Impact of COVID-19 restrictions on mental health of international students in higher education: a narrative review

Introduction

Since the coronavirus disease 2019 (COVID-19) outbreak, international students all over the world have been found to be facing a number of unprecedented challenges, which have posed a risk to their mental health. It is estimated that 43.8% of the 5.3 million international tertiary students are enrolled in higher education institutions (HEIs). The countries that receive the greatest number of international students include United States, United Kingdom, Australia, Germany, and France (1). Each of these nations is experiencing some level of COVID-19 impact, with being most seriously affected (2).

COVI-19 restrictions and mental health of international students

In December 2019, SARS-coronavirus 2 (SARS-CoV-2) was found to be the source of pneumonia in an individual in Wuhan City, Hubei Province, China. The World Health Organization (WHO) officially recognized SARS-CoV-2 as COVID-19 in 2020 on February 11. Over 722,435 individuals had been infected as of March 29, 2020 and over 33,997 have died as a result of the virus’s global spread (3). Fever, dry cough, and severe fatigue are common symptoms of a COVID-19 infection, which can lead to life-threatening pulmonary complications (4). This means that the overwhelming majority of people are potentially vulnerable to catching SARS-CoV-2. Most infectious diseases are spread not only from person to person, but also from wild animal hosts through respiratory droplets and direct interaction (5). As a result of the pandemic, the governments and authorities in the countries that are currently being impacted have been forced to implement preventative measures such as quarantine, self-isolation, social distancing, and lockdowns (6). This also included banning foreign nationals from traveling and the shutdown of public facilities and transit to mitigate the effects of the spread of COVID-19 transmission (7). Moreover, university students, like the rest of society, have likely suffered psychologically and physiologically as a result of the subsequent lockdowns and social restrictions (8).

Students in higher education have had to deal with a lot of transition and ongoing pressure as they adjust to new academic settings and requirements. The mental health and academic performance of students can be negatively impacted by prolonged stress (9).

In addition, during this time period, students were required to reside away from their families, which had the effect of negatively impacting their psychological well-being (10). Kim and Kim [2021] discovered that trouble sleeping, anxiety, and depression have been found to be the most prevalent forms of mental illness among students enrolled in higher education. After the outbreak of the COVID-19 pandemic, nearly half of university students in the United States reported having trouble sleeping and experiencing anxiety, while in China, 56.8% of university students stated having depression (7).

Mental health issues are a real concern for international students due to the unique stresses they face while studying in a foreign country, including language barriers, adjusting to local customs, and separation from loved ones back home (9). In addition, in the midst of the current pandemic of COVID-19, it is more difficult for international students to maintain their emotional health than it is for their domestic counterparts. the following factors are likely to have an even more detrimental impact on their mental health including variations in learning potential as a result of factors such as language, health, stress, finances, location, length of stay overseas, familiarity with local customs, and availability of social networks at home (7).

Health status and psychological impact

The time spent studying at a university is one of the most crucial periods for the growth and maintenance of one’s mental health. Anxiety and depression are two mental health conditions that can have detrimental effects on the physical health and academic performance of young individuals (11). Moreover, there has been a rise in concern about the prevalence and severity of mental health issues among both domestic and international students (12). Although international students have a higher prevalence of mental health issues than local students, they are less likely to seek assistance from available services. Furthermore, studying in a foreign country presents major hurdles for international students, including cultural adjustment, language barriers, homesickness, and economic hardship (13).

It has been found that, additional stresses, such as acculturative stress, potential discrimination, and language proficiency concerns, exist for international students who migrate abroad for higher education. Also, international students studying abroad are cut off from their traditional social networks. Hence, the presence of these risk factors has been linked to mental health problems among students studying abroad (14). Similarly, another study stated that students from other countries who faced higher discrimination seemed to have lower self-esteem, a reduced eagerness in learning, decreased satisfaction with their education, less confidence in their ability to discuss to their peers, and increased homesickness and psychological distress (15).

