Medical students’ relative immunity, or lack thereof, against COVID-19 emotional distress and psychological challenges; a descriptive study from Jordan

Version Changes

Revised. Amendments from Version 1

The manuscript has been updated with some technical notes such as response rate. As well, the buffering effect of social media on mental health domains investigated is only a suggested direction for future research and is not a mere conclusion of the article.

Abstract

Background: Emotional distress is a major impact of COVID-19 among not only the general public but also healthcare workers including medical students. This study aimed at describing self-reported changes in emotional reactions associated with COVID-19 among medical students in Jordan and to assessing the potential effect of social media utilization on emotional distress among this group.

Methods: A cross-sectional design was utilized to collect data early on during the outbreak in Jordan. All medical students in Jordan were eligible to complete an online questionnaire assessing self-reported emotional reactions to COVID-19 that covered four main domains: negative emotion (anxiety, worry, depression, panic, loneliness, and nervousness), positive emotion (happiness, joy, and excitement), sleep disorders (insomnia, shallow sleep, nightmares, and insufficient sleep), and aggression (verbal argument and physical fighting). The frequency of social media utilization as a main source of COVID-19 information was also assessed.

Results: 59.9% of participants were females, 64.9% were enrolled at the two major medical schools in Jordan, and 59.6% were in the pre-clinical stage (years). A significant proportion of participants self-reported increased negative emotional levels of anxiety (49.2%), worry (72.4%), depression (23.1%), panic (22.6%), and nervousness (38.2%) and decreased positive emotional levels of happiness (44.8%), joy (47.3%), and feelings of excitement (45.1%). Self-reported sleep disorders were not as common (less than 15% for any of the four items), while arguing with others was at 26.7%. Significant differences by gender and academic year were detected. Almost half of participants reported using social media as a main source of COVID-19 information “most/all-the-times” with a significant effect of such on reducing emotional distress.

Conclusion: The results suggest a potential effect of COVID-19 on the emotional distress of medical students. Addressing and mitigating such effects is crucial. The potential buffering effect of social media should be further investigated.

Introduction

COVID-19 is shadowing its effect on almost all individuals living today. The health, safety, and well-being of individuals and communities are all expected to be affected. These effects may include anxiety, fear, frustration, loneliness, anger, boredom, depression, stress, and avoidance behaviour ( Talevi et al., 2020) and may simply translate into emotional disturbances not only among those with the disease but also the general population and other sub-groups ( Pfefferbaum & North, 2020).

Certain population subgroups may be more vulnerable than others to the psychosocial effects of COVID-19. Healthcare workers, including medical students, especially in resource-limited countries, are particularly vulnerable to emotional distress during COVID-19 given their high risk of exposure to the infection, potential shortage of personal protective equipment, longer work hours, and involvement in emotionally and ethically fraught resource-allocation decisions ( Greenberg, 2020; Loch et al., 2020; Samrah, Al-Mistarehi, Aleshawi, et al., 2020; Talevi et al., 2020; Vindegaard & Eriksen Benros, 2020).

Studies have reported that medical schools have one of the most demanding academic programs ( Wolf, 1994) and include students at higher risk for developing anxiety disorders, compared to the general population, even under normal circumstances ( Quek et al., 2019). Medical emergencies destabilize medical students’ already vulnerable psychological status leading to unfavourable effects on their learning journey ( Al-Rabiaah et al., 2020), physical and mental health, and their professional identity formation ( Chandratre, 2020). While medical students may experience increasing level of anxiety and stress due to the COVID-19 disruption ( Lasheras et al., 2020; Ullah & Amin, 2020), they are the least likely to seek support for mental health problems ( Chandratre, 2020).

During outbreaks, medical students are expected to become part of the frontline workforce ( Kinder & Harvey, 2020; O’Byrne et al., 2020), which may further expose them to psychological distress. Therefore, it is important to assess and safeguard medical students’ mental health status and to implement proper strategies to support their mental well-being. Providing a clear understanding of the extent of psychological impact of COVID-19 infection should, then, be clearly established.

Jordan is a developing country in the Middle East region and reported its first case of SARS-CoV-2 infection in early March, 2020 ( Samrah, Al-Mistarehi, Ibnian, et al., 2020). A series of strict non-pharmaceutical intervention (NPI) measures were then implemented ( Kheirallah et al., 2020; Samrah, Al-Mistarehi, Aleshawi, et al., 2020) that included a curfew and a total shutdown. By mid-March, 2020, all educational institutions, including medical schools, were ordered closed and online education was, suddenly, the only option ( Sindiani et al., 2020). This may have increased the level of psychological distress among medical students ( Elsalem et al., 2020). The current study described the self-reported changes in emotional reactions associated with COVID-19 among medical students in Jordan and investigated the potential effect of utilizing social media as a main source of COVID-19 information on these emotional changes.

