Quantitative and qualitative analysis of medical students’ symptoms and feelings during COVID-19 pandemic

doi:10.21203/rs.3.rs-3886676/v1

Background

Due to the COVID-19 pandemic, traditional face-to-face teaching was disrupted, leading to a transition to online activities. Social restrictions and isolation during this period may have contributed to various physical and emotional disorders, such as anxiety, depression, reduced perception of happiness, and a decline in overall quality of life. The objective of our study was to assess the perceptions of medical students regarding their emotions, anxiety and depression symptoms, and daily experiences during the pandemic.

Methods

We conducted a prospective study with both quantitative and qualitative components involving students in their 1st to 4th year of medicine at a private university in São Paulo, Brazil in 2020 and 2021. Participants completed online questionnaires, including the State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI), Oxford Happiness Questionnaire (OHQ), and Medical Student Quality-of-Life Questionnaire (VERAS-Q). Additionally, they engaged in online focus group discussions.

Results

A total of 313 students completed the questionnaires, and 200 participated in the focus group. Women exhibited higher scores for anxiety (p = 0.002) and depression (p = 0.007), while men demonstrated better quality of life (p = 0.042). The students aged 18 to 24 years (p = 0.048) presented better quality of life and lower trait anxiety (p = 0.001). Both trait and state anxiety were strongly associated with depression (p < 0.01) and inversely related to quality of life, showing a moderate association with happiness (p < 0.01). Depression was strongly linked to both trait and state anxiety (p < 0.01) and moderately negatively correlated with happiness and quality of life (p < 0.01). The focus groups revealed recurring negative feelings among students, such as anxiety, depression, tiredness, discouragement, loneliness, difficulty managing time, poor sleep quality, exacerbation of harmful habits, and challenges in relationships, resulting in reduced mental and physical health during the pandemic. Coping strategies were discussed, including the adoption of new healthy habits, religious practices, and reconnection with family.

Conclusion

Depression and anxiety symptoms were more prevalent among females, while quality of life improved for younger and male students. The qualitative analysis enhanced our understanding of the determinants and consequences of students' recurring negative feelings, and also showed positive aspects like greater proximity to family and religiosity.

medical students

mental health

quality of life

happiness

anxiety

depression

COVID-19

Medical students and the new coronavirus pandemic

The COVID-19 pandemic caused worldwide concern and spread rapidly throughout several countries, causing significant social and economic impacts. As a consequence of the pandemic, face-to-face teaching was interrupted, and in most places, teaching activities began to be carried out online in response to the need for social isolation to reduce the occurrence of new cases of the disease [1]. The social restrictions applied during the pandemic, which were necessary to protect the health of the population, also caused physical and emotional disorders that affected undergraduate students, and especially those in health-related programs, such as medical students [2–4].

The students in the medical course may have experienced a constant state of alert, loss of autonomy and courage, and a need to adapt to their new scenario of study and work. Those in direct contact with patients may have also felt frustration at the abrupt increase in the number of cases of severe acute respiratory syndrome and fear regarding their own well-being, as well as that of friends and family [5–7].

Therefore, as classes and in-person activities were disrupted amid the pandemic, efforts were made to adapt to virtual learning environments and leverage new teaching technologies whenever feasible. While these resources were already available in many institutions, they became the sole means of education due to isolation protocols [8–10]. Several studies have highlighted the isolation effects of the pandemic on medical and health students, including a constant sense of alertness, disruptions to rest and leisure activities, challenges in the learning process, heightened levels of anxiety and depression, and a decline in overall quality of life [8, 9]. The ability of medical students to adapt to these new circumstances and develop coping strategies may be linked to personal aspects of resilience [10, 11].

Medical students have a worse perception of quality of life and a higher prevalence of psychosocial suffering than does the general population [12, 13]. Adequate time management, among other factors, can also play a protective role in improving quality of life [12]. In a challenging scenario such as a pandemic, difficulties in medical training can be balanced with positive aspects of training, which include intellectual stimulation, the feeling of usefulness when caring for patients, the feeling of satisfaction of having your mission fulfilled and the acquisition of knowledge and skills [1, 14, 15].

During a pandemic, moral values linked to the medical profession and the desire to help can play important roles in medical students’ actions [1]. Interventions to improve the quality of life and time management of medical students are of paramount importance, given the relevance of these professionals in a public health scenario [12]. The mental health of medical students has been negatively impacted by the COVID-19 pandemic in a significant way [16]. Our study, in addition to verifying the influence of the pandemic on the lives of medical students, explored students' thoughts and perceptions regarding these symptoms.

Considering this, in the present study, we aimed to evaluate the self-perception of medical students in relation to their feelings, symptoms of anxiety and depression and daily experiences during the COVID-19 pandemic.

Participants and procedure, ethics and study design

A prospective study with both quantitative and qualitative components was undertaken involving students from the 1st to the 4th year of the medical program at a private university in São Paulo, Brazil. The study was conducted between December 2020 and August 2021 utilizing a convenience sample. Ethical approval was obtained from the Research Ethics Committee of the University City of São Paulo - UNICID, with opinion number 4,467,869 (Supplementary material 1). All the students consented to the online consent form, and participant identities were kept anonymous.

The inclusion criteria were as follows: medical students enrolled in the basic and clinical stages, belonging to the same university, who answered the questionnaires. Fifth and sixth year students were excluded from the study.

