The Journal of School Nursing
2021, Vol. 37(4) 241-248
© The Author(s) 2021
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DOI: 10.1177/1059840520988548
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This study aimed to examine the prevalence and predictors of depression and anxiety among senior high school students in Jordan during the COVID-19 pandemic. The study used an anonymous online survey that targeted senior high school students in Jordan. Almost two thirds of students reported depressive symptoms and anxiety. Father’s level of education, mothers’ level of education, perceived difficulties in online education, gender, and age were significant predictors of depression, while father’s level of education, difficulties in online education, gender, and age were significant predictors of anxiety (p < .05). Among those identified as having depression, 30.7% were male and 50.7% were female. The prevalence of anxiety among students was high, and the prevalence of anxiety in females (46.9%) is greater than males (27.6%). School health nurses and mental health counselors at schools need to emphasize the mental health and psychosocial support needs for senior high school students.
anxiety, depression, COVID-19, high school students, home quarantine, online education, school nurses
High school students are increasingly vulnerable to social and psychological disturbances, due to developmental and academic requirements (Alfoukha et al., 2019). The pandemic of COVID-19 has forced senior high school students in many countries around the world to stay home and adhere completely to online education, including in Jordan. Recent studies showed that home quarantine is affecting physical and psychological health of young people (Al-Rabiaah et al., 2020). For example, college students during COVID-19 outbreak suffered post-traumatic stress disorder, anger, fear, sadness, nervousness, and emotional disturbances (Brooks et al., 2020; Cao et al., 2020). This has the potential of jeopardizing the psychological well-being of senior high school students who are preparing for their final year at high school and required to sit for high school exams that determine their university enrollment. COVID-19 has forced public health authorities to call on governments to implement strict social and public health procedures including quarantine and curfew (Abuhammad et al., 2020). Such procedures contributed to increased worry among the general population across all age groups (Abuhammad, 2020; Kim, 2020).
High school students are among those groups who lack coping skills to manage challenges posed by the pandemic. Adolescents are still maturing and therefore lack the psychological and social skills to manage overwhelming situations (Crone & Dahl, 2012). Adolescence is considered a stage of life when individuals are vulnerable to accelerated developmental changes that affect both their psychological and social health (American Psychiatric Association [APA], 2013; WHO, 2017). Hence, adolescents could be more substantially influenced by emotional responses due to the outbreak of COVID-19 and its associated quarantine and public health restrictions (Fegert et al., 2020).
In Jordan, the COVID-19 pandemic resulted in the activation of strict public measures to prevent the spread of the disease. Moreover, nationwide regulations on quarantine resulted in the closing of schools, which has made it more difficult and largely impractical for students to attend classes regularly and to perform their day-to-day routines, particularly for those who lack the facilities and the internet access to manage their educational needs. This supports Cao and colleagues’ (2020) findings that online education among high school students has increased the level of stress and pressure among students and increased their vulnerability to psychological problems. High school students experienced anxiety during the COVID-19 pandemic and consequently, reported poor quality of life and academic difficulties (Liang et al., 2020). In a recent study (Hamdan-Mansour et al., 2020), high school students reported serious mental health problems such as substance use and lack of social support. In another study (AlAzzam et al., 2020), the results indicated that both anxiety and depression are prevalent among adolescents and are associated with higher risks of suicide and disease prevalence. Such situations prior to the pandemic of COVID-19 were considered serious, exacerbating the psychosocial consequences of the pandemic. Suggesting that the mental health of senior high school students is compromised. Moreover, in some parts of the world, similar to Jordan, online and distance teaching is not yet well established, and trouble with online access and lowered academic performance are still observed. Despite teachers’ best efforts, students still experience increased levels of distress due to uncertainties, inability to use online platforms appropriately, and inability to comply with the requirements of online learning (Agha, 2020).
The literature indicated that changes to current lifestyle and students’ perceived danger of acquiring COVID may increase the risk of developing depression and anxiety (WHO, 2020; Xiang et al., 2020). Such problems, if left unaddressed by proper psychological interventions during adolescence, often persist into adulthood and elevate the risk of experiencing further mental health problems and disorders (APA, 2013). School mental health professionals including school nurses need to be aware of the additional psychological and social support needs of high school students during the pandemic. Moreover, school nurses are in a special position to play an important role in supporting emotional well-being, screening for mental well-being and early intervention programs, and helping to monitor the continued treatment of mental health (AlAzzam et al., 2017; Pryjmachuk et al., 2011). The Centers for Disease Control and Prevention (CDC, 2014) reported that schools are one of the most significant networks for connecting children and young people with health services and activities.
