A Study To Assess The Perceived Stress And Coping Strategies Among B.Sc. Nursing Students Of Selected Colleges In Pune During COVID-19 Pandemic Lockdown

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International Journal of Science and Healthcare Research
Vol.5; Issue: 2; April-June 2020
Website: ijshr.com
Original Research Article ISSN: 2455-7587
International Journal of Science and Healthcare Research (www.ijshr.com) 280
Vol.5; Issue: 2; April-June 2020
A Study to Assess the Perceived Stress and Coping
Strategies among B.Sc. Nursing Students of Selected
Colleges in Pune during COVID-19 Pandemic
Lockdown
Deepika Sheroun1
, Dapple D Wankhar2
, Amita Devrani3
, Lissamma PV4
, S Gita5
,
Keka Chatterjee6
1
MSc Nursing Student (Psychiatric Nursing), Department of Psychiatric Nursing, College of Nursing, AFMC -
Pune -40
2
Asst Professor (Psychiatry Nursing), Department of Psychiatric Nursing, College of Nursing, AFMC, Pune -40.
3
Principal and HoD Department of Child Health Nursing, College of Nursing, AFMC Pune -40
4
Professor and Vice Principal, College of Nursing , AFMC Pune-40
5
Professor and HoD, Department of Med &Surg Nursing , College of Nursing, AFMC , Pune-40 .
6
Asst Professor , Department of Obs & Gynae Nursing, College of Nursing, AFMC , Pune -40.
Corresponding Author: Deepika Sheroun
ABSTRACT
Introduction: The global pandemic has
proven to be challenging for students in more
ways than one. Ever since in-person classes
moved online and “Stay Home Stay Safe”
executive order was implemented; many
students have faced a distressing change in their
employment status. The present study aimed to
assess perceived stress and coping strategies
amidst the COVID 19 lockdown, among the
BSc Nursing students studying in nursing
colleges located in Pune
Objectives: The objectives of the study are to
assess the perceived stress and coping strategies
of the BSc Nursing students of all batches in
regard to COVID 19 lockdown, and to
determine the association of stress and coping
with selected demographic variables.
Materials and Methods: This cross-sectional
online study was undertaken from 15th
to 20th
of
May 2020. Participants were BSc Nursing
Students (1st -4th year), whose perceived stress
and coping strategies related to COVID 19,
were assessed using an online questionnaire.
The tool has 3 sections consisting of
demographic data as section A, Perceived Stress
Scale as Section B, and Coping Strategies Scale
as section C. Score was categorised into three
parts as good, moderate and low
Results: A total of 427 nursing students
completed the questionnaire. Male students had
more perceived stress score (22.73) than female
students (21.86). Majority of participants were
between 21-25 years. The maximum mean
perceived stress score (22.56) was observed in
4th
year students, and least mean perceived
stress score (20.20) was found in 2nd
year
students. On the whole the maximum mean
coping score (78.45) was found among 1st
years
and least coping score (71.23) was found among
4th
year BSc Nursing students
Conclusion: The present study indicates
moderate level of perceived stress with mean
perceived stress score of the students Nurses
being 21.88 (+4.30) and the mean coping
strategies score was 74.38 (+12.30). The IV
Year Nursing students have the highest stress
score with a mean of 22.56 ± 4.207. Hence there
is a need to take measures by the authorities to
reduce stress among the students.
Keywords: COVID 19, Pandemic, Perceived
Stress, Coping Strategies, Nursing Students,
Psychological support
INTRODUCTION
‘History has shown us that courage can
be contagious and hope can take on a life
of its own’
-Michelle Obama
Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among B.Sc. nursing
students of selected colleges in Pune during COVID-19 pandemic lockdown
International Journal of Science and Healthcare Research (www.ijshr.com) 281
Vol.5; Issue: 2; April-June 2020
The world has seen outbreaks of
epidemics and pandemic since prehistoric
times - 5000 BC China , 430 BC Plague of
Athens , AD 165-180 Antonine Plague , The
Black Death 1346-1353 Asia to Europe ,
American Plague 16th
century , to the
present age like Great Plague of London
1665-1666 , Great Plague of Marseille
1720-1723 , Philadelphia yellow fever
epidemic 1793 , Spanish Flu 1918-1920 ,
Asian Flu: 1957-1958 , SARS pandemic
2003 , H1N1 Swine Flu pandemic: 2009-
2010 , West African Ebola epidemic: 2014-
2016 , Zika Virus epidemic: 2015-present
day. [1]
Covid Pandemic, which is currently
affecting the world with its origin in Wuhan,
China started in Dec 2019. Affecting nearly
all the countries in the world it is a historic
health emergency condition the world has
ever seen which is even worse than world
war II.
The rate of contagion and patterns of
transmission is threatening the whole
mankind.
Pandemic is the outbreak of a disease that
occurs over a wide geographic area and
affects an exceptionally high proportion of
the population: a pandemic outbreak of a
disease. [2]
The occurrence of Pandemic had
increased over the last years with global
warming, urbanization, globalization, and
exploitation of natural resources. With the
previous epidemic and pandemic, the
International Health Regulation and WHsO
prepared to meet specific standards for
detecting, reporting on, and responding to
outbreaks. [3]
Despite these improvements,
significant gaps and challenges exist in
global pandemic preparedness. Pandemics
not only impact the mortality morbidity but
also stagger the economic growth, delays
development. There is social disruption,
political tension and individual behavioural
changes, such as fear-induced aversion to
workplaces and other public gathering
places. [4]
Pandemic affects the mental
health of individual as a total result.
Pandemics like COVID 19, affects
the mental health due to numerous reasons –
Uncertainty, poor prognosis, economic loss,
insecurity, confusion, emotional isolation,
stigma, school/work closure, inadequate
resources for medical response, and
deficient distribution of necessities. As a
result people experience a lot of emotional
disturbances such as stress, insomnia,
frustration, irritability which could lead to
psychiatric disorders like depression,
anxiety, behavioural changes (substance
abuse), also post-traumatic stress disorder in
later stages. [5]
Some groups may be more
vulnerable than others to the psychosocial
effects of pandemics. In particular, people
who contract the disease, those at
heightened risk for it (including the elderly,
people with compromised immune function,
and those living or receiving care in
congregate settings), and people with pre-
existing medical, psychiatric, or substance
use problems are at increased risk for
adverse psychosocial outcomes. [6]
The psychological issue can worsen
with social distancing and the lockdown
measures taken by administrations as
observed in many countries worldwide.
