*Article* **Students' Views towards Sars-Cov-2 Mass Asymptomatic Testing, Social Distancing and Self-Isolation in a University Setting during the COVID-19 Pandemic: A Qualitative Study**

**Holly Blake 1,2,\*, Holly Knight 3, Ru Jia 3, Jessica Corner 4, Joanne R. Morling 2,3, Chris Denning 5, Jonathan K. Ball 5,6, Kirsty Bolton 7, Grazziela Figueredo 8, David E. Morris 9, Patrick Tighe 6, Armando Mendez Villalon 9, Kieran Ayling <sup>3</sup> and Kavita Vedhara <sup>3</sup>**

	- <sup>3</sup> School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK; holly.knight@nottingham.ac.uk (H.K.); ru.jia@nottingham.ac.uk (R.J.); kieran.ayling@nottingham.ac.uk (K.A.); kavita.vedhara@nottingham.ac.uk (K.V.)
	- <sup>4</sup> University Executive Board, University of Nottingham, Nottingham NG7 2RD, UK; jessica.corner@nottingham.ac.uk
	- <sup>5</sup> Biodiscovery Institute, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; chris.denning@nottingham.ac.uk (C.D.); jonathan.ball@nottingham.ac.uk (J.K.B.)
	- <sup>6</sup> School of Life Sciences, University of Nottingham, Nottingham NG7 2RD, UK; paddy.tighe@nottingham.ac.uk
	- <sup>7</sup> School of Mathematical Sciences, University of Nottingham, Nottingham NG7 2RD, UK; kirsty.bolton@nottingham.ac.uk
	- <sup>8</sup> School of Computer Sciences, University of Nottingham, Nottingham NG8 1BB, UK; g.figueredo@nottingham.ac.uk
	- <sup>9</sup> Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; david.morris@nottingham.ac.uk (D.E.M.); armando.mendez@nottingham.ac.uk (A.M.V.)
	- **\*** Correspondence: holly.blake@nottingham.ac.uk; Tel.: +44-(0)-115-82-31049

**Abstract:** We aimed to explore university students' perceptions and experiences of SARS-CoV-2 mass asymptomatic testing, social distancing and self-isolation, during the COVID-19 pandemic. This qualitative study comprised of four rapid online focus groups conducted at a higher education institution in England, during high alert (tier 2) national COVID-19 restrictions. Participants were purposively sampled university students (*n =* 25) representing a range of gender, age, living circumstances (on/off campus), and SARS-CoV-2 testing/self-isolation experiences. Data were analysed using an inductive thematic approach. Six themes with 16 sub-themes emerged from the analysis of the qualitative data: 'Term-time Experiences', 'Risk Perception and Worry', 'Engagement in Protective Behaviours', 'Openness to Testing', 'Barriers to Testing' and 'General Wellbeing'. Students described feeling safe on campus, believed most of their peers are adherent to protective behaviours and were positive towards asymptomatic testing in university settings. University communications about COVID-19 testing and social behaviours need to be timely and presented in a more inclusive way to reach groups of students who currently feel marginalised. Barriers to engagement with SARS-CoV-2 testing, social distancing and self-isolation were primarily associated with fear of the mental health impacts of self-isolation, including worry about how they will cope, high anxiety, low mood, guilt relating to impact on others and loneliness. Loneliness in students could be mitigated through increased intra-university communications and a focus on establishment of low COVID-risk social activities to help students build and enhance their social support networks. These findings are particularly pertinent in the context of mass asymptomatic testing programmes being implemented in educational settings and high numbers of students being required to self-isolate. Universities need to determine the support needs of students during self-isolation and prepare for the long-term impacts of the pandemic on student mental health and welfare support services.

**Citation:** Blake, H.; Knight, H.; Jia, R.; Corner, J.; Morling, J.R.; Denning, C.; Ball, J.K.; Bolton, K.; Figueredo, G.; Morris, D.E.; et al. Students' Views towards Sars-Cov-2 Mass Asymptomatic Testing, Social Distancing and Self-Isolation in a University Setting during the COVID-19 Pandemic: A Qualitative Study. *Int. J. Environ. Res. Public Health* **2021**, *18*, 4182. https:// doi.org/10.3390/ijerph18084182

Academic Editor: Sven Bremberg

Received: 30 March 2021 Accepted: 8 April 2021 Published: 15 April 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

**Keywords:** COVID-19; SARS-CoV-2; coronavirus; mass testing; social isolation; social distancing; mental health; students; focus groups; qualitative

#### **1. Introduction**

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The World Health Organization declared the outbreak of coronavirus disease (COVID-19) a pandemic in March 2020. During this time, restrictions on movement were put into place worldwide, to flatten the curve of infection through social distancing. The functioning of colleges and universities during the pandemic presents a challenge. Globally, strategies to manage the situation have included containment and mitigation, such as access control with contact tracing and quarantine, hygiene, sanitation, ventilation, and social distancing. In the United Kingdom (UK), this required rapid development of local organisational COVID-19 policies in universities, requiring regular adaptation in line with evolving updates from the UK Higher Education Taskforce, and rapid changes in government policy and guidance, as the national situation changes. In the UK, universities rapidly transitioned to online teaching and learning during the first surge of COVID-19 in March 2020, followed by large-scale reopening of campuses for the new academic year in September/October 2020. This mass movement of students from across the UK and overseas aligned with a second surge of COVID-19 across the UK [1] and the establishment of a national tiered system of restrictions to address local outbreaks of COVID-19 (Supplementary File S1).

