This article assesses the impact of longer lockdowns versus shorter lockdowns during COVID-19 on medical students in Australia.

Angeline Kavitha Sathiakumar, Cynthia Nga Yu Leung, Tamarangi Keerthipala, Rebecca Martin

Available Online: 27/11/24

Abstract

Background

The COVID-19 pandemic brought unprecedented challenges globally. Many medical students faced social, financial, and academic adversities. Studying the impacts of the lockdown on the medical student experience, by comparing those in shorter versus longer lockdown lengths, gave us further insight into the implications of online learning as a permanent mode of education delivery and how medical education may adjust to future pandemics. 

Aim

To investigate the impact of COVID-19 on medical students’ mental health, financial situation, and education and compare these factors between  students experiencing shorter versus longer lengths of lockdown.

Methods

Medical students across Australia responded to an anonymous online survey regarding their experience as a medical student during COVID-19 between July 2021 and September 2021. The survey consisted of both open and closed ended questions pertaining to participants’ demographic information as well as COVID-19’s impact on their medical education, financial situation and mental health. Students that lived in states with longer lockdowns (Victoria) versus shorter lockdowns (all other Australian states) were compared using Pearson’s Chi-Squared tests, multiple linear regression, and were qualitatively analysed as well.

Results 

 The survey involved 413 participants (F:M, ~3:1). We compared students subject to longer lockdowns versus shorter lockdowns. When answering statements evaluating mental health and whether the pandemic had a negative impact on their medical education, there were no statistically significant outcomes. However, gender, age, and lockdown status together predicted a correlation between financial situation, and academic capacity F(3, 403)=2.757, p=0.042, R²=0.020. Furthermore, a wealth of qualitative results captured both the advantages and disadvantages of transitioning to online learning.

Conclusion

There was no statistically significant difference between the experience of medical students subject to longer versus shorter lockdowns. However, both positive and negative impacts of lockdown were experienced by students regardless of lockdown length.

Learning points

• The impact of online education on medical students in the domains of education, financial situation, and mental health did not significantly differ between students who lived in long lockdowns versus shorter lockdowns.
• Positive impacts are focussed on greater flexibility, exposure to telehealth, and savings of time and money.
• In contrast, negative impacts included medical studies being affected by technological difficulty, increased distractibility, social isolation, and inability to effectively learn all aspects of medicine, such as  clinical skills.

Full Article

Introduction

Medical students are at an increased risk of experiencing stress, poor mental health, and burnout compared to the general population [1-4]. Distress and poor mental health amongst medical students have significant ramifications on professionalism and ethically sound practice [5], and are also linked to increased rates of suicide and substance use [4].

The COVID-19 pandemic intensified these experiences of stress, poor mental health, and burnout, with university students facing disruptions in their education, as well as substantial social, financial and academic adversities [6]. Globally, medical students were impacted significantly, as the pandemic inflicted additional stressors on them including, but not limited to, rapid adjustment to online learning, cancellation of practical learning opportunities, loss of peer interactions, increase in social isolation, and loss of part-time employment [7-10].  These factors may further drive deterioration of mental health and academic burnout [11], particularly due to unplanned changes in learning environments and styles. The impact of the pandemic on university students has been demonstrated in existing literature [6, 10-13]. In particular, a study on Australian university students found that 86.8% of participants reported that the pandemic had significantly impacted their studies, and almost three quarters of participants reported low or very low well-being [14]. 

During COVID-19, different Australian states and territories experienced different levels of restriction. These restrictions included those on social distancing, leaving the house and gathering limits. In 2020, Victorian students experienced two main periods of lockdown, totalling to 154 days of specified restrictions. Lockdown one commenced on the 30th of March and ended on the 12th of May (43 days). Lockdown two commenced on the 8th of July and ended on the 27th of October (111 days) [15]. Most states in 2020 experienced lockdown durations between a few days to weeks, depending on exact location, while New South Wales had a total lockdown period of around two months in locations near Sydney [16]. South Australian students also experienced a second lockdown period in 2020. This was a short lockdown, lasting three days, at the end of October 2020.

However, it is worth noting that the lockdown period continued into 2021. Victorians endured 263 lockdown days in 2020-2021, significantly more than other states. New South Wales and Queensland residents experienced 159 and 67 days respectively, as the second and third longest in duration over the two-year period (2020-2021). Thus, analysing Victorian experiences as more prolonged and severe remains justified.   

