Review: Impact of COVID-19 on mental wellbeing of undergraduate medical students in Pakistan

Summary

We conducted a study at Sahiwal Medical College, Sahiwal, to find out the impact of COVID-19 on mental wellbeing of undergraduate students. The data has been collected through online distribution of questionnaires via Whatsapp Messenger from 410 medical from different universities of Pakistan as mentioned by the author. Cross sectional research design has been used and the data is collected from five classes ranging from 1^st year to 5^th year students of MBBS, and the students were administered Impact of Event Scale revised version (IES-R). The data has been analyzed using Frequency distributions and Chi-Square test by using SPSS verision-20. The prevalence of rate of different cases of post-traumatic stress were also calculated and P value of less than 0.05 was taken as statistically significant. The results of the study states that the students were severely effected by post-traumatic stress 72/410 (17%) which is found to be higher in females (77.80%) comparatively. Furthermore, students of 3^rd year and 4^th year of MBBS were found to be affected more from moderate to severe post-traumatic stress due to COVID-19 which has been attributed to the uncertainties prevailing regarding closure of medical colleges due to lock down in this pandemic and also due to the fact that the future of the examinations is also in doubt.

Strengths/Advantages:

• The article is of worth importance especially in this chronic situation of COVID-19. So, the research is fulfilling the demand of information in the market which is of dire need.
• The research is of first in its kind, such research has not been done yet which is measuring mental wellbeing of MBBS students and of course in Pakistan.
• The research is a good addition in the world of research which has opened the gateways of new researches in the field. The new researcher can get idea of such research with needed improvements.
• The study is a vital count for new researcher to be referred as literature.
• The cross-sectional research design was a wise choice to collect epidemiological data and to assess the acute and chronic effect of COVID-19 on mental wellbeing of students which was needed to be known in order to take precautions in this epidemic situation, instead of using longitudinal study design.
• The used sample size (410 participants) is enough to generalize within the field that means the results are easily generalizable among MBBS students.

Weaknesses/Limitations:

• First of all either the topic or the results of the research are ambiguous, because topic is talking about general mental wellbeing, while the results mentioned only post-traumatic stress disorder (which is a specific kind of mental illness), which is not even mentioned to be measured by any criterion.
• As mentioned by the authors the sample for the article was collected from different universities of Pakistan but the name of the universities is not mentioned properly else than two universities that may affect the idea regarding generalization of the research results.
• Another critique that can be raised is the online collection of data, though it was done due to the lockdown imposed all over the country because of COVID-19. Still the data collected online has little reliability and the authors did not even discussed how these factors of their study were limitations.
• Though the sample size is good enough for generalization but the problem is that the sample is taken only from MBBS students, and there may be a lot of other stressors for MBBS students to develop stress or anxiety, like a research done by Shaikh et.al (2004) found that academics, exams, hopelessness, and other psychological pressures were the common causes of stress among the students of medical college. Hence the result may have limited generalization to the general population and students of other fields.
• Also the data has been analyzed using SPSS version-20 which is outdated comparatively SPSS version-25 which is mentioned as the best version of SPSS, so the statistical analysis may also has been impacted due to usage of obsolete version of software.
• Cross-sectional study design has been used which according to James (1994) is best for epidemiological data collection, but is unable to explain the real causes behind the disorder.
• The data may has been biased because firstly the author mentioned spontaneously that participation of 4^th year students were higher comparatively due to the fact that the data has been collected by some students of 4^th
• The result states that prevalence of PTSD was higher is females vis a vis males, this is straightly because of the higher participation by females (74.9%) as compared to males 25.1%).
• The research lacks referrals and literature review, may be due to inability of literature to be published regarding this issue until now.

Suggestions & Recommendations:

The article is a good peace of a research and providing a very vital information regarding impact of COVID-19 upon mental health of MBBS students. In this pandemic situation this kind of research is indispensable and can prove to be requisite to devise precautionary measures to improve mental health. But the research is lacking above mentioned some major research essentials. First of all the major mistake is the “Abstract” it is not an appropriate way to write an abstract of a study is generally written in a paragraph form, it doesn’t include headings, it’s basically summary of the whole article or research in a paragraph or two, other than that the most important factor; “age range” and number of male and female (also percentiles) participants are missing from the abstract. Further, the “title” of the research is little ambiguous, it is talking about general mental wellbeing, while the results are talking about post-traumatic depression it may be due to the “unexplained measures” (the scale which has been used, what is it measuring or so…) so also include the “Measures” portion where in the used measures (scales) can be explain (their author, what is it measuring, how the results are to be interpreted, the validity and reliability of the scale and other information related to scale), or the “unexplained variable measures” like the definition of mental illness is missing that what mental illness actually is according to the current research and according to the past theorists and researchers? So the inclusion of “Conceptual and Operational Definitions” portion must help. The “Introduction” portion also needs some improvements, it seems to be very small and unsatisfactory.

Moreover, it is recommended to generate “hypothesis”, and if generated, must mention them beneath the introduction and literature review portion. Other than hypothesis, “research questions” also has not been stated upon which the base of whole research has to be erected. “Literature review” for the article is not written, may be it is lacking in the research market due to the recent eruption of pandemic about which the research has been conducted, still literature review is the most important part of any research which explains the worth of the research, so it cannot be totally ignored.

The study design portion give a little explanation about cross-sectional study design and also reference. The rationale (to whom and how it can be benefited?) and objective (why the research actually has been conducted, what was the need? And why the corresponding topic has been chosen) of the research are not clearly mentioned which needs to be explained in at least a paragraph or two.

In the methodology portion, explanation regarding participants can be given, how many males? Females? Distribution according to classes and so on. And one more critique can be raised that it is written that data has been collected from different Universities of Pakistan, while it should clearly be mentioned how many students from which university has been taken? Also the sampling method has not been explained, was it a random sampling, snowball/chain sampling? Stratified sampling or which on? And why that sampling method was chosen? Also the study should clarify the “inclusion” and “exclusion criterion” for the research participants.

The study needs to state their “reliability or validity of results”, which can be determined through the used measures or is analyzed statistically by data using any software; like SPSS, and in the applied statistics (chi square) Cronback Alpha or Confidence level can explain the reliability of the results. Additionally, the pilot study method is explained to be the best one up till now.

There are little doubts related to the usage of chi-square test which are unable to explain properly because of the incomplete provided information. It is not known which scale exactly has been used (of which authors?), is it likert kind of scale, if it is, it must be explained how chi-square has been used because it is inappropriate to use chi-square for likert kind of scales in some conditions. Also the first priority of the researchers is to use parametric tests, while chi-square is a non-parametric test which is used if the data is not meeting the standards of parametric test like normal distribution or so, hence regression should have been the first priority for cross-sectional design, and if the standard was not meeting to apply regression test it should have to be explained in the “Data Analysis” portion which is also completely missing. After chi-square ANOVA was also a good option to analyze the differences of mental illness among all five classes.

The research is missing the “limitation and recommendations” portion, at least mention some of them, like online data collection, biasness in results may be due to more participation of females and 4^th year students. It should be recommended how the new researchers can replicate the research with little changes like it can be recommended to conduct research upon general population or else than MBBS students for wide generalizability, to use other study design like the research has used cross-sectional study design, while cause and effect study design can explain more clearly regarding the causes behind the mental illness, or other analysis method like T-test or Pearson Product Moment Correlation Coefficient and also the use of SPSS version-25 may prove to be more significant and provide imperative outputs and so on.

Discussion is attempted in a good way, but the studies to whom the result is related can be explained one or two lines as well, conclusion also needs a little more elaboration.

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