On March 11, 2020, the World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19 ) as a global pandemic ever since it has manifested itself as serious public health and developmental challenge that has viciously affected all the domains of quality of life including health, socioeconomic, and education1 COVID-19 . However, vaccines are now available, and it still takes more than a year to fully cover all the people around the globe2,3 4 5 students are not enlisted in a high-risk group, they are severely affected during the lockdown period socially and economically given their immigration status6 students , particularly from low and middle-income countries (LMICs) are already facing challenging circumstances including financial crunches. Lockdown measures add to their plight and potentially lead them to social and psychological stress 6
Pakistan takes students from different parts of the world for higher education in the medical and nonmedical fields. Most of the international students stay in hostels provided by their universities . Amid the COVID-19 pandemic, they are confined to the hostels. Disruption in education, travel restrictions, closure of the mess, isolation, and closed border amid the lockdown have impaired their daily activities. Fear of infection, anxiety, hoax calls, cyberbullying, and financial crisis may cause a substantial impact on mental health amid COVID-19 preventive activities7–10 COVID-19 pandemic is crucial. Such information can be a milestone to make concerned authorities aware of adverse consequences that may arise in case of obliviousness in managing their daily activities.
To the best of our knowledge, this is the first of its kind study designed to evaluate the challenges faced by international medical students residing in university hostels amid the COVID-19 lockdown and their perceptions and preparedness toward it which might help the concerned authorities to prepare relevant public health strategies.
Methods
Ethics approval
The ethics approval was received from the Institutional Ethics Review Board of the University of the Punjab, Lahore, Pakistan (Reference number:183/DFEMS). Informed verbal consent was obtained from the participants after giving an explanatory statement with the study objectives. All procedures performed in studies involving human participants were in accordance with the ethical standards of IRB of the University of the Punjab and with the Declaration of Helsinki, 1964, and its later amendments or comparable ethical standards.
Study design
A qualitative research methodology was adopted as it is flexible and focuses on non-numeric data that consent to an in-depth understanding of the respondent’s perspective. Moreover, qualitative analysis supports identifying and filling in gaps that are left unnoticed by the quantitative types. The COREQ (consolidated criteria for reporting qualitative research) checklist was utilized for reporting qualitative studies11 https://links.lww.com/IJSGH/A17
Instrument development
A semi-structured interview guide was developed (Supplementary file 2, Supplemental Digital Content 2, https://links.lww.com/IJSGH/A18 Pakistan . It was pretested and verified for accuracy and consistency.
Respondents sampling and inclusion criteria
The study was conducted in Punjab Province, which is the most developed, populated, and second-largest province of Pakistan . The participants in the study were recruited using the purposive sampling technique based on their availability until saturation was achieved. A total of 11 international medical students residing in university hostels were finally selected for interview. The targeted participants were international students from various faculties of medicine such as pharmacy, veterinary, medical , and dental in universities around Punjab Province, Pakistan .
In‑depth face‑to‑face interviews
After giving an explanatory statement with the study objectives to the participants, verbal consent was taken. To ensure privacy, the identity of the respondents was kept confidential and the anonymity of opinions was also confirmed by using codes by the 2 researchers (SK and MS). Interviews were continued until the saturation point from where new data does not occur. The respondents were aware of voluntary involvement in the interview, and the independence to drop participation at any time. The co-authors of the study interviewed the participants in their hostel rooms between April 2020 and June 2020 in the English language. All the interviews were audio-taped, and additional field notes were taken by the principal investigator SK (male). Suitable probing was done to seek out more information. The respondents were free to describe additional views on the topic. The duration of each interview was ~20–30 minutes.
Analysis
All the recorded interviews were transcribed verbatim. Based on the method described by Braun and Clarke, the data were thematically analyzed manually by in-depth penetration into the interviews12
Results
Demographics of the participants
A total of 11 participants from seven different Universities in Pakistan were included in the study (n=11). The majority of them were from Universities located in Lahore (n=8). The participants belonged to 6 different countries of the Eastern Mediterranean Region (n=3), South-East Asia Region (n=2), and African Region (n=1). The majority of the respondents were male (n=8) and undergraduate students (n=9). The majority of the participants (n=6) were from the pharmacy faculty. All the participants were staying in Pakistan for more than 1 year.
A flow diagram of the participants’ recruitment is given in Figure 1
Figure 1: A flow diagram of the participants’ recruitment for the qualitative interviews.
The demographic distribution of the participants is described below in Table 1 .
