International Journal of

Environmental Research
and Public Health

Review
Prevalence of Anxiety in Medical Students during the
COVID-19 Pandemic: A Rapid Systematic Review
with Meta-Analysis
Isabel Lasheras 1 , Patricia Gracia-García 2 , Darren M. Lipnicki 3 , Juan Bueno-Notivol 2, *,
Raúl López-Antón 4,5,6 , Concepción de la Cámara 4,5 , Antonio Lobo 5 and
Javier Santabárbara 1,4,5
1 Department of Microbiology, Pediatrics, Radiology and Public Health, Faculty of Medicine, University of
Zaragoza, Building A, 50009 Zaragoza, Spain; [email protected] (I.L.); [email protected] (J.S.)
2 Psychiatry Service, Hospital Universitario Miguel Servet, Paseo Isabel la Católica, 1-3, 50009 Zaragoza,
Spain; [email protected]
3 Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales Medicine,
Randwick 2052, Australia; [email protected]
4 Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Ministry of Science and
Innovation, Avenue Monforte de Lemos, 3-5, Pavilion 11, Floor 0, 28029 Madrid, Spain;
[email protected] (R.L.-A.); [email protected] (C.d.l.C.)
5 Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, Spain, Avenue San Juan Bosco, 13,
50009 Zaragoza, Spain; [email protected]
6 Department of Psychology and Sociology, Universidad de Zaragoza, Pedro Cerbuna, 12,
50009 Zaragoza, Spain
* Correspondence: [email protected]; Tel.: +34-659-743-354




Received: 8 August 2020; Accepted: 7 September 2020; Published: 10 September 2020


Abstract: The novel coronavirus disease (COVID-19) pandemic has brought a great deal of pressure
for medical students, who typically show elevated anxiety rates. Our aim is to investigate the
prevalence of anxiety in medical students during this pandemic. This systematic review and mini
meta-analysis has been conducted following the PRISMA guidelines. Two researchers independently
searched PubMed on 26 August 2020 for cross-sectional studies on medical students during the
COVID-19 outbreak, with no language restrictions applied. We then performed a manual search
to detect other potentially eligible investigations. To the 1361 records retrieved in the initial search,
4 more were added by manual search on medRxiv. Finally, eight studies were finally included
for qualitative and quantitative analysis, which yielded an estimated prevalence of anxiety of 28%
(95% CI: 22–34%), with significant heterogeneity between studies. The prevalence of anxiety in medical
students is similar to that prior to the pandemic but correlates with several specific COVID-related
stressors. While some preventive and risk factors have been previously identified in a non-pandemic
context, knowledge and cognitions on COVID-19 transmission, treatment, prognosis and prevention
negatively correlate with anxiety, emerging as a key preventive factor that may provide a rationale
for why the levels of anxiety have remained stable in medical students during the pandemic while
increasing in their non-medical peers and the general population. Other reasons for the invariability
of anxiety rates in this population are discussed. A major limitation of our review is that Chinese
students comprised 89% the total sample, which could compromise the external validity of our work

Keywords: anxiety; COVID-19; prevalence; medical students; meta-analysis

Int. J. Environ. Res. Public Health 2020, 17, 6603; doi:10.3390/ijerph17186603 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2020, 17, 6603 2 of 12