International students’ experience of mental health during COVID-19

Individuals, particularly international students, experienced significant psychological effects during the COVID-19 pandemic. It is widely believed that this pandemic will have lasting psychological effects on all humans worldwide (14,16). Even though the risk of major health problems after infection is lower in younger people, it is evident that living through a pandemic had greatly affected the mental health of both the general population and younger individuals, especially college and university students (16). Moreover, many international students were facing mental health concerns like psychological distress and anxiety disorder as a result of their fear from the outbreak of COVID-19. Due to their mental health concerns, they may experience difficulties in social and academic interactions, which may hinder their pursuit of future professional aspirations (17).

The impact of COVID-19 restrictions on individual students was mostly reported in recently published literature to be academic issues in many countries with high proportion of international students’ enrolments (18). A number of studies found increased likelihood of anxiety symptoms in line with the evidence of loneliness and self-isolation that seem specific triggers for social anxiety symptoms (18-20). Similarly, an increasing amount of time spent online on social media platforms was also frequently reported during the COVID-19 restrictions which was perceived as an opportunity to be connected, and thus appearing as a potential risk for causing mental health issues (21,22).

A study evaluated the students from other nations who were studying in China and the assessment showed that these individuals have seen firsthand the severe measures that were taken to prevent the disease’s spread. As the pandemic progressed, many students experienced strict restrictions on their freedom of movement, shifted to taking classes online rather than attending traditional classrooms, reduced or stopped engaging in social activities, and underwent regular medical examinations which could have exacerbated international students’ social and emotional stress (23).

Pandemic related stressors

The global adoption of containment measures in response to the spread of COVID-19 has significantly and extensively disrupted the daily lives of students all over the world in the past years, resulting in widespread reports of psychological distress. Specifically, students’ physical mobility and the impact on internationalization efforts in higher education have been cited as areas of worry as the pandemic continues. The international higher education sector has been considerably impacted by the pandemic and its accompanying control measures, such as international travel restrictions and social and physical distancing measures (24). Additionally, prolonged closures of schools and universities have left young people vulnerable to feelings of isolation and loneliness (25).

Several studies have examined the widespread impact of the COVID-19 on the lives of students in higher education, highlighting a wide range of different psychological symptoms like stress, difficulties focusing, anxiety, depression, eating disorders, alcohol/substance abuse, sleep disorders, and suicidal behaviours (26). For instance, Russell et al. [2023] evaluated data gathered from international students in Australia who reported worsening circumstances during the COVID-19 outbreak (14). The most common pandemic stressors were worries about one’s mental health (70.8%), future employment prospects (72.0%), connection to university classmates (82.5%), and connection to friends (74.8%). Additionally, international students reported significantly higher rates of racial discrimination (38.5%) than domestic students.

Coping mechanisms and support

Coping strategies or acts that promote adaptations and ways to respond to problems, are frequently used by people confronted with adversity, like the pandemic. The term “coping” refers to a set of responses humans employ when faced with a difficult situation (27). The decisions taken by governments and universities in response to the COVID-19 pandemic have had an impact on the mental health of international students. As universities return to “business as usual,” it is essential to remind them of their obligation to these young individuals. Lessons gained from the pandemic era should inform strategies to promote the well-being of international students as they recommence their studies in their host country (28).

According to research by Lai et al. [2020], students who were affected by the COVID-19 pandemic primarily used three coping mechanisms: listening to music (78%), eating or cooking (66%), and playing video or mobile games (61%). Moreover, the intensity of anxiety, depression, and sleeplessness symptoms was strongly associated with eating or cooking (9). At the same time, Antwi et al. [2022] found students who routinely exercised reported significantly lower levels of stress, anxiety, and depression than those who did not (23). Additionally, the study by Al-Oraibi et al. [2022] also indicated that activities including viewing movies, talking to loved ones, reading, completing at-home workouts, and taking up new hobbies were all beneficial during the time of isolation. These diversions were employed as healthy coping mechanisms to manage self-isolation and COVID-19 constraints, and they were appreciated for their favourable effects on mental health and for making the isolation period seem shorter (13).

