key: cord-0996019-ypigpslx
authors: Dash, Sarah; Bourke, Matthew; Parker, Alexandra G.; Dadswell, Kara; Pascoe, Michaela C.
title: Lifestyle behaviours and mental health and wellbeing of tertiary students during COVID-19 lockdown in Australia: A cross-sectional study
date: 2022-05-10
journal: Compr Psychiatry
DOI: 10.1016/j.comppsych.2022.152324
sha: 7b420f72ceaa81b888c0ff5ba2b73e3028a87a06
doc_id: 996019
cord_uid: ypigpslx

BACKGROUND: Australia experienced significant COVID-19 lockdown restrictions throughout 2020 that had an impact on mental health and disrupted health-promoting lifestyle behaviours. Lockdowns may have exacerbated existing mental health concerns among tertiary students, who experience higher levels of mental health concerns compared to the wider community. This study aimed to investigate the association between modifiable lifestyle factors and wellbeing of students at a Melbourne-based tertiary education institution during COVID-19 lockdown. METHODS: This quantitative, cross-sectional study was conducted across campuses in Melbourne and Sydney. Data was collected via online questionnaire during the 7th week of a second-wave lockdown. Descriptive statistics were calculated for demographic variables (n = 239). Linear regression models were estimated to determine multivariate associations between lifestyle variables and psychological distress. RESULTS: Participants were on average 30.98 years old (SD = 9.78), predominantly female, domestic students, undergraduate, not the first member of their family to attend university and living out of family home. Mindfulness, diet quality, sleep quality and moderate-vigorous physical activity (MVPA) were all inversely correlated with psychological distress. Unadjusted and adjusted models show that mindfulness, sleep quality, and MVPA were all independently inversely related to psychological distress. Greater mindfulness, sleep quality and engagement in MVPA were associated with lower psychological distress during COVID-19 lockdowns. LIMITATIONS: As this study is cross-sectional and we cannot rule out reverse causality. CONCLUSION: This study highlights the potential for lifestyle focused mental-health promotion delivered through tertiary education institutions to support students in times of crisis as well as more generally.

The International Physical Activity Questionnaire Short Form to assess moderate-vigorous physical activity (MVPA), which was assessed using MET-minutes (Craig et al., 2003) . MET minutes for moderate -vigorous activity were computed by multiplying MET score (4.0 for moderate, 8.0 for vigorous) with duration (minutes) of activity and frequency (days) of activity). Total MET minutes for moderate and vigorous activity were then summed for a continuous score.

The dataset was checked for missingness. Overall, 7.68% of values were missing, and data were missing completely at random (Little's χ2 = 204.97, p = .711). However, to retain all cases and increase statistical power, missing data was imputed using multiple imputations. A total of 10 imputed datasets were created using Markov chain Monte Carlo with predictive mean matching. Imputation models were estimated to impute data for psychological distress and all modifiable health behaviours with all covariates and demographic variables included, as well as auxiliary variables that were highly correlated (r < .50) with psychological distress or modifiable health behaviours. Results from multiple imputed datasets were combined using Rubin's Rule (Rubin, 1996) .

Descriptive statistics were calculated for demographic variables. Differences in psychological distress based on demographic variables were estimated with independent sample t-tests for dichotomous demographic variables, linear regression with dummy codes for categorical demographic variables with more than two categories, and Pearson correlation for continuous demographic variables.

Pearson correlation coefficients were estimated to determine bivariate correlations between psychological distress and modifiable health behaviours. Linear regressions models were estimated to determine multivariate associations with psychological distress. First models were run unadjusted with MVPA, diet quality, sleep quality, and mindfulness as independent variables. Next models were run with the same independent variables and adjusted for the effect of age. The pooled r-squared for multivariate models were calculated as the average of r-squares from imputed datasets (van Ginkel, 2019). Pooled standardized coefficients were calculated based on standardized predictors and outcomes (i.e. z-scores), which were standardized before analysis and pooling (van Ginkel, 2020) .