Table 1 -
Demographics of the participants.
Characteristics
Parameters
Frequency (n)
Percentage (%)
Gender
Male
8
72.72
Female
3
27.27
Age
<25 y
8
72.72
>25 y
3
27.27
Education (level)
Undergraduate
9
81.82
Postgraduate
2
18.18
Education (discipline)
Medicine
3
27.27
Pharmacy
6
54.55
Dentistry
1
9.09
Veterinary science
1
9.09
Stay duration
<1 y
0
0
>1 y
11
100
Country of origin
Nepal
6
54.55
Sri Lanka
1
9.09
Syria
1
9.09
Yemen
1
9.09
Iran
1
9.09
Kenya
1
9.09
Thematic analysis of the content
The thematic analysis of the content of the interview led to 5 major themes: (1) familiarity with COVID-19 (knowledge), (2) perceptions and attitudes towards COVID-19 (attitude), (3) preparedness for safety against COVID-19 (practice/action), (4) barriers to lifestyle (experience/outcome), and (5) psychological perspectives (experience/outcome) (Table 2 ).
Table 2 -
Thematic analysis of the interview data and selected quotes of the respondents.
Theme 1 Familiarity with COVID-19 (Knowledge)
Knowledge about COVID-19 pandemic—Overview
Knowledge about COVID-19 —Transmission
Knowledge about COVID-19 –Management
“Ok! COVID-19 pandemic basically is a viral disease that spreads very fast around the globe. So, Hm! Most of the symptoms of that are related to the respiratory system.” (IMS-4)
“Ah! Ah! It transmits through the droplet infection and as it is an infectious disease of the respiratory tract, it affects the respiratory system.” (IMS-1)
Therapy: “Until now no medications are approved by WHO but are under clinical trial. ” (IMS-9)
Prevention: “I cannot say these can prevent 100% of transmission but certainly lower the spread transmission rate.” (IMS-2)
Effectiveness of therapies:“I have no enough knowledge about that to answer this question .” (IMS-7)
“Ah! Ah! Not completely! But these are only studies and these are not officially approved for the treatment of coronavirus.” (IMS-11)
Theme 2 Perceptions and attitudes towards COVID-19 (Attitude)
Risk of contracting COVID-19
Community level-lock down approach
Institutional level-university/hostel management
Personal level-tackling aspects
Perception to rules and guidelines
“Especially we are in a hostel, if the sweeper or colleague or anyone inside the hostel, they are affected, you know, by corona, is easily transmitted from them.” (IMS-3)
“Lockdown is very important and effective for preventing a spread of COVID-19 .” (IMS-5)
“I think this is not good at facilities.” (IMS-11)
“Ok! What I will do is, I will report. You know there is a number I’m supposed to call if I show such kind of symptoms. I will report and then, from there, I will take the instruction they will give me” (IMS-10)
“Umm! Yes! I want to comment that let’s hope for the best and let’s follow the guidelines that are provided by the local authorities and our government, and let’s stay strong. We will get through this.” (IMS-1)
“Yes! Good! Right! Right!” (IMS-9)
Theme 3 Preparedness for safety against COVID-19 (Practice/Action)
Preventive measures
Vaccination
“Hand sanitizing, wearing a mask, and social distancing.” (IMS-7)
“Yes! I will.” (IMS-10)
“Yes! I am somehow prepared to Ah! Ah! Prevent from this disease.” (IMS-5)
“I am not 100% sure about its long term safety and efficacy.” (IMS-4)
Theme 4 Barriers to lifestyle (Experience/Outcome)
Impact of movement restriction
Effect on daily activities
“Yes! I was going back home but couldn’t because of a virus.” (IMS-9)
“Yes! Because it reduces the daily physical activities and forces us to do our work almost at home.” (IMS-11)
“I only go to buy necessary things, like, once in a week or twice maybe, sometimes to buy goods; the necessary goods, the food that is necessary.” (IMS-8)
Lifestyle dropped due to COVID-19 : “Ah! Yes! It changes lifestyle because we have to stay at a hostel and we can’t do daily activities like as usual.” (IMS-5)
Lifestyle adopted due to COVID-19 : “Currently, I am mostly using social media. Then in free time like you can say, after getting bored from social media, I read a book.” ( IMS-2)
Theme 5 Psychological perspectives (Experience/Outcome)
Fear of COVID-19
Self – esteem
Loneliness
Stress
Contraction: “Yes! I am scared a little bit.” (IMS-3)
“No! Like in the early days, it was kind of enjoyable like we were getting holidays from university. It was relaxing eating but nowadays, as the days are increasing, it’s like more loneliness or something like that. We are more alone. We are bored by doin g the same thing daily. So, kind of someday sometimes we get frustrated. We are given a single room, so it’s not enjoyable.” (IMS-8)
