How Are Brazilian University S

PLOS ONE
RESEARCH ARTICLE
How are Brazilian university students coping

with the COVID-19 pandemic? Results of an
online survey on psychosocial well-being,
perceived burdens, and attitudes toward
social distancing and vaccination
Aneliana da Silva Prado ID1,2,3,4*, Elisabeth Kohls4,5☯, Sabrina Baldofski ID4☯, Alessandra
Sant’Anna Bianchi2☯, Luciano Imar Palheta Trindade2, Joanneliese de Lucas Freitas2‡,
a1111111111
Christine Rummel-Kluge4,5‡
a1111111111
a1111111111 1 Faculty of Life Sciences, Wilhelm Wundt Institute for Psychology, Leipzig University, Leipzig, Sachsen,
a1111111111 Germany, 2 Department of Psychology, Federal University of Parana, Curitiba, Parana, Brazil, 3 Campus
a1111111111 Curitiba, Federal Institute of Education, Science and Technology of Parana, Curitiba, Parana, Brazil,
4 Department of Psychiatry and Psychotherapy, Medical Faculty, Leipzig University, Leipzig, Sachsen,
Germany, 5 Department of Psychiatry and Psychotherapy, University of Leipzig Medical Center, Leipzig,
Sachsen, Germany
☯ These authors contributed equally to this work.

OPEN ACCESS ‡ JLF and CR-K shared last authorship to this work.
* Aneliana.daSilvaPrado@medizin.uni-leipzig.de
Citation: Prado AdS, Kohls E, Baldofski S, Bianchi
AS, Trindade LIP, Freitas JdL, et al. (2023) How are
Brazilian university students coping with the
COVID-19 pandemic? Results of an online survey Abstract
on psychosocial well-being, perceived burdens,
and attitudes toward social distancing and
vaccination. PLoS ONE 18(4): e0284190. https://
Background
doi.org/10.1371/journal.pone.0284190
The COVID-19 pandemic caused significant disruption to education systems worldwide,
Editor: Flávia L. Osório, University of São Paulo,
BRAZIL increasing pre-existing concerns regarding university students’ mental health. Brazil was
among the countries most affected by COVID-19 cases and deaths and was considered a
Received: September 15, 2022
pandemic epicenter. This study aimed to investigate Brazilian university students’ mental
Accepted: March 24, 2023
health status and perceived burdens during the COVID-19 pandemic.
Published: April 26, 2023
Copyright: © 2023 Prado et al. This is an open Material and methods

access article distributed under the terms of the
From November 2021 to March 2022, a cross-sectional and anonymous online survey was
Creative Commons Attribution License, which
permits unrestricted use, distribution, and conducted among students of a Brazilian federal university. Mental health status (depres-
reproduction in any medium, provided the original sive symptoms, alcohol and drug consumption) and social and emotional aspects in the
author and source are credited. pandemic context (social support, perceived stress, loneliness, resilience, and self-efficacy)
Data Availability Statement: The data of this study were assessed with standardized measures. Students’ attitudes toward the COVID-19 pan-
cannot be made publicly available due to ethical demic and vaccination and perceived burdens of the pandemic were also investigated.
restrictions imposed by the Brazilian National
Health Council (CNS), represented by the Federal
University of Parana Ethics Committee, in Brazil. Results
Requests for use of the data can be directed to the
A total of N = 2,437 students completed the online survey. The PHQ-9 mean sum score was
Federal University of Parana Ethics Committee
(email: cometica.saude@ufpr.br). The request will 12.85 (SD = 7.40), while n = 1,488 (61.10%) participants reported a sum score of 10 or
be taken to the steering committee of the Federal more, indicating clinically relevant depressive symptoms. Further, n = 808 (33.1%) of the
PLOS ONE | https://doi.org/10.1371/journal.pone.0284190 April 26, 2023 1 / 23

PLOS ONE Mental health of Brazilian students in COVID-19 pandemic
University of Parana and discussed further taking total sample reported suicidal thoughts. Levels of depressive symptoms, perceived stress,
Brazilian privacy and legal regulations into account. and loneliness were higher among undergraduate/bachelor students than doctoral students.
Funding: ASP acknowledges the financial support Almost all participants (97.3%) reported being fully vaccinated against COVID-19. Multiple
of the German Academic Exchange Service (DAAD) regression analyses showed that being single, having an income decreased during the pan-
under the program “Bi-nationally Supervised
Doctoral Degrees/Cotutelle, 2021/22” (grant no.
demic, having a previous mental illness, having a chronic somatic condition, not finding posi-
57552338). The funders had no role in study tive aspects in the pandemic, lower self-efficacy, lower social support, lower resilience, and
design, data collection and analysis, decision to higher experienced loneliness were significantly associated with higher levels of
publish, or preparation of the manuscript. This
depression.
publication was funded by the Open Access
Publishing Fund of Leipzig University, supported by
the German Research Foundation within the Conclusions
program Open Access Publication Funding.
The study showed high levels of depressive symptoms and suicidal ideation among Federal
Competing interests: “The authors declare that the
University of Parana students. Therefore, health care providers and universities need to rec-
research was conducted in the absence of any
commercial or financial relationships that could be ognize and address mental health issues; psychosocial policies must be enhanced to miti-
construed as a potential conflict of interest. CRK gate the impact of the pandemic on students’ mental health and wellbeing.
received lecture honoraria from Recordati and
Servier outside and independent of the submitted
work. This does not alter our adherence to PLOS
ONE policies on sharing data and materials.
Introduction
The COVID-19 pandemic caused the most significant disruption to education systems in his-
tory, affecting an estimated 1.6 billion students in more than 190 countries [1]. Due to the pan-
demic, students had their face-to-face academic activities interrupted or changed to the online
format and experienced an interruption of their social life and support. The closure of schools
and other educational spaces affected about 94% of students worldwide and 99% of students in
low- and middle-income countries [1]. Fear of a COVID-19 infection, the prevention mea-
sures, and overload of media information related to it, economic changes, interruption of aca-
demic activities, difficulties in adapting to online classes, uncertainty regarding academic
development and success and professional future, and decrease in social interaction and sup-
port were some burdens pointed by the students [2–10].
In addition to health issues, the outbreak of the COVID-19 virus as a public health problem
in 2019 and as a global pandemic from March 2020 onwards has also impacted people’s mental
health around the globe. Collateral effects of social distancing and its outcomes have been
broadly stated [11–20], and negative impacts such as feelings of despair, anxiety, confusion,
anger, irritability, fear, frustration, and boredom have been reported among the general popu-
lation [11–13, 20–24]. Besides, increased perceived stress, sleep disorders, post-traumatic stress
symptoms, and suicidal ideation have also been described as possible outcomes of the pan-
demic [11, 13, 21, 23, 25–27], and less perceived support has been associated with suicidal idea-
tion [23].
Regarding university students, some of the consequences of the pandemic include an
increased socioeconomic and emotional vulnerability and a significant decrease in mental
health, interpersonal relationships, and available social support [8, 28–30]. Before the pan-
demic, several studies pointed out a high prevalence of mental disorders in university students,
drawing attention to the vulnerability of this population to emotional struggles [31–36]. Aca-
demic pressure, financial problems, lack of social support, and fear of the future are examples
of some stressors present in student life [35–38]. Thus, student mental health concerns have
increased since the pandemic outbreak.
In Brazil, the latest national survey about socioeconomic and cultural profiles of undergrad-
uate students of federal institutions showed an increasing rate of undergraduate students’

