key: cord-256132-ufs9kw3o
authors: AlAteeq, Deemah A.; Aljhani, Sumayah; AlEesa, Dalal
title: Perceived stress among students in virtual classrooms during the COVID-19 outbreak in KSA
date: 2020-08-01
journal: J Taibah Univ Med Sci
DOI: 10.1016/j.jtumed.2020.07.004
sha: 
doc_id: 256132
cord_uid: ufs9kw3o

OBJECTIVES: The Coronavirus Disease (COVID-19) is a novel infection caused by the coronavirus, which rapidly became a global pandemic. As disease outbreaks can adversely affect mental health, in this study, we explored the perceived stress levels among students during the COVID-19 outbreak that led to the adjournment of face-to-face teaching in KSA. METHODS: We conducted a cross-sectional survey of 367 students from KSA, which assessed their socio-demographic characteristics, Perceived Stress Scale, emotions, and concerns during the COVID-19 outbreak. RESULTS: Most participants were female (74.7%) and secondary school (79.8%) students. More than half of the participants showed moderate levels of stress (55%), while 30.2% registered high levels. Females and university students showed a significant association with stress level (p-value = 0.003 and 0.049, respectively). CONCLUSIONS: There was a moderate to high level of stress among students in KSA at the start of the COVID-19 outbreak. This study found a significant correlation between a high level of stress and female university students. The integration of online counselling and stress management programs would help mitigate the stress of students during distance learning.

. Females and university students showed a significant association with stress level (p-value ¼ 0.003 and 0.049, respectively).

Conclusions: There was a moderate to high level of stress among students in KSA at the start of the COVID-19 outbreak. This study found a significant correlation between a high level of stress and female university students. The integration of online counselling Q8 and stress management programs would help mitigate the stress of students during distance learning. 

The World Health Organization (WHO) defined pandemic as the spread of a certain disease worldwide or across international borders, affecting a large number of people. 1 COVID-19 is a newly discovered infectious coronavirus that spreads from one person to another through droplets. 2 The virus emerged in December 2019 and was first discovered in Wuhan, China. It was declared as a public health emergency of international concern in January 2020. 1, 2 Among other countries, KSA implemented Q10 strict precautions on its citizens in an attempt to control the spread. The country Q11 transferred Q12 its in-person educational system to virtual learning, closing public places of aggregation Q13 , invoking travel bans and curfews, and even suspending the Umrah pilgrimage. 3, 4 The literature on recent outbreaks, such as Ebola, the Severe Acute Respiratory Syndrome (SARS), and Middle Eastern Respiratory Syndrome (MERS), showed unique consequences of mental health burden during pandemics. Several factors were identified in the process of understanding how the public would respond during disease outbreaks, including disease course, media and misinformation, quarantine, neuropsychological sequelae of the infected individual, and the mental health burden among health care workers. During a quarantine, people face many consequences of physical and emotional social distancing, including isolation and future uncertainty. Degrees of isolation vary between individuals, ranging from physical (i.e., contact) or symbolic (i.e., separation from loved ones), and affect the human psyche. 5 Previous studies showed that disease outbreaks impacted individual mental health and well-being. Multiple risk factors were addressed. It was found that women and those aged between 16 and 24 years exhibited a great risk of developing psychological distress. 6 Similarly, recent studies showed a positive response to feeling panicked, depressed, or emotionally disturbed during the H1N1 pandemic. 7 During the SARS outbreak, a population-based survey showed post-crisis mental distress. 8 Comparably, during MERS, the level of stress was high in medical students in KSA. 9 To our knowledge, there are currently no studies that have assessed stress among students during the quarantine related to the COVID-19 pandemic. Therefore, this study aimed to Q14 explore the perceived stress level among students due to the coronavirus disease outbreak and the resulting suspension of in-person teaching in KSA.

The data for this study were obtained Q15 using a crosssectional survey, which was distributed from 18th until 28th of March 2020, during the coronavirus disease outbreak Q16 .

This study included both male and female Arabic speaking students, over 12 years old, living in KSA Q17 .

