INTRODUCTION:

From the end of 2019, the world was under the attack of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which caused a deadly infectious disease called coronavirus disease 2019 (COVID-19). As more confirmed and dead cases reported, the World Health Organization (WHO) declared the COVID-19 as a global pandemic on 11^th March 2020, with deeply concerned both by the alarming levels of spread and severity¹. While nationally, Malaysia had been reported the cumulative confirmed cases to over 100 thousand and death cases to over 400 on 3^rd January 2021². In order to keep the spread and mortality of COVID-19 under control, the Ministry of Health implemented a Movement Control Order (MCO) on 18^th March 2020, which restricted the mass movement and gathering at all places nationwide in terms of reducing person-to-person interaction³. Consequently, the universities across the nation locked down their campuses and moved all kind of teaching to the online platform. The MCO along with online teaching subsequently changed the social and environmental setting of university students and inevitably affect their physical activity (PA), mental health (MH) and sedentary behaviour (SB) to a certain extent.

Mental health (MH) includes social, psychological and emotional well-being. It is all about how people think, feel and behave which can affect our daily life, physical health and relationships with others⁴. People with positive mental health is able to cope with the stresses of life, work productively, as well as realize the full potential and make meaningful contributions to their communities. University students were consistently reported to have higher levels of mental distress compared to the general population⁵. Additionally, students had been reported had poorer MH compared to those were employed⁶. According to findings from the global burden of disease (GBD) study 2010, mental and substance use disorder were notable contributors to the GBD, accounting for about 7.4% (183.9 million disability-adjusted life years) of disease burden worldwide, directly. The prevalence of population with depression ranged from 2 to 6%, with around 264 million people experienced depression and that of anxiety disorders across the world varied from 2.5% to 7%, with estimating 284 million people suffered anxiety in 2017⁷.

Physical activity (PA) as defined by the WHO as any bodily movement produced by skeletal muscles which require energy expenditure. PA includes activities undertaken while working, travelling, playing, engaging in recreational pursuits and carrying out household chores⁸. It plays an important role in the development and maintenance of the human body’s health structures and functions⁹ . Physical inactivity (PI) has been defined as an insufficient level of guideline defined PA¹⁰. WHO also reported that insufficient physical activity was one of the leading risk factors for global mortality. Additionally, physical inactivity also had been regarded as a contributing factor in the development of a variety of non-communicable diseases such as diabetes mellitus, cancer and heart diseases which caused an estimated 3.2 million deaths in the world ¹¹. Despite the disease burden, the economic burden of PI cannot be neglected. In terms of Malaysia economic, 0.28 million and 0.12 million of international $ was spent in physical inactivity direct and indirect cost¹². In recognition of the strong relationship between PA and non-communicable diseases, member states of WHO agreed to a 10% relative reduction in the prevalence of insufficient PA by 2025. The risk for depression can be decreased up to 45% by participating in more PA. It is also stated that 60 min of PA each week can help to prevent 12% of new cases of depression¹³. Sedentary behaviour (SB) in distinct from physical inactivity, which has been defined as any waking behaviour with an energy expenditure less than 1.5 metabolic equivalents (METs) while in sitting, reclining or in lying posture¹⁰. The most commonly used subtype of SB was the total sitting or sedentary time, total lying time, screen time (e.g., television, computer, mobile phone or video games) and occupational sedentary time (e.g., attendance to lecture, private study time)¹⁴^,¹⁵. In addition, there were increasing evidence of the link between excessive SB and adverse health outcome, which included increased all-cause mortality, cardiovascular disease cancer, type 2 diabetes, obesity and mental disorder or poor MH ¹⁶^,¹⁷. Furthermore, studies showed that PA can attenuate the deleterious association between sedentary time and mortality to some extent¹⁸^,¹⁹. Nonetheless, PA and SB may be mutually exclusive²⁰.

Students from health science (HS) discipline have studied subjects related to health promotion, healthy lifestyles, psychology and sport in order to acquired health-related knowledge before moving to promote health, prevent disease and deliver health care. For sure, HS student will become a health care professional in the future, which mean they will play a critical and central role in promoting public health and improving the quality of life of the patient. As mentioned before, poor MH, PI and SB will lead to a certain disease or economic burden. As for health science students, the meaning of poor MH, PI and SB can grow bigger. For instance, less practising in PA may disfavour the practitioner in delivering PA or exercise training to their patient, which is an important element in promoting health⁹. By having poor mental and physical health, the student may be unable to bear the responsibility and achieve the task as a health care professional in the future. Hence, there is a need to assess PA, MH and SB among HS students as it is important for developing relevant policy and bringing out personal awareness about self-physical and mental health as well as develop interventions to address this unhealthy behaviour.