It was this large difference in lockdown experience that inspired the methods chosen for this project. This study aims to measure the ways in which lockdown experiences varied between Victorian medical students, who were subject to a more extensive lockdown period, compared to non-Victorian students, to better understand the effects of COVID-19 and online education on medical students over differing periods of time.

Materials and methods

The study period for this project spanned from July 2021 until September 2021.  Anonymous surveys were conducted on an online survey platform, Google Forms. Ethics approval (RM03171) for this project was obtained from the Bond University Human Research Committee.

Recruitment

The survey was distributed through social media platforms, under the banner of the General Practice Student Network (GPSN) to medical students in Australian universities (both with and without a GPSN club). This included the National GPSN page, university specific GPSN, and individual university medical society Facebook pages. 

Participants

Participants were separated into two groups – those located in the state of Victoria and those in other Australian states. Victoria, in comparison to all other states of Australia, sustained a relatively ‘long duration of lockdown’, which included a cumulative lockdown duration of 154 days in 2020. For this reason,  participants from Victoria were allocated to the ‘long duration of lockdown’ group, and participants from all other Australian states and territories were allocated to the ‘short duration of lockdown’ group. 

Survey structure

The survey contains deidentified demographic questions, including the age and gender of the participant, their state/territory of residence, their student status (international/domestic), their stage of medical education (pre-clinical/clinical), their university (in order to make conclusions on response rates and diversity of responses), their living status (living at home, out of home, or on campus), financial status (employed/unemployed), and access to financial aid.

Both open- and close-ended questions were employed to collect both quantitative and qualitative data in three sections with a distinct focus as detailed below:

• Section 1: impacts of the transition from face-to-face teaching to online teaching and any barriers participants perceive, such as internet access.
• Section 2: financial impacts from COVID-19 and their consequences
• Section 3: mental health impacts based on GAD-7 (Generalised Anxiety Disorder-7) and PHQ-9 (Patient Health Questionnaire-9) standardised mental health questionnaires. Only key statements from the GAD-7 and PHQ-9 questionnaires were included in the survey to capture the most relevant mental health impacts in medical students whilst maintaining an accessible length of the survey.

Analysis

Chi-squared testing and multiple logistic regression analysis were used to quantitatively analyse the data using the International Business Machines (IBM) Statistical Package for Social Sciences Version 26.

Codes were developed from the qualitative data by the lead author to ensure congruity and comprehensiveness. This data was semantically analysed to generate initial themes; minimal interpretation was necessary due to the short length of responses. All authors individually reviewed the full qualitative dataset, with final codes and themes being agreed upon by consensus. No differences in themes were observed between years, hence themes were drawn from the full data set.

Qualitative data, generated from the three open-ended questions included in the survey, were analysed separately. All authors manually reviewed the full qualitative dataset, highlighted key passages and generated initial themes, making comparisons that related to the primary research variables [17]. When there was a disparity in interpretation of the analysis between the authors, a consensus was formed by careful discussion of each viewpoint and consideration of the editor’s viewpoint . Final codes and themes were derived through consensus, facilitated by using the program Taguette, a qualitative data analysis tool.

Results

Table 1.  Characteristics of participants.

Variable	Students facing long duration of lockdown (Victoria) (n = 153) n (% of overall)	Students facing short duration of lockdown (Non-Victorian States) (n = 262) n (% of overall)	Overall
Gender	–
Male	46 (36.8%)	79 (63.2%)	125
Non-binary	1 (50%)	1 (50%)	2
Prefer not to say	1 (25%)	3 (75%)	4
Female	105 (37%)	179 (63%)	284
Age
Mean	23.4	23.4	23.4
Interquartile range	21-24	21-24	21-24
Enrolment Status
Domestic	134	224	358
International	19	38	57
Level of study
Pre- Clinical	47	152	199
Clinical	106	110	216
Financial Aid
Centrelink1	78	113	188
JobKeeper²	11	13	24
Scholarship	5	11	16
Other	3	3	6
None	57	128	185
Living situation
Living on campus	13	32	55
Living at home	65	78	143
Living out of home elsewhere/other	75	141	216
Employed	155	93	248

¹Centrelink- agency that delivers social security payments and services to Australians [18]

²Jobkeeper – a wage subsidy given to small businesses and employees introduced in the beginning of the COVID-19 pandemic to lessen financial impacts of the pandemic [19]

 The survey included 415 participants, aged between 18 to 45 years old. The majority of participants were female (68%) and domestic students (86%). Our cohort of participants was almost evenly divided between being in their pre-clinical years and clinical years (48.2% and 51.8%). Whilst the majority of students had living arrangements away from home, only a third of the participants lived at home and a small proportion lived in on-campus accommodation.