Of the total of 239 students completed the survey, 235 lived in Melbourne. Participants were on average 30.98 years old (SD = 9.78), predominantly female (87%), domestic students (85%), undergraduate (56%), not the first member of their family to attend university (62%) and living out of the family home (55%). Table 1 shows demographic characteristics and differences in distress based on demographic variables. Participants reported a mean mindfulness score of 20.16 (SD 11.80, total scores range 14 to 56) indicating relatively low mindfulness. The mean diet quality score was 7.47 (SD 2.73, total score range 0 to 16), indicating substantial room for dietary improvement, which is comparable to a previous study among students (Bergeron, Al-Saiegh, & Ip, 2017) . Sleep quality, on average, among participants was poor (mean 4.18, SD 2.67, total score 0-15). The median MVPA score for J o u r n a l P r e -p r o o f participants was 607.90 (Q1 1980.00;Q3 1429.10) , which is below averages reported elsewhere for similar cohorts (Fagaras, Radu, & Vanvu, 2015; Maher & Olds, 2011) .

Participants reported an average score on the DASS-21 scale of 20.16 (SD = 11.80, Median = 19.00), which is above previous reported averages for comparable age groups (median 7, mean 9.43; SD 9.66) (Henry & Crawford, 2005) , and those elsewhere reported among Australian university students (Larcombe et al., 2016) , however, was similar or below the levels of psychological distress reported by adults in Europe, the United States and Asia during COVID-19 (Wang et al., 2021) . ***TABLE 1 HERE***

The correlations between health behaviours and psychological distress are in Table 2 . Results show that mindfulness, diet quality, sleep quality and MVPA were all inversely correlated with psychological distress. Results from multivariate linear regression models are in Table   3 . Results from both the unadjusted and adjusted models show that mindfulness, sleep quality, and MVPA were all independently inversely related to psychological distress. The unadjusted model and adjusted models explained 28.5% and 32.3% of the variance in psychological distress in university students during lockdown, respectively, indicating medium and large effect sizes (Cohen, 1992) . 

The current study aimed to investigate associations between modifiable lifestyle behaviours and the wellbeing of students at a Melbourne-based tertiary education institution during mandated COVID-19 lockdown with severe restrictions. Overall, it was found that Melbournian tertiary students were experiencing high levels of psychological distress.

Additionally, on average, participants scored in the lower half of scales for each of the examined lifestyle behaviours. Overall, higher mindfulness, better sleep quality and greater engagement in MVPA were associated with lower levels of psychological distress during lockdown. Although diet quality was significantly correlated with fewer symptoms of J o u r n a l P r e -p r o o f psychological distress, it was not associated with psychological distress in the final adjusted multivariate model.

During lockdown, tertiary students were experiencing much higher levels of psychological distress compared to the general Australian adult population (Crawford, Cayley, Lovibond, Wilson, & Hartley, 2011) and Melbourne-based university students prior to lockdown (Larcombe et al., 2016) . This increase in distress is consistent with studies conducted with university students during lockdown globally (Elmer et al., 2020; Zhai & Du, 2020) . In a study of 1535 university students in Greece, 65% reported that their symptoms of anxiety had increased a lot since lockdown was enforced, and one third of respondents reported the same increase for depressive symptoms (Patsali et al., 2020) . Similarly, perceived stress increased, while mental wellbeing decreased rapidly between the beginning of lockdown and the 5-

week point in a sample of university students in the United Kingdom (Savage et al., 2020) .

Students may be impacted more significantly than their non-student peers during the lockdown period. The turmoil of shifting to remote online learning, diminished in-person social interactions and access to student services in addition to what is generally a challenging environment (e.g., academic and financial pressures, significant lifestyle changes), is possibly exacerbating already heightened psychological distress in students (Burns, Dagnall, & Holt, 2020) .

