Introduction

According to the American Psychiatric Association, anxiety disorders are the most common type of psychiatric disorder.1 In spite of the increased prevalence rates of anxiety disorders, they are often under-recognized and undertreated clinical problems.2 Anxiety disorders are common in a highly stressful new environment such as medical school, because of high academic obligations, and limited time to achieve them.3

Globally, many studies have reported an increased rate of anxiety among medical students. It is also reported that anxiety is more prevalent among medical students from the Middle East and Asia as compared to other parts of the world.4 It has been demonstrated that the quality of health care provided by anxious medical students was negatively affected, as they were less empathetic when dealing with chronically ill patients, and were less efficient in their work. These findings underscore the importance of conducting research on anxiety and its implications on the future of health care, as there is limited data available regarding the impact of student distress on academic performance.5

Females are the key members of a community as well as the medical profession. An anxious female may not only have a negative health outcome for herself but also has negative implications on her personal and professional life. Anxiety is reported to be more prevalent in female medical students,5,6 which can negatively affect their studies and professional achievements.

Globally, Covid 19 pandemic has affected the physical and mental health of human beings. Internationally, various studies have explored the psychological impact of the Covid 19 pandemic among the general population,7 as well as among healthcare workers.8,9 Also, studies have been conducted among students. A study in Chennai, India found that levels of anxiety and stress have increased in medical students during COVID19.10 A study in China also showed an increased level of anxiety among college students because of the COVID19 pandemic effects.11

In Saudi Arabia, various studies have been conducted to explore the psychological impact of the COVID19 pandemic among the general population.12–17 Researchers have studied the prevalence of anxiety and stress among healthcare workers during the COVID-19 pandemic in Saudi Arabia.18–21 Few studies are also conducted to determine the psychological impact of the pandemic on students,22,23 including dental students,24 and nursing students.25 COVID19 pandemic is reported to have more psychological impact on females and students.26 However, there is a dearth of literature regarding the psychological impact on medical students in Saudi Arabia generally and in Qassim province particularly.

Because of the demanding and stressful nature of medical studies, it is important to explore the added psychological impact of the COVID-19 pandemic on medical students. Moreover, the effect of various strategies for the prevention of Covid 19 among medical students, such as the introduction of online education, needs to be determined. In this context, we designed the current study to determine the prevalence of anxiety during Covid 19 pandemic among female medical students, identify the factors associated with anxiety in female medical students, and to explore the effect of COVID19-related circumstances on the anxiety level of medical students in Qassim University, Qassim region, Saudi Arabia.

Methods

A cross-sectional study was conducted among female medical students at Qassim University, Saudi Arabia. A self-administered questionnaire was designed in English and translated into Arabic. The questionnaire was back-translated to check the accuracy of the translation. The questionnaire consisted of 2 sections. The first section gathered personal data (age, marital status, year of study, academic performance, and household income) and information related to the Covid19 pandemic. The second section comprised the Beck Anxiety Inventory (BAI) which is a 21-item scale consisting of statements measuring the severity of anxiety. BAI is a validated instrument with high internal consistency (α=0.92) and test-retest reliability.27 The items comprise of symptoms such as ‘numbness or tingling’, ‘unable to relax’, 'dizzy or lightheaded, and ‘terrified or afraid’. There are four response options ranging from 0 to 3 for each item, where 0 stands for 'not at all 1 for ‘mildly but it didn’t bother me much’, 2 for 'moderately, it wasn’t pleasant at times, and 3 for 'severely, it bothered me a lot. The maximum score for all items is 63, with the score of 0-21 categorized as 'low anxiety; a score of 22-35 as ‘moderate anxiety’ while a score of 36 and above, as ‘severe anxiety’. The questionnaire was pre-tested for clarity and understandability.

The data were collected by an online survey, designed and submitted to the WhatsApp groups of female medical students, using Google Forms. All Qassim university female medical students of the first year, 2nd year, 3rd year, 4th year, and 5th year, were invited to participate in the survey. The study was facilitated by the group leader for each year. To improve the response rate, multiple reminders were sent to the participants. The data were collected from August to December 2021.

The data collected were coded and cleaned in Microsoft Excel. Variables were processed and analyzed using IBM SPSS Statistics (version 21). The results were expressed as means, medians, frequencies, and percentages. Relevant inferential statistical tests were used to determine the significance. Statistical significance was considered as a two-tailed p-value <0.050.

Ethical Considerations

The study was approved by the Qassim Research Ethics Committee (registration no. H-04-Q-001). The study was conducted in accordance with the principles of the Declaration of Helsinki. An explanation of the study’s objectives, as well as the informed consent form, were included in the questionnaire. The survey was anonymous, and data were kept confidential. The participation was voluntary, and the participants were informed that they could withdraw from the survey at any time. The respondents did not receive any compensation for their participation in the survey.

Results

The questionnaire was distributed to 278 female medical students. Out of these, 179 students responded and completed the study questionnaire, leading to a response rate of 64.4%.

