https://orcid.org/0000-0001-5330-9069
Figures
Abstract
Introduction
Mental health is recognized as a critical component of public health Given the close relationship between mental health and life style and the importance of students as valuable human resources, the present study aimed at determining the relationship between life style and mental health among medical students in Sousse during COVID-19 pandemic.
Methods
We conducted a cross-sectional observational study in university students from the first to the fifth grade of the Faculty of Medicine of Sousse during the academic year 2020/2021. Data were collected anonymously via an online questionnaire published on the Facebook groups of each grade, on december 2020. The online survey consisted of three sections. The first one aimed to collect sociodemographic information. The second section of the survey addressed recent lifestyle choices and the third one assessed psychological distress using the French version of 12 items of The General Health Questionnaire (GHQ-12). The significance level was considered 0.05.
Results
Overall 147 were studied. Using the bimodal scoring, the total score was between 0 and 12, to evoke psychiatric disorders, we set the threshold of 4. For our sample, the median scale was 7 [4-9], and more than half of the students (68%; n = 100) had a score higher than 4. Psychiatric disorder was significantly more frequent in female students (73.3% vs 42.3%; p = 0.002). Higher GHQ-scale was found in younger students, foreigners, students who need more than 30 minutes to get to the faculty, unemployed students, and students of fifth grade. However, differences were not statistically significant. Regarding lifestyle choices, we found that physical inactivity, no smoking habits, no alcohol use, no illicit substance use, other substance use, changing in eating habits, and absence of coping methods of stress were higher in students with psychiatric disorders. However, this association was statistically significant only for physical activity (p = 0.016). The results of the regression analysis suggest female gender as an independent predictor of high GHQ-12 scores. Practicing physical activity was found as protective factor for psychiatric disorders.
Citation: Ghali H, Ghammem R, Baccouche I, Hamrouni M, Jedidi N, Smaali H, et al. (2022) Association between lifestyle choices and mental health among medical students during the COVID-19 pandemic: A cross-sectional study. PLoS ONE 17(10): e0274525. https://doi.org/10.1371/journal.pone.0274525
Editor: Tauseef Ahmad, King Saud University, SAUDI ARABIA
Received: April 12, 2022; Accepted: August 28, 2022; Published: October 7, 2022
Copyright: © 2022 Ghali et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the article and its Supporting Information files.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Mental health is recognized as a critical component of public health [1]. The World Health Organization (WHO) describes mental health as a “state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” [2]. Similarly, mental health is an essential component of healthy living, and vice versa.
Furthermore, mental health is a requisite for the sustainability of social, occupational, and academic performance of people in society [3, 4].
Leading a healthy life is beneficial for one’s well-being. According to the WHO, a healthy lifestyle means regular physical activity, abstaining from smoking, limiting alcohol consumption, eating well to prevent overweight and non-communicable diseases. Such a lifestyle will have benefits on mental health. [5–7].
The full impact of the COVID-19 pandemic on health, economy, interpersonal relations, and daily habits has resulted in changing in individuals’ wellbeing, mental health and lifestyle-related behaviors [8, 9].
Thus, it is a truism to state that the Covid-19 pandemic had a major impact on our society, in Tunisia as elsewhere, in terms of health, economy and professional, family and social life [10, 11]. This impact has manifested itself as a sleep disorder and psychological disorders according to some studies [12]. Young people are particularly vulnerable to the disruptions caused by the pandemic, and many are being left behind in education, economic opportunities, health and well-being during a crucial stage of their development and education [13]. All these changes can lead to dangerous behaviors such as suicidal ideation [14, 15].
As the epidemic continues to spread, authorities have been forced to tighten isolation measures and close all schools and universities [8]. In Tunisia, since the 1st of March 2020, all schools, colleges, and universities indefinitely suspended their attendance, and, where possible, activated online learning as an alternative.
Even before COVID-19, it was clear that university students are uniquely vulnerable to mental health problems [16]. In fact, the concern about academic performance coupled with relationship difficulties and feelings of loneliness make students susceptible to developing mental problems [8, 17]. According to the Turkish study on perceived stress during the COVID-19 outbreak, generalized anxiety disorder was found in 52% of students and depression in 63% [18].
