Youth COVID-19 stressors and associations with self-perceived health, depression, anxiety, and at-risk alcohol and cannabis use
Abstract
Adolescents and young adults have been particularly vulnerable to disruptions caused by the COVID-19 pandemic. The objectives were to identify youth's self-reported pandemic-related stressors and examine how these stressors were related to six negative health outcomes: self-perceived, fair-to-poor physical, and mental health, depression, anxiety, and at-risk alcohol and cannabis use. Data were from the Well-Being and Experiences Study (The WE Study) from Manitoba, Canada (17–22 years old; n = 587; collected from November 2021 to January 2022). The COVID-19 stressors reported most frequently since pandemic onset included: (1) not being able to spend time with friends (78.5%); (2) feeling lonely or isolated (69.9%); and (3) remote learning for school, college, or university (68.4%). In reference to the “past month”, frequently reported stressors were (1) remote learning (42.6%); (2) feeling lonely or isolated (41.2%); and (3) uncertainty about the future (41.1%). Overall, 26.1% of the sample perceived their physical health as fair-to-poor and 59.1% perceive their mental health as fair-to-poor. A number of stressors were related to fair-to-poor mental health, depression, and anxiety; fewer were related to fair-to-poor physical health and at-risk alcohol and cannabis use. These findings can inform future pandemics and recovery efforts to improve pandemic-related health risks among youth.
Introduction
The stress experienced by individuals and families during COVID-19 was prolonged as successive waves of the pandemic were met by government measures imposed to reduce transmission of the virus (Holmes et al. 2020). In Canada, public health strategies were implemented in March 2020 and continued in varying forms for more than 2 years. These unprecedented public health measures included: physical distancing; mandatory masking in public; quarantines; lock downs; travel restrictions; childcare and business closures; remote learning; and limited provision of community-based social programming and healthcare services. In Manitoba, the first lock down, referred to as the first wave, occurred in March 2020 with many restrictions lifted in June 2020. The second wave occurred in September 2020 corresponding with the second lock down with restrictions being reduced in January 2021. The third wave and lock down occurred in April 2021. Vaccines became available in the spring of 2021. The fourth wave and final lock down occurred in November 2021 with restrictions not fully lifting until May 2022.
The disruptions of the COVID-19 pandemic may have been particularly difficult for adolescents and young adults who encountered the pandemic at a pivotal point in their lives, typically marked by milestones and life course decisions about education, employment, friendships, relationships, and family formation. Although many important studies were conducted in the early months and first year of the COVID-19 pandemic (Glowacz and Schmits 2020; Essau and de la Torre-Luque 2021; Jones et al. 2021; Meherali et al. 2021; Minhas et al. 2021; Mohler-Kuo et al. 2021a; Segre et al. 2021; Villanti et al. 2022), more research is needed to better understand the stressors that youth experienced during the second year of pandemic restrictions, when circumstances such as frequency and length of lock downs changed. Little is known as to whether stressors for youth were only experienced at the start of the pandemic, or if they continued into year two. Chronic stressors over a prolonged period can illicit biological responses and have negative effects on health (Schneiderman et al. 2005). More specifically, it has been noted that the prolonged COVID-19 pandemic may have especially impacted youth when considering stress resilience and mental health (Manchia et al. 2022). A better understanding of stressors that affected youth later in the COVID-19 pandemic in year two is needed to address knowledge gaps on how those experiences were related to their physical and mental well-being and to inform policy and practice.
Research on the pandemic effects indicates that among youth, COVID-19 was related to an increased likelihood of stress, distress, substance use, anxiety, and depression symptoms (Glowacz and Schmits 2020; Essau and de la Torre-Luque 2021; Jones et al. 2021; Meherali et al. 2021; Minhas et al. 2021; Mohler-Kuo et al. 2021b; Segre et al. 2021;Villanti et al. 2022; Craig et al. 2023; Foster et al. 2023). It should be noted that many of the COVID-19 studies do not allow for causal inferences in relationships by nature of design. However, a systematic review and meta-analysis of 53 longitudinal child and adolescent cohort studies from 12 countries conducted before and during the COVID-19 pandemic found evidence indicating that depression and anxiety symptoms increased during the pandemic (Madigan et al. 2023). Some studies observed an increase in substance use among youth, while other found a decrease (Dumas et al. 2020; Papp and Kouros 2021; Sarvey and Welsh 2021). Reasons for inconsistencies in the substance use literature are unclear. Importantly, research has reported that young adults may use substances to cope with COVID-19-related stress (Arterberry et al. 2023). Additionally, less research has examined specific COVID-19-related experiences that were regarded as stressors by adolescents and young adults and whether those stressors were associated with their physical health, mental health, and substance use. Such data are needed to inform future pandemics and pandemic recovery intervention efforts for those still perceiving a need for help.
The aims of the current study were to (1) determine what COVID-19 experiences youth identified as stressors since the onset of the pandemic and in the past month (in the second year of the pandemic); and (2) examine associations between these stressors and fair-to-poor self-perceived physical and mental health, depression, anxiety, and at-risk alcohol and cannabis use in the second year of the pandemic.
Methods
Data and sample
The Well-being and Experiences (WE) Study, an intergenerational longitudinal study, was conducted in Manitoba, Canada. Adolescent and parent dyads were recruited in 2017–2018 (baseline; N = 1002) via random digit dialing (21%), community advertisements (38.4%), and referrals (40.6%) (Afifi et al. 2020). No differences in the distribution of many key variables (i.e., age, grade, race/ethnicity, and adversity experiences) were found based on random digit dialing versus convenience sampling, suggesting that inferences are likely unbiased due to differences in the sampling methods. In addition, Forward Sortation Areas (a geographical designation system) informed by postal codes, sex, income, and race/ethnicity were tracked during data collection to ensure that the demographic characteristics of the community sample closely represented the population from which it was drawn (Statistics Canada 2017). Data for the WE Study were collected in seven waves (two data collection waves for parents and five data collection waves for adolescents/young adults) starting in 2017 and ending in 2023.
