Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has swiftly spread to more than 200 regions and countries worldwide since it was first reported in December 2019. Reference Kanu, James and Bah1–Reference Wang, Hu and Hu3 The World Health Organization (WHO) announced that COVID-19 was an international public health emergency on January 31, 2020, and later, classified it as a global pandemic on March 11, 2020. Reference Gohel, Patel and Shah4–Reference Al Hourani, Alkhatib and Abdullah6 It has the characteristics of strong infectivity, long latency, and rapid disease progression. Reference Rossi, Socci and Talevi7,Reference Azzi, Parides and Alani8 The population is generally susceptible to COVID-19. Globally, as of 6:33 pm CEST, September 2, 2022, there have been 601,189,435 confirmed cases of COVID-19, including 6,475,346 deaths, reported to WHO; surprisingly, there were 618,970 new cases thereof in the past 24 h. China, as one of many seriously affected countries, has reported 6,477,468 confirmed cases of COVID-19, including 24,883 deaths. 9 The COVID-19 pandemic has led to an unprecedented setback for the lives and health of the public, the production of enterprises, and the global economy. Reference Awadasseid, Wu and Tanaka10–Reference Ren and Xie12
The first outbreak of COVID-19 occurred in Wuhan, Hubei Province, China, at the end of December 2019. Reference Chan, Yip and To13 Since then, the overall situation of the pandemic in mainland China was characterized by sporadic or local, small-area clustering. The second outbreak occurred in the Shanghai and Jilin Provinces, China, in March 2022. Reference Chan, Yip and To13 More than 500,000 confirmed cases of COVID-19 were reported from March 1 to April 20, 2022, and worryingly, more than 20,000 new cases thereof were reported daily, since early April 2022. In response to this pandemic, governments and health administrative departments issued policies of prolonged lockdown, isolation, cessation of work, and postponement of university and school semesters. Reference Tu, Tu and Gao14,Reference Yang, Liu and Ma15 Therefore, this pandemic continues to be a global public health crisis.
In the battle against the COVID-19 pandemic, health professionals were the main force in treating confirmed cases, observing people isolated because of close contact with confirmed cases, and performing epidemiological investigations during the COVID-19 pandemic. As of February 28, 2020, the National Health Commission of China had organized more than 330 medical teams and 40,000 medical staff in mainland China to support Hubei Province, China. 16 In April 2022, the National Health Commission of China organized more than 5000 medical staff in mainland China to support Jilin Province, and more than 38,000 medical staff, also in mainland China, to support Shanghai. Furthermore, in the initial stages of the pandemic, there were also problems such as the shortage of medical supplies and protective equipment. Therefore, medical workers not only had to complete high-intensity work, but also faced the risk of infection and strong psychological pressure. Reference Ashton17–Reference Gordon, Scanlan and Tooman19 Unfortunately, as of March 6, 2020, the COVID-19 pandemic had infected nearly 3000 medical workers, and more than 30 have died. 20 The pandemic was not only a major public health emergency, but also a major psychological crisis. The pandemic caused medical staff to experience a variety of psychological crises, according to several studies. Reference Elbay, Kurtulmuş and Arpacıoğlu21,Reference Xiong, Fritzsche and Pan22
Medical students, who are the reserves and future of the medical profession, paid close attention to the pandemic situation. Reference Muntz, Franco and Ferguson23,Reference Soled, Goel and Barry24 Therefore, the conditions of frontline medical workers fighting against the COVID-19 pandemic will inevitably have a psychological impact on medical students. Reference Hu, Huang and Liu25,Reference Salem, Al Hanafy and Bayad26 The attitudes of medical students toward their profession, not only directly affects how they develop far-reaching professional ideals and cultivate noble professional ethics during their studies, but also affects their ability to adhere to professional commitment and good professional ethics in the future, when they become fully qualified medical workers. There are several studies that have addressed COVID-19 in students, such as the psychological status (anxiety or depression) of students during the pandemic Reference Cao, Fang and Hou27–Reference Zhang, Zhang and Ma29 ; the knowledge, attitude, and practice regarding COVID-19 among students Reference Jia, Ma and Bai30,Reference Alrasheedy, Abdulsalim and Farooqui31 ; and the willingness of medical students to work in frontline jobs during the pandemic. Reference Seah, Ho and Liaw32–Reference Kim, Kim and Kim34 However, there has been no scientific assessment or in-depth analysis of the impact of the pandemic on the professional attitudes of medical students in China. Therefore, exploring the difference in professional attitudes before and after the COVID-19 pandemic is essential as doing so will benefit the development of the medical students.