Other dangerous behaviors, such as drug and alcohol consumption and even self-harm are frequently initiated during the lockdown [19]. Indeed, Canadian and Spanish studies showed that students’ high alcohol and tobacco consumption were significantly compounded during the pandemic [20, 21]. Additionally, the lockdown and staying at home will cause a change in lifestyle habits including the limitation of physical activity [8]. In fact, it was found that the current quarantine negatively affected the practice of physical exercise by the student population [22].
Moreover, constant mass-media reports about COVID-19 death rates lead to distress [23], and thus, people are more likely to choose less healthy ‘comfort foods’ [24, 25], smoke more cigarettes [26], and more frequently reach for alcohol [27]. Furthermore, during the lockdown, there is a substantial risk of increasing substance use [28].
Thus, students are at risk of developing mental health problems especially since they are already vulnerable and highly susceptible to addiction and psychological crises.
Most studies have focused on studying the impact of the pandemic on either the general population or medical and paramedical personnel. However, the impact on the student population requires more attention as students find their lifestyles totally changed [8].
According to Nilufar S et al, the mental health of medical students is associated with their lifestyle choices. Thus, changing it in a healthy way will improve their mental health [29]. According to Davarinejad O et al. [30], a statistically significant negative association was found between mental health scores and those assessing different lifestyle domains.
In this context, our study aimed to investigate lifestyle and behavioral choices experienced by Tunisian medical students due to the epidemiological situation and their association with mental health.
Material and methods
1. Study design
We conducted a cross-sectional observational study in the Faculty of Medicine of Sousse during the academic year 2020/2021.
2. Study population
The survey was aimed at university students from the first to the fifth grade. Data were collected anonymously via an online questionnaire published on the Facebook groups of each grade, during one month on december 2020.
3. Data collection
The online survey consisted of three sections.
The first one aimed to collect sociodemographic information, including gender, age, residence, activities other than studies, income source, etc.
The second section of the survey addressed recent lifestyle choices that were a result of the pandemic : physical activity, eating habits (quantity, frequency of meals and type of food), tobacco use, alcohol use, illicit-substance use (cannabis and cocaine), other substance use (drugs, stimulant and energy drinks), and coping methods for stress defined as reading books on personnel development, practicing art activities, relaxation and attention techniques. These elements were assessed using questions where the answer was either yes or no.
While there is an on-going debate about the validity of self-reported alcohol consumption compared to objective data, recent studies conclude that self-report can reliably estimate alcohol consumption in low to moderate drinkers [31]. Such items are regularly used in epidemiological studies on alcohol consumption [32]. Current smoking was assessed using one item: “Do you smoke?” Answer categories were ‘no’, ‘yes’.
The last section of the survey included the questionnaire aimed to assess psychological distress using the French version of 12 items of The General Health Questionnaire (GHQ-12) [33, 34].
The 12-item General Health Questionnaire (GHQ-12) is a self-report measure of psychological morbidity, intended to detect psychiatric disorders in community settings and non-psychiatric settings. It is widely used in clinical practice, epidemiological research and for research in psychology. Due to its brevity, is probably the most popular and so, has been extensively evaluated in terms of its validity and reliability as a one-dimensional indicator of the severity of psychological morbidity.
The 12-Item General Health Questionnaire (GHQ-12) [35] consists of 12 items, each one assessing the severity of a mental problem over the past few weeks using a 4-point Likert-type scale (from 0 to 3). The score was used to generate a total score ranging from 0 to 36. The positive items were corrected from 0 (always) to 3 (never) and the negative ones from 3 (always) to 0 (never). High scores indicate worse health.
Three rating systems were proposed:
- Dimensional rating: Likert scale rated from 0 to 3, with 0 corresponding to the first modality, and 3 to the last modality.
- Dichotomous scoring 0-0-1-1: The 2 responses reflecting an improvement compared to the usual situation can be scored "0", while the 2 responses reflecting an aggravation will be scored "1".
- Dichotomous scoring, known as cGHQ: Positively worded items are scored 0-0-1-1 and negatively worded items are scored 0-1-1-1. This scoring allows for long-lasting conditions for which subjects may feel that their health status has not changed from usual.
Whatever the scoring system, the addition of the responses obtained for each item makes it possible to calculate an overall score considered to indicate psychological damage (or a high probability of psychological damage) when it is high. It is difficult to know which scoring system is best. The dichotomous 0-0-1-1 scoring system seems to be the most satisfactory according to Goderberg [36]. We used the bimodal scoring (scoring 0 for " better than usual" or "as usual" and 1 for " less well than usual" or "much less than usual"). Interpretation: 0–4: Normal subject 5–12: Existence of a psychiatric disorder.
