A cross-sectional online survey of relationship between the psychological impact of coronavirus disease 2019 and the resilience among postgraduate health sciences students from Maharashtra, India :Ajinkya Sureshrao Ghogare, Swapnil Arun Aloney, Mamidipalli Sai Spoorthy, Pradeep Shriram Patil, Ranjit S Ambad, Ashish Wasudeorao Bele, International Journal of Academic Medicine

ORIGINAL ARTICLE
Year : 2021 | Volume : 7 | Issue : 2 | Page : 89--98

A cross-sectional online survey of relationship between the psychological impact of coronavirus disease 2019 and the resilience among postgraduate health sciences students from Maharashtra, India

Ajinkya Sureshrao Ghogare¹, Swapnil Arun Aloney¹, Mamidipalli Sai Spoorthy¹, Pradeep Shriram Patil¹, Ranjit S Ambad², Ashish Wasudeorao Bele³,
¹ Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Maharashtra, India
² Department of Biochemistry, Datta Meghe Medical College, Nagpur, Maharashtra, India
³ Department of Community Health Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Maharashtra, India

Correspondence Address:
Dr. Ajinkya Sureshrao Ghogare
Assistant Professor, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Maharashtra
India

Abstract

Introduction: Because of the rapid global spread, coronavirus disease 2019 (COVID-19) has caused a state of an emergency situation. Postgraduate (PG) health sciences students (HSSs) are the frontline healthcare workers who are susceptible to psychological issues like depression, anxiety and stress during such stressful pandemic period. The objective of this study was to assess the relationship between the psychological issues such as depression, anxiety and stress and the level of resilience among PG HSSs during the COVID-19 pandemic. Materials and Methods: The present cross-sectional online survey was conducted by the department of Psychiatry of tertiary health care center from Maharashtra state of India over a 10 days period (from April 15, 2020 to April 24, 2020), with a sample size of 195 which was calculated by using the formula of sample size calculation for the cross-sectional study design. Data were collected using the purposive sampling method from the PG HSSs. Data were recorded from the study participants in an online structured questionnaire prepared for the study using the sociodemographic details and the two scales namely Depression, Anxiety, and Stress Scale-21 item (DASS-21) and Brief Resilience Scale (BRS). DASS-21 scale was used to assess the presence and severity of depression, anxiety, and stress, while BRS scale was used to assess the level of resilience among the PG HSSs. Data were collected and analyzed using the SPSS software version 15.0, Fisher's exact test, and Pearson's correlation test. Results: Prevalence of depression, anxiety, and stress were 43.1%, 68.7%, and 11.3%, respectively. There was a high positive correlation between all three subscales of DASS-21 (depression, anxiety, and stress subscales). On BRS, 2 (1.0%) study participants had high resilience, 120 (61.5%) had normal resilience, and 73 (37.5%) Conclusion: Study concluded that significant proportion of PG HSSs had psychological impact of COVID-19 in the form of depression, anxiety and stress. Programs such as timely evaluation of mental health status and stress management to address these psychological issues should be a priority. In long terms, increasing the resilience of PG HSSs can have protective value against the psychological issues during the stressful events of infectious disease outbreaks like COVID-19 pandemic. The following core competencies are addressed in this article: Medical knowledge, Patient care, Professionalism, Practice based learning and improvement.

How to cite this article:
Ghogare AS, Aloney SA, Spoorthy MS, Patil PS, Ambad RS, Bele AW. A cross-sectional online survey of relationship between the psychological impact of coronavirus disease 2019 and the resilience among postgraduate health sciences students from Maharashtra, India.Int J Acad Med 2021;7:89-98

How to cite this URL:
Ghogare AS, Aloney SA, Spoorthy MS, Patil PS, Ambad RS, Bele AW. A cross-sectional online survey of relationship between the psychological impact of coronavirus disease 2019 and the resilience among postgraduate health sciences students from Maharashtra, India. Int J Acad Med [serial online] 2021 [cited 2023 Jun 10 ];7:89-98
Available from: https://www.ijam-web.org/text.asp?2021/7/2/89/319794

