Introduction
Globally, till date, novel coronavirus disease (COVID-19) has infected 103 million people, taking 2.22 million lives.[1] Initially, COVID-19 was discovered as a cluster of pneumonia cases in the Wuhan city of Hubei Province in China during the month of November.[2] During the 1960s, the first-ever occurrence of coronavirus (CoV) was identified. CoV belongs to a large family of coronaviridae.[3] Most people infected with CoV infection experience mild-to-moderate respiratory illness, whereas older adults and those with preexisting medical conditions such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely to develop a serious illness such as severe acute respiratory syndrome (SARS).[4,5] Over the past half a century, several epidemic outbreaks of CoV family have occurred, and rarely, they gained more full recognition except SARS-CoV and the Middle East Respiratory Syndrome CoV (MERS-CoV).[6] COVID-19 is believed to have zoonotic origin which means that it can be transmitted between animals and humans, and it also belongs to the family of coronaviridae. The International Committee on Taxonomy of Viruses has officially announced the name of COVID-19 as SARS-CoV-2.[7] Due to its global widespread and public health threats, the World Health Organization (WHO) had declared COVID-19 as a pandemic.[8] India, which has a population of over 1.34 billion people and is the world's second biggest, will face difficulties in handling serious COVID-19 cases since it only has 49,000 ventilators, which is a small number. It was proven to be disaster for India due to increased number of COVID-19 cases throughout the country.[9] The outbreak of such viruses and their transmission had significantly affected the Indian economy.[10]
The outbreak of CoV pandemic not only affects the health but also alters the mental health of the people.[11] Along with other health-care professionals (HCPs), undergraduate (UG) medical interns and postgraduate (PG) medical residents are the first-line warriors battling against the sudden emergence of SARS-CoV-2.[12] During the time of infectious disease outbreak, UG medical interns and PG medical residents as at the higher risk of developing an infection as they are directly involved in the various medical procedures and comes in contact with suspected and confirmed infected patients. However, there is already a shortage of HCP in India.[13] This extreme pandemic condition has predisposed HCPs to significant psychological stress and has possessed a negative impact on the overall mental health of them. As a result, there is an extreme pressure on HCPs to meet the need of patients and to provide them with the best care.
Fewer studies were conducted to assess the depression among the HCPs and stress symptoms that appear later on and last for an extended period time. However, these studies do not reflect the actual stress and anxiety level medical students felt during the time of the actual event.[14,15,16] Al-Rabiaah et al. have reported the emergence of outbreak put significant psychological pressure that may further lead to unfavorable effects on the overall mental health and learning of medical students.[17] Nevertheless, limited data is available on the mental health of UG medical interns and PG medical residents during the SARS-CoV-2 pandemic outbreak in India. Therefore, this study aims to assess the psychological status among the medical intern and PG residents and study the factors influencing stress and anxiety in them.
Methods
Study design and participants
A web-based, self-administered cross-sectional survey was conducted in the month of March 2020. The questionnaire covered the domains of sociodemographic details, knowledge assessment, perceived stress assessment, generalized anxiety disorder-7 (GAD-7) assessment, and assessment of the perceived level of change in social habits and personal hygiene related to COVID-19 outbreak. The readability, clarity, and completion time of the developed survey instrument were assessed through a pilot study that was conducted among the twenty purposively selected UG medical interns and PG medical residents. They were eventually excluded from data analysis. Refinements were made as required to facilitate better comprehension and to organize the questions before the final survey distribution to the study population. Following this, we randomly selected and recruited different UG medical interns and PG medical residents working in various departments to participate in this study. A self-rated questionnaire was developed online with the help of Google form and distributed to all the participants of the Guru Gobind Singh Medical College and Hospital. It is one of the PG Teaching Hospitals in Punjab. All participants have to fill informed consent before questionnaire.
Ethical Consideration
The study was carried out in compliance with the ethical standards for biomedical research on human participants Ethics committee affiliated to Baba Farid University of Health science approved the proposal under decree code of BFUHS/ UCER/ 2021/3413. The informed consent page presented two options (I agree/I disagree). Participants who chose I agree option were allowed to fill the questionnaire, and the participants could take back their name at any time during the process.
Measures
The first part of the survey assesses the sociodemographic characteristics of the participants, which consisted of age, gender, education qualification, and the region of living and income status.
The second domain consisted of 8 questions on knowledge of SARS-CoV-2 virus and disease caused by it, and responses of these questions were recorded as true, false, and do not know. The items were designed based explicitly on SARS-CoV-2, mode of transmission, incubation period, and host cell receptors. Before this, knowledge questions were subjected to facial and content validation by taking assistance from faculty members of medical sciences and pharmaceutical sciences.
