Perceived Risk and Preventive Measures

It has been identified that the compliance of university students with protective measures has not been sufficient to prevent the outbreak. In general, the number of measures taken by students is below average (Table 1). With the early stages of the COVID-19 outbreak, many organizations have taken actions for protective measures of the pandemic, have prepared, and published a lot of printed, visual, and audio materials. Special information has been provided to university students. ³⁷ Despite these efforts, it has been found that a group of students has complied with measures, but all the students have not followed these measures, and sufficient awareness and consciousness have not been achieved for taking multiple measures.

There are different conclusions on this subject in the literature. Elhadi et al. (2020) and Alves et al. (2020) reported that the number of measures taken by students has always been under the average. ^{Reference Elhadi, Msherghi and Alsoufi14,Reference Alves, Samorinha and Knowledge38} However, the studies conducted in India, Jordan, the Philippines, and China have indicated students’ compliance to be 80% and above. ^{Reference Knowledge12,Reference Olaimat, Aolymat and Elsahoryi15,Reference Prasad Singh, Sewda and Shiv16,Reference Zhang, Li and Du39}

In this study, the number of measures taken by female students is more. Similar to this result, many previous studies have also reported that female students have shown a better attitude toward implementing the measures. ^{Reference Ding, Du and Li13,Reference Alves, Samorinha and Knowledge38–Reference Galle, Sabella and Da Molin41} Raising the awareness of students will affect their level to take measures. Yet, it should be remembered that it may be necessary to develop different strategies to reach male students. The fact that students do not believe the social support they receive from their friends is insufficient has increased the number of measures taken (Table 3). It is known that adolescents, including university students, display more risky behaviors when they are together with their peers than when they are alone. ^{Reference Albert, Chein and Steinberg42,Reference Knoll, Magis-Weinberg and Speekenbrink43} It may have had a positive effect that students have obtained suggestions mostly from media, television, official publications by keeping away from social circles due to restrictions. In such a case, university students have preferred to act less risky instead of being affected by their peers. Anxiety, risk, seriousness, and competence perception are also among the variables that have affected the number of measures taken by students (Table 3). This may be explained by Health Belief Model. According to this model, some components motivate an individual to take a measure and to protect his/her life. Some of these components are perceived sensitivity, perceived seriousness, and self-efficacy. ^{Reference Champion and Skinner44}

Physical and Mental Health With Associated Factors

This study has also examined the physical and mental health perceptions, sleep problems, suicidal thoughts, and study problems of university students in Turkey and determined the risk factors regarding these issues. Increasing age has shown a protective characteristic for mental health in this study. It is considered that not being able to start face-to-face education, get acquainted with university life, and meet the socialization needs due to the COVID-19 increased their stress levels and resulted in deterioration of mental health perception.

Being a female student is a risk factor for mental health perception. Prior studies on this subject have reported that women are at higher risk than men in terms of problems such as depression, loneliness, and daily life fatigue. ^{Reference Patsali, Mousa and Papadopoulou28,Reference Bartoszek, Walkowiak and Bartoszek45} Kuehner reports that women experience depression more often because of their greater exposure to stressors known to increase the risk of depression, such as violence, childhood sexual abuse, and gender inequality. ^{Reference Kuehner46} On the other hand, other researchers have tried to explain this by fluctuations in women’s sex hormones, such as estrogen and progesterone, during their lifetime and more frequent exposure of women to gender-based violence than men. ^{Reference Li and Graham47,Reference Oram, Khalifeh and Howard48} Female students have fewer study problems than male students in this study. In the related literature, studies are showing that female students show better performance at school. ^{Reference Duckworth, Shulman and Mastronarde49,Reference Stoet and Geary50} The result achieved in our study is of importance in presenting sex differences in the study problems experienced by students studying at the university in case of a pandemic.

Being a student in medicine is a risk factor for physical health. It is disputable whether medical students can be assigned to the care of COVID-19 patients due to the increasing number of cases and the need for physicians. ^{Reference Soled, Goel and Barry51} Collado-Boira et al. have reported that final year nursing and medical students have tension, a sense of uncertainty, and fear regarding their immediate inclusion in the health system due to the pandemic. ^{Reference Collado-Boira, Ruiz-Palomino and Salas-Media52} In addition, the news on the death of health-care professionals caused stress for these students.

Increasing anxiety score for the COVID-19 is a risk factor for perceived physical and mental health and sleep problems. Previous studies have also shown that stress and anxiety increased due to the COVID-19 have caused mental problems such as depression and sleep problems, ^{Reference Marelli, Castelnuovo and Somma35} as well as physical problems such as headache, digestive problems, and fatigue. ^{Reference Majumdar, Biswas and Sahu34} Feeling incompetent to cope with the pandemic has been identified to be a risk factor for perceived physical and mental health, sleep, and study problems due to the reasons such as increased fear, anxiety, and stress. When examining the health-protective behaviors of individuals, those with self-confidence in coping with the pandemic show more protective behaviors. ^{Reference Yıldırım and Güler53} On the contrary, behaviors concerning protecting physical and mental health may decrease due to reasons such as decreased motivation, fear, and anxiety in the individuals feeling incompetent to cope with the disease. ^{Reference Wong and Yang54}

The perceived social support of family, friends, and instructors is an important risk factor affecting students’ physical and mental health, sleep, and study problems. The problems in the transition to online education may be a reason why students felt insufficient social support. The studies on adolescents and youth have shown that social support and feeling socially connected during the COVID-19 quarantine is a protective factor for poor mental health ^{Reference Magson, Freeman and Rapee55} and insomnia symptoms. ^{Reference Zhou, Wang and Yang56} Together with perceived less social support, having communication restrictions with family was the risk factor for suicidal thoughts. Because the continuity of education came to the forefront at the beginning of the pandemic, especially in online education, the need for students to access learning resources (Internet, computer, smartphone, educator, etc.) may have brought along mental health problems. In the literature, the cases have been reported, who tried to commit suicide as they could not participate in lessons due to the lack of a television or smart phone at their family houses or family conflicts about online education. ^{Reference Lathabhavan and Griffiths57,Reference Mamun, Chandrima and Griffiths58}

Another result achieved is that communication restriction with friends has unexpectedly reduced suicidal thoughts. This result can be explained by the fact that, when students reduce their communication with their friends, their frequency of talking about the pandemic, the fear of being infected, and negative situations that may occur in the study life decrease. We consider that such conversations may cause an increase in suicidal thoughts by raising the level of stress, hopelessness, and fear related to COVID-19 as reported in prior studies. ^{Reference Caballero-Domínguez, Jiménez-Villamizar and Campo-Arias59,Reference Dsouza, Quadros and Hyderabadwala60}

There are some limitations of the study. The cross-sectional study design cannot provide empirical evidence in causal relationship, and the instruments used in the present study did not have robust evidence in their psychometric properties. Additionally, the participants were recruited using convenience sampling, and the representativeness of the sample was low. The participants completed the questionnaires by means of online self-report and could have social desirability bias and single rater bias.