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Original research
Mental burden and perception of the study situation among undergraduate students during the COVID-19 pandemic: a cross-sectional study and comparison of dental and medical students
  1. Jennifer Guse1,
  2. Annabel Susan Weegen1,
  3. Ines Heinen1,
  4. Corinna Bergelt1,2
  1. 1Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  2. 2Department of Medical Psychology, University Medicine Greifswald, Greifswald, Germany
  1. Correspondence to Dr Jennifer Guse; j.guse{at}uke.de

Abstract

Objectives To investigate levels of distress, depression, anxiety, stress and perception of their current study situation during the COVID-19 pandemic among undergraduate dental and medical students.

Design Observational, cross-sectional study including two consecutive surveys (May and July 2020).

Setting A large medical school in Germany.

Participants All first year dental and medical students were invited. 132 participating first year students (44 dental, 88 medical) from the first survey and 150 students (50 dental, 100 medical) from the second were included in our analyses.

Primary and secondary outcome measures Mental burden (distress thermometer, Patient Health Questionnaire-4, Perceived Stress Scale-4) and self-reported changes in mental health and perception of study situation during the COVID-19 pandemic (self-developed items) were compared. Open-ended questions were analysed by conventional content analyses.

Results A considerable proportion of students (t1: May 2020: 84.1%; t2: July 2020: 77.3%) reported distress levels above cut-off. In July 2020, dental students reported significantly higher distress scores than medical students (dental: M=7.0, SD=2.3; medical: M=5.7; SD=2.1; p<0.001). More dental than medical students reported mild, moderate and severe levels of anxiety and depression symptoms. The majority stated that their mental health and study motivation had not changed during the pandemic. Logistic regression showed that being a dental student was significantly associated with a higher likelihood for serious worries regarding the study situation during COVID-19 at t1 (OR 4.0; 95% CI 1.1 to 14.2). At t2 higher distress was significantly associated with a higher likelihood for experiencing serious worries (OR 1.8; 95% CI 1.3 to 2.5). Regarding current concerns related to the pandemic, students most frequently reported difficulties with self-regulated learning (15.2%), study-related worries and uncertainty (14.4%), missing feedback of students and lecturers (11.4%) and lack of practical training (9.8%).

Conclusion The results suggest that high mental burden and the lack of practical training among medical and dental students is an increasing problem, with a possibly even higher urgency in dental students. Tailored psychological and educational support offers during and after the COVID-19 pandemic might help them as they progress through (medical and) dental school.

  • medical education & training
  • COVID-19
  • mental health
  • qualitative research

Data availability statement

No additional data are available. As ethical approval was not obtained to make data sharing possible outside of the listed research team.

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Strengths and limitations of this study

  • This study offers in-depth exploration of students’ mental health and perception of their study situation during the COVID-19 pandemic by combining quantitative data and qualitative data.

  • This study included well-established and valid instruments (quantitative data) and applied conventional content analyses with inductive categorisation (qualitative data).

  • Response rates of this study were high (65.3%–87.2%).

  • It is a single-institution study and the cross-sectional design does not allow causal statements about longitudinal developments.

Introduction

The COVID-19 pandemic and its consequences have an impact on the private, professional and social life of all people.1 It has brought widespread disruption to undergraduate medical education.2 3 Thus, medical students worldwide face major changes regarding their medical training and study motivation decreased.4 Many medical schools have made changes to their curricula and campus life to protect patients and students by social distancing. Roles of medical students’ during the COVID-19 pandemic are discussed controversial.5 Even in the absence of the COVID-19 pandemic, mental burden is common among medical students6–8 and several studies report lower mental health outcomes for medical students in the course of their medical studies compared with population reference samples.9 In particular, depression and anxiety symptoms are reported among medical7 10 and dental students.11–13 Often students feel that they do not have adequate coping strategies to deal with study-related workload and stress.14 Dental students are highly burdened and perform at a comparable or higher stress level than medical students.15 Studies have shown that the stress level increases with each semester, especially due to the high proportion of practical training in dental studies.13 16