Although HS students have a deeper knowledge of health promotion, the practice of knowledge is unknown. The reason to conduct this study is to find out whether a HS student, who will be responsible to promote health in the future, has good mental and physical health. Since the health care professional is the one treating and taking care of the patient, if the HS student present with poor MH or PA level, the student may be unable to bear the responsibility and achieve the task as a health care professional. Besides, this may give a negative image of the health care professional to the patient. The risk of getting an injury during treatment also can be increased. If there is alarming prevalence of PI, DAS symptoms and SB, the institution may need to focus on the present issue as a serious issue instead of regarding it as a normal phenomenon among students’ study in health care discipline. Besides, the result also can bring awareness to the HS student and remind them to improve themselves in terms of PA, SB and MH. Although similar studies have been done, most of the study cannot be generalized due to limitation such as study methodology and population. These findings can serve as the basis for the development of programs of disease prevention and student MH care, as well as collaborating with reflections on the teaching-learning processes in university courses. Hence, the Objective of this study is 1. To evaluate the level of physical activity levels, mental health and sedentary behaviour of Health Science students in UTAR. 2. To analyse the correlation between Physical Activity, Mental Health and Sedentary Behaviour among Health Science students in UTAR. 3.To analyse the correlation between Physical Activity and Mental Health among Health Science students depending on the study course and gender in (UTAR.)

METHODOLOGY:

This study was ethically approved by the Scientific and Ethical Review Committee (U/SERC/171/2020) of Universiti Tunku Abdul Rahman (UTAR). The study followed the STROBE 2010 checklist. The study design was a cross-sectional study with convenient sampling, conducted as an online survey. The questionnaire was in the Google form and mostly sent via social media, such as WhatsApp and Facebook. The responses were gathered within 4 weeks, started from 26^th October 2020 to 26^th November 2020. The participants were the students from Bachelor of Physiotherapy, Nursing, Medicine and Bachelor of Surgery and Chinese Medicine in UTAR. The sample size was calculated by Open Source Epidemiologic Statistics for Public Health software for cross-sectional study ²¹. The population size was 599 and the population portion will be 50% of the total population. With the confidence limit is set as 0.05, the sample size was 235. 95% confidence level and 9% of drop out percentage was considered, so after calculation, the total sample size will be 258. The inclusion criteria were year 1 to year 4 students from M.B.B.S, Nursing, Chinese Medicine and Physiotherapy. The exclusion criteria of this study were students from other universities as well as graduated HS students. Outcome measures were:

For assessing mental health:

Depression Anxiety Stress Scale-21 items (DASS-21)

The scale that was found to be more reliable was the Depression, Anxiety, and Stress scale- 21 items (DASS-21)²². It has been claimed by Breedvelt et al. (2020) as the most widely used, freely available, self-reported tool for use with a general, non-clinical population in a systemic review across 127 studies from 2008 to 2018. In addition, the finding also showed that the DASS-21 had great construct validity and internal consistency²³. The respondents need to rate all 21 items by a 4-point scale depend on how often they experience them in the past week. The scale is ranging from 0 (did not apply to me at all) to 3 (applied to me very much, or most of the time).

For assessing PA and SB level:

International Physical Activity Questionnaire-short form (IPAQ-SF)

The IPAQ was commenced in Geneva in 1998 and was followed by extensive reliability and validity testing was undertaken across 12 countries during 2000. The result showed that this questionnaire had acceptable measurement properties for use in numerous setting and different languages²⁴. In this study, the IPAQ short form (IPAQ-SF) was used to assess PA levels and SB. Also, the IPAQ-SF appeared to be the most reliable questionnaire of sedentary time when the test-retest duration was short. This questionnaire can help to provide common instruments to obtain internationally comparable data on health-related PA and SB. There are 7 questions in the IPAQ-SF, the questions will ask about the time being spent on physical activity in the last 7 days. The PA levels will be categorised into low, moderate and high level.

