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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 240-246

The impact of perceived stress on risk evaluations among health-care students during coronavirus disease-2019 outbreak


1 Department of Physiology, Usküdar University Faculty of Medicine, Istanbul, Turkey
2 Department of Psychology, Faculty of Art and Science, Istinye University, Istanbul, Turkey

Date of Submission04-Jul-2021
Date of Acceptance03-Nov-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Zozan Guleken
Department of Physiology, Usküdar University Faculty of Medicine, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnbs.jnbs_31_21

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  Abstract 


Aims and Objectives: Perception has an important role in managing crisis situations such as pandemics. While studies have been conducted on the risk and stress perceptions of health-care workers, there has not been any study on the stress and risk perceptions of health science students who have not yet started this profession, which was investigated herein. Materials and Methods: Participants (n = 225) reported their physiological changes, the level of perceived stress (PSS) caused by the coronavirus disease-2019 (COVID-19) outbreak, and the evaluations of the risk perception through questionnaire form. Two cut-off scores of the PSS-14 were calculated as low (<M-SD), moderate (>M-SD and <M + SD), and high level (>M + SD) of perceived stress. The correlation between the PSS-14 and risk perception scores was analyzed using Spearman's rho correlation coefficient. The Wilcoxon Signed Rank test was used to evaluate pairwise risky situation comparisons. Two logistic regression was conducted to test the association between PSS-14 scores and appetite routine. Results: Mean PSS was higher among female students. The participants with a high level of perceived stress have a higher difference between the own risk perception and own risk perception referred to others, and there was a difference between own and own referred to others in the items of risk perception for shaking hands, prayer room, protection against disease, and protection against COVID-19 virus. Conclusions: Finally, people's perception of risk could be biased regarding their perceived stress level, and this may lead to not make the right judgments for the risky decisions.

Keywords: Coronavirus disease-2019, health care students, pandemic, perceived stress, risk perception


How to cite this article:
Guleken Z, Sutcubasi B. The impact of perceived stress on risk evaluations among health-care students during coronavirus disease-2019 outbreak. J Neurobehav Sci 2021;8:240-6

How to cite this URL:
Guleken Z, Sutcubasi B. The impact of perceived stress on risk evaluations among health-care students during coronavirus disease-2019 outbreak. J Neurobehav Sci [serial online] 2021 [cited 2022 Aug 8];8:240-6. Available from: http://www.jnbsjournal.com/text.asp?2021/8/3/240/333759




  Introduction Top


On December 31, 2019, 27 cases of pneumonia of unknown etiology were detected in Wuhan City, Hubei Province, China.[1] Wuhan is the most populous city in the center of China with a population of over 11 million. It is reported that patients had clinical symptoms such as dry cough, shortness of breath, and fever. The causative agent of the disease was identified from the throat swab samples run by the Chinese Center for Disease Control and Prevention on January 7, 2020, and later called Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses in the wake of an outbreak of pneumonia of unknown cause in Wuhan city, China.[2],[3] Furthermore, another diagnose was made by the detection of bilateral lung infiltrates on tomography images. Some patients had shown various fatal complications such as organ failure, septic shock, edema, severe pneumonia, and Acute Respiratory Distress Syndrome (ARDS).[4],[5],[6] The WHO global health emergency declared China's coronavirus disease-2019 (COVID-19) epidemic on February 11, 2020, as the International Public Health Emergency, which poses a high risk for countries with vulnerable health systems. The emergency committee advised to prevent the spread of COVID-19 with preventions such as early detection, isolation, rapid treatment, and restriction on people's contact with each other may be useful protection for controlling the disease.[7] According to the WHO recommendation, governments took precautions to prevent contamination for public health. Authorities in Turkey recommended the public to minimize face-to-face interaction and socially isolate themselves for preventing the spreading of virus almost 1.5 years.

The sudden and unexpected situations caused some psychological reactions among people. It is known that perception is very important for these unexpected situations, as well as, there are individual differences in the perceived stress levels in society. People who experienced fear and anxiety may be more tending to think negatively, and their risk perceptions can be exaggerated.[8] It has shown that the psychological consequences of the previous outbreak (SARS-CoV-1 in 2002) are more evident in health-care workers.[9],[10] Furthermore, there are recent studies indicated that health-care workers reported a higher risk perception and higher anxiety compared to general population.[11] The researchers suggested that the other demographics such as psychological state, sex, and living area are less related to the risk and stress perceptions. Taken all together, there has not been any study on the stress and risk perceptions of health science students who have not yet started this profession, which was investigated herein.

