Effect of the COVID-19 Pandemic on Medical Students at the University of Jeddah, Saudi Arabia

Background This study aims to identify the coronavirus disease 2019 (COVID-19) pandemic impact on the academic, financial, psychological, and hygienic aspects of medical students at the University of Jeddah. Methodology Three hundred fifty medical students from the University of Jeddah were sent an online questionnaire using a simple consecutive type of sampling for this cross-sectional study. Students from the preclinical and clinical years were included. The survey consisted of 39 items: four questions were for the demographic domain, 14 items were for the academic domain, another 14 were for hygienic, psychological, and financial aspects, and seven items assessed the effect on elective. A P-value of less than 0.05 was regarded as significant during the statistical analysis, which was conducted using Statistical Package for Social Sciences (SPSS) version 25 (IBM Corp., Armonk, NY, USA). Results There were 333 responses, 174 (52.3%) of them were males. The commonest age group was 21-23 years (n=237, 71.2%). Most of the participants were living in Jeddah (n=307, 92.2%). The majority (54%, n=180) agreed or strongly agreed that “Fluctuations in lecture timing is one of the downsides of online teaching” and “The hands-on experience has suffered greatly” and 42% (n=140) strongly agreed on "Technical issues like poor WiFi connection and lack of computer or mobile devices make online teaching difficult”. One hundred five (31.5%) of the participants had an elective during the pandemic, of which 41 (39%) did not have it in training centers. In terms of the mental aspect, 154 (46.2%) students were impacted by the COVID-19 pandemic, and 111 (72.1% of them) developed anxiety or depression. Social media (n=150, 45%) was the most preferable source of information during the pandemic.”. Conclusion The COVID-19 pandemic affected the academic advancement of medical students, particularly during the years of their clinical training at the University of Jeddah. Our findings also showed that the COVID-19 pandemic had an impact on the students' financial, hygienic, and mental health, which led to increased depression and concern about visiting hospitals and providing care for patients, which ultimately prevented them from acquiring the necessary clinical skills.


Introduction
On Jan 30, 2020, the World Health Organization (WHO) proclaimed coronavirus disease 2019 (COVID-19) to be a global public health emergency, and on March 11 2020 declared the outbreak as a pandemic [1,2]. The first incident in Saudi Arabia was announced on March 7 [2]. Afterward, the government responded quickly and effectively, beginning with a social media campaign advising people to stay at home and obey the Ministry of Health's recommendations [2]. Moreover, human civilization is likely to be at its most critical crossroads in this millennium, which has made a large number of the world's population isolated from their external surroundings due to the preventive measures imposed by the affected countries to limit the spread of the virus [3].
The COVID-19 pandemic has had significant ramifications for public institutions as it forced countries into lockdowns and dramatically altered their routine and rituals and many governments have established stayat-home directives, which led to the shutdown of many colleges and universities. People from all around the world, including medical students, were affected by raising specific concerns for medical schools [4,5]. In the United Kingdom (UK), although many medical students are preparing for or participating in exams that need clinical exposure, COVID-19 had a significant impact, as multiple teaching hospitals in the UK have reported COVID-19 incidents, with several suspending medical and observership students from clinical attachments [6]. On March 17, 2020, due to the rapid spread of the pandemic in the United States of America, the Association of American Medical Colleges (AAMC) issued decisions and directives, which were the first in modern US history, to stop all clinical courses immediately [4]. Numerous difficulties with these decisions were reported at Alfaisal University's College of Medicine in Riyadh, Saudi Arabia, including problems with communication, student evaluation, technology use, online experience, pandemic-related anxiety or stress, time management, and technophobia [7]. A study was conducted among 40 UK medical schools to learn about medical students' perspectives on the use of online learning in facilitating medical education during the COVID-19 pandemic. The flexibility of online education platforms was referred to as one of the most attractive features. Whereas family distraction and a poor internet connection were two of the most commonly identified impediments to adopting online education platforms [8]. Moreover, a crosssectional study on 418 undergraduate and postgraduate medical students from around the world was conducted, revealing that 96% of students went through difficulties with learning, including trouble with memorization, concentration, and making mistakes. In addition, 90% stated overall learning struggles during the pandemic in relation to the pre-pandemic era [9].
In regard to the mental aspect, a systematic review of 43 studies measuring psychiatric symptoms and morbidities associated with COVID-19 illustrates that the general public displayed decreased psychological well-being and increased scores of anxiety and depression in contrast to the pre-COVID-19 eras [10]. In order to protect themselves from the virus, individuals needed to adopt a routine of handwashing and disinfecting objects, as well as isolation and social distancing. A cross-sectional study conducted in March 2020 in Jordan, utilizing an online questionnaire to assess certain precautions that medical students were taking toward COVID-19, concluded that more than 80% of the participants took certain precautions as their main defense against COVID-19, such as social isolation, constant hand washing, and improved personal hygiene [11].
Universities and other educational institutions in Saudi Arabia, including medical learning facilities, were forced to adopt stronger regulations in order to maintain their instructional programs. Therefore, this article aims to highlight the impact of COVID-19 on the academic, as well as financial, psychological, and hygienic aspects on medical students in order to improve how universities handle such pandemics and enable students to continue and develop their own methods of training even under such circumstances.

