ARTICULO ORIGINALREVISTA DE LA FACULTAD DE MEDICINA HUMANA 2021 - Universidad Ricardo Palma
1Universidad Ricardo Palma, Lima, Perú.
2Universidad Nacional del Centro del Perú, Huancayo, Perú.
3Universidad Continental, Huancayo, Perú.
4Universidad Nacional Mayor de San Marcos, Lima, Perú.
5Universidad Nacional Hermilio Valdizán, Huánuco, Perú.
6Universidad Nacional San Antonio Abad del Cusco, Cusco, Perú.
7Universidad Nacional Amazónica de Madre de Dios, Puerto Maldonado, Perú.
Introduction: The COVID-19 quarantine has greatly affected university students in Peru, generating a series of physical, psychological and behavioral effects. Objective: To determine the factors associated with anxiety, depression, somatization and experiential avoidance in peruvian university students quarantined by COVID-19. Methods: A cross-sectional observational study was carried out. The sample was made up of 1264 university students from various departments of Peru, anxiety, depression, somatization and experiential avoidance were taken as dependent variables, which were evaluated with the questionnaire "The Inventory of unadjusted psychosocial behavior, in the presence of COVID-19 in the Peruvian population ”and the AAQ II, for the statistical analysis the chi square was used Results: More than half of the university students in Peru present between 3 and 6 of the 6 anxiety indicators, and this same number of depression indicators is presented by 45% of the sample. 30% of the sample has between 3 and 6 indicators of somatization and 40.3% of the sample is located in the middle upwards on the experiential avoidance scale. Conclusions: There are differences in the levels of anxiety, somatization and experiential avoidance between men and women, it was also found that older students had lower levels of anxiety, depression and experiential avoidance, but not in somatization.
Key words: Anexiety, depression, somatoform disorders, experiental avoidance, COVID-19, quarantine, pandemics. (Source: MeSH NLM)
Introducción: La cuarentena por COVID-19 ha afectado de gran manera a los estudiantes universitarios del Perú, generando una serie de efectos físicos, psicológicos y conductuales. Objetivo: Determinar los factores asociados a ansiedad, depresión, somatización y evitación experiencial en estudiantes universitarios del Perú en cuarentena por COVID-19. Métodos: Se realizó un estudio observacional transversal. La muestra estuvo constituida por 1264 estudiantes universitarios de diversos departamentos del Perú, se tomó como variables dependientes a la ansiedad, depresión, somatización y evitación experiencial, las cuales se evaluaron con el cuestionario de “El Inventario de comportamiento psicosocial desajustado, ante la presencia del COVID-19 en la población peruana” y el AAQ II, para el análisis estadístico se empleó el chi cuadrado. Resultados: Más de la mitad de los estudiantes universitarios del Perú, presenta entre 3 y 6 de los 6 indicadores de ansiedad, y este mismo número de indicadores de depresión lo presenta el 45% de la muestra. El 30 % de la muestra presenta entre 3 y 6 indicadores de somatización y el 40,3% de la muestra se ubica de la mitad hacia arriba en la escala de evitación experiencial. Conclusiones: Existen diferencias en los niveles de ansiedad, somatización y evitación experiencial entre varones y mujeres, asimismo se encontró que los estudiantes de mayor edad presentaban niveles más bajos de ansiedad, depresión y evitación experiencial, pero no en somatización.
Palabras clave: Ansiedad, depresión, trastorno somatomorfo, evitación experiencial, COVID-19, cuarentena, pandemia. (Fuente DeCS)
COVID-19 is a disease caused by a coronavirus, discovered in November, 2019 in Wuhan, China. This virus has affected a large part of the world's population, and in most cases has led to the various governments to establish a series of measures to try to control the infection. Within those measures, the main one has been the quarantine, where persons infected with or exposed to the virus were isolated and activities were restricted with the aim of preventing their spread. However, despite the measures taken due to the virus characteristics and the speed at which the disease is spread, it has become a pandemic(1).
Nevertheless, the quarantine to which the inhabitants of many countries and Peru have been subjected has caused different physical, psychological and behavioral reactions which have led to the realization of a series of investigations in this regard. Some of the psychological conditions are depression, anxiety that is a psychic distress in dangerous situations(2); somatization, which is the manifestation of psychological problems through the body(3) and the experiential avoidance, which is a new term that refers to the tendency of the subject to escape from unpleasant situations that trigger aversive responses or even without the presence of those situations. The hypothesis held that under conditions of quarantine by COVID-19 most university students had medium and high levels of anxiety, depression, somatization and experiential avoidance, these four variables differed according to gender, the professional area, age group, department of origin, level of advancement in the career and whether or not they have relatives or friends affected by the COVID-19(4-6) however, research in Peru on the subject and its various aspects is still in the initial phase.