Lockdown measures across the world are associated with disruptions to mental healthpromoting behaviours (Ammar et al., 2020) . Pre-pandemic evidence suggests that diet quality, physical activity, sleep quality and mindfulness are all predictors of good mental health (J. . The results of the current study also demonstrate low levels of healthy lifestyle behaviours, and are in partial agreement with J o u r n a l P r e -p r o o f previous literature, with sleep mindfulness, and MVPA remaining significantly associated with psychological distress in our final model. This has been demonstrated in research both prior to (Doré, O'Loughlin, Schnitzer, Datta, & Fournier, 2018; Medvedev, Norden, Krägeloh, & Siegert, 2018; Milojevich & Lukowski, 2016) and during COVID-19 lockdowns (Baiano, Zappullo, The Lab, & Conson, 2020; Ingram, Maciejewski, & Hand, 2020; Rogowska et al., 2020) , highlighting the importance of mindfulness, sleep and physical activity to mental health. In the current study, mindfulness and sleep quality may have more directly addressed drivers of psychological distress during the pandemic (i.e., fear, worry, uncertainty), both of which have been shown to have benefits for student mental health in the past (Baiano et al., 2020; Hindman, Glass, Arnkoff, & Maron, 2015; Milojevich & Lukowski, 2016) . A previous meta-analysis has identified the benefits of digital CBT tools for treating insomnia (Soh, Ho, Ho, & Tam, 2020) , which may support improving sleep among this cohort without risk of COVID-19 spread. Findings supporting the inverse relationship between mindfulness and psychological distress may be of particular importance, as although other lifestyle interventions (diet, physical activity) have known benefits for mental health, they often benefit from supervision and support that may not be feasible under lockdown or crisis conditions. Previous interventions have shown mindfulness interventions delivered briefly or online to improve psychological distress (Canby, Cameron, Calhoun, & Buchanan, 2015; Flett, Conner, Riordan, Patterson, & Hayne, 2020; Orosa-Duarte et al., 2021; Sass et al., 2019) , suggesting interventions targeting mindfulness may be the most feasible under pandemic or crisis conditions. As dispositional mindfulness is a modifiable factor, these findings highlight the potential for mindfulness-based strategies to support student wellbeing.

Although overall physical activity (e.g., incidental activity) is likely to have decreased during lockdown, analysis of big data from Australia, the UK and USA shows that community J o u r n a l P r e -p r o o f interest in exercise surged following lockdown and though it declined, remained higher than pre-lockdown (Ding, del Pozo Cruz, Green, & Bauman, 2020) . This may be a result of physical activity being one of the only reasons to leave home, adding extrinsic motivation to many physical activities (e.g., walking, exercising outdoors). Despite reduced activity overall, students may have participated in leisure time physical activity, which has positive associations with mental health (White et al., 2017) .

Our finding of a lack of association between diet and psychological distress differs from previous literature (Deasy, Coughlan, Pironom, Jourdan, & McNamara, 2015; Richard, Rohrmann, Vandeleur, Mohler-Kuo, & Eichholzer, 2015; Whatnall, Patterson, Siew, Kay-Lambkin, & Hutchesson, 2019) . There is evidence to suggest that diet can be used as a coping or escape-avoidance strategy during times of stress (Deasy et al., 2015) and increases in emotional eating during COVID-19 have been demonstrated elsewhere (Bemanian et al., 2021) . Given that it is habitual diet over the long-term that has been associated with mental health (Jacka, Mykletun, Berk, Bjelland, & Tell, 2011) , the relatively short-term changes resulting from lockdowns may not supersede the effects of habitual diet. However, the impact of short-term dietary changes as a result of a stressor on mental health has not been well average, participants demonstrated low mindfulness, poor sleep, moderate diet quality and below average moderate-vigorous physical activity. As this study is cross-sectional, it is not clear whether these levels reflect increases or decreases in lifestyle behaviours compared to pre-pandemic levels. Given the low levels of lifestyle behaviours in this cohort, this may indicate that even small increases in these behaviours may be associated with improvements in mental health during times of crisis. Importantly, our sample was, on average, older than a typical sample of tertiary students (M= 30 years). This may mean that students in the current study may have additional responsibilities and stressors that impacted lifestyle behaviours, compared to a younger cohort, such as possible caregiving, employment or home-schooling responsibilities.

