Abstract
Background:
Mental well-being is important for medical students to perform effectively. The COVID-19 pandemic posed different stressors to medical students increasing their vulnerability to distress and impaired well-being.
Aim:
To assess the effect of the COVID-19 pandemic on the well-being of medical students and its relation with COVID-related psychological distress and fear as well as sleep quality.
Materials and Methods:
We planned a cross-sectional study on medical students with the help of an online Google Form including sociodemographic data, medical students well-being index (MSWBI), Psychological Distress Scale, fear of COVID-19 Scale (FCV-19S), and Pittsburgh Sleep Quality Index (PSQI).
Results:
48.13% of students reported higher distress and impaired mental well-being. Impaired well-being is correlated with COVID-related psychological distress, fear of COVID-19, and disturbed sleep quality. Regression analysis showed that joint family and sleep disturbances significantly predicted distress or poor well-being in medical students.
Conclusion:
Almost half of the medical students revealed impaired mental well-being underlining the role of COVID-related stressors in worsening the psychological health of students. In this situation, it is important to take prompt measures to identify vulnerable students and help them.
Keywords: COVID-related psychological distress, Fear of COVID, Sleep disturbances
The World Health Organization declared COVID-19 a pandemic on March 11, 2020. Having no effective treatment or vaccination and higher mortality associated with it, most of the countries imposed lockdowns to prevent its rapid spread in the community. The COVID-19 pandemic along with its all restrictions and changed lifestyle created many problems like uncertainty about life, deficient hospital resources, job loss, financial difficulties, and even difficulty in the supply of day-to-day needed things. All these things caused an increase in psychological problems in the community as a whole.[1,2] Student population was affected in a major way due to this pandemic. Closing down of colleges and shifting to an online mode of education, no direct interaction with teachers, uncertainty about completing courses and exams, and social media overuse were all major causes of stress to the students increasing psychological problems in the student population.[3,4] Particularly, medical students who are already more vulnerable than their peers in other fields were affected adversely due to changed circumstances in the COVID-19 pandemic. Apart from stressors faced by other students, medical students also faced some extra challenges like helping in patient management which imposed increased risk of infection and halt in practical learning which is a necessary part of medical education.[5,6] All these things had led to increased stress levels in medical students in the pandemic era which has been pointed out by some researchers.[7]
Psychological well-being is a state of mind in which a person can fulfill all needs in psychological domains of life and is able to cope successfully with stress. The concept of well-being goes beyond just the absence of psychological problems like depression or anxiety. Rather well-being is a positive concept rather than a neutral one. Assessment of psychological health in medical students is essential considering their vulnerability to increased levels of stress. However, most available literature in this regard has assessed the psychological health of medical students by measuring their stress, depression, anxiety, or other specific mental health problem, and there is a gap in research regarding well-being evaluation in medical students. Psychological well-being is essential for working efficiently which is important for medical students to learn their medical knowledge and perform clinical work efficiently to manage patients in medical school which is important for their medical practice also in the future. However, increased stress during the COVID-19 pandemic period harmed the well-being of medical students making them vulnerable to other mental health disorders and impairing their performance.[8]
COVID pandemic particularly added up to this psychological distress because of the increased risk of infection, strict social distancing regulations, and other COVID-related changes in lifestyle.[7,9] This increased COVID-related psychological distress and fear of COVID-19 infection had played an important role in the psychological health and well-being of medical students as medical students have to be in hospitals and interact with patients during this vulnerable period. Among many other parameters, sleep quality is one of the important indicators of a person’s psychological health and well-being.[10] Sleep quality is bidirectionally related to psychological well-being. Sleep can be impaired because of increased distress as well as impaired sleep quality due to other reasons that can cause impairment in psychological health. Having extensive academic and clinical learning as well as an increased workload in the pandemic may affect the sleep quality of medical students. So, while considering the well-being of medical students, all these factors have to be taken into account.
