Students are having to choose between physical and mental health

Guess what? Traditional halls of residence involving “households” of up to 30 people do not appear to be suitable in a pandemic situation. And so next term we should reduce the density of students living in halls of residence.

When Scotland’s Education Secretary and Deputy First Minister John Swinney made his staggering announcement about the return to campus in January the other day, I complained that despite the Scottish Government repeatedly promising that it would “learn the lessons” from this term, we never seem to be told what they are.

As I said over on Wonk Corner, the accompanying press release to the Swinney announcement merely said that universities and other student accommodation providers are to plan for how best to manage shared accommodation in ways that reduce the risk of transmission between students and between households “drawing on lessons learned from the autumn term”.

When I then suggested that one of the lessons that would be ignored would be that reducing your campus capacity by 70 per cent but keeping your halls at 100 per cent is probably a bad idea, what I didn’t know was that a couple of days later, Scotland’s lead national agency for improving and protecting people’s health and wellbeing would publish a paper that would say exactly that. (Yo) ho hum and all that.

There’s two really helpful publications here. The first is a summary of three strands of work undertaken by Public Health Scotland (PHS) to support decision making around the start of next term. The second describes the experience of students who self-isolated due to Covid-19 while living in term-time accommodation.

They’re a deeply unpleasant read, but I cannot recommend reading them enough if you have any responsibility for students at all in higher education and are keen to understand what this term has felt like for students.

You are my density

Let’s get into this accommodation issue first. In her daily briefing the other day, First Minister Nicola Sturgeon previewed the PHS report by lifting out the finding that almost 3,000 cases have been associated with student accommodation since the summer – almost two thirds of which occurred in a three week period in late September and early October, and more than three quarters of those were in Edinburgh and Glasgow. In fact, she said:

A high proportion … were specifically in Pollock Halls in Edinburgh, and the Murano Halls in Glasgow.”

The good news, we were assured, was that the PHS report would draw out lessons for the next semester – many of which she said were set out to parliament by the deputy first minister the day before – such as increased testing, staggered arrival times for students, and students reducing social contact both before and after traveling. She added:

The report is a reminder – if any of us needed it though – of how hard all of us need to work to reduce the risk of the virus spreading in shared accommodation, and I continue to be grateful to all students who are having their education disrupted in ways that are not fair to them but unfortunately inevitable during a global pandemic. But I am also grateful to universities and colleges for the efforts that everyone has made to help us curb transmission during this very difficult period.

What she didn’t make clear were the conclusions reached by PHS on halls density, the management of “households” within them and quite how the figures had managed to be reduced.

The PHS report shows that specific university halls accounted for a significant number of cases associated with university accommodation settings, and the mean and median age of index cases unsurprisingly suggests first-year students contributed to the majority of cases.

But its analysis of case figures is unequivocal – large outbreaks in student Covid-19 cases at the end of September and the beginning of October were caused by the opening of university accommodation.

A survey of Health Protection Teams (HPTs) in NHS Boards, covering university towns and cities in Scotland, reveals why. Along with types of student social activity, accommodation type in relation to both size and living density was identified as a key factor:

Large corridors of the halls of residence, particularly in “traditional” halls of residence where there are no flats, but rather large numbers of bedrooms on each floor and sharing of kitchen/bathroom facilities… the hypotheses are household transmission, close compact living and cohorting capacity fuelled the transmission of the virus.

And it’s not just size and density. Remember that stuff about identifying household bubbles within halls that we’ve been banging on about on the site almost all year?

Beforehand, the university had thought that by telling students which ‘household’ they were in, they could split each floor into two households. However, there was no meaningful barrier, making this infeasible as an approach.

That of course meant that:

In traditional halls of residence where there are no flats, but rather large numbers of bedrooms on each floor, with people sharing kitchen/bathroom facilities, HPTs in NHS Boards had to define each floor as a household.”

As we predicted, that’s why so many were then told to self isolate. And so:

Traditional halls of residence involving “households” of up to 30 people do not appear to be suitable in a pandemic situation.

What’s hugely frustrating here is how utterly predictable this specific problem was. And as such you’re left asking – if students ended up having to self-isolate for weeks in their full occupancy hotel-style halls because, given the constraints of the pandemic, they had too many people in them and providers didn’t delineate households properly (university and private) – shouldn’t they all be getting a significant rent rebate?

Measures for measures

Elsewhere in the report PHS hedges its bets on whether it was measures taken by universities or students themselves during/after the initial outbreaks that were successful in reducing transmission/number of subsequent outbreaks.

It’s kind of a moot point – clearly universities will have asked students to reduce social contact in halls, self-isolate and stick to their household bubbles – and students will have complied. But later in the report we’re reminded of the mental health costs that students incurred by doing so:

65% of respondents indicated that their wellbeing and mental health had worsened since starting in the autumn term of 2020: 33% said it was ‘slightly worse’, 32% said it was ‘much worse’. Students are significantly more anxious than the general population of Great Britain (6.5 compared with 4.3, respectively), where 0 is ‘not anxious at all’ and 10 is ‘completely anxious’.

