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Answered By: Jon Allinder Last Updated: Jan 29, 2023 Views: 115054
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This paper is in the following e-collection/theme issue:
Published on 20.8.2020 in Vol 22 , No 8 (2020) :August
Digital Inequality During a Pandemic: Quantitative Study of Differences in COVID-19–Related Internet Uses and Outcomes Among the General Population
Authors of this article:
Original Paper
- Alexander JAM van Deursen, Prof Dr
University of Twente, Enschede, Netherlands
Corresponding Author:
Alexander JAM van Deursen, Prof Dr
University of Twente
Drienerlolaan 5
Enschede, 7500AE
Netherlands
Phone: 31 622942142
Fax:31 534893200
Email: [email protected]
Background: The World Health Organization considers coronavirus disease (COVID-19) to be a public emergency threatening global health. During the crisis, the public’s need for web-based information and communication is a subject of focus. Digital inequality research has shown that internet access is not evenly distributed among the general population.
Objective: The aim of this study was to provide a timely understanding of how different people use the internet to meet their information and communication needs and the outcomes they gain from their internet use in relation to the COVID-19 pandemic. We also sought to reveal the extent to which gender, age, personality, health, literacy, education, economic and social resources, internet attitude, material access, internet access, and internet skills remain important factors in obtaining internet outcomes after people engage in the corresponding uses.
Methods: We used a web-based survey to draw upon a sample collected in the Netherlands. We obtained a dataset with 1733 respondents older than 18 years.
Results: Men are more likely to engage in COVID-19–related communication uses. Age is positively related to COVID-19–related information uses and negatively related to information and communication outcomes. Agreeableness is negatively related to both outcomes and to information uses. Neuroticism is positively related to both uses and to communication outcomes. Conscientiousness is not related to any of the uses or outcomes. Introversion is negatively related to communication outcomes. Finally, openness relates positively to all information uses and to both outcomes. Physical health has negative relationships with both outcomes. Health perception contributes positively to information uses and both outcomes. Traditional literacy has a positive relationship with information uses and both outcomes. Education has a positive relationship with information and communication uses. Economic and social resources played no roles. Internet attitude is positively related to information uses and outcomes but negatively related to communication uses and outcomes. Material access and internet access contributed to all uses and outcomes. Finally, several of the indicators and outcomes became insignificant after accounting for engagement in internet uses.
Conclusions: Digital inequality is a major concern among national and international scholars and policy makers. This contribution aimed to provide a broader understanding in the case of a major health pandemic by using the ongoing COVID-19 crisis as a context for empirical work. Several groups of people were identified as vulnerable, such as older people, less educated people, and people with physical health problems, low literacy levels, or low levels of internet skills. Generally, people who are already relatively advantaged are more likely to use the information and communication opportunities provided by the internet to their benefit in a health pandemic, while less advantaged individuals are less likely to benefit. Therefore, the COVID-19 crisis is also enforcing existing inequalities.
Introduction
The World Health Organization considers coronavirus disease (COVID-19) to be a public emergency threatening global health [ 1 ]. Governments worldwide have taken stringent action, including requiring social distancing, closing public services, schools and universities, and canceling cultural events [ 2 , 3 ]. People are being advised or ordered to stay at home and socially isolate themselves to avoid being infected [ 4 ]. The ongoing pandemic represents an outbreak of an unparalleled scale, and it has induced widespread fear and uncertainty.
In this paper, we focus on the role of the internet during the crisis. The internet has become a crucial source for the general public, as it provides access to general information, the latest national and international developments, and guidelines on behavioral norms during the crisis. In this respect, the internet plays an important role in the great challenges facing governments regarding the transfer of knowledge and guidelines to the population at large. When individuals understand the need and rationale behind government-enforced measures, they are more motivated to comply and even adopt measures voluntarily [ 5 , 6 ]. In addition to informational purposes, the internet enables individuals to share news and experiences with people they cannot meet face-to-face, remain in contact with friends and family, seek support, and ask questions of official agencies, including health agencies. Further, the internet enables people to take initiatives such as raising money or preparing packaged meals for people in need, such as health workers or people who have lost their jobs. In sum, the internet plays a vital role for people of all social strata and backgrounds during a time of worldwide crisis. All people should thus be able to use the internet as a source of information and communication.
However, digital inequality research has shown that internet access is not evenly distributed among the general population [ 7 , 8 ]. The basic idea of digital inequality stems from a comparative perspective of social and information inequality, as there are benefits associated with internet access and negative consequences of lack of access [ 9 ]. Calamities are often a story of inequality [ 10 ]; therefore, in this paper, we aimed to gain a deeper and broader understanding of the differences in how people use the internet to cope during the COVID-19 crisis. Van Dijk’s resources and appropriation theory [ 8 ] explains differences or inequalities of internet access by considering personal and positional categories of individuals and the individuals’ resources. Internet access itself is considered to be a process of appropriation involving attitudinal access, material access, skills access, and in the final stage, usage access. The latter entails differences in the type of activities that people perform on the internet. The consequences of the process are the outcomes of internet use. These outcomes in turn reinforce personal and positional inequalities and an unequal distribution of resources [ 8 ] ( Figure 1 ). The first goal of this paper is to provide a timely understanding of how different people use the internet and the outcomes they gain from it in relation to the COVID-19 pandemic.
Internet use and outcome differences between groups of people are likely to have profound consequences on how people manage a crisis. For example, older people are most in danger of being infected with the virus and most likely to die from the infection [ 11 ], and they also use the internet less and have the fewest internet outcomes [ 12 ]. The latter may further endanger their peculiar situation, as limited internet use and outcomes may result in a lack of critical information or necessary support.
COVID-19–Related Internet Uses and Outcomes
To study differences in internet uses and outcomes during the COVID-19 pandemic, it is necessary to understand the types of uses and outcomes that are at play. Typically, uses and outcomes are studied by following conceptual classifications that distinguish different domains, such as economic, social, cultural, or personal domains [ 13 ]. Here, we take the COVID-19 pandemic as the domain of interest. Within this domain, we consider two main and conceptually different types of uses and outcomes: information and communication [ 14 , 15 ]. Information internet uses involve searching for information on all aspects of COVID-19. Potential information outcomes include becoming better informed about the disease, understanding why certain measures are necessary, and limiting the risk of becoming infected by developing greater awareness of one’s own behavior. Communication internet uses include talking to friends about the crisis, asking questions on social media or online fora, giving advice, or offering support to others. Communication outcomes include finding people on the internet who can offer support or share concern, being less lonely, and protecting others from potential COVID-19 risks. Studying both types of uses and outcomes is important, as prior research has shown that communication uses can compensate for information uses to attain beneficial internet outcomes [ 16 ].
