INTRODUCTION

The outbreak of coronavirus disease 2019 (COVID-19) was first confirmed in China at the end of December 2019, and rapidly spread worldwide. As in other countries, Japan experienced numerous infections and deaths, prompting the implementation of various countermeasures. The first confirmed case in Japan occurred in Hokkaido on January 28, 2020, leading the prefecture to declare a state of emergency before nationwide measures were adopted by the Japanese government [1]. In the educational sector, responses included online classes and assigned seating designed to maintain physical distance between students as a countermeasure against the COVID-19 pandemic. Online classes allowed students to participate in lectures from home, thereby reducing the physical contact associated with commuting to campus. However, emergency declarations and semi-emergency measures can negatively impact health by decreasing physical activity [2]. Physical inactivity is linked to adverse psychological outcomes, such as depression and anxiety, and is also associated with increased mortality from chronic diseases [3]. A global study assessing changes in the prevalence of major depressive and anxiety disorders before and after the pandemic across 204 countries and territories estimated an increase of 53.2 million (27.6%) and 76.2 million (25.6%) new cases of major depressive and anxiety disorders, respectively. This rise was especially pronounced among women aged 15-39 years [4]. A meta-analysis of children and adolescents reported that the prevalence of depression before the pandemic was approximately 13%, but increased to about 25% after the pandemic, a 2-fold rise [5].

In Japan, an online longitudinal survey of 7893 individuals was conducted after the first and second emergency declarations were lifted in February 2021. Among younger participants (aged 18-29 years), depression did not improve even after the second emergency declaration [6]. While the number of suicides in Japan had been declining for many years, it increased in 2020. Notably, there was a rise in suicides among young people and women, believed to be attributable to the pandemic [7]. Factors such as decreased household income and concerns about losing housing, which contributed to poor mental health during the pandemic, were also predictors of anxiety and depression [8]. The most consistent predictor of mental health during the pandemic was extreme isolation, which was strongly associated with both increased severity of depressive symptoms and a greater likelihood of moderate depression [9]. In Japan, high levels of loneliness and limited social networks were also closely correlated with depression during COVID-19 [6]. Additionally, factors such as younger age (15-29 years), lower income, caregiving burdens, domestic violence, and fear of COVID-19 were linked to severe psychological distress during the pandemic [10]. Because most existing studies examined changes immediately after the pandemic, there remains insufficient knowledge regarding the association between lifestyle and psychological factors in the later stages of the COVID-19 pandemic. In particular, it is important to understand the perceived impact of COVID-19 in different regions of Japan, as the pandemic’s effects have varied regionally. For this reason, the present study utilized a web-based questionnaire to identify factors associated with depression among college students in Hokkaido, Japan, during the pandemic.

This study was conducted at a single university in Hokkaido, Japan, since Hokkaido was the first region in the country to experience a COVID-19 outbreak, and efficient access to participants could be ensured.

METHODS

Participants

In April 2022, 1851 students (591 men, 31.9%) were enrolled at Hokkaido Bunkyo University, a private college with a total of 2200 students and 2 faculties. The university is located in Eniwa City, Hokkaido, which has a population of 70 000. Many students commute from the nearby city of Sapporo, which has a population of 1.95 million. A web-based questionnaire was distributed to all students via their university email addresses. Only responses submitted using the registered university email address were included; responses from any other address were excluded. The survey was conducted between April 15, 2022 and May 9, 2022, and 188 students agreed to participate. The final analysis included 187 students (65 men, 118 women, and 4 of unknown gender) with complete data.

Data Collection

A questionnaire was developed in Japanese using Google Forms (Google LLC, Mountain View, CA, USA). An email containing a link to the questionnaire was sent to all students, and responses were collected online. The questionnaire consisted of items used in previous studies and included a variety of measures: depression, average sleep duration [11], exercise habits [12], and food frequency score (FFS) [13]. Psychological assessments included the Center for Epidemiologic Studies Depression Scale (CES-D) [14], the World Health Organization-Five Well-Being Index (WHO-5) [15], and the Fear of Coronavirus-19 Scale (FCV-19S) [16]. Physical activity was evaluated by the average monthly step count (considered a proxy for physical activity) from January 2022 to March 2022 [17]. Demographic data collected included age, gender, height, weight, and grade [18]. Additional variables examined were type of residence as of March 2022 (family residence, living alone, dormitory, or other) [18], part-time job participation [19], club activities [19], and alcohol consumption (none, 1-2 times a month, 1-2 times a week, or 3 or more times a week) [20]. Other factors included mode of transportation to university (bicycle, bus, car, metro/tram/train, motorbike, or on foot) [21] and mode of study (online, face-to-face, or hybrid) [22].