This study will enlighten public health policy makers toward integration of mental health and psychosocial support and well-being materials as part of online education (Abuhammad, 2020). Although the topic has been considered a research concern, the impact of depression and anxiety and factors contributing to these problems have not adequately addressed. In Jordan, senior high school students (12th-grade students) compete in one national exam that determines their eligibility for university enrollment. This situation increases the pressure on Jordanian senior high school students. The purpose of the current study is to explore the prevalence of depression and anxiety, as well as the sociodemographic and personal predictors of depression and anxiety among senior high school students in Jordan during the COVID-19 pandemic. The objectives of the study were to:
A cross-sectional descriptive-correlational design was utilized. The study used an anonymous online survey targeting senior high school students in Jordan.
The study population consisted of 12th-grade high school students living in the country of Jordan during the COVID-19 pandemic. Jordan is a developing country that is located in the Middle Eastern area in Asia continent. Almost 9.5 million individuals from all ages live in Jordan with more than 98% of Arab origin (Nasir & Al-Qutob, 2005). Almost 35% of the Jordanian population are children aged less than 14 years old, with less than 5% aged more than 60 years old. The governorates of Jordan are divided among the north region, central region, and the south region. These governorates are based on geographical connectivity, with most services located at the central and north regions.
A convenience sampling technique was used to recruit the students. The inclusion criteria were (1) senior high school student, (2) able to read and write in Arabic, (3) able to use software program to fill out survey questionnaire, and (4) access to social media.
After obtaining ethical approval from Al al-Bayt University, a campaign approach using a combination of online social media and web-based survey software was implemented to advertise the survey, recruit survey participants, and collect data for the study. The researchers used different methods to recruit the participants, including personal messages and postings in senior high school students’ sites and social media. The survey information was provided to the students by the research assistants via social media, according to the preference of the students. An online consent form was attached to the survey questionnaire, and the students were requested to read and sign it before completing the survey. The consent form notified the participating senior high school students that their participation was voluntary and that their responses might contribute to an increase in the understanding of the use of online teaching methods. Furthermore, they were assured that their identifiable health information would be protected due to the strict privacy and confidentiality procedures employed by the research study including assigning anonymous number for each participant. The research team did not ask for any identifiable information from the participants such as names. After signing the consent form, the students filled in the questionnaire online. On average, participants reported that it took approximately 8 min to complete the survey. Data were saved to passwordsecured computer. Those who reported severe symptoms or who inquire more information were advised and provided with referral information for specialists.
Data were collected using Arabic version of self-report questionnaires. The instrument included the following sections:
The data were analyzed utilizing the Statistical Package for the Social Sciences (IBM-SPSS Version 25). Descriptive analyses of the data were carried out to determine the means, standard deviation (SDs), frequencies, and percentages of the responses. In addition, standardized multiple regressions were carried out to determine the sociodemographic and personal predictors of depression and anxiety among senior high school students. Alpha was set to .05.
A total of 384 senior high school students who met the eligibility criteria completed and returned the survey. The analysis (see Table 1) showed that the mean age of the students was 17.59 (SD = 0.5) years. Most of the students (60.2%) were females and 39.8% were males. Just over half of the students (55.73%) were from governorates in the north of the country, while 39.84% and 4.43% were from governorates in the middle and south of the country, respectively. Nearly two thirds of the students (60.4%) were categorized as having middle socioeconomic status.
Depression. The analysis (see Table 2) showed that the mean score for depression for students was 11.2 (SD = 7.0) and scores ranged from 0.0 to 27. Those who scored 5.0 or above (mild to severe depression) represented 72.4% (n = 278), with 14.6% (n = 56) of the students found to be severely depressed and 16.9% (n = 65) suffering moderately severe depression.
The analysis also showed a significant difference between males and females in mean score of depression (t = 4.14, p < .001) with mean of depression score for females (M = 12.4, SD = 7.0) much higher than males (M = 9.4, SD = 6.3). Moreover, and although 3.0% of adolescent are working, the mean depression score was much less (M = 5.3, SD = 4.4) among working students than among nonworking adolescents (M = 11.4, SD = 7.0) with significance difference between the two groups (t = 2.90, p = .004). There was no significant difference in depression in relation to type of schools (private vs. governmental; p > .05). Regarding difference in depression and anxiety related to mothers’ and fathers’ level of education, the analysis, using analysis of variance (ANOVA), showed that there was a significant difference in depression related to fathers’ level of education in depression F(3, 383) = 7.57, p < .001 and anxiety F(3, 383) = 8.1, p < .001. The post hoc comparison (Scheffe) showed that differences in depression observed between adolescents whose fathers completed their postgraduate level and all others, and in anxiety between those who completed postgraduate studies and those who completed elementary and high school level only.