The proportion of asymptomatic infection among COVID-19 positive persons is found to be high, with a substantial transmission potential [2]. A systematic review found that in two general population studies, the proportion of asymptomatic COVID-19 infection at time of testing was 20% and 75%, respectively, and among three studies in contacts it was 8.2% to 50% [2]. In the absence of a national strategy or policy, some universities developed local capability for frequent and regular mass asymptomatic SARS-CoV-2 testing programmes [3,4] in effort to reduce the risks [5] of viral transmission between asymptomatic students. This approach aimed to maximise the safety of staff, students, and local communities, and aligned with recommendations made by the UK's Independent SAGE Behavioural Advisory Group [6]. Without national guidance, there was hesitancy around asymptomatic testing, as the implications for students' social behaviours and wellbeing were unknown.

The success of mass testing approaches relies on high levels of testing and social isolation [7,8] to reduce viral transmission. Further, a combination of moderate physical distancing measures, self-isolation, and contact tracing is more likely to achieve control of severe virus transmission [7]. However, we know little about students' views towards these approaches to mitigation and containment. Although adherence to COVID-19 social regulations was generally high in the UK population (>90%), less than half of the population adhered to full self-isolation (duration adjusted adherence to full self-isolation was 42.5%) [9]. Additionally, 46% of 'resisters' to the lockdown rules were from younger age groups (16–24 years) [10]. Since 1 in 3 people aged 18 to 24 years were in full time education [11] it is possible that education settings host a high proportion of individuals who are less likely to adhere to social isolation. There is a high prevalence of younger age groups in universities; in 2019/20 there were 2.46 million students at UK higher education institutions [12], with 18–19 year-olds making the largest contribution to the Higher Education Initial Participation (HEIP) measure (the sum of the initial entry percentages in each of the age groups from 17 to 30 years, in a given academic year) [13].

This study was conducted at a university in England, in October 2020, at the beginning of the Autumn term, at the time of a second surge of COVID-19 in the UK. Earlier in the year (April–October 2020), a pilot asymptomatic testing programme was implemented at the same institution with a high reported acceptability of SARS-CoV-2 asymptomatic testing and logistics (virus—swab and saliva; antibody—finger prick), and a high willingness to engage in future testing (94.9%) [4]. Self-reported adherence to weekly virus testing in this pilot delivery was high (92.4% completed ≥6 tests; 70.8% submitted all 10 swabs; 89.2% completed ≥1 saliva sample) and 76.9% submitted ≥3 blood samples [4]. Although there was a paucity of evaluations, high uptake of asymptomatic testing was also demonstrated at another UK institution [3,14].

However, at our institution, at the start of the Autumn term, there was a wide-scale deployment of local asymptomatic testing in residential student halls with much lower uptake than was found in the pilot service. Uptake amongst students first offered an asymptomatic test in residence-based deployments was 13% up to the end of October. During October there was a marked decrease in testing uptake, beginning at 58% in the first deployment in early October and decreasing to as low as 5% in a late-October deployment. Concurrently during this time there were around 2000 self-reports of positive SARS-CoV-2 tests in students, the majority of which were associated with symptomatic infection. A significant minority of these reports were associated with students following advice to seek confirmatory UK National Health Service (NHS) community testing, in response to a positive test identified through the University's asymptomatic testing service. The institution had one of the highest reported rates of COVID-19 in the country at that time [15], although it was anticipated that the asymptomatic testing programme would identify cases earlier and more quickly as it rolled out through the term and detected positive cases that might have otherwise remained undetected. The testing service was intended to reduce asymptomatic transmission and the number of future cases. Nevertheless, the impact of COVID-19 on social isolation at our institution was dramatic during this time, with many more students reporting entering isolation than reporting positive tests. Despite publication of isolation numbers being uncommon, the total number of people self-isolating across 45 universities with positive cases reported to be above 3540 within just 9 weeks [16], suggesting that this was a common experience across UK universities. The overall aim of the study was therefore to explore university students' perceptions and experiences of SARS-CoV-2 asymptomatic testing and strategies for mitigation (social distancing) and containment (self-isolation) in a higher education setting. The findings provide insight into students' barriers to testing uptake and adherence to social restrictions, contribute to a wider debate around mass testing approaches in a pandemic [17–20], and the impact of mitigation and containment strategies on young people's social behaviours and wellbeing.

