• Syed Shabbir Afzal Ziauddin University, Karachi, Pakistan
  • Mohammad Aadil Qamar Ziauddin University, Karachi, Pakistan
  • Rubaid Dhillon Medical College, Riphah International University
  • Maria Bhura The Aga Khan University, Karachi, Pakistan
  • Muhammad Hashir Khan Medical College, Aga Khan University, Karachi, Pakistan
  • Qosain Suriya Aga Khan University, Karachi, Pakistan
  • Shiza Siddiqui DOW International Medical College, Karachi, Pakistan
  • M. Raafe Ali Khan Ziauddin University, Karachi, Pakistan
  • Syed Akbar Abbas Aga Khan University Hospital, Karachi, Pakistan




COVID-19, Medical Education, Medical Students, Mental Health


Background: Due to the Novel Coronavirus Disease, medical education has transformed from a physical to an online-medium. The importance of physical education in low-and-middle-income countries (LMICs), where online education can be challenging there is a need to explore the factors that affect online education. This study assesses the perspective and mental health of students whose medical education has been impacted by the pandemic. Methods: An online-questionnaire was distributed through social media platforms from October-to-December 2020 through Google-Forms among medical students across Pakistan. Two grading-scales were used to score anxiety and depression. Descriptive statistics and a logistic regression analysis were used to identify factors associated with anxiety and depression among medical students. p<0.05 was considered as significant. Data was analyzed using STATA v.15. Results: Total of 433 medical students participated in the study where 68.1% had some form of depression and 10.9% had anxiety. Around 65%-participants disagreed with the preference for online-classes. Seventy percent agreed on “Has the thought of the pandemic made you worry about your academic future” being associated with COVID-19 related-depression (OR: 2.03, 95%CI: 1.32-3.11). Multivariate analysis showed agreeing to “COVID affected my educational performance” was associated with anxiety (OR:1.45, 95%CI: 1.03-2.06) and depression (OR: 1.27, 95%CI: 1.03-1.56). Conclusion: Being part of the Low- and-Middle-Income Countries (LMIC), online-education itself becomes a challenge. Given the continued shutdown of universities across the country and the growing anxiety and depression amongst the students, adequate measures should be taken to help in coping up with the current challenge.

Author Biographies

Syed Shabbir Afzal, Ziauddin University, Karachi, Pakistan

3rd year MBBS

Mohammad Aadil Qamar, Ziauddin University, Karachi, Pakistan

3rd year MBBS

Rubaid Dhillon, Medical College, Riphah International University


Maria Bhura, The Aga Khan University, Karachi, Pakistan

Department of Pediatrics and Child Health

Muhammad Hashir Khan, Medical College, Aga Khan University, Karachi, Pakistan


Qosain Suriya, Aga Khan University, Karachi, Pakistan

Department of Histopathology

Shiza Siddiqui, DOW International Medical College, Karachi, Pakistan


M. Raafe Ali Khan, Ziauddin University, Karachi, Pakistan


Syed Akbar Abbas, Aga Khan University Hospital, Karachi, Pakistan

Department of Otolaryngology Head and Neck Surgery 


Zhu X, Liu J. Education in and after Covid-19: Immediate responses and long-term visions. Postdigital Science and Education. 2020 Oct;2(3):695-9.

Sahu P. Closure of universities due to coronavirus disease 2019 (COVID-19): impact on education and mental health of students and academic staff. Cureus. 2020 Apr;12(4).

Kecojevic A, Basch CH, Sullivan M, Davi NK. The impact of the COVID-19 epidemic on mental health of undergraduate students in New Jersey, cross-sectional study. PloS one. 2020 Sep 30;15(9):e0239696.

Bao W. COVID‐19 and online teaching in higher education: A case study of Peking University. Human Behavior and Emerging Technologies. 2020 Apr;2(2):113-5.

Cision P. Financial Troubles due to Coronavirus Pandemic. [Internet]. Student Loan. 15 April 2020. [cited 2021 May 5]. Available from: https://www.prnewswire.com/news-releases/4-out-of-5-college-students-face-financial-troubles-due-to-coronavirus-pandemic-301041312.html

Kearns LR. Student assessment in online learning: Challenges and effective practices. Journal of Online Learning and Teaching. 2012 Sep 1;8(3):198.

Daroedono E, Siagian FE, Alfarabi M, Cing JM, Arodes ES, Sirait RH, Suryowati T, Sunarti LS, Ahmad LN, Wiyanto M, Kurniaty L. The impact of COVID-19 on medical education: our students perception on the practice of long distance learning. International Journal of Community Medicine and Public Health. 2020;7(7):2790-6.

Kroenke K, Spitzer RL, Williams JB. The PHQ‐9: validity of a brief depression severity measure. Journal of general internal medicine. 2001 Sep;16(9):606-13.

Lee SA. Coronavirus Anxiety Scale: A brief mental health screener for COVID-19 related anxiety. Death studies. 2020 Jul 2;44(7):393-401.

Abbasi S, Ayoob T, Malik A, Memon SI. Perceptions of students regarding E-learning during Covid-19 at a private medical college. Pakistan Journal of Medical Sciences. 2020 May;36(COVID19-S4):S57.

Raosoft I. Sample size calculator. [Internet]. Raosoft Inc. 20 March 2004. [cited 2021 May 5]. Available from: http://www.raosoft.com/samplesize.html

Faiza I. Covid Third wave intensifies in Punjab. [Internet]. Dawn. 15 March 2021. [cited 2021 May 5]. Available from https://www.dawn.com/news/1612592/covid-third-wave-intensifies-in-punjab

Bettinger EP, Fox L, Loeb S, Taylor ES. Virtual classrooms: How online college courses affect student success. American Economic Review. 2017 Sep;107(9):2855-75.

Moutinho IL, Maddalena ND, Roland RK, Lucchetti AL, Tibiriçá SH, Ezequiel OD, Lucchetti G. Depression, stress and anxiety in medical students: A cross-sectional comparison between students from different semesters. Revista da Associação Médica Brasileira. 2017 Jan;63(1):21-8.

Ansar F, Ali W, Khattak A, Naveed H, Zeb S. Undergraduate students’ perception and satisfaction regarding online learning system amidst COVID-19 Pandemic in Pakistan. Journal of Ayub Medical College, Abbottabad: JAMC. 2020 Dec 25;32(4):S644-50.

Chandavarkar U, Azzam A, Mathews CA. Anxiety symptoms and perceived performance in medical students. Depression and anxiety. 2007;24(2):103-11.

Elhadi M, Buzreg A, Bouhuwaish A, Khaled A, Alhadi A, Msherghi A, Alsoufi A, Alameen H, Biala M, Elgherwi A, Elkhafeefi F. Psychological impact of the civil war and COVID-19 on Libyan medical students: a cross-sectional study. Frontiers in Psychology. 2020;11.

Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, Zheng J. The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry research. 2020 May 1;287:112934.

Jungmann SM, Witthöft M. Health anxiety, cyberchondria, and coping in the current COVID-19 pandemic: Which factors are related to coronavirus anxiety?. Journal of anxiety disorders. 2020 Jun 1;73:102239.

Al Saadi T, Addeen SZ, Turk T, Abbas F, Alkhatib M. Psychological distress among medical students in conflicts: a cross-sectional study from Syria. BMC medical education. 2017 Dec;17(1):1-8.

Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Academic medicine. 2006 Apr 1;81(4):354-73.

Zhai Y, Du X. Mental health care for international Chinese students affected by the COVID-19 outbreak. The Lancet Psychiatry. 2020 Apr 1;7(4):e22.