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   Table of Contents      
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 14-20

Perceived Stress Among Medical Students and Doctors in India During COVID-19 Pandemic


1 Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi, India
2 National Vector Borne Disease Control Programme, Ministry of Health and Family Welfare, Government of India, New Delhi, India
3 Department of Paediatrics, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi, India
4 Department of Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi, India

Date of Submission17-Feb-2021
Date of Decision18-Feb-2021
Date of Acceptance11-Mar-2021
Date of Web Publication28-Apr-2021

Correspondence Address:
Dr. Anurag Mishra
Professor, Department of Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_17_21

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  Abstract 


Objective: The present study was undertaken to assess the perceived stress levels in medical students and doctors in India during coronavirus disease (COVID-19) pandemic. Various studies have been done to assess the perceived stress levels among medical professionals and other associated health care workers, but no significant study has been done among medical students. This study is done with a special emphasis on the latter. Methods: A semi-validated online questionnaire was used to collect stress scores among medical students and doctors using Perceived Stress Scale. The aggravating and relieving factors of stress were also recorded and analyzed. Results: A total of 346 responses were analyzed from across various medical schools of country. The mean cumulative stress score among participants was 18.2 ± 6.8 indicating moderate stress with 34 (9.8%) respondents reporting high stress scores. Female gender was identified as a risk factor (OR 2.76, 95% CI: 1.58, 4.78; P < 0.001). Stress scores were higher among those not directly involved in COVID-19 care (OR 1.08, 95% CI: 0.57, 2.05; P = 0.47). Education and health of the family were major concerns recorded in 39% and 38% participants, respectively. The main stress aggravating factors were found to be news/media (39%) and unsafe work environment (16%). Among the stress relieving factors, hobbies (31%), family support (25%), and meditation (23%) were common. Conclusions: A moderate to high stress was reported in medical students and doctors. Educational concerns should be equally addressed as health care delivery and personal safety.

Keywords: Anxiety, education, meditation, mental health, undergraduate students


How to cite this article:
Agrawal N, Sharma H, Dabas A, Mishra A. Perceived Stress Among Medical Students and Doctors in India During COVID-19 Pandemic. MAMC J Med Sci 2021;7:14-20

How to cite this URL:
Agrawal N, Sharma H, Dabas A, Mishra A. Perceived Stress Among Medical Students and Doctors in India During COVID-19 Pandemic. MAMC J Med Sci [serial online] 2021 [cited 2021 Jun 12];7:14-20. Available from: https://www.mamcjms.in/text.asp?2021/7/1/14/314881




  Introduction Top


Novel coronavirus disease (COVID-19) has engulfed the entire globe as a deadly and unrelenting enemy. As on May 6, 2020, India reported 33,514 active cases and 1694 deaths due to COVID-19.[1] It has left global leaders, administrators, mission directors, policy makers, and health care providers feeling anxious, helpless, and distressed. The pandemic and the subsequent social distancing measures and lockdown have led to disruption in daily routine of people across the globe.

In the early literature from the affected regions in China regarding perceived stress among general population and survivors or contacts of COVID-19, it was reported that the concerns ranged from self-health to health of family and friends. Lack of social interaction, loss of movement, and general panic among colleagues and family members also resulted in increased anxiety and stress.[2] Health care providers are at a higher risk of stress than general public due to associated occupational risk. Government of India imposed pan India lockdown from March 26, 2020. Since then, all the colleges across country have been shut down indefinitely. The uncertainty and potential negative impact on academic progression may have an adverse effect on the mental health of students.[3] Though online classes via means of web-based applications and online portals have been initiated, the lack of primary firsthand experience during clinical rotations might also be a contributing factor to increasing stress among medical students.

There have been several studies in different countries to assess the stress among health care professionals, but similar data on medical students during COVID-19 pandemic are lacking. The present study was undertaken to assess perceived stress among medical students and health professionals in India through an online survey.