### **2. Methods**

#### *2.1. Study Design*

This was a qualitative focus group study involving four online focus groups with a total of 25 participants undertaken in a two-week period, during October 2020. The study design adhered to the consolidated criteria for reporting qualitative studies (COREQ) guidelines [21] (Supplementary File S2). The research protocol was approved by the University of Nottingham Faculty of Medicine and Health Sciences Research Ethics Committee (Ref: FMHS 76-0920).

### *2.2. Study Context*

During this time, England was subject to national coronavirus restrictions. The participating university was in a region categorised as 'tier 2 high alert', during which government restrictions prevented people from meeting indoors with individuals or groups from outside of their household or support bubble. At this time, people were advised that no households should mix indoors or in groups of more than 6 outdoors with social distancing, remote working (and studying), other restrictions on travel, facilities, and services (Supplementary File S1). Students had to contend with abrupt changes in the way that education was delivered, the risks of COVID-19 more broadly, significant reductions in social contact, and separation from friends and family due to social distancing measures. Large numbers of students had to adapt to confinement strategies in residential education

settings, including shared student accommodation and houses in multiple occupation. Due to increasing numbers of positive cases locally and nationally, many students were required to self-isolate during this time, which meant staying in their home or place of residence and not going outside for any reason, including not travelling to a different place of residence. At the time of data collection, a mass asymptomatic SARS-CoV-2 testing programme was underway at the participating university [4], with testing deployments taking place in a small number of university halls of residence, with plans for a rapid roll out of testing to all university staff and students being developed.

#### *2.3. Participants, Sampling, and Recruitment*

Participants were university students recruited from a single higher education institution via an established cohort study of students living on and off campus [22]. Purposive sampling was used to provide a diverse range of ages, genders, living circumstances (on/off campus), SARS-CoV-2 testing, and self-isolation experiences (Table 1 and Supplementary File S3). Students required to self-isolate were those that tested positive for SARS-CoV-2, lived with someone who had symptoms or had tested positive, or were identified as a contact of someone who had tested positive by the NHS 'Test and Trace'. Of the 25 students in the sample, 12 were tested, of which 11 were symptomatic and one was asymptomatic. All participants were currently residing in the UK and gave informed consent online to be approached for interview via Jisc Online Surveys, and additional verbal consent was provided and audio-recorded prior to the start of the focus group. Recruitment continued until achievement of maximum variation sampling, in terms of the pre-specified interviewee characteristics. The 2-week data collection period allowed for rapid data analysis so that findings of the study could feed into university COVID-19 strategy around mass testing and student support. Students were not compensated for their participation. Online data collection was necessary due to social isolation policy. However, online focus groups are commonly used in health research to capitalise on group interaction in diverse and geographically dispersed participants, to collect rich responses to questions posed in a cost saving and convenient way [23].


**Table 1.** Characteristics of participants.

Note: † International student; <sup>a</sup> Not tested for SARS-CoV-2, Tested Asymptomatic (University Asymptomatic Testing Service), Tested Symptomatic (NHS Symptomatic Community Testing); <sup>b</sup> Self-isolated for any reason.

### *2.4. Online Focus Groups*

Students took part in one of four focus groups (*n* = 3–11 in each group) held online using video-conferencing facilities. The focus groups lasted for 58 to 70 min (mean = 64 min). Two psychologists (H.B./H.K.) generated the question guide, moderated the focus groups and analysed the data. We used a semi-structured question guide focused on the research outcomes of several studies [4,22,24], to cover the main topics related to the outcomes of the study. A draft topic guide was developed by the same two psychologists (H.B./H.K.). To judge the relevance of the topics and the possible emotional impact on students, the topic guide was discussed with experts who had expertise in mass SARS-CoV-2 testing (*n* = 2), psychology (*n* = 2), university operations (*n* = 2), student wellbeing (*n* = 3) and student members of a Patient and Public Involvement and Engagement (PPIE) group (*n* = 2). Following feedback, the draft topic guide was pilot tested for comprehensibility and level of burden with two students who were not participants in the study, which resulted in minor amendments to question wording. Both moderators were trained in qualitative research and interview skills and were not involved in delivery of the asymptomatic SARS-CoV-2 testing programme. Focus groups were conducted according to recommendations from NHS England's focus group guide [25]. A funnel approach was used with broader, generic questions at the outset (e.g., introductions), leading to more directed questioning (e.g., views on specific issues). The purpose was to build rapport within the group and ensure there was enough 'lead-in' time for participants to feel comfortable about contributing to the discussion. Due to the nature of the discussion, and the timing of data collection amidst a surge in the pandemic, it was not deemed appropriate to require all students to respond to every question, although every effort was made to encourage participation within the group. All focus groups followed the same questioning route (Supplementary File S4), were audio-recorded and transcribed verbatim. Participants are referred to as new students (first year students beginning their studies in the Autumn term) and returning students (those resuming their studies in the Autumn term following a summer break).