Limacaoco et al (Apr 2020) In a
descriptive study titled Anxiety, worry and
perceived stress in the world due to the
COVID-19 pandemic, March 2020 which
was conducted in 41 countries, revealed that
significant higher scores of perceived stress
were observed among women, youth,
students, and among those who expressed
concern and those who perceived increased
susceptibility to the COVID-19. [7]
Lee J in an article published in
Lancet (Apr 2020) explains the effects of
COVID 19 pandemic on students. In a
survey, which included 2111 participants up
to age 25 years with a mental illness history
in the UK, 83% said the pandemic had made
their conditions worse, 26% said they were
unable to access mental health support; peer
support groups and face-to-face services
have been cancelled, and support by phone
or online can be challenging for some young
people. [8]
According to India Today (07 Apr
20) there are three major education
Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among B.Sc. nursing
students of selected colleges in Pune during COVID-19 pandemic lockdown
International Journal of Science and Healthcare Research (www.ijshr.com) 282
Vol.5; Issue: 2; April-June 2020
problems that students and educators
currently face due to the Covid-19
pandemic: 1. Students caught in the cross-
wire. These are those students who are
caught in the limbo on account of education
outcomes being withheld due to the Covid-
19 pandemic. Some of them do not have a
result because exams either did not happen
or were left in the middle. 2 .Students one
year away from school or college-leaving
exams. 3. Education disruption. In response
to the Covid-19 scare, many schools and
colleges have moved online and parents
seem to have assumed the role of teachers.
Again, while there are a ton of fantastic
resources which are available, there are not
too many resources which mimic the school
that is, provide for multidisciplinary
learning, encourage connections across
different domains and inspire ideas which
help a child develop 21st century skills and
prepare themselves for the jobs of the
future. [9]
A survey done was by Dartlet et al
2020 (US) to assess the effect of COVID 19
on college students. 4 in 5 students see their
institutes as trustworthy sources of COVID-
19 information. 4 in 5 students report having
to make large or drastic life changes to
accommodate the current COVID-19
situation. Despite being digital natives, most
students are not fully comfortable with an
exclusive online learning medium. [10]
Thus
it is obvious that the covid 19 pandemic has
a negative impact on the student’s life.
With the imposing stress of COVID
19 on the students, the present study is
focused on the perceived stress by the BSc
nursing students . Previous studies from UK
and India have revealed that nursing
students face comparatively higher level of
stress as compared to their counterparts in
other colleges. [11-12]
Senturk et al (2018) in Turkey
determined in a descriptive study done on
the nursing students that the level of stress
faced by them was above moderate level. [13]
Therefore, dealing with the hectic
student nursing life the drastic lifestyle
changes imposed due to COVID 19
pandemic can be very challenging. As there
is no current study done in India among
nursing student, the present study attempts
to explore the perceived stress and the
coping strategies utilized by the BSc nursing
students in the COVID 19 pandemic
lockdown.
Title of the study: A study to assess the
perceived stress and coping strategies
among BSc Nursing students of selected
colleges in Pune during covid 19 pandemic
lockdown.
Objectives:
1. To assess the perceived stress of the BSc
Nursing students of all batches in regard
to covid 19 lockdown.
2. To assess the coping strategies adopted
by the BSc Nursing students of all
batches in regard to covid 19 lockdown.
3. To find the association of the perceived
stress level of the BSc Nursing students
with selected socio demographic
variable.
4. To find the association of Coping
strategies adopted by the BSc Nursing
students with selected socio
demographic variable.
Inclusion Criteria:
1. All BSc Nursing students can participate
in the survey
2. Age should be 17-25 yrs
Exclusion Criteria:
1. Participants residing in other cities than
Pune city were not included in the study.
Operational Definition:
1. BSc Nursing Students: All students
undergoing I , II, III , IV Basic BSc Nursing
course in various Nursing colleges in Pune.
2.Lockdown: Restrictions imposed on the
general public to remain indoors and
maintain social distancing with each other in
the outbreak of pandemic.
3. Perceived Stress: Perceived stress is the
feelings or thoughts which the BSC Nursing
students have about how much stress they
are since being under lockdown in the past
one month.
Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among B.Sc. nursing
students of selected colleges in Pune during COVID-19 pandemic lockdown
International Journal of Science and Healthcare Research (www.ijshr.com) 283
Vol.5; Issue: 2; April-June 2020
4. Coping strategies: Coping strategies
refer to the specific efforts, both behavioral
and psychological, that the BSc Nursing
students are employing to master, tolerate,
reduce, or minimize stressful events during
lockdown.
MATERIALS AND METHODS
Design : Cross sectional Descriptive study
Population : College Students
Target population: BSc Nursing students
Accessible population : BSc Nursing
Students of various colleges in Pune
Sampling Method : Purposive sampling
Data collection tool : Online Questionnaire
consisting of 3 sections
i) Sociodemographic data
ii) Modified Perceived Stress Scale
iii) Modified Brief Coping Strategies Scale
i) Sociodemographic Data :
It conists of 10 questions – Gender , Age ,
Year of study , Basic qualification ,
Religion , Residing with family or in hostel ,
Family status , Parents qualification,
Comorbidity in the family and Source of
information about COVID 19 .
ii) Perceived Stress Scale
Perceived Stress Scale was developed by
Sheldon Cohen in the year 1983. [14]
The Perceived Stress Scale (PSS) is the
most widely used psychological instrument
for measuring the perception of stress. The
scale also includes a number of direct
queries about current levels of experienced
stress. The items are easy to understand, and
the response alternatives are simple to
grasp. Moreover, the questions are of a
general nature and hence are relatively free
of content specific to any subpopulation
group. The questions in the PSS ask about
feelings and thoughts during the last month.
In each case, respondents are asked how
often they felt a certain way.