Procedure:

Firstly, the questionnaires were distributed via social media, such as Facebook and WhatsApp, in order to recruit a sufficient sample size for the current study. This questionnaire consisted of three parts. The first part had 5 questions for demographic data. The second part had 21 questions from the Depression Anxiety Stress Scale-21 (DASS-21) for general mental health assessment. The third part had 7 questions from the International Physical Activity Questionnaire short form (IPAQ-SF) to assess the intensity of PA and sitting time that people do as part of their daily lives. The purpose of this study and further instructions were informed in the questionnaire. Prior to answering the questionnaire, the participants were asked to sign the consent form as well as Personal Data Protection act form for the confidentially of their personal information in this study. The personal details of the participant will not be disclosed throughout and after this study. The questionnaire took 10 to 15 minutes to complete, and the participants can withdraw from the survey whenever they wanted.

Data Analysis Strategies:

Data collected was computed and analysed using the IBM Statistical Package for the Social Science (SPSS) software (version 21) and Microsoft Excel to produce the study results. Descriptive analysis, using the mean and standard deviation, was used to examine the demographic data. Besides, the correlations between PA and MH, SB and MH, PA and SB were evaluated by Spearman Rank correlation test. The level of significant difference was set at p < 0.05.

RESULTS

Demographic analysis:

There was a total of 258 participants in this study, with 182 (70.5%) of females and 76 (29.5%) of males. The mean age was 21 years (SD=1.842), with a more or large proportion in age 20 (25.6%) and 21(19%). The race for the entire sample was reported as follows: 95.3% Chinese, 2.1% Malays, 0.8% Indian, and 0.8% reported as “Others”. The distribution of HS students from each academic year was 16.7% from year 1, 22.9% from year 2, 24.8% from year 3, 24.4% from year 4, and 11.2% from year 5. On the other hand, most of the students were Physiotherapy (44.6%) students and followed by M.B.B.S (27.5%), Chinese Medicine (19.0%) and Nursing (8.9%) students.

Prevalence of depression, anxiety and stress of HS students:

Table 1 Prevalence of depression, anxiety and stress of HS students

	Depression			Anxiety		Stress
	N		%	N	%	N	%
Normal	133		51.55%	87	33.72%	151	58.53%
Mild	35		13.7%	29	11.24%	41	15.89%
Moderate	47		18.22%	63	24.42%	34	13.18%
Severe	21		8.14%	35	13.57%	26	10.08%
Extremely severe	22		8.53%	44	17.05%	6	2.33%
Mean score (SD)	11.69 (9.64)			11.67 (8.38)		13.85 (8.92)
Total	258	100%		258	100%	258	100%

Table 1.1 Prevalence of depression, anxiety and stress of HS students according to gender

		Female			Male
		N	%	Mean (SD)	N	%	Mean (SD)
Depression	Normal	101	55.49%		32	42.11%
	Mild	23	12.64%		12	15.79%
	Moderate	34	18.68%	10.49 (9.31)	13	17.10%	12.87 (10.27)
	Severe	9	4.95%	10.49 (9.31)	12	15.79%	12.87 (10.27)
	Extremely severe	15	8.24%		7	9.21%
	Total	182	100%		76	100%
Anxiety	Normal	61	33.52%		26	34.21%
	Mild	20	10.99%		9	11.84%
	Moderate	42	23.08%	12.10 (8.30)	20	26.32%	10.66 (8.51)
	Severe	26	14.29%	12.10 (8.30)	9	11.84%	10.66 (8.51)
	Extremely severe	33	18.13%		12	15.79%
	Total	182	100%		76	100%
Stress	Normal	109	59.89%		42	55.26%
	Mild	25	13.74%		16	21.05%
	Moderate	24	13.19%	13.78 (9.07)	10	13.16%	14.03 (8.59)
	Severe	19	10.43%	13.78 (9.07)	7	9.21%	14.03 (8.59)
	Extremely severe	5	2.75%		1	1.31%
	Total	182	100%		76	100%

Table 1.2 Prevalence of depression, anxiety and stress of HS students according to study courses

