Alcohol use, mental health status, and alcohol-related problems in university students amid COVID-19 pandemic

doi:10.21203/rs.3.rs-3202403/v1

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Research Article

Alcohol use, mental health status, and alcohol-related problems in university students amid COVID-19 pandemic

https://doi.org/10.21203/rs.3.rs-3202403/v1

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Background

Alcohol is widely used by university students worldwide and associated with mental health problems, but little is known about its prevalence amid the COVID-19 pandemic, particularly in Asian regions. We aimed to investigate alcohol use, mental health status, and alcohol-related problems in university students amid the COVID-19 pandemic.

Methods

In this secondary analysis of a randomized controlled trial study, we recruited students with Alcohol Use Disorder Identification Test (AUDIT) ≥ 8 from 10 local universities during the pandemic (2020–2022) in Hong Kong. Alcohol-related problems were measured by the Academic Role Expectations and Alcohol Scale (AREAS). Anxiety and depressive symptoms were measured by General Anxiety Disorder-2 (GAD-2) and two-item Patient Health Questionnaire (PHQ-2). Socio-demographic and alcohol-drinking behaviors were also assessed. Adjusted unstandardized coefficients (b) for AREAS score and odds ratio (AOR) for the academic problems were calculated, and interactions by mental health status were assessed.

Results

Of 772 participants (mean age: 21.2, 47.9% male), the mean AREAS score was 2.4 (SD 3.2) and 68.2% had underage drinking. 69.3% binge drank and 28.9% had heavy drinking in the past 30-day, and 38.0% reported increased drinking amid the COVID-19 pandemic. 28.3% and 28.8% had anxiety and depressive symptoms, respectively. Higher drinking frequency, binge drinking, heavy drinking, anxiety, and depressive symptoms were associated with higher AREAS scores (adjusted b range 0.78–1.85, all P < 0.05). Binge drinking was associated with late for class, class absenteeism, class inattention, and late assignment submission (AORs range 1.75–3.89, all P < 0.05). Participants with anxiety or depressive symptoms had stronger associations of higher drinking frequency (anxiety: b 1.72 vs. 1.03; depression: 2.47 vs. 0.83), binge drinking (anxiety: b 2.77 vs. 1.73; depression: 2.94 vs. 1.63), and heavy drinking (anxiety: b 2.42 vs. 1.17; depression: 2.61 vs. 1.27) with AREAS scores (all P for interactions < 0.05).

Conclusions

University students had a high prevalence of binge drinking, heavy drinking, and mental health problems amid the COVID-19 pandemic. Alcohol use in the pandemic was associated with multiple alcohol-related problems, particularly in university students with mental health problems. Interventions are warranted to reduce alcohol use and related harm in the future.

Alcohol use

Mental health status

Alcohol-related problems

University students

China

COVID-19 pandemic

Alcohol use causes substantial disease burden and health loss in Hong Kong (HK) and globally [1]. It is one of the leading risk factors of disability-adjusted life years (DALYs) loss in young adults [2]. Since the HK government implemented zero alcohol tax on alcoholic beverages with a strength of less than 30% to promote HK as the Asian wine hub in the world, the prevalence of monthly alcohol drinking in young adults has doubled (19–40%) in a decade between 2007 and 2016 [3]. University students were more vulnerable to alcohol-related harms than non-university attending peers [4], risk factors including more social gatherings, peer pressures on drinking, and increased academic stress within the university environment [5]. The COVID-19 pandemic has worsened alcohol use globally. Social distancing measures implemented during the pandemic have increased the risks of excessive alcohol use among university students [6, 7]. However, the effect of the COVID-19 pandemic on alcohol-drinking behaviors (e.g., drinking frequency, binge drinking, and heavy drinking) and alcohol-related harms were underexamined.

Governments worldwide have implemented stringent measures to prevent the spread of COVID-19. After the first confirmed case in HK (23 January 2020), the government adopted various policies, including quarantine of confirmed cases, school suspensions, and the shutdown of non-essential services and bars to mitigate the spread of COVID-19 [8]. University students experienced more psychological distress than before as they fear contracting COVID-19 and lack social support [6, 9]. These students were more likely to use alcohol to cope with stress and pandemic uncertainty [6]. A study examined the impact of pandemic alcohol use on alcohol-related harms in university students; students who reported increased drinking during the COVID-19 pandemic were significantly associated with more alcohol-related injuries and poorer academic performance at the end of the semester compared to non-drinking students [10]. Understanding the mental health status and alcohol-drinking behaviors might facilitate the design of interventions to prevent subsequent alcohol-related harms in university students.

