Table 2: Year of Studies versus Frequency of medical students' mental health that is affected with COVID-19 pandemic Cross tabulation.


						Frequency of medical students' mental health that is affected with COVID-19 pandemic						Total
						yes		No		Maybe
Year of Studies	Year 1		Count			10		1		7		18
			Expected Count			9.6		2.1		6.2		18.0
			% within Year of Studies			55.6%		5.6%		38.9%		100.0%
	Year 2		Count			14		5		9		28
			Expected Count			15.0		3.3		9.7		28.0
			% within Year of Studies			50.0%		17.9%		32.1%		100.0%
	Year 3		Count			13		3		14		30
			Expected Count			16.0		3.6		10.4		30.0
			% within Year of Studies			43.3%		10.0%		46.7%		100.0%
	Year 4		Count			10		2		1		13
			Expected Count			7.0		1.5		4.5		13.0
			% within Year of Studies			76.9%		15.4%		7.7%		100.0%
	Year 5		Count			7		1		4		12
			Expected Count			6.4		1.4		4.2		12.0
			% within Year of Studies			58.3%		8.3%		33.3%		100.0%
Total			Count			54		12		35		101
			Expected Count			54.0		12.0		35.0		101.0
			% within Year of Studies			53.5%		11.9%		34.7%		100.0%
Chi-Square Tests
		Value		df	Asymp. Sig. (2-sided)		Exact Sig. (2-sided)		Exact Sig. (1-sided)		Point Probability
Pearson Chi-Square		7.970^a		8	.436		.448
Likelihood Ratio		9.041		8	.339		.420
Fisher's Exact Test		8.193					.394
Linear-by-Linear Association		.627^b		1	.428		.435		.228		.026
N of Valid Cases		101

a. 7 cells (46.7%) have an expected count of less than 5. The minimum expected count is 1.43.

b. The standardized statistic is .792.

Table 3: Race of medical students versus Frequency of medical students' mental health that is affected with COVID-19 pandemic Cross-tabulation.


			Frequency of medical students' mental health that is affected with COVID-19 pandemic			Total
			yes	No	Maybe	Total
Race of medical students	Malay	Count	30	8	26	64
		Expected Count	34.2	7.6	22.2	64.0
		% within Race of medical students	46.9%	12.5%	40.6%	100.0%
	Chinese	Count	5	1	0	6
		Expected Count	3.2	.7	2.1	6.0
		% within Race of medical students	83.3%	16.7%	0.0%	100.0%
	Indian	Count	17	3	9	29
		Expected Count	15.5	3.4	10.0	29.0
		% within Race of medical students	58.6%	10.3%	31.0%	100.0%
	Others	Count	2	0	0	2
		Expected Count	1.1	.2	.7	2.0
		% within Race of medical students	100.0%	0.0%	0.0%	100.0%
Total		Count	54	12	35	101
		Expected Count	54.0	12.0	35.0	101.0
		% within Race of medical students	53.5%	11.9%	34.7%	100.0%

Chi-Square Tests
	Value	df	Asymp. Sig. (2-sided)	Exact Sig. (2-sided)	Exact Sig. (1-sided)	Point Probability
Pearson Chi-Square	6.447^a	6	.375	.367
Likelihood Ratio	9.120	6	.167	.197
Fisher's Exact Test	6.264			.339
Linear-by-Linear Association	2.448^b	1	.118	.126	.064	.012
N of Valid Cases	101

a. 7 cells (58.3%) have an expected count of less than 5. The minimum expected count is .24. b. The standardized statistic is -1.565.

The cross-tabulation table 3 shows that 46.9% of Malay, 83.3% of Chinese, 58.6% of Indians and 100.0% of Others said “Yes” that their mental health is affected by the pandemic Covid 19. In addition, 12.5% of Malay, 16.7% Chinese, 10.3% Indians and 0.0% Others reported that they are not affected by the pandemic COVID-19 while 40.6% of Malay, 0.0% Chinese, 31.0% Indian and 0.0% Others are answered “Maybe” their mental health is affected by pandemic COVID19. In this table, seven cells have an expected count of less than 5%. Thus, if the expected count <5 is more than 20% and the assumption is met, then Fisher Exact test value will be used. The p-value > 0.05(p= 0.339) and thus does not reject the null hypothesis of the study. There is no significant association between the race of medical students and their mental health status during the pandemic COVID19. The others race have a higher proportion to having mental health issues compared to the Malay, Chinese and Indians.

