Abstract
Background and aim of the work:
Since December 2019, the world has been facing the coronavirus disease 2019 (COVID-19) pandemic. Medical students could not remain uninvolved. Our aim is to investigate the impact of COVID-19 on their mental health, and to evaluate their awareness and aptitude for contributing to the fight against COVID-19.
Methods:
An in-depth search of the literature was performed in Pubmed database, for studies investigating the preferred source of information about COVID-19, the knowledge on virus transmission, COVID-19 clinical symptoms and preventive measures against its spread, and the impact of COVID-19 on mental health among medical students. Their potential roles during the COVID-19 pandemic were also investigated.
Results:
Twenty studies were included. The majority of medical students prefer social media to acquire knowledge about COVID-19. They are adequately informed about COVID-19 transmission and symptoms, as well as preventive measures against COVID-19, although wearing a face-mask is not so popular among them. Their mental health is affected, mainly expressed as a fear of infection. Possible alternative roles of students during pandemic may be providing information to the public and tracing contacts of infected people.
Conclusions:
Medical students have an adequate level of knowledge upon COVID-19 and implement proper strategies to prevent its spread. Further training is essential to improve some aspects in this field. Despite the negative impact of COVID-19 on their mental health, they could assist healthcare systems under appropriate precautions. (www.actabiomedica.it)
Keywords: COVID-19, medical students, mental health, preventive behavior
Introduction
Since December 2019, humanity came face to face with the new emergency situation of Coronavirus Disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (1). World Health Organization (WHO) characterized the crisis as a pandemic on 11th of March 2020 (2). A theory on COVID-19 origin indicates that the first transmission among humans came from animals, as a significant amount of people who visited an animal market in Wuhan, China were infected (1). This highly infectious virus is now easily transmitted from human to human via close contact and respiratory droplets and COVID-19 is mainly presented with fever, dry cough and difficulty in breathing (3,4).
As there is no specific medication or vaccine against COVID-19 yet, the WHO carried out unprecedented, aggressive measures such as nationwide mandatory lockdowns, in order to interrupt and decelerate further transmission (1,5). Another measure is the recruitment of a significant number of medical students (MSs) in the battle against COVID-19 in several roles (6).
Our purpose is to assess COVID-19 related knowledge, preventive behaviors and mental health among MSs and to propose ways on how they can safely be involved against COVID-19.
Methods
A literature review was conducted via PubMed electronic database using the following terms: “medical students and COVID-19”, “mental health of medical students and COVID-19”, “knowledge of medical students and COVID-19”, “preventive behavior of medical students and COVID-19”.
An independent investigator screened the titles and abstracts. Only information that refers to MSs’ roles and behaviors during COVID-19 pandemic and studies in English language were included. No restriction on article type, publication date or text availability was applied. A second investigator evaluated full texts. Relative data were also extracted.
Results
A total of twenty articles met inclusion criteria, five of which assess the sources which MSs prefer to be informed about COVID-19, eight assess knowledge of MSs on COVID-19, seven present whether they demonstrate appropriate preventive behavior according to international guidelines and seven examine the impact of the pandemic on their mental health. Some articles combine more than one of the previously mentioned domains. The researchers of the included articles based their results on questionnaires answered by MSs. Five studies consider their role on the side of trained and certified healthcare workers.
Sources of Information Related to COVID-19 among Participants
The major sources of information that MSs preferred in order to update their knowledge on the COVID-19 outbreak were investigated (Table 1).
Table 1.