#### *2.5. Data Analysis*

The audio recordings were professionally transcribed. Two experienced researchers independently familiarised themselves with the data (H.K./H.B.). We performed inductive thematic analysis [26]. Data were examined for patterns and recurrent instances, which were then systematically identified across the dataset. Due to the rapidity of the study, one researcher (H.K.) coded all focus groups transcripts using open coding [27] into codes and subcodes. To ensure reliability of data interpretations, two researchers (H.K./H.B.) then independently read the emerging codes and supporting quotations to enhance the accountability of the analysis [26]. Codes were individually and critically examined by both researchers, and the overlapping codes and subcodes were further refined and grouped together. Codes and subcodes with similar characteristics were then grouped into meaningful overarching themes that emerged organically from the data. Themes, codes and subcodes were confirmed by two student participants. Given the aim of the study, the sample specificity, the rich dataset, in-depth insights into the phenomena of interest and the analysis approach adopted, the qualitative sample was deemed to have sufficient information power [28].

#### **3. Results**

Six themes emerged from the analysis of the qualitative data from the focus groups— 'Term-time Experiences', 'Risk Perception and Worry', 'Engagement in Protective Behaviours', 'Openness to Testing', 'Barriers to Testing', and 'General Wellbeing'. A thematic map illustrating the relationships between the key themes and subthemes is provided in Supplementary File S5. Table 2 shows the list of all key themes and subthemes and the representative quotes, together with the frequency (and %) of students contributing independent statements of agreement within each subtheme.


**Table 2.** Examples of key themes, subthemes, frequency and their representative quotes.

Participant 5


**Table 2.** *Cont.*


\* Number of participants who contributed independent statements towards each theme. These figures do not reflect contextual or behavioural factors, such as nodding in agreement or participant agreement with the statements provided by others. PPE = personal protective equipment; and NHS = UK National Health Service.

#### **4. Discussion**

This study explored university students' perceptions and experiences of university life during COVID-19, SARS-CoV-2 mass testing, and strategies for mitigation (social distancing) and containment (self-isolation) of the virus, during the second surge of the COVID-19 pandemic in the UK, with six emerging themes. Theme 1 ('Term-time Experiences') highlights the impacts of COVID-19 on practical issues surrounding students' daily life and academic studies, alongside university approaches to protect and safeguard. Themes 2 and 3 ('Risk Perception and Worry'; 'Engagement in Protective Behaviours') demonstrate the individual and structural drivers of students' engagement with social behaviours that protect against virus transmission. Themes 4 and 5 ('Openness to Testing', 'Barriers to Testing') highlight students' openness to mass asymptomatic testing alongside the barriers and enablers of testing and its consequences. Theme 6 ('General Wellbeing') highlights the broader impacts of the pandemic on social and mental wellbeing, which are core concepts interwoven within Themes 1–6.

#### *4.1. Impacts on University Life during a Pandemic*

We found that COVID-19 impacted significantly on student experience of university life. It is clear that students in university-managed accommodation experienced some practical complications in accessing basic supplies at the start of the term, and although these issues likely contributed to student anxiety, they were temporary and quickly resolved at a local level. Nevertheless, there were students for whom access to food and basic supplies was likely to be more challenging during this time (e.g., students living offcampus in privately owned accommodation, particularly international students arriving to the UK for the first time). These groups might be at particular risk since food insecurity (worry about how, and where, to access food) was identified in 35% of students during COVID-19 lockdown, and students' living arrangements during the pandemic was found to be the strongest predictor of food insecurity [29].

The University's approach to safeguarding students while managing the continuation of studies was well received, although the pandemic had dramatically impacted the social aspects of learning and university life. Many students reported that the university had provided sufficient cleaning equipment and safety measures to make students feel comfortable on campus. This applied across different campus settings, including accommodation, libraries, lecture halls and gym facilities. Although perceptions of safety on campus were high, some felt that the safe-guarding measures negatively impacted the broader student experience. In particular, individuals undertaking laboratory-based research reported that their studies were heavily impacted by university-wide safe-guarding building closures. To some, the safe-guarding processes surrounding self-isolation in halls of residence were viewed to be particularly restrictive. However, this was mitigated by regular communications from university staff that improved students' experience of university life, and appeared to enhance students' feelings of connectedness, particularly during periods of social isolation.

The crisis-response migration of universities to online education early in the pandemic was essential and enabled the continuation of education in universities at that time [30] but the transition was not without its impacts. Impacts on studies were particularly notable at the start of the Autumn term alongside efforts to shift to online teaching and learning, and to mobilize mitigation and containment strategies in a short period. Students endorsed varying levels of adjustment to learning online. Many students described adapting well to online functioning, noting that the course conveners had also adapted well to this shift, and consequently, their education did not suffer. Some students enjoyed the novelty of self-guided learning. However, multiple students found this format to be disorganized at the outset, with classes cancelled or rescheduled at the last minute at the start of the Autumn term. The transition to unfamiliar online learning environments was particularly challenging for new students who had not yet established their friendship groups and international students for whom English was not their native language. It was also noted that the move to online learning resulted in the loss of potential networking opportunities that might have arisen through the course if it were delivered face-to-face. The immediate challenges for higher education institutions were apparent, with regards to access to technical infrastructure, pedagogies for distance learning, competences (of students and staff), and managing the requirements of specific fields of study (e.g., hands-on learning requirements, field work, assessments) [31]. This rapid transition to online teaching and learning might precipitate enhanced teaching and learning opportunities in the future [32], by increasing opportunities for flexible learning approaches [31]. However, the requirement to adapt at speed to unfamiliar online e-learning approaches in the context of the pandemic is challenging for some.