Stress among nursing students was
measured using a previously validated
(Cronbach's α coefficient of internal
consistency 0.85) perceived stress scale
(PSS). The scale yielded a single score, with
high scores indicating higher levels of stress
and lower levels indicating lower levels of
stress. [13]
iii) Brief Cope Strategy Scale :
The Brief-COPE is a 28 item self-
report questionnaire designed to measure
effective and ineffective ways to cope with
a stressful life event. [15]
“Coping” is defined
broadly as an effort used to minimize
distress associated with negative life
experiences. The scale can determine
someone’s primary coping styles such as
Emotion Focused Coping, Problem Focused
Coping, Adaptive Coping and Maladaptive
Coping.
Validity: The Brief-Cope was developed as
a short version of the original 60-item
COPE scale (Carver et al., 1989), which was
theoretically derived based on various
models of coping. The Breif-Cope was
initially validated on a 168 participant
community sample whom had been
impacted by a hurricane (Carver, 1997), and
shown to have adequate factor structure.
Data Measurement : Data measurement
was done by self administered online survey
Method of data collection :
1. Permission was taken from the
psychiatric department to conduct the
study and ethical clearance was
obtained.
2. Participants who were meeting the
inclusion criteria were selected by
convenient sampling.
3. Consent from the participants were
obtained and the purpose of the study
was explained to them through online
survey questionnaire.
4. The self administered questionnaire
consisted of socio demographic data,
Perceived Stress Scale and Brief Coping
Strategies Scale.
5. An email was provided to the
participants to give their comments or to
write to the authors.
6. Participants who were unwilling to
complete the questionnaire due to
personal reasons were free to withdraw
from the study .
Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among B.Sc. nursing
students of selected colleges in Pune during COVID-19 pandemic lockdown
International Journal of Science and Healthcare Research (www.ijshr.com) 284
Vol.5; Issue: 2; April-June 2020
7. The questionnaire were taken from the
participants and analysis was done
further .
8. Confidentiality of the collected data was
maintained and used only for the
research purpose .
9. Data collection was done from 427
participants on in the second week of
May.
Statistical Analysis:
The collected data were organized as
descriptive, and they included the student’s
age, gender, year of study etc, the data were
analysed and tabulated as percentage
distribution (Table 01). The mean score and
SD were tabulated for each of the measures
under research, year in college, gender, age,
religion, basic qualification, family type,
parents’s occupation, comorbidity in the
family and place of residing presently.
Inferential statistical analysis was done for
the perceived stress and coping strategies.
The mean score and SD were tabulated. The
data were analysed using the Statistical
Package for the Social Sciences statistical
software (SPSS -21) .
Association between socio demographic
data was analysed using ANOVA and Mann
Whitney test
RESULTS
A total of 427 responders took the
survey from different Nursing Colleges. The
study was carried out through online survey
after the questionnaires were prepared on
Google form and passed on to the
participants through email and WhatsApp
messages. The main findings of the study
indicate that the mean perceived stress score
among the participants was 21.88 (+4.30)
and the mean coping strategies score was
74.38 (+12.30).
Demographic Characteristics: The
demographic characteristics of the
participants are presented in Table 01.
Most of participants were of age group 21-
25 years (60.2). Out of total 427
participants, 11 were males and rest
females. The maximum number of
participants were in their final year of study
(31.9%).
Hinduism was the most followed religion
(81.0%). Almost all of the participants were
residing in hostel (92.3%) belonging to
nuclear family (86.2%) and with basic
qualification of higher secondary school
(82.9%).
The participants reporting of comorbidity in
the family were only 20.2% and 61.4% of
the participants parents were government
employed. Maximum of the participants
received information of COVID 19 through
the internet.
Perceived Stress Score (PSS) in nursing
Students:
 The high PSS score was seen in 13.35 %
of the participants while 82.67% of the
participants experienced moderate
perceived stress. (Fig 1)
 Among the years of study, fourth year
students had the highest scores for PSS,
followed by third -year students.
Second-year students had the lowest
score.
None of the socio demographic variables
showed association with the PSS score.
Coping Strategies Adopted by the
students:
 As depicted in Table 2, maximum of the
participants were found to be having
moderate coping strategies score 76.58
%, while as only 18.5% of the
participants had high coping strategy
scores and 4.9% of the participants had
low coping strategies.
 On observing the type of coping strategy
style as seen in Table 3 – Maladaptive
coping scores were highest with mean –
31.5 (+5.19) and adaptive coping being
the least 9.44 (+2.64).
 Association of age with coping
strategies was seen, with age group of
17-20 years showing higher scores of
coping strategy as against age group of
20-25 yrs.
 Significant association was found out
with the year of study and coping
Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among B.Sc. nursing
students of selected colleges in Pune during COVID-19 pandemic lockdown
International Journal of Science and Healthcare Research (www.ijshr.com) 285
Vol.5; Issue: 2; April-June 2020
strategies score with F value of 7.93 at
p<0.0001. Higher coping strategies
score was seen in I year followed by III
year and least by IV year participants.
 Association of coping strategies was
also seen with the place of residence, the
participants staying with relatives
having highest score than staying alone
or with family.
Table No 1 Socio economic data
Table 2: Coping strategies adopted by BSc Nursing students in
regard to COVID 19 lockdown
Coping score No of students Percentage
28 – 56 (Low) 21 4.92
57 – 84 (Moderate) 327 76.58
85 – 112 (High) 79 18.5
Total 427 100
Table 3: Coping strategies adopted by BSc Nursing students in
regard to COVID 19 lockdown
Minimum Maximum Mean SD
PFC 6 24 16.57 4.14
EFC 6 24 16.87 4.16
AC 4 16 9.44 2.64
MAC 13 48 31.5 5.19
Figure 1: Perceived stress score of BSc Nursing students in
regard to COVID 19 lockdown
DISCUSSION
Public health emergencies can have
psychological effects on the students like
Criteria Parameters No of cases Percentage (n=427)
Age (Yrs) 17 – 20 167 39.1
21 – 25 257 60.2
26 & above 3 0.7
Gender Male 11 2.6
Female 416 97.4
Year of education I year BB Sc Nsg. 112 26.2
II year BB Sc Nsg. 101 23.7
III year BB Sc Nsg. 78 18.3
IV year BB Sc Nsg. 136 31.9
Religion Hindu 346 81.0
Muslim 12 2.8
Christian 56 13.1
Others 13 3.0
Residing presently Hostel 394 92.3
With family 27 6.3
With relatives 3 0.7
Others 3 0.7
Basic qualification Higher secondary 354 82.9
Graduation 67 15.7
Post graduation 6 1.4
Type of family Joint 59 13.8
Nuclear 368 86.2
Parent occupation Govt. employee 262 61.4
Pvt. Employee 82 19.2
Self employee 63 14.8
Unemployed 20 4.7
Comorbidity Present 86 20.1
Absent 341 79.9
Source of information for COVID 19 Internet 285 66.7
Television 122 28.6
Peers 7 1.6
Others 13 3.0
0
10
20
30
40
50
60
70
80
90
100
%
of
cases
0 – 13 (Low) 14 – 26 (Moderate) 27 – 40 (High)
Stress score
Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among bsc nursing students
of selected colleges in Pune during covid-19 pandemic lockdown
International Journal of Science and Healthcare Research (www.ijshr.com) 286
Vol.5; Issue: 2; April-June 2020
stress, anxiety, worry etc With COVID19
having psychological impact on college
students like anxiety and distress; [14]
nursing students do not remain untouched
with this gigantic problem. The aim of the
study was to assess the perceived stress and
coping strategies adopted by the BSc
Nursing students during COVID 19
pandemic.