There are several limitations that warrant consideration in interpreting these results. Firstly, this study is cross-sectional in nature, which precludes examining the temporal nature of lifestyle behaviours on mental health, and we cannot rule out reverse causality. It is arguably equally plausible that changes in lifestyle behaviour are impacting mental health, as it is that changes in mental health are impacting lifestyle, and likely that the association is bidirectional (Merlo & Vela, 2021) . However, the evidence related to this question of directionality indicates that interventions targeting lifestyle behaviours are associated with improvements in mental health. For example, a meta-analysis of physical activity interventions for people with mental illness showed that physical activity improved depression symptoms and quality of life among individuals with mental illness (Rosenbaum, Tiedemann, Sherrington, Curtis, & Ward, 2014) . Additionally, a systematic review by Spijkerman et al., (2016) identified that online mindfulness interventions had benefits for depression and stress reduction (Spijkerman, Pots, & Bohlmeijer, 2016) . Similarly, a 2021 meta-analysis of randomised controlled trials demonstrated that improving sleep quality J o u r n a l P r e -p r o o f improved mental health, including depression, anxiety, rumination and stress (Scott, Webb, Martyn-St James, Rowse, & Weich, 2021) . These findings are in line with a large metareview of lifestyle psychiatry interventions which showed the critical role of modifiable lifestyle factors including physical activity, sleep, diet and smoking in the prevention and treatment of mental disorders (Firth et al., 2020) . Although the current study is not able to identify causal relationships between lifestyle factors and psychological distress, it adds to the larger body of literature that has indicated the direct links between lifestyle and mental health.

Further, as this study is unable to compare psychological distress during lockdown with pre-pandemic levels psychological distress, it cannot disentangle the causal relationships between lifestyle factors and psychological distress, or whether the relationship changed due to the pandemic and lockdowns. It does however that show that lifestyle and mental health are intimately linked, even in situations of high stress and uncertainly. Therefore the promotion of a healthy lifestyle remains important even in situations when behaviours that might be considered 'non-essential,' such as physical activity, might otherwise be ceased.

This work supports earlier work highlighting the importance of lifestyle in mental health and extends earlier work by demonstrating that the relationship remains even in unpredicted, high stress situations. Additionally, this study does not allow for comparisons to students' prepandemic behaviours and wellbeing and thus cannot address the direct impact of lockdown on changes in behaviour and mental health. Finally, the average age of the current sample is slightly older than the previously reported average of 26 years and 11 months (Brugge, 2012) and participants were predominantly female. Thus, our findings may not be generalisable to all tertiary students and participants in the current study may have slightly different behaviours due to age related factors (i.e. increased responsibilities, caregiving, etc.).

The current study has several strengths, including examining a range of protective lifestyle factors and their impact on wellbeing, and examining these relationships during extremely strict lockdown conditions. The findings add to the growing body of knowledge on tertiary student mental health during COVID-19 lockdown and has important implications for both a mental health prevention and treatment framework at tertiary education institutions. Sundarasen et al. (2020) (Sundarasen et al., 2020) highlight the strong appeal for the tertiary education sector to acknowledge the critical need for policy and action it to effectively manage the impacts of COVID-19 on student wellbeing and be prepared for any similar crises in the future. Mindfulness-Based Interventions have demonstrated effectiveness in reducing psychological distress in university student samples generally (Lynch, Gander, Nahar, Kohls, & Walach, 2018) and in adult samples during COVID-19 lockdown (Galante et al., 2021) . In addition, sleep education has shown to improve sleep behaviours, sleep quality and reduce depressive symptoms in university students (Hershner & O'Brien Louise) .

Similarly, university students who meet exercise guidelines report better overall and mental health in general (Murphy et al., 2018) and throughout COVID-19 lockdown (Meyer et al., 2020) . Mindfulness training and sleep hygiene education should at least be an available option to university students through their institutions, or as a component of their courses (Conversano et al., 2020) . In addition, measures to promote and opportunities to engage in physical activity should be considered for students. Given the low cost and low risk nature of mindfulness practices, healthy sleep habits and regular exercise as modifiable health behaviours, and their clear benefits for mental wellbeing, all are critical considerations for wellbeing strategies. This has implications for how education institutions support individual lifestyle behaviours, and also provides support for institution-level programs and policies that encourage lifestyle approaches to mental health promotion. Future research should aim to understand how some students may have maintained positive lifestyle behaviours that are J o u r n a l P r e -p r o o f associated with mental health during times of crisis, as well as examining interventions to increase mindfulness and lifestyle behaviours generally and in crisis.

