Journal of Integrated Health Sciences

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 9  |  Issue : 2  |  Page : 54--59

Anxiety disorder among undergraduate medical students of a rural tertiary care hospital of Gujarat, India due to Coronavirus Disease-19 pandemic lockdown


Hanee Dinesh Patel1, Grishma Dinesh Chauhan1, Dhairya Naresh Jain2, Rudra Patel3,  
1 Department of Community Medicine, SBKS Medical Institute and Research Centre, Sumandeep Vidhyapeeth, Vadodara, Gujarat, India
2 Department of Community Medicine, Government Medical College, Surat, Gujarat, India
3 Department of Community Medicine, N.H.L. Municipal Medical College, Gujarat, India

Correspondence Address:
Dr. Hanee Dinesh Patel
37, Bhagirath Bungalows, Opp. Jiviba School, Ghodasar, Ahmedabad - 380 050, Gujarat
India

Abstract

Context: Mental wellbeing is of utmost importance in the 21st century but the coronavirus pandemic and simultaneous lockdown have brought uncertainty, fear among other issues disturbing the normal equilibrium and leading to disharmony in the mental wellbeing of university-going students. Aim: Find out prevalence and risk factors of anxiety disorder among undergraduate medical students of sbks medical institute and research center because of lockdown. Materials and Methods: It was a cross-sectional study. Participants were sent a preformed questionnaire that included a GAD-7 scale along with risk factors and socio-demographic questions via college social media groups. Simple random sampling method was used to select students. Results: Out of the 301 responses analysed, results showed 11.63% were screened to be experiencing severe anxiety, 19.27% moderate anxiety, 29.57% mild anxiety. Disturbance in academic study schedule (odds ratio [OR] = 8.461, 95% confidence interval [CI] (4.159,17.212), P < 0.001), inability of the participants to go outside as a routine (OR = 2.837, 95% CI (1.701,4.734), P < 0.001), inability to perform extracurricular activities (OR = 2.017, 95% CI (1.223, 3.328), P = 0.006) and the lack of offline/On-campus experience were significant factors leading to increased anxiety for the students (OR = 4.185, 95% CI (2.494, 7.022), P < 0.001). Conclusions: 30.90% of the participants tested positive for anxiety disorder and disturbance in academic study schedule, lack of offline/on-campus experience, and inability to perform extracurricular activities were significant factors affecting anxiety levels of students.



How to cite this article:
Patel HD, Chauhan GD, Jain DN, Patel R. Anxiety disorder among undergraduate medical students of a rural tertiary care hospital of Gujarat, India due to Coronavirus Disease-19 pandemic lockdown.J Integr Health Sci 2021;9:54-59


How to cite this URL:
Patel HD, Chauhan GD, Jain DN, Patel R. Anxiety disorder among undergraduate medical students of a rural tertiary care hospital of Gujarat, India due to Coronavirus Disease-19 pandemic lockdown. J Integr Health Sci [serial online] 2021 [cited 2022 Jun 25 ];9:54-59
Available from: https://www.jihs.in/text.asp?2021/9/2/54/339649


Full Text



 Introduction



The coronavirus disease (COVID-19) pandemic in India is part of the 2019 global (COVID-19) pandemic caused by the Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. On January 27, 2020, the first case of COVID-19 was reported in Kerala, India.[1] SARS-CoV-2 is very virulent with airborne transmission and immoderate infectivity rate.[2] Due to its high level of infectivity and the increase in mortality among the general population, many countries, including India, have locked their populations and quarantined them to control the spread of the disease. These restrictive measures have proven to be effective, although there have been many concerns about their psychological impact and their impact on the mental health of the general population.[3] The Government of India had implemented lockdown from March 24, 2020, all over the country to avoid the spread of the infection.