HK is one of the most westernized cities in China. Poorer mental health and increased alcohol use were observed among university students in European [9], and North American countries amid the COVID-19 pandemic [11], but the prevalence and alcohol-related harms were understudied in Asian regions, particularly Chinese population. Alcohol use and mental health problems are public health concerns worldwide due to the adverse effects on young adults' growth and development [12, 13]. Therefore, this study aimed to assess: (1) the alcohol-drinking behaviors and mental health status; (2) the harms associated with alcohol-drinking behaviors; and (3) the moderating effects of mental health status on these associations among university students amid the COVID-19 pandemic in HK.

Study design

We conducted a secondary analysis of a two-group, pragmatic, randomized controlled trial on university student drinkers in HK. The trial was registered with ClinicalTrials.gov, number NCT04025151. From October 2020 to May 2022, we recruited participants from 10 local universities using the face-to-face approach and online platforms (e.g., university bulk emails and social media promotion). Trained student helpers and research nurses proactively approached potential participants on campus and used Alcohol Use Disorder Identification Test (AUDIT) to determine eligibility. Participants were HK residents aged 18 years or older who were able to read and communicate in Chinese; had stayed in HK for 12-month; had installed instant messaging (IM) apps on a smartphone; and had AUDITs ≥ 8 [14]. We excluded participants with histories of psychiatric disorders or participating in other alcohol treatment programmes. Ethical approval was sought from the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (Ref. UW 19–103). A coupon of HK$50 (about US$6.4) was given to eligible participants who joined the study as a small incentive. The results of the trial will be published elsewhere.

Measures

We collected participants' socio-demographic characteristics (e.g., sex, age, and perceived family affluence) and alcohol-drinking behaviors at baseline. Alcohol-drinking behaviors included past 30-day drinking frequency, weekly alcohol consumption (alcohol units) [15], binge drinking in the past 30-day (4 or more standard drinks for women; 5 or more standard drinks for men on one occasion) [15], heavy drinking in the past 30-day (8 or more standard drinks for women; 15 more standard drinks for men per week) [15], age of first drinking, and drinking behavior amid pandemic (reduced drinking/no change/increased drinking). These tools used to measure drinking quantity and frequency have been extensively validated and used with this population [15]. The main outcome was alcohol-related problems, measured by the Academic Role Expectation and Alcohol Scale (AREAS) [16]. The AREAS included four alcohol-related academic problems, which measured the frequency of late for class, class absenteeism, class inattention, and late assignment submission due to alcohol consumption in the past 3-month. The response options were: 0= "not at all", 1= "once", 2= "twice", 3= "three times", and 4= "four times or more". The combined score on the scale ranged from 0–16, with higher scores indicating more academic problems.¹⁶ The internal consistency of the scale was measured by Cronbach's alpha with a coefficient of 0.76 [16]. We measured mental health status by General Anxiety Disorder-2 (GAD-2) and the two-item Patient Health Questionnaire (PHQ-2) (both scores range from 0–6; ≥ 3 indicating anxiety or depressive symptoms). Both scales are reliable in measuring depression and anxiety in university students, with Cronbach's alpha of 0.82 and 0.78, respectively [17].

Statistical analysis

Descriptive statistics were used to describe the socio-demographic characteristics, alcohol-drinking behaviors, and the prevalence of anxiety (GAD-2 score ≥ 3) and depression (PHQ-2 score ≥ 3) of the participants. The associations of alcohol-drinking behaviors (baseline AUDITs, drinking frequency, age of first drinking, binge drinking in the past 30-day, and heavy drinking in the past 30-day) and mental health status (anxiety and depressive symptoms) with the AREAS score were analyzed using multivariable linear regression (adjusted unstandardized coefficient, b), adjusting for baseline socio-demographic characteristics and weekly alcohol consumption (alcohol unit). Multiple logistic regression (adjusted odds ratio, AOR) was used to measure the associations of alcohol-drinking behaviors and mental health status with each alcohol-related academic problem (late for class, class absenteeism, class inattention, late assignment submission), adjusting for baseline socio-demographic characteristics and weekly alcohol consumption (alcohol unit). For the analysis, the response option of 0= "not at all" was coded as 0= "never", and 1= "once", 2= "twice", 3= "three times", and 4= "four times or more" were combined and coded as 1= "ever". Effect modifications by anxiety and depressive symptoms (< 3/ ≥ 3) on the association of alcohol-drinking behaviors with the AREAS score were analyzed using multiplicative interaction terms. All analyses were conducted in Stata 15.1. A two-sided P-value smaller than 0.05 was considered statistically significant.