Figure 1.  Location of participants for the majority of 2020  by state/territory.

Table 2. University Attended.

Australia National University	5
Bond University	27
Curtin University	8
Deakin University	20
Flinders University	16
Griffith University	7
James Cook University	2
Macquarie University	6
Monash University	74
University of Adelaide	5
University of Melbourne	56
University of New England	25
University of New South Wales	24
University of Newcastle	58
University of Notre Dame Sydney	4
University of Queensland	45
University of Sydney	14
University of Tasmania	14
Western Sydney University	4

Our study received responses from medical students residing in every state and territory of Australia. Victoria and New South Wales were the most represented states, with each state constituting roughly one third of our responses. This was followed by Queensland, which represented one fifth of our responses. We received fewer responses from the Northern Territory, Western Australia, Australian Capital Territory, and Tasmania.

Supplementary Table 1. “The Impact of COVID-19 on Australian Medical Students’ Mental Health, Financial Situation, and Education” survey.

Question	Answer Options
Demographics
What is your age?	Text-box
What is your gender?	Female Male Non-binary Other Prefer not to say
Are you a Domestic or International Student?	Domestic International
What state or territory were you living in for the majority of your time in 2020?	Australian Capital Territory Queensland New South Wales Northern Territory South Australia Tasmania Western Australia Victoria
What university do you attend?	Australian National University Bond University  Curtin University  Deakin University Flinders University Griffith University James Cook University Monash University University of Adelaide  University of Melbourne University of Newcastle  University of New England University of New South Wales University of Notre Dame Fremantle  University of Notre Dame Sydney University of Queensland University of Sydney University of Tasmania University of Western Australia  Western Sydney University University of Wollongong
Did border restrictions (both domestic and international restrictions) impact your ability to engage in face to face learning with the rest of your cohort?	Yes No
What is your level of study in Medicine?	Pre-clinical Clinical
What best describes your living arrangements?	Living at home with parents/family Living on campus Living out of home elsewhere (not on campus)
During 2020, did you receive any financial aid? e.g. scholarships, Centrelink, Jobkeeper	Scholarship Centrelink Jobseeker Other None
During 2020, were you employed for any period of time?	Yes No
Section 1: COVID-19 impact on educational experience in 2020
I have had adequate access to technology for participation in online teaching	Strongly Agree Agree Neither Agree Nor Disagree Disagree Strongly Disagree
I have had problems with internet connection when participating in online teaching.	Strongly Agree (internet connection issues almost every day or every day) Agree (internet connection issues at least once a week) Neutral (internet connection issues a few times a fortnight) Disagree (internet connection issues a few times a month) Strongly Disagree (internet connection issues a few times a year)
The pandemic has had a negative impact on my learning and medical education	Strongly Agree Agree Neither Agree Nor Disagree Disagree Strongly Disagree
Being in a different timezone to the majority of my cohort has affected my ability to study	Not in a different time zone Not applicable   If in a different time-zone Strongly Agree Agree Neither Agree Nor Disagree Disagree Strongly Disagree
Section 2: COVID-19 impact on finance in 2020
During the pandemic, my total income from any source decreased compared to before the pandemic	Strongly Agree Agree Neither Agree Nor Disagree Disagree Strongly Disagree
My financial situation during the pandemic has impacted my ability to study	Strongly Agree Agree Neither Agree Nor Disagree Disagree Strongly Disagree
My financial situation during the pandemic has impacted my mental  health.	Strongly Agree Agree Neither Agree Nor Disagree Disagree Strongly Disagree
Section 3: COVID-19 impact on mental health in 2020
During the pandemic, I felt more down, depressed and/or hopeless than before the pandemic.	Strongly Agree Agree Neither Agree Nor Disagree Disagree Strongly Disagree
During the pandemic, I felt more nervous, anxious and/or on edge than before the pandemic.	Strongly Agree Agree Neither Agree Nor Disagree Disagree Strongly Disagree
During the pandemic, I had more trouble with falling asleep, duration of sleep, and/or energy levels than before the pandemic.	Strongly Agree Agree Neither Agree Nor Disagree Disagree Strongly Disagree
The pandemic has negatively affected my motivation to study medicine.	Strongly Agree Agree Neither Agree Nor Disagree Disagree Strongly Disagree
Describe how the pandemic has affected your mental health	(leave text box open for typing)
Tell us about any challenges you faced during online learning?	(leave text box open for typing)
Tell us about any benefits you faced during online learning?	(leave text box open for typing)

Table 3. Comparing psychosocial impacts, impact on education, and financial impact of COVID-19 on medical students in long lockdown and short lockdown states.

