Prevalence of pre-exam Anxiety among Medical and Paramedical Students in The Arab World during COVID-19: a Cross-Sectional Study

doi:10.21203/rs.3.rs-3346426/v1

Background

Pre-exam anxiety is a condition that affects students before their exams, and significantly affects their academic performance, mental, and physiological state. Medical and paramedical students are more likely to experience exams related stress and anxiety. Here we aimed to evaluate the prevalence of exam anxiety and its associated risk factors among undergraduate Arab medical and paramedical students.

Methods

We performed a multicenter cross-sectional study in six Arab countries: Egypt, Syria, Iraq, Palestine, Algeria, and Libya from March to April 2021. We used Epi Info version 7.2 software to calculate the sample size. An online questionnaire including The Depression, Anxiety, and Stress Scale − 21 Items (DASS-21) was used to measure exam-related anxiety. We used IBM SPSS for Windows version 26 statistical software and R programming language version 3.6.3. data analysis.

Results

A total of 18979 participants filled out the questionnaire, 71.3% of them were females. The majority of the study participants were between the ages of 20 to 21 years 42.4% (n = 8055). On the DASS, 38.8% of participants experienced severe symptoms of depression, 47.6% of them experienced severe symptoms of anxiety, and 30.2% experienced severe symptoms of stress. Of the three subscales of the DASS, Females had a significantly higher risk than males to develop Depression, Anxiety, and Stress (B = 2.454, P < 0.001), (B = 4.256, P < 0.001), (B = 3.516, P < 0.001) respectively. Participants aged 22 years or more were less susceptible to test-related depression (B= -0.907, P < 0.001) and anxiety (B= -0.958, P < 0.001). Students who study between 13 and 18 hours per week were considerably more likely to have lower scores on all DASS subscales than those who study more than 18 hours per week, depression (B= -0.983, P < 0.001), Anxiety (B= -1.334, P < 0.001) and stress (B= -1.693, P < 0.001).

Conclusion

The prevalence of test-related anxiety, stress, and depression is high among medical and paramedical students in the Arab region. Medical educators should be aware of the impacts of this comorbidity and should work on implementing new and effective strategies to help students cope with psychological changes during exams.

Epidemiology

Psychiatry

Anxiety

Exam

Performance

Medical field

Arab Countries

Exam anxiety is a set of responses that includes worry, physiological stress, depression, nervousness, irrelevant thinking, and behavioral actions that accompany concern about failure or lack of confidence. Exam anxiety can present with mental and physical manifestations along with emotional reactions that affect the ability to perform well on exams (1). Plenty of studies have investigated the complex pattern of relations between anxiety and a wide array of conventional measures of study performance at different stages and levels (1–3).

Tests and evaluative situations have emerged as a potent class of anxiety-evoking stimuli, which consider a problematic issue in the learning process in general (4). Academic excellence is required in the medical field more than any other field and is even used as a method of ranking doctors (5). Such requirements and stress cause a negative effect on medical students’ psychological well-being and can increase exam anxiety, which will affect the academic performance of these students (6).

Typically, Medical students often take longer time to finish their study than those in other fields (7). Also studying medicine itself is considered to be associated with much higher levels of physical and mental stress than any other discipline (8), which in the long run could affect their mental health as well as clinical performance.

Burnout is described by varying degrees of depersonalization (i.e., feeling separated from or cruel toward the patients), emotional weariness, and a poor sense of personal achievement (9). A recent cross-sectional by Vidhukumar et al 2020, stated that burnout prevalence was 48.5% among medical students under study (10), another study in Malaysia by Chin et al 2016, estimated the prevalence of burnout to be 67.9% among medical students (11). And as long as mental health is getting worse, medical professionalism and clinical performance will deteriorate which can affect the general health of the students, their ability to learn, and their future attitude to the patients (12).

This study aims to investigate the prevalence and associated factors of exam anxiety among undergraduate students at different medical facilities (Medicine - Dentistry- Pharmacy- Nursing- Science- Physiotherapy- Veterinary Medicine) in the Arab world. We also discussed the epidemiological and social factors associated with this issue. This study gives a better understanding of the level of test anxiety and its predictors, which will enable the responsible authorities to intervene, based on the findings.

Study design:

The study is a multi-center cross-sectional study, conducted in Arab countries; Egypt, Syria, Iraq, Palestine, Algeria, and Libya to assess exam anxiety among medical students using a self-administered online questionnaire between March 2021 and April 2021. The study was performed according to strengthening the Reporting of Observational Studies in Epidemiology checklist (appendix)(13). Fayoum University Supreme Committee approved this study for Scientific Research Ethics (FU-SCSRE) under research code: EC 2126.

Inclusion Criteria:

The inclusion criteria were university students (more than 18 years) living in Arab countries who study in biomedical fields (Medicine, pharmacy, nursing, physiotherapy, dentistry, science, and veterinary) who are currently having exams or in the period of final. Non-Arab students, non-biomedical students, and students not having an exam within days of the questionnaire were excluded.

Sampling:

The sample size was calculated by Epi Info version 7.2 software using this equation N = z2 {P (1-P) / d2} according to each country’s criteria. Where; n = sample size, z = z statistic for the level of confidence, P = expected prevalence, and d = allowable error, putting into consideration confidence interval (CI) 95%, z = 1.96, d = 5%. The safe limit sample size was 398, We randomly included all participants going with our inclusion criteria.

Questionnaire development:

The questionnaire was an online-based survey consisting of three main sections: Demographic details, studying status pre-exams period, and The Depression, Anxiety and Stress Scale − 21 Items (DASS-21) Scale items.

