The Impact of COVID-19 on Adolescents’ Mental Health in Catalonia (Spain): A Qualitative Study

Introduction

The coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic on March 11th, 2020. Many countries followed precautionary principles and imposed restrictions on citizens to limit the spread of the virus, such as promoting physical distancing, limiting the movement of people, and closing educational institutions and workplaces (Heavey et al., 2020). To control the contagion of COVID-19, the Spanish Government declared, on March 14th, 2020, a State of Alarm and confinement for the entire population (Pizarro-Ruiz & Ordóñez-Camblor, 2021).

From March 14th to April 26th, 2020, the population of Spain was confined at home for 6 weeks. To control the spread of COVID, the Spanish government announced the closure of schools and colleges throughout the country on March 14th. This closure was maintained until September 14th, 2020, when adolescents and children returned to face-to-face classes at educational centers, which led to essential changes in the management and maintenance of classes for both children and adolescents. In addition, online teaching methods were adopted by most educational centers, causing changes in routines and negatively influencing emotional well-being and organization in the learning acquisition of teenagers (Tarkar, 2020).

Factors associated with mitigation measures, such as social distancing, family discord, school closures, fear of the future, and quarantine, altered the lives of adolescents (Bosch et al., 2022; OECD, 2020). These disruptions include changes in routines and breaks in the continuity of learning associated with school closures. In addition, early research has indicated an increased impact on mental health in adolescents, presenting higher levels of depression and anxiety and a greater likelihood of posttraumatic stress symptoms (O'Sullivan et al., 2021; Pizarro–Ruiz & Ordóñez–Camblor, 2021; Wang et al., 2020; Zhou et al., 2020).

Previous evidence with the adolescent population indicates high levels of stress, anxiety, and other psychosomatic symptoms due to COVID-19, identifying protective factors such as being able to talk to friends and sleeping for an adequate time (Zou et al., 2020; Cohen et al., 2021). Risk factors include having suffered from COVID-19 or having family members or acquaintances previously diagnosed with COVID-19 (Wang et al., 2020). The dimension of fear or anxiety during the pandemic has been related to high uncertainty and concern about losing close people, with younger people being the most affected (Ozamiz-Etxebarria et al., 2020). On the other hand, other studies also identified the loss of social contact, changes in social relationships, loneliness, and anxiety about homeschooling as factors associated with worsening adolescents’ mental well-being (McKinlay et al., 2022; O'Sullivan et al., 2021). In addition, families face multiple challenges: reorganization of daily life, coping with the stress of quarantine and social distancing, homeschooling, increased pressure to work from home and care for school-aged children at home at the same time, reduced freedom and privacy, and economic concerns due to business closures (Fegert et al., 2020; Pizarro–Ruiz & Ordóñez–Camblor, 2021).

Regarding the emotional consequences of health events, a preliminary study conducted in the province of Shaanxi (China) during the second week of February 2020, in which the Chinese population was confined, showed that the most common psychological and behavioral disorders of 320 children and teenagers were bonding problems, distraction, irritability, and fear of asking questions about the pandemic. Furthermore, regarding differences according to age, children between 6 and 18 years showed more attention problems and persistent inquiry (Jiao et al., 2020).

Evidence from Europe with parents and adolescents evaluates the initial impact of quarantine in three countries (Spain, Portugal, and Italy), showing that parents see their children as more irritable, lonely, restless, and uncomfortable (Francisco et al., 2020). Another study conducted in Spain on people between 19 and 84 years of age during the confinement period showed high levels of emotional impact, reflected by frequent problems in falling asleep and emotional symptoms such as worry, stress, hopelessness, anxiety, nervousness, and restlessness (Sandín et al., 2020). However, in Catalonia (Spain), evidence regarding adolescents’ experiences managing the COVID-19 lockdown and its impact on mental health is scarce. These data are crucial to highlight the needs of students and the educational system, especially during health crises. Therefore, this study aimed to understand the experiences of adolescents between 12 and 18 years of age regarding the self-perceived impact of COVID-19 on their mental health.

