|Ahead of print publication
Coronavirus anxiety and cyberchondria among undergraduate medical students during the COVID-19 pandemic in a tertiary care hospital: A cross-sectional study
D Sravani1, C Gowtham Reddy1, PS Murthy1, Suprakash Chaudhury2
1 Department of Psychiatry, Santhiram Medical College and General Hospital, Nandyal, Andhra Pradesh, India
2 Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||08-Nov-2020|
|Date of Decision||21-May-2021|
|Date of Acceptance||02-Jun-2021|
Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Despite widespread rise in anxiety due to the COVID-19 pandemic, there is a paucity of studies of coronavirus anxiety and cyberchondria, which is searching for more health-related information, among medical students. Aim: The aim of the study is to assess the prevalence of coronavirus anxiety and cyberchondria in the context of COVID-19 in undergraduate medical students. Materials and Methods: This is a cross-sectional study done between August 24, 2020 and September 5, 2020. A total of 280 students have given consent to participate in the study by filling online self-designed questionnaire, coronavirus anxiety scale, and cyberchondria severity scale-12. Data analysis was done by SPSS version 20 using appropriate statistical tests. Results: Coronavirus-related anxiety was present in 55% of the students. Moderate and severe cyberchondria were seen in 39% and 50% of the students, respectively. Association between coronavirus anxiety and severity of cyberchondria was statistically significant (P < 0.001). Majority of the students spent >2 h in watching or reading COVID-19 related news. Conclusions: As significant number of medical students had anxiety and cyberchondria related to COVID-19, medical colleges have to implement necessary psychological interventions to safeguard the students' mental health.
Keywords: Coronavirus anxiety, COVID-19, cyberchondria, medical undergraduates
|How to cite this URL:|
Sravani D, Reddy C G, Murthy P S, Chaudhury S. Coronavirus anxiety and cyberchondria among undergraduate medical students during the COVID-19 pandemic in a tertiary care hospital: A cross-sectional study. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Nov 30]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=337805
| Introduction|| |
The emergence of novel coronavirus causing the coronavirus disease (COVID-19) has created havoc across the world. The first outbreak of coronavirus was seen in Central Hubei province of China in December 2019. Later, there came a widespread of disease among all the countries in the world. The World Health Organization declared COVID-19 as a pandemic on March 11, 2020. As of May 21, 2021, globally 165,860,973 cases have been confirmed and 3,444,989 deaths have been reported. India is now in the second position with 25,772,440 confirmed cases and 287,122 deaths. The advent of such a novel virus and highly contagious pandemic and its uncertainty is likely to raise anxiety and have a psychological impact on the whole community. Lockdown and social distancing can be effective in the containment of the virus; concern has arisen about their possible psychological impact on the well-being of the general population and individuals who might be vulnerable to mental health diseases.,
Coronavirus anxiety refers to feelings of dizziness or paralysis, difficulty in falling or staying asleep, loss of interest in eating, and feeling of nausea upon either reading or listening to news and thinking about coronavirus. Furthermore, there will be a fear of contraction of disease and its spread to other family members and fear of isolation. Media can play a role in pandemics. The use of media represents safety-seeking behavior and can trigger further safety-seeking behavior because of possible disturbing information. Cyberchondria, a common safety-seeking behavior, refers to the unfounded escalation of anxiety regarding the state of one's health as a result of searching for medical information on the Internet.
Medical students are experiencing increasing anxiety as COVID-19 gradually affects their physical, emotional, and mental well-being. Assessment of mental health of medical students (n = 530) from Bangalore demonstrated self-reported anxiety in 20.7% of participants. Another study of medical students (n = 7143) from Changzhi Medical School, China, demonstrated self-reported anxiety in 25% of participants. Unlike other students, medical students have a deeper understanding of the disease, which could increase awareness of its severity and impact.
However, there is currently a lack of research on coronavirus anxiety and cyberchondria in the context of the COVID-19 pandemic among medical students. This study was aimed to explore the anxiety and cyberchondria related to coronavirus and possible factors associated with anxiety and cyberchondria that medical students experienced during pandemic.
| Materials and Methods|| |
Study design and participants
This cross-sectional study included a sample of students from 4 years of the medical course at a tertiary care medical center attached to a Medical College. The project was approved by the Institutional Ethics Committee (IEC application ID: IEC/2020/061 approved on August 19, 2020) and was conducted between August 24 and September 5, 2020. Convenient sampling method was followed in selecting the students. All students officially enrolled in the medical course were invited to take part; those who did not complete the questionnaire or refused to take part in the study were excluded from the study.
