Health literacy and fear among Iranian medical students due to COVID‐19: An observational study

Abstract Introduction The coronavirus disease of the 2019 (COVID‐19) pandemic has created a sense of fear due to uncertainties in medical students’ personal and professional lives. Medical education is challenging and poses a more significant academic and emotional rigor when compared with other professional programs. With the COVID‐19 having limited treatment options, health literacy (HL) is crucial for managing and responding to the pandemic. This research aims to examine the impact of HL on COVID‐19‐associated fear among Iranian medical students. Methods A cross‐sectional study was conducted measuring the HL and fear of COVID‐19 using validated scales. Two hundred and seventy‐eight survey responses were received and analyzed descriptively by using SPSS software inferential statistics. Results Mean age of participants was 22.93 ± 5.427 years. The correlation between students’ total health literacy (HELIA) scores and their fear of COVID‐19 (FCV‐19S) scores was −0.279 (p value = .019). The FCV‐19S has a negative correlation with total HELIA in the group of females and males, single and married people, bachelor and MD students, and students living in rural areas and urban areas. The negative correlation of FCV‐19S with total HELIA in males and students who reside in rural areas was the only one that was not significant. In associate degree students, the correlation between FCV‐19S and total HELIA was positive but not significant. Education grades had a significant impact on FCV‐19S. Furthermore, the place of residence also had a significant impact on FCV‐19S. However, the gender and marital status did not significantly impact FCV‐19S. Conclusions The present study showed that students with higher HL scores had lesser fear of COVID‐19. The key stakeholders require several positive strategies to reduce fear and improve health, and such vital policies will assist in improving the students’ health and achieving the sustainable developmental goals.


INTRODUCTION
The novel coronavirus disease 2019  pandemic is having an adverse effect due to stress on the public (Committee, 2020;Khademian et al., 2021). On February 18, 2020, Iran became the second country globally to report two deaths due to COVID-19 after China (Rassouli et al., 2020). After the COVID-19 outbreak in Iran, lockdown, restrictions, and other measures were placed for controlling the disease throughout the country. Despite all efforts, as of December 3, 2021, more than six million COVID-19 cases and about 130,000 deaths due to the disease have been reported in Iran (Iran (Islamic Republic of) - WHO Coronavirus, n.d.). Such large-scale deaths and associated negative impacts of COVID-19 witnessed by the public have caused an aggravation of mental health problems (Shahriarirad et al., 2021).
In the current pandemic, the adverse effects had a major toll upon the students due to quarantines and other restrictions that have made their academia and life unpredictable. Furthermore, the rapid spread of COVID-19 (Ismail et al., 2020), social isolation, frustration, worries about contracting the illness, and concerns about friends and families were associated with negative emotions and psychological distress (Lin, 2020).
Conflicting messages and associated negative publicity in the social media about the COVID-19 pandemic have instilled many emotional reactions. Most commonly, emotional reactions like anger, guilt, fatigue, and tension are associated with COVID-19 due to the impact of COVID-19 on personal and professional lives (Sánchez et al., 2021).
One such negative emotion that has been highly associated with the current COVID-19 is the high amount of fear (Ahorsu et al., 2020b;Taghrir et al., 2020). There is ample evidence about the impact of fear on quality of life and mental health (Al Falasi & Ab Khan, 2020; Ghaderi et al., 2021). Medical students are often found resilient; however, they are not immune to such fears. Studies have shown that increased academic pressure and workload, financial concerns, and exposure to suffering and death have led to more stress and fear among medical students. (Dyrbye et al., 2006). The current pandemic led to the closure of universities, irregular schedules, transitioning to online medical education, cancellation of clinical placements, and fear of acquiring poor academic grades (Sandhu & de Wolf, 2020). Worries about future failure in medical careers coupled with nonacademic stressors due to health, fear of getting infected and transmitting it to others, especially their families and other personal factors, have led to fear among medical students (Alnaser et al., 2021;Marazziti et al., 2020).
Fear can have a bidirectional effect, both beneficial or detrimental to medical students' physical or mental health. Fear can be a motivational factor leading to increased risk of perception, risk aversion leading to washing hands, social isolation, and maintaining physical distancing (Broche-Pérez et al., 2020b). In contrast, fear can cause extreme psychological distress leading to higher levels of anxiety, depression, frustration, and inability to reason when making judgments among medical students and healthcare professionals (Shanafelt et al., 2020). Furthermore, evidence suggests fear of an epidemic can lead to a multitude of associated health problems (Zolotov et al., 2020) Several studies have studied anxiety and mental health-related problems among medical students in Iran (Nakhostin-Ansari et al., 2020;Nemati et al., 2020). Though fear and anxiety are interchangeable, there is conflicting evidence regarding their origin, response pattern, and time courses (Steimer, 2002;Sullivan, 1995). Perkins et al. (2007) argue both as separable emotions, with fear having a significant impact on performance than anxiety (Perkins et al., 2007). Furthermore, such a hypothesis is strengthened by a meta-analysis suggesting both emotions as distinct traits (Sylvers et al., 2011).
Health literacy (HL) is defined as the degree to which individuals can find, understand, and use information and services to inform healthrelated decisions and actions for themselves and others (Health literacy in Healthy People 2030 | Health.Gov, n.d.). Evidence suggests that strengthening HL can positively impact medical students' resilience, health behavior, and wellness (Barsell et al., 2018). HL would allow students to be more knowledgeable and informed. HL would allow students to be personally prepared and act in solidarity and achieve public health measures concerning COVID-19 (Paakkari & Okan, 2020).
Many studies in Iran have examined the psychological association of anxiety and depression associated with COVID-19 (Salari et al., 2020;Vahedian-Azimi et al., 2020), and few studies have examined the relationship of COVID-19 anxiety with HL (Mohammadkhah et al., 2021).
The current work was designed to examine the variables of HL that can affect fear related to COVID-19. The current work stemmed from the hypothesis that HL can affect fear during COVID-19. The study aimed to identify the impact of HL on COVID −19 fear among medical students.