You get the distinct impression that when it comes to those two balloons we were talking about ages ago, students started the term looking after their mental health by socialising, but then had to sacrifice it for physical health by isolating.

It’s a miserable set of choices – and raises a crucial question about whether mental and physical health are actually simultaneously achievable for first year students in hotel-style halls during a pandemic. It doesn’t look like it.

Before the sector is tempted to congratulate itself at reducing infection rates, it should remember who has sacrificed what to get there – and what it will be asking students to do next term to maintain the situation.

You can do better

Looking to Christmas and January, the report includes a set of improvements based on interviews with students and looks at their experience of self-isolation in terms of the communication they received, their access to practical support and their suggestions for change going forward.

Students ask that those who have to remain in halls (especially international students) are adequately catered for both practically and socially. They ask that those running halls are clearer on what constitutes a household and that consideration is given to whether a household should have a maximum number of students and the accommodation arranged accordingly.

They ask for increased and better mental health support, including a proactive and personal approach from the university to students required to self-isolate rather than hotlines and helplines. And – making the experience of being an isolating student sound almost exactly like prison – they ask for practical support like “the provision of a period of exercise outside for isolating students”.

They ask for alternative accommodation for students who test positive where they can mix with other students, have exercise and their health can be regularly checked. They ask for services that check regularly on isolating students and who phone or actually see people in person, even if at a distance wearing personal protective equipment.

They ask that universities consider forming a unit which coordinates all Covid-19 interventions and communicates with staff and students so they don’t get constant mixed messages. They ask that universities to have a consistent approach to student discipline throughout Scotland with regard to breach of guidance. They ask that sanctions are used carefully, and only threaten to expel students in the most extreme cases. 

And they ask that there be an understanding by the further/higher education sector and policy-makers that students have different issues and needs than other parts of the population, for example, in relation to household definition and accommodation design.

They ask, in other words, for things that it’s astonishing somehow weren’t predicted, provided or promised without interventions like this.

Empathy

If all of the above feels like a sobering read, then you’ll need a sit down for the other report. Its intro says that as well as looking at the epidemiology and lessons from international practice, Public Health Scotland (PHS) decided it was also important to hear from students themselves about what their experience of self-isolation had been – and if they had any suggestions for how to return home safely. Refreshing.

The caveat of course is that the students involved were self-selecting, having responded to a call for their views and so PHS reminds us that they cannot be seen as representative of the student body in any way, and the findings therefore are not generalisable and only represent the views of these particular students at this particular time. But they’re still powerful.

Although students had been told to remain in their rooms as much as possible, some decided to isolate as a flat so that they could mix – sensibly prioritising their mental health over attendance at face to face teaching:

Some of us were told we could go out on the 5th and then the latest was the 10th. So we all decided, we’re all going out on the 10th. That’s a collective date. So we didn’t need to stagger the kitchen times or avoid the toilets or anything.

Some students developed symptoms and found that getting to testing centres could be problematic if they did not have their own transport. Some students found it hard to obtain tests at all – so their isolation period lasted beyond the 10 days from when they started showing symptoms, as the 10 days was counted from the date of the positive test. Some students were not clear who they should inform if they were isolating.

One student was on a corridor of 18 people and had had several periods of self-isolation because other students kept testing positive. Some students were aware that the combination of large households and a student lifestyle that involved a lot of socialising within that household would inevitably lead to increased infections. Others:

…lived alone, which meant there were fewer problems with isolating from other members of the household but could lead to issues of loneliness.”

The bottom end of Maslow

I honestly never thought I’d read an official report into higher education where the opening of a section would say:

Access to food while self-isolating was a concern expressed by many of the students.

Some found that the food was not enough (it was often only delivered once a day). Some described how the communal kitchens were closed off so students could not make hot drinks (they are not allowed kettles, etc. in their rooms) and the result was:

You were hungry by the evening again, by the time you were going to sleep”

Some in catered halls who were not self-isolating also described having to collect their food and eat it in their rooms alone, and sometimes having to queue in a socially distanced manner for up to 25 minutes to collect the food.

Several of the students spoke about the issue of having to stay in what was often a small room and not being able to access any fresh air or exercise. And in the initial quarantining period, some students said that they had been told they must not mix with other members of their household, if possible – which led to them doing things such as texting each other when they needed to use the toilet to check it was vacant.

This is a particularly grim quote:

I am a foreigner. I arrived mid-September. So I enter my apartment and I was supposed to stay there 2 weeks. The problem is I don’t know anyone, so how to get food and I was living alone, so I think, you know, this is easy. I’ve moved a lot in my life in different countries, but this time it was really hard because you need to be able to order on Tesco or whatever. You need to have a phone number, you need to receive a SIM card, how do you buy it when you’re actually, you know, self-isolating? So it was hard to get food … I couldn’t open a bank account.”