Purpose and significance of this study

This literature review seeks to determine how the restrictions imposed by COVID-19 impacted on the mental health of international students studying in countries abroad who have the highest enrollments in higher education programmes. This research also explores the factors that put international students at risk for developing mental health issues such as depression and anxiety during COVID-19.

The findings of this study can be used by university professors and administrators to obtain a deeper understanding of the mental health of their international students. In addition, it will assist students who are considering studying abroad by giving them suggestions and recommendations. Health and Medical professionals are able to utilize the results of this study to better understand, recognize and respond to the warning signs of depression and anxiety in students, as well as to take timely preventative action. We present this article in accordance with the Narrative Review reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-175/rc).

Methods

This research review seeks to fill the gap in the available literature and understanding of how the COVID-19 restrictions impacted the psychological well-being of international students and to evaluate the factors associated with the mental health of students in relation to the COVID-19 restrictions. The main research question that this narrative literature review sought to address was, “what effect did the COVID-19 restrictions have on the mental health of international students enrolled in higher education programmes?

To find relevant articles, a literature search was conducted using the widely used electronic databases PubMed Central, ProQuest Central, Science Direct, SCOPUS, CINAHL. Electronic searches were conducted using both qualitative and quantitative criteria to identify specialized literature that strengthened the article’s credibility. Multiple search terms were used to locate relevant articles. The details of the search strategy are presented in Table 1, as well as the Table 2 provides summary of search terms/keywords and their combinations (Boolean operators) which were used in various databases.

Search outcomes

The initial search of electronic databases yielded 741 results, 19 from SCOPUS limit to countries that include only China, Australia, the United States, Canada, and Germany (as these are the countries with the highest number of international students, according to the International Institute of Education’s Project Atlas), 5 from PubMed Central, 648 from ProQuest Central, 68 from Science Direct and 1 from CINAHL. This literature review identified and selected the final 12 most relevant studies, consisting of 8 quantitative, 1 qualitative study, 1 mixed method studies as well as 2 questionnaire studies as summarized in Figure 1.

Figure 1 PRISMA flowchart: summary of literature identification, screening, and selection. Modified from Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev 2021;10:89. Available online: https://doi.org/10.1186/s13643-021-01626-4.

Key findings

This literature review analysed the key findings from 12 selected primary studies as per the inclusion/exclusion criteria. The selected articles discussed the impact of COVID-19 restrictions on the mental health of international students. Consequently, mental health concerns and COVID-19-related stressors were identified as the main theme. Therefore, understanding the mental health of their international students, helping these students achieve their academic goals, and providing interventions and social support all become possible after identifying mental health problems and its risk factors during COVID-19 restrictions. A thematic analysis was performed to discuss the diverse perspectives on various themes and sub-themes identifying the knowledge gap in the literature available on the topic. A summary of primary articles selected for this literature review is given in Table 5.

The key findings from the literature selected have addressed and provided context for mental health issues among international students. Several factors influencing the mental health of international students during the COVID-19 pandemic were critically analysed and discussed, along with the identified themes and subthemes as presented in Table 6.

Discussion

Impact of sociodemographic factors on international students’ mental health

Age

Five of these articles (23,25,32,34,35) specifically addressed the topic of age and its correlation to international students’ mental health. The evaluated papers revealed a complex connection between age and mental health among international students. Three articles (23,25,35) suggested that certain age groups within the international student population may be more vulnerable to mental health issues under certain conditions. Song et al. [2021], for example, revealed a strong association relating to higher DASS depression, anxiety, and stress subscale scores and international students aged 20–23 (34). Likewise, Lu et al. [2022] noted that older students may have more knowledge as well as coping techniques for dealing with depression, anxiety, and stress, resulting in a more stable psychological orientation (32). The results obtained are consistent with the findings of another study (37), which indicated that younger students may be at a greater risk than older students, as they appear to be more worried with their studies and financial demands. Contrarily, Antwi et al. [2022] discovered that older (35 and above years old) international students were much more stressed than their younger counterparts (23).