Furthermore, we administered 10-item perceived stress scale, each item is coded from zero to four as per the frequency of different stress symptoms, and the total score was calculated by adding the responses from each question. PSS overall scores were categorized as per the score categories mentioned in the original scale (i.e., 0–13 = low stress, 14–26 = moderate stress, and 27–40 = high perceived stress).[18]
Moreover, we have also administered 7-item GAD-7 scale, in which each item is coded from zero to three, according to the frequency of different anxiety symptoms.[19] GAD-7 total scores were categorized as per the score categorization given in original scale (i.e., 0–4 = minimal anxiety, 5–9 = mild anxiety, 10–14 = moderate anxiety, and >14 = severe anxiety). Along with it, the survey assessed the perceived level of change in their social habits and personal hygiene habits with five responses. The final part of the study was added to know about the various sources of information from which the participants were getting appropriate or inappropriate information.
Statistical analysis
Statistical analysis was carried out by the Statistical Package for the Social Science (SPSS) version 24.0 IBM (SPSS Inc., Chicago, Illinois, USA).[20] Mean, median, and standard deviation were used to describe the descriptive data, and percentage with frequency was used for categorical variables. The data of the participants were assessed for normality distribution using the Kolmogorov–Smirnov test and Shapiro–Wilk test withP< 0.001 and <0.001, respectively. The results showed that data of the study participants were not normally distributed (i.e., knowledge score, perceived stress level score, and GAD-7 anxiety score). The data which comes out to be not normally distributed, Mann–Whitney U-test, and Kruskal–Wallis nonparametric tests were used. A P < 0.05 was considered statistically significant.
Results
Sociodemographic characteristic of participants
Two hundred participants responded to the survey (out of 400 approached participants) with a response rate of 50%. More than half of the participants were male (61%, n = 122). A higher proportion of respondents (78%, n = 156) belonged to the age group 18–26 years. However, the majority (63.5%, n = 127) of the participants were having postgraduation as their education level, and the rest of them were (36.5%, n = 73) UG. In addition to this, majority of them were belonging to urban residence (65%, n = 65) of living. [Table 1] presents a detail description of the sociodemographic characteristics of the studied participants.
Table 1: Sociodemographic characteristics of the respondent (n=200)
Assessment of knowledge in respondents
The knowledge of UG medical interns and PG residents on COVID-19 outbreak caused by the virus SARS-CoV-2 is described in Table 2. The knowledge questionnaire consisted of 8 items, and the mean knowledge score of 200 participants was 4.27 ± 1.45. While the number of participants had the minimum score was zero of eight and the maximum score was seven of eight.
Table 2: Assessment of knowledge of participants on coronavirus disease-2019
Perceived stress and anxiety level of participants
The descriptive statistics of all the question variables among participants are described in Table 3. Participant students had mean perceived stress score of 18.35 ± 6.28 and a median of 19. On the other hand, a mean GAD-7 score of 6.04 ± 4.49 and a median of 6 were observed, respectively.
Table 3: Descriptive statistics of knowledge, perceived stress, and anxiety score among participants
The percentage of perceived stress level among surveyed participants is described in Figure 1. Of 200 participants, moderate stress (score 14–26) reported in 69% (n = 138) of the participants and 21% (n = 42) of the participants reported low stress (0–13), whereas only 10% (n = 20) of the participant reported high perceived stress level (27–40).
Figure 1: Distribution of participants according to the perceived level stress score
The distribution of participants, according to GAD-7 anxiety level score, is described in Figure 2. Among 200 responses received, 41% (n = 82) of the participant reported mild anxiety (score 5–9), followed by 39% (n = 78) of the participants reported minimal anxiety (score 0–4), while moderate anxiety (score 10–14) was reported in 16% (n = 32) of the participant and 4% (n = 8) of the participants reported severe anxiety (score >14). After the survey, one question was asked regarding anxiety problem, how difficult have these problems impact your work, take care of things at home, or get along with other people? 49% (n = 98) of the participant answered somewhat difficult, followed by 15% (n = 30) found it very difficult that these problems were affecting their daily activities.
Figure 2: Distribution of patients according to the Generalized Anxiety Disorder-7 anxiety level score
The perceived level of changes in attitude, social habits, and personal hygiene of students. A 10- item scale was used to determine the perceived level of change in attitude, social habits, and personal hygiene of students. 10-items were assessed on a 5-point scale to determine the change in attitude and own hygiene habits of students after the CoV pandemic outbreak as described in Table 4. It was observed that 52% (n = 104) participant handwashing habits had changed very much followed by 14% (n = 28) participant handwashing habits had moderately altered after the outbreak. More than half proportion of the participants (53%, n = 106) avoid contact with people having flu-like symptoms. It has been observed that after the outbreak, participants concern for own individual necessity, and desires have changed very much as compared to previous days.
Table 4: Description of the perceived level of change in attitude, perception, social practices, and personal hygiene habits among participants
Figure 3 describes the percentage of different information resources used by the participants. The WHO websites were the most accessible source of information (45%), followed by information circulated through various social networking sites such as Facebook, WhatsApp, and Instagram (19%), and the third most common source of information was the notifications provided by the ministry of health and family welfare under Government of India. Other resources of information were research work published in a reputed journal (4%) and different websites (3%).