Data were from Wave 1 (collected in 2017–2018), Wave 2 (collected in 2019), and Wave 4 (collected in 2021–2022), with most of the data in the current study were drawn from the WE Study Wave 4 (collected from November 2021 to January 2022) and pertain to older adolescents and young adults (17–22 years, n = 587; 58.6% retention rate from the baseline data collection in 2017). The data used for this work when referring to the past month corresponded with the fourth wave of the COVID-19 pandemic in the province. Unlike the baseline data collection for the WE Study, where participants had to attend at a research facility in person to complete a self-administered survey, subsequent data collections were completed online using personal electronic devices. Surveys were administered in English. Ethics approval was obtained from the Health Research Ethics Board at the University of Manitoba. All participants provided prior informed written consent to participate.
Measures
Independent variables
A list of possible stressors was collaboratively developed by the research team, which included individuals with clinical and research expertise in child and youth mental health, stress, and well-being. From a list of 19 COVID-19-related experiences, respondents marked those that they found stressful (a) since the onset of the COVID-19 pandemic (over the entire pandemic from March 2020 until data collection between November 2021 and January 2022; Wave 4), as well as stressors that were specific to (b) the past 30 days of the pandemic (data collected between November 2021 and January 2022). In addition to “Nothing”, respondents had the option of selecting: (1) worrying about you or your family getting COVID-19; (2) public health restrictions (wearing masks, physical distancing, and lock downs); (3) not being able to spend time with friends; (4) not being able to spend time with family; (5) not being able to spend time with a partner (e.g., boyfriend or girlfriend); (6) feeling lonely or isolated; (7) loss of recreational activities such as sports; (8) being at school, college, or university with public health restrictions; (9) remote learning for school, college, or university; (10) adjusting to changes at your workplace or working virtually; (11) job loss or financial burden; (12) grieving the death of a friend or family member during the pandemic; (13) increased conflict in your relationships (friends or family); (14) travel restrictions; (15) limited access to shopping and restaurants; (16) not having time alone; (17) uncertainty about the future; (18) missing significant life events (e.g., graduations, weddings, funerals, birth of a family member, etc.); and (19) disrupted or poor sleep. As well as calculations of the prevalence of each stressor, the number of stressors was summed for: (a) since the onset of the pandemic (from March 2020 until the current data collection) and (b) for the past 30 days of the pandemic. To examine internal consistency of the stressor items, alphas were computed; the internal consistency was high (Cronbach's alpha = 0.81 and 0.86).
Dependent variables
Six dependent variables were examined: self-perceived physical health, self-perceived mental health, depression, anxiety, at-risk alcohol use, and at-risk cannabis use collected at Wave 4. Self-perceived physical and mental health were assessed by asking respondents to rate their health on a five-point scale, which was dichotomized to increase statistical power, into two categories: “poor” or “fair” versus “good”, “very good”, or “excellent” (Findlay and Arim 2020; Afifi et al. 2022).
Depressive symptoms were assessed using the nine-item Patient Health Questionnaire (PHQ-9). The seven-item General Anxiety Disorder (GAD-7) was used to assess anxiety symptoms. For both instruments, based on a four-point scale, respondents rated how bothered they have had been by certain problems over the past 2 weeks. A summed score of 10 or more is considered clinically significant and coded as a probable diagnosis of depression or anxiety (Kroenke et al. 2010; Manea et al. 2015).
At-risk alcohol and cannabis use was determined using the Alcohol Use Disorders Identification Test (AUDIT) and the Cannabis Use Disorder Identification Test—Revised (CUDIT-R), respectively. The AUDIT is a psychometrically validated 10-item instrument assessing past-year alcohol use, with most questions rated on a five-point scale. The CUDIT-R (Adamson et al. 2010) is an eight-item revised and psychometrically validated version of the original CUDIT instrument that assesses past 6-month cannabis use with the majority of questions also rated on a five-point scale. While the original study and AUDIT instrument manual (Saunders et al. 1993; Babor et al. 2001) suggest a score of eight or more to assess at-risk alcohol use, several psychometric studies of the AUDIT among younger populations of adolescents and (or) young adults (primarily college or university students), recommend using a lower cut-off score (Knight et al. 2003; Kokotailo et al. 2004; Cortés-Tomás et al. 2016; Liskola et al. 2018; Coulton et al. 2019; Reichenheim et al. 2021). AUDIT cut-off score recommendations for youth (adolescents and young adults) range widely (e.g., a score of 2 or more to 8 or more), likely varying due to several sociodemographic factors (e.g., age, clinical sample or general population, sex or gender, etc.) of the sample, country where the AUDIT was assessed, or definition of problematic/at-risk/hazardous/harmful alcohol use (Knight et al. 2003; Kokotailo et al. 2004; DeMartini and Carey 2012; Cortés-Tomás et al. 2016; Liskola et al. 2018; Coulton et al. 2019; Reichenheim et al. 2021). While the sample in the current study ranged in age from 17 to 22 years old, the majority were young adults; therefore, we decided to lower the cut-off score to 6 or more to assess at-risk alcohol use, similar to a published study of students at a large midwestern university in the United States (mean age 20.3 years old) (Kokotailo et al. 2004). As recommended by Schultz et al. (2019), who studied a younger sample of college students not seeking treatment, a cut-off score of six or more was used to assess at-risk cannabis use.
