Gender Differences in COVID-19 Anxiety Syndrome Among Filipino Nursing Students

Results: Results showed that the composite score in the C19ASS was 3.92 (SD=.69) indicating a moderate to a high level of anxiety syndrome features associated with COVID-19 among nursing students. The mean scores in the preservation and avoidance factors were 3.94 (SD=.76) and 3.88 (SD=.91), respectively. Female nursing students had a significantly higher (p=.004) COVID-19 anxiety syndrome compared to male nursing students.


INTRODUCTION
COVID-19 is a very infectious and potentially lethal disease with an estimated global case fatality rate of 3.7% (Tee et al., 2020a). The disease outbreak has resulted in overwhelming changes in the lives of many (Nikčević & Spada, 2020). It has affected all sectors of society and the education sector was not exempted (Moralista & Oducado, 2020;Rabacal et al., 2020). It has caused not only a health catastrophe but social, economic, and educational crisis as well (Sugiyanto et al., 2020).
The COVID-19 outbreak was declared the sixth Public Health Emergency of International Concern under International Health Regulations that affected several countries around the world (Aylie et al., 2020;Levkovich & Shinan-Altman, 2021;Rabacal et al., 2020). As of 17 January 2021, there are already 93,194,922 recorded cases of COVID-19 worldwide (World Health Organization, 2021) and the number of confirmed COVID-19 cases in the Philippines has reached over half a million

MATERIALS AND METHOD
A cross-sectional research design was utilized in this study. A convenience sample of 175 nursing students was recruited for this study and completed the online survey in November 2020. Nursing students enrolled in the first semester of academic school year 2020-2021 were included in the study. Participants were reminded at the beginning of the survey that proceeding and completing the survey indicates voluntary consent to participate in the study. Anonymity and confidentiality were maintained throughout the study. The COVID-19 Anxiety Syndrome Scale (C-19ASS) by Nikčević & Spada (2020) was the primary measure used in this study. The C-19ASS is a 9-item self-report measure loading on two factors: preservation (C-19ASS-P) and avoidance . Participants were asked to indicate their level of agreement on each item using a 5-point Likert-type scale with answers ranging from "1-Not at all" to "5-Nearly https://doi.org/10.37341/jkg.v0i0.170 JURNAL KEPERAWATAN GLOBAL every day". Both the C-19ASS-P (6 items; α = .86) and the C-19ASS-A (3 items; α = .77) demonstrated acceptable levels of reliability (Nikčević & Spada, 2020). The C-19ASS had a reliability of α = .83 among Filipino graduate students (Oducado, Parreño-Lachica, et al., 2021). For this study, the overall C-19ASS had a reliability of α = .80 while the C-19ASS-P had α = .79 and the C-19ASS-A had α = .72. Higher scores indicate a higher level of anxiety syndrome. Data were analyzed using SPSS version 23. Test of normality revealed a p-value of .000. The Mann-Whitney U test was used to test for differences according to gender. A p-value of less than .05 was considered significant. Table 1 shows that the average age of the participants was 19.55 (SD=1.02). The majority were females (80.6%). The Level 1 or first-year participants were comprised of 37.7%, the Level 2 or second-year participants were 36%, and the Level 3 or third-year participants were 26.3%.  Table 2 shows the composite score in the C-19ASS was 3.92 (SD=.69). The mean scores in the preservation and avoidance factors were 3.94 (SD=.76) and 3.88 (SD=.91), respectively.  Table 3 shows that there were significant differences in the general COVID-19 anxiety syndrome of nursing students based on gender (p=.004). In addition, there were significant differences in the preservation subscale (p=.006), however, no significant differences in the avoidance domain (p=.083) according to gender.

