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The Inequitable Psychological Impacts of the COVID-19 Pandemic on Post-Secondary Students with Preexisting Health Conditions: A Longitudinal Study

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Title: The Inequitable Psychological Impacts of the COVID-19 Pandemic on Post-Secondary Students with Preexisting Health Conditions: A Longitudinal Study
Language: English
Authors: Sarah Kuburi (ORCID 0000-0001-7816-0643), Chloe A. Hamza, Antonio Lorenzo, Altea Kthupi, Shaza A. Fadel, France Gagnon
Source: Journal of American College Health. 2025 73(4):1780-1786.
Availability: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 7
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: COVID-19, Pandemics, College Students, Mental Health, Depression (Psychology), Anxiety, Stress Variables, Foreign Countries, Chronic Illness, Diseases
Geographic Terms: Canada
DOI: 10.1080/07448481.2024.2435955
ISSN: 0744-8481
1940-3208
Abstract: Objective: Evidence suggests young adults in post-secondary school experienced increased distress during the COVID-19 pandemic, but students' experiences likely varied. Effects may have also changed over time as students adapted. This study examined the mental health of students with and without preexisting health conditions at two points during the pandemic (winter 2020/2021 and spring/summer 2021). Methods: Participants (N = 1465) completed a baseline and follow-up questionnaire assessing their health history, depressive symptoms, anxiety symptoms, stress, and COVID-19-related worry and perceived vulnerability of severe infection. Results: At both time points, students with preexisting health conditions reported greater distress than those without preexisting health conditions. Stress increased from time 1 to time 2 for all students, and participants with preexisting health conditions significantly increased in their COVID-19 perceived vulnerability of severe infection over time. Conclusions: Findings highlight the need for additional and ongoing mental health supports for vulnerable students throughout the pandemic.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1472985
Database: ERIC
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  Value: <anid>AN0184444298;acl01apr.25;2025Apr15.05:17;v2.2.500</anid> <title id="AN0184444298-1">The inequitable psychological impacts of the COVID-19 pandemic on post-secondary students with preexisting health conditions: A longitudinal study </title> <p>Objective: Evidence suggests young adults in post-secondary school experienced increased distress during the COVID-19 pandemic, but students' experiences likely varied. Effects may have also changed over time as students adapted. This study examined the mental health of students with and without preexisting health conditions at two points during the pandemic (winter 2020/2021 and spring/summer 2021). Methods: Participants (N = 1465) completed a baseline and follow-up questionnaire assessing their health history, depressive symptoms, anxiety symptoms, stress, and COVID-19-related worry and perceived vulnerability of severe infection. Results: At both time points, students with preexisting health conditions reported greater distress than those without preexisting health conditions. Stress increased from time 1 to time 2 for all students, and participants with preexisting health conditions significantly increased in their COVID-19 perceived vulnerability of severe infection over time. Conclusions: Findings highlight the need for additional and ongoing mental health supports for vulnerable students throughout the pandemic.</p> <p>Keywords: Chronic health condition; COVID-19; longitudinal research; mental health; university students</p> <hd id="AN0184444298-2">Introduction</hd> <p>On March 11, 2020, the World Health Organization declared COVID-19 a pandemic,[<reflink idref="bib1" id="ref1">1</reflink>] resulting in the implementation of global intervention strategies to mitigate the transmission of the virus.[<reflink idref="bib2" id="ref2">2</reflink>] In North America, many states and provinces introduced measures in response to the pandemic including the closure of schools and widespread stay-at-home orders.[<reflink idref="bib3" id="ref3">3</reflink>] As a result of mitigation efforts, many emerging adults (ages 18–25 years) in post-secondary schools were required to complete 12–15 months of education off campus, and as a result many students reported that they experienced planned work placement postponement and cancellations, causing them to feel worried about their studies, financial situations, and future job prospects.[[<reflink idref="bib4" id="ref4">4</reflink>], [<reflink idref="bib6" id="ref5">6</reflink>]]</p> <p>The effects of the pandemic on student psychological well-being have been well documented. In several cross-sectional studies conducted at the height of the pandemic, university students reported high levels of anxiety, depression,[<reflink idref="bib7" id="ref6">7</reflink>]<sups>,</sups>[<reflink idref="bib8" id="ref7">8</reflink>] and stress.[<reflink idref="bib9" id="ref8">9</reflink>] Later longitudinal findings[<reflink idref="bib10" id="ref9">10</reflink>]<sups>,</sups>[<reflink idref="bib11" id="ref10">11</reflink>] and large-scale literature reviews substantiate these findings.[<reflink idref="bib12" id="ref11">12</reflink>]<sups>,</sups>[<reflink idref="bib13" id="ref12">13</reflink>] However, emerging evidence suggests that the pandemic's impact on university student mental health was highly variable across different subsamples.