Assessment of the Attitude, Anxiety Episodes and Perceived Psychological Impact of the Pandemic on Medical Undergraduate Students – a Retrospective Study

Abstract

Background: The COVID-19 pandemic has caused widespread public concern and stress, particularly among medical undergraduates, who faced heightened anxiety due to the uncertainty of the disease resurgence. This study aimed to assess the knowledge, attitudes, anxiety experiences and perceived mental healthcare needs of undergraduate medical students in India through an online multicentric survey.

Methods: A semi-structured pilot-tested questionnaire was administered online via Google Forms and distributed through social media platforms. The survey was carried out over a period of three months during the pandemic (2020-2021). Students were given five days to respond and incomplete or late submissions were excluded. Data were collected and analyzed using MS Excel and appropriate statistical tests, with a significance level of 0.05.

Results: Out of all respondents to the survey, 55.3% reported frequently thinking about the pandemic, while 5.9% were always paranoid about infection. Social contact avoidance was common, with 40.5% of respondents always avoiding contact and 36.3% avoiding large gatherings. Sleep disturbances were reported by 16.9% occasionally and 3.8% regularly. Social media posts about COVID-19 affected 56.1% of participants. Notably, 62.4% expressed a desire to discuss pandemic-related worries and 85.2% acknowledged the need for mental health support during periods of heightened panic. Most respondents (86.5%) agreed that mental health professionals should assist in managing pandemic-related stress.

Conclusion: The study highlights significant psychological impacts of COVID-19 on medical students, with emphasizing the need for targeted mental health interventions. Raising awareness and providing accessible mental health resources are crucial to addressing their needs, particularly as the threat of new COVID-19 variants persists. Studying mental health impacts across diverse populations will aid in planning effective strategies for broader pandemic-related mental health challenges.

Keywords::Covid-19, pandemic, anxiety, mental health, medical undergraduates.

INTRODUCTION

Pandemic-like situations due to any unknown pathogens always tend to have devastating effects on human beings (1-4), especially on the healthcare professionals and medical students who study about the pathogenesis. Thinking about such situations every time takes a toll on their mental health. Very recently, we came across such a highly contagious pandemic. Although a number of years passed after its emergence, most of us are still clueless about its emergence, spread, treatment and mortality rate. Altogether, such unprecedented situations cause confusion, anxiety and fear to variable extents among undergraduate medical students. Recent evidence suggests that individuals in the form of anxiety, anger, confusion and post-traumatic stress symptoms (5). Hence, it is important to study these domains amongst undergraduate medical students. Mental health issues are also major health concerns, which are expected to increase day by day during this epidemic. There is a paucity of research that evaluates the mental health concerns during such pandemic. Considering the relevance of all the above-mentioned factors, the present study was aimed to evaluate the knowledge, attitude, anxiety and perceived mental healthcare needs amongst medical undergraduates towards pandemic-like situations.

MATERIALS AND METHODS

This was a cross-sectional observational multicentric retrospective study. The survey was carried out over a period of three months during the pandemic (2020-2021). So, known faculties of various medical colleges throughout India were randomly approached to encourage their undergraduates to participate in our survey. The study population comprised undergraduate medical students in India who were willing to participate in the survey and submit their responses within the stipulated time. Participation in the study was voluntary. Undergraduate medical students throughout India aged 18 years and above, who could understand English, were willing to give their consent and had internet access were all included.

Assessment tools

An online semi-structured questionnaire was developed by using Google forms, with a consent form appended to it. The questionnaire was in English and include simpler terms, so that students found it easy to comprehend and respond to (8). The link of the questionnaire was sent to all investigators’ contacts through emails, WhatsApp and other social media. Participants were encouraged to roll out the survey to as many people as possible. Thus, the link was forwarded to people apart from the first point of contact and so on. On receiving and clicking the link, the participants got directly into the information about the study and informed consent. After accepting to take the survey, they had to fill up the demographic details. Then, participants had to answer a set of several questions that appeared sequentially. Data were collected for five days after that the link was automatically closed. Perceived stress scale (PSS), a classic stress assessment instrument, was used to precisely measure the level of stress. The tool, while originally developed in 1983, remains a popular choice for helping us understand how different situations affect our feelings and perceived stress. Individual scores on the PSS can range from 0 to 40 (0-13 low stress; 14-26 moderate stress and 27-40 high perceived stress), with higher scores indicating higher perceived stress.

