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OPEN Psychological disturbances

encountered by selected
undergraduates studying
at the University of Ruhuna,
Sri Lanka during the Covid‑19
pandemic: a cross‑sectional study
T. H. M. Kaushani  & E. B. Weeratunga *

University undergraduates are increasingly recognized as a vulnerable population with a higher

level of psychological disturbances. During the Covid-19 pandemic, universities closed all over the
world, resulting in the psychological well-being of this population being severely affected across the
globe. This study examined the prevalence of stress, anxiety, and depressive symptoms encountered
by undergraduates of the selected five faculties at the University of Ruhuna in Southern Sri Lanka
due to the Covid-19 pandemic, its associated factors, and the correlations between stress, anxiety,
and depressive symptoms. An online, cross-sectional, descriptive study was conducted among
undergraduates using pre-tested, self-administered questionnaires from the randomly selected
five faculties: Allied Health Sciences, Engineering, Humanities and Social Sciences, Management
and Finance, and Medicine. Undergraduates were invited to complete the Google Form. Socio-
demographic details and a 21-item Depression, Anxiety, and Stress Scale (21-DASS) were used for
data collection. Stress, anxiety, and depressive symptoms were evaluated using a Sinhala version of
the 21-DASS scale. Ethical permission was granted by the Ethics Review Committee of the Faculty
of Allied Health Sciences, University of Ruhuna. Among the 359 undergraduates, the majority were
represented by females (62.1%). The mean age of the sample was 23.67 years (SD ± 1.6). Stress,
anxiety, and depressive symptoms were found to be prevalent in 53.7%, 41.8%, and 63.8% of
undergraduates respectively. Younger and female undergraduates had more impact on psychological
issues than their counterparts. It revealed a significant positive correlation between anxiety and
depressive symptoms (r = 0.646, p < .001), anxiety and stress (r = 0.868, p < .001), and stress and
anxiety (r = 0.786, p < .001). Most undergraduates experienced considerable levels of stress, anxiety,
and depressive symptoms during the Covid-19 as increasing stress, anxiety, or depressive symptoms,
tend to increase all types of psychological disturbances. The development of mental health among
undergraduates is essential and needs innovative strategies to improve the psychological well-
being of undergraduates. The initiation of a stress management programme and expanded available
counseling services are also important. Further studies are needed to be conducted on the extended
topic of how the Covid-19 era is affecting the psychological well-being of undergraduates from
different universities (state/non-state), locations, and different study departments.

Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) is the cause of Covid-19 which was an extremely
contagious airborne disease from 2019 ­onwards1,2. World Health Organization (WHO) initially declared that this
is a ‘Global Pandemic’ on the 30th of January ­20203, and an increase in confirmed cases and deaths was reported
­ anka4. Due to Covid-19, all people had to practice lifestyle modifications such as wearing a facemask,
in Sri L
washing hands continuously, using sanitizers, maintaining distance, etc.5 At the community level, mitigation

Department of Nursing, Faculty of Allied Health Sciences, University of Ruhuna, Galle, Sri Lanka. *email: eranthiw@
ahs.ruh.ac.lk

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efforts include banning travel, lock-down cities/countries, and travel restrictions to reduce the number of cases
by reducing large g­ atherings6. Many countries employed a range of control measures like restricting daily activi-
ties, community screening, and promotion of safety measures to control the transmission of Covid-19 among
­humans4,7–10.
The closure of universities and education organizations directly affects the education of the student/under-
graduate population in the w ­ orld11–13 such as either postponing or canceling all events, workshops, conferences,
and sports and shifting rapidly to the transition of various courses and programs from face-to-face to online mode
while being confined to hostels or any kind of living p ­ lace13 facing significant challenges such as disruptions of
teaching and learning activities were influenced by the school and university ­sectors14. According to the United
Nations Educational Scientific and Cultural Organization (UNESCO), the education of more than one billion
students in 129 countries in the world has been affected due to Covid-1915.
University undergraduates are identified as a population with weak mental health and reported as a “very
high-risk population” with a higher prevalence of mental illnesses such as depressive symptoms, anxiety, stress,
etc., than the adult population; the psychological health of university undergraduates is considered internation-
ally as an essential public health ­issue2,14,16–20. Stress is defined as “a particular relationship between the person
and the environment that the person considers being taxing or exceeding his or her resources and putting his or
her well-being at risk”21. Stress is not a novel problem for university students; they are a special group of people
who are going through a critical transition period in which they are going from adolescence to adulthood, and
this can be the most stressful time in one’s life. Depression is defined as “a common mental disorder that presents
with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed
sleep or appetite, and poor concentration”22. The past ten years have seen a rise in interest in researching univer-
sity undergraduates’ mental health, with university undergraduates showing a 24–34% incidence of depressive
­symptoms23. Anxiety is a behavioral, physiological, and psychological r­ eaction24.
There were ample research findings that Covid-19 has impacted peoples’ emotions such as healthcare pro-
fessionals, the general public, and patients, etc.25–27. Numerous research has confirmed that the Covid-19 crisis
caused a high prevalence of stress and a moderate prevalence of anxiety and d ­ epression28–32. One study in China
found that 53.8% of respondents had severe to moderate psychological disturbances in female u ­ ndergraduates15.
The private and academic/university lives among undergraduates in Saudi Arabia were affected severely by Covid-
19 and reported the profound psychological impact on university u ­ ndergraduates33,34.
As reported in some studies, human mental health and well-being are influenced by changing environmental
factors such as Covid-192,14. Almost all people must deal with the new normalcy of not only the disease itself
but also the after-effects of the Covid-19 pandemic. Most university undergraduates have faced many challenges
because of numerous unanticipated changes and a new normal, which has increased several psychological dis-
turbances, particularly depression symptoms, anxiety, and stress during the Covid-19 ­pandemic35. Therefore,
undergraduates must cope with their new lifestyle although they are at home and need to continue their ongoing
education. Due to all circumstances, many undergraduates have reported that they have poor mental h ­ ealth36.
Further, variations in daily routine such as lack of outdoor activity, interrupted sleeping patterns and social dis-
tancing have impacted the mental well-being of many u ­ ndergraduates16. In this vulnerable population, mental
health needs to be closely monitored during lockdown ­periods16. Due to such changes, undergraduates had to face
many issues related to technology (e.g., connection and internet problems), new devices (smartphones/laptops,
tab, etc.), and economic h ­ ardships36. Most educational institutes have been changed to remote/distance learning
and online learning; due to such experiences, extra burdens such as low internet quality, no proper access to new
technology, few resources at home, the trouble of managing available technical devices and learning aids when
continuing their studies had impacted on their e­ ducation37.
When compared to the global impact of Covid-19, Sri Lanka started the battle during the first few months
of 2020. According to the emerging situation, the Government of Sri Lanka endorsed lockdown and travel
restrictions as Western countries. In addition, Sri Lanka as a developing country is going through the most ter-
rible economic ­crisis38 which influenced every aspect of the life of people. Therefore, most undergraduates in
government universities live under many socio-economic constraints/hardships usually, and face difficulties in
buying smartphones/devices, and internet facilities to continue their online teaching–learning activities which
was a drastic change in the Sri Lankan education system not perceived ­before18. Sri Lankan state universities
are located across the country and have their university sub-culture on factors such as history, geographical
location, regionalism, university size, residential pattern, and political ­ideology18. Unlike the Western literature,
a few researchers in Sri Lanka have been studying psychological problems and coping strategies encountered
by undergraduates studying in some state and non-state universities. The distance-learning undergraduates at
the Open University of Sri Lanka experienced nearly 51% psychological distress due to the distance mode of
education while having low levels of anxiety and d ­ epression39. Some studies have reported psychological ill-
being among undergraduates due to the combat of Covid-1940. However, there have been no published studies
on psychological disturbances caused by the Covid-19 epidemic in undergraduates studying in the Southern
province of Sri Lanka when compared with the Western province of Sri Lanka. The virulence of the disease
was slightly lower in the Southern province to a certain extent than in the Western province comparatively and
university academics in the Southern province were able to initiate some academic activities (e.g., online/virtual
or physical) before the other universities in Sri Lanka.
The University of Ruhuna (UoR) is situated in the Matara district, Southern province of Sri Lanka. Therefore,
this study aimed to investigate the psychological disturbances encountered by undergraduates of the selected
five faculties at the UoR, Southern Sri Lanka due to the Covid-19 pandemic. This study aimed to examine the
prevalence of anxiety, stress, and depressive symptoms among undergraduates, its associated factors, and cor-
relations of anxiety, stress, and depressive symptoms. The study findings were an overview of undergraduates’
mental health of the UoR which had not been encountered earlier due to the pandemic situations and new

