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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
A study on the health status of adolescent school students in North Kerala during the COVID-19 pandemic lockdown


1 Department of Pediatrics, Malabar Medical College and Hospital, Kozhikode, Kerala, India
2 Department of Community Medicine, Malabar Medical College and Hospital, Kozhikode, Kerala, India

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Date of Submission18-Apr-2022
Date of Decision12-Jul-2022
Date of Acceptance12-Jul-2022
Date of Web Publication05-Sep-2022
 

  Abstract 


Introduction: During the initial phase of COVID-19 pandemic crisis, the schools and educational institutions were closed countrywide. Hence, more than 90% of students admitted to educational institutions worldwide are affected as 188 countries have implemented COVID restrictions. Hence, this study focuses on the health status of adolescent students during the shutdown of educational institutions during the COVID-19 pandemic. Aim and Objective: This study assesses mental health, dental health, eye health, physical activity, immunization, and nutrition in adolescents during the COVID-19 pandemic among adolescent boys and girls. Materials and Methods: The current cross-sectional study was done among school-going adolescent children. One hundred and eighty students from different syllabus systems and urban and rural parts of north Kerala participated. The data collected were entered into an excel sheet and analyzed using the SPSS software. Results: 59.4% of students have gained weight due to sedentary behaviour. Students spend more time in front (95%) of a digital screen, leading to computer vision syndrome. Loss of social interactions adversely affected students' mental health by 37.8%. Thirty percentage of physically active students were involved in indoor physical activities such as Zumba and aerobics. In addition, 77% of students have not taken their routine immunization. Conclusion: The newer learning methods have impacted the students' knowledge. There is no uniformity in the form of teaching. Multiple factors have played a role in improving the lockdown situation, including the families, schools, local authorities, government, digital media, and newspapers.

Keywords: Academic performance, adolescent health, behavioral health, COVID-19, digital eye strain, home-based comprehensive health assessment tool, mental health, physical activity, school health, weight gain


How to cite this URL:
Shrinath G, Muhammed Basheer K T, Bhanusali V, Premlal K S. A study on the health status of adolescent school students in North Kerala during the COVID-19 pandemic lockdown. Apollo Med [Epub ahead of print] [cited 2022 Sep 27]. Available from: https://apollomedicine.org/preprintarticle.asp?id=355646





  Introduction Top


SARS COVID-19 disease impacted the world in 2019 October in Wuhan, China. The first case of the COVID-19 pandemic in Kerala was confirmed in Thrissur on January 30, 2020.[1]

According to the WHO, “A pandemic is an outbreak of an infectious disease that has spread across a large region, for instance, multiple continents or worldwide, affecting a substantial number of people.” The current pandemic is the first time in human history that educational institutes have been closed because of an invisible infectious agent, the COVID-19 virus.

The epidemiology triad involved in the disease transmission is the agent, host, and environment, as shown in [Figure 1].
Figure 1: Epidemiological triad

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Proper knowledge of host and agent factors is needed to prevent disease transmission since COVID-19 pandemic was a sudden outbreak. However, the knowledge involved in disease transmission was unclear. Therefore, epidemiologists globally were involved in conducting observation studies to know the multiple factors of disease transmission. Since this COVID-19 is an emerging disease and has resulted in the sudden death of people in various countries. At the beginning of the COVID-19 pandemic, the health authorities had to use robust disease control mechanisms such as lockdowns and school shutdowns to prevent further disease transmission.

We often misjudge by thinking that adults are affected by lockdowns because most have lost their only source of income. However, school children have entirely lost their social connection, which is the basis of their psychological and physical development.[2] Undoubtedly, the health-care workers involved in COVID-care were the most affected globally. Moreover, many people have lost their loved ones in the family due to COVID-19. People who had a job were distressed due to overload; on the other hand, those who lost their job were under immense pressure to lead an economically productive life. The ones who are very severely affected are the adolescents. Early adolescence is when young kids need more attention, and developments occur at multiple levels, including physical, psychological, biological, social, and behavioral changes.[3] Adolescents were exposed to more screen time for assignments and academic sessions, while parents are helpless in limiting their screen time. The homeschooling system during the COVID-19 lockdown has developed a tendency to get exposed to unhealthy eating habits due to low to nil outdoor activities and in-person human interaction.[4] Unhealthy eating patterns and being sedentary at an early age can be determinantal. However, the long-term effects will be seen as physical illnesses such as obesity, hypertension, diabetes, and cardiovascular disease.


  materials and methods Top


Study setting

The current research is a cross-sectional study in North Kerala. Ethical Clearance was obtained from the Institutional Ethical Committee, with Ethical Clearance Number MMCHandRC/IEC/2020/17. The study was conducted from January 2021 to March 2021.

