The rapid spread since the reporting of the first case of coronavirus disease 2019 (COVID-19) and the severity of this deadly virus forced the government of Pakistan to impose a nationwide lockdown. This resulted in the physical closure of educational institutions, including medical universities, leading to academic life coming to a standstill. Our study aimed to understand how online education methods during the COVID-19 pandemic differed between public and private medical universities in Karachi, Pakistan. We also sought to uncover the specific challenges faced by undergraduate medical students in this new learning environment. We conducted a cross-sectional study from September 2021 to February 2022, reaching out to MBBS students aged 18-26 across various public and private universities in Karachi. Using a structured questionnaire shared via social media platforms, we gathered data on student background, their experiences with online learning methods, the difficulties they encountered, and their perception of online education. Our analysis using logistic regression unveiled significant differences between students in public and private universities. Public university students reported more difficulties with their academic performance (p=0.039), while those in private universities expressed higher satisfaction with the support they received during the transition (p=0.026). Private university students also showed greater confidence in practicing clinical skills (p=0.003). Public university students faced challenges such as limited interaction with faculty (p=0.035) and interruptions in internet/electricity supply (p=0.04). Our findings underscore the unique challenges and perspectives of medical students in public and private universities navigating the shift to online education. Tailored strategies are essential to address these challenges effectively and enhance the quality of online medical education in similar settings.

Coronavirus disease, Online learning, Pandemic, Undergraduate medical students, Private sector, Public sector, Challenges.

The COVID 19 pandemic is considered a significant health calamity of recent times, which was followed by a negative impact on different aspects of human life and their surroundings. The World Health Organization (WHO) declared the COVID-19 infection a Public Health Emergency of International Concern (PHEIC) on January 30, 2020, and subsequently announced it as a pandemic on March 11, 2020.[1,2] In Pakistan, the first case of COVID-19 was reported in the most populated city, Karachi, on February 26, 2020. To date, 937,434 have been reported in Pakistan, with the deadly infection claiming 21,529 lives.[3] The rapid spread since the reporting of the first case and the severity of this deadly virus forced the government of Pakistan to impose a nationwide lockdown. This resulted in the physical closure of educational institutions, including medical universities, leading to academic life coming to a standstill. Therefore, in this crucial time, distance online learning has emerged as a new medium of teaching to maintain the continuity of medical education.[4]

Online learning can be divided into synchronous and asynchronous teaching. The former includes an online class replicating the traditional in-person learning of students with their instructors as closely as it can, while asynchronous technology is a student-centered teaching method where learning can occur at any time of the day incorporating significant delays in time between instructions given and their reception (e.g., e-mail, recorded video lectures, discussion forums, etc.)[5] technologically resourceful countries have systems in place for e-learning. To date, many international medical universities have successfully transitioned their educational environment to emergency distance learning, and most students appear comfortable with technology adaptations for such a curriculum.[6] However, this was not the case in most developing countries, such as the Philippines[7,8] and Indonesia[9]. Students there encountered poor internet connection, lack of access or ownership of gadgets and resources, and confined study space at home. Moreover, substandard infrastructure, limited face-to-face interaction, insufficient technical support staff, and funding issues for maintaining the platform were all identified as major challenges.

In Pakistan, most medical colleges follow the traditional teaching methods. Therefore, most of the faculty members had no or little previous experience in online teaching and had no choice but to provide online delivery of lectures and educational content.[10] Farid et al. identified the following major barriers to the implementation of online learning; instructional design, frequent power breakdowns, lack of interest from faculty to adopt new teaching methods, and cultural norms.[11] Studies conducted in Pakistan provide evidence that online learning was always an effective way for those who are technology-oriented, but the teaching and learning process in health care is diverse, a major part of which involves learning clinical skills in the wards and clinics and scientific skills in laboratories. This decreases the confidence level of medical students when it comes to managing patients.[12,13] Thus, identifying student perceptions about the impact of online education on both academic and career choices between these universities.

A cross-sectional study was conducted among the undergraduate medical students of both the public and private universities of Karachi from September 2021 to February 2022. After approval from the Jinnah Sindh Medical University (JSMU) ethics review board (JSMU/IRB/2021/-551), the sample size was calculated assuming a 67% frequency[14] with a 95% confidence level (CL) using the OpenEpi calculator.[15] The sample was raised using random sampling, taking subjects from among MBBS students of all five academic years, aged 18-26 years. A conscious effort was made by the investigators to identify and forward (through social media platforms) the questionnaire among participants belonging to public and private universities equally. The objective of the study was included in the questionnaire, and the participants voluntarily gave their informed consent as anonymity and confidentiality were ensured.