Figure 5 shows the frequency of how often the medical students felt upset because of something that happened unexpectedly during the pandemic.

The pie chart (figure 5) above shows that among 101 medical students that responded to the question, 17(16.83%) of them have very often felt upset because of something that happened unexpectedly during the pandemic while the majority of medical students have somewhat often felt upset because something happened unexpectedly with a frequency of 47(46.53%). 30 (29.70%) of them not so often felt upset because of something that happened unexpectedly. However, a minority of students do not feel upset at all with a frequency of 7(6.93%).

Figure 6 shows the frequency of how often medical students have felt unable to control the important things in their life during the pandemic.

The pie chart (figure 6) summarizes the frequency of medical students feeling unable to control the important things in their lives. 33(32.67%) medical students not so often felt unable to control the important things in their lives. In addition, 43 (42.57%) of them were answering “somewhat often” which takes part as the majority of them felt unable to control the important things in their lives. Meanwhile, 18(17.82%) of them answer very often and 7(6.93%) of them answer not at all in feeling unable to control the important things in their lives.

Figure 7 shows the frequency of how often medical students have felt nervous and stressed during the pandemic.

The pie chart (Figure 7) indicates 19.80% of medical students have very often felt nervous and stressed. In fact, “somewhat often” feeling nervous and stressed become the dominant symptoms of mental health issues which 44 (43.56%) of them take part in. Next, about a third of them not so often felt nervous and stressed during a pandemic (29.70%). After all, a minority of them answered “not at all” for feeling nervous and stressed with a frequency of 7 (6.93%).

Figure 8 shows the frequency of how often medical students have faced difficulties in their studies during the pandemic.

The pie chart (Figure 8) displays the frequency of how often medical students have faced difficulties in their studies. 23 of them seem to have very often difficulties in their studies involving 22.77% of the sample size while 48 medical students take part in the majority of them “somewhat often” face difficulties in their studies (47.52%). Meanwhile, 25 (24.75%) and 5 (4.95%) of them are not so often and not at all face difficulties in their studies.

Figure 9 shows the frequency of how often medical students are effectively coping with important changes that are occurring in their life during the pandemic.

The pie chart (Figure 9) confirms the frequency of how often medical students are effectively coping with important changes that are occurring in their life. 15 (14.85%) of them are very often effectively coping which means a positive effect on their mental health. Meanwhile, “somewhat often” was the choice of the majority of medical students with a frequency of 43 (42.57%) of them. Still, 40 (39.60%) medical students are “not so often” effectively coping with important changes. However, the negligible amount with a frequency of 3(2.97%) medical students are “not at all” felt to effectively cope with important changes that occur in their lives.

Figure 10 shows the frequency of how often the medical students found that they could not cope with all the things that they needed to do during the pandemic.

The pie chart (Figure 10) states the frequency of how often the medical students found that they could not cope with all the things that they needed to do. Of the minority of medical students involving 9 of them (8.91%) chose “very often” because they could not cope with all the things that they needed to do. Next, 42 of them found that they “somewhat often” could not cope with all things. Conversely, 40 (39.60%) and 10 (9.90%) of them chose “not so often” and “not at all” as their answers, which shows they could not cope with all the things that they needed to do.

Figure 11 shows the frequency of how often the medical students felt that things were not going their way during the pandemic.

The pie chart (Figure 12) illustrates the frequency of how often the medical students felt that things were not going their way. The majority of them involved 37 medical students (36.63%) who felt “Somewhat often” and “Not so often” for each answer because things were not going their way. Besides, 24 medical students (23.76%) choose “Very often” as they felt things were not going their way and a minority of them (3, 2.97%) felt “Not at all” as the answer for things were not going their way.

Figure 12 shows the frequency of how often the medical students felt not confident about their ability to handle personal problems during the pandemic.

