The aim of this study was to investigate psychosomatic symptoms such as digestive disorders, headache and fear of COVID-19 associated with lifestyle changes due to the COVID-19 pandemic and dynamic and unpredictable social restrictions measures in Chile. In-depth analysis of these issues can help to study potentially comparable contexts of vulnerability and isolation, even post-pandemic.
The target population was composed of university students attending the University of Desarrollo, Santiago de Chile. Participants to the survey reported to have experienced headache, digestive disorders and high fear of getting infected by SARS-Cov-2 during lockdown and pandemic. All of these factors were significantly associated with lifestyle changes, such as nutrition, weight changes, physical activity and the presence of COVID-19 symptoms. Additionally, sleep quality, mnemonic difficulties and performance reduction were found to be associated with digestive disorders and headache.
This survey confirms a gender susceptibility to psychosomatic outcomes such as digestive disorders. Previous studies had in fact demonstrated how vulnerability to stress involved much more the female gender than males (21, 22). Surveys of the general population have shown that compared to men, women are more likely to report temporary and persistent pain, particularly more severe pain, more frequent pain, and long-lasting pain (23). Recently, neuroimaging studies showed sex-related differences in brain response to visceral and psychological symptoms, which cannot be explained by sensory input differences. Looking at the brain it is possible to see an inhibition of limbic regions, such as the amygdala when men are experiencing gastrointestinal symptoms; in the same condition, females tend to show greater activation of affective and autonomic areas, like ventromedial prefrontal cortex, amygdala and inferior cingulate (24). This brain activity pattern could be related to a different experience of gastrointestinal symptoms following stressful situations, which could explain the different report of digestive disorders in our sample between males and females. Our survey, which confirms a trend of this type, follows the need to provide gender-based medicine and care (25). This study found that physical activity, diet, weight changes and symptoms of COVID-19 are associated with digestive disorders. Social isolation reduced the time spent outdoors and physical activities, leading to weight gain. In fact, 49.9% of students reported gaining weight and 27.1% worsening their eating habits. This trend could be explained by the immediate access to food during the quarantine and an increase in the number of snacks during the day, especially for women (26). However, a trend reversal was seen in 24.6% of respondents who experienced weight loss. This could stem from concerns about weight gain due to disruption of sporting opportunities (thereby reducing caloric intake) or from increased physical activity at home. Exposure to stress can alter both the quantity and quality of caloric consumption (26) and stressful events such as the pandemic can lead to activation of the hypothalamic-pituitary-adrenal (HPA) neuroendocrine axis and increased glucocorticoid synthesis (27). Triggering behaviors of this type can lead to non-adherence to a varied and healthy diet, leading to gastrointestinal distress (28) and headache (29). These trends should be prevented in the university settings, by greater promotion of nutritional health courses and access to dietary services.
Among the factors that have contributed to an impact on digestive disorders there have also been changes in lifestyle habits. For example, increased telephone use and poor quality sleep have been associated with worsening or onset of digestive disorders. An increase in phone usage of more than 6 hours of screen time per day was found in almost half of the sample. The relationship between phone use and digestive upset may be multidirectional. In fact, people often adopt unhealthy eating habits while using the phone (e.g. eating snacks, drinks, irregular meals) (30, 31), leading to an increase iof gastrointestinal disorders (32).
Furthermore, during the covid-19 pandemic, one of the main sources of information for university students was social media or the internet (33, 34). A great deal of information may have been found online, which included misinformation and conspiracy theories. This large amount of information that should be filtered and processed quickly, coupled with the variable nature of information associated with dynamic blocking mode, can foster feelings of uncertainty. All these factors could cause an information overload in the population, which consequently resulted in an increase of stress levels, depression and anxiety (35) manifesting at a psychosomatic level with digestive disorders. However, the relationship between phone use and psychosomatic disorders is two-way: the combination of high amounts of stress and self-doubt has in turn been associated with a higher risk of cell phone addiction (36). The COVID-19 infodemic requires spending more time with a smartphone and online sources to keep properly updated, increasing the stress and insecurity that lead to cell phone addiction, and therefore creating a vicious cycle. Self-reported stress, depression and anxiety have been associated with gastrointestinal disorders (37). Therefore this association of increased time in front of the screen and increased discomfort could indirectly explain the higher prevalence of digestive disorders and our study confirms this trend by focusing on the need for psychoeducation courses for the correct use of electronic devices and information. In addition to digestive complaints, the clinical outcome of headache was also observed in 86% of respondents. This is consistent with other studies that have shown headache to be a clinically significant problem during lockdown (38, 39). However, the relationship between isolation and headache remains controversial: other studies have identified an improvement in symptoms during the pandemic among patients already suffering from severe migraine (40). Regarding the worsening trajectory of headache, we could identify several contributing factors: social isolation (41) ,changing sleep habits (42) and eating habits (43). Changes and obstacles in medical care (basic and specialist) may have contributed to the consolidation of this clinical outcome in a problematic direction (44, 45). In this study age was also negatively associated with the onset of headache episodes. The age variability of the participants in this study is not large enough to allow inferences related to changes in headache and migraine over the years, but we can hypothesize that younger students were less exposed to "awareness". The recipients of this questionnaire were in fact university students, therefore with a high level of education and previous surveys had highlighted how this could represent a factor of vulnerability as a high level of education could lead to greater awareness and consequently anguish (22) and psychosomatic symptoms such as headache.
