key: cord-354959-0iwdqbu6 authors: Saddik, B.; Hussein, A.; Sharif-Askari, F. S.; Kheder, W.; Temsah, M.-H.; Koutaich, R. A.; Haddad, E. S.; Al-Roub, N. M.; Marhoon, F. A.; Hamid, Q.; Halwani, R. title: Increased levels of anxiety among medical and non-medical university students during the COVID-19 pandemic in the United Arab Emirates. date: 2020-05-13 journal: nan DOI: 10.1101/2020.05.10.20096933 sha: doc_id: 354959 cord_uid: 0iwdqbu6 Introduction: The COVID-19 pandemic is likely to increase anxiety levels within the community and in particular medical students who are already considered psychologically vulnerable groups. Since the COVID-19 outbreak, no study has yet estimated the effect of this pandemic on university students in the UAE or its impact on the psychological well-being of medical students. Methods: In this study, we surveyed 1485 medical (comprising medical and dental) and non-medical university students across 4 emirates within the UAE. We used an online platform to assess knowledge, sources of information, changes in hygienic behavior, perceptions of fear and worry and anxiety levels using the generalized anxiety disorder 7 (GAD-7) scale. The GAD-7 score was measured at three time points; during hospital visits for medical/dental students, before the introduction of online learning and after online learning for all students. Results: The majority of students demonstrated high levels of knowledge and utilized reliable sources of information. Non-medical students exercised higher compliance with social restrictions, while medical students practiced better hand hygiene. Almost half of students reported anxiety levels ranging from mild to severe with females reporting higher anxiety scores during hospital visits (OR=2.02, 95% CI,1.41 to 2.91) and medical students reporting lower anxiety levels in comparison to dental students (OR=0.61, 95% CI,0.45 to 0.84). Medical students reported higher levels of anxiety during their clinical rotations which decreased with the introduction of online learning, yet, non-medical student's anxiety levels increased with online learning. Conclusions: This is the first study to provide important information on the initial response and anxiety levels in university students across the UAE during the COVID-19 pandemic. The findings from our study can be used to support the development of effective screening strategies and interventions to build psychological resilience among university students during the COVID-19 pandemic or any other public health emergencies in the future. study, we aim to assess medical student's psychological distress and concerns during the recent 85 COVID-19 pandemic, their degree of perceived information about the disease, and their overall 86 attitude, practices and behaviors during the outbreak. We also evaluate students' perceptions on 87 the precautionary measures in place and the effectiveness of educational strategies in reducing 88 anxiety levels in the United Arab Emirates. This makes our study the first in the UAE to discuss 89 this aspect in the current pandemic. Committee (REC-20-03-03-02) prior to participant recruitments. 104 Sample size 105 A study conducted in Saudi Arabia during the MERS-COV outbreak found that 77% of medical 106 students reported minimal anxiety levels [11] . Using this proportion and a confidence level of 95% 107 and margin of error of 5%, we calculated the minimum required sample size to be 278 for each of 108 the medical and non-medical groups. To account for non-response the sample size was increased 109 by 20%, making the minimum sample size required for this study 333 students for each of the 110 medical and non-medical groups. to not worried at all, and their opinion about the public fear associated with COVID-19 being 121 justifiable or dysfunctional, measured on a 5-point Likert scale, ranging from strongly agree to 122 strongly disagree, 5) perception of receiving enough information on COVID-19 on a 5-point Likert 123 scale, ranging from strongly agree to strongly disagree, 6) the sources of information students 124 resorted to for information on COVID-19 and 7) Measurement of anxiety levels. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 13, 2020 . . https://doi.org/10.1101 /2020 In order to measure anxiety levels, we used the generalized anxiety disorder scale (GAD-7) [14] 126 which is a 7-item questionnaire asking participants how often they were bothered by each symptom 127 such as feeling nervous, trouble relaxing, irritable and afraid that something awful might happen 128 during the last 2 weeks. Response options were "not at all," "several days," "more than half the 129 days," and "nearly every day," scored as 0, 1, 2, and 3, respectively. A score of 10 or greater 130 represents a reasonable cut point for identifying cases of anxiety with a sensitivity of 89% and 131 specificity 82%, internal consistency (Cronbach α=.92) and Test-retest reliability (intraclass 132 correlation=0.83) [14] . The GAD-7 has also been identified as a screener for panic disorder, social 133 phobia and PTSD ( with a cutoff score of 8 sensitivity 77% and specificity 82%) [15] . In our study, 134 the GAD-7 score was totaled for each student and classified into cut-off points of (0-4 minimal, 5-135 9 mild, 10-14 moderate and 15-21 severe) levels of anxiety. Levels of anxiety were measured using 136 the GAD-7 scale at three different time points. In addition to calculating the mean GAD-7 score, 137 scores were classified into 3 categories (minimal, mild and moderate/severe anxiety). During the launch of data collection for this study, the