Full Text

Introduction

December 2019 was the period when the novel coronavirus disease 2019 (COVID-19) outbreak emerged in Wuhan city of China.[1] COVID-19 has gathered the attention of whole world because of its global spread.[2],[3],[4] By March 2020, the WHO declared it as a pandemic and health emergency.[5] We all know the fact that postgraduate (PG) health sciences students (HSSs) of medical colleges are the backbone of the health-care system of public hospitals in India as well as that of other countries. PG students constitute the majority of front-line health-care workers (HCWs) who are treating the COVID-19 patients. When performing COVID-19 duties, HCWs including PG HSSs are facing greater amount physical and psychological pressures. Physical pressures may involve the risk of getting infected and possibility of dying because of COVID-19. Psychological pressures may involve frustration, overwork, discrimination from the society, isolation, self-quarantine, handling patients and caretakers with negative emotions and behaviors, lack or loss of contact with their own family members, exhaustion, stress, anxiety, and depression.[6],[7]

More than a decade ago, during an outbreak of severe acute respiratory syndrome (SARS), HCWs were found at high risk of developing the psychological problems such as depression, anxiety, and stress.[8],[9]

Other psychological problems such as insomnia, fear, anger, and denial are also common. As PG HSSs are frontline HCWs, they are more susceptible to psychological consequences secondary to COVID-19. They are directly coming in contact with confirmed or suspected cases of COVID-19 while treating those who are the sources of potential infection. So risk is very high to the life of PG HSSs. Psychological problems among PG HSSs during the current pandemic are secondary to inadequate personal protective equipment (PPE), increased work load in terms of shortage of manpower as well as excessive working hours at hospitals, media news, and feelings of getting inadequate support.[10],[11],[12] Working without PPE is instilling in PG HSSs the thoughts of fear and worry about their own health and of others including their family members, as PG HSSs themselves can act as the source of infection for others. Psychological problems among PG HSSs during such period not only affect their decision making capacity, understanding, and concentration at the work place, but they could also have long-lasting deleterious effects on their academics and well-being. That's why protecting and promoting mental health of our front line workers is most important task to effectively deal with COVID-19. Not only the patients but the PG HSSs also are vulnerable to the psychological impact of COVID-19.[13] Once HCWs including the PG HSSs become victim to COVID-19 infection, it may instill frustration, feelings of helplessness, and adjustment issues that might be secondary to stigma and fear of discrimination in medical staff.[14]

Rationale for the study

During COVID-19 pandemic, gap in mental health services has been widened potentially which is testing the resilience of PG HSSs who are our front-line HCWs.[15] Resilience is defined as ability to bounce back or recover from the stress, to adapt to stressful circumstances, to not become ill despite significant adversity, and to function above the norm in spite of stress or adversity.[16]

Social isolation and economic uncertainty due to COVID-19 have led to significant increase in psychological issues including depression, stress, anxiety, loneliness, and suicidal thoughts.[17] But, people show wide variations in how they respond to challenges in their lives. This ability to withstand the challenges, adapt positively, and bounce back from adverse conditions is defined as the “resilience.”[18] Lower resilience was associated with greater worry about the effects of COVID-19.[19]

During current pandemic, there has been increased in mental health issues among PG HSSs like stress, anxiety, and depression.[20] In India, first case of COVID-19 was detected in Kerala on January 30, 2020. Since then count is steadily increasing. On March 25, 2020, government of India had declared nationwide lockdown in India to prevent the spread of COVID-19 in the community. This lock down period is having two sides like that of a coin. One important side is that it is very crucial in preventing and slowing the community spread of coronavirus, but at the same time, other side being perceived by the people as socially isolating and being lost in touch from surrounding world. Being socially isolated, working in high risk situations, and having contact with infected people are common causes of mental health problems among HCWs.[21],[22] Similarly, PG HSSs were exposed to stressors during virus outbreak, but this group is often overlooked.[23]

Objective of the study

The primary objective of the present study was to assess the relationship between the psychological issues such as depression, anxiety, and stress and the level of resilience among PG HSSs during the COVID-19 pandemic.

Prespecified hypothesis of the study

Based on the previous study finding,[19] we hypothesized that the respondents with high resilience will have lower rates of depression, anxiety, and stress.

Materials and Methods

Study design

This was the cross-sectional internet-based online survey.

Study setting, location, and relevant dates

Study was conducted by the department of Psychiatry of a tertiary health-care center from Maharashtra state of India. Study was conducted over a period of 10 days from April 15, 2020, to April 24, 2020, through a predesigned questionnaire, using the purposive sampling method.