emotional issues that influenced their academic performance. Anxiety, discouragement and
demotivation, sleep disorders, helplessness or feelings of despair, loneliness, persistent sadness,
and increased suicidal ideation over the years were reported [38].
Brazil was one of the countries most affected by COVID-19 cases and deaths. Until May
2022, the country had registered more than 30,564,536 cases and around 664,139 deaths (data
available until May 8th, 2022; [39]). Social distancing was one of the measures adopted by the
Brazilian government to flatten the infection rate curve [40, 41]. Despite the late start of vacci-
nation in the country [42, 43] and the conflicts between the national government and state
governments on the topic, due to a structured universal healthcare system and its immuniza-
tion strategy, Brazil rapidly increased the vaccination status of its population as soon as the
COVID-19 vaccine was available [44, 45]. Also, differing from other countries (e.g., India [46]
and Iran [47] where vaccination hesitancy was high even among healthcare professionals),
COVID-19 vaccine hesitancy was low among Brazilians [48].
As reported by the United Nations Educational, Scientific and Cultural Organization [1],
the whole educational system was affected by social distancing measures worldwide, and there
was no difference in Brazil [40, 41]. Brazil did not have lockdown measures comparable to
European countries; nevertheless, most public universities and federal institutes stopped face-
to-face activities in March 2020 and shifted to online teaching [40, 41, 49, 50].
In this context, an online cross-sectional survey in a Brazilian federal university reported
difficulties related to time management and procrastination, studying, and performing physi-
cal activities as the main difficulties faced by undergraduate and graduate students during the
pandemic [3]. Among graduate students, 51% addressed difficulties writing their master/doc-
torate thesis. Lack of motivation, lack of concentration, difficulties in writing and studying at
home, anxiety in the face of the pandemic, and discouragement were the major perceived bur-
dens regarding academic life [3].
An online cross-sectional survey revealed that Brazilian undergraduate students presented
symptoms of depression (60.5%), anxiety (52.5%), and stress (57.5%) [51]. In a study of medi-
cal students from both public and private universities in Brazil, losses in concentration levels
(79.5%) and academic performance (59.8%) were reported during the pandemic [9].
This study aims to provide a comprehensive overview of how the pandemic affected univer-
sity students in Brazil in terms of their mental health status and perceived burdens.
The study design was based on an anonymous online survey conducted in Germany in
2020 [8] and 2021 [10]. Screening instruments for depressive symptoms, alcohol, and drug
consumption were included. Social support, loneliness, self-efficacy, perceived stress, and resil-
ience were included in the explorative study. Based on literature [5, 8, 10, 51], we hypothesize
that students struggling with the burdens of the pandemic would, therefore, present significant
sum scores for depressive symptoms, especially those with lower income. We also hypothe-
sized that there would be differences in depressive symptoms and socioemotional aspects
(loneliness, perceived stress, social support, self-efficacy, and resilience) between the COVID-
19-related income changes (decreased income and increased income) and the four levels of
courses that students were enrolled (undergraduate/bachelor courses, specialization/MBA/
medical residency, master, and doctor courses).
Material and methods

Pandemic context of the study
The Federal University of Parana (UFPR), Brazil, has around 39,000 students and campuses in
six cities in the state. It is the oldest Brazilian university, founded in 1912, and it has positioned
itself as one of the most prestigious universities in the country [52]. It can be considered

representative of public universities in Brazil and of the Federal Institutes regarding under-
graduate/bachelor and graduate students.
When the survey took place, the COVID-19 situation was the following: on November 3rd,
2021, 54.68% of the population was fully vaccinated, the reproduction rate (R) of COVID-19
cases was 0.96, and the rate of new deaths per million was 1.05. When the survey ended on
March 21st, 2022, 74.35% of the population was fully vaccinated, the reproduction rate (R) of
COVID-19 cases was 0.82, and the rate of new deaths per million was 1.36 [53]. In Brazil, the
Ministry of Education allowed resuming face-to-face academic activities on August 5th, 2021,
under the observation of local regulations of states and municipalities–the higher education
system had an exception and could not resume face-to-face teaching at that moment [54]. The
UFPR was the first Brazilian federal university to resume face-to-face teaching on February
14th, 2022 [55]. Therefore, at the time of the survey, the sanitary measures to prevent contagion
were milder, and face-to-face activities were taking place at the university again.
Participants and procedures

The cross-sectional study was conducted online from November 3rd, 2021, to March 21st,
2022. The survey was set up in the online tool EFS Survey Unipark (Version 21.1) in Portu-
guese. All students at the university were invited via email, social media channels, and the uni-
versity’s website to participate. The inclusion criteria were being currently enrolled as a
student and 18 years or older. A total of N = 2,437 students completed the online survey.
Undergraduate and graduate students from 12 sectors and five campuses at the Federal Uni-
versity of Parana participated in the study. The Ethics Committee of the UFPR approved the
study (Register CAAE: 42886821.9.0000.0102, Approval no. 4.625.252). All participants pro-
vided an online informed consent via an opt-in function before participating, where they were
informed about the voluntary nature of participation and the guarantee of anonymity.
Measures
Questions related to sociodemographic and academic information (level of course, faculty,
income, and change of income, residential situation, relationship status, migration back-
ground, and being a parent), chronic somatic conditions, times of personal and indirect social
contact, as well as media and social media use, and media used for information about COVID-
19 were asked. The four levels of courses were undergraduate/bachelor, specialization/MBA/
medical residency (lato sensu), master, and doctor (both stricto sensu) courses. Lato sensu
courses are graduate courses of short duration which are focused on professional development.
Stricto sensu courses (master and doctor) are focused on research training. Moreover, the fol-
lowing measures were used:
Mental health measures

The Patient Health Questionnaire-9 (PHQ-9; [56, 57]) was used to assess depressive symptoms
over the past 14 days. The questionnaire comprises nine items on a 4-point Likert scale from 0
= "not at all" to 3 = "nearly every day," with a sum score ranging from 0 to 27, with higher
scores indicating higher levels of symptoms (e.g., “Over the last two weeks, how often have you
been bothered by any of the following problems? Little interest or pleasure in doing things?). A
sum score of 10 or more indicated clinically relevant depressive symptoms. The item 9
(“thoughts that you would be better off dead, or of hurting yourself”) indicates suicidality
when answered with a score of � 1: "0 = Not at all," 1 = "Several days," 2 = "More than half the
days," and 3 = "Nearly every day." The internal consistency of the PHQ-9 scale was excellent in
the current sample: α = 0.90.