Method

This was an exploratory qualitative study. This design allows one to understand a specific phenomenon in a specific context and is very useful when studying little-known phenomena (Polit & Beck, 2004). Within the “Escoles Sentinella” (https://escolessentinella.cat/escoles-sentinella/) project, this study aimed to understand the experiences of adolescents between 12 and 18 years old regarding the self-perceived impact of COVID-19 on their mental health. Preliminary data collected during the 2020–2021 academic year already highlighted the negative impact of the confinement period, as part of the pandemic, on their mental health, especially among older schoolchildren. Thus, adolescents aged between 12 and 18 from nine sentinel schools belonging to different sociocultural contexts of Catalonia were invited to participate in the study. Heterogeneous sampling was sought to include diversity in the data, thus not limiting the results to a specific group or location (Robinson, 2014).

The study obtained the approval of the Ethics Committee IDIAP Jordi Gol (reference 20/192-PCV). The centers then proceeded with the collection of information. Before starting the study, participants resolved their doubts with a research team member. Likewise, efforts were made to ensure that complete information was provided to participants and their families (in the case of minors) and that they signed an informed consent document before the interviews. All recruitment management was carried out entirely by team members of researchers through contact and direct coordination with educational centers.

Data were obtained through semistructured interviews, a tool that allows personal information to be obtained in a guided manner with maximum credibility (Polit & Beck, 2004). The interview script was created based on previous evidence and the research team's interests. Two mental health nurses agreed upon the first draft of the interview, an expert qualitative researcher, and two secondary school teachers. The interview script included the following topics: (for adolescents) description of previous and current mental health status, self-perception of the impact of COVID-19 on mental health, emotional management of the pandemic, barriers and facilitators to promoting mental health during the pandemic, perception of the impact of social limitations, perception of the impact of the virtualization of teaching, living with the family longer than usual, and the fear of becoming infected. In addition, parents and teachers were asked about their perception of their own children/students’ mental health status in adolescence; possible causes and consequences; barriers and facilitators to improvement, management, and promotion of mental health in school; and management of incidents related to adolescent mental health at school or home. It should be clarified that the interviews with parents and teachers were only used to confirm our conclusions and interpretations from the data collected from the adolescents.

Two authors interviewed students in the schools after coordinating with the center directors. All interviews were audio-recorded and conducted in a safe and private space within an educational center. Given the diversity of contexts, it was estimated that approximately 80 students would be interviewed. Nevertheless, this was reduced to 30 when data saturation was identified. In addition, three mothers and three teachers were interviewed to discuss the experiences described by the students. This action was fundamental in confirming the results’ interpretation, including complementary views. All information regarding the identity and origin of the participants was kept anonymous. The transcripts were kept in a secure space within university facilities, protected with a security key, and with limited access to the qualitative research team.

The data were analyzed following the thematic analysis method proposed by Braun and Clarke (2022). It includes six key moments:(a) familiarization with the data, (b) coding, (c) categorization, (d) review of the categories, (e) definition and naming of the categories, and (f) writing the report. Two researchers performed this procedure in parallel to provide more credibility and consistency in results. In addition, Atlas.ti^® software was used to facilitate the management of texts and data analysis, providing greater rigor to the procedure. Guba and Lincoln's (1981) criteria for credibility, transferability, dependence, and reflexivity were applied throughout the process. Consensus meetings were conducted with two expert researchers, constant discussions, and debriefing sessions. Reflective and critical thinking guided the entire process and provided robustness to the findings. Each data analyst reviewed the codes, themes, and interview quotations separately, and all disagreements were resolved through discussion. Finally, the findings were discussed with five experts in three sessions, and no changes were proposed.

Findings

Twenty adolescents (17 girls) participated in this study. Further details on age are presented in Table 1. Three mothers (M_age, 45 years) and three teachers (M_age, 40 years) also participated in the study. Pseudonyms were used to preserve participants’ identities.

OPEN IN VIEWER

Table 1.

Characteristics of the Sample.

	Frequency	Female	Male
Gender
Male	13
Female	17
Age (years)
12–15	18	7	11
16–18	12	10	2

Three themes and numerous descriptive codes emerged. The latter was reduced to 11 (Table 2). The data did not reveal gender or age differences in speech.

OPEN IN VIEWER

Table 2.

Codes and Themes.