“Yes! I am missing them. I miss them so badly that I cried some days like I can’t say but the condition is so worse that I can’t even go.” (IMS-8)
“Yes! Lots of changes. It’s mentally challenging.” (IMS-1)
“Umm! I am not scared! And if we take precaution, there is no way of transmission of this disease.” (IMS-5)
“I have never stayed in the room for 2 mo as we are right now so I am getting too much bored.” (IMS-4)
Death: It’s not that deadly. Its mortality rate is only 2% and 98% of people get recoveries from it. (IMS-8)
“Certainly! I am missing my family.” (IMS-2)
“Yes! I am sort of yea, I am like, I am scared that what will happen. I am in Pakistan , I am not with my family members.” (IMS-8)
Isolation: “It’s not enjoyable. It’s difficult.” (IMS-7)
Effect on career or studies:“Oh! I’m making my article. I have 20 articles in my room.” (IMS-9)
Theme 1: Familiarity with COVID-19
Knowledge about COVID-19 pandemic—overview. The participants were interviewed regarding their knowledge of the COVID-19 pandemic. All of them answered in a similar way regarding the nature of the disease, origin, and causative agent, Table 2 .
Knowledge about COVID-19 transmission. The responses of all participants were almost similar regarding the modes of transmission, Table 2 .
Knowledge about COVID-19 management. The majority of the participants had an appropriate concept of the therapy for COVID-19 . Some of the participants were a little bit confused regarding the name of the drugs used as a treatment option. However, many of them had an appropriate concept about ongoing trials for therapeutic and prophylactic agents and the use of only supportive therapy, and the best possible option of treating agents available for COVID-19 management.
Therapy. The respondents’ views are provided in Table 2 .
Prevention. Answering a query regarding social distancing, hand washing, and using masks, gloves, and goggles as preventive measures; a majority of the respondents stated that these can only lower the transmission rate but cannot prevent it at 100%. Some of the participants believed that these measures help in the complete prevention of transmission of COVID-19 . Different students expressed various views about the availability and survival of coronavirus in different mediums, Table 2 .
Effectiveness of therapies. Though the majority of the students reported that the adopted treatment methods are only being used as the best possible option, some of them were not able to express a clear answer regarding the effectiveness of the ongoing therapy (Table 2 ).
Theme 2: Perception and attitudes towards COVID-19
Risk of contracting COVID-19 . Regarding the risk of contracting COVID-19 , all of the participants considered that they are at risk but some participants claimed that they are in a safer state than any other persons as they were confined in the hostels (Table 2 ).
Community level-lock down approach. Regarding the lockdown approach as a containment strategy to prevent COVID-19 , all the respondents showed a positive response (Table 2 ).
Institutional level-university/hostel management. The mixed views were obtained upon asking for university and hostel management amid the COVID-19 pandemic. Some of the respondents even indicated dissatisfaction with the local scene as the people were not taking the lockdown seriously (Table 2 ).
Personal level-tackling aspect. Upon a question related to tackling COVID-19 in case their fellow hostelers get infected with COVID-19 , most of them asserted that they would suggest isolation and quarantine, while some of the respondents were intending to take them to hospital, while others did not state about isolation, quarantine, but discussed supportive therapy and other laboratory tests to conduct.
While replying to the query “What will you do if symptoms of flu that resemble COVID-19 occur?”, the respondents emphasized calling an emergency number, some of them were intending to get the test done and isolate themselves, while others said that they follow preventive measures to tackle such scenario (Table 2 ).
Perception of rules and guidelines . All of the respondents were found positive towards complying with the rules and guidelines set for the management of such a global health threat in an optimistic way (Table 2 ).
Theme 3: Preparedness for safety against COVID-19
Preventive measures. Regarding preventive measures adopted against the COVID-19 pandemic, it was found that they carry hand sanitizer, wear masks and gloves, usually wash their hands with soap water, and follow social distancing as per guidelines (Table 2 ).
Vaccination . Regarding vaccination, mixed views were obtained (Table 2 ).