A self-report questionnaire
This was specially prepared for the study to collect information on age, gender, year of study, total family income, time in hours spent for watching or reading COVID-19-related news, reason for anxiety, and knowledge about COVID-19.
Coronavirus anxiety scale
Coronavirus anxiety scale (CAS) measures anxiety due to coronavirus. It consists of five items. Each item of the CAS was rated on a 5-point scale, from 0 (not at all) to 4 (nearly every day), based on experiences over the past 2 weeks. A CAS total score ≥9 indicates probable dysfunctional coronavirus-related anxiety. Elevated scores on a particular item or a high total scale score (≥9) may indicate problematic symptoms for the individual that might warrant further assessment and/or treatment.
Construct validity of the CAS was demonstrated with correlations between CAS scores and demographics, coronavirus diagnosis, coronavirus fear, history of anxiety, functional impairment, alcohol/drug coping, religious coping, hopelessness, and suicidal ideation. The CAS showed the discrimination ability for functional impairment (area under the curve = 0.88), while the original cut score of ≥9 (76% sensitivity and 90% specificity) showed the strongest diagnostic effectiveness among scores.
Cyberchondria severity scale-12
The Cyberchondria severity scale-12 (CSS-12) was developed as a short-form version of the original 33-item CSS. It is a brief, reliable, and valid measure of worry/anxiety attributable to cyberchondria. It consists of 12 questions. Each question had five options (no way, rarely, sometimes, frequently, and always), and they were scored from 1 to 5. The CSS-12 has excellent internal consistency (α =0.90). Confirmatory bifactor modeling indicated that the majority of item covariance was accounted for by a general cyberchondria factor. Construct validity was assessed by examining associations with the short health anxiety inventory (SHAI) and generalized anxiety disorder assessment (GAD-7), with stronger correlations observed between the CSS-12 and the SHAI (compared to the GAD-7).
Data collection took place by sending questionnaire through Google Form in social media, i.e., Whatsapp. The objectives and implications of the study were explained and confidentiality of the data were guaranteed, and the students gave their consent and then answered the questionnaire. All the questions were made mandatory to obviate the chances of incomplete responses. To avoid multiple submissions by a single student, response form per participant was limited to one.
The data collected were keyed into Excel for Windows and statistical analysis was carried out using the software package SPSS version 20.0 (IBM Inc., Chicago, Illinois, USA). Descriptive analysis with measurements of frequency and mean was used to express sociodemographic variables and results from the scales and questionnaires. The association for demographic, socioeconomic, and mental health variables was tested using the Chi-square test. Multiple regression analyses were run to determine the predictors of coronavirus anxiety and cyberchondria. P < 0.05 was considered to be statistically significant.
| Results|| |
A total of 280 students completed the questionnaires. Mean (standard deviation) age of the students was 20.896 (1.401) years. Range of age was 18–24 years. Demographic characteristics of the sample are depicted in [Table 1]. COVID-19-related characteristics of the medical students are shown in [Table 2]. There was a statistically significant association between year of MBBS study, duration of watching or reading COVID-19 news, total family income, and knowledge about COVID-19 and coronavirus anxiety [Table 3]. Severity of cyberchondria was significantly associated with year of study, coronavirus anxiety, and hours spent on COVID-19 news but not with knowledge about COVID-19 [Table 4].
|Table 3: Association between coronavirus anxiety and its related variables|
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A multiple regression was run to predict coronavirus anxiety in medical undergraduate students from sex, year of study, parents occupation, family income, domicile, marital status, religion, type of family, education of mother and father, staying at home or hostel before pandemic, alcohol consumer, increased alcohol consumption during pandemic, smoking, increased smoking during the pandemic, comorbid medical and psychiatric illness, time spent in reading or watching news, starting new medication during pandemic, increased screen exposure during pandemic, duration of exercise, concentration on academics, phobia of going out, reason for anxiety, CSS score, and knowledge about COVID-19.
Using the stepwise method for multiple regression, a significant model emerged (F2,277 = 303.439, P < 0.000). Adjusted R2 was 0.670. Significant predictors of coronavirus anxiety were increased screen exposure (Beta= −0.081; P < 0.017) and CSS score (Beta = 0.817; P < 0.000) [Table 5], [Table 6], [Table 7].
