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ORIGINAL ARTICLE
Year : 2023 | Volume
: 67
| Issue : 1 | Page : 35-40
A cross-sectional study on anxiety due to COVID-19 and its predictors among undergraduate medical students in a tertiary care teaching hospital of Kolkata, West Bengal
Vanlaldiki Chhakchhuak1, Kuntala Ray2, Sanjay Kumar Saha2, Mausumi Basu3
1 Junior Resident, Department of Community Medicine, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
2 Associate Professor, Department of Community Medicine, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
3 Professor and Head of Department, Department of Community Medicine, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
Correspondence Address:
Mausumi Basu
Department of Community Medicine, IPGME&R and SSKM Hospital, 1st Floor, Academic Building, 244 AJC Bose Road, Kolkata, West Bengal
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijph.ijph_690_22
Abstract
Background: Medical education is recognized as stressful globally. COVID-19 pandemic is an additional source of anxiety to the medical students. Objectives: This study was conducted to assess the prevalence and to identify the factors associated with anxiety due to COVID-19 among undergraduate medical students in a teaching hospital of Kolkata, West Bengal. Methods: An observational cross-sectional study was conducted among 363 undergraduate medical students using the stratified random sampling of a medical college from June to July 2021. Data were collected using a predesigned, pretested, and structured online questionnaire, including “Coronavirus Anxiety Scale.” Descriptive statistics were used to estimate the prevalence of anxiety. Pearson's Chi-square test was performed to find out the factors associated with anxiety due to COVID-19. Results: About 25.6% of the medical students were found to have anxiety due to COVID-19. About 28.9% of them reported COVID-19 infection in family in recent past and 11.0% had themselves tested positive. Nearly 20% reported loss of family members, relatives, and close friends due to COVID-19. The factors associated with anxiety due to pandemic were socioeconomic status, social stigma, sleep disturbances, history of COVID-19 in family, loss of job. and vaccination status of family members missing practical classes and exam-related anxiety. Conclusion: The study found that one-fourth of the medical students had anxiety due to COVID-19. Social stigma due to COVID-19 and loss of job of parents were the most significant predictors. It is recommended that targeted psychological and clinical interventions need to be taken to alleviate students' anxiety due to COVID.
Keywords: Anxiety, COVID-19, pandemic, undergraduate medical students
Introduction 
The COVID-19 pandemic has not only impacted human life but also economy, entertainment, government policies, and education.[1] This pandemic could have also affected mental health of people. It may lead to psychological distress, loneliness, fear, anger, anxiety, depression, panic attacks, and concern about the socioeconomic status. Because of social distancing and self-isolation, emotional health and social wellness had been challenged during this pandemic.[2] Screening of mental health is important for psychological well-being of any individual during the pandemic.[3]
In a recent large survey of people highly susceptible to the coronavirus infection (i.e., Chinese medical workers), the prevalence rate of traumatic stress was at an alarming 73.4%, depression was at 50.7%, generalized anxiety was at 44.7%, and insomnia was at 36.1%.[4]
Medical students are known to have higher levels of psychological stress than the general population. Medical curriculum are characterized by huge competition and exclusive dedication than any other profession; their academic stress supress their nonacademic domains of life like family and friends; there is lacking time for leisure activities or social contacts due to spending most of their time on studies; all of which lead to poorer mental health as compared to general population.[5],[6],[7] Result of many studies documented that the prevalence of anxiety and stress among medical students is higher compared to other students and same age peers; the documented stressors include academic workload, competition with peers, conflicts in work-life balance, family demands, financial difficulties, and exposure to human suffering.[7],[8],[9],[10]
The COVID-19 pandemic is an additional source of anxiety to them.[10] Isolation, loss of social support, risk of infections to relatives and friends, staying back home and continuing their studies online are further compromising the resilience of these students. Medical students are, therefore, especially vulnerable to mental health problems, including stress, anxiety, depression burnout, addiction, and posttraumatic stress disorder. Early detection and intervention may help in preventing and minimizing the effects of distress on the students.[11]
The aim of this study is to bring the awareness of the specific needs of medical students in response to unprecedented changes in the surrounding environment due to COVID-19. With this knowledge, tracking the psychological impacts of COVID-19 will help to determine the best paths forward during the ongoing pandemic and will also help in preparing to cope up for future events that may disrupt medical education.