The hazardous alcohol use subscale of the Alcohol Use Disorders Identification Test
(AUDIT-C; [58]) was used to assess alcohol consumption. On a 5-point Likert scale ranging
from 0 = "never" to 4 = "4 or more times a week," the frequency of participants having alcoholic
drinks was assessed (e.g., “How often do you have a drink containing alcohol?”–never,
monthly or less, two to four times a month, two to three times per week, four or more times a
week), the typical quantity they drink when consuming alcohol (0 = “1 or 2” up to 4 = “10 or
more”), and the frequency of heavy alcoholic drinks consumed (i.e., six or more drinks on one
occasion; 0 = "never" to 4 = "one a week”). The AUDIT-C total score ranges from 0 to 12, with
higher scores indicating higher alcohol consumption and related risk. The internal consistency
of the scale was acceptable in the current sample: α = 0.81. Besides, changes in drinking behav-
ior during the pandemic were assessed (no change, drinking less, drinking more). To assess
drug consumption, one AUDIT item was rephrased to "drug or substance abuse," and the
potential change in drug consumption (no change, consuming less, consuming more) was also
assessed. Besides, lifetime diagnosed mental disorders and current treatment of these disorders
were examined. Further, the treatment for mental disorders during the months when the pan-
demic situation was more severe (in terms of mortality rates) in Brazil (from March to June
2021) was investigated.
Additionally, changes in body weight during the pandemic and their relation to the pan-
demic from the participant’s perspective were assessed.
Social and emotional aspects of the COVID-19 pandemic

The ENRICHED Social Support Inventory (ESSI; [59]) was used to assess social support. It
was translated to the Portuguese language using a back translation method. It has five items
(e.g., “Is there someone available to whom you can count on to listen to you when you need to
talk?”) rated on a 5-point Likert scale from 0 = “none of the time” to 4 = “all of the time,” with
a total score ranging from 5 to 25, in which higher scores indicate a higher level of social sup-
port. In the current sample, the scale had excellent internal consistency, showing a Cronbach’s
alpha coefficient of 0.93.
The UCLA 3-Item Loneliness Scale was used to assess experienced loneliness (e.g., “How
often do you feel that you lack companionship?”) [60, 61]. The 4-point Likert scale ranges
from 0 = “never” to 3 = “often” in each item, with a total score ranging from 0 to 9. Higher
scores indicate more loneliness experienced. The internal consistency of the scale was good in
the current sample: α = 0.86.
The perceived self-efficacy was assessed using the ten items General Self-Efficacy Scale
(GSE; [62, 63]), which evaluates adaptation after experiencing stressful life events (e.g., “I can
always manage to solve difficult problems if I try hard enough.”). It has a 4-point Likert scale
ranging from 1 = “not at all true” to 4 = “exactly true,” with a composite score ranging from 10
to 40. Higher values indicate higher levels of self-efficacy. The internal consistency of the scale
was excellent in the current sample: α = 0.90.
The Brief Resilience Scale (BRS; [64, 65]) was used to measure the ability to bounce back or
adapt well in the face of adversity (e.g., “I tend to bounce back quickly after hard times.”), with
a 5-point Likert scale ranging from 1 = “strongly disagree” to 5 = “strongly agree,”. The total
score was ranging from 1 to 5. Higher values indicate higher levels of resilience. The internal
consistency of the scale was good in the current sample: α = 0.86.
The Perceived Stress Scale (PSS-4; [66, 67]) was used to assess the degree to which situations
in the individual’s life are appraised as stressful (e.g., “In the last month how often have you
felt you were unable to control the important things in your life?”). The four items were
answered on a 5-point Likert scale from 0 = “never” to 4 = “very often,” with a total score

ranging from 0 to 16. Higher scores indicate more perceived stress. The internal consistency of
the scale was acceptable in the current sample: α = 0.75.
The frequency of personal or indirect contact was assessed retrospectively regarding the
period from March to June 2021, when the rates of new deaths per million reached their high-
est point in Brazil (14.54 on 01 April 2021, and 14.54 on 11 April 2021) [53]. The German
research team developed the items [8, 10] and were translated to Portuguese using a back
translation method and adapted to the Brazilian context. Some examples of the items are:
“How many times per week did you personally meet with people (family members, friends,
neighbors, etc.) beside your own household during the highest infection rate level (as from
March to June 2021)?” and “How many times per week did you have indirect contact, e. g., via
phone, with other persons (family members, friends, neighbors, etc.) beside your own house-
hold?”. These items were rated on a 6-point Likert scale from 1 = “not at all” to 6 = “multiple
times a day.”
Furthermore, lifestyle aspects (social and cultural activity, healthy eating, dating behavior,
and sexual activity) during the pandemic were assessed through the question: “We would like
to ask you a few questions in what way the corona pandemic relates to your lifestyle. How do
you evaluate your personally experienced restrictions in the following areas?–social and cul-
tural activity, healthy eating, dating behavior, and sexual activity”. The items were translated to
Portuguese using a back translation method.
COVID-19 pandemic: Attitudes towards social distancing and vaccination,

and perceived burdens
Questions regarding attitudes toward the COVID-19 pandemic and vaccination, stockpile
behavior, psychosocial consequences, and perceived burdens as a result of the social distancing
measures were asked. The items used in the German survey [8] were translated to Portuguese
using a back translation method and then adapted to the Brazilian context (e.g., “I am worried
because of COVID-19.”; “I am particularly at risk from the coronavirus due to existing medical
conditions.”; “The pandemic is part of a larger conspiracy.”). The questions on attitudes were
designed as single items reflecting single attitudes toward the pandemic and the related restric-
tions, therefore, no total score was computed.
Statistical analysis
All analyses were conducted using IBM SPSS Statistics version 27.0. The level of significance
applied to statistical testing was α = 0.05 (two-tailed). First, differences in sociodemographic
variables were analysed between drop-outs with available sociodemographic data and comple-
ters, namely those participants who completed the survey until the last question of the Patient
Health Questionnaire (PHQ-9). A one-way ANOVA was performed for continuous variable
(age), and chi-squares analyses were performed for categorical variables (gender, being parent,
migration background, relationship status, higher degree finished, level of currently enrolled
course, change of income, income before the pandemic, and income after the pandemic). Sec-
ond, descriptive statistics were performed for sociodemographic and socioeconomic variables.
Students who did not report their income were only considered in descriptive analyses of the
sample and when comparing completers’ and drop-outs’ sociodemographic characteristics. In
this paper, the income is presented in Real (the Brazilian currency), which symbol is “R$.” At
the moment this paper was written, 1 US$ (one dollar) was equivalent to R$ 5,18 (five reals
and eighteen cents).
Third, one-way ANOVAs were performed to analyse potential differences in depressive
symptoms (PHQ-9 sum score) between three groups of students with different self-rated