Methods

A descriptive cross-sectional design collected data on medical students between March 17 and 20, 2020, shortly after Jordan initiated the NPI measures stated earlier. Data were collected from all medical schools (N = 6) in Jordan and included all years (year 1 to year 6). The 6-year program consists of two stages: preclinical, the first three years of the program, and clinical, the last three years. The minimum sample size required to detect a 10% difference in any of the emotional items under investigations was estimated at 600 students (alpha = 0.05, power = 0.8). Considering a response rate of around 20% for online questionnaires among the sample population ( Khasawneh et al., 2020), an online data collection tool, using Google forms, was utilized and a link was emailed to a randomly selected sample (N = 3,000 out of the total estimated number of medical students in Jordan) that was proportionate to the year of study and the medical school.

Participants’ emotional reactions to COVID-19 pandemic were self-reported using 15 items covering four main domains: negative emotions (anxiety, worry, depression, panic, loneliness, and nervousness), positive emotions (happiness, joy, and excitement), sleep disorders (insomnia, shallow sleep, nightmares, and insufficient sleep), and aggression (verbal argument and physical fighting). Medical students compared the frequency of each item after the onset of the pandemic with before the pandemic using a three-point scale (from “1 = less compared to the days before the pandemic” to “3 = more compared to the days before the pandemic”). For selected items, responses were randomized. Participants were also asked to assess their usage of social media as a main source of information for COVID-19 using a three-point Likert scale (from “1 = never” to “3 = most/all the time”). The questionnaire was reviewed by expert panel before being piloted on 20 students.

The Institutional Review Boards of The Hashemite University (5/2/2019/2020) and Al-Balqa Applied University (26/3/1/804) approved this study. An online consent form was obtained by all participants prior to being directed to take the questionnaire.

Each emotional item was reported overall and by gender, academic level and by social media utilization using numbers and percentages. A Chi-squared test was used to compare percentages for each emotional item. The Alpha level was set at 0.05.

Results

A total of 1,404 students participated in the current study (response rate = 46.8%). The distribution of participants by gender, university, and year is presented in Table 1. About two-thirds (59.9%) of participants were females, 64.9% were enrolled at the two well-established medical schools at the University of Jordan (39.1%) and Jordan University of Science and Technology (JUST) (25.8%), and 59.6% were in the pre-clinical stage of their medical education.

Table 1. Study participants’ background characteristics.

		Number	Percent
Gender
	Female	836	59.5
	Male	568	40.5
	Total	1,404	100.0
University
	Al-Balqa`	117	8.4
	Hashemite	192	13.7
	Jordan	550	39.1
	JUST	362	25.8
	Mutah	62	4.4
	Yarmouk	121	8.6
	Total	1,404	100.0
School Year
Pre-clinical	1 st year	145	10.3
	2 nd year	348	24.8
	3 rd year	343	24.5
Clinical	4 th year	264	18.8
	5 th year	176	12.5
	6 th year	128	9.1
	Total	1,404	100.0

Overall, almost half of the participants (49.2%) self-reported that they experienced increased levels of anxiety. This was significantly more prevalent among females (58.6%) than males (35.5%) (p<0.0001). Self-reported worry, which was the most commonly reported negative emotion experienced among all participants (72.4%), was significantly more prevalent among females than males (79.5% vs 61.9%, p<0.0001). Similarly, self-reported depression and panic, respectively, were more prevalent among females (26.8% and 28.9%) compared with males (17.8% and 13.4%) (p-value for both comparisons <0.0001) ( Table 2).

Table 2. Distribution of study participants by study items and by gender and academic study level (N = 1,404).