1. Introduction
The outbreak of the novel coronavirus disease (COVID-19) in Wuhan, China, in December 2019
has rapidly escalated into a global health crisis and was declared a pandemic by the World Health
Organization (WHO) on 11 March 2020 [1]. To date (2 September 2020), there have been 25,602,665
confirmed cases of COVID-19 worldwide and 852,758 deaths [2]. Due to the rising numbers of
disease cases and deaths, and the highly contagious nature of the disease, some countries began
quarantining their population for indefinite periods of time in order to prevent the spread of the
disease [3]. While such restrictive measures can be effective in the containment of the virus, concern has
arisen about their possible psychological impact on the well-being of the general population and
individuals who might be vulnerable to mental health diseases [4], as anxiety and depression have
been demonstrated to stem from similar circumstances in the past [5,6].
Several sources of stressors related to pandemics and their Public Health management have been
described in the past, such as the unpredictable nature of the disease [7,8], the lack of timely and
transparent information disclosure by authorities [3], the loss of personal freedom, sudden changes
and impossibility of future planning and social distancing, together with the worry about one’s own
health and that of one’s relatives and acquaintances [8], and the large financial losses expected [9].
A recent systematic review on the psychological impact of previous confinements related to the
Ebola, H1N1 influenza, Middle East respiratory syndrome (MERS-CoV) and equine influenza disease
outbreaks, found that a long duration of quarantine, fear of infection, inadequate information, stigma,
or financial loss were related to higher levels of anxiety, anger, confusion, and post-traumatic stress [10].
This is underpinned by a recent meta-analysis reporting a prevalence of anxiety of 31.9% among the
general population during the COVID-19 pandemic [11].
For medical students specifically, high anxiety levels were also found during the previous
MERS-CoV and SARS-CoV-1 outbreaks [12,13]. Medical students are recognized as an at-risk group for
developing anxiety disorders [14], with significantly larger rates than the general population, even under
normal circumstances, especially for those residing in the Middle East and Asia [14,15]. Besides being
less likely to seek support when affected by psychological distress [14], their distinctive personality
traits, such as the high proportion of students with maladaptive perfectionism [16], might make them
especially sensitive to the distress and disruption of routine caused by COVID-19 and its associated
Public Health measures [17]. Moreover, unlike other students, they have a deeper understanding of the
disease, which could increase awareness of its severity and impact [18]. Furthermore, they have been
subject to different strategies in regard to disease control. While some medical schools have forbidden
students from any patient interaction, as recommended by the American Association of Medical
Colleges (AAMC), stripping the students of a fundamental part of their curriculum, other students
have been recruited for hospital-based roles to counteract the health system saturation [19]. Either way,
the psychological consequences of such drastic changes in their education should be addressed.
There have been several reports, opinion articles and studies recently published on the
psychological impact of the COVID-19 pandemic on college and medical students specifically. Our goal
is to conduct a systematic review and meta-analysis of studies investigating the prevalence of anxiety
in medical students during the COVID-19 pandemic.

2. Materials and Methods

This meta-analysis follows the PRISMA guidelines for reporting systematic reviews and
meta-analysis [20] (Supplementary Materials Table S1).

2.1. Search Strategy

Two researchers (J.B.-N. and P.G.-G.) searched for all cross-sectional studies reporting
the prevalence of anxiety published until 26 June 2020 using MEDLINE via PubMed.
The Pubmed search was: (covid or covid-19 OR coronavirus OR “corona virus” OR
Int. J. Environ. Res. Public Health 2020, 17, 6603 3 of 12

SARSCoV-2 OR “Coronavirus”[Mesh] OR “severe acute respiratory syndrome coronavirus

2”[Supplementary Concept] OR “COVID-19”[Supplementary Concept] OR “Coronavirus
Infections/epidemiology”[Mesh] OR “Coronavirus Infections/prevention and control”[Mesh] OR
“Coronavirus Infections/psychology”[Mesh] OR “Coronavirus Infections/statistics and numerical
data”[Mesh]) AND (anxiety OR anxiety symptoms OR anxiety disorders OR anxious OR “Trauma
and Stressor Related Disorders”[Mesh] OR “Anxiety”[Mesh] OR “Anxiety Disorders”[Mesh] OR
“Anxiety/epidemiology”[Mesh] OR “Anxiety/statistics and numerical data”[Mesh]). No language
restriction was made. References from selected articles were also inspected to detect additional
potential studies. We then performed a manual search of the “grey literature” (e.g., medRxiv or
Google Scholar) to detect other potentially eligible investigations. Any disagreement was resolved by
consensus with a third and fourth reviewer (J.S. and I.L.). This search was updated on 26 August 2020.