The objective of this study was to estimate the prevalence of anxiety regarding the COVID-19 pandemic among the undergraduate medical students in a tertiary care teaching hospital of Kolkata, West Bengal and to find out the predictors of anxiety due to COVID-19 disease among the study population in reference to their sociodemographic and epidemiological characteristics.
Materials and Methods A descriptive study with cross-sectional design was conducted in Institute of Post Graduate Medical Education and Research (IPGME&R) and Seth Sukhlal Karnani Memorial Hospital (SSKMH), Kolkata from June to July 2021. The study population were the undergraduate medical students (1st, 3rd, and 6th semesters) of IPGME&R and SSKMH Individuals who did not give e-consent to participate in the study were excluded. IPGMER-SSKMH is a Tertiary Care Government Medical Institute having 200 undergraduate seats and is a representative sample of medical colleges in West Bengal.
Taking proportion of anxiety P as 17.2% (0.172) from a meta-analysis[12] conducted by Lasheras et al., q = 1 − p = 0.828, confidence interval = 95% and absolute error L as 5%; sample size was calculated using Cochran's formula as follows:
n = (Zα2pq)/(L) 2 = [(1.96) 2 × 0.172 × 0.828]/(0.05) 2] = 219
After considering a design effect of 1.5% and 10% nonresponse, final sample size was 363.
These 363 students were selected by the stratified random sampling [Figure 1].
Figure 1: 363 study participants selected by stratified random sampling. PPS: Probability proportional to size A predesigned, pretested, and structured questionnaire (Google form) was used as the study tool for data collection.
The questionnaire was divided into three sections:
Sociodemographic profileCOVID specific questions (containing 19 questions)Anxiety due to COVID-19 (4 questions) and Coronavirus Anxiety Scale (CAS) (5 items).CAS: This scale is developed by Lee and validated 2020[13] The CAS is a self-report mental health screener of dysfunctional anxiety associated with the coronavirus crisis. Because a significant number of people experience clinically significant fear and anxiety during an infectious disease outbreak, the CAS was developed to help clinicians and researchers to efficiently identify cases of individuals functionally impaired by coronavirus-related anxiety.[14] It is a screening tool used to check the dysfunctional anxiety which could be associated with the ongoing COVID-19 pandemic. The tool has 5 items based on experiences over the last 2 weeks. Each item was scored on a scale with the following scores: 0 (not at all), 1 (rare, less than a day or 2), 2 (several days), 3 (more than 7 days), and 4 (nearly every day over the past 2 weeks). A total score of ≥9 depicts the presence of dysfunctional coronavirus anxiety. Elevated scores on a particular item or a high total scale score (≥ 9) may indicate problematic symptoms for the individual that might warrant further assessment and/or treatment.
The study tool was a predesigned, pretested structured questionnaire. It was designed by a team of three specialists-among whom 2 were public health experts and 1 was psychiatrist. It was prepared in English. The questionnaire was then pretested among 30 randomly selected undergraduate medical students for its validity and reliability. The students who were selected for pretesting were not included in the final study population. Content validity was obtained from two experts from community medicine. After incorporating the modifications suggested by them, the questionnaire was approved for its usage.
The study technique was self-administered online questionnaire (Google Form).
For data collection, link to Google form containing questionnaire was sent to students during online class. Only those students who gave E-consent were able to access the electronic questionnaire.
The dependent variable was anxiety.
The independent variables were:
Sociodemographic variables included age, gender, academic semester, religion, permanent and current residence, socioeconomic statusCOVID specific variables were family member tested positive, job lost, vaccination status, social stigma, sleeping pattern, online classes, missing out practical/clinical classes, and exam related.All 363 data collected were included in the analysis. Data were analyzed using the IBM Corp. released 2017. IBM SPSS Statistics for windows, version 25.0. (Armonk, NewYork, USA) Descriptive statistics were used to summarize the data. Univarable binary logistic regression was performed to ascertain the relationship between anxiety and the sociodemographic characteristics. All independent variables having P < 0.20 were considered biologically plausible to be included in the multivariable binary logistic regression model. Data were checked for multi-collinearity (variance inflation factor <10) and variables with P < 0.05 were considered statistically significant.
Ethical consideration
Institutional Ethics Committee permission was obtained before the start of the study (Institute name/IEC/2021/388 dated July 22, 2021). Electronic-consent was obtained from each participant and all ethical principles were strictly adhered to throughout the course of the study.
