Letter to the editor
Sounira Mehri1 and Josef Finsterer 2
1Neurology Department, Neurology and Neurophysiology Center, Vienna, Austria (Correspondence to Josef Finsterer:
Citation: Mehri S, Finsterer J. Comments on: "COVID-19 and political instability may not be the only factors affecting students’ mental health". East Mediterr Health J. 2024;30(9):650–651. https://doi.org/10.26719/2024.30.9.650.
Keywords: posttraumatic stress, students, SARS-CoV-2 infection, mental health, political instability
Dear Editor,
We read with interest the article by Mohamed et al on a web-based cross-sectional study among students from 11 universities in Khartoum State, Sudan, which quantified the extent of post-traumatic stress disorder (PTSD) and coping strategies using the Impact of Events Scale-Revised (IES-R) and the Coping Orientation to Problems Experienced (brief-COPE) (1). The mean PTSD score was 31.2, and 36% of the students had a PTSD score of >37. The most commonly used coping strategies were religion and acceptance of the situation, while substance use was the least common. Students who had been infected with COVID-19 differed significantly in the use of coping strategies from those who had not been infected. In contrast, students whose family members or friends had been infected did not differ significantly in the use of coping strategies from students whose family members or friends had not been infected. The study is convincing; however, we would like to highlight a few shortcomings in the article.
First, the study was based on a questionnaire sent electronically. Electronic questionnaires have several disadvantages. It is difficult to ensure that the addressee who completed the questionnaire is actually the student and not a relative, friend or caregiver. Missing data cannot be added if an addressee does not answer all the questions, desirable new data cannot be generated and added to the data set, and it is difficult to verify the student's data.
Second, the authors did not mention whether the SARS-CoV-2 infection among the students, their relatives or friends was mild, moderate or severe. Knowing the severity of the SARS-CoV-2 infection is important because the burden of the infection strongly depends on whether the infected person had to be treated in an intensive care unit, for example, or was asymptomatic. Depending on the severity of the disease, IES-R and COPE can provide different results.
Third, there was no mention of how SARS-CoV-2 was diagnosed among the students. We should know how many of the students, relatives and friends were diagnosed with SARS-CoV-2 by RT-PCR, the antigen test or by measuring the concentration of neutralizing antibodies against the spike protein. It is crucial to know the type of test used, as the sensitivity of each test varies greatly.
Fourth, it was not mentioned how many were vaccinated against SARS-CoV-2. Vaccinated students may develop different coping strategies and may perform differently on IES-R and COPE than unvaccinated students. Therefore, it is imperative to know how many were fully or partially vaccinated and how many were not.
Fifth, the infection of the person in the IES-R and COPE can be assessed differently than the infection of father, mother, sisters, brothers, or friends. Therefore, the study should be repeated with students who were infected.
Sixth, the political situation and the pandemic may not be the only variables influencing IES-R and COPE scores. Students may also have experienced stress from studying, examinations, study conditions, living conditions, financial situation, partnership, and comorbidities.
In conclusion, we would like to say that this interesting study had limitations that relativize the results and their interpretation. Students' IES-R and COPE scores may not only depend on political circumstances and the pandemic, but also on numerous other factors. Addressing these limitations in a further study could strengthen the conclusions and reinforce the message of the study.
References
- Mohamed MS, Panda DS, Fadul FA, Saadeldin AA, Idriss MT, Khan YH, Hussain MA, Mallhi TH. Assessment of the impact of COVID-19 and political instability on mental health of university students in Sudan. East Mediterr Health J. 2024 May 14;30(4):272-282. doi: 10.26719/2024.30.4.272.
Response by the authors
Dear Editor
We would like to express our heartfelt gratitude to the authors of tis letter to the editor for reading our paper and providing invaluable comments. Their keen insights and constructive feedback, especially in noting the limitations of the study, are very useful for enhancing the quality of our current and future work on the subject.
We acknowledge the limitations associated with electronic questionnaires and that the intended respondents may not have filled the questionnaire, but this limitation is inherent in this method. Due to various restrictions imposed by the political turmoil in Sudan and the COVID-19 pandemic, we could not collect our data through face-to-face interviews. In this context, data collection via electronic questionnaire was the safest and most appropriate method. This approach gained wide popularity during the COVID-19 pandemic when movements were restricted to prevent the spread of the virus.
The authors highlighted the issue of severity of COVID-19 infection among respondents and their relatives and friends. We agree that the severity of the disease can affect the severity of mental health issues. Although this aspect was not assessed in our study, we will consider it in future research. We would like to note that self-reported severity of disease carries inherent limitations, as such reporting often raises questions about its legitimacy. We included only a few demographic variables because our questionnaire was lengthy, adding more questions may have resulted in lower response rates.
The authors also suggested explaining the methods used for diagnosing COVID-19. We did not include this information because it was beyond the scope of our research. Similarly, we did not include information about vaccination status because a pilot study had indicated the reluctance to share such information. Given the low vaccination rate in Sudan, it is reasonable to assume that most participants were either unvaccinated or were only partially vaccinated.
We would like to clarify that we assessed all demographic variables against PTSD and its 3 domains. Please refer to Table 2 in the published paper, which shows the association between participants infected with COVID-19 and those with infected relatives and friends.
Lastly, we acknowledge that various other factors, such as study burden, financial conditions, social status, and health problems, may influence IES-R and COPE scores. Unfortunately, our study did not capture these variables. As previously mentioned, the questionnaire was already lengthy, and we aimed to maximize response rate by limiting the number of demographic questions. However, we greatly appreciate these suggestions and will consider them in our current study.