The pie chart (Figure 12) shows the frequency of how often the medical students felt not confident about their ability to handle personal problems. 15 (14.85%) of them chose “very often” and 36 (35.64%) of them chose “somewhat often” as their answers for feeling not confident about their ability to handle personal problems. In addition, 38 of them “not so often” felt not confident about their ability involving 37.62% of respondents and this took the majority of the answer. Still, some medical students felt confident about their ability to handle personal problems involving 12 of them (11.88%).

Figure 13 shows how often medical students are not able to control irritations in their life during the pandemic.

The pie chart above as in figure 13 depicts the frequency of how often medical students are not able to control irritations in their life. 22 (21.78%) and 29 (28.71%) of them need to give more attention to the fact that they are chosen “very often” and “somewhat often” not to be able to control irritations in their lives. Besides, the majority of students involving 44 (43.56%) of them are “not so often” unable to control irritation which is considered normal in their lives. In addition, few medical students can control irritation in their lives as they chose “not at all” as their answer involving 6 of them (5.94%).

Figure 14 shows the frequency of how often the medical students felt that they were not on top of things during the pandemic.

The pie chart above (Figure 14) explains the frequency of how often the medical students felt that they were not on top of things. There are 27(26.73%) and 41(40.59%) medical students who need to get more attention because they “very often” and “somewhat often” felt that they were not on top of things. Besides, 25.74% of the total sample size “not so often” felt that they are not on top of things. However, the minority of them felt they were on top of things in fact to the answer of “not at all” involving 7 medical students (6.93%).

To study the factors that affected the mental health of medical students the most:

Figure 15 shows the factors that affected the mental health of medical students the most during the pandemic.

The bar chart (Figure 15) shows the factors that affected the mental health of medical students the most. A majority of medical students answered that the pandemic has increased the level of social isolation involving 29 of them (28.71%). In addition, the second highest followed by class workload. The effect of COVID-19 on class workload has increased among medical students with a frequency of 21 of them (20.79%). Meanwhile, 13 of them (12.87%) experienced disruption to their sleeping habits caused by COVID-19 while 11 of them indicated that covid19 increased their level of fear and worry about their health and the health of their loved ones. Besides, there are a few students (9,8.91%) who stated that the pandemic has resulted in significant changes in the living environment. When asked about the impact of the COVID-19 pandemic on depressive thoughts, 8(7.92%) mentioned that they were experiencing some depressive thoughts. Also, COVID-19 has negatively impacted the eating patterns of 6 medical students (5.94%). A minority of 2 students (1.94%) expressed their concerns about their financial difficulties being impacted by COVID-19. Alarming, there are 2 students (1.94%) stated that the pandemic has led to some suicidal thoughts.

Figure 16 shows the frequency of medical students' rates on their mental health during the pandemic.

The bar chart (Figure 16) shows the frequency of medical students’ rates of mental health. Surprisingly, 4 of them have excellent mental health during the pandemic COVID 19 involving (3.96%). 7 of them (6.93%) have very good mental health conditions as they seem to rate it as 9. Meanwhile, rates 8 and 7 have a similar frequency of medical students which is 17 (16.83%) of them have good mental health conditions. However, the majority of medical students rate mental health themselves as 6 which is considered a need to be careful if it gets worse. This rate of 6 involves 22 medical students (21.78%). In addition, 18(17.82%) and 8 (7.92%) of them rate their mental health conditions at 5 and 4. Still, there are a few medical students who rate 1, 2, and 3 as their level of mental health conditions involves 2(1.98%), 1(0.99%), and 5 (4.95%) of them. These students need more attention and counselling due to the impact of COVID-19 on their mental health.

DISCUSSION:

Medical students comprise a population that is considered particularly vulnerable to mental health concerns [6]. The findings of this study bring into focus the effects of pandemic-related transitions on the mental health and well-being of this specific population. To start with, in this study, there is some social demographic data that has been collected before the questions which are related to the topic. The demographic data was gender, year of study and also race. Thus, from the data, the association between the demographic profile with the mental health of medical students were determined by calculating the p-value.

Based on the study conducted, there were more female respondents (66.34%, 67 respondents) than male respondents (33.66%, 34 respondents). The p-value was more than 0.05(p= 0.232) and thus does not reject the null hypothesis of the study. Thus, there is no significant association between the gender of medical students with their mental health status during the pandemic COVID19. Research by Sartorao Filho et al. (2020) [7], indicated that female medical students were more likely than male medical students to suffer depression symptoms during the pandemic. In contrast, a study from Frederiksen et al., (2020) [8] reported that when compared to males, females are more proactive in their response and awareness of the epidemic resulting in more stability in their mental health.