Results The sociodemographic characteristics of the study population are shown in [Table 1].
Out of 363 undergraduate medical students, 132 (36.4%) were from 1st semester, 132 (36.4%) were from 3nd semester and 99 (27.3%) were from 6th semester. Approximately three-fifth of them was male 228 (62.8%). About 60.1% of the study population were from urban area while 39.9% were from rural. Regarding the current residence, more than half of them (57.6%) were living in hostel. Majority 246 (67.8%) belonged to upper class (Class-I) as per Modified BG Prasad Scale 2021. About 105 (28.9%) of them reported COVID-19 infection in family in recent past and 11.0% had themselves tested positive. Nearly 20% reported loss of family members, relatives and close friends due to COVID-19 and about 36.9% of them were from the family where all the eligible family members were not vaccinated.
Prevalence of anxiety
The prevalence of anxiety among the undergraduate medical students during COVD-19 pandemic was 25.6%.
Highest prevalence was seen among the students of 1st semester (31.8%), followed by the students of 6th semester and 3rd semester, respectively (28.3% and 17.4%).
32.7% of the students reported that they felt anxious due to post-COVID-19 complications in their family, and about 69.4% of them had anxiety due to online classes. Most of the study population (85.9%) had anxiety due to missing out on practical/clinical classes in any of the subjects, while 84.2% of them felt anxious before appearing examination during pandemic.
[Table 2] shows the distribution of the study population as per their responses to CAS.
Table 2: Distribution of the study population as per their responses to Coronavirus Anxiety Scale (n=363)More than 10% of the study population felt dizziness, light headedness on hearing the news of coronavirus and 8.3% reported trouble in falling or staying asleep (recall period of 7 days). More than 52% lost interest in eating when thought about coronavirus. More than 37% student became nauseous or had stomach problem when exposed to the information of corona.
Factors influencing undergraduate medical students' anxiety during COVID-19 pandemic
[Table 3] shows multivariable binary logistic regression predicting anxiety due to COVID-19. Social stigma being a medicos (adjusted odds ratio [aOR] = 2.533, P = 0.002) and loss of job of family members (aOR = 0.301, P = 0.002) were the most significant predictors of anxiety. Other predictors were academic semester (2nd semester), middle socioeconomic status, history of COVID-19 in family, vaccination status of family members, sleep disturbances, and online classes (all these predictors had P < 0.05).
Table 3: Mulitvariate binary logistic regression predicting anxiety due to COVID-19 (n=363) Discussion The COVID-19 pandemic has a negative effect on both physical and mental health and well-being. The purpose of this cross-sectional study was to assess the prevalence and to identify the factors associated with anxiety due to COVID-19 among the MBBS students.
During the pandemic, medical schools had to Halt traditional classroom teaching and resume to some other alternative means of education (online) to ensure safety students as well as faculty and staff. This was true for nearly all academic programs. However, the academic burden of medical students has increased during the lockdown due to the shift from hands-on learning to online learning which hampered the essential practical education unique to medical students. Therefore, this might lead to an increase in anxiety due to academic delays even though the stress from hectic college hours and clinical duties have decreased. Sudden shift from face to face to virtual or online learning was not an easy task, especially in developing country like India. Basic infrastructure such as a dedicated computer system, software, a premium Internet connectivity in the institute as well as for all student confined in the home during the lockdown period is not easily available and feasible task. During the beginning stage of the crisis, most of the students residing in the rural areas could not attend virtual class. This may lead to anxiety to the students.
The prevalence of anxiety due to COVID-19 in this present study was found to be 25.6%, whereas the finding was less in the study conducted by Muhammad Alfareed Zafar et al.[2] in healthcare professionals, medical students, and general population of Pakistan (4.6%); Saraswathi et al.[10] in a medical college in Chennai, Tamil Nadu (21.2%); Vala et al.[11] among 1st year MBBS students of Shri MP Shah Government Medical College in Jamnagar, Gujarat (17.20%) and Cao et al.[15] among the undergraduate medical students of Chanzhi Medical College in China (24.9%). However, the estimated prevalence was higher in a multi-centric study conducted by Liu et al.[4] in China involving 1563 medical staff (44.7%); Lasheras et al.[12] among medical students in a Systematic Review (28%); Chatterjee et al.[16] among the doctors in West Bengal (39.5%); Soltan et al.[17] among Fayoum medical students in Egypt (56.4%), Jia et al.[18] among Medical students in a systematic review and Meta-Analysis involving 41 studies on 36608 medical students; Halperin et al.[19] among 428 students from 40 US medical schools (30.6%); and Bhowmick et al.[20] in a tertiary care teaching hospital in the metropolitan Kolkata (89.47%).
