Zoom fatigue related to online learning among medical students in Thailand: &nbsp;Prevalence, predictors, and association with depression

Veevarin Charoenporn; Sirashat Hanvivattanakul; Kanathip Jongmekwamsuk; Rinradee Lenavat; Korravit Hanvivattanakul; Thammanard Charernboon

doi:10.12688/f1000research.146084.2

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Research Article

Revised

Zoom fatigue related to online learning among medical students in Thailand: Prevalence, predictors, and association with depression

[version 2; peer review: 2 approved, 1 approved with reservations]

Veevarin Charoenporn^1,2, Sirashat Hanvivattanakul³, Kanathip Jongmekwamsuk⁴, Rinradee Lenavat³, Korravit Hanvivattanakul⁵, Thammanard Charernboon ^1,6

Veevarin Charoenporn^1,2, Sirashat Hanvivattanakul³, [...] Kanathip Jongmekwamsuk⁴, Rinradee Lenavat³, Korravit Hanvivattanakul⁵, Thammanard Charernboon ^1,6

PUBLISHED 27 Aug 2024

Author details Author details

¹ Department of Psychiatry, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
² Department of Psychiatry, Thammasat University Hospital, Pathumthani, Thailand
³ Faculty of Medicine, Thammasat University, Pathumthani, Thailand
⁴ Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
⁵ College of Dental Medicine, Rangsit University, Pathumthani, Thailand
⁶ Department of Clinical Epidemiology, Faculty of Medicine, Thammasat University, Pathumthani, Thailand

Veevarin Charoenporn
Roles: Conceptualization, Methodology, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Sirashat Hanvivattanakul
Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation

Kanathip Jongmekwamsuk
Roles: Conceptualization, Data Curation

Rinradee Lenavat
Roles: Conceptualization, Data Curation

Korravit Hanvivattanakul
Roles: Conceptualization, Data Curation

Thammanard Charernboon
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

Amidst the COVID-19 pandemic, the learning pattern of medical students shifted from onsite to online. This transition may contribute to what has been called “Zoom fatigue.” This study aimed to evaluate the prevalence of Zoom fatigue related to online learning, identify associated factors of Zoom fatigue, and explore its correlation with depression among medical students during the COVID-19 pandemic.

Methods

This cross-sectional study was conducted among 1st to 6th-year Thai medical students. The online survey was administered using a demographic and health behavior questionnaire, the Patient Health Questionnaire-9 (PHQ-9), and the Thai version of the Zoom Exhaustion & Fatigue Scale (ZEF-T).

Results

Among the 386 participating students, 221 (57%) were female, with a mean age of 20.6 years. The prevalence of high Zoom fatigue was 9.6%. In the multivariable regression analysis, a lower academic year and a higher number of online learning sessions were significant predictors of Zoom fatigue (p < 0.001), while regular exercise emerged as a protective factor (p = 0.009). The prevalence of depressive disorder was 61.9%, and a significant correlation was found between having a depressive disorder and experiencing Zoom fatigue (p = 0.004).

Conclusion

Zoom fatigue among medical students was correlated with depression. Consequently, medical students experiencing Zoom fatigue should undergo further assessment for depression. It is crucial to closely monitor medical students in lower academic years with a high number of online sessions for signs of Zoom fatigue. Additionally, implementing strategies, such as reducing the frequency of online sessions and promoting regular exercise, may help alleviate the symptoms.

Keywords

depression, medical students, online learning, videoconferencing fatigue, Zoom fatigue

Corresponding author: Thammanard Charernboon

Competing interests: No competing interests were disclosed.

Grant information: The article processing charge was supported by the Research Group in Clinical Epidemiology, Faculty of Medicine, Thammasat University.

Copyright: © 2024 Charoenporn V et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Charoenporn V, Hanvivattanakul S, Jongmekwamsuk K et al. Zoom fatigue related to online learning among medical students in Thailand: Prevalence, predictors, and association with depression [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2024, 13:617 (https://doi.org/10.12688/f1000research.146084.2) First published: 11 Jun 2024, 13:617 (https://doi.org/10.12688/f1000research.146084.1) Latest published: 27 Aug 2024, 13:617 (https://doi.org/10.12688/f1000research.146084.2)

Revised Amendments from Version 1

In this revised article, we have made notable improvements, particularly in explaining the research gap, addressing the study's limitations, and providing additional details about the methodology to enhance the clarity of the manuscript.

See the authors' detailed response to the review by Jonathan Salim
See the authors' detailed response to the review by Pichai Ittasakul

Introduction

Since the start of 2020, COVID-19, caused by the SARS-CoV-2 virus, has quickly spread worldwide, becoming a major global health crisis. This pandemic has led to unpredictable and mandatory transformations on a global scale, profoundly impacting the lives of individuals worldwide.¹ The WHO has recommended implementing several preventive strategies, such as social distancing measures, restrictive regulations, self-quarantine, and transitioning to remote work, to reduce the spread of the COVID-19 pandemic and minimize mortality rates.² In the realm of education, these changes have contributed to the new normal lifestyle where face-to-face and onsite learning have become impractical. Online lectures have become the standard, common, and fostering the widespread use of online meeting applications like Google Classroom, Google Meet, Zoom, Webex, and Microsoft Teams as major platforms for online learning.³

Zoom emerged as one of the most popular videoconferencing platform for online learning during the COVID-19 pandemic. It is used for both personal and business purposes. The number of daily users skyrocketed from 10 million in December 2019 to 300 million in April 2020, making it the fastest-growing application in 2020.⁴ However, excessive use of videoconferencing can lead to the novel phenomenon called “Zoom fatigue” or “Zoom exhaustion,” defined as physical and mental exhaustion from participating in virtual meetings through any online meeting application.⁵ This condition may manifest in several domains, including general, emotional, visual, motivational, and social fatigue.⁶

The study postulated the phenomenon of Zoom fatigue, linked to the excessive use of nonverbal communication in video conferencing. In comparison to regular meetings, video conferencing requires heightened concentration and attention. Various factors contribute to Zoom fatigue, including eye strain from prolonged close-range staring, increased cognitive load processing information in video calls, self-consciousness from constant self-reflection during calls, and restricted body movements in online sessions. Additionally, external factors beyond one’s control, such as internet disruptions, the pressure to respond to speaker questions, and environmental conditions, can exacerbate Zoom fatigue. Therefore, the condition of Zoom fatigue may impact individuals’ overall well-being.⁷

A specific assessment tool to measure video-related fatigue, called the Zoom Exhaustion and Fatigue (ZEF) scale, was developed at Stanford University in 2021.⁶ It comprises 15 items and assesses five domains: general fatigue, visual fatigue, social fatigue, motivation fatigue, and emotional fatigue. The scale has been translated into several languages.⁸^,⁹

Medical students have faced profound challenges due to the COVID-19 pandemic and the transition to online learning. In a cross-sectional study conducted at a Brazilian medical school using the ZEF scale, findings revealed that up to 56% of participants experienced high levels of Zoom fatigue.¹⁰ Beyond Zoom fatigue, studies also indicate a substantial increase in depression, anxiety, and mental problems, especially among university students, during the COVID-19 pandemic.¹¹^–¹⁴ These findings suggest that university students, particularly medical students, are among the populations most affected by the mental health consequences of the pandemic, facing a heightened risk of developing depression and psychological problems.¹⁴

In addition, several studies have demonstrated the relationship between Zoom fatigue and mental health conditions. A national survey conducted in the United States during the pandemic found a link between Zoom fatigue and depressive symptoms.¹⁵ Another study also showed a positive correlation between Zoom fatigue and depression, anxiety, and stress, while showing a negative correlation between Zoom fatigue and life satisfaction and academic well-being.¹⁶

Due to its relatively recent emergence, Zoom fatigue has been the subject of limited research. studies specifically focusing on medical students are even scarcer. Medical students differ significantly from other student populations, undergoing a six-year curriculum that includes clinical practice and often demanding on-call shifts. Understanding the risk factors for Zoom fatigue in this population could inform tailored prevention strategies and potentially mitigate negative impacts on academic performance and clinical decision-making.