In light of novel circumstances during the COVID-19 pandemic, uncertainty relating to personal and professional future and rapid changes dental and medical students may be even more at risk of experiencing severe mental burden during the pandemic than before. Increased incidence rates of stress and mental burden are an expected response under the current conditions.17

Studies have shown the negative impact of past pandemics18 and the COVID-19 pandemic19 on the general population, as well as on specific groups.20 Health professionals may be particularly affected,21 as pandemic-specific stressors are added to the general ones.22 High prevalence for mental health symptoms among healthcare workers exposed to COVID-19 was found.20 Students are also highly burdened while facing new challenges raised by the pandemic’s consequences.23 24 COVID-19-related mental stress, higher rates of depression and a high symptom burden from the acute stress response according to the COVID-19 pandemic are common especially among healthcare students,25 as they have to cope with mental and emotional issues, including stress and anxiety.

In contrast to the exposure of students in general during the COVID-19 pandemic, the mental burden of medical and dental students in particular is still poorly addressed in the international literature even though they are facing special challenges in healthcare.26

Therefore, the aim of this study was to assess the magnitude of distress, depression, anxiety and stress among undergraduate dental and medical students in the course of the COVID-19 pandemic. Second, we aimed to explore students’ perception of the study situation during the pandemic and compare dental and medical students’ perception during the first lockdown period and thereafter.

Methods

Design and setting

This observational study consists of two cross-sectional surveys conducted at the University Medical Center Hamburg-Eppendorf (UKE), Germany, from 28 May 2020 to 7 June 2020 (t1) and from 16 July 2020 to 31 July 2020 (t2). During this period and before (since mid-March 2020), the German government announced several public health measures to suppress the spread of COVID-19 by increasing social distancing, that is, the closure of schools, daycare, playgrounds and non-essential shops, the prohibition to meet more than one person from another household and depending on regional regulations the prohibition to leave the apartment without reason.27 Concurrently lectures and seminars at the universities were predominantly held in a digital format to reduce interpersonal contact and to protect patients, students and faculty.28 Thus, the learning environment and examination conditions for students have changed significantly. Many medical schools have discontinued their undergraduate medical training and transitioned most of their teaching to digital formats.29 This included but was not limited to the transformation of objective structured clinical examinations30 into multiple choice tests.

Participants

All first year dental students (n=68) enrolled in the integrated dental degree programme iMED DENT launched in 2019 and medical students (n=352) enrolled in the integrated medical degree programme iMED established in 2012 at the Medical School of the University of Hamburg, Germany31 were invited to participate in the online surveys. Students were asked to complete an anonymous questionnaire linked to the voluntary curriculum evaluation conducted by the dean’s office in regular intervals during the course of the year. A few days in advance the students were informed via e-mail of the study aims, voluntary participation and data protection regulations. Participants did not receive any incentives for answering the questionnaire.

Measures

We developed an online questionnaire and focused on symptoms of distress, depression, anxiety and stress by using established self-reporting questionnaires. Furthermore, we assessed the perception of the study situation during the pandemic and study motivation with self-developed items. Demographic characteristics (age in categories, gender) were also self-reported.

Distress

We assessed students’ distress at t1 (May 2020) and t2 (July 2020) using the German version of the distress thermometer (DT), a brief screening instrument developed by the National Comprehensive Cancer Network.32 The DT is a single-item instrument with a scale from 0 to 10. Higher scores indicate higher distress. Internationally a cut-off score of 4 is established as a signal that a person is distressed and needs support. The DT is a reliable and efficient screening instrument.32

Depression and anxiety

We measured depression and anxiety using the German version of the four-item Patient Health Questionnaire (PHQ-4), an ultrabrief screening instrument that consists of a two-item depression scale (PHQ-2) and a two-item Generalised Anxiety Disorder scale (GAD-2).33 It assesses the amount of depression and anxiety symptoms the individual has felt during the past 2 weeks. A score of 3 or higher on the PHQ-2 and GAD-2 is established as a reasonable cut-off score clinically relevant levels of depressive and anxiety symptoms. The total PHQ-4 score is considered as an overall measure of symptom burden with the following categories: 0–2 normal, 3–5 mild, 6–8 moderate, 9–12 severe. It is an efficient screening instrument with good internal consistency and construct validity and areas under the curve between 0.84 (anxiety) and 0.79 (depression) among students.34