The survey was conducted online via the Google Forms platform and Google Meet. The dissemination of the invitation and questionnaire was carried out via email, WhatsApp and phone. Study design: Approximately 700 students were invited to participate, and 387 were excluded because they did not meet the inclusion criteria (internship students, did not respond to all questionnaires, etc.). A total of 313 students answered the questionnaires. A total 200 students participated in online focus groups, in groups ranging from 5 to 10 students (Fig. 1). There was a flow of communication with the university for referral to psychological care, and all the students were free to ask questions or express doubts to the research group.

Measurements

Demographic characteristics and questionnaires

A questionnaire developed by the group researchers (Supplementary material 2) was used to collect demographic data (gender, age, year of study, etc.). The reliability of the data was assessed by using the Cronbach's alpha coefficient for standardized questionnaires [17–19], which had values above 0.700 (Supplementary material 3).

Anxiety Assessment - Spielberger State-Trait Anxiety Inventory (STAI)

Spielberger’s State-Trait Anxiety Inventory [20] is a self-administered questionnaire composed of two scales with 20 items of up to 4 points each, where one scale evaluates the state and the other evaluates the trait of anxiety; the higher the score is, the worse the level of anxiety [21, 22]. Some authors classified the level of anxiety as low (< 33), medium (33–49) or high (> 49), which is the classification that we used in this study [23, 24].

Beck Depression Inventory II

The Beck Depression Inventory II (IDB) evaluates the intensity of depressive symptoms from the respondent’s self-perception. It consists of 21 items, each with 4 alternatives ranging from 0 to 3 points, indicating the severity of depressive symptoms. The higher the score is, the worse the depressive symptoms. Values between 0 and 13 are considered "minimum depression", values between 14 and 19 are considered "mild depression", values between 20 and 28 are considered "moderate depression", and values above 28 are considered "severe depression" [25, 26].

Oxford Happiness Questionnaire

The Oxford Happiness Questionnaire (OHQ) was used to assess the degree of happiness. It consists of 29 questions on a 6-point Likert scale, where 1 represents the lowest possible level of happiness and 6 represents the highest. The total score can reach 174 points. The sum of item scores serves as the happiness measure, with a higher score indicating a better observed degree of happiness [27, 28].

Quality of life assessment - VERAS-Q questionnaire

The quality-of-life questionnaire VERAS-Q (Student and Resident Life of the Health Area) is used specifically to assess the quality of life of the student and resident of health and medicine and has 45 questions. It is divided into 4 domains: Time Use—evaluates student time management and whether the other activities can be reconciled with the course; Psychological—positive and negative feelings, concentration, support, level of self-esteem and charging; Physical Health—health care, sleep, leisure, physical activity and appearance; and Teaching Environment—educational environment, course organization, relationships with teachers, classmates and educational institutions [29, 30].

For each domain, a score is calculated, and the total score is obtained as the sum of its items. The VERAS-Q was initially developed in Portuguese and was subsequently translated into English [29, 30]. There is no minimum acceptable quality of life score, and the analyses were performed by comparing the different groups among themselves, such as by sex and course year. Thus, the higher the value of each score is, the better the quality of life; one can also analyze each statement separately [31].

Focus groups

The focus group is a qualitative data analysis technique designed to facilitate interactions between participants and researchers. The data were collected through the use of 7 guiding questions (Supplementary Material 4) about the lives of medical students during the pandemic. These questions were grounded in the domains of the VERAS-Q quality-of-life questionnaire and the State-Trait Anxiety Inventory (STAI) and were adapted to investigate the impact of the pandemic on the students' academic and personal lives. Each participant shared their opinions and feelings regarding the events and the impacts of the events on their personal and academic lives. The focus groups were administered in accordance with the Critical Appraisal Skills Program method (CASP, 2013)[32]

All participants were informed about the confidentiality of their responses, and their permission was obtained for recording and subsequent transcription, with complete confidentiality regarding their identity assured. The focus group was conducted via the Google Meet platform.

Focus groups were conducted with duration of twenty to forty minutes; two researchers—a group coordinator and another for support—were involved. Participants responded without interference from moderators and with freedom to express their thoughts. The topics covered included how the course was conducted during the pandemic; the impact of social isolation on students; associated feelings and symptoms; habits; effects on sleep; time management; changes in the course; their effects; level of demand; and students' relationships with peers, professors, and family. A pretest was conducted, where the questions were administered to eight medical students (undergraduate research students) before the final survey was administered, and the survey was adjusted based on their responses.

Data analysis

Descriptive statistical analysis was used to assess sociodemographic data. For the analysis of questionnaire items, responses were classified according to each specificity and based on the study level, sex, and age; the Mann‒Whitney test was used. Correlations between instruments were determined using the Pearson correlation coefficient, which was categorized as weak (0.20–0.39), moderate (0.40–0.69), or strong (0.70–0.89) [37, 38]. The significance level was set at p < 0.05. For quantitative analysis, SPSS (Statistical Package for Social Sciences) version 22 was utilized.

The qualitative data analysis included transcripts of the recorded interviews, floating reading, highlighting subjects by relevance and repetition, discussion with the research group and presentation of results in a descriptive manner with quotations from the students' narratives [33–35]. Two independent researchers conducted the analysis of the results, which were combined based on similarity of meaning, and a third researcher reviewed the analysis. The results were categorized into analytical categories, items, and examples of discourse.