Covariates
Models were adjusted for age (17–22 years old), sex (male or female), race/ethnicity from Wave 1 data collection, and self-perceived mental health at Wave 2 data collection coded into two categories: “poor” or “fair” versus “good”, “very good”, or “excellent”.
Statistical analyses
Descriptive statistics for COVID-19 stressors were computed by period (since pandemic onset and past month). Relationships between COVID-19 stressors and the six dependent variables were assessed for each period using logistic regression equations, adjusting for participant age, sex, race/ethnicity, and self-perceived mental health at Wave 2. Three levels of p values are provided for the logistic regression models at *p ≤ .05; **p ≤ .01; ***p ≤ .001 so that one can interpret statistical significance at more conservative levels if desired.
Results
Table 1 presents descriptive sample statistics. Table 2 provides the prevalence of respondents who identified each of the COVID-19 experiences as stressful since the onset of the pandemic and in the past month. In our sample, 2.1% and 12.4% of respondents reported no stressors since the onset of the pandemic and in the past month of the pandemic, respectively. The mean number of stressors reported were 8.9 since pandemic onset and 4.7 for the past month. Frequently reported COVID-19 stressors since the onset of the pandemic were: (1) not being able to spend time with friends (78.5%); (2) feeling lonely or isolated (69.9%); and (3) remote learning for school, college, or university (68.4%). For the past month, the top three reported stressors were: (1) remote learning for school, college, or university (42.6%); (2) feeling lonely or isolated (41.2%); and (3) uncertainty about the future (41.1%). Regardless of the period, fewer than 3% of respondents indicated “other” as a COVID-19 stressor. Examples of written responses for other stressors since the onset of the pandemic included: being alienated, loss of trust in government, and worsening physical health. Examples of written responses for other stressors in the past month included: overwhelmed healthcare system, low vaccination rates, lack of motivation, and issues with government and politics.
Table 1.
| % (n) | |
|---|---|
| Age at Wave 1, mean (SE) | 15.3 (0.5) |
| Age at Wave 4, mean (SE) | 19.0 (0.5) |
| Sex at Wave 1 | |
| Male | 43.8 (256) |
| Female | 56.2 (328) |
| Education at Wave 1 | |
| Grade 7 or 8 | 10.4 (61) |
| Grade 9 | 25.9 (152) |
| Grade 10 | 26.1 (153) |
| Grade 11 | 23.7 (139) |
| Grade 12 | 12.1 (71) |
| Graduated or post-secondary | 1.9 (11) |
| Education at Wave 4 | |
| Dropped out of high school | 1.0 (6) |
| Currently in high school | 11.2 (65) |
| Graduated high school | 24.2 (140) |
| Dropped out of post-secondary | 5.0 (29) |
| Currently in post-secondary (college or university) | 56.7 (328) |
| Graduated post-secondary (college or university) | 1.9 (11) |
Table 2.
| Since pandemic onset (%) | Past month (%) | |
|---|---|---|
| COVID-19 stressor count, mean (SE) | 8.9 (0.2) | 4.7 (0.2) |
| Not being able to spend time with friends | 78.5 | 32.5 |
| Feeling lonely or isolated | 69.9 | 41.2 |
| Remote learning for school, college, or university | 68.4 | 42.6 |
| Worrying about you or your family getting COVID-19 | 59.1 | 32.1 |
| Uncertainty about the future | 58.4 | 41.1 |
| Public health restrictions (i.e., wearing masks, physical distancing, and lock downs) | 56.5 | 29.0 |
| Missing significant life events (e.g., graduations, weddings, funerals, birth of a family member, etc.) | 56.0 | 21.5 |
| Loss of recreational activities such as sports | 52.4 | 21.7 |
| Not being able to spend time with family | 50.9 | 21.1 |
| Travel restrictions | 47.1 | 24.7 |
| Limited access to shopping and restaurants | 42.6 | 16.5 |
| Being at school, college, or university with public health restrictions | 38.7 | 26.0 |
| Not being able to spend time with a partner (e.g., boyfriend or girlfriend) | 37.5 | 15.1 |
| Disrupted or poor sleep | 33.9 | 23.2 |
| Adjusting to changes at your workplace or working virtually | 32.1 | 15.1 |
| Not having time alone | 27.3 | 15.1 |
| Increased conflict in your relationships (friends or family) | 23.2 | 13.4 |
| Job loss or financial burden | 22.2 | 11.2 |
| Grieving the death of a friend or family member during the pandemic | 14.3 | 6.5 |
| Other | 2.8 | 2.6 |
Overall, 26.1% of the sample perceived their physical health as fair-to-poor and 59.1% perceive their mental health as fair-to-poor. Self-perceived physical and mental health in the sample worsened from Wave 1 in 2017–2018 when 18.7% of the sample rated their physical health as fair-to-poor and 32.8% rated their mental health as fair-to-poor, although causal inferences related to worse self-perceived health at Wave 4 cannot be made. Associations between COVID-19 stressors and fair-to-poor self-perceived mental and physical health after adjusting for age, sex, and race/ethnicity from Wave 1, and self-perceived mental health from Wave 2 are presented in Table 3. Two COVID-19 stressors were significantly associated with increased odds of reporting fair-to-poor self-perceived physical health since the onset of the pandemic only: (1) worrying about getting COVID-19 (themselves or their family members) (adjusted odds ratio (AOR) = 2.37; 95% confidence interval (CI) = 1.51–3.72) and (2) uncertainty about the future (AOR = 1.63; 95% CI = 1.06–2.50). Two stressors that were associated with perceptions of fair-to-poor physical health for both periods, including since the onset of the pandemic and in the past month, were (1) job loss or financial burden (AOR = 1.61; 95% CI = 1.00–2.56 since the onset of the pandemic and AOR = 1.84; 95% CI = 1.02–3.33 for past month) and (2) disrupted or poor sleep (AOR = 1.64; 95% CI = 1.08–2.50 since the onset of the pandemic and AOR = 1.60; 95% CI = 1.02–2.52 for past month).