Gender

The relationship between gender and the mental health of international students was explored in the selected and discussed studies in this review (23,25,32,34,35). First, the works of above cited researchers revealed that depression is experienced more by female international students in comparison to their male counterparts. These results are consistent with another study conducted in Hungary (38), discovered a statistically significant gender gap in the incidence of depressive symptoms among overseas students and women. On the other hand, Song et al. [2020] found that anxiety and stress levels were much lower among females (34). Meanwhile, Lin et al. [2022] and Xu [2021] identified no correlation between the gender of students and their degree of psychological distress when studying abroad. The absence of a gender disparity in this study could be attributable to the belief that both male and female international students were equally susceptible to a COVID-19 epidemic. Also, these findings highlighted the complex nature of gender differences in mental health outcomes among international students. While some studies reveal that female students have higher levels of sadness and stress than male students, other studies show contradictory or inconclusive results (31,35). Furthermore, to better comprehend the complex relationship between gender and mental health in international student populations, additional research into the causes of these differences between the sexes is necessary.

Location

In terms of mental health issues and their relationship to a student’s location during the pandemic, Russell et al. [2023] and Lin et al. [2022] revealed that those who remained in their country of study had a poorer mental health than those who returned home, presumably due to fears of virus transmission and difficulties adjusting to a new environment (14,31). These findings are consistent with the work of Lai et al. [2020] which found that students who remained abroad reported higher levels of stress due to social isolation under mandatory lockdown in their institution’s home country, amidst misinformation and disputed regulations (9). Conversely, Iftikhar et al. [2022] and Song et al. [2020] found that those who returned to their home country reported more severe psychological symptoms than those who remained abroad (29,34). Meanwhile, Yu et al. [2023] observed no mental health differences between international students who returned home and those who stayed abroad (36). Furthermore, these results highlight the diverse experiences of international students during the pandemic, with staying in the country of study often associated with poorer mental health outcomes. Nonetheless, variations among studies suggest the need for further investigation and consideration of contextual factors that may influence these results.

Employment

Another sociodemographic factor addressed in this review is the employment status of international students in relation to their mental health. The four articles (14,29,30,33) discussed the connection between international students’ employment and their mental health. Based on the findings, The majority of students encountered a deterioration in their mental health as a direct result of job loss, increased workloads, and demanding working conditions. Similar to a previous study (39), specialists in student affairs and services (SAS) found that due to the pandemic, many students in Europe lost their part-time employment, making it more difficult for them to make ends meet. Therefore, these studies show the COVID-19 pandemic’s profound impact on international students, notably in terms of work stability, food security, and psychological well-being. The findings highlight the unique problems that this population faces, as well as the critical need for help and resources to alleviate the pandemic’s negative consequences on their life.

Impact of lockdown-related stressors on international students’ mental health

Economic pressure

Russell et al. [2023], Yu et al. [2023], Lin et al. [2022], Mihrshahi et al. [2022], and Song et al. [2021] investigated the effect of economic challenges on the mental health of international students during COVID-19 restrictions, and their findings suggested an association between international students’ mental health issues and their financial difficulties (14,31,33,34,36). This observation is to be expected given the widespread consensus in existing literature that stress and depression are intensified by financial constraints (37). Furthermore, food insecurity, which has been reported to be disproportionately high among international students, exacerbated economic pressure. Russell et al. [2023] and Mihrshahi et al. [2022] discovered that overseas students studying in Australia were more likely than local students to experience food insecurity or be unable to acquire food during the COVID-19 pandemic (14,33). Results such as these allow us to conclude that the COVID-19 pandemic made international students more vulnerable to relationship issues, financial stress, and food insecurity. Furthermore, the same emphasised the urgent need for specific assistance and initiatives to address the problems this vulnerable community is facing.