Quantitative analysis

Demographic characteristics

A total of 313 responses to the questionnaires were analyzed. Most participants were female (N= 223, 71.3%), aged between 18 and 24 years (75.3%), in either the first or second year (55.6%) or the third or fourth year of the course (44.4%). Additionally, 10.2% (N=32) of the students reported having some underlying health condition, and 12.1% (N=38) of the participants reported regular use of medication (Table 1).

Table 1 Demographic data

DATA	N (%)
GENDER
Female	223 (71.3)
Male	90 (28.7)
Total	313 (100.0)
AGE
18–24	244 (75.3)
>25	18 (5.6)
Years (medical school)
1–2 (Basic)	174 (55.6)
3–4 (Clinic)	139 (44.4)
PREVIOUS DISEASES
Yes	32 (10.2)
No	281 (89.8)
Rhinitis	22 (7.0)
Asthma	6 (1.9)
Depression	3 (0.9)
Hypothyroidism	2 (0.9)
Others (obesity, diabetes, etc.)	3 (1.9)
CONTINUOUS MEDICATION USE
Yes	38 (12.1)
No	275 (87.9)
CONTACT WITH SUSPECTED OR CONFIRMED CASES OF COVID-19
Yes	5 (1.6)
No	308 (98.4)

Scores and averages on each questionnaire

Table 2 shows the average score of the entire group and the percentage of the total score on each questionnaire.

The group obtained medium to high average scores for both state and trait anxiety. There was a prevalence of minimal symptoms of depression according to the self-reports of the students (N=210, 67.0%) (Table 2).

Table 2 Sample characteristics for the main study variables and percentages compared to the maximum score of each questionnaire

Questionnaire	N (%)	Maximum score	Mean (SD)	% maximum score
QUALITY OF LIFE (VERAS-Q)
Total	313 (100.0)	225	143.10 (1.17)	63.6
Use of Time		60	33.48 (0.63)	55.8
Psychological		60	36.63 (0.55)	61.0
Physical Health		35	25.13 (0.39)	71.8
Learning Environment		70	47.83 (0.50)	68.3
HAPPINESS (OHQ)	313 (100.0)	174	122.89 (1.07)	70.6
ANXIETY (STAI)
TRAIT	313 (100.0)	80	46.46 (0.77)	58.0
Low	21 (6.7)		30.09 (0.52)	37.6
Medium	155 (49.5)		41.12 (0.35)	51.4
High	137 (43.8)		57.65 (0.52)	72.0
STATE	313 (100.0)	80	46.09 (0.84)	57.6
Low	33 (10.5)		28.18 (0.42)	35.2
Medium	135 (43.1)		40.67 (0.37)	50.8
High	145 (46.3)		58.23 (0.54)	72.8
DEPRESSION (BDI)
Total	313 (100.0)	63	10.52 (0.64)	16.7
Minimal	210 (67.0)		6.18 (0.27)	9.8
Mild	50 (16.0)		16.34 (0.22)	25.9
Moderate	38 (12.2)		23.36 (0.41)	37.0
Severe	15 (4.8)		34.20 (1.92)	54.3

SD—standard deviation. VERAS-Q—Life of Students and Residents of Health Professions. STAI—State-Trait Anxiety Inventory; low (<33), medium (33-49), high (≥ 49). BDI= Beck Depression Inventory; 0–13= minimal, 14–19= mild, 20–28= moderate, >28= severe.

Comparison by sex

A better quality-of-life score was observed in the physical health domain among men (p= 0.042). There was no significant difference between the total score and that in the Psychological and Teaching Environment domains when comparing quality of life by sex. A higher score was obtained for females (p=0.002), as well as in relation to depression levels (p=0.002) (Table 3).

Table 3 Comparison between men and women regarding quality of life, happiness, trait and state anxiety and depression

	Gender	N	Median (25-75%)	p
QUALITY OF LIFE (VERAS-Q)
Total	Female	223	139.00 (123.00-156.00)	0.146
	Male	90	145.00 (130.75-159.00)
Use of Time	Female	223	34.00 (26.00-39.00)	0.384
	Male	90	34.00 (27.00-40.00)
Psychological	Female	223	36.00 (30.00-41.00)	0.178
	Male	90	37.50 (31.00-43.00)
Physical Health	Female	223	24.00 (20.00-28.00)	0.042*
	Male	90	26.00 (22.00-29.00)
Learning Environment	Female	223	47.00 (43.00-52.00)	0.902
	Male	90	48.00 (43.00-51.00)
HAPPINESS (OHQ)	Female	223	124.00 (111.00-133.00)	0.676
	Male	90	121.00 (114.00-132.25)
ANXIETY (STAI)
State	Female	223	48.00 (38.00-58.00)	0.002*
	Male	90	44.00 (37.75-54.25)
Trait	Female	223	48.00 (40.00-56.00)	0.082
	Male	90	42.00 (38.00-53.00)
DEPRESSION (BDI)
Total	Female	223	10.00 (6,00-17,00)	0.007*
	Male	90	7.50 (3,00-15,00)
Minimal	Female	144	6.50 (3.00-10.00)	0.014*
	Male	66	5.00 (1.00-8.00)
Mild	Female	37	16.00 (15.00-17.50)	0.465
	Male	13	16.00 (15.50-18.00)
Moderate	Female	30	24.00 (21.00-26.00)	0.112
	Male	8	21.50 (20.25-23.75)
Severe	Female	12	31.50 (29.25-38.25)	0.633
	Male	3	30.00 (29.50-34.00)

* p < 0.05 = statistically significant. N=313. SD—standard deviation. Mann‒Whitney test. The bold values indicate that the p value is <0.05

Comparison by age group

In the assessment of quality of life, differences were observed in the Teaching Environment domain, with higher scores among students aged 18 to 24 years (p= 0.048) and in trait anxiety (p= 0.001) (Table 4), which was greater among the younger age group.