4. Data analysis
Statistical analysis was performed using SPSS ver. 25.0 (IBM, Chicago, IL, USA).
Data are represented as number and percentage for categorical variables, and mean ±standard deviation or median and interquartile range in square brackets [IQR] for continuous variable. The Kolmogorov-Smornov test was performed in order to evaluate variables distribution.
Chi square test was used to compare categorical variables, and Student t-test to compare means. To study associations between sociodemographic characteristics, lifestyle choices and mental helath, binary logistic regression model was used. Variables at a p value ≤ 20% in the univariate analysis were the variables used in the model. The fit of the final model was evaluated with the Hosmer and Lemeshow test. Significant p value was set at 0.05.
Results
1. Participants’ characteristics
The studied group included a total number of 147 participants, within which 120 were female (81.6%) and 26 were male (17.7%). The mean age of the respondents was 21.62±1.9 years. Only 1.4% of the students were not of Tunisian nationality. Most of the participants were from Sousse (32.7%).
The highest response rate was noted among the fifth grade students (36.1%).
A detailed description of the demographic characteristics of the study group is presented in Table 1.
2. Lifestyle factors
We assessed seven lifestyle factors which were : physical activity, changes in eating habits, tobacco use, alcohol use, illicit-substance use, other substance use, and coping methods for stress. Descriptive values of lifestyle factors are presented in Fig 1.
3. Mental health
Using the GHQ-12 scale, the mean scale was 19±6.45 with the extremes ranging from 5 to 35.
Distributions of students by GHQ-12 items are summarized in Table 2.
Using the bimodal scoring, the total score was between 0 and 12, to evoke psychiatric disorders, we set the threshold of 4.
For our sample, the median scale was 7 [4–9], and more than half of the students (68% ; n = 100) had a score higher than 4.
4. Factors associated with mental health : Univariate analysis
Psychiatric disorder was significantly more frequent in female students (73.3% vs 42.3% ; p = 0.002). Higher GHQ-scale was found in younger students, foreigners, students who need more than 30 minutes to get to the faculty, unemployed students, and students of fifth grade.
However, differences were not statistically significant (Table 3).
Regarding lifestyle choices, we found that physical inactivity, no smoking habits, no alcohol use, no illicit substance use, other substance use, changing in eating habits, and absence of coping methods of stress were higher in students with psychiatric disorders.
However, this association was statistically significant only for physical activity (p = 0.016). (Table 4).
5. Factors associated with mental health : Multivariate analysis
A logistic regression was performed to predict GHQ-12 as dependent variable, in relation to sociodemographic characteristics and the lifestyle choices items. The results of the regression analysis suggest female gender as an independent predictor of high GHQ-12 scores. However, practicing physical activity was found as protective factor for psychiatric disorders (Table 5).
Discussion
The results of a systematic review carried out to assess the mental health of medical students in Asian countries indicated that 11% of the medical students were suffering from depression, while the prevalence of depression was higher in students in the preclinical level and students residing at home [37]. In another systematic review conducted to analyze the mental health of medical students in Brazil, it was reported that the prevalence of depression and anxiety in the students was 30.6% and 46.1%, respectively [38].
Lifestyle plays an important role in determining certain medical and psychiatric conditions. Indeed, a healthy lifestyle (eating healthy foods, getting more physical activity, quitting smoking, avoiding alcohol and illicit substances), will improve these conditions in a positive way [39].
The current COVID-19 pandemic have changed life satisfaction and mental health. The current study investigated lifestyle and behavioral changes experienced by Tunisian medical students due to the epidemiological situation and their effect on their mental health.
A lot of studies have shown that medical students are more prone to depression, more tired, and more prone to emotional exhaustion, depersonalization, and burnout syndrome than other students. Likewise, symptoms of depression, suicidal ideas, and dissatisfaction with personal accomplishments show the greatest prevalence during medical studies, while it subsequently declines in a physician’s career [40].
Many Polish students confirmed the neglect of their daily lives in relation to experiencing significant psychological distress related to the pandemic [8]. In accordance with our results, that suggest that the ability to maintain a physical activity and using coping methods of stress were related to lower psychological distress, regularizing and maintaining daily routines has been previously mentioned as a protective factor during the COVID-19 pandemic [41].