2.2. Selection Criteria

Studies were included if: (1) reporting cross-sectional data on the prevalence of anxiety, or sufficient
information to compute this, conducted during the COVID-19 outbreak; (2) focused on medical students;
(3) included a validated instrument to assess or diagnose anxiety disorders; (4) the full text was available.
We excluded studies focusing on community-based samples or specific samples that were not medical
students (e.g., medical professionals, patients), as well as review articles.
A pre-designed data extraction form was used to extract information on the following: country,
sample size, prevalent rates of anxiety, proportion of females, average age, instruments used to assess
anxiety, response rate, and sampling methods.

2.3. Methodological Quality Assessment

Articles selected for retrieval were assessed by two independent reviewers (J.B.-N. and J.S.) for
methodological validity before they were included in the review using the Joanna Briggs Institute (J.B.I.)
standardized critical appraisal instrument for prevalence studies [21] (Table S2). Quality was evaluated
according to nine criteria, each yielding a score of zero or one. One score was obtained for each criterion
if the study was affirmative in the next questions: (1): Was the sample frame appropriate to address the
target population? (2): Were study participants recruited in an appropriate way? (3): Was the sample
size adequate? (4): Were the study subjects and setting described in detail? (5): Was data analysis
conducted with sufficient coverage of the identified sample? (6): Were valid methods used for the
identification of the condition? (7): Was the condition measured in a standard, reliable way for all
participants? (8): Was there appropriate statistical analysis? (9): Was the response rate adequate, and if
not, was the low response rate managed appropriately?
Any disagreements that arose between the reviewers were resolved through discussions, or by
further discussion with a third reviewer (P.G.-G.).

2.4. Data Extraction and Statistical Analysis

Frequency measures (prevalence) for anxiety and the 95% confidence interval (95% CI) were
obtained from each included study. A generic inverse variance method with a random effect model was
used to estimate pooled prevalence rates [22]. Random effect models are more appropriate than fixed
effect models when the number of studies included in the meta-analysis is low (<10) [23]. The Hedges
Q statistic was reported to check heterogeneity across studies, with statistical significance set at p < 0.10.
Following the recommendations for a small number of studies [24], the I2 statistic was also used to
quantify heterogeneity. I2 values between 25% and 50% are considered as low, between 50% and 75%
as moderate, and 75% or more as high. Sources of heterogeneity can include differences in study
design or in demographic characteristics. We performed meta-regression and subgroup analyses to
explore the sources of heterogeneity expected in meta-analyses of observational studies. We conducted
a sensitivity analysis to determine the influence of each individual study on the overall result by
Int. J. Environ. Res. Public Health 2020, 17, 6603 4 of 12

Int. J. Environ. Res. Public Health 2020, 17, x 4 of 13

omitting studies one by one. Publication bias was determined through visual inspection of a funnel
plot and Egger test (p values < 0.05 indicate publication bias).
J.B.-N., I.L. and J.S. conducted data extraction and the assessment of methodological quality.
J.B.-N., I.L. and J.S. conducted data extraction and the assessment of methodological quality.
Periodic meetings were held to minimize the risk of errors at each step of the review process. In the
Periodic meetings were held to minimize the risk of errors at each step of the review process. In the
case of disagreement between researchers, they were asked to reach consensus.
case of disagreement between researchers, they were asked to reach consensus.
Statistical analyses were conducted by J.S. and run with STATA software (version 10.0; College
Statistical analyses were conducted by J.S. and run with STATA software (version 10.0;
Station, TX, USA).
College Station, TX, USA).
2.5. Data Availability Statement
2.5. Data Availability Statement
Data are available to qualified investigators on request to the corresponding author. Data will
Data are available to qualified investigators on request to the corresponding author. Data will be
be shared at the request of other investigators.
shared at the request of other investigators.
3.
3. Results
Results