Determinants of COVID-19–Related Internet Uses and Outcomes
Digital inequality research suggests that the vast amount of web-based information and communication possibilities around the COVID-19 pandemic are likely to be difficult to grasp and conceptualize for sections of the general population [ 7 ]. Some frequently observed personal categorical inequalities are gender, age, personality, and health [ 7 ]. Earlier research revealed that men and women differ in their internet activities; women are more likely to use email and social media, whereas men are more likely to use the internet to obtain information [ 17 , 18 ]. Age in general has a negative impact on all types of internet uses and outcomes [ 7 ]. In the COVID-19 crisis, older people are especially vulnerable; therefore, it is very important for them to know how to behave and be safe. We hypothesize that (H1) men are more likely to be involved in information-related uses and outcomes while women are more likely to be involved in communication-related internet uses and outcomes regarding COVID-19-related internet uses and outcomes. We also hypothesize that (H2) age contributes negatively to COVID-19–related internet uses and outcomes.
An individual’s personality may hinder or stimulate their engagement in certain COVID-19–related activities. Cognitive appraisal theory suggests that individuals complete two types of cognitive appraisal processes in a crisis [ 19 ]. The process starts with an evaluation of the crisis as a potential source of danger or life disruption. If the crisis is not determined to be dangerous, it is not considered a stressor and does not require intervention. If the crisis is determined to be relevant, it is considered a stressor and must be evaluated further by balancing the demands of the crisis and the person’s resources [ 20 ]. At this point, personality enters the equation [ 20 ]. There is a general consensus regarding the Big Five model when personality traits are studied. This model proposes five personality traits of agreeableness, neuroticism, conscientiousness, introversion, and openness [ 21 ]. However, there is no agreement as to whether these traits contribute to or detract from resisting disturbance [ 20 ]. There is also no consensus on how the Big Five personality traits relate to internet use [ 7 , 22 ]. For example, conscientiousness relates to people who abide by rules. On one hand, one might argue that this would result in a greater need for information on how to behave. On the other hand, the internet is unstructured, and rules and policies are absent to a large extent. When linking personality traits to internet use for psychological adjustments to the COVID-19 crisis, it is not evident whether these traits will support or hinder COVID-19–related internet uses and outcomes. We hypothesize that (H3a) agreeableness, (H3b) neuroticism, (H3c) contentiousness, (H3d) introversion, and (H3e) openness are related to COVID-19–related internet uses and outcomes.
An individual’s health may play an important role in how they approach COVID-19. To gain an elaborate understanding of how health relates to COVID-19–related internet uses and outcomes, we followed earlier research that distinguishes between different health aspects [ 23 ]: A person’s physical functioning or the degree to which their health currently interferes with activities such as sports, carrying groceries, climbing stairs, and walking, their mental health or psychological distress and well-being, and their health perception concerning their own health rating in general. During a crisis, we expect that people with health issues are more likely to turn to the internet for comfort and reassurance. We hypothesize that (H4a) physical functioning, (H4b) mental health, and (H4c) health perception contribute negatively to COVID-19–related internet uses and outcomes.
The final type of personal inequality considered in this study is traditional literacy, which is known to have a substantial impact on how the internet is used [ 24 , 25 ]. We consider literacy to be the ability to read, write, and understand text, which is also framed under the umbrella terms functional literacy or fundamental literacy [ 24 ]. Functional or traditional literacy can be considered as the basic dimension of all literacy concepts [ 26 ]. Considering the crucial role the internet is playing in the COVID-19 crisis, a low level of literacy is a potentially large inhibitor of understanding information and being involved in web-based communication. We hypothesize that (H5) traditional literacy contributes positively to COVID-19–related internet uses and outcomes.
Education is the most observed positional categorial inequality in digital divide research, and it is likely to play a role in the current context. People with higher levels of education are better equipped to comprehend web-based information and benefit from internet use [ 7 ]. We hypothesize that (H6) education contributes positively to COVID-19–related internet uses and outcomes.
When studying differences in internet uses and outcomes, the resources people can access are often derived from Pierre Bourdieu’s capital theory [ 27 ], which stresses the importance of including not only economic but also social and cultural resources to determine one’s status and position in society. In the COVID-19 pandemic, economic and social resources are likely to be important, as earlier research has shown that people with greater economic resources—mostly operationalized as income in digital inequality research—are known to use the internet more efficaciously and productively [ 7 , 28 ]. People with more social resources are more likely to have access to family, friends, or other contacts on the internet [ 29 ]. We hypothesize that (H7a) economic and (H7b) social resources contribute positively to COVID-19–related internet uses and outcomes.
The Internet Appropriation Process
The core of the resources and appropriation theory is access to technology, which is considered as a process of appropriation involving attitudinal, material, skills, and usage access. Attitudinal access concerns a person’s attitude towards the internet; according to theories of technology adoption, this type of access is crucial for using the internet [ 30 ]. Material access can be defined in terms of the different devices that people use to access the internet and all other web-based resources, including desktop computers, laptop computers, tablets, smartphones, game consoles, and interactive televisions [ 31 ]. Skills access concerns the skills necessary to use the internet, ranging from operational and information skills to social and content creation skills [ 32 ]. Prior research has revealed that all three types of internet access directly affect internet uses and outcomes [ 16 ]. We hypothesize that (H8a) attitudinal internet access, (H8b) material internet access, and (H8c) skills internet access contribute positively to COVID-19–related internet uses and outcomes.
The Effects of COVID-19–Related Internet Uses on Their Corresponding Outcomes
A recent multifaceted consideration of digital inequality revealed a strong effect of internet uses on outcomes [ 12 ]. Further, people’s internet activities appeared to be more important than their personal characteristics with regard to inequalities in outcomes of internet use. This suggests that the variables discussed in the prior sections will become less important for obtaining information outcomes when people are involved in COVID-19–related internet information uses. This is also true for COVID-19–related communication uses and outcomes. The second goal of this paper is to reveal the extent to which the indicators discussed remain important for obtaining internet outcomes after people are involved in the corresponding uses.