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normalcy. Further, this study would assist in identifying remedial action to reduce or prevent such psychological
imbalances and would help to increase the academic performances and student support services of undergradu-
ates when there are occurrences of future pandemics. The research will be useful for future policymakers to
establish welfare events and psychological support services such as counseling for undergraduates not to suffer
from psychological ill-being.

Material and methods

Study designs, setting, and participants
A descriptive, cross-sectional study design was used to investigate the psychological disturbances (e.g., distress,
anxiety, and depressive symptoms) encountered by undergraduates of the selected five faculties, at the UoR,
Matara, Southern Province in Sri Lanka due to the Covid-19 pandemic. The UoR is the only state university in
the Southern Province and it consists of ten faculties, some of them are located away from the main premises and
are in different study settings like Galle [e.g., Faculty of Allied Health Sciences (FoAHS), Faculty of Engineering
(FoE), and Faculty of Medicine (FoM)] and Matara [e.g., Faculty of Humanities and Social Sciences (FoHSS)
and Faculty of Management and Finance (FoMF)]. The undergraduate population of the university is more than
10,000. This study was conducted from mid-June to August 2022. The study participants were undergraduates
who were in 1st year to 4th year and studied in the -above-mentioned faculties of the UoR.

Sample size and sampling procedure

The sample was calculated by using the following f­ ormula41 (n = ­Z2 P (1 − P)/d2 [n = size of the sample, Z = 1.96,
P = anticipated population proportion, d = absolute precision required for the estimate to fall within given, per-
centage point of the proportion = 5%]. The sample size was calculated using the prevalence of the previous study
(n = 383.62)42. After adding a 10% non-responsive rate, the final sample size was taken as 422; a stratified sampling
procedure was applied (422/5 = 84) and 84 students were randomly selected from each faculty using a random
table and incorporated the name register of the undergraduates. Further, among some students who studied in
the 1st year to 4th year; nearly 21 undergraduates were selected each year to represent whole undergraduates in
the faculty and taken as strata. Undergraduates received an electronic questionnaire via batch representatives
and professional networks. An equal number of students from each faculty were sought for the survey.
Undergraduates who studied in the FoAHS, FoM, FoE, FoHSS, and FoMF, at the University of Ruhuna, could
read and/or understand English or Sinhala, and were in good psychological well-being (i.e., who do not have
psychological disorders or were taking treatments for psychological disorders) were considered as inclusion
criteria and undergraduates who have studied in the other faculties in addition to the above-mentioned faculties
and were unable to read and/or understand Sinhala or English were not recruited. Undergraduates who fulfilled
the above criteria were selected using the above sampling procedure and invited to participate in this survey.

Data collection tool

A self-administered questionnaire was prepared by authors, pre-tested using another ten undergraduates, and
administered as an online survey due to the pandemic situation. This Google Form consisted of two parts; socio-
demographic details (e.g., age, gender, faculty, academic year, and monthly parents’ income) and a 21-item DASS
­scale43. The internal consistencies for each scale of the original DASS scale were: depression 0.91; anxiety 0.84;
stress 0.90; also, supported for convergent and discriminant v­ alidity43. In 2008, good-to-excellent internal con-
sistency was obtained for three sub-scales (depression-0.96, anxiety-0.89, stress-0.93), and satisfactory criterion
validity (r = 0.65)44. Also, in 2012, excellent test–retest reliability was achieved for 21-DASS (r = 0.71–8.81)45.
Sinhalese version of 21-DASS46 had reported satisfactory internal consistencies for depression- 0.83, anxi-
ety-0.76, and stress-0.80. The validity was checked using a Patient Health Questionnaire (PHQ) and DASS anxi-
ety, and obtained a positive correlation for three sub-scales (0.544, 0.473, and 0.333); the DASS stress scale had a
positive correlation with PHQ (0.558). The factor structure of the 21-DASS was similar to the original scale and
proved the confirmatory factor structure too. Every subscale consists of seven items and was used to calculate
levels of depression (items 3, 5, 10, 13, 16, 17 and 21), anxiety (items 2, 4, 7, 9, 15, 19 and 20), and stress (items
1, 6, 8, 11, 12, 14 and 18). Every question of DASS-21 has four responses 0 to 3. The responses were; 0—didn’t
apply to me at all, 1—applied to me to some degree or occasionally, 2—applied to me at a considerable level or
frequently, and 3—applied to me a lot or frequently. The validated DASS-21 was used to examine depressive
symptoms, anxiety, and stress., and the scoring method is presented in Table 1.