Changes in mental health and perception of study situation during the COVID-19 pandemic

Furthermore we administered five self-developed items to assess changes in students’ mental health and perception of the study situation: Students were asked whether their mental health has changed since the beginning of the pandemic with five answer options (clearly improved; rather improved; unchanged; rather worsened; clearly worsened). They were asked if the assessment of their study situation has changed in the context of the pandemic with three answer options (No, I am as worried or unworried as before; Yes, I am somewhat worried; Yes, I am seriously worried). In addition students were asked if the pandemic affected their possibility to participate in exams with five options to answer (No exams took place since the beginning of the pandemic; Exams took place without changes; Exams did not take place, but a new date is scheduled; Exams did not take place and no new date is scheduled yet; I was not able to attend exams due to quarantine or illness). Students were asked if their study motivation had changed since the beginning of the pandemic. Answers were rated on a 5-point Likert-type scale (clearly increased; rather increased; unchanged; rather decreased; clearly decreased). Finally, students were asked for free text responses regarding the question what currently is occupying them most in their current study situation and what they experience as particularly helpful.

Stress

In the second survey, students’ perception of stress was quantified with the Perceived Stress Scale (PSS-4). The 4-item self-report instrument with reverse coding for two items assesses on a five-point Likert scale the degree to which situations in one’s life were perceived as stressful in the past month.35 Higher scores on the PSS-4 indicate higher stress levels.

Burdening aspects

For the second data collection in July 2020, we developed six items based on the qualitative results from the first survey to assess burdening aspects experienced by the students' quantitatively. The respondents had the possibility to answer in four levels (1 = ‘not at all burdensome’ to 4 = ‘very burdensome’).

Data analysis

We matched dental students to medical students according to age and gender in the ratio of 1:2 in order to harmonise the initially inhomogeneous sample sizes and enhance comparability of the samples. In May 2020, the final sample consisted of n=132 students (44 dental and 88 medical students). In July 2020, the sample comprised 150 students (50 dental and 100 medical students). With 74% (t1) and 69% (t2) female students the gender ratio of the sample is comparable to the ratio of first year students at German medical schools.36 We used descriptive statistics to characterise the sample. Group comparisons were carried out using χ2 tests for categorical variables and t-tests for differences of means.

We conducted descriptive analyses to examine the magnitude of DT, depression and anxiety (PHQ-4) and stress (PSS-4). The results of the entire sample as well as of the subgroups (dental and medical students) were compared with PHQ-4 data of a German medical student sample (n=321, mean age=21.8 years, 60.7% women) from a previous study at the same faculty8 with one-sample t-tests. To examine the likelihood for serious worries (dichotomous) regarding the study situation during the COVID-19 pandemic at t1 we conducted a binary logistic regression model with sex, subject of study, the magnitude of distress, depression and anxiety as potential predictors. Non-significant variables were excluded via backward elimination and dropped at the level of p<0.05. We applied likelihood ratio method, which is recommended for stepwise methods.37 To avoid multicollinearity, we analysed Variable Inflation Factors scores. We conducted effect size calculations and considered according to Cohen’s f2=0.02 to be a small effect, f2=0.15 as a medium effect, and f2=0.35 as a large effect.38 All quantitative analyses were carried out using IBM SPSS V.27.

We used conventional content analyses with inductive categorisation to analyse the free text responses.39 Two researchers familiarised themselves with the qualitative data (IH and JG). They identified key concepts and generated labels of codes for recurring themes independently. Next, both sorted codes into categories independently, which were reviewed by all authors. We developed final definitions for categories and codes with iterative consultations and discussions until consensus was achieved. We chose excerpts to exemplify each category and translated them into English. For the qualitative data analysis, we used MAXQDA 2020 (VERBI Software, 2019).

Following the inductive categorisation, we recoded answers for each category into dichotomous variables (mentioned vs not mentioned) to enhance data transparency and to provide evidence for our interpretation.40 When students provided more than one category per response, all responses, respectively, categories were categorised. The qualitative results of the first survey served as the basis for developing six quantitative items for the second survey.