Study design
It was an observational descriptive cross-sectional study. Conducted among medical students at the University of Jeddah, Jeddah, Saudi Arabia in 2022.

Eligibility and participants
Samples were taken randomly using a simple consecutive type of sampling from our target population of 350 medical students, who were currently enrolled at the time of the study's conduction.
Our inclusion criteria actively involved MBBS undergraduate students and interns at the University of Jeddah, Saudi Arabia who experienced the teaching process during the COVID-19 era. However, students who weren't subjected to the medical educational system during the COVID-19 pandemic, and missing data are all excluded. Students are classified by their academic years (Starting from the second to the internship year).

Sample size
The sample size was calculated using the Raosoft calculator. We determined the sample size based on recent data, estimating the total number of medical students at the University of Jeddah to be 700. A sample size of 294 was needed to achieve a 95% confidence interval with a 5% margin of error. Since it was anticipated that fewer respondents would complete an online survey, the sample size was increased.

Settings and sources
Students filled out an e-questionnaire (Appendix 1). The questionnaire was modified from a pre-existing and valid version with the permission of the authors [12]. A few questionnaire questions regarding the students choosing what university they study at were omitted to make it fit our inclusion criteria.
The data collection period lasted from June to July 2022. Age, gender, academic year, residence area, university, and GPA were among the demographic variables assessed. We investigated the impact of the pandemic on academic components (we inquired about its impact on GPA, lectures, and the effect on professors, clinics, and rounds), hygienic behaviors, psychological stress, financial consequences, and the impact on elective training.

Ethical consideration
The study's application number, UJ-REC-067, was authorized by the Institutional Review Board (IRB) of the University of Jeddah. Consent was obtained at the beginning of the questionnaire and was also required to finish it.

Statistical analysis
The statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 25 (IBM Corp., Armonk, NY, USA). The data were imported into SPSS after being inserted into a Microsoft Excel 2010 worksheet. The ordinal variables (e.g., the Likert Scale) were described using mean/median (IQR/SD), while the nominal variables (e.g., gender) were described using counts (frequency). The information acquired was summarized and organized into tables.
Missing data were not included in the total number of participants for each variable; thus, the percentages in the tables only represent the valid percentages. The mean of the items in each variable group was calculated to get a score of 10 points. This score was created to reflect the financial, hygienic, and academic implications of COVID-19. The higher this score, the larger the effect of COVID-19 on the aforementioned aspects. Scores are summarised and reduced into five classes: 1 and 2 are referred to as "strongly disagree", 3 and 4 as "disagree", 5 and 6 are "Neutral", "agree" is assigned for 7 and 8, and 9 and 10 are considered "strongly agree".
The Chi-Square test was used to study the difference in the effect of the COVID-19 pandemic on academic achievement, mental health, and hygiene behaviors among gender and year of study (i.e., basic vs. clinical years). P values < 0.05 is considered to be statistically significant. All underlying assumptions were met unless otherwise indicated.