In fact, maintaining a daily routine as a protective factor is addressed in several studies, for exemple, on post-traumatic stress during natural disasters, [42] or populations living in high-stress environments, like forced immigrants [43].
Furthetmore, some early studies on eating behaviors amidst the COVID-19 crisis have already reported changes in food intake as a result of the pandemic [44–48].
The results of our study indicate that having received other substances such as other medications stimulant and energy drinks was related to higher psychopathological distress.
Another interesting, however concerning finding is, that higher psychological distress was found in students who do not smoke, not drink alcohol, neither use illicit substances.
Indeed, our findings suggest that, although only a small percentage of the studied population reported consumption of tobacco, alcohol and illicit substances, they were not significantly related to a higher psychopathological distress.
A study by Lechner et al. [49] conducted among college students at the onset of the pandemic and campus closure, reported an increase in alcohol consumption with an additional finding that those students who reported depression or anxiety demonstrated a higher increase in alcohol consumption. An explanation for why only 10.9% of the studied group reported consumption of alcohol could be related to the fact that most of respondents lived either with their families or in dormitories were they are not free. On the other hand, the absence of student gatherings following the closure of the universities may explain the considerable reduction in opportunities for alcohol consumption [8]. This hypothesis is also supported by the aforementioned study [49], where the authors have found that an increase in the consumption of alcoholic drinks was accompanied by an increase of drinking occasions overall, which at that time in Tunisa was unlikely.
In the study conducted by Davarinejad, et al [30], a positive and significant correlation was found between mental health and life style dimensions so that the variables of psychological health, social health, exercise, and health and environmental health were the best predictors of mental health. Also, in the study of Esfahani et al. [50], who studied mental health with an Islamic life style, reported a positive and significant correlation between the two categories.
According to our findings, coping methods of stress was related with mental well-being. In fact, theWorld Health Organization (WHO) defines life skills as “abilities for adaptive and positive behavior, that enable individuals to deal effectively with the demands and challenges of everyday life.” [51]. It has been noted that those who find themselves able to adapt to this changed circumstances have better mental health.
On the other hand, we noted that those who maintained physical activity, good stress management and an unmodified diet had better mental health.
The results of our multivariate analysis identified only two independent variables significantly associated with the mental health of our students which were female gender and physical activity.
Thus, it can be said that the mental health of medical students may be partly influenced by their lifestyle choices. As such, it is recommended that their behaviours be addressed to improve their mental health.
The results of this study should be generalized to other Tunisian universities with caution due to its small sample size, and thus, the present sample does not have good representativeness.
In fact, despite the fact that we solicited and encouraged students to participate in our study, the response rate remains low, and we couldn’t reach directly the students because of the sanitary situation.
In spite of all this, our study is the first, as far as we are aware, to analyze the mental health of medical students during the lockdown in relation to their lifestyle choices. Thus, a national multicenter study on a generalizable sample of selected universities is recommended.
Conclusion
Among the repercussions of the COVID-19 pandemic, we can note the switch of university education to the virtual one, which has generated as a consequence the modification of the students’ lifestyle. However, the impact of this new lifestyle on mental health remains to be studied. Based on this observation, we interviewed students of the Faculty of Medicine of Sousse about the changes in their life choices and the potential alterations of their psychological state.
Students reported changing in their eating habits, lack of physical activity and use of both illicit substances and other substances such as drugs and energetic drinks. These changes were accompanied by a psychiatric disorder, although this association was significant for only lack of physical activity and female gender.
Thus, there are many factors that can influence the relationship between lifestyle and mental health. Therefore, special attention should be given to students in general and medical students in particular to improve overall health in the community.
Acknowledgments
The authors gratefully acknowledge all of the investigators for their contributions to the study.
Participant consent
Data were collected anonymously via an online questionnaire. Before answering the questionnaire, the students were asked to answer the question whether or not they agreed to participate in the study. Only those who accept can answer the questionnaire. Data were collected by the project medical doctors and treated anonymously. Our study population is made up of students over the age of 19, so it does not include minors.
References
- 1. Herman H, Jané-Llopis E. Mental health promotion in public health. Promot Educ. juin 2005;12(2_suppl):42–7.
- 2.
Weltgesundheitsorganisation. Promoting mental health: concepts, emerging evidence, practice; a report. Herrman H, éditeur. Geneva: World Health Organization; 2005. 288 p.