|Table 5: Multiple regression analysis for predictors of coronavirus anxiety: Model summaryc|
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|Table 6: Multiple regression analysis for predictors of coronavirus anxiety: ANOVAa|
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|Table 7: Multiple regression analysis for predictors of coronavirus anxiety: Coefficientsa|
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Another multiple regression was run to predict cyberchondria severity in medical undergraduate students from sex, year of study, parents occupation, family income, domicile, marital status, religion, type of family, education of mother and father, staying at home or hostel before pandemic, alcohol consumer, increased alcohol consumption during the pandemic, smoking, increased smoking during the pandemic, comorbid medical and psychiatric illness, time spent in reading or watching news, starting new medication during pandemic, increased screen exposure during pandemic, duration of exercise, concentration on academics, phobia of going out, reason for anxiety, corona anxiety scale score, and knowledge about COVID-19. Using the stepwise method for multiple regression, a significant model emerged (F 5,274 = 133.721, P < 0.000). Adjusted R2 was 0.704. Significant predictors of cyberchondria were CAS score (Beta = 0.749; P < 0.000), duration of exercise (Beta-0.088; P < 0.017), sex (Beta = −0.096; P < 0.008), increased alcohol consumption during the COVID pandemic (Beta = 0.078; P < 0.017), and parents occupation (Beta = 0.067; P < 0.049) [Table 8], [Table 9], [Table 10].
|Table 8: Multiple regression analysis for predictors of cyberchondria: Model summaryf|
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|Table 9: Multiple regression analysis for predictors of cyberchondria: ANOVAa|
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|Table 10: Multiple regression analysis for predictors of cyberchondria: Coefficientsa|
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| Discussion|| |
Many previous studies on virus outbreaks have shown that college students experience pandemic-related anxiety and other psychological problems. The current study was one of the few studies on anxiety and cyberchondria related to COVID 19 and factors influencing them. Our web-based study highlights the need of interventions at student level in alleviating the psychological problems.
The pandemic had a considerable impact on health-care communities. Initially, the health-care workers were placed in a stressful condition due to the uncertainty about the mode of disease transmission and implementation of protocols to control infection. Similarly, medical students were exposed to similar stressors during the outbreak, but usually, this group is often overlooked, despite having possible adverse effects on their academic achievements. In this study, we have used CAS to assess the prevalence of anxiety related to coronavirus. Most of the students (55%) reported to have dysfunctional coronavirus anxiety and 45% had no coronavirus anxiety. If left untreated, this anxiety may progress further and cause academic underachievement which needs timely intervention in the form of providing treatment and psychological support. Significant number of students (61%) mentioned fear of spreading virus to other family members as their reason for anxiety. We asked a question regarding the knowledge about COVID-19 transmission and prevention. Even though a significant number of students felt that they had knowledge about COVID-19, still 42% of the students were not having sufficient knowledge about COVID-19 which was noteworthy. This finding underscored the need for providing necessary information to the students. This finding is in line with an earlier Indian study.
During the COVID-19 lockdown, media have become a major source for disseminating all sort of information to the public such as status of COVID-19 cases, medical knowledge, and played an important role as direct communication was minimized to a greater extent. In the current study, when enquired about the amount of time students spent in watching COVID-19-related news in a day, majority (59%) students reported it to be between 2 and 4 h a day followed by ≤2 h by 40% of the students. Severity of cyberchondria was measured related to coronavirus pandemic, in which half (50%) of the students had severe cyberchondria, followed by 39% being moderately affected by coronavirus-related cyberchondria.
Coronavirus anxiety was seen in majority, i.e., 77% of 3rd-year students with a mean of 9.760, 67% of 1st year students with a mean of 9.314, and only 39% of final-year students with a mean of 8.400 and 34% of 2nd year students with a mean of 8.046. However, these findings were not consistent with results in a cross-sectional study, in which there was a gradual decrease in the proportion of moderate-to-severe anxiety by university year, whereby 41.4% of 1st-year participants reported moderate-to-severe anxiety compared to 40.0% among 2nd year, 39.8% among 3rd year, and only 25.6% among 4th year.
With respect to gender, the prevalence of coronavirus anxiety was more with 68% in male students and only 40% in the female students. Findings in this study were in line with a study done in Bangladesh, in which females (33.67%) had lower anxiety symptoms than males (66.33%). However, these findings were not in concordance with a study from China, in which the prevalence of anxiety was significantly higher in females compared to male students (P = 0.015). The multiple regression analysis run in our study also did not support sex as a predictor for corona anxiety scale scores. Further studies are required in this issue.
While considering the time spent for watching or reading COVID-19-related news, majority, i.e., 169 students fell into the category of watching or reading news for >2 h a day. Out of 169 students, majority (n = 109) had dysfunctional coronavirus anxiety, whereas among 111 students who watched or read COVID-19 news for ≤2 h, majority had no coronavirus anxiety. This concludes that the time spent on watching or reading COVID-19 news had a direct impact on coronavirus anxiety. This is in agreement with our multiple linear regression findings and underlines the importance of receiving right and authentic information. These findings were consistent with the results in a study done among the Indian population, in which a significant positive correlation was found between the number of hours people spend on mass media for news daily and how often they felt nervous and anxious after watching the news on COVID-19 (r = 0.54; P < 0.01).