Recruitment
This study used a web-based survey and drew upon a sample collected in the Netherlands. To obtain a representative sample of the population, we used PanelClix, a professional organization for market research, to provide a panel of approximately 110,000 people. Members of the panel received a small incentive for every survey they completed. In the Netherlands, 98% of the population uses the internet; therefore, the internet user population is very closely representative of the general population in terms of its sociodemographic makeup. The panel included novice and advanced internet users. In total, we aimed to obtain a dataset with approximately 1700 respondents over the age of 18. Eventually, this resulted in the collection of 1733 responses over a 1-week period in April 2020. During the data collection period, three amendments to the sampling frame were made to ensure the representativity of the Dutch population. Accordingly, the analyses revealed that the gender, age, and formal education of our respondents largely matched official census data. As a result, only very small post hoc corrections were needed.
The web-based survey used software that checked for missing responses and prompted users to respond. The survey was pilot-tested with 10 internet users over two rounds. Amendments were made based on the feedback provided. No major comments were provided in the second round. The average time required to complete the survey was 20 minutes.
We initially developed 11 survey items pertaining to COVID-19–related internet use. Respondents were asked to indicate the extent to which they used the internet for various activities in the past month using a 5-point scale (“not” to “multiple times a day”) as an ordinal-level measure. Principal component analysis with varimax rotation was used to determine two underlying usage clusters, one related to information and one to communication. Factor loadings were employed at 0.4 and above for each item [ 33 ]. In total, 8 items (3 for information and 5 for communication) were retained in a two-factor structure with eigenvalues over 1.0, together accounting for 76% of the total variance.
For COVID-19-related information and communication internet outcomes, we developed 14 items mapped onto the use items. A 5-point agreement scale as an ordinal level measure was used. Principal component analysis with varimax rotation resulted in a structure that matched the conceptual definition of information outcomes (4 items) and communication outcomes (4 items). The two factors showed eigenvalues over 1.0 and explained 65% of the variance.
Gender was included as a dichotomous variable, and age was directly asked (mean 50.2, SD 17.0).
Personality was measured with the Quick Big Five personality questionnaire [ 34 ], which consists of 30 adjectives reflecting a valid and reliable measure of the Big Five traits. Participants were asked to rate the extent to which a particular adjective applied to them on a 7-point scale, ranging from completely untrue to completely true. The Cronbach α values for the five traits were .89 for agreeableness, .88 for neuroticism, .88 for conscientiousness, .87 for introversion, and .81 for openness.
Physical health, mental health, and health perception were measured with the Dutch version of the Medical Outcomes Study (MOS) Short-Form General Health Survey (SF-20) [ 35 ]. This instrument enables respondents to assess their general health and generates composite summary scores representing different types of health. We normalized the scales, with higher scores representing better functioning. Physical health was measured with 5 items (2-point scale; α=.89; mean 1.75, SD 0.34), mental health with 5 items (5-point scale; α=.85; mean 3.65, SD 0.77), and health perception with 5 items (5-point scale; α=.86; mean 3.39, SD 0.85).
To measure traditional literacy, we used the validated 11-item Diagnostic Illiteracy Scale [ 36 ]. Sample items included “I have difficulties with reading and understanding information from my municipality” and “I find it difficult to read and understand my telephone bill.” A 5-point agreement scale was used. Scores on the scale exhibited high internal consistency. Items were recoded so that higher scores corresponded with higher levels of literacy (α=.94; mean 4.33, SD 0.71).
To assess education, data regarding degrees earned were collected and used to create three groups: low (primary), middle (secondary), and high (tertiary) educational achievement.
Economic resources were objectively measured by seeking the annual family income in the last 12 months. Twelve categories were recoded into three categories of low for <€30,000 (US $35,503.50), middle for €30,000 to €70,000 (US $35,503.50 to $82841.50), and high for >€70,000 (>US $82841.50). For social resources, we used the MOS Social Support Survey [ 37 ]. Respondents completed 18 items covering emotional support (eg, “Someone you can count on to listen when you need to talk”), informational support (eg, “Someone to give you good advice about a crisis”), and tangible support (eg, “Someone to help you if you were confined to bed”). All items were rated on a 5-point Likert scale with anchors of none of the time (1) and most of the time (5). We computed an aggregate measure of support availability (α=.96; mean 3.83, SD 0.85).
Attitudinal internet access was measured by three items adapted from the Digital Motivation Scale [ 38 ]. A 5-point agreement scale was used, and all items were balanced for the direction of response (α=.74; mean 4.10, SD 0.70). An example statement is “Technologies such as the internet and mobile phones make life easier.” To measure material internet access, we considered 7 devices used to connect to the internet (mean 3.43, SD 1.53). Included were desktop computer, laptop computer, tablet, smartphone, smart TV, game console, and smart device (eg, activity tracker). Finally, skills internet access was adapted from the conceptual idea behind the Internet Skills Scale [ 32 ]. We proposed 30 items reflecting operational, information navigation, social, and creative internet skills. A 20-item single skills construct resulted from the principal component analysis. All items were scored on a 5-point scale that ranged from “not at all true of me” to “very true of me” and exhibited high internal consistency (α=.96; mean 3.67, SD 0.97). Example items are “I know how to open downloaded files,” “I find it hard to decide what the best keywords are to use for online searches,” and “I know which information I should and shouldn’t share online.”
Statistical Analysis
To test the hypotheses and account for the sequentiality between COVID-19–related internet uses and outcomes, hierarchical regression analyses were used. In the first model, we tested our hypotheses by analyzing the significant determinants for the two types of COVID-19–related internet uses and the two corresponding outcomes. In the second model, we sought to determine the changes in the significance of the determinants after the internet uses were added to the models.
Table 1 provides an overview of the sample of people surveyed in the study.
Table 2 shows the mean scores of the survey questions related to internet uses and internet outcomes.
The first goal of this paper was addressed in the first model, as presented in Table 3 , where several significant determinants for COVID-19 uses and outcomes are revealed.
a Low: primary; middle: secondary; high: tertiary.
a COVID-19: coronavirus disease.
b RIVM: Rijksinstituut voor Volksgezondheid en Milieu.