Perceived stress is a measure of the
degree to which situations in one’s life are
appraised as stressful.This survey revealed
that as much as 82.67 % of the students had
moderate level of perceived stress score and
13.35% had high perceived stress scores
because of COVID 19 outbreak and
lockdown. Lockdown and social distancing
were undertaken throughout the country in
order to prevent the spread of infection and
due to the devastating effect on health due
to increasing mortality and morbidity as
seen in many other countries. [16]
The state
of lockdown which was followed in many
parts of the world has leads to changes in
everyday routine life. With the spread of
COVID19 anxiety, worry and stress has
increased among the masses, including in
India. [17]
The shortage of sanitizers, medical
supply, the overwhelming and sensational
news headlines, and erroneous news reports
have also added to anxiety and fear. [18]
Social distancing amidst the crisis
has contributed greatly to the perceived
stress as reduction in interpersonal
communication leads to increase in
psychological distress. [19]
Maximum of the
students (92.3%) had been residing in
hostels away from home (Table 01) which
could be contributing factor to stress in
students. This stress adds on to the already
stress perceived by nursing students who
experience stress related to assignments and
clinical work. [20]
Analysis of variance reveals that
there is no association between perceived
stress and any of the socio demographic
variables. This is in contrast with study by
Limacao 2020, where age (less than 30
yrs), and sex (females) was associated with
higher perceived stress. However perceived
stress is higher in students than employed or
unemployed individuals co-relating to the
findings of the present study. [7]
The second aspect explored in the
study is the coping strategies adopted by the
students. "Coping is the process of
managing demands that are appraised as
taxing or exceeding the resources of the
person." (Shelley E. Taylor, 2003). [21]
Thus,
coping is not a one-time action that
someone takes; rather, it is a set of
responses, occurring over time, by which
the environment and the person influence
each other’s. [22]
Coping helps individual to adapt to
new and challenging situations and is
important for stabilization. In the times of
lockdown and COVID 19 pandemic it
important to adapt ourselves to the new and
modified routine. In the present study Brief
Cope was used to assess the Coping
Strategies of the students using ‘Brief Cope
– By Carver ‘.
The study revealed that 76.58 % of
the participants had moderate Coping
Strategies, while as 18.5 had high Coping
Strategies and only 4.92 % had low Coping
Strategies. Maximum of the participants
utilized maladaptive coping as compared to
the other types of emotion focused ,
problem focused and adaptive coping .
Analysis of variance revealed that
the socio demographic variable like age
were significantly associated with Coping
strategies utilized by the participants. Age
group of 17-20 had maximum coping
strategies. Religion, gender, basic
qualification, type of family of the
participants, co morbidity in family and
sources of information regarding COVID
19, was not associated with the coping
strategies. The year of study was associated
significantly with coping strategies, with I
year adopting maximum coping strategies,
followed by III year and least by IV year.
Maximum coping was showed by those
participants who were residing with
relatives than those staying in hostel or
home. Those participants whose parents
Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among bsc nursing students
of selected colleges in Pune during covid-19 pandemic lockdown
International Journal of Science and Healthcare Research (www.ijshr.com) 287
Vol.5; Issue: 2; April-June 2020
were private employees showed maximum
coping.
Coping strategies in the pandemic
and lockdown have been utilized by the
masses indifferent ways, along with the
mentioned coping styles; the behavioural
coping includes – washing or disinfecting
their hands more often than usual , avoiding
public places/events , avoiding public
transport (subway, tram, bus, train),
avoiding contact with risk groups (old
people, people with previous illnesses) etc
are being used by the masses today. [23]
In the difficult times like the COVID
19 pandemic, living in lockdown is requires
a lot of lifestyle modification leading to
psychological distress and stress. The
present study focuses on the perceived stress
by the Nursing Students and the Coping
Strategies adopted by them. In the present
times the coping strategies adopted by the
students would help them not only in the
present difficult situation but have
outlasting effects in the future too.
CONCLUSION
The present study highlights the
perceived stress by nursing students who
already lead a hectic routine and lifestyle.
The mean perceived stress score among the
participants was 21.88 (+4.30), the mean
coping strategies score was 74.38 (+12.30)
with maladaptive coping strategy being the
highest in the participants. Stress was not
affected by any of the socio demographic
variables, while as coping strategies score
was found to be more in the I year of study
as compared to other years and in the age
group of 17-20 yrs. We believe that
providing Nursing students psychological
support and assurance can help the students
to overcome the stress to cope in the
lockdown and perform better in their
studies.
Conflict of Interest
The authors have no conflict of interest.
Funding and sponsorship
The study was self-funded research.
ACKNOWLEDGEMENT
We thank the nursing students who have
actively taken part in this study. We are greatly
indebted to the valuable contributions made by
the faculty of other nursing colleges who have
co-operated in the survey carried out.
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How to cite this article: Sheroun D, Wankhar
DD, Devrani A et.al. A study to assess the
perceived stress and coping strategies among
B.Sc. nursing students of selected colleges in
Pune during COVID-19 pandemic lockdown.
International Journal of Science & Healthcare
Research. 2020; 5(2): 280-288.