Table 4 Comparison between age groups and quality of life, happiness, trait-state anxiety and depression

Age		N	Median (25-75%)	p
QUALITY OF LIFE (VERAS-Q)
Total	18-24	238	142.00 (126.75-161.00)	0.245
	>25	75	140.00 (122.00-151.00)
Use of Time	18-24	238	34.00 (27.00-40.00)	0.054
	>25	75	32.00 (26.00-37.00)
Psychological	18-24	238	36,00 (30.00-42.00)	0.172
	>25	75	38,00 (32.00-41.00)
Physical Health	18-24	238	25.00 (20.00-29.00)	0.106
	>25	75	24.00 (21.00-27.00)
Learning environment	18-24	238	48.00 (43.75-52.25)	0.048*
	>25	75	46.00 (42.00-50.00)
HAPPINESS (OHQ)	18-24	238	123.00 (111.00-132.00)	0.385
	>25	75	122.00 (114.00-134.00)
ANXIETY (STAI)
State	18-24	238	48.00 (40.00-56.00)	0.001*
	>25	75	42.00 (37.00-51.00)
Trait	18-24	238	52.00 (42.00-62.00)	0.171
	>25	75	56.00 (45.00-63.00)
DEPRESSION (BDI)	18-24	238	10.00 (5.00-17.00)	0.139
	>25	75	7.00 (4.00-16.00)

* p < 0.05 = statistically significant. N=313. Mann‒Whitney test. The bold values indicate that the p value is <0.05.

Analysis by stage

The students' responses were also evaluated in relation to their college education or years of study in medicine, and no difference was observed (Table 5) (Supplementary material 5).

Table 5 Comparison between course stage (years of study) in medicine and quality of life, happiness, trait-state anxiety and depression

Questionnaire	Years	*N (%)**	Median (25-75%)	p*
QUALITY OF LIFE (VERAS-Q)
Total	1-2	174	140.00 (126.00-157.00)	0.543
	3-4	139	143.00 (126.00-158.00)
Use of Time	1-2	174	33.00 (26.00-38.00)	0.062
	3-4	139	35.00 (27.00-40.00)
Psychological	1-2	174	37.00 (31.00-41.25)	0.454
	3-4	139	36.00 (30.00-42.00)
Physical Health	1-2	174	24.00 (20.00-28.00)	0.288
	3-4	139	25.00 (21.00-29.00)
Learning environment	1-2	174	47.50 (42.00-52.00)	0.940
	3-4	139	48.00 (43.00-52.00)
HAPPINESS (OHQ)	1-2	174	123.00 (112.00-132.00)	0.755
	3-4	139	122.00 (112.00-133.00)
ANXIETY-
Trait	1-2	174	54.00 (45.00-61.00)	0.147
	3-4	139	52.00 (43.00-61.00)
State	1-2	174	53.00 (44.00-62.00)	0.391
	3-4	139	52.00 (42.00-62.00)
DEPRESSION (BDI)	1-2	174	8.00 (4.75-16.00)	0.553
	3-4	139	10.00 (5.00-16.00)

*p < 0.05 = statistically significant. N=313. Mann–Whtiney test.

Pearson correlation analysis

When trait anxiety was correlated with the other instruments, a strong positive association was observed with state anxiety (R= 0.84, p= 0.000) and depression levels (R= 0.77, p= 0.000). Additionally, there was a moderate negative association with quality of life (R= -0.67, p=0.000), the Time Use domain of the VERAS-Q questionnaire (R= -0.44, p= 0.000), and the degree of happiness (R= -0.60, p= 0.000) (Table 6).

Regarding quality of life, there was a moderate negative association with trait anxiety (R= -0.67, p= 0.000) and depression (R= -0.66, p= 0.000) and a strong association with state anxiety (R= -0.71, p=0.000). Additionally, there was a strong association with the Time Use domain of the same questionnaire (R= 0.85, p= 0.000) and a moderate association with the degree of happiness (R= 0.50, p= 0.000). Similar results were observed when the Time Use domain was considered an independent variable. Comparable outcomes were also noted when comparing the degree of happiness and depression levels with other instruments (Table 6).

Additionally, when comparing the degree of happiness with the other parameters, we observed a moderate inverse association with the trait anxiety (R = -0.60, p = 0.000), state anxiety (R = -0.55, p = 0.000) and depression (R = -0.54, p = 0.000), in addition to a moderate association with quality of life (R = 0.51, p = 0.000). Finally, when depression was compared as an independent variable with the other questionnaires, we observed a strong positive association with trait anxiety (R = 0.76, p = 0.000) and state anxiety (R = 0.73, p = 0.000) and a moderate inverse association with quality of life (R = - 0.67, p = 0.000) and the degree of happiness (R = -0.54, p = 0.000) (Table 6).