In this study, we used two self-report surveys. We used the Perceived Stress Scale with 14 items (PSS-14) which created by Cohen[12] in Turkish version[13] to determine the perceived stress caused by the COVID-19 outbreak. It is known that increased perceived stress events are associated with more negative perceptions, and lead to depression, for this reason, we preferred to use PSS-14 with adding “COVID-19 related” before the evaluation of all items. Measuring and determining the risk perception is substantial for risky individuals, which have a negative bias on information processing.[14] Since the pandemic is a recent phenomenon and a proper task has not yet been developed to assess the risk perception for the pandemic situations. We were inspiring Knoll et al. and used the risk perception task without social influence effect and modified the risky situations related to COVID-19.[15] To evaluate risk perceptions of the participants, we showed some photographs to state the situations that might pose a risk, related to the COVID-19 outbreak. The participants supposed to evaluate their own risk perception and others' risk evaluation for all photos. In this way, we hypothesized to find a difference between their risk evaluation and their risk perception referred to others for the pandemic process. Moreover, we examine whether there is a relationship between a self-report perceived stress of the participants and risky situation evaluations. As the perceived stress level increases, we expect to find the difference between their own and others' risk assessments to widen. Therefore, the purpose of this study is to measure the perceived stress in health sciences students and to evaluate their risk evaluations according to perceived stress. Furthermore, the association between perceived stress and self-report physiological and psychological behaviors such as sleep quality and appetite was also examined.


  Materials and Methods Top


This study was performed in line with the principles of the Declaration of Helsinki, as revised in 2013. Our study protocol was approved by the Uskudar University Ethics Committee on non-Interventional Research Ethics (with the number 61351342-2020-0016and date 04.05.2020). All respondents provided written informed consent. We conducted the study on the different departments of faculty of health science students to investigate their COVID-19-related perceived stress and perception of risk (n = 225). Faculty of health science consists of different departments such as perfusion, midwifery, child development, and neuroscience. The targeted population has to spend 1 or 2 years of their education in university hospitals as a clinical course before their graduation. We selected the group who has not begun the clinical course in the hospital to control the perception of stress and risk related to COVID-19. Participants with access to internet connection, able to write and read in Turkish, and willing to give informed consent were included. We conducted our study using an online survey from March 30 to April 30.

On the date March 18 with the guidance of authorities, dialog education replaced to online education classes for the protection and prevention of COVID-19. We announced our study on our online lessons and posted on social platforms for whom in our inclusion criteria. Our surveys were completed on free online survey platform using Google Docs (https://docs.google.com/forms/u/0/).

To get some background information on participant's demographics gathered from the survey included gender, level of education, some information about health statuses such as chronic illness, heart failure, or respiratory diseases, constantly used drugs and current location. In this study, we used the PSS-14 which is consisted of 14 questionnaires created by Cohen[12] to assess the degree to which the participant has appraised the situations in their life as stressful over the past month. It is validated in Turkey by Eskin and Demirkiran. The scale has two factors; factor I: insufficient self-efficacy perception and factor II: stress/discomfort perception.[13] Participants rated items on a 4-point Likert scale ranging from 1 “Never” to 4 “Very often” ranging from 1 to 56 with higher scores indicating greater perceived stress. PSS-14 has some reverse scoring items, which are positively stated items with the questions numbered 4, 5, 6, 7, 9, 10, and 13 and the total score consists of summing the scores across all 14 items. PSS-14 has two subscales named as Factor I: Insufficient self-efficacy perception and Factor II: Stress/discomfort perception. The items numbered 4, 5, 6, 9, 10, and 13 are considered as Factor I, and others as Factor II. This test is suitable to administrate mailed out or over the phone with the average response time 8–10 min. Moreover, some questions are about the difference in their lifestyle during the COVID-19 outbreak. For example, we added some items whether they had physiological changes such as a disturbance in their sleep quality and they have to scale to the level of anxiety (between 1 and 10) about developing CoV-like symptoms tomorrow. Another item was related to their self-report about the risk of infecting with COVID-19 with a short answer. In addition, other items are about if they were avoided to being in crowded places before the officials announced the outbreak in the country. These additional items were developed for this particular research based on previous studies, and the purpose of doing this was to obtain additional information about COVID-19. Besides, we were inspiring the risk perception task created by Knoll et al. with 15 items without social influence effect.[15] We prepared some photographs related to pandemic to manipulate risky situations that may cause infection. All questions had two sections. One for own risk evaluation for the risky situations between a scale 0 and 10 and other with a question “what do you think about others risk evaluation for this risky situation' to consider own risk evaluation referred to others. The items of the form and mean values and standard deviations for risk evaluation are shown in [Table 1].
Table 1: Description items of risk perception with mean±standard deviation according to the photos that presents situations may cause COVID-19 outbreak