	Chinese Medicine		M.B.B.S		Nursing		Physiotherapy
	N	%	N	%	N	%	N	%
Depression
Normal	25	51.0%	37	52.1%	17	73.9%	54	47.0%
Mild	6	12.2%	12	16.9%	0	0.0%	17	14.8%
Moderate	9	18.4%	12	16.9%	4	17.4%	22	19.1%
Severe	5	10.2%	4	5.6%	0	0.0%	12	10.4%
Extremely severe	4	8.2%	6	8.5%	2	8.7%	10	8.7%
Mean (SD)	10.78 (9.83)		11.18 (9.91)		7.39(10.50)		12.14 (9.14)
Total	49	100%	71	100%	23	100%	115	100%
Anxiety
Normal	13	26.5%	26	36.6%	15	65.2%	33	28.7%
Mild	6	12.2%	8	11.3%	1	4.3%	14	12.2%
Moderate	9	18.4%	17	23.9%	3	13.0%	33	28.7%
Severe	7	14.3%	9	12.7%	1	4.3%	18	15.7%
Extremely severe	14	28.6%	11	15.5%	3	13.0%	17	14.8%
Mean (SD)	14.20 (10.04)		10.62 (7.76)		8.17 (8.57)		11.95 (7.65)
Total	49	100%	71	100%	23	100%	115	100%
Stress
Normal	26	53.1%	45	63.4%	17	73.9%	63	54.8%
Mild	4	8.2%	11	15.5%	1	4.3%	25	21.7%
Moderate	11	22.4%	8	11.3%	1	4.3%	14	12.2%
Severe	7	14.3%	6	8.5%	2	8.7%	11	9.6%
Extremely severe	1	2.0%	1	1.4%	2	8.7%	2	1.7%
Mean (SD)	15.22 (9.60)		13.01 (8.36)		10.78 (11.08)		14.40 (8.39)
Total	49	100%	71	100%	23	100%	115	100%

PA levels of HS students in UTAR

Table 2 PA levels of HS students in UTAR

	Category	N	%
PA	Low	97	37.6%
	Moderate	55	21.3%
	High	46	17.8%
	Valid data	198	76.7%
	Missing data	60	23.3%
	Total	258	100%

Table 2.1 PA levels of HS students according to gender

		Female		Male
		N	%	N	%
Physical activity level
	Low	72	39.6%	25	32.9%
	Moderate	33	18.1%	22	28.9%
	High	35	19.2%	11	14.5%
	Missing data	42	23.1%	18	23.7%
	Total	182	100%	76	100%

Table 2.2 PA levels of HS students according to study course

	Chinese Medicine		M.B.B.S		Nursing		Physiotherapy
	N	%	N	%	N	%	N	%
PA level
Low	17	34.7%	31	43.7%	10	43.5%	39	33.9%
Moderate	15	30.6%	10	14.1%	3	13.0%	27	23.5%
High	11	22.4%	9	12.7%	5	21.7%	21	18.3%
Missing data	6	12.2%	21	29.6%	5	21.7%	28	24.3%
Total	49	100%	71	100%	23	100%	115	100%

The prevalence of SB of HS students in UTAR

Table 3 Prevalence of SB of HS students in UTAR.

SB (hr/wks)	N	%	Mean (SD)
0-7	101	39.1
>7	94	36.4	7.69 (3.63)
Missing data	63	24.4
Total	258	100

Correlations between PA and MH, SB and MH, PA and SB

Table 4 Correlations between PA, SB and depression, anxiety and stress.

	Depression	Anxiety	Stress	PA	SB
PA	-.009	.005	.022	1	-.288^**
SB	.016	-.010	.058	-.288^**	1

**Correlation is significant at the 0.02 level (2 tailed)

Fig 1 The correlation A) between depression and PA; B) between anxiety and PA; C) between stress and PA; D) between SB and PA

Spearman correlation coefficient was computed to assess the relationship among SB, PA and depression, anxiety and stress. There were negligible, negative correlations of depression (rs = -0.009, n = 198, p =0 .895), anxiety (rs = 0.05, n = 198, p = 0.944), stress (rs = 0.022, n = 198, p = 0.757) with PA. Based on table 4.5, the correlations were not significant in the set value of 0.05. Besides, the correlations between depression (rs = 0.016, n = 195, p =0 .826), anxiety (rs = -0.010, n = 195, p =0 .887), stress (rs =0.058, n = 195, p =0 .423) and SB time were negligible as well. The correlations between depression, anxiety, stress and SB time did not show significane in the set value of 0.05. The results indicated that increased in PA or decreased in SB was not much related to decrease in DAS symptoms. In addition, there was a significant, weak, negative correlation between PA and SB (rs = -0.288, n = 163, p <0.01), which increased in PA was related with decreased in SB.

