in a study conducted on Chinese university students, observed that students from all provinces in China, irrespective of “severity of the risk,” showed similar symptoms of anxiety and fear as a result of “mass hysteria.”[35] Other studies associated heightened mental health problems with proximity of an epicenter of an outbreak.[26],[36],[37],[38] There is no denying that health systems around the world are getting overwhelmed with increased demands for necessary health assistance, especially for COVID-19 patients. Hence, limited health facilities, together with unmet needs, especially for people at higher risk, propel widespread panic among health-care students. Studies have indicated that students often experience serious mental health problems during public health emergencies.[26],[39]

Previous studies of depression among university students in India have found that students from lower socioeconomic backgrounds are more likely to be depressed than those from higher socioeconomic backgrounds.[40]

The use of a standardized measure for sleep quality and DASS is another advantage of the present study. To the best of our knowledge, no other study has looked at the link between psychological distress and sleep quality using both the DASS-21 and PSQI standard measures. As it is still unclear if factors linked to poor sleep quality are a cause, a result, or just a comorbidity, further research is needed to determine the best solution. Furthermore, these data may suggest a bidirectionally relationship between sleep quality and mental health problems.

The validity of these observations is subjected to various issues. For example, data were collected quickly within 2 weeks. However, the participants' subsequent experiences in the coming weeks will provide more insight into the phenomena described here. Generalized stress, anxiety, depression, and subjective sleep quality were all assessed using self-rating measures. As a result, the danger of erroneous judgment and social desirability biases cannot be discounted. This study, which is cross-sectional in nature, might not accurately explain the causal relation between stress, anxiety, depression, and subjective sleep quality with explanatory factors.

Furthermore, data were collected from a small population sample using social media, covering only Erode district students, and may not be generalized to other settings and populations. A large-scale, countrywide research would reveal a variety of experiences and concerns. As a result, rigorous lengthier follow-up studies are required to evaluate the influence of COVID-19 on the public's mental health, particularly among India's youth.

  Conclusion Top

Depression, anxiety, and stress levels among nursing, female, and 3rd to 4th year students, high in Erode district, were found to be high when assessed during the second wave of COVID-19 pandemic. Furthermore, approximately half of the students reported poor sleep quality during the epidemic. It is, therefore, strongly recommended to initiate to strict monitoring mechanism to detect the presence of mental ailments among health-care college students, and to offer necessary supports through family, community, and institutional agencies to curb psychological problems, especially during this unprecedented health emergency.

The policymakers, guided by expert opinion, should launch a nationwide epidemiological study addressing the nature and magnitude of mental health problems, including anxiety, depression, as well as stress, and relevant issues with an emphasis on young adults. Based on the outcomes, they should implement age-specific emergency psychological interventions and supports – for infected, suspected, and noninfected individuals. Second, during the ongoing health emergency, the University Grants Commission of India, in collaboration with government health authorities, should provide the necessary information by establishing a support network using available online platforms to assist students, faculty, and other professionals involved in higher education in combating mental illnesses.


We are thankful to all the participants and the anonymous reviewers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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