PMC:7796111 / 18704-47550 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7796111","sourcedb":"PMC","sourceid":"7796111","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7796111","text":"3. Results\n\n3.1. Survey Results\nThe study sample included 99 respondents (93 P-ATS participants, 6 nonparticipants). Sample characteristics are shown in Table 2. Mean age was 20.36 years (SD 1.69). Table 3 provides an overview of self-reported anxiety levels within the total sample and across key groupings. Of respondents, 31.3% had high anxiety (score of \u003e= 10) as measured by GAD-7 (43.3% of final-year and 26.1% of first-year students). Mean anxiety levels were higher in students living in private accommodation compared with students in university halls of residence. G*Power (version 3.1.9.7) [14] was used to calculate post hoc statistical power. All independent t-tests are underpowered (\u003c0.8) and, therefore, the risk of false negatives was inflated and the results (including null findings) should be interpreted with caution.\n\n3.1.1. Reasons for Testing\nStudents’ top three reasons for taking part were “helping to keep campus safe”, “contributing to the national effort to control the virus”, and “being involved in COVID-19 research” (see Figure 1). Table 4 provides an overview of participants’ experiences of the P-ATS. The majority of respondents reported they would take part in a COVID testing programme in the future (94.9% of P-ATS participants, 50% of non-participants), and would recommend university asymptomatic COVID testing to others (98% of participants, and 100% of non-participants). Reasons for nonparticipation were unrelated to COVID-19 or testing (e.g., not physically present at the university during this time) and there were no observable differences in demographics between participants and nonparticipants informed by descriptive statistics. Due to the small sample size group mean differences could not be tested using inferential statistics.\n\n3.1.2. Case Identification\nOnly four positive SARS-CoV-2 cases were identified through the P-ATS in this sample. Three of these students reported that they were notified of their positive result within 24 h by the Clinical Virologist, and one student reported that they had been notified after 2 days. All four students were compliant in notifying the university the same day using an online reporting form. All received the official test kit and all self-isolated as advised. One of the students stayed exclusively in their own room during self-isolation, the other three self-isolated within their household but had contact with other household members.\n\n3.1.3. Acceptability and Programme Satisfaction\nTest kits were collected by individuals or members of their household and almost all of the participants did not report any issues with drop off and collection procedures. More than three quarters of respondents (79.6%) indicated they were confident in the outcome of their COVID-19 test result. Indicators of acceptability are shown in Table 4 and Table 5. In general, students were highly satisfied with the information they received about the testing programme (97.5%) and how the information was communicated to them (89.2%). Respondents were satisfied with the approach to communicating positive test results, but over one-third were dissatisfied with receiving negative test results via a group email (e.g., indicating that all individuals who tested positive had been informed), rather than being told their negative result individually (the process in place during the pilot deployment).\n\n3.1.4. Testing Adherence\nAdherence could be meaningfully determined for students in their first year who had participated in the P-ATS, as they were the target population and had all been offered the full P-ATS provision (testing provision for final year and staff was individualised, so highly variable). Reported adherence to testing related to COVID was relatively high among first year students. Of the first-year survey respondents who had participated in P-ATS (n = 65), 70.8% (n = 46) submitted all 10 swab tests in weeks 1–10 (full swab provision), and 93.9% (n = 61) submitted 5 or more swabs (at least half the swab provision). With regard to saliva samples only, 89.2% (n = 58) of first years completed one or more samples, and 16.9% (n = 11) completed two or more saliva samples. For both types of test combined, 92.3% (n = 60) completed 6 or more tests, and 47.7% (n = 31) completed all 12 tests (10× swab, 2× saliva). Reported PCR test completion is provided in Figure 2, Figure 3, Figure 4 and Figure 5 for the first year P-ATS participants (n = 65). The change from swab test to saliva sample was initiated at week 10 of 12, in preparation for alignment with deployment of the main university testing service. Engagement willingness may be underestimated from the number of tests completed, due to brief period of test kit stock depletion during the study period.\nAs would be expected, due to a longer period in the P-ATS, first-year students completed significantly more PCR tests than final-year students during the pilot: Xfirst year = 10.13, SD = 2.82, n= 65; Xfinal year= 2.68, SD = 1.12, n = 28; t (91) = 12.51, p \u003c 0.001. Figure 4 stratifies these reported frequencies across year groups. Across the whole sample (n = 93), reported adherence to PCR testing was significantly higher in those who had been required to self-isolate at any point during the P-ATS (Xself-isolate= 9.03, SD= 2.98, n = 34; Xno self-isolate= 7.15, SD = 4.82, n = 59; t (91) = 2.19, p = 0.031, Xdifference: 1.99), and those with lower levels of anxiety (Xlow anxiety = 8.70, SD = 4.24, n = 64; Xhigh anxiety = 6.07, SD = 3.99, n = 29; t (91) = −2.83, p = 0.006). Adherence to PCR testing was also higher in those students who lived on campus (n = 63) compared with those who lived elsewhere (X = 10.15on campus, SD = 2.67, n = 61; Xoff campus = 3.56, SD = 2.99, n = 32; t(91) = −10.14, p \u003c 0.001), although this is not unexpected, given that almost all of the on-campus students were in their first year (n = 62) and were offered the full 12 weeks of P-ATS. Among the first-year students specifically (n = 65), adherence to PCR testing was significantly higher in those with lower levels of anxiety (Xlow anxiety = 10.71, SD = 2.47, n = 48; Xhigh anxiety = 8.47, SD = 3.14, n = 17; t (63) = −2.98, p = 0.004).