Table 6 Correlations between the questionnaires used

Questionnaires			STAI-Trait	STAI-State	VERAS-Q	TIME USE	OHQ	BDI
Trait anxiety (STAI-Trait)t	R	1		0.84^**	-0.70^**	-0.44^**	-0.59^**	0.77^**
Trait anxiety (STAI-Trait)t	p			0.000	0.000	0.000	0.000	0.000
State anxiety (STAI-State)	R	0.84^**		1	-0.71^**	-0.52^**	-0.55^**	0.730^**
State anxiety (STAI-State)	p	0.000			0.000	0.000	0.000	0.000
Quality of life (VERAS-Q)	R	-0.669^**		-0.710^**	1	0.855^**	0.50^**	-0.67^**
Quality of life (VERAS-Q)	p	0.000		0.000		0.000	0.000	0.000
Time use (VERAS-Q)	R	-0.44^**		-0.52^**	0.85^**	1	0.34^**	-0.46^**
Time use (VERAS-Q)	p	0.000		0.000	0.000		0.000	0.000
Happiness (OHQ)	R	-0.60^**		-0.55^*	0.51^**	0.34^**	1	-0.54^**
Happiness (OHQ)	p	0.000		0.000	0.000	0.000		0.000
Depression (BDI)	R	0.76^**		0.73^**	-0.67^**	-0.46^**	-0.54^**	1
Depression (BDI)	p	0.000		0.000	0.000	0.000	0.000

*p < 0.05 = statistically significant. N=313. **R: Pearson correlation coefficient. CI—confidence interval. Correlations: weak (0.20-0.39), moderate (0.40-0.69) or strong (0.70-0.89).

Qualitative analysis

The main categories and themes observed based on the students' reports, along with some examples of discourse, are described in Tables 6, 7, and 8. Most students reported that quality of life was compromised during the pandemic. Despite this, some mentioned positive aspects, such as increased closeness with family, which they considered beneficial during social isolation (Table 7).

Both mental and physical health were reported to be affected during the pandemic, as was the quantity and quality of sleep. Self-demand was also emphasized and was often associated with an overload of activities. The positive aspects experienced during isolation included habits related to self-esteem and self-organization (Table 7).

Several students described interpersonal relationships with peers, family, and teachers as superficial and cold. Some mentioned that relationships with friends they had before the pandemic strengthened, while relationships with teachers and new classmates were more distant. Family interference in the study routine was frequently mentioned, along with difficulty in sharing spaces and increased conflicts, often following a trend before the pandemic, with a decline in academic performance mainly related to distractions in the family environment, with some exceptions (Table 7).

Various negative feelings affected students during the period of social isolation, with frequent reports of stress, anxiety, depression, loneliness, fatigue, low productivity, and constant irritability, among others. Feelings aroused or exacerbated during the pandemic also impacted students' study routines and academic performance. Despite this, some students developed coping mechanisms and found motivation to study (Table 7).

Table 7 Summary of the results of the qualitative analysis—categories, themes and examples of students' narratives—of health and feelings during the pandemic

CATEGORIES	THEMES	EXAMPLES
Health	Self-perception of quality of life	"It affected in various ways, performance, motivation to study, everything got worse in my life..."
	Mental and physical health	"The most affected for me was my mental health because there was a lot of anxiety and panic."
	Sleep	"I felt that my sleep was completely disrupted; some days I slept too much, and others too little. I had insomnia or felt sleepy even after sleeping at night."
	Self-demand	"I put a lot of pressure on myself, especially during online classes because I keep thinking that since I'm at home, I need to study!"
	Self-esteem	"I learned to do my nails during the pandemic, and that was good...it improved my self-esteem."
	Interpersonal relationships	"One thing I know is that the professor on the other side is doing his best in terms of advice, helping, but we can see that it's a superficial thing."
Feelings	Feelings that directly affected individuals	“I had symptoms of anxiety, depression, along those lines...For example, I wouldn't care if I died; I had that in my mind...bad feelings…”
	Feelings that directly affected studies	“When we used to go to college, it was a stressful environment, and at home, it was peaceful. Now, an environment that was peaceful is stressful.”

The perception of the medicine course during the pandemic was also compromised, with frequent reports of associated negative feelings. However, some students described the challenge as a positive aspect to be overcome during social isolation. The absence of practical activities was often cited as a discouraging point for student practice. Overload was a constant theme in students' discourse, as was demotivation for learning. Despite this, some incoming students reported dealing well with online content (Table 8).

Academic performance was affected, even though it was not associated with a decrease in grades. Although students reported adapting to the new scenario and not being negatively affected in terms of grades, demotivation was a constant theme in their statements, with feelings of stress, frustration, irritability, and decreased productivity, among others (Table 8).

Feelings of insecurity and fear were constant at the beginning of social isolation. Among the adaptations to remote learning, the overload of activities was also frequently mentioned, leading to a decline in performance and practical activities. Regarding negative factors, the lack of practical activities was once again a constant theme in students' reports, along with concerns about their own training and preparation for professional life. Despite this, there were also positive reports regarding coping strategies, more available study time, and no loss in course content.

The pandemic increased feelings of demotivation, difficulties in interpersonal relationships, and a lack of practical activities. However, positive aspects also emerged in the discourse, including coping strategies that enabled online learning and more time available for studies (Table 8).