Table 3.
| Self-perceived physical health | Self-perceived mental health | |||
|---|---|---|---|---|
| Since pandemic onset | Past month | Since pandemic onset | Past month | |
| AORs (95% CI) | AORs (95% CI) | AORs (95% CI) | AORs (95% CI) | |
| COVID-19 stressor count | 1.03 (0.98, 1.08) | 1.03 (0.98, 1.08) | 1.06 (1.02, 1.11)** | 1.06 (1.01, 1.11)* |
| Worrying about you or your family getting COVID-19 | 2.37 (1.51, 3.72)*** | 1.27 (0.83, 1.94) | 1.22 (0.84, 1.76) | 1.11 (0.75, 1.65) |
| Public health restrictions (i.e., wearing masks, physical distancing, and lock downs) | 0.81 (0.53, 1.24) | 1.18 (0.76, 1.83) | 1.12 (0.77, 1.62) | 0.77 (0.51, 1.14) |
| Not being able to spend time with friends | 1.06 (0.64, 1.74) | 1.05 (0.69, 1.61) | 1.07 (0.67, 1.69) | 1.01 (0.68, 1.48) |
| Not being able to spend time with family | 0.95 (0.62, 1.46) | 0.95 (0.58, 1.57) | 1.17 (0.80, 1.72) | 1.10 (0.71, 1.72) |
| Not being able to spend time with a partner (e.g., boyfriend or girlfriend) | 1.21 (0.80, 1.83) | 1.23 (0.72, 2.11) | 1.30 (0.89, 1.90) | 1.25 (0.75, 2.06) |
| Feeling lonely or isolated | 1.42 (0.89, 2.27) | 1.38 (0.92, 2.08) | 3.54 (2.33, 5.37)*** | 3.08 (2.09, 4.55)*** |
| Loss of recreational activities such as sports | 0.68 (0.45, 1.02) | 0.86 (0.52, 1.42) | 1.08 (0.74, 1.57) | 1.07 (0.69, 1.65) |
| Being at school, college, or university with public health restrictions | 1.32 (0.87, 2.00) | 1.34 (0.85, 2.12) | 1.11 (0.76, 1.61) | 1.21 (0.80, 1.85) |
| Remote learning for school, college, or university | 1.43 (0.91, 2.25) | 1.19 (0.79, 1.78) | 1.28 (0.86, 1.91) | 1.41 (0.98, 2.04) |
| Adjusting to changes at your workplace or working virtually | 0.82 (0.53, 1.27) | 1.34 (0.78, 2.28) | 1.17 (0.79, 1.75) | 1.19 (0.72, 1.98) |
| Job loss or financial burden | 1.61 (1.00, 2.56)* | 1.84 (1.02, 3.33)* | 1.48 (0.94, 2.35) | 1.84 (0.97, 3.48) |
| Grieving the death of a friend or family member during the pandemic | 1.44 (0.83, 2.49) | 1.28 (0.59, 2.80) | 0.87 (0.52, 1.47) | 1.32 (0.62, 2.79) |
| Increased conflict in your relationships (friends or family) | 1.19 (0.74, 1.91) | 1.28 (0.72, 2.26) | 1.42 (0.90, 2.24) | 1.85 (1.03, 3.33)* |
| Travel restrictions | 0.74 (0.49, 1.11) | 0.79 (0.49, 1.29) | 0.90 (0.62, 1.30) | 0.73 (0.48, 1.11) |
| Limited access to shopping and restaurants | 0.75 (0.49, 1.13) | 0.92 (0.53, 1.61) | 1.03 (0.71, 1.49) | 1.10 (0.68, 1.78) |
| Not having time alone | 0.82 (0.51, 1.31) | 1.03 (0.59, 1.80) | 1.10 (0.73, 1.67) | 1.50 (0.89, 2.53) |
| Uncertainty about the future | 1.63 (1.06, 2.50)* | 1.31 (0.87, 1.97) | 1.53 (1.06, 2.23)* | 2.19 (1.50, 3.20)*** |
| Missing significant life events (e.g., graduations, weddings, funerals, birth of a family member, etc.) | 1.16 (0.77, 1.77) | 1.06 (0.65, 1.73) | 1.46 (1.01, 2.12)* | 1.08 (0.69, 1.69) |
| Disrupted or poor sleep | 1.64 (1.08, 2.50)* | 1.60 (1.02, 2.52)* | 2.03 (1.36, 3.04)*** | 2.48 (1.54, 3.98)*** |
| Other | 1.95 (0.53, 7.18) | 0.63 (0.13, 3.09) | 2.02 (0.58, 7.00) | 0.63 (0.18, 2.21) |
*
p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001. AOR (95% CI), AOR = adjusted odds ratio, CI = confidence interval. AOR adjusted for age, sex, and race/ethnicity at Wave 1, and self-perceived health at Wave 2 data collection.