The academic effect of COVID-19
The students' median response to the question of whether the COVID-19 pandemic had a negative impact on their academic grades was 5 (IQR: 3-8) ( Table 2), and there was no statistically significant difference between the groups as shown in Table 3. As for online teaching, 68.1% (n=227) and 55.8% (n=186) agreed or strongly agreed that "technical issues are online teaching difficult" and "teachers not being familiar with technology is one of the main issues facing online teaching", respectively. Likewise, the majority (54%, n=180) agreed or strongly agreed that "Fluctuations in lecture timing is one of the downsides of Online teaching" and "The hands-on experience has suffered greatly" with a median of 7 (IQR=5-9). On the other hand, 143 (42.9%) of participants strongly agreed with "Recorded lectures are better than live lectures as they enable the student to set their own learning time" while a small minority of 17 (5.1%) strongly disagreed, and to that "The home environment is suitable for attending online lectures", 117 (35.2%) strongly agreed and 31 (9.1%) strongly disagreed with a median of 7 (IQR=5-10) ( Table 2). Furthermore, Table 3 illustrates a significant difference in terms of agreeing that "hands-on experience has suffered greatly", of 7.3% between the males (n=88,50.6%) and females (n=92,57.9%) (P=0.002), and 22.4% difference between basic year (n=109,47.2%) and clinical year (n=71,69.6%) (P=0.001).   In terms of clinics and rounds, only 10.8% (n=36), 12% (n=40), 12.3% (n=41), 13.8% (n=46), 14.4% (n=48), and 15.6% (n=52) students disagreed or strongly disagreed with the statements "I feel the clinics/rounds have been affected negatively during COVID-19", "the clinics/rounds limit the number of students present", "the clinics/rounds became shorter", "patient in the hospital became less cooperative", "there are fewer patients to examine", and " the clinics/rounds became less informative, respectively ( Table 2).

The effect of COVID-19 on elective training and mental health
One hundred five students (31.5%) had electives during the COVID-19 pandemic. Of the 105, 41 (39%) had it online and 64 (61%) had it at training centers. Regarding the elective place, a total of 94 (89.5%) had it in Saudi Arabia, and 11 (10.5%) had it elsewhere. COVID-19 had an impact on 154 (46.2%) students' mental health. Of those 154, a total of 111 (72.1%) developed anxiety or depression, while the remaining 43 (27.9%) denied having either. A third (34.5%) of people whose mental health was affected developed an obsession with getting the illness ( Table 4). There is a significant difference in the number of people affected from each gender, as more than half (53.5%) of the females were mentally affected by the COVID-19 pandemic, compared to only 39.7% of males (P=0.012) ( Table 3).

The effect of COVID-19 on hygiene behaviors and financial aspects
As shown in Table 1, social media (n=150, 45%) was the most used source of information during the COVID-19 pandemic, with World Health Organization (WHO) (n=122, 36.6%) being the second. The medians regarding the COVID-19 pandemic impact on hygienic behaviors were 7 or more, with 231 (69.3%) agreeing or strongly agreeing with "Always wash your hands for at least 20 seconds and in an appropriate way", and the majority (n=176, 52.8%) strongly agreed with "Became more aware of sanitizing medical equipment after examining each patient". In terms of patient awareness, the majority (n=234,70.2%) either agreed or strongly agreed on "Helped in raising hygiene awareness of people around me", and 66.9% (n=223) agreed or strongly agreed with "Noticed a rising in patients' awareness of self-hygiene" ( Table 5). Regarding the abovementioned points, Table 3 illustrated a male-to-female ratio of less than 5%, yet there is a difference between basic and clinical students of 7.5% to 13.3%.  In regards to financial aspects, 150 (45%) agreed or strongly agreed with "The Pandemic made me budget more carefully", while 219 (65.7%) ranged from strongly disagree to neutral in regards to "household suffered financially" ( Table 5). Both males (n=78, 44.8%) and females (n=72, 45.3%) showed similar results with regard to "the pandemic made me think of my budgeting more carefully". In terms of the pandemic's impact on future specialty choices, clinical year students (n=32, 31.4%) showed a higher percentage at an increase of 8% over basic year students (n=54, 23.4%) (P=0.124) ( Table 3).