COVID-19-related income changes (no change, decreased income, and increased income)
and also between the four groups of students with different income ranges both before and
after the pandemic (in the latter analyses, the students with no answer were not included
because the goal was to evaluate the differences between all students who chose to report their
income).
Further, a one-way ANOVA was performed to test for potential differences between stu-
dents enrolled in four different levels of study (undergraduate/bachelor courses, specializa-
tion/MBA/medical residency, master, and doctor courses) in depressive symptoms (PHQ-9
sum score). A chi-squares analysis was performed to test if the number of students answering
the PHQ-9 item 9 � 1 (suicidality) differed between the four groups formerly mentioned. Bon-
ferroni correction was applied to correct for multiple testing when applicable.
Following, one-way ANOVAs were performed to test for potential differences between stu-
dents enrolled in four different levels of study (undergraduate/bachelor courses, specializa-
tion/MBA/medical residency, master, and doctor courses) in perceived stress (PSS-4 sum
score), social support (ESSI sum score), loneliness (UCLA-3 sum score), self-efficacy (GSE
sum score) and resilience (BRS sum score). All effect sizes were interpreted as suggested by
Cohen [68].
A multiple linear regression analysis was performed to predict depressive symptoms (PHQ-
9 sum score) based on the following predictors: sociodemographic variables (age, gender, rela-
tionship status, residential status, being a parent, migration background, change in income),
mental health outcomes (loneliness–UCLA-3, social support–ESSI, self-efficacy–GSE, and
resilience–BRS), lifetime mental disorder, chronic somatic condition, and social and emo-
tional aspects (opinion about positive and negative aspects of the pandemic). Categorical vari-
ables with more than two categories were either dichotomized (relationship status, being a
parent) or recoded into dummy variables (gender, migration background, change in income,
lifetime mental disorder); gender was recoded into two new dummy variables: female and
diverse because they presented higher mean scores for depressive symptoms (PHQ-9) than
male participants, similar to previous studies. All predictors were entered simultaneously
(enter-method). The assumption of no or little multicollinearity was not violated (Variance
Inflation Factor [VIF] < 10; correlation matrix check, r � .85) for multiple linear regression
analyses. Perceived stress (PSS-4) was not included among the predictors due to missing data.
The residuals for this regression model do not have a constant variance (heteroscedasticity)
based on the scatterplot of the standardized residual and the standardized predicted value.
Finally, descriptive statistics were also performed for attitudes toward social distancing and
vaccination, perceived burdens of the COVID-19 pandemic, mental health measures, and life-
style and social and emotional aspects of the pandemic.
Results
A total of N = 2,442 students completed the survey until the Patient Health Questionnaire
(PHQ-9), covering the main study outcome measures. Of these, n = 5 were excluded for
implausible data; therefore, the final sample comprised N = 2,437 participants. Sociodemo-
graphic information on the final sample is displayed in Table 1. Next to these completers,
n = 807 were considered drop-outs. Sociodemographic data were available for n = 645 of the
drop-outs.
There were significant differences between drop-outs and completers in the following
sociodemographic variables: age (completers were older), Welch’s F(1,1171.618) = 42.932, p <
.001, η2 = 0.01; being parent, χ2(1) = 4.606, p = .032; level of currently enrolled course, χ2(3) =
23.24, p < .001; income before the pandemic, χ2(4) = 17.582, p = .001; and current income,

Table 1. Sociodemographic characteristics of the total sample (N = 2,437).

Variable n, %
Total 2,437 (100)
Gender
Female 1,579 (64.8)
Male 821 (33.7)
Diverse 37 (1.5)
Age
< 20 years 260 (10.7)
20–25 years 928 (38.1)
26–30 years 569 (23.3)
> 30 years 680 (27.9)
Relationship status
In a relationship 1,349 (55.4)
Single 1,088 (44.6)
Residential status
Alone 319 (13.1)
Not alone 2,118 (86.9)
Being parent
Yes 335 (13.7)
No 2,102 (86.3)
Migration background
Self 28 (1.2)
Parents 27 (1.1)
None 2,382 (97.7)
Income
Before COVID-19 pandemic
No incomea 527 (21.6)
0–1100 R$/mo 549 (22.5)
1101–3300 R$/mo 796 (32.7)
> 3301 R$/mo 487 (19.6)
No answer 87 (3.6)
After COVID-19 pandemic
No incomea 380 (16.1)
0–1100 R$/mo 564 (23.1)
1101–3300 R$/mo 914 (37.5)
> 3301 R$/mo 507 (20.8)
No answer 72 (3.0)
Change in income
Decrease 682 (28.0)
No change 1,354 (55.5)
Increase 401 (16.5)
a
Participants indicated not receiving any own income on a regular basis.
https://doi.org/10.1371/journal.pone.0284190.t001
χ2(4) = 26.159, p < .001. There were significant differences between drop-outs and completers
regarding socioeconomic data: being a parent (10.5% in drop-outs, 13.7% in completers);
being enrolled in undergraduate/bachelor (66.7% in drop-outs, 57.6% in completers) or in a
doctor course (13.0% in drop-outs, 20.7% in completers); having an income range before the

pandemic of R$ 0–1100 (27.8% in drop-outs, 22.5% in completers) or higher than R$ 3301

(14.4% in drop-outs, 19.6% in completers). After the pandemic, there were significant differ-
ences between having an income range of R$ 0–1100 (28.5% in drop-outs, 23.1% in comple-
ters), higher than R$ 3301 (14.4% in drop-outs, 20.8% in completers), and among those who
did not want to report their income range (5.4% in drop-outs, 3.0% in completers).
Of the N = 2,437 students who completed the survey, n = 1,579 (64.8%) were female,
n = 821 (33.7%) were male, and n = 37 (1.5%) diverse. The participants age ranged from 18–71
years old (M = 27.84, SD = 8.40); 97.7% (n = 2,382) declared not having a migration back-
ground; and 86.9% (n = 2,118) of the participants lived together with others.
Regarding their educational situation, n = 1,404 (57.6%) participants were currently
enrolled in undergraduate/bachelor courses, n = 506 (20.8%) in master degree, n = 504
(20.7%) in doctor degree, and n = 23 (0.9%) in specialization/MBA/medical residency courses
(lato sensu courses).
In total, n = 383 (15.7%) reported that they suffered from a chronic somatic condition,
while n = 502 (20.6%) agreed or fully agreed with the statement that they were particularly at
risk of coronavirus due to existing medical conditions.
The most common sources of income were by family support (n = 633, 20.8%), full-time
job (n = 590, 19.4%), having a scholarship (n = 542, 17.8%), and having a paid internship
(n = 233, 7.7%; multiple answers possible). Regarding the financial situation, n = 1,354 (55.5%)
of the students reported that their income did not change during the COVID-19 pandemic,
while n = 682 (28.0%) indicated a decrease in income, and n = 401 (16.5%) reported an
increase. The main reported reasons for a decreased income were unemployment/job loss/end
of the contract (n = 192, 30.5%), perceived decreased purchasing power due to inflation
(n = 155, 24.6%), having businesses affected by the pandemic (n = 96, 15.3%), and the end of
the scholarship/social benefits (n = 38, 6.0%). For an increased income, reported reasons were
getting a new job/changing workplace (n = 152, 40.6%), getting a paid internship (n = 67,
17.9%), getting a scholarship to take a graduate course (master, doctor or postdoc; n = 44,
11.8%), and getting a promotion (n = 34, 9.1%)–multiple answers were possible.
The three groups of students with different self-rated income changes during the pandemic
(no change, decreased income, increased income) showed the following PHQ-9 scores: no
change: M = 11.97, SD = 7.20; decreased income: M = 15.19, SD = 7.35; and increased income:
M = 11.83, SD = 7.28. The level of depressive symptoms differed significantly between the
groups, Welch’s F(2,999.499) = 48.450, p < 0.001, η2 = .04. Tukey HSD post-hoc-analysis
revealed that the significant main effect was based on higher PHQ-9 sum scores in the group
of students reporting a decreased income than those reporting an increased income or report-
ing no income change (both p < .001). There was no significant difference between the latter
two groups (p = .934).
One-way ANOVAs were conducted to compare the level of depressive symptoms between
the students’ income categories both before and after the pandemic. The level of depressive
symptoms differed significantly between the income categories both before, Welch’s F
(3,1222.826) = 22.827, p < 0.001, η2 = 0.03, and after the pandemic, Welch’s F(3,1111.541) =
29.870, p < 0.001, η2 = 0.04.
The students with different self-rated income ranges before the pandemic showed the fol-
lowing PHQ-9 scores: no income: M = 13.15, SD = 7.09; R$ 0-1100/mo: M = 14.39, SD = 7.22;
R$ 1101-3300/mo: M = 12.80, SD = 7.38; > R$ 3301/mo: M = 10.64, SD = 7.42. The students
with different self-rated income ranges after the pandemic showed the following PHQ-9
scores: no income: M = 13.58, SD = 7.15; R$ 0-1100/mo: M = 14.25, SD = 7.29; R$ 1101-3300/
mo: M = 13.04, SD = 7.35; > R$ 3301/mo: M = 10.29, SD = 7.19. Post-hoc Tukey’s HSD test
referring to the income before the pandemic revealed that the PHQ-9 sum score of the