The difference of estimated prevalence may be due to different tool use and different setting.
In this study, CAS was the tool used for the assessment of anxiety, while in the study conducted by Vala et al.[11] and Chatterjee et al.[16] Depression, Anxiety and Stress Scale was used and in the study done by Cao et al.[15] General Anxiety Disorder-7 was the tool used for anxiety assessment. CAS is a brief mental health screener that the researchers can readily use to find out probable cases of dysfunctional anxiety associated with the coronavirus. Dizziness, which is the first item of the CAS, is a major symptom of panic attacks; sleep disturbance, which is the second item of the CAS, is a common symptom of both generalized anxiety disorder and posttraumatic stress disorder. Thus, CAS items concentrate on anxiety and trauma-related reactions. They are also exclusively focused on distressing bodily symptoms, make them highly relevant to somatic symptom.[13],[14]
Predictors of anxiety found in the current study were social stigma being a medicos, loss of job of family members, students of 2nd semester, middle socioeconomic status, family member tested positive for COVID-19, sleep disturbance, online class and family members vaccinated, whereas in the study done by Saraswathi et al. at Chennai[10] poor sleep quality, higher levels of baseline depression, anxiety, and stress, COVID-19 patients in family/friends and direct interactions with COVID-19 patients were found to be significant predictors of negative mental health; study by Vala et al. at Jamnagar[11] revealed gender-based prevalence, i.e., prevalence of anxiety was higher in females (9.60%) than in males (7.60%). Moreover, in the study conducted by Chatterjee et al. in West Bengal,[16] predictors of anxiety were working hours, high risk procedures such as rendering service in isolation ward, use of 70% alcohol-based hand sanitizer and being ostracized in work place, while in the study done by Cao et al. in China[15] relatives or acquaintances infected with COVID-19, economic influences and academic delays were the significant predictors and living in urban areas, family income stability and living with parents were protective factors against anxiety. Anxiety was significantly associated with gender and personal history of psychiatric illness (P = 0.033 and 0.001, respectively) in the study done by Soltan et al. in Egypt.[17] The study conducted by Orrù et al.[21] among Italian population found that the CAS scores tended to increase with age, with older subjects exhibiting higher scores than younger subjects. In addition, respondents with lower educational levels demonstrated higher scores on both the CAS. Respondents living with older people and/or experiencing the death of one or more relatives due to COVID-19 exhibited corresponding outcomes more anxiety. Halperin et al.[19] at US study demonstrated that higher anxiety among females, preclinical students, and those with a friend or relative diagnosed with COVID-19. Bhowmick et al.[20] at Kolkata observed that females were more affected with anxiety compared to males and participants residing with their family members reported to be more anxious than with those staying alone or with their friends
Limitations
There could have been a possibility of social desirability bias as some respondents might have given socially favorable responses. Moreover, as only one medical college was chosen, the results of this study may not be applicable to the universe to medical students. Thus, the results of this study (at the given time point) may under-or over-estimates the psychological impact of the COVID-19 pandemic. The use of single-item scales can reduce the complexity and validity of the psychological, attitudinal, and coping constructs that are measured.
Finally multiple-item scales are designed to sample a broader range of meanings to cover the full range of a construct, while the use of single-item scales can reduce the complexity and validity of the psychological, attitudinal, and coping constructs that are measured and the respondent is left with greater ambiguity to interpret the meaning of the item.
Future research should implement longitudinal and multisite designs to track the psychological effects of the pandemic crisis in different medical colleges.
Conclusion The study found that anxiety was present among the medical students due to COVID-19. Social stigma due to COVID-19 and loss of job of family member were the most significant predictors of anxiety. This study provides essential data regarding the psychological effects of COVID-19. Hence, this study conclude that early evaluation and intervention is recommended that need to be taken to alleviate students' anxiety at the institutional level thus promote the reduction of stress and anxiety.
Acknowledgments
The author would like to acknowledge the study participants who spend their valuable times and for full cooperation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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