Therefore, an online pre-post-like survey was conducted among medical students, through network platforms, from March 23 to April 19, 2021, which assessed the difference in professional attitudes among Chinese medical students before and after the pandemic and identifies the determinants associated with it. This study explores the weaknesses of education in professional attitudes among college students and provides precise and scientific evidence in favor of an educational strategy to enhance these professional attitudes.
Methods
Study Design
An online pre-post-like survey was conducted among medical students from March 23 to April 19, 2021. The professional attitudes after the outbreak of the COVID-19 pandemic were measured based on current-pandemic attitudes of professionalism, and those before the outbreak of the pandemic were measured based on previously recalled answers to the same questions in professional attitudes.
Participants
In total, 5069 medical students participated in the study. After removing participants with incomplete questionnaires for quality control, 5022 participants aged 15-27 y (mean: 21.23 ± 1.72 y) from 31 provinces in mainland China were included in the study. The effective response rate was 99.07%. Of the 5022 participants, 1986 (39.55%) were males, and 3036 (60.45%) were females. There were 2292 (45.64%) participants living in urban areas and 2730 (54.36%) participants living in rural areas. The provincial spatial distribution of the participants is presented in Figure 1 (Panels A through D). The inclusion criteria for the participants were full-time medical students in Mainland China. This study was approved by the ethical committee of Qiqihar Medical University (ref: [2021] 31). This study was approved by the ethical committee of Qiqihar Medical University (ref: [2021] 31). All participants provided online informed consent.
The spatial distribution of the participants by provinces. (A) Gender of the subjects. (B) Region of the subjects. (C) Age of the subjects. (D) Participants and their proportion by provinces.
Investigation Method
An anonymous online pre-post-like survey was conducted through the Wen-Juan-Xing platform in China (https://www.wjx.cn/app/survey.aspx). First, an electronic 2-dimensional code for the questionnaire was created through this online platform. Second, it was sent to the counselors by the researchers. Finally, the code was sent to the potential participants through QQ and WeChat. Furthermore, the participants were also encouraged to recruit valid respondents in the same way as above. The participants voluntarily participated in this study and scanned the electronic 2-dimensional code of the questionnaire with electronic equipment and completed it. Each IP address was set to submit anonymously only once. Identity information and sensitive content of the questionnaire were excluded.
Assessment Tools and Procedures
A self-made questionnaire was administered to participants. It consisted of 25 items, including socio-demographic information (13 items) and professional attitudes (12 items) before and after the COVID-19 pandemic. The 12 questions on professional attitudes of the medical students, were scored on a 5-point scale in terms of “strongly disagree” (1 point), “disagree” (2 points), “basically agree” (3 points), “agree” (4 points), and “strongly agree” (5 points). The sum of the scores of each item was the total score. The highest score for professional attitudes was 60, and responses ranged from 12 to 60. The mean score of professional attitudes was equal to the total score divided by 12. If the mean score of professional attitudes was less than 3, it was considered “disturbed”, and if it was more than or equal to 3, it was considered “undisturbed. The questionnaire was designed according to the “Pneumonia Prevention and Control Plan for Novel Coronavirus Infection (Second Edition),” “Health Education Manual for Novel Coronavirus Pneumonia,” and “Guidelines for Public Protection of Novel Coronavirus Pneumonia.” 35–37 Moreover, the questionnaire was enriched and perfected through expert consultation, argumentation, and presurvey and finally formalized. The Cronbach’s alpha coefficient of the questionnaire was 0.898.