  Methodology Top


A cross-sectional study was conducted during April 8–17, 2020, almost 3 weeks after total lockdown was implemented in India. An informed consent was taken from all respondents before filling the form. The data were collected through an online, semi-validated questionnaire (Annexure 1) for recording COVID-19 associated stress among medical students and doctors across India. The responses to the questionnaire were anonymous and were used to collect the information pertaining to demographic details of the participants and perceived stress using a validated tool (Perceived Stress Scale [PSS]).[4] The PSS score was classified based on cumulative score (range 0–40) as “low stress” if 0 to 13, “moderate” if from 14 to 26, and “high” if score was from 27 to 40. Qualitative parameters relating to factors aggravating or relieving stress were also collected. The study was approved by the Institutional Ethics Committee.

A sample size of 323 participants was calculated with desired precision of 0.05% and 95% confidence level based on an earlier study that reported mental distress in 71.5% health care workers during COVID-19 pandemic from China.[5]

Date Analysis

Data were compiled using MS Excel and analyzed using MS Excel and Statistical Package for Social Sciences version 25.0 (IBM Corp.). Quantitative data were expressed by mean and standard deviation and significance level of differences between the means were tested by Student t test (unpaired). Noncontinuous data were expressed as proportions compared between groups by chi-square test. Risk was calculated using odds ratio with 95% CI. A P < 0.05 was considered statistically significant.


  Results Top


A total of 351 responses were recorded and from which five responses were removed as they did not fit in the eligibility criterion to maintain homogeneity of data. A total of 346 responses from medical students and doctors were evaluated in the final analysis. [Table 1] shows the demographic distribution of the participants, where majority (86.4%) were from 15 to 30 years of age. The demographic distribution was found to be similar to the population in a medical school. The study participants belonged to 17 states, the majority of whom (260, 75%) were from Delhi.
Table 1 Demographic characteristics of study population (N= 346)

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[Table 2] shows the distribution of respondents for different components of the score. The cumulative stress score was 18.2 ± 6.8 (range 0–40), which indicates moderate stress in the study participants. Overall, 84 (24.3%) had low, 228 (65.9%) had moderate, and 34 (9.8%) had high stress. Age did not show any statistical association with total stress score (r = –0.12, P = 0.8). [Table 3] shows the risk factors evaluated for moderate or high stress. Female gender was identified as an important risk factor. The stress scores were slightly higher among those who were not directly involved with care of COVID-19 patients, though not significant statistically (P>0.05). The stress scores were higher in postgraduates and residents when compared to students or faculty (P>0.05).
Table 2 Proportion of respondents for components of Stress stress score, N = 346 [(Data data shown as n (%)][%])

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Table 3 Risk factors for moderate or high stress scores (N=346)

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Sixty-nine (20%) participants had felt stressed or nervous “often” or “very often” in last 30 days. Overall, the chief areas of concern were found to be education and health of the family among 135 (39%) and 129 (37%) respondents, respectively [Figure 1]a. Health of family (31, 48%), health of self (26, 39%), work (21, 32%), and education (20, 30%) were major concerns among people directly involved in providing care to COVID-19 patients [Figure 1]b. The PSS score was higher in residents and postgraduate students than undergraduate students and faculty; P > 0.05 [Table 2]. Over 80% of the postgraduate students and senior residents felt stressed, indicating higher stress among those who were posted or soon to be posted in COVID-19 duty [Figure 1]c.
Figure 1 Concern areas for those on duty

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A total of 219 participants responded to the question on stress aggravating factors. Eighty-six (39%) respondents identified news/media as the most common cause of stress. The other top responses for factors increasing stress were work environment (36, 16%), public behavior (26, 12%), academics (23, 11%), health concerns (18, 8%), and lack of activity (17, 8%) [Figure 2] and [Figure 3]a]. Other factors mentioned included deliberations and discussions about COVID-19, piling of work, ill treatment of health care workers, the burden of disease, being lonely, and implications of lockdown.
Figure 2 Factors affecting stress. (a) Stress relievers, (b) stress aggravators, and (c) suggestions for stress relieving activities in campus

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Figure 3 Effects of social media: overall and according to categories

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A total of 241 responses were recorded for stress relieving factors. Hobbies were the most frequent response in 75 respondents (31%), followed by family time (61, 25%), yoga/meditation/exercise (55, 23%), phone calls (55, 23%), and television/online entertainment (46, 19%) [Figure 2]b. Other responses were working/studying, sleeping, video/mobile games, government initiative/positive research, staying off news, playing with pets, and eating. Only one respondent mentioned smoking as a stress relieving factor.