Correlation between MH and PA depending on gender

Table 5 Correlations between DAS symptoms and PA depending on gender.

		Depression	Anxiety	Stress	PA
Female	PA	-.015	.056	.024	1
Male	PA	-.054	-.041	-.033	1

Fig 2 The correlation between depression and PA in A) female B) male.

According to table 5, female had positive, negligible correlation of anxiety (rs = 0.056, n = 136, p= 0.520), stress (rs = 0.024, n = 136, p= 0.777) with PA, and had negative, negligible correlation of depression (rs = -0.015, n = 136, p= 0.860) with PA. Besides, male had negative, negligible correlations of depression (rs = -0.054, n = 62, p= 0.677), anxiety (rs = -0.041, n = 62, p= 0.754), stress (rs = -0.033, n = 62, p= 0.797) with PA. This indicated that increased PA is not bringing obvious impact in reducing DAS symptoms among both genders.

The correlation between MH and PA depending on study course

Table 6 Correlations between depression, anxiety, stress and PA depending on study course

		Depression	Anxiety	Stress
Chinese Medicine	PA	0.092	0.069	0.240
M.B.B.S	PA	0.080	-0.009	0.127
Nursing	PA	-0.209	-0.277	-0.279
Physiotherapy	PA	-0.121	-0.074	-0.162

Fig 3 The correlation between A) depression and PA in Physiotherapy B) anxiety and PA in M.B.B.S C) anxiety and PA in Nursing D) stress and PA in Chinese Medicine

There was a negligible, positive correlation between depression (rs = -0.092, n = 43, p= 0.557), anxiety (rs = 0.069, n = 43, p= 0.660) and PA in Chinese Medicine. Besides, there was a weak, positive correlation between stress (rs = 0.240, n = 43, p= 0.121) and PA in Chinese Medicine, which indicated that increased in PA related to increase in stress. On the other hand, the correlation between depression (rs = 0.080, n = 50, p= 0.579), anxiety (rs = -0.009, n = 50, p= 0.953) and PA showed negligible in M.B.B.S, with positive correlation in depression and negative correlation in anxiety. With the regard of stress, the correlation showed weak and positive with PA in M.B.B.S (rs = 0.127, n = 50, p= 0.379), which indicated that increased in PA related to increase in stress. There were negative, weak correlation between depression (rs = -0.209, n = 18, p= 0.404), anxiety (rs =-0.277, n = 18, p= 0.266), stress (rs = -0.279, n = 18, p= 0.263) and PA in Nursing. Additionally, the correlation between depression (rs = -0.121, n = 87, p= 0.263), stress (rs = 0.162, n = 87, p= 0.134) and PA were weak and negative while the correlation between anxiety (rs = -0.074, n = 87, p= 0.497) and PA were negligible and negative in Physiotherapy. The above-mention correlations did not show significance in set value of 0.05.

DISCUSSION:

The current study aimed to investigate the level of PA, MH and SB among HS students in UTAR, as well as find the relationship between PA, SB and MH. Here were the main findings, 1) HS students in UTAR showed a high prevalence of DAS symptoms, PI and SB, 2) female had a higher prevalence in anxiety and stress while male showed more prevalence in depression, 3) Chinese Medicine students were reported with the most alarming MH while Nursing students reported the opposite 4) Female were more physically inactive than male, 5) Chinese Medicine students were reported as the most active while M.B.B.S students were reported as the least active 6) no significant correlation found between PA and MH as well as SB and MH 7) but weak negative correlation was found between PA and SB. A total of 258 students, mean age 21 years, participated in this study. The study population was dominated by the female population, which was reflected in the sample size, with 70.5% of participants were females. Most of the students (44.6%) were from physiotherapy and followed by M.B.B.S (27.5%), Chinese Medicine (19.0%) and Nursing students (8.9%).