\nWith regards antibody tests, 76.9% (n = 50) of first-year students reported completing three or more of the six tests offered during the P-ATS, and 41.5% (n = 27) of first-year students completed all six tests. Figure 5 stratifies these reported frequencies across year groups.\n\n3.1.5. Correlates of Self-Testing\nPearson and Kendall’s Tau-b correlation coefficients were calculated to examine the association between reported test compliance, mental health and programme satisfaction for all student participants in the P-ATS (combined PCR swab and saliva samples, Table 6; antibody tests; Table 7). Increased PCR test adherence was associated with increased worry about friends and family contracting COVID-19, greater satisfaction with drop-off location, increased satisfaction with how negative tests were communicated, greater satisfaction with the information received and greater satisfaction with how information was communicated. A higher frequency of completed antibody tests were associated with greater worry about friends and family contracting COVID-19, greater satisfaction with information received and how it was communicated, and satisfaction with drop-off location.\nDue to the exploratory nature of this study, a stepwise entry method was used (with the exception of covariates) to specify regression analysis. The frequency of combined reported PCR testing (swab and saliva) completion was used as the dependent variable. Gender was dummy coded, with males set as the referent group. Covariates (gender and year of study) were entered in block one (forced entry), followed by student’s mental wellbeing variables (block two, stepwise entry), and satisfaction with programme services and communication (block three, stepwise entry). See Table 8 and Table 9 for overview. Two standardised residuals (\u003e+/−3.0) were identified as extreme scores and were removed from this analysis (n = 91). Increased PCR test adherence was significantly associated with being in the first year of study (as expected due to the higher number of tests available for first years compared with final years), lower levels of anxiety, increased worry about contracting COVID-19 and increased satisfaction with the way in which information was communicated (see Table 8). The final regression model accounted for 78.2% of the explained variance in the dependent variable (adjusted R2 = 0.769, SE = 2.06). The statistical correlates associated with the frequency of antibody tests were determined with several study variables (see Table 7). Increased frequency of antibody tests completed during the pilot was statistically significantly associated with being first year of study (again, as expected due to the higher number of tests offered to first year compared with final years), lower level of anxiety symptoms, having greater worry about friends or family contracting COVID-19, increased satisfaction with the drop-off point for completed tests and greater confidence in the outcome of the test. The final regression model explained 57.9% of the total variance (adjusted R2= 0.579, SE = 1.54; see Table 9).\n\n3.1.6. Correlates of Mental Health\nA regression analysis was conducted to examine the correlates of mental health (specifically, anxiety measured by the GAD-7) and testing procedures or concerns regarding COVID-19. A three-step hierarchical regression was conducted using a stepwise entry method. Gender was dummy coded, with males set as the referent group. The final regression model accounted for 46.2% of the total explained variance: adjusted R2 = 0.431, SE = 4.48. See Table 10 for overview of regression results and block entry method. Increased anxiety among students was associated with (listed in descending order of magnitude of association strength): increased worry about contracting COVID-19, decreased satisfaction with the way in which information was communicated through the pilot and increased worry about friends and family contracting COVID-19.\n\n3.1.7. Protective Health Behaviours\nPerceived risk of COVID-19 (before and after the testing pilot) and the perceived importance of protective health behaviours is shown in Table 11 for the entire sample, and across sub-groups (positive tests, participants in pilot, and those that have self-isolated). Independent t-tests were calculated to test group mean difference. It is important to note that all t-tests were underpowered, with an elevated risk of false negatives (Type II error). Therefore, null results should be interpreted with caution. Those who opted not to take part in the pilot programme reported a lower perceived risk of COVID-19 than pilot participants pre- (July) and post-pilot (October) compared with those who had taken part, although the difference only reached statistical significance for the pre-pilot rating. There were nonsignificant trends towards lower perceived importance of protective behaviours in nonparticipants, those who had received a positive test result and those who had needed to self-isolate during the intervention period. However, it is important to note that, due to limited sample size of one comparison group, these tests have limited statistical power (resulting in an inflated risk of type II error) and should be interpreted with caution.