The first section was demographic details including age, gender, city of school location, marital status, grade, year of entry to the university, employment status, country of residence, countries in conflict statement, and family average salary
The second section assesses the studying status during the pre-exam period including the average of weekly studying hours, academic average, the average duration of exams, the field of studying, and the year.
The third section consists of the DASS-21 Scale which is a set of three self-report subscales designed to assess the emotional states of depression, anxiety, and stress. Each item is scored on a 4-point “Likert scale” ranging from zero (“did not apply to me at all”) to three (“applied to me very much”) (14). Final scores were classified into five categories: Normal, Mild, Moderate, Severe, and Extremely Severe (Table 1).

Data collection:

We recruited collaborators for data collection from the six participating Arab countries using a distributed online google form. data collection began in March 2021 and ended in April 2021 through an online questionnaire using also a google form. distributed on various social media websites including Twitter, Facebook, and WhatsApp. We targeted medical and paramedical students from the participating Arab countries. The participants were informed about the aim of the study and the general instructions were explained at the beginning of the online form. Furthermore, participation consent was obtained from individuals before they filled out the questionnaire. All the data were kept confidentially on the author's laptop.

Statistical analysis:

Data were analyzed using IBM SPSS for Windows version 26 statistical software and R programming language version 3.6.3. Categorical data were reported as frequency/percentage and continuous data as mean/standard deviation. Univariate analyses were performed using linear regressions to determine the presence and strength of associations between individual variables and scores on each of the three scales (DASS-stress, DASS-anxiety, and DASS-depression). A p-value of < 0.05 was considered statistically significant.

Demographic characteristics of the study population

A total of 18979 responses were collected in this study, 27.7% of them were from Syria, 13.1% from Egypt, 27.6% from Iraq, 6% from Algeria, 17.7% from Palestine, and 7.9% from Libya.

Of them, 71.3% were females. Most of the study population were single 95.3% (n = 18090), ages between 20 and 21 years 42.4% (n = 8055), had lower-middle income 45.2% (n = 8576) with only 7.7% (n = 1465) of them work while studying. Other demographic details present in Table 2.

Association between sociodemographic variables and the psychological impact of the exams

It was found that the female gender was significantly associated with higher risk than males in all three subscales of the DASS, depression, anxiety, and stress (B = 2.454, P < 0.001), (B = 4.256, P < 0.001), (B = 3.516, P < 0.001) respectively. With respect to age, those equal to or more than 22 years were found to be significantly less susceptible to adverse mental health outcomes with (B= -0.907, P < 0.001) for depression and (B= -0.958, P < 0.001) for anxiety, they were also less susceptible to stress but the result was insignificant (B= -0.273, P = 0.187) Table 3.

Being married was significantly associated with lower scores on depression subscales of the DASS (B= -1.312, P = 0.001). Students who work while studying were significantly more likely to have lower scores on all subscales of the DASS; depression (B= -1.824, P < 0.001), anxiety (B= -1.668, P < 0.001), and stress (B= -1.576, P < 0.001). Surprisingly, students who have wars in their country also had significantly lower scores on depression (B= -0.468, P = 0.018) Table 3.

Students who live in rural areas were more likely to have a high score on the anxiety subscale of the DASS with (B = 0.493, P = 0.011). In comparison to low family income, students with high income, upper middle, and lower middle family income were significantly associated with lower scores on all subscales of the DASS Table 3.

Students who study from 13 to 18 hours and from 9 to 12 hours weekly were significantly more likely to have lower scores on all subscales of the DASS than those studying more than 18 hours weekly. Students whose grades were decreased were associated with higher scores on all subscales of the DASS Table 3.

In comparison to students who live in Syria; students who live in Iraq, Egypt, Palestine, and Algeria were associated with significantly higher scores on all subscales of the DASS Table 3.

In comparison to students at the faculty of medicine, students in the faculty of nursing were more likely to have lower scores on depression subscale of the DASS with (B= -1.681, P < 0.001). Furthermore, Students in the faculty of dentistry, physiotherapy, veterinary medicine, science, and pharmacy were more likely to have higher scores on anxiety subscale of the DASS than students of faculty of medicine. In addition, students in the faculty of dentistry and science were more likely to have lower scores on Stress subscale of the DASS than students of the faculty of medicine (B= -0.46, P = 0.047) and (B= -1.212, P < 0.001) respectively Table 3.

The prevalence of exam stress among biomedical students, and student performance on the three subscales of the Depression, Anxiety, and Stress Scale − 21 Items (DASS-21).

On the DASS, 17.7% had normal scores on the stress subscale, 17.9% on the anxiety subscale, and 14.4% on depression subscale. Severe symptoms of stress were experienced by 24.9%, 11.7% experienced severe symptoms of anxiety and 15.9% experienced severe symptoms of depression. In the faculty of medicine, 39.5% of students experienced symptoms of extremely severe depression while 45.6% experienced extreme anxiety and 31.9% experienced severe stress. In the faculty of nursing, 33.3% experienced extreme depression, 47.8% experienced extreme anxiety, and only 25% experienced extremely severe stress. Results from other faculties are illustrated in Table 4.

Prevalence of exam depression, anxiety, and stress are shown in Figs. 1, 2, and 3 respectively.

Educational psychologists state that an acceptable level of anxiety may enhance the learners’ performance. Yet, excessive stress and anxiety may lead to mental health disturbance and affect performance (15). The prevalence of mental health troubles among healthcare personnel is increasing worldwide (16). Medical and paramedical sciences students are under high mental stress due to the training systems’ nature, making them more susceptible to these troubles. A high prevalence of anxiety was found in many reports from different countries such as India and Saudi Arabia and India (4, 5, 17). Sharma and Wavare reported that examination is one of the most important stress factors in paramedical and medical students (18). In our study, the levels of test-related anxiety, stress, and depression were assessed using the DASS score.