The questionnaire was divided into three sections. The first section inquired about the demographic features, including gender, age, medical institute, year of study, and educational sector. The second section was designed to gather information regarding the online teaching methods and modalities used for theoretical and practical learning at the participants’ university and the challenges they face while studying online in comparison to classroom learning. The final section assessed the impact of online learning on students’ academics, their learning of essential practical and clinical skills, and how it is affecting their career choices. The questions in this section were 5-point Likert scale questions. The choices are strongly agree, agree, neutral, disagree, and strongly disagree.[16]

The questions determined the online platforms mostly used for e-learning during the COVID-19 pandemic, prior experience, common issues faced, comparing theoretical understanding and clinical and practical dexterity being learned through e-learning, and comparing online learning with classroom learning. Some questions focus on the impacts of e-learning, including the timely response of instructors, performance assessment on given assignments, arrangement and management of online sessions, students’ confidence in appearing in examinations, and the use of learned practical skills on patients, and their preference for blended learning, e-learning, clinics, and in-classroom learning.[16]

Table 1: Questions regarding the mode of education and the perceived impact of online education

Participant Characteristics: In this cross-sectional study, we conducted an extensive analysis of students enrolled in various medical colleges in Karachi, encompassing both the public and private sectors. Our study sample comprised 443 individuals who were invited to participate, resulting in a response rate of 99.4%. Only 2 students declined to participate, yielding a total of 441 participants.

The gender distribution of our participants revealed that 258 of them were female and 183 were male, accounting for 58.5% and 41.5% respectively. Notably, 52.3% (n=231) of respondents fell within the common age group of 21-23 years. The distribution of questionnaires was almost evenly split between students from the public and private sectors, representing 51.0 % (n= 225) and 48.97 % (n=216) of the participants, respectively.

In terms of academic years, 50.57% (n=223) of students were from clinical years, while 49.43% (n=218) were from preclinical years. The study examined the most frequently used platforms for online learning in both public and private medical institutes in Karachi. The leading platform was Zoom (32.2%), followed by Google classroom (28.6%) and Google meet (8.2%).

Table 2: Demographic characteristics of participants

Result Analysis: The logistic regression analysis conducted to examine the challenges encountered by undergraduate medical students during the transition to online learning revealed significant associations with the education sector (public or private), indicating notable differences in experiences between the two sectors. Likelihood ratio tests assessing the model’s goodness of fit identified several variables that played meaningful roles in distinguishing academic experiences between public and private university students. “online learning has adversely negatively affected my academic performance” emerged as a significant discriminator (p=0.039), with public university students more likely to report negative impacts compared to their private university counterparts. Additionally, “sufficient support was provided by the university, making the transition to online learning easy” (p=0.026) and “online learning is adequate for learning clinical and practical skills” (p=0.007) were significantly associated with student satisfaction, with private university students expressing higher levels of agreement. Conversely, “I am confident enough to practice clinical skills on patients after completion of the syllabus through online learning” (p=0.003) was notable, indicating greater confidence among private university students. Significant obstacles for public university students included “home chores, household distractions” (p=0.009), “no practical demonstration” (p=0.009), and “no/little feedback from teachers” (p=0.014). However, lack of self-motivation was not statistically significant (p=0.184), suggesting it operates as an individual rather than sector-dependent factor.

The likelihood ratio test revealed that the inclusion of the “lack of self-motivation” variable did not significantly improve the model (χ²=3.385, p=0.184), indicating its lack of influence on distinguishing academic experiences between public and private university students. Similarly, the perception of physical examination confidence after online learning did not vary significantly by educational sector (p=1.00). Conversely, “lack of interaction with faculty meant fewer research opportunities for me” (χ²=16.559, p=0.035) emerged as a statistically significant variable, suggesting that limited faculty interaction hinders research opportunities, particularly notable for public university students. Additionally, internet and electricity breakdowns (p=0.04) were identified as significant variables impacting the performance of public university students. Notably, lack of self-motivation was not statistically significant (p=0.42), suggesting its role as an individual rather than sector-dependent factor. The final model exhibited statistical significance and good fit, with low -2 Log Likelihood and high pseudo-R-squared values (Cox and Snell=0.838, Nagelkerke=0.949, McFadden=0.849). In the classification analysis, the logistic regression model demonstrated an overall accuracy of 94.1%.

Medical institutions worldwide have resorted to online education platforms to maintain the continuity of academic activities among students during the COVID-19 pandemic.[17] Before the era of COVID-19, online learning was not adopted as a modality of teaching within medical schools, but has suddenly become an academic norm. A review by Kauffman, published in Research in Learning Technology in 2015, stated that certain individual characteristics of students might be a reason for achieving success with online learning and may not be an appropriate medium for the students.[18] Therefore, understanding student attributes is essential in drafting the online curriculum.