\n\n3.2. Qualitative Results\nFive themes (with 13 sub-themes) emerged from the analysis of the qualitative data from student and staff interviews and focus groups: “emotional responses to COVID-19”, “university life during COVID-19”, “influences on testing participation”, “testing physical and logistical factors” and “testing effects on wellbeing”. A thematic map illustrating the relationships between the key themes and subthemes is provided in Supplementary File S4. Table 12 shows a summary of key themes and subthemes and their representative quotes. Further quotations to support Themes 1–5 are provided in Supplementary File S5.\n\n3.2.1. Theme 1: Emotional Responses to COVID-19\n(i) Negative Feelings\nParticipants expressed complex emotional reactions to COVID-19, including physical exhaustion and a range of psychological responses such as frustration, uncertainty, anxiety and fear. Fear was alluded to not only in the context of the risk to themselves and their families of contracting COVID-19 but also in respect to a sense of guilt they would feel should they receive a positive test result and risk spreading the virus to others. While a minority were less concerned by the virus, there was widespread acknowledgement that the pandemic had impacted significantly on mental health for both students and staff, “in the beginning when it all went into lockdown it felt really alien and it made me quite anxious” (P128, female, staff, academic). Students expressed frustration with regard to the negative media representation of university students, and they perceived mixed messages from the government had encouraged them to “eat out, to help out”, and subsequently “blamed students for going out, and spreading COVID-19”.\n(ii) COVID-19 around Me\nVariations observed in participants’ emotional reactions to COVID-19 (students and staff) and their level of concern about COVID-19 appeared to be related directly to their personal experiences. Anxiety and fear were much more pronounced in those reporting greater personal exposure to the negative impacts of COVID-19 than those who had no prior experience of the virus or its impacts. For example, interviewees were seemingly more anxious and concerned if they had received a positive test result, had (or knew someone who had) self-isolated during the pandemic, had an underlying health condition that increased health risk, or knew someone who had become seriously ill due to COVID-19: “one of my friends was on a ventilator for ten weeks because of… being affected by COVID, he was a nurse working with elderly people so that was quite a scary experience” (P126, female, staff, academic).\n(iii) Coping with COVID-19\nParticipants referred to a diverse range of coping mechanisms adopted in response to the virus, which included participation in the university asymptomatic testing provision, media avoidance, distractions, and an acceptance that outcomes were beyond their control, all of which appeared to reduce their anxiety. Many students alluded to peer support both with relation to shared engagement with peers in the testing processes (e.g., within household “bubbles”) and accessing support from peers during self-isolation. It was suggested that students who live off campus may have less peer support and may find periods of self-isolation more challenging than those living in halls. A small number of students had struggled to cope during the pandemic, particularly when self-isolating, and staff indicated that further support was required for mental wellbeing, particularly for those students with existing mental health concerns. “We have had situations where students have significant mental health crises during self-isolation and that has put a lot of stress on the other students in the house where they are in an isolating situation… we need to make sure we have enough support 24 h a day, seven days a week, for these students” (P129, male, staff, academic).\n\n3.2.2. University Life during COVID-19\n(i) Adaptation to a New Normal\nStudents indicated they would rather be present at university being tested for SARS-CoV-2 (COVID-19), than go home. Some staff reported feeling initially anxious about their return to work at the university during the pandemic, but they were keen to do so and had quickly adapted to this and the regular testing. With the emotional responses to COVID-19 in mind, participants described extensive adaptations required in order to adapt to a “new normal” in the ongoing pandemic. This included compliance with national restrictions, such as social distancing and self-isolation, but also the acknowledgement of the further challenges these restrictions presented to university life with relation to social engagement (and for first year students, making new friendships) as well as impacts on teaching and learning activities.\nOverall, students and staff reported adapting well to the changes resulting from COVID-19 (e.g., online learning and remote working). During the intervention period, the experience of testing became more normalised as households engaged in testing processes together and it became a shared habit. Periods of self-isolation were seen to be the “new normal” during the pandemic, but participants raised difficulties experienced because of this. Some were disappointed to have missed family events, others spoke about the acute impact of self-isolating on mental health and the tensions that had arisen in households as a result of the mental health impact of COVID-19. First-year students who had not yet established friendship networks were concerned about missing out on university life: “there is a fear of not making friends at uni, so, when people come here, everyone wants to make lots of friends because that is where you’re here to do at uni, so it is kind of hard having those restrictions kind of prevent that.” (P98, female, Yr1, student).