- 3.
Matingwina T. Health, Academic Achievement and School-Based Interventions. In: Bernal-Morales B, éditeur. Health and Academic Achievement [Internet]. InTech; 2018 [cité 9 févr 2022]. Disponible sur: http://www.intechopen.com/books/health-and-academic-achievement/health-academic-achievement-and-school-based-interventions
- 4. Hsieh YC, Apostolopoulos Y, Hatzudis K, Sönmez S. Social, Occupational, and Spatial Exposures and Mental Health Disparities of Working-Class Latinas in the US. J Immigr Minor Health. juin 2016;18(3):589–99. pmid:26044667
- 5. Velten J, Bieda A, Scholten S, Wannemüller A, Margraf J. Lifestyle choices and mental health: a longitudinal survey with German and Chinese students. BMC Public Health. déc 2018;18(1):632. pmid:29769115
- 6. tz Ou H, Su CT, Luh WM, Lin CY. Knowing is Half the Battle: the Association Between Leisure-Time Physical Activity and Quality of Life Among Four Groups with Different Self-Perceived Health Status in Taiwan. Appl Res Qual Life. déc 2017;12(4):799–812.
- 7. Kamolthip R, Fung XCC, Lin CY, Latner JD, O’Brien KS. Relationships among Physical Activity, Health-Related Quality of Life, and Weight Stigma in Children in Hong Kong. Am J Health Behav. 30 sept 2021;45(5):828–42. pmid:34702430
- 8. Fila-Witecka K, Senczyszyn A, Kołodziejczyk A, Ciułkowicz M, Maciaszek J, Misiak B, et al. Lifestyle Changes among Polish University Students during the COVID-19 Pandemic. Int J Environ Res Public Health. 11 sept 2021;18(18):9571. pmid:34574496
- 9. Alimoradi Z, Ohayon MM, Griffiths MD, Lin CY, Pakpour AH. Fear of COVID-19 and its association with mental health-related factors: systematic review and meta-analysis. BJPsych Open. mars 2022;8(2):e73. pmid:35307051
- 10. Li YP, Lin CY, Kuo YJ, Chen YP, Griffiths MD. Gender Differences in the Factors Associated With the Fear of COVID-19 Among Taiwanese Older People. Inq J Health Care Organ Provis Financ. janv 2021;58:004695802110555. pmid:34812083
- 11. Kuo YJ, Chen YP, Wang HW, hsiu Liu C, Strong C, Saffari M, et al. Community Outbreak Moderates the Association Between COVID-19-Related Behaviors and COVID-19 Fear Among Older People: A One-Year Longitudinal Study in Taiwan. Front Med. 17 déc 2021;8:756985. pmid:34977064
- 12. Alimoradi Z, Broström A, Tsang HWH, Griffiths MD, Haghayegh S, Ohayon MM, et al. Sleep problems during COVID-19 pandemic and its’ association to psychological distress: A systematic review and meta-analysis. EClinicalMedicine. juin 2021;36:100916. pmid:34131640
- 13. Michaud PA, Vassalli JD, Schmitt PA, Jaffé PD, Ambresin AE. [Impact of the COVID-19 pandemic on adolescent health and development: a role to play for physicians]. Rev Med Suisse. 20 janv 2021;17(722):150–4.