Theme 4: Barriers to the lifestyle
The lockdown approach and social distancing adopted as a containment strategy were considered barriers to the everyday lifestyle during the COVID-19 pandemic. They were not shaking hands, hugging friends, sharing stuff such as phones and utensils, or touching any surfaces outside the room which they felt unusual, though following these as a guideline (Table 2 ).
Impact of movement restriction . Not getting an opportunity for conventional classes, not going out from the hostel frequently, not being able to go home, and being confined within the hostel premises were among the responses obtained (Table 2 ).
Effect on daily activities. The majority of the respondents replied that changes in routine which disturbed the timing to go for internship, physical activities, and meal timing were the most affected daily activities by the COVID-19 pandemic (Table 2 ).
Lifestyle dropped due to COVID-19 . Regarding lifestyle changes due to the COVID-19 pandemic, the responses are depicted in Table 2 .
Lifestyle adopted due to COVID-19 . Pastime activities of most of the respondents during the COVID-19 pandemic were reading books including course books and news articles, playing games, and using social media (Table 2 ).
Theme 5: Psychological perspectives
Fear of COVID-19 . There were mixed reactions regarding fear of COVID-19 such as some were scared, while others were cautious rather than scared (Table 2 ).
Contraction. The responses are depicted in Table 2 .
Death. Though the respondents were scared of being infected, they did not have fear of death (Table 2 ).
Isolation. Mixed views were obtained regarding isolation (Table 2 ).
Effect on career or studies. Although the respondents indicated interruption of regular classes, they were managing time for study in the hostel room and some of them had even started scientific writing (Table 2 ).
Self-esteem. Upon a question related to the lowering of self-esteem due to either the COVID-19 pandemic or due to lock down or both, mixed reactions were obtained. Some of the respondents stated both as a reason for lowering self-esteem. However, the majority of the respondents reported no lowering at all in their self-esteem as those approaches were adopted for a good reason (Table 2 ).
Loneliness. The majority of the respondents were missing their family members back home, while some were frustrated and facing difficulties (Table 2 ).
Stress .stress as they were far from family members, staying inside the hostel room for so long, and their minds were filled with the uncertainty of disease progression (Table 2 ).
Discussion
The outcome of this study has portrayed the typical picture of international medical students amid the COVID-19 pandemic from several aspects such as; knowledge about COVID-19 , perceptions and attitudes towards it, and preparedness and safety against it.
The present study reported that the international medical students had adequate knowledge about the origin, causative agent, nature, and treatment strategy of COVID-19 . However, some of them had less information about its treating agents and vulnerability issues. Our findings are in line with the findings of studies conducted in different parts of the world13–16 medical students was found moderate17
The unavailability of proven therapeutic agents and lockdown and social distancing adopted as preventive measures to contain such pandemic has disturbed the normal pattern of life everywhere5,18 students . Social distancing, hand washing with soap and water or using sanitizer, wearing masks and gloves, maintaining social distancing, limiting movements, changing and washing clothes frequently, and taking showers were the most frequently adopted preventive measures to avoid infection. Different studies have demonstrated the effectiveness of preventive measures as an appropriate strategy to limit the spread of coronavirus4,19 medical students in a study conducted by Khasawneh et al15 medical students were least compliant towards the adoption of such preventive approaches in a study conducted by Haque et al20 COVID-19 in mass, effective contact tracing, increasing number of hospital beds, capacity of intensive care units, ventilators, and effective facility of quarantine and isolations are need of an hour21 COVID-19 indicates the requirement of the counseling sessions and stringent preventive measures. Willingness to stay in quarantine or in isolation in case of being exposed to or infected with COVID-19 exhibits a positive attitude. Our findings contrast with the results of a study conducted in Jordan where 4.2% of students were intended to escape isolation in case they were tested COVID-19 positive15
The present study also demonstrates the social nature of students such as; willingness to help society with the COVID-19 pandemic and support friends in case of getting infected. Such an attitude depicts peace of mind. However, the concept of “first me” expressed in some cases might be attributed to the adverse scenario and mental stress caused by such pandemic.
The respondents of the study believe that lockdown is the proper approach for the management of such pandemics. Contrary to this, different studies suggest that the theoretical research used for implementing the lockdown approach was farther than the practical aspect which had neglected the associated psychological effects22,23 22 23 psychological distancing.