The patient health questionnaire (PHQ-9) was used to evaluate depression or negative psychological impact, with scores between 0-5 indicating mild symptoms, 6-10 moderate symptoms, 11-15 moderately severe symptoms, 16-20 severe depression. In addition, the generalised anxiety disorder questionnaire (GAD-7) was used for anxiety, with scores between 0-5 in- dicating mild anxiety, 6-10 moderate anxiety, 11-15 moderately severe anxiety and 15-21 severe anxiety.

Statistical analysis

Descriptive statistics was used to analyze the data. Chi-Square Test was used to compare categorical data, such as the difference in anxiety episodes between male and female students. Pearson’s or Spearman’s correlation analysis was used to assess any possible association between anxiety levels and perceived psychological impact.

RESULTS

Medical undergraduates throughout the country participated in the present study. A total number of 237 responses were recorded over a period of three months (June 2021-August 2021). Out of the 237 participants, 135 were males and 132 females. Incomplete responses were not considered for further statistical analysis. Among respondents, 72.2% lived in urban regions and an equal percentage of 13.9% were from suburban and rural populations.

When asked about how often they thought about covid, 36.3% of subjects answered that they were often thinking about it, while 19% answered they were always thinking about it (Figure 1).

When asked about getting paranoid about pandemic, only 5.9% of students were always paranoid about getting infected. To keep themselves protected from being infected, 40.5% of respondents always avoided social contact, while 36.3% always avoided large social gatherings.

The majority (56.1%) of the respondents often felt affected by the posts on social media, newspapers or news channels about coronavirus disease and 42.6% of them occasionally felt freaked out by such posts. Moreover, the majority (76.8%) of them had often or occasionally the experience of fright that anyone in their social circle would be affected. Also, 62.4% of them thought that it would be nice to talk to someone about their worries about the COVID-19 pandemic and 85.2% felt the necessity to get mental health help. Most of them (86.5%) believed that it would be beneficial if mental health professionals helped people in dealing with the COVID-19 pandemic situation and hence, they suggested that those who were highly affected by it to look for mental health support. Stress levels regarding the pandemic were low; however, participants were moderately anxious about them. There were no significant differences in anxiety episode and perceived psychological impact between male and female students (p>0.05).

DISCUSSIONS

Pandemics are a periodic phenomenon. People in the community face several challenges during such periods. Lack of awareness often leads to an indifferent attitude, which may skeptically affect the preparedness to face these challenges. Pandemic burden is often intense, which may negatively affect the mental health of a given population. The constant fear and anxiety of getting affected also influences the normal behavior of people in the community. In most cases, people start behaving erratically, which not only disturbs the internal harmony of the individual but also drastically affects an entire society. Hence, our study attempted to evaluate the awareness, attitude, anxiety and perceived mental healthcare needs among the medical undergraduates who are most vulnerable to such illness.

Brooks et al (5) carried out a similar study during the swine flu outbreak in the United Kingdom. They conducted a telephone survey over four days which involved the native population who heard the term "swine flu" and was able to speak English. There are several similarities between swine flu and COVID-19, with both illnesses having a viral origin, involving the respiratory system and spreading by droplet infection. Similar precautions are often recommended for the prevention of both above-mentioned infections. A previous study found that health professionals often had better awareness, positive attitudes towards epidemics/pandemics and frequently experienced low levels of anxiety (6), while a study from Ethiopia showed that healthcare professionals had poor knowledge and erroneous beliefs during the Ebola virus outbreak in 2015, which was therefore urging for their intense training (7).