Severity levels Stress Anxiety Depression

Normal 0–10 0–6 0–9
Mild 11–18 7–9 10–12
Moderate 19–26 10–14 13–20
Severe 27–34 15–19 21–27
Extremely severe 35–42 20–42 28–42

Table 1.  Scoring method of stress, anxiety, and depression levels.

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Data collection procedure

Prior permission was obtained from the Vice Chancellor of the University of Ruhuna and the Deans of all facul-
ties. Further, the respective e-mail addresses of undergraduates were received from assistant registrars of all facul-
ties and invited to the selected undergraduates via an e-link. Socio-demographic details and answers of 21-DASS
were collected using a web-based, self-administered questionnaire (Google Form); their voluntary consent was
obtained after providing adequate facts via an information sheet (e.g., purpose, responsibilities of participants,
potential benefits and risks to the participant, confidentiality and anonymity of data collection, and procedure
and period of data storage). After reading the information sheet, a voluntary informed consent form appeared;
once given the consent using an electronic format, undergraduates were able to answer e-questionnaires. The
medium of the questionnaire was English or Sinhala and they had an opportunity to select the best choice of
language. After filling in all questions, they had to submit a Google Form to the given e-mail of the first author.
To ensure the privacy and accuracy of the data, an anonymous questionnaire was used for the survey, and data
accessibility was in the custody of the authors.

Data quality assurance

All probable interventions were taken to increase the quality of data during the whole process. The question-
naire was pre-tested as mentioned earlier before starting the data collection and then any necessary improve-
ments were made. The purpose of the study and the nature of the study were informed to all participants via an
e-information sheet. Participants had the right not to respond to the questionnaire and leave at any time without
providing any clarifications. As only the principal investigator had the authority about data and data collection
was only done by the principal investigator, confidentiality was ensured. Every undergraduate was identified
using a code/serial number to protect their privacy and anonymity, their rights were respected, and confidential-
ity of information was strictly maintained. Before analysis, data were checked for consistency. Answers from the
participants were accessible only to investigators, and confidentiality was protected using passwords employed
to control the quality of data.

Data analysis
Statistical Package for Social Science (SPSS) software was used to analyze data. Socio-demographic data were
examined using descriptive analysis such as frequency and percentage, which can be summarized by using a
graph/chart. According to the recommended cut-off values, the depressive symptoms, anxiety, and stress were
divided into five categories: normal, mild, moderate, severe, and extremely s­ evere43. Categorical variables were
tabulated using the Chi-square test and association was checked using the Pearson correlation coefficient. All
results were regarded as statically significant at p < 0.05.

Ethical clearance
Ethical approval was obtained from the Ethics Review Committee of the Faculty of Allied Health Science, Uni-
versity of Ruhuna, Sri Lanka (Ref, no: 61.11.2021). All research procedures were carried out corresponding to
the relevant guidelines and regulations by the Declaration of Helsinki. Necessary approvals were obtained from
the authorities of the selected five faculties and the University of Ruhuna. Participants were invited using the
Google Form and by an e-link due to the status of the country according to the health guidelines. Identification/
serial numbers were given to maintain the anonymity and confidentiality of each undergraduate and therefore
all responses were anonymous. Only the investigator had accessed the participant’s information. Voluntary par-
ticipation was highly expected and written informed consent was undertaken from the study participants before
the data collection. The rights of participants were respected, and the privacy, and confidentiality of information
were strictly maintained while not taking identifying information.

Results
Socio‑demographic details of the participants
Although 389 students agreed to participate, 359 students were included in the final analyses. Table 2 demon-
strates the socio-demographic characteristics of the undergraduates. The mean (SD) age was 23.67 years (standard
deviation (SD = 1.619)), and the majority were female undergraduates (62.1%).
The major ethnic and religious group was Sinhalese-Buddhist (data not shown). From the sample, an approxi-
mately equal proportion of undergraduates (1st–4th year) was represented. The majority of participants (income
of parents of undergraduates) (n = 90; 25%) earned between LKR. 40,000 and LKR. 59,999 per month and 18.7%
of participants had a lower income than LKR. 20,000.00.

Prevalence of stress, anxiety, and depressive symptoms

Stress among undergraduates
Different levels of stress are exhibited in Fig. 1. Of the sample, many respondents (n = 168; 47%) showed a normal
level of stress, followed by mild stress (n = 85; 24%), moderate stress (n = 63; 18%), severe stress (n = 41; 11%),
and extremely severe stress (n = 1; 0%).

Anxiety among undergraduates

As shown in Fig. 2, most undergraduates had a normal level of anxiety (n = 206; 58%) while only 15% of respond-
ents (n = 53) reported extremely severe symptoms and 17% of undergraduates (n = 59) had a moderate level of
anxiety.

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Demographic variables n %
Gender
Female 223 62.1
Male 136 37.9
Name of the Faculty
FoAHS 102 28.4
FoE 76 21.2
FoHSS 62 17.3
FoMF 61 17
FoM 58 16.2
Academic year
1st year 96 26.7
2nd year 88 24.5
3rd year 84 23.4
4th year 91 25.4
Monthly income of parents (LKR)
Below 20,000/= 67 18.7
Between 20,000/= − 39.999/= 69 19.2
Between 40,000/= − 59,999/= 90 25.1
Between 60,000/= − 79,999/= 60 16.7
Between 80,000/= − 99,999/= 27 7.6
Above 100,000/= 46 12.8

Table 2.  Demographic characteristics of the undergraduates (N = 359). Frequency (n); percentage (%); LKR—
Sri Lankan Rupees. Higher values are in [bold].