In this study we found that the female gender was associated with higher scores in all the three subscales of the DASS; Depression, Anxiety, and Stress (B = 2.454, P < 0.001), (B = 4.256, P < 0.001), (B = 3.516, P < 0.001) respectively. This is in line with previous reports on test anxiety (19–22). Also, we found that students of 20 years old or higher had a lower score in all the three subscales of the DASS than those between 17 to 19 years old. In comparison to low family income, students with high income, upper middle, and lower middle family income were significantly associated with lower scores on all of the DASS subscales. However, some investigations found that depression may not be related to gender, financial situation, or even age (23–25).

Students who live in rural areas were more likely to have higher scores on the anxiety subscale of the DASS which was also reported by de Luna et al 2020 (26), and Students who work while studying were more likely to have lower scores on all the subscales of the DASS. Furthermore, we found that students who have wars in their country were more likely to have lower scores on the depression subscale of the DASS, a previous report revealed that there was no direct relation between psychological distress among Syrian medical students and the ongoing conflict in Syria (20).

Students whose grades were decreased were significantly associated with higher scores on all subscales of the DASS. Better psychological resilience and emotion regulation among students with high academic performance may be protective factors (2, 27). These students can cope with tests more easily since they have developed effective learning ways, while students with poor grades have unrealistic beliefs about the exams leading to high anxiety (27). Yet, a study conducted in Iran showed no significant association between low previous grades and test anxiety (28). Besides, higher exam-related stress can be considered as a debilitating condition leading to decreased efficiency and poorer average grades (29, 30).

Other factors that have been identified to have a relation to exam anxiety are studying all night before the exam, long duration of examinations, decreased physical activity, undue course loads, being the first year, low social support, oral tests, lack of study plan, unpleasant exam experiences, having psychological distress, and procrastination (6, 21, 22, 24, 31). Students having academic procrastination may be more susceptible to develop test anxiety and irrational thoughts (24, 32). This was less common in students with high grades (33).

Debilitating stress can lead to reduced performance (30) and may have a negative impact on professional development and professionalism leading to many troubles such as substance abuse and academic dishonesty (34). Some reports suggested that anxiety among medical students may influence patient safety and their quality of care (35, 36). Students who are influenced by their worries and fear of failure may not be able to structure their learning schedule or focus on the learning material at hand and therefore adopt a surface learning approach (37). Many coping methods exist including Rational coping strategies (problem-solving, emotional support from others, and positive reappraisal (29, 38). These measures should be taken into consideration to decrease this phenomenon and to provide good psychological support for this category of students.

Although this report has several strengths, such as the use of a simple, concise, and validated test tool and the good response rate. First, its observational nature may be a source of limitation since it cannot allow changes in the psychological profile over time. Also, our study was conducted during the COVID-19 pandemic. Increased levels of anxiety, depression, and perceived having been reported by undergraduate students in this special situation. They also reported the existence of insomnia which is correlated with high levels of depression and stress; therefore, our results may be overestimated by the effects of the pandemic (39).

The levels of test-related anxiety, stress, and depression are relatively high among medical and paramedical students in the Arab region. Counseling services should be implemented to deeply understand the reasons for exam anxiety and control this psychological morbidity and avoid its debilitating results. Educators in Arab countries may also reinforce the use of deep learning approaches and other coping strategies to reduce this anxiety.

DASS-21: Depression, Anxiety, and Stress Scale - 21 Items; FU-SCSRE: Fayoum University Supreme Committee approved this study for Scientific Research Ethics

Ethics approval and Consent to participate: Ethical approval for this study was obtained from Fayoum University Supreme Committee for Scientific Research Ethics (FU-SCSRE) 11th April 2021 (Registration No. EC 2126), all methods were carried out in accordance with relevant guidelines and regulations and according to strengthening the Reporting of Observational Studies in Epidemiology checklist (STROBE checklist). Prior to study participation, all participants received written document outlining the aim of the study, intended methods, the voluntary nature of participation, the right to discontinue at any time, and the right not to respond specific questions. We had informed consent from each participant.

Consent for publication: Not Applicable

Availability of data and material: All data generated or analyzed during this study are included in this published article or the data repositories listed in References

Conflicts of interest: All the authors declare no conflict of interest

Funding: Not Applicable

Code availability: EC 2126.

Authors contributions:

Elgendy A.M.N, Benmelouka A.Y, Abd-ElGawad M, Douba Z, Rasmy J: idea generation, questionnaire development, and study design. Elgendy A.M.N, Benmelouka A.Y: data collection. Attia A.M, Rasmy J: statistical analysis. Brimo M.Z, Zazo A, Mohandes AF, Elgendy A.M.N, Benmelouka A.Y, Abd-ElGawad M, Douba Z, Rasmy J, Attia A.M: writing - original draft. Mohammed Y.A: writing and reviewing the manuscript. Abd-El Gawad M: supervision of all authors and peer-review.