Table 8. Summary of the results of the qualitative analysis—categories, themes and examples—of self-perception and the impact of the pandemic

CATEGORIES	THEMES	EXAMPLES
	Perception of the course during the pandemic	"Discouraging, tiring and individualistic."
Self-perception	Perception of online classes	"The online classes are having a very big overload...It does more out of necessity and does not pay attention if we are really learning."
	Perception of academic performance	"It got worse for sure."
Impact of the pandemic and social isolation	Adaptations in studies	"...Nobody knew how it would be...neither we nor the teachers knew how to handle it, but over time, it didn't affect my study so much...the effort wasn't the same."
	Course adaptations	"...A lot of content in a short period...the performance is lower. The activities can be submitted on time, but they are never well done..."
	Positive and negative factors observed in the course	"I think it affected a lot, especially because I'm in the fourth year...we would have a lot of in-person activities, a lot of practical classes, a lot of clinical practice..."
	Positive and negative effects of the pandemic	"Negative factors: lack of healthy interpersonal relationships. Positive: ...even with the difficulty, I feel that my understanding of the content is more effective."

There were also operational difficulties regarding access to remote content for a portion of students from more distant regions or with fewer technology-related resources. Time management was reported to be compromised according to many students, although a minority noted positive aspects due to time savings related to commuting. In terms of positive aspects, many students reported adopting new healthy habits during isolation, such as physical activity, reading, cooking, and religiosity. Despite these positive aspects, various negative habits, such as alcoholism and smoking, were also mentioned in relation to the pandemic (Table 9).

Table 9 Summary of qualitative analysis—categories, themes and examples—of accessibility, new habits and time management

CATEGORIES	THEMES	EXAMPLES
Affordability	Difficulty in obtaining remote access	"I live in the countryside and do not have internet access with good connection, because of this, I ended up missing enough class."
New habits during the pandemic	New positive habits	"I started practicing physical exercises...I started doing meditation and studying more...."
	New negative habits	"....I drank almost every day!"
Spirituality	Religiosity	"I think I got close to God because of anxiety, and I also got closer to my family"
Time management	Time management	"I did not manage; in fact, I feel that I mixed things a lot— moments of leisure with moments of study; before my routine was well regulated"

In our study, we analyzed medical students' self-perceptions regarding their emotions, anxiety symptoms, depression, and daily experiences during the COVID-19 pandemic to understand how they were affected during this turbulent time. Our study was conducted during the COVID-19 pandemic, and our findings indicate that men exhibited better quality of life, lower anxiety levels, and decreased levels of depression. The quality of life was also better among younger students. In terms of anxiety levels, they were more common among younger individuals, likely due to increased social isolation. We also observed an increase in state anxiety that was accompanied by an increase in trait anxiety, along with a worsening of quality of life and happiness, and an increase in depression levels.

Similarly, through the use of the VERAS-Q, KOBAYASI (2018), in a study involving residents from various medical specialties, also demonstrated lower quality of life in females than in males [17]. RAJAPURAM et al. (2020) also reported a greater level of distress among female medical students [36].

These data align with our findings, as in the present study, we also observed better quality of life in males and lower anxiety. It is important to note that our study was conducted during a time of crisis.

An online survey was conducted in 2020 by IDOWU et al. (2022), which included 1010 medical students from preclinical and clinical levels in Nigeria. They used a single questionnaire with twelve items (GHQ-12 - General Health Questionnaire). The study showed that the pandemic led to psychological distress, which was more significant in females than in males [37], similar to the findings of our study, where anxiety levels among women were higher.

In another study published in 2022 (COCKBURN et al.) that included preclinical and clinical medical students in Malaysia during the pandemic, significantly worse mental health was also evident for female students [38]. PEDRAZ-PETROZZI et al. (2021) studied 375 people, including health care professionals, the general population, and preclinical and clinical medical students, and demonstrated that being female and younger were associated with pandemic-related depression and stress. They also found that being frontline personnel is associated with increased stress, along with other findings [39].

The better quality of life among younger students, as evidenced in our study in the Teaching Environment domain, was similar to that reported in a study conducted with 283 nursing internship students by GRANDE et al. (2021) during the pandemic. In that study, it was also observed that men had better quality of life than women and that a greater quality of life was associated with a younger age [40]. According to VILLAS-BOAS et al. (2018), the strongest predictor of quality of life for young adults is social support, followed by income. In other words, the greater the social and family support and income are, the better the quality of life [41].

PATTANASERI et al. (2022) revealed that 35.7% of 224 preclinical and clinical medical students surveyed during the pandemic (2020) reported experiencing depression, which aligns with our findings [42]. Similar to our study, VARMA et al. (2021) did not find a relationship between depression and age in a study conducted in China during the pandemic with 687 health care professionals (including doctors) [43].

In another study conducted in Jordan with 415 basic and clinical medical students (2020), AL-HUSBAN et al. (2021) indicated that mental health was affected in more than two-thirds of students, and the majority became more anxious or depressed, with no significant difference between gender and academic performance. Clinical-stage students did not show more fear of contracting infections than did students in their basic years [44].

Medical students showed moderate to high levels of anxiety in our study. Similarly, in an online study of 243 medical students from the first to the fifth years, ABDULGHANI et al. (2020) used a questionnaire with only ten questions about psychological distress (K10— Psychological Distress Instrument). Among other aspects, it was observed in this research that most students experienced stress, and higher levels were observed among women, students aged 18 to 21 years, those in the third year of the course, and those who considered online learning to be a burden [45]

According to a review carried out by JHAJJ et al. (2022) on the impact of the pandemic on medical students worldwide, it was observed that, compared with the general population, medical students have higher levels of stress, anxiety and depression; additionally, among other aspects, the study revealed that the pandemic and remote learning had many negative impacts on medical education, mainly related to the loss of clinical practice and increased feelings of anxiety, stress and isolation [46].