Regular exercise was defined as engaging in exercise at least twice per week [12]. The FFS was calculated using a questionnaire that assessed the weekly frequency of consumption for 10 major food groups within the Japanese diet. For each group, responses were scored as follows: eat mostly every day (3 points), 3 or 4 days a week (2 points), 1 or 2 days a week (1 point), or rarely eat (0 points). The FFS was the sum of scores for all 10 food groups (range, 0-30) [13].

The CES-D is a 20-item instrument designed to assess depressive symptoms in the general population, focusing on the previous week. This scale has demonstrated reliability and validity in this population [14]. The CES-D yields a total score by summing the responses to 20 items scored 0-3 (range, 0-60), with higher scores reflecting greater severity of depressive symptoms. A score of 16 or higher indicates depressive symptoms. The Japanese version of the CES-D has also been validated [23].

The WHO-5 Well-Being Index is a five-item self-report questionnaire that measures positive aspects of mental health during the previous 2 weeks [15]. Each item is rated on a five-point scale (0=“at no time,” 5=“all of the time”), with total scores ranging from 0 to 25; a score below 13 indicates low well-being.

The FCV-19S is a seven-item self-report scale measuring fear of COVID-19, and has been used internationally, including in Japan [16]. Each item is rated on a five-point Likert scale (1=“strongly disagree,” 5=“strongly agree”), yielding total scores from 7 to 35; higher scores reflect greater fear. A score of 21 was used as a reasonable cutoff to identify populations with significant fear of COVID-19 [24].

To assess physical activity, participants were instructed to check their past step count records using a smartphone pedometer app and complete the questionnaire accordingly. iOS users used the “Health Care” app (Apple Inc., Cupertino, CA, USA), while Android users used “Google Fit” (Google LLC) to report their average monthly step count from January 2022 to March 2022 [17,25]. The mean of these three months was used as the representative step count.

Statistical Analysis

Normality of all data was assessed using the Kolmogorov–Smirnov test. The significance threshold was set at 5%. After evaluating gender differences, participants were classified into 2 groups: those with CES-D scores below 16 (non-depression) and those with scores of 16 or above (depression). Comparisons between these groups were performed for each variable. The Mann–Whitney U-test was applied to continuous variables lacking normality and to nonparametric variables, while categorical variables were analyzed using the chi-squared test. Logistic regression analysis was performed with depression status (depression group=1, non-depression group=0) as the dependent variable and other factors as independent variables.

Odds ratios (ORs) and 95% confidence intervals (CIs) for the depression group were estimated using three models, adjusted for age, gender, and body mass index (BMI), as well as for lifestyle factors and variables that were significant in univariate analyses. Lifestyle factors (specifically, sleep duration and eating and exercise habits) were included to reflect the core elements of sleep, diet, and exercise, respectively.

All analyses were performed using SPSS version 25.0 (IBM Japan Ltd., Tokyo, Japan). The threshold for statistical significance was set at p-value <0.05.

Ethics Statement

The questionnaire informed participants that completion constituted consent to participate. This study was approved by the Ethics Committee of Hokkaido Bunkyo University (approval No. 03019; Eniwa, Japan).

RESULTS

The Kolmogorov–Smirnov test was performed for each variable, and none of the variables exhibited a normal distribution. Table 1 presents the characteristics of the study participants. The mean CES-D score for the overall population was 18.2±9.9 points, with 95 participants (50.8%) in the depression group.

Table 2 presents a comparison between the depression and non-depression groups. Participants in the non-depression group were significantly more likely to have part-time jobs and regular exercise habits (p<0.05). Additionally, FFS, WHO-5, and FCV-19S scores were significantly higher in the non-depression group (FFS and FCV-19S, p<0.05; WHO-5, p<0.01).