A large number (315, 91.4%) of respondents expressed their wish toward having certain stress relieving activities in campus on regular basis. The most frequent suggestion was meditation (86, 43%), in-campus counselling service (54, 27%), group interaction activities (52, 27%), outdoor games/yoga (36, 18%), and cocurricular activities (20, 10%) [Figure 2]c.

Respondents were asked to comment on the perceived role of social media on stress. Of them, 146 (42%) participants felt that social media aggravated the stress, whereas 76 (22%) felt that it decreased the stress. Among the rest, 15% of the participants stated that social media had no effect on the stress and 21% did not opine. The negative impact of social media was perceived more by faculty and senior residents. Views were divided among medical undergraduates and postgraduate students. Similar pattern was seen among educational subgroups, where students in higher semesters were more negatively impacted than those in lower semesters. Males and females were found to be equally affected by social media. People staying in hostels were more negatively impacted by social media as compared to those staying at home, with about 55% of respondents staying in hostels reporting negative impact of social media as compared to 40% of those staying at home.


  Discussion Top


The present study reports a moderate level of perceived stress among medical students and doctors. The primary respondents of our study questionnaire were medical students and young doctors of ages from 15 to 30 years. The majority of respondents were concerned about the health of their family and the potential threat of contracting the disease themselves or further spread of virus.

The pandemic of COVID-19 has underlined the role of medical staff to public, but it is also arguably increasing the stress and performance pressure on health care workers. The study showed moderate stress score in the study population. This was the period when most administrative decisions for dealing with the pandemic were in place in most states with complete lockdown being enforced. Few respondents reported uncoordinated political and administrative efforts as a cause for stress, though many expressed that strict and proactive initiatives by the government acted as stress busters. Live address of the Prime Minister and initiatives to acknowledge health staff were welcomed steps. Therefore, the extreme and early precautionary measures taken by the Government of India could have been a mitigating factor for the stress.

Most of the available literature has focused on concerns of health care providers who are at a higher risk of stress than the general public for associated occupational risk. The added fear of social isolation and stigmatization while caring for infected people/patients and the physical and mental exhaustion due to long duties, isolation and lack of recreational opportunities, legislative hassles and perceived helplessness, lack of personal protective gear, and privacy are known risk factors for stress among health care providers, which were similarly reported in our study.[6]

Medical students remain a vulnerable group. A meta-analysis of 69 studies comprising 40,348 medical students reported higher stress among students from Middle-East and Asia with one in three students reporting higher stress as compared to general population.[3] COVID-19 crisis was an additional risk factor as after the complete lockdown from March 26, 2020 was initiated in India, all the educational institutions were shut down indefinitely. Medical students faced an added disadvantage of missing the clinical rotations and interaction with patients, aside from lack of regular classes. The present study also reported higher stress levels in those who were not directly involved in providing COVID-19 care (mostly medical students) than frontline health workers. The additional concerns included health of self and family. A study from 194 cities of China of over 1200 respondents showed moderate to severe stress in 54% participants along with depression and anxiety. The public was worried about health of self and family and the risk of stress was higher among female gender, students and those with physical symptoms of COVID-19, similar to our study.[2] The uncertainty and potential negative impact on academic progression had an additional adverse effect on the mental health of students.[2]

Stress is an important factor responsible for poor performance of medical students medically, professionally, and socially. On the one hand, stress is associated with several diseases[7], and on the other it is recognized as a cause of loss of interest, unprofessional behaviors, and burnouts.[8]

Online classes via means of web-based applications and online portals were initiated in a few medical institutions; however, clinical and practical training has no alternative. The students are young and inexperienced and can be misled through wrong and depressing information. Students can also get demotivated by the perceived apathy and helplessness of the health care linkages, which may be devastating for their future medical career. The high level of anxiety among medical students was worrisome as students may get disillusioned to continue their career in this noble profession soon if corrective steps are not taken timely.