In this research, the greater the degree of happiness was, the better the time management and quality-of-life scores were; an increase in happiness was also accompanied by lower levels of anxiety and depression.

The Oxford Happiness Questionnaire (OHQ) was used in an online study of 369 preclinical and clinical medical students in China (2021); no difference was observed between the groups regarding happiness and stress. Factors related to a higher degree of happiness were satisfaction with health and a physical exercise program [47]. This result reinforces the importance of physical exercise for controlling many symptoms, such as those related to anxiety and depression, which contributes to improving happiness.

The Korean version of the Dundee Ready Education Environment Measure (DREEM) was used by LIN et al. (2021) in a study of first- and second-year medical students before and after the pandemic. Two multiple-choice questions about happiness and professional identity were also administered, and no differences were observed between these factors [48].

In a study conducted by DRAGUN et al. (2022) that included adolescents and medical students before and after the pandemic, a positive association was observed between stress and anxiety, and a negative association was found between these characteristics and happiness, being optimistic about the future, and quality of life [49], similar to our study. In a study conducted with women (in the general population), CREGO et al. (2021) reported that higher levels of mindfulness were associated with greater happiness and lower symptoms of anxiety and depression [50].

In a study with physiotherapists, PIGATI et al. (2022) reported that professionals with low resilience (in a group that had contact with COVID-19 patients) had lower quality-of-life and happiness levels than professionals in other groups [51]. In another study, the same authors found that low resilience was associated with working with COVID-19 patients, higher levels of depression, anxiety, and stress, and experiencing greater impacts from the pandemic [52].

When comparing the levels of depression with those of the other instruments, we observed that the higher the level of depression, the greater the level of anxiety, and the greater the quality of life and degree of happiness. In a related manner, ALBANI et al. (2022) assessed (online) the impact of the COVID-19 pandemic on mental health, happiness, and religiosity in nursing students (Greece) using, among others, the Hospital Anxiety and Depression Scale (HADS), the Greek version of the SF-36 health-related quality-of-life questionnaire, and a Subjective Happiness Scale [53–55]. The majority of students considered themselves unhappy and demonstrated very high levels of stress and anxiety during the pandemic [55].

On the other hand, in a study conducted in Malaysia with university students during the pandemic, YUNUS et al. (2021) showed that more than one-third of students had moderate to extremely severe symptoms of stress, anxiety, and depression. However, half considered themselves happy or very happy. Younger students had higher levels of anxiety, stress, and depression, while older students scored higher for happiness, which is considered a protective factor against high stress, anxiety, and depression [56].

In our study, with the use of focus groups during a period of social isolation, stress was expressed in various accounts: "When we went to college, it was a stressful environment, and at home, it was a peaceful environment. Now, an environment that was peaceful has become a stressful environment".

Even before the COVID-19 pandemic, several studies had already shown that medical students experience higher levels of anxiety and depression, burnout, and perceived stress and a decrease in quality of life [57–59]. We also found various reports of anxiety, depression, and a decrease in quality of life during the pandemic in our study.

Personal events and disruptions in relationships were factors that may have contributed to interference in the students' study process. Changes in academic performance and mentions of factors, such as fatigue and demotivation, could have influenced the study routine. Academic workload during the pandemic was also highlighted in our study: "...No matter how much we do, it seems like there's always something pending for the next day; it bothers me a bit, makes me demand a bit more from myself." Time management was strongly affected according to the majority of the reports: "I didn't manage it; actually, I feel like I mixed things up a lot, leisure moments with study moments...".

Feelings of distress and difficulties related to the pandemic were also common among the students in our study. Impairment in interpersonal relationships emerged in many discourses in relation to teachers, colleagues, friends, and family. Additionally, difficulties in readapting to the family environment were also frequently mentioned among students. As a positive aspect, many students mentioned improvements in lifestyle, such as the adoption of physical activities, new healthy habits, and increased religiosity. We also observed impairments in mental health and a sense of insecurity among the students in this study.

Similarly, KHALIL et al. (2021) described the main categories identified in focus groups with medical students: educational impact, time management, challenges encountered, and preferences for the future. This study also revealed positive aspects related to the acceptance of online classes and references to better use of time due to the lack of commuting, as well as difficulties such as understanding the content of classes, insufficient internet connections, and challenges in adapting to online learning [60].

Several accounts of academic performance impairment emerged in our study, despite most reports indicating no impact on grades. As a positive aspect, new coping strategies, such as physical activity, arose in the face of challenges during isolation and family coexistence. Discussion and positive aspects, such as new ways of learning, were also highlighted in our study, as were concerns about the future. However, there are various reports of negative habits, such as increased alcohol consumption and smoking.

Similarly, aiming to assess the impact of the COVID-19 pandemic, ROSS (2022) conducted focus group research with eighteen fifth-year medical students. Emerging themes revolved around stress, mental health impairments, and the development of coping strategies related to teaching and learning; high levels of stress and anxiety were evident [61].

As mentioned in the study by CAPDEVILA-GAUDENS et al. (2021), the prevalence of mental disorders is higher among medical students than among other groups of university students or the general population. The limitations imposed by academic life can pose obstacles to social and personal life, such as distance from family and loved ones, poor sleep quality, and burnout, among other factors that can impact the mental health of students [62].

The consistency between self-perceived levels of anxiety and depression found in our study was expressed in various reports, corroborating the association between depression and anxiety. There were also significant self-reports of suicidal thoughts, along with feelings of distress, anxiety, and depression.