This unprecedented situation generated a series of questions, so the objectives of this study were to determine the predominant levels of anxiety, depression, somatization and experiential avoidance in Peruvian university students under COVID-19 quarantine conditions and differentiate anxiety levels, depression, somatization and experiential avoidance in Peruvian university students based on variables such as gender, professional area, age group, department of origin, level of career advancement and whether or not they have relatives or friends affected by the COVID-19.
Design and study area
Observational, descriptive-comparative study carried out in university students in various Peruvian cities.
Population and sample
The population of the present study is all university students from the various cities of Peru during 2020, a non-probabilistic sampling was carried out, where a total sample of 1264 students from 11 universities was obtained, among which we have the Universidad Nacional Mayor de San Marcos (UNMSM) - Lima, Universidad Ricardo Palma (URP) - Lima, Universidad Enrique Guzmán y Valle National (La Cantuta) - Lima, Universidad Femenina (UNIFÉ) - Lima, Universidad Nacional del Centro del Perú (UNCP) - Huancayo, Universidad Continental (UC) – Huancayo, Universidad Alas Peruanas (UAP) – Huancayo, Universidad Nacional Hermilio Valdizán (UNHV) – Huánuco, Universidad Nacional San Antonio Abad del Cusco, Universidad Los Ángeles de Chimbote (ULADECH) – Chimbote, Universidad Nacional Pedro Ruiz Gallo – Lambayeque.. Students from the various cities of Peru from the different careers in State universities and individuals who were quarantined were included. Excluded those who did not sign the informed consent and who had incomplete questionnaires
Variables and instruments
Sex, professional area, age group, department of origin, level reached in the career and whether or not they have relatives or friends affected by COVID-19 were taken as independent variables. As dependent variables, we have anxiety, depression, somatization and experiential avoidance. To evaluate them, we used two instruments: the first performed by Sánchez et al(5), referred to as “The Unadjusted Psychosocial Behavior Inventory, in presence of COVID-19 in the Peruvian population”. This test consists of 10 scales with a total of 62 reagents of which 18 were taken, corresponding to the indicators of depression, anxiety, and somatization. The authors validated the test using the expert judgment system finding high validity rates, the reliability of the instrument was established by Cronbach’s Alpha which yielded an internal consistency index equal to 0.89. And the second instrument was Acceptance and Action Questionnaire II (AAQ II) to evaluate experiential avoidance(7).
For the study, the survey technique was used, so a virtual questionnaire was designed with the general data and adapted to the format of the AAQ II instrument, also these were preceded by informed consent and instructions for the correct filling. The dissemination of the questionnaire was made using social networks to reach the student population of the different universities in the country during the year 2020, this allowed the indirect observation of the variables under study. Finally, a spreadsheet was generated for the data collected in Microsoft Excel 2019 (v19.0).
The data were processed using the SPSS 25 Software, the comparisons were made using the Chi-square test, given the categorical nature of the same and because the variables are not normally distributed in the population.
To ensure the participants anonymity, privacy and confidentiality, the principles of the Declaration of Helsinki were followed. The project was presented and approved by the Ethics Committee of the Universidad Ricardo Palma.
The results reveal that under conditions of quarantine by COVID-19, in the university students
surveyed (table 1), more than half of the students present between 3 and 6 of the
6 anxiety indicators, 8 out of 100 students would have between 5 and 6 out of a total of 6 indicators of
depression, 3 out of 100 students would encounter high levels of somatization, finally, on the indices
of experiential avoidance (Table 2), 15.7% of students are in the top three levels
of the scale that has a total of seven levels, but if we incorporate the intermediate level, the
percentage rises to 40.3%, this means that just over 15% have high levels of experiential avoidance.
Table 3 shows the comparative analysis and gender relationship with respect to the areas evaluated, where 56.8% of males and 44.9% were found to be in the low level of anxiety (two or less indicators) and 45.2% in the middle level against 36.7% of males. On the other hand, in the analysis with respect to professional areas, significant differences were found in all cases, the university students who presented the highest levels in the areas evaluated were those from the Humanities area accompanied alternately by students from the Engineering and Business Sciences area, compared with those in the area of Health Science who had the lowest levels in the four areas evaluated.
On the other hand, in the comparison according to age groups (from 15 to 20, from 21 to 25 and from 26 to more), it was found that students over the age of 26 would have less anxiety, depression and experiential avoidance than minors; but that there would be no differences between ethereal groups in somatization. Then, in the analysis according to the department of origin, differences were found in the four variables studied, in all cases students from the department of Cusco were oriented more than their analogues towards the top of the scales, that is, at the middle and high levels, while those of Huánuco were oriented predominantly towards the bottom of them. When students were compared taking into account the level of advancement of the professional career, there are no differences in the indicators of anxiety or somatization, but if in those of depression and experiential avoidance, the first semesters have the highest indicators of depression and the last semesters less experiential avoidance.
