Introduction

The COVID-19 pandemic forced every country to implement measures to reduce its spread, which led to changes in the economy, society, health and education. The latter has been one of the most affected fields, as governments around the world temporarily closed educational institutions of all levels to prevent transmission. In Peru, on March 12, 2020, the cancellation and postponement of the start of classes and teaching activities in public and private institutions was announced ¹. Therefore, universities adopted strategies to allow the continuity of classes through online education. On October 11, 2021, after almost two years of online education, the Ministry of Education announced the return to in-person classes as of March 2022 ².

Returning to in-person activities encouraged people to think and take responsibility as a society at the educational level. The repercussions of returning to educational activities in terms of physical and emotional health were unknown. An example is what happened in the United Kingdom from June to July 2021, a period in which high numbers of the Delta variant were reported in the 17-24 age group, probably due to low vaccination rates in this group and suboptimal mitigation strategies in schools and universities ³. Similarly, the Philippines showed interest and concern for the health of young people returning to school, who were at high risk especially because the healthcare system continued to struggle with COVID-19 ⁴.

During the pandemic, it could be observed that the cases of anxiety and depression among university students increased significantly ⁵. Similarly, an Italian study of medical students reported extreme fear in almost half of the respondents ⁶. Returning to in-person activities includes certain variables that may increase this baseline condition. These consist of fear of catching COVID-19, worrying about transmitting the infection to loved ones, trust in government policies, among others.

A previous literature review showed neither studies addressing factors associated with fear of COVID-19 prior to returning to in-person classes nor the implementation of pertinent strategies to prevent and treat the students’ mental health. Therefore, this study was proposed to determine the factors associated with fear of COVID-19 prior to returning to in-person classes among medical students, specifically at Universidad Peruana Los Andes in 2021.

Materials and methods

Results

A total of 252 students were surveyed. The median age was 22 [20-23] years and the female gender prevailed, with 166 (65.87 %) students. A total of 47.22 % of the students reported a history of SARS-CoV-2 infection and 62.30 % stated having the complete three-dose COVID-19 vaccination series (Table 1). The FCV-19S showed the following scores: a mean of 14.99 ± 6.32 points, a median of 14 [10-19.5] and a range of 7 to 35. When classifying this variable, a high level of fear of COVID-19 was reported in 68 (26.98 %) students.

According to DASS-21, 30.95 % of the respondents had some level of depression, mostly moderate (11.51 %). Likewise, 31.75 % had some level of anxiety, mostly moderate (11.90 %). Finally, 28.57 % showed some level of stress, mostly mild (17.86 %) (Figure 1).

Figure 1 Frequency of depression, anxiety and stress (DASS-21) in the study population 

Table 2 shows a statistically significant positive correlation between the DASS-21 subscales (depression, anxiety and stress) individual scores and the FCV-19S total score (< 0.001, < 0.001, < 0.001, respectively).

The bivariate analysis showed that those students with a complete COVID-19 vaccination schedule were 0.64 (cPR: 0.64; 95 % CI: 0.43-0.96) less likely to have a high level of fear of COVID-19 compared to those with an incomplete vaccination schedule. On the other hand, those who suffered from some level of depression, anxiety or stress were 1.76 (cPR: 1.76; 95 % CI: 1.18-2.62), 2.42 (cPR: 2.42; 95 % CI: 1.63-3.59) and 2.22 (cPR: 2.22; 95 % CI: 1.50-3.28) more likely to have a high level of fear of COVID-19 than those who did not suffer from these conditions.

Finally, in the multivariate analysis, the variables were adjusted, thus determining that the participants who had a complete vaccination schedule or trust in university policies and guidelines were 65 % (aPR: 0.65; 95 % CI: 0.43-0.99) and 50 % (aPR: 0.50; 95 % CI: 0.29-0.87) less likely to have a high level of fear of COVID-19. On the contrary, those who had trust in government policies (aPR: 1.76; 95 % CI: 1.01-3.09) and anxiety (aPR: 2.18; 95 % CI: 1.16-4.10) were more likely to show high levels of fear (Table 3).

Discussion

The mean fear of COVID-19 score was 14.99 ± 6.32 points. This result is similar to that found by Yeni et al. ¹⁰ in a group of medical students, with a mean of 15.57 ± 5.99, and different from that described by Nguyen et al. ¹¹ in medical students from Vietnam, with a mean score of 16.7 ± 5.3. During the pandemic, “coronaphobia” affected a large number of medical students, mainly concerning the risk of transmission. In the present study, another factor was added: the return to in-person classes after a long period of online education, so there would be greater exposure to the coronavirus. Despite this, the figures found in this study were lower than those previously reported. This could be due to the fact that the population is adapting, leaving aside or downplaying coronavirus. Thus, it is important that each student has the necessary information to correctly follow health protocols such as mask wearing, social distancing and handwashing. Similarly, each institution should take the pertinent safety measures such as improving ventilation in its facilities; implementing an area of occupational medicine; controlling the spread of the virus through testing, detection and tracking of positive cases, with subsequent isolation to prevent transmission.

As for depression, similar results were observed. A total of 30.95 % of the surveyed students reported having depression. This finding is similar to that described by Shofler et al. ¹², who found that 34.7 % of the medical students showed depressive symptoms. This similarity occurred despite the fact that both studies used different instruments and contexts to assess depression. On the other hand, medical students from China ¹³ showed a prevalence of 57.5 % and medical students from Spain ¹⁴ a prevalence of 41 %. It was previously described that the high prevalence of depression among medical students is common due to overloaded schedules, academic stress and family conditioning. Furthermore, as demonstrated by the current study, the pandemic could be a possible conditioning factor for depression since, according to PérezAbreu et al. ¹⁵, COVID-19, like other diseases, emotionally affects those who are exposed to or suffer from it.