During the COVID-19 pandemic, all lectures at our university were delivered online, exposing the entire medical student body to this learning modality. To our knowledge, there are still only a few studies examining the prevalence of Zoom fatigue, its risk factors, and its potential association with depression, with no such study conducted among medical students in Thailand. To fill this knowledge gap, our study aims to assess the prevalence of Zoom fatigue in medical students during the COVID-19 pandemic, identify associated potential risk factors, and investigate its correlation with depression.

Methods

A cross-sectional online survey was conducted among medical students at Thammasat University, Thailand, from January to July 2022. This study received approval from the Human Research Ethics Committee of the Faculty of Medicine, Thammasat University (number 028/2565; date of approval: January 26, 2022), in accordance with the Declaration of Helsinki. Signed informed consent was waived by the Ethics Committee due to the online nature of the survey; however, participants were provided with study information on the first page.

Participants

The recruitment process involved 386 medical students from Thammasat University. To meet the inclusion criteria, participants had to be Thammasat medical students aged at least 18 and proficient in Thai. They were requested to complete an anonymous online survey questionnaire using Google Forms, which was distributed through various online platforms such as LINE, university forums, and an exclusive Facebook group for Thammasat medical students. The survey tool automatically verified that all questions were completed before submission; therefore, our study had no missing data. No compensation or incentives were offered to participants. Confidentiality and privacy of data were ensured throughout the study process.

Measures

The questionnaire comprised demographic data, the Thai version of the Patient Health Questionnaire (PHQ)-9, and the Thai version of the Zoom Exhaustion and Fatigue Scale (ZEF-T).

Demographic Data

The basic general information includes gender, age, academic year, underlying disease, the number of online sessions per day, duration of each online session, time taken for each break during online sessions, exercise frequency, sleep problems, and experience of failing an examination.

The Zoom Exhaustion & Fatigue Scale (ZEF)

The ZEF is a questionnaire comprising 15 items that assess the symptoms experienced by participants during video conferences. The questions are categorized into five domains, including general fatigue, visual fatigue, social fatigue, motivation fatigue, and emotional fatigue. Each question on the questionnaire is scored from 1 to 5 (1 = not at all, 2 = slightly, 3 = moderately, 4 = very, 5 = extremely), resulting in a total score ranging from 15 to 75 points. A higher score indicates a higher level of Zoom fatigue.⁶^,⁸ The average total ZEF score is calculated by dividing the total ZEF score by 15. We established a cutoff score for Zoom fatigue as an average total ZEF score of ≥4 to identify individuals experiencing Zoom fatigue. The ZEF was granted permission to be used and translated by Fauville G. The Thai version of the ZEF was developed using forward and backward translation. The details and other psychometric properties are presented in Charoenporn and Charernboon (2023).⁸

The Patient Health Questionnaire (PHQ-9)

The Patient Health Questionnaire (PHQ-9) is a self-assessment tool comprising nine questions designed to evaluate the frequency of symptoms associated with depression over a two-week period. The questionnaire employs a rating scale ranging from 0 to 3 points, with categories including none (0 points), some days but not often (1 point), quite often (2 points), and almost every day (3 points). The total score obtained ranges from 0 to 27 points, with a higher score indicating more severe depressive symptoms.¹⁷ In this study, we applied a cutoff score of ≥9 points, based on the PHQ-9 Thai version, to identify individuals experiencing depression.¹⁸ PHQ-9 is publicly available, and no permission is required to use, reproduce, or distribute the tools. https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf.

Statistical analyses

The sample size was determined using the infinite population proportion formula, with proportion = 0.48,¹⁰ error (d) = 0.05, alpha (α) = 0.05, and Z = 1.96. The calculated sample size was determined to be at least 384 students. Participant characteristics were presented using descriptive statistics. Multivariable linear regression analysis was employed to examine the factors associated with Zoom fatigue scores. Exact tests were utilized to analyze the association between depression and Zoom fatigue. All statistical calculations were performed using STATA Version 14.0 (StataCorp LLC, College Station, TX, USA), with statistical significance set at a p-value less than 0.05.

Results

Demographic data and possible associated risk factors

Most participants were female (57.3%), with a mean age of 20.6 years. The majority were third-year medical students (29.3%), followed by first-year (26.4%). About 18.4% of participants reported having an underlying disease. The average number of Zoom sessions per day was 1.9, with 83.7% of participants having sessions lasting one hour or more. Regarding sleep, 56.0% of participants reported not getting enough sleep, and 62.2% reported exercising sometimes. (Table 1).

Table 1. Demographic data.

Variables (n = 386)	N (%)
Gender: female	221 (57.3%)
Age: mean (SD)	20.6 (2.0)
Education year
1	102 (26.4%)
2	54 (14.0%)
3	113 (29.3%)
4	64 (16.5%)
5	33 (8.6%)
6	20 (5.2%)
Underlying disease	71 (18.4%)
Number of zoom session per day: mean (SD)	1.9 (1.0)
Duration of zoom session per session
- <1 hour/session	63 (16.3%)
- ≥1 hour/session	323 (83.7%)
Break time during each session
- 0-30 minutes	158 (40.9%)
- >30 minutes	228 (59.1%)
Sleep
- enough	170 (44.0%)
- not enough	216 (56.0%)
Exercise
- no	88 (22.8%)
- sometimes	240 (62.2%)
- regular	58 (15.0%)
Had failed an exam
- no	194 (50.3%)
- yes	192 (49.7%)

Zoom Exhaustion and Fatigue (ZEF) score

Table 2 shows the mean total ZEF score and its subscales, including general fatigue, visual fatigue, social fatigue, motivation fatigue, and emotional fatigue. The average total mean score for the ZEF was 2.8 indicating a slight level of Zoom fatigue. The highest subscores were observed in the general fatigue and social fatigue domains at 9.2 points, while the emotional fatigue had the lowest score at 7.3.

Table 2. Zoom Exhaustion and Fatigue (ZEF) total score and subscale scores.

	Mean (SD)
General fatigue	9.2 (3.0)
Visual fatigue	7.9 (3.2)
Social fatigue	9.2 (3.1)
Motivational fatigue	8.9 (2.9)
Emotional fatigue	7.3 (2.9)
Total ZEF score	42.5 (12.5)
Average total ZEF score	2.8 (0.83)

Prevalence of Zoom fatigue

Table 3 presents the levels of Zoom fatigue. The majority of participants (54.1%) reported experiencing no or only a slight level of Zoom fatigue. The overall prevalence of Zoom fatigue among participants was found to be 9.6%, categorized as a very/extremely high level of Zoom fatigue, with an additional 36.3% experiencing a moderate level of Zoom fatigue.