UAE Ministry of Education declared 139 university campuses to move to online learning to prevent the spread of COVID-19 and classes 140 moved online on March 8. In order to determine levels of anxiety of students during the transition 141 to online learning, medical and dental students were asked to respond to the GAD-7 questions 142 reflecting back to the time they were attending hospital visits within the previous two weeks. This 143 was to assess whether higher levels of anxiety were associated with hospital visits. All students 144 were asked to respond to the GAD-7 questions reflecting on "before the introduction of online 145 learning", and "after the introduction of online learning". The final version of the questionnaire was piloted to ensure clarity and consistency between survey 147 items. To ensure face and content validity of the survey instrument, the survey was sent to a group 148 of 9 experts which consisted of students, tutors, faculty and a psychiatrist who reviewed the survey 149 for content accuracy, clarity and comprehensiveness and whether the survey met its objectives. As Descriptive statistics, including means, medians, frequencies and percentages were used to 154 summarize data and to illustrate the demographic and other selected characteristics of students. Normality of data was tested visually using the Q-Q plots and statistically using the Smirnov test. Bivariate analysis using Chi-square ( 2 ) and Mann-Whitney U tests explored the 157 associations between student demographic characteristics and anxiety levels. Spearman's 158 correlation coefficient, r, was used to evaluate the association between knowledge score and GAD- In total, 1484 students responded to the questionnaire and data were analyzed for 1385 completed 166 surveys (completion rate 93.3%) from 4 different emirates across the UAE. The mean age of 167 students was 20 years and most participants were females (72%). Almost three quarter of the 168 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 13, 2020. . https://doi.org/10.1101/2020.05.10.20096933 doi: medRxiv preprint students were studying medicine or dental medicine and from those students a third (35%) were in 169 their clinical years of study and were completing clinical ward rotations. Of these students, (12%) 170 reported being in contact with an infected or suspected case of COVID-19. Demographic 171 characteristics are shown in Table 1 . The majority of students reported increased hand hygiene (85%), increased use of hand sanitizer 174 (85.5%), avoiding people with flu like symptoms (80%) and decreased visits to crowded places 175 (77%). A lower proportion of students reported wearing gloves and masks (58%), decreased social 176 visits (62%) or decreased hand shaking (58%). We combined medical and dental students together 177 as the medical group, and all other specialties made up the non-medical group. When medical and 178 non-medical students were compared, more non-medical students avoided being in contact with 179 people with flu-like symptoms, had decreased social visits, decreased visits to crowded places and 180 use of public facilities as displayed in Figure 1 . 182 Most students agreed they had heard enough information on the symptoms, prognosis, 183 transmission and prevention of COVID-19. When we compared medical and non-medical 184 students, significantly more medical students reported having heard sufficient information on 185 COVID-19 prognosis,  2 (2, N=1385) = 55.20, p<0.001 and COVID-19 transmission,  2 (2, 186 N=1385) = 17.88, p<0.001. (Table 2 ). Overall, students had good knowledge of COVID-19 with 187 over 70% of students answering correctly on the COVID-19 knowledge questions with a median 188 score of 5 (from a maximum score of 7). When we compared participant's' knowledge scores by 189 field of study, gender and contact with COVID-19, we found that medical students, females and 190 students who had been in contact with COVID-19 cases had significantly higher knowledge scores 191 than their counterparts, as shown in Table 2 . Student sources of information on Students' main sources of information were official websites, press releases from the Ministry of The median GAD-7 scores for medical students during their hospital visits, for all students before 200 introduction of online learning and after online learning were 4, 4 and 3, respectively. When we 201 compared GAD-7 scores for medical students by gender, specialty (dental or medical), contact 202 with COVID-19, rotation type and clinical phase of study, we found that females, dental medicine 203 students, students who had been in contact with COVID-19 patients and students in their clinical 204 phase of study reported statistically significant higher anxiety levels. More students (27%) in low-205 risk ward rotations reported mild anxiety while the majority of students who reported moderate to 206 severe levels of anxiety (26%) were attending high risk ward rotations  2 (3, N=1385) = 10.92, 207 p=0.027 (Table 3) . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 13, 2020. . https://doi.org/10. 1101 /2020 Overall, females reported higher levels of anxiety in GAD-7, both before and after online learning. The medical students reported higher levels of anxiety before online learning in comparison to 210 non-medical students (Table 3) . 