3.1. Identification
Identification and
and Selection
Selection of Articles
Figure 1 shows aa flowchart
flowchart of
of the
the literature
literature search
search strategy
strategy and
and study
study selection
selectionprocess.
process.Initially,
Initially,
1361 potential records were identified, from which 1338 were excluded after the screening of the titles
and abstracts for failing to meet the inclusion criteria.
criteria. To
To the
the remaining 23 articles
articles we added 4 more
found by the manual
manual search. After reading these 27 articles in full, we included88in
search. After reading these 27 articles in full, we included inour
ourmeta-analysis.
meta-analysis.

Figure 1.
Figure Flowchart of
1. Flowchart of the
the study
study selection.
selection.

3.2. Characteristics of the Studies Included

Table 1 summarizes the characteristics of the eight included studies. The percentage of women
was not reported in one study [25], and was only specified for the totality of the sample (medical and
non-medical students) in another one [6], but reached almost 70% of medical students in the largest
Int. J. Environ. Res. Public Health 2020, 17, 6603 5 of 12

3.2. Characteristics of the Studies Included

Table 1 summarizes the characteristics of the eight included studies. The percentage of women
was not reported in one study [25], and was only specified for the totality of the sample (medical and
non-medical students) in another one [6], but reached almost 70% of medical students in the largest
study of all [26]. Four studies investigated the prevalence of anxiety in students residing in China,
specifically from Fujian Medical University (Fujian) [25], Changzhi Medical College (Hubei) [26],
Tongji Medical College (Hubei) [18], Capital Medical University (Beijing) and Huazhong University
of Science and Technology (Wuhan) [27], whereas the remaining investigated medical students from
universities located in the United Arab Emirates [6], Iran [28], Brazil [29], and India [30]. Data were
retrieved from February to May, with students being quarantined at the time of the study in all of them.
All studies were carried out using an online survey which comprised demographic information (not
provided in one case) [25] and the evaluation of anxiety levels with the 7-item Generalized Anxiety
Disorder Scale (GAD-7) in five cases [6,18,26,27,29] and the State-Trait Anxiety Inventory (STAI-6) [25],
the Beck Anxiety Inventory (BAI) [28], and the Depression Anxiety Stress Scale (DASS-21) [30],
in one case.

Table 1. Characteristics of included studies in the meta-analysis.

Prevalence
Females Sample Response Sampling Anxiety Quality
Author (Year) Country of Anxiety
(%) Size (n) Rate (%) Method Assessment Score
(%)
Cao et al. Cluster
China 69.65% 7143 100% GAD-7 1 24.9% 9
(2020) [26] sampling
Lin et al. Not Not Convenience
China 2086 STAI-6 2 38.1% 6
(2020) [25] reported reported sampling
Liu et al. Not Convenience
China 41.5% 217 GAD-7 1 22.1% 7
(2020) [18] reported sampling
Nakhostin-Ansari Random
Iran 52.3% 323 64.6% BAI 3 38.1% 8
et al. (2020) [28] sampling
United
Saddik et al. Not Not Convenience
Arab 418 GAD-7 1 22.7% 7
(2020) [6] reported reported sampling
Emirates
Sartorao-Filho et Convenience
Brazil 73.80% 340 97.98% GAD-7 1 46.17% 9
al. (2020) [29] sampling
Vala et al. Not Convenience 4
India 56% 250 DASS-21 17.20% 6
(2020) [30] reported sampling
Xiao et al. Convenience
China 70.1% 933 96.2% GAD-7 1 17.1% 9
(2020) [27] sampling
1 GAD-7: Seven-item General Anxiety Disorder Scale. 2
STAI-6: Six-item State-Trait Anxiety Inventory.
3 BAI: Beck Anxiety Inventory. 4 DASS-21: Twenty one-item Depression Anxiety Stress Scale.