Table 3. Prevalence of zoom fatigue.

Average total Zoom Exhaustion and Fatigue score	N (%)
1-1.99 (not at all)	63 (16.3%)
2-2.99 (slightly)	146 (37.8%)
3-3.99 (moderately)	140 (36.3%)
≥4-4.99 (very/extremely)	37 (9.6%)

The relationship between Zoom fatigue and depression

The prevalence of depression among the participants was 61.9% (n = 239). The results reveal a statistically significant relationship between having depression and Zoom fatigue (p = 0.004). Participants experiencing Zoom fatigue had a higher prevalence of depression compared to those without Zoom fatigue (83.8% vs 59.6%) (Table 4).

Table 4. Association between zoom fatigue and depression.

	Depression		Total
Zoom fatigue	Yes	No	Total
Yes	31 (83.8%)	6 (16.2%)	37 (9.6%)
No	208 (59.6%)	141 (40.4%)	349 (90.4%)
Total	239 (61.9%)	147 (38.1%)	386 (100%)

Factors associated with Zoom fatigue

Table 5 presents a multivariable linear regression analysis demonstrating factors associated with the ZEF total scores. The analysis found that education year, regular exercise, and the number of Zoom sessions per day were significantly associated with total ZEF scores. Specifically, a lower education year was associated with higher ZEF scores (coefficient = -2.44, p < 0.001), while regular exercise was associated with lower ZEF scores (coefficient = -5.27, p = 0.009). Conversely, a higher number of Zoom sessions per day was associated with higher ZEF scores (coefficient = 2.72, p < 0.001). Gender, age, underlying disease, not getting enough sleep, duration of breaks between sessions, and having failed an exam were not found to be statistically significant factors associated with ZEF scores.

Table 5. Factors associated with Zoom Exhaustion and Fatigue (ZEF) total scores using multivariable linear regression analysis.

Variable	Coefficient	p-value
Gender: female	2.27	0.061
Age (year)	0.46	0.231
Education year	-2.44	<0.001
Underlying disease	2.94	0.057
Exercise
- no	Ref	Ref
- sometimes	-1.36	0.353
- regular	-5.27	0.009
Sleep: not enough	2.39	0.053
Had failed an exam	-0.51	0.674
Number of zoom session/day	2.72	<0.001
Break time during each session
- >30 minutes	Ref	Ref
- 0-30 minutes	-0.54	0.655

Discussion

To the best of our knowledge, this study represents the first investigation in Thailand into the prevalence of Zoom fatigue, associated factors, and its correlation with depression among Thai medical students during the COVID-19 pandemic. The results of the study reveal a 9.6% prevalence of Zoom fatigue among Thai medical students as a consequence of online learning during the pandemic. Furthermore, the study uncovers a significant relationship between Zoom fatigue and depression, emphasizing the importance of addressing both conditions, as they may impact students’ well-being and overall quality of life.¹⁵

Our study revealed that the occurrence of Zoom fatigue among medical students was significant and supports the idea that it is a common phenomenon among individuals using online platforms for learning. The high prevalence may be explained by the implementation of social distancing measures throughout the country, with the university mandating the use of online learning for all lectures and restricting onsite sessions. This led to the necessity of attending at least two online sessions per day, each averaging over an hour per session. These online sessions demanded prolonged concentration, extended close-range staring, and a high cognitive load in learning and using videoconference programs.⁵^,⁶

The prevalence in our study aligns with previous research conducted during the COVID-19 pandemic, which demonstrated moderately to high Zoom fatigue ranging from 48% to 68.6%.¹⁰^,¹⁹ Slight variations may be attributed to various factors such as videoconferencing time, study faculty, study type (hybrid or online only), and the type of online learning (lecture or more interactive meeting). Another crucial factor is that Zoom fatigue is a relatively new concept, lacking a worldwide standard criteria like major depressive disorder in DSM-5 or ICD-10. Therefore, the definition may vary between studies and depend on the questionnaires used. Consequently, it might be challenging at this time to directly compare the prevalence of Zoom fatigue between studies.

The study identified a significant correlation between Zoom fatigue and depression, with a substantial number of participants experiencing both Zoom fatigue and depression. Consistent with our findings, other studies, such as those by Elbogen et al. and Montag et al., also reported similar findings, indicating that depressive symptoms exhibited a significant association with Zoom fatigue, even when adjusting for demographic, psychosocial, and clinical covariates.¹⁵^,²⁰ The connection between these two conditions might be explained by the overlapping symptoms observed in both Zoom fatigue and depression. For instance, social fatigue translates into an unwillingness to engage with others after videoconferences, while motivation fatigue reflects a diminished drive following such sessions. These symptoms bear a striking resemblance to the loss of interest commonly seen in major depressive disorders. Moreover, irritability and moodiness can also be found in depressive disorders. The connection between Zoom fatigue and depression may also be elucidated by the social isolation and loneliness associated with both conditions. Higher videoconference use might indicate increased social isolation and loneliness, contributing to the development or exacerbation of depression. Additionally, several studies have indicated that Zoom fatigue is linked not only to depression but also to psychological distress and lower life satisfaction.¹⁶

This finding is unsurprising and aligns with the majority of previous studies that have demonstrated a correlation between an increased number of video conferencing sessions and higher fatigue.⁶^,¹⁹^,²¹ Our study also identified lower academic years as another notable risk factor. This observation may be attributed to the relatively greater number of lecture hours in the preclinical years (1st – 3rd year) compared to the clinical years (4th – 6th year). Clinical medical students dedicate a substantial amount of time to engaging with patients in hospitals and participating in hands-on learning activities, including basic skill workshops and bedside teaching. Their education primarily focuses on real patient cases encountered in a hospital setting, rather than relying on theory-based lectures. Even during the pandemic, clinical students continue to work in hospitals and participate in bedside teaching, resulting in lower video conferencing usage. On the other hand, preclinical students mainly learn through lectures. Therefore, the challenges brought about by the transition to online learning during the pandemic may have affected preclinical students more than clinical students. This is consistent with previous studies conducted on both medical and non-medical students, which revealed that students in the lower academic years were more susceptible to experiencing mental distress related to their studies.²²

Regular exercise has been identified as a protective factor against Zoom fatigue, suggesting that students consistently engaging in physical activity may exhibit better resilience to online learning challenges, reducing the likelihood of experiencing Zoom fatigue. This association can be explained by considering one of the underlying causes of Zoom fatigue—limited mobility or constrained body movements. Regular exercise promotes increased body movement, potentially mitigating the onset of Zoom fatigue.⁷ Furthermore, compelling evidence indicates that exercise prevents various mental disorders, such as depression and anxiety disorders, offering multiple beneficial effects on both physical and mental health. Therefore, exercise may also play a role in preventing Zoom fatigue.²³

Strength and limitations

This study represents the initial exploration of the adverse effects of online learning on medical students in Thailand, revealing a potential connection between Zoom fatigue and depression. However, certain limitations must be acknowledged. Participants were recruited from a single site, which may limit the generalizability of the findings, and the results might not be applicable to other faculties. The cross-sectional nature of the study prevents the establishment of a causal relationship. Additionally, the reported prevalence might be underestimated due to voluntary sample collection, potentially excluding highly fatigued students from survey participation. The novelty of the concept of Zoom fatigue has resulted in relatively limited studies on this topic, leading to a lack of standardized criteria in various studies, which hampers direct prevalence comparisons. Lastly, the study did not clearly differentiate between the use of online meeting programs for lectures or interactive meetings. Further investigations are recommended to distinguish Zoom fatigue arising from online lectures and meetings distinctly.