[[<reflink idref="bib14" id="ref13">14</reflink>], [<reflink idref="bib16" id="ref14">16</reflink>]] One important factor that may predispose some students to greater distress in the context of the pandemic, is the presence of preexisting health conditions (medical vulnerabilities, chronic health conditions, or diseases).</p> <p>Throughout the pandemic, it was commonly suggested that young people were expected to experience less severe outcomes from COVID-19 infection.[<reflink idref="bib17" id="ref15">17</reflink>] That said, students with preexisting health conditions may have experienced heightened risk of severe COVID-19 outcomes, compounding existing worries about infection with concerns over the pandemic's impact on their future prospects making them more at risk.[<reflink idref="bib18" id="ref16">18</reflink>] Cross-sectional work, conducted early on in the pandemic, suggests that students with preexisting health conditions experienced heightened anxiety and health anxiety,[<reflink idref="bib19" id="ref17">19</reflink>] and were at increased risk for depression,[<reflink idref="bib20" id="ref18">20</reflink>]<sups>,</sups>[<reflink idref="bib21" id="ref19">21</reflink>] and stress than students without preexisting health conditions.[<reflink idref="bib22" id="ref20">22</reflink>]<sups>,</sups>[<reflink idref="bib23" id="ref21">23</reflink>] However, longitudinal work on students with and without preexisting health conditions has been largely lacking in the literature. Assessing differences in student risk over time can help to identify students who may be vulnerable to ongoing distress (versus acute) in the aftermath of the pandemic, and in need of further support and intervention.</p> <hd id="AN0184444298-3">Present study</hd> <p>It is crucial to understand how individuals with preexisting health conditions responded to the pandemic in order to inform future crisis response strategies. Existing research, often early and cross-sectional, leaves gaps in understanding how students with and without preexisting health conditions faired over time as the pandemic waned on. In the present study, the mental health of university students with and without preexisting health conditions was examined in Canada at two time points during the pandemic (winter 2020/2021 to spring/summer 2021). Unlike most prior work in this area, specific questions about worry of COVID-19 infection and perceived vulnerability for severe outcomes after infection were also examined. It was hypothesized that students with preexisting health conditions would experience higher depressive symptoms, anxious symptoms, and stress in the context of the pandemic, relative to students without preexisting health conditions. It was also expected that students with preexisting health conditions would be more worried about COVID-19 infection and potential serious complications stemming from infection compared to their peers. Finally, the examination of changes in distress and COVID-19 worry and perceived vulnerability of infection over time was explored to determine the extent students experienced changes in mental health across the two time points.</p> <hd id="AN0184444298-4">Methods</hd> <p></p> <hd id="AN0184444298-5">Participants</hd> <p>The current study included 1465 (M<subs>age</subs> = 23.5, SD = 4.68) undergraduate, graduate, and professional students from a cohort study at a university in Canada. Participants were surveyed three times from December 18, 2020, to January 4, 2022, and the present study uses data collected from the first two assessment points. Data were not utilized from the third assessment as measures of perceived worry of infection and perceived vulnerability for severe infection were not completed by students once they indicated that they were vaccinated (which the vast majority were by time 3). Eligible participants were fluent in English, at least 17 years old, residing in the region in which data were collected, and enrolled as a student for the 2020–2021 academic year. Participants also had to meet at least one of the following criteria: (<reflink idref="bib1" id="ref22">1</reflink>) registered for a minimum of one course that was being delivered in-person or <emph>via</emph> a hybrid model during the Fall 2020 semester, (<reflink idref="bib2" id="ref23">2</reflink>) or resided in the university's residences or apartments during Fall 2020.</p> <hd id="AN0184444298-6">Procedure</hd> <p>On December 5, 2020, the university's Office of the Vice-Provost, for student affairs, sent an email to students inviting those who were eligible to participate. Interested students were directed to the study's website for details and encouraged to contact the research coordinator for further inquiries. Interested students completed an eligibility questionnaire and consented to participate <emph>via</emph> a secure online platform. At time 1, participants completed a baseline questionnaire available from December 18, 2020, to March 30, 2021. Participants also completed a supplementary baseline questionnaire available from January 29, 2021, to March 30, 2021, as part of the first time point of data collection, which included additional survey questions measuring students' worries and perceived vulnerability surrounding COVID-19. At time 2, participants completed a follow-up questionnaire available from April 3, 2021, to September 15, 2021, which included all the baseline and supplementary measures. This study was approved by the Research Ethics Board of the university prior to its initiation (Protocol #40019).