As is this:

I came here two weeks before the semester … my contract actually specified that I’d get mental health support in the form of constant communication and phone calls from a dedicated mental health expert … I received one automatically generated email at 12 days in, but that’s about all I got … And in an empty building, two weeks before semester starts, it’s lonely. There was no one here. I’m in a spot in the building where I can see all the other rooms in my building and it’s just empty. And so I’m sitting here, I don’t have work to do because my courses haven’t started, and I’m just here in an empty building. I don’t have food and I don’t have mental health support.”

Health? Well, the fear of repeat self-isolation for some students was such that they mentioned self-harm in one of the interviews. From other interviews it was clear that this fear has meant that the system is in danger of breaking down completely:

I’ve heard anecdotally from people, that people are showing symptoms and they’re not getting tested, because they’re done with isolation, they don’t think they can mentally do it again, which is a scary thought really.’

And I know it’s vital for protection and stuff, but [name] could be in the trap of self-isolating until January, February, and it’s not nice. I mean I went through it for 10 days, and I would never do it again, ever.

Maybe that’s why that ONS data suggests that more students have had Covid than we thought.

Teaching and learning

The good news is that some students described how self-isolation had given them the chance to catch up on work and meet deadlines. But not everyone had a positive experience.

Some students said they did not feel they were properly set up for studying and needed in-person support for, for example, ensuring their IT equipment was properly set up. Some students (particularly those undertaking practical courses) understood the need for online learning but felt that they were being disadvantaged and had concerns about the potential impact on their grades and progression, causing significant stress.

Others faced access issues:

For somebody like me, I lipread, I can see all of you but when you get into a tutorial and there’s nearly 80 people in it, it was hopeless.

The duty in the Equalities Act is anticipatory. But that need was certainly not anticipated.

Some students made the point that isolation and having Covid-19 can affect academic performance but there did not seem to be a consistent approach to accounting for this in the grading system. Finding out that different universities and colleges had different policies around self-isolation meant that some students felt hard done by. And disparities were present inside universities too – while some students had been contacted by their supervisors and/or personal tutors while isolating, others had not.

The lack of employment opportunities as a result of the pandemic was also a source of concern for students. Some felt that the risk of having to self-isolate (because employers assumed all students behaved in a manner that meant self-isolation was inevitable) meant that they were struggling to find work.

The frame game

With all of this going on, you’d think the comms to students would be empathetic. Maybe not.

Much of the communication that came from the university, after telling them you’re self-isolating, was very much, like, it was twisted in a way, like this is your fault that you’re in isolation, and when you come out of isolation, and you’re breaking guidelines, we will find you, we are coming after you.”

Some students also felt that the communication they had received implied they were a burden to the university and some were very critical of the language that had been used to them in emails or on public forums such as Facebook.

It goes on. The increasing feeling of being under surveillance was not always welcome and students said they disliked the increasingly widespread use of CCTV and the system of fines. Students said they had not been able to plan for Christmas because of the uncertainty around what would be allowed. As speculation mounted, so did the anxiety – students said being asked to isolate for two weeks before being allowed home wouldn’t work as their mental health would not withstand it.

As in the other paper, there’s then a set of recommendations from students themselves. And again, they’re striking not so much for their ambition but for their modesty. They include:

• Make sure that those who were unable to return home over Christmas have somewhere to go.
• Develop a network of people who are staying over Christmas and allowing them to form bubbles so they can physically mix.
• Recognise that not all students have parents and homes to go to so allowing them to choose another home, for example, a friend’s home, where they are allowed to join the household temporarily.
• Reduce the capacity of halls of residence to 80% or below.
• Encourage lecturers and/or tutors to reach out to students.
• Increased and better mental health support, including a proactive approach from the university or college to students required to self-isolate rather than just a link to a website or receiving a generic email.
• Ensure food boxes are tailored to dietary needs, for example, gluten free, and that they contain nutritionally balanced food including fruit and vegetables.
• Ensure that students in isolation have a time and place they can exercise outside their accommodation in the fresh air.

There’s lots, lots more “lived experience” in the report itself that it’s worth reflecting on – and at some stage it will be important to try to work out why so much of this sort of stuff came as such a surprise.

I owe you

So students didn’t cause the second wave and infection rates are down. But let’s not celebrate yet. As PHS makes clear, to get there, students paid for that physical health with major deteriorations to their mental health. They behaved. We owe them.

But for now the important thing is that we get sorted for what’s coming next. I’ve not seen a lot of science that suggests that staggering people’s arrival will solve the halls occupancy issue, the households issue, the mental health issue or the food issue.

But it is a pretty good bet that packing students into halls again (adding in some international arrivals) will result either in the same viral transmission problems or the same social isolation problems that we’ve seen this term – and probably both.

As universities around the UK deliberately cock half a snook at guidance on staggering students’ return to avoid rent rebate calls, they ought to foresee that thousands of students arriving back into halls and HMOs for New Year’s Eve will be highly viral in lots of senses of the word – and deadly if lateral flow testing doesn’t start until a week or so later.

And then later in January, must we really go through the same grim cycle of students starting the term by looking after their mental health by socialising, but then having to sacrifice it for physical health by isolating – when we could just pay their rent for a few weeks instead, and let them organise some safe face to face activity on campus when they’re back?