Conclusion

To date, the use of video conferencing in education persists beyond the pandemic, becoming a part of our new normal lifestyle. It is imperative for instructors and users to recognize Zoom fatigue as a potential negative consequence. The significant prevalence of Zoom fatigue among medical students, along with its correlation with depression, emphasizes the importance of screening for both conditions, especially in lower academic years. Implementing proactive strategies, such as reducing session lengths and frequency, and promoting regular exercise, may contribute to symptom prevention.

Ethics and consent

This study received approval from the Human Research Ethics Committee of the Faculty of Medicine, Thammasat University (number 028/2565; date of approval: January 26, 2022), in accordance with the Declaration of Helsinki. Signed informed consent was waived by the Ethics Committee due to the online nature of the survey; however, participants were provided with study information on the first page.

Data availability

Underlying data

The data supporting the findings of this study are available on Figshare: “Zoom fatigue among medical students” at https://doi.org/10.6084/m9.figshare.25407883. This project contains the raw data of the study.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Extended data

A copy of the Thai version of the ZEF questionnaire used in the study is available on Figshare: “Zoom Exhaustion & Fatigue Scale - Thai Version (ZEF-T)” at https://doi.org/10.6084/m9.figshare.25407931. The original English version of the ZEF can be accessed from Fauville G, Luo M, Queiroz ACM, Bailenson JN, Hancock J. Zoom Exhaustion & Fatigue Scale. Comput Hum Behav Rep. 2021;4:100119.⁶

Checklist for the manuscript is available on Figshare: “STROBE checklist Zoom fatigue” at https://doi.org/10.6084/m9.figshare.25487410.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgement

We would like to express our gratitude to the staff in the Student Affairs Department of the Faculty of Medicine at Thammasat University for their valuable assistance in distributing the electronic invitation poster and online survey link. Additionally, we extend our thanks to all the students who participated in this study. During the proofreading of this manuscript, the authors utilized ChatGPT for proofreading and improving readability. All authors have reviewed and approved the final manuscript.

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Version 2

VERSION 2 PUBLISHED 11 Jun 2024

Author details Author details

Veevarin Charoenporn
Roles: Conceptualization, Methodology, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Sirashat Hanvivattanakul
Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation

Kanathip Jongmekwamsuk
Roles: Conceptualization, Data Curation

Rinradee Lenavat
Roles: Conceptualization, Data Curation

Korravit Hanvivattanakul
Roles: Conceptualization, Data Curation

Thammanard Charernboon
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The article processing charge was supported by the Research Group in Clinical Epidemiology, Faculty of Medicine, Thammasat University.

Article Versions (2)

version 2

Revised

Published: 27 Aug 2024, 13:617

https://doi.org/10.12688/f1000research.146084.2

version 1

Published: 11 Jun 2024, 13:617

https://doi.org/10.12688/f1000research.146084.1

© 2024 Charoenporn V et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Charoenporn V, Hanvivattanakul S, Jongmekwamsuk K et al. Zoom fatigue related to online learning among medical students in Thailand: Prevalence, predictors, and association with depression [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2024, 13:617 (https://doi.org/10.12688/f1000research.146084.2)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Open Peer Review

Current Reviewer Status: ?

Key to Reviewer Statuses VIEW HIDE

ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions

Version 2

VERSION 2

PUBLISHED 27 Aug 2024

Revised

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Reviewer Report 03 Oct 2024

Aidos Bolatov, Astana Medical University, Astana, Kazakhstan

Approved with Reservations

https://doi.org/10.5256/f1000research.170098.r323401

The paper titled "Zoom fatigue related to online learning among medical students in Thailand: Prevalence, predictors, and association with depression" investigates the prevalence of Zoom fatigue, its contributing factors, and its relationship with depression in a sample of Thai medical students. The authors conducted a cross-sectional survey using the Patient Health Questionnaire-9 and the Thai version of the Zoom Exhaustion & Fatigue Scale. The study identified that 9.6% of participants experienced high levels of Zoom fatigue, with a significant correlation between Zoom fatigue and depression.
This paper addresses a timely and relevant topic, especially in the context of post-pandemic education. The study is well-designed and provides valuable insights into the mental health challenges faced by medical students during online learning. However, there are several areas where the paper could be strengthened:
1. The methods section needs to be expanded. First, specify how all the variables presented in Table 1 were evaluated.
2. Was it known which underlying disease the respondents had, were there any respondents with depression or other mental conditions among them?
3. Please provide data on the internal consistency (cronbach's alpha) of the scales used in the study.
4. For table 4, please provide complete statistical analysis data (chi-squared value).
5. It would also be important to assess the correlation between levels of Zoom exhaustion (with all subscales) and depression.
6. Regarding Table 5, it would be more correct to present all the variables (gender, both female and male, also for sleep, and so on), or specify in a more accessible way using "ref" or "vs". And also add 95%CI values for the coefficient.
7. Another limitation of the study is the self-reporting nature of the questionnaire, which may introduce bias in the responses. Participants could have consciously or unconsciously misrepresented their answers, which can affect the accuracy and reliability of the data collected.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: mental health, medical education, genetics, social psychology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report 30 Aug 2024

Jonathan Salim, Kalideres District General Hospital, West Jakarta, Jakarta, Indonesia

Approved

https://doi.org/10.5256/f1000research.170098.r317690

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Author Response 17 Sep 2024

Thammanard Charernboon, Department of Psychiatry, Thammasat University, Bangkok, Thailand

17 Sep 2024

Author Response

Thank you for your valuable feedback.
1. Duplication Issue: We appreciate your suggestion and will add the duplication issue to the limitations section in the next version of the manuscript.
... Continue reading Thank you for your valuable feedback.
1. Duplication Issue: We appreciate your suggestion and will add the duplication issue to the limitations section in the next version of the manuscript.
2. Ethics Approval: Regarding the timing of data collection, we confirm that no data collection began before the ethics approval was granted. The approval was received on January 26, 2022, and we commenced survey distribution shortly thereafter, at the end of January 2022.
Thank you for your valuable feedback.
1. Duplication Issue: We appreciate your suggestion and will add the duplication issue to the limitations section in the next version of the manuscript.
2. Ethics Approval: Regarding the timing of data collection, we confirm that no data collection began before the ethics approval was granted. The approval was received on January 26, 2022, and we commenced survey distribution shortly thereafter, at the end of January 2022.
Competing Interests: No competing interests were disclosed. Close
Report a concern
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COMMENTS ON THIS REPORT