Besides, the majority of the respondents were year 3 students. Similar to gender, the p-value of years of study is more than 0.05(p= 0.394) and thus does not reject the null hypothesis of the study. Thus, there is also no significant association between years of studies of medical students and their mental health status during the pandemic COVID-19. The last social demographic which is race also depicts a similar pattern with other demographic profiles in which the p-value is more than 0.05(p= 0.339). Thus, it does not reject the null hypothesis of the study resulting in no significant association between the race of medical students and their mental health status during the pandemic COVID-19.

Since we did not find any significant association between all the demographic variables with mental health among medical students, likely, the worsening of the mental health status of the medical students found in our study is associated with COVID-19-related factors. These factors were obtained through data collection and other questions as mentioned in the result. By conducting an online survey through google Forms amid the pandemic, we found that more than half of medical students experienced mental health issues during the pandemic COVID-19. Our findings suggest a considerable negative impact of the COVID-19 pandemic for a variety of reasons.

Most of the respondents agreed that the pandemic has increased the level of social isolation that leads to depletion in their mental health. Anxiety, sadness, self-harm, and suicidal behaviour were all found to be strongly linked to social isolation [9]. This finding was supported by Reynolds et al., (2008) [10] whereby research found that social isolation for a longer period might harm mental health such as depression. In a recent study conducted in India during the COVID-19 outbreak, one-fifth of adults were found to be depressed or stressed, and one-fourth were found to be anxious [11].

In addition, the second highest factor that led to mental health issues was class workload. From the study, it was revealed that students during online learning are more prone to fatigue and emotional exhaustion as a result of changes in interpersonal interactions among colleagues. Knebel (2021) reported that students have a strong need to interact with their peers during physical class [12]. However, due to COVID-19, online learning and quarantine procedures reduced student interaction, which, in our opinion, contributed to colleague-related burnout.

The change to online learning happened all of a sudden. Thus, they have to adapt to the new learning environment of online classes at home which can cause some disruption from family members making the learning environment more stressful. Moreover, students are also attached to their responsibilities at home such as doing house chores and many more. Thus, aside from academic matters, the students are also burdened with their environment’s work resulting in a massive workload which eventually disturbs their mental health.

Meanwhile, some medical students have a disruption to their sleeping habits caused by COVID-19. In fact, due to the physically and emotionally challenging and intense training that medical students undergo, they are more prone to poor sleep quality according to Wong et al., 2005 [13]. The same was concurred by Suganya et al., 2022 [14]. However, due to lockdown measures and travel restrictions, students are experiencing decreased physical activity, a lack of schedule, altered living conditions, more screen time and time spent on social media, and an altered sleep-wake cycle, including increased daytime nap duration according to Majumdar, Biswas and Sahu, 2020 [15]. Therefore, all of these variables, combined with the increased responsibilities of medical school, have resulted in poor sleep, which has an impact on mental health. Furthermore, based on some studies, sleep deprivation harms neurocognitive and psychomotor performance, emotional well-being, working capacity, academic performance, physical and mental health, and life quality [16-19].

Besides, 11 out of 101 respondents suggested that COVID-19 increased their level of fear and worry about their health and the health of their loved ones. Medical students, as required, have to do the clinical posting physically in the hospital which would be at risk and have a higher possibility of in-contact with various patients. Thus, it was acceptable for them to be worried as long as it would not disturb their daily life. In a study of medical students in Pakistan, over 76 per cent expressed concern about contracting COVID-19 during clinical placements and were even more concerned about receiving inadequate care and treatment if they got the illness [20].

In addition, other matters make the medical student worried. For example, their involvement as frontline workers with insufficient clinical training, concern about the future, lack of understanding, and lack of access to personal protection equipment has instilled fear in them. Thus, medical students felt worried during the pandemic till their mental health got disturbed.