Table 3 shows the ORs and 95% CIs for the associations between each variable and the presence of depression.

Logistic regression analysis indicated that, in both the univariate models (model 1) and models adjusted for age, gender, and BMI (model 2), there were statistically significant associations between depression and the following factors: part-time jobs (model 1: OR, 0.50; 95% CI, 0.27 to 0.92; model 2: OR, 0.44; 95% CI, 0.23 to 0.84; p<0.05), exercise habits (model 1: OR, 0.41; 95% CI, 0.21 to 0.82; model 2: OR, 0.38; 95% CI, 0.18 to 0.80; p<0.05), and WHO-5 score (model 1: OR, 0.80; 95% CI, 0.74 to 0.86; model 2: OR, 0.80; 95% CI, 0.74 to 0.87; p<0.01).

In model 3, which included part-time job status, sleep duration, exercise habits, FFS, WHO-5, and FCV-19S as independent variables, part-time job (OR, 0.36; 95% CI, 0.17 to 0.79; p<0.05), WHO-5 (OR, 0.78; 95% CI, 0.71 to 0.86; p<0.01), and FCV-19S (OR, 1.09; 95% CI, 1.02 to 1.16; p<0.05) remained significantly associated with depression.

DISCUSSION

In this study, a web-based questionnaire survey was conducted to identify factors associated with depression among university students during the COVID-19 pandemic in Hokkaido, Japan. The results showed an average CES-D score of 18.2±9.9, indicating that approximately half of the respondents exhibited symptoms of depression. These findings are consistent with a previous study conducted in Hokkaido, Japan, in November 2021, which also targeted university students and reported a mean CES-D score of 18.5±10.7, with 52.2% scoring 16 or higher [26]. Various reports on CES-D scores among Japanese university students before the COVID-19 pandemic have been published, including scores of 17.2 by Iwata and Buka [27] and 21.3 by Araki et al. [28]. Thus, it can be inferred that, 2 years after the onset of the pandemic, depressive tendencies among students had returned to pre-pandemic levels. Regarding gender differences, this study found significantly higher scores among women than among men (18.9 vs. 15.9, respectively). Other studies have reported similar trends, with mean scores of 17.5 for men and 18.7 for women [29]. When comparing different world regions, CES-D scores among university students are known to be significantly higher among Native Americans and Japanese, with scores of 16.8 and 17.2, respectively, than among Anglo-Americans, whose average score is 13.4 [27].

University students’ CES-D scores during the COVID-19 outbreak have varied by region and time period. For example, in China, mean scores were 13.5 in March 2020 [30] and 16.4 in both May 2020 and December 2020 [31]. In Saudi Arabia, average scores for male and female students were 15.6 and 18.1, respectively, in August 2020 [32]. Although the impact of the global pandemic varies by region, the CES-D scores observed in this study offer a valuable insight into the mental health status of college students in the Hokkaido region of Japan.

The proportion of individuals with regular exercise was significantly higher in the non-depression group compared to the depression group. Additionally, FFS scores were also significantly higher among those without depression. Previous studies have demonstrated that associations between lifestyle and depressive symptoms in college students are related to sleep duration, breakfast intake, and exercise habits [33]. The present study also found an association between healthy eating and exercise habits and lower depression scores. In contrast, low sleep quality and short sleep duration have been linked to higher depression scores in prior research [34]; however, no such association was observed in this study. Notably, sleep quality was not assessed, and future studies should investigate this variable to further clarify its relationship with depression.

Logistic regression analysis demonstrated that, in both univariate analysis and models adjusted for age, gender, and BMI, part-time work, exercise habits, and WHO-5 scores were significantly associated with depression. In models that included additional variables, part-time job status, WHO-5, and FCV-19S remained significant. The WHO-5 is a measure of well-being and is consistently associated with depression risk [15]. Consistent with previous research, this study found that higher WHO-5 scores were associated with a reduced risk of depression in all models. Additionally, fear of COVID-19, as measured by the FCV-19S, was significantly associated with depression. Prior studies have also shown that fear of COVID-19 can exacerbate depressive symptoms [10,35]. Although the current survey was conducted more than 2 years after the start of the COVID-19 pandemic (between the sixth and seventh waves) [1], some respondents continued to express fear of the disease, indicating that persistent fear may contribute to ongoing depressive symptoms.