Each increase in the number of stressors experienced was significantly associated with higher odds of fair-to-poor self-perceived mental health both since the onset of the pandemic (AOR = 1.06; 95% CI = 1.02–1.11) and in the past month (AOR = 1.06; 95% CI = 1.01–1.11). These models indicate that each one unit increase in the number of stressors corresponds with 1.06 times increased odds of fair-to-poor self-perceived mental health since the onset of the pandemic and 1.11 times increased odds of fair-to-poor self-perceived mental health in the past month. Missing significant life events as a stressor since the onset of the pandemic, but not in the past month was associated with higher odds of self-perceived fair-to-poor mental health (AOR = 1.46; 95% CI = 1.01 – 2.12). Stressors associated with fair-to-poor self-perceived mental health in both periods were: (1) feeling lonely or isolated (AOR = 3.54; 95% CI = 2.33–5.37 since the onset of the pandemic and AOR = 3.08; 95% CI = 2.09–4.55 for past month); (2) uncertainty about the future (AOR = 1.53; 95% CI = 1.06–2.23 for since the onset of the pandemic and AOR = 2.19; 95% CI = 1.50–3.20 for past month); and (3) disrupted or poor sleep (AOR = 2.03; 95% CI = 1.36–3.04 since the onset of the pandemic and AOR = 2.48; 95% CI = 1.54–3.98 for past month). One stressor that was significantly associated with higher odds of fair-to-poor mental health only in the past month was increased conflict with friends or family (AOR = 1.85; 95% CI = 1.03–3.33).
In the sample, 13.8% met criteria for a probable depression diagnosis, and 31.3% met criteria for a probable anxiety disorder diagnosis. Table 4 presents associations between COVID-19 stressors and depression and anxiety while adjusting for age, sex, and race/ethnicity from Wave 1, and self-perceived mental health from Wave 2. An increase in the number of stressors was associated with increased odds of experiencing both depression and anxiety since the onset of the pandemic and in the past month. Four stressors were significantly associated with higher odds of experiencing both disorders: not being able to spend time with a partner; feeling lonely or isolated; increased conflict with friends and family; and not having time alone. The following stressors were associated with increased odds of depression only, either since the onset of the pandemic or in the past month: (1) loss of recreational activities such as sports (past month only); (2) being at school, college, or university with public health restrictions (since the onset of the pandemic and past month); (3) adjusting to changes at your workplace or working virtually (since the onset of the pandemic); (4) job loss or financial burden (since the onset of the pandemic only); and (5) limited access to shopping and restaurants (past month only). Grieving the death of a friend or family member during the pandemic (past month only) was the only stressor associated with anxiety only (AOR = 2.16; 95% CI = 1.02–4.55).
Table 4.
| Depression | Anxiety | |||
|---|---|---|---|---|
| Since pandemic onset | Past month | Since pandemic onset | Past month | |
| AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | |
| COVID-19 stressor count | 1.12 (1.06, 1.17)*** | 1.10 (1.05, 1.15)*** | 1.12 (1.06, 1.18)*** | 1.09 (1.04, 1.14)*** |
| Worrying about you or your family getting COVID-19 | 1.09 (0.75, 1.60) | 1.28 (0.87, 1.89) | 1.44 (0.95, 2.17) | 1.15 (0.76, 1.75) |
| Public health restrictions (i.e., wearing masks, physical distancing, and lock downs) | 1.05 (0.72, 1.54) | 1.25 (0.84, 1.87) | 1.31 (0.87, 1.97) | 1.03 (0.67, 1.59) |
| Not being able to spend time with friends | 0.85 (0.53, 1.35) | 1.35 (0.92, 1.99) | 0.83 (0.50, 1.35) | 1.29 (0.86, 1.95) |
| Not being able to spend time with family | 0.88 (0.60, 1.30) | 1.04 (0.66, 1.62) | 1.24 (0.83, 1.88) | 1.39 (0.87, 2.23) |
| Not being able to spend time with a partner (e.g., boyfriend or girlfriend) | 1.45 (1.00, 2.12) | 1.71 (1.04, 2.81)* | 1.49 (1.00, 2.22)* | 1.80 (1.07, 3.03)* |
| Feeling lonely or isolated | 4.08 (2.51, 6.62)*** | 2.84 (1.94, 4.15)*** | 3.43 (2.03, 5.81)*** | 2.18 (1.46, 3.26)*** |
| Loss of recreational activities such as sports | 1.42 (0.97, 2.08) | 1.74 (1.12, 2.71)* | 1.18 (0.79, 1.77) | 1.30 (0.81, 2.09) |
| Being at school, college, or university with public health restrictions | 1.62 (1.11, 2.36)* | 1.60 (1.05, 2.43)* | 1.34 (0.90, 2.01) | 1.45 (0.93, 2.25) |
| Remote learning for school, college, or university | 1.44 (0.95, 2.17) | 1.18 (0.82, 1.71) | 1.15 (0.74, 1.79) | 1.04 (0.70, 1.54) |
| Adjusting to changes at your workplace or working virtually | 1.54 (1.04, 2.27)* | 1.60 (0.98, 2.63) | 1.25 (0.83, 1.89) | 1.35 (0.80, 2.29) |
| Job loss or financial burden | 1.96 (1.26, 3.06)** | 1.78 (0.99, 3.19) | 1.52 (0.96, 2.40) | 1.53 (0.84, 2.77) |
| Grieving the death of a friend or family member during the pandemic | 1.30 (0.78, 2.18) | 1.29 (0.62, 2.69) | 1.59 (0.94, 2.70) | 2.16 (1.02, 4.55)* |
| Increased conflict in your relationships (friends or family) | 1.89 (1.22, 2.92)** | 2.09 (1.22, 3.58)** | 1.78 (1.14, 2.79)* | 2.60 (1.51, 4.47)*** |
| Travel restrictions | 1.23 (0.85, 1.79) | 1.01 (0.66, 1.55) | 1.21 (0.81, 1.80) | 1.22 (0.78, 1.90) |
| Limited access to shopping and restaurants | 1.20 (0.83, 1.73) | 1.73 (1.07, 2.81)* | 1.34 (0.90, 1.99) | 1.54 (0.92, 2.56) |
| Not having time alone | 1.12 (1.06, 1.17)*** | 1.10 (1.05, 1.15)*** | 1.12 (1.06, 1.18)*** | 1.09 (1.04, 1.14)*** |
| Uncertainty about the future | 1.09 (0.75, 1.60) | 1.28 (0.87, 1.89) | 1.44 (0.95, 2.17) | 1.15 (0.76, 1.75) |
| Missing significant life events (e.g., graduations, weddings, funerals, birth of a family member, etc.) | 1.05 (0.72, 1.54) | 1.25 (0.84, 1.87) | 1.31 (0.87, 1.97) | 1.03 (0.67, 1.59) |
| Disrupted or poor sleep | 0.85 (0.53, 1.35) | 1.35 (0.92, 1.99) | 0.83 (0.50, 1.35) | 1.29 (0.86, 1.95) |
| Other | 0.88 (0.60, 1.30) | 1.04 (0.66, 1.62) | 1.24 (0.83, 1.88) | 1.39 (0.87, 2.23) |
*
p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001. AOR (95% CI), AOR = adjusted odds ratio, CI = confidence interval. AOR adjusted for age, sex, and race/ethnicity at Wave 1 data collection, and self-perceived health at Wave 2 data collection.