******

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A Study To Assess The Perceived Stress And Coping Strategies Among B.Sc. Nursing Students Of Selected Colleges In Pune During COVID-19 Pandemic Lockdown

  • 1. International Journal of Science and Healthcare Research Vol.5; Issue: 2; April-June 2020 Website: ijshr.com Original Research Article ISSN: 2455-7587 International Journal of Science and Healthcare Research (www.ijshr.com) 280 Vol.5; Issue: 2; April-June 2020 A Study to Assess the Perceived Stress and Coping Strategies among B.Sc. Nursing Students of Selected Colleges in Pune during COVID-19 Pandemic Lockdown Deepika Sheroun1 , Dapple D Wankhar2 , Amita Devrani3 , Lissamma PV4 , S Gita5 , Keka Chatterjee6 1 MSc Nursing Student (Psychiatric Nursing), Department of Psychiatric Nursing, College of Nursing, AFMC - Pune -40 2 Asst Professor (Psychiatry Nursing), Department of Psychiatric Nursing, College of Nursing, AFMC, Pune -40. 3 Principal and HoD Department of Child Health Nursing, College of Nursing, AFMC Pune -40 4 Professor and Vice Principal, College of Nursing , AFMC Pune-40 5 Professor and HoD, Department of Med &Surg Nursing , College of Nursing, AFMC , Pune-40 . 6 Asst Professor , Department of Obs & Gynae Nursing, College of Nursing, AFMC , Pune -40. Corresponding Author: Deepika Sheroun ABSTRACT Introduction: The global pandemic has proven to be challenging for students in more ways than one. Ever since in-person classes moved online and “Stay Home Stay Safe” executive order was implemented; many students have faced a distressing change in their employment status. The present study aimed to assess perceived stress and coping strategies amidst the COVID 19 lockdown, among the BSc Nursing students studying in nursing colleges located in Pune Objectives: The objectives of the study are to assess the perceived stress and coping strategies of the BSc Nursing students of all batches in regard to COVID 19 lockdown, and to determine the association of stress and coping with selected demographic variables. Materials and Methods: This cross-sectional online study was undertaken from 15th to 20th of May 2020. Participants were BSc Nursing Students (1st -4th year), whose perceived stress and coping strategies related to COVID 19, were assessed using an online questionnaire. The tool has 3 sections consisting of demographic data as section A, Perceived Stress Scale as Section B, and Coping Strategies Scale as section C. Score was categorised into three parts as good, moderate and low Results: A total of 427 nursing students completed the questionnaire. Male students had more perceived stress score (22.73) than female students (21.86). Majority of participants were between 21-25 years. The maximum mean perceived stress score (22.56) was observed in 4th year students, and least mean perceived stress score (20.20) was found in 2nd year students. On the whole the maximum mean coping score (78.45) was found among 1st years and least coping score (71.23) was found among 4th year BSc Nursing students Conclusion: The present study indicates moderate level of perceived stress with mean perceived stress score of the students Nurses being 21.88 (+4.30) and the mean coping strategies score was 74.38 (+12.30). The IV Year Nursing students have the highest stress score with a mean of 22.56 ± 4.207. Hence there is a need to take measures by the authorities to reduce stress among the students. Keywords: COVID 19, Pandemic, Perceived Stress, Coping Strategies, Nursing Students, Psychological support INTRODUCTION ‘History has shown us that courage can be contagious and hope can take on a life of its own’ -Michelle Obama
  • 2. Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among B.Sc. nursing students of selected colleges in Pune during COVID-19 pandemic lockdown International Journal of Science and Healthcare Research (www.ijshr.com) 281 Vol.5; Issue: 2; April-June 2020 The world has seen outbreaks of epidemics and pandemic since prehistoric times - 5000 BC China , 430 BC Plague of Athens , AD 165-180 Antonine Plague , The Black Death 1346-1353 Asia to Europe , American Plague 16th century , to the present age like Great Plague of London 1665-1666 , Great Plague of Marseille 1720-1723 , Philadelphia yellow fever epidemic 1793 , Spanish Flu 1918-1920 , Asian Flu: 1957-1958 , SARS pandemic 2003 , H1N1 Swine Flu pandemic: 2009- 2010 , West African Ebola epidemic: 2014- 2016 , Zika Virus epidemic: 2015-present day. [1] Covid Pandemic, which is currently affecting the world with its origin in Wuhan, China started in Dec 2019. Affecting nearly all the countries in the world it is a historic health emergency condition the world has ever seen which is even worse than world war II. The rate of contagion and patterns of transmission is threatening the whole mankind. Pandemic is the outbreak of a disease that occurs over a wide geographic area and affects an exceptionally high proportion of the population: a pandemic outbreak of a disease. [2] The occurrence of Pandemic had increased over the last years with global warming, urbanization, globalization, and exploitation of natural resources. With the previous epidemic and pandemic, the International Health Regulation and WHsO prepared to meet specific standards for detecting, reporting on, and responding to outbreaks. [3] Despite these improvements, significant gaps and challenges exist in global pandemic preparedness. Pandemics not only impact the mortality morbidity but also stagger the economic growth, delays development. There is social disruption, political tension and individual behavioural changes, such as fear-induced aversion to workplaces and other public gathering places. [4] Pandemic affects the mental health of individual as a total result. Pandemics like COVID 19, affects the mental health due to numerous reasons – Uncertainty, poor prognosis, economic loss, insecurity, confusion, emotional isolation, stigma, school/work closure, inadequate resources for medical response, and deficient distribution of necessities. As a result people experience a lot of emotional disturbances such as stress, insomnia, frustration, irritability which could lead to psychiatric disorders like depression, anxiety, behavioural changes (substance abuse), also post-traumatic stress disorder in later stages. [5] Some groups may be more vulnerable than others to the psychosocial effects of pandemics. In particular, people who contract the disease, those at heightened risk for it (including the elderly, people with compromised immune function, and those living or receiving care in congregate settings), and people with pre- existing medical, psychiatric, or substance use problems are at increased risk for adverse psychosocial outcomes. [6] The psychological issue can worsen with social distancing and the lockdown measures taken by administrations as observed in many countries worldwide. Limacaoco et al (Apr 2020) In a descriptive study titled Anxiety, worry and perceived stress in the world due to the COVID-19 pandemic, March 2020 which was conducted in 41 countries, revealed that significant higher scores of perceived stress were observed among women, youth, students, and among those who expressed concern and those who perceived increased susceptibility to the COVID-19. [7] Lee J in an article published in Lancet (Apr 2020) explains the effects of COVID 19 pandemic on students. In a survey, which included 2111 participants up to age 25 years with a mental illness history in the UK, 83% said the pandemic had made their conditions worse, 26% said they were unable to access mental health support; peer support groups and face-to-face services have been cancelled, and support by phone or online can be challenging for some young people. [8] According to India Today (07 Apr 20) there are three major education