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Statistical analysis

The independent samples t-test was used to compare the mean scores of perceived stress scale between female and male participants. Two cutoff scores of the PSS-14 were calculated using the mean score (M) and standard deviation (SD) of the participants to divide into three groups; low (<M-SD), moderate (>M-SD and <M + SD), and high level (>M + SD) of perceived stress. Furthermore, we calculated difference scores between the subjective and others risk perception by subtracting the others' scores from the subjective ones for 15 risky situations mentioned above. Then, one-way analysis of variance (ANOVA) was used to determine whether the evaluation of 15 risky situations differed based on the three PSS-14 groups and whether the difference between the subjective and others' risk perceptions differed based on the PSS-14 scores. Moreover, the correlation between the PSS-14 and risk perception scores was analyzed using Spearman's rho correlation coefficient. Furthermore, total scores were computed for risky situations by summing up the scores of 15 risky situations, and the mean scores were compared between subjective and others risk perception using paired t-test. Since the risk perception scores were not normally distributed, the Wilcoxon Signed Rank Test was used to evaluate pairwise (subjective vs. others) risky situation comparisons. Two logistic regression was conducted to test the association between PSS-14 scores and low sleep quality and between PSS-14 scores and appetite routine. Statistical analyses were conducted by the SPSS (IBM SPSS Statistics for Windows, version 25.0. Armonk, NY: IBM Corp). P < 0.05 was considered statistically significant.


  Results Top


All the participants were students in health-related departments and aged between 18 and 25 years (34% of the participants were ergo therapy, 32.4% child development, 28.9% perfusion, and 4% neuroscience). Among the participants, 84.4% were females and 15.6% were males. About 77% of the participants were from urban areas.

Among the participants, 76.9% reported that they had some changes in their sleep quality and 54.2% indicated that they had some problems in their appetite during the ongoing pandemic. 55.1% of the responders specified that they would be “highly” or “extremely” worried if they had some CoV such as symptoms tomorrow. 23.6% of the participants stated that they were “always” or “highly” worried about being infected by CoV within last week. Among the participants, 10.2% believed that they would be infected “high probability” or “absolutely” by CoV in the next month [Figure 1]. Nearly 72.4% of the participants regarded that the other people in the society would be infected “high probability” or “absolutely” by CoV in the next month [Figure 2]. A Wilcoxon Signed Rank Test indicated that there was a significant difference between the probabilities of themselves and others being infected in the next month (Z = −11.516, P < 0.001). About 80.4% of the responders mentioned that they avoided going to crowded places before the quarantine started. Among the participants, 67.1% reported cleaning their hands “always” or “often” after touching something, which might cause contamination.
Figure 1: The participants' risk evaluations of the probability of own being infected in the next month

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Figure 2: The participants' risk evaluations of the probability others being infected in the next month

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The PSS-14 mean score of the participants was 37.29 and the standard deviation was 6.32. The mean scores of two subscales were as following: insufficient self-efficacy: M = 18.78, SD = 3.46 and stress/discomfort perception: M = 18.52, SD = 3.89. The mean score of PSS in women (M = 38.09, SD = 6.16) was significantly higher than in men [M = 32.94, SD = 5.40; P > 0.001; [Figure 3]]. Furthermore, female (insufficient self-efficacy: M = 19.07, SD = 3.73; stress/discomfort perception: M = 19.03, SD = 3.84) has also higher scores compared to male (insufficient self-efficacy: M = 17.20, SD = 3.58; stress/discomfort perception: M = 15.74, SD = 2.95) for the two subscales of PSS-14, but this result was not significant.
Figure 3: The mean scores and standard deviations for the PSS-14 score and two subscales in females and males. Factor I: insufficient self-efficacy perception and Factor II: stress/discomfort perception.