Patient and public Involvement

We did not involve patients in our study. Research questions were developed by the principal investigators (CB and JG) and discussed with the Curriculumkommitee iMED, Hamburg (CK iMED) in April 2020. CK iMED is a committee consisting of students, teachers and a member of the dean’s office, which has the task of further developing and optimising the structure and content of the reformed medical degree programme iMED. Subsequently, all enrolled students were informed by email about the design, conduct, the outcome measures and the recruitment and encouraged to give feedback. After publication a summary of the results will be presented in plain language on the website of the University Medical Center Hamburg-Eppendorf.

Results

Of 68 first year dental students enrolled in the dental education programme at the UKE in May 2020, 44 (65.3%) completed the first survey (t1) in May 2020 and were matched to 88 medical first year students who completed the t1 survey as described above (overall response rate of the medical students was 87.2%). The response rate of the second survey (t2) was 81% among first year dental students and 82% among first year medical students. With 75.0% (t1) and 70.0% (t2) female dental students and 39.7% (t1) and 40.0% (t2) aged 20 years and younger, both samples are similar to the population of first year dental students at the faculty. The demographic characteristics of the final samples are shown in table 1.

Table 1

Sample characteristics among dental and medical students participating in the first (n1=132) and second survey (n2=150)

Distress, depression and anxiety

Overall, high levels of distress, anxiety and depression were found in both dental and medical students. Compared with a German reference sample41 with an overall mean PHQ-4 score of 1.8 (SD=2.0) and of 1.5 (SD=2.0) for a student subsample, our samples reported on average significantly higher anxiety and depression (PHQ-4) scores at t1 and t2: In May 2020, 79.5% of the dental students and 86.4% of the medical students reported moderate or severe distress scores and 25.0% of the dental students and 23.8% of the medical students reported moderate to severe anxiety and depression scores. In July 2020, dental students reported significantly higher levels of distress and anxiety than medical students (table 2). With regard to gender differences, the scores of male and female students did not differ significantly in the whole sample at t1 and t2. However, female dental students (t1: M=4.7; SD=2.6; t2: M=4.6; SD=2.8) reported significantly higher PHQ-4 scores than male dental students (t1: M=2.8; SD=1.5; t2: M=2.9; SD=2.6) at t1 (t(42)= −2.2, p=0.031) and t2 (t(48)= −2.1, p=0.043).

Table 2

Amount of self-reported distress, depression and anxiety and stress among dental and medical students in May 2020 (n1=132) and July 2020 (n2=150)

In July 2020 (t2), dental students reported significantly higher scores of distress and anxiety than medical students, while both groups were comparable with regard to their overall anxiety and depression symptom burden (24.0% with moderate or severe symptoms in dental students, 19.0% in medical students). With regard to self-perceived stress (only assessed in the second survey), dental students reported higher stress levels than medical students (table 2).

Changes in mental health and perception of the study situation

Overall, about one-third of the students (36.4% dental students vs 29.5% medical students) reported that their mental health had worsened because of the pandemic at t1. Likewise, a total of 35.6% (45.5% dental vs 30.7% medical students) reported a decrease in their study motivation at t1 and 36.7% at t2 (36.0% dental vs 37.0% medical students). With regard to worries about the current study situation more medical students (t1: 46.4%; t2: 47.5%) than dental students (t1: 31.8%; t2: 34.7%) reported to be unperturbed and slightly more dental than medical students were seriously worried at t1 (18.2% vs 6.0%) and at t2 (14.3% vs 10.1%). However, in both surveys dental and medical students did not differ statistically significant regarding their self-reported changes of mental health, study motivation or worries about the current study situation (table 3). Likewise, we did not find statistically significant differences between male and female students.

Table 3

Perception of current study situation, changes of self-reported mental health caused by the COVID-19 pandemic and changes of study motivation of dental and medical students in may 2020 (n1=132) and July 2020 (n2=150)

Burdening aspects

Many of students felt burdened due to the lack of interaction with fellow students. In comparison to medical students, significantly more dental students stated that they were burdened with regard to the exams and the general uncertainty (table 3).