Figure 1.  Stress distribution among undergraduates (n = 358).

Normal

15% Mild
4%
Moderate
17% 58%
6% Severe

Extremely severe

Figure 2.  Anxiety distribution among undergraduates (n = 354).

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Depressive symptoms among undergraduates

Overall, it was discovered that 37% (n = 131) of the subjects had increased (moderate to severe) depressive
symptoms as presented in Fig. 3. From the sample, 12% of undergraduates (n = 41) had extremely severe levels
of depressive symptoms while 36% (n = 128) were at a normal level.

Factors associated with stress, anxiety, and depressive symptoms

In Table 3, associations between socio-demographic variables and different levels of psychological disturbances
are exhibited. Undergraduates who were between the ages of 23 and 24 had significantly severe stress (p < 0.001).

Normal

Mild
12%
36%
17%
Moderate
20% 15%
Severe

Extremely severe

Figure 3.  Depressive symptoms distribution among undergraduates (n = 354).

Categories/levels
Stress Anxiety Depressive symptoms
Mean (SD) 13.05 (9.68) 8.15 (8.74) 14.38 (9.63)
Depressive symptoms
Stress (n = 358) Anxiety (n = 354) (n = 354)
Variables N M Mo S ES N M Mo S ES N M Mo S ES
Age (y)
≤ 22 49 24 12 5 0 60 6 19 0 5 43 11 15 15 5
23 35 33 14 19 0 50 10 13 1 22 25 14 21 25 21
24 40 9 5 14 0 38 3 6 12 9 27 12 16 4 9
≥ 25 54 19 32 3 1 58 4 21 12 17 32 17 20 25 6
p value 0.000** 0.000** 0.000**
Gender
Female 92 58 46 26 1 127 20 25 9 37 68 33 41 43 33
Male 76 27 17 15 0 79 3 34 4 16 60 21 31 16 8
p value 0.06 0.002** 0.008**
Faculty
FoAHS 57 16 23 4 1 57 16 23 4 1 41 21 17 17 6
FoE 40 16 8 12 0 40 16 8 12 0 32 10 24 1 9
FoHSS 18 19 9 16 0 18 19 9 16 0 18 5 9 8 17
FoMF 24 21 13 3 0 24 21 13 3 0 14 11 16 17 3
FoM 29 13 10 6 0 29 13 10 6 0 23 7 6 16 6
p value 0.000** 0.036* 0.000**
Academic Year
1st year 56 16 11 13 0 56 16 11 13 0 45 17 16 5 11
2nd year 44 22 13 9 0 44 22 13 9 0 34 11 18 19 6
3rd year 33 19 20 10 1 33 19 20 10 1 21 13 16 21 10
4th year 35 28 19 9 0 35 28 19 9 0 28 13 22 14 14
p value 0.233 0.331 0.044*

Table 3.  Correlations between socio-demographic variables and levels of stress, anxiety, and depressive
symptoms. Categories; N-Normal; M-Mild; Mo-Moderate; S-Severe; ES- Extremely severe. FoAHS-Faculty of
Allied Health Sciences, FoE-Faculty of Education, FoHSS-Faculty of Humanities and Social Sciences, FoMF-
Faculty of Management and Finance, FoM-Faculty of Medicine. **The 0.01 level of significance for correlation
(2-tailed) and *0.05 level of significance for correlation (1-tailed). Higher values in S and ES categories are in
[bold].

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Considering the stress levels and faculties, FoHSS had a significantly higher number of participants with severe
stress compared to other faculties (p < 0.001). However, gender (p = 0.06) and academic year (p = 0.233) did not
show any significant association with stress levels.
Like stress levels, undergraduates who were aged 23, 24, and ≥ 25 years had a significant level of severe and
extremely severe anxiety during the Covid-19 period (p < 0.001) (Table 3). Female undergraduates had a signifi-
cantly severe and extremely severe level of anxiety than male undergraduates (p < 0.001). As for stress level, many
undergraduates of FoHSS showed a significantly more severe anxiety level (p < 0.05) than other faculty under-
graduates. Many undergraduates studied in the first year reported more severe anxiety than other academic years.
Additionally, it was shown that 23 and ≥ 25 years of age undergraduates have significantly reported more severe
and extremely severe depressive symptoms (p < 0.001) than other age groups (Table 3). More female undergradu-
ates showed significantly severe and extremely severe levels of depressive symptoms than male undergraduates
(p < 0.001). Also, undergraduates in FoAHS, FoHSS, and FoMF have reported significant severe and extremely
severe levels of depressive symptoms (p < 0.001). Participants who were in the 3rd and 4th academic year showed
a significant level of depressive symptoms (severe and extremely severe) than their counterparts (p < 0.05).
As reported, positive and significant correlations were found among each other psychological disturbances;
stress and anxiety (r = 0.786; p < 0.001), stress and depression (r = 0.868; p < 0.001), and anxiety and depression
(r = 0.646; p < 0.001); increasing stress, anxiety, and depression caused to increase in all reported psychological
illnesses again.