			Total (N = 1,404)		Female (N = 835)		Male (N = 569)		P-Value	Pre-clinical (N = 837)		Clinical (N = 567)		P-Value
	Item	Response	n	%	n	%	n	%		n	%	n	%
Negative emotions	Anxiety	No	713	50.8%	346	41.4%	367	64.5%	0.000	414	49.5%	299	52.7%	0.232
		Yes Increased	691	49.2%	489	58.6%	202	35.5%		423	50.5%	268	47.3%
	Worry	No	387	27.6%	170	20.4%	217	38.1%	0.000	218	26.0%	169	29.8%	0.128
		Yes Increased	1,017	72.4%	665	79.6%	352	61.9%		619	74.0%	398	70.2%
	Depression	No	1,079	76.9%	611	73.2%	468	82.2%	0.000	620	74.1%	459	81.0%	0.003
		Yes Increased	325	23.1%	224	26.8%	101	17.8%		217	25.9%	108	19.0%
	Panic	No	1,087	77.4%	594	71.1%	493	86.6%	0.000	613	73.2%	474	83.6%	0.000
		Yes Increased	317	22.6%	241	28.9%	76	13.4%		224	26.8%	93	16.4%
	Loneliness	No	909	64.7%	565	67.7%	344	60.5%	0.006	522	62.4%	387	68.3%	0.026
		Yes Increased	495	35.3%	270	32.3%	225	39.5%		315	37.6%	180	31.7%
	Nervousness	No	868	61.8%	452	54.1%	416	73.1%	0.000	481	57.5%	387	68.3%	0.000
		Yes Increased	536	38.2%	383	45.9%	153	26.9%		356	42.5%	180	31.7%
Sleep disorders	Insomnia	No	1,231	87.7%	720	86.2%	511	89.8%	0.047	715	85.4%	516	91.0%	0.002
		Yes Increased	173	12.3%	115	13.8%	58	10.2%		122	14.6%	51	9.0%
	Shallow sleep	No	1,222	87.0%	712	85.3%	510	89.6%	0.019	715	85.4%	507	89.4%	0.029
		Yes Increased	182	13.0%	123	14.7%	59	10.4%		122	14.6%	60	10.6%
	Nightmares	No	1,256	89.5%	726	86.9%	530	93.1%	0.000	739	88.3%	517	91.2%	0.092
		Yes Increased	148	10.5%	109	13.1%	39	6.9%		98	11.7%	50	8.8%
	Insufficient sleep	No	1,230	87.6%	717	85.9%	513	90.2%	0.017	717	85.7%	513	90.5%	0.008
		Yes Increased	174	12.4%	118	14.1%	56	9.8%		120	14.3%	54	9.5%
Aggression	Argue with others	No	1,029	73.3%	610	73.1%	419	73.6%	0.854	587	70.1%	442	78.0%	0.001
		Yes Increased	375	26.7%	225	26.9%	150	26.4%		250	29.9%	125	22.0%
	Physical fight	No	1,333	94.9%	787	94.3%	546	96.0%	0.173	778	93.0%	555	97.9%	0.000
		Yes Increased	71	5.1%	48	5.7%	23	4.0%		59	7.0%	12	2.1%
Positive emotions	Happiness	No	775	55.2%	445	53.3%	330	58.0%	0.090	457	54.6%	318	56.1%	0.585
		Yes Decreased	629	44.8%	390	46.7%	239	42.0%		380	45.4%	249	43.9%
	Joy	No	740	52.7%	416	49.8%	324	56.9%	0.009	433	51.7%	307	54.1%	0.384
		Yes Decreased	664	47.3%	419	50.2%	245	43.1%		404	48.3%	260	45.9%
	Feeling excitement	No	771	54.9%	418	50.1%	353	62.0%	0.000	447	53.4%	324	57.1%	0.172
		Yes Decreased	633	45.1%	417	49.9%	216	38.0%		390	46.6%	243	42.9%

About 35% and 38% of surveyed students self-reported increased levels of loneliness and nervousness, respectively. While significantly more males (39.5%) than females reported increased level of loneliness (p=0.006), more females (45.9%) than males (26.9%) self-reported increased nervousness levels (p<0.001).

On the other hand, self-reported anxiety and worry were not significantly different between students in the pre-clinical vs clinical years while depression and panic, respectively, were significantly higher among students in pre-clinical years (25.9% and 26.8%) compared with their counterparts in the clinical years (19.0% and 16.4%) (p=0.003 and <0.001). Similarly, self-reported loneliness and nervousness, respectively, were significantly more common among students in the pre-clinical years (37.6% and 42.5%) compared to their counterparts in the clinical years (31.7% and 31.3%) (p=0.026 and <0.001).

About 13% of students self-reported experiencing increased insomnia, shallow sleep, nightmares, or insufficient sleep. In general, females self-reported experiencing significantly more sleeping problems than males. Likewise, students in the pre-clinical years experienced sleep problems (insomnia, shallow sleep, and insufficient sleep) significantly more frequently than those in their clinical years.