During this coronavirus pandemic, most of the educated people and health professionals were aware of the infection, so preventive measures such as social distancing and government initiatives were taken to limit the spread of infection. However, the public had increased worries and apprehensions about acquiring COVID-19. People had higher perceived needs to deal with their mental health difficulties. There was a need to intensify the awareness program and address people’s mental health issues during the COVID-19 pandemic. To our knowledge, no study has evaluated the mental health perspectives of people during the COVID-19 pandemic. It is important to explore the mental health impacts in various populations (general populations, cases of COVID-19, close contacts of infected people and healthcare workers) for planning effective targeted intervention strategies (8).

Mental health issues were alarmingly high among college students, particularly in the United States, with every eight in ten students experiencing frequent stress episodes in 2019 (9). An eight-country study of 13,984 first-year college students under the World Health Organization’s (WHO) World Mental Health Surveys found that the lifetime and annual prevalence of suicidal ideation in this group was 32.7% and 17.2%, respectively, which corresponded to the high distress levels in the students’ subgroup (10).

Mental health problems adversely affect numerous aspects of life. For college students, academic performance is the first one to be affected. A Belgian study found that mental health problems had reduced college students’ grade point average (GPA) by 0.2 to 0.3 points (11). Depressive disorders among students were associated with cognitive impairments and real-world functioning (12). The psychological impact among students further extended to the risk of adopting maladaptive behaviors, including binge drinking, smoking, substance abuse, overeating, risky sexual activities, dependence on social media and sleep deprivation (12-14). Stigma and embarrassment were also commonly associated with mental health problems among youth (15).

Besides its direct impact on physical health, the COVID-19 pandemic had a severe toll on the psychological well-being of individuals due to fear, uncertainty, quarantine measures, lockdowns, social isolation, “infodemic” (or outpouring of news through various outlets, including social media) and so on (16-19).

In a study performed during the post-phase two lockdown periods in India, college students had higher stress and anxiety levels than the general population (20). Many universities have closed in-person classes, vacated dormitories and introduced online teaching, which led to tremendous academic stress among students (21). The adverse psychological outcomes have been compounded for students who are already facing higher levels of distress. Loneliness and insufficient perceived social support are known to be detrimental to mental health (22), both of which have been accentuated during the COVID-19 pandemic.

Further studies conducted in France, Ethiopia, China and Malaysia also pointed to a high negative impact of the COVID-19 pandemic on the psychosocial health of college students (23-25). Another study from China found that the prevalence of post-traumatic stress disorder and depression among college students rose to 2.7% and 9.0% during the COVID-19 pandemic (26).

To our knowledge, the meta-analysis conducted by Batra et al (27) provides the first collective evidence of the negative psychological burden of COVID-19 on the mental health of college students. This evidence is critical to inform colleges, universities and other educational institutions in designing interventions and policies to improve college students’ mental health. Previous global evidence indicated that psychological morbidities were long-standing issues among college students even before the pandemic, with nearly 50% of mental issues starting at an early age of 14 years (28-30).

CONCLUSIONS

The findings of the present study underscore the significant psychological impact of the COVID-19 pandemic on medical students, revealing high levels of pandemic-related anxiety, social avoidance and sleep disturbances. Social media emerged as a notable stress amplifier, affecting over half of the respondents. A substantial majority expressed a clear need for mental health support and emphasized the role of mental health professionals in managing pandemic-in- duced stress. These results highlight the urgent necessity of implementing targeted mental health interventions, awareness programs and accessible counseling services for medical undergraduates. Addressing these challenges is essential, especially as the threat of new COVID-19 variants looms, to ensure the well-being of future healthcare professionals.

Conflicts of interest: none declared.

Financial support: none declared.

FIGURE 1.

Frequency of thoughts about the COVID-19 pandemic

FIGURE 2.

Sleep difficulties among medical students during the COVID-19 pandemic