IMPACT OF COVID-19 ON EDUCATION OF UNDERGRADUATE MEDICAL STUDENTS OF PAKISTAN

METHODOLOGY: A validated questionnaire of this cross-sectional analytical study was distributed among 900 undergraduate MBBS students of different medical colleges and universities across Pakistan. Results were assessed by using SPSS version-24. BACKGROUND & OBJECTIVE: COVID-19 has caused unrest among medical students all over the world including Pakistan. The objective of this study was to assess the impact of COVID-19 on education of undergraduate medical students of Pakistan by assessing their responses to a survey. CONCLUSION: There is a huge impact of COVID-19 on medical education of the students in Pakistan. It affected them both physically and mentally and created great phobia in them related to future of their education.


INTRODUCTION:
The Corona Virus Disease-2019 (COVID- 19) pandemic caused by novel coronavirus known as SARS-CoV-2 (formerly called 2019-nCoV) has become global health emergency and the greatest challenge of the present time. The first case of COVID-19 was reported in Wuhan City, Hubei State of China in December 2019 and then it erupted and unrolled with tremendous [1] speed . The virus infected more than 118000 people and caused 4291 deaths in 114 countries within 3 months and WHO declared it a [2] pandemic . This pandemic followed no boundaries and caused catastrophic effect that th spanned the globe. On January 13 , 2020 Thailand recorded first case outside the mainland China and then continued to spread [3] throughout the globe . Italy was hit badly by COVID-19 with highest mortality. In Pakistan, first case of COVID-19 was reported by ministry of Health on 26 Feb, 2020 after which it spread [4] swiftly all over the Pakistan . The world is still witnessing its spread due to which countries are facing disastrous social, economic and political crisis. Particularly it is affecting already trembling economy of developing countries like Pakistan. Despite of direct burden over health sector, the pandemic has also affected the ways humans facing the world in different ways ranging from transportation to social events [5] including the lifestyle . The novel COVID-19 pandemic has hit medical education seriously. Worldwide, the suspension of formal classes of MBBS in the wake of COVID-19 pandemic precipitated a tremendous spike in [2] uncertainty among medical community . Due to suspension of classes it was a challenge for medical faculty to re-engage students in study. The COVID-19 pandemic forced a rapid switch to technology to provide students a platform to certify their participation in study during pandemic. The implementation of online forum for study has given a unique method to facilitate [6] the students during pandemic . To alleviate viral transmission and to prevent the exposure of medical students to COVID-19 medical colleges and universities have also cancelled clinical work for students. This loss of clinical attachment is raising alarm about the future performance of medical students in wards and causing great confusion among students regarding how to proceed during pandemic. Due to this, students are losing opportunities for enhancement of their clinical skills. This situation is particularly troublesome for students of clinical years like final year and [7] fourth year MBBS .  [9] below 0.05 hence 1.96 is used in formula .
Unfortunately, the situation is worse in Pakistan where loss of collaboration, no ward rotation and lack of facilities to integrate with technology is highlighting the irreplaceable value of face to face or class room study and most of students are not equipped fully to cope up with this online [7] system of study . In addition the knowledge regarding COVID-19 is not upto mark in our [8] population . Considering all these problems and ongoing efforts of online classes and assignments managed by our medical educational institutes, we tried to analyze the impact of these efforts which are introduced in consequences of pandemic on medical education by conducting survey over more than 750 medical undergraduates studying in different medical colleges of Pakistan.
The impact of COVID-19 on medical education of undergraduate MBBS students was assessed by a validated questionnaire. We calculated the frequencies and percentages of the responses. Major part of the participants (90.8%) agreed to the fact that COVID-19 has affected their study duration. This was also proved by the fact that 75.4% of the survey participants were of the view that this pandemic has caused more wastage of time. Many students (89.8%) were found to be concerned about their professional exam due to current situation. The ward rotation of the MBBS students was also severely affected by the pandemic (67.3%)( Table-II). Slightly more than half of the participants (55.4%) thought about doing some clinical services during pandemic but actually only 6.4% of the students did any clinical service. Majority (65.1%) also agreed that their teachers had given them enough information related to COVID-19. Ninety six percent of the students had online classes during this COVID-19 but more than half of the students (52.8%) were of the view that it's hardly effective. It was also evident by the fact that 69.7% of the students were unsatisfied with this method of learning. Interestingly 91.5% of the students participating in the survey showed that they have lost interest in studies. 90.5% of the students also agreed that increase in social media use has affected their studies. Performance in clinical wards would also be affected by this pandemic according to 89.8% students. Online assessment as an alternative to the physical exam was also rejected by an overwhelming number of the students (88.0%). A great difficulty was faced by the students in establishing boundaries between work and home (84.0%). Almost eighty five percent of t h e s t u d e n t s m i s s e d t h e i r c l a s s r o o m environments. Though majority belonged to urban areas but still 86.3% thought that elearning was not feasible for the students living in rural areas. Human connection with instructors was also missed to a great deal (80.7%) by the students. Nearly two third of the students were of the view that students may never come back to the institutions. Students also shared their fears related to this pandemic. Difficulty of studying at home in the current situation was most feared (39.3%) by the MBBS students. Deterioration of psychological state due to negative news and events was feared by 17.6% of the total survey population. Fear of getting sick or passing on the disease to one's relatives was felt by 16.9% of the total 765 students. Loss of loved one Only undergraduate MBBS students were included in the survey while allied health sciences students, graduate and post graduate students were excluded. Convenient sampling technique was used.