Table 1 shows the baseline socio-demographic characteristics, alcohol-drinking behaviors, and mental health status of 772 participants. 52.1% of participants were female, the mean age was 21.1 (SD 3.5), and 75.2% perceived their family affluence as average or above. The mean AUDITs and weekly alcohol consumption (alcohol unit) were 12.8 (SD 5.1) and 8.7 (SD 3.7), respectively. 87.3% drank two times per month or more, 68.2% had underage drinking, 69.3% binged drinks in the past 30-day, 28.9% had heavy drinking in the past 30-day, and 38% reported increased drinking amid the COVID-19 pandemic. 28.3% had anxiety symptoms, and 28.8% had depressive symptoms.

Table 1

Socio-demographic characteristics, alcohol-drinking behaviors, and mental health status of 772 participants
	mean/ n	SD/ %
Sex
Male	370	47.9%
Female	402	52.1%
Age ^a.	21.1	3.5
Perceived family affluence
Poor	36	4.7%
Below average	153	20.1%
Average	508	66.6%
Above average	66	8.6%
Alcohol Use Disorder Identification Test score ^a.	12.8	5.1
Weekly alcohol consumption (alcohol unit) ^{a, b}.	8.7	3.7
Drinking frequency
Never	10	1.3%
Monthly	87	11.3%
2–4 times per month	469	61.1%
2–3 times per week	179	23.3%
Everyday	22	2.9%
Age of first drinking
12 years or below	66	8.6%
13–17 years	458	59.6%
18 years or above	245	31.8%
Binge drinking ^c.
Never	236	30.7%
Monthly	268	34.9%
2–4 times per month	227	29.6%
2–3 times per week	34	4.4%
Everyday	3	0.4%
Heavy drinking ^d.
Never	546	71.1%
Monthly	166	21.6%
2–3 times per month	43	5.6%
Every week	13	1.7%
Drinking behavior amid pandemic
No change	215	28.1%
Reduced drinking	259	33.9%
Increased drinking	290	38.0%
Anxiety symptoms ^e.
< 3	550	71.7%
≥ 3	217	28.3%
Depressive symptoms ^f.
< 3	547	71.2%
≥ 3	221	28.8%
a. Data are mean (SD).
b. One alcohol unit contains 10g of pure alcohol.
c. Binge drinking is defined as consuming 4 or more standard drinks for women; 5 or more standard drinks for men on an occasion.
d. Heavy drinking is defined as consuming 8 or more standard drinks for women; 15 or more standard drinks for men per week.
e. Measured by General Anxiety Disorder-2 (GAD-2). ≥ 3 indicated anxiety symptoms.
f. Measured by two-item Patient Health Questionnaire (PHQ-2). ≥ 3 indicated depressive symptoms.

Table 2 shows the mean AREAS score was 2.4 (SD 3.2). The most common alcohol-related problem of the past 3-month was class inattention (46.3%), followed by class absenteeism (28.3%), late for class (27.5%), and late assignment submission (16.2%).

Table 2

Prevalence of alcohol-related problems of 772 participants
	mean /n	SD/ %
Academic Role Expectation and Alcohol Scale (AREAS) ^a.	2.4	3.2
Late for class (past 3-month)
Never	557	72.5%
Ever	211	27.5%
Class absenteeism (past 3-month)
Never	551	71.7%
Ever	217	28.3%
Class inattention (past 3-month)
Never	412	53.7%
Ever	355	46.3%
Late assignment submission (past 3-month)
Never	644	83.8%
Ever	124	16.2%

a. Total score 0-16. Higher scores indicated more alcohol-related academic problems in the past 3-month.