Responses of medical students to questions on sources of information related to COVID-19.
| Reference | Social media | News | Official websites | Medical search engine |
| Khasawneh et al. (3) (n=1404) | 531 | 501 | 432 | 379 |
| Taghrir et al. (4) (n=240) | – | – | – | 68 |
| Ikhlaq et al. (5) (n=384) | 204 | 42 | 26 | – |
| Olum et al. (7) (n=741) | 518 | 438 | 354 | – |
| Çalıkan et al. (8) (n=860) | 642 | – | 349 | 138 |
| Total, % (n/N) | 55.9 (1895/3389) | 38.8 (981/2529) | 34.3 (1161/3389) | 23.4 (585/2504) |
The majority of the participants used social media (SM) and news (TV/radio/newspapers/journals) to acquire knowledge regarding COVID-19 (55.9% and 38.8% respectively). Less than 35% of MSs relied on medical search engines (like PubMed, MEDLINE, Google Scholar, EMBASE, etc.) and official websites (like National Ministry of Health official websites and WHO official website) for their information.
Knowledge on Transmission of COVID-19 among Medical Students
Awareness among participants on potential ways for transmission of SARS-CoV-2 was assessed (Table 2).
Table 2.
Responses of medical students to questions on knowledge of transmission of COVID-19.
| Reference | Coughing and sneezing | Animals | Close contact(kissing/handshaking) | Contaminated surface |
| Echoru et al. (1) (n=52) | 49 | 13 | 42 | 46 |
| Khasawneh et al. (3) (n=1404) | 1277 | 597 | 1322 | 1368 |
| Taghrir et al. (4) (n=240) | 223 | 198 | 220 | – |
| Ikhlaq et al. (5) (n=384) | – | – | 374 | – |
| Olum et al. (7) (n=741) | 734 | – | 735 | 667 |
| Çalıkan et al. (8) (n=860) | 777 | 189 | – | 774 |
| Gao et al. (9) (n=388) | 388 | – | 175 | 275 |
| Modi et al. (10) (n=517) | 363 | – | – | 154 |
| Total, % (n/N) | 90.7 (3811/4202) | 39.0 (997/2556) | 89.4 (2868/3209) | 82.9 (3284/3962) |
The majority of MSs knew that SARS-CoV-2 can be transmitted through coughing and sneezing, through close contact (kissing/handshaking) with infected people and through contact with a contaminated surface (90.7%, 89.4% and 82.9%, respectively). Only 39.0% of the responders were aware that the virus can be transmitted through the contact with infected animals.
Knowledge on Clinical Symptoms of COVID-19 among Medical Students
An estimation of the MSs’ awareness of the clinical presentation of SARS-CoV-2 was conducted (Table 3).
Table 3.
Responses of medical students to questions about COVID-19 clinical symptoms.
| Reference | Fever, fatigue, dry cough | Dyspnea | Diarrhoea |
| Echoru et al. (1) (n=52) | 41 | 39 | – |
| Taghrir et al. (4) (n=240) | 216 | 216 | 216 |
| Ikhlaq et al. (5) (n=384) | 353 | 353 | 140 |
| Olum et al. (7) (n=741) | 667 | 649 | 67 |
| Çalıkan et al. (8) (n=860) | – | – | – |
| Gao et al. (9) (n=388) | 386 | – | 248 |
| Total, % (n/N) | 92.1 (1663/1805) | 88.7 (1257/1417) | 38.3 (671/1753) |
Most of the students (92.1%) were acquainted with fever, fatigue and dry cough as common clinical symptoms of COVID-19, while a respective percentage (88.7%) knew that the disease could manifest with dyspnea. Only 38.3% of the respondents were aware that diarrhea is a less typical symptom.
Preventive Behaviors Implemented by Medical Students against COVID-19
An evaluation of the strategies adopted by MSs to protect themselves and people around them from SARS-CoV-2 was carried out (Table 4).
Table 4.
