Hopelessness among Medical Students Caused Due to COVID-19 Pandemic Linked Educational Hiatus: A Case Study of Bursa Uludag University, Türkiye
, Guven Ozkaya 2, Ilker Mustafa Kafa 3, Shafiul Haque 4,5,6,* and Zuleyha Alper 1,*
Round 1
Reviewer 1 Report
Sustainability Review 2134438
This article examines using a validated measurement scale, the Beck Hopelessness Scale, during three periods of the COVID-19 pandemic (from March 2020 to July 2020). Additional data were collected on modifying factors such as socio-economic status, family problems, health problems, dearth of the working environment, etc. Although this reviewer has many criticisms of this article that are laid out below, the discussion is well-reasoned and logical and may contribute to the now substantial literature attempting to understand how medical and other students experienced the COVID-19 pandemic from the standpoint of stress, anxiety and hopelessness; but also resilience, resourcefulness and self-regulation and self-autonomy (not discussed in this article). The article must be edited by a professional editor as it uses syntax and grammar that are not standard British or American English.
This reviewer has some serious concerns about the overall hypotheses and interpretation of the results in this study. They have looked at a very narrow window of the multiyear COVID-19 pandemic that is still ongoing to this day that has been artificially termed “silent,” “proactive,” and “active.” It is unclear how the Medical School “crisis-response” strategies relate to the lived student experience. Did the students experience any significant changes on April 28th and July 7th compared to March 28th? Did synchronous training start on April 28 exactly along with asynchronous training? A timeline graph showing the dates of the survey and what actually happened to students in terms of how their lived medical school experience changed at the time they took each survey.
This reviewer is concerned that the changes seen on the Beck Hopelessness Scale have nothing to do with what the medical school was doing with the “crisis-response” and everything to do with the natural course of the pandemic that occurred in the first year of the pandemic. And this reviewer is surprised at how small some of the overall score changes were in the Beck Hopelessness Scale during the first 3 1/2 months of the pandemic, when overwhelm and fear of the unknown would be at its greatest.
The fact that there was no way to have a control group of medical students not exposed to the COVID-19 pandemic (although there are valuable pre-pandemic studies on stress and anxiety in medical students at the very same Medical School in Turkey, Edis et al 2017); and that the survey period was so short (3 ½ months) may account for the modest rise in the Beck Hopelessness Scale observed during the “proactive” period and may again have nothing to do with the institutional crisis-response and the implementation of asynchronous and synchronous online learning.
“This study was divided into three periods based on their dates and institutional crisis-respond strategies adopted at that time. The "Silent period," according to this, was the first period mainly dealt with meetings and planning and lasted until March 28, 2020 (when asynchronous training begun). During the second "Proactive period,", all the necessary preparations for synchronous training as well as asynchronous training applications were made until April 28. The "Active period" was the last period, which was ended on July 7, 2020, during which synchronous training applications and online evaluations were made.”
One of the most striking observations about this data set that to me is inexplicable is the fact that as seen in Table 2 for virtually all categories (financial problems, housing problems, family problems, health problems, lack of working environment, have no problems, etc.), there is a moderate rise in the factors identified in the Beck Hopelessness Scale from Silent to Proactive; and then a return to baseline levels in the Active period—all in the incredibly short period of 3 ½ months while we know the effects of the pandemic continued on with rising hospitalization and deaths throughout 2020 and beyond 2020, yet the authors data suggest that the factors of hopelessness returned essentially to normal just 3 ½ months after the begining of the -pandemic—how is this possible?
The RESULTS section is WAY TOO LONG and spends too much time on minor results of questionable significance. How do the authors know that these are just normal fluctuations due to unknown hidden factors caused by the pandemic. This reviewer is really struggling with the meaning, value and ultimate impact of these overall results. The results should be greatly condensed and just make observations about the salient findings, not diving into the weeds to explain myriad minor results.
Table 6 in the manuscript does not have male versus female data shown. What are you referring to then? Table 6: “In our study, the general scores of BHS were found to be higher in female students, which is consistent with the published literature (Table 6).”
“The factors (based on % rank) that played a role in impacting the hopelessness level of the Turkish medical students identified through this study were "lack of working environment", "socioeconomic problems", "family problems", "health problems", and "housing problems". In the surveys conducted in all the three periods, 50.4% of the students reported that they did not have any problem affecting the education process.” Based upon this observation in the Discussion, this reviewer is actually curious about what personality factors (resilience, resourcefulness, self-autonomy, etc.) might be responsible for the 50% of the individuals who reported no problems with respect to their education process during the pandemic—that 50.6% percent is just as remarkable if not more so than the moderate increase in the Beck Hopelessness Scale of those medical students who reported being affected by the COVID-19 pandemic.
This statement below really brings home the need in future studies for a mixed methods approach with focus groups and follow-up interviews at each of the three time periods so that data may be triangulated and one can go well beyond just speculation as to why these statistical differences were observed; as it is the authors have no real clue as to what is causing these differences, and this is also true for many of the other statistically significant differences observed.