Poor sleep quality, memory difficulties and reduced performance increased the risk of developing two of the symptoms examined, headache and digestive disorders. The relationship between sleep and physical disorders such as headache (46) and gastrointestinal disorders (47) has already been widely described in the literature, as well as the link between epidemics and chronic sleep disorders (48) and our investigation confirms these difficulties also in a dynamic and unpredictable context in terms of restrictions. The disruption of sleep quality and quantity has a negative impact on memory performance, furthermore it could affect other aspects such as mental health and quality of life (49).
In general, fear of COVID-19 and stress have been associated with depression (50), so future follow up studies should investigate the level of depression in this population to see if this association is also consistent in a context such as Chile.
This study provides a better understanding of the impact of pandemics on the psychological and physical health of students in a country where lockdown measures were not managed at the national level, but at the community level. While not all participants may have experienced social isolation, overall headache, indigestion and fear of covid appear to be common outcomes for young adults (19). All of these health outcomes appear to be strongly influenced by decreased physical activity and worsening nutrition, so preventive interventions should be undertaken to maintain these healthy behaviors also when outdoor activity is limited. Sleep quality has an impact on headache and digestive upset, so promoting sleep hygiene practices will improve students’ health. The "dynamic quarantine" policy adopted in Chile, may have created a sense of insecurity and uncertainty in the population. This insecurity can explain the high fear ratios of covid that we have registered in almost half of the students. This aspect could contribute to increased levels of stress and symptoms of anxiety and depression (50). Fear of the physical consequences caused by the disease, of being a vector of contagion for others, and uncertainty about the future developments may have impacted the study population, negatively influencing the psychophysical well-being of the students. Psychoeducation and teletherapy interventions can be useful to improve the students’ mental health (51). Wider use of telehealth and teletherapy can help address mental health conditions (52, 53). Affordable remote medical and mental health care can provide early diagnosis to minimize the severity of the effects of isolation and can have direct consequences for a reduction in school dropouts(54).It has been shown that mindfulness-based psychological interventions have demonstrated a significant improvement in the feeling of loneliness that could emerge in these situations(55) and this should be taken into account in programs to promote well-being in the university contest(56).
Poor accessibility to health systems (57), poor nutrition (58), isolated conditions (59), concerns about economic factors (60) and poor quality of sleep (61) are all problems that concern not only pandemic events but also some realities of minorities. The findings from this study should be addressed by public health professionals as they can be generalized to other contexts leading to social isolation that were not specifically considered in our study. The situations in which the problem of isolation and forced marginalization arises in potentially healthy populations concern in particular refugees, immigrants, and prisoners. Risk factors such as racism, discrimination, language barriers and separation from family members predispose immigrants and refugees to an increased risk of social isolation and the occurrence of these clinical outcomes without adequate care. This is becoming especially real in the Chilean context, as Chile is increasingly becoming a host country for South-South migration (62).
Another context in which enforced social isolation becomes very significant is prison. Prison is an acute form of social exclusion (63) which does not allow access to key areas of social life (64). An analysis on a sample of Chilean inmates identified the stress and loss of autonomy due to the prison regime as factors that negatively affect mental well-being (65). Lack of autonomy and consequent stress are factors that have characterized the pandemic and restriction scenario. In the contexts of social isolation of the prison, other elements also follow the critical elements of the lock-down due to the pandemic: limitations in contact with the outside world, lack of freedom of movement (Haney, 2001); lack of access to consumer services and deprivation of time management opportunities and deprivation of a sense of security (Sykes, 2021).
These elements of continuity between the pandemic scenario that has affected everyone in a dynamic way in Chile and contexts of vulnerability affecting minorities should help understanding the mechanisms useful for preventing clinically significant consequences that also have a negative impact on the costs of health systems.