		Agree or strongly agree	Neutral, disagree or strongly disagree	p-value
A) During the pandemic, I felt more down, depressed and/or hopeless than before the pandemic.				0.504
	Long lockdown state	97 (64%)	55 (36%)
	Short lockdown state	175 (67%)	86 (33%)
B) During the pandemic, I felt more nervous, anxious and/or on edge than before the Pandemic.				0.970
	Long lockdown state	108 (71%)	44 (29%)
	Short lockdown state	185 (71%)	76 (29%)
C) During the pandemic, I had more trouble with falling asleep, duration of sleep, and/or energy levels than before the pandemic.				0.393
	Long lockdown state	91 (60%)	61 (40%)
	Short lockdown state	146 (56%)	116 (44$)
D) The pandemic has negatively affected my motivation to study medicine.				0.679
	Long lockdown state	76 (50%)	76 (50%)
	Short lockdown state	125 (48%)	136 (52%)
E) The pandemic has had a negative impact on my learning and medical education				0.399
	Long lockdown state	123 (81%)	29 (19%)
	Short lockdown state	202 (77%)	59 (23%)
F) My financial situation during the pandemic has impacted my ability to study				0.088
	Long lockdown state	28 (18%)	124 (82%)
	Short lockdown state	67 (26%)	193 (74%)
G) My financial situation during the pandemic has impacted my mental health				0.211
	Long lockdown state	54 (36%)	98 (64%)
	Short lockdown state	109 (42%)	152 (58%)

†Comparison of psychosocial impacts on respondent in long lockdown and short lockdown states by Pearson’s chi-squared test

Pearson’s Chi-squared tests were carried out to compare the psychosocial impact between students that resided in states with long lockdowns versus shorter lockdowns. Psychosocial impacts included participants’ motivations to study medicine, reported feelings of depressed and anxious mood, as well as sleep and energy levels. Overall, 65.8% of study participants reported feeling increased depressed mood during the pandemic, whilst 71.4% reported increased anxious mood. Over half (57.4%) of participants reported increased trouble with sleep and decreased energy levels compared to before the pandemic. There was no statistically significant correlation between the number of participants reporting increased psychosocial impact due to the pandemic compared to whether they lived in a long lockdown versus short lockdown state. The p-value for the 4 questionnaire items exploring psychosocial impacts ranged from p=0.393-p=0.970 (Table 3) by Pearson’s Chi-squared test (i.e. no significant difference between participants in long versus short lockdown).

The pandemic’s impact on participants’ medical education and learning was also compared using Pearson’s Chi-sSquared test. Again, there was no statistically significant correlation between responses and whether the respondent lived in a long lockdown versus short lockdown state (p=0.399, Table 3).

Lastly, Pearson’s Chi-squared test was used to assess respondents’ financial status and whether there was a statistically significant difference in how it impacted their ability to study and mental health. When comparing respondents living in a long lockdown versus short lockdown state, rhere was no statistical difference in both statements, “My financial situation during the pandemic has impacted my ability to study” and “My financial situation during the pandemic has impacted my mental health” (p = 0.088 and 0.211, Table 3). 

We ran multiple linear regressions to assess whether the variables of age, male or female gender, and lockdown duration predicted the impacts of the pandemic on mental health and education. The results of one multiple linear regression revealed that gender, age, and lockdown duration in combination did predict answers to the statement, “my financial situation during the pandemic has impacted my ability to study” F(3, 403)=2.757, p=0.042, R²=0.020 (data not shown). However, when testing if each variable could independently predict the impact on mental health and education, age (p=0.064), gender (0.271), and lockdown duration (p=0.081) were not statistically significant (Table 4).

Table 4. Impact of age, gender, and state on mental health and education.