</p> <hd id="AN0184444298-7">Measures</hd> <p></p> <hd id="AN0184444298-8">Demographics</hd> <p>To measure the demographics of the included sample, participants were asked to report their age, ethnicity, sex, gender, university faculty, program type, and living arrangements at time 1. Participants were also asked to provide information on their medical history to determine preexisting health condition status. Participants first self-reported having one of the four major chronic diseases identified by the World Health Organization (chronic lung disease, chronic heart disease, cancer, or diabetes).[<reflink idref="bib24" id="ref24">24</reflink>] Additionally, participants may have self-reported having asthma, chronic liver disease, chronic kidney disease, or being obese, immunocompromised, or immunosuppressed. Participants may have also self-disclosed as having an "other chronic health condition that was not included." These chronic health conditions were assessed using criteria published by Public Health Ontario which considered stroke, high blood pressure, and conditions or taking medications that can weaken the immune system to increase risk of COVID-19.[<reflink idref="bib25" id="ref25">25</reflink>] Based on the responses to the questions above, participants were categorized into the preexisting health condition group or no preexisting health condition group. The data for this study was derived from a larger investigation focused on immunology during the COVID-19 pandemic among university students residing on campus or participating in on-campus activities at a Canadian university. Consequently, preexisting mental health conditions of the participants were not assessed in this study.</p> <hd id="AN0184444298-9">Psychological outcomes</hd> <p>Participants completed the PHQ-9,[<reflink idref="bib26" id="ref26">26</reflink>] GAD-7,[<reflink idref="bib27" id="ref27">27</reflink>] and PSS-10,[<reflink idref="bib28" id="ref28">28</reflink>] to measure their depression, anxiety, and stress levels over the past 2 weeks, respectively. The PHQ-9 evaluates the severity of depressive symptoms and participants were asked to rate how bothered they had been by any of the problems listed in the questionnaire from 0 (<emph>not at all</emph>) to 3 (<emph>nearly every day</emph>). Cronbach's Alpha for time 1 was α =.88 and for time 2 was α =.92, indicating high internal consistency. The PSS-10 captures perceived stress by asking participants to rate how often they felt or thought a certain way from 0 (<emph>never</emph>) to 4 (<emph>very often</emph>). Cronbach's Alpha for time 1 was α =.87 and for time 2 was α =.90, indicating high internal consistency. Lastly, the GAD-7 evaluates the presence of generalized anxiety disorder by asking participants to rate how often the listed items had occurred for them from 0 (<emph>not at all sure</emph>) to 3 (<emph>nearly every day</emph>). Cronbach's Alpha for time 1 was α =.91 and for time 2 was α =.94, indicating high internal consistency. All psychological outcomes were treated as continuous variables, and higher scores on each measure indicated greater symptom severity.</p> <hd id="AN0184444298-10">COVID-19 pandemic worries and perceived vulnerability</hd> <p>To assess COVID-19 related worry and perceived vulnerability, two questions were used. The first question assessed participants' worries of getting infected ('How worried are you about the possibility of becoming infected with COVID-19?') and the second question measured perceived vulnerability of severe infection ('If you become infected with COVID-19, how likely do you think you are to become seriously ill?'). Participants rated the degree of their COVID-19 worry of infection and perceived vulnerability of severe infection both from 1 (<emph>not at all likely</emph>) to 4 (<emph>very likely</emph>). COVID-19-related worry and perceived vulnerability measures were developed in collaboration with researchers at a Canadian university. The research team, including post-secondary students, piloted these questions to ensure clarity and comprehension. Although these measures were specifically designed for this study, they are comparable to those used in other COVID-19 research studies.[<reflink idref="bib29" id="ref29">29</reflink>] In the current sample, both measures demonstrated strong test-retest reliability, with a reliability coefficient of 0.77 and 0.77 respectively. The variables were treated as continuous, with higher scores indicating greater COVID-19-related worry or perceived vulnerability.</p> <hd id="AN0184444298-11">Missing data</hd> <p>Missing data occurred due to participant attrition over time. In total, 64.6% of participants completed both the baseline and follow-up questionnaire, and 59% of participants completed the supplementary questionnaire at baseline. Given the missing responses across time, imputation was used to replace the missing data. Prior to imputation, missing values analysis was conducted to determine if participants who completed only one time point differed from those who completed both time points. It was found that participants did not differ in terms of age, depressive symptoms, anxiety symptoms, stress, and COVID-19 related worry and perceived vulnerability. However, participants did differ on sex, such that participants who completed two time points were more likely to be female rather than male, <emph>t</emph>(1463) = −4.87, <emph>p</emph> <.001, 95% CI [-0.176, −0.075]. Missing values were imputed using the expectation-maximum (EM) algorithm. EM is an iterative maximum-likelihood (ML) procedure in which a cycle of calculating means and covariances followed by data imputation is repeated until a stable set of estimated missing values is reached. Methodological research has demonstrated that ML estimation is preferable to pair-wise deletion, list-wise deletion, or means substitution.