Academic aspect
Influences of many factors on the performance of medical students are being evaluated, where many studies assessed the premedical, academic, maturity, and familial support and its relation to the medical students' performance [13], this study indicates that online teaching may benefit or undermine the education system in the COVID-19 era. For instance, technical difficulties, changes in lecture timing, patients being less cooperative, a lack of hands-on experience, and teachers' lack of expertise with technology are some drawbacks that students experienced. However, recorded lectures and suitable home environments made online teaching more favorable for students. A study in Oman that evaluated various factors influencing clinical teaching indicates that insufficient technologies and audiovisual resources were concerns for more than half of the students [14]. This might be the outcome of their first exposure to technology throughout medical education. As to previous research on medical schools in the area, 41.8% of faculty and students said they had little to no experience with online teaching and learning [7].
It has been hypothesized that the impact was greater during the clinical years than during the basic years.
Online classes have proven to be a fantastic option for theoretical courses like basic sciences, according to a survey that was done to assess how students felt about them. They are nevertheless inappropriate for clinical disciplines like clinical skills [15].

Mental aspect
The numbers indicate that medical students were susceptible to poor mental health during the COVID-19 pandemic, with females being more severely affected. This may be brought on by a decline in interpersonal communication during the COVID-19 era, which increases the likelihood of anxiety disorders [16]. Moreover, this mental deterioration includes concerns in regard to studies, or having a sick family member, and may reach a percentage of 68% [17]. According to a study by Wenjun Cao, living away from one's parents and being a student in a rural location are both positively correlated with anxiety symptoms. Moreover, It is suggested that in order to give college students timely, high-quality psychological assistance focused on crises, the government, and educational institutions should work together to find a solution to this issue [18].

Hygienic aspect
Although no difference between males and females, basic-year and clinical-year students, the overall results illustrate that the COVID-19 pandemic had a positive effect in regard to the hygienic aspect of the participants. More than 60% agreed with washing their hands in a proper way, being aware of sanitizing medical equipment after use, sanitizing hands before touching one's face, raising awareness of the surrounding people, and noticing a rise in patients' self-hygiene. This high number could be due to the fear of contracting the disease or from the country's efforts to educate the public on proper hygiene in order to avoid being infected. According to a cross-sectional study conducted on Jouf University students in 2020, the Saudi Ministry of Health's education program was potent in terms of raising awareness and educating the public in regard to COVID-19 [19]. Similar results can be found in a 2020 cross-sectional study conducted in Turkey which states that the hygienic practices of academic and student participants have increased during the COVID-19 pandemic [20].

Financial aspect
The financial aspect wasn't affected as severely as other sections, since only around one-third of the participants had their household suffer with respect to money and explored different options in order to lower transport costs. This might be because the working members of those families weren't in jobs that required real-life interactions and could work from home during the lockdown. Another explanation could be that the lockdown allowed for some money-saving in terms of gasoline for the car and spending on activities outside of the house like malls and arcades. Around 45% of the participants stated that they had to start budgeting more carefully during the lockdown, which is close in value in relation to a 2020 cross-sectional study conducted on medical students in Jordanian universities which concluded that almost half of the participants were budgeting more carefully during the pandemic [12].

Limitations
Almost all of the University of Jeddah's medical students participated in this study, which is the first to investigate how the COVID-19 pandemic has affected medical students there. However, it is important to emphasize that our study had a number of limitations; since this survey only included medical students from the University of Jeddah and did not take into account medical students from other universities, and other factors affecting academic performance were not included which may lead to a less valid assessment of academic performance. Moreover, this study only evaluated academic, financial, hygienic, and specialty/elective aspects. Therefore, further research is required, involving students and educators from many universities, to go into greater detail about the effects of the COVID-19 pandemic and possible outcomes in other aspects.

Conclusions
The COVID-19 pandemic had a significant impact on medical students' academic growth at the University of Jeddah, with a more pronounced impact during clinical years. Despite this, several advantages of online instruction were noted, such as the flexibility of online classrooms. Additionally, the COVID-19 pandemic had an effect on the students' financial, mental, and hygienic well-being, making them unhappier and reluctant to visit hospitals and provide treatment for patients, according to our findings. Our analysis thus offered workable remedies to current negative consequences and potential future issues of a similar nature. Included in this are creating awareness campaigns on proper hand washing and how to handle potential infectious crises in the future.  Based on the Technical and Ethical review of the proposed research project, the committee grants approval for this proposal to commence for one year from the issue of this letter. The committee considers the methodology, technical and ethical aspects of the proposal to be adequate for the involved research processes set out in the proposal. The committee considers that the applicants expertise level is satisfying the purposes of this research proposal to conduct this research in compliance with the University of Jeddah regulations and policies of scientific research. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.