Discussion
Prevalence of stress, anxiety, and depressive symptoms
This research examined the prevalence of stress, anxiety, and depressive symptoms experienced among university
undergraduates at the selected faculties of the UoR, Sri Lanka, during the Covid-19 pandemic, its associated
factors, and the correlations of those psychological disturbances. The prevalence of stress, anxiety, and depressive
symptoms was 53%, 42%, and 64%, respectively in this study. Therefore, a higher percentage of undergraduates
encountered stress, anxiety, and depressive symptoms in the current study.
The Covid-19 pandemic has significantly affected different types of university undergraduates worldwide,
making them more susceptible to the emergence of several mental diseases like stress, anxiety, depression, etc.,
which are in line with some studies that reported higher ­prevalence33,34,47–50 and slightly lower ­prevalence1,2,29,51–53.
Covid-19 and the lock-down caused different types of psychological problems among the Chinese p ­ opulation10;
Arabian, Chinese, and Polish researchers found that undergraduates displayed mild to moderate anxiety symp-
toms (1–22%) but very low levels of severe anxiety symptoms (0–1%)29,31,51,52,54 compared to the current find-
ings. According to another study from Malaysia, respondents suffered from mild to moderate anxiety levels
(6%-20%) and 2.8% had severe anxiety l­ evels15 but lower than the anxiety levels in the current study. However,
some undergraduates had higher levels of anxiety (50–60%)48,50, and 18.1% of severe levels of anxiety in line
with the current fi­ ndings50.
In India, levels of anxiety and stress were higher during the Covid-19 pandemic than b­ efore55; 269 Indian
medical undergraduates were evaluated for levels of anxiety and stress and reported 21.2% anxiety and 20.7%
stress which was lower than this study fi ­ ndings55. A higher level of stress was found among Jordan undergradu-
ates which was around 60% during the home-quarantine period and reported mild (15.5%), moderate (19.6%),
severe (13.6%), extremely severe (10.0%) levels of ­stress49 and around 56% of stress was reported among Polish
­undergraduates54. Some undergraduates in the United States of America perceived an increased level of study‐
related stress (e.g., due to related campus closure and shift to virtual classes) after the outbreak of the Covid‐19
­pandemic35. A lower level of stress was found among undergraduates in France than among non-students who
scored 33.1%16.
Depressive symptoms are a very common and widespread problem among undergraduates. In response to
this stress, some undergraduates become d ­ epressed19. The past ten years have seen a rise in interest in research-
ing undergraduates’ mental health; a 24–34% incidence of depressive symptoms was reported in the very early
­period23. Another study conducted in one of the large universities in Saudi Arabia during 2012–2013, reported
prevalence of depressive symptoms was 46% before the p ­ andemic56 and was not much different from the cur-
rent depression levels although studies were done with or without Covid-19. However, above 80% of depres-
sive symptoms were evidenced in the Bangladesh u ­ ndergraduates50 than the current findings and 78.7% had
depressive symptoms in the Jordan s­ tudy49. Severe levels of depression symptoms were in the range of 10–12%50.
Not only the higher values, a considerable level of depressive symptoms was found among France and Arabic
undergraduates (32% and 49%) due to Covid-1916,33 and lower depressive symptoms (10–20%)31,52. In 2020,
61.4% of undergraduates in Jordan (N = 1165) were diagnosed with moderate-to-severe d ­ epression57 and this was
consistent with the current findings. As mentioned by Saraswathi et al.55 depressive symptoms had not changed
during the pandemic whereas anxiety and stress increased due to the pandemic. Wang et al.52 also reported 12.2%
of depressive symptoms which was very lower than the current depressive symptom levels. Among studied 3044
undergraduates in Saudi Arabia, 47.7% of individuals reported having severe depressive s­ ymptoms34.
Similar impacts were stated in Sri Lanka as well. Therefore, it is necessary to effectively report the psycho-
logical disturbances of Sri Lankan undergraduates due to Covid-19—how it could affect their academic perfor-
mances; how this type of unexpected circumstances affect the very gentle personalities the young population
have; and how their normal education which is not normal to them as previous is impacted. However, studies
related to other undergraduates are s­ carce40,58–60 compared to the studies done among medical undergraduates
in Sri ­Lanka12,61–64. Several research findings about the prevalence of psychological issues and factors associated
with the Covid-19 disease among undergraduates in Sri Lanka were r­ eported7,40,58,59,62,63. It was evidenced by a