211 Interestingly, anxiety levels significantly decreased for females and for medical students after 212 switching to the online learning, with  2 (2, N=1385) = 12.22, p<0.001 and  2 (2, N=1385) = 20.99, 213 p<0.001, respectively, with a higher percentage of decreased anxiety among dental students; whilst 214 non-medical students reported higher levels of anxiety after the introduction of online learning ( 2 215 (4, N=1385) = 36.38, p<0.001) (Table 3) . The majority of students (73%) reported being worried about transmitting COVID-19 to one of 217 their family members or friends, while 65% of them were worried about catching the virus 218 themselves. Almost half (49%) of medical students reported being worried about transmitting 219 COVID-19 to others and were less likely (29%) to worry about catching it themselves, in 220 comparison to non-medical students (35%), although the differences were not statistically 221 significant ( 2 (2, N=1385) = 2.85, p=0.24). Most students (61%) agreed that the public fear was 222 justifiable and (46%) of students did not perceive it as dysfunctional . A cumulative odds ordinal logistic regression with proportional odds was performed to determine 224 predictors of anxiety levels during the different time points. The effect of gender, specialty, contact 225 with COVID-19, rotation type, clinical phase of study and knowledge score on the GAD-7 score 226 during hospital visits was modelled. We included knowledge score in the regression model because 227 we found a positive, but weak, correlation between knowledge score and anxiety score using 228 Spearman's correlation (rs=0.086, p=0.015). The odds of females having higher anxiety scores 229 during hospital visits was 2.02 (95% CI, 1.41 to 2.91) times that for males, and medical students 230 reported lower anxiety levels in comparison to dental medicine students (OR=0.61, 95% CI, 0.45 231 to 0.84). Furthermore, being in a rotation and demonstrating higher knowledge scores predicted 232 higher GAD-7 scores during hospital visits (Table 4) . Similarly, gender, field of study and 233 knowledge score predicted higher GAD-7 scores before online learning, but only gender and field 234 of study predicted GAD-7 scores after switching to online learning (Table 4) . Overall, students in our study demonstrated good knowledge of COVID-19 and reported using 247 reliable sources such as official statements and press releases from the ministry of health and the 248 WHO website. Although the use of these sources was higher among medical students, social media 249 was the main source of information for both medical and non-medical students. This finding is 250 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 13, 2020. . https://doi.org/10. 1101 /2020 consistent with the literature and emphasizes the role that social media can play in risk perception 251 and dissemination of reliable information during a pandemic such as . However, other studies have also reported that young people tend to obtain a large amount of 253 information from social media which can easily be a trigger for stress and anxiety [22] . Good knowledge may also explain students' compliance with hygienic practices in our study. Most 255 students reported significant change in their hygienic behavior since the COVID-19 outbreak, 256 particularly for increased hand hygiene, avoiding crowded places and avoiding being in contact 257 with people with flu like symptoms. However, even though levels of knowledge were significantly 258 higher among medical students, compliance with hygienic practices were similar for both groups. The results from the current study confirm that anxiety levels due to COVID-19 among university 276 students are high, ranging from mild to severe, especially amongst females, which is in accordance 277 with previous research [22, 30, 31] . The majority of students in our study were females, which 278 reflects the gender imbalance in higher education within the UAE. More than two thirds of students 279 reported mild anxiety levels and one third of students reported severe anxiety. What makes this 280 study unique, is that medical and non-medical students were compared, and within the medical 281 student group, we compared medical and dental students. Furthermore, this study assessed anxiety 282 levels at three different time points: during hospital visits for medical and dental students, before 283 online learning and after switching to the online learning for all students. Among the 284 medical/dental group, students in their clinical phase of study and who had rotations in high risk 285 wards or who had been in contact with COVID-19 patients reported significantly higher (moderate 286 to severe) levels of anxiety, demonstrating that high risk perception of COVID-19 may contribute 287 to higher levels of anxiety. Medical/dental students continued attending the hospitals at the early 288 onset of COVID-19 when fear and worry associated with the outbreak would have been at their 289 peak and before lockdown restrictions were in place, which could also explain their high 290 compliance with infection control measures. Medical students high risk perceptions associated 291 with attending hospitals during infectious disease outbreaks has been reportedly associated with 292 higher levels of anxiety [12, 21] . However, when we compared between medical and dental 293 students, dental students reported higher levels of anxiety and these remained significant with 294 further multivariate analysis. Previous studies have established that medical and dental programs 295 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 13, 2020. . https://doi.org/10.1101/2020.05.10.20096933 doi: medRxiv preprint are highly competitive and students generally experience high levels of stress during their training 296 [32, 33] . Yet, dental students suffer from greater levels of perceived stress than medical students 297 due to their role as providers of care and earlier exposure to patients in the dental clinics [34] . 