Table 2. Descriptive and statistical analysis of the mental health measures regarding the course levels students are currently enrolled in (n = 2,437).
Mental health measures Total sample Bachelora Lato sensub Master Doctor Test value
Depressive Symptoms (PHQ-9) 12.85 13.6 7.91 12.33 11.5 Welch’s F(3,107.521) = 17.514, p < .001, η2 = 0.02
(M, SD) (7.40) (7.37)i (5.37)ii (7.33)ii (7.32)ii
Perceived Stressc 7.81 8 6.06 7.74 7.49 Welch’s F(3,77.571) = 7,410, p < .001, η2 = 0.01
(PSS-4) (2.52) (2.50)i (2.21)ii (2.52)i,iii (2.5)ii,iii
(M, SD)
Loneliness (UCLA-3) 5.25 5.64 4.39 4.81 4.66 Welch’s F(3,108.097) = 32,182, p < .001, η2 = 0.04
(M, SD) (2.35) (2.30)i (1.55)i,ii (2.33)ii (2.30)ii
Social Support (ESSI) 18.04 17.31 19.87 18.94 19.08 Welch’s F(3,109.110) = 24,891, p < .001, η2 = 0.03
(M, SD) (5.15) (5.29)i (3.15)i,ii (4.81)ii (4.81)ii
Self-efficacy (GSE) 28.23 27.35 31.35 28.66 29.93 Welch’s F(3,109.065) = 33,583, p < .001, η2 = 0.04
(M, SD) (5.92) (5.98)i (3.60)ii,iii (5.87)ii (5.41)iii
Resiliencec 2.75 2.67 3.28 2.84 2.88 Welch’s F(3,101.367) = 11,706, p < .001, η2 = 0.01
(BRS) (0.86) (0.85)i (0.80)ii (0.87)ii (0.88)ii
(M, SD)
PHQ-9: Patient Health Questionnaire-9; PSS-4: Perceived Stress Scale; ESSI: ENRICHED Social Support Inventory; UCLA-3: UCLA 3-Item Loneliness Scale; GSE:
General Self-Efficacy Scale; BRS: Brief Resilience Scale.
The different superscript letters i,ii,iii indicate the differences between the groups.
a
Bachelor and undergraduate students were considered.
b
Lato sensu refers to all specialization/MBA/Medical residency students.
c
Reduced sample due to missing data (PSS-4, n = 1,708; BRS, n = 2,393).
students that reported monthly earning more than R$ 3301 per person was the only one that
differed significantly from all other three income categories (p < .001), showing the lowest lev-
els of depressive symptoms. In addition, the R$ 0–1100 income range differed from R$ 1101–
3300 (p < .001)–students earning the latter income range had the highest sum score in PHQ-
9. There was no significant difference between the other income ranges after Bonferroni cor-
rection (all p > .013).
Moreover, the post-hoc Tukey HSD test referring to self-reported income after the pan-
demic revealed that the PHQ-9 sum score of the students that reported earning more than R$
3301 per person was the only one that differed significantly from all three other income ranges
(p < 0.001), showing the lowest levels of depressive symptoms. Furthermore, the R$ 0–1100
income range differed from R$ 1101–3300 (p = .010)–students earning the latter income range
had the highest score in PHQ-9. There was no significant difference between the other income
ranges after the pandemic after Bonferroni correction.
A one-way ANOVA was conducted to compare students of the four course levels of higher
education (undergraduate/bachelor, specialization/MBA/medical residency, master, and doc-
tor) regarding their levels of depressive symptoms (PHQ-9). The mean PHQ-9 scores are dis-
played in Table 2. The level of depressive symptoms differed significantly between the groups,
Welch’s F(3,107.521) = 17.514, p < .001, η2 = 0.02, with Tukey HSD post-hoc test revealing sig-
nificantly higher PHQ-9 scores in undergraduate/bachelor students in relation to all other
groups as following: specialization/MBA/medical residency (p = .001), master (p = .006), doctor
(p < .001). There was no significant difference between the students enrolled in specialization/
MBA/medical residency, master, and doctor degrees after Bonferroni correction (all p > .013).
Regarding suicidality, a chi-square test showed there was a statistical difference in the num-
ber of students who answered PHQ-9 item 9 � 1 (“thoughts that you would be better off dead,
or of hurting yourself”), χ2(3) = 36.590, p < .001, when comparing the four groups of students:
undergraduate/bachelor (66.1%, n = 534), specialization/MBA/medical residency (n = 4,
0.5%), master (n = 138, 17.1%), and doctor (n = 132, 16.3%).

A one-way ANOVA was conducted to compare students of the four course levels of higher
education (undergraduate/bachelor, specialization/MBA/medical residency, master, and doc-
tor) regarding perceived stress, loneliness, social support, self-efficacy, and resilience–the
mean scores of these scales and the statistical analysis are displayed in Table 2. The level of per-
ceived stress, loneliness, social support, self-efficacy, and resilience differed significantly
between the groups of students. Overall, post-hoc-analysis revealed that undergraduate/bache-
lor students presented the highest levels of perceived stress and loneliness and the lowest levels
of social support, self-efficacy, and resilience.