Besides, a few students stated that the pandemic has resulted in significant changes in the living environment. They need to adapt to the new environment which causes a few problems and challenges. For instance, the challenge that students confront with online learning is that working from home makes it difficult to maintain a healthy work-life balance. Students had the opportunity to develop a healthy work-life balance before the pandemic by dividing their time and focusing on school and healthy family and friends-oriented activities [21]. Working from home has blurred the line between the two, causing worry.

Unfortunately, two students stated that the pandemic has led to some suicidal thoughts. This situation can be considered severe and requires help from professionals to avoid any unpleasant incident to occur. Suicidal thoughts are one of the signs that their mental health is in the worst state. According to a study from Bergmann, Muth and Loerbroks [22], when compared to the general population, medical students' mental health was shown to be even worse. The findings of this study were also supported by Marshall et al. (1996) [23], in which the research claimed that medical students were also shown to have higher rates of depression, suicidal ideation, suicide rates, substance abuse, and mental health issues. Despite having better access to mental health treatment than the general population, medical students were less likely to seek help, owing to the stigma associated with mental health illnesses.

Next, according to the pie chart shown in figure 7, 19.80% of medical students have very often felt nervous and stressed. When compared to pre-COVID-19 levels, similar longitudinal studies in college students reported a significant rise in sadness and anxiety [24,25]. The stressful impact of the pandemic could be attributed to medical students' sudden academic challenges, uncertainty about the future, fear of infection, news about a shortage of personal protective equipment, quarantine-induced boredom, frustrations, lack of freedom, and fears caused by rumours and misleading news in the media [26,27].

In addition, family distractions and lack of internet access also appear to be the factors that contribute to the higher level of stress among medical students. These two problems were the most significant obstacles to virtual learning as they may put students with large families or restricted internet connections at a disadvantage. Furthermore, students' mental health, which has recently been found to be influenced by the COVID-19 epidemic, may be negatively impacted due to a lack of engagement with friends and colleagues, which has led to an increase in stress levels.

Besides, the pie chart in figure 8 depicts the frequency of how often medical students have faced difficulties in their studies. 23 out of 101 students seem to have very often difficulties in their studies. According to Bolatov et al. (2021), medical students enrolled in online learning showed changes in academic performance in terms of burnout syndrome, depression, anxiety, and dissatisfaction with academic performance [28]. The finding of this research was also supported by Son et al. (2020), in which concerns about academic performance become a stressor related to elevated levels of stress, anxiety, and depressive thoughts among students [29].

Furthermore, medical students also have fewer physical interactions with their colleagues, which is one of the factors that led to the difficulties in the studies. According to Furrer and Skinner (2003), students who have had pleasant connections with their peers are more motivated, show greater engagement, and perform better academically [30]. Plus, they often face challenges such as abrupt changes in their training schedule, such as teaching and assessment via online sessions, less patient contact, and decreased peer interactions. These changes result in more screen time, possibly disrupting their training.

Additionally, during this pandemic, most examinations were conducted virtually. Thus, most exams that are open book and in an unrestricted setting are expected to be less prone to exam anxiety. However, this does not address the family and noise disturbances which may still affect the exam performance. Lastly, aside from maintaining academic performance, medical students were also concerned about obtaining the essential skills to feel secure in their ability to practise in the future. As medical students are in unfamiliar territory, all of these elements may have an impact on their mental and emotional well-being.

CONCLUSION:

In a nutshell, the impact of COVID-19 on mental health among medical students has been studied. Due to the long-lasting pandemic situation and numerous measures such as lockdown and stay-at-home orders, COVID-19 brings negative impacts on higher education of medical students, self and social isolation, disconnection from friends and teachers resulting in more medical students than ever experiencing feelings of helplessness, isolation, grief, anxiety and depression. The issue of mental health is not only relevant but crucial. Demand for health support services has increased exponentially as a result.

In this study, severity levels of depression and anxiety, stressors related to the pandemic, and barriers students experienced in handling the pandemic-related stress have increased due to many factors such as social isolation, own health and the health of loved ones, financial difficulties, depressive thoughts, class workload, changes in modified living environment, eating patterns and sleeping habits.

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Received on 22.12.2022 Modified on 29.01.2023

Research J. Pharm. and Tech 2023; 16(2):809-820.

DOI: 10.52711/0974-360X.2023.00139

METHODOLOGY:

Variables