Eligibility criteria for study participants and sources and methods of selection of study participants

Inclusion/eligibility criteria adopted for the study were participants who consented to participate in the present study, those who belonged to PG HSSs category and those who were well versed in the English language. Exclusion criteria for the study were those participants who were not willing for participation in the study and those who didn't belonged to PG HSSs category. Each participant's identity was kept anonymous. Before starting the survey, all study participants were provided with details of time required to complete the survey, nature of the survey, and information that filling in survey implies provision of informed consent by the participants. PG HSSs from all the departments were allowed to participate in the survey. Survey questionnaire was circulated using E-mail and WhatsApp to the study participants.

Data sources/measurement

Survey was in English language. In this survey, we have used two scales the Depression, Anxiety, and Stress Scale-21 item (DASS-21) and the Brief Resilience Scale (BRS).

DASS-21 is a 21-item scale, which is having a set of 3 self-report subscales designed to measure the emotional states of depression, anxiety, and stress.[24] Each item is rated on a scale of 0 to 3. Each of the subscales contain 7 items for depression, anxiety, and stress. Scores of all 3 subscales are calculated by summing scores for relevant items. Final scores are obtained by multiplying total scores of all 3 subscales by two. On depression subscale of DASS-21, scores up to 9 indicate no depression, 10 to 13 indicate mild depression, 14 to 20 indicate moderate depression, 21 to 27 indicate severe depression, and 28 and above indicate extremely severe depression. On anxiety subscale of DASS-21, scores up to 7 indicate no anxiety, 8 to 9 indicate mild anxiety, 10 to 14 indicate moderate anxiety, 15 to 19 indicate severe anxiety, and 20 and above indicate extremely severe anxiety. On stress subscale of DASS-21, scores up to 14 indicate no stress, 15 to 18 indicate mild stress, 19 to 25 indicate moderate stress, 26 to 33 indicate severe stress, and 34 and above indicate extremely severe stress. Reliability of DASS-21 showed that it has excellent Cronbach's alpha values of 0.81, 0.89, and 0.78 for subscales of depression, anxiety, and stress, respectively.[25] It has excellent internal consistency, discriminative, concurrent, and convergent validities. Depression and anxiety subscales of DASS-21 had good correlations with self-rating depression scale and state trait anxiety inventory.[25] DASS-21 was found to have commendable psychometric properties. It is reliable, valid, and easy to administer. Its utility by the clinicians can enhance diagnoses of depression, anxiety, and stress among university students.[25]

BRS assesses an ability to bounce back or recover from the stress.[16] It also provides unique and important information about the people coping with health-related stressors. It is the measurement of coping with difficulties. BRS consists of 6 items. Each item is rated on a scale of 1 to 5. For scoring, add responses varying from 1 to 5 for all 6 items giving a range from 6 to 30. Then divide the total sum by the total number of questions/items answered. BRS scores of 1.00 to 2.99 indicates low resilience, 3.00 to 4.30 indicates normal resilience, and 4.31 to 5.00 indicates high resilience.[16] Factor analysis reveals a single factor with eigenvalues above 1.0, which accounted for 73.54% of total variance. Reliability analysis using Cronbach's Alpha was 0.93, indicating that the scale has good reliability.[16] Study has demonstrated that BRS is appropriate to be used by college personnel and counsellors to examine and identify resiliency among the college students.[26] Smith et al. observed that BRS was predictably related to personal characteristics, social relations, coping, and health in their study participants.[16] They also observed that BRS was negatively related to depression, anxiety, negative affect, and physical symptoms when the measures such as social support and type D personality were controlled.[16]

Apart from the above-mentioned two scales, we had formulated a set of common worries as well as concerns related to role in patient care, COVID-19 pandemic and activities affected during COVID-19 lockdown among PG HSSs. We included PG HSSs from medical, dental, physiotherapy, and nursing faculties. Those worries and concerns related to patient care, COVID-19 pandemic and activities affected during COVID-19 lockdown included role in patient care, worry related to studies, worry related to perceived academic loss and future due to COVID-19 pandemic on a scale of 0 to 10 where ”0 indicates no worry and “10” indicates the highest level of worry, worry about contracting COVID-19 to self, worry about contracting COVID-19 by family member (s), change in internet use during COVID-19 lockdown, most bothering thing during COVID-19 lockdown, sleep pattern affected during COVID-19 lockdown, and common time-pass activity during COVID-19 lockdown.

Bias

It was an open and voluntary online survey. The participants were not provided any incentives for participation in and for completion of the survey. They could only fill survey once through a device, i.e., the users with same IP address were not able to access survey twice, thus preventing duplication of responses.