While about one-quarter of participants (26.7%) self-reported increased level of arguing with others, 5.1% self-reported increasing physical fight. However significant differences in aggression variables were not detected by gender, students in the pre-clinical years self-reported higher levels of both arguing with others (26.9%), compared with their counterparts in the clinical years (22.0%) (p=0.001), and physical fights (7.0%), compared with clinical years students (2.1%) (p<0.001).

Approximately half of the participants self-reported a decrease in their level of positive emotions, namely happiness (44.8%), joy (47.8%), and excitement (45.1%). Self-reported decrease in the levels of joy and excitement, respectively, were statistically more prevalent among females (50.2% and 49.9%) compared with males (43.1% and 38.0%) (p=0.009 and <0.001). Significant differences in each of the three positive emotions by academic levels were not statistically significant.

Overall, 37.9% of study participants reported never using social media as a source of information for COVID-19, while almost half (45.6%) reported using it “most/all the times” ( Table 3). Statistically significant relationships were detected between social media as a source for COVID-19 information and anxiety (p=0.002), worry (0.016), panic (<0.001), loneliness (0.003), and nervousness (0.004). Among those who reported to use social media most/all the times as a source of information about COVID-19, the prevalence estimates of self-reported anxiety, worry, panic, loneliness, and nervousness, respectively, were less than that among their counterparts who never used it (47.3% vs 55.6%, 70.9% vs 77.8%, 20.3% vs 28.9%, 31.7% vs 41.5%, and 36.1% vs 44.2%). Changes in sleep disorder and aggression variables, on the other hand, were not significantly different by social media.

Table 3. Distribution of study participants by social media use as a main source of COVID-19 information and by items under investigation.

				Use of social media as a main source of COVID-19 Information
Item				Never (N=532)		Rarely/sometimes (N=232)		Most/All the times (N=640)		P-value
				Number	Percent	Number	Percent	Number	Percent
	Overall			532	37.9%	232	16.5%	640	45.6%
Negative emotion	Anxiety	No		241	46.1%	135	58.2%	337	52.7%	0.002
		Yes Increased		291	55.6%	97	41.8%	303	47.3%
	Worry	No		125	23.9%	76	32.8%	186	29.1%	0.016
		Yes Increased		407	77.8%	156	67.2%	454	70.9%
	Depression	No		405	77.4%	181	78.0%	493	77.0%	0.841
		Yes Increased		127	24.3%	51	22.0%	147	23.0%
	Panic	No		381	72.8%	196	84.5%	510	79.7%	0.000
		Yes Increased		151	28.9%	36	15.5%	130	20.3%
	Loneliness	No		315	60.2%	157	67.7%	437	68.3%	0.003
		Yes Increased		217	41.5%	75	32.3%	203	31.7%
	Nervousness	No		301	57.6%	158	68.1%	409	63.9%	0.004
		Yes Increased		231	44.2%	74	31.9%	231	36.1%
Sleep disorders	Insomnia	No		456	87.2%	207	89.2%	568	88.8%	0.213
		Yes Increased		76	14.5%	25	10.8%	72	11.3%
	Shallow sleep	No		454	86.8%	211	90.9%	557	87.0%	0.105
		Yes Increased		78	14.9%	21	9.1%	83	13.0%
	Nightmares	No		469	89.7%	207	89.2%	580	90.6%	0.388
		Yes Increased		63	12.0%	25	10.8%	60	9.4%
	Insufficient sleep	No		466	89.1%	200	86.2%	564	88.1%	0.749
		Yes Increased		66	12.6%	32	13.8%	76	11.9%
Aggression	Argue with others	No		388	74.2%	173	74.6%	468	73.1%	0.888
		Yes Increased		144	27.5%	59	25.4%	172	26.9%
	Physical fight	No		500	95.6%	225	97.0%	608	95.0%	0.220
		Yes Increased		32	6.1%	7	3.0%	32	5.0%
Positive emotion	Happiness	No		298	57.0%	128	55.2%	349	54.5%	0.879
		Yes Decreased		234	44.7%	104	44.8%	291	45.5%
	Joy	No		272	52.0%	124	53.4%	344	53.8%	0.650
		Yes Decreased		260	49.7%	108	46.6%	296	46.3%
	Feeling excitement	No		277	53.0%	138	59.5%	356	55.6%	0.148
		Yes Decreased		255	48.8%	94	40.5%	284	44.4%

Discussion

The current descriptive study assessed the self-reported emotional changes following the COVID-19 pandemic among medical students in Jordan. Participants were found to have increased levels of almost all self-reported negative emotions and decreased levels of almost all positive emotions. These changes were more prevalently the case with females and preclinical students. Utilizing social media as a main source of COVID-19 information should be further investigated as having a potential “buffering effect” against emotional changes under investigation.