Codes	Themes
Effect of restrictions	The challenge of living confined
Daily life in confinement
Benefits of the period of confinement
Adolescent concerns
Prepandemic emotional stability	The footprint of COVID-19 on the mental health of young people
Adolescent concerns
Strengthening of the family bond
Need for emotional support
Self-responsibility
Assessment of virtual classes	The dynamics of the school during lockdown
Learning quality
School approach to public spaces

Discussion

This study showed how the experiences of adolescents between 12 and 18 years of age on the self-perceived impact of COVID-19 on mental health were fundamentally focused on confinement, the mark it has left on their mental health, and the dynamics of the school during this period. In general, the results coincided with recent findings from other investigations regarding the impact of COVID-19 on adolescents’ social and emotional development. For example, in a study by Liang et al. (2020), adolescents reported higher rates of depression and anxiety associated with the pandemic, and 14.4% of teenagers reported posttraumatic stress disorder, whereas 40.4% reported having depression and anxiety. In another study focused on girls, life satisfaction decreased from 81% before COVID-19 to 62% during the pandemic, with the oldest teenage girls reporting the lowest life satisfaction values during COVID-19-related restrictions (Soest et al., 2020).

Regarding the period of confinement and its repercussions on adolescents, it was worth noting the lack of freedom to carry out different daily life activities such as playing sports, getting together with friends, and using leisure and fun. This finding coincides with the study by Zeiler et al. (2021), carried out with girls who suffered from anorexia nervosa, stating that they felt imprisoned and limited in their usual activities during the pandemic. Furthermore, daily life during the lockdown was affected by global efforts to control the pandemic, social distancing, and school closures, which drastically changed the lives and routines of adolescents who stayed at home for long periods and limited their social contact with peers (Shoshani & Kor, 2022). These disruptions to typical social and physical routines may lead to decreased social support, poorer stress regulation, increased loneliness, social isolation, and distress (Fegert et al., 2020). Similarly, it is essential to highlight adolescents’ self-perceived benefits attributed to the confinement period. This fact coincides with the study by Zhang et al. (2020) regarding the benefits of the pandemic in developing resilience and individual coping strategies because of confinement.

Another aspect identified in this study involved the concerns reported by adolescents, especially the fear of losing loved ones or that the confinement will never end, topics that have already been explored (Masuyama et al., 2022), and gave rise to further research. For instance, the DESK cohort, a project aimed at monitoring high-school students aged 12 to 18 in Central Catalonia over time, analyses their behavior and other relevant aspects that may affect their health and social and educational life (http://deskcohort.cat/en/about-deskcohort/). Regarding mental health among young people, fear was the emotion that had the most significant impact on the participants in this study. Adolescence involves numerous biopsychosocial changes and challenges, including independence from parents, exploration of various domains of identity, coping with daily life, and school attendance difficulties. The concerns of adolescents during the COVID-19 pandemic identified in this study coincided with the available evidence on the subject; thus, adolescents were concerned about the restrictions established by the government and not about the virus itself. These worries were associated with increased anxiety, new (or worsening) depressive symptoms, and decreased life satisfaction (Hawes et al., 2022; Magson et al., 2021).

Moreover, evidence showed that adolescents who suffered a decrease in their family income and those who knew a close person or relative who died of COVID-19 were more likely to report poor overall well-being (Folch et al., 2022). Researchers currently point out that a long-term examination of the consequences of the pandemic on adolescents’ mental health will be necessary (Lee, 2020; Viner et al., 2022). This need is supported by evidence that adolescent trauma can predict mental health impairments in adulthood (Johnson et al., 2018).

Recent research (Distor & Nicomedes, 2020) indicates that during the pandemic, higher levels of resilience have been associated with lower stress levels and, therefore, better mental health. These data support the results of this study, given that adolescents who were less emotionally labile and more empowered in their self-esteem were less affected by the consequences of the pandemic and favoring/probably being able to develop better health.

As previously described and following similar evidence (Waselewski et al., 2020), the adolescents participating in this study experienced unmet needs for emotional support and a negative impact on mental health due to COVID-19. Connecting with friends and peers through virtual mediums while maintaining social distancing was critical in coping with the impact of the pandemic, particularly given the critical growth and development that occurs during adolescence. The data from this study highlights the need for emotional support for adolescents. Specifically, participants demanded the presence of an expert mental health professional in the educational centers to whom they could turn when needed. Given the nonexistence of the resource or difficulty in accessing it, adolescents effectively self-managed the situation through self-responsibility and mutual care. In short, adolescents learned to care for each other among their peers, confirming the friendship protection hypothesis proposed by Boulton et al. (1999), which shows how friendship factors can improve the impact of COVID-19 among adolescents (Espinoza & Hernandez, 2022). This study identified the online learning methods implemented during the COVID-19 pandemic as a stressor and source of student dissatisfaction. There is currently a debate about the pros and cons of online learning, especially among children and adolescents. Few researchers believe that online learning at this age results in notable academic progress among students (He et al., 2021). Furthermore, many parents of adolescents report concern not only about the academic effects of this type of learning but also about the physical problems that online learning may cause their children, such as obesity or vision problems (Robinson et al., 2017; Strasburger et al., 2010).