Author Response 17 Sep 2024

Thammanard Charernboon, Department of Psychiatry, Thammasat University, Bangkok, Thailand

17 Sep 2024

Author Response

Thank you for your valuable feedback.
1. Duplication Issue: We appreciate your suggestion and will add the duplication issue to the limitations section in the next version of the manuscript.
... Continue reading Thank you for your valuable feedback.
1. Duplication Issue: We appreciate your suggestion and will add the duplication issue to the limitations section in the next version of the manuscript.
2. Ethics Approval: Regarding the timing of data collection, we confirm that no data collection began before the ethics approval was granted. The approval was received on January 26, 2022, and we commenced survey distribution shortly thereafter, at the end of January 2022.
Thank you for your valuable feedback.
1. Duplication Issue: We appreciate your suggestion and will add the duplication issue to the limitations section in the next version of the manuscript.
2. Ethics Approval: Regarding the timing of data collection, we confirm that no data collection began before the ethics approval was granted. The approval was received on January 26, 2022, and we commenced survey distribution shortly thereafter, at the end of January 2022.
Competing Interests: No competing interests were disclosed. Close
Report a concern

Version 1

VERSION 1

PUBLISHED 11 Jun 2024

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Reviewer Report 11 Jul 2024

Jonathan Salim, Kalideres District General Hospital, West Jakarta, Jakarta, Indonesia

Approved with Reservations

https://doi.org/10.5256/f1000research.160123.r291515

Thank you for the opportunity to review this Zoom Fatigue article on the F1000 platform.

The article corroborates that excessive online learning using Zoom or similar apps can exacerbate or induce student fatigue. It may lead to mental issues such as depression.

Online learning and Zoom fatigue have become an essential topic to be discussed since the lockdown of the pandemic. However, some improvements are required to be addressed:

1. The article needs more reasons why it should be done in the first place, or simply the research gap. Reproducing the ZEF questionnaire into many languages and producing a paper just because of differences in language would result in over a hundred papers on the same thing.

2. Why the sample used in this study is medical students? Please address the sample selection and limited generalisability.

3. Please elaborate on what you mean by "academic year 2565". Is the academic year in Thammasat different from the calendar year?

4. Why are there no criteria for zoom usage in the participants' inclusion criteria? Adult students who just enrolled in the university and are proficient in Thai but do not do any Zoom online learning then can be included as study samples, which can lead to bias

5. The study did account for missing data by making the questions required, yet did the authors filter for duplicates? since the survey was distributed through a lot of different medium. One student may fill in the survey from both the LINE group and Facebook group for example.

6. It would be nice if the authors could provide how the ZEF questionnaire was translated into the Thai version. An invalid or unreliable translation method or procedure may generate invalid results.

7. English language improvements are needed in some areas for an increase in readability and coherency.

Thank you.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Medical Research and Application; Epidemiology; NTDs

CITE

Report a concern

Author Response 27 Aug 2024

Thammanard Charernboon, Department of Psychiatry, Thammasat University, Bangkok, Thailand

27 Aug 2024

Author Response

Reviewer 2

Thank you for your comments. We have responded to all of your concerns and hope our revisions address them comprehensively.

Reviewer Comment:
Online learning and Zoom ... Continue reading Reviewer 2

Thank you for your comments. We have responded to all of your concerns and hope our revisions address them comprehensively.

Reviewer Comment:
Online learning and Zoom fatigue have become an essential topic to be discussed since the lockdown of the pandemic. However, some improvements are required to be addressed:

1. The article needs more reasons why it should be done in the first place, or simply the research gap. Reproducing the ZEF questionnaire into many languages and producing a paper just because of differences in language would result in over a hundred papers on the same thing.
Author Response: Thank you for your comments. We have responded to all of your concerns and hope our revisions address them comprehensively.

I have added to and rewritten our introduction as follows:
“Due to its relatively recent emergence, Zoom fatigue has been the subject of limited research. Studies specifically focusing on medical students are even scarcer. Medical students differ significantly from other student populations, undergoing a six-year curriculum that includes clinical practice and often demanding on-call shifts. Understanding the risk factors for Zoom fatigue in this population could inform tailored prevention strategies and potentially mitigate negative impacts on academic performance and clinical decision-making.
During the COVID-19 pandemic, all lectures at our university were delivered online, exposing the entire medical student body to this learning modality. To our knowledge, there are still only a few studies examining the prevalence of Zoom fatigue, its risk factors, and its potential association with depression, with no such study conducted among medical students in Thailand. To fill this knowledge gap, our study aims to assess the prevalence of Zoom fatigue in medical students during the COVID-19 pandemic, identify associated potential risk factors, and investigate its correlation with depression.”

Reviewer Comment:
2. Why the sample used in this study is medical students? Please address the sample selection and limited generalisability.
Author Response: We focused on medical students because this program is demanding, spans six years, and includes clinical practice, which differentiates this sample from those in other faculties. We acknowledge this limitation in generalizability and have addressed it in the discussion as follows: “However, certain limitations must be acknowledged. Participants were recruited from a single site, which may limit the generalizability of the findings, and the results might not be applicable to other faculties.”

Reviewer Comment:
3. Please elaborate on what you mean by "academic year 2565". Is the academic year in Thammasat different from the calendar year?
Author Response: We have removed this sentence to reduce confusion. We now describe the study period as follows: “A cross-sectional online survey was conducted among medical students at Thammasat University, Thailand, from January to July 2022.”

Reviewer Comment:
4. Why are there no criteria for zoom usage in the participants' inclusion criteria? Adult students who just enrolled in the university and are proficient in Thai but do not do any Zoom online learning then can be included as study samples, which can lead to bias
Author Response: The study was conducted during the COVID-19 pandemic when the university mandated the use of videoconferencing for all lectures. Therefore, we believe that all participants were exposed to online learning. We have added this information to the Introduction section as follows: “During the COVID-19 pandemic, all lectures at our university were delivered online in compliance with government regulations, exposing the entire medical student body to this learning modality.”

Reviewer Comment:
5. The study did account for missing data by making the questions required, yet did the authors filter for duplicates? since the survey was distributed through a lot of different medium. One student may fill in the survey from both the LINE group and Facebook group for example.
Author Response: We did not check for the duplication of participants. Due to the confidentiality of the survey, we did not record names, surnames, or other identifying information of the participants. However, since there is no incentive for the survey, we expect that duplication should be very low.

Reviewer Comment:
6. It would be nice if the authors could provide how the ZEF questionnaire was translated into the Thai version. An invalid or unreliable translation method or procedure may generate invalid results.
Author Response: The Thai version of the ZEF was translated using the forward and backward translation method and was examined for psychometric properties, including factor validity, convergent validity, internal consistency, and test-retest reliability, in our previous publication. We have added this sentence to the manuscript: “The Thai version of the ZEF was developed using forward and backward translation. The details and other psychometric properties are presented in Charoenporn and Charernboon (2023).”

Reviewer Comment:
7. English language improvements are needed in some areas for an increase in readability and coherency.
Author Response: We have rechecked and edited the manuscript with the help of our English speaker and ChatGPT-4.

Thank you.
Reviewer 2

Thank you for your comments. We have responded to all of your concerns and hope our revisions address them comprehensively.