Study population

The school-going adolescent students from 13 to 17 years in North Kerala.

Sample size

The sample size was calculated using the following formula N = 4pq/d2. (N = sample size P = prevalence from previous study q = 100 − P, d = relative precision). Absolute precision is approximately taken as 15 (%) of 50. N = 4 × 50 × 50/7.52 N = 4 × 50 × 50 ×/56.25 N = 177.77 i.e., approximately = 180.

Study tool

a closed-ended questionnaire was used in the data collection.

Sampling method

purposive sampling. The sampling was done, so that representation of the student population had all the variations. The investigator included different variables, including age, gender, area, government and private schools.

Data collection

a questionnaire was prepared, and data were collected through the interview method.

Data analysis

data were entered in MS office Excel 2019 16.0 and analyzed in IBM SPSS. (IBM, New York, SPSS version20.0). The categorical variables were presented as frequency and percentage.


  Results Top


A total of 180 students participated in the current research. In our research, most students (95%) spent more than 2 h/day in front of a digital screen for academic purposes. However, only 44 (%) of boys and 47.2 (%) of girls use more than 8 h of screen time. 17.6 (%) of boys and 21.3 (%) of girls use screen time for 4-6 h, among 33 (%) of boys and 27 (%) of girls use 2–4 h of screen time. About 2.7 (%) of boys and 2.2 (%) of girls have a screen time usage of fewer than 2 h [Table 1].
Table 1: Distribution of study participants according to screen time

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Despite students experiencing eye strain, they did not get an eye checkup. As a result, 80 (%) of eye checkups were not, to reduce unnecessary hospital visits during the lockdowns. This is adversely affecting the eye health of the individuals.[5] as in [Figure 2].
Figure 2: The percentage of students who have done and not done eye checkups

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Exam fears among boys and girls: The percentage of students stressed about the examination is 62.8 (%). For example, the school provides comparatively more resources than CBSE and ICSE schools from the government educational council and government. On the other hand, only 40.2 (%) of students have received academic support from their school, while 59.8 (%) do not. Moreover, as we all know, due to the COVID-19 pandemic, schools have been closed due to lockdown, and students, especially high school (10th board) and higher secondary (plus one and two exam students), have been unable to receive proper guidance.

Academic performance

Only 35.6 (%) of the students improved their academics during the lockdown, and 64.4 (%) of students' performance depreciated or did not show any academic improvement, which may cause mental stress in school-going students [Figure 3].
Figure 3: Distribution of study participants according to improvement in academics

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Oral health

The dental health of the school-going students has a role in their day-to-day activities. From the above graph, mostly girls brush their teeth more regularly than boys; out of the total number of students, only 23 boys and 59 girls brush their teeth regularly. It is found that 46.3 (%) brush their teeth and 53.7 (%) do not brush their teeth twice a day. Which in turn leads to detrimental effects concerning oral health.

Moreover, 21.6 (%) of girls had behavioral changes. Behavioral differences were observed in 60.6% of the 180 students.

Of 180 participants, 52 (%) students have dental caries, 31.3 (%) have a toothache, and 16.8 (%) suffer from swelling gums. Social interaction has dropped down to 45.2 (%). Out of 180 students, behavioral changes were absorbed in 39.3 (%) students. Among 39.3 (%) students, 17.7 (%) of boys had behavioral changes and 21.6 (%) of girls had behavioral changes. Behavioral differences were Not observed in 60.6% of the 180 students. [Figure 4]
Figure 4: Distribution of study participants according to the dental problem among students

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Out of 180 students, 27.20 (%) have to get academic support in government-aided schools have 8.88 (%), CBSE has 17.22 (%), and Icse schools have 6.10 (%). Of 180 students, boys' social interaction has only 17.70 (%) and girls have only 26.10 (%). 48.2 (%) of students did not have any social interactions.