Mindfulness, sleep and moderate-vigorous physical activity were associated with decreased psychological distress among tertiary students based in Australia, who experienced significant levels of psychological distress during COVID-19 lockdowns. This study highlights that the association between lifestyle factors and mental health exists even in unpredicted, high stress situations and therefore the potential for lifestyle focused mentalhealth promotion delivered through tertiary education institutions to support students in times of stress should be further explored. Future studies should investigate factors that allowed some students to maintain mental-health promoting behaviours during lockdown.

Additionally, given that lifestyle interventionsparticularly mindfulness -are relatively low cost and low risk to deliver, the feasibility of delivering these programs and addressing student needs and preferences should be investigated.

J o u r n a l P r e -p r o o f 

An Investigation into the Lifestyle, Health Habits and Risk Factors of Young Adults

Effects of home confinement on mental health and lifestyle behaviours during the COVID-19 outbreak: Insight from the "ECLB-COVID19" multi countries survey. medRxiv

Emerging Adulthood: What Is It, and What Is It Good For?

Tendency to Worry and Fear of Mental Health during Italy's COVID-19 Lockdown

Emotional Eating in Relation to Worries and Psychological Distress Amid the COVID-19 Pandemic: A Population-Based Survey on Adults in Norway

An Analysis of California Pharmacy and Medical Students' Dietary and Lifestyle Practices

The psychological impact of quarantine and how to reduce it: rapid review of the evidence

Under the Radar: The Mental Health of Australian University Students

Assessing the Impact of the COVID-19 Pandemic on Student Wellbeing at Universities in the United Kingdom: A Conceptual Analysis

The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research

A Brief Mindfulness Intervention for Healthy College Students and Its Effects on Psychological Distress

Prevalence and Psychosocial Correlates of Mental Health Outcomes Among Chinese College Students During the Coronavirus Disease (COVID-19) Pandemic

A power primer

An evaluative review of outcome research on universal mental health promotion and prevention programs for higher education students

Mindfulness, Age and Gender as Protective Factors Against Psychological Distress During COVID-19 Pandemic

International physical activity questionnaire: 12-country reliability and validity

Percentile Norms and Accompanying Interval Estimates from an Australian General Adult Population Sample for Self-Report Mood Scales

Psychological distress and lifestyle of students: implications for health promotion

Is the COVID-19 lockdown nudging people to be more active: a big data analysis

Psychological Wellbeing and Academic Experience of University Students in Australia during COVID-19

The longitudinal association between the context of physical activity and mental health in early adulthood

Brief report: The factor structure of mood states in an early adolescent sample

Health Promoting Behaviours and Lifestyle Characteristics of Students at Seven Universities in the UK

Students under lockdown: Comparisons of students' social networks and mental health before and during the COVID-19 crisis in Switzerland

Stress and behavioral changes with remote E-exams during the Covid-19 pandemic: A cross-sectional study among undergraduates of medical sciences

The Level of Physical Activity of University Students

Setting-based interventions to promote mental health at the university: a systematic review

A meta-review of "lifestyle psychiatry": the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders

App-based mindfulness meditation for psychological distress and adjustment to college in incoming university students: a pragmatic, randomised, waitlist-controlled trial

Effectiveness of providing university students with a mindfulness-based intervention to increase resilience to stress: 1-year follow-up of a pragmatic randomised controlled trial

The impact of isolation measures due to COVID-19 on energy intake and physical activity levels in Australian university students. medRxiv

The Impact of Isolation Measures Due to COVID-19 on Energy Intake and Physical Activity Levels in Australian University Students

The short-form version of the Depression Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large nonclinical sample

The Impact of a Randomized Sleep Education Intervention for College Students

A Comparison of Formal and Informal Mindfulness Programs for Stress Reduction in University Students

Stress and anxiety among university students in France during Covid-19 mandatory confinement

Changes in Diet, Sleep, and Physical Activity Are Associated With Differences in Negative Mood During

The association between habitual diet quality and the common mental disorders in communitydwelling adults: the Hordaland Health study

Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication

Patterns of multiple health risk-behaviours in university students and their association with mental health: application of latent class analysis. [Profils de multiples comportements à risque pour la santé des étudiants universitaires et leurs liens avec la santé mentale : utilisation de l'analyse des classes latentes]. Health promotion and chronic disease prevention in Canada : research, policy and practice