An online survey was distributed using Q18 non-probability convenient sampling to students from different levels living in KSA. Google Forms was used to create a link for the survey, which was posted in an announcement on the Noon Academy platform; a reminder was sent five days Q19 later. Noon Academy is an online educational platform in the Middle East and North Africa (MENA), where people Q20 can study live with their facilitators and friends in an interactive and engaging manner. Six million students are registered on the platform, from seven countries: KSA, Kuwait, Jordan, Iraq, Oman, Egypt, and India. 10

The online survey consisted of three components: 1) Socio-demographic characteristics that included age, gender, level of education, and region of residence. 2) Perceived Stress Scale (PSS) of Sheldon Cohen. 11 The scale consists of ten questions that are used to measure the perception of stress experienced by the participants over the past month. It includes a 5-point Likert scale that capture responses ranging from never (0) to very often. 4 Total mean scores of 0e13 are considered to be low stress, 14e26 indicate moderate stress, and 27e40 indicate high stress. The PSS is an easily and widely used tool with acceptable psychometric properties. 12e14 An Arabic-validated version was used. 15 3) A qualitative exploratory question was also included Q21 : 'Describe your emotions and concerns during the current outbreak'.

A statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 23.0 software (SPSS Inc., Chicago, IL, USA). Categorical variables were expressed as percentages. The Chi-square test was used to compare between perceived stress scales (low, moderate, and high perceived stress). ManneWhitney U and Kruskale Wallis tests were also used. When p-values were less than 0.05, the differences were considered statistically significant.

A total of 367 students responded to the survey. The demographic characteristics of the surveyed population are presented in Table 1 Table 2 displays the responses to the 10 items of the PSS provided by the participants. Through the month preceding the survey, the following trends were observed: 58

.1% of the students (fairly or very) often felt nervous and stressed; 58% were often angered due to things that happened outside of their control; 50.5% often felt that difficulties were piling up so high that they could not overcome them; 43% often found that they could not cope with all the things that they had to do; 42.2% often felt that they were unable to control the important things in their life; 34.9% were often upset because of something that happened unexpectedly. Conversely

, 49.3% of the students often felt confident in their ability to handle personal problems, 30.8% often were able to control irritations in their lives, 26.5% often felt that things were going their way, and 25.6% often felt that they were on top of things. The mean value of the total PSS scores was 22.12 AE 7.33, with an absolute range of 1e38, median of 23, and inter-quartile range of 17e27. The cut off limits for the 25th, 50th Q26 , and 75th percentiles were 17, 23, and 27, respectively. In general, 55% of the students had moderate stress, and 30.2% had high stress ( Table 3 ). As shown in Table 1 , there were significant associations between the level of stress and three sociodemographic variables: gender, age, and educational level. Females had a significantly higher mean score of perceived stress level compared to males (22.75 versus 20.27; p Q27 -value ¼ 0.003). However, more than half of them (52.9%) had moderate levels of stress, whereas 33.9% had high stress levels. University students had a significantly higher mean score of perceived stress compared to intermediate and secondary school students (25.30 versus 22.98 and 21.72, respectively; p-value ¼ 0.049). However, more than half of them had moderate levels of stress (60.9%), whereas 39.1% had high stress levels.

The qualitative exploratory question regarding the emotions and concerns of the participants showed diversity. Students reported feeling depressed, stressed, anxious, fearful, angry, and unmotivated. Difficulties related to studying, problem solving, and time management were also reported. Secondary school students who were aiming for high scores to get accepted in Q28 universities were worried about their grades and their Q29 future. One student reported that she was diagnosed with anxiety and was currently taking an antidepressant for her symptoms Q30 , which helped her feel that she was able to control things, although she believed that she might panic in a given situation.