RESULTS:
and (many people stayed abroad due to the closure of borders) was feared by 15.8% of the students. Finally the fear of losing scholarship due to pandemic was sensed by only 1.2% of the students (Table-II).
When prevalence rate of students' interest was cross tabulated with MBBS classes then it was rd found out that 3 year and final year students lost their interest in the studies with maximum rates (95.4% and 95.2% respectively). Though the association was found to be statistically non-significant (p=0.127) ( Table-IV). Students' concern towards the conduction of professional examination was cross tabulated with MBBS classes. Result was statistically nonsignificant (P=0.197) but more than 80% of the students of all the MBBS classes showed great concern that their professional examinations may be affected due to pandemic ( Table-V).
Different prevalence rates were also calculated for different attitude of the students towards pandemic. Prevalence of students' fear during pandemic according to MBBS classes was calculated and it was found out that almost 84% of the first year students showed that their time is more wasted than others due to this pandemic. The association was also found to be statistically significant (p=0.045) (Table III).

DISCUSSION:
Students (90.8%) were agreed upon the fact that COVID-19 has affected their studies a lot. A recent study done in Karachi also showed the [9] same result . A big wastage of time during COVID-19 is also suggested by majority (75.4%) of the participants of the survey. It can be attributable to the fact that students were mentally drained because of the phobia [10] created by COVID-19 . Many students (89.8%) also showed their concern about their professional examination. There was much news circulating in the media regarding postponement of final exams of MBBS due to   We also calculated the inferential statistics of our data by calculating prevalence rates according to MBBS classes. Our results showed statistically significant results (p=0.045) when compared between MBBS classes and students' thought that this pandemic has caused more wastage of time than being useful (Table-III). Though the other results did not show statistically significant P-value yet majority of students agreed that they have lost interest now in studies. Students of senior classes were more concerned about their professional exams as they are senior most classes but the results were statistically non-significant. A previous study though showed statistically significant [10] result for students' fears towards pandemic . [11] COVID-19 that caused great unrest among [12] medical students . As majority of the study population belonged to higher classes of MBBS th (final year, 4 year and third year), so there was a big worry (86.9%) among the students that their clinical ward rotation is affected a lot. This concern was also shown by students in a study [13] conducted by Wang et al. . Though students agreed that they should do some clinical service in this pandemic yet a bleak number of students actually did some good service clinically in this pandemic (6.4%). This difference in thinking and actual work by medical students can be due to many factors like non-availability of proper resources, social distancing and complete lockdown in some areas of Pakistan and non- [14] cooperation from their families . Majority of our survey population (65.1%) agreed that the knowledge about COVID-19 was abundantly and precisely given by the teachers. A recent study showed that the faculty members of medical fraternity were a major factor in spreading the correct information related to [15] COVID- 19 . Many medical universities and colleges across the country did arrange the online classes within their own domains and students confirmed that in our study. But only 8.8% of the students agreed that these classes were quite effective; hence they rejected this mode of learning. It can be attributed to the fact that students generally lack interest in Elearning courses because they are not used to it. A recent study conducted in Bangladesh in contrary showed that students accepted e- [16] learning as mode of learning . 69.7% of the students were dissatisfied with this mode of e- [17] learning again contrary to a recent study . Even 91.5% of the students lost their interest in studies due to online classes which was a surprising fact found by our survey. A great number of students (90.5%) also blamed the increase use of social media as the cause of decrease study periods during COVID-19. This fact is also supported by the former study conducted at China. Including only 321 medical students, much smaller sample size than [18] current study . Increase in social media use is addictive for students as they are the sources of e n t e r t a i n m e n t . E -l e a r n i n g s h o u l d b e discontinued according to the view of our survey population (86.4%) because they thought that this mode of learning cannot replace the physical mode of learning as done in the classrooms. It was contrary to a previous study done by Kamal Z et al., but that study was also conducted on lesser number of students as [19] compared to our study . Ward rotation was also affected badly in this pandemic as outdoor services for general public were closed in Pakistan and this led to the concern shown by the students in our survey related to future performance in wards (89.8%). Major part of our survey population (84%) faced difficulty in establishing boundaries between work and home routines. This finding was similar to the [20] one found in a recently concluded study . As there are other family members living in the same vicinity hence it is always difficult to create such classroom environments at home. Classroom involvement and human connection with teachers was greatly missed by the students (82.7% and 80.7% respectively). As there is long history of class room teaching in Pakistan and students are habitual of it. Though majority of our survey participants belonged to urban population yet 86.3% of the students showed that e-learning mode of teaching are not feasible for rural areas.
Students who responded to the questionnaires also showed their fears related to this wrath of COVID-19. Students feared that there was a great difficulty for them to study at home. It could be due to non-ideal conditions for many to study at homes and could also be due to the fact that there was great panic among general public [21] because of COVID- 19 .