Finally, when comparing university students who had close friends or family who had or had had COVID-19 with those who had not, significant differences were found in the four variables studied. In all cases, those who had no friends or relatives with COVID-19 tended to accumulate at the lower levels of the respective scales
Table 1. Levels of anxiety, depression and somatization in university students
Table 2. Sample distribution on the experiential avoidance scale
Table 3. Factors associated with anxiety, depression, somatization and experiential avoidance in university students
|Independent Variables||Anxiety||Depression||Somatization||Experiential avoidance|
|Chi-square||P value||Chi-square||P value||Chi-square||P value||Chi-square||P value|
|Department of origin||27.847||0.001||21.320||0.006||21.226||0.007||1399.637||0.000|
|Relatives or friends with COVID-19||23.126||0.000||13.321||0.001||28.504||0.000||986.289||0.000|
In the study, it was found that more than 50% of university students presented medium to moderate levels
of anxiety. These results are close, although higher than those found by Gonzáles(8), who found 40% of anxiety due to lockdown in university students in Mexico.
Similar results have been reported by Johnson(4) in Argentina and by De Cássia
et al(9) in Minas Gerais. However, the percentage of high anxiety in
university students would be lower than that of the Peruvian population (21%). According to what was
reported by Sánchez et al(5), this could mean that university students would
have more resources to understand and face the quarantine situation than the non-university population
because they have more access to information. On the other hand, university students have been forced to
respond to subjects demands during quarantine time, which would have focused their energy and worries on
other aspects of the disease. This fact might have contributed to reduce their levels of anxiety.
Likewise, when the indicators of depression were evaluated, it was evident that 45% of university
students had from medium to high depression levels. These results are higher than those of Perales et.
al(10), who studied the factors associated with suicidal behaviors before
COVID-19 and quarantine in students of a university from Lima and those of Zancan et. Al(11) who found that up to 23.6% university students had severe or moderate
depression in the context of quarantine, in Brazil. In this way, it can be said that Mexican students
had lower rates of depression (4.9%) than all groups mentioned(8) and that
those from Minas Gerais in Brazil have the highest rates of depression (52%)(9). Our findings show that even in high depression levels, the percentage of
university students (8%) is lower than that of the overall Peruvian population (18%) in quarantine
conditions, according to what Sánchez et al(5) reported. In contrast, it was
found that most of students have low levels of somatization (70%). Which means that university students
in Peru somatize much less than they get depressed and anxious. Even the presence of medium-to-high
somatization levels is lower than what was reported by Gonzáles et al(8), who
found a 5.9% in mexican students. However, the percentage of high levels of somatization in university
students is the same as that in the other variables and lower than that of the Peruvian population
(23%). All together would confirm that despite all of this, university students are less psychologically
affected, at least in the studied variables here that the rest of the Peruvian population. Finally, with
regard to experiential avoidance, it was found that few students had high rates. Those results are far
below that what was reported in Spain by Sanabria et al(12), who found 71% of
score corresponding to experiential avoidance with AAQ. This finding is extremely important if we
consider that high scores in the experiential avoidance test are associated with pathologies that
usually require therapeutic intervention(13,14).
Differences were found between men and women in terms of the presence of anxiety, somatization and experiential avoidance, but not in depression; that is, women tend to somatize and show greater experiential avoidance than men, while no significant differences were found with respect to depression. These findings match with those reported by Sánchez et al(5) for the Peruvian population, except for depression, where they found differences between both sexes. In contrast with our study, similar results were found by Johnson et al(4) in Argentina. This could mean that the significant differences between the education received by men and women in Peru make differences have greater indicators of imbalance than those. In this regard, what is observed here is that female university students tend to follow the same pattern, except for indicators of depression. The results of Aragón et al(15), who found higher levels of anxiety in female than in male university students in Mexico, are in the same line; as well as those of Agudelo et al(16), who reported higher levels of anxiety and depression in female than in male university students in Medellín-Colombia; and those of Sanabria et al(12), who reported greater experiential avoidance in female than in male university students, which was associated to the reduced physical activity of the former compared to latter ones. As you can see this without the COVID-19 quarantine condition. But apparently the quarantine does not modify the phenomenon pointed out since Gonzáles et. al(9) has reported similar results to ours as has Zancan et al(11). However, these differences between men and women are not recorded in all places or at all times. For example, Cardona et. al(17) found high rates of prevalence of anxiety in university students in Medellin, Colombia, but no differences between men and women, which could be evidence of how external factors influence anxiety and depression in different ways. Among other psychological reactions, they would not be inherent to both sex and sociocultural factors. That would explain why there are no differences between men and women regarding depression indicators in our results.