[<reflink idref="bib30" id="ref30">30</reflink>]</p> <hd id="AN0184444298-12">Data analytic strategy</hd> <p>Participants means and standard deviations of study variables were examined using descriptive analyses. A repeated-measures ANOVA was used to examine changes in psychological outcomes and COVID-19 related worry and perceived vulnerability across time. A between-subjects factor was included to determine whether there was an interaction effect of preexisting health condition. Follow-up analyses included examining significant differences among the two groups at time 1 and time 2 using paired samples t-tests and between groups at time 1 and time 2 using independent samples t-tests. SPSS version 28.00[<reflink idref="bib31" id="ref31">31</reflink>] was used to analyze the data and given that this work was exploratory, a liberal alpha of.05 was used.</p> <hd id="AN0184444298-13">Results</hd> <p></p> <hd id="AN0184444298-14">Preliminary results</hd> <p>Participant demographic information is presented in Table 1 and participants' preexisting health conditions information is presented in Table 2. Approximately 12% of participants in this sample had a preexisting health condition. The most reported preexisting health condition for this sample was asthma (70%).</p> <p>Table 1. Sample characteristics.</p> <p> <ephtml> <table><thead><tr><td /><td>Preexisting health conditions</td><td>No preexisting health conditions</td><td>Overall</td></tr><tr><td /><td>(<italic>N</italic> = 181)</td><td>(<italic>N</italic> = 1284)</td><td>(<italic>N</italic> = 1465)</td></tr></thead><tbody valign="top"><tr><td>Demographics</td><td /><td /><td /></tr><tr><td> Age</td><td /><td /><td /></tr><tr><td> Mean (SD)</td><td char=".">24.1 (5.97)</td><td char=".">23.4 (4.47)</td><td char=".">23.5 (4.68)</td></tr><tr><td> Sex</td><td /><td /><td /></tr><tr><td> Female</td><td char=".">119 (65.7%)</td><td char=".">841 (65.5%)</td><td char=".">960 (65.5%)</td></tr><tr><td> Male</td><td char=".">62 (34.3%)</td><td char=".">443 (34.5%)</td><td char=".">505 (34.5%)</td></tr><tr><td> Gender</td><td /><td /><td /></tr><tr><td> Woman</td><td char=".">113 (62.4%)</td><td char=".">810 (63.1%)</td><td char=".">923 (63.0%)</td></tr><tr><td> Man</td><td char=".">62 (34.3%)</td><td char=".">441 (34.3%)</td><td char=".">503 (34.3%)</td></tr><tr><td> Other§</td><td char=".">3 (1.7%)</td><td char=".">8 (0.6%)</td><td char=".">11 (0.8%)</td></tr><tr><td> Prefer not to answer</td><td char=".">1 (.6%)</td><td char=".">16 (1.2%)</td><td char=".">17 (1.1%)</td></tr><tr><td> Did not identify</td><td char=".">2 (1.1%)</td><td char=".">9 (.7%)</td><td char=".">11 (0.8%)</td></tr><tr><td> Ethnicity</td><td /><td /><td /></tr><tr><td> White</td><td char=".">93 (51.4%)</td><td char=".">549 (42.8%)</td><td char=".">642 (43.8%)</td></tr><tr><td> East Asian or Pacific Islander</td><td char=".">31 (17.1%)</td><td char=".">314 (24.5%)</td><td char=".">345 (23.5%)</td></tr><tr><td> South Asian</td><td char=".">23 (12.7%)</td><td char=".">167 (13%)</td><td char=".">190 (13.0%)</td></tr><tr><td> Other<xref ref-type="table-fn" rid="tfn1">*</xref></td><td char=".">34 (18.8%)</td><td char=".">254 (19.7%)</td><td char=".">288 (19.7%)</td></tr><tr><td>Residence factors</td><td /><td /><td /></tr><tr><td> Campus residency</td><td /><td /><td /></tr><tr><td> On campus</td><td char=".">58 (32%)</td><td char=".">402 (31.4%)</td><td char=".">460 (31.4%)</td></tr><tr><td> Off campus</td><td char=".">121 (66.9%)</td><td char=".">875 (68.1%)</td><td char=".">996 (68.0%)</td></tr><tr><td> Missing</td><td char=".">2 (1.1%)</td><td char=".">7 (0.5%)</td><td char=".">9 (0.6%)</td></tr><tr><td> Household arrangement</td><td /><td /><td /></tr><tr><td> Living alone</td><td char=".">48 (26.5%)</td><td char=".">304 (23.7%)</td><td char=".">352 (24.0%)</td></tr><tr><td> Living with relatives</td><td char=".">47 (26%)</td><td char=".">393 (30.6%)</td><td char=".">440 (30.0%)</td></tr><tr><td> Living with non-relatives</td><td char=".">84 (46.4%)</td><td char=".">560 (43.6%)</td><td char=".">644 (44.0%)</td></tr><tr><td> Missing</td><td char=".">2 (1.1%)</td><td char=".">27 (2.1%)</td><td char=".">29 (2.0%)</td></tr><tr><td>Academic factors</td><td /><td /><td /></tr><tr><td> Program type</td><td /><td /><td /></tr><tr><td> Graduate</td><td char=".">62 (34.3%)</td><td char=".">431 (33.6%)</td><td char=".">493 (33.7%)</td></tr><tr><td> Undergraduate</td><td char=".">119 (65.7%)</td><td char=".">849 (66.1%)</td><td char=".">968 (66%)</td></tr><tr><td> Missing</td><td char=".">0 (0.0%)</td><td char=".">4 (0.3%)</td><td char=".">4 (0.3%)</td></tr><tr><td> Faculty</td><td /><td /><td /></tr><tr><td> Arts and Science</td><td char=".">93 (51.4%)</td><td char=".">548 (42.7%)</td><td char=".">641 (43.8%)</td></tr><tr><td> Medicine</td><td char=".">33 (18.2%)</td><td char=".">281 (21.9%)</td><td char=".">314 (21.5%)</td></tr><tr><td> Dentistry</td><td char=".">10 (5.5%)</td><td char=".">86 (6.7%)</td><td char=".">96 (6.6%)</td></tr><tr><td> Law</td><td char=".">9 (5.0%)</td><td char=".">67 (5.2%)</td><td char=".">76 (5.2%)</td></tr><tr><td> Other†</td><td char=".">35 (19.3%)</td><td char=".">290 (22.6%)</td><td char=".">325 (22%)</td></tr><tr><td> Missing</td><td char=".">1 (0.6%)</td><td char=".">12 (0.9%)</td><td char=".">13 (0.9%)</td></tr></tbody></table> </ephtml> </p> <p>1 Other includes Black, Indigenous, Hispanic, Middle Eastern and Central Asian, and multiracial participants as well as participants who did not know and chose not to answer.</p> <ulist> <item>2 §Other gender groups include agender, nonbinary, man and woman, transmasculine, and transfeminine.