\nStaff spoke of the heavy impacts of the pandemic on their workload, particularly with relation to teaching and learning activities, such as the transition to remote working, re-scheduling of assessments for students who were self-isolating and the additional work required to support partial face-to-face teaching in a COVID-safe environment. One of the more significant challenges for staff was the management of student welfare. They reported escalating mental health concerns among students that were exacerbated by periods of self-isolation and compounded in the early stages of P-ATS by practical issues for students living on and off campus that were later resolved (e.g., “teething problems” around the organisation of food delivery and laundry services). With the potential for students being required to isolate more than once, staff perceived that adaptation to the new normal of COVID-19 and the success of mass testing approaches would require a substantial focus on student welfare and support for mental wellbeing.\n(ii) Improving University Life\nParticipants made various suggestions for how the challenges of COVID-19 and adapting to the new normal might be addressed. There was a strong appetite for wider-spread testing across all campuses to maximise perceptions of safety in the student and staff body. There was a desire for more university-led events to entertain students, facilitate social activity to assist with friendship building and to reduce the boredom of self-isolation. There was a general consensus that personal contact and support is essential to reduce the fear and anxiety experienced during this time. Students requested personal support from university staff with managing the challenges of missed opportunities or learning experiences due to self-isolation (e.g., lectures or practice rotations). They spoke of the importance of regular check-ins from staff during periods of self-isolation to minimise the mental health impacts: “it doesn’t need to be a lot, simple email, not even every day like every other day, how are you doing? Do you need anything?” (P116, female, Yr1, student). Staff were commended by students for the level of support they had provided during this time. Some participants believed that there should be increased education around repercussions or regulation defiance for the minority of students that were not adhering to social distancing advice. Students acknowledged that some positive support was already in place from the university with practical tasks, including shopping, and were aware of the workload pressures that this added for staff. However, staff disclosed pressures associated with increased student support, particularly with relation to the workload and challenges associated with supporting students after they received a test result and through periods of self-isolation: “So, some support around, for the students, around what happens when you get a positive result would be extremely useful to come alongside that [the testing], so that did increase our workload quite considerably.” (P129, male, staff, academic).\n\n3.2.3. Theme 3: Influences on Testing Participation\n(i) Testing Freedom\nConsidering the challenges faced by participants, several students and staff expressed the motivation to participate in the pilot scheme based on the concept of “testing freedom”. For many, this seemed to be a psychological response of acquiring “peace of mind” from knowing they were not an asymptomatic COVID-19 carrier and they were making efforts to protect their friends, families and local communities. This response then engendered a practical freedom whereby individuals felt that participation in the testing would allow them to visit family members, or made them feel more comfortable to take part in general social activities: “I just wanted to know if I was positive so that I could take steps not to spread it and to kind of know that I was you know at risk and people near me were at risk so that was my main driver” (P128, female, staff, academic). However, the freedom of testing could also have more negative impacts on behaviour, as discussed in theme four.\n(ii) External Influences\nParticipants referred to many external influences that acted as drivers to their participation in the programme. Many students had been encouraged to take part by family or friends, as well as university staff. Students alluded to being “in it together” and spoke of the expectation from other students that they would take part in the testing “yes, [it’s] like an activity so you would feel left out if you didn’t do it” (P93, female, Yr1, student). Some participants were driven to take part since they viewed this as a mechanism by which university students could contribute to the national effort.\n(iii) Curiosity\nSome students and staff were motivated to take part in the testing because of an underlying curiosity about their personal health status (i.e., COVID-19 negative or positive, potential immunity to COVID-19), or a scientific interest in the testing processes and the aligned research study.