For students in our study, many had adapted well to online learning, despite the early hitches of the transition period. While students generally felt that the university had appropriately managed safeguarding, the combined impact of safeguarding and the transition to online learning had limited opportunities for important social contact. Students who seemed to fare better were those who had received more regular contacts from university staff during the pandemic, and particularly through periods of self-isolation. As a result, universities should act on generating opportunities for social support and networking, which could be delivered through academic departments, sports, wellbeing facilities, clubs and societies.

#### *4.2. Risk Perceptions, Adherence and Social Behaviours*

With regards COVID-19 mitigation, students in our study were highly conscious of the risks of COVID-19, although many who considered themselves to be in good health were more concerned with the asymptomatic spread of COVID-19 to others than the risk of contracting the virus themselves. Previous experience with COVID-19 also heightened students' fears about the impact of the virus on others, particularly those in vulnerable groups (e.g., older relatives). However, those with a pre-existing health condition they felt put them at increased risk, conveyed a strong concern about the potential impact of contracting COVID-19 themselves. Students with pre-existing health conditions described concern about going into public settings for fear that others might put them at risk.

In our sample, there were two factors that were perceived to reduce compliance with social distancing in a minority of students and this did not seem to be related to risk perception, but more to the environment and desire for social contact. First, some of the residences and educational buildings had narrow corridors and 'bottlenecks', preventing the 2-m distancing between people that is required by UK government restrictions, which was seen to present an environmental constraint. Second, some students had an overwhelming desire to socialize that meant they were non-compliant with peers, despite adhering to social distancing in other contexts (with strangers). However, students perceived that only a small minority of the general student body were non-adherent to social distancing.

Although some improvement occurred over time, levels of adherence to test, trace, and isolate are low in the UK [10]. Our participants suggested that adherence to self-isolation might be more likely in students who experienced COVID-19 symptoms than in those who were self-isolating for other reasons. This might be due to greater perceptions of risk and disease severity in those who had personal experience of COVID-19 (e.g., [22]), and that people with high risk perception around infectious diseases tend to take preventive behaviour [33]. However, risk perceptions can only partially explain this, since adherence to self-isolation in young people is strongly related to structural vulnerabilities and availability of resources (e.g., social support with food access and caregiving responsibilities, financial hardship, and space in living accommodation) [34].

Students' concerns about passing on COVID-19 to vulnerable loved ones indicates that adherence of university students to COVID-19 protective behaviours might be associated with a sense of social responsibility, and this was also identified in other populations of young people [35,36]. Although adherence to social distancing and protective behaviours was found to be lower in younger adults than other age groups [37], students in our study reported adhering to protective behaviours and observing compliance across the university more broadly. Nonetheless, they reported seeing or hearing that a minority of students were non-compliant with social distancing behaviours or self-isolation. This echoes data from the UK Office for National Statistics (ONS) Student Covid Insights Survey (SCIS) [38], which found that that 9 out of 10 university students reported complying with social distancing around the time of the study and were more likely to avoid leaving their accommodation completely than the general public, although the non-adherent minority were more likely to be from younger age groups [11].

Some studies indicated that non-compliance with public health advice during COVID-19 is associated with weaker feelings of moral obligation, low trust in authorities and individual characteristics related to antisocial potential [39]. Alternatively, it might be that non-compliant students simply perceive being around their peers, particularly in a campus environment and shared living accommodation, to be low risk, due to their familiarity with each other, and so the concept of social responsibility might feel less relevant to some individuals in this context. This could partially explain the high prevalence of COVID-19 outbreaks on university campuses across the UK.

Higher education providers are encouraged by the government to consider incentives for compliance, and disincentives for non-compliance including, in serious cases, the use of disciplinary measures [40]. For those willingly or repeatedly breaching University or Government guidance, policies, or laws in relation to COVID-19, there might, for example, be disciplinary investigations, fines, temporary or permanent withdrawal of students from university activities or a course of study, or referral to Police, Public Health, or Border Agencies. Nevertheless, a deeper understanding of the structural, psychological and social barriers to adherence might help reduce the occurrence of regulation breaches and noncompliance. Overall, social interaction is an integral part of students' lives. Universities and colleges should consider the social impact of protective behaviours and offer social outlets for students when appropriate (e.g., providing opportunity for monitored socializing outdoors when it is safe to do so). Given the highlighted structural difficulties some students experienced with their accommodation providers, the university should set out clear guidance for both students and providers on practical, social, and emotional supports for students, on return to campus following national lockdown and during periods of self-isolation. These strategies might improve adherence to self-isolation and reduce fear of self-isolation, which might equally enhance uptake of testing.