“In studies conducted before COVID-19 pandemic, it is reported that prevalence of depression and anxiety of first and last grade students were higher than other grades. The most probable reason for this elevated depression and anxiety is the academic intensity of the first grade and the employment anxiety of the last grade students [28, 33]. To the best of our knowledge, this is the very first study reporting the appraisal of academic hopelessness levels in Turkish medical students with respect to different time periods of COVID-19 pandemic.
In our study, according to BHS total score and “Loss of motivation”, the estimations made during all the three periods, a significant difference was observed only between G1 and G4 periods. The BHS total score of G4 students was higher than that of G1 students. Based upon the results, it can be speculated that this is because, G4 students are at the beginning of their clinical education training and think that they haven’t learned enough basic medicine skills due to education hiatus linked with COVID-19 pandemic.”
Under the Figure Legends the authors have referred to them as Figures but the data presented in the PDF to this reviewer is all Tables, so please change the Figures to Tables in the Figure Legends.
Table Legends should go above each and every Table with asterisks for footnotes under the Tables. One should be able to completely interpret the data from just the Table legend at the top of the Table.
They have done no qualitative follow up such as interviews of some of these individuals so the entire results rest on survey results that are all self-reported.
Author titles and affiliations should be listed under the title. This is critical to establish that data from the current article has not been published previously or elsewhere by the same authors.
This manuscript requires full editing by a native English speaker as it has many unusual uses of the English language that must be corrected before publication.
Author Response
Dear Reviewer,
We thank you for your valuable feedback. The language of the article was rearranged. We respond to your criticism point by point so that the hypotheses and analyzes in the article can be better understood.
First of all, we would like to make an explanation to one point in particular. Our study was carried out in the early phase of the pandemic. It is possible to find studies based on this phase in the literature. The uncertainty in the early phase affected more than the general population, health care providers, who are the main actors in the fight against the pandemic, and medical students, who are the closest candidates for this struggle. Below you can find our point-by-point answers to your criticisms:
1. “The article must be edited by a professional editor as it uses syntax and grammar that are not standard British or American English.”
Done.
2. “Did the students experience any significant changes on April 28th and July 7th compared to March 28? Did synchronous training start on April 28 exactly along with asynchronous training? A timeline graph showing the dates of the survey and what actually happened to students in terms of how their lived medical school experience changed at the time they took each survey.”
As stated in paragraph 4 of page 3 of the article, the periods are determined not according to the case course of the pandemic, but according to the plans and actions of the institution regarding the educational process.
Silent period: March 13 - March 28 (The period when educational preparations are made. The students know nothing about educational policies of faculty)
Proactive period: 28 March-28 April (Asynchronous education period. )
Active period: 28 April - 7 July (Synchronous education and evaluation period)
So during the silent period, students were unaware of the upcoming educational program. Conversely, during the proactive and active periods, their education progressed synchronously or asynchronously.
3.“Reviewer is surprised at how small some of the overall score changes were in the Beck Hopelessness Scale during the first 3 1/2 months of the pandemic, when overwhelm and fear of the unknown would be at its greatest.”
We posit that this scenario lends support to the hypothesis that "clarification of faculty education policies may be a factor that reduces student hopelessness", which is one of the primary hypotheses of our article.
4. “One of the most striking observations about this data set that to me is inexplicable is the fact that as seen in Table 2 for virtually all categories (financial problems, housing problems, family problems, health problems, lack of working environment, have no problems, etc.), there is a moderate rise in the factors identified in the Beck Hopelessness Scale from Silent to Proactive; and then a return to baseline levels in the Active period—all in the incredibly short period of 3 ½ months while we know the effects of the pandemic continued on with rising hospitalization and deaths throughout 2020 and beyond 2020, yet the authors data suggest that the factors of hopelessness returned essentially to normal just 3 ½ months after the begining of the -pandemic—how is this possible?”
When controlling for situations known to impact student hopelessness using statistical methods (binary logistic regression) and accounting for the negative effects of the pandemic, our analysis suggests that the most significant factors influencing BHS scores are the elimination of uncertainty surrounding the educational process and the alignment of the process with student expectations. You can see in attached table (Table: Multivariable binary logistic regression analysis. We did not include this table in the article due to a large number of supplementary files. You may see in attached file.)
5. “The RESULTS section is WAY TOO LONG and spends too much time on minor results of questionable significance.”
The results section was shortened according to your suggestions.
6. “Table 6 in the manuscript does not have male versus female data shown. What are you referring to then? Table 6: “In our study, the general scores of BHS were found to be higher in female students, which is consistent with the published literature (Table 6).”
The table reference in the last line of paragraph 4 of the discussion section has been rearranged.
7. “The factors (based on % rank) that played a role in impacting the hopelessness level of the Turkish medical students identified through this study were "lack of working environment", "socioeconomic problems", "family problems", "health problems", and "housing problems". In the surveys conducted in all the three periods, 50.4% of the students reported that they did not have any problem affecting the education process.” Based upon this observation in the Discussion, this reviewer is actually curious about what personality factors (resilience, resourcefulness, self-autonomy, etc.) might be responsible for the 50% of the individuals who reported no problems with respect to their education process during the pandemic—that 50.6% percent is just as remarkable if not more so than the moderate increase in the Beck Hopelessness Scale of those medical students who reported being affected by the COVID-19 pandemic.”