In India, the situation of the pandemic was the same including social restrictions, changes in the education system as well as the increased workload on the healthcare system. However, considering differences in the medical education system, and differences in the cultural and social system, a study on Indian medical students was necessary. Hence, the present study was planned to assess the effect of the COVID-19 pandemic on the well-being of medical students and its relation with COVID-related psychological distress and fear as well as sleep quality.
MATERIAL AND METHODS
This cross-sectional observational study was carried out on undergraduate students of a medical college in Western Maharashtra, India. The sample of medical students was selected by convenience sampling. For the study, a specially made online Google Form was distributed through emails and social media among medical students, and students were asked for voluntary participation in the study. All subjects gave written informed consent. The subjects were assured of confidentiality and anonymity of their responses. Approval of the Institutional Ethical Committee was obtained before starting the study (IESC/111/2022 dt 08/08/2022). The proforma made for the study consisted of the following sections.
Sociodemographic information—It included questions regarding age, gender, year of study, relationship status, family type, socioeconomic status, present residence, and background where the participant was brought up.
Medical students well-being index (MSWBI)—MSWBI is a validated instrument for assessing distress in medical students. It consists of seven questions regarding stress, depression, fatigue, burnout, and quality of life in medical students asking them to answer in “No” or “Yes” and rating them 0 or 1 giving a total score ranging from 0 to 7. The higher the score, the greater the distress is.[11]
Psychological distress scale—the scale is used to assess psychological distress in healthy people in COVID-19-affected regions, and it contains 14 items indicating COVID-19-related distress measuring it on two dimensions—anxiety and fear and suspicion about COVID-19 infection. Each response is taken on a five-point Likert scale, scoring 1 to 5 points, respectively. Higher psychological distress is indicated by a higher score.[12]
Fear of COVID-19 scale (FCV-19S)—it is seven-item scale for assessing fear about COVID-19. The respondents have to rate their responses on a five-point Likert scale ranging from “1—Strongly Disagree” to “5—Strongly Agree.”[13]
Pittsburgh Sleep Quality Index (PSQI)—the study used the brief version of PSQI. This scale asks questions to the participants regarding their usual sleep habits in the last month which describes seven components of their sleep. The responses are rated from 0 to 3. Higher the score, more the severity of sleep problems. We considered sleep problems in two dimensions, viz. sleep disturbances and daytime dysfunction.[14]
Statistical analysis
The data were analyzed by SPSS Software (IBM, Atlanta, USA) using both descriptive and inferential statistics. Descriptive statistics were done by data summarization in percentages, mean, range, and standard deviation. Inferential statistics were carried out with the help of the Mann–Whitney U test and Spearman’s correlation. Stepwise multiple regression analysis was done. A P-value of <0.05 was considered significant for all statistical correlations.
RESULTS
Total of 401 students filled up the complete proforma which could be taken up for final analysis. Out of 401 students, 161 (40.15%) were males and 240 (59.85%) were females. The mean age of the students was 21.62 ± 1.36 years (males—21.76 ± 1.41, females—21.52 ± 1.32). Other sociodemographic characteristics of the sample are depicted in Table 1. The scores of MSWBI, Psychological Distress Scale, FCV-19S, and PSQI scored by the total sample population as well as male and female students are shown in Table 2. Using a threshold of ≥4 for MSWBI, 193 (48.13%) of total students including 60 (37.27%) male students and 133 (55.42%) female students showed impaired well-being. Comparison between males and females showed that distress as indicated by MSWBI, fear of COVID-19, and disturbed sleep quality (sleep disturbances P = 0.025, daytime dysfunction P = 0.012) were significantly more in females than males. Table 3 shows the Spearman correlation of different variables. It shows impaired well-being is significantly correlated with joint family, COVID-related psychological distress, fear of COVID-19, and disturbed sleep quality (sleep disturbances and daytime dysfunction). A stepwise multiple regression was run to predict medical students well-being from daytime sleep dysfunction, disturbed sleep quality, and family type. These variables statistically significantly predicted medical students’ well-being, F (3, 397) =40.135, p <.000. Joint family (regression coefficient= -0.159, P < 0.001) and disturbed sleep quality [sleep disturbances (regression coefficient = 0.218, P < 0.001), daytime dysfunction (regression coefficient = 0.280, P < 0.001)] significantly predicted distress or poor well-being in medical students [Table 4].