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According to the one-way ANOVA, there was a significant difference in online education scores among PSS groups (F (2, 222) = 2.993, P < 0.05). A Tukey post hoc test revealed that the participants with a low level of PSS evaluated the online education riskier compared to a moderate level of PSS during the pandemic (P < 0.05). There was no statistically significant difference among other PSS groups or risky situations. Moreover, there was a significant finding for the difference scores of prayer rooms among PSS groups (F (2, 222) = 3.216, P < 0.05). Pairwise post hoc comparisons showed that the participants with high level of PSS have more difference between the subjective and other risk perception for the prayer rooms compared to moderate level of PSS during pandemic (P < 0.05). There was a significant finding for difference scores of crowded places among PSS groups (F (2, 222) = 3.59, P < 0.05). A Tukey post hoc test indicated that the participants with low level of PSS have more difference between the subjective and other risk perception for the crowded places compared to moderate level of PSS during pandemic (P = 0.06).

[Figure 4] shows the items that participants reported own risk perception and own risk perception referred to others. Pairwise comparisons of risky situations (subjective vs. others) showed that there was a significant difference between the subjective and others risk perception for shaking hands (Z = −2.175, P < 0.05; subjective: M = 7.40, SD = 3.52, others: M = 7.12, SD = 3.14; prayer room (Z = -5.678, P < 0.01; subjective: M = 7.60, SD = 3.06, others: M = 6.74, SD = 3), protection against disease (Z = −4.569, P < 0.01; subjective: M = 7.06, SD = 2.34, others: M = 6.5, SD = 2.41), and protection against COVID-19 virus (Z = −4.087, P < 0.01; subjective: M = 7.19, SD = 2.21, others: M = 6.73, SD = 2.24).
Figure 4: The mean scores and standard deviations for own and own risk perceptions referred to others. A logistic regression showed a significant association between PSS scores and alterations on sleep quality (B = −0.083, *P < 0.05) and appetite (B = 0.067, *P < 0.05). In the participants with an increasing level of perceived stress was associated with alterations on sleep quality and appetite routine

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Moreover, there was not any significant difference between the total scores of subjective and others risk perception. There was not any significant correlation between difference scores (subjective vs. others) of 15 risky situations and PSS scores after correcting the P values for multiple comparisons.

A logistic regression showed a significant association between PSS scores and alterations on sleep quality (B = −0.083, P < 0.005) and appetite (B = 0.067, P < 0.005). Increased perceived stress was correlated with alterations in sleep quality and appetite routine.


  Discussion Top


The aim of the current study was to investigate the perceived stress in health sciences students and to measure their evaluations of risky situations according to perceived stress. In the findings, the PSS was found higher in female students compared to men. The participants with a high level of perceived stress have a higher difference between the own risk perception and own risk perception referred to others. Moreover, there were differences between own and own referred to others in the items of risk perception for shaking hands, prayer room, protection against disease and protection against COVID-19 virus.

This paper presents that there are some significant differences on COVID-19-related perceived stress and risk perception on health-related students. The health-related students reported that the most changed physiological processes based on self-report were related with sleep quality and routine appetite during the pandemic. The results showed that these physiological changes can be explained with alterations in perceived stress, and the increased level of perceived stress was associated with big changes in physiological processes. Besides, the students reported that “highly” or “extremely” worried if they had some CoV-like symptoms tomorrow. An important finding was some of the participants reported that they are “always” or “highly” worried about being infected by CoV within the last week. The score was very high and indicated that the health-care students were highly worried during the pandemic. One of our finding was about the perceived stress score (PSS-14), the stress level was more significant on female than men were. Studies showed that[16] PSS-14 scores were moderately correlated with depression scores. For this reason, young and women health-related groups need more attention. Researchers showed that, during COVID-19, there are similar results about anxiety and perceived mental health needs on different societies.[17] Furthermore, there is similar study, which was written during and after SARS outbreak to investigate the effect of stress among survivals. Chua et al. showed the increase of general stress and negative physiological effects during outbreak among health-care workers. In our study, we showed that not only health-care workers but also health-related students had general stress and negative psychological effects during outbreak.[18] As it is known that health-care workers are very essential and important, this may lead to a difference in their preference for health-related departments.