Table 3 shows that men are more likely to be involved in COVID-19–related communication uses. Age is positively related to COVID-19–related information uses and negatively related to COVID-19 communication uses and outcomes. Concerning personality traits, agreeableness is negatively related to COVID-19–related information and communication uses and to communication outcomes. Neuroticism is positively related to both uses and to communication outcomes.
Conscientiousness is not related to any of the uses or outcomes. Introversion is negatively related to COVID-19–related communication uses and outcomes, suggesting that this is performed more by extraverted people. Finally, openness relates positively to information uses and to both outcomes.
The results further show that concerning the three health indicators, physical health is negatively related to communication uses and outcomes. Mental health did not contribute to any uses or outcomes. Health perception contributes positively to information uses and to both outcomes.
Traditional literacy has a positive relationship with information-type uses and with both outcomes, and education has a positive relationship with COVID-19–related information and communication uses. Economic and social resources were not related to any COVID-19 uses or outcomes.
Attitudinal internet access is positively related to information uses and outcomes but is negatively related to communication uses and outcomes. Material internet access contributes positively to all uses and outcomes, and skills access has a positive relationship with all uses and outcomes. Table 4 provides an overview of the hypotheses.
a ns: no significant contribution.
b –: significant negative contribution.
c R: reject.
d +: significant positive contribution.
e PS: partial support.
f S: support.
Finally, to address the second goal of the study, we tested what would happen to the contribution of the outcome determinants when the corresponding uses were added to the analyses (Model 2: see Tables 5 and 6 ). Adding the uses significantly increased the explained variance; also, several of the relationships between personal and positional categories and between resources and outcomes became insignificant. The relationships that remained significant for information outcomes were age, health perception, and traditional literacy. Furthermore, attitudinal internet access remained significant. For communication outcomes, the relationships that remained significant were age, openness, and traditional literacy.
a N/A: not applicable.
Principal Results
This paper aims to provide a comprehensive examination of digital inequality in the case of an unprecedented health pandemic. The first goal of the study was to reveal how inequality manifests itself in COVID-19–related internet information and communication uses and outcomes. The findings revealed several relationships between the background variables and the two types of internet uses and outcomes.
Older people were found to be less equipped to use the internet for information and communication during a time of crisis. However, they were more likely to engage in information-type COVID-19–related internet uses, possibly because they are at greatest risk from the disease [ 11 ]. This did not result in more beneficial information outcomes. Internet skills play an important role in translating internet uses into beneficial internet outcomes [ 39 ], and prior research has shown that older people have lower internet skill levels in general [ 32 ]. The finding that older people are less likely to perform communication activities or obtain communication-related outcomes is in line with prior studies [ 15 ]; however, these outcomes are important, as older people are more at risk of having severe complications when diagnosed with COVID-19. Regarding gender, contrary to general internet use, men were found to be more likely to engage in communication-type COVID-19–related internet uses during the crisis than women. A possible explanation is that men and women may respond to crisis news in different ways [ 40 ].
The positive effect of neuroticism suggests that a tendency to experience negative emotions such as anger, anxiety, or depression fuels the need to turn to the internet for COVID-19–related information and communication. People who score higher on the neuroticism scale may be more in need of guidelines on how to mitigate risks or may need more support from others to be comforted. Also, the openness trait supports both information and communication internet use and outcomes. A possible explanation is that a major crisis triggers adventure, unconventional ideas, imagination, awareness of feelings, curiosity, or a variety of experiences, all of which are aspects linked to high openness [ 21 ]. The negative contribution of agreeableness raises questions. A possible explanation is that agreeable people are less frequently sought out for communication activities. However, the internet may also be a very inviting environment for less agreeable people. Conscientiousness did not appear to be a significant determinant. People who are more stubborn and focused or more flexible and spontaneous both appear to be involved in information- and communication-type COVID-19–related internet uses and outcomes. Extroversion emerged as a trait that supports using the internet for communication uses and outcomes; this can be expected, as extroversion is marked by pronounced engagement with the external world [ 21 ].
Although we expected that psychological distress would play a role in the current context, as there would be a relatively high need for information and support from others, mental health did not surface as a significant contributor. Furthermore, we did find that physical health problems appear to encourage web-based COVID-19–related communication uses and outcomes. The most likely explanation is that people with underlying health problems are more at risk (and thus more bound to their homes) and thus have higher needs for communication with friends and family. A possible reason for the positive effect of health perception is that people who believe their personal health to be good may feel better equipped to support others during the COVID-19 pandemic.
As expected, traditional literacy played an important role. A lack of general ability to read, write, and understand text further disadvantages individuals in the case of the COVID-19 pandemic, as they have less access to information and communication sources. COVID-19 is a new, unknown, and complicated disease with characteristics that are often described in difficult medical language that is not easy to read. Similar findings were found for educational attainment. Research has long shown that education is one of the most prominent positional variables in digital divide research [ 7 ]. However, our results suggest that when less educated individuals are involved in information and communication internet uses, they are as likely to achieve the corresponding outcomes as people with higher levels of education. This is an important finding for designing interventions for those of lower levels of education.
An effect of economic resources did not emerge in relation to COVID-19–related internet uses and outcomes. The participants’ income did not make a difference in obtaining information and communication COVID-19–related internet outcomes. Earlier research often showed that income is especially important to consumptive and work-related internet uses [ 17 ], topics that are not considered here. Unexpectedly, social resources were not found to be influential. Apparently, a person who has an offline support network will not necessarily turn more to web-based information and communication support during a crisis.
Concerning internet access, we can first conclude that a person’s internet attitude is important for engaging in information uses and gaining information outcomes. Unexpectedly, there was a negative contribution of internet attitude to communication uses and outcomes, suggesting that individuals who have a negative evaluation of the internet in general are more likely to engage in communication uses in the event of a major crisis. Both material and skills internet access played important roles in achieving all uses and outcomes. Using a higher diversity of devices was related to higher COVID-19–related internet use and to more outcomes. The opportunities devices offer are known to be related to inequalities in internet uses and outcomes. As each device offers its own specific characteristics and advantages, a higher diversity of devices supports a larger range of use activities and outcomes [ 31 ]. Furthermore, internet skills play a fundamental role in COVID-19–related uses and in obtaining beneficial outcomes [ 12 ].
