General Health Status of Medical Students During COVID-19 Pandemic and Relevant Factors in Medical Students of Arak University of Medical Sciences in 2021

Background and aims: The present study examined the general health status following the COVID-19 pandemic and relevant parameters among internship and externship medical students. Methods: In this cross-sectional study, 400 externship and internship medical students at Arak University of Medical Sciences in 2021 were recruited, to whom the 28-item general health questionnaire developed by Goldberg was administered. In the questionnaire, 23 is considered the cut-off point, and higher scores indicate worse general health. The data were statistically analyzed using SPSS version 23.0. Results: The mean general health score was 25.24 ± 9.71, and the prevalence of general health disorders was 51%. The results represented no significant difference between the externship and internship students concerning the total general health score and subscales of somatic symptoms, anxiety and insomnia, and social dysfunction. However, interns had a significantly higher depression score compared to externs ( P = 0.029). Age, gender, marital status, history of COVID-19, and residence status were not statistically significantly related to the general health score. Conclusion: More than half of the interns and externs at Arak University of Medical Sciences developed general health disorders during the COVID-19 outbreak. The results revealed no significant relationship between the total score of general health and gender, age, marital, residence, and COVID-19 status.


Introduction
An unknown virus was detected in Wuhan, China, in December 2019, which quickly spread to different continents. 1 Therefore, the World Health Organization (WHO) introduced it as one of the most important public health concerns worldwide.This pathogen belongs to the RNA betacoronavirus family, known as SARS-COV-2.This pandemic affected all aspects of life. 1,2ealthcare personnel are often on the front line of the fight against epidemics.They face significant threats worldwide because of exposure to severe and contagious diseases such as COVID-19.In addition, the COVID-19 pandemic is considered one of the leading causes of death in many trained and experienced healthcare specialists worldwide. 3,4ealth crises such as the coronavirus pandemic lead to mental changes caused by fear, anxiety, depression, and insecurity in people and healthcare personnel. 2,5,6In general, all health-related aspects should be considered to check the health status of individuals.Given the coronavirus pandemic, the unknown nature of the disease, and the creation of mental crises, 7 mental health tools should be used to evaluate the health status.The Goldberg 28-item General Health Questionnaire (GHQ-28) is one of the useful questionnaires used for evaluating the health status. 8This questionnaire contains the general health dimensions of somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression.It can inform health system planners about mental disorder prevention. 9Little is known about what is happening among people in the real world after the COVID-19 pandemic. 10,11Medical students, 12 including externs and interns, have fought against the deadly coronavirus, whose mental health has been influenced by several parameters during the COVID-19 pandemic. 10,12Therefore, assessing the general health of this group and identifying influential factors can help design efficient interventions to enhance health status. 13The present study examines the general health status following the COVID-19 pandemic and relevant parameters among internship and externship medical students.

Type of Study
The present cross-sectional study evaluated the general health of externship and internship medical students at Arak University of Medical Sciences in 2021.

Study Population
After obtaining ethical approval and collaborating with the education department of the university for collecting data, the researcher referred to the education departments where the interns and externs (target group) attended.Then, the data were gathered following the explanation of the objectives of the study and obtaining the subjects' consent to participate in the study.
The inclusion criteria were having physical and mental health, being internship and externship medical students at Arak University of Medical Sciences, and having no history of diagnosed mental illness, depression, and anxiety.Further, the other inclusion criteria were the lack of detected underlying and chronic diseases and no experience of stressful events such as the death of relatives or acquaintances due to COVID-19 leading to depression and anxiety.The individuals who filled out the questionnaire incompletely and presented insufficient information were excluded.

Sample Size and Sampling Method
According to the study by Hayati et al, about 50% of staff in hospitals affiliated to Tehran University of Medical Sciences were suspected of having general health disorders. 14Finally, considering an alpha error of 5%, the sample size of this study was determined to be 384 people, which was increased to 400 people to compensate for possible dropouts.After obtaining informed consent, 400 internship and externship medical students were selected using a stratified random sampling method.Then, the Goldberg 28-item general health questionnaire (GHQ-28) was given.

Data Collection Tool
The questionnaire consists of demographic information such as marital status and educational level, the type of vaccine, and history of infection with COVID-19.The main GHQ includes 60 questions.However, the 28-item version was utilized to examine general health in the present study.
In a study on students at Shiraz University, Taghavi et al evaluated the validity and reliability of this questionnaire, and Cronbach's alpha was 0.90. 15The GHQ-28 assesses an individual's health status during the last month and comprises four subscales, each with seven questions.Questions 1-7, 8-14, 15-21, and 22-28 are related to the subscales of somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression, respectively.The score of each dimension was separately determined for each subject, followed by calculating the total score by summing the obtained values for four subscales.The lower score reflects better mental health, and the cut-off point is 23.Accordingly, the individuals getting 23 or less are healthy or have no mental disorder, while those with a score of 24 or higher are candidates for a mental disorder. 15

Statistical Analysis
The quantitative variables were described as mean ± SD, and the number (%) was determined for categorical and ordinal data.The independent sample t-test was employed to compare the mean general health score between two groups of medical students (externs and interns).Pearson's correlation coefficient was used to evaluate the relationship between quantitative variables such as age and GHS score.SPSS version 23.0 was applied for statistical analysis.A significance level of 0.05 was considered in all tests.