The age of the respondents ranged from 18 to 26 years, with a mean of 22.45 (±1.57) years. Table 1 shows the demographic characteristics of the participants. More than half of the participants (55.3%) belonged to the 23–26-year-old age group. Most of the respondents (n=84, 46.9%) perceived their academic performance as ‘Good’. A total of 50 (27.9%) students reported their family income ranging from 10,000 to 14,999 Saudi Riyals. A vast majority of the students (89.9%) were living with their parents.

Table 1. Demographic characteristics of the study participants (n=179)
Variables Number (n) Percentage (%)
Age Group (Years):
18-22 80 44.7
23-26 99 55.3
Academic performance:
Poor 8 4.5
Fair 33 18.4
Good 84 46.9
Very good 33 18.4
Excellent 21 11.7
Study level:
First/ Second year 29 16.2
Third/Fourth/Fifth year 150 83.8
Marital status:
Single 176 98.3
Married 3 1.7
Income/household income:
Less than 5000 18 10.1
5000 - 9999 31 17.3
10000 - 14999 50 27.9
15000 - 20000 30 16.8
More than 20000 50 27.9
Living status:
With parents 161 89.9
With husband 3 1.7
with Relatives/friends/alone 15 8.5

The study participants were asked whether they or their family members had suffered from COVID-19. A total of 34 (19%) respondents suffered from COVID-19. Regarding COVID-19 among immediate family members, 50.3% (n=90) students answered in affirmation; out of these 76.7% (n=69) reported that the affected family member was living in the same household. Among the family members suffering from COVID-19, 24.4% were admitted to the hospital.

Table 2. COVID-19 among the study participants and their family members (n=179)
Variables Number (n) Percentage (%)
Suffered from Covid-19
Yes 34 19
No 133 74.3
Don’t know 12 6.7
Immediate Family member suffered from Covid-19
Yes 90 50.3
No 89 49.7
Family members affected by COVID-19 living in your household (n=90)
Yes 69 76.6
No 21 23.4
Family members affected by COVID-19 got admitted to the hospital (n=90)
Yes 22 24.4
No 68 75.6

Figure 1 shows the study participants’ level of anxiety according to the Beck Anxiety Inventory (BAI). A total of 31 (17.3%) participants had moderate and 17 (9.5%) had a severe levels of anxiety according to Beck Anxiety Inventory. Thus, the overall prevalence of anxiety among study participants was 26.8% (n=48).

Figure 1. Study participants’ level of anxiety by the Beck Anxiety Inventory (n=179)

The study participants were asked about their thoughts and feelings regarding COVID-19 and related situations. In response to the statement, ‘During past one year, I have felt anxious and worried about COVID-19’. A total of 48 (26.8%) respondents were worried either most of the time or all the time regarding online learning and 72 (40.2%) were worried either most of the time or all the time about their academic performance due to online learning (Table 3).

Table 3. Study participants’ feelings regarding COVID-19 and related situations (n=179)
During the past 1 year, I have felt anxious, worried, and nervous about .. Never/ Occasionally Half of the time Most of the time/ All the time
Covid-19 113 (63.2%) 37 (20.7%) 29 (16.2%)
Lock down 127 (71%) 28 (15.6%) 24 (13.4%)
Online learning 104 (58.1%) 27 (15.1%) 48 (26.8%)
Academic performance due to online learning 81 (45.3%) 26 (14.5%) 72 (40.2%)

Out of the total 63 scores, the overall mean anxiety score among study participants was 14.6 (±13.5) with a minimum of 0 and a maximum of 58 while the overall median score was 11 (IQR=21). Table 4 shows the association between anxiety scores and the demographic characteristics of the study participants. The younger age group (18-22 years) had higher median anxiety scores [15 (28.5)] as compared to the 23-26 years age group [8 (21)]. This difference was statistically significant at p=0.042. The participants who perceived their academic performance as ‘poor or fair’ had higher anxiety scores as compared to those considering their performance as 'good, very good, or excellent, with a statistically significant difference of p=0.018. Similarly, there was a statistically significant difference in anxiety scores among those living with parents or husbands as compared to those living alone or with relatives and friends (p=0.01).

Table 4. Association between Demographic characteristics of the participants and anxiety score (n=179)
Variables Mean (SD) Median (75%IQR) p-value
Age Group (Years):
18-22 16.36±12.89 15 (28.50) .042*
23-26 13.10±13.82 8 (21)
Academic performance:
Poor / Fair 19.24 (13.25) 17(31) .018¶
Good 13.36(12.84) 11(20.75)
Very good / Excellent 12.87(14.04) 8.50(18.25)
Study level:
First / Second year 20.03±14.11 20(31.50) .019*
Third / Fourth / Fifth year 13.50±13.13 10(20)
Income/household income (Saudi Riyals):
Less than 5000- 15000 16.31±13.06 15(28) .016*
More than 15000 12.38±13.74 9.50(18.75)
Living status:
With parents/ husband 13.90±13.52 10(21.75) .010*
With relatives/friends/alone 21.80±10.92 19(32)

* Mann Whitney U test Kruskal Wallis Test

As regards the association between COVID-19-related situations of the participants and total anxiety scores, we found no statistically significant association of anxiety scores with COVID-19-related anxiety, lockdown, online learning, and performance due to online learning. On exploring the association between anxiety scores and being affected by COVID-19, anxiety scores were statistically significantly higher among those whose family members got hospitalized due to COVID-19 (p=0.035).