  • 3. Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among B.Sc. nursing students of selected colleges in Pune during COVID-19 pandemic lockdown International Journal of Science and Healthcare Research (www.ijshr.com) 282 Vol.5; Issue: 2; April-June 2020 problems that students and educators currently face due to the Covid-19 pandemic: 1. Students caught in the cross- wire. These are those students who are caught in the limbo on account of education outcomes being withheld due to the Covid- 19 pandemic. Some of them do not have a result because exams either did not happen or were left in the middle. 2 .Students one year away from school or college-leaving exams. 3. Education disruption. In response to the Covid-19 scare, many schools and colleges have moved online and parents seem to have assumed the role of teachers. Again, while there are a ton of fantastic resources which are available, there are not too many resources which mimic the school that is, provide for multidisciplinary learning, encourage connections across different domains and inspire ideas which help a child develop 21st century skills and prepare themselves for the jobs of the future. [9] A survey done was by Dartlet et al 2020 (US) to assess the effect of COVID 19 on college students. 4 in 5 students see their institutes as trustworthy sources of COVID- 19 information. 4 in 5 students report having to make large or drastic life changes to accommodate the current COVID-19 situation. Despite being digital natives, most students are not fully comfortable with an exclusive online learning medium. [10] Thus it is obvious that the covid 19 pandemic has a negative impact on the student’s life. With the imposing stress of COVID 19 on the students, the present study is focused on the perceived stress by the BSc nursing students . Previous studies from UK and India have revealed that nursing students face comparatively higher level of stress as compared to their counterparts in other colleges. [11-12] Senturk et al (2018) in Turkey determined in a descriptive study done on the nursing students that the level of stress faced by them was above moderate level. [13] Therefore, dealing with the hectic student nursing life the drastic lifestyle changes imposed due to COVID 19 pandemic can be very challenging. As there is no current study done in India among nursing student, the present study attempts to explore the perceived stress and the coping strategies utilized by the BSc nursing students in the COVID 19 pandemic lockdown. Title of the study: A study to assess the perceived stress and coping strategies among BSc Nursing students of selected colleges in Pune during covid 19 pandemic lockdown. Objectives: 1. To assess the perceived stress of the BSc Nursing students of all batches in regard to covid 19 lockdown. 2. To assess the coping strategies adopted by the BSc Nursing students of all batches in regard to covid 19 lockdown. 3. To find the association of the perceived stress level of the BSc Nursing students with selected socio demographic variable. 4. To find the association of Coping strategies adopted by the BSc Nursing students with selected socio demographic variable. Inclusion Criteria: 1. All BSc Nursing students can participate in the survey 2. Age should be 17-25 yrs Exclusion Criteria: 1. Participants residing in other cities than Pune city were not included in the study. Operational Definition: 1. BSc Nursing Students: All students undergoing I , II, III , IV Basic BSc Nursing course in various Nursing colleges in Pune. 2.Lockdown: Restrictions imposed on the general public to remain indoors and maintain social distancing with each other in the outbreak of pandemic. 3. Perceived Stress: Perceived stress is the feelings or thoughts which the BSC Nursing students have about how much stress they are since being under lockdown in the past one month.
  • 4. Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among B.Sc. nursing students of selected colleges in Pune during COVID-19 pandemic lockdown International Journal of Science and Healthcare Research (www.ijshr.com) 283 Vol.5; Issue: 2; April-June 2020 4. Coping strategies: Coping strategies refer to the specific efforts, both behavioral and psychological, that the BSc Nursing students are employing to master, tolerate, reduce, or minimize stressful events during lockdown. MATERIALS AND METHODS Design : Cross sectional Descriptive study Population : College Students Target population: BSc Nursing students Accessible population : BSc Nursing Students of various colleges in Pune Sampling Method : Purposive sampling Data collection tool : Online Questionnaire consisting of 3 sections i) Sociodemographic data ii) Modified Perceived Stress Scale iii) Modified Brief Coping Strategies Scale i) Sociodemographic Data : It conists of 10 questions – Gender , Age , Year of study , Basic qualification , Religion , Residing with family or in hostel , Family status , Parents qualification, Comorbidity in the family and Source of information about COVID 19 . ii) Perceived Stress Scale Perceived Stress Scale was developed by Sheldon Cohen in the year 1983. [14] The Perceived Stress Scale (PSS) is the most widely used psychological instrument for measuring the perception of stress. The scale also includes a number of direct queries about current levels of experienced stress. The items are easy to understand, and the response alternatives are simple to grasp. Moreover, the questions are of a general nature and hence are relatively free of content specific to any subpopulation group. The questions in the PSS ask about feelings and thoughts during the last month. In each case, respondents are asked how often they felt a certain way. Stress among nursing students was measured using a previously validated (Cronbach's α coefficient of internal consistency 0.85) perceived stress scale (PSS). The scale yielded a single score, with high scores indicating higher levels of stress and lower levels indicating lower levels of stress. [13] iii) Brief Cope Strategy Scale : The Brief-COPE is a 28 item self- report questionnaire designed to measure effective and ineffective ways to cope with a stressful life event. [15] “Coping” is defined broadly as an effort used to minimize distress associated with negative life experiences. The scale can determine someone’s primary coping styles such as Emotion Focused Coping, Problem Focused Coping, Adaptive Coping and Maladaptive Coping. Validity: The Brief-Cope was developed as a short version of the original 60-item COPE scale (Carver et al., 1989), which was theoretically derived based on various models of coping. The Breif-Cope was initially validated on a 168 participant community sample whom had been impacted by a hurricane (Carver, 1997), and shown to have adequate factor structure. Data Measurement : Data measurement was done by self administered online survey Method of data collection : 1. Permission was taken from the psychiatric department to conduct the study and ethical clearance was obtained. 2. Participants who were meeting the inclusion criteria were selected by convenient sampling. 3. Consent from the participants were obtained and the purpose of the study was explained to them through online survey questionnaire. 4. The self administered questionnaire consisted of socio demographic data, Perceived Stress Scale and Brief Coping Strategies Scale. 5. An email was provided to the participants to give their comments or to write to the authors. 6. Participants who were unwilling to complete the questionnaire due to personal reasons were free to withdraw from the study .