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study conducted among children, adolescents, and youth in Sri ­Lanka12, that there were significant psychosocial
stressors, and it may tend to develop more psychological morbidity among that population.
In some literature, lower levels of stress and anxiety were found. Covid-19 epidemic had a significant impact
on medical students’ psychological health (25.1%) and (1.6%) of students reported having anxiety and stress levels
that were over the recommended ­levels61. One study done in Sri Lanka in 2020, including Indian and Russian
undergraduates, reported that 3.16% of undergraduates experienced stress and 11.58% of undergraduates had
anxiety due to Covid-19 which was remarkably lower than the current s­ tudy7. Another finding of nursing under-
graduates of KAATSU International University (KIU) reported the prevalence of anxiety and stress as 13% and
3%65 which were also much lower. In the first phase of the Covid-19 epidemic, 22% of students at the Sri Lanka
Institute of Advanced Technological Education (SLIATE) showed mild anxiety, 7% showed significant anxiety,
and just 2% showed severe anxiety. Thirty undergraduates were used in the study by Athukorala and ­Joniton58
which revealed that they were under stress throughout Covid-19. According to the findings of the DASS-21, 3
(10%), 18 (60%), 4 (13%), 3 (10%), and 2 (6%) of the undergraduates displayed signs of normal, mild, moderate,
severe, and extremely severe stress status, r­ espectively58.
Another study of 384 undergraduates of both state and non-state universities/higher educational institutes
reported 41% severe and 36% moderate stress levels due to the pandemic (during the year 2020) similar to the
current ­evidence40 and another study of medical ­students64. It was also found that online learning experience
and university workload affected many undergraduates during the Covid-19, and experienced more challenges
with the information technology capabilities/infrastructure (50%) and increased workload (75%) which was a
novel experience for the new entrants and majority of students who had economic h ­ ardships40. They did not
discuss the influence of any socio-demographic characteristics on stress and found that new challenges and
difficulties in carrying out day-to-day activities affected their stress. Further, they were more distressed about
semester grades and how the class would impact their ­future40 and career opportunities. The start and end dates
of degree programmes and postponements of planned examinations in educational settings may be influenced
by the prevalence of certain stresses due to unexpected delays in educational activities.
According to a study by Galhenage et al.62, 78.2% of medical students were worried and had stress levels
higher than those of working doctors, which was higher than the findings at the time of Covid-19. Distressed
medical students were concerned about their own and their loved ones’ health. Like doctors, those undergradu-
ates believed that stress interfered with their everyday activities and that they had a high risk of getting Covid-19
(63.5%). Additionally, half of the students stated that while learning about Covid-19 was generally beneficial,
it also led to more distress (24%)62. Before the pandemic, Sri Lankan research (N = 327) indicated that 40.4%
of medical undergraduates had serious psychological ­distress46 while a much higher level of distress (78.2%)
occurred due to the Covid 19. Among 527 medical undergraduates, the reported prevalence of anxiety and stress
was 34% and 24.7%63. Possible explanations for these findings include that medical undergraduates being directly
exposed to the clinical settings than other undergraduates would be a cause of having higher stress scores than
our findings although we had not discussed about exposure status of studied undergraduates.
As evidenced, medical students had 9.6% depressive symptoms due to Covid-19 according to the DASS-2161.
According to another study (N = 208), 40% of undergraduates reported mild to severe depressive symptoms and
only 3% had severe s­ ymptoms59, and 40.8% of medical students reported depressive symptoms in a study of 527
­undergraduates63. Slightly similar findings were reported in a previous study done among undergraduates from
Sri Lanka, India, and Russia; 11.58% of students had elevated depressive symptoms due to Covid-197. A low
level of depression was reported during the study period among nursing undergraduates who studied at KIU,
Sri Lanka; the revealed prevalence of depression was 7%65. When considering previous studies done in Western
countries, undergraduates of the current study and other studies reported a considerably higher level of stress,
anxiety, and depressive symptoms which may be due to new experiences with the pandemic (e.g., some countries
have been exposed to H1N1, SARS, Bird’s flu, etc.) such as lock-down, quarantine, precautionary measures, and
rising of cases and deaths globally. It has caused disruptions of ongoing physical education which had not been
experienced by Sri Lankans due to a disease condition. Thus, adolescents and youth in Sri Lanka have experienced
significant psychosocial stressors, making them more vulnerable to developing psychological morbidity due to
the current crisis as reported in s­ tudies12,66.
A recent study conducted among 100 undergraduates of the same university, the UoR in Sri Lanka from
December 2021-January 2022 revealed environmental factors and other associated factors of stress and psychi-
atric illnesses; 68% of undergraduates were psychologically distressed and 50% of the students were moderate
to severely ­distressed67 similar to the current results. Reported main environmental factors that caused high
stress were lack of time for leisure/sports activities (40–50%), following Covid-19 (30–40%), and issues related
to online learning and evaluation (30%)67. However, they had studied many more reasons than the current study
which focused on Covid-19 disease itself. Before Covid-19, 51.1% of nursing undergraduates at the University
of Peradeniya, Sri Lanka had mild to extremely severe depressive symptoms same as our findings although not
done during the Covid-19 p ­ eriod68. This argument was proved by the authors in Sri L ­ anka12 who stated that Sri
Lankan adolescents usually have experienced higher levels of psychosocial stressors. As previously reported, stu-
dent’s age, academic year, satisfaction with the nursing program, physical well-being elements, potential stresses,
self-rated physical health, and self-rated mental health were all related to depressive s­ ymptoms68. Therefore, dif-
ferences among psychological disturbances could occur due to socio-cultural, religious, and ethnic differences,
and due to the usage of various scales/tools (e.g., 21-DASS, PHQ-9, GAD, SAS, CES-D scale, etc.) to measure
stress, anxiety, and depressive symptoms, which might affect the outcome.

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Factors that influence stress, anxiety, and depressive symptoms and correlations between
stress, anxiety, and depressive symptoms
Several factors associated with stress, anxiety, and depressive symptoms were found in the current study. Age and
type of faculty were significantly associated with three types of psychological disturbances. Gender was signifi-
cantly influenced by anxiety and depressive symptoms while depressive symptoms were significantly influenced
by academic year. As reported in the current study, each psychological problem caused increased stress, anxiety,
and depressive symptoms among undergraduates of the UoR.
As mentioned earlier in a study by Galhenage et al.62, medical students had higher levels of stress, and getting
more information about the disease also increased their stress. When considering the medical undergraduates
of the current study, they did not study about such a risk. However, the type of faculty or type of undergraduates
had some influence on stress, anxiety, and depression in the current findings, respectively (p < 0.001; p < 0.05;
p < 0.001). Medical undergraduates/FoM showed an impact on depressive symptoms while a higher number of
humanities undergraduates/FoHSS had shown an impact on stress, anxiety, and depressive symptoms which
may be due to low exposure to contagious disease or less awareness about the disease compared to the medi-
cal undergraduates. As another study of medical students in Sri Lanka in that period revealed, some factors
of depression were the presence of economic difficulties (p < 0.05); previous contact with psychiatric services
(p < 0.01); the presence of medical/surgical impairment); anxiety [e.g., previous contact with psychiatric ser-
vices (p < 0.001)]; and stress, e.g., perceived lack of support from the university administration and difficulty
accessing internet facilities, previous contact with psychiatric services (p < 0.001); presence of medical/surgical
­impairment]61. Another study’s findings were also similar showing depression (p < 0.01), anxiety (p < 0.05), and
stress (p < 0.01) were significantly higher in medical students with a history of psychiatric d ­ isorders63 which
was not studied in the current study. A working experience of nursing undergraduates who studied at KIU, Sri
Lanka had a significant association with depression (p < 0.001), anxiety (p = 0.006), and stress (p = 0.011) and was
further evidence for the type of u ­ ndergraduates65 who were exposed to the clinical settings as medical students
during their training period.
Female undergraduates in the current study had a significant impact on stress, anxiety, and depressive symp-
toms than their male counterparts similar to the previous medical students’ ­study61,64 and are similar in most
Western ­studies33,34. However, gender significantly had an impact on depression (p < 0.05) and anxiety (p < 0.05).
The Covid-19 epidemic caused psychological disturbances in 59% of female students compared to 49% of male
students and stress, anxiety, and depressive symptoms were more common in female s­ tudents5. A possible
explanation for female undergraduates being more susceptible to psychological stressors compared with male
undergraduates is that extra responsibility relates to caregiving activities and engaging with family members
during the ­pandemic33,34. Our female undergraduates are largely socialized and capable of doing many duties
and home activities simultaneously as explained by another study which states that girls played different roles
within the f­ amily53. Also, their self-confidence about the disease condition being impacted by their low nutri-
tion levels, low income, etc., during that period, may have contributed to higher distress, anxiety, and depres-
sion levels. Although women had more depression, men had a significant risk of severe depression symptoms
(p < 0.05)33. A study by Rohanachandra et al.63 did not report any gender differences in anxiety, depression, or
stress; these inconsistencies may be related to cross-cultural differences and unique traditions as suggested by
Rogowska et al.54.
Further, older/senior undergraduates showed a significant influence on stress, anxiety, and depressive symp-
toms than younger participants as found in the current study (p < 0.001) while age was associated with the level
of depression among nursing undergraduates at KIU (p = 0.016)65. It was discovered that being younger was a
protective factor against experiencing depression s­ ymptoms33. A study of medical students reported the reason
for having higher stress among senior students might be due to the difficulty in making career choices, and
opinions, and a lack of self-confidence in fitness for future clinical p­ ractice69. In contrast to the current findings,
younger and distance learners in OUSL (e.g., Humanities and social sciences, Natural science, Engineering,
Education and Health sciences faculties) had reported significantly higher levels of stress, anxiety, and depressive
symptoms although they used 21-DASS scale like the current ­study39. However, only depressive symptoms had
a significant impact by the academic year in the current study (p < 0.05). As in other findings, first-and second-
year medical students had higher depressive symptoms compared to the fourth year (p < 0.05)63; the final years
reported additional psychological distress and burnout than first -fourth, and fifth-year students evidenced
lower positive mental health than first year s­ tudents64 which could be a reason of increased responsibilities in
the final clinical years of training.
Some studies found no significant difference in stress, anxiety, and depression among undergraduates regard-
ing ­age7, ­gender7,63, and type of ­degree7. Additionally, some nations mentioned reasons for lesser mental illnesses
as developed healthcare systems and the wide range of emergency medical treatments and facilities for Covid-19.
As a result, undergraduates in these nations were less concerned about safety precautions and other Covid-
19-related resources than ­others33,53 compared to the condition in our country. Additionally, putting strict health
protocols into practice, such as using face masks and hand washing, telling people to "stay at home," and closing
public places, may have increased their sense of security although it increased their psychological problems.
However, during that time, longer lockdowns and increased Covid-19 cases/deaths led to higher levels of stress
and anxiety because of the closure of religious sites like mosques and fully covered female attire (e.g., Abhaya)34
mostly relevant to Arabic countries/Islamic ethnic groups but related to our nations as well.
Furthermore, our study discovered a significant positive correlation between depression, anxiety, and stress
(depressive symptoms-anxiety: r = 0.646, p < 0.001; depressive symptoms-stress: r = 0.868, p < 0.001; and anxiety-
stress: r = 0.786, p < 0.001). In 2016, a survey conducted among nursing undergraduates in Sri Lanka evidenced
that most similar correlations are in line with the current findings. The reported significant positive relationships