#### 4.2.1. Communications and Social Behaviours

Our study suggests that students on the whole are predominantly adherent to protective behaviours, but reduced compliance with social distancing and self-isolation guidance was also associated with perceived inadequacies in university communications at the time of the study, which were not always seen to be timely. Students reported that they were most likely to comply with guidance if it was presented in a simple format, supported by elucidation of the reasons behind the guidance. Students noted that communications from both the government and university were text heavy, and difficult to read and comprehend, particularly for international students. Students thought communications could be improved through the use of infographics rather than text. Multiple students reported that

university communications were also relatively slow, meaning that students had already engaged in activities that could have caused spread of virus (e.g., use of communal space). Some students also reported finding it difficult to follow guidance, as a result of gaps in the government and university information pertinent to them.

However, students in this study recognized the challenges associated with communicating with large numbers of people in frequently changing national and global circumstances. Similarly, previous research conducted at the same institution found that most student participants were largely satisfied with university communications, with dissatisfaction expressed by a minority that was specifically related to an early approach to communicating negative test results at this institution, which was subsequently changed in response to student preference [4].

Government guidance emphasized that higher education providers should ensure that the rationale for protective behaviours is understood via clear and consistent messaging, while not assuming that everyone understands official guidelines [40]. We propose that institutional communications around COVID-19 might need to be more accessible and inclusive, since messaging at the time of the study was not universally understood amongst students, and the needs of certain groups (e.g., postgraduate students, international students, off-campus students) were not being met. It is important to consider these findings in the context of a fast moving and uncertain crisis situation, during which institutional COVID-19 strategies had to be developed and operationalized at speed. This required high responsivity to changes in local and national guidelines and procedures, with rapid communication of changes to university staff and students. It was advocated that organisational communications during the COVID-19 crisis should be succinct, to be read and understood [41]. Our findings might highlight a tension between the need for simplicity and readability of communications by the target audience, particularly students for whom English was not their first language. Additionally, the importance of communications (e.g., clarity, inclusion, and timeliness) in maximizing adherence to protective behaviours should not be underestimated. Given the identified link between desire for social contact and adherence to protective behaviours, messaging should emphasize the desirability of adhering to public health protocols, and signpost activities that minimize the boredom of self-isolation and maximize opportunities for social contact and activity engagement (e.g., virtual social interactions, exercise classes) [42].

#### 4.2.2. Communication Approaches

Given the high proportion of young people in universities, COVID-19 information provided to young people should be clear, delivered by a trusted source, should avoid giving visibility to non-adherence, and should promote positive behaviours to enact, rather than avoid negative behaviours [34]. Ideally, messages for students would be co-created with students [43], since it is well-established that young people are often more heavily influenced by their peers than by other age groups and are more likely to heed advice from those in similar age groups. Thus, 'using the young person's voice' to deliver messaging would be helpful to reach higher education students in younger age groups. As 'social influence agents' who support or undermine health-related behaviours [44], peers both model, and influence, healthy and unhealthy behaviours [45]. Therefore, communications could emphasize social norms related to adherence to protective behaviours (e.g., what peers think, what peers do) [34]. Since young people in particular are generally more oriented towards short-term rewards rather than long-term consequences [46], messaging could emphasize the immediate impacts of COVID-19 such as the risks to loved ones, and young people should be thanked for their contribution to reduction of virus transmission. Communications should not just instruct young people on what to do but should include clear guidelines on how to enact protective behaviours (e.g., how to socialize in a COVIDsafe way, how to socially distance in specific situations, and how to engage with peers who are non-adherent) [34].

#### *4.3. Students and COVID Testing*

Our study suggests that students at this institution remained positive towards the availability of local asymptomatic testing for SARS-CoV-2 and generally felt safe on the university campus at the time of the study (high alert, UK second surge) with mass testing in place, and during a time when the national situation had dramatically changed, and cases were rising [1]. With regards to the practicalities of testing, no particular problems were raised relating to any of the testing processes or procedures (NHS symptomatic community test—throat swab; University asymptomatic test—saliva). Some students reported that the throat swab test was uncomfortable, yet prior work suggests that students did not raise this as a barrier to the uptake of testing [4]. Studies in other populations suggest that discomfort was relatively low in both throat and nasal swabs, although nasal swabs were less likely to induce nausea or vomiting [47]. There is little published evidence in this area, although unpublished work suggests that saliva tests are a less intrusive approach with university students as compared to nasal swabs [48]. Testing uptake and self-isolation adherence could be low in education settings (e.g., [36]). Greater student adherence to SARS-CoV-2 asymptomatic testing is associated with their level of satisfaction with university communications [4]. Intrusiveness and convenience of testing procedures should also be considered and balanced alongside test sensitivity, to maximize testing uptake. Overall, our study showed that the availability of testing was seen by students to be an important approach to 'getting control' of the virus, although engagement with testing was more likely to be related to the emotional impacts of self-isolation and its consequences. To maximize uptake of asymptomatic testing, there needs to be significant support in place to manage the impacts of self-isolation on students' social relationships and mental wellbeing. Further, the risk of unintended behavioural consequences of mass testing could not be dismissed, since our findings suggest that for a minority, a negative test result might instill a sense of false security and perceived immunity to COVID-19.