Acknowledgment:

1 Akram Bouchagoura. [email protected]

2 Abdulrhman Andelnaby Mohamed emam. [email protected]

3 Manar Mohamed Jassim. [email protected]

4 Abdallah Mattar. [email protected]

5. Aisha Elrokae. [email protected]

Collaborators:

1 Mounir Shhada. [email protected]

2 Marah khalil. [email protected]

3 Wafik Mayo. [email protected]

4 Worood shehadeh. [email protected]

5 Abdallah Aladna. [email protected]

6 Rama Mohammad Amir Zannerni. [email protected]

7 Bayan Tabbakh. [email protected]

8 Shahd Maarrawi. [email protected]

9 Yaman Mokresh. [email protected]

10 Lanah Almahairi. [email protected]

11 Ahmad Damlakhi. [email protected]

12 Turfa Moudarres. [email protected]

13 Sdrah Diab. [email protected]

14 Muhammad sami diabi. [email protected]

15 Esraa Naser Etaeb. [email protected]

16 AHLAM MOHAMMED ALI ELZWEI. [email protected]

17 Sarah abdulmagied sulaiman. [email protected]

18 Hawwa Altaeb. [email protected]

19 Hossam Tharwat Ahmed Ali. [email protected]

20 Rahma Sameh Mohamed. [email protected]

21 Maya Magdy Abdelwahab. [email protected]

22 Taghreed khaled Mohamed. [email protected]

23 Moatasem Salah Sayed. [email protected]

24 Ziad Soliman. [email protected]

25 Bishoy Wageh Fahim. [email protected]

26 Mario Farag. [email protected]

27 Amira Benyagoub. [email protected]

28 Ayoub Rezkallah. [email protected]

29 Asma Korti. [email protected]

30 Henni abdlhamid. [email protected]

31 Ahmed Radey Mater. [email protected]

32 Ranya Osam Al-Jumaili. [email protected]

33 Mojjtaba abbas fadel. [email protected]

34 Jaafar D. Al-Dabagh. [email protected]

35 Ekhlas fahim ouda aljanabi. [email protected]

36 Al Zahara Riyadh Sajet. [email protected]

37 Mohamed farag abdulreda. [email protected]

38 Inas Qafeshah. [email protected]

39 Raghad Saleh. [email protected]

40 Farah Shahin. [email protected]

41 Rahaf Al-Juneidi. [email protected]

42 Mona Hassan Aljadba. [email protected]

43 Sa'ed shalalfeh. [email protected]

44 Abdelrhman janem. [email protected]

45 Suliman borghal. [email protected]

46. Asmaa Alzabadiah. [email protected]

Ventura M, Roberts RD, Zeidner M. Assessment in Schools–Affective Domain. 2010;
von der Embse N, Jester D, Roy D, Post J. Test anxiety effects, predictors, and correlates: A 30-year meta-analytic review. J Affect Disord. 2018;227:483–93.
Thomas CL, Cassady JC, Heller ML. The influence of emotional intelligence, cognitive test anxiety, and coping strategies on undergraduate academic performance. Learn Individ Differ. 2017;55:40–8.
Zeidner M. Test anxiety in educational contexts: Concepts, findings, and future directions. In: Emotion in education. Elsevier; 2007. p. 165–84.
Wolf T. Stress, coping and health: enhancing well‐being during medical school. Med Educ. 1994;28(1):8–17.
Aktekin M, Karaman T, Senol YY, Erdem S, Erengin H, Akaydin M. Anxiety, depression and stressful life events among medical students: a prospective study in Antalya, Turkey. Med Educ. 2001;35(1):12–7.
Bond AR, Mason HF, Lemaster CM, Shaw SE, Mullin CS, Holick EA, et al. Embodied health: the effects of a mind–body course for medical students. Med Educ Online. 2013;18(1):20699.
Adams J. Straining to describe and tackle stress in medical students. Med Educ. 2004;38(5):463–4.
Maslach C, Jackson SE, Leiter MP. The Maslach Burnout Inventory Manual (Third Edition). Eval Stress a B Resour [Internet]. 1997;(June 2015):191–218. Available from: https://www.researchgate.net/publication/277816643
Vidhukumar K, Hamza M. Prevalence and correlates of burnout among undergraduate medical students-a cross-sectional survey. Indian J Psychol Med. 2020;42(2):122–7.
Chin RWA, Chua YY, Chu MN, Mahadi NF, Yusoff MSB, Wong MS, et al. Prevalence of Burnout among Universiti Sains Malaysia Medical Students. Educ Med J. 2016;8(3).
Sattar K, Yusoff MSB, Arifin WN, Mohd Yasin MA, Mat Nor MZ. A scoping review on the relationship between mental wellbeing and medical professionalism. Med Educ Online. 2023;28(1):2165892.
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet (London, England). 2007 Oct;370(9596):1453–7.
Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales. Psychology Foundation of Australia; 1996.