There were 23.3% and 24.42% of missing data in evaluating PA levels and SB. This was due to the IPAQ-SF consists of 7 open-ended questions, which allowed the respondents to answer in open text format and not being limited to a set of options. Hence, the respondents can answer “Not Sure” if they do not know how much time they spent on each activity. However, based on the scoring protocol of IPAQ-SF, if the data were missing for time and days then that case needed to be removed from data analysis²⁵. Thus, there will be a total of 76.7% and 75.58 of valid data in evaluating the PA levels and SB respectively. The prevalence of anxiety was found higher than either depression or stress, which was in line with other studies²⁶. When compared to the mean scores, the mean scores of HS students were lower than one study among university students in Malaysia²⁷. Additionally, the prevalence of DAS also showed higher than the general population in China during the COVID-19 pandemic⁶. The wide range of differences among the prevalence of depression, anxiety and stress after comparison may be due to the cultural or education type differences between countries or institutions as well as the influence of COVID-19 pandemic. Hence, we cannot conclude that the MH among HS students was comparatively better or worse to university students, as there were a lot of uncertain factors needed to be considered, especially the COVID-19.

In this study, individuals who were classified had low PA was regarded as PI. After excluding the cases with missing data, there was 48.99% of students were categorized in low PA. First of all, the prevalence of low PA among UTAR HS students in the current study was about half higher than the general population, which was 25.1%²⁸. According to WHO, the age standardizes estimate of the prevalence of insufficient PA among Malaysians aged 18 years and above was 38.75% in 2016, which was much lower than the results of the current study (48.99%). Hence, the current findings showed that HS students in UTAR were less active than the general population. Besides, the prevalence of physical inactivity was higher than Italian adults during the pandemics²⁹.

According to the new global guidelines on SB and health for adults by Dempsey et al. (2020), there was insufficient evidence to identify a specific or quantified threshold for sedentary time, which associated with increased health risk of public health. This was due to the variations of measurement in SB, which included self-reported and device- measured SB³⁰. As a reference, the current study followed the suggestion of a meta-regression analysis with more than 1 million of participants by Ku et al. (2018), which defined the cut-off point of self-report SB was 7 hours, in relevant of all-cause mortality. In the current study, the prevalence of SB (sitting time >7 hours) was 48.10%, which was higher than the Malaysian adult ³¹. In comparison to the mean sitting time of HS students with university students, which was 7.69 hours, it showed higher than other previous studies³²^,³³.

According to gender, the females had a higher prevalence of moderate to extremely severe anxiety and stress than males, but with only less than 5 % of the difference. On the other hand, males had a higher level of depression compared to females, with around a 10% higher ratio in moderate to extremely severe depression. Current findings were in line with one study in Hong Kong, with female nurses more likely to report anxiety and stress, while male nurses tended to report depression³⁴. The gender differences in anxiety and stress can be explained by the theory supported by Eaton et al. (2012), which involved a notion that women ruminate more frequently than men, focusing on their negative emotions and issues repetitively rather than engaging in more active problem-solving. The theory of rumination was strongly related to neuroticism, such that more neurotic individuals tended to ruminate more frequently, and this was largely accounted for genetic effects³⁵. Besides, Li and Graham (2017) proposed that the fluctuations of sex hormones during menstruation could results in heightened vulnerability to anxiety and stress-related disorder in women.

In this study, the prevalence of physical inactivity was higher among females (51.43%) when compared to their male counterparts (43.10%). According to IPH (2020), the prevalence of physical inactivity in females (28.2%) was higher than in males (22.1%). In addition, the age standardizes estimate of the prevalence of insufficient PA among Malaysian aged 18 years and above was higher in females (42.79%) than males (34.64%) ⁸. The sex difference in PA participation can be explained by the sexual stereotype and gender roles learned during childhood which may affect the individual’s self-perceptions of competence and value attributed to the sport, and in turn influencing the participation and performance in sport³⁶. Besides, the sex differences in psychosocial factors, which including self-efficacy, social support, and motivation, were substantiated had compelling influences on PA³⁷.

The findings of the present study showed that Chinese Medicine had the most severe MH status compared to other study courses, even higher than M.B.B.S students, who were mostly reported had alarming MH issues. This may be explained by the minority of Chinese Medicine in the current health care system. Although Chinese medicine constitutions made obvious progress in the past several decades, most of the studies were related to the contribution of Chinese medicine and less concern about the psychological factors that affect MH of Chinese Medicine students or practitioner.