Table 3 shows that drinking 2 times per week or more (adjusted b, 95% CI: 1.05, 0.11–1.99), binge drinking once (adjusted b: 1.06, 0.43–1.70) or 2 times per month or more (adjusted b: 1.85, 1.17–2.53), heavy drinking monthly or more (adjusted b: 1.39, 0.77–2.01), and having anxiety (adjusted b: 0.78, 0.20–1.36) or depressive symptoms (adjusted b: 1.12, 0.54–1.69) were significantly associated with higher AREAS score.

Table 3

Associations of alcohol-drinking behaviors and mental health status with Academic Role Expectation and Alcohol Scale (AREAS) in 772 participants
	Academic Role Expectation and Alcohol Scale (AREAS) ^a.
	mean (SD)	Crude b (95% CI)	Adjusted b (95% CI) ^b.
Baseline AUDITs ^c.		0.02 (-0.03, 0.06)	0.02 (-0.02, 0.08)
Drinking frequency ^d.
Monthly or less	1.49 (2.65)	0	0
2–4 times per month	2.29 (2.98)	0.80 (0.10, 1.50) *	0.49 (-0.32, 1.30)
2 times per week or more	3.13 (3.79)	1.64 (0.87, 2.41) ***	1.05 (0.11, 1.99) *
Age of first drinking
18 years or above	2.23 (3.19)	0	0
13–17 years	2.54 (3.23)	0.31 (-0.19, 0.81)	0.02 (-0.55, 0.59)
12 years or below	2.11 (3.16)	-0.12 (-0.99, 0.75)	-0.47 (-1.48, 0.54)
Binge drinking ^e.
Never	1.24 (2.12)	0	0
Monthly	2.32 (3.06)	1.09 (0.55, 1.62) ***	1.06 (0.43, 1.70) **
2 times per month or more	3.53 (3.74)	2.29 (1.75, 2.83) ***	1.85 (1.17, 2.53) ***
Heavy drinking ^f.
Never	1.94 (2.86)	0	0
Monthly or more	3.54 (3.72)	1.60 (1.11, 2.09) ***	1.39 (0.77, 2.01) ***
Drinking behavior amid pandemic
No change	2.07 (2.97)	0	0
Reduced drinking	2.41 (3.45)	0.34 (-0.24, 0.92)	0.50 (-0.17, 1.18)
Increased drinking	2.69 (3.16)	0.62 (0.05, 1.18) *	0.60 (-0.04, 1.24)
Anxiety symptoms ^g.
< 3	2.22 (3.12)	0	0
≥ 3	2.88 (3.41)	0.66 (0.16, 1.17) *	0.78 (0.20, 1.36) **
Depressive symptoms ^h.
< 3	2.07 (2.98)	0	0
≥ 3	3.23 (3.60)	1.15 (0.66, 1.65) ***	1.12 (0.54, 1.69) ***
a. Total score 0–16. Higher score indicated more alcohol-related academic problems in the past 3-month.
b. Regression: adjusted for sex, age, family affluence, and baseline weekly alcohol consumption (alcohol unit).
c. AUDITs stands for Alcohol Use Disorder Identification Test score.
d. Never combined with monthly as monthly or less. Everyday combined with 2–3 times per week as 2 times per week or more.
e. 2–3 times per week, and everyday combined with 2–4 times per month as 2 times per month or more.
f. Every week, and 2–3 times per month combined with monthly as monthly or more.
g. Measured by General Anxiety Disorder-2 (GAD-2). ≥ 3 indicated anxiety symptoms.
h. Measured by two-item Patient Health Questionnaire (PHQ-2). ≥ 3 indicated depressive symptoms.
* P < 0.05; P < 0.01; * P < 0.001

Table 4 shows that binge drinking 2 times per month or more was significantly associated with being late for class (AOR, 95% CI: 3.03, 1.78–5.17), class absenteeism (AOR: 3.89, 2.31–6.53), class inattention (AOR: 1.96, 1.26–3.05), and late assignment submission (AOR: 1.75, 1.00-3.05). Binge drinking monthly was significantly associated with being late for class, class absenteeism, and class inattention (AORs range 1.81–2.85, all P < 0.01). Heavy drinking monthly or more was significantly associated with being late for class, class absenteeism, and class inattention (AORs range 1.91–2.32, all P < 0.01). Increased drinking amid pandemic was significantly associated with class inattention (AOR: 1.69, 1.13–2.52). Participants with anxiety or depressive symptoms were significantly associated with class inattention (anxiety: AOR 1.70, 1.18–2.46; depression: AOR 2.05, 1.41–2.97) and late assignment submission (anxiety: AOR 1.71, 1.10–2.65; depression: AOR 2.52, 1.63–3.89).