The survey of 441 students from different public and private medical institutes in Karachi revealed that the students, regardless of their locality, encountered several barriers as they tried to adapt to online learning. Our investigation exhibits that only 26% of the students favored online learning, which clearly shows the degree of dissatisfaction with online learning. This finding supports previous study conducted in Sharjah, which stated that 68.7% students were dissatisfied with online learning and 41.6% would not recommend online learning to others.[19]

Our study demonstrated that the most widely used online teaching platform adopted by universities in both sectors is Zoom Application (32.2%). Another study conducted at Harvard Medical School also reported this. Students found online learning demanding and required moderate technical skills (like technological gadgets and a stable internet connection) compared to face-to-face learning. Developing countries like Pakistan were most affected as they were not equipped for online education at any stage during COVID-19, and therefore, a higher percentage of students attributed poor internet connection and frequent power failures as a compromise of learning. This is in line with previous studies associating connectivity issues with a potential obstacle to e-learning. [20]

Moreover, the lack of self-motivation, communication gap with teachers, lack of practical demonstrations, and lack of time management were also identified as significant challenges for the students. However, a recent study led by H. IIlagaz et al demonstrated the student’s perception that online exams are fair, reliable, and successful. The conceivable difference might be the unorganized execution of web-based learning, technical loopholes, and inexperience.

Students in their clinical years were significantly more dissatisfied than those in non-clinical years, which implies that the unavailability of the clinical experience possibly produces a more adverse effect on theory learning than the inability to undertake practical work. Moreover, students will require time-intensive training upon return to the clinical environment to retain the expected level of competency in clinical skills.[21]

However, online learning may serve as an efficient resource for medical students if the method is upgraded through the integration of modalities such as virtual simulation technologies and computer-based models of real-life processes. Being a low-middle-income country, the implementation of such an upgraded system can be challenging for us. Our study also found that students would like online teaching sessions to be more interactive, as 76% of the students agreed that online learning made it difficult to interact and get feedback from teachers. This could be achieved via a student response system incorporating methods such as polls, quizzes, or online Q&A sessions to improve student engagement, and the active communication between lecturers and students allows ambiguous concepts to be addressed immediately, creating a more active learning environment.[22]

The training of the future generation of doctors hangs in the balance as universities grapple with physical distancing, decisions about in-person teaching, and how to deliver quality education online.[23]

One possible approach to increase the effectiveness of online learning is the use of recorded lectures to compensate for internet connectivity issues and to avoid clerkship and student overload. Some students choose recorded lectures over live interaction online because it allows them the freedom to choose the best time to study.[24]

In Pakistan, online learning is at a nascent stage; it needs further investments to create more adoption and overcome limitations. In this study, a limited number of students were selected from each medical university, and the perception of faculty members was not considered. Moreover, some medical colleges may have been disproportionately represented with a larger number of responses compared with newer medical colleges, skewing the results due to sample bias. A larger sample with respondents from each university, including both students and faculty members, can produce more generalized results. Furthermore, some aspects of the questionnaire depended on the participants’ recall memory, perhaps introducing recall bias. To truly understand the impact of COVID-19 on student performance and online teaching, an in-depth, qualitative analysis should be conducted in collaboration with medical colleges to gather more accurate results.

Online teaching enabled the continuation of medical education in both clinical and preclinical years during unprecedented COVID-19 times. To maximize the benefits of online learning and increase the efficacy of medical education in the future, we suggest incorporating interactive learning with virtual clinical case studies.

Not reported

None to declare

Corresponding Author:
Fabeeha Shaheen
Department of Medicine
Jinnah Sindh Medical University, Karachi, Pakistan
Email: fabeeha2shaheen@gmail.com

Co-Authors:
Tooba Umair, Rabia Amir, Afrah Hassan, Ghazala Usman
Department of Internal Medicine
Jinnah Sindh Medical University, Karachi, Pakistan

All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation, and writing – review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.

Ethical approval from the Jinnah Sindh Medical University (JSMU) ethics review board (JSMU/IRB/2021/-551).

We declare that there are no financial disclosures or conflicts of interest for any of the authors regarding the publication of this manuscript.

None

https://doi.org/10.63096/medtigo30622416

Fabeeha S, Tooba U, Rabia A, Afrah H, Ghazala U. Challenges Faced by the Undergraduate Medical Students Due to Online Learning During COVID-19 Pandemic: A Comparison between the Public and Private Sector. medtigo J Med. 2024;2(4):e30622416. doi:10.63096/medtigo30622416 Crossref