Through the findings, we can know that M.B.B.S students had the highest level of PI, while the Chinese Medicine students had the lowest. The findings were in line with another study, which showed the medicine students were the most physically inactive compared to other health-related study courses³⁸. The priority of academic, heavy clinical workload, fear that PA affects academic performance, unsupportive policy were reported as the barriers of PA among medical students³⁹. According to Dąbrowska-Galas et al. (2013), the comparatively high prevalence of moderate and high PA in physiotherapy students may be due to having a greater awareness of the health benefits of regular PA. However, there was no relevant study about the facilitator of PA in Chinese Medicine students in the current scientific literature that can explain the low prevalence of PI in Chinese Medicine students.

In the current study, the impact of PA and SB on MH was investigated by finding the correlation between total PA-MET-min/week, sitting time, and the score of DAS subscale. However, there was no sufficient evidence to suggest that high PA or low SB was associated with DAS symptoms. This indicated either an increase in self-report PA or a decrease in SB did not have much impact to improve the level of DAS, vice versa. This was in line with a previous systematic review, which concluded that no noticeable change for MH with exercise therapies⁴⁰. Besides, according to Feng et al. (2014), no significant associations were found between PA, screen time, and anxiety. However, the current findings were incongruent with the previous studies during the COVID-19 pandemic, which suggested that increased in PA was related with a better mental health and less psychological symptoms, namely depression and anxiety²⁹,⁴¹. Concerning SB, one systematic review reported no conclusion can be drawn on the relationship of depression and anxiety with SB, as different studies report different relationships of these 3 variables⁴². Nevertheless, the current finding was inconsistent with previous study during the COVID-19 pandemic, which reported that increased in SB was related to more prevalent of depression⁴¹. Besides, the study by Meyer at al. (2020) also reported that higher screen time was related to high level of depression, stress and loneliness during the pandemic. Similar findings also reported in China, which high screen time was correlated with a higher level of anxiety, depression, and psychopathological symptoms⁴³. Besides, the elevation of depression, anxiety, and stress was found related to an increased in SB⁴⁴. Although the current study showed an insignificant relationship between PA and MH, as well as between SB and MH, there was increasing evidence showed that more frequent PA and less SB were associated with better MH. Hence, the benefits of staying active and sitting less should not be overlooked.

The current study also investigated the correlation between PA and MH depending on gender and study course during the pandemic. The correlation between PA and MH showed negligible when compared between genders, though the evidence was insufficient. However, the study of Maugeri et al. (2020) reported that the correlation between PA and psychological well-being depending on gender showed a higher positive correlation in females than male. This indicated that the impact of PA on psychological well-being was stronger in female than male ²⁹. On the other hand, current study was the first study correlate the PA and MH depending on study course during the COVID-19 pandemic. While depending on the study course, the current findings indicated that an increase in PA showed benefits for improving depression among Nursing and Physiotherapy students but not Chinese Medicine and M.B.B.S students. On the other hand, the current study also showed that a high level of PA was related to a low level of anxiety among Nursing students. In the meantime, the current study also reported that an increase in PA will worsen the stress level in Chinese Medicine students. However, the situation was the opposite in Nursing and Physiotherapy students. Need to be mentioned that, the correlations above-mention were insignificant. The possible reason why the findings showed non-significant may be due to the insufficient sample size. Another reason for the lack of significant results can be due to the measurement used. According to the meta-regression analysis of Ku et al., using IPAQ for assessing SB can lead to an underestimate of total daily SB ranging from 2 to 3. 5 hours. Besides, Jayasinghe et al. (2020) also suggested overreliance on self-reported data had inherent limitations, promotion of objective-measurement used of PA was an urgent needed.

The current study also investigated the correlation between PA and SB during the pandemic, the result showed a small inverse correlation between PA and SB. So far, there was not relevant study conducted during the pandemic. The current finding was in concordance with a systematic review, which reported there was an inverse relationship between PA and SB among adults, the relationship was ranging from small to large ⁴⁵. According to Mansoubi et al., the wide range of the strength of the relationship was depending on the measurement used, which showed that objective monitoring studies reported a larger association between PA and SB. With evidence support, the weak correlation between PA and SB can be explained by the measurement used.