Arbabisarjou A, Zare S, Shahrakipour M, Ghoreishinia G. Analyzing test anxiety among medical sciences students of Zahedan in 2015. Int J Med Res Heal Sci. 2016;5(7):334–7.
Barry S, Ward L. Undergraduate nursing students’ understandings of mental health: A review of the literature. Issues Ment Health Nurs. 2017;38(2):160–75.
Ali N, Jusof K, Ali S, Mokhtar N, Salamat ASA. THE FACTORS INFLUENCING STUDENTS’PERFORMANCE AT UNIVERSITI TEKNOLOGI MARA KEDAH, MALAYSIA. Manag Sci Eng. 2009;3(4):81–90.
Sharma B, Wavare R. Academic stress due to depression among medical and para-medical students in an indian medical college: Health initiatives cross sectional study. J Heal Sci. 2013;3(5):29–38.
Talbot L. Test anxiety: Prevalence, effects, and interventions for elementary school students. James Madison Undergrad Res J. 2016;3(1):5.
Al Saadi T, Zaher Addeen S, Turk T, Abbas F, Alkhatib M. Psychological distress among medical students in conflicts: a cross-sectional study from Syria. BMC Med Educ. 2017;17:1–8.
Tsegay L, Shumet S, Damene W, Gebreegziabhier G, Ayano G. Prevalence and determinants of test anxiety among medical students in Addis Ababa Ethiopia. BMC Med Educ. 2019;19:1–10.
Khoshhal KI, Khairy GA, Guraya SY, Guraya SS. Exam anxiety in the undergraduate medical students of Taibah University. Med Teach. 2017;39(sup1):S22–6.
Madhan B, Barik AK, Patil R, Gayathri H, Reddy MSR. Sense of humor and its association with psychological disturbances among dental students in India. J Dent Educ. 2013;77(10):1338–44.
Bolbolian M, Asgari S, Sefidi F, Zadeh AS. The relationship between test anxiety and academic procrastination among the dental students. J Educ Health Promot. 2021;10.
Mahdavi P, Valibeygi A, Moradi M, Sadeghi S. Relationship between achievement motivation, mental health and academic success in university students. Int Q Community Health Educ. 2021;0272684X211025932.
de Luna MEM, Franco LEO, Pérez AH. Percepción de adolescentes sobre las prácticas de crianza de sus padres y madres. Comparativo de género en contextos rural y urbano. Clivajes Rev Ciencias Soc. 2020;(14):183.
Liu Y, Pan H, Yang R, Wang X, Rao J, Zhang X, et al. The relationship between test anxiety and emotion regulation: The mediating effect of psychological resilience. Ann Gen Psychiatry. 2021;20:1–9.
Kashfi SM, Jeihooni AK, Kashfi SH, Yazdankhah M. The relationship between test anxiety and educational performance among the students at school of health and nutrition, shiraz university of medical sciences in 2011. J Contemp Med Edu. 2014;2(3):158–62.
Crego A, Carrillo-Diaz M, Armfield JM, Romero M. Stress and academic performance in dental students: the role of coping strategies and examination‐related self‐efficacy. J Dent Educ. 2016;80(2):165–72.
Sanders AE, Lushington K. Effect of perceived stress on student performance in dental school. J Dent Educ. 2002;66(1):75–81.
Hashmat S, Hashmat M, Amanullah F, Aziz S. Factors causing exam anxiety in medical students. Journal-Pakistan Med Assoc. 2008;58(4):167.
Desai M, Pandit U, Nerurkar A, Verma C, Gandhi S. Test anxiety and procrastination in physiotherapy students. J Educ Health Promot. 2021;10.
Custer NR. Test anxiety and academic procrastination among pre-licensure nursing students. Indiana University of Pennsylvania; 2016.
Shah M, Hasan S, Malik S, Sreeramareddy CT. Perceived stress, sources and severity of stress among medical undergraduates in a Pakistani medical school. BMC Med Educ. 2010;10:1–8.
Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):358–67.
Mareiniss DP. Decreasing GME training stress to foster residents’ professionalism. Acad Med. 2004;79(9):825–31.
Biggs J, Tang C, Kennedy G. Teaching for quality learning at university. McGraw-hill education (UK); 2022.
Ahmad MS, Md Yusoff MM, Razak IA. Stress and its relief among undergraduate dental students in Malaysia. Southeast Asian J Trop Med Public Heal. 2011;42(4):996.
Alyoubi A, Halstead EJ, Zambelli Z, Dimitriou D. The impact of the COVID-19 pandemic on students’ mental health and sleep in Saudi Arabia. Int J Environ Res Public Health. 2021;18(17):9344.