298 Furthermore, dental students are in very close proximity to patients and are dealing directly with 299 patients' dental care during a potentially highly transmissible respiratory virus. This may explain 300 the higher levels of anxiety among dental students in our study and the overall decrease in anxiety 301 among all medical students following the introduction of online learning. Psychological support 302 should be tailored to each students' needs and incorporated into the online remote curriculum. Screening university students on a regular basis with tools such as the GAD-7 could help faculty 304 in the early identification of highly anxious students and guide students to receive help from 305 targeted interventions that promote psychological well-being, offer counselling, mental health 306 support and coping mechanisms [35] . Non-medical students reported higher levels of anxiety before and after online learning in 308 comparison to medical students and whilst medical student anxiety levels decreased following the 309 introduction of online learning, non-medical student's anxiety levels increased. This may be due To the best of our knowledge, this is the first study to provide important information on the initial 331 response and anxiety levels in university students across the UAE immediately following the 332 period COVID-19 was declared a global pandemic. More than half of university students reported 333 mild to severe anxiety levels with a quarter of students reporting severe anxiety. Specifically, 334 medical students reported higher levels of anxiety during their clinical rotations which decreased 335 with the introduction of online learning, yet, non-medical student's anxiety levels increased with 336 online learning. The findings from our study can be used at the government and university level to 337 develop effective screening strategies and to formulate interventions that improve mental health 338 of students. Such strategies will reduce unnecessary stress and anxiety among university students, 339 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 13, 2020. . https://doi.org/10. 1101 /2020 as well as build psychological resilience during the COVID-19 pandemic or any other public health 340 emergencies in the future. The authors declare that the research was conducted in the absence of any commercial or financial 343 relationships that could be construed as a potential conflict of interest. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 13, 2020 . . https://doi.org/10.1101 /2020 CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 13, 2020 . . https://doi.org/10.1101 /2020 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 13, 2020. . https://doi.org/10. 1101 /2020 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 13, 2020 . . https://doi.org/10.1101 /2020 CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 13, 2020. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 13, 2020 . . https://doi.org/10.1101 /2020 Coronavirus Infections-More Than Just the Common 356 2. WHO. World Health Organisation Director General's opening remarks at the media 358 briefing on COVID-19 Psychological distress among 364 medical students in conflicts: a cross-sectional study from Syria. BMC medical education The Global Prevalence 368 of Anxiety Among Medical Students: A Meta-Analysis. International journal of environmental 369 research and public health A brief measure for assessing generalized 397 anxiety disorder: the GAD-7. Archives of internal medicine Anxiety disorders in primary 400 care: prevalence, impairment, comorbidity, and detection. Annals of internal medicine 16. IBM Corp. Released 2017. IBM SPSS Statistics for Windows VA, NY: IBM Corp Peer mentoring for medical 405 students during COVID-19 pandemic via a social media platform Middle East Respiratory Syndrome (MERS): Comparing the knowledge, attitude and practices 409 of different health care workers Media's effect on 22 A nationwide survey of psychological 426 distress among Chinese people in the COVID-19 epidemic: implications and policy 427 recommendations. General psychiatry Functional Fear Predicts Public Health 431 Compliance in the COVID-19 Pandemic. International journal of mental health and addiction 2019-nCoV epidemic: address mental health care to 435 empower society COVID-19 and mental health: A review of the existing literature Stabilization and Sustainability Framework: An Integration of the Maslow Hierarchy of Needs Disaster medicine and public health preparedness Accepting Personal Restrictions to Fight the COVID-19 Pandemic: Results from a Danish Adult 447 Long-449 term psychological and occupational effects of providing hospital healthcare during SARS 450 outbreak. Emerging infectious diseases Psychological 454 responses to the SARS outbreak in healthcare students in Hong Kong Prevalence and predictors of PTSS 458 during COVID-19 outbreak in China hardest-hit areas: Gender differences matter Immediate Psychological Responses Curriculum versus a Case-Based Integrated Curriculum A comparative study of 474 professional student stress Mental health of students of medicine: exploraty study in the 477 Use of Rapid Online Surveys to Assess People's Perceptions During 480 Infectious Disease Outbreaks: A Cross-sectional Survey on COVID-19 The authors would like to thank all students who participated in the study. The survey used to collect data for this study is provided as supplementary material.