  • 5. Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among B.Sc. nursing students of selected colleges in Pune during COVID-19 pandemic lockdown International Journal of Science and Healthcare Research (www.ijshr.com) 284 Vol.5; Issue: 2; April-June 2020 7. The questionnaire were taken from the participants and analysis was done further . 8. Confidentiality of the collected data was maintained and used only for the research purpose . 9. Data collection was done from 427 participants on in the second week of May. Statistical Analysis: The collected data were organized as descriptive, and they included the student’s age, gender, year of study etc, the data were analysed and tabulated as percentage distribution (Table 01). The mean score and SD were tabulated for each of the measures under research, year in college, gender, age, religion, basic qualification, family type, parents’s occupation, comorbidity in the family and place of residing presently. Inferential statistical analysis was done for the perceived stress and coping strategies. The mean score and SD were tabulated. The data were analysed using the Statistical Package for the Social Sciences statistical software (SPSS -21) . Association between socio demographic data was analysed using ANOVA and Mann Whitney test RESULTS A total of 427 responders took the survey from different Nursing Colleges. The study was carried out through online survey after the questionnaires were prepared on Google form and passed on to the participants through email and WhatsApp messages. The main findings of the study indicate that the mean perceived stress score among the participants was 21.88 (+4.30) and the mean coping strategies score was 74.38 (+12.30). Demographic Characteristics: The demographic characteristics of the participants are presented in Table 01. Most of participants were of age group 21- 25 years (60.2). Out of total 427 participants, 11 were males and rest females. The maximum number of participants were in their final year of study (31.9%). Hinduism was the most followed religion (81.0%). Almost all of the participants were residing in hostel (92.3%) belonging to nuclear family (86.2%) and with basic qualification of higher secondary school (82.9%). The participants reporting of comorbidity in the family were only 20.2% and 61.4% of the participants parents were government employed. Maximum of the participants received information of COVID 19 through the internet. Perceived Stress Score (PSS) in nursing Students:  The high PSS score was seen in 13.35 % of the participants while 82.67% of the participants experienced moderate perceived stress. (Fig 1)  Among the years of study, fourth year students had the highest scores for PSS, followed by third -year students. Second-year students had the lowest score. None of the socio demographic variables showed association with the PSS score. Coping Strategies Adopted by the students:  As depicted in Table 2, maximum of the participants were found to be having moderate coping strategies score 76.58 %, while as only 18.5% of the participants had high coping strategy scores and 4.9% of the participants had low coping strategies.  On observing the type of coping strategy style as seen in Table 3 – Maladaptive coping scores were highest with mean – 31.5 (+5.19) and adaptive coping being the least 9.44 (+2.64).  Association of age with coping strategies was seen, with age group of 17-20 years showing higher scores of coping strategy as against age group of 20-25 yrs.  Significant association was found out with the year of study and coping
  • 6. Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among B.Sc. nursing students of selected colleges in Pune during COVID-19 pandemic lockdown International Journal of Science and Healthcare Research (www.ijshr.com) 285 Vol.5; Issue: 2; April-June 2020 strategies score with F value of 7.93 at p<0.0001. Higher coping strategies score was seen in I year followed by III year and least by IV year participants.  Association of coping strategies was also seen with the place of residence, the participants staying with relatives having highest score than staying alone or with family. Table No 1 Socio economic data Table 2: Coping strategies adopted by BSc Nursing students in regard to COVID 19 lockdown Coping score No of students Percentage 28 – 56 (Low) 21 4.92 57 – 84 (Moderate) 327 76.58 85 – 112 (High) 79 18.5 Total 427 100 Table 3: Coping strategies adopted by BSc Nursing students in regard to COVID 19 lockdown Minimum Maximum Mean SD PFC 6 24 16.57 4.14 EFC 6 24 16.87 4.16 AC 4 16 9.44 2.64 MAC 13 48 31.5 5.19 Figure 1: Perceived stress score of BSc Nursing students in regard to COVID 19 lockdown DISCUSSION Public health emergencies can have psychological effects on the students like Criteria Parameters No of cases Percentage (n=427) Age (Yrs) 17 – 20 167 39.1 21 – 25 257 60.2 26 & above 3 0.7 Gender Male 11 2.6 Female 416 97.4 Year of education I year BB Sc Nsg. 112 26.2 II year BB Sc Nsg. 101 23.7 III year BB Sc Nsg. 78 18.3 IV year BB Sc Nsg. 136 31.9 Religion Hindu 346 81.0 Muslim 12 2.8 Christian 56 13.1 Others 13 3.0 Residing presently Hostel 394 92.3 With family 27 6.3 With relatives 3 0.7 Others 3 0.7 Basic qualification Higher secondary 354 82.9 Graduation 67 15.7 Post graduation 6 1.4 Type of family Joint 59 13.8 Nuclear 368 86.2 Parent occupation Govt. employee 262 61.4 Pvt. Employee 82 19.2 Self employee 63 14.8 Unemployed 20 4.7 Comorbidity Present 86 20.1 Absent 341 79.9 Source of information for COVID 19 Internet 285 66.7 Television 122 28.6 Peers 7 1.6 Others 13 3.0 0 10 20 30 40 50 60 70 80 90 100 % of cases 0 – 13 (Low) 14 – 26 (Moderate) 27 – 40 (High) Stress score
  • 7. Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among bsc nursing students of selected colleges in Pune during covid-19 pandemic lockdown International Journal of Science and Healthcare Research (www.ijshr.com) 286 Vol.5; Issue: 2; April-June 2020 stress, anxiety, worry etc With COVID19 having psychological impact on college students like anxiety and distress; [14] nursing students do not remain untouched with this gigantic problem. The aim of the study was to assess the perceived stress and coping strategies adopted by the BSc Nursing students during COVID 19 pandemic. Perceived stress is a measure of the degree to which situations in one’s life are appraised as stressful.This survey revealed that as much as 82.67 % of the students had moderate level of perceived stress score and 13.35% had high perceived stress scores because of COVID 19 outbreak and lockdown. Lockdown and social distancing were undertaken throughout the country in order to prevent the spread of infection and due to the devastating effect on health due to increasing mortality and morbidity as seen in many other countries. [16] The state of lockdown which was followed in many parts of the world