</item> <item>3 †Other faculty groups include architecture, education, information, kinesiology and physical education, applied science and engineering, management, music, nursing, pharmacy, public health, and social work.</item> </ulist> <p>Table 2. Preexisting health condition sample characteristics.</p> <p> <ephtml> <table><thead><tr><td>Chronic health condition</td><td>Number of preexisting health conditions in this sample (<italic>N</italic> = 198)</td></tr><tr><td>Sum (%)</td></tr></thead><tbody valign="top"><tr><td>Asthma</td><td char=".">126 (69.6%)</td></tr><tr><td>Chronic liver, kidney, lung, or heart disease</td><td char=".">9 (5.1%)</td></tr><tr><td>Obesity</td><td char=".">15 (8.3%)</td></tr><tr><td>Immunosuppressed</td><td char=".">17 (9.4%)</td></tr><tr><td>Immunocompromised</td><td char=".">10 (5.5%)</td></tr><tr><td>Cancer</td><td char=".">0 (0.0%)</td></tr><tr><td>Diabetes</td><td char=".">7 (3.9%)</td></tr><tr><td>Other chronic health conditions*</td><td char=".">14 (7.7%)</td></tr></tbody></table> </ephtml> </p> <ulist> <item>4 Participants may have self-disclosed having more than one of the above health conditions.</item> <item>5 *Other health conditions include Lupus, Hemophilia, Hemochromatosis, Crohn's disease, Graves' Disease, Autonomic Dysfunction, Ehlers-Danlos Hypermobile Type, Thalassemia, G6PD Deficiency, Heart Defect, Hashimoto's Thyroiditis.</item> </ulist> <hd id="AN0184444298-15">Primary results</hd> <p>There was a significant effect of time on stress, such that both students with and without preexisting health conditions increased over time (see Table 3). There were also significant between group effects, and follow-up independent t-tests showed that participants with preexisting health conditions reported higher depressive symptoms at time 1, <emph>t</emph>(1463) = −3.05, <emph>p</emph> <.05, 95% CI [-2.32, −0.5] and time 2, <emph>t</emph>(1463) = −2.18, <emph>p</emph> <.05, 95% CI [-1.85, −0.09] and higher stress at time 1, <emph>t</emph>(1463) = −2.46, <emph>p</emph> <.05, 95% CI [-2.65, −0.3] and time 2, <emph>t</emph>(1463) = −3.14, <emph>p</emph> <.05, 95% CI [-2.83, −0.65] compared to participants without preexisting health conditions. Anxiety did not change over time within groups, but participants with preexisting health conditions reported greater anxiety symptoms at both time 1, <emph>t</emph>(1463) = −2.72, <emph>p</emph> <.05, 95% CI [-2.03, −0.33] and time 2 than participants without preexisting health conditions, <emph>t</emph>(1463) = −2.01, <emph>p</emph> <.05, 95% CI [-1.62, −0.02] (see Table 4).</p> <p>Table 3. Repeated-measures ANOVA results.</p> <p> <ephtml> <table><thead><tr><td /><td>Within subjects (time)</td><td>Within subjects (time x group)</td><td>Between subjects (group)</td></tr><tr><td /><td><italic>df</italic></td><td>F</td><td>η<sup>2</sup></td><td><italic>df</italic></td><td>F</td><td>η<sup>2</sup></td><td><italic>df</italic></td><td>F</td><td>η<sup>2</sup></td></tr></thead><tbody valign="top"><tr><td>PHQ-9</td><td char=".">1,1463</td><td char=".">3.02</td><td char=".">.002</td><td char=".">1,1463</td><td char=".">1.87</td><td char=".">.001</td><td char=".">1,1463</td><td char=".">7.84**</td><td char=".">.005</td></tr><tr><td>PSS-10</td><td char=".">1,1463</td><td char=".">4.63<xref ref-type="table-fn" rid="tfn6">*</xref></td><td char=".">.003</td><td char=".">1,1463</td><td char=".">.52</td><td char=".">.000</td><td char=".">1,1463</td><td char=".">8.65**</td><td char=".">.006</td></tr><tr><td>GAD-7</td><td char=".">1,1463</td><td char=".">2.64</td><td char=".">.002</td><td char=".">1,1463</td><td char=".">1.5</td><td char=".">.001</td><td char=".">1,1463</td><td char=".">6.41<xref ref-type="table-fn" rid="tfn6">*</xref></td><td char=".">.004</td></tr><tr><td>COVID-19 Worry</td><td char=".">1,1463</td><td char=".">.01</td><td char=".">.000</td><td char=".">1,1463</td><td char=".">6.29<xref ref-type="table-fn" rid="tfn6">*</xref></td><td char=".">.004</td><td char=".">1,1463</td><td char=".">14.20**</td><td char=".">.010</td></tr><tr><td>COVID-19 Perceived Vulnerability</td><td char=".">1,1463</td><td char=".">10.58**</td><td char=".">.007</td><td char=".">1,1463</td><td char=".">4.97<xref ref-type="table-fn" rid="tfn6">*</xref></td><td char=".">.003</td><td char=".">1,1463</td><td char=".">188.63***</td><td char=".">.114</td></tr></tbody></table> </ephtml> </p> <ulist> <item>6 <emph>p</emph> <.05, **<emph>p</emph> <.01, ***<emph>p</emph> <.001.</item> <item>7 GAD: generalized anxiety disorder; PHQ: patient health questionnaire; PSS: perceived stress scale; group: students with and without preexisting health conditions; time: data collection periods.</item> </ulist> <p>Table 4. Variable means and SDs by group.</p> <p> <ephtml> <table><thead><tr><td /><td>Mean (SD) T1</td><td>Mean (SD) T2</td></tr></thead><tbody valign="top"><tr><td>PHQ-9</td><td /><td /></tr><tr><td>No preexisting health condition</td><td char=".">7.95 (5.78)</td><td char=".">8.44 (5.65)</td></tr><tr><td>Preexisting health condition</td><td char=".">9.36<xref ref-type="table-fn" rid="tfn9">*</xref> (6.16)</td><td char=".">9.42<xref ref-type="table-fn" rid="tfn9">*</xref> (5.60)</td></tr><tr><td>PSS-10</td><td /><td /></tr><tr><td>No preexisting health condition</td><td char=".">18.38 (7.57)</td><td char=".">18.64 (7.01)</td></tr><tr><td>Preexisting health condition</td><td char=".">19.85<xref ref-type="table-fn" rid="tfn9">*</xref> (7.21)</td><td char=".">20.38<xref ref-type="table-fn" rid="tfn9">*</xref> (6.73)</td></tr><tr><td>GAD-7</td><td /><td /></tr><tr><td>No preexisting health condition</td><td char=".">7.24 (5.43)</td><td char=".">7.66 (5.17)</td></tr><tr><td>Preexisting health condition</td><td char=".">8.42<xref ref-type="table-fn" rid="tfn9">*</xref> (5.64)</td><td