The mean PHQ-9 score of the total sample was 12.85 (SD = 7.40), while n = 1,488 (61.1%) par-
ticipants reported a sum score of 10 or more, indicating clinically relevant depressive symp-
toms, and n = 808 (33.2%) reported suicidal thoughts on at least several days per week over the
past two weeks. Descriptive statistics (means and standard deviations) of perceived stress,
social support, loneliness, self-efficacy, and resilience are displayed in Table 2.
Regarding mental disorders, n = 887 (36.4%) of students reported to have been diagnosed
with the following disorders: anxiety disorder (n = 568, 23.3%), unipolar depression (n = 433,
17.8%), attention deficit hyperactivity disorder (n = 118, 4.8%), bipolar disorder (n = 108,
4.4%), obsessive-compulsive disorder (n = 67, 2.7%), personality disorder (n = 49, 2.0%), eat-
ing disorder (n = 92, 3.8%), and others (n = 157, 6.4%); multiple answers possible. Also,
n = 316 (35.6%) participants indicated they were currently not receiving any treatment for
mental disorders, whereas n = 131 (14.8%) were in psychotherapeutic treatment, n = 195
(22.0%) were taking medication, and n = 238 (26.8%) reported both taking medication and
receiving psychotherapeutic treatment. Among those that reported not having been diagnosed
with a mental disorder in the past, n = 202 (13.1%) indicated they were currently receiving psy-
chotherapy, n = 51 (3.3%) reported they were taking medication, and n = 43 (2.8%) reported
taking both medication and receiving psychotherapy.
Regarding alcohol consumption, from n = 2,421 participants whose data were available,
n = 578 (23.7%) participants consumed more alcohol during the pandemic, n = 1,241 (50.9%)
reported no change, and n = 600 (24.6%) reported they consumed less alcohol. Regarding drug
consumption, n = 229 (9.4%) reported using more drugs, n = 2,053 (84.2%) indicated no
change, and n = 138 (5.7%) reported consuming less drugs during the pandemic. The mean
score of the AUDIT-C hazardous alcohol use subscale was M = 2.8 (SD = 2.52); the frequency
of drinking alcohol is displayed in Table 3.
Concerning weight changes in the last three months, n = 741 (30.6%) reported no weight
change, and n = 1,681 (69.4%) indicated their weight changed–among the latter, n = 1,161
(69.1%) reported having gained weight, while n = 520 (30.9%) reported having lost weight, and
n = 827 (73.0%) connected their weight changes to the pandemic.
To examine predictors of depressive symptoms, an explorative multiple regression analysis
was conducted with the available data of n = 2,394 (see Table 4). The variables included by
enter-method in the model explained a significant amount of variance in the level of depressive
symptoms, F(16,2377) = 114.455, p < .001, R2 = .43 (adjusted R2 = .43).
Being single (p = .012), having the income decreased during the pandemic (p < .001), hav-
ing a previous mental illness (p < .001), having a somatic condition (p = .004), not finding pos-
itive aspects in the pandemic (p < .001), lower self-efficacy (p < .001), lower social support (p
< .001), lower resilience (p < .001), and higher experienced loneliness (p < .001) were signifi-
cantly related to higher levels of depression. Age, being female, being diverse, living alone,

Table 3. Alcohol and drug consumption and changes during the COVID-19 pandemic based on AUDIT-C
(n = 2,421).
Variable n, %
Current alcohol consumption
Abstinent 547 (22.6)
Less than once a month 729 (30.1)
2–4 times a month 768 (31.7)
2–3 times a week 301 (12.4)
4 or more times a week 76 (3.1)
Change in drinking behavior during the COVID-pandemica
Less 600 (24.8)
No change 1,241 (51.3)
More 578 (23.9)
Current drug or substance use
Abstinent 2,074 (85.7)
Less than once a month 169 (7.0)
2–4 times a month 57 (2.4)
2–3 times a week 28 (1.2)
4 or more times a week 93 (3.8)
Change in drug/substance use during the COVID-pandemica
Less 138 (5.7)
No change 2,053 (84.8)
More 229 (9.5)
AUDIT-C: subscale of the Alcohol Use Disorders Identification Test.

a
Reduced sample due to missing data.
having a migration background, and finding negative aspects of the pandemic did not show
any significant association with depressive symptoms (all p > .05).

Overall, 96.1% (n = 2,343) of students indicated they experienced negative aspects, while
60.3% (n = 1,471) reported they experienced positive aspects during the pandemic. Also,
86.0% (n = 2,095) of participants indicated they were rather or fully worried about COVID-19,
and 61.0% (n = 1,486) reported feeling personally rather or fully in danger because of COVID-
19. Most participants (n = 2,138, 87.7%) agreed or fully agreed with the statement that the
social distancing/isolation measures hit the students hard, and 76.9% (n = 1,874) rather or
fully agreed with the statement that the pandemic completely affected their academic activities.
Most participants (n = 2,295, 94.2%) supported or fully supported the use of masks and the
personal and environmental sanitary measures to slow down the spread of the coronavirus.
Accordingly, 91.8% (n = 2,238) rather or fully disagreed that the social distancing measures,
the use of masks, and the personal and environmental sanitary measures caused more harm
than benefits.
Most of the students disagreed or highly disagreed with the statements that the widespread
fear about the coronavirus was exaggerated (n = 1,879, 77.1%) and that the pandemic was part
of a larger conspiracy (n = 2,191, 89.9%). Further, n = 1,985 (81.5%) rather or highly disagreed
with the statement that they felt responsible for the COVID-19 crisis.

Table 4. Linear regression analysis for predictors of depressive symptoms (PHQ-9) (n = 2,394).
Variable Unstandardized B SE B Standardized B 95% Confidence Interval (CI) t p
Age -.023 .018 -.026 -0.058,0.013 -1.257 .209
Gender
Female .163 .0249 .011 -0.325,0.651 0.654 .513
Diverse 1.207 .962 .020 -0.680,3.095 1.255 .210
Being parent 0.852 .431 .039 0.008,1.697 1.979 .048
Residential status -0.040 .353 -.002 -0.733,0.653 -0.113 .910
Relationship status -0.647 .257 -.044 -1.150,-0.144 -2.523 .012
Migration background 0.029 .775 .001 -1.491,1.549 0.038 .970
Decreased income 1.528 .263 .093 1.013,2.043 5.820 < .001
Psychiatric conditions prior to pandemic 1.365 .251 .089 0.872,1.858 5.428 < .001
Chronic somatic conditions 0.913 .315 .045 0.295,1.532 2.896 .004
Positive aspects of the pandemic 1.112 .242 .074 0.639,1.586 4.604 < .001
Negative aspects of the pandemic -0.782 .612 -.020 -1.982,0.417 -1.279 .201
Self-efficacy (GSE) -0.252 .025 -.202 -0.300,-0.204 -10.245 < .001
Social support (ESSI) -0.114 .029 -.079 -0.171,-0.057 -3.911 < .001
Loneliness (UCLA-3) 0.873 .068 .278 0,740,1.006 12.866 < .001
Resilience (BRS) -1.476 .170 -.173 -1.809,-1.142 -8.682 < .001
R2 (R2 adjusted) .435 (.431)
F 114.455
p < .001
Gender variable recoded into dummy variables "female" and "diverse". Relationship status dichotomised into "in a relationship" and "single". Being parent dichotomised
into "being parent" and "not being parent". Bold font indicates statistical significance, p < .05.
GSE: General Self-Efficacy Scale; ESSI: ENRICHED Social Support Inventory; UCLA-3: UCLA-3 Item Loneliness Scale; BRS: Brief Resilience Scale.
When asked about stockpiling, n = 508 (20.8%) reported stockpiling behavior, especially
regarding food, hygiene products, and medicine.
Regarding COVID-19 infection, n = 631 (25.9%) participants reported they had already
been infected, and n = 480 (76.1%) reported their infection was proved by a test. Also,
n = 1,732 (71.0%) had someone in their household or family member infected, 67.7%
(n = 1,650) had a friend or a neighbor, and 57.4% (n = 1,398) had an acquaintance who was
infected with the coronavirus. Only 1.0% (n = 24) reported not knowing anyone that was
infected with the coronavirus. Further, n = 1,957 (80.3%) participants reported knowing some-
one who died because of COVID-19.
The participants were retrospectively asked about having medical or psychological appoint-
ments during the months of March to June of 2021, when the numbers of deaths were highest
in Brazil. Face-to-face appointments were the most common way participants reported they
used when having a medical appointment (n = 1,166, 47.8%), followed by those who used a
videoconference (n = 433, 17.8%). The videoconference was the main communication means
used by the students when they had psychological appointments (n = 735, 30.2%). Some partic-
ipants indicated that despite being in need of help, they did not get medical (n = 102, 4.2%) or
psychological (n = 196, 8.0%) appointments.
The students were retrospectively asked about having direct and indirect personal contact
during the months of March to June 2021: n = 1,230 (50.5%) participants reported having no
personal contact with other people outside their household during that period, n = 834
(34.2%) reported having had contact once or twice a week, and n = 374 (15.4%) three or more