Study size

The sample size was calculated using a sample size formula for the cross-sectional study design. The formula was n = 4 pq/L2, where “p” is the prevalence of the psychiatric disorders like anxiety and depression, “q” = 100 − p, and “L” is the allowable error and it is 20% of the “p.”[27]

By considering the previous study findings, we have selected the “p” as 34.[9],[28],[29],[30] So, at P = 34, 95% confidence and 20% allowable error of margin, the minimum sample size required was 194.11 which was rounded to 195. When the survey responses hit the completely solved number of 195, the web based open e-survey link was closed for accepting further responses and analysis was carried out on the required calculated sample size.

Statistical methods

Data from both scales were entered with the help of Microsoft Excel version 2007. Final data were analyzed with the help of SPSS statistical software version 15 (IBM, Chicago, Illinois, US). The continuous data were presented as mean and standard deviation (SD), and the categorical data were presented as frequency and percentage. Fisher's exact test was used to determine the level of significance. Pearson's test of correlation was used to test the correlation between the three subscales of DASS-21 scale. Association of resilience with presence of depression, anxiety, and stress was assessed by Chi-square test. Level of significance was set at 0.05.

Results

Sociodemographic parameters of study participants

[Table 1] show that 80.0% of the study participants were in the age group of 25 to 30 years, with age range from 25 to 35 years and mean (SD) age of 28.05 (2.64) years. In the present study, preponderance was high of the participants who belonged to the female gender (71.8%), medical faculty (42.6%), urban area of residence (53.8%), nuclear families (72.8%), those who were unmarried (88.7%) and those belonged to the Hindu religion (86.7%).{Table 1}

Role in patient care, worries related to COVID-19 pandemic and activities affected during COVID-19 lockdown among study participants

[Table 2] shows that 33.3% of study participants were PG students actively involved in patient care. The highest percentage of study participant had rated “8” (24.1%) on a scale of 0 to 10 points as regards to worry about their studies, perceived academic loss and future because of COVID-19 pandemic. The highest percentage of study participants (37.4%) had worry of “mild degree” of contracting COVID-19 by themselves. The highest percentage of study participants (32.3%) had worry of “moderate degree” of contracting COVID-19 by their family members. The highest percentage of study participants (38.5%) had severe increase in internet use, 58.5% were sleeping more than the usual period during the lockdown, and boredom (25.6%) and media news about COVID-19 (25.6%) were the most common things that bothered during the lockdown and to deal with them most common activity to pass time was use of internet over the smartphones (47.7%) for the recreational purposes as well for gaining an information regarding COVID-19.{Table 2}

Distribution of the severity of depression, anxiety, and stress among study participants according to Depression, Anxiety, and Stress Scale-21 subscale scores

[Table 3] shows that depression was present in 84 (43.1%) study participants. 54 (27.7%) had mild, 26 (13.3%) had moderate and 4 (2.1%) had severe depression. Anxiety was present among 134 (68.7%) study participants. 60 (30.8%) had mild, 55 (28.2%) had moderate, 16 (8.2%) had severe and 3 (1.5%) had extremely severe anxiety. Stress was present among 22 (11.3) study participants. 17 (8.7%) had mild and 5 (2.6%) had moderate stress.{Table 3}

Correlation between the depression, anxiety, and stress subscales of Depression, Anxiety, and Stress Scale-21 among study participants:

[Table 4] shows that there was a high positive correlation between all the 3 subscales of DASS-21. All correlations were significant at 0.01 level (2 tailed).{Table 4}

Distribution of the level of resilience among study participants according to Brief Resilience Scale scores

[Table 5] shows that 73 (37.5%) study participants had low resilience, 120 (61.5%) had normal resilience, and only 2 (1.0%) had high level of resilience. On BRS, scores ranged from 1 to 4.5, with a mean (SD) score of 2.96 (0.76).{Table 5}

Relationship of resilience with depression, anxiety, and stress among study participants

[Table 6] shows that respondents with high resilience had less frequent depression, anxiety, and stress. Respondents with low resilience had more frequent depression, anxiety, and stress. This suggests that individual's capacity to bounce back may protect him or her from experiencing psychological issues like depression, anxiety, and stress.{Table 6}

Discussion

COVID-19 is having a mortality rate of 2%, but higher transmission and mortality rates than that of combined SARS and Middle East respiratory syndrome.[31] So COVID-19 has created lot of stress among HCWs including PG HSSs. During mid-March 2003, SARS had erupted and Professor Cameron from emergency department of Wales's hospital wrote in Australian journal of emotional burden on him and his family and sense of isolation he faced after his family left. He had felt threatened by the nature of his work for the first time.[32] Another physician had reflected on her professional journey of struggling as a caregiver, a victim, and a spreader. Hence, there is a need to maintain hope in one hand and courage to face constant fear of death in another hand.[33] Similarly, HSSs were exposed to the stressors during virus outbreak, but this group is often neglected.[23] Hence, there is a need to pay attention toward psychological problems and needs of HSSs also during the current COVID-19 pandemic.