Regarding satisfaction with learning during the pandemic, it should be noted that in Canada, students who attended the institute partially, with the rest of the time online, reported being partially satisfied, and those who did all their learning online reported less satisfaction (Vaillancourt et al., 2022). On the other hand, in India, adolescent students showed great acceptance and positive attitudes toward online learning during the COVID-19 crisis (Khan et al., 2020). Therefore, the variability in student satisfaction with these methods may differ.

Consistent with other available evidence (Tarkar, 2020), this study identifies online classes or “e-learning” as disruptive for students, teachers, and parents alike. During adolescence autonomy is developed through the redefinition of roles and ties in the family (Fioretti et al., 2020); however, this study shows that confinement truncated this process despite the efforts to adapt using spontaneous self-management strategies such as the use of video calls with friends, seeking mutual support, engaging in social networking, and practicing introspection. Some of the adolescents stated that the lack of face-to-face interaction with teachers and peers made it difficult to maintain motivation and commitment to one's learning. The transition to the virtual classroom may have hindered the learning process, as it limited their access to immediate support and feedback. It should be noted that this disruption and changes in the learning environment during the pandemic could also have affected the cognitive and intellectual growth of the learners. The lack of interactive and personalized instruction on guidance could have hindered the development of critical thinking and problem-solving skills. In addition, the predominant emphasis on homework and assessments could have hindered the development of critical thinking and problem-solving skills. The online classes required a high degree of self-study and autonomous work, which forced adolescents to quickly develop this competency. Although no one was prepared for the impact of a pandemic, students managed it autonomously by drawing on their own personal resources.

This finding could be explained considering that adolescents have a resilience capacity that helps them develop their social and emotional skills, as well as their emotional regulation (Leipold et al., 2019), which seems to reduce stress even in moments like those experienced during a pandemic (Sakka et al., 2020). In addition, the adolescents interviewed emphasized that their schools did not adequately address how to manage on an emotional level all that happened during the pandemic. This finding is explained by the fact that during the COVID-19 pandemic, most of the educational institutions that worked with adolescents prioritized health measures to stop the spread of the virus, leaving aside the emotional aspects.

This study has some limitations that must be considered. First, it must be noted that most of the adolescents who agreed to participate were those motivated and interested in the topic; thus, some voices may have remained unheard and could have affected the results. Second, even though, some mothers and teachers were interviewed, their discourses were used only to verify adolescents’ experiences. It would have been positive to include more parents and teachers to explore the phenomenon from a broader approach; however, this was not the aim of this research.

Implications for Practice

The COVID-19 pandemic posed a challenge for adolescents because most of their socialization activities were abruptly interrupted. Mainly, the confinement had negative consequences on the adolescents’ mental health, due to the fear of becoming infected and being able to infect their loved ones and having to adapt their activities with family, friends and school. Regarding the latter, the adolescents emphasized that they perceived a lack of emotional support from the educational centers.

The results of this study highlight the importance of promoting mental health in adolescents at all levels. Therefore, professional specialization and advanced practice in treating and preventing mental health problems in schools, especially in countries where school nurses are not common. Consequently, it is imperative to engage management and coordination between educational centers and health care centers, not only in terms of controlling health within the school but also in managing adolescent emotions in educational contexts. Furthermore, in training future nurses, it is essential to establish content focused on emotional self-management, not only as a tool for personal growth but also as a fundamental competence of humanized care offered to people.

This study shows that professional specialization and advanced practice in the treatment and prevention of mental health problems in schools is required, especially in countries where school nurses are not common. This requires a commitment on the part of political, administrative, and professional bodies to promote management and coordination between schools and health centers, not only in terms of health control within the school but also in the management of the emotions of adolescents in educational contexts. It is not a matter of referring students to specialized professionals in the field of mental health or having them come to schools from time to time but of school nurses taking on this role by educating, preventing, and treating mental health problems in schools. Finally, there is a need for a regular and stable space in schools where students can share with their school nurse their emotions and their personal resources to cope with difficulties. These spaces will allow early detection of irregular situations and rapid intervention.