Female gender reported higher stress in the present study. This finding corresponds to previous epidemiological studies which reported that females were at higher risk of developing stress under disarmed situations.[1],[9] In a study conducted in Egypt, where PSS was used, female medical students reported to have higher stress than nonmedical students (OR 2.55, 95% CI: 1.2, 5.5).[10] One of the reasons may have been underreporting of stress by males as they consider it as sign of weakness and not fitting to masculinity.[11]

Respondents living at home or hostel (89.9%) were found to be more secured in the present study. Thus, a safe and warm environment with a minimal degree of human interaction was found to be helpful as also suggested by previous studies.[6],[12]

It was also found that people were worried by the misinformation circulated in newspapers and TV channels. This negative impact was seen more with advancing age and work experience. The usage pattern might be an important factor and needs to be studied further. As people mentioned social media as both relieving and aggravating factors for stress, the content and source were most likely the decisive factors for this difference. A review of 24 papers on impact of quarantine reported that measures such as rapid, effective communication and information and maintaining essential general and medical supplies were a few of the supportive factors during quarantine periods.[13] The use of valid information portals by the government and health authorities like Aarogya Setu app was also recommended.[1],[14]

Various support models have been suggested to relieve stress among health care providers. Some of these include provision of basic needs, improved communication, social support, flexible working hours, and reorganization of tasks to cater to urgent-only tasks.[6] In addition, provision of a positive environment and psychological support has also been advocated in a few centers. These services should be destigmatized along with improving their outreach. Health care providers should be helped and supported for self-care and awarded frequent appreciation and encouragement to keep their morale high.[15],[16]

Educational authorities need to focus on and incorporate more case-based discussions and develop applications to give a parallel clinical experience to students. As tested in Africa in collaboration with European universities, concept of blended learning, that is, using a mixture of online resources and materials, synchronous online interaction between students and teachers across different colleges or even countries complemented by face-to-face meetings, and in-class interaction between students and tutors should be promoted.[17]

Interventions based on mindfulness are proven to have decreased stress, anxiety, and depression and improve mindfulness, mood, self-efficacy, and empathy among medical students. Mindfulness training can be adapted and integrated into health professional training program relatively easily due to the range of presentation.[18] Practicing meditation and seeking spiritual freedom should also be advocated as a means to calm the mind and soul and de-stress the body. Hobbies were listed as one of the de-stressor activities by respondents in the present study, which usually lose out on their importance due to overemphasis on academic performance during routine work. This pandemic has made students realize the importance of creativity and cocurricular activities as well.

Yoga/meditation is becoming more and more popular in youth and is also expressed by the respondents in this study. They identified it as a potent stress buster. TV and online entertainment content proved to be a major boon at this time. Several respondents specially mentioned the initiative of Doordarshan to air old classics especially Ramayan. Contrary to popular belief that people now are losing touch with culture and old values, Ramayan became the most viewed program in the world during this time.[19]

People also could find time to spend with family playing games such as cards and Ludo, chitchatting, cooking, and engaging in other leisure hobbies. It is well established that students/professionals with creativity can handle stress better.[20] These were indeed welcomed from daily hustle and busy schedule. Social ties and leisure activities have been reported to reduce stress in medical students.[12] Other corrective measures that can be taken to lower the stress would include introduction and active management of online anonymous talk platforms and support platforms. Online psychological interventions in the form of psychotherapy could also be worked upon.[2] Additional workplace-related stressors should be minimized, virtual meetings should be encouraged even in health care facilities, logistics should be ensured to be smooth by leaders, and peer support should be promoted.[15] The authorities should also play a supportive and appreciative role to keep up the morale of workers of all tiers during such unforeseen conditions.The present study however has a few limitations as it lacks equal representation from other medical colleges and states. Thus, the findings may not be generalizable to all parts of the country. The survey was administered only at one time. Probably a repeat survey after better administrative preparedness and lockdown relaxation measures would have affected the stress scores. However, the present study measures stress and related factors in a large sample, including medical students, whose concerns have not been addressed earlier.

Rudolf Virchow said “Medicine is a social science, and politics is nothing more than medicine on a large scale.” During these difficult times, the social concerns of medical fraternity need to be seriously cared for as they are vulnerable to stress. If we can take care of the medical fraternity, they will surely take care of the society.