Anxiety. Regarding students’ anxiety, the analysis (see Table 2) showed that the mean score of anxiety was 7.1 (SD = 5.9), with score ranging from 0.0 to 21.0. Students with mild to severe level of depression were 74.9% (n = 288), while 16.7% (n = 64) reported having severe anxiety and 58.1% (n = 224) reported mild to moderate level of anxiety.
Regarding differences in anxiety scores, male and female adolescents were also significantly different in their anxiety mean score (t = 4.0, p < .001) with mean score of anxiety of females (M = 10.1, SD = 6.2) higher than male adolescents (M = 7.6, SD = 5.2). The analysis showed that the mean anxiety score was much less among working adolescents (M = 4.2, SD = 3.7) than nonworking adolescents (M = 9.2, SD = 5.9) with significant difference between the two groups (t = 2.81, p = .005). There was no significant difference in anxiety between adolescents in private and governmental schools (p > .05). Regarding mothers’ level of education, the analysis, using ANOVA, showed that there was no significant difference in anxiety related to mothers’ level of education in depression F(3, 383) = 2.3, p = .085 and anxiety F(3, 383) = 2.1, p = .098.
The multiple standardized regression analysis (see Table 3) showed that a family history of psychiatric illness, type of school (private or government), age, working status, father’s working status, gender, GPA, experiencing difficulties with online education, number of family members, father’s level of education, and mother’s level of education were significant F(11, 384) = 7.23, p ≤ .001. The model could explain 18% (R2 = 17.8) of the variation in depression scores among the students. The model showed that gender, age, difficulties with online education, father’s level of education, and mother’s level of education were significant predictors of depression. Fathers’ level of education was identified as a protective factor, while being female, older, mothers’ higher level of education, and having difficulties in online education were associated with higher scores of depression.
The multiple standardized regression analysis (see Table 4) showed a family history of psychiatric illness, type of school, age, working status, father’s working status, gender, GPA, having difficulties in online education, number of family members, father’s level of education, and mother’s level of education were significant F(11, 384) = 5.94, p ≤ .001. The model could explain 15% (R2 = 15.1) of the variation in anxiety scores among the students. The model showed that gender, age, having difficulties in online education, and father’s level of education were the significant predictors of anxiety and depression. Fathers’ level of education was identified as a protective factor, while being female, older, and having difficulties with online education were associated positively with higher anxiety.
Depression and anxiety are serious mental health problems that contribute to psychosocial and academic dysfunction (Alfoukha et al., 2019). This study clarifies the significant contribution of the COVID-19 pandemic on adolescents’ mental health. In general, the findings of this study indicate that senior high school students experienced depression and anxiety that is impacted by their parent’s level of education and problems with online education. In addition, female students and older students were found to suffer depression and anxiety at higher levels than males and younger students. The results identified the role of parents, challenges with online education and gender as significant indicators of depression and anxiety. This study contributes to the understanding of adolescents’ mental health problems and related factors during the pandemic. Previous reports (Cao et al., 2020) indicated that high school students constitute one of the most vulnerable populations at risk for anxiety and depression during the COVID-19 outbreak due to the closure of school, social restrictions, and curfew. One explanation could be students’ limited coping and psychosocial skills needed to manage the overwhelming psychological, social, and academic demands (Alfoukha et al., 2019; Cao et al., 2020). The results of this study are in line with findings from other studies showing that high school students, in general, are suffering psychological and mental health disturbances (Alharbi et al., 2019; Brooks et al., 2020), and at higher risk for serious mental health problems if not addressed appropriately (Alfoukha et al., 2019; Alharbi et al., 2019; Cao et al., 2020). These findings support the international guidelines on the need for school mental health services and the integration of psychosocial support and mental health promotion intervention among public health policies during the pandemic of COVID-19 (WHO, 2020).
Inconsistent with our findings regarding predictors of depression and anxiety, Hakamy and his colleagues (2017), a study of Saudi students reported that demographics characteristic especially place of residence, parents’ educational background and parent’s marital status are significant correlates for anxiety and depression among high school students. One explanation could be that in Jordan, students go to university based on the results of their one national exam in 12th grade. This may psychologically burden families and students. In addition, and during the pandemic of COVID-19, students and their families suffered economic, social, and psychological hardships that compromise their ability to manage their biopsychosocial needs, many findings observed in other studies of university students with similar public health restrictions and online education challenges (Shehadeh et al., 2020).