When associating the professional areas, they found the highest levels levels of anxiety, depression, somatization and experiential avoidance in the Human Sciences area, unlike the Health Sciences area, where we found the lowest levels of the studied issues. These results lead us to assume that being an university student, and therefore having more information about the pandemic helps to reduce the levels of anxiety, depression, somatization and experiential avoidance. Regarding the other population sector, being a student of Health Sciences grants more resources to deal with the quarantine and pandemic, than students from other areas. This idea is strengthened by the fact that according to our results, students of upper semesters are also less psychologically affected than those of lower semesters, at least in depression and experiential avoidance. But it would also show that the curricula of humanities careers should incorporate subjects and competencies that provide them with better psychological resources to face situations such as that generated by the pandemic. Psychological differences depending on careers and subjects have also been reported by Zancan et. al(11), which strengthens the idea that careers and subjects studied provide students with more or less resources to cope with situations a person perceives as dangerous. This should be considered by those responsible for designing curricular policies, looking for a near future.
The results have also revealed that except for somatization, university students differ in the three remaining variables according to the age group to which they belong. This means that older students have lower levels of anxiety, depression and experiential avoidance than younger students. Similar results were recently reported by Sánchez et al(5) for the Peruvian population. As well as those in Mexico, by González et al(8) in quarantine conditions due to COVID-19. That allows us to assume that an older age and experience is usually supposed to grant the university student and people in general with more resources to cope more successfully with situations that disrupt daily life. A similar situation was found when comparing the subgroups according to the department of origin. Students in the city of Cusco had higher levels on the scales, unlike what was found in the city of Huánuco, where they had lower levels. This situation is difficult to explain because in both departments the quarantine lasted longer than in others, so it is necessary to carry out studies that can explain the situation described. However, the hypothesis that socio-economic conditions in both departments could underlie the differences might be stated. In fact, it is possible to say that the quarantine caused more radical changes in the inhabitant life in Cusco than in other departments, including university students. Indeed, Cusco is the city with the highest tourism index, which decrease to zero. So not only social but also economic conditions changed suddenly and radically. However, unveiling this—a mystery now—, is important from a political and social perspective. The knowledge of the causes of the mentioned differences should lead to political decisions, so that factors that affect the university students psychology in Cusco might be improve or decrease. Psychological differences in anxiety, depression and somatization have also been revealed by Sánchez et al(5) in the Peruvian population according to geographical variables. However, little has been related between the psychological variables and the geographical ones, so it is necessary to carry out studies in this regard.
Finally, the registered differences in the four variables between students who had relatives or friends infected by coronavirus and those who did not, seem to show that being close to the consequences of the infection would have a negative effect on young people psychology. As a result, their scores on tests of anxiety, depression, somatization and experiential avoidance increased significantly. In fact, the mortality caused by the virus and its sequels in those infected and therefore, the way this modifies their relatives and close friends lives or routines would make it difficult for them to escape their psychological sequels. Although they differ in terms of depression indicators, our results correspond partially to those of Sánchez et al(5) in the Peruvian population. However, the data available at the moment do not explain this difference. Therefore, it will also be necessary to formulate new researches to help clarify the phenomenon described. However, it is possible to state that in the case of the Peruvian population, there may be other factors that increase depression even in people who do not have infected friends or relatives, such as the enormous economic difficulties generated by quarantine, lockdown in confined areas and forced inactivity, among others. Within the limitations we have to perform a non-probabilistic sampling to limit the representativeness of the study by not reaching the total target population and that the results cannot be extrapolated, but the data and its potency are adequate.
It was found that most university students have low to medium levels of anxiety and depression. Only a small percentage has a high level of somatization and 40.3% of the sample is placed from the middle to the top of the experiential avoidance scale. Likewise, women somatize more and show greater experiential avoidance than men, as well as younger students have higher levels of depression, anxiety and experiential avoidance. Students in the Human Sciences area have higher levels in the four areas of evaluation than those in the Health Sciences area, as well as those students from first semesters have higher levels of depression. Finally, those students who have or had a family member or friend affected by COVID-19 had higher levels in all the tested areas.
Authorship contributions: The authors participated in the genesis of the idea, project
design, data collection and interpretation, analysis of results and preparation of the
manuscript of this research work.
Funding sources: Self-financed.
Conflicts of Interest: The authors declare there are no conflicts of interest.
Recibido: October 22, 2020
Aprobado: February 15, 2021
Correspondence: Héctor Hugo Sánchez-Carlessi
Address: 33, Av. Alfredo Benavides 5440, Santiago de Surco 15039, Perú.
Telephone number: (01) 7080000