Table 1. Scoring Guide for DASS-21 Scale.

DASS-21 Scoring	Depression	Anxiety	Stress
Normal	0-4	0-3	0-7
Mild	5-6	4-5	8-9
Moderate	7-10	6-7	10-12
Severe	11-13	8-9	13-16
Extremely Severe	14+	10+	17+

Table 2. Demographic characteristics of participants.

	Syria		Egypt		Iraq		Algeria		Palestine		Libya
	Count	Percent	Count	Percent	Count	Percent	Count	Percent	Count	Percent	Count	Percent
Gender
Female	3370	64.20%	1543	62.10%	3682	70.30%	1004	87.80%	2631	78.30%	1307	86.70%
Male	1878	35.80%	942	37.90%	1554	29.70%	139	12.20%	728	21.70%	201	13.30%
Age
between 17 to 19 years	1412	26.90%	648	26.10%	1462	27.90%	102	8.90%	1085	32.30%	78	5.20%
between 20 to 21 years	2033	38.70%	1242	50%	2351	44.90%	236	20.60%	1541	45.90%	652	43.20%
equal to or more than 22	1803	34.40%	595	23.90%	1423	27.20%	805	70.40%	733	21.80%	778	51.60%
Marital-status
divorced	12	0.20%	1	0.00%	18	0.30%	3	0.30%	5	0.10%	5	0.30%
married	176	3.40%	32	1.30%	294	5.60%	43	3.80%	208	6.20%	59	3.90%
single	5043	96.10%	2451	98.60%	4916	93.90%	1096	95.90%	3142	93.50%	1442	95.60%
widow	17	0.30%	1	0%	8	0.20%	1	0.10%	4	0.10%	2	0.10%
work
no	4657	88.70%	2375	95.60%	4924	94%	1063	93%	3224	96%	1271	84.30%
yes	591	11.30%	110	4.40%	312	6%	80	7%	135	4%	237	15.70%
Residence
rural	1276	24.30%	1015	40.80%	720	13.80%	144	12.60%	1013	30.20%	303	20.10%
urban	3972	75.70%	1470	59.20%	4516	86.20%	999	87.40%	2346	69.80%	1205	79.90%
war
no	191	3.60%	2333	93.90%	167	3.20%	1135	99.30%	355	10.60%	252	16.70%
yes	5057	96.40%	152	6.10%	5069	96.80%	8	0.70%	3004	89.40%	1256	83.30%
Monthly income
High income	511	9.70%	155	6.20%	246	4.70%	115	10.10%	996	29.70%	110	7.30%
low income	1276	24.30%	466	18.80%	1453	27.80%	108	9.40%	539	16%	204	13.50%
lower-middle	3065	58.40%	1044	42%	2014	38.50%	767	67.10%	1057	31.50%	629	41.70%
upper-middle	396	7.50%	820	33%	1523	29.10%	153	13.40%	767	22.80%	565	37.50%
Year
fifth	632	12%	115	4.60%	307	5.90%	267	23.40%	254	7.60%	92	6.10%
first	1154	22%	466	18.80%	1904	36.40%	69	6%	753	22.40%	432	28.60%
forth	986	18.80%	433	17.40%	695	13.30%	200	17.50%	631	18.80%	186	12.30%
second	1082	20.60%	784	31.50%	1225	23.40%	104	9.10%	887	26.40%	348	23.10%
sixth	320	6.10%	156	6.30%	122	2.30%	391	34.20%	122	3.60%	27	1.80%
third	1074	20.50%	531	21.40%	983	18.80%	112	9.80%	712	21.20%	423	28.10%
study hours weekly
from 13 - 18 hrs	1143	21.80%	695	28%	1030	19.70%	276	24.10%	995	29.60%	390	25.90%
from 9 - 12 hrs	2797	53.30%	796	32%	3144	60%	507	44.40%	1466	43.60%	754	50%
more than 18 hrs	1308	24.90%	994	40%	1062	20.30%	360	31.50%	898	26.70%	364	24.10%
decrease in your grade
no	2805	53.40%	1483	59.70%	3501	66.90%	606	53%	1717	51.10%	610	40.50%
yes	2443	46.60%	1002	40.30%	1735	33.10%	537	47%	1642	48.90%	898	59.50%
Average duration of exams
month	2662	50.70%	644	25.90%	666	12.70%	92	8%	548	16.30%	481	31.90%
more than month	2030	38.70%	366	14.70%	360	6.90%	302	26.40%	566	16.90%	350	23.20%
three weeks	144	2.70%	783	31.50%	1003	19.20%	121	10.60%	797	23.70%	266	17.60%
two weeks	199	3.80%	474	19.10%	2134	40.80%	188	16.40%	1145	34.10%	226	15%
week	213	4.10%	218	8.80%	1073	20.50%	5	0.40%	303	9%	185	12.30%
week or less	-	-	-	-	-	-	435	38.10%	-	-	-	-
Faculty
Faculty Of Dentistry	663	12.60%	134	5.40%	1114	21.30%	125	10.90%	439	13.10%	425	28.20%
Faculty Of Medicine	2642	50.30%	1057	42.50%	1624	31%	782	68.40%	1349	40.20%	496	32.90%
Faculty of Physiotherapy	-	-	347	14%	109	2.10%	7	0.60%	185	5.50%	10	0.70%
Faculty Of Nursing	276	5.30%	177	7.10%	365	7%	56	4.90%	368	11%	84	5.60%
Faculty of Pharmacy	1045	19.90%	414	16.70%	671	12.80%	79	6.90%	530	15.80%	401	26.60%
Faculty Of Science	448	8.50%	196	7.90%	935	17.90%	85	7.40%	438	13%	37	2.50%
Faculty Of Veterinary Medicine	174	3.30%	160	6.40%	418	8%	9	0.80%	50	1.50%	55	3.60%
Depression
extremely severe	1841	35.10%	1069	43%	2208	42.20%	449	39.30%	1284	38.20%	506	33.60%
mild	595	11.30%	223	9%	401	7.70%	129	11.30%	307	9.10%	157	10.40%
moderate	1168	22.30%	483	19.40%	1133	21.60%	226	19.80%	738	22%	315	20.90%
normal	868	16.50%	302	12.20%	672	12.80%	175	15.30%	431	12.80%	290	19.20%
severe	776	14.80%	408	16.40%	822	15.70%	164	14.30%	599	17.80%	240	15.90%
Anxiety
extremely severe	2120	40.40%	1245	50.10%	2807	53.60%	537	47%	1676	49.90%	651	43.20%
mild	340	6.50%	125	5%	251	4.80%	54	4.70%	143	4.30%	85	5.60%
moderate	1006	19.20%	422	17%	829	15.80%	216	18.90%	568	16.90%	278	18.40%
normal	1129	21.50%	401	16.10%	763	14.60%	204	17.80%	568	16.90%	331	21.90%
severe	653	12.40%	292	11.80%	586	11.20%	132	11.50%	404	12%	163	10.80%
Stress
extremely severe	1394	26.60%	804	32.40%	1728	33%	368	32.20%	1014	30.20%	432	28.60%
mild	562	10.70%	217	8.70%	509	9.70%	114	10%	305	9.10%	151	10%
moderate	982	18.70%	420	16.90%	869	16.60%	190	16.60%	584	17.40%	245	16.20%
normal	947	18%	397	16%	901	17.20%	196	17.10%	585	17.40%	332	22%
severe	1363	26%	647	26%	1229	23.50%	275	24.10%	871	25.90%	348	23.10%

Table 3. Association between sociodemographic variables and the psychological impact of the exams