Sociodemographic characteristics

In the present study, majority of study participants were female PG HSSs (71.8%). Finding similar to the present study was observed by Lai et al. where females (76.7%) had outnumbered males.[34] A similar finding was also observed by Wong et al. who observed that in their study majority of HCWs were females (65.7%).[35] These findings might reflect that females were more interested and responsive toward participating in the study. In the present study, majority of the participants belonged to the medical faculty (42.6%), while the least belonged to the dental faculty (15.9%). The study of Lai et al. had 39.2% doctors and 60.8% nurses.[34] Such a difference in the distribution of HCWs might reflect differences in the study setting and selection criteria of the study participants as they had only included physicians and nurses in their study,[34] while in the present study we had included study participants from medical, dental, physiotherapy and nursing faculties. In the present study, majority of the study participants belonged to an urban area of residence (53.8%). Finding similar to the present study was observed by Lai et al. with majority of study participants from urban area (97.1%).[34] In the present study, majority of study participants were from nuclear families (72.8%). Joint families obviously have more family members who might share various responsibilities among themselves to take care of a person suffering from any physical and psychological problems. Cao et al. found that college students who were living with their parents had less frequent anxiety during the COVID-19 outbreak.[36] In the present study, majority of the study participants were unmarried (88.7%). In contrast to this, Lai et al. observed that majority of study participants were married (66.7%).[34] This difference might reflect differences in the study setting and differences in the selection criteria of the study participants as they have included the study participants with broader age range starting from 18 years of age to more than 40 years of age,[34] while in the present study the participants belonged to the age group of 25 to 35 years.

Role in patient care, worries related to COVID-19 pandemic, and activities affected during COVID-19 lockdown

In the present study, majority of the participants (33.3%) were directly involved in the patient care. Lai et al. found a similar finding that majority of the HCWs (41.5%) were directly involved in the care of COVID-19 patients.[34] In the present study, majority of study participants rated their worry related to studies, perceived academic loss and future due to COVID-19 pandemic on the score of “8.0” (24.1%) on a Likert scale of 0 to 10 where “0” indicated no worry and “10” meant the highest level of worry. Wong et al. had recorded mental distress caused by the virus outbreak by a single item 11-point Likert scale where “0” was no distress and “10” meant very distressed. Majority of the respondents in their study scored 6.19 which was nearer to the value recorded in the present study.[35] Al-Rabiaah et al. stated that medical students were exposed to the stressors during virus outbreak because students had adverse effects on their academic achievement through increased avoidance of learning activities and reduced psychomotor concentration.[23]

As regards to the worry about contracting COVID-19 by self, majority of the study participants (37.4%) had “mild degree of worry”. As regards to the worry about contracting COVID-19 by the family members, majority of the study participants (32.3%) had ”moderate degree of worry. Wong et al. observed that sources of stress among HCWs include feelings of vulnerability, loss of control and concerns about health of self, others and family, spread of the virus, changes in work, and being isolated from loved ones.[35] Most bothering thing during the COVID-19 lockdown were the boredom (25.6%) as well as the media news about COVID-19 (25.6%) which were equally prevalent and to cope with them the majority of the study participants (47.7%) had reported of spending most of their time on using internet over the smartphones for recreational purposes and to gain information about the COVID-19. In the present study, majority of study participants reported of severe increase in their internet use (38.5%) than usual during COVID-19 lockdown. Al-Rabiaah et al. observed that students who use internet more often than other media were more informed about viral disease.[23] Another study found that more the disease was mentioned in media, the more its seriousness was overlooked by students and vice versa.[37] As regards sleep pattern, majority of the study participants (58.5%) had reported that they were sleeping more than the usual, while 15.9% had reported of sleeping less than usual and 3.1% had reported of not able to fall asleep at all during the COVID-19 lockdown . Since outbreak of COVID-19 pandemic and its social consequences of mass home and institutional confinement/quarantine, global stressful condition has been developed. Being socially isolated, forced to stay at home for self-quarantine purpose, working from home, home-schooling with children, severely minimized outings, hampered social interaction, working for many hours under the stressful conditions, and managing own as well as others health risks, can have major impact on day-time functioning and on night-time sleep. Huang et al. observed that the factors like being younger than 35 years of age and following COVID-19 news updates for more than 3 hours a day were associated with increased levels of anxiety which could have resulted in sleep disturbances.[38]