Reviewer Comment:
Online learning and Zoom fatigue have become an essential topic to be discussed since the lockdown of the pandemic. However, some improvements are required to be addressed:

1. The article needs more reasons why it should be done in the first place, or simply the research gap. Reproducing the ZEF questionnaire into many languages and producing a paper just because of differences in language would result in over a hundred papers on the same thing.
Author Response: Thank you for your comments. We have responded to all of your concerns and hope our revisions address them comprehensively.

I have added to and rewritten our introduction as follows:
“Due to its relatively recent emergence, Zoom fatigue has been the subject of limited research. Studies specifically focusing on medical students are even scarcer. Medical students differ significantly from other student populations, undergoing a six-year curriculum that includes clinical practice and often demanding on-call shifts. Understanding the risk factors for Zoom fatigue in this population could inform tailored prevention strategies and potentially mitigate negative impacts on academic performance and clinical decision-making.
During the COVID-19 pandemic, all lectures at our university were delivered online, exposing the entire medical student body to this learning modality. To our knowledge, there are still only a few studies examining the prevalence of Zoom fatigue, its risk factors, and its potential association with depression, with no such study conducted among medical students in Thailand. To fill this knowledge gap, our study aims to assess the prevalence of Zoom fatigue in medical students during the COVID-19 pandemic, identify associated potential risk factors, and investigate its correlation with depression.”

Reviewer Comment:
2. Why the sample used in this study is medical students? Please address the sample selection and limited generalisability.
Author Response: We focused on medical students because this program is demanding, spans six years, and includes clinical practice, which differentiates this sample from those in other faculties. We acknowledge this limitation in generalizability and have addressed it in the discussion as follows: “However, certain limitations must be acknowledged. Participants were recruited from a single site, which may limit the generalizability of the findings, and the results might not be applicable to other faculties.”

Reviewer Comment:
3. Please elaborate on what you mean by "academic year 2565". Is the academic year in Thammasat different from the calendar year?
Author Response: We have removed this sentence to reduce confusion. We now describe the study period as follows: “A cross-sectional online survey was conducted among medical students at Thammasat University, Thailand, from January to July 2022.”

Reviewer Comment:
4. Why are there no criteria for zoom usage in the participants' inclusion criteria? Adult students who just enrolled in the university and are proficient in Thai but do not do any Zoom online learning then can be included as study samples, which can lead to bias
Author Response: The study was conducted during the COVID-19 pandemic when the university mandated the use of videoconferencing for all lectures. Therefore, we believe that all participants were exposed to online learning. We have added this information to the Introduction section as follows: “During the COVID-19 pandemic, all lectures at our university were delivered online in compliance with government regulations, exposing the entire medical student body to this learning modality.”

Reviewer Comment:
5. The study did account for missing data by making the questions required, yet did the authors filter for duplicates? since the survey was distributed through a lot of different medium. One student may fill in the survey from both the LINE group and Facebook group for example.
Author Response: We did not check for the duplication of participants. Due to the confidentiality of the survey, we did not record names, surnames, or other identifying information of the participants. However, since there is no incentive for the survey, we expect that duplication should be very low.

Reviewer Comment:
6. It would be nice if the authors could provide how the ZEF questionnaire was translated into the Thai version. An invalid or unreliable translation method or procedure may generate invalid results.
Author Response: The Thai version of the ZEF was translated using the forward and backward translation method and was examined for psychometric properties, including factor validity, convergent validity, internal consistency, and test-retest reliability, in our previous publication. We have added this sentence to the manuscript: “The Thai version of the ZEF was developed using forward and backward translation. The details and other psychometric properties are presented in Charoenporn and Charernboon (2023).”

Reviewer Comment:
7. English language improvements are needed in some areas for an increase in readability and coherency.
Author Response: We have rechecked and edited the manuscript with the help of our English speaker and ChatGPT-4.

Thank you.
Competing Interests: None. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 27 Aug 2024

Thammanard Charernboon, Department of Psychiatry, Thammasat University, Bangkok, Thailand

27 Aug 2024

Author Response

Reviewer 2

Thank you for your comments. We have responded to all of your concerns and hope our revisions address them comprehensively.

Reviewer Comment:
Online learning and Zoom ... Continue reading Reviewer 2

Thank you for your comments. We have responded to all of your concerns and hope our revisions address them comprehensively.

Reviewer Comment:
Online learning and Zoom fatigue have become an essential topic to be discussed since the lockdown of the pandemic. However, some improvements are required to be addressed:

1. The article needs more reasons why it should be done in the first place, or simply the research gap. Reproducing the ZEF questionnaire into many languages and producing a paper just because of differences in language would result in over a hundred papers on the same thing.
Author Response: Thank you for your comments. We have responded to all of your concerns and hope our revisions address them comprehensively.

I have added to and rewritten our introduction as follows:
“Due to its relatively recent emergence, Zoom fatigue has been the subject of limited research. Studies specifically focusing on medical students are even scarcer. Medical students differ significantly from other student populations, undergoing a six-year curriculum that includes clinical practice and often demanding on-call shifts. Understanding the risk factors for Zoom fatigue in this population could inform tailored prevention strategies and potentially mitigate negative impacts on academic performance and clinical decision-making.
During the COVID-19 pandemic, all lectures at our university were delivered online, exposing the entire medical student body to this learning modality. To our knowledge, there are still only a few studies examining the prevalence of Zoom fatigue, its risk factors, and its potential association with depression, with no such study conducted among medical students in Thailand. To fill this knowledge gap, our study aims to assess the prevalence of Zoom fatigue in medical students during the COVID-19 pandemic, identify associated potential risk factors, and investigate its correlation with depression.”

Reviewer Comment:
2. Why the sample used in this study is medical students? Please address the sample selection and limited generalisability.
Author Response: We focused on medical students because this program is demanding, spans six years, and includes clinical practice, which differentiates this sample from those in other faculties. We acknowledge this limitation in generalizability and have addressed it in the discussion as follows: “However, certain limitations must be acknowledged. Participants were recruited from a single site, which may limit the generalizability of the findings, and the results might not be applicable to other faculties.”

Reviewer Comment:
3. Please elaborate on what you mean by "academic year 2565". Is the academic year in Thammasat different from the calendar year?
Author Response: We have removed this sentence to reduce confusion. We now describe the study period as follows: “A cross-sectional online survey was conducted among medical students at Thammasat University, Thailand, from January to July 2022.”

Reviewer Comment:
4. Why are there no criteria for zoom usage in the participants' inclusion criteria? Adult students who just enrolled in the university and are proficient in Thai but do not do any Zoom online learning then can be included as study samples, which can lead to bias
Author Response: The study was conducted during the COVID-19 pandemic when the university mandated the use of videoconferencing for all lectures. Therefore, we believe that all participants were exposed to online learning. We have added this information to the Introduction section as follows: “During the COVID-19 pandemic, all lectures at our university were delivered online in compliance with government regulations, exposing the entire medical student body to this learning modality.”

Reviewer Comment:
5. The study did account for missing data by making the questions required, yet did the authors filter for duplicates? since the survey was distributed through a lot of different medium. One student may fill in the survey from both the LINE group and Facebook group for example.
Author Response: We did not check for the duplication of participants. Due to the confidentiality of the survey, we did not record names, surnames, or other identifying information of the participants. However, since there is no incentive for the survey, we expect that duplication should be very low.