Additionally, some of them investigated variables related to the students’ sources of information,
perceived sufficiency of information and media exposure [6,25], their level of knowledge on COVID-19
statements related to its transmission, treatment, prognosis and prevention [6], their cognitions from
the epidemic and preventive response [6,25,26], some COVID-related stressors such as the influence
of the epidemic on their economy, academic delays and daily life [26], partaking in high-risk ward
clinical rotation, contact with suspected infected patients [6] and having a relative or acquaintance
be infected [26]. For instance, Saddik et al. [6] reported a higher median score for knowledge of
Covid-19 in medical students than in non-medical students (p < 0.0001), as well as a higher perception
of knowledge of prognosis and transmission of the virus (p < 0.0001). Similarly, protective factors such
as availability of social support and living with parents were surveyed in two studies [6,26], and some
investigated additional psychological responses to the epidemic, such as feelings of fear, avoidance and
embarrassment [6,25] and presence of depression as evidenced by the Patient Health Questionnaire-9
(PHQ-9) [18], Beck Depression Inventory (BDI) [28] or DASS-21 [30].
Int. J. Environ. Res. Public Health 2020, 17, x 6 of 13

Xiao et al.
Convenience
(2020) China 70.1% 933 96.2% GAD-7 1 17.1% 9
sampling
[27]
Int. J. Environ.
1 GAD-7: Res. Public Health
Seven-item 2020, 17,
General 6603 Disorder Scale. 2 STAI-6: Six-item State-Trait Anxiety Inventory.6 of 12
Anxiety
3 BAI: Beck Anxiety Inventory. 4 DASS-21: Twenty one-item Depression Anxiety Stress Scale.

3.3.
3.3. Quality
Quality Assessment
Assessment
The
The risk
risk of
of bias
bias scores
scores ranged
ranged from
from 66 to
to 99 out
out of
of aa possible
possible total
total of
of 9,
9, with
with aa mean
mean score
score of
of 7.6
7.6
(Table
(Table S2). The most common limitations were: (a) response rate not reported, or large number of
S2). The most common limitations were: (a) response rate not reported, or large number of
non-responders (five studies), and (b) recruitment of participants not appropriate (two studies),
non-responders (five studies), and (b) recruitment of participants not appropriate (two studies), and and (c)
study subjects
(c) study andand
subjects setting not not
setting described in detail
described (two(two
in detail studies).
studies).
3.4. Meta-Analysis of the Prevalence of Anxiety
3.4. Meta-Analysis of the Prevalence of Anxiety
The estimated overall prevalence of anxiety in medical students during the COVID-19 pandemic
The estimated overall prevalence of anxiety in medical students during the COVID-19 pandemic
was 28% (95% CI: 22–34%), with significant heterogeneity between studies (I22 = 97.5%, p < 0.001)
was 28% (95% CI: 22−34%), with significant heterogeneity between studies (I = 97.5%, p < 0.001)
(Figure 2).
(Figure 2).

Figure 2.
Figure 2. Forest
Forest plot.
plot.

3.5. Meta-Regression and Subgroup Analysis

3.5. Analysis
only relevant
The only relevant finding
finding waswas aa slightly
slightly lower
lower prevalence
prevalence of
of anxiety
anxiety for
for the
the studies
studies using
using the
the
GAD-7 (26% [95% CI: 19–33%]) [25] compared to those using the STAI-6, BAI or DASS-21 (31% [95%
GAD-7
CI: 20–43%])
CI: 20–43%]) [6,16,27],
[6,16,27],and
andforforthe
thestudies
studiescarried
carriedoutout
in China (China:
in China 25% 25%
(China: [95%[95%
CI: 17–34%] vs. other
CI: 17–34%] vs.
countries:
other 30% [95%
countries: CI: 18–44%]),
30% [95% according
CI: 18–44%]), to subgroup
according analysis.
to subgroup Sampling
analysis. Sampling method
method(cluster or
(cluster
random
or randomsampling:
sampling:25% [95%
25% CI:CI:
[95% 24–26%]
24–26%] vs. vs.
convenience
conveniencesampling: 27%27%
sampling: [95% CI: CI:
[95% 17–37%]) waswas
17–37%]) not
a moderator.
not OurOur
a moderator. meta-regression
meta-regression showed
showed that
thatthe
theprevalence
prevalenceofofanxiety
anxietywas
was independent
independent of thethe
methodological quality
methodological (p =
quality (p = 0.725).