Responses of medical students to questions on implemented preventive behaviors for protection against COVID-19.
| Reference | Cover when cough/ sneeze | Avoid close contacts | Face masks | Avoid crowded areas | Wash hands regularly | Disinfectants | Avoid touching face | Stay home |
| Echoru et al. (1) (n=52) | 50 | 41 | 49 | 44 | 41 | 18 | – | 16 |
| Haque et al. (2) (n=704) | 645 | 652 | 542 | 662 | 669 | 552 | 604 | 619 |
| Khasawneh et al. (3) (n=1404) | – | 1040 | 136 | 1067 | 1222 | 966 | – | 1167 |
| Taghrir et al. (4) (n=240) | – | 227 | – | 239 | 232 | – | – | – |
| Olum et al. (7) (n=741) | – | 631 | 170 | – | – | – | 359 | – |
| Rzymski & Nowickib (11) (n=85) | – | – | 37 | – | – | – | – | – |
| Xiao et al. (12) (n=933) | – | – | 898 | – | 303 | – | 504 | 914 |
| Total, % (n/N) | 91.9 (695/756) | 82.5 (2591/ 3141) | 46.7 (1832/ 3919) | 83.8 (2012/ 2400) | 74.0 (2467/ 3333) | 71.0 (1536/ 2160) | 61.7 (1467/ 2378) | 87.8 (2716/ 3093) |
The top four preventive behaviors implemented were covering nose/mouth when cough or sneeze (91.9%), staying at home (87.8%), avoiding crowded areas (83.8%) and avoiding close contacts (like shaking hands, kissing etc.) (82.5%). Additionally, more than 70% of the MSs adopted behaviors like washing hands regularly with soap and water or using disinfectants. Avoiding touching face and wearing a face mask were the less popular precautionary measures among them, with a percentage of 61.7% and 46.7% respectively.
Impact of COVID-19 on medical students’ mental health
The degree of the psychological impacts amongst participants due to the widespread disease was also investigated (Table 5).
Table 5.
Impact of COVID-19 on medical students’ mental health.
| Reference | Fear of COVID-19/ infection | Stress/anxiety | Depression |
| Ikhlaq et al. (5) (n=384) | 215 | – | – |
| Liu et al. (13) (n=217) | – | 48 | 77 |
| Çalıkan et al. (8) (n=860) | 556 | – | – |
| Xiao et al. (12) (n=933) | – | 160 | 236 |
| Nguyen et al. (14) (n=5423) | 3370 | 416 | – |
| Meo et al. (15) (n=530) | 171 | 206 | 125 |
| Liet al. (16) (n=764) | – | 190 | – |
| Total, % (n/N) | 59.9 (4312/7197) | 13 (1020/7867) | 26.1 (438/1680) |
Fear of infection by COVID-19 is evident among a large part of MSs (59.9%). The results also demonstrate that the prevalence of depression is 26.1%, while 13% of MSs experience some state of anxiety/stress.
Contribution of medical students to the pandemic
Many authors agree that MSs could provide updated information about the disease, correcting at the same time common misconceptions (17,18,19,20). Moreover, they supported the opinion that MSs could raise public’s awareness about the importance of preventive behaviors, by explaining why such measures are useful against the pandemic (17,18,19,20). They could work in call centers by answering calls of concerned people and providing guidance and instructions (6,17,18,19,20). Furthermore, it is proposed that MSs could aid healthcare professionals with childcare and other personal responsibilities that might distract them from work (17,18,20). It had been noticed that MSs’ assistance in tracing contacts of infected people and screening was of immense value, while a study suggested that they could work in COVID-19 labs focused on testing and results distribution (6,18).
Discussion
Inevitably, MSs could not remain uninvolved in the fight against COVID-19. The present study evaluates the related knowledge on COVID-19, preventive behaviors and mental health among MSs, as well as ways they can be involved in efforts to curb the SARS-CoV-2 pandemic.
As far as acquisition of knowledge about COVID-19 is concerned, a considerable number of MSs (55.9%) relied on SM, whereas a lesser portion used verified sources of information like Medical search engines or health organization official websites (23.4% and 34.3% respectively). This could be a worrying trend when imagining MSs’ information-seeking behaviors as future practicing physicians. It should raise governments’ awareness regarding the major role that SM play in public information and at the same time underlines the need of making reliable sources of information more attractive (3).