Reviewer Comment:
6. It would be nice if the authors could provide how the ZEF questionnaire was translated into the Thai version. An invalid or unreliable translation method or procedure may generate invalid results.
Author Response: The Thai version of the ZEF was translated using the forward and backward translation method and was examined for psychometric properties, including factor validity, convergent validity, internal consistency, and test-retest reliability, in our previous publication. We have added this sentence to the manuscript: “The Thai version of the ZEF was developed using forward and backward translation. The details and other psychometric properties are presented in Charoenporn and Charernboon (2023).”

Reviewer Comment:
7. English language improvements are needed in some areas for an increase in readability and coherency.
Author Response: We have rechecked and edited the manuscript with the help of our English speaker and ChatGPT-4.

Thank you.
Reviewer 2

Thank you for your comments. We have responded to all of your concerns and hope our revisions address them comprehensively.

Reviewer Comment:
Online learning and Zoom fatigue have become an essential topic to be discussed since the lockdown of the pandemic. However, some improvements are required to be addressed:

1. The article needs more reasons why it should be done in the first place, or simply the research gap. Reproducing the ZEF questionnaire into many languages and producing a paper just because of differences in language would result in over a hundred papers on the same thing.
Author Response: Thank you for your comments. We have responded to all of your concerns and hope our revisions address them comprehensively.

I have added to and rewritten our introduction as follows:
“Due to its relatively recent emergence, Zoom fatigue has been the subject of limited research. Studies specifically focusing on medical students are even scarcer. Medical students differ significantly from other student populations, undergoing a six-year curriculum that includes clinical practice and often demanding on-call shifts. Understanding the risk factors for Zoom fatigue in this population could inform tailored prevention strategies and potentially mitigate negative impacts on academic performance and clinical decision-making.
During the COVID-19 pandemic, all lectures at our university were delivered online, exposing the entire medical student body to this learning modality. To our knowledge, there are still only a few studies examining the prevalence of Zoom fatigue, its risk factors, and its potential association with depression, with no such study conducted among medical students in Thailand. To fill this knowledge gap, our study aims to assess the prevalence of Zoom fatigue in medical students during the COVID-19 pandemic, identify associated potential risk factors, and investigate its correlation with depression.”

Reviewer Comment:
2. Why the sample used in this study is medical students? Please address the sample selection and limited generalisability.
Author Response: We focused on medical students because this program is demanding, spans six years, and includes clinical practice, which differentiates this sample from those in other faculties. We acknowledge this limitation in generalizability and have addressed it in the discussion as follows: “However, certain limitations must be acknowledged. Participants were recruited from a single site, which may limit the generalizability of the findings, and the results might not be applicable to other faculties.”

Reviewer Comment:
3. Please elaborate on what you mean by "academic year 2565". Is the academic year in Thammasat different from the calendar year?
Author Response: We have removed this sentence to reduce confusion. We now describe the study period as follows: “A cross-sectional online survey was conducted among medical students at Thammasat University, Thailand, from January to July 2022.”

Reviewer Comment:
4. Why are there no criteria for zoom usage in the participants' inclusion criteria? Adult students who just enrolled in the university and are proficient in Thai but do not do any Zoom online learning then can be included as study samples, which can lead to bias
Author Response: The study was conducted during the COVID-19 pandemic when the university mandated the use of videoconferencing for all lectures. Therefore, we believe that all participants were exposed to online learning. We have added this information to the Introduction section as follows: “During the COVID-19 pandemic, all lectures at our university were delivered online in compliance with government regulations, exposing the entire medical student body to this learning modality.”

Reviewer Comment:
5. The study did account for missing data by making the questions required, yet did the authors filter for duplicates? since the survey was distributed through a lot of different medium. One student may fill in the survey from both the LINE group and Facebook group for example.
Author Response: We did not check for the duplication of participants. Due to the confidentiality of the survey, we did not record names, surnames, or other identifying information of the participants. However, since there is no incentive for the survey, we expect that duplication should be very low.

Reviewer Comment:
6. It would be nice if the authors could provide how the ZEF questionnaire was translated into the Thai version. An invalid or unreliable translation method or procedure may generate invalid results.
Author Response: The Thai version of the ZEF was translated using the forward and backward translation method and was examined for psychometric properties, including factor validity, convergent validity, internal consistency, and test-retest reliability, in our previous publication. We have added this sentence to the manuscript: “The Thai version of the ZEF was developed using forward and backward translation. The details and other psychometric properties are presented in Charoenporn and Charernboon (2023).”

Reviewer Comment:
7. English language improvements are needed in some areas for an increase in readability and coherency.
Author Response: We have rechecked and edited the manuscript with the help of our English speaker and ChatGPT-4.

Thank you.
Competing Interests: None. Close
Report a concern

Views

Reviewer Report 26 Jun 2024

Pichai Ittasakul, Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital,, Mahidol University, Bangkok, Thailand

Approved

https://doi.org/10.5256/f1000research.160123.r291510

I am writing to provide my opinion regarding the research paper I was invited to review for F1000Research. The paper explores the prevalence of Zoom fatigue related to online learning among medical students and identifies associated factors and correlations with depression in this population.
I find the topic highly relevant and interesting, particularly in light of the increased use of Zoom for teaching during the COVID-19 pandemic in Thailand. This research contributes valuable insights into medical education and the mental health of medical students.
Overall, the paper is well-written and presents its findings clearly. However, I recommend that the authors address the limitations regarding the generalizability of their findings, as the sample was collected from a single medical school in Thailand. Including this discussion would enhance the robustness of the study.
Thank you for the opportunity to review this paper.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Mood disorders, Psychiatry

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

CITE

Report a concern

Author Response 27 Aug 2024

Thammanard Charernboon, Department of Psychiatry, Thammasat University, Bangkok, Thailand

27 Aug 2024

Author Response

Author Response: Thank you for the comment. We have added the limitation as follows:

“This study represents the initial exploration of the adverse effects of online learning on medical ... Continue reading Author Response: Thank you for the comment. We have added the limitation as follows:

“This study represents the initial exploration of the adverse effects of online learning on medical students in Thailand, revealing a potential connection between Zoom fatigue and depression. However, certain limitations must be acknowledged. Participants were recruited from a single site, which may limit the generalizability of the findings, and the results might not be applicable to other faculties.”
Author Response: Thank you for the comment. We have added the limitation as follows:

“This study represents the initial exploration of the adverse effects of online learning on medical students in Thailand, revealing a potential connection between Zoom fatigue and depression. However, certain limitations must be acknowledged. Participants were recruited from a single site, which may limit the generalizability of the findings, and the results might not be applicable to other faculties.”
Competing Interests: None. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 27 Aug 2024

Thammanard Charernboon, Department of Psychiatry, Thammasat University, Bangkok, Thailand

27 Aug 2024

Author Response

Author Response: Thank you for the comment. We have added the limitation as follows:

“This study represents the initial exploration of the adverse effects of online learning on medical ... Continue reading Author Response: Thank you for the comment. We have added the limitation as follows:

“This study represents the initial exploration of the adverse effects of online learning on medical students in Thailand, revealing a potential connection between Zoom fatigue and depression. However, certain limitations must be acknowledged. Participants were recruited from a single site, which may limit the generalizability of the findings, and the results might not be applicable to other faculties.”
Author Response: Thank you for the comment. We have added the limitation as follows:

“This study represents the initial exploration of the adverse effects of online learning on medical students in Thailand, revealing a potential connection between Zoom fatigue and depression. However, certain limitations must be acknowledged. Participants were recruited from a single site, which may limit the generalizability of the findings, and the results might not be applicable to other faculties.”
Competing Interests: None. Close
Report a concern

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Version 2

VERSION 2 PUBLISHED 11 Jun 2024

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Version 2 (revision) 27 Aug 24		read	read
Version 1 11 Jun 24	read	read

Pichai Ittasakul, Mahidol University, Bangkok, Thailand
Jonathan Salim, Kalideres District General Hospital, West Jakarta, Indonesia
Aidos Bolatov, Astana Medical University, Astana, Kazakhstan

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Reviewer Report

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03 Oct 2024 | for Version 2

Aidos Bolatov, Astana Medical University, Astana, Kazakhstan

3 Views Cite this report Responses(0)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

mental health, medical education, genetics, social psychology

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Reviewer Report

5 Views

30 Aug 2024 | for Version 2

Jonathan Salim, Kalideres District General Hospital, West Jakarta, Jakarta, Indonesia

5 Views Cite this report Responses(1)

Approved

Thank you for the authors' response.
Authors have satisfactorily answered the previous comments.
However, it would be nice if the duplication issue although minor could be added to the limitation section.
Please also elaborate on why the protocol ethic was approved in late January yet the data sampling begin in January. Does it begin before the approval is even approved?

Thank you.

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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14 Views

11 Jul 2024 | for Version 1

Jonathan Salim, Kalideres District General Hospital, West Jakarta, Jakarta, Indonesia

14 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Medical Research and Application; Epidemiology; NTDs

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Responses (1)

Author Response

27 Aug 2024

Thammanard Charernboon, Department of Psychiatry, Thammasat University, Bangkok, Thailand

Reviewer 2

Thank you for your comments. We have responded to all of your concerns and hope our revisions address them comprehensively.

Reviewer Comment:
Online learning and Zoom fatigue have become an essential topic to be discussed since the lockdown of the pandemic. However, some improvements are required to be addressed:

1. The article needs more reasons why it should be done in the first place, or simply the research gap. Reproducing the ZEF questionnaire into many languages and producing a paper just because of differences in language would result in over a hundred papers on the same thing.
Author Response: Thank you for your comments. We have responded to all of your concerns and hope our revisions address them comprehensively.

I have added to and rewritten our introduction as follows:
“Due to its relatively recent emergence, Zoom fatigue has been the subject of limited research. Studies specifically focusing on medical students are even scarcer. Medical students differ significantly from other student populations, undergoing a six-year curriculum that includes clinical practice and often demanding on-call shifts. Understanding the risk factors for Zoom fatigue in this population could inform tailored prevention strategies and potentially mitigate negative impacts on academic performance and clinical decision-making.
During the COVID-19 pandemic, all lectures at our university were delivered online, exposing the entire medical student body to this learning modality. To our knowledge, there are still only a few studies examining the prevalence of Zoom fatigue, its risk factors, and its potential association with depression, with no such study conducted among medical students in Thailand. To fill this knowledge gap, our study aims to assess the prevalence of Zoom fatigue in medical students during the COVID-19 pandemic, identify associated potential risk factors, and investigate its correlation with depression.”

Reviewer Comment:
2. Why the sample used in this study is medical students? Please address the sample selection and limited generalisability.
Author Response: We focused on medical students because this program is demanding, spans six years, and includes clinical practice, which differentiates this sample from those in other faculties. We acknowledge this limitation in generalizability and have addressed it in the discussion as follows: “However, certain limitations must be acknowledged. Participants were recruited from a single site, which may limit the generalizability of the findings, and the results might not be applicable to other faculties.”

Reviewer Comment:
3. Please elaborate on what you mean by "academic year 2565". Is the academic year in Thammasat different from the calendar year?
Author Response: We have removed this sentence to reduce confusion. We now describe the study period as follows: “A cross-sectional online survey was conducted among medical students at Thammasat University, Thailand, from January to July 2022.”

Reviewer Comment:
4. Why are there no criteria for zoom usage in the participants' inclusion criteria? Adult students who just enrolled in the university and are proficient in Thai but do not do any Zoom online learning then can be included as study samples, which can lead to bias
Author Response: The study was conducted during the COVID-19 pandemic when the university mandated the use of videoconferencing for all lectures. Therefore, we believe that all participants were exposed to online learning. We have added this information to the Introduction section as follows: “During the COVID-19 pandemic, all lectures at our university were delivered online in compliance with government regulations, exposing the entire medical student body to this learning modality.”

Reviewer Comment:
5. The study did account for missing data by making the questions required, yet did the authors filter for duplicates? since the survey was distributed through a lot of different medium. One student may fill in the survey from both the LINE group and Facebook group for example.
Author Response: We did not check for the duplication of participants. Due to the confidentiality of the survey, we did not record names, surnames, or other identifying information of the participants. However, since there is no incentive for the survey, we expect that duplication should be very low.

Reviewer Comment:
6. It would be nice if the authors could provide how the ZEF questionnaire was translated into the Thai version. An invalid or unreliable translation method or procedure may generate invalid results.
Author Response: The Thai version of the ZEF was translated using the forward and backward translation method and was examined for psychometric properties, including factor validity, convergent validity, internal consistency, and test-retest reliability, in our previous publication. We have added this sentence to the manuscript: “The Thai version of the ZEF was developed using forward and backward translation. The details and other psychometric properties are presented in Charoenporn and Charernboon (2023).”

Reviewer Comment:
7. English language improvements are needed in some areas for an increase in readability and coherency.
Author Response: We have rechecked and edited the manuscript with the help of our English speaker and ChatGPT-4.

Thank you.

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Competing Interests

None.

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Reviewer Report

10 Views

26 Jun 2024 | for Version 1

Pichai Ittasakul, Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital,, Mahidol University, Bangkok, Thailand

10 Views Cite this report Responses(1)

Approved

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Mood disorders, Psychiatry

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Zoom fatigue related to online learning among medical students in Thailand: Prevalence, predictors, and association with depression

Abstract

Background

Methods

Results

Conclusion

Keywords

Revised Amendments from Version 1

Introduction

Methods

Participants

Measures

Statistical analyses

Results

Demographic data and possible associated risk factors

Table 1. Demographic data.

Zoom Exhaustion and Fatigue (ZEF) score

Table 2. Zoom Exhaustion and Fatigue (ZEF) total score and subscale scores.

Prevalence of Zoom fatigue

Table 3. Prevalence of zoom fatigue.

The relationship between Zoom fatigue and depression

Table 4. Association between zoom fatigue and depression.

Factors associated with Zoom fatigue

Table 5. Factors associated with Zoom Exhaustion and Fatigue (ZEF) total scores using multivariable linear regression analysis.

Discussion

Strength and limitations

Conclusion

Ethics and consent

Data availability

Underlying data

Extended data

Acknowledgement

References

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