It was also observed that the prevalence of anxiety in the study participants was 31.75 %, which is similar to the prevalence of 34.1 % among Turkish medical students described by Karagöl et al. ¹⁶, and different from the prevalence of 75.4 % among medical students from a private university in Lima according to Saravia-Bartra et al. ¹⁷ This difference could be explained by the fact that, during the course of the study, the city of Lima had the highest number of infections and deaths. However, at present, the number of cases, deaths and hospitalizations due to COVID-19 has decreased ¹⁸. In this regard, although the risk factors for the increase of these disorders have been reduced, it should be taken into account that COVID-19 prevalence is still significant and could increase due to the relaxation of restrictions.

Out of the respondents, 28.57 % had stress, representing the least frequent disorder. This figure is well below that reported by O’Bryne et al. ¹⁹, with 90.9 %. In Peru, Sandoval et al. ²⁰ found that 23.90 % of medical students from Ayacucho suffered from stress during the COVID-19 pandemic. The difference between these figures could be due to the different current situations of each country. The studies that reported a higher prevalence of anxiety were from Ireland and Saudi Arabia. In addition, these studies were conducted during the lockdown and online classes, which differs from the present study, which was conducted in the period prior to returning to in-person classes. The Peruvian study carried out with medical students from Ayacucho showed similar figures to this study’s, demonstrating that there is no significant change due to this exposure.

It is known that a widespread crisis arose from fear of and anxiety about the COVID-19 outbreak. The potential risk of rapid transmission, severity and death from COVID-19 increased the psychological stress on healthcare professionals ²¹. With the announcement of the vaccine development and the initiation of vaccination, this level of fear was markedly reduced. Karayürek et al. ²² found that 76 % of odontologists experienced fear and anxiety before vaccination and, on the contrary, 35.6 % stated that fear and anxiety decreased in the post-vaccination period. In the bivariate and multivariate regression analysis carried out in this study, vaccination was considered a protective factor for high fear of COVID-19. For this reason, promoting vaccination among medical students prior to returning to in-person classes is recommended since this would not only reduce transmission but also create a sense of psychological security.

In this study, trust in government policies was considered a risk factor for high fear of COVID-19. This result was similar to that of Krishnaratne et al. ²³, who also found negative effects when trusting in government policies in the school setting, thus increasing the level of fear, especially in social, economic and ecological research studies. Different results were found in the study by Talic et al. ²⁴, who described a reduction in the number of infections and fear of COVID-19 when trusting in the implemented measures such as handwashing, mask wearing and physical distancing. It would be believed that trust in government policies would reduce the level of fear among students; however, throughout the pandemic, a great deal of distrust in government policies was described. This would be mainly related to the fact that the effectiveness of the restrictive measures was not uniform across all countries, even more in Latin America, where the spread of the virus and the number of deaths remained high ²⁵.

On the other hand, trust in university policies and guidelines was considered a protective factor for high fear of COVID-19. This result was similar to the one found in the study by Nussbaumer-Streit et al. ²⁶, where protective effects for fear of COVID-19 were shown by trusting in non-pharmacological and public health measures. This similarity of results is due to students’ trust in the ability of entities to implement these measures and also in the efficacy of these strategies in reducing transmission. It is important that both the university and students adopt these measures rigorously to avoid undesirable outcomes.

In the study, a significant positive correlation was found between the FCV-19S and DASS-21 subscales scores. Additionally, in the univariate regression analysis, these subscales were a risk factor for high fear of COVID-19. Similar results were reported by Khalaf et al. ²⁷ and Rodríguez-Hidalgo et al. ²⁸, who also found a positive correlation between the subscales and fear. Likewise, Caycho-Rodríguez et al. ²⁹, by means of a structural equation, identified that fear of COVID-19 positively predicted anxiety and depressive symptoms. This could explain why elevated levels of fear of infecting family members or close relatives with SARS-CoV-2 generate increased levels of stress. Therefore, if stress levels are not controlled, they can lead to anxiety and depression, as shown by the study of COVID-19 survivors by Mazza et al. ³⁰, where a close relationship between high levels of fear of COVID-19 and the subscales anxiety and depression was described.

One of the main limitations of this study was using a nonprobabilistic convenience sampling. On the other hand, all the factors that can influence fear of COVID-19 were not considered. Data collection was carried out by means of a self-administered survey, which could imply information bias. Since this was a cross-sectional study, it was not possible to determine causality between variables.

In conclusion, the present study demonstrated that there are different factors that could be associated with fear of COVID-19 among medical students in the context of the return to in-person classes. It was shown that more than one third of the students had a high level of fear of COVID-19, depressive symptoms, anxiety and stress. It was also determined that it is important to take into account protective factors such as trust in each institution’s health protocols, as well as having a complete COVID-19 vaccination schedule. These results suggest that each educational institution should adopt the necessary measures and strategies to provide safe places that reduce the transmission of COVID-19 and enable students to academically perform well. Likewise, they can provide programs that help students to adequately cope with situations that may affect their mental health. In this way, the increase of depression, anxiety and stress that medical students usually present could also be avoided.