Data collection
Data collection was done through a web-based questionnaire to assess the demographics, HL, and the level of fear associated with COVID-19.
The inclusion criteria were (1) being a medical student, (2) age 18 years or older, and (3) being able to understand the Persian language. All study participants met the inclusion criteria, and no one was excluded from the study. The study instrument was tested for clarity by conducting a pilot test sample on 56 participants. No changes were made to the survey instrument after pilot sampling. Later the participants were included in the final study. A convenience sampling method was used.
With a 5% level of significance and 80% power to detect a minimum of 5% difference, the total sample size required to test the null hypothesis of correlation between HL and fear of COVID-19 was calculated to be 194.
All 919 students studying at Jiroft University of Medical Sciences were invited to participate through a web-based questionnaire. A total of 278 students responded to participate in the study out of 919 students (response rate 30.25% participants).

Survey measures
1. Sociodemographic variables include gender, marital status (single, married), educational grade (associate, bachelors, doctor of medicine), and place of residence (rural, urban). 3. Fear of COVID-19 (FCV-19S) is a seven-item unidimensional, standardized, reliable, and valid tool that has been used to assess general community fear of the COVID-19 pandemic (Ahorsu et al., 2020b). Participants express their level of agreement using a fivepoint Likert scale (1 = strongly disagree, 2 = disagree, 3 = neither disagree nor agree, 4 = agree, and 5 = strongly agree). The minimum possible score for each question is 1, and the maximum is 5.
By adding the scores of each question, the total score can be calculated. A higher score indicates a greater fear of the COVID-19. The reliability and validity of the FCV-19S have been tested in several studies and found to be a valid and reliable tool with robust psychometrics (Ahorsu et al., 2020a;Bitan et al., 2020;Pang et al., 2020;Sakib et al., 2020;Soraci et al., 2020). In our study, the reliability of the FCV-19S measured had a CA of 0.86.

Data analysis
Statistical analysis was conducted using the SPSS computer package SPSS (Version 23.0) (SPSS, 2015). Data were summarized depending on the variable type, mean, standard deviation or frequency, and frequency percentage. The relationship between fear of COVID-19 and HL and its subdomains was examined using the Pearson correlation coefficient. Independent t-test and ANOVA tests were used to assess HL scores and fear of COVID-19 in the subgroups of demographic variables. The correlation coefficient, independent t-test, and ANOVA tests were two-tailed tests. A significance level of 5% was considered significant.

RESULTS
A total of 278 students completed the survey (student participation rate = 30.25%). The mean age of participants was 22.93 ± 5.427 years. The demographic data of respondents are summarized in Table 1.
HELIA had a good internal consistency and reliability with a Cronbach (p = .133) scores were higher in females than males, such difference was not statistically significant (Tables 2 and 3).
A one-way ANOVA test (Table 3)  The correlation between the total HELIA scores and its subdomains with the total FCV-19S score is reported in  score.
Because age grouping was not considered during the study, only the correlation between total HELIA and FCV-19S was reported by age in  in SPSS obtained zero for some statistical tests, but since there is no absolute zero measurement error, the p value is reported as p < .001.
p Value <.05 is considered significant, so according to the reported p value, the correlation between HELIA and FCV-19S scores is significant in females as opposed to males. In both males and females, irrespective of being single or married or living in rural or urban areas, the FCV-19S correlated negatively with total HELIA. However, such a negative correlation of FCV-19S with total HELIA was not significant in males and rural students. Among these, only the negative correlation of FCV-19S with total HELIA in males and rural students was not significant. The correlation between FCV-19S and total HELIA was positive but not significant r = 0.117 (p = .644) in associate degree students. In addition to the above, the correlation of FCV-19S with HELIA subdomains in terms of demographic variables was reported in Table 6.