In a study conducted by WATHELET et al. (2020) with university students in France, high rates of suicidal thoughts, distress symptoms, depression, anxiety, and stress were observed during the COVID-19 pandemic [63], similar to some of the reports in this study.

The impact on sleep was an important aspect observed by many students in our research, both in terms of quality and quantity. The fear of contagion through exposure to the SARS-CoV-2 virus was expressed in some testimonials, as was the fear of seeking professionals for mental health treatment.

According to the study by YANG and colleagues (China, 2022), physical activity during social isolation improved depressive symptoms among university students [64]. In this research, many students reported adopting new healthy habits, such as physical activity, as positive aspects.

In our study, not only were negative aspects, such as fatigue, discouragement, and concerns about the future, associated with social isolation, but there were also positive aspects. Students mentioned coping strategies that facilitated online learning, as well as having more time available for studies.

MORTAZAVI & GHARDASHI (2022) conducted a study with virtual focus groups involving 52 medical students in the health field. Themes such as stress and anxiety, concerns about family health, fear of infection, and obsession with hygiene emerged. The pandemic imposed high levels of stress on students, especially those residing in dormitories; boredom and substantial concern about the future were recurring [65], similar to our findings, where students expressed substantial concern about the lack of practical activities and the future. Additionally, we also observed frequent reports of impaired quality of life among students.

Similarly, in a study conducted by MINH et al. (2022), medical and nursing students had below-average quality-of-life levels during the COVID-19 pandemic, with lower vitality and mental health scores, which were not associated with fear of pandemic-related contagion [66].

Care aimed at improving the mental health of medical students should be the responsibility of both individuals and institutions [13, 67, 68]. This study, conducted during a catastrophic event, i.e., the COVID-19 pandemic, highlighted various aspects related to the mental and physical well-being of undergraduate medical students. The presence of negative symptoms necessitates specific and continuous attention and care. Therefore, there is a clear need to strengthen access to care, prevention, and surveillance of the mental health of students.

Limiting factors in this study include the sample being composed of students from a single university, most of the students were female, which may have influenced the results in some way, and the fact that 5 questionnaires were administered, some of which were long, may have influenced the sample size. The lack of face-to-face contact in the realization of the focus groups, which were performed online, may have inhibited student participation and greater spontaneity.

In addition, this study evaluated several factors related to the mental health and quality of life of students through the use of a comprehensive sample and several other comprehensive quantitative and qualitative analyses that were also carried out during the COVID-19 pandemic.

In this study, which was conducted during the COVID-19 pandemic with medical students, approximately one-third of the population reported symptoms of depression, and depression and anxiety symptoms were more prevalent among females. The quality of life improved for younger and male students during the isolation period.

Higher happiness was associated with lower levels of anxiety and depression, as well as better quality of life. There was an association between symptoms of depression and anxiety. An increase in trait anxiety was accompanied by an increase in state anxiety among the students.

Recurrent among students were negative feelings, such as anxiety, depression, tiredness, discouragement, loneliness, difficulty managing time, poor sleep quality, exacerbation of harmful habits, relationships and losses to mental and physical health during the COVID-19 pandemic. In terms of positive aspects, strategies for coping with the pandemic and social isolation were cited, including adopting new healthy habits, practicing religion, and reconnecting with family.

Thus, faced with several reports on negative aspects related to the pandemic and academic and personal difficulties among medical students, the need to strengthen access to care, prevention and mental health surveillance among students is evident. It is also important to propose strategies to improve skills related to coping with critical situations such as those experienced during the COVID-19 pandemic and promote a healthier lifestyle.

Acknowledgments

Not applicable.

Authors’ contributions

SNF, BMSR, IFLCT and FMAC participated in the study design. SNF, APLC, JMA and LRSF collected the data. SNF, ATC, BMSR, RK, MAM and IFLCT analyzed the data and carried out the statistical analysis. SNF, BMSR, IFLCT, RK and APLC wrote the main manuscript. APLC, BMSR, JMA and SNF conducted the qualitative analysis. BMSR, IFLCT, DB, PZT, RK, MLBG, MAM and FMAC reviewed the manuscript. All the authors read, revised and approved the final manuscript.

Funding

Not applicable.

Availability of Data

The data that support the findings of this study are available from the corresponding author upon reasonable request. The authors have chosen to keep datasets publicly unavailable in accordance with UNICID institutional guidelines and recommendations to maintain participant anonymity.

Ethics approval and consent to participate

The study was performed in accordance with the Declaration of Helsinki. All methods were performed in accordance with relevant guidelines and regulations. This study received approval from the Research Ethics Committee of the University of São Paulo City – UNICID, Number of Approval Protocols: 4.467.869. Informed consent was obtained from all participating students.

Competing interests

The authors declare no competing interests.

Consent for publication

Not applicable.

Supplementary Information

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No competing interests reported.

Quantitative and qualitative analysis of medical students’ symptoms and feelings during COVID-19 pandemic

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Medical students and the new coronavirus pandemic

Methods

Participants and procedure, ethics and study design

Measurements

Demographic characteristics and questionnaires

Anxiety Assessment - Spielberger State-Trait Anxiety Inventory (STAI)

Beck Depression Inventory II

Oxford Happiness Questionnaire

Quality of life assessment - VERAS-Q questionnaire

Focus groups

Data analysis

Results

Comparison by sex

Qualitative analysis

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1