Prevalence and socio-demographic correlates of psychological distress among students at an Australian university

The convergent, discriminant, and nomological validity of the Depression Anxiety Stress Scales-21 (DASS-21)

Mental health and academic attitudes and expectations in university populations: results from the healthy minds study

Impact of COVID-19 Pandemic on University Students' Physical Activity Levels: An Early Systematic Review

Impact of COVID-19 Pandemic on University Students

Mindfulness-Based Coping With University Life: A Randomized Wait-List Controlled Study

Minutes, MET minutes, and METs: unpacking socioeconomic gradients in physical activity in adolescents

Impact of COVID-19 lockdown on sleep quality in university students and administration staff

Students' mental health problems before, during, and after COVID-19 lockdown in Italy

Investigating Unique Contributions of Dispositional Mindfulness Facets to Depression, Anxiety, and Stress in General and Student Populations

Mental health in lifestyle medicine: A call to action

Changes in Physical Activity and Sedentary Behavior in Response to COVID-19 and Their Associations with Mental Health in 3052 US Adults

Sleep and Mental Health in Undergraduate Students with Generally Healthy Sleep Habits

Active Students Are Healthier and Happier Than Their Inactive Peers: The Results of a Large Representative Cross-Sectional Study of University Students in Ireland

Mindfulness-based mobile app reduces anxiety and increases self-compassion in healthcare students: A randomised controlled trial

Psychological Symptoms During the Two Stages of Lockdown in Response to the COVID-19 Outbreak: An Investigation in a Sample of Citizens in Northern Spain

The impact of stress on students in secondary school and higher education

University students' changes in mental health status and determinants of behavior during the COVID-19 lockdown in Greece

Starting the conversation performance of a brief dietary assessment and intervention tool for health professionals

Associations between fruit and vegetable consumption and psychological distress: results from a population-based study

Does Physical Activity Matter for the Mental Health of University Students during the COVID-19 Pandemic?

Physical Activity and Sedentary Lifestyle in University Students: Changes during Confinement Due to the COVID-19 Pandemic

Physical activity interventions for people with mental illness: a systematic review and metaanalysis

Multiple Imputation after 18+ Years

Complementary Medicine, Exercise, Meditation, Diet, and Lifestyle Modification for Anxiety Disorders: A Review of Current Evidence. Evidence-Based Complementary and Alternative Medicine

Lifestyle medicine for depression

Lifestyle medicine for depression

A brief mindfulness intervention reduces depression, increases nonjudgment, and speeds processing of emotional and neutral stimuli

Mental health and movement behaviour during the COVID-19 pandemic in UK university students: Prospective cohort study

Improving sleep quality leads to better mental health: A meta-analysis of randomised controlled trials

Efficacy of digital cognitive behavioural therapy for insomnia: a meta-analysis of randomised controlled trials

Effects of COVID-19 on College Students' Mental Health in the United States: Interview Survey Study

Effectiveness of online mindfulness-based interventions in improving mental health: A review and metaanalysis of randomised controlled trials

Psychological distress in university students: A comparison with general population data

Psychological Impact of COVID-19 and Lockdown among University Students in Malaysia: Implications and Policy Recommendations

Significance Tests and Estimates for R2 for Multiple Regression in Multiply Imputed Datasets: A Cautionary Note on Earlier Findings, and Alternative Solutions

Standardized Regression Coefficients and Newly Proposed Estimators for $${R}^{{2}}$$R2 in Multiply Imputed Data

Measuring mindfulness-the Freiburg Mindfulness Inventory (FMI)

A chain mediation model on COVID-19 symptoms and mental health outcomes in Americans

Are Psychological Distress and Resilience Associated with Dietary Intake Among Australian University Students?

Domain-Specific Physical Activity and Mental Health: A Meta-analysis

Australia: Timeline of key social & economic COVID-19 events affecting Australian business

Impact of COVID-19 pandemic on mental health in the general population: A systematic review

Examining the Dimensionality, Reliability, and Invariance of the Depression, Anxiety, and Stress Scale-21 (DASS-21) Across Eight Countries

Addressing collegiate mental health amid COVID-19 pandemic