In this study, we have found that female adolescents reported higher scores in depression and anxiety than male adolescents with significant differences. Although adolescents are ignored in Jordan in terms of mental health care and underresearched, the results infer that female school adolescents do support the theme that females are under strict and close family observation that might affect their willingness to express their mental health concerns (Alfoukha et al., 2019; Arabiat et al., 2018; Hamdan-Mansour et al., 2007). The social and family restrictions and obligation of females even during their adolescence phase might explain the higher score of depression and anxiety. In recent studies, fewer females have been reported to mental health agencies seeking treatment from mental and substance use disorders compared to males, confirming the greater social pressure and stigmatization of mental health treatment for females (Al-Khawaldeh et al., 2020). One notable finding was that fathers’ education was a significant factor in which adolescents of fathers with lower educational level scored much higher depression and anxiety than those with fathers with higher levels of education, supporting previous reports (Hakamy et al., 2017). This infers that fathers’ level of education might contribute to the development of psychological disturbances of their children assuming lacking appropriate information on managing their children’s psychological problems. The COVID-19 outbreak, social restrictions, home quarantines, and curfew require that parents should be knowledgeable on how to manage children’s psychological needs in which fathers with lower level of education might have less access to information.
Limitation of this study includes measurement of depression and anxiety using a self-report clinical interview format. Another limitation is related to using a cross-sectional approach in which depression and anxiety are measured at one point of time, limiting analysis of the long-term consequences of depression and anxiety on wellness of high school students. Moreover, using the online survey may limit which students may have responded as many students might not have an online access and did not have the ability to participate. Also, the response rate from the south region of the country was low comparing to other regions, and this might impact the study outcomes.
This study found that Jordanian senior high school students are suffering depression and anxiety and that their social characteristics and online educational difficulties are significant predictors of depression and anxiety. The study confirms that online education is a source of mental health problems for high school students, which needs further investigation. The study has implications for school health professionals, school nurses, and mental health counselors. Integration of psychosocial and mental health intervention should be considered as part of the online education programs. Teachers and instructors need to allocate time for mental health support to relieve students’ concerns and worries to mitigate depression and anxiety. Mental health school nurses and counselors need to develop interventional online packages to support high school students in managing stress, anxiety, and depression related to home quarantine and academic online education demands. More attention should be given to female adolescents with mental health disorders. Further qualitative studies are needed to enhance our understanding of how high school students are adjusting and managing their psychological needs during pandemic and online education difficulties. In addition, interventional studies are needed to test the effectiveness of telemental health and psychosocial support on high school students during home quarantine and intensive online education.
The authors thank all students who participated in the current study.
All authors participated in all steps of this project until the last edit was sent to the journal.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Predictors of Depression and Anxiety among Senior High School Students during COVID-19 Pandemic: The Context of Home Quarantine and Online Education.
Manar AlAzzam, RN, MSN, PhD, CNS https://orcid.org/0000-0002-3997-3913
Sawsan Abuhammad, PhD, RN https://orcid.org/0000-0001-5817-8950
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Manar AlAzzam, RN, MSN, PhD, CNS, is an acting dean of nursing and associate professor in psychiatric mental health at Princess Salma Faculty of Nursing, Al-Albayt University, Jordan.
Sawsan Abuhammad, PhD, RN, is an assistant professor in maternal and child health, faculty of nursing, WHO Collaborating Center, Jordan University of Science and Technology, Jordan.
Asem Abdalrahim, PhD, RN, is an assistant professor in psychiatric mental health at Princess Salma Faculty of Nursing, Al-Albayt University, Jordan.
Ayman M. Hamdan-Mansour, PhD, is a professor in psychiatric nursing, School of Nursing, The University of Jordan, Jordan.
1 Psychiatric Mental Health, Princess Salma Faculty of Nursing, Al-Albayt University, Al-Mafraq, Jordan
2 Maternal and Child Health, Faculty of Nursing, WHO Collaborating Center, Jordan University of Science and Technology, Ar-Ramtha, Jordan
3 School of Nursing, The University of Jordan, Amman, Jordan
Corresponding Author:Manar AlAzzam, RN, MSN, PhD, CNS, Psychiatric Mental Health, Princess Salma Faculty of Nursing, Al-Albayt University, Mafraq 25113, Jordan.Email: alazzam@aabu.edu.jo