# Prevalence of pharmacological and non-pharmacological coping mechanisms for anxiety management during the COVID-19 pandemic: exploring the transition to online learning among medical students – BMC Psychiatry – BMC Psychiatry | Team Cansler

### Study design and participants

We conducted a cross-sectional study in Saudi Arabia during the pandemic from September to November 2020 using a standardized questionnaire to assess the impact of COVID-19 and the transition to synchronous online learning on student mental health. During this time, the kingdom took strict measures to limit the spread of COVID-19, including a stay-at-home curfew. travel bans; Closure of schools, universities, shopping malls and mosques. As of November 30, 2020, there were ~357,623 confirmed cases and 5907 deaths [24]. A minimum sample size of 380 was calculated using the following formula:

$$N=\frac{Z_{a/2}^2\times P\times \left(1-P\right)}{d^2}$$

An acceptable margin of error of 0.05 for the proportion was estimated at a 95% confidence level. Based on participants’ responses, it increased to 7116. Non-medical students or medical students living outside of Saudi Arabia were excluded.

We used an online platform hosted by SurveyMonkey Inc. (San Mateo, California, USA; www.surveymonkey.com) to mail the questionnaire along with a cover letter attached to a consent form. Participation was voluntary, with the option to opt out at any time. All replies were anonymous with no tracking of email addresses or ID information. The Institutional Review Board (IRB) of the Imam Mohammed Ibn Saud Islamic University (IMSIU) in Riyadh, Saudi Arabia has reviewed and approved this project (HAPO-01-R-011, Project No. 79-2020).

### study measures

The questionnaire consisted of 19 items divided into six sections. In the first section, we included questions about demographic information such as gender, year of medical school, university, and region.

In the second section, we assessed anxiety levels using the Generalized Anxiety Disorder Scale (GAD-7), accounting for school suspension, online learning, and lockdown. The GAD-7 is a seven-item anxiety scale based on seven core symptoms, ranging from 0 to 3. Total scores on the scale range from 0 to 21, with cut-off scores of 5, 10, and 15 representing mild, moderate, and severe anxiety symptoms, respectively. Symptoms were reported by respondents using a 4-point Likert rating scale from 0 (not at all) to 3 (almost every day). The GAD-7 scale is an efficient and sensitive instrument for screening for anxiety and has shown excellent internal consistency (Cronbach’s a= 0.92) [25, 26].

In the third section, we assessed perceived psychological stress using a single-item measure of stress [27] to determine the extent to which respondents experienced stress after transitioning to online synchronous learning and their normal levels of stress during traditional classroom learning. Responses were recorded using a 5-point Likert scale from 0 (not at all) to 4 (very much).

In the fourth section, we examined factors contributing to stress in the transition to online learning and testing. After searching the literature and conducting informal interviews with several medical students from different grade levels, the research team provided eight of the most frequently reported items for respondents to choose from.

In the fifth section, we reported the history and pattern of anti-anxiety drug use and associated characteristics during the traditional learning phase and the switch to online learning. Some questions about anti-anxiety drug use and pattern were adapted from a previously validated questionnaire after permission was obtained from the appropriate author [21]. Four main anti-anxiety drugs were studied: propranolol (Inderal®), benzodiazepine (Xanax®, Valium®), pregabalin (Lyrica®), and antidepressants (SSRI, TCA, and MOA).

In the last section we used the inventory of the short coping orientation on experienced problems (letter COPE). [28] to determine the respondent’s coping strategies. The short COPE responses were rated from 1 to 4, ranging from “I didn’t do that at all” to “I did that a lot”. The 24-item scores were pairwise averaged to obtain 14 coping strategy scores. Linear regression modules for each pair of coping strategies were fitted to estimate differences in mean coping strategies by gender, medication use, and medical grade level with 95% confidence intervals (CIs).

To validate the clarity of the questionnaire, we tested the final version of the questionnaire on 20 randomly selected medical students. These students were excluded from the final analysis. Face and content validity were determined by three experts specializing in pharmacology, psychiatry and medical education. We then further modified and updated the questionnaire for clarity and comprehensibility.

### Distribution of the survey

The survey was disseminated nationwide using a multi-faceted approach. A list of all 38 medical colleges (government and private) in all regions of Saudi Arabia was compiled [the list is reported separately see Supplementary Table 1, Additional file 1]. According to the MOH in Saudi Arabia [29]the total number of enrolled medical students at 38 medical schools for the 2019-2020 academic year is 32,696.

To ensure successful distribution, a recruitment form was sent to data collectors (medical students) in all regions of Saudi Arabia via each university’s email addresses. A total of 150 respondents out of 1250 were carefully selected to participate in our study as data collectors. To facilitate normalization across all variables, we matched four students from each university with equal gender and grade level representation. A well-structured handbook with clear descriptions and instructions for the study was provided to all data collectors. The data collectors then distributed the questionnaire to their colleagues via email, social media platforms or on-site distribution. We actively monitored data collectors to ensure a representative sample from each region.

### Statistical analysis

We analyzed the data using IBM® Statistical Package for the Social Sciences (SPSS) version 26.0. We used descriptive statistics (eg, frequencies, percentages, means, and standard deviations) to describe, summarize, and prepare the data analysis. We also used the chi-square test and one-way ANOVA to compare the groups and test for differences between groups. We then performed univariate linear regression to determine whether gender, medication use, and year of study were significant predictors of coping strategies. The assumptions of the One Way ANOVA model were evaluated to validate the method prior to performing the analysis. Normality was assessed using the Shapiro-Wilk test; Homoscedasticity was assessed using Levene’s test. We have a pvalue < 0.05 and a 95% confidence interval to indicate statistical significance and estimates in this study.