Table 4

Associations of alcohol-drinking behaviors and mental health status with late for class, class absenteeism, class inattention, and late assignment submission in 772 participants
	Late for class (never/ever) AOR (95% CI) ^a.	Class absenteeism (never/ever) AOR (95% CI) ^a.	Class inattention (never/ever) AOR (95% CI) ^a.	Late assignment submission (never/ever) AOR (95% CI) ^a.
Baseline AUDITs ^b.	1.02 (0.99, 1.06)	1.03 (1.00, 1.07)	0.99 (0.96, 1.02)	1.00 (0.96, 1.04)
Drinking frequency ^c.
Monthly or less	1	1	1	1
2–4 times per month	1.35 (0.73, 2.52)	1.29 (0.70, 2.37)	1.24 (0.74, 2.08)	1.64 (0.78, 3.48)
2 times per week or more	1.54 (0.77, 3.10)	1.55 (0.79, 3.06)	1.17 (0.65, 2.13)	1.80 (0.78, 4.13)
Age of first drinking
18 years or above	1	1	1	1
13–17 years	1.10 (0.73, 1.64)	0.93 (0.63, 1.37)	1.24 (0.86, 1.77)	0.96 (0.61, 1.50)
12 years or below	0.64 (0.29, 1.37)	0.83 (0.41, 1.70)	0.74 (0.39, 1.41)	0.53 (0.21, 1.36)
Binge drinking ^d.
Never	1	1	1	1
Monthly	2.85 (1.71, 4.75) ***	2.30 (1.38, 3.82) **	1.81 (1.20, 2.74) **	1.16 (0.67, 2.00)
2 times per month or more	3.03 (1.78, 5.17) ***	3.89 (2.31, 6.53) ***	1.96 (1.26, 3.05) **	1.75 (1.00, 3.05) *
Heavy drinking ^e.
Never	1	1	1	1
Monthly or more	2.32 (1.54, 3.52) ***	2.09 (1.38, 3.16) ***	1.91 (1.29, 2.85) **	1.56 (0.97, 2.51)
Drinking behavior amid pandemic
No change	1	1	1	1
Reduced drinking	1.47 (0.90, 2.37)	1.02 (0.64, 1.63)	1.30 (0.85, 2.00)	1.50 (0.85, 2.65)
Increased drinking	1.49 (0.94, 2.35)	0.99 (0.64, 1.53)	1.69 (1.13, 2.52) *	1.67 (0.98, 2.85)
Anxiety symptoms ^f.
< 3	1	1	1	1
≥ 3	1.07 (0.71, 1.61)	1.22 (0.82, 1.82)	1.70 (1.18, 2.46) **	1.71 (1.10, 2.65) *
Depressive symptoms ^g.
< 3	1	1	1	1
≥ 3	1.49 (1.00, 2.20) *	1.30 (0.88, 1.93)	2.05 (1.41, 2.97) ***	2.52 (1.63, 3.89) ***
a. Regression: adjusted for sex, age, family affluence, and baseline weekly alcohol consumption (alcohol unit).
b. AUDITs stands for Alcohol Use Disorder Identification Test score.
c. Never combined with monthly as monthly or less. Everyday combined with 2–3 times per week as 2 times per week or more.
d. 2–3 times per week, and everyday combined with 2–4 times per month as 2 times per month or more.
e. Every week, and 2–3 times per month combined with monthly as monthly or more.
f. Measured by General Anxiety Disorder-2 (GAD-2). ≥ 3 indicated anxiety symptoms.
g. Measured by two-item Patient Health Questionnaire (PHQ-2). ≥ 3 indicated depressive symptoms.
* P < 0.05; P < 0.01; * P < 0.001

Table 5 shows that the association of alcohol-drinking behaviors with the AREAS score was modified by anxiety and depressive symptoms. Participants with anxiety or depressive symptoms had stronger associations of higher drinking frequency (anxiety: adjusted b 1.72 vs. 1.03; depression: adjusted b 2.47 vs. 0.83), binge drinking (anxiety: adjusted b 2.77 vs. 1.73; depression: adjusted b 2.94 vs. 1.63), heavy drinking (anxiety: adjusted b 2.42 vs. 1.17; depression: adjusted b 2.61 vs. 1.27), and increased drinking amid pandemic (anxiety: adjusted b 1.52 vs. 0.21; depression: adjusted b 1.84 vs. 0.37) with the AREAS score (all P for interactions < 0.05).