In this paper, several indicators surfaced for people’s web-based COVID-19–related uses and outcomes. The variety of important indicators raises the question of whether general policies to address digital inequalities in a time of crisis will be effective. The complex relationships between the different indicators on one hand and internet uses and outcomes on the other hand demand more focused policies, such as those related to health indicators and the need for information to enhance health outcomes. This study reveals that the greater an individual’s existing advantages, the more they benefit from the internet at a time of crisis; the converse is true as well. Marginalized people are likely to have fewer types of access available to take actions, behave as requested, or be comforted by help, creating a vicious cycle where already marginalized groups are further marginalized in a time of crisis.
To end on a positive note, the situation may become slightly less complex when we address the second goal of this paper. When people engage in information and communication internet uses in a crisis situation, their personal characteristics become less important to achieving the corresponding outcomes. This suggests that to achieve information and communication outcomes, policy or research should especially focus on encouraging people to engage in the corresponding internet uses, as we can assume to some extent that engagement with information and communication-related COVID-19 uses is the best way to achieve beneficial outcomes at a time when they are most needed.
Limitations
The current study was conducted in the Netherlands, a country whose citizens have very high household internet penetration and high levels of educational attainment. Although differences in educational background and income are present and were taken into consideration, the observed inequalities may be even stronger in countries with a less homogeneous population. Given that the greatest burden of deaths has been in countries with very diverse populations, race and associated factors are likely to play a major role.
The aim of this study was to provide a broader picture of inequality in relation to how the internet is used in the case of a major global health crisis. A broad range of determinants was considered, and the relative importance of these indicators was revealed. However, a deeper understanding and further investigation to reveal the exact underlying mechanisms that cause these indicators to play a role would provide additional explanations. This suggests that further qualitative research is needed not only to obtain in-depth understanding of the mechanisms but also to understand the consequences of the observed inequalities to complement the findings of the current quantitative approach.
Conclusions
Digital inequality is a major concern among national and international scholars and policy makers. In this paper, we aimed to provide a broader understanding in the case of a major health pandemic by using the ongoing COVID-19 crisis as a context for empirical work. Several groups of people were identified as vulnerable, such as older people and people with lower levels of education, physical health problems, higher levels of neuroticism, low literacy levels, and low levels of trust. The general conclusion is that people who are already relatively advantaged are more likely to use the information and communication opportunities provided by the internet to their benefit in a health pandemic, while more disadvantaged individuals are less likely to benefit. Therefore, the COVID-19 crisis is also an enforcer of existing inequalities.
Conflicts of Interest
None declared.
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Abbreviations
Edited by G Eysenbach; submitted 11.05.20; peer-reviewed by S LaValley, T Hale; comments to author 13.07.20; revised version received 16.07.20; accepted 03.08.20; published 20.08.20
©Alexander JAM van Deursen. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 20.08.2020.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
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What is Qualitative research ? - "an approach to research that is primarily concerned with studying the nature, quality, and meaning of human experience. It asks questions about how people make sense of their experiences, how people talk about what has happened to them and others, and how people experience, manage, and negotiate situations they find themselves in. Qualitative research is interested both in individual experiences and in the ways in which people experience themselves as part of a group. Qualitative data take the form of accounts or observations, and the findings are presented in the form of a discussion of the themes that emerged from the analysis. Numbers are very rarely used in qualitative research."
Willig, C. (2016). Qualitative research. In L. H. Miller (Ed.), The Sage encyclopedia of theory in psychology . Thousand Oaks, CA: Sage
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Effects of the COVID-19 pandemic on medical students: a multicenter quantitative study
- Aaron J. Harries ORCID: orcid.org/0000-0001-7107-0995 1 ,
- Carmen Lee 1 ,
- Lee Jones 2 ,
- Robert M. Rodriguez 1 ,
- John A. Davis 2 ,
- Megan Boysen-Osborn 3 ,
- Kathleen J. Kashima 4 ,
- N. Kevin Krane 5 ,
- Guenevere Rae 6 ,
- Nicholas Kman 7 ,
- Jodi M. Langsfeld 8 &
- Marianne Juarez 1
BMC Medical Education volume 21 , Article number: 14 ( 2021 ) Cite this article
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The COVID-19 pandemic disrupted the United States (US) medical education system with the necessary, yet unprecedented Association of American Medical Colleges (AAMC) national recommendation to pause all student clinical rotations with in-person patient care. This study is a quantitative analysis investigating the educational and psychological effects of the pandemic on US medical students and their reactions to the AAMC recommendation in order to inform medical education policy.
The authors sent a cross-sectional survey via email to medical students in their clinical training years at six medical schools during the initial peak phase of the COVID-19 pandemic. Survey questions aimed to evaluate students’ perceptions of COVID-19’s impact on medical education; ethical obligations during a pandemic; infection risk; anxiety and burnout; willingness and needed preparations to return to clinical rotations.
Seven hundred forty-one (29.5%) students responded. Nearly all students (93.7%) were not involved in clinical rotations with in-person patient contact at the time the study was conducted. Reactions to being removed were mixed, with 75.8% feeling this was appropriate, 34.7% guilty, 33.5% disappointed, and 27.0% relieved.
Most students (74.7%) agreed the pandemic had significantly disrupted their medical education, and believed they should continue with normal clinical rotations during this pandemic (61.3%). When asked if they would accept the risk of infection with COVID-19 if they returned to the clinical setting, 83.4% agreed.
Students reported the pandemic had moderate effects on their stress and anxiety levels with 84.1% of respondents feeling at least somewhat anxious. Adequate personal protective equipment (PPE) (53.5%) was the most important factor to feel safe returning to clinical rotations, followed by adequate testing for infection (19.3%) and antibody testing (16.2%).
Conclusions
The COVID-19 pandemic disrupted the education of US medical students in their clinical training years. The majority of students wanted to return to clinical rotations and were willing to accept the risk of COVID-19 infection. Students were most concerned with having enough PPE if allowed to return to clinical activities.