Sedentary behaviour

Out of 180 students, the percentage of boys and girls who have gained weight is 33.3 (%) and 26.1 (%.) Moreover, no change in weight is 18.8 (%) and 21.6 (%). Hence, a total of 180 students, 59.4 (%), have gained weight and 40.6 (%) did not change their weight.

Out of 180 students, 77.1 (%) were not immunized and only 22.9 (%) were vaccinated with routine vaccinations during the COVID-19 pandemic lockdown. Of 180 students, 60.4 (%) of students have attended online classes. However, 39.3% of students did not participate in online classes as in [Table 2].
Table 2: Sociodemographic variables in the study population

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The physical activity of the students was different. First, most of the students were involved in Zumba and aerobics, followed by other activities such as running 13.3 (%), walking 13.3 (%), skipping (15.6%), and yoga16.7 (%), jogging 6.7 (%), and least being sprinting 4.4 (%).

Among active physical students, 30 (%) were involved in Zumba and aerobics, 16.7 (%) were doing yoga, 15.6 (%) were skipping, 13.3 (%) were walking, 13.3 (%) were running, and 6.7% were doing jogging, and only 4.4% were sprinting [Figure 5].
Figure 5: Distribution of study participants according to activities done among students during lockdown

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  Discussion Top


A total of 180 students' case was by consulting their parents, of which 92 were boys and 88 were girls. Our study results show that 53.3 (%) of girls and 46.7 (%) of boys showed fear of attending exams after going through online classes due to a lack of direct interactions with teachers. In addition, a study conducted in Korea by David d.Lee. showed that 52 (%) of students showed fear in attending exams after the lockdown.[6]

Our study results show that 37.8 (%) of students lacked interaction with society, severely affecting their mental health. Many of them experienced mood swings and anxiety disorders. A study by tang showed that 24.9 (%) of students suffered from an anxiety disorder.[7]

According to our survey, around 64.4 (%) of parents and students feel that online classes were not practical and had no improvement in academics. A recent study conducted in America by Ezra Golberstein, Hefei wen, and benjamin f miller showed that more than 60 (%) felt the online education system was ineffective.[8] Our study results also show increased screen time among children over 8 h daily. Before the advent of online classes for learning, the digital eye strain affected only a small group of people using computers and a digital screen daily as part of their employment, like IT professionals and bank employees. However, children are equally affected by the long hours of screen time as part of their daily lives.

According to our study, 52 (%) of students reported dental caries during the lockdown days due to increased intake of junk food, among which maximum cases were reported in the age group of 13–14. In addition, our study noted an increase in weight and decreased physical activity among students, a 33.3 (%) increase in boys and a 26.1 (%) increase in girls.


  Conclusion Top


The conclusions are based on the study conducted in North Kerala. The pandemic has presented a new set of challenges that countries attempt to overcome. The study reveals that the COVID-19 pandemic impacts adolescent students aged 13–17 years. The study mainly focused on the school-going adolescent students' mental health, eye health, dental health, academic, routine immunization, physical activities, and nutrition. Our study revealed that during the COVID pandemic, 79.9% of students did not have an eye checkup done, and only 20.1% have done an eye checkup. Many parents were worried about their child's increased screen time. In the case of academics, the fear of appearing for the exam is 62.8% among the students; due to the lack of educational resources, only 40.2% of the students get help from the school. Lack of guidance has shown decreased academic improvement, i.e., only 35.6% showed improvement in their studies during the pandemic rest of 64.4% of students' performance either decreased or showed no change in their academics.

In the case of dental health, the students either suffer from dental caries, toothache or gum swelling. Due to the risk of the spread of disease, many people ignore dental issues. This study highlighted the importance of mental health during the COVID-19 era. Mental health is another pillar of a healthy community and physical health. During the COVID-19 outbreak, we must look after our mental health.[9] This helps in preventing suicides and other mental issues. Individuals should be encouraged to undergo psychiatric screening to maintain a healthy mental status if they are experiencing any problems in their life. The students have shown many behavioural changes during this pandemic lockdown 60.6% of students showed behavioral changes, primarily boys.