Among the sample, 31.1% reported at-risk alcohol use and 23.3% reported at-risk cannabis use. Associations between COVID-19 stressors and at-risk alcohol and cannabis use are presented in Table 5. None of the stressors were associated with increased odds of at-risk alcohol use except selecting “other” as a stressor in the past month. Reports of feeling lonely or isolated since the onset of the pandemic only, and job loss or financial burden in the past month only, were both associated with increased odds of at-risk cannabis use.
Table 5.
| Alcohol | Cannabis | |||
|---|---|---|---|---|
| Since pandemic onset | Past month | Since pandemic onset | Past month | |
| AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | |
| COVID-19 stressor count | 1.02 (0.98, 1.07) | 1.03 (0.99, 1.08) | 1.02 (0.97, 1.08) | 1.00 (0.95, 1.05) |
| Worrying about you or your family getting COVID-19 | 1.00 (0.68, 1.46) | 1.08 (0.73, 1.61) | 0.92 (0.60, 1.42) | 0.91 (0.58, 1.43) |
| Public health restrictions (i.e., wearing masks, physical distancing, and lock downs) | 0.99 (0.68, 1.45) | 0.81 (0.54, 1.23) | 1.39 (0.89, 2.15) | 0.87 (0.55, 1.38) |
| Not being able to spend time with friends | 1.09 (0.68, 1.75) | 0.92 (0.62, 1.37) | 0.93 (0.56, 1.54) | 0.73 (0.46, 1.16) |
| Not being able to spend time with family | 0.80 (0.54, 1.18) | 1.01 (0.64, 1.60) | 1.00 (0.65, 1.55) | 1.10 (0.66, 1.83) |
| Not being able to spend time with a partner (e.g., boyfriend or girlfriend) | 1.13 (0.77, 1.66) | 1.30 (0.78, 2.15) | 1.40 (0.92, 2.14) | 1.59 (0.92, 2.74) |
| Feeling lonely or isolated | 1.33 (0.88, 2.03) | 1.43 (0.98, 2.09) | 2.10 (1.25, 3.52)** | 1.38 (0.90, 2.10) |
| Loss of recreational activities such as sports | 1.35 (0.92, 1.99) | 1.16 (0.75, 1.81) | 1.14 (0.75, 1.75) | 1.15 (0.70, 1.89) |
| Being at school, college, or university with public health restrictions | 0.90 (0.61, 1.33) | 1.24 (0.81, 1.90) | 1.02 (0.66, 1.58) | 1.01 (0.62, 1.64) |
| Remote learning for school, college, or university | 1.07 (0.71, 1.61) | 1.16 (0.79, 1.68 | 0.89 (0.57, 1.39) | 0.70 (0.46, 1.07) |
| Adjusting to changes at your workplace or working virtually | 1.13 (0.76, 1.69) | 1.46 (0.89, 2.40) | 1.22 (0.79, 1.90) | 1.16 (0.66, 2.04) |
| Job loss or financial burden | 1.11 (0.70, 1.73) | 1.32 (0.74, 2.37) | 1.60 (0.99, 2.58) | 2.20 (1.21, 3.99)** |
| Grieving the death of a friend or family member during the pandemic | 1.21 (0.72, 2.06) | 1.90 (0.92, 3.92) | 0.63 (0.33, 1.21) | 0.59 (0.22, 1.61) |
| Increased conflict in your relationships (friends or family) | 1.01 (0.65, 1.58) | 1.60 (0.94, 2.71) | 0.80 (0.48, 1.33) | 0.88 (0.47, 1.66) |
| Travel restrictions | 1.24 (0.85, 1.81) | 1.22 (0.80, 1.87) | 1.00 (0.65, 1.52) | 0.69 (0.41, 1.15) |
| Limited access to shopping and restaurants | 1.12 (0.77, 1.63) | 1.18 (0.72, 1.94) | 1.35 (0.89, 2.06) | 1.23 (0.71, 2.15) |
| Not having time alone | 1.14 (0.75, 1.73) | 1.18 (0.71, 1.94) | 0.92 (0.57, 1.48) | 1.06 (0.60, 1.89) |
| Uncertainty about the future | 1.06 (0.73, 1.55) | 0.91 (0.62, 1.33) | 0.87 (0.57, 1.33) | 0.73 (0.47, 1.12) |
| Missing significant life events (e.g., graduations, weddings, funerals, birth of a family member, etc.) | 1.14 (0.78, 1.67) | 1.45 (0.93, 2.26) | 0.93 (0.61, 1.43) | 1.08 (0.65, 1.79) |
| Disrupted or poor sleep | 1.09 (0.73, 1.62) | 1.24 (0.80, 1.93) | 1.23 (0.79, 1.90) | 1.01 (0.62, 1.65) |
| Other | 2.21 (0.68, 7.13) | 3.62 (1.09, 12.09)* | 1.97 (0.55, 7.10) | 0.90 (0.18, 4.44) |
*
p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001. AOR (95% CI), AOR = adjusted odds ratio, CI = confidence interval. AOR adjusted for age, sex, and race/ethnicity at Wave 1 data collection, and self-rated health at Wave 2 data collection.