times per week; n = 1,142 (46.9%) reported having indirect contact (e.g., phone or video call)
every day or several times a day.
Regarding vaccination against COVID-19, 97.3% (n = 2,372) of the participants reported to
be fully vaccinated, and 1.6% (n = 40) partly vaccinated. Concerning their attitudes towards
vaccines in general, 96.9% (n = 2,361) reported being favourable or rather favourable, 1.1%
(n = 26) partly, 1.3% (n = 32) rather or hostile refusing, and 0.8% (n = 18) preferred not to say
or did not know.
The sources to get information about the COVID-19 pandemic most commonly reported
by the participants were online newspapers (n = 1,544, 63.3%), official websites (n = 1,366,
56.1%), television (n = 1,150, 47.2%), Instagram (n = 899, 36.9%), Twitter (n = 560, 23.0%),
and Facebook (n = 368, 15.1%); multiple answers were possible.
When asked how their lifestyle was affected by the pandemic-related restrictions, n = 518
(21.3%) participants agreed or fully agreed with the statement that they felt severely restricted
by the social distancing measures. Despite the finding that n = 1,153 (47.3%) rather or fully
agreed with the statement that "overall, it is good to me not to go out so much and have less
contact with other people," n = 1,541 (63.2%) rated social life as an aspect that was significantly
restricted. Cultural activities and exercising were also rated as significantly restricted by
n = 1,420 (58.3%) and n = 887 (36.4%), respectively.
Hobbies were rated as being significantly restricted by n = 737 (30.2%) participants, while
n = 509 (20.9%) reported it as not being restricted. Dating was reported as significantly
restricted by n = 692 (28.4%) participants, while being not restricted by n = 536 (22.0%). Sexual
activity was reported to have been significantly restricted by n = 678 (27.8%), while it was not
restricted to n = 694 (28.5%) participants. Healthy eating was pointed out as an aspect that was
not affected by n = 996 (40.9%) participants. Alcohol and drugs were reported to be signifi-
cantly restricted by n = 272 (11.2%) participants, while n = 643 (26.4%) reported it was not
restricted.
Discussion
This survey presents remarkable and, to our knowledge, the first comprehensive information
regarding Brazilian students’ mental health, attitudes, social and emotional aspects, and some
burdens of the COVID-19 pandemic. The survey was conducted when at least half of the Brazil-
ian population was fully vaccinated, and the rates of contagious and deaths were considerably
lower when compared with the months when the rates of new deaths per million reached its
highest point in Brazil. Nevertheless, as already pointed before [1, 2, 4, 8, 10], the results of this
survey also show that the students are facing the burdens of the pandemic substantially and that
the psychosocial and emotional impact of the pandemic may be long-lasting and extensive.
There were differences between drop-out and completers. Completers were more often
parents (13.7% in this sample vs. 10.5% in drop-out), were enrolled in higher course levels
(20.7% enrolled in doctor course in the sample vs. 13.0% in drop-out), and had a higher
income range before and after the pandemic–especially in the category income higher than R$
3301. Drop-out students were more often enrolled in lower course levels (66.7% of drop-outs
were enrolled in undergraduate/bachelor courses vs. 57.6% in this sample) and had lower
income ranges before and after the pandemic, especially in the income range of R$ 0–1100.
The number of students who did not want to report their income after the pandemic was
higher among participants who dropped out (5.4%) than in the completers’ sample (3.0%).
Similarly to previous studies, most participants were female (64.8%), similar to previous stud-
ies [40, 41, 69]. Moreover, most university students (both undergraduate/bachelor and graduate
students) in Brazil are female [70], which is representative of Brazilian university students.


The level of depressive symptoms in this sample was higher than in the general population in
Brazil [71–73], although, in the study of Goularte and colleagues, depression was present in
68% of the sample [5]. Nevertheless, this result was very similar to other study conducted from
September to October 2020 with N = 1,224 students from five public universities also in Parana
state [51].
The mean PHQ-9 score of 12.85 in this sample is considered a status of moderate depressive
symptoms (PHQ-9 score between 10 and 14), and a score higher than 10 represents clinically
relevant depressive symptoms [56]. Besides, every third student reported suicidal thoughts on
at least several days per week over the past two weeks.
Levels of depressive symptoms differed between participants with different self-rated
income changes during the pandemic, with higher PHQ-9 sum scores in the group of students
reporting a decreased income than those reporting an increased income, which was similarly
pointed by Lopes and Nihei [51]. Accordingly, students with higher income both before and
after the pandemic presented lower PHQ-9 sum score.
Although the financial situation did not change for 55.5% of the students, the consequences
might be critical for those whose income decreased due to the pandemic. Post-hoc-analysis
revealed a significant difference in depressive symptoms in this sample between students with
decreased income in relation to those whose income stayed stable or had their income
increased. Job loss/unemployment and inflation were pointed as the main reasons the students
had an income decrease, which might illustrate the burdens of the pandemic in the Brazilian
economy.
Furthermore, the level of depressive symptoms differed significantly between the income
categories before and after the pandemic, in which students with higher income ranges (more
than R$ 3301 per person) showed lower levels of depression. Also, students earning R$ 0–1100
presented higher levels of depression in relation to those earning R$ 1101–3300. Low income
and lower level of education were also reported to be associated with higher severity of symp-
toms in the general Brazilian population by Goularte and colleagues [5]. It highlights the
importance of having financial support programs for students and the need to update and cor-
rect the scholarship grants according to the inflation rate [69].
Moreover, regarding differences between the course levels, post-hoc-analyses revealed that
undergraduate/bachelor students scored higher for depressive symptoms than the students
enrolled in specialization/MBA/medical residency, master, and doctorate courses. These
results should be carefully observed as students seem to have an increased risk of developing
mental health problems since psychiatric disorders often first appear between the ages of 18
and 24 [74]. It reveals that younger adults are experiencing more depressive symptoms, which
indicates that further studies are needed to investigate mental health outcomes and special pre-
vention programs–therefore, longitudinal studies or comparison studies between first-year
students and seniors could be particularly useful. It also indicates that there might be differ-
ences in characteristics in these populations that require different approaches to mental health
promotion and prevention interventions in a university environment, based on these popula-
tions’ specificities in psychological distress, as already suggested [6].
Further, as a cultural practice, it is notable that the number of students who reported being
currently in psychotherapeutic treatment, taking medication, or both, despite not having a
diagnosis. Anxiety and depression were the most common mental disorders reported by the
participants, which is comparable with the data of the general population in Brazil [5].
Regarding alcohol and drug consumption, the results show that most participants reported
they consumed equal or fewer amounts, which could be related to fewer social gatherings (e.g.,

parties or events) due to social distancing and the need to prioritize their expenses, for
example.
As expected, the regression analyses showed that having lower self-efficacy, lower social
support, lower resilience, and higher experienced loneliness were related to higher levels of
depression. Regarding health conditions, having a previous mental illness or a chronic somatic
condition were risk factors for depressive levels, which is corroborated by previous studies [10,
72]. In addition, being in a relationship (vs. being alone) seems to be a protective factor, while
not finding positive aspects in the pandemic revealed to be a predictor for depression in the
model [10]. Moreover, as the financial aspect already pointed out earlier [8, 10, 72], having
income decrease during the pandemic was a predictor to depressive symptoms.
Surprisingly, differently from what was observed in other studies with university students
and the general population [5, 21, 51, 73, 75], this sample did not show a significant statistical
difference among female or diverse genders as predictor variables of depressive symptoms,
and neither to not being a parent [5, 8, 21, 27, 73].