This study is the first to explore the level of perceived stress during the COVID-19 outbreak in KSA. Students were included from all five regions of the country and various educational levels of both secondary and tertiary education. The mean score of the perceived stress scale in this study was 22.12 AE 7.33, and a high-moderate perceived stress was endorsed by 30.2e55% of the participating students. These scores are comparable to other national and international studies that were conducted in KSA, 16e18 India, 19, 20 Iran, 21 and Malaysia. 22 However, these studies were conducted among students from competitive specialties, such as medicine and dentistry. The result is not surprising as, at the time of conducting the survey, the total number of confirmed cases of COVID-19 in KSA reached 900, with two coronavirus-related-deaths. The curfew measures have been extended in terms of the total amount of hours, and a prohibition was placed on both entering and exiting Riyadh, Makkah, and Almadinah Almunawwarah. 23 Furthermore, three items on the 5-point Likert scale of perceived stress (in Table 2 ) were endorsed by more than half of the sample, which are often (fairly or very) felt nervous, stressed, and angered and unable to overcome piled up difficulties. Similar results were recently found in other studies, which Q31 evaluated the mental health of university students during COVID-19 in China 24 and Spain 25 and reported anxiety, stress, and depression. These psychological responses are more likely to occur and worsen due to the lack of interpersonal communication during the social distancing. 26, 27 In addition, distance learning was also found to be associated with stress, which is due to academic, financial, and social difficulties. 28 Coping with the online mode might become a challenge for students. This includes students' ability to deal with technology, sufficient Q32 home resources facilitating online learning, or stable internet connection. 29 Previous studies regarding mental health during the pandemic have studied general populations in other regions of the world. 30e32 The outbreak of the virus and the implementation of sudden control measures may cause excessive fear and social isolation, while the lack of infectious disease knowledge can foster widespread panic. 30 The novelty of the virus itself and the unpredictability and uncertainty of when the situation will be entirely controlled has put people under excessive stress, especially when social face-to-face interactions are lost. 31 Patients infected by the virus or who are suspected to have contracted the illness experience the fear of its potential fatality. 32 In our study, university students scored significantly higher in terms of levels of stress compared to students from intermediate and secondary schools. This is most Q33 likely because university students are emerging adults who pursue identity exploration, work toward independence, and have different roles to fulfil. 33 Other sources of stress include the frequency of and performance on examinations, broad curriculums, parental pressure, loneliness, and worrying about the future. 34 Finally, female students reported significantly higher levels of stress, which may be due to female participants representing the majority of the sample. However, similar results were reported in previous related surveys. 18, 19, 21, 34 High levels of stress among females have been attributed to various factors, including hormonal changes and expression of emotions and thoughts regarding their social situation. 35, 36 Limitations Although our study represents the first survey of stress levels during the COVID-19 outbreak in KSA, we acknowledge several limitations Q34 . One of them is a convenient sample using an online platform, which limits the generalisability of the results. Another possible limitation is reporting bias, as the study depends on self-reported information that may be affected by participants' interpretation of the items or their tendency to report their emotions in a certain manner. Finally, the cross-sectional design precludes the ability to make causal Q35 conclusions.

This study showed high to moderate levels of stress among students in KSA during the COVID-19 outbreak. This is most likely due to the mandatory curfew and distance learning. Female and university students showed a higher level of stress. Online stress management programs are recommended to improve stress and coping strategies, as well as prevent Q36 further psychological consequences. Further studies are necessary to conduct longitudinal assessments of psychiatric disorders, such as depression and anxiety, to produce evidence-based mental health interventions during crises. Furthermore, as this is the first survey on the psychological impact of COVID-19 on Saudi students, these results could be used as a baseline to investigate the stressors and the extent of their impact. 

The author have no conflict of interest to declare.

Ethical approval was obtained from the Institutional Review Board at Princess Nourah bint Abdulrahman University (PNU) in Riyadh, KSA. Informed consent was obtained from the participants after the aims of the study were explained.

DAA conceptualised and designed the study. DDA, SAA, and DHA drafted the questionnaire. DAA and SAA analysed Q37 and interpreted the data. DAA, SAA, and DHA wrote the manuscript. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript. 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60  61  62  63  64  65   66  67  68  69  70  71  72  73  74  75  76  77  78  79  80  81  82  83  84  85  86  87  88  89  90  91  92  93  94  95  96  97  98  99  100  101  102  103  104  105  106  107  108  109  110  111  112  113  114  115  116  117  118  119  120  121  122  123  124  125  126  127  128  129  130 JTUMED628_proof ■ 1 August 2020 ■ 5/6

Please cite this article as: AlAteeq DA et al., Perceived stress among students in virtual classrooms during the COVID-19 outbreak in KSA, Journal of Taibah University Medical Sciences, https://doi.org/10.1016/j.jtumed.2020.07.004 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41 

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The authors would like to thank Noon Academy and Noura Alfulaij for their kind support in data collection. This research was funded by the Deanship of Scientific Research at Princess Nourah bint Abdulrahman University through the Fast-track Research Funding Program. 