char=".">8.48<xref ref-type="table-fn" rid="tfn9">*</xref> (4.99)</td></tr><tr><td>COVID-19 Worry</td><td /><td /></tr><tr><td>No preexisting health condition</td><td char=".">2.70 (0.58)</td><td char=".">2.67 (0.53)</td></tr><tr><td>Preexisting health condition</td><td char=".">2.82<xref ref-type="table-fn" rid="tfn9">*</xref> (0.57)</td><td char=".">2.86** (0.55)</td></tr><tr><td>COVID-19 perceived vulnerability</td><td /></tr><tr><td>No preexisting health condition</td><td char=".">2.15 (0.47)</td><td char=".">2.17 (0.45)</td></tr><tr><td>Preexisting health condition</td><td char=".">2.60** (0.58)</td><td char=".">2.68** (0.57)</td></tr></tbody></table> </ephtml> </p> <ulist> <item>8 An asterisk indicates that the preexisting health condition group scored statistically significantly higher than the no preexisting health condition group on the corresponding measure at that time point.</item> <item>9 <emph>p</emph> <.05, **<emph>p</emph> <.001.</item> <item>10 SD: standard deviation; GAD: generalized anxiety disorder; PHQ: patient health questionnaire; PSS: perceived stress scale.</item> </ulist> <p>There was a significant interaction effect for worry of COVID-19 infection, indicating that COVID-19 related worry varied across time for students with and without preexisting health conditions (see Table 3). Paired samples t-tests revealed that participants without preexisting health conditions significantly decreased in their COVID-19 related worry across time 1 to time 2, <emph>t</emph>(1283) = 3.37, <emph>p</emph> <.001, 95% CI [.02,.06], whereas participants with preexisting health conditions stayed the same in their COVID-19 related worry across time 1 to time 2, <emph>t</emph>(<reflink idref="bib180" id="ref32">180</reflink>) = −1.5, <emph>p</emph> =.136, 95% CI [-0.09,.01]. Independent samples t-tests revealed that participants with preexisting health conditions reported higher COVID-19 worry at time 1, <emph>t</emph>(1463) = −2.58, <emph>p</emph> <.05, 95% CI [-0.21, −0.03] and time 2, <emph>t</emph>(1463) = −4.58, <emph>p</emph> <.001, 95% CI [-0.28, −0.11] (see Table 4).</p> <p>There was a significant interaction effect for perceived vulnerability of severe COVID-19 infection, indicating that perceived vulnerability varied over time for students with and without preexisting health conditions (see Table 3). Paired samples t-tests revealed that participants without preexisting health conditions did not significantly differ in their COVID-19 related perceived vulnerability of severe infection from time 1 to time 2, <emph>t</emph>(1283) = −1.49, <emph>p</emph> =.138, 95% CI [-0.03,.01], whereas participants with preexisting health conditions significantly increased in their COVID-19 related perceived vulnerability of severe infection scores across time 1 to time 2, <emph>t</emph>(<reflink idref="bib180" id="ref33">180</reflink>) = −2.58, <emph>p</emph> <.05, 95% CI [-0.13, −0.02]. Independent samples t-tests revealed that participants with preexisting health conditions reported higher perceived vulnerability of severe COVID-19 infection than participants without preexisting health conditions at time 1, <emph>t</emph>(1463) = −11.74, <emph>p</emph> <.001, 95% CI [-0.53, −0.38] and time 2 <emph>t</emph>(1463) = −13.99, <emph>p</emph> <.001, 95% CI [-0.58, −0.44] (see Table 4).</p> <hd id="AN0184444298-16">Discussion</hd> <p>To inform mitigation efforts for future pandemics or crises on post-secondary campuses, it is important to understand the psychological impacts of the COVID-19 pandemic over time, as well as identify individuals who may be most at risk for distress. Past research has been largely cross-sectional, conducted in the early days of the pandemic, and there has been limited exploration of understanding of the experiences of students with preexisting health conditions. To address these gaps, the effects of the COVID-19 pandemic were examined on university students with and without preexisting health conditions across two time points in the present study. As hypothesized, it was found that participants with preexisting health conditions showed higher depressive symptoms, anxiety symptoms, stress, COVID-19 related worry, and perceived vulnerability to infection at each time point compared to those without preexisting health conditions. Additionally, participants with preexisting health conditions increased in their COVID-19 perceived vulnerability over time, while participants without preexisting health conditions decreased in their COVID-19 related worries. Findings highlight the need to take preexisting health status into account when determining who is most at psychological risk during public health emergencies.</p> <p>The present results extend cross-sectional findings in other countries on disparities in mental health during the early days of the pandemic.[[<reflink idref="bib19" id="ref34">19</reflink>], [<reflink idref="bib21" id="ref35">21</reflink>], [<reflink idref="bib23" id="ref36">23</reflink>]] In this study, both students with and without preexisting health conditions showed increased stress over time, indicating a potentially sustained impact of the pandemic from winter 2020/2021 to spring/summer 2021. However, students with preexisting health conditions also exhibited consistent worry about infection and heightened concern about vulnerability to severe illness over time. Findings suggest that students with preexisting health conditions continued to experience psychological distress as the pandemic waned on. During the study, (at the end of time 1 and throughout time 2), the provincial government implemented strategies to gradually lift public health restrictions; however, on both occasions these strategies were halted due to rising COVID-19 infection rates and the emergence of new variants in the province.