\n\n3.2.4. Theme 4: Testing—Physical and Logistical Factors\n(i) Communication\nCommunication was a pivotal factor throughout the process. Most of the participants referred to the appropriateness and acceptability of communications from the university, including the clear sign-up instructions provided at the outset, concise information about testing and the processes, and appropriate approaches to communication of test results: “yes it was good, we didn’t get told when we had negative results but then we got an email at the end of the day saying that anyone who was positive had been contacted so obviously you knew that you were negative” (P121, female, Yr1, student). Others highlighted problems that had occurred with communications, such as delays in the provision of instructions, and some “less clear” communications that had led to misunderstanding about the purpose of the testing, how to take the swab tests and how samples would be used “I think it would have been better if you got an email every time, just because then you’re kind of like well did they do my test?... There is always a little thing in the back of your head like did it actually test negative? Or did my test not get there?” (P101, female, Yr5, student). Both students and staff had expected to receive their antibody test results but had not received it during the study period, and the lack of communication related to when, or if, results would be available affected adherence to the antibody testing element of the programme. Staff highlighted some inadequacies in university-wide communications about the self-isolation processes and support that students could expect to receive, and the time they spent clarifying communications with students had significantly increased staff workloads.\n(ii) Physical Testing\nThe act of testing itself was acceptable to the vast majority of participants, and there was no consensus on the preferred methods of testing between saliva or swabs (for presence of SARS-CoV-2) or finger-prick antibody test (for prior exposure). Several students spoke of the efforts staff had made to assist in the process, and video materials, leaflets and explanatory emails were particularly valued to assist with self-testing. A minority referred to negative aspects of the testing (such as swab tests being physically unpleasant to undertake or a fear of needles), but these factors did not appear to deter any of the students from participating and were not reported as reasons for missed tests.\n(iii) Practicalities of Testing\nNo students or staff raised any significant concerns related to the testing processes. There was a general consensus that the frequency of testing was appropriate, and the collection and drop-off locations were convenient, particularly for those who were based on campus: “I thought it was really easy, erm and erm we noticed because the drop off and the collection station is opposite our office, we noticed that the participation from the students… who are living on campus was really, really good.” (P123, female, staff, administrator). Some participants raised practical barriers, such as the logistics of collecting tests when self-isolating, periods of stock depletion which meant swabbing was unavailable, or further challenges related to timetabling, “I think it was pretty much all positive, the only thing was the timings. It was a bit annoying rushing through like some lecture or like running over to put them in before the deadline” (P94, female, Yr1, student). Furthermore, the logistical challenges associated with maintaining adequate supplies of test kits and ensuring all students had access to them, were highlighted by staff.\n\n3.2.5. Theme 5: Testing—Effects on Wellbeing\n(i) Improved Mental Wellbeing\nThe P-ATS was perceived to be extremely important by participants. Despite the negative mental wellbeing impacts of COVID-19 and self-isolation, both students and staff identified positive impacts on wellbeing that were directly associated with the provision of virus testing at the university.\nThese positive impacts included reassurance about their personal health status, increased perception of safety on campus, reduced anxiety, increased confidence and greater feelings of satisfaction with, and support from, the university during the pandemic: “it was a good kind of confidence boost, you knew that it wasn’t going to spread around university as much as if people were asymptomatic and weren’t being tested. You knew that there was a bit more of a like safety net in a way” (P121, female, Yr1, student).\n(ii) Behavioural Change\nThe positive impacts noted by participants were closely associated with behavioural change. The clear communications had made it easy for students to follow testing instructions and adhere to social distancing guidance on campus. Generally, students and staff felt comfortable with being present on campus while the testing programme was in place. Participants reported feeling happier to visit loved ones and to socialise (in a socially distanced way); final-year students were able to attend rotations (clinical placements), which in some cases were activities that would not have occurred in the absence of testing: “yes I think there has been a few times when I have gone home just for the day to see my family and what not, which I probably wouldn’t have done if the testing wasn’t in place so in that regard it has like changed my behaviour in sort of that way” (P103, female, Yr5, student). Participants who had been required to self-isolate reported that they had been adherent to self-isolation guidance, as had their peers, and they believed that self-isolating was important. Although students did feel more comfortable socialising as a result of the testing programme, those interviewed spoke of the importance of adhering to guidelines and protective behaviours. However, a minority of interviewees had observed a small number of students being less compliant with government COVID-19 restrictions because they were being tested—a negative consequence of “testing freedom”. This frustrated the majority of students who claimed to be compliant: “five out of six of us would be following the same rules anyway to be honest, I would say there is definitely a couple of people that I know that yes are a bit more oh well I am negative so I am just going to do what I want sort of thing” (P102, male, Yr5, 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