Discussion
Several novel findings in this study contribute to our understanding of the prevalence of COVID-19-related stressors among youth, and how stressors were associated with negative outcomes, notably, poor mental health. These data can inform efforts to promote recovery among adolescents and young adults who may still be struggling in the aftermath of the pandemic and future preventive interventions should another pandemic occur. Importantly, 97.9% of youth reported experiencing stressors since the onset of the pandemic and 87.6% indicated experiencing stressors within the past month (i.e., second year of the pandemic), which is consistent with previous research (Watson et al. 2023). In addition, in the current study, many youth reported high numbers of stressors since the onset of the pandemic (mean = 8.9) and in the past month (mean = 4.7). In summary, eight stressors plus stressor count were associated with two or more outcomes, 15 stressors plus stressor count were associated with one or more outcomes, and five stressors were not associated with any outcomes in the current study. More significant relationships were noted for perceived mental health, depression, and anxiety, and less for perceived physical health, at-risk alcohol use, and at-risk cannabis use.
Some prevalent stressors (e.g., loneliness/isolation) were strongly and consistently associated with negative mental health outcomes. Other less prevalent stressors also had significant associations with negative health outcomes. For example, increased conflict in relationships was associated with an increased likelihood of reporting fair-to-poor self-perceived mental health, depression, and anxiety. Job loss or financial burden was associated with increased odds of reporting fair-to-poor self-perceived physical health, depression, and cannabis use. However, it should be noted that while many stressors were related to increased odds of depression and anxiety, very few stressors were related to at-risk alcohol use and at-risk cannabis use.
Research conducted since 2020 has repeatedly shown that the pandemic was stressful for youth and young adults (Glowacz and Schmits 2020; Essau and de la Torre-Luque 2021; Jones et al. 2021; Meherali et al. 2021; Minhas et al. 2021; Segre et al. 2021; Craig et al. 2023; Foster et al. 2023; Madigan et al. 2023). The findings of the present analyses provide further evidence and additional insight. In our study, multiple stressors were reported since the onset of the pandemic, but fewer were mentioned in reference to the past month, which may reflect reporting of stressors in a shorter period (since onset and past month) but may also indicate some relief in the second year of the pandemic. The COVID-19 stressors reported most frequently since the pandemic onset included: (1) not being able to spend time with friends (78.5%); (2) feeling lonely or isolated (69.9%); and (3) remote learning for school, college, or university (68.4%). In reference to the “past month”, frequently reported stressors were: (1) remote learning (42.6%); (2) feeling lonely or isolated (41.2%); and (3) uncertainty about the future (41.1%).
Loneliness/isolation was a prevalent and potent stressor in the present study. In fact, loneliness/isolation was the stressor with the most robust relationships in this work. More specifically, loneliness/isolation was associated with fair-to-poor perceived mental health, depression, anxiety, and at-risk cannabis use. This is consistent with a US study that found that self-isolation during the pandemic was associated with depression among youth and adults (Narita et al. 2023). Other U.S. research also found social and relationship stressors to be associated with anxiety and depression symptoms (Graupensperger et al. 2022). A study from the US identified alcohol consumption as a means of coping with social isolation during the pandemic among a sample of young adults (Cho et al. 2023). Although, feeling isolated or lonely was not significantly associated with alcohol use in our study, the effect size and wider CI may indicate an underpowered model and a Type II error. In addition to loneliness/isolation, we found that job loss or financial burden and increased conflict with friends and family were strongly associated with negative health outcomes. Importantly, indicating “other” stressor as associated with an increased likelihood of at-risk alcohol use in the past month. This indicates that stressors other than those asked about in this study may be important and including youth voices in future research to better understand what might be included in this other category is needed. Findings from the current study extend knowledge and may signal the need to focus on ways to foster in-person connections and relationships with friends and family, and ensure good supports are in place related to employment.
Importantly, the findings from this work indicate that six stressors were only associated with one outcome and five stressors were not related to any of the health outcomes included in the study. More specifically, public health restrictions (i.e., wearing masks, physical distancing, and lock downs), not being able to spend time with friends, not being able to spend time with family, remote learning, and travel restrictions were not associated with any health outcomes in the current study since the pandemic or in the past month. These findings are important from a public health perspective since they are all related to restrictions that were put in place to reduce COVID-19 infections.