Research has shown that reduced physical activity (and, in parallel, heightened sedentary behavior) is associated with adverse physical and mental health outcomes, such as loss of muscular and cardiorespiratory fitness, weight gain, psychosocial problems, poor academic achievement, and ophthalmic issues. Evidence suggests that the negative impacts may have ripple effects throughout adulthood.[10]

In this study, our findings indicated that the COVID-19 outbreak had significantly impacted students' mental health, education, and daily routine. The COVID-19-related interruptions highlight critical challenges and provide an opportunity to further evaluate alternative measures in the education sector. The new policies and guidelines in this direction would help mitigate some of the adverse effects and prepare educators and students for the future health crisis.

Recommendation

  • Children should be guided and informed that if their eyes hurt, they must communicate to their parents or teachers at the earliest so that they get an eye break every 20 min on the screen
  • Capacity-building sessions for the family members, carers, school teachers, and pediatricians to identify the health issues at home such as eye health, mental health, oral health, and behavioral problems at the earliest
  • The importance of the mental health status of children during the lockdown should be given
  • Promote a healthy and nutritious diet at home
  • Reduce screen time other than academic sessions by engaging them in other physical activities
  • Improve oral hygiene by brushing teeth twice daily and avoiding foods that precipitate dental caries.


Limitations of study

  • There are some difficulties in making causal interference
  • The situation may provide differing results if another time frame had been chosen
  • There are some insufficient sample sizes for satisfactional measurements
  • Another limitation is missing data, notably if a significant amount of data is missing. Finally, on surveys, respondents may not answer a specific question accidentally or because they are uncomfortable or do not want to answer the question.


Acknowledgment

We would like to thank all the students and parents for participating in the study.

Conflicts of interest

There are no conflicts of interest.

Author's contribution

Dr Shrinath G -Conception of the idea, drafting the article, Critical revision of the article and Final approval of the version to be published. Dr Basheer K T -Drafting the article, Data analysis, and Final approval of the version to be published. Dr Vasant Bhanusali -Drafting the article, Data representation, and Final approval of the version to be published. Dr K.S.Premlal-Statistical interpretation, Critical revision of the article and Final approval of the version to be published.

Financial support and sponsorship

Nil.



 
  References Top

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Adolescent Health. Available from: https://www.who.int/health-topics/adolescent-health#tab=tab_1. [Last accessed on 2022 Jan 26].  Back to cited text no. 4
    
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Kim J, Hwang Y, Kang S, Kim M, Kim TS, Kim J, et al. Association between exposure to smartphones and ocular health in adolescents. Ophthalmic Epidemiol 2016;23:269-76.  Back to cited text no. 5
    
6.
'It's Destroying Education': Dissent Over South Korea's 8-Hour College Exam. South China Morning Post; 2021. Available from: https://www.scmp.com/week-asia/people/article/3156412/south-koreas-infamous-8-hour-suneung-college-exam-faces-growing. [Last accessed on 2022 Jan 27].  Back to cited text no. 6
    
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Newby JM, O'Moore K, Tang S, Christensen H, Faasse K. Acute mental health responses during the COVID-19 pandemic in Australia. PLoS One 2020;15:e0236562.  Back to cited text no. 7
    
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Coronavirus Disease 2019 (COVID-19) and Mental Health for Children and Adolescents | Adolescent Medicine | JAMA Pediatrics | JAMA Network. Available from: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2764730%C2%A0%C2%A0. [Last accessed on 2022 Jan 27].  Back to cited text no. 8
    
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Currier D, Lindner R, Spittal MJ, Cvetkovski S, Pirkis J, English DR. Physical activity and depression in men: Increased activity duration and intensity associated with lower likelihood of current depression. J Affect Disord 2020;260:426-31.  Back to cited text no. 9
    
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Porras-Segovia A, Rivera M, Molina E, López-Chaves D, Gutiérrez B, Cervilla J. Physical exercise and body mass index as correlates of major depressive disorder in community-dwelling adults: Results from the PISMA-ep study. J Affect Disord 2019;251:263-9.  Back to cited text no. 10
    

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Correspondence Address:
KS Premlal,
Department of Community Medicine, Malabar Medical College and Hospital, Modakallur, Kozhikode, Kerala
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_60_22



    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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    -  Muhammed Basheer K T
    -  Bhanusali V
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