Statistical Analysis
SPSS V.22.0 was used for statistical analysis. Categorical variables of the socio-demographic characteristics were expressed as frequency and percentages (%). The Kolmogorov-Smirnov test was applied for assessing the normality. Continuous variables of professional attitudes were expressed as a mean ± SD (standard deviation, SD). Difference of professional attitudes, before and after the pandemic, were compared using the chi-squared test, or Fisher’s exact probability for categorical variables and the paired t-test, and 1-way analysis of variance (ANOVA) for normally distributed continuous variables. Multinomial logistic regression was performed, to identify the determinants associated with professional attitudes. The risks of the determinants were shown as odds ratios (OR) and the corresponding 95% confidence intervals (CIs). The professional attitudes before and after the COVID-19 pandemic, were taken as the dependent variable, which included 4 groups, namely “undisturbed-undisturbed,” “undisturbed-disturbed,” “disturbed-undisturbed,” and “disturbed-disturbed.” The “undisturbed-undisturbed” term, represented the professional attitudes of participants who were all undisturbed before and after the COVID-19 pandemic, was taken as the reference for dependent variables in the multinomial logistic regression model. The “undisturbed-disturbed” term represented the professional attitudes of participants who were undisturbed before the pandemic, but challenged after the pandemic, that is, the professional attitudes of these participants had been altered during the COVID-19 pandemic. The “disturbed-undisturbed” term represented the professional attitudes of participants who were disturbed before the pandemic, but unaltered thereafter, that is, their professional attitudes had been strengthened during the COVID-19 pandemic. The “disturbed-disturbed” term represented the professional attitudes of participants who were all disturbed before and after the COVID-19 pandemic. The stepwise method was used to filter independent variables. The P-value < 0.05 (2-sided) was considered statistically significant.
Results
Differences in Professional Attitudes of the Participants Before and After the COVID-19 Pandemic
A total of 5022 medical students participated in this study. The mean scores of professional attitudes of the 5022 participants before the COVID-19 pandemic was 3.89 ± 0.62, which was statistically significantly lower than after the COVID-19 pandemic (3.95 ± 0.62), t = −24.47; P < 0.0001. Furthermore, the mean scores of professional attitudes of the participants in the group of “disturbed-undisturbed” before the COVID-19 pandemic was 2.80 ± 0.14, which was statistically significantly lower than after the COVID-19 pandemic (3.35 ± 0.41), t = −8.57, P < 0.0001; while the mean scores of professional attitudes of the participants in the group of “undisturbed-disturbed” before the COVID-19 pandemic was 3.44 ± 0.34, which was statistically significantly higher than after the COVID-19 pandemic (2.79 ± 0.16), t = 6.97, P < 0.0001.
For the professional attitudes of 5022 medical students, 305 (6.07%) were disturbed and 4717 (93.93%) were undisturbed before the COVID-19 pandemic; 271 (5.40%) were disturbed and 4751 (94.60%) were undisturbed after the pandemic. The proportion of medical students whose professional attitudes were disturbed after the COVID-19 pandemic were significantly lower than before the COVID-19 pandemic (5.40% vs 6.07%, χ 2 = 15.6216; P < 0.0001). The details are shown in Table 1.
The professional attitudes of the participants before and after the COVID-19 pandemic
Note: Data are shown as frequency and percentages (%).
Socio-demographic Characteristics of the Participants and Association With Professional Attitudes Before and After the COVID-19 Pandemic
Table 2 shows the socio-demographic characteristics of the participants and association with professional attitudes before and after the COVID-19 pandemic. There were not statistically significant differences between gender, major, regions, only child, poor student, student leader, parents or relatives have medical workers and professional attitudes of students before and after the COVID-19 pandemic. A significant correlation was found between professional attitudes and grades (χ 2 = 128.7893; P < 0.0001), the adjusting for majors (χ 2 = 16.3470; P = 0.0010), considered the reason for choosing medicine (χ 2 = 224.9531; P < 0.0001), internship experience (χ 2 = 47.1316; P < 0.0001), and family members or friends who had experienced COVID-19 (P = 0.0005).
Socio-demographic characteristics of the participants and association with professional attitudes before and after the COVID-19 pandemic
Note: Data are shown as frequency and percentages (%).
a P<0.05 and the difference were statistically significant.
b Difference of professional attitudes before and after the COVID-19 pandemic was compared using Fisher’s exact probability.
Multinomial Logistic Regression for Identification of the Determinants Significantly Associated With Professional Attitudes Before and After the COVID-19 Pandemic
The “undisturbed-undisturbed” group was taken as the reference for dependent variables in the multinomial logistic regression model. Compared with the “undisturbed-undisturbed” group, grades, considered the reason for choosing medicine, and students had family, relatives, or friends who experienced COVID-19, were significantly associated with the “undisturbed-disturbed” status (decreased professional attitudes), that is, the professional attitudes of these participants had been altered during the pandemic. The results showed that grade was the risk factor for “undisturbed-disturbed” status with a 1.664-fold risk as grade increased (OR = 1.664; 95% CI = 1.041 to 2.659). There was a 3.269-fold risk of “undisturbed-disturbed” status if the choice of a medical career was suggested by others rather than originating from their own desire (OR = 3.269; 95% CI = 1.226 to 8.716), and a 7.557-fold risk of “undisturbed-disturbed” status if the students’ family, relatives, or friends were infected with COVID-19 (OR = 7.557; 95% CI = 1.898 to 30.084).