[<reflink idref="bib32" id="ref37">32</reflink>] In the United States, conflicting messaging was also evident, with federal authorities downplaying the urgency and severity of the pandemic while delaying a national response and clear public guidelines for risk mitigation, as case counts continued to rise.[<reflink idref="bib33" id="ref38">33</reflink>] Conflicting public messaging, coupled with rising COVID-19 infections, may have heightened feelings of vulnerability to severe COVID-19 outcomes among students with preexisting health conditions in North America.</p> <p>Findings also provide new insight into university students' experiences in Canada, where there were stringent containment measures,[<reflink idref="bib34" id="ref39">34</reflink>] and lengthy school closures.[<reflink idref="bib4" id="ref40">4</reflink>] These results may also be relevant to other North American countries, such as the United States, which faced similar prolonged school closures and stringent containment measures.[<reflink idref="bib35" id="ref41">35</reflink>] The major interruptions in teaching and assessment during the pandemic may have resulted in students having to postpone internships, final examinations, and graduation which may have led to increased stress.[<reflink idref="bib36" id="ref42">36</reflink>] Given that students with preexisting health concerns had higher distress than their peers without at both time points, these students may have had a harder time adjusting to the pandemic as they experienced the same disruptions to their education, finances, and careers as other students, but in conjunction with heightened worries about contracting and becoming more severely ill from COVID-19. These findings underline the necessity for continuous student support and targeted interventions for those with preexisting health conditions in North America, as they may experience heightened psychological distress.</p> <hd id="AN0184444298-17">Limitations and future directions</hd> <p>Despite the strengths of the present study, this study is not without limitations. First, there was no assessment of student mental health before the pandemic. Therefore, it's challenging to ascertain whether student mental health changed during the pandemic or if students with preexisting health conditions were already vulnerable. Nevertheless, a strength of the present study was that two measures specific to COVID-19 distress were included to capture distress in the context of the pandemic. Second, it should also be noted that only physical preexisting health conditions were assessed in the present study. However, research suggests that individuals with preexisting mental health conditions may also have been more vulnerable in the context of the pandemic.[<reflink idref="bib37" id="ref43">37</reflink>] Future research should explore the impact of both physical and mental preexisting health conditions. Third, the sample primarily consisted of White, East Asian, and South Asian respondents, highlighting the need for further research with more diverse populations to better understand how preexisting health conditions intersect with various identities. Previous research on pandemic-related inequities has shown that women,[<reflink idref="bib14" id="ref44">14</reflink>] racialized individuals,[<reflink idref="bib38" id="ref45">38</reflink>] and those with low incomes[<reflink idref="bib15" id="ref46">15</reflink>] were disproportionately affected. Therefore, it is crucial to investigate how these intersecting identities and preexisting health conditions contribute to vulnerability during the pandemic. Fourth, it is also important to note that 70% of our sample of students with preexisting health conditions self-reported having asthma. Therefore, it is not clear whether results may generalize to a more diverse sample with different physical health concerns.</p> <hd id="AN0184444298-18">Conclusions</hd> <p>The psychological impacts of the COVID-19 pandemic on students with and without preexisting health conditions over time were examined in the present study. It was found that participants with preexisting health conditions showed higher depressive symptoms, anxiety symptoms, stress, and COVID-19 related worry and perceived vulnerability at each time compared to participants without preexisting health conditions. Participants with preexisting health conditions also significantly increased in their COVID-19 perceived vulnerability while participants without preexisting health conditions decreased in their COVID-19 related worry across times. These findings extend previous research by providing further insight into the impacts of the pandemic longitudinally, at later stages of the pandemic, and among students without and without preexisting health conditions. Findings underscore the necessity of further research and ensuring equitable and sustainable access to quality mental health services for all students, especially those most vulnerable.</p> <hd id="AN0184444298-19">Acknowledgments</hd> <p>The authors acknowledge the Office of the Vice-Provost, Students, the Institutional Research and Data Governance Office, campus housing deans and staff, and the University for their support. The authors also acknowledge Dr. Vivek Goel for his vision and support in launching this study, and to Caroline Godbout, Lee Vernich, and Dr. Sharon Iziduh for their project management support. Finally, the authors acknowledge all participants and the broader student community for their resilience throughout the COVID-19 pandemic.</p> <hd id="AN0184444298-20">Conflict of interest disclosure</hd> <p>The authors report there are no competing interests to declare. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of Canada and received approval from the University of Toronto Research Ethics Board.</p> <ref id="AN0184444298-21"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> World Health Organization. Coronavirus disease (COVID-19) pandemic. 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: The Inequitable Psychological Impacts of the COVID-19 Pandemic on Post-Secondary Students with Preexisting Health Conditions: A Longitudinal Study