The agreeable response of international students regarding availability and efficacy of vaccines implies their satisfaction towards policy, administration, and trust towards the immediate development of scientific research. However, at the same time, some of them were in a wait and see mood for long-term efficacy of vaccines. This supports the conclusions of several studies where the safety profile was demonstrated in majority cases24,25 26–28 students . Such poor compliance urges for an immediate policy response tailored to public health awareness programs26
The present study identified mixed responses from international students about the university and hostel management towards their welfare amid the COVID-19 pandemic. The majority of the respondents reported a satisfactory response, however, some of them were found a little bit dissatisfied with the authority. The respondents said that their normal routine has been disturbed due to the university shut down, restriction in movement, and confinement within the hostel periphery. In addition to this lack of physical activity, mess closure, and the uncertainty of the situation make them miss their family more which may lead to psychosocial stress . Opening of mess for international students , proper hygiene and sanitation measures, virtual teaching-learning process, and online awareness training and webinar regarding the containment aspect of disease to protect themselves and to the society is required. School closure and loss in their learning are some of the prime concerns raised by the respondents. Lockdown has affected the global education system. The education system in LMICs was already facing many challenges, COVID-19 adds more stress to it. This establishes the urgent need for multimodal approaches for achieving the course content objectives enabling learners in analytical reasoning to deal with the complexity of online education29 medical students as it is mandatory to have a significant understanding and education that enhances performances in such pandemics for the safety of the country17
The study reports the compliance of respondents with the COVID-19 containment strategies of the government. The safety and security concerns, opening groceries for international students for a limited time, medical facilities, as well as regular and authentic sharing of COVID-19 information through newspapers are praiseworthy steps taken by the government. The majority of respondents’ intact self-esteem even at a bit frustrating scenario like this implies their intact mental status as well as good governance.
Multiple stressors may contribute to psychological stress and anxiety such as the perceived risk of infection, reduced social communications, and augmented worries on academic performance30 COVID-19 is very low as compared with many other common diseases31 14 medical students during clinical rotation that decreased with online learning. Crisis like the COVID-19 pandemic gives substantial psychosocial burdens on humankind. Therefore, developing interventions and preventive strategies are crucial to address the psychological impact on international students due to such a pandemic30 32 33 stress and anxiety30
This study depicts the compliance of international students with the guidelines for effective management of the COVID-19 pandemic. The finding of the study aligns with the study by Saddik et al where medical students were found to be utilizing reliable sources of information for COVID-19 management14 students were timely and productive as well. Many of them were engaged in scientific publications which was a quality fruitful way to live for medical students .
Conclusion
The study furnishes important information on the perception and preparedness of international medical students regarding the COVID-19 pandemic. Respondents believed that maintaining personal hygiene using masks, gloves, and sanitizers and frequent hand-washing; maintaining social distancing; and complying with lockdown measures aid in COVID-19 management. The majority of them had a clear understanding of the COVID-19 pandemic. The support from the universities is the primary requirement for international students to cope with such pandemic as there is no approved therapy and preventive measures cannot always be adequate to sufficiently thwart COVID-19 . Furthermore, the chance of psychological stress is high that could substantially harm their quality of life. The judicious and evidence-based interactive teaching-learning program could ensure significant understanding that enhances performances in such pandemics for global safety and also maintains their mental health and make them self-motivated. In such a situation, the students prefer to use their time productively and this could have a long-term effect on their careers and academic progress. The respondents’ perspectives from the present study help government to prepare relevant health strategies for international medical students based on population-focused approaches for effective management of such a disaster.
Ethical approval
The ethics approval was received from the Institutional Ethics Review Board of the University of the Punjab, Lahore, Pakistan (Reference number: 183/DFEMS). The informed verbal consent was obtained from the participants after giving an explanatory statement with the study objectives. All procedures performed in studies involving human participants were in accordance with the ethical standards of IRB of University of the Punjab and with the Declaration of Helsinki, 1964 and its later amendments or comparable ethical standards.
Sources of funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Author contribution
S.K. and M.U.: conceptualization.S.K., M.U., R.P.G., Y.B., and J.S.: methodology.S.K., M.U., M.S., H.R., and M.A.: formal analysis.S.K., S.G., and M.U.: writing-original draft.M.S., H.R., and S.G.: writing-review and editing. All authors approved the final manuscript.
Conflicts of interest disclosure
The authors declare that they have no financial conflict of interest with regard to the content of this report.
Research registration unique identifying number (UIN)
None.
Guarantor
Sitaram Khadka.
Acknowledgments
The authors are highly grateful to the international medical students who responded in this qualitative study.
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