Compared with the “undisturbed-undisturbed” group, internship experience was significantly associated with the “disturbed-undisturbed” status (increased professional attitudes), that is, the professional attitudes of these participants strengthened during the COVID-19 pandemic. The results showed that the students with internship experience for “disturbed-undisturbed” status was 2.933-fold than those without internship experience (OR = 2.933; 95% CI = 1.293 to 6.652).
Compared with the “undisturbed-undisturbed” group, grades and the reason for choosing medicine were significantly associated with the “disturbed-disturbed” status. The results showed that grade was the risk factor for “disturbed-disturbed” status with a 1.569-fold risk as grade increased (OR = 1.569; 95% CI = 1.369 to 1.799). There was a 5.162-fold risk of “disturbed-disturbed” status if the choice of a medical career was suggested by others rather than originating from their own desire (OR = 5.162; 95% CI = 3.876 to 6.874). The details are shown in Table 3.
Multinomial logistic regression for analysis of the determinants significantly associated with professional attitudes before and after the COVID-19 pandemic
Note: The professional attitudes before and after the COVID-19 pandemic, were taken as the dependent variable, which included 4 groups, namely “undisturbed-undisturbed,” “undisturbed-disturbed,” “disturbed-undisturbed,” and “disturbed-disturbed.” The “undisturbed-undisturbed” group was taken as the reference for dependent variables in the multinomial logistic regression model.
Discussion
This nationwide pre-post-like study simultaneously investigated the professional attitudes of medical students before and after the outbreak of the COVID-19 pandemic, through a current and a retrospective survey. Although a retrospective survey could carry a possible recall bias, nevertheless, this study could be a valuable first contribution as it was the first published manuscripts that address the importance of medical professionalism attitudes due to a public health emergency and the urgently need of strengthen these attitudes. The professional attitudes of medical students directly affected their ability to establish far-reaching professional and ethical habits in medical school, which is of great significance for their development.
The results of this study showed that the proportion of medical students whose professional attitudes were altered after the COVID-19 pandemic were significantly lower than before the pandemic, that is, the professional attitudes of medical students strengthened after the pandemic. The reasons for the results are as follows: medical workers were the main force fighting against the COVID-19 pandemic, and they not only had to complete high-intensity work, but also faced the risk of infection and strong psychological pressure. Reference Ashton17–Reference Gordon, Scanlan and Tooman19 However, when faced with difficulties and risks, the medical workers actively participated in the prevention and control of the pandemic and the treatment of patients, and worked in the front-line against it. During the COVID-19 pandemic, medical workers have demonstrated their lofty professionalism through their practical actions and made significant contributions to prevention and control. Reference Giulio, Maggioni and Montroni38–Reference Vance and Morganstein40 Therefore, medical workers set a great professional example for medical students, which may strengthen their professional attitudes.