Participation in part-time jobs was associated with lower levels of depression. However, previous studies have indicated that work-related stress, including responsibility, busyness, and harassment, can contribute to depression [36]. Furthermore, during the pandemic, concerns about unexpected unemployment or reduced income were found to worsen mental health [37].

The participants in this study were college students, many of whom worked part-time for their own benefit rather than to support their families. This likely explains the observed protective effect of part-time jobs against depression; having a part-time job provided increased social connections, which outweighed potential stressors related to work responsibility or pressure. A previous Japanese online survey found that participants experiencing both high levels of loneliness and low social networks had the highest estimated prevalence of depression (35.3-54.8%), whereas those with low loneliness and strong social networks had the lowest rates (0.4-0.7%) [6]. These findings suggest that repeated lockdowns may have cumulatively increased social isolation and intensified feelings of loneliness. In this study, participation in part-time jobs may have helped students maintain their social networks, thereby reducing the psychological impact of social isolation. Moreover, part-time work may have partially compensated for the loss of other social interactions, such as club activities, which were greatly curtailed during the pandemic. A Japanese survey conducted before COVID-19 reported that roughly 50% of university students participated in club activities [38]. In contrast, the participation rate in this study was as low as 11.2%. This decline may reflect club inactivity or a lack of attractive clubs at the surveyed universities, but is likely also due to pandemic-related restrictions. Consequently, it can be inferred that students sought the social structure and networks once provided by club activities in their part-time jobs.

This study had some limitations. First, the questionnaire response rate was 10.2%, which is relatively low. Although other online surveys among college students have had response rates of less than 10% [39], our study required participants to access step-count data via a smartphone application and to complete a questionnaire using a smartphone or computer. This process may have been cumbersome, especially for participants less accustomed to using computers. Second, men were underrepresented in this sample (35%). However, this proportion is likely reflective of the university’s overall gender distribution (591 of 1851 students; 31.9%). The study was conducted at a single institution and used a non-random sampling method; thus, the findings are not representative of all 80 000 university students in Hokkaido. Nonetheless, as the sample included students from urban Sapporo as well as suburban and rural regions, the results may capture important characteristics of the broader student population in Hokkaido. Third, there are limitations regarding the analysis of gender differences. To explore potential gender-specific associations, we conducted additional analyses including interaction terms between gender and explanatory variables. Among these, only the interaction between gender and sleep duration was statistically significant, suggesting a possible gender difference for this variable. However, interactions with other variables—such as part-time job, exercise habits, FFS, WHO-5, and FCV-19S—were not significant. Given the limited sample size, particularly among men students, we did not perform fully stratified analyses. Further studies with larger and more balanced samples are necessary to explore gender-specific patterns more thoroughly. Fourth, as this was a cross-sectional study, causal relationships between depression and the associated factors cannot be established. Although many studies have examined COVID-19 and depression, the timing and nature of countermeasures have varied by country and region, making direct comparisons difficult. Thus, findings from diverse regions remain essential. Nonetheless, this study provides valuable insight by identifying factors associated with depression among university students in Hokkaido, Japan.

This study investigated the factors associated with depression among college students in Hokkaido, Japan, during the COVID-19 pandemic. The results demonstrated that, even after adjusting for other variables, WHO-5, FCV-19S, and part-time job participation remained significantly associated with depression. These findings indicate that well-being, fear of COVID-19, and participation in part-time work continued to be related to mental health even 2 years after the outbreak began. Overall, the results suggest that part-time jobs may play a protective role against social isolation among college students.

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Acknowledgements

The authors would like to acknowledge the study participants, data collectors, and analysis advisor for their contributions in this research.

Author Contributions

Conceptualization: Mizumoto A, Tsuji R, Echizen K. Data curation: Mizumoto A, Tsuji R, Echizen K. Formal analysis: Mizumoto A, Takata Y. Funding acquisition: None. Methodology: Mizumoto A, Takata Y. Visualization: Mizumoto A. Writing – original draft: Mizumoto A. Writing – review & editing: Mizumoto A, Tsuji R, Echizen K, Takata Y.

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