Results
A total of 400 subjects were included in the study (218 externs (54.5%) and 182 interns (45.5%)), with a mean ± SD age of 24.73 ± 1.57 years.Additionally, the mean time interval from the last COVID-19 vaccine dose was 4.45 ± 2.26 months.The results of the Spearman test (r = 0.004) indicated no statistically significant relationship between age and general health score (P = 0.933).
As shown in Table 1, no significant relationship was observed between general health score and gender, marital status, and residence.The type of vaccine was not significantly related to the mean general health score; however, the mean value was higher among those who received live vaccines such as AstraZeneca and Sputnik.Furthermore, the mean general health score was insignificantly higher among individuals with a history of General health status of medical students during COVID-19 COVID-19 (P = 0.279).
The mean general health score was 25.24 ± 9.71.Based on the cut-off point of 23 for the total health score, 196 (49%) subjects were healthy, and 204 (51%) suffered from general health disorders.Table 2 compares general health scores and their dimensions between the externship and internship periods.As demonstrated, the internship and externship medical students were not significantly different in the total general health score, the subscales of somatic symptoms, anxiety and insomnia, and social dysfunction.However, the interns were considerably more depressed than the externs (P = 0.029).

Discussion
During the COVID-19 pandemic, externs and interns have fought against the deadly coronavirus, and their mental health has been affected by various factors.Due to fear, anxiety, depression, and insecurity, health crises such as the coronavirus pandemic caused mental changes among people and healthcare personnel. 2,6,10In general, the health status of individuals should be evaluated by considering all health-related aspects.In this regard, using mental health tools is essential due to the coronavirus pandemic, the unknown nature of the disease, and the formation of mental crises.Therefore, examining general health in medical students and identifying influencing parameters can help design efficient interventions for promoting health status.
Based on the results of the present study, the mean general health score was 25.24 ± 9.71 among the medical students.In addition, more than 50% of the medical students suffered from general mental health disorders.This issue is essential in the educational planning of the group and reveals the necessity of therapeutic counseling and preventive measures for interns and externs.The results align with those of Hayati et al, who demonstrated that 47.5% of individuals were suspected of having general health disorders. 14According to Saraswathi et al, 10 the COVID-19 pandemic negatively influenced the mental health of externship medical students by increasing the prevalence and level of anxiety and stress, as well as intensifying depressive symptoms.Addressing and reducing the adverse effect of COVID-19 on the mental health of this population are considered crucial. 10avarinia Motlagh Quchan et al 11 found a low mental health level among the nurses at the therapeutic center in Sabzevar City during the COVID-19 pandemic.
The results of the present study represented no significant difference in the mean general health score between externs and interns.Further, the somatic symptoms, anxiety and insomnia, and social dysfunction were not significantly related to the educational level.
Regarding the three dimensions, the interns and externs were not significantly different.However, the mean depression score was higher among interns, which may be ascribed to their longer exposure to the clinical departments in the hospital and higher attendance in the therapeutic departments.Furthermore, job strain, heavy shifts, and more prolonged exposure to patients during the COVID-19 pandemic can be addressed as the reasons for the higher depression score of interns compared to the externs.The other causes include a heightened awareness of the nature of the disease as well as fear and anxiety.Ranjbar Roghani et al reported medical students' proper understanding and attitude towards COVID-19 and significantly more attention among individuals in the higher semesters and educational level. 13Based on the results of a study conducted in China during the severe outbreak of SARS, 89% of the healthcare personnel involved in high-risk conditions expressed mental symptoms and depression.The personnel presented a complex psychological response to the infectious disease epidemic. 16Distress may be induced by the sense of vulnerability, loss of control, worry about the health of one's family and others, virus spread, change in work, and separation. 16,17n the present study, the age, gender, and general health of the subjects were not significantly different.It is worth noting that females are successful in doing social and academic duties, especially in medicine and its difficulties, despite their more fragility and less tolerance to mental problems, trauma, and depression compared to males.
The results indicated an insignificantly higher mean general health score among married students compared to single ones.Additionally, no significant difference was detected in the mean general health score of native and non-native individuals, but the non-native ones had a higher standard.According to the study conducted by Arjmandi et al, there was no significant difference in depression and anxiety scores between native and nonnative students. 18Similarly, Norouzinia et al found that mental health and anxiety are not significantly different among native and non-native students, as well as married and single ones. 19egarding the present study, the subjects who received AstraZeneca and Sputnik COVID-19 vaccines had higher general health scores.At the same time, more individuals got a score below the cut-off point and were healthy following the injection of other vaccines.However, the differences were insignificant.No study has highlighted this issue.][22][23][24] Further, the students with and without a history of COVID-19 were similar in terms of the mean general health score.Accordingly, the general health score was not significantly related to the history of COVID-19.However, the infection with COVID-19 and recovery may significantly affect patients' mental health because of being hospitalized in the in-patient department and observing the death or illness of others.

Conclusion
The results represented general health disorders in around half of the internship and externship medical students at Arak University of Medical Sciences during the outbreak of COVID-19.The results represented no statistically significant difference between the externship and internship students in the total general health score and subscales of somatic symptoms, anxiety, insomnia, and social dysfunction.However, interns had a significantly higher depression score compared to the externs.The results revealed no significant relationship between the total score of general health and gender, age, marital status, residence, and history of COVID-19.

Table 1 .
General Health Status of Internship and Externship Medical Students at Arak University of Medical Sciences by Demographic Variables

Table 2 .
Scores of General Health and its Subscales among Internship and Externship Medical Students at Arak University of Medical Sciences