Binary logistic regression indicated that dental students (O: 4.0; 95% CI 1.1 to 14.2) were significantly more likely to experience serious worries regarding the current study situation during COVID-19 than medical students in May 2020. In July 2020 higher distress (OR 1.8; 95% CI 1.3 to 2.5) was associated with a higher likelihood for reporting serious worries regarding the current study situation during COVID-19 (table 4).

Table 4

Binary logistic regression models on the association of study subject, depression and distress with serious worries in dental and medical students during the COVID-19 pandemic

Current concerns and helpful aspects

A total of 52 students (39.4%) provided optional free-text responses regarding the question ‘What is currently occupying you most in your current study situation?’. We identified five categories in a multistage inductive process. The most frequent categories were ‘difficulties with self-regulated learning and self-motivation’, followed by ‘study-related worries and uncertainty’, ‘lack of feedback from other students and lecturers’ and ‘lack of practical training’. Significantly more dental (20.5%) than medical students (4.5%) reported concerns about the lack of practical training (χ2=8.4; df=1; p=0.004) (table 5).

Table 5

Categories, examples and quantified responses by category for the questions ‘what is currently occupying you most in your current study situation?’ in May 2020 (n=132)

Furthermore, 53 students (40.2%) completed optional free-text responses to the question ‘What do you currently experience as particularly helpful?’. Again five categories were identified through a multistep inductive process. The most common categories were ‘Exchange with other students and lecturers’, followed by ‘flexibility due to online lessons’, ‘self-regulation, self-motivation and self-structuring’, and ‘balance through sports and leisure’. Dental and medical students did not differ significantly in their answers with regard to helpful aspects (table 6).

Table 6

Categories, examples and quantified responses by category for the questions ‘what do you currently experience as particularly helpful?’ in May 2020 (n=132)

Discussion

This study investigated the mental burden and study situation among undergraduate dental and medical students after the initial stage of the COVID-19 pandemic from May 2020 to July 2020. In line with previous studies conducted before the pandemic dental and medical students reported high levels of distress, anxiety and depression.8 12 42 Compared with the norm population students of both professions reported significantly higher levels of anxiety and depression, consistent with findings of other studies.8 43 In light of the COVID-19 pandemic, the presence of additional pandemic-specific stressors is likely.22 A recent study showed that for most students isolation from student social networks is associated with increased anxiety levels.24 According to our qualitative data, the lack of direct contact with fellow students, which could only take place via online media, affects both student professions negatively. These findings complement a recent empirical study in which undergraduate medical students reported lack of interactions with peers, faculty and patients in practice as negative aspects of digital teaching.44 For dental students, the lack of practical training played a major role, as dentists usually take dental courses from the first semester onwards to learn the practical skills from early stage on.45 In comparison, this issue does not yet affect medical students as much in the early stages of their studies, as the undergraduate medical curriculum in Germany includes fewer practical training during this time.46 In sum this probably accounts for our findings that reported levels of anxiety and depression are even higher than among students of the same medical school prior to the Corona pandemic.8

With regard to the study situation, medical and in particular dental students were concerned about their current study situation. This trend continued in the further course of the pandemic. These results corroborate recent findings in a representative sample in Austria with a notable decline in mental health during the pandemic.47

In line with the findings of Stangvaltaite-Mouhat et al female dental students showed more pronounced anxiety symptoms than male dental students in our study.11 This underlines that mental burden may be higher among female students in general.48 Recent studies also suggest that women are particular burdened during the COVID-19 pandemic.47 49–52 Furthermore several studies showed that certain age groups, including individuals between 18 and 25 years — the most common age group in students — suffered more from mental distress.47 49 51 53 Qiu et al suspect social media to be one of the causes.49 Previous research seems to confirm this hypothesis as younger people tend to receive a large amount of information via social media, which can easily trigger stress.54 The easy accessibility and constant presence of pandemic information may lead to an increase in the duration of information consumption. This increasing duration reinforces the potential negative influence on mental health.55 A noteworthy finding is that dental students reported increased levels of distress, anxiety and more worries in the second survey whereas medical students’ scores were slightly lower at the second survey.

