Improving emotional, economic and behavioural resilience to COVID-19 in African University students

Lead Research Organisation: University of Nottingham
Department Name: School of Medicine


The Covid-19 pandemic has had significant adverse effects on university students, whose education and training has been severely disrupted and their social contacts and job prospects lost. Even before the pandemic around of a third of students would had had symptoms of depression, with students who are economically disadvantaged at greatest risk. Depressed students do less well academically which has negative impacts on their employment prospects and they are also less likely to follow health advice. Thus depressed students are particularly vulnerable to the health and economic impacts of the COVID-19 pandemic. This is a particular concern for students in less developed countries such as Zambia where access to mental health services is limited by the lack of resources and by the stigma associated with psychiatric illness. This study aims to address this cycle of disadvantage by providing targeted access to an effective, online treatment programme for depression (moodgym) to a 1000 students who identify themselves as having symptoms of depression. These students will be recruited from universities in Zambia, Malawi and Botswana: all countries identified as eligible for overseas development assistance. Moodgym is based on principles of cognitive behavioural therapy and aims to reduce the risk of depression by helping users to recognize and change those negative thoughts and behaviour patterns which can drive and sustain low mood. The 5 modules are particularly aimed at young people aged 15 to 25 and include exercises, practical assignments and quizzes. This study will investigate whether combining moodgym with a university-wide online COVID-19 prevention programme will improve students' mental health and enhance their ability to withstand the health and economic challenges of COVID-19. The online COVID-19 prevention program, adapted for each local context, will portray health-promotion behaviours such as social distancing and face coverings as a normal part of student life. We will collect feedback data from the prevention programme and survey data before and after the moodgym/ COVID-19 prevention programme intervention to look for improvements in depression, academic performance and COVID prevention behaviours and to check whether benefits are felt equally by men and women. We will also interview participants to try to understand how moodgyam helped them and to explore their feelings about the impact of COVID-19 on their mood and their studies. We also want to find out which factors are associated with improved mental health and academic outcomes so that we can ensure the intervention's sustainability and successful implementation in other less developed countries.


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Description Analysis of baseline data from 620 vulnerable students (50.2% female with self-reported symptoms of depression found 74% scored above the threshold for possible anxiety disorder. Three-way ANOVA showed lower COVID-19 protective behaviours such as mask wearing and social distancing, in students with possible anxiety disorder (p=.024) and those with low self-efficacy (p<0.001). Only 168 (27%) said they would accept vaccination against COVID-19, with male students being twice as likely to be willing to accept COVID-19 vaccination (p<0.001). Of 50 students interviewed. 30 (60%) expressed fears about the vaccination and 16 (32%) were concerned about a lack of information. Only 8 (16%) participants expressed doubts about effectiveness.

Thematic analysis of interviews revealed 4 overarching themes with 12 subthemes. The first theme 'COVID-19 has caused stress and impacted wellbeing' captured the ways in which the pandemic had affected students mental, social and physical wellbeing

"It's been devastating at multiple levels.. I've seen at least three of my closest family members die of the pandemic" (P18)"

The second theme 'COVID-19 has impaired the quality of students' educational experience' reflected the negative impact of the disruption to education and the problems of remote learning in low income country
"You are at home and you are a girl child you have to clean you have to cook. So maybe you have class at 12hrs that's lunch time, you are expected to be cooking not learning at that particular time .," (P 23)

The third theme 'Moodgym helped to support mental wellbeing' described the ways in which moodgym had improved their understanding of the relationship between thoughts and mood and consequently helped them to manage their own emotions, understand others better and improve their studies.
"It was very useful. I still do use it. I use it, I go back to what I have already done just to refresh my mind. It helped me to look at things in a positive way, it helped me understand the next person. It was really worth it.(P 6)".

The fourth, less prominent, theme "There were challenges to using moodgym" reflected some of the potential technical and cultural barriers to using mood gym.
" the context that was being used there was a bit western we see most of those things happening in the US and stuff' (P21).

At 8 weeks follow-up 195 (31.5%) participants completed the follow-up survey (52% female). Most participants (88%) rated moodgym as good or very good and said that they would recommend moodgym. Only 4% found moodgym difficult to use. Participants reported significantly lower anxiety at follow-up (p=0.02) but no significant change in depressive symptoms. Anxiety change was significantly negatively correlated with change in perceived academic performance (p<0.001) with reduction in anxiety associated with improvement in academic performance.

As part of the project we have worked with a social enterprise in Zambia and students to develop an online, interactive education tool to help students protect their mental and physical health during the COVID-19 pandemic. COVID-19 Education for African Students (COVEDAS) has been distributed widely through the student population in Zambia and has received very positive feedback. We used the qualitative findings to adapt COVEDAS to include sections on vaccination and address some of the myths fuelling vaccination hesitancy.
Exploitation Route The findings suggest that online CBT-based interventions for vulnerable students in low income countries are an acceptable and effective intervention to reduce anxiety and thus potentially improve levels of health protective behaviours and educational outcomes during a health crisis such as the COVID-19 pandemic. The research also provides a useful model for the development of effective health communications. . .
Sectors Education,Healthcare

Description Findings have been used to support implementation of an online cognitive behaviour therapy (moodgym) as an adjunct to usual care within the university counselling service for students with anxiety or depression. Feedback has now been obtained from students and staff . Feedback from students: 1. They found moodgym to be useful as it helped academically by motivating them to study using a structured schedule. 2. Moodgym improved their relationships with parents and friends as they understood themselves better. 3. It helped them respond to unforeseen circumstances such as break ups or failing examinations by thinking differently. 4. Some students felt it would be helpful to have a counsellor continuing with face to face sessions alongside moodgym to ensure all issue are addressed as moodgym may not address all. Feedback from therapists 1. It reduced the workload. 2. Felt it would be helpful if they had a way of monitoring students' progress with moodgym. .
First Year Of Impact 2022
Sector Education,Healthcare
Description Implementation of moodgym in University counselling service
Geographic Reach Africa 
Policy Influence Type Contribution to new or Improved professional practice
Impact Evidence of acceptability and effectiveness of online CBT was use to increased encourage mental health professional to expand repertoire of usual care. This i currently being monitored.
Title COVID-19 Education for African Students 
Description COVEDAS is an engaging, online education program featuring local students and local settings. It includes video, photo montages, voiceover and a quiz to reinforce knowledge. It is designed to help students keep themselves and their communities safe from COVID-19 by following simple advice around mask wearing, handwashing and social distancing. COVEDAS also contains advice to help students look after their mental health at this difficult time. It was developed in collaboration with BongoHive - Zambia's first technology and innovation hub. COVEDAS was updated in 2022 to include sections on COVID-19 vaccination in an attempt to dispel fears and address the communication gap that was evident from our interviews with students. 
Type Of Technology Webtool/Application 
Year Produced 2021 
Open Source License? Yes  
Impact COVEDAS has been distributed to students at Universities in Zambia and Malawi. The distribution was widened to students across Zambia. It is freely available via HELM open; the University of Nottingham Health E-Learning and Media (HELM) e-learning resources. The link to COVEDAS is also available in the associated BMC Public Health publication. 
Description Launch of COVID-19 Education for African Students programme at University of Zambia 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact The COVEDAS virtual launch involved a speech by the PI (Cris Glazebrook) about the aims of the project, international collaborations and the funders. This was followed by a speech by the Vice Chancellor of University of Zambia. The launch was televised on Zambian television .
Year(s) Of Engagement Activity 2021