### *4.4. General Wellbeing and Mental Health*

Overall, the long-lasting pandemic situation and associated restrictions have had psychological consequences in the general population [49], with young adults being particularly at risk for mental ill-health [22,24]. Specifically, in university students, mental health concerns were identified globally during the pandemic, with high rates of stress, anxiety, depression, and evidence of clinically relevant post-traumatic stress disorder [4,22,50–52].

Confinement strategies associated with COVID-19 were unavoidable during the COVID-19 pandemic but were shown to impact mental health and exacerbate social inequalities in university students [53]. Our study suggests that mental health plays a key role in students' behavioural decision-making about engagement in protective behaviours, not least as a negative impact of self-isolating (e.g., avoidance of self-isolation to avoid emotional impact). For example, we found that students worried about how they would cope if they had to self-isolate, and experience high anxiety, low mood, and loneliness when self-isolating, coupled with a fear of re-experiencing these negative emotions if they were asked to self-isolate again. They also exhibited a strong sense of guilt if household members had to self-isolate because of them and fear the interpersonal conflict this situation might bring. Participants in our study believed that this might be a factor for young adults in decision-making related to COVID-19 testing, particularly for those who are asymptomatic. Students' emotions seem to override their willingness to engage in COVID-19 testing when they are asymptomatic, due to the risk of self-isolation for themselves and others, despite viewing onsite testing as convenient, and seeing testing as an important national and local strategy for controlling the virus. The same pattern occurs with other protective behaviours, since people socialize to avoid feeling lonely, and loneliness is a barrier to social distancing adherence in adult populations [54]. Further, young adults are more likely to report loneliness during COVID-19 restrictive measures than other age groups [55].

Overall, our findings are consistent with others suggesting that mental health is a key driver in both testing behaviour [4], and adherence to COVID-19 protective behaviours [34]. Further exploration of students' mental health impacts and support needs is warranted.

#### *4.5. Diversity and Inclusion*

Our participants proposed that the mental health impacts of social distancing and self-isolation differed between student groups. These were most notable for newly arriving students who registered at the University in October 2020, during the second surge of COVID-19 in the UK and were living in University accommodation. This was likely to be associated with a lack of social networks; these (primarily) young people had not yet established local support networks, yet social support predicts mental health and quality of life in university students [56].

The disproportionate impact of COVID-19 on young people [10,24], not only highlights a need for targeted communications to younger populations more broadly, but demonstrates the significance of structural barriers in adherence to public health messages, and the potential value of segmenting audiences for messaging to avoid making generalizations about behaviours and circumstances of particular groups [34] (such as university students). For communications in a higher education context, 'one-size-does-not-fit-all' and as we observed, some groups of students might feel forgotten. For example, working students (e.g., often international students, self-funded students, students with caregiving responsibilities) might have experienced a loss of income as a result of the COVID-19 related lockdown restrictions, leading to further worry, spiraling debt, uncertainty about the future, and risk of 'falling through the cracks in the system', all impacting on mental health [57]. The UK government 'COVID-19 Mental Health and Wellbeing Surveillance Report' shows that marginalised or disadvantaged groups might be disproportionally affected by the wider implications of the pandemic [58]. COVID-19 had an impact on equity and inclusion in educational settings, with young people from diverse backgrounds being at greater risk of increased vulnerability and less likely to receive the support and extra services they need [59]. Further research might be needed to explore the experiences and support needs of particular groups known to be at risk for mental health concerns, such as students with financial hardship, LGBTQI+ students, and students with special educational needs.

#### *4.6. Study Strengths*

Whilst vaccination levels at the time of the study were still insufficient to control population-level transmission, mass asymptomatic testing remained a prominent candidate for controlling transmission in educational settings, against the background of significant community prevalence of SARS-CoV-2 infection. Given the discovery of new variants that might be more transmissible [60], and therefore require more efficient control measures (including B.1.1.7), understanding experiences of testing and protective social behaviours in young people in schools, colleges, and universities is particularly relevant. This study sits in the context of a national debate around the implementation of mass asymptomatic testing programmes in schools and universities, which is divisive [18,19,61–65]. England's Department for Education advocates weekly testing in educational settings from January 2021 [66], and despite the potential for transmission from students to other members of the community, there is little evidence of how students interpret and respond to these approaches, and the impacts of mass testing on social behaviour and wellbeing. This study therefore contributes [67] to the wider debate around mass testing and informs mitigation and containment strategies for COVID-19 in educational settings.

Remotely conducted focus group interviews were a suitable approach for exploring commonality and differences in attitudes and experiences of university students, in the context of rapidly changing national policy. Due to the crisis situation, this rapid approach allowed for early sharing of qualitative findings, which was identified as important during complex health emergencies (e.g., Ebola [68]). Early study findings were provided to the Department for Education in England and used in real-time to support institutional efforts to engage students, public health, and behavioural experts in COVID-19 messaging content and approaches to communication with students and staff. Finally, the sample included students who lived in university residences, and those who had tested for SARS-CoV-2, either at the university or via local government public health services.