The majority of MSs display an adequate level of knowledge about COVID-19. More than 89% identified fever, cough, fatigue and difficulty in breathing as the most common manifestations of the disease, while only 38.3% were aware that diarrhea is also a symptom. The last may be due to the fact that diarrhea appears at a lower rate among symptoms and in its insufficient promotion by SM (5).
Perception of MSs on ways of transmission of COVID-19 was higher in the order of “Coughing and sneezing” > “Close contact (kissing/handshaking)” > “Contaminated surface” > “Animals”, which confirms that they are aware of the main pathways of transmission, so they are able to protect themselves and others from getting infected. More specifically, 91.9% of the participants cover their mouth/nose when coughing/sneezing while approximately 83% avoid close contacts and crowded areas or prefer to stay home at a rate of 87.8%. More than 70% of MSs responded that they wash their hands regularly and use disinfectants. These findings conform to the opinion that there is a connection between someone’s level of education and precautionary measures adopted (2). Nevertheless, an unexpectedly low percentage (46.7%) reported wearing a mask when being outside as a preventive measure. This could be explained by differences in policies imposed by governments, differences in the level of education, attitudes and cultures, previous exposures to similar situations or by the misguided perception that people who wear masks are infected and should be avoided (3,11). A higher level of training is crucial as far as protection provided by face-masks is concerned (3).
Only a minority of MSs had to deal with mental disorders including stress/anxiety and depression (13% and 26.1% respectively). It seems that they cope appropriately with the pandemic’s pressure and its aftermaths (15). The same is not true about the feeling of fear; approximately 60% of MSs were afraid of the virus and had thoughts that they or their family could be infected. It is noted that as the level of training raises, fear diminishes proportionally (8). Again, better education is essential for the establishment of a better attitude against COVID-19. Nguyen et al. noticed that there are some predisposing factors which render participants more vulnerable to the sense of fear, such as first academic years, female gender, limited capability of affording remedies and lower level of health training (14). In addition, the extended misinformation about COVID-19, as well as MSs’ suddenly increased workload and rearrangement of their academic program, could disrupt their mental balance and make them feel stressed (13).
During COVID-19 pandemic, a significant number of MSs felt the need to support national healthcare systems (6). Even if they are not certified physicians, their contribution could be of paramount importance. However, it has been suggested that their valuable assistance should be restricted outside hospitals, as they do not have the appropriate experience and knowledge - especially in the preclinical stage of education - to take over patients and responsibilities on their own without supervision (6,19). Additionally, participating within the front line of this battle by treating infected people in hospitals means that MSs are exposed to great danger of infection. In this way, they could be the major link in the chain of SARS-CoV-2 transmission among hospital patients, their families and people with whom they socialize (6,18,20). For these reasons, many authors recommend that they should volunteer in other ways, like providing up-to-date information about COVID-19, setting themselves as examples by adopting the recommended precautionary behaviors and urging the public to implement these measures (17,18,19,20). They could also volunteer in call centers responding to public’s questions and clarifying potential misconceptions that may cause distress (6,17,18,19,20). Moreover, it is proposed that they could relieve healthcare workers from personal daily responsibilities (17,18,20). Finally, handling, sampling and distribution of results in labs, or even assistance in tracing contacts of infected people and screening, may be alternative ways for MSs to reinforce the fight against COVID-19 (6,18).
In conclusion, this study identifies MSs to be well informed regarding COVID-19 transmission and symptoms, even if they select SM as the primary source of information. The preventive behaviors they have adopted are adequate, excluding wearing a mask, which is not such a popular measure among them. A significant proportion admitted being afraid of the virus or getting infected, while the minority dealt with depression or anxiety disorders. During this difficult period, MSs who have a sense of duty can still contribute to the mission for which they signed up for, without danger of being infected, by informing the public of the importance of proper precautionsand volunteering in labs or call centers.
Conflict of Interest:
Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article
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