Distribution and relation of depression, anxiety, stress, and resilience

In the present study, DASS-21 total score ranged from 0 to 96, with a mean score of 30.10 ± 8.94. In the present study, the total score on depression subscale of DASS-21 ranged from 14 to 42 with a mean score of 20.04 ± 6.52. 54 (27.7%) study participants had mild, 26 (13.3%) had moderate, and 4 (2.1%) had severe depression. In the present study, the prevalence of depression was 43.1%. Tan et al. observed that 24 (8.1%) medical HCWs had depression on the basis of DASS-21 depression subscale.[39] The mean score (SD) of depression subscale in their study was 2.54 (5.23).[39]

In the present study, the total score on anxiety subscale of DASS-21 ranged from 14 to 46, with a mean score of 19.36 ± 6.34. 60 (30.8%) study participants had mild, 55 (28.2%) had moderate, 16 (8.2%) had severe, and 3 (1.5%) had extremely severe anxiety. In the present study, the prevalence of anxiety was 68.7%. Al-Rabiaah et al. observed in their study that 134 (77.0%) study participants had minimal, 32 (18.4%) had mild, 8 (4.6%) had moderate, and none of them reported severe anxiety.[23] Tan et al. found that 32 (10.8%) medical HCWs had anxiety based on DASS-21 anxiety subscale.[39] Mean score of anxiety subscale in their study was 2.45 (4.28).[39] Most HCWs working in isolation units and hospitals do not receive any training for providing mental health care.[13] Anxiety in particular area or hospital may rise following first death due to COVID-19, increased media reporting, and increasing number of new cases. Hence, mass lock down and quarantine is likely to raise anxiety significantly. Elevated anxiety may also have knock-on implications for other health measures including mental health measures.[40]

In the present study, the total score on stress subscale of DASS-21 ranged from 14 to 48, with a mean score of 20.82 ± 6.38. 17 (8.7%) study participants had mild and 5 (2.6%) had moderate stress. In the present study, the prevalence of stress among study participants was 11.3%. Tan et al. found that 19 (6.4%) medical HCWs in their study had stress. The mean (SD) score of stress subscale in their study was 3.82 (5.74).[39] Tan et al. did not mention about severity levels of depression, anxiety, and stress based on DASS-21 subscale scores,[39] which was in contrast to the present study finding.

In the present study, there was a high positive correlation between all 3 subscales of DASS-21. All correlations were significant at 0.01 level (2 tailed). In the present study, on BRS, the total score ranged from 1 to 4.5, with a mean score of 2.96 ± 0.76. In the present study, based on BRS scores, 2 (1.0%) had high, 120 (61.5%) had normal, and 73 (37.5%) had low resilience. Liu et al. observed that COVID-19 outbreak had highlighted potential gaps in mental health services and testing the resilience of HCWs and medical system.[15] In the present study, those respondents had high resilience had shown lower depression, anxiety and stress scores, while those who had low resilience level had shown higher depression, anxiety, and stress scores. This suggests that individual's capacity to bounce back may protect him or her from experiencing depression, anxiety and stress during the stressful period of COVID-19 outbreak and lockdown.

Killgore et al. had observed that lower resilience was associated with greater worry about the effects of COVID-19.[19] Duan and Zhu had also observed a similar finding and stated that psychological problems such as depression, anxiety, and stress had increased during COVID-19 outbreak.[20] Thus, resilience helps a person to cope with the psychological problems.[20] Hence, the health sciences colleges and universities should focus on resilience enhancing interventions, which can include long-term interventions such as physical intervention (exercise), relaxation techniques (progressive muscle relaxation), and psychotherapies (cognitive behavior therapy, well-being therapy and mindfulness) as well as short-term interventions such as taking staff feedback sessions and treatment of psychiatric disorders with psychotropic agents such as antidepressant, anxiolytic and other agents.[41],[42] Maunder et al. observed that using modern computer-based technology, HCWs can be trained in resilience promoting activities so that they can effectively deal with the pandemics.[43]

Limitations

The present study has few limitations. First, it was conducted on small number of study participants who were the PG HSSs, thus limiting the generalizability of results found. Second, although respondents answered self-administered questionnaires based on their actual performance, overestimation, or exaggeration may exist as a questionable factor. Third, past history and family history of psychiatric disorders among the study participants were not assessed owing to its online web-based nature. Enquiring about the details of past and family history of psychiatric disorder (s) could have helped in understanding the psychopathology among the study participants at a deeper level as psychiatric disorders tend to have recurrences and genetic predisposition.