Table 5

Association of alcohol-drinking behaviors with Academic Role Expectation and Alcohol Scale (AREAS) by anxiety and depressive symptoms in 772 participants
	Academic Role Expectation and Alcohol Scale (AREAS) ^a.
	Adjusted b (95% CI) ^b.		Adjusted b (95% CI) ^b.
	Anxiety symptoms ^c.		Depressive symptoms ^d.
	< 3	≥ 3	< 3	≥ 3
Baseline AUDITs ^e.	0.01 (-0.04, 0.06)	0.06 (-0.01, 0.11)	0.01 (-0.04, 0.06)	0.10 (0.04, 0.16) *
Interaction	< 0.05		< 0.001
Drinking frequency ^f.
Monthly or less	0	0	0	0
2–4 times per month	0.36 (-0.61, 1.34)	1.32 (0.22, 2.41) *	0.51 (-0.46, 1.49)	1.49 (0.36, 2.61) *
2 times per week or more	1.03 (-0.07, 2.12)	1.72 (0.34, 3.10) *	0.83 (-0.28, 1.94)	2.47 (1.16, 3.78) ***
Interaction	< 0.05		< 0.001
Age of first drinking
18 years or above	0	0	0	0
13–17 years	0.10 (-0.57, 0.76)	0.89 (0.04, 1.74) *	0.11 (-0.54, 0.76)	0.97 (0.16, 1.78) *
12 years or below	-0.16 (-1.38, 1.06)	-0.25 (-1.90, 1.39)	-1.17 (-2.48, 0.13)	1.16 (-0.27, 2.60)
Interaction	0.11		< 0.01
Binge drinking ^g.
Never	0	0	0	0
Monthly	0.90 (0.16, 1.64) *	1.98 (0.98, 2.98) ***	0.87 (0.14, 1.60) *	2.34 (1.30, 3.37) ***
2 times per month or more	1.73 (0.96, 2.51) ***	2.77 (1.73, 3.80) ***	1.63 (0.86, 2.42) ***	2.94 (1.98, 3.91) ***
Interaction	< 0.001		< 0.001
Heavy drinking ^h.
Never	0	0	0	0
Monthly or more	1.17 (0.47, 1.87) **	2.42 (1.42, 3.42) ***	1.27 (0.57, 1.98) ***	2.61 (1.64, 3.58) ***
Interaction	< 0.001		< 0.001
Drinking behavior amid pandemic
No change	0	0	0	0
Reduced drinking	0.46 (-0.31, 1.23)	0.81 (-0.31, 1.93)	0.46 (-0.32, 1.25)	1.37 (0.32, 2.43) *
Increased drinking	0.21 (-0.54, 0.96)	1.52 (0.60, 2.43) *	0.37 (-0.37, 1.12)	1.84 (0.90, 2.78) ***
Interaction	< 0.05		< 0.05
a. Total score 0–16. Higher score indicated more alcohol-related academic problems in the past 3-month.
b. Regression: adjusted for sex, age, family affluence, and baseline weekly alcohol consumption (alcohol unit).
c. Measured by General Anxiety Disorder-2 (GAD-2). ≥ 3 indicated anxiety symptom.
d. Measured by two-item Patient Health Questionnaire (PHQ-2). ≥ 3 indicated depressive symptom.
e. AUDITs stands for Alcohol Use Disorder Identification Test score.
f. Never combined with monthly as monthly or less. Everyday combined with 2–3 times per week as 2 times per week or more.
g. 2–3 times per week, and everyday combined with 2–4 times per month as 2 times per month or more.
h. Every week, and 2–3 times per month combined with monthly as monthly or more.
* P < 0.05; P < 0.01; * P < 0.001

This is the first study to assess the impact of the COVID-19 pandemic on alcohol-drinking behaviors, mental health status, and alcohol-related problems among Chinese university students. The prevalence of binge drinking (69.3%) amid the COVID-19 pandemic was greater than in some North American countries, including Canada (60%) [11], and the US (24.6%) [10]. The prevalence of reported increased drinking (38%) was comparable to the US (33%) [12] and German students (46%) [18]. Fear of contracting COVID-19 and strict social distancing measures increased stress and anxiety [8], and these psychological distresses might trigger alcohol cravings [6]. Loneliness, lack of social contact, and disrupted academic life during home isolation were associated with increased alcohol consumption in university students [19]. The shutdown of non-essential services restricted students from accessing face-to-face counseling and seeking alcohol treatment services [18].