Coronavirus anxiety was found in majority (68%) of the students with a family income between Rs. 50,000 and 75,000, whereas coronavirus anxiety was not seen in majority of students with a family income of below Rs. 50,000 and above Rs. 75,000. These findings were not consistent with the results of a Turkish study, in which it was found that the family income of students below the minimum monthly wage increases anxiety (P = 0.00).
When knowledge about transmission and prevention of coronavirus was enquired, 163 students reported that they had knowledge, among which majority (60%) had coronavirus anxiety, whereas among those who answered no or not sure about the transmission and prevention of coronavirus, majority (53%) had no coronavirus anxiety. However, these findings were not consistent with the results in a study done by Torun et al., in which the mean score of anxiety was higher (6.57) in those who were not sure than those who had knowledge (5.79) and the difference was statistically significant with P = 0.02.
People who are overly distressed or anxious about COVID-19 crisis perform excessive or repeated COVID-19-related searches on the Internet, only to become more distressed or frightened, which we define as cyberchondria. In our study, we found that 73% of the 3rd-year students and 64% of the 1st-year students were severely affected with cyberchondria. However, majority of the final year students and 2nd-year students were moderately affected. It was found that majority (95%) of males were affected with cyberchondria compared to 82% of the female students. These findings were in line with the results in a cross-sectional study, in which it was seen that among 51 study participants who had cyberchondria, majority 33 (64.7%) were male and 18 (35.3%) were female.
Among 111 students who watched or read COVID-19-related news for ≤2 h, majority (62%) had moderate cyberchondria, whereas among 166 students who watched for more than 2 h, 64% were severely affected with cyberchondria which indicates that the amount of time spent in watching or reading COVID-19 news had its impact on the severity of cyberchondria. This can be attributed to the reason that excessive search for information may have started in the hope of gaining information, but, on the contrary, resulting in a wealth of ambiguous information and increased anxiety. This was in concordance with the findings in a study done on health science students, in which it was found that, as the frequency of online health scanning increased, the health anxiety scores (F: 4.803 P: 0.008) and the cyberchondria scores (F: 19.010 P: 0.00) also showed a significant increase. Similar results were found in a cross-sectional study done in which, among the study participants who had cyberchondria 76.5% were using the Internet for ≤5 h/day and 70.6% were using the Internet for ≤6 h/day.
In our study, among 153 students who had coronavirus anxiety, majority (90%) were severely affected with cyberchondria, whereas among 127 students who had no coronavirus anxiety, 75% were moderately affected with cyberchondria. With these findings, it can be said that severity of cyberchondria was positively associated with the presence of coronavirus anxiety. This is also in agreement with the results of multiple linear regression. In an earlier study also, it was found that coronavirus anxiety showed a positive correlation with cyberchondria (P < 0.001).
In this study, irrespective of the prior knowledge about transmission and prevention of COVID-19, majority of the students were severely affected with cyberchondria. However, the finding of exercise as a negative predictor of cyberchondria is a pointer to preventive measures.
Strengths and limitations
The strength of this study was that this was the first to evaluate the anxiety and cyberchondria related to COVID-19 in the medical students. Furthermore, the scale used for measuring coronavirus anxiety-CAS was designed specifically for the COVID-19 pandemic. However, it has certain limitations. This was a cross-sectional study rather than longitudinal, and therefore, the findings cannot be used to explain causal relationships. This research was done only in one medical college. For this reason, it does not represent all medical colleges. A comparative group from the general population would have been added. Moreover, we followed convenient sampling method which can have selection bias.
| Conclusions|| |
This study found that a significant number of medical students had anxiety (55%) and cyberchondria (89%) related to COVID-19. It gives us a view that medical students are not resilient for coronavirus anxiety and cyberchondria despite common assumption of having considerable medical knowledge. Male medical students had higher anxiety and cyberchondria compared to females. There was a direct relationship between the time spent for watching or reading COVID-19-related news and having anxiety and severe cyberchondria. Exercise could help to prevent cyberchondria. Students should pay attention in distinguishing credible and noncredible sources of health information. Medical colleges and health authorities should offer prevention, early detection, and psychological interventions for mental health disorders in medical undergraduate students. In addition, they have to play a proactive role in providing right information about the pandemic.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]