Our results suggest that medical students may not be immune against COVID-19 emotional distress and increased psychological challenges. This could potentially usher a period of adjustment and may produce significant mental health issues. Addressing and mitigating the negative effects of public health emergencies on the mental health of medical students seem to be critical.

Overall, preclinical level students seemed to have a greater increase in almost all negative emotions compared with clinical students. The reason why preclinical students might have had a greater increase in negative emotions could be attributed to their lesser experience in the clinical field and lesser understanding of the pandemic in general. However, it is interesting to note that the two negative emotions that showed no significant difference between preclinical and clinical students were worry and anxiety. When considering that medical students are already exposed to high levels of anxiety disorders ( Quek et al., 2019), higher levels of anxiety are than expected. Exacerbation of a pre-existing emotional distress among medical students due to COVID-19 were previously suggested ( Ullah & Amin, 2020).

Gender differences observed in the current study suggest vulnerability of female medical students to emotional distress more than male students. Females are generally more susceptible to emotional changes due to the hormonal fluctuations that are part of their physiology. It can be expected, thus, that several chemical mediators have a potential of elevating emotional distress in females. Beyond biological considerations, the conservative gender roles present different expectations of behaviours based on gender. Previous research have emphasized the gender roles and traits (masculinity in particular) and explained part of the gender differences in emotional distress and coping mechanisms ( Mayor, 2015). On the other hand, gender differences in emotional intelligence, test stress, coping and academic stress were also suggested to contribute to similar observations ( Alzahem et al., 2011; Babar et al., 2015; Elsalem et al., 2020). Our findings that female medical students self-reported higher rates of depression, anxiety, worry, nervousness, and panic, while male students reported higher rates of loneliness, are in line with the literature addressing such gender roles.

In Jordan, about 7% of medical students reported that they became obsessed with precautionary measures related to COVID-19 ( Khasawneh et al., 2020), while about half self-reported distance education as a main source of worry and stress. Such negative emotions were attributed to the learning and assessment models used during the pandemic as students were not familiar with distance learning ( Elsalem et al., 2020). The difference in prevalence estimates of distress in different studies may be attributed to several factors among which are the length of quarantine period, environment, contact with COVID-19 patients, and different coping styles of individuals.

Medical students who self-reported utilizing social media as a source of COVID-19 information more frequently reported lower levels of emotional distress compared to those who never utilized it for such. The role that social media can play in risk perception and dissemination of reliable information during pandemics could be critical ( Albarrak et al., 2019). While the information available about the pandemic may be a concern for COVID-19 infodemic among the general public, medical students seem to have utilized social media as a mitigation source to better understand the disease dynamics. This could have been reflected on the lower level of emotional distress reported among students who used social media more often. Medical students, therefore, by accessing social media, may be better equipped to avoid misinformation and to distinguish rumours from reality ( Karasneh et al., 2020). Still, our results contradict reports where young people tend to obtain a large amount of information from social media which can easily be a trigger for stress and anxiety ( Qiu et al., 2020). Assessment of the role of social media on medical students’ emotional distress should be further investigated using both qualitative and quantitative methods.

It is important to note that, in the current study, all estimates were self-reported and that we did not use standardized tools. This could have called out for over-estimation of the prevalence rates and over presentation of reported emotional changes. The cross-sectional nature of the study limits temporality. It will be imperative for other research groups to include longitudinal aspects in their study design and to use standardized screening tools as well as clinical assessment among this vulnerable group.

Conclusion

Our results support the notion to screen for mental health problems among medical students and to invest in mental health infrastructures. Psychoeducation, and psychosocial support should be seriously considered within health education programs at medical schools and should be fine-tuned by gender. The role of social media within the context of a classical medical educational system should be further investigated and utilized as a mediating factor towards better mental health and psychosocial support.

Funding Statement

The author(s) declared that no grants were involved in supporting this work.

Underlying data

In compliance with IRB guidelines specified for this research activity, data will be shared by the corresponding author following official request for research with clear objectives that is initially approved by the corresponding author.

Consent

Written informed consent for publication of the participants’ details was obtained from the participants.