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were; anxiety and depression (r = 0.689, p < 0.001), anxiety and stress (r = 0.785, p < 0.001), and depression and
stress (r = 0.763, p < 0.001)68; this significant relationship also suggests a reduced risk for psychiatric illness in
undergraduates. It means that if there is no risk of having a higher level of stress, they are prone to low anxiety
and/or depression in other w ­ ays68. These negative emotional sensations can lead to poor mental health, which
impairs learning and limits academic success. Hence, when the undergraduates are overburdened, it may cause
further emotional instabilities and deplete them physically and ­mentally70. As explained by Rogowska et al.54
it could be summarized that if students worry too much about their health, their level of stress may increase,
which may be an additional source of anxiety, and they would end up with severe stress and depression which
may need medical assistance.
Considering a very vulnerable population, university undergraduates face a very important transition from
high school to ­university71,72 which is a vital event in late adolescence associated with structural and social
changes that influence relationships, routines, assumptions, and individualization in roles such as moving out
of home, becoming independent from parents, searching/meeting new friends, facing a new guidelines/respon-
sibility and higher workload of education. Those are some critical events as evidenced during their transition
which led to negative consequences such as loneliness, stress, anxiety, depression, etc. in their ­life71,72 as studied
in this study which need more attention by both parents and university academics.

Original contribution and relevance

However, when compared to the Western Province of Sri Lanka, no studies have been published on the psycho-
logical problems due to the Covid-19 outbreak in undergraduates in the Southern Province. Therefore, it was
better to find out the impact of the disease on the education of undergraduates at the UoR which is the only state
university in Southern Sri Lanka. Further, we were able to assess the psychological impact of different five facul-
ties rather than focusing only on medical undergraduates as done by most researchers in Sri Lanka. Universities
must develop and implement effective screening procedures to closely monitor undergraduates’ exposure to
different stressors and mental health adjustment and to increase the academic performances and student sup-
port services of undergraduates in future pandemics. This research will be vital for higher educational sectors
and policymakers to create welfare programmes and psychological support services for future undergraduates.
Further, this study has important implications for university administration in identifying, treating, and pre-
venting mental health problems among undergraduates during acute, large-scale stressors like infectious disease
outbreaks or natural disasters.

Limitations
Due to the institutions being closed at the time of the survey, data were gathered using an online question-
naire, which prevented participants from asking questions regarding the survey or its components. A lack of
availability of internet facilities may have predisposed the response rates of students. Additionally, the survey
did not allow the contributors to seek explanations about the survey or items in the questionnaire. This study
used a cross-sectional design, which makes it impossible to determine the cause and effect/causal relationship
among variables. Data were gathered from a single university in Sri Lanka; respondents’ impressions may differ
depending on unique aspects of the setting, degree programmes, and the curriculum. Also, some variables such
as income, ethnicity, religion, and academic/examination workload were not included in this study and may
have some correlations. Because the sample was representative of the population of university undergraduates,
the results were rather reliable, but they cannot be generalized to other settings and the whole of Sri Lanka. Yet,
the current study incorporated standardized scales to examine the stress, anxiety, and depression symptoms.