Peer Review reports
The COVID-19 pandemic has tested the limits of healthcare systems and challenged conventional practices in medical education. The rapid evolution of the pandemic dictated that critical decisions regarding the training of medical students in the United States (US) be made expeditiously, without significant input or guidance from the students themselves. On March 17, 2020, for the first time in modern US history, the Association of American Medical Colleges (AAMC), the largest national governing body of US medical schools, released guidance recommending that medical students immediately pause all clinical rotations to allow time to obtain additional information about the risks of COVID-19 and prepare for safe participation in the future. This decisive action would also conserve scarce resources such as personal protective equipment (PPE) and testing kits; minimize exposure of healthcare workers (HCWs) and the general population; and protect students’ education and wellbeing [ 1 ].
A similar precedent was set outside of the US during the SARS-CoV1 epidemic in 2003, where an initial cluster of infection in medical students in Hong Kong resulted in students being removed from hospital systems where SARS surfaced, including Hong Kong, Singapore and Toronto [ 2 , 3 ]. Later, studies demonstrated that the exclusion of Canadian students from those clinical environments resulted in frustration at lost learning opportunities and students’ inability to help [ 3 ]. International evidence also suggests that medical students perceive an ethical obligation to participate in pandemic response, and are willing to participate in scenarios similar to the current COVID-19 crisis, even when they believe the risk of infection to themselves to be high [ 4 , 5 , 6 ].
The sudden removal of some US medical students from educational settings has occurred previously in the wake of local disasters, with significant academic and personal impacts. In 2005, it was estimated that one-third of medical students experienced some degree of depression or post-traumatic stress disorder (PTSD) after Hurricane Katrina resulted in the closure of Tulane University School of Medicine [ 7 ].
Prior to the current COVID-19 pandemic, we found no studies investigating the effects of pandemics on the US medical education system or its students. The limited pool of evidence on medical student perceptions comes from two earlier global coronavirus surges, SARS and MERS, and studies of student anxiety related to pandemics are also limited to non-US populations [ 3 , 8 , 9 ]. Given the unprecedented nature of the current COVID-19 pandemic, there is concern that students may be missing out on meaningful educational experiences and months of clinical training with unknown effects on their current well-being or professional trajectory [ 10 ].
Our study, conducted during the initial peak phase of the COVID-19 pandemic, reports students’ perceptions of COVID-19’s impact on: medical student education; ethical obligations during a pandemic; perceptions of infection risk; anxiety and burnout; willingness to return to clinical rotations; and needed preparations to return safely. This data may help inform policies regarding the roles of medical students in clinical training during the current pandemic and prepare for the possibility of future pandemics.
We conducted a cross-sectional survey during the initial peak phase of the COVID-19 pandemic in the United States, from 4/20/20 to 5/25/20, via email sent to all clinically rotating medical students at six US medical schools: University of California San Francisco School of Medicine (San Francisco, CA), University of California Irvine School of Medicine (Irvine, CA), Tulane University School of Medicine (New Orleans, LA), University of Illinois College of Medicine (Chicago, Peoria, Rockford, and Urbana, IL), Ohio State University College of Medicine (Columbus, OH), and Zucker School of Medicine at Hofstra/Northwell (Hempstead, NY). Traditional undergraduate medical education in the US comprises 4 years of medical school with 2 years of primarily pre-clinical classroom learning followed by 2 years of clinical training involving direct patient care. Study participants were defined as medical students involved in their clinical training years at whom the AAMC guidance statement was directed. Depending on the curricular schedule of each medical school, this included intended graduation class years of 2020 (graduating 4th year student), 2021 (rising 4th year student), and 2022 (rising 3rd year student), exclusive of planned time off. Participating schools were specifically chosen to represent a broad spectrum of students from different regions of the country (West, South, Midwest, East) with variable COVID-19 prevalence. We excluded medical students not yet involved in clinical rotations. This study was deemed exempt by the respective Institutional Review Boards.
We developed a survey instrument modeled after a survey used in a previously published peer reviewed study evaluating the effects of the COVID-19 pandemic on Emergency Physicians, which incorporated items from validated stress scales [ 11 ]. The survey was modified for use in medical students to assess perceptions of the following domains: perceived impact on medical student education; ethical beliefs surrounding obligations to participate clinically during the pandemic; perceptions of personal infection risk; anxiety and burnout related to the pandemic; willingness to return to clinical rotations; and preparation needed for students to feel safe in the clinical environment. Once created, the survey underwent an iterative process of input and review from our team of authors with experience in survey methodology and psychometric measures to allow for optimization of content and validity. We tested a pilot of our preliminary instrument on five medical students to ensure question clarity, and confirm completion of the survey in approximately 10 min. The final survey consisted of 29 Likert, yes/no, multiple choice, and free response questions. Both medical school deans and student class representatives distributed the survey via email, with three follow-up emails to increase response rates. Data was collected anonymously.
For example, to assess the impact on students’ anxiety, participants were asked, “How much has the COVID-19 pandemic affected your stress or anxiety levels?” using a unipolar 7-point scale (1 = not at all, 4 = somewhat, 7 = extremely). To assess willingness to return to clinical rotations, participants were asked to rate on a bipolar scale (1 = strongly disagree, 2 = disagree, 3 = somewhat disagree, 4 = neither disagree nor agree, 5 = somewhat agree, 6 = agree, and 7 = strongly agree) their agreement with the statement: “to the extent possible, medical students should continue with normal clinical rotations during this pandemic.” (Survey Instrument, Supplemental Table 1 ).
Survey data was managed using Qualtrics hosted by the University of California, San Francisco. For data analysis we used STATA v15.1 (Stata Corp, College Station, TX). We summarized respondent characteristics and key responses as raw counts, frequency percent, medians and interquartile ranges (IQR). For responses to bipolar questions, we combined positive responses (somewhat agree, agree, or strongly agree) into an agreement percentage. To compare differences in medians we used a signed rank test with p value < 0.05 to show statistical difference. In a secondary analysis we stratified data to compare questions within key domains amongst the following sub-groups: female versus male, graduation year, local community COVID-19 prevalence (high, medium, low), and students on clinical rotations with in-person patient care. This secondary analysis used a chi square test with p value < 0.05 to show statistical difference between sub-group agreement percentages.
Of 2511 students contacted, we received 741 responses (29.5% response rate). Of these, 63.9% of respondents were female and 35.1% were male, with 1.0% reporting a different gender identity; 27.7% of responses came from the class of 2020, 53.5% from the class of 2021, and 18.7% from the class of 2022. (Demographics, Table 1 ).