Figure 3: Distribution of participants as per various information accessed resources
This study further analyzed the UG medical interns and PG resident's sociodemographic characteristic that may influence their knowledge score, perceived stress level, and GAD-7 anxiety level as described in Table 5. Of 4 characteristics tested, only age of the participant had a significant effect on the knowledge score (P = 0.003). Moreover, participants having age 18–25 years had higher mean perceived stress as compared to other age groups and age of the participants had a significant impact on the perceived stress score (P < 0.001). On the other hand, the female participant had higher perceived stress as compared to male participants, and gender has a significant influence on perceived stress score (P < 0.001). Participants aged between 18 and 25 years had higher mean GAD-7 anxiety score, and it was observed that GAD-7 anxiety score decreases with the increasing age. Age and gender have a significant effect on GAD-7 anxiety score (P < 0.001,P= 0.012) and the female participant had higher stress and anxiety level as compared to female. UG students had significantly higher mean perceived stress as compared to postgraduate students (P = 0.037).
Table 5: Influence of participants sociodemographic and professional characteristics on knowledge, perceived stress score, and anxiety score
Discussion
The outbreak of COVID-19 is one of the deadliest disasters in the last few decades. Almost, this virus outbreak has affected all the major countries in the world. This virus has posed a threat to national as well as international public health.[21] The pandemic outbreak had a significant impact on the global economy. Therefore, we have designed this study to investigate the mental health of UG medical interns and PG residents as they work in a stressful condition due to their direct contact with the suspected or confirmed infected patients. We chose to survey health-care students/professionals, immediately after the outbreak of COVID-19 pandemic in India. We have used the perceived stress scale and the GAD- 7 anxiety scale to evaluate the mental health of the frontline workers.
Similarly, few studies were conducted to assess the mental health of medical students during previous outbreak, and the study results suggested that the medical student's overall psychological health and learning has been adversely affected during previous pandemic outbreak due to significant reduction in their psychomotor concentration. Another study has suggested that when the SARS epidemic hit, it not only affect the mental health of medical staff but also sometimes may lead to psychological trauma.[22]
The outbreak of the same family virus that is MERS-CoV in 2014 had a significant adverse effect on public anxiety in the affected countries. There was widespread stress and anxiety among HCPs as mentioned in the previously published studies that 30% HCPs were found to be positive for infection and majority of infections were hospital-acquired.[23,24] In 2003, the outbreak of SARS and the explosion of influenza A/H1N1 pandemic in 2009 has hugely affected the health of the global population. Various studies reported high psychological stress among HCPs, and the younger age participants were found to be more worried and concerned.[25,26,27]
The result of our study is very similar with the results of another study in which the authors have suggested high-stress level in students during the outbreak, especially who are working in a clinical setting or medical field. It has been observed that UG medical students had more anxiety level as compared to PG medical students.[28] In our study, there was a significantly higher perceived stress score of 19.51 ± 5.83 observed in UG students. Furthermore, some research recommended that students from nonmedical universities were more anxious as compared to medical students.[29,30] In our study, females were having significantly higher perceived stress and anxiety level, whereas the results from another study have reported the same finding that female students of health as well as nonhealth universities have more anxiety level.[31] Another study was conducted on students to know about the perception of risk and stress evaluation in nurses and it was found that females were having significantly more fear of contracting the virus as compared to males.[32]
Perceived stress scale is a precise measure to determine individual stress level; scale consists of 10 questions to know about personal feelings and thoughts of individual within the last month. In each case, you have to indicate how often you feel or thought a certain way. Participants who scored within a range of 27–40 in this 10-item scale had high perceived stress. GAD-7 is another screening tool that has been applied in the study to assess the individual anxiety level; participants who scored ≥15 in this 7-item scale had severe anxiety level and symptoms that can affect their daily life work. Moreover, it was observed that the websites or online courses were the most common accessible source of information, followed by notification from the Ministry of Health and Family Welfare. However, according to another study, higher the number of resources accessed by the individual and the higher the knowledge score about the infectious disease. Moreover, the media plays a very pivotal role in spreading appropriate knowledge about the pandemic outbreak. Researcher has suggested that the more the condition is mentioned in media, the more the students get to know about the disease.[33]
Limitation
Using self reported questionnaire and assessing the knowledge of SARS-CoV-2 virus and disease with a self- devised (not a specific reliable and valid measure) are main limitation of current study.
Conclusion
In conclusion, the results of the study demonstrate that a very high proportion of UG medical interns and PG residents in the SARS-CoV-2 pandemic outbreak is suffering from high perceived stress and severe anxiety symptoms. We recommend colleges and regulatory authorities to focus on medical students and resident's mental health, especially during an infectious disease outbreak as they have a high risk of infection. These results highlight the need to establish mental health tools or programs to protect the mental health of medical students, and they are acting as frontline workers during such a critical situation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
Authors are thankful to Baba Farid University of Health Science, Faridkot, Punjab, India, and Indo-Soviet Friendship College of Pharmacy, Moga, India, for providing the authors with all the necessary facilities and timely guidance.
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