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Sarah+Kuburi%22">Sarah Kuburi</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-7816-0643">0000-0001-7816-0643</externalLink>)<br /><searchLink fieldCode="AR" term="%22Chloe+A%2E+Hamza%22">Chloe A. Hamza</searchLink><br /><searchLink fieldCode="AR" term="%22Antonio+Lorenzo%22">Antonio Lorenzo</searchLink><br /><searchLink fieldCode="AR" term="%22Altea+Kthupi%22">Altea Kthupi</searchLink><br /><searchLink fieldCode="AR" term="%22Shaza+A%2E+Fadel%22">Shaza A. Fadel</searchLink><br /><searchLink fieldCode="AR" term="%22France+Gagnon%22">France Gagnon</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+American+College+Health%22"><i>Journal of American College Health</i></searchLink>. 2025 73(4):1780-1786.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 7
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink><br /><searchLink fieldCode="EL" term="%22Postsecondary+Education%22">Postsecondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22COVID-19%22">COVID-19</searchLink><br /><searchLink fieldCode="DE" term="%22Pandemics%22">Pandemics</searchLink><br /><searchLink fieldCode="DE" term="%22College+Students%22">College Students</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Depression+%28Psychology%29%22">Depression (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Anxiety%22">Anxiety</searchLink><br /><searchLink fieldCode="DE" term="%22Stress+Variables%22">Stress Variables</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Chronic+Illness%22">Chronic Illness</searchLink><br /><searchLink fieldCode="DE" term="%22Diseases%22">Diseases</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Canada%22">Canada</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/07448481.2024.2435955
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0744-8481<br />1940-3208
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: Evidence suggests young adults in post-secondary school experienced increased distress during the COVID-19 pandemic, but students' experiences likely varied. Effects may have also changed over time as students adapted. This study examined the mental health of students with and without preexisting health conditions at two points during the pandemic (winter 2020/2021 and spring/summer 2021). Methods: Participants (N = 1465) completed a baseline and follow-up questionnaire assessing their health history, depressive symptoms, anxiety symptoms, stress, and COVID-19-related worry and perceived vulnerability of severe infection. Results: At both time points, students with preexisting health conditions reported greater distress than those without preexisting health conditions. Stress increased from time 1 to time 2 for all students, and participants with preexisting health conditions significantly increased in their COVID-19 perceived vulnerability of severe infection over time. Conclusions: Findings highlight the need for additional and ongoing mental health supports for vulnerable students throughout the pandemic.
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  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1472985
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1472985
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  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1080/07448481.2024.2435955
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 7
        StartPage: 1780
    Subjects:
      – SubjectFull: COVID-19
        Type: general
      – SubjectFull: Pandemics
        Type: general
      – SubjectFull: College Students
        Type: general
      – SubjectFull: Mental Health
        Type: general
      – SubjectFull: Depression (Psychology)
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      – SubjectFull: Anxiety
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      – SubjectFull: Stress Variables
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      – SubjectFull: Foreign Countries
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      – SubjectFull: Chronic Illness
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      – SubjectFull: Diseases
        Type: general
      – SubjectFull: Canada
        Type: general
    Titles:
      – TitleFull: The Inequitable Psychological Impacts of the COVID-19 Pandemic on Post-Secondary Students with Preexisting Health Conditions: A Longitudinal Study
        Type: main
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          Name:
            NameFull: Sarah Kuburi
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            NameFull: Shaza A. Fadel
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            NameFull: France Gagnon
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              Type: published
              Y: 2025
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              Value: 0744-8481
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              Value: 1940-3208
          Numbering:
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              Value: 73
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