		Depression					Anxiety					Stress
	N (%)	B	P-value	R2	95% (CI)		B	P-value	R2	95% (CI)		B	P-value	R2	95% (CI)
Faculty
Faculty of Pharmacy	3140(16.5%)	0.2400	0.33	-0.000004	-0.243	0.723	0.777	0.001	0.0008	0.307	1.248	-0.231	0.3	0.000006	-0.669	0.206
Faculty Of Science	2139(11.3%)	-0.143	0.614	-0.00007	-0.701	0.414	1.267	<0.001	0.001	0.722	1.813	-1.212	<0.001	0.002	-1.72	-0.704
Faculty Of Veterinary Medicine	866(4.6%)	0.669	0.11	0.0001	-0.153	1.493	1.11	<0.001	0.0007	0.307	1.913	0.04	0.915	-0.0001	-0.707	0.788
Faculty Of Nursing	1326(7%)	-1.681	<0.001	0.002	-2.365	-0.997	0.395	0.244	0.00003	-0.27	1.061	-2.242	<0.001	0.005	-2.867	-1.617
Faculty of Physiotherapy	658(3.5%)	-0.052	0.912	-0.00011	-0.987	0.882	1.206	0.009	0.0006	0.297	2.115	-0.343	0.425	-0.00004	-1.189	0.501
Faculty Of Dentistry	2900(15.3%)	-0.137	0.59	-0.00006	-0.637	0.362	0.509	0.04	0.0002	0.022	0.996	-0.46	0.047	0.0002	-0.915	-0.005
Faculty Of Medicine	7950(41.9%)	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref
Gender
Female	13537(71.3%)	2.454	<0.001	0.009	2.09	2.817	4.256	<0.001	0.028	3.902	4.61	3.516	<0.001	0.022	3.184	3.848
Male	5442(28.7%)	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref
Age
between 20 to 21 years	8055(42.4%)	-0.365	0.082	0.0001	-0.778	0.046	-0.39	0.061	0.0001	-0.799	0.018	-0.039	0.838	-0.00007	-0.417	0.338
equal to or more than 22	6137(32.3%)	-0.907	<0.001	0.001	-1.347	-0.467	-0.958	<0.001	0.001	-1.39	-0.527	-0.273	0.187	0.00006	-0.679	0.133
between 17 to 19 years	4787(25.2%)	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref
Marital status
widow	33(0.2%)	2.035	0.314	0.0000007	-1.929	6.001	1.243	0.531	-0.00003	-2.651	5.137	-2.702	0.145	0.00006	-6.341	0.937
married	812(4.3%)	-1.312	0.001	0.0004	-2.128	-0.496	0.307	0.452	-0.00002	-0.494	1.11	-0.133	0.727	-0.00004	-0.883	0.616
divorced	44(0.2%)	-1.403	0.423	-0.00001	-4.838	2.031	-0.393	0.819	-0.00005	-3.766	2.979	-2.368	0.14	0.00006	-5.52	0.782
single	18090(95.3%)	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref
Work
yes	1465(7.7%)	-1.824	<0.001	0.001	-2.442	-1.206	-1.668	<0.001	0.001	-2.276	-1.061	-1.576	<0.001	0.001	-2.144	-1.007
no	17514(92.3%)	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref
War
yes	14546(76.6%)	-0.468	0.018	0.000239	-0.858	-0.078	-0.217	0.267	0.00001	-0.6	0.166	-0.31	0.089	0.00009	-0.669	0.048
no	4433(23.4%)	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref
residence
rural	4471(23.6%)	0.065	0.742	-0.00004	-0.323	0.454	0.493	0.011	0.0002	0.111	0.876	0.127	0.484	-0.00002	-0.23	0.485
urban	14508(76.4%)	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref
Monthly income
high income	2133(11.2%)	-2.025	<0.001	0.006	-2.644	-1.407	-3.139	<0.001	0.016	-3.743	-2.534	-1.301	<0.001	0.003	-1.869	-0.732
upper middle	4224(22.3%)	-1.07	<0.001	0.002	-1.57	-0.57	-1.693	<0.001	0.005	-2.189	-1.198	-0.876	<0.001	0.001	-1.34	-0.412
lower middle	8576(45.2%)	-1.076	<0.001	0.001	-1.509	-0.642	-1.88	<0.001	0.005	-2.305	-1.454	-0.917	<0.001	0.001	-1.314	-0.519
low income	4046(21.3%)	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref
study hours per week
from 13 : 18 hrs	4529(23.9%)	-0.983	<0.001	0.001	-1.448	-0.519	-1.334	<0.001	0.003	-1.792	-0.876	-1.693	<0.001	0.006	-2.113	-1.273
from 9 - 12 hrs	9464(49.9%)	-0.03	0.882	-0.00006	-0.43	0.369	-1.379	<0.001	0.003	-1.772	-0.987	-1.889	<0.001	0.006	-2.257	-1.521
more than 18 hrs	4986(26.3%)	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref
Decrease in your grade
yes	8257(43.5%)	4.959	<0.001	0.044	4.633	5.285	3.539	<0.001	0.023	3.215	3.862	3.579	<0.001	0.027	3.277	3.881
no	10722(56.5%)	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref
Average duration of exams
month	5093(26.8%)	-1.878	<0.001	0.006	-2.362	-1.393	-1.776	<0.001	0.005	-2.243	-1.308	-2.143	<0.001	0.01	-2.579	-1.708
three weeks	3114(16.4%)	-1.292	<0.001	0.002	-1.837	-0.746	-0.62	0.023	0.0005	-1.158	-0.082	-2.032	<0.001	0.009	-2.525	-1.54
two weeks	4366(23.0%)	-0.8	0.001	0.001	-1.296	-0.304	0.058	0.814	-0.0001	-0.428	0.544	-1.674	<0.001	0.006	-2.127	-1.221
week	1997(10.5%)	0.207	0.517	-0.00009	-0.419	0.834	0.976	0.002	0.001	0.355	1.597	-1.132	<0.001	0.002	-1.702	-0.563
week or less	435(2.3%)	-0.642	0.275	0.00004	-1.797	0.511	-0.78	0.174	0.0001	-1.906	0.345	-1.205	0.021	0.0009	-2.235	-0.176
more than month	3974(20.9%)	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref
Country
Algeria	1143(6%)	0.925	0.015	0.0007	0.176	1.673	1.792	<0.001	0.003	1.089	2.495	0.956	0.004	0.001	0.29	1.622
Palestine	3359(17.7%)	1.408	<0.001	0.003	0.909	1.906	2.5	<0.001	0.0117	2.018	2.982	0.751	0.001	0.001	0.298	1.204
Egypt	2485(13.1%)	2.369	<0.001	0.008	1.813	2.925	2.681	<0.001	0.012	2.152	3.211	1.373	<0.001	0.003	0.875	1.87
Iraq	5236(27.6%)	2.002	<0.001	0.007	1.56	2.444	3.623	<0.001	0.025	3.192	4.054	1.052	<0.001	0.002	0.647	1.457
Libya	1508(7.9%)	-0.576	0.09	0.0002	-1.244	0.09	0.848	0.008	0.0008	0.214	1.482	-0.439	0.153	0.0001	-1.043	0.164
Syria	5248(27.7%)	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref	ref