Conclusion/InterpretatioN

Findings of the current study show that respondents with high resilience had less frequent depression, anxiety, and stress. This suggests that individual's capacity to bounce back may protect him or her from experiencing psychological issues like depression, anxiety, and stress. Hence, we recommend that health authorities should address the psychological needs of PG HSSs who are frontline HCWs more frequently in the present as well as in the future, especially during the periods of emergency crisis like COVID-19 pandemic. The results of current study highlighted importance of establishment of psychological support programs for PG HSSs during infectious disease outbreak to strengthen their mental health through boosting their resilience. It is advisable that government in collaboration with professional bodies and relevant experts should develop plan for implementation of psychoeducational programs in emergency preparedness. Such programs will help PG HSSs to deal effectively with depression, anxiety, and stress through strengthening of resilience and coping skills.

Acknowledgment

We sincerely thank all the study participants who participated in the study for their cooperation. We are also grateful to all the COVID Warriors (post graduate health sciences students and all other health care workers) and their supporting family members across the globe for their selfless and kind services to the mankind.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this study declare that this scientific work complies with reporting quality, formatting and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation study was approved by the institutional ethics committee (IEC) and the corresponding approval number is [– (DMIMS/IEC/2020/8700 – A, dated April 4, 2020)].

References

1	Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet 2020;395:470-3.
2	Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.
3	Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.
4	The Lancet. Emerging understandings of 2019-nCoV. Lancet 2020;395:311.
5	Eurosurveillance Editorial Team. Note from the editors: World Health Organization declares novel coronavirus (2019-nCoV) sixth public health emergency of international concern. Euro Surveill 2020;25:200131e.
6	Ghogare AS, Patil PS, Spoorthy MS, Aloney SA, Bele AW, Ambad RS. A cross-sectional online survey of depression, anxiety, stress and resilience among undergraduate health sciences students of rural tertiary health-care centre from Maharashtra during coronavirus disease 2019 lockdown. Natl Med J India [Internet] 2020 [cited 2020 Aug 1];33:e1-e8. Available from: http://www.nmji.in/aheadofprint.asp.
7	Vinkers CH, van Amelsvoort T, Bisson JI, Branchi I, Cryan JF, Domschke K, et al. Stress resilience during the coronavirus pandemic. Eur Neuropsychopharmacol 2020;35:12-6.
8	Wu KK, Chan KS, Ma M. Posttraumatic stress after SARS. Emerg Infect Dis 2005;11:1297-300.
9	Wu KK, Chan KS, Ma M. Posttraumatic stress, anxiety, and depression in survivors of severe acute respiratory syndrome (SARS). J Trauma Stress 2005;18:39-42.
10	Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, et al. Psychological impact and coping strategies of frontline medical staff in hunan between January and march 2020 during the outbreak of coronavirus disease 2019 (COVID-19) in Hubei, China. Med Sci Monit 2020;26:e924171.
11	Lee SM, Kang WS, Cho AR, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry 2018;87:123-7.
12	Styra R, Hawryluck L, Robinson S, Kasapinovic S, Fones C, Gold WL. Impact on health care workers employed in high-risk areas during the Toronto SARS outbreak. J Psychosom Res 2008;64:177-83.
13	Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry 2020;7:228-9.
14	Rana W, Mukhtar S, Mukhtar S. Mental health of medical workers in Pakistan during the pandemic COVID-19 outbreak. Asian J Psychiatr 2020;51:102080.
15	Liu S, Yang L, Zhang C, Xiang YT, Liu Z, Hu S, et al. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry 2020;7:e17-8.
16	Smith BW, Dalen J, Wiggins K, Tooley E, Christopher P, Bernard J. The brief resilience scale: Assessing the ability to bounce back. Int J Behav Med 2008;15:194-200.
17	Killgore WD, Cloonan SA, Taylor EC, Dailey NS. Loneliness: A signature mental health concern in the era of COVID-19. Psychiatry Res 2020;290:113117.