Lee et al. studied on SARS survivors during the outbreak and 1 year after, to evaluate stress and physiological distress. Their findings showed that the survivals still had elevated stress levels and psychological distress 1 year after SARS. In addition, they reported participants showed high levels of depression, anxiety, and posttraumatic symptoms. An alarming proportion (64%) scored with a psychiatric morbidity.[19] Both SARS and COVID-19 viruses presented a global epidemic threat but has spread rapidly around the world with the cases more than 1,290,000 with over 76,000 deaths. Considering these results, we think that, for the COVID-19-related high-stress level, authorities should take preventions for mental health well for COVID-19 survivors.[20]

In our study, there were significance on avoiding going to crowded places before the quarantine started and washing hands “always” or “often” after touching something could be protective for COVID-19. Kim and Kim reported for Middle East Respiratory Syndrome (MERS) outbreak responders believed that washing hands with soap and water and keeping away from the crowded places were protective for MERS[21] besides Smith reported the same beliefs and responses for SARS outbreak[22]. Our participants reported very similar responses for COVID-19. Our results are coherent to SARS and MERS risk perception.

Another interesting result was about the relationship between the beliefs about the online education and perceived stress level. Participants with low score of PSS-14 evaluated the quality of education will decrease with online education compared to the participants with moderate score of PSS during pandemic. This could be interpreted as students with low perceived stress are interested in and worried about their education rather than their health-related issues. Moreover, the participants with high level of PSS and not moderate level believe that they can change more the prayer rooms for their health compared to other people in the society. Besides, participants with low level of PSS and not moderate level believe that the other people in the society will avoid more being crowded places compared to them. When all results evaluated together, it can be interpreted that if the perceived stress get higher, health-related students are more likely willing to change their habits in daily life.

Our results showed that the health-related students have a belief that the other people in the society would be infected in with a “high probability” or “absolutely” by CoV in the next month. Furthermore, pairwise comparisons of risky situations showed that there was a difference between own and own referred to others in the situations of risk perception for shaking hands, prayer room, protection against disease, and protection against COVID-19 virus. Overall, participants believe that their behaviors are less risky than others' behaviors related to COVID-19. Based on this finding, we can speculated that the health-care students believe that own risk behavior is more accurate than others' behavior. According to the social influence, it is not consistent with our results, which regarded due to the pursuit of acceptance by others as well as the belief that others' behavior is more accurate than our own.[23] This is an unexpected finding and might be related with the increase in conformity and more confidence in their own perception of a situation though their young age. Otherwise, this result might be interpreted with error management theory.[24] According to his theory, the perceptual judgments under uncertainty can contain errors or biases. Error management biases can be observed in both nonsocial and social domains.[25] COVID-19 is an uncertain and completely new pandemic situation. However, none of the available models reflects the symptoms of the disease and the outbreak is a completely new situation, no one has experienced this situation before. We can interpret that, in such cases, people's perception of risk can be biased, and this may lead to not make the right judgments for the risky decisions.

The present study has some limitations. First, only students who can reach to the Internet and speak Turkish participated to the study. Second, the proportion of male and female participants are not equal, more women participants joined to the present study. Indeed, there are more women students in the health-related majors compared to men. The unequal distribution of study population can be found in the sample itself. Moreover, the sample of the study consists of the health-related students, so the results cannot be generalized to the whole population. The perceived stress, belief to the other people's behaviors may be different in the other groups like nonhealth-related students.


  Conclusions Top


Unfortunately, there is no definite antiviral therapy for COVID-19 yet. The recommendations for the personal guarding rules for health care and community are hypnotized to change the progression of the clinical outcomes of the COVID-19 outbreak. This present study, as well as an outbreak report of actual evaluation of COVID-19 by health-related students, shows that people have perceived needs to deal with their mental health difficulties. There is a need to intensify the awareness program and address the mental health issues of people during this COVID-19 pandemic.

Consequentially, coordinated mental health services, specific rehabilitation applications, and improved follow-up during and after outbreak should be delivered. In addition, increased stress could lead to the risk of mood and stress-related disorders. Besides, we offer that an urgent strategic planning and coordination are required for the confidence of health-care workers around the world, otherwise, the number of students preferring to health-related departments could decrease, which could lead to problems in public health services.

Patient informed consent

Informed consent was obtained.

Ethics committee approval

The ethics committee approval has been obtained from the Uskudar University noninterventional research ethics committee (61351342/2020-5).

Financial support and sponsorship

No funding was received.

Conflict of interest

There are no conflicts of interest to declare.

Author contribution subject and rate

  • Zozan Guleken (50%) designed the research, data collection, and wrote the whole manuscript.
  • Bernis Sutcubasi (50%) contributed with comments and data analysis.




 
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