DISCUSSION
In our study, we aimed to assess the effect of HL on COVID-19 associated fear among Iranian medical students. Our results highlight a COVID-19-associated fear among medical students. Also, there was an inverse correlation between HL scores among students and the

Variable Group
Total HELIA (mean ± SD) FCV-19S (mean ± SD)  (Bahramian et al., 2020;Chajaee et al., 2018), and hence can be inferred that a higher level of knowledge leads to higher HL. Therefore, in our study, students with sufficient knowledge were less afraid of COVID-19. It can be inferred that higher HL in students leads to less fear of COVID-19. Our findings are in line with a cross-sectional study conducted by Duplaga et al., who found that during the COVID-19 pandemic, people with higher HL scores experienced less future anxiety (Duplaga & Grysztar, 2021). In contrast, the study conducted by Shaukat et al. showed that HL did not predict fear of COVID-19 among university students in Pakistan (Shaukat et al., 2021). One reason for this discrepancy could be the precedence of Pakistan's religious beliefs and cultural issues over health awareness (Abdullah & Zakar, 2019).
Furthermore, the current study results showed that the HL score is highest among MD students, followed by the associate and bachelor students. In our study, those with higher education grades and higher HL scores had reduced fear of COVID-19, and our study is in line with Nguyen et al. (2020). Factors such as senior academic year, being male, and higher levels of HL may protect medical students from fear during the COVID-19 epidemic .
Interestingly, the total HELIA score and FCV-19S score in the married group were higher than those who were single. Also, in the married group, the negative correlation between HL and fear of COVID-19 is significantly higher than those who are single. One of the main reasons for higher scores of fear in the married group could be the fear of infecting their loved ones and their families or losing their families due to COVID-19 (Bernild et al., 2021;Mertens et al., 2020). Furthermore, females were more fearful than males. Our results highlight the fact that both the total HL score and the fear of COVID-19 score was higher in females when compared to males. However, such a difference was not statistically significant. Our study findings are in line with other studies that showed women were more fearful than men. This could be related to variation in gender responses to stress and life events (Alsharawy et al., 2021;Bitan et al., 2020;Broche-Pérez et al., 2020a;RS et al., 2020).
Current evidence suggests fear of the epidemics and pandemics may cause various health concerns (de Paiva Teixeira et al., 2020;Gaisenok, 2021;Ornell et al., 2020;Wessler et al., 2020). Such fears can impact increased mortality and morbidity along with the associated increased incidence of heart disease or diabetes (Pouwer et al., 2010;Wessler et al., 2020). In 2015, The global agenda was set by the United Nations and the members' states to achieve 17 sustainable developmental goals (SDGs) with 169 targets by 2030 (Assembly, 2015). Our study highlights the relationship between HL and COVID-19 fear and its impact on many SDGs and targets, in particular, SDG3 (good health and well-being), SDG4 (quality education), SDG8 (decent work and economic growth), and SDG17 (partnerships to achieve the goal). One of the critical objectives for policymakers is to reduce and alleviate the fear during the COVID-19 pandemic. HL is vital to such goals. The ability to read, comprehend, and act on appropriate healthrelated information is vital. Individual and social resilience can be developed by improving HL. Studies have found that having a high level of HL protects against depression and anxiety, especially during the pandemic (Duplaga & Grysztar, 2021;Matterne et al., 2021;Tran et al., 2020). Detrimental effects of poor HL could be due to inadequate understanding of the COVID-19 symptoms, infection prevention methods, difficulty finding information, misconception, and misinformation about COVID-19 and vaccination (Biasio et al., 2021;McCaffery et al., 2020). HL is considered a key factor in public health (Kindig et al., 2004). Though the current pandemic is limited by treatment, one such improvement is to mitigate the associated fears with the COVID-19 pandemic through education. This could be concerning the duration of quarantine, fears of infection, inadequate supplies of medications, daily provisions, finances or stigma, or need for information and services (Brooks et al., 2020;Paakkari & Okan, 2020).
The main strength of our study is that the study was conducted  Future research is required to investigate further how HL could be delivered effectively to improve perceptions, beliefs, and positive health outcomes.

CONCLUSION
There is a significant negative association between HL and fear of COVID-19 among medical students. Females have higher COVID-19associated fear than males. Students with higher HL scores had lower COVID-19 fear levels than the rest. The key stakeholders must implement several positive strategies to reduce fear and improve health.
Such key policies will assist in improving the health of the students and achieving the SDGs.

ACKNOWLEDGMENTS
Many thanks to the Jiroft University of Medical Sciences for helping with this research project. We would also want to express our gratitude to all of the physicians and nurses who have worked tirelessly to combat COVID-19 across the world.

CONFLICT OF INTEREST
The authors declare that there is no conflict of interest regarding the publication of this paper.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author at reasonable request.