3.6. Sensitive Analysis

Excluding each study one-by-one from the analysis did not substantially change the pooled
prevalence of depression, which varied between 25% (95% CI: 20–32%), with Sartorao-Filho et al. [29]
Int. J. Environ. Res. Public Health 2020, 17, 6603 7 of 12

excluded, and 30% (95% CI: 23–37%), with Xiao et al. [27] excluded. This indicates that no single study
had a disproportional impact on the overall prevalence.

3.7. Publication Bias

Visual inspection of the funnel plot (Figure S1) give the impression of perfect symmetry around
the vertical axis, and the results from Egger’s test imply that there was no statistically significant
systematic relationship between the results of each study and its size (p = 0.722).

4. Discussion
Medical students show higher baseline rates of anxiety compared to the general population [10]
and their age-matched peers [31]. There are several proposed mechanisms, including a high proportion
of students with neurotic and perfectionistic personalities [16,31], and a particularly academically and
emotionally demanding training [16,32,33].
Since student distress and untreated anxiety are reported to negatively impact academic
performance, professionalism and empathy towards patients, and contribute to academic dishonesty
and attrition from medical school [16,31], addressing the effect of COVID-19 on this specific population
is of uttermost importance. In addition, the personal costs of anxiety should not be overlooked,
since it is associated with a lower quality of life [34], loss of relationships [35] and depression [36],
among other things.
We estimate a prevalence of anxiety among medical students during the COVID-19 pandemic
of 28%. Sociodemographic correlates varied across studies. For instance, while higher levels of
anxiety were found for female Saudi, Brazilian and Iranian students [6,28,29], this difference was
only significant in one Chinese study [27]. A higher prevalence of anxiety in women would be
consistent with evidence from the prior epidemic of the Middle East Respiratory Syndrome-Corona
Virus (MERS-CoV) [37]. With regard to the students’ location, neither Cao et al. [26], nor Liu et al. [18],
found any differences in living inside or outside Hubei, the epicenter of the pandemic. On the contrary,
Xiao et al. [27] found a significantly higher prevalence of anxiety in students attending university in
Wuhan than those in Beijing, a far less severely affected area by COVID-19. Likewise, higher anxiety
levels were noted for students living in rural areas, perhaps due to poorer economic conditions and
less sanitary resources and preventive strategies [26].
Other stressors identified in the medical student population include worry about the economic
influences, academic delays, and the impacts on their daily life [26]. Curricular factors, such as
unstructured or online learning, might promote distress and burnout among medical students [31,38],
and could be contributing to anxiety. In this sense, two Chinese studies revealed that the impact
of online learning appeared to be higher in students from senior years rather than previous-year
students, most likely due to a more tightly packed curriculum [4,27]. This hypothesis, however, was not
supported by other studies on medical students included in our meta-analysis, since Cao et al. [26]
and Liu et al. [18] found no association between grade and anxiety and Lin et al. [25] found a gradual
decrease in the proportion of moderate-to-severe anxiety by grades.
In a similar fashion, some other risk factors correlating with the presence and severity of anxiety,
such as the unsteadiness or lowness of family income, having COVID-19 symptoms or having a relative
or an acquaintance infected with COVID-19 [18,26,28], are not exclusive to the student population,
as they have been identified in the general population [5,39]. Nevertheless, the impact of the pandemic
on student’s financial ability to continue on course was identified as a major source of anxiety and
depressive symptoms in medical students and should be addressed by the authorities [29].
Interestingly, a prevalence of anxiety of 28% is lower than the prevalence prior to COVID-19 for
medical students globally, which was estimated as 33.8% in a recent meta-analysis [14], and similar to
the baseline rates reported in Chinese students by a systematic review published last year, where the
mean prevalence of anxiety was 27.2% [15]. This finding also contrasts with the tendency of anxiety
rates in the general population, where it could have increased by four-fold [11]. Moreover, further
Int. J. Environ. Res. Public Health 2020, 17, 6603 8 of 12