  Conclusion Top


The present study highlights moderate stress levels in medical students and doctors. Education, health, and safety at work were main concerns. The study emphasizes the need to provide stress relieving activities such as meditation and counselling and develop facilities for recreational activities in medical institutes.

Acknowledgement

We express sincere gratitude to all participants who took out time for this study even in busy times like these.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest



 
  References Top

1.
Ministry of Health and Family Welfare, Government of India. COVID-19, India. Available from: https://www.mohfw.gov.in/. [Accessed on May 6, 2020].  Back to cited text no. 1
    
2.
Wang C, Pan R, Wan X et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020;17:1729.  Back to cited text no. 2
    
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Quek TT, Tam WW, Tran BX et al. The global prevalence of anxiety among medical students: a meta-analysis. Int J Environ Res Public Health 2019;16:2735.  Back to cited text no. 3
    
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Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:386-96.  Back to cited text no. 4
    
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Petzold MB, Plag J, Ströhle A. Umgang mit psychischer Belastung bei Gesundheitsfachkräften im Rahmen der Covid-19-Pandemie [Dealing with psychological distress by healthcare professionals during the COVID-19 pandemia]. Der Nervenarzt 2020;91:417-21.  Back to cited text no. 6
    
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Barefoot JC, Dahlstrom WG, Williams RB Jr. Hostility, CHD incidence, and total mortality: a 25-year follow-up study of 255 physicians. Psychosom Med 1983;45:59-63.  Back to cited text no. 7
    
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Dyrbye LN, Massie FS Jr, Eacker A. et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA 2010;304:1173-80.  Back to cited text no. 8
    
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Lim GY, Tam WW, Lu Y, Ho CS, Zhang MW, Ho RC. Prevalence of depression in the community from 30 countries between 1994 and 2014. Sci Rep 2018;8:2861.  Back to cited text no. 9
    
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Seedhom AE, Kamel EG, Mohammed ES, Raouf NR. Predictors of perceived stress among medical and nonmedical college students, Minia, Egypt. Int J Prev Med 2019;10:107.  Back to cited text no. 10
[PUBMED]  [Full text]  
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Misra R, McKean M. College students’ academic stress and its relation to their anxiety, time management, and leisure satisfaction. Am J Health Stud 2000;16:41-51.  Back to cited text no. 11
    
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Bergmann C, Muth T, Loerbroks A. Medical students’ perceptions of stress due to academic studies and its interrelationships with other domains of life: a qualitative study. Med Educ Online 2019;24:1603526.  Back to cited text no. 12
    
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Brooks SK, Webster RK, Smith LE et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020;395:912-20.  Back to cited text no. 13
    
14.
Aarogya Setu mobile app. Available from: https://www.mygov.in/aarogya-setu-app/. [Accessed on April 30, 2020].  Back to cited text no. 14
    
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Chen Q, Liang M, Li Y et al. Mental health care for medical staff in China during the COVID19 outbreak. Lancet Psychiatry 2020;7:e15-e16.  Back to cited text no. 15
    
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Dehnavieh R, Kalavani K. Management-supportive measures for managers of healthcare organization during the COVID19 epidemic. Infect Control Hosp Epidemiol 2020;41:878.  Back to cited text no. 16
    
17.
Protsiv M, Rosales-Klintz S, Bwanga F, Zwarenstein M, Atkins S. Blended learning across universities in a South-North-South collaboration: a case study. Health Res Policy Syst 2016;14:67.  Back to cited text no. 17
    
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McConville J, McAleer R, Hahne A. Mindfulness training for health profession students-the effect of mindfulness training on psychological well-being, learning and clinical performance of health professional students: a systematic review of randomized and non-randomized controlled trials. Explore (NY) 2017;13:26-45.  Back to cited text no. 18
    
19.
Doordarshan National. Thanks to all our viewers!! #RAMAYAN- World record!! https://twitter.com/DDNational/status/1256433231773069313: 2020 May 2 [cited 2020 May 5] [Tweet] Available from @DDNational. Social media content… posted by Govt organisation.  Back to cited text no. 19
    
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Vasasova Z. Creativity and its relation to stress perception. Ad Alta: Journal of Interdisciplinary Research 2011;1:113-5  Back to cited text no. 20
    


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