18	Lutha SS, Cicchetti D. The construct of resilience: Implications for interventions and social policies. Dev Psychopathol 2000;12:857-85.
19	Killgore WD, Taylor EC, Cloonan SA, Dailey NS. Psychological resilience during the COVID-19 lockdown. Psychiatry Res 2020;291:113216.
20	Duan L, Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry 2020;7:300-2.
21	Wu P, Fang Y, Guan Z, Fan B, Kong J, Yao Z, et al. The psychological impact of the SARS epidemic on hospital employees in China: Exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry 2009;54:302-11.
22	Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003;168:1245-51.
23	Al-Rabiaah A, Temsah MH, Al-Eyadhy AA, Hasan GM, Al-Zamil F, Al-Subaie S, et al. Middle East Respiratory Syndrome-Corona Virus (MERS-CoV) associated stress among medical students at a university teaching hospital in Saudi Arabia. J Infect Public Health 2020;13:687-91.
24	Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. 2^nd ed.. Sydney: Psychology Foundation; 1995.
25	Cocker AO, Cocker OO, Sanni D. Psychometric properties of the 21-item Depression Anxiety Stress Scale (DASS-21). Afr Res Rev 2018;12:135-42.
26	Amat S, Subhan M, Jaafar W, Mahmud Z, Johari K. Evaluation and psychometric status of the brief resilience scale in a sample of Malaysian international students. Asian Soc Sci 2014;10:1-7.
27	Ghogare AS, Patil PS. A cross-sectional study of co-morbid generalized anxiety disorder and major depressive disorder in patients with tension-type headache attending tertiary health care centre in central rural India. Niger Postgrad Med J 2020;27:224-9.
28	Au A, Chan I, Li P, Chan J, Chan YH, Ng F Correlates of psychological distress in discharged patients recovering from acute respiratory syndrome in Hong Kong. The International Journal of Psychosocial Rehabilitation. 2004;8:41–51.
29	Cheng SKW, Wong CW, Tsang CW, Wong KC Psychological distress and negative appraisals in survivors of severe acute respiratory syndrome (SARS). Psychol Med. 1999;34:1187–95.
30	Hawryluck L, Gold WL, Robinson S, Pogorski S, Galea S, Styra R SARS control and psychological effects of quarantine, Toronto, Canada. Emerg Infect Dis. 2004;10:1206–12.
31	Mahase E. Coronavirus covid-19 has killed more people than SARS and MERS combined, despite lower case fatality rate. BMJ 2020;368:m641.
32	Cameron PA. The plague within: An Australian doctor's experience of SARS in Hong Kong. Med J Aust 2003;178:512-3.
33	Tse D. The psychological journey of SARS: Observations and reflections of a physician. HKSPM Newsletter; November, 2003.
34	Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
35	Wong TW, Yau JK, Chan CL, Kwong RS, Ho SM, Lau CC, et al. The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope. Eur J Emerg Med 2005;12:13-8.
36	Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, et al. The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Res 2020;287:112934.
37	Young ME, Norman GR, Humphreys KR. Medicine in the popular press: The influence of the media on perceptions of disease. PLoS One 2008;3:e3552.
38	Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: A web-based cross-sectional survey. Psychiatry Res 2020;288:112954.
39	Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, et al. Psychological Impact of the COVID-19 Pandemic on Health Care Workers in Singapore. Ann Intern Med. 2020;173:317-320. doi: 10.7326/M20-1083. PMID: 32251513; PMCID: PMC7143149.
40	Rubin GJ, Wessely S. The psychological effects of quarantining a city. BMJ. 2020;368:m313. doi: 10.1136/bmj.m313. PMID: 31992552.
41	Kunzler AM, Helmreich I, Chmitorz A, König J, Binder H, Wessa M, et al. Psychological interventions to foster resilience in healthcare professionals. Cochrane Database Syst Rev 2020;7:CD012527.
42	Heath C, Sommerfield A, von Ungern-Sternberg BS. Resilience strategies to manage psychological distress among healthcare workers during the COVID-19 pandemic: A narrative review. Anaesthesia 2020;75:1364-71.
43	Maunder RG, Lancee WJ, Mae R, Vincent L, Peladeau N, Beduz MA, et al. Computer-assisted resilience training to prepare healthcare workers for pandemic influenza: A randomized trial of the optimal dose of training. BMC Health Serv Res 2010;10:72.