Clinical implications
These results of the current study are useful in detecting the need for psychological support programmes to find
undergraduates with a high risk of psychological disturbances. Further, it would be better to find reasons for
higher levels of psychological disturbances among undergraduates studying in the Southern province than the
Western province studies while the Southern province had lower severity than the Western province. Universities
must plan short-term and long-term psychological amenities for undergraduates and inspire undergraduates to
get support from mental health professionals when essential. Further, examination/investigations and a clinical
diagnosis by a psychiatrist may be required for undergraduates who scored extremely severe levels for stress
and depressive symptoms. Mental health support strategies specifically need to be focused on undergraduates
who are their older ages, females, studying in non-health-related degree programmes, and first-final years. The
undergraduates with diagnosed mental problems, such as depression or anxiety disorder, should be under con-
stant monitoring of psychological and psychiatric s­ ervices73.

General conclusions
There has been an increase in psychological problems among undergraduates due to the Covid-19 outbreak.
Overall, a significant level of stress, anxiety, and depressive symptoms were reported among undergraduates
selected from five faculties, at the University of Ruhuna in Sri Lanka. Age, gender, and type of faculty significantly
influenced the level of stress, anxiety, and depressive symptoms while academic year was significantly correlated
with depressive symptoms. Further, stress, anxiety, and depression were significantly and positively associated
with each other aspect.
Early detection of psychological issues and their associated factors is essential. Furthermore, parents should
be stimulated to generate a friendly and positive family environment for undergraduates without imposing pres-
sure on their future academic careers. It is necessary to develop stress management strategies including coping
mechanisms and expand counseling opportunities for undergraduates. To prevent mental health problems among

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undergraduates, it is essential to plan effective programmes and policies. The government and universities should
collaborate to provide quick, accurate, and cost-effective psychological support to undergraduates to reduce the
escalating mental health issues.

Strengths
A strength of our study was that this is one of the few studies that examine the self-reported prevalence of stress,
anxiety, and depression among different university undergraduates in Sri Lanka and the only study conducted in
the Southern Province, not just focusing especially on medical degree programmes, etc., but vital for observing
all stakeholders of the university population and as community health research. Another positive factor of this
study was the high response rate comparatively. This study was conducted during the Covid-19 pandemic and
provided us further awareness of the possible increase in psychological health problems that undergraduates
might face due to different reasons: health and educational concerns; disruption of normal life; economic chal-
lenges; and concerns about the future causing a higher level of stress, anxiety, and depressive symptoms especially
by those who were in the Southern province who were not much affected as those in the Western province of Sri
Lanka. Nevertheless, the usage of a validated screening tool was measured as a cost-effective method to explore
the situation in general and the first time that we applied many components of the research process online which
was not experienced earlier.

Recommendations for policymakers and stakeholders of higher education

University/government/authorities should plan short-term and long-term goals and/or psychological services
for undergraduates. Short-term goals are;

1. Immediate actions need to be taken to uplift the psychological well-being of undergraduates.

2. The university authorities must consider the associated factors for increased psychological disturbances
and must expand resources such as online/distance learning facilities, infrastructure, supervision, and
academic instruction when needed.
3. Take action to provide financial assistance and authorities should expand facilities/resources for providing
resources for sports, music, and cultural events as suggested by another a­ uthor67.
4. There is also a need to raise awareness of the mental health of undergraduates through training and edu-
cational programmes that promote their mental health in future pandemics.
5. Additionally, it is crucial to create efficient interventions and strategies to reduce psychological health dif-
ficulties among university undergraduates. Authorities should emphasize making sure there are enough
facilities and resources.
6. To compare the psychological health of university undergraduates across Sri Lanka, more research is
required using a validated s­ cale12; undergraduates from various faculties, university settings/types (state
and non-state), and locations should be included in future studies.
7. This research focused on the start of Covid-19 and the quarantine once the psychological level may be at
its highest level; longitudinal and qualitative surveys are necessary to identify changes in undergraduates’
mental health over time (to assess the relationship between different associated factors using a wide range
of explanatory variables that can explain psychological disturbances). Further, in-depth interviews/discus-
sions are recommended to explore such issues.
8. Empower the existing programmes, and educational professionals to implement measures to improve
emotional well-being and professional organizations.
9. Reinforce the capacity of the mental health helpline/chatline 1926 by the National Institute of Mental
Health to provide for children/adolescents, raise awareness of this s­ ervice12, and encourage undergraduates
to get support from mental health professionals when necessary.
10. Promote awareness about mental health promotional activities using electronic and printed media.
11. Make youth-friendly informative videos and posts on social media about psychological well-being, rec-
onciliation, social responsibility, ­etc12.
12. Conduct mental health promotional activities and improve awareness about coping strategies (e.g., adap-
tive/constructive/problem-based coping strategies and maladaptive/destructive/emotional-based coping
strategies) of undergraduates through available departments of psychiatry and psychology already estab-
­ anka12.
lished in all state universities in Sri L
13. Both the government and universities must plan collective strategies to find a solution to academic delays,
academic and professional uncertainty, and financial insecurity due to unexpected circumstances.

Long-term goals are;

1. Universities should establish all-inclusive online-based educational programs for undergraduates living in
remote areas with or without devices and provide scholarships or student loans who are in need.
2. If such social distancing measures are implemented in future diseases, telehealth, digital mental health ser-
vices, and tele-counseling programmes can be used as strategies (economy-oriented psychological support)
to make these vulnerable people.
3. Universities should actively assess the mental illness of undergraduates at various stages of their academic
careers and set up and announce helplines and other forms of support.
4. The Department of Psychiatry or Medical Centre in the Universities should take the initiative and take the
lead in developing suitable psychological support services within the faculty since it plays a vital role in

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providing this information; authoritative personnel/medical officials could offer to be freely available for
in-person or online discussions with undergraduates and, if necessary, to direct them to alternative mental
health services. Additionally, they can conduct meetings about the effects of Covid-19 on mental health and
promote the help-seeking behavior of undergraduates.
5. Offer more human resources (e.g., medical and nursing officers, and allied health professionals) and monetary
facilities to government child and adolescent mental health s­ ervices12.

Data availability
The data analyzed throughout the current study are not publicly available due to ethical reasons. The survey data
will be made available on reasonable request to the corresponding author.

Received: 6 January 2023; Accepted: 20 November 2023

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Author contributions
M. K. was involved with study conception, design, data collection, data entering. E. W. was involved with study
conceptualization and design, supervising, data analyzing, drafting, and revising the article. All authors have
read and agreed to the published version of the manuscript.

Competing interests
The authors declare no competing interests.

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