differences were found by two studies that compared medical students to their non-medical peers
during the confinement: one of them found medical students to be less likely than non-medical students
to suffer from moderate anxiety [40] and the other one found lower anxiety levels in comparison to
dental medicine students [6].
This could be explained by several reasons. First of all, medical students were found to have a
higher perceived sufficiency of information on COVID’s prognosis and transmission, and a broader
knowledge of the disease compared to their counterparts, perhaps due to a significantly higher use of
official sources of information (WHO website, press releases from the Ministry of Health and hospital
announcements) [6], which could contribute in turn to a reduction in their fears and anxiety [6,41].
This has already been shown in medical staff facing previous health crises, where perceived sufficiency
of information about the A/H1N1 influenza prognosis was independently associated with reduced
degree of worry [42]. While the correlation of COVID-19 knowledge and anxiety did not reach
statistical significance in another study conducted on midwifery students [43], it showed contribution
to lowering perceived levels of stress, which do correlate with anxiety [26]. This reinforces how timely
and transparent information, which is critical for healthy psychological self-adaptation regarding fast
onset emergencies [3], might not have been accurately delivered to the general population, who could
have been more exposed to sensational misinforming news reports in unofficial channels, whereas
medicine students could have been prematurely aware of a belated official information disclosure [3,44].
For instance, a study on Wuhan’s university population claimed that many students were aware of the
existence of a respiratory disease before the release of the first government notice on 30 December
2019 [3].
Secondly, medical students show high levels of resilience, which positively correlates with adaptive
coping strategies when facing a problem [45], and has been shown to prevent the development of
anxiety, as well as post-traumatic stress disorder and depression [46].
Thirdly, since many of the reasons for baseline high levels of anxiety in medicine students are
academic-related, it is possible that online learning might have eased the burden of over-loaded
academic programs. In fact, one study revealed that 87% of students perceived less income knowledge
from online classes and over half of the students were totally satisfied with it [29], and, in another
study, anxiety levels significantly decreased and knowledge score stopped being a predictor for
medical students’ anxiety after switching to the online learning, in contrast with their non-medical
peers [6]. Another reason for this could be that minimization of medical students’ presence in hospitals
might have helped control their anxiety symptoms due to being distant from the perceived risk of
COVID-19 [6]. This hypothesis is supported by Nakhostin-Ansari et al. [28] and underpinned by
the findings of the highest levels of anxiety in medical students who continued their high-risk ward
rotations during the pandemic [6]. This is in line with some studies conducted on frontline health care
workers, where those engaged in direct diagnosis, treatment, and care of patients with COVID-19 show
a higher risk of depression, anxiety, insomnia and distress [47,48].
Moreover, it is also possible that a higher degree of knowledge of the disease could have a positive
impact on the students’ preventive behavioral response to the epidemic, boosting a feeling of safeness,
since, in one study, medical students showed a greater compliance with avoidance of contact with
symptomatic people, as well as a decrease in social visits, attendance of crowded places and use of
public facilities [6]. This finding, however, did not reach statistical significance, perhaps mitigated by
the positive association of anxiety and compliance with hygienic practices.
Finally, home confinement can bring opportunities for family cohesion and increase the availability
of support for medical students who might otherwise struggle to seek it. In fact, living with parents
and social support were found to be protective factors for anxiety, along with living in urban areas and
family income stability [6,17,26]. Co-residence with parents is common in Chinese society, driven not
only by highly resilient traditional values but also by more modern models and needs [49]. We believe
it would be beneficial to further study the effect of the pandemic on family cohesion and its relationship
with anxiety levels, for which a newly-developed tool could be used [50].
Int. J. Environ. Res. Public Health 2020, 17, 6603 9 of 12