Table 1.
Demographic variables of the medical students
| Variable | Total sample (n=401) | Female (n=240) | Male (n=161) | t/chi square | P | |
|---|---|---|---|---|---|---|
| Age | Mean (SD) | 21.62 (1.36) | 21.52 (1.32) | 21.76 (1.41) | -1.76 | 0.79 |
| MBBS year | First year | 04 | 04 | 00 | Fishers exact test | 0.309 |
| Second year | 54 | 35 | 19 | |||
| Third year | 193 | 108 | 85 | |||
| Fourth year | 104 | 63 | 41 | |||
| Intern | 44 | 29 | 15 | |||
| Family type | Nuclear | 280 | 183 | 97 | 12.02 | 0.002 |
| Joint | 114 | 53 | 61 | |||
| Broken | 7 | 4 | 3 | |||
| Relationship | Yes | 91 | 53 | 38 | 0.165 | 0.681 |
| No | 310 | 188 | 122 | |||
| Socioeconomic status | Upper | 201 | 124 | 77 | 4.002 | 0.135 |
| Middle | 190 | 113 | 77 | |||
| Lower | 10 | 03 | 07 | |||
Table 2.
Scores on the psychological tests
| Psychological tests | Total | Female | Male | Mann–Whitney U value | P | |
|---|---|---|---|---|---|---|
| MSWBI | Mean | 3.37 | 3.68 | 2.90 | 15509.50 | 0.001 |
| SD | 2.29 | 2.24 | 2.29 | |||
| Median | 3.00 | 3.00 | 4.00 | |||
| PDS | Mean | 34.07 | 34.80 | 32.98 | 17214.50 | 0.064 |
| SD | 10.16 | 9.72 | 10.72 | |||
| Median | 35.00 | 35.00 | 35.00 | |||
| FCV-19S | Mean | 15.01 | 15.53 | 14.25 | 16773.50 | 0.024 |
| SD | 3.69 | 6.19 | 6.23 | |||
| Median | 14.00 | 14.00 | 14.00 | |||
| PSQI (SDS) | Mean | 3.87 | 4.18 | 3.41 | 16790.50 | 0.025 |
| SD | 3.69 | 3.73 | 3.59 | |||
| Median | 3.00 | 3.00 | 3.00 | |||
| PSQI (DDS) | Mean | 1.48 | 1.63 | 1.24 | 16608.50 | 0.012 |
| SD | 1.69 | 1.72 | 1.62 | |||
| Median | 1.00 | 1.00 | 1.00 | |||
MSWBI=medical students well-being index, PDS=Psychological Distress Scale, FCV-19S=fear of COVID-19 scale, PSQI (SDS) = Pittsburgh Sleep Quality Index (sleep disturbance), PSQI (DDS) = Pittsburgh Sleep Quality Index (daytime dysfunction)
Table 3.
Spearman correlation of different variables
| Variable | Family type | MSWBI | PDS | FCV-19S | SDS | DDS |
|---|---|---|---|---|---|---|
| Family Type | 1.000 | -0.188** | -0.014 | -0.003 | -0.009 | -0.093 |
| MSWBI | 1.000 | 0.187** | 0.152** | 0.424** | 0.436** | |
| PDS | 1.000 | 0.694** | 0.329** | 0.243** | ||
| FCV-19S | 1.000 | 0.278** | 0.188** | |||
| SDS | 1.000 | 0.620** | ||||
| DDS | 1.000 |
MSWBI=medical students well-being index, PDS=Psychological Distress Scale, FCV-19S=fear of COVID-19 scale, PSQI (SDS) = Pittsburgh Sleep Quality Index (sleep disturbance), PSQI (DDS) = Pittsburgh Sleep Quality Index (daytime Dysfunction). **significant at P=0.001
Table 4.