#### *4.7. Study Limitations and Considerations*

Due to the timescale, we were unable to triangulate findings with all participants, although we confirmed themes with two participants. Students who had taken a test as part of the participating university deployment of asymptomatic testing in university residences were under-represented. Further research is needed to fully ascertain the views and experiences of marginalised groups to ensure supportive services are equitable. While students in our study were willing to express concerns in this focus group setting and talk about other students' behaviour or compliance to COVID-19 restrictions, there might be some reservations about openly discussing any personal breaches of COVID-19 guidelines, especially given that the focus group moderators were University employees. These data relate to the views of students in a higher education setting, which might vary from that of the general public in terms of personal and attitudinal variables [69]. The frequencies presented in Table 2 do not reflect the contextual or behavioural factors that were considered during analysis, such as nonverbal cues (i.e., nodding) or participant agreement with the statements provided by others. Therefore, the number of students agreeing with the statement contributing towards each theme is likely to be underestimated. Finally, it should be noted that data were collected when the participating institution had one of the highest rates of COVID-19 in the country, although by December 2020, this had dropped below the national average for cases per 100,000 population.

### *4.8. Summary and Future Recommendations*

The key findings and recommendations for practice and policy that emerged from our data are presented in Table 3.

**Table 3.** Key points and policy recommendations.

#### **Practical impacts during Autumn return to campus**


#### **Emotional impacts during Autumn return to campus**


• However, students do not feel unsafe being at university during the pandemic.

#### **Risk perceptions**


#### **Engagement in protective behaviours (social distancing, self-isolation)**


#### **Mass asymptomatic testing on campus**


#### **Broader and longer-term impacts of COVID-19**


#### **Recommendations**


#### **5. Conclusions**

Mental health of students is significantly impacted by the COVID-19 pandemic, and social isolation is a key factor in this. Fear of self-isolation is likely to influence uptake of asymptomatic testing and adherence to social restrictions, due to anxiety, guilt and low mood experienced during self-isolation. The adequacy of practical, social and emotional support for students will be paramount to encourage adherence to self-isolation, and ultimately reduce virus transmission in pandemics. Loneliness in students could be mitigated through increased intra-university communications and a focus on establishment of low transmission-risk social activities to help students build and enhance their social support networks. University communications around outbreaks and mental health support need to be timely and inclusive to reach groups of students that currently feel marginalised and are at risk of 'falling through the cracks' in the system. The practical and emotional support needs of students who have to self-isolate during a pandemic need to be determined, and this has relevance for other educational settings globally, particularly those in which mass testing might be implemented. Worldwide, universities need to prepare for the long-term impacts of the pandemic on student mental health and support services.

**Supplementary Materials:** The following are available online at https://www.mdpi.com/article/10 .3390/ijerph18084182/s1. File S1: Tier 2 High Risk Alert National Restrictions; File S2: Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist, File S3: Individual characteristics of participants; File S4: Focus Group Question Guide; and File S5: Thematic map illustrating the relationships between the key themes and subthemes.

**Author Contributions:** Conceptualization, H.B., H.K., and K.V.; data curation, H.K. and H.B.; formal analysis, H.K. and H.B.; funding acquisition, K.V., H.B., and J.C.; investigation, H.B., H.K., and R.J.; methodology, H.B. and H.K.; project administration, H.K.; writing—original draft, H.B. and H.K.; writing—review and editing, K.V., R.J., J.C., J.R.M., C.D., J.K.B., K.B., G.F., D.E.M., P.T., A.M.V., and K.A. All authors have read and agreed to the published version of the manuscript.

**Funding:** The study was funded by the Medical Research Council (Reference: MC\_PC\_20027, Principle Investigator J.B.) and the Institute for Policy and Engagement at the University of Nottingham (QR Duning Award, H.B., J.R.M., and K.V.). J.R.M. receives salary support from a Medical Research Council Clinician Scientist Fellowship [grant number MR/P008348/1]. The sponsors had no involvement in the study design, the collection, analysis, and interpretation of data, or the preparation of the article. The views expressed are those of the authors and not necessarily those of the funders.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Research Ethics Committee of the University of Nottingham Faculty of Medicine and Health Sciences (Ref: FMHS 76-0920).

**Informed Consent Statement:** Informed consent was obtained from all participants involved in the study.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author. The data are not publicly available due to risk of participant identification.

**Acknowledgments:** The authors would like to thank the Track-COVID PPIE group for their review of the questioning guide, and Pamela Pepper for administrative assistance.

**Conflicts of Interest:** All authors were employees of University of Nottingham, the institution at which data were collected. J.C. sits on the Executive Board for UoN; C.D., J.K.B. and P.T. were involved in the delivery of the asymptomatic testing service, but none were involved in data collection or analysis for this research. No other conflicts of interest were declared.

#### **References**