Undoubtfully, human life was largely influenced by the pandemic in 2020, there was a great possibility that the high prevalence of physically inactivity, DAS symptoms as well as the SB were related to the Covid-19 crisis. According to Coughenour et al. (2020), there was a significant decrease in self-reported minutes of PA after the stay-at-home order during the pandemic. Besides, the step counts also decreased worldwide after COVID-19 was declared as a global pandemic ⁴⁶. Globally, the COVID-19 pandemic attack had shown a negative effect on the practice of PA⁴⁷^,⁴⁸^,⁴⁹ especially in walking⁴⁹^, ⁵⁰. However, one study also showed that there was a total of 76.3% of participants in 18 countries either maintained or increased their exercise levels during the pandemic⁵¹. Besides, a significant increase in PA time also had been reported ⁵². In terms of SB, the rising of sitting time also had been reported⁴⁹^,⁵⁰^,⁵² with a maximum increase of 3 hours⁴⁹. Alarmingly, numerous studies reported that university students were more depressed, anxious and stressed compared with the time prior to the COVID-19 pandemic⁵³^,⁵⁴. According to Wang. X et al. (2020), this finding can result from the high levels of academic, health and lifestyle changes and concern. As for academic concerns, majority of students indicated that difficulty in concentrating, adjustment of distance learning, as well as fear and worry about academic progress and performance as major concerns⁵⁴. Additionally, worries about one’s family and friends, worries about the future career, living alone, being faced with problems usually suppressed, and less contact and support from the personal network were reported had association with worsening of MH⁵³. As observed, COVID-19 pandemic had a negative effect on PA, MH and SB, which may lead to the high prevalence of physical inactivity, depression, anxiety, stress and SB among UTAR HS students in the current study. Thus, the future study of evaluating the PA, SB and MH may be conducted after the COVID-19, with the comparison of findings between prior and after the pandemic, so that we can get a clearer image of PA, MH and SB among HS students in UTAR, and come out with an appropriate solution for this alarming phenomenon.

Suggestions for future practice:

The institution may follow the suggestions from WHO for increasing the PA level, such as improve sports and recreation facilities which provide opportunities for the students to do sports and modify the policies to encourage physical activity¹¹. Besides, the PA curriculum can be considered as a way to improve the PA levels of students. Additionally, the environmental intervention also can be considered, as it showed a positive effect in improving SB⁵⁵. For instance, replace some of the traditional sitting desks with the stand-based desks in the lobby or cafeteria. Besides, the stand-based desk also can be installed in the classroom which can allow the students to have some “standing break” but still able to focus on the lecture. With the regard of COVID-19 pandemic, home-based exercises can be promoted as a way to improve the PA level. While considering the gender gap in PA practising, psychological factors which discussed before should be considered when conducting intervention or exercise programs. There is an urgent need for the university to implement a systematic and continuous method to monitor the MH of their students. Universities or any institutions should conduct a similar type of survey to assess the mental health status of students on regular basis. This kind of monitoring would allow the universities or institutions to assess the mental health needs of their students as well as assess and improve the efficacy of their existing counselling programs. Besides, destigmatization of mental illness also can be promoted as it was very important to improve help-seeking behaviours and subsequently improve MH ⁵⁶. Thus, anti-stigma programs can be considered conducted via indirect (webinar) or direct (talk) way by universities or institutions.

CONCLUSION:

In conclusion, through this cross-sectional study, we can get to know that the prevalence of DAS symptoms, PI and SB was rising to an alarming level. From government to institution, adequate and regular surveillance, policy monitoring and further research should be taken to overcome this issue. Concerning DAS symptoms, females had a higher prevalence of anxiety and stress while males had a higher prevalence of depression. In addition, Chinese Medicine students reported the highest prevalence of DAS symptoms while Nursing students reported the least. With the regards of PA, females were found to be less active than male. Additionally, Chinese Medicine students and M.B.B.S students were found to be the most active and least active group respectively. Besides, no significant correlation was found between PA and MH as well as PA and SB. On the other hand, a weak correlation between PA and SB was found in the current study.

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Received on 31.03.2021 Modified on 21.11.2021

Research J. Pharm. and Tech. 2022; 15(7):3125-3136.

DOI: 10.52711/0974-360X.2022.00523