Information on stressors related to poor health can assist clinicians in being alert to and aware of the types of stressors that are associated with mental health problems. Among youth presenting with mental health impairment, perhaps asking them about stressors and the ways in which they are trying to cope can help identify specific supports and appropriate coping strategies. It is notable that many stressors were associated with increased odds of depression and anxiety. In the current study, stressors were more consistently related to depression more so than other outcomes. It may be helpful for clinicians to be aware of the prevalence of those stressors and the extent to which they are linked to mental health problems. For individuals who experienced negative health outcomes, understanding the nature of stressors and the tendency to use particular coping mechanisms may provide insight and aid recovery.
These findings are important not only to understand how COVID-19 stressors impacted health outcomes among youth, even 2 years after the start of the pandemic, but also to recognize that while stressor did decrease, recovery may be ongoing for some. There is a need for greater investment in health and social services to address the challenges that may have arisen or been exacerbated during the pandemic. The findings from the current study can inform the intervention strategies to assist youth who may require ongoing care for a full or more optimal recovery. Some stressors such as remote learning for school, college, or university, or other stressors related to public health restrictions may no longer be present. However, lost learning because of this experience and how this may be related to later employment or job security may still exist and need to be addressed. As well, stressors that may still be present and persist for some time such as feeling lonely or isolated, increased conflict, and job loss or financial burden should be identified as areas in need of possible interventions among youth who may still be recovering from the pandemic. This may require strategies to foster social connections and healthy communication and assistance with employment.
Findings from this research should be considered along with important study limitations. Given the cross-sectional survey design, inferences regarding causation cannot be made. Second, data for this work were drawn from a community sample from Manitoba. It is not representative of the province of Manitoba or Canada; generalizability of the findings could be limited. Third, although we were able to retain almost 60% of our sample from Wave 1 to Wave 4, it is possible that attrition affected the sociodemographic characteristics in the sample and the study findings. This level of sample retention with this young age group, especially during the COVID-19 pandemic, should be considered a good retention rate. Finally, the COVID-19 stressors were not derived from a validated scale and would not be possible due to the fast onset of the pandemic; however, Cronbach's alphas indicated good reliability.
An important finding to highlight is that 26.1% of adolescents and young adults perceived their physical health as fair-to-poor, and 59.1% perceive their mental health as fair-to-poor. Nearly all (97.9%) the youth in our sample indicated experiencing COVID-19 stressors. Notably, five of the stressors included in the study were not related to any poor health outcomes and all other stressors were related to one or more, but not all of the health outcomes. However, several of these stressors (i.e., 12 stressors plus the COVID-19 stressor count) remained associated with poor physical and mental health outcomes almost 2 years after the start of the pandemic. Although not all youth will require intervention to recover from the pandemic, it is imperative for clinicians and those working in public health and social services to understand what these stressors are, and the relationships these stressors have with poor health outcomes among youth. This knowledge can be used to guide clinical efforts and policy decisions to improve health and ensure optimal recovery for youth following the COVID-19 pandemic. For some, pandemic recovery may continue even though public health restrictions have been lifted and some time has passed. Investments need to be made to healthcare as well as health and social programs and policy to assist when recovery remains ongoing. Importantly, these findings can help to guide pandemic recovery efforts with knowledge specifically related to relationships between COVID-19 stressors and self-perceived health, depression, anxiety, at-risk alcohol use, and at-risk cannabis use among youth to promote recovery from pandemic-related health risks.
Acknowledgements
The authors thank the parents and adolescents who participated in the Well-being and Experiences Study and took the time to share their experiences for this work.
TOA is supported by a Tier I Canada Research Chair in Childhood Adversity and Resilience. This work was supported by a Canadian Institutes of Health Research (CIHR) operating grant: understanding and mitigating the impacts of the COVID-19 pandemic on children, youth and families in Canada. HLM is supported by the Chedoke Health Chair in Child Psychiatry. AG is supported by a Tier II Canada Research Chair in Family Health and Preventive Interventions.
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FACETS
Volume 9 • Number 1 • January 2024
Pages: 1 - 10
Editor: Jessica Grahn
History
Received: 5 September 2023
Accepted: 3 September 2024
Version of record online: 13 November 2024
Copyright
© 2024 Authors Afifi, Fortier, Salmon, Taillieu, Osorio, Ross, Stewart-Tufescu, Gonzalez, Kimber, Sareen, MacMillan, and The Crown. This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
Data Availability Statement
Data are not available due to ethics requirements.
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Author Contributions
Conceptualization: TOA, JF, TT, LR, AS, LT, AG, MK, JS, HLM
Data curation: TOA, JF, SS
Formal analysis: TOA, JF, SS, TT, AO
Funding acquisition: TOA, LT, AG, MK, JS, HLM
Investigation: TOA
Methodology: TOA, SS, LR, AS, LT, AG, MK, JS, HLM
Project administration: TOA
Resources: TOA
Visualization: TOA, TT
Writing – original draft: TOA, JF, SS, TT, AO, LR, AS, LT, AG, MK, JS, HLM
Writing – review & editing: TOA, JF, SS, TT, AO, LR, AS, LT, AG, MK, JS, HLM
Competing Interests
The authors declare there are no competing interests.
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Tracie O. Afifi, Janique Fortier, Samantha Salmon, Tamara Taillieu, Ana Osorio, Leslie Roos, Ashley Stewart-Tufescu, Lil Tonmyr, Andrea Gonzalez, Melissa Kimber, Jitender Sareen, and Harriet L. MacMillan. 2024. Youth COVID-19 stressors and associations with self-perceived health, depression, anxiety, and at-risk alcohol and cannabis use. FACETS.
9(): 1-10. https://doi.org/10.1139/facets-2023-0160
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