Multiple regression analysis for predictors of medical students well-being index: Coefficientsa
| Model | Unstandardized Coefficients |
Standardized Coefficients |
t | Sig | 95.0% Confidence Interval for B |
Collinearity Statistics |
||||
|---|---|---|---|---|---|---|---|---|---|---|
| B | Std Error | Beta | Lower bound | Upper bound | Tolerance | VIF | ||||
| 3 | (Constant) | 3.237 | 0.310 | 10.424 | 0.000 | 2.626 | 3.847 | |||
| PSQI (DDS) | 0.381 | 0.074 | 0.280 | 5.143 | 0.000 | 0.235 | 0.527 | 0.651 | 1.537 | |
| PSQI (SDS) | 0.135 | 0.034 | 0.218 | 4.022 | 0.000 | 0.069 | 0.202 | 0.656 | 1.525 | |
| Family type | -0.756 | 0.211 | -0.159 | -3.588 | 0.000 | -1.170 | -0.342 | 0.990 | 1.010 | |
a. dependent variable: medical students well-being index. VIF=variance inflation factor, PSQI (SDS) = Pittsburgh Sleep Quality Index (sleep disturbance), PSQI (DDS) = Pittsburgh Sleep Quality Index (daytime dysfunction)
DISCUSSION
Psychological well-being is essential for medical students to help them grow into well-balanced physicians who can contribute effectively to the healthcare system. However, considering multiple stressors in medical education evaluation of well-being in medical students is important to identify at-risk students. The COVID-19 pandemic created a special situation for medical students adding up further to their distress. In the present study, we evaluated the well-being of medical students during this COVID-19 pandemic. Using the Medical Student Well-Being Index (MSWBI) threshold of ≥4 showed ≥90% sensitivity and specificity for identifying students with high distress and students with a low mental quality of life or recent suicidal ideation/serious thoughts of dropping out.[15] In our study, 193 (48.13%) students, of whom 60 (37.27%) were male students and 133 (55.42%) female students showed scores above this threshold indicating high levels of distress and impaired psychological well-being in medical students. This increased distress and impaired well-being in medical students during the COVID-19 pandemic have been highlighted by previous research.[16,17]
The COVID-19 pandemic added many additional stressors to medical student’s life. Apart from changes in academics, COVID infection-related fear and distress caused by it have played an important role in the impairment of the psychological well-being of medical students. The findings of our study showed that higher levels of distress and impaired well-being in medical students have a significant association with COVID-19-related distress and fear of COVID-19 emphasizing the role of these stressors in increasing distress levels in medical students. This study has also shown that sleep disturbances in medical students have been associated with high distress and impaired well-being. Sleep disturbances can be associated with psychological problems in many ways. Previous studies done in this regard have concluded that sleep disturbances could be either cause, symptom, or co-morbidity of stress or other psychological problems.[18,19] Impaired well-being has also been found to be associated with joint family. This may be due to differences in culture and a greater number of family members to worry about including vulnerable grandparents.
Looking at the gender difference distress levels or impaired well-being, fear of COVID-19 and sleep disturbances were more common in females as compared to males. Even by other researchers, fear of COVID infection is greater in females than males making them more vulnerable to increased distress.[20] Other researchers have also found that sleep disturbances during COVID-19 were more common in females due to multiple reasons including emotional reactions to the pandemic and feeling more anxious.[21]
Limitations
Our study was a cross-sectional study and did not consider the baseline emotional status of students before the pandemic making it difficult to interpret the exact impact of the pandemic. Another limitation can be the voluntary participation of respondents which can create bias as people with certain psychological states may have participated. Additionally, the study is limited to one medical college and the findings cannot be generalized to other medical students.
CONCLUSION
The study has provided insight into how the COVID-19 pandemic has affected the psychological well-being of medical students. Particularly, COVID-related distress, fear of COVID infection, and sleep disturbances were highlighted as major stressors related to impaired well-being. Almost half of the students were in high distress and impaired well-being. Hence, it is recommended to take prompt measures to screen for vulnerable students and engage them in counseling or other treatments.
Financial support and sponsorship
ICMR STS 2022-11430.
Conflicts of interest
There are no conflicts of interest.
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