Academic difficulties

Six articles (13,14,29,30,33,35) investigated the impact of COVID-19 restrictions on the mental health and academic performance of international students. Throughout the COVID-19 pandemic, various factors that lead to the academic challenges of overseas students were identified. Specifically, three common factors were identified, this included rapid transition to online learning, lack of communication, and prolonged disruptions to studies.

Moreover, international students believed that learning online contributed to their mental stress, which may be due to a lack of engagement caused by a poor internet connection, unfamiliarity, difficulty expressing their concerns about their studies, difficulty adapting to online lessons and maintaining focus for long periods (14,29,30). These results are comparable to that of a previous study by Song et al. [2021], which indicated both academic pressure and satisfaction were associated with increased levels of depression and isolation (34). Specifically, students with higher levels of academic stress and lower levels of academic satisfaction were also reported higher levels of depression and social isolation. However, the study by Xu [2021] reported that most overseas students in China said they had adapted to the new online teaching approach (35).

Inadequate university communication with international students is identified as another academic issue in this review. Four articles (13,14,30,33) observed that the decline in social connections with peers and the absence of face-to-face interactions with colleagues and teachers negatively impacted the educational experience of international students. Furthermore, Iftikhar et al. [2022] stated that students who took long breaks from their studies showed signs of stress about meeting deadlines for their work and a lack of motivation and interest (29). Nonetheless, Jagroop-Dearing et al. [2022] suggested that the connection between pandemic stress and poor academic performance was hardly emphasized. Furthermore, the results show that international students had considerable academic difficulties during the pandemic. Language problems, limited access to resources, difficulties adapting to online learning, and heightened feelings of isolation are among the challenges revealing the widespread impact of these barriers, underlining the need for tailored assistance and interventions for overseas students (30).

Prolonged isolation

International students are often faced with psychological and practical difficulties associated with being far from home. Al-Oraibi et al. [2022], Jagroop-Dearing et al. [2022], Lin et al. [2022], and Xu, [2021] explored the effects of prolonged isolation on the mental health of international students (13,30,31,35). For instance, most international students’ mental health was substantially affected by feelings of isolation because they were unable to participate in activities and loneliness because they were away from their friends and the school environment (14,30). Additionally, Lin et al. [2022] found that students whose remote course participation negatively impacted their personal relationships had a greater likelihood of depression and anxiety (31). These findings were supported by Aristovnik et al. [2020] study, which found that studying alone at home presents its own set of unique challenges, including the need for increased motivation, self-discipline, and initiative on the part of the student (37). However, Xu [2021] suggested, however, that the timing of students’ social withdrawal while studying was not always related to the level of their mental distress (35). As a result of their isolation, international students experienced both practical and psychological anguish, and the disruption to their social connections during the pandemic as well as their inability to engage in normal activities had a substantial impact on their mental health and well-being.

Lack of support

Subsequently, three studies (13,14,29) evaluated how international students’ mental health was affected by a lack of support during COVID-19 restrictions where stress levels were found to be higher due to a lack of both social and institutional support. While many international students in England felt alone and alone, the majority did not seek help from mental health specialists (13). These findings are consistent with those of Lai et al. [2020], who discovered that foreign students in Hong Kong may be hesitant to seek help for emotional problems due to stigma and a desire for coping on their own. In general, the COVID-19 pandemic has drawn attention to the special issues that international student face, such as a lack of social support and limited access to resources. Institutions must prioritize their well-being and provide specialized support to enable their success during these exceptional circumstances (9).

Mental health coping mechanisms

Exercise

Regular exercise has been associated with reduced stress, anxiety, and depression in international students (23). Additionally, self-isolated international students who engage in physical activity report a boost in mental health and a reduction in the adverse effects of isolation (13). Similar with the findings of another study found that international students in Sweden viewed participating in physical activities such as playing football as critical for managing stress (40). Thus, promoting regular exercise among international students can be a valuable strategy for enhancing their mental well-being and resilience during the COVID-19 pandemic. Integrating physical activity as part of support programs can contribute to their overall adjustment and coping strategies.