Most student respondents (74.9%) had a clinical rotation that was cut short or canceled due to COVID-19 and 93.7% reported not being involved in clinical rotations with in-person patient contact at the time of the study. Regarding students’ perceptions of cancelled rotations (allowing for multiple reactions), 75.8% felt this was appropriate, 34.7% felt guilty for not being able to help patients and colleagues, 33.5% felt disappointed, and 27.0% felt relieved.
Most students (74.7%) agreed that their medical education had been significantly disrupted by the pandemic. Students also felt they were able to find meaningful learning experiences during the pandemic (72.1%). Free response examples included: taking a novel COVID-19 pandemic elective course, telehealth patient care, clinical rotations transitioned to virtual online courses, research or education electives, clinical and non-clinical COVID-19-related volunteering, and self-guided independent study electives. Students felt their medical schools were doing everything they could to help students adjust (72.7%). Overall, respondents felt the pandemic had interfered with their ability to develop skills needed to prepare for residency (61.4%), though fewer (45.7%) felt it had interfered with their ability to apply to residency. (Educational Impact, Fig. 1 ).
Perceived educational impacts of the COVID-19 pandemic on medical students
A majority of medical students agreed they should be allowed to continue with normal clinical rotations during this pandemic (61.3%). Most students agreed (83.4%) that they accepted the risk of being infected with COVID-19, if they returned. When asked if students should be allowed to volunteer in clinical settings even if there is not a healthcare worker (HCW) shortage, 63.5% agreed; however, in the case of a HCW shortage only 19.5% believed students should be required to volunteer clinically. (Willingness to Participate Clinically, Fig. 2 ).
Willingness to participate clinically during the COVID-19 pandemic
When asked if they perceived a moral, ethical, or professional obligation for medical students to help, 37.8% agreed that medical students have such an obligation during the current pandemic. This is in contrast to their perceptions of physicians: 87.1% of students agreed with a physician obligation to help during the COVID-19 pandemic. For both groups, students were asked if this obligation persisted without adequate PPE: only 10.9% of students believed medical students had this obligation, while 34.0% agreed physicians had this obligation. (Ethical Obligation, Fig. 3 ).
Ethical obligation to volunteer during the COVID-19 pandemic
Given the assumption that there will not be a COVID-19 vaccine until 2021, students felt the single most important factor in a safe return to clinical rotations was having access to adequate PPE (53.3%), followed by adequate testing for infection (19.3%) and antibody testing for possible immunity (16.2%). Few students (5%) stated that nothing would make them feel comfortable until a vaccine is available. On a 1–7 scale (1 = not at all, 4 = somewhat, 7 = extremely), students felt somewhat prepared to use PPE during this pandemic in the clinical setting, median = 4 (IQR 4,6), and somewhat confident identifying symptoms most concerning for COVID-19, median = 4 (IQR 4,5). Students preferred to learn about PPE via video demonstration (76.7%), online modules (47.7%), and in-person or Zoom style conferences (44.7%).
Students believed they were likely to contract COVID-19 in general (75.6%), independent of a return to the clinical environment. Most respondents believed that missing some school or work would be a likely outcome (90.5%), and only a minority of students believed that hospitalization (22.1%) or death (4.3%) was slightly, moderately, or extremely likely.
On a 1–7 scale (1 = not at all, 4 = somewhat, and 7 = extremely), the median (IQR) reported effect of the COVID-19 pandemic on students’ stress or anxiety level was 5 (4, 6) with 84.1% of respondents feeling at least somewhat anxious due to the pandemic. Students’ perceived emotional exhaustion and burnout before the pandemic was a median = 2 (IQR 2,4) and since the pandemic started a median = 4 (IQR 2,5) with a median difference Δ = 2, p value < 0.001.
Secondary analysis of key questions revealed statistical differences between sub-groups. Women were significantly more likely than men to agree that the pandemic had affected their anxiety. Several significant differences existed for the class of 2020 when compared to the classes of 2021 and 2022: they were less likely to report disruptions to their education, to prefer to return to rotations, and to report an effect on anxiety. There were no significant differences with students who were still involved with in-person patient care compared with those who were not. In comparing areas with high COVID-19 prevalence at the time of the survey (New York and Louisiana) with medium (Illinois and Ohio) and low prevalence (California), students were less likely to report that the pandemic had disrupted their education. Students in low prevalence areas were most likely to agree that medical students should return to rotations. There were no differences between prevalence groups in accepting the risk of infection to return, or subjective anxiety effects. (Stratification, Table 2 ).
The COVID-19 pandemic has fundamentally transformed education at all levels - from preschool to postgraduate. Although changes to K-12 and college education have been well documented [ 12 , 13 ], there have been very few studies to date investigating the effects of COVID-19 on undergraduate medical education [ 14 ]. To maintain the delicate balance between student safety and wellbeing, and the time-sensitive need to train future physicians, student input must guide decisions regarding their roles in the clinical arena. Student concerns related to the pandemic, paired with their desire to return to rotations despite the risks, suggest that medical students may take on emotional burdens as members of the patient care team even when not present in the clinical environment. This study offers insight into how best to support medical students as they return to clinical rotations, how to prepare them for successful careers ahead, and how to plan for their potential roles in future pandemics.
Previous international studies of medical student attitudes towards hypothetical influenza-like pandemics demonstrated a willingness (80%) [ 4 ] and a perceived ethical obligation to volunteer (77 and 70%), despite 40% of Canadian students in one study perceiving a high likelihood of becoming infected [ 5 , 6 ]. Amidst the current COVID-19 pandemic, our participants reported less agreement with a medical student ethical obligation to volunteer in the clinical setting at 37.8%, but believed in a higher likelihood of becoming infected at 75.6%. Their willingness to be allowed to volunteer freely (63.5%) may suggest that the stresses of an ongoing pandemic alter students’ perceptions of the ethical requirement more than their willingness to help. Students overwhelmingly agreed that physicians had an ethical obligation to provide care during the COVID-19 pandemic (87.1%), possibly reflecting how they view the ethical transition from student to physician, or differences between paid professionals and paying for an education.
At the time our study was conducted, there were widespread concerns for possible HCW shortages. It was unclear whether medical students would be called to volunteer when residents became ill, or even graduate early to start residency training immediately (as occurred at half of schools surveyed). This timing allowed us to capture a truly unique perspective amongst medical students, a majority of whom reported increased anxiety and burnout due to the pandemic. At the same time, students felt that their medical schools were doing everything possible to support them, perhaps driven by virtual town halls and daily communication updates.