- 14. Ahorsu DK, Pramukti I, Strong C, Wang HW, Griffiths MD, Lin CY, et al. COVID-19-Related Variables and Its Association with Anxiety and Suicidal Ideation: Differences Between International and Local University Students in Taiwan. Psychol Res Behav Manag. nov 2021;14:1857–66. pmid:34815723
- 15. Pramukti I, Strong C, Sitthimongkol Y, Setiawan A, Pandin MGR, Yen CF, et al. Anxiety and Suicidal Thoughts During the COVID-19 Pandemic: Cross-Country Comparative Study Among Indonesian, Taiwanese, and Thai University Students. J Med Internet Res. 24 déc 2020;22(12):e24487. pmid:33296867
- 16. Blanco C, Okuda M, Wright C, Hasin DS, Grant BF, Liu SM, et al. Mental Health of College Students and Their Non–College-Attending Peers: Results From the National Epidemiologic Study on Alcohol and Related Conditions. Arch Gen Psychiatry. 1 déc 2008;65(12):1429. pmid:19047530
- 17. Mikolajczyk RT, Maxwell AE, Naydenova V, Meier S, El Ansari W. Depressive symptoms and perceived burdens related to being a student: Survey in three European countries. Clin Pract Epidemiol Ment Health. 2008;4(1):19. pmid:18598340
- 18. Aslan I, Ochnik D, Çınar O. Exploring Perceived Stress among Students in Turkey during the COVID-19 Pandemic. Int J Environ Res Public Health. 2 déc 2020;17(23):8961. pmid:33276520
- 19. Lange KW, Nakamura Y. Lifestyle factors in the prevention of COVID-19. Glob Health J. déc 2020;4(4):146–52. pmid:33520339
- 20. Romero-Blanco C, Rodríguez-Almagro J, Onieva-Zafra MD, Parra-Fernández ML, Prado-Laguna M del C, Hernández-Martínez A. Physical Activity and Sedentary Lifestyle in University Students: Changes during Confinement Due to the COVID-19 Pandemic. Int J Environ Res Public Health. 9 sept 2020;17(18):6567. pmid:32916972
- 21. Bertrand L, Shaw KA, Ko J, Deprez D, Chilibeck PD, Zello GA. The impact of the coronavirus disease 2019 (COVID-19) pandemic on university students’ dietary intake, physical activity, and sedentary behaviour. Appl Physiol Nutr Metab. mars 2021;46(3):265–72. pmid:33449864
- 22. López-Valenciano A, Suárez-Iglesias D, Sanchez-Lastra MA, Ayán C. Impact of COVID-19 Pandemic on University Students’ Physical Activity Levels: An Early Systematic Review. Front Psychol. 15 janv 2021;11:624567.
- 23. Neria Y, Sullivan GM. Understanding the Mental Health Effects of Indirect Exposure to Mass Trauma Through the Media. JAMA. 28 sept 2011;306(12):1374. pmid:21903818
- 24. Di Renzo L, Gualtieri P, Pivari F, Soldati L, Attinà A, Cinelli G, et al. Eating habits and lifestyle changes during COVID-19 lockdown: an Italian survey. J Transl Med. déc 2020;18(1):229.
- 25. Yılmaz C, Gökmen V. Neuroactive compounds in foods: Occurrence, mechanism and potential health effects. Food Res Int. févr 2020;128:108744. pmid:31955786
- 26. Đogaš Z, Lušić Kalcina L, Pavlinac Dodig I, Demirović S, Madirazza K, Valić M, et al. The effect of COVID-19 lockdown on lifestyle and mood in Croatian general population: a cross-sectional study. Croat Med J. août 2020;61(4):309–18. pmid:32881428
- 27. Becker HC. Influence of stress associated with chronic alcohol exposure on drinking. Neuropharmacology. août 2017;122:115–26. pmid:28431971
- 28. Mallet J, Dubertret C, Le Strat Y. Addictions in the COVID-19 era: Current evidence, future perspectives a comprehensive review. Prog Neuropsychopharmacol Biol Psychiatry. mars 2021;106:110070. pmid:32800868
- 29. Nilufar Safaie, Sara Ketabi, Naimossadat Kia, Majid Mirmohammadkhani, Mohammad Reza Moonesan, Fatemeh Paknazar. Exploration of mental health problems in association with health-promoting lifestyle profile in Iranian medical students: A cross-sectional study.
- 30. Davarinejad O, Hosseinpour N, Majd T, Golmohammadi F, Radmehr F. The relationship between Life Style and mental health among medical students in Kermanshah. J Educ Health Promot. 2020;9(1):264. pmid:33282969
- 31. Gmel G, Rehm J. Measuring Alcohol Consumption. Contemp Drug Probl. sept 2004;31(3):467–540.
- 32. Skogen JC, Knudsen AK, Hysing M, Wold B, Sivertsen B. Trajectories of alcohol use and association with symptoms of depression from early to late adolescence: The Norwegian Longitudinal Health Behaviour Study: Trajectories of alcohol use and depression. Drug Alcohol Rev. mai 2016;35(3):307–16.
- 33. Salama-Younes M, Montazeri A, Ismaïl A, Roncin C. Factor structure and internal consistency of the 12-item General Health Questionnaire (GHQ-12) and the Subjective Vitality Scale (VS), and the relationship between them: a study from France. Health Qual Life Outcomes. déc 2009;7(1):22.