As mentioned in the methodology section, professional attitudes of medical students were divided into 4 groups. Compared with the “undisturbed-undisturbed” group, we found that grades, considered the reason for choosing medicine, and students had family, relatives, or friends who experienced COVID-19, were significantly associated with the “undisturbed-disturbed” status, which is, the professional attitudes of these participants had been challenged during the pandemic. There was a 1.664-fold risk of students for “undisturbed-disturbed” status as grade increased. The reason may be that senior students are facing multiple pressures, such as graduation and employment. Furthermore, medical workers were the main force to undertake high-intensity work, and faced the risk of infection and strong psychological pressure during the pandemic. Reference Ashton17–Reference Gordon, Scanlan and Tooman19 Therefore, the conditions of frontline medical workers fighting against the COVID-19 pandemic would inevitably have a certain psychological impact on medical students, especially the senior students facing employment. A systematic review about the impact of COVID-19 pandemic on mental health in the general population reported that the prevalence of anxiety symptoms among the general population worldwide ranged from 6.33% to 50.9%. Reference Xiong, Lipsitz and Nasri41 A cross-sectional study conducted on college students during the COVID-19 outbreak in China revealed that 18.78% of the participants had anxiety symptoms. Reference Jia, Qi and Bai11 Therefore, the COVID-19 pandemic was not only a major public health emergency, but also a major psychological crisis. It is recognized that negative emotions such as tension, anxiety, and depression not only endanger physical and mental health, but also may affect the professional attitudes of medical students during the COVID-19 pandemic. Moreover, studies had confirmed that the level of knowledge–attitude–practice (KAP) regarding COVID-19 was significantly negatively correlated with anxiety symptoms, and understanding the level of KAP during COVID-19 pandemic can contribute to reduce the psychological damage. Therefore, we considered that a healthy psychological status and good KAP regarding COVID-19 will be conducive to strengthening professional attitudes of medical students. Thus, it is urgent for us to actively pay attention to the mental health and KAP of medical students during a major public health emergency and carry out timely and effective mental health screening and intervention measures. Our further research direction is to explore the relationship among the professional attitudes of medical students, KAP regarding COVID-19, and psychological status. This study also showed that, if the choice of a medical career was suggested by others rather than originating from their own desire, there was a 3.269-fold risk for these students’ professional attitudes to be challenged during the COVID-19 pandemic. The reason may be that these students do not have enough knowledge and in-depth love of their major. Moreover, there was a 7.557-fold risk of “undisturbed-disturbed” status if the students’ family, relatives, or friends were infected with COVID-19. Therefore, in a public health emergency outbreak, medical schools should implement precise, targeted, and scientific interventions about professional attitudes education for the medical students. This is of great significance for strengthening the professional attitudes of these medical students.
Compared with the “undisturbed-undisturbed” group, internship experience was significantly associated with the “disturbed-undisturbed” status, which is, the professional attitudes of these participants had been strengthened during the COVID-19 pandemic. The results showed that the students with internship experience for “disturbed-undisturbed” status was 2.933-fold than those without internship experience. The reason may be that, first, the students with internship experience may pay more attention to the pandemic, and thus have stronger professional attitudes. Second, these students may have more in-depth learning of medical knowledge; finally, they may have a deeper understanding of the work and responsibilities of medical workers and their future career development. Therefore, it is likely that they will recognize and love their majors more, and thus strengthen their professional attitudes. Thus, all these results demonstrated that the provision of targeted education for professional attitudes should be implemented among medical students during a public health emergency.
Strengths and Limitations
The major innovations of this study are that this was the first nationwide pre-post-like study of the impact of the pandemic on the professional attitudes of medical students in mainland China. Moreover, this study simultaneously investigated the professional attitudes of medical students before and after the COVID-19 pandemic and aimed to assess the differences in such attitudes. It also identifies the determinants considerably associated with it. This study may help to explore the weaknesses of education in professional attitudes among medical students and provide precise and scientific evidence for implementing precision education to professional attitudes. Therefore, this study is of great significance for the development of the medical students. The limitations of this study are that probability sampling was not performed. Additionally, the professional attitudes of medical students before the COVID-19 pandemic were a retrospective survey, which may have recall bias.
Conclusions
The professional attitudes of medical students have been strengthened during the COVID-19 pandemic. A significant correlation was found between grades, the reason for choosing medicine, and students whose family, relatives, or friends experienced COVID-19 and the “undisturbed-disturbed” status (decreased professional attitudes), while an internship experience was significantly associated with the “disturbed-undisturbed” status (increased professional attitudes). The results provide evidence of the importance of education on professional attitudes among medical students during public health emergencies, and attention must be focused on students from higher grades, choosing medicine as suggested by others, whose family, relatives, or friends experienced COVID-19, and students without internship experience.
Acknowledgments
Thanks to all the 5069 medical students who had voluntarily participated the survey, and thanks to all the authors in present study for their efforts on this project.
Funding statement
This work was supported by the Department of Education, Heilongjiang Province (Grant numbers 2020-KYYWF-0051 and 2020-KYYWF-0054); and the Social Science Foundation of Qiqihar Medical University (Grant number QYSKL2023-04YB).
Competing interests
There are no conflicts of interest.
Ethical standard
This study was approved by the ethical committee of Qiqihar Medical University (ref: [2021] 31). This study adheres to the Helsinki declaration. Participants in this research participate voluntarily and conduct anonymously through an online platform. The researchers had provided electronic informed consent for all subjects before the survey. The electronic informed consent included all ethical considerations of the study and the survey, the private use of the information, and the use only for research purpose. The participants read and selected “Agree” at the interviewee’s informed consent were considered as consent to participate in our investigation. All participants provided online informed consent.