Despite the fact that when the survey was conducted, 97.3% of the students reported being
fully vaccinated or partly vaccinated (1.6%) against COVID-19, most of them (86.0%) indi-
cated they were rather or fully worried about COVID-19 and felt personally in danger (61.0%).
Despite the late start of the vaccination in Brazil–similar to other low-income countries [43,
44] –the country’s solid immunization strategy within the universal healthcare system and set-
tled infrastructure might have contributed to the high vaccination acceptance among the par-
ticipants [48]. Also, higher income and educational level are some of the factors related to
higher willingness to vaccinate [76]. Different studies have indicated that higher levels of trust
in information from government sources [77], knowledge about the COVID-19 vaccine and
risk perception of COVID-19, and supporting attitude towards vaccinations in general [78]
are related to vaccine acceptance [79]. Considering the kind of sources to get information
about the COVID-19 pandemic most reported by the participants, it could be argued that
trustworthy sources of information may have positively affected how students behaviorally
[80] and emotionally [23] responded to mitigate the spread of the coronavirus.
Although Brazil did not have homogenous governmental measures to slow down the spread
of the coronavirus, and this was sometimes controversial [81–83], students supported the
restrictions and health measures prescribed by health professionals. In this regard, studies
have shown a connection between compliance to protective behaviors, such as mask-wearing,
and individual characteristics and sociodemographic factors [84]. Being female, having a
higher age, having a higher income, living in urban areas, and having a university degree were
shown to be related to a higher likelihood of wearing a mask [84–86]. In terms of beliefs and
attitudes, the perceived severity of COVID-19 and perceived benefits have been also associated
with the likelihood of wearing a mask [87]. Self-efficacy has been associated with vaccine
acceptance and mask-wearing [87, 88].
Even if it is widely known that Brazil became one of the countries with the highest tolls of
deaths due to COVID-19, the high number of students who knew someone who died because
of COVID-19 is still surprising. It indicates that grief, as a collective shared experience, became
an important aspect to be considered when it comes to students’ mental health. Further, stu-
dents presented elevated levels of perceived stress and loneliness, low levels of social support,
self-efficacy, and resilience. These results are comparable to other international studies with
university students [8, 10].

Due to social distancing measures, social life and cultural activity were reported to have
been significantly restricted during the pandemic by the students. If social support was consid-
ered a strong protective factor against mental health problems and has been suggested as a
valid coping strategy in this pandemic [11], the decrease in its availability under pandemic
conditions might have had the opposite impact. Accordingly, Chung and colleagues [89] sug-
gested that higher compliance to protective behaviors (e.g., regular handwashing, regular ven-
tilation maintenance, and social distancing) seems to be related to less psychosocial distress,
whereas reduced gatherings with family or friends were associated with higher psychological
distress.
Moreover, the overload of information and misinformation regarding the pandemic, the
uncertainty regarding their academic and professional future, the socioeconomic long-lasting
side effects of the pandemic, and grief–to mention a few burdens–might lead to decreased
quality of life [83] and intermediate socioemotional aspects.
Strengths and limitations

This study has some limitations. First, because the data collection was online, the sample com-
prised only students with internet access. Second, in the multiple linear regression, the per-
ceived stress score could not be inserted in the model due to missing data, which probably
improved its variance. Third, because Brazil has a multidimensional inequality and presents a
very diverse income configuration [90], the results on income and income changes during the
pandemic should not be generalized to the population of students in Brazil. It reflects a partic-
ular group of higher education students from south Brazil. However, this study also has several
strengths. It has a relatively large sample compared to other studies with the same population
in Brazil. Besides, it uses several statistical tests to explore the relationships examined here,
mainly regarding the differences among students from different degree levels, which has been
a topic neglected so far.
Conclusion
This study showed high levels of depressive symptoms and suicidal ideation among students of
the Federal University of Parana, which places them as a vulnerable group for mental disor-
ders. Being single, having income decreased during the pandemic, having a previous mental
illness, not finding positive aspects in the pandemic, having lower self-efficacy, lower social
support, lower resilience, and higher experienced loneliness were risk factors for higher
depressive symptoms. The results suggest that healthcare providers and universities must rec-
ognize and address mental health issues. Also, social policies must be enhanced, especially in a
developing country such as Brazil. Psychosocial preventive and supportive programs can be
helpful [91], either face-to-face or online, especially considering the long-lasting and extensive
effects of the pandemic on students’ mental health and well-being [10].
Acknowledgments
The authors would like to thank all the students for participating in the survey. The first-
named author acknowledges the Federal Institute of Education, Science, and Technology of
Parana, Brazil, for the study leave.
Author Contributions
Conceptualization: Aneliana da Silva Prado, Elisabeth Kohls, Sabrina Baldofski, Alessandra
Sant’Anna Bianchi, Joanneliese de Lucas Freitas, Christine Rummel-Kluge.

Formal analysis: Aneliana da Silva Prado.

Funding acquisition: Aneliana da Silva Prado.
Investigation: Aneliana da Silva Prado, Luciano Imar Palheta Trindade.
Methodology: Aneliana da Silva Prado, Elisabeth Kohls, Sabrina Baldofski, Alessandra
Sant’Anna Bianchi, Joanneliese de Lucas Freitas, Christine Rummel-Kluge.
Project administration: Aneliana da Silva Prado.
Resources: Elisabeth Kohls, Sabrina Baldofski, Christine Rummel-Kluge.
Software: Aneliana da Silva Prado.
Supervision: Elisabeth Kohls, Joanneliese de Lucas Freitas, Christine Rummel-Kluge.
Validation: Sabrina Baldofski, Alessandra Sant’Anna Bianchi.
Writing – original draft: Aneliana da Silva Prado.
Writing – review & editing: Aneliana da Silva Prado, Elisabeth Kohls, Sabrina Baldofski,
Alessandra Sant’Anna Bianchi, Joanneliese de Lucas Freitas, Christine Rummel-Kluge.
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How are Brazilian university students coping

☯ These authors contributed equally to this work.

Copyright: © 2023 Prado et al. This is an open Material and methods

PLOS ONE | https://doi.org/10.1371/journal.pone.0284190 April 26, 2023 1 / 23

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Material and methods

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Participants and procedures

Mental health measures

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Social and emotional aspects of the COVID-19 pandemic

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COVID-19 pandemic: Attitudes towards social distancing and vaccination,

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Table 1. Sociodemographic characteristics of the total sample (N = 2,437).

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pandemic of R$ 0–1100 (27.8% in drop-outs, 22.5% in completers) or higher than R$ 3301

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Mental health measures

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AUDIT-C: subscale of the Alcohol Use Disorders Identification Test.

COVID-19 pandemic: Attitudes towards social distancing and vaccination,

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Mental health measures

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COVID-19 pandemic: Attitudes towards social distancing and vaccination,

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Strengths and limitations

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Formal analysis: Aneliana da Silva Prado.

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