N= number. B= B Coefficient

Table 4. The prevalence of exam stress among biomedical students, and students' performance on the three subscales of the Depression, Anxiety and Stress Scale - 21 Items (DASS-21).

		Depression	Anxiety	Stress
Total	Score, Mean ± SD	22.76 ±11.60	18.95 ± 11.41	25.90 ± 10.67
	Categories, N (%)
	Normal	2738(14.4%)	3396(17.9%)	3358(17.7%)
	Mild	1812(9.5%)	998(5.3%)	1858(9.8%)
	Moderate	4063(21.4%)	3319(17.5%)	3290(17.3%)
	Severe	3009(15.9%)	2230(11.7%)	4733(24.9%)
	Extremely severe	7357(38.8%)	9036(47.6%)	5740(30.2%)
	Total	18979(100%)	18979(100%)	18979(100%)
Faculty Of Medicine
	Categories, N (%)
	Normal	1167(14.7%)	1530(19.2%)	1332(16.8%)
	Mild	797(10%)	423(5.3%)	785(9.9%)
	Moderate	1663(20.9%)	1396(17.6%)	1347(16.9%)
	Severe	1180(14.8%)	977(12.3%)	1950(24.5%)
	Extremely severe	3143(39.5%)	3624(45.6%)	2536(31.9%)
	Total	7950(100%)	7950(100%)	7950(100%)
Faculty of Pharmacy
	Categories, N (%)
	Normal	429(13.7%)	523(16.7%)	531(16.9%)
	Mild	300(9.6%)	163(5.2%)	301(9.6%)
	Moderate	639(20.4%)	551(17.5%)	541(17.2%)
	Severe	534(17%)	357(11.4%)	818(26.1%)
	Extremely severe	1238(39.4%)	1546(49.2%)	949(30.2%)
	Total	3140(100%)	3140(100%)	3140(100%)
Faculty Of Dentistry
	Categories, N (%)
	Normal	419(14.4%)	520(17.9%)	528(18.2%)
	Mild	280(9.7%)	171(5.9%)	277(9.6%)
	Moderate	633(21.8%)	505(17.4%)	502(17.3%)
	Severe	440(15.2%)	320(11%)	705(24.3%)
	Extremely severe	1128(38.9%)	1384(47.7%)	888(30.6%)
	Total	2900(100%)	2900(100%)	2900(100%)
Faculty of Physiotherapy
	Categories, N (%)
	Normal	87(13.2%)	93(14.1%)	106(16.1%)
	Mild	59(9%)	35(5.3%)	63(9.6%)
	Moderate	142(21.6%)	119(18.1%)	131(19.9%)
	Severe	124(18.8%)	82(12.5%)	166(25.2%)
	Extremely severe	246(37.4%)	329(50%)	192(29.2%)
	Total	658(100%)	658(100%)	658(100%)
Faculty Of Veterinary Medicine
	Categories, N (%)
	Normal	108(12.5%)	148(17.1%)	146(16.9%)
	Mild	60(6.9%)	32(3.7%)	71(8.2%)
	Moderate	199(23%)	151(17.4%)	161(18.6%)
	Severe	146(16.9%)	106(12.2%)	206(23.8%)
	Extremely severe	353(40.8%)	429(49.5%)	282(32.6%)
	Total	866(100%)	866(100%)	866(100%)
Faculty Of Science
	Categories, N (%)
	Normal	284(13.3%)	339(15.8%)	426(19.9%)
	Mild	199(9.3%)	95(4.4%)	198(9.3%)
	Moderate	480(22.4%)	366(17.1%)	377(17.6%)
	Severe	369(17.3%)	249(11.6%)	577(27%)
	Extremely severe	807(37.7%)	1090(51%)	561(26.2%)
	Total	2139(100%)	2139(100%)	2139(100%)
Faculty Of Nursing
	Categories, N (%)
	Normal	244(18.4%)	243(18.3%)	289(21.8%)
	Mild	117(8.8%)	79(6%)	163(12.3%)
	Moderate	307(23.2%)	231(17.4%)	231(17.4%)
	Severe	216(16.3%)	139(10.5%)	311(23.5%)
	Extremely severe	442(33.3%)	634(47.8%)	332(25%)
	Total	1326(100%)	1326(100%)	1326(100%)

Notes: Data are Mean ± SD or n (%).

Prevalence of pre-exam Anxiety among Medical and Paramedical Students in The Arab World during COVID-19: a Cross-Sectional Study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Methods

Study design:

Inclusion Criteria:

Sampling:

Questionnaire development:

Data collection:

Statistical analysis:

Results

Demographic characteristics of the study population

Association between sociodemographic variables and the psychological impact of the exams

Discussion

Conclusion

Abbreviations

Declarations

References

Tables

Status:

Version 1