Medical education is considered to be one of the most academically and emotionally demanding training programs out of any profession.[4] The medical students may experience a loss of external control which may harm their psychological well-being,[5] and can precipitate anxiety symptoms. As the rate of spread of the COVID-19 virus was increasing, lockdown was the only workable option available to slow down the spread of infection. This resulted in all the medical colleges discontinuing their offline lectures, practical sessions, workshops, conferences, sports, and other activities.[6] Instead, were conducting online classes and instructing their students to stay at home and practice social distancing. The examinations were postponed because of the implemented lockdown. There was a state of chaos among every medical student with no certainty to when this lockdown would ease or be called off. Although many educational institutes had launched online classes, it was difficult for the student to adapt to sudden transition from routine teaching methods and was stressful. This was true especially in the case of slow learners.[7] Generally speaking, it is well known that medical students have a higher degree of depression, anxiety, stress, and other forms of psychological disorders than the general population; this is due to the high-stress and competitive environment in which they study. In succession, the chaos created by the COVID-19 virus and lockdown is considered to be a source of additional tension and suffering for the general population, especially health workers and medical students.[8],[9]

One of the main issues in response to this lockdown that affected the medical students was isolation. Although isolation helps in achieving the goal of reducing infections, reduced access to family, friends, and other social support systems caused loneliness and boredom increasing mental issues like anxiety and depression.[10],[11]

We had done the present study to find and co-relate the findings for the above-mentioned problems among the undergraduate medical students of Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, to find out the psychological impact, i.e., anxiety disorder because of COVID 19 pandemic lockdown.

 Materials and Methods



It was a cross-sectional study conducted during June and July 2020. The primary aim of the study was to find the prevalence of Generalized Anxiety Disorder (GAD) in the medical students of Smt. B. K. Shah Medical Institute and Research Center due to the first COVID-19 pandemic lockdown. The GAD-7 scale was used to measure the Anxiety levels, and we took a cut-off value of 10. The value above 10 was considered as a provisional diagnosis of GAD. All participants were students of Sumandeep Medical College, Gujarat, India. All the participants pursuing their undergraduate degree from years 1st to 4th were invited to the study and it included those who gave consent in the study. The primary variable was to study the prevalence of GAD in the medical students of our college. There were a few secondary test variables and included a correlation of other stressors toward the development of GAD. We selected the participants by the simple random sampling method.

Study tool

The Study tool was comprising a structured questionnaire which inquired the socio-demographic details, including age, gender, and current year of study of the participants. There was an inquiry about the profession of their father, living status, their first source of information about COVID-19. We asked them to grade the amount of information present to them about the COVID-19 virus and to share their opinion on whether lockdown will control the spread of the COVID-19 virus in India. The effect of lockdown on time spent with gadgets and addictions (if any) was noted. The medical students also filled in the Generalised Anxiety Disorder Scale-7 (GAD-7).[12] It is an easy-to-use self-administered patient questionnaire, used as a screening tool and severity measure for Generalised Anxiety Disorder (GAD). This scale shows outstanding consistency (Cronbach's alpha = 0.911)[13],[14] It consists of seven items answered on a 4point Likert scale as follows:

0 = “not at all”1 = “several days”2 = “more than half of the days”3 = “nearly every day.”

The total score of GAD-7 scale ranges between 0 and 21[15] and depending on the score, severity of anxiety disorder can be categorised as follows:

Mild anxiety: “5–9”

Moderate anxiety: “10–14”

Severe anxiety: “15–21”

Data analysis

The data was compiled in Excel (2016) file and analysed using SPSS software version 26 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows. Armonk, NY: IBM Corp). Various statistical features such as Mann–Whitney test, one-way ANOVA analysis, and multiple regression test were used. Spearman's correlation coefficient r was used to evaluate the association of different variables/COVID-19 related stressors with each other. P < 0.05 was considered statistically significant. The imputation of lost values was not carried out.

Ethical considerations

This study was initiated after getting proper approval from the ethics committee of Sumandeep Vidyapeeth Institute. Valid consent was provided by all the participants to take part in the study. Confidentiality of personal information was maintained throughout the entire process.