has leads to changes in everyday routine life. With the spread of COVID19 anxiety, worry and stress has increased among the masses, including in India. [17] The shortage of sanitizers, medical supply, the overwhelming and sensational news headlines, and erroneous news reports have also added to anxiety and fear. [18] Social distancing amidst the crisis has contributed greatly to the perceived stress as reduction in interpersonal communication leads to increase in psychological distress. [19] Maximum of the students (92.3%) had been residing in hostels away from home (Table 01) which could be contributing factor to stress in students. This stress adds on to the already stress perceived by nursing students who experience stress related to assignments and clinical work. [20] Analysis of variance reveals that there is no association between perceived stress and any of the socio demographic variables. This is in contrast with study by Limacao 2020, where age (less than 30 yrs), and sex (females) was associated with higher perceived stress. However perceived stress is higher in students than employed or unemployed individuals co-relating to the findings of the present study. [7] The second aspect explored in the study is the coping strategies adopted by the students. "Coping is the process of managing demands that are appraised as taxing or exceeding the resources of the person." (Shelley E. Taylor, 2003). [21] Thus, coping is not a one-time action that someone takes; rather, it is a set of responses, occurring over time, by which the environment and the person influence each other’s. [22] Coping helps individual to adapt to new and challenging situations and is important for stabilization. In the times of lockdown and COVID 19 pandemic it important to adapt ourselves to the new and modified routine. In the present study Brief Cope was used to assess the Coping Strategies of the students using ‘Brief Cope – By Carver ‘. The study revealed that 76.58 % of the participants had moderate Coping Strategies, while as 18.5 had high Coping Strategies and only 4.92 % had low Coping Strategies. Maximum of the participants utilized maladaptive coping as compared to the other types of emotion focused , problem focused and adaptive coping . Analysis of variance revealed that the socio demographic variable like age were significantly associated with Coping strategies utilized by the participants. Age group of 17-20 had maximum coping strategies. Religion, gender, basic qualification, type of family of the participants, co morbidity in family and sources of information regarding COVID 19, was not associated with the coping strategies. The year of study was associated significantly with coping strategies, with I year adopting maximum coping strategies, followed by III year and least by IV year. Maximum coping was showed by those participants who were residing with relatives than those staying in hostel or home. Those participants whose parents
  • 8. Deepika Sheroun et.al. A study to assess the perceived stress and coping strategies among bsc nursing students of selected colleges in Pune during covid-19 pandemic lockdown International Journal of Science and Healthcare Research (www.ijshr.com) 287 Vol.5; Issue: 2; April-June 2020 were private employees showed maximum coping. Coping strategies in the pandemic and lockdown have been utilized by the masses indifferent ways, along with the mentioned coping styles; the behavioural coping includes – washing or disinfecting their hands more often than usual , avoiding public places/events , avoiding public transport (subway, tram, bus, train), avoiding contact with risk groups (old people, people with previous illnesses) etc are being used by the masses today. [23] In the difficult times like the COVID 19 pandemic, living in lockdown is requires a lot of lifestyle modification leading to psychological distress and stress. The present study focuses on the perceived stress by the Nursing Students and the Coping Strategies adopted by them. In the present times the coping strategies adopted by the students would help them not only in the present difficult situation but have outlasting effects in the future too. CONCLUSION The present study highlights the perceived stress by nursing students who already lead a hectic routine and lifestyle. The mean perceived stress score among the participants was 21.88 (+4.30), the mean coping strategies score was 74.38 (+12.30) with maladaptive coping strategy being the highest in the participants. Stress was not affected by any of the socio demographic variables, while as coping strategies score was found to be more in the I year of study as compared to other years and in the age group of 17-20 yrs. We believe that providing Nursing students psychological support and assurance can help the students to overcome the stress to cope in the lockdown and perform better in their studies. Conflict of Interest The authors have no conflict of interest. Funding and sponsorship The study was self-funded research. ACKNOWLEDGEMENT We thank the nursing students who have actively taken part in this study. We are greatly indebted to the valuable contributions made by the faculty of other nursing colleges who have co-operated in the survey carried out. REFERENCES 1. Jarus O. Twenty worst pandemics in the world.[Internet.] 2020.[updated 2020 May ; cited 2020 May 15 ] . Available from http//:livemedicine.com/worst-epidemics- and-pandemics-in-history.html 2. Definition taken from Webster dictionary. [Internet.]. Available from http//:www.merriam-webster.com 3. International Health regulation (2005). 3rd edn.WHO Available from [Internet] https://www.who.int/ihr/publications/97892 41580496/en/ 4. Madhav N, Oppenheim B, Gallivan M, et al. Pandemics: Risks, Impacts, and Mitigation. In: Jamison DT, Gelband H, Horton S, et al., editors. Disease Control Priorities: Improving Health and Reducing Poverty. 3rd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2017 Nov 27. Chapter 17. Available from: https://www.ncbi.nlm.nih.gov/books/NBK5 25302/ doi: 10.1596/978-1-4648-0527- 1_ch17 5. Pfefferbaum , B North S Carol . Mental Health and the Covid-19 Pandemic . n engl j med: 13 Apr 2020; DOI: 10.1056/NEJMp2008017 6. Bhagat. Covid 19 will aggravate mental health issue. Hindustan times. [Internet]. 2020 Mar 05 [cited 2020 May 16] . Available from: https://www.hindustantimes.com/analysis/c ovid-19-will-aggravate-mental-health- issues-analysis/story- RtnJ6JhiHKkNRb67n7oR6L.html 7. Limcaoco G S R , Mateos M E , Fernández M J , Roncero C. Anxiety, worry and perceived stress in the world due to the COVID-19 pandemic, March 2020. Preliminary results. Biomedical Research Institute of Salamanca. Doihttps://doi.org/10.1101/2020.04.03.2004 3992 8. Lee J. Mental health effects of school closures during COVID-19. The Lancet .
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