DISCUSSION
This study investigated COVID-19 anxiety syndrome among nursing students. It was demonstrated that nursing students experienced moderate to high levels of COVID-19 anxiety syndrome as indicated by the above midpoint score obtained in the C-19ASS. Findings of other studies similarly reported prevalence of moderate to high levels of COVID-19 anxiety, stress, fear, extremely negative emotions, and other psychological distress among nursing students. It was found that moderate and severe anxiety was 42.8% and 13.1% respectively among nursing students in Israel (Savitsky et al., 2020b) while 22.9% and 18.1% respectively among nursing students in Nepal (Dangal & Bajracharya, 2020). Likewise, nursing students in Spain reported that stress increased substantially during lockdown (Gallego-Gómez et al., 2020). It was also found that Australian nursing students reported significantly higher levels of anxiety, difficulty sleeping, concentrating, and eating (Kochuvilayil et al., 2021). A moderate to a high level of fear was also noted among nursing students in the Philippines (Oducado, Tuppal et al., 2021). Recent studies also found that nursing students practiced avoidant behaviors to prevent COVID-19 transmission. For instance, among nursing students in Saudi Arabia (Begum, 2020) and Nigeria (Kanikwu & Nwazuruoke, 2020), the majority practiced COVID-19 prevention protocols, followed social distancing to avoid contact with infected persons, and avoided going to crowded places. The findings suggest that nursing students may experience mental health concerns related to the pandemic and that the COVID-19 crisis has resulted in unparalleled stressful situations among nursing students (Savitsky et al., 2020a). While it seems noteworthy that nursing students tend to follow health protocols that prevent virus transmission and students take appropriate preventive and control to break the chain of COVID-19 spread (Purnamasari & Raharyani, 2020), caution is warranted that this will not lead to obsessional thinking and become overly excessive resulting in psychological distress.
This study also demonstrated that female nursing students reported a higher level of COVID-19 anxiety syndrome compared to male nursing students. This result of this study indicates that women compared to men tend to be more avoidant and careful at the same time constantly monitor and worry more about COVID-19. This result is relatively consistent with other prior studies that found females tend to report higher levels of emotional reactions and preventive behaviors to COVID-19 than males. Women showed more severe anxiety and fear than men in a study conducted in China among nurses and nursing students (Huang et al., 2020). The anxiety level of female students was higher than males among nursing students in Israel (Savitsky et al., 2020b). It was also noted that the level of stress by females was higher than that of males in a study among nursing students in Turkey (Aslan & Pekince, 2020). Correspondingly, females were more prone to anxiety as compared to males among nursing students in Nepal (Dangal & Bajracharya, 2020). Likewise, female nursing students had higher fear and perceived COVID-19 impact than male nursing students in a study conducted in the Philippines (Guillasper et al., 2021;Oducado, Tuppal et al., 2021). Gender was also a factor that affected Chinese nursing students' COVID-19 https://doi.org/10.37341/jkg.v0i0.170 JURNAL KEPERAWATAN GLOBAL prevention behavior . A study in Israel furthermore revealed that women exhibited higher levels of precautionary behavior and emotional responses than men (Levkovich & Shinan-Altman, 2021). The result of this study may be attributed to biological and hormonal changes, sociocultural factors, emotional regulation, and gender trait differences among men and women (Aslan & Pekince, 2020;Huang et al., 2020;Oducado, Tuppal et al., 2021;Sugiyanto et al., 2020). Additionally, women may believe that being more careful and concerned can help reduce their risk of being severely affected by COVID-19 (Galasso et al., 2020). The finding suggests that female nursing students may require more support and guidance (Oducado et al., 2017) during a crisis like this COVID-19 pandemic.
This study is limited to the self-report of a convenient sample of nursing students in the Philippines. The results cannot be generalized to all nursing students in the country and abroad. Also, whether anxiety changes over time cannot be answered by the cross-sectional research design of this study. The researcher warrants caution in the use and interpretation of the findings of the current study.

CONCLUSION
This study highlighted that the global COVID-19 outbreak has resulted in extraordinary anxiety syndrome causing constant worrying, checking, monitoring of threat, fear, and avoidance among nursing students. The findings of this study suggest that the mental health of nursing students especially females requires focal attention during the pandemic and in times of crisis. Neglecting to look into the negative psychological impact of the COVID-19 crisis among students may result in unfavourable concerns. Nursing students may benefit from additional support and guidance during this pandemic. It may be necessary for academic nursing institutions to develop interventions that foster positive coping and to generate strategies that promote mental health to help allay the anxiety and stress of nursing students during the worldwide health crisis.