Study setting and participants’ recruitment
We used a cross-sectional descriptive design to conduct the study. Our target population was MSs and interns from all levels (i.e., first-year to internship year) across the six medical schools in Jordan: The University of Jordan, Mut’ah University, Jordan University of Science & Technology, Hashemite University, Yarmouk University, and Al-Balqa Applied University. The estimated number of all MSs in Jordan is around 10,000. A respondent-driven sampling approach was adopted to recruit the participants. We contacted the dean of each of the six medical schools in Jordan and gained their permission to distribute the questionnaire to the students. After getting permission from all schools of medicine, we reached the student representatives for each batch across the universities to facilitate distributing the questionnaire for eligible participants. The questionnaire was sent to all students enrolled in the medical program through emails and was posted in the main official social media groups of each batch (e.g., Facebook, WhatsApp, Linked In, and Twitter). These groups are private groups, including MSs only, and under the supervision of the student’s representative of the concerned batch. We were able to reach responses from a total of 2104 participants in our study during the period between 21 and 30 April 2021. This period was during the COVID-19 second wave in Jordan during which the reported cases were close to 7000 and the death toll was exceeding 100 per day according to official figures from the Ministry of Health [22].
Questionnaire administration
The students were invited to participate in the study with a cover letter briefly introducing the study protocol, aims, and anonymity of the data. The questionnaire was administered in the form of an Online-based Google Form survey link. Students were asked to fill the questionnaire after acknowledging an informed consent. It was clearly stated that participation is voluntary, and the participant can withdraw at any point in time without any consequences. It was also clarified that no direct benefits will be gained from participation aside from contributing to an activity that will add to existing knowledge. No personal identifiers were obtained, and participants were encouraged to disclose the required information with transparency to help reach accurate conclusions.
Measurement tool
A structured online-based English self-administered questionnaire was used for data collection. It consisted of four parts: the participants’ demographics section, the Patient Health Questionnaire 4 (PHQ-4 scale), the Fear of Coronavirus-19 Scale (FCV-19S), and the single item Sleep Quality Scale (SQS).
Demographics
Participants’ demographic characteristics were collected, including age, gender, university, study level (first year to internship year), and planned future specialty, which was categorized into medical specialities, surgical specialities, psychiatry, and no plans to specialize. Also, personal and family/close friend history of mental illness was assessed using direct Yes/No questions: do you have any mental illness? and does any of your family members/close friends suffer from any mental illness?
Psychological distress (PHQ-4 scale)
Psychological distress was assessed using the validated Patient Health Questionnaire 4 (PHQ-4 scale) [23]. The PHQ-4 consists of four items answered on a 4-point Likert-type scale: not at all, several days, more than half days, and nearly every day. It allows ultra-brief and accurate measurement of core features of Dep and AX by combining the two-item measure (PHQ-2), consisting of core criteria for Dep, and a two-item measure for AX (GAD-2), both of which have independently been shown to be good brief screening tools. The PHQ-4 scale is a reliable and valid tool for screening for Dep and AX among college students as proved by psychometric testing with a reported α= 0.81 [24] and α= 0.73 in our study. The total score of PHQ-4 ranges between 0 and 12 and is represented as the following PD categories: none (0–2), mild (3–5), moderate (6–8), and severe (9–12). Previous research has established that a score of 3 or greater on the Dep subscale or AX subscale represents a reasonable cut-off point for identifying potential cases of Dep or AX, respectively [25]. Therefore, these cut-offs were used to label the participants in our study as positive screening as yes and negative screening as no.
Fear of COVID-19 (FCV-19S)
Fear of COVID-19 was assessed using the Fear of Coronavirus-19 Scale (FCV-19S) that was developed and validated by Ahorsu et al. [26]. FCV-19S composed of seven items answered on a 5-point Likert-type scale (strongly disagree, disagree, neutral, agree, strongly agree). The minimum possible score for each item is 1 (strongly disagree), and the maximum score is 5 (strongly agree). The total score is calculated by adding up the items’ scores (range between 7 and 35). The higher the reported score on FCV-19S, the higher the fear of the COVID-19 pandemic. Since FCV-19S was developed back in March 2020, it has been validated on several populations including college students [27].
Sleep quality (SQS)
To assess participant’s SQ, we used the validated single-item SQ Scale (SQS) [28]. SQS is a self-rated, global SQ assessment tool developed based on a literature review of key aspects of SQ, critical components of the Pittsburgh SQ Index (PSQI), the morning questionnaire-insomnia (MQI), and direct expert and patient input. Participants are asked to rate their SQ in the past 7 days based on the following factors: total sleeping hours they got each night, how easily they fell asleep, how often they woke up during the night (except to go to the bathroom), how often they woke up earlier than they had to in the morning, and how refreshing was their sleep. The rating is on a 1 to 10 scale, with 1 being terrible and 10 excellent. A score of ≤3 is regarded as poor, 4 to 6 regarded as fair, 7 to 9 regarded as good, and 10 regarded as excellent SQ.
Ethical considerations
The study protocol was written according to the ethical principles of the declaration of Helsinki, and it was reviewed and approved by the Institutional Review Board (IRB) at University of Jordan, Amman, the Hashemite Kingdom of Jordan on 20/04/2021 (reference number: 101/2021/9341) in meeting No. 7/2021.Written informed consent was obtained from all participants before filling the questionnaire. The data was collected and proceeded confidentially and stored eventually on a personal computer device that only the authors have access to.
Statistical analysis
After finalizing data collection, data was extracted from Type-form into a customized Microsoft Excel (2016) password-protected spreadsheet then imported into IBM SPSS Statistics for Windows, version 25 (IBM Corp., Armonk, NY, USA) for analysis. Responses were first examined for missing values, outliers, and assumptions of linearity, normality, and homoscedasticity. Descriptive statistics were generated to summarize the quantitative and categorical variables. The summary scores of the PHQ-4 scale, FCV-19S, and SQS were calculated and categorized accordingly. PHQ-4 total score was categorized into normal, mild, moderate, and severe. Anxiety (AX) and Depression (Dep) subscales of PHQ-4 were categorized into positive screening/negative screening. SQS score was categorized into poor, fair, good, and excellent. The reliability of the PHQ-4 scale items and FCV-19S items was assessed using Cronbach’s alpha to confirm the internal consistency of each scale. Appropriate Chi-square, t-tests, and ANOVA were used to establish the associations between the covariates and AX subscale, Dep subscale, PHQ-4 total score, and FCV-19S summary score. Bonferroni correction was used to adjust the multiple comparisons for ANOVA associations. Pearson correlation coefficient was used to determine the relationships between FCV-19S, PHQ-4 total score, AX sub-score, and Dep sub-score. A p-value of α < 0.05 was set to determine the statistical significance of the reported results.