 Results



The mean age of the participants was 20.53 (±1.30) years. Out of the total 301 participants, 161 (53.49%) were female and 140 (46.51%) were males. The participant distribution year-wise was 74 (24.58%) from 1st year, 65 (21.59%) from 2nd year, 90 (29.90%) from 3rd year, and 72 (23.92%) from 4th year. Of the 301 medical students, about 119 participants (39.53%) had no symptoms of anxiety, and 89 (29.57%) of students reported mild symptoms, a total of 208 (69.30%) which were screened negative, whereas the number of students with moderate, and severe anxiety was 58 (19.27%), 35 (11.63%), adding to 30.90%, which were screened to be positive.

Univariate analysis

The participant site of living, participant father's profession, and gender had no significant effect on anxiety (P > 0.05). A very low number of participants (N = 10) reported using any addictive substance, therefore we couldn't make any derivations from it. We also screened other factors through multivariate analysis but there were no significant findings to further warrant individual screening of the variables.

Increased time spent with gadgets is significantly associated with higher anxiety levels in medical students as shown in [Table 1]. Gaming may provide some medical students an escape from their reality. To not face the worries or stresses of real-life they might get addicted to gaming, resulting in negative consequences, such as academic failure or mental health issues.{Table 1}

[Table 2] represents the ordinal regression of the variables associated with anxiety. Chi-square value = 26.185, P < 0.001 shows a good model fit with the observed values.{Table 2}

Correlation between the coronavirus disease-19 lockdown related stressors (including on-campus experience and levels of anxiety during the coronavirus disease-19 pandemic)

The regression analysis clearly denotes that disturbance in academic study schedule is significantly associated with high levels of anxiety in medical students (r = 0.378, P < 0.001). The inability of the participants to go outside as a routine was positively related to the anxiety levels (r = 0.234, P < 0.001), and the inability to perform extracurricular activities was a significant factor for the development of anxiety in the participants (r = 0.160, P = 0.006). The lack of offline/On-campus experience was also a major factor affecting the anxiety levels of the students (r = 0.322, P < 0.001).

Furthermore, the results suggested a negative association between having adequate information about COVID-19 and the anxiety levels, i.e., participants who had adequate information were less likely to be anxious than those who thought that the information was not adequate (Z = −3.746, P < 0.001). The participants having no change in their routine gadget usage time were less prone to anxiety than those having their time spent increased (Z = ‒2.724, P = 0.006).

Analyzing participants' father's occupation revealed that 142 (47.18%) were professionals, 126 (41.86%) had their own business, 18 (5.98%) were into agriculture and the rest 15 (4.98) had another profession. Further, we came to know that the major source of information regarding the pandemic for over half of the participants (N = 204 (68.44%)) was the Internet, the second most common mode of information was News TV channels (N = 58 (19.27%)), other sources were friends/relative/colleagues (N = 30 (9.97%), newspaper (N-6 (1.99%)) and books (N-1 [0.33%]).

 Discussion



Massive outbreaks of infectious diseases like COVID-19, swine flu, etc., can lead to a poor mental health outcome.[16] Anxiety, Fear, worry, and others are some of the psychological effects experienced by college-going students because of pandemics or health emergencies.[17] There is so much uncertainty and lack of information during a pandemic that it can severely hamper the mental health of many individuals.[18],[19]

The primary test variable in our study was the prevalence of GAD prevalence among undergraduate students during the COVID-19 pandemic lockdown which came out to be 29.57% of students reported mild anxiety symptoms and 11.63% with severe anxiety symptoms. This result showed stark similarity to a study by Cao[11] in their GAD prevalence where 0.9% experienced severe anxiety and 21.3% experienced mild anxiety. Cao mentioned multiple factors associated with anxiety in college-going students regarding the pandemic lockdown like the place they will be inhabiting during the lockdown, source of money, fear of their family members or other relatives being infected with the COVID-19 virus. Cao mentioned several factors regarding the anxiety of college students due to a pandemic lockdown, such as where they will live during the closure period, funding sources, and fear that family members and other relatives would be infected with the COVID 19 virus.

A significant impact can be seen on students' studies which may have a long-term consequence. This effect may result from the direct psychological effect of the lockdown. Furthermore, some students may find it difficult to handle the new teaching methods, such as online classes and apps. It is also a possibility that the students might think that they are lacking behind compared to their colleagues in such a highly competitive field, which is an additional source of anxiety.