Nevertheless, it should not be overlooked that lockdown may prevent students from engaging
in other beneficial activities such as exercise [51,52], which, together with peer support, has been
shown to be the most effective non-pharmacological therapy in the college and university student
population [53], and was found to alleviate general negative emotions in college students specifically
during the pandemic [54]. Similarly, strict quarantine regulations and movement control may
also limit access to counselling services, leading to a worsening of previously established anxiety
disorders [17,53,54]. It should also be noted that, although their effect might be strengthened under the
current circumstances, some of these stressors and protective and risk factors have been previously
identified in medical students in a non-pandemic context [14–16,31].
Lastly, our study has several limitations. Firstly, it only includes eight studies, one of which had a
much larger sample size than the others. However, some research has shown that meta-analysis of few
studies could still provide valid information [55]. Secondly, even though only half of the studies were
conducted in China, their larger sample sizes resulted in 89% of students being Chinese, which could
restrict the generalization of the results. Nevertheless, while significant baseline differences in anxiety
have been noted regarding medical students’ continent of residence [14], our study revealed a small
difference between the included Chinese and non-Chinese studies, both of which reported lower mean
anxiety levels in medical students compared to baseline reference review studies [14,15]. It is worth
noting that the tools used for the evaluation of anxiety in all studies have been previously validated for
the populations under study. The Chinese version of the State-Trait Anxiety Inventory used in the study
by Lin et al. has been duly validated [55] and the Seven-item General Anxiety Disorder Scale used in
the other three studies has also been validated for Chinese [56] and Arabic-speaking populations [57].
However, the assessment of anxiety by self-reported scales rather than clinical interviews might bias
prevalence rates, because respondents may not respond truthfully but in a socially acceptable way [58].

5. Conclusions
In conclusion, the overall level of anxiety in medicine students does not appear to be increased
during the COVID-19 outbreak. We hypothesize that this could be related to a broader or earlier
knowledge on the virus, a high level of resilience and healthy coping systems, a reduction in the
academic load and an increased availability of support within the family.
Nevertheless, we believe an invariable numeric report of the already-high levels of anxiety in
this population should not hinder implementation of specific anxiety-reducing strategies, since the
several COVID-related stressors identified in this population could significantly affect their typical
behavioral cycle of anxiety, as occurred to a sample of American college students (unknown major) in
an ecological study, whose increased levels of anxiety and depression did not return to baseline over
the break, as typically observed [51].
Furthermore, the protective effect of knowledge on COVID-19 in the development of anxiety,
previously evidenced in healthcare workers highlights the importance of transparent information
disclosure during health emergencies.

Supplementary Materials: The following are available online at http://www.mdpi.com/1660-4601/17/18/6603/s1,

Table S1: PRISMA Checklist, Table S2: Risk of bias assessment, Figure S1: Funnel plot, Reference [8] is cited in the
supplementary materials.
Author Contributions: Conceptualization, I.L., J.B.-N. and J.S.; methodology, I.L., J.B.-N. and J.S.; software,
R.L.-A.; validation, J.S., R.L.-A. and C.d.l.C.; formal analysis, J.S.; investigation, J.B.-N. and P.G.-G.; resources,
C.d.l.C. and J.S.; data curation, I.L. and J.B.-N.; writing—original draft preparation, I.L., P.G.-G., J.B.-N. and
J.S.; writing—review and editing, I.L., J.B.-N., J.S. and D.M.L.; visualization, I.L.; supervision, A.L. and D.M.L.;
project administration, J.S.; funding acquisition, C.d.l.C., A.L. and J.S. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.
Int. J. Environ. Res. Public Health 2020, 17, 6603 10 of 12

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