- 34. Shevlin M, Adamson G. Alternative Factor Models and Factorial Invariance of the GHQ-12: A Large Sample Analysis Using Confirmatory Factor Analysis. Psychol Assess. juin 2005;17(2):231–6. pmid:16029110
- 35.
David P Goldberg; Paul Williams. A user’s guide to the General Health Questionnaire. NFER-NELSON. 1988. 129 p.
- 36. Goldberg DP, Gater R, Sartorius N, Ustun TB, Piccinelli M, Gureje O, et al. The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med. janv 1997;27(1):191–7. pmid:9122299
- 37. Cuttilan AN, Sayampanathan AA, Ho RCM. Mental health issues amongst medical students in Asia: a systematic review [2000–2015]. Ann Transl Med. févr 2016;4(4):72. pmid:27004219
- 38. Pacheco JP, Giacomin HT, Tam WW, Ribeiro TB, Arab C, Bezerra IM, et al. Mental health problems among medical students in Brazil: a systematic review and meta-analysis. Rev Bras Psiquiatr. 31 août 2017;39(4):369–78. pmid:28876408
- 39. Zaman R, Hankir A, Jemni M. Lifestyle Factors and Mental Health. Psychiatr Danub. sept 2019;31(Suppl 3):217–20. pmid:31488729
- 40. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, et al. Burnout Among U.S. Medical Students, Residents, and Early Career Physicians Relative to the General U.S. Population: Acad Med. mars 2014;89(3):443–51. pmid:24448053
- 41. Hou WK, Lai FT, Ben-Ezra M, Goodwin R. Regularizing daily routines for mental health during and after the COVID-19 pandemic. J Glob Health. déc 2020;10(2):020315.
- 42. Goodwin R, Sugiyama K, Sun S, Aida J, Ben-Ezra M. Psychological distress after the Great East Japan Earthquake: two multilevel 6-year prospective analyses. Br J Psychiatry. mars 2020;216(3):144–50.
- 43. Hou WK, Liu H, Liang L, Ho J, Kim H, Seong E, et al. Everyday life experiences and mental health among conflict-affected forced migrants: A meta-analysis. J Affect Disord. mars 2020;264:50–68. pmid:31846902
- 44. Buckland NJ, Swinnerton LF, Ng K, Price M, Wilkinson LL, Myers A, et al. Susceptibility to increased high energy dense sweet and savoury food intake in response to the COVID-19 lockdown: The role of craving control and acceptance coping strategies. Appetite. mars 2021;158:105017.
- 45. Jia P, Liu L, Xie X, Yuan C, Chen H, Guo B, et al. Changes in dietary patterns among youths in China during COVID-19 epidemic: The COVID-19 impact on lifestyle change survey (COINLICS). Appetite. mars 2021;158:105015. pmid:33121998
- 46. Deschasaux-Tanguy M, Druesne-Pecollo N, Esseddik Y, de Edelenyi FS, Allès B, Andreeva VA, et al. Diet and physical activity during the coronavirus disease 2019 (COVID-19) lockdown (March–May 2020): results from the French NutriNet-Santé cohort study. Am J Clin Nutr. 6 avr 2021;113(4):924–38. pmid:33675635
- 47. Mitchell ES, Yang Q, Behr H, Deluca L, Schaffer P. Self-reported food choices before and during COVID-19 lockdown [Internet]. Nutrition; 2020 juin [cité 2 févr 2022]. Disponible sur: http://medrxiv.org/lookup/doi/10.1101/2020.06.15.20131888
- 48. Sidor A, Rzymski P. Dietary Choices and Habits during COVID-19 Lockdown: Experience from Poland. Nutrients. 3 juin 2020;12(6):1657. pmid:32503173
- 49. Lechner WV, Laurene KR, Patel S, Anderson M, Grega C, Kenne DR. Changes in alcohol use as a function of psychological distress and social support following COVID-19 related University closings. Addict Behav. nov 2020;110:106527. pmid:32679435
- 50. Darbe Esfahani F, Motaghedifard M, Arfaei F, Shekari A, Abbasi Moghadam M. Correlation of Islamic Lifestyle with Life Satisfaction and Mental Health. islife. 1 sept 2018;2(3):131–5.
- 51.
Oxford World School. Life-skills based education: Why is it important? [Internet]. Disponible sur: https://oxfordworldschool.com