Consistent with this study, disturbances in academic study schedules were positively related to the levels of anxiety in medical students included in our study. The inability of the participants to go outside as a routine and to perform extracurricular activities was also noted a significant factor for the development of anxiety. The lack of offline/On-campus experience was also a major variable that affect anxiety levels. No change was seen in time spent on gadgets with less anxiety than participants with increased time spent on gadgets as seen in the study by Matar Boumosleh.[20]

According to our study, despite living with parents about 30.90% showed anxiety in moderate and severe forms, this was in contrast to findings by Cao,[11] which showed living arrangements with parents was a favorable factor to reduce anxiety. The fact that most participants live in buildings inside their houses with little contact with the outer world might explain the above findings.

The present study shows that the occupation and financial situation of the parents was not a significant factor to be considered in causing an increase in the anxiety of the students which is contradictory with a study by Liu[21] The study stated that the financial stability of the family during a lockdown is a significant factor that can be associated with anxiety in a student. The closure of an entire country undoubtedly affects various businesses, commercial activities, and trading's causing an instability in the income of a family. This economic pressure may be a burden on some causing anxiety symptoms and other psychological disturbances.

Husky[22] in their study reported that moderate-to-severe life stress was elevated in the overall sample (61.6%) and a high percentage of anxiety seen among those who did not change their residence (71.6%) compared to those who moved (50.5%). This might be possible because, those who moved lived in better houses, with family, with exposure to exterior spaces like yards and gardens, and had a sense of mobility compared to those who stayed at the same place.

If we compare the anxiety levels of the current COVID-19 lockdown with that of 2009 caused by the H1N1 pandemic high anxiety was also detected.[23] It mentioned that those in quarantine experience monotony, aloneness, irritation, worsening anxiety, and mental distress.

This lockdown has been a bad influence on the mental health condition of patients already suffering from a psychiatric illness. From the viewpoints of immuno-psychiatry service, psychiatric patients were more likely to report moderate to severe worries about their physical health.[24] In the students who were already dealing with a psychiatric illness had an aggravation in the severity of their disease and also an increase in the number of their episodes.

A negative association between having adequate information about COVID-19 and the anxiety levels, i.e., participants who had adequate information, were less likely to be anxious than those who thought that the information was not adequate. We noticed gender disparity in our results with a higher percentage of females (59.1%) suffering from GAD compared to males (40.9%) this finding was in contrast to the findings by Moreno[25] in their study, their study showed that male or female gender was equally stressed and had negative emotions because of pandemic.

Limitations

Regarding limitations, first, this was a cross-sectional study that was carried out in a rural tertiary care hospital and medical college set up under pandemic circumstances, the biggest limitation faced was the small sample size. Larger the sample size and variation among the target audience could have helped analyse the prevalence of Generalised anxiety disorder better. Second, our study was to identify the prevalence of Generalised Anxiety Disorder and other stressors among undergraduate medical students of a single university. There is a need to identify psychological disorders and stressors affecting anxiety and the perception of the general population regarding the situation.

 Conclusions



This study proves that there has been an increase in the prevalence of GAD in medical students as a result of the COVID-19 pandemic lockdown in India. The main stressors with a significant impact were disturbances in academic study schedule and lack of campus experience.

Universities and colleges should sanction special facility to assist students in coping with such anxious situations. There should be awareness programs set up periodically for the same.

The study also shows that there is a strong need for education facilities and the relevant ministries to recognize the need for an immediate and holistic policy to identify and manage the psychological impact of COVID-19 pandemic lockdown or any other future pandemics on students.

Ethics approval

The Sumandeep Vidyapeeth Institutional Ethics Committee approved this study.

Consent to participate

All the participants voluntarily gave their informed consent to take part in the study. Confidentiality and privacy were maintained during the entire process.

Consent for publication

All the participants voluntarily gave their informed consent.

Availability of data and material

Original Data and Material available on request to the corresponding author.

Financial support and sponsorship

Self-funding.

Conflicts of interest

There are no conflicts of interest.

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