Trends in secondary analysis show important differences in the impacts of the pandemic. Women were more likely to report increased anxiety as compared to men, which may reflect broader gender differences in medical student anxiety [ 15 ] but requires more study to rule out different pandemic stresses by gender. Graduating medical students (class of 2020) overall described less impact on medical education and anxiety, a decreased desire to return to rotations, but equal acceptance of the risk of infection in clinical settings, possibly reflecting a focus on their upcoming intern year rather than the remaining months of undergraduate medical education. Since this class’s responses decreased overall agreement on these questions, educational impacts and anxiety effects may have been even greater had they been assessed further from graduation. Interestingly, students from areas with high local COVID-19 prevalence (New York and Louisiana) reported a less significant effect of the pandemic on their education, a paradoxical result that may indicate that medical student tolerance for the disruptions was greater in high-prevalence areas, as these students were removed at the same, if not higher, rates as their peers. Our results suggest that in future waves of the current pandemic or other disasters, students may be more patient with educational impacts when they have more immediate awareness of strains on the healthcare system.
A limitation of our study was the survey response rate, which was anticipated given the challenges students were facing. Some may not have been living near campus; others may have stopped reading emails due to early graduation or limited access to email; and some would likely be dealing with additional personal challenges related to the pandemic. We attempted to increase response rates by having the study sent directly from medical school deans and leadership, as well as respective class representatives, and by sending reminders for completion. The survey was not incentivized, and a higher response rate in the class of 2021 across all schools may indicate that students who felt their education was most affected were most likely to respond. We addressed this potential source of bias in the secondary analysis, which showed no differences between 2021 and 2022 respondents. Another limitation was the inherent issue with survey data collection of missing responses for some questions that occurred in a small number of surveys. This resulted in slight variability in the total responses received for certain questions, which were not statistically significant. To be transparent about this limitation, we presented our data by stating each total response and denominator in the Tables.
This initial study lays the groundwork for future investigations and next steps. With 72.1% of students agreeing that they were able to find meaningful learning in spite of the pandemic, future research should investigate novel learning modalities that were successful during this time. Educators should consider additional training on PPE use, given only moderate levels of student comfort in this area, which may be best received via video. It is also important to study the long-term effects of missing several months of essential clinical training and identifying competencies that may not have been achieved, since students perceived a significant disruption to their ability to prepare skills for residency. Next steps could be to study curriculum interventions, such as capstone boot camps and targeted didactic skills training, to help students feel more comfortable as they transition into residency. Educators must also acknowledge that some students may not feel comfortable returning to the clinical environment until a vaccine becomes available (5%) and ensure they are equally supported. Lastly, it is vital to further investigate the mental health effects of the pandemic on medical students, identifying subgroups with additional stressors, needs related to anxiety or possible PTSD, and ways to minimize these negative effects.
In this cross-sectional survey, conducted during the initial peak phase of the COVID-19 pandemic, we capture a snapshot of the effects of the pandemic on US medical students and gain insight into their reactions to the unprecedented AAMC national recommendation for removal from clinical rotations. Student respondents from across the US similarly recognized a significant disruption to their medical education, shared a desire to continue with in-person rotations, and were willing to accept the risk of infection with COVID-19. Our novel results provide a solid foundation to help shape medical student roles in the clinical environment during this pandemic and future outbreaks.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
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Aaron J. Harries, Carmen Lee, Robert M. Rodriguez & Marianne Juarez
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All authors made substantial contributions to the study and met the specific conditions listed in the BMC Medical Education editorial policy for authorship. All authors have read and approved the manuscript. AH as principal investigator contributed to study design, survey instrument creation, IRB submission for his respective medical school, acquisition of data and recruitment of other participating medical schools, data analysis, writing and editing the manuscript. CL contributed to background literature review, study design, survey instrument creation, acquisition of data, data analysis, writing and editing the manuscript. LJ contributed to study design, survey instrument creation, acquisition of data from his respective medical school and recruitment of other participating medical schools, data analysis, and editing the manuscript. RR contributed to study design, survey instrument creation, data analysis, writing and editing the manuscript. JD contributed to study design, survey instrument creation, recruitment of other participating medical schools, data analysis, and editing the manuscript. MBO contributed as individual site principal investigator obtaining IRB exemption acceptance and acquisition of data from her respective medical school along with editing the manuscript. KK contributed as individual site principal investigator obtaining IRB exemption acceptance and acquisition of data from her respective medical school along with editing the manuscript. NKK contributed as individual site co-principal investigator obtaining IRB exemption acceptance and acquisition of data from his respective medical school along with editing the manuscript. GR contributed as individual site co-principal investigator obtaining IRB exemption acceptance and acquisition of data from her respective medical school along with editing the manuscript. NK contributed as individual site principal investigator obtaining IRB exemption acceptance and acquisition of data from his respective medical school along with editing the manuscript. JL contributed as individual site principal investigator obtaining IRB exemption acceptance and acquisition of data from her respective medical school along with editing the manuscript. MJ contributed to study design, survey instrument creation, data analysis, writing and editing the manuscript.
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Correspondence to Aaron J. Harries or Marianne Juarez .
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This study was reviewed and deemed exempt by each participating medical school’s Institutional Review Board (IRB): University of California San Francisco School of Medicine, IRB# 20–30712, Reference# 280106, Tulane University School of Medicine, Reference # 2020–331, University of Illinois College of Medicine), IRB Protocol # 2012–0783, Ohio State University College of Medicine, Study ID# 2020E0463, Zucker School of Medicine at Hofstra/Northwell, Reference # 20200527-SOM-LAN-1, University of California Irvine School of Medicine, submitted self-exemption IRB form. In accordance with the IRB exemption approval, each survey participant received an email consent describing the study and their optional participation.
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Additional file 1: table s1..
Survey Instrument
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Harries, A.J., Lee, C., Jones, L. et al. Effects of the COVID-19 pandemic on medical students: a multicenter quantitative study. BMC Med Educ 21 , 14 (2021). https://doi.org/10.1186/s12909-020-02462-1
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Received : 29 July 2020
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DOI : https://doi.org/10.1186/s12909-020-02462-1
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