The present study showed that the prevalence of anxiety (28.3% vs. 14%) and depressive symptoms (28.8% vs. 19%) among university students were greater than the general population in HK amid the COVID-19 pandemic [8]. Younger age was one of the positive predictive factors for poorer mental health outcomes [18]. University students had lower resilience compared to older age groups when adapting to abrupt changes in daily life as they had less financial support and unstable income [20]. These abrupt changes amid the COVID-19 pandemic were associated with higher anxiety and depressive symptoms [10]. Isolation further deprived students of social activities that were important to their mental wellbeing [19, 21]. Our study provided implications that university students were more vulnerable to mental health problems than other age groups. Longitudinal studies are needed to investigate the changes and co-occurrence of mental health problems and alcohol use during the COVID-19 pandemic.

University students experienced various types of alcohol-related academic problems amid the COVID-19 pandemic; the most prevalent problem was class inattention (46%). The COVID-19 pandemic caused changes in the education sector, and school curricula had to adapt to a non-face-to-face modality (e.g., Zoom). During home isolation, the risk exposed to alcohol drinking increased compared to the pre-pandemic period when students had more time spent at school [6]. Alcohol use significantly predicted lower concentration and poorer academic performance among university students [4, 22]. Drinking students with poor academic performance had lower motivation to learn and further decreased class attendance [23]. Interventions are warranted to reduce alcohol use in university students and prevent subsequent alcohol-related harms amid the COVID-19 pandemic.

University student drinkers with anxiety or depressive symptoms were associated with more alcohol-related academic problems compared to students without mental health problems. The findings were supported by a systematic review, which showed a clear association between poor mental health and delayed study progress in university students [24]. Students with depressive symptoms had four times the risk of experiencing low academic self-efficacy compared to students without mental health problems [12]. Anxiety and depressive symptoms contributed to worriedness, and in combination with procrastination and avoidance behaviors [24], which delayed students' learning progress. In addition, alcohol use further worsens mental health by impairing the brain's inhibitory systems and triggering more psychological distresses [18, 22]. Health promotion activities are needed to target alcohol use among university students with mental health problems.

This study has some limitations. First, the causal inference could not be drawn as the cross-sectional data was used. The relations between alcohol use, mental health problems, and alcohol-related problems were multidirectional, and cohort studies are needed to confirm our observations. Second, the data are self-reported and might be subject to social-desirability bias, but under-reporting was less likely to occur due to the normalization of alcohol-drinking behaviors among university students [25]. Third, the representativeness of the study might be limited as participants were university students, and whether the findings are generalizable to non-university student drinkers needed to be tested.

University students had a high prevalence of mental health problems and alcohol use, including binge drinking and heavy drinking, amid the COVID-19 pandemic. Alcohol use was associated with multiple academic problems, and these associations were stronger in students with anxiety or depressive symptoms. Our study implies that universities should implement mental health promotion programs to increase awareness of mental health problems and alcohol use among university students. Intervention should be personalized for young adults and delivered by digital platforms (e.g., mobile devices) to overcome the barriers to accessing treatment services amid the COVID-19 pandemic.

Acknowledgments

The authors thank the study participants for participating in this study. This study is not supported by any grant or funding.

Authors' contributions

Study conception and design: MPW, Design of literature search strategy: SLC, MPW, Literature search and screening: SLC, MPW, Analysis and result presentation: SLC, YCW, YW, MPW, Interpretation of results: SLC, YCW, YW, MPW, Manuscript preparation: SLC, MPW. All authors reviewed the results and approved the final version of the manuscript.

Funding

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethical approval and consent to participate

All participants provided written and oral informed consents before participating in the study, in accordance with the Declaration of Helsinki, and researchers guaranteed the anonymity of data. This study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (Ref. UW 19-103).

Consent for publication

Not applicable.

Competing interests

None to declare.

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No competing interests reported.

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Alcohol use, mental health status, and alcohol-related problems in university students amid COVID-19 pandemic

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