Social support

Students from other countries were able to get through the pandemic by staying in touch with family and friends back home and their international classmates (30). This result is consistent with a previous study conducted in Indonesia (41), which demonstrated that four out of five participants believed that their parents helped them overcome difficulties during the COVID-19 period. Therefore, communicating to their loved ones back home proved to be a relaxing experience for international students studying in Sweden (40). Moreover, Lin et al. [2022] found that international students with higher social support rating scale (SSRS) scores had lower rates of depression and anxiety (31). Similarly, Lu et al. [2022] discovered a strong negative correlation between perceived social support and depressive symptoms (32). Meanwhile, Xu [2021] discovered that official social support reduced psychological pain but not informal family and friend support (35). Furthermore, the findings of the studies discussed the importance of social support in promoting international students’ mental health, with high levels of perceived social support correlating with lower symptoms of depression and anxiety, whereas informal support from family and friends may not have a significant impact on psychological distress.

Institutional support

Lastly, institutional assistance was considered crucial in meeting the requirements of international students, as evidenced by the fact that students from a variety of countries turned to their universities for help during the pandemic (13,30,35) highlight the importance of institutions providing support that is specifically customized to international students, which can greatly decrease their psychological distress. Moreover, as the majority of international students do not have close relatives in the same country, they may rely on their educational institution for assistance as they adjust to life in a new culture (42). For these at-risk students, university campuses serve as essential social hubs and authoritative figures. Therefore, findings emphasized the necessity of institutional support and the use of school resources in meeting the requirements of international students during the pandemic, emphasizing the importance of targeted help and effective communication. Universities can assist the well-being and success of overseas students in overcoming the hurdles provided by COVID-19 by offering proper support.

Limitations of this review

The limitations of this research can be categorized as limitations with the study methodology and limitations with the sources examined. An integrative literature review approach was employed to collect and synthesize the data for this research. The weaknesses of integrative literature review include the potential for decreased accuracy, bias, or rigour when combining multiple techniques and study designs. Moreover, the methods for doing some parts of an integrative review are not yet established. A further limitation of the integrative literature review approach is the possibility of selection bias in the sources used. Another limitation is that the selection of primary articles from countries with a high concentration of international students also limits our ability to access potentially relevant articles from countries that are not included in the Project Atlas of the International Institute of Education.

Conclusions

The evidence obtained from the reviewed studies revealed that international students were subjected to a range of pandemic-related stresses, resulting in significant levels of depression, stress, and anxiety throughout the lockdown period. Consequently, the findings of this research provided valuable insights for universities and HEIs to develop effective programs aimed at supporting international students in navigating this global health crisis.

International students at various universities worldwide are taking steps to deal with mental health issues despite increased anxiety, depression, and stress related to contracting the COVID-19 infection. Moreover, in times of emergency, such as pandemics, universities should designate trained professionals to oversee the safety of their international students. Also important during this threat to worldwide health safety is the ability of mental health professionals to provide services to assist international students. In the future, HEIs are expected to improve their readiness for outbreak and pandemic management strategies that may affect local communities. In the event of a worldwide pandemic, HEIs should also develop an innovative and practical strategy for promoting and resolving students’ mental health concerns. It is suggested that the universities immediately begin preparing their students and faculty for the adoption of an online-blended method of learning and enhance their Information and Communication Technology (ICT) resources and abilities. Moreover, the results of this integrative literature review can be used by social workers to improve existing methods of supporting international students during crises and other traumatic events like the recent COVID-19 outbreak. The prevalence of food insecurity and mental health problems on campus should be tracked on a regular basis. Establishing a comprehensive food policy and food sustainability on campus is an important initiative in the higher education sector. It is imperative to prioritize the mental health needs of international students and ensure their access to appropriate resources and support systems, ultimately helping them successfully navigate these challenging times.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-175/rc

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-175/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-175/coif). S.M.S. serves as an unpaid editorial member of Journal of Public Health and Emergency from December 2022 to November 2024. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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