There are some limitations of our study. The cross-sectional surveys at two different times do not allow causal statements about longitudinal developments. Another limitation is the univariate nature of the analysis conducted. The univariate model is less comprehensive compared with multivariate models and does not consider the potential influence of other factors. The small sample size limits representativeness. However, due to the high response rates (65%–87% in the first and 81%–82% in the second survey) one may assume that a majority of the respondents participated in both surveys. Thus, these single-institutional and cross-sectional surveys achieve a high level of comparability and representativeness. Still there was a considerable proportion of students that did not participate in the surveys, which might lead to a volunteer bias.56 Non-volunteers may encompass students who suffer from high levels of distress, anxiety and/or depression. Thus some of the parameters reported in the study may be underestimating the true burden.

Furthermore, no comparisons can be made with the situation before the outbreak of the pandemic, among the same population. Nevertheless, the study by Heinen et al conducted at the same medical school with the same measures serves as a valid context to frame our findings.8

Considering the worsened levels of psychological distress among students during the COVID-19 pandemic57 58 academic institutions should provide timely services in terms of tailored interventions, which address the specific worries of dental and medical students. Other authors already provided valuable and concrete recommendations how to reduce the impact of COVID-19 on student-athlete mental health.59 60 Grubic et al proposed a framework to manage student-athlete mental health during the pandemic including ‘goal setting/motivation’ and ‘support system/social network’ as potential positive influencers. These aspects could be addressed by medical schools in the form of mentoring. Mentoring was identified as valuable intervention for undergraduate medical students due to its association with improved emotional well-being of students before the pandemic.61 During the pandemic, a novel near-peer mentoring intervention via social media was reported with promising first results.62 Thus, the implementation of mentoring at medical schools or the transfer of existing mentoring interventions digital formats might help to reduce the negative impact of the COVID-19 pandemic on dental and medical students. At the same time, longitudinal research is needed to monitor the mental health of students during the pandemic and after as well as rigour evaluation of all interventions.

Conclusion

Overall students of medicine and dentistry are particularly affected by high mental distress and burden due to the demanding contents and structure of their studies. It is likely that the concomitant symptoms of the pandemic have an additional negative impact on the levels of stress, anxiety and depression of the students.

Especially dental students reported higher levels of burden which might be associated with the high practical content early in their studies. The increase in anxiety levels of dental students might be associated with the duration of the restrictions of especially the practical content during the undergraduate study. Against this background, further monitoring of both dental and medical students during the pandemic would be important in order to develop and introduce tailored prevention concepts adapted to the specific study situation.

Data availability statement

No additional data are available. As ethical approval was not obtained to make data sharing possible outside of the listed research team.

Ethics statements

Patient consent for publication

Ethics approval

Institutional ethical approval was obtained from the local ethics board of the Center for Psychosocial Medicine at the University Medical Center Hamburg-Eppendorf, approval number LPEK-0161, prior to commencement of this research. Only students who provided informed consent were able to participate in the study.

Acknowledgments

We would like to thank all students who participated in the study and the evaluation team of the faculty who administered the online survey.

References

Footnotes

  • JG and ASW are joint first authors.

  • JG and ASW contributed equally.

  • Correction notice This article has been corrected since it was first published. The authors Annabel Susan Weegen and Jennifer Guse contributed equally to the article (shared first authorship).

  • Contributors JG designed the study and contributed to the analysis and interpretation of the data. She critically revised the manuscript during the internal revision process and wrote continuing drafts as well as the final draft of the manuscript. ASW analysed the data and contributed to the interpretation of the data. She wrote the first draft of the manuscript and critically revised the manuscript during the internal revision process. IH contributed to the analysis and interpretation of the data. She was involved in drafting the article and critically revised the manuscript during the internal revision process. CB designed the study, analysed the data and contributed to the interpretation of the data. She wrote the first draft of the manuscript and critically revised the manuscript during the internal revision process. CB is responsible for the overall content as the guarantor. All authors gave their final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.