Discussion

Medical students are in a highly stressful field during their medical training.3 Because of the stressful situation, they may become anxious, and their career can be negatively affected if anxiety is not identified and minimized.5 A study in Saudi Arabia during the COVID-19 pandemic showed that females were having higher levels of anxiety, and most of them were students during the peak of the outbreak.17

In our study, 17.3% had moderate, and 9.5% had potentially concerning levels of anxiety, leading to an overall anxiety prevalence of 26.8%, according to the Beck Anxiety Inventory (BAI). In a meta-analysis on the prevalence of anxiety among medical students, the overall prevalence of anxiety was found to be 33.8% among medical students globally, which is substantially higher than the general population. Similar to the findings of our study, a study done in Saudi Arabia found 21.5% of the respondents having “minimal to moderate”, and 13% experiencing “severe to extreme” levels of anxiety.23

A study was done at college students in Almaarefa University, Saudi Arabia, during the COVID-19 pandemic to see the impact of distance learning method on anxiety, using the GAD-7 scale. It was found that anxiety was mild in 32.2%, moderate in 36.2%, and severe in 22.8%.22 A study in Jazan found that 31% of undergraduate students at Jazan University had psychological distress.28 Similarly, a study of the prevalence and predictors of anxiety and depression among female medical students in King Abdulaziz University, Jeddah, Saudi Arabia showed that 33.3% and 34.9% of students had borderline and morbid anxiety, respectively.29 The prevalence of anxiety (moderate and severe) among medical students was found to be 40% in a study exploring the correlation between academic performance and anxiety in medical students of Majmaah University, Saudi Arabia.6

The present study showed a significant association between age and anxiety; the younger the age, the higher the anxiety scores. Also, there is a significant association between higher anxiety scores and junior year of study (first and second year). This finding is in line with other studies.30–33 Similar to the findings of our study, a study was done in Saudi Arabia measuring the anxiety level of university students during COVID-19 and found that students in their fourth year were more anxious compared to students in their fifth year or final year.23A decrease in anxiety symptoms of senior medical students may be attributed to a gradual adaptation to the environment and the study courses.32 Internationally, a study conducted in Egypt showed a significant association between stress and student age of more than 20 years (p=0.049).34 On the contrary, other studies showed higher levels of anxiety among senior study years in comparison to first-year medical students.6,10

Our study found a significant association between increased levels of anxiety and lower levels of income. Similarly, a study from Syria found higher anxiety prevalence among those reporting insufficient income.30Another study conducted among medical students in Egypt found a significant association of stress scores with lower socioeconomic class, as higher stress scores were detected in low and very low socioeconomic groups.34

One of the findings of the current study was the significant association between lower levels of anxiety and participants’ perceived ‘very good/ excellent’ academic performance. Likewise, a lower anxiety score was found among students who were satisfied with their educational performance in India.10

In the present study, those who had their family members hospitalized due to COVID-19 were having higher scores of anxiety. This finding is similar to another study done in Saudi Arabia that showed higher anxiety among those who had a vulnerable household member at increased risk of COVID-19.17

Limitations

Our study has certain limitations. Firstly, the study included only female medical students, studying in a medical university in a single city, leading to the limited generalizability of the study. Secondly, the study was conducted as an online survey through a self-administered questionnaire. Thus, some of the questions might be misunderstood by the study participants. However, the questionnaire was pre-tested for clarity and understandability.

Conclusion

According to the Beck Anxiety Inventory (BAI), the prevalence of anxiety among female medical students during the COVID-19 pandemic was 26.8%. There was a significant association of anxiety with the junior level of study, lower household income, and perceived poor academic performance. Our study has highlighted the need for accessible mental health services for medical students, specially counselling and mental health education. We recommend that medical colleges focus their efforts on educating medical students about their mental health and encouraging them to seek help when needed. Supportive strategies to minimize stress, such as stress management courses, can also be introduced in medical colleges. Furthermore, we recommend that medical colleges collaborate with mental health specialists to have specialized approaches to alleviate anxiety in medical students. For the students needing treatment, psychotherapy may be included in the treatment plan as it has an important role in the management of anxiety disorders.


Acknowledgments

We would like to thank all medical students who participated in this study.

Authors’ Contribution

AAM designed the study, collected the data, performed data analysis, and drafted the manuscript. SJ participated in the design of the study, and data analysis, and critically revised the manuscript for its intellectual content. AAM had the final responsibility to submit for publication. Both authors approved the final version of the manuscript for publication.

Conflict of Interest

The authors declare that they have no conflicts of interest.

Funding

None.

Conference Presentation

None.

Data Availability

The data used to support the findings of this study are included within the research article and are available from the corresponding author upon request.