It is recommended that future studies also include data on the personality factors of the participants/students for a more comprehensive understanding.
8. “This statement below really brings home the need in future studies for a mixed methods approach with focus groups and follow-up interviews at each of the three time periods so that data may be triangulated and one can go well beyond just speculation as to why these statistical differences were observed; as it is the authors have no real clue as to what is causing these differences, and this is also true for many of the other statistically significant differences observed.”
The scales were administered to varying numbers of students across the three time periods examined in this study. To enhance the statistical rigor of the study and reduce speculation, it would have been beneficial to analyze student responses to the questions using a longitudinal approach. However, this was not feasible due to the high number of survey studies and participants becoming increasingly unwilling to participate, resulting in an increase in missing data which would have hindered the ability to conduct a longitudinal analysis.
9. “Under the Figure Legends the authors have referred to them as Figures but the data presented in the PDF to this reviewer is all Tables, so please change the Figures to Tables in the Figure Legends.”
Although we uploaded the figures of the study to the system, we think that you did not receive them. We sent it back to the editor over the system.
10. “Table Legends should go above each and every Table with asterisks for footnotes under the Tables. One should be able to completely interpret the data from just the Table legend at the top of the Table.”
Done.
11. “They have done no qualitative follow up such as interviews of some of these individuals so the entire results rest on survey results that are all self-reported.”
We added this query to the limitations part of our study.
12. “Author titles and affiliations should be listed under the title. This is critical to establish that data from the current article has not been published previously or elsewhere by the same authors.”
Done.
13. “This manuscript requires full editing by a native English speaker as it has many unusual uses of the English language that must be corrected before publication.”
Done.
Author Response File: 
Author Response.docx
Reviewer 2 Report
The title accurately reflects the article's content. The keywords are precisely defined and capture the essence of the research. The abstract is an independent, informative summary of the entire article. In the introduction, the purpose of the study is clearly defined and presented. The author(s) conducted a comprehensive literature review. The research methodology is well-developed and thoroughly described. Each of the methods is described in detail. The outcomes align with the objective of the study. Results are evaluated critically and form the basis for conclusions.
This research is innovative from a scientific standpoint and contributes to international theory and practise.
This research paper examines hopelessness among medical students as a result of the COVID-19 pandemic based on the experience of Bursa Uludag University in Turkey. The topic seems original and relevant to the field of research, and it certainly fills a scientific gap. It uses the Beck Hopelessness Scale on Turkish medical students, and, as far as I'm informed, there are no similar works in contemporary literature. This is partly due to the fact that it is about a very current issue (COVID 19). The paper is conceptually and methodologically correct, meeting all requirements for a scientific paper. The conclusions are supported by the evidence and arguments presented. Additionally, the references are appropriate, and the entire research is presented at a scientific level.
Author Response
Dear Reviewer,
We thank you for your valuable feedback. The language of the article was rearranged. We have submitted the revised version of the article, incorporating the suggestions from all reviewers, to the relevant system.
Sincerely..
Zuleyha ALPER, MD
Reviewer 3 Report
1. The abstract does not provide an adequate digest of the study. Particularly in the methods (Research design and sampling technique, software, ….) and findings( status of Hopelessness in 3 different periods and samples characteristics , briefly) sections
2. Repeated Measure ANCOVA is suggested to assesses changes in the hopelessness levels thorough periods
3. It seems that the study has been conducted using longitudinal trends study.
4. Please provide theoretical and practical implications of the study
Author Response
Dear Reviewer,
We thank you for your valuable feedback. The language of the article was rearranged. Below you can find our point-by-point answers to your criticisms:
1. “The abstract does not provide an adequate digest of the study. Particularly in the methods (Research design and sampling technique, software, ….) and findings( status of Hopelessness in 3 different periods and samples characteristics , briefly) sections”
Due to the word limit of the abstract section, as per the journal's guidelines, all data related to the article could not be included. However, based on your suggestions, the editor will be consulted about the possibility of making an exception to this rule.
2-3. “Repeated Measure ANCOVA is suggested to assesses changes in the hopelessness levels thorough periods.
It seems that the study has been conducted using longitudinal trends study.”
Dear reviewer, thank you for your suggestion. However, conducting a longitudinal study following the students during the pandemic period proved to be challenging. There would have been a high probability of missing data, which would have led to difficulties in the statistical analysis. Additionally, we were unable to achieve the desired sample size. Due to the large number of survey studies conducted during the pandemic period, the response rate decreased significantly.
4. Please provide theoretical and practical implications of the study.
In emergency situations, it is crucial for institutions to establish policies that ensure the continuity of education. In developing countries like Turkey, crisis management, particularly sustainable policies, cannot be implemented as systematically as in developed countries. In this study, we attempted to address an exceptional process during an extraordinary period.
Round 2
Reviewer 1 Report
The manuscript has a much better flow but is still very long and densely written. In future authors should focus on a much shorter and more concise manuscript, which is an art in itself but greatly appreciated by readers and reviewers.
Reviewer 3 Report
Accept