Independent variable	Coefficient (β)1	SE2	95% CI		p
Gender	0.055	0.045	-0.39	0.139	0.064
Age	-0.092	0.005	-0.02	0.001	0.271
Victoria vs non-victoria states	0.043	0.043	-0.16	0.009	0.081

¹Beta coefficient

 ²Standard error

Common themes regarding the advantages and disadvantages of online learning in 2020 were captured with qualitative open-ended responses. Over three quarters of participants responded to the prompt “Tell us about any challenges you faced during online learning” (n=317, 77%). One of the most commonly cited challenges was the lack of social interaction and being unable to make friends (n=117, 37%; one such response was “low moods sometimes due to lack of face-to-face interactions with friends”). Additionally, a quarter of participants found it more difficult to engage with online learning and reported being easily distracted (n=83, 26%). One student described that ‘[they] struggled with motivation due to [the repetitiveness] of zoom classes and having no face to face interaction with my peers’. Furthermore, many students directly and indirectly experienced technology issues which negatively impacted their learning (n=141, 44%). Responses included, “online environments aren’t as useful for interactive learning and are often interrupted by internet failures”, and “teachers were not well prepared or suited to use technology, so teaching style was not the best”. Respondents also felt they missed out on vital areas of their medical education. In particular, over a third of participants felt stressed about receiving less clinical experience and practical skill learning (n=109, 35%). One participant describes, “it was very hard to conduct clinical practice training in this format. Usually in semester 1 of first year, we would have learnt how to do certain histories and certain examinations, but due to the online format, we were only practising histories for the entire semester.” Another commented, “I suffered a lack of any practical learning which affects my confidence”.

 The prompt, “Tell us about any benefits you have experienced from online learning”, received 309 responses (74%). The most commonly mentioned theme was reduction in commute time and associated expenses (n=133, 43%; eg, “saving time on commute and saving travel costs was a nice positive”). Furthermore, a large proportion of students valued the increased flexibility and being able to study at their own pace (n=117, 38%), including the ability to pause online lectures and access online learning materials anytime. Students found that this helped them better personalise their learning – one respondent stated: “I like online learning because I can pause videos/take screen shots/google things I don’t understand”. Students were also exposed to additional, extra-curricular events, for example, one participant answered that they were “able to attend heaps free webinars”. Lastly, a few participants (n=6, 2%) found that online learning allowed them to learn about telehealth and prepared them for increased reliance on technology in future medical practice; “taking histories over Zoom was a very useful experience. It felt a bit like Telehealth which is an important aspect of medicine”.

Discussion

This study describes the experiences of Australian medical students and explores the impact of lockdown duration on their  mental health, financial situation and education. Our quantitative results indicated no statistically significant difference in mental health, educational experiences, and financial situation  between students in locations of greater lengths of lockdown compared  to those in locations of shorter lengths.  However, the qualitative results showed that mental health was a significant concern for most medical students during the pandemic, irrespective of the length of lockdown experienced. An abundance of qualitative responses from medical students, including those in both short and long lockdowns, emphasised  that the reduction in social connection was a major contributor to decreased levels of mental health. The study highlights the student experience in the hopes that it can inform future developments and  changes in teaching delivery methods, specifically  online learning, during future global pandemics.

Technology has long been acknowledged as a key element of a well-rounded medical education [18], and the COVID-19 pandemic has resulted in further immersion of technology into the medical teaching paradigm [19]. Our qualitative responses highlighted that many Australian medical students found it challenging to learn practical skills online, demonstrating that online teaching may be inadequate for all aspects of medical learning. Interestingly, a Polish study studying medical students’ perspectives on electronic learning found there was no statistical difference between their  opinions on online and face-to face learning in regards to ability to increase knowledge However this study found electronic learning was considered less effective in increasing clinical skills and social competences, which was also reflected in our qualitative findings [20].

Furthermore, many respondents identified difficulties with their own internet connectivity or with teaching staff experiencing technology issues. Importantly, the expanding reliance on home-based electronic learning can exacerbate the educational disparities faced by students with limited access to personal technology. This issue intertwines with the pivotal role of financial circumstances in shaping the experiences of medical students, profoundly affecting their learning trajectory and prospects for future practice [21]. Hence, whenever feasible, it is advisable to adopt a blend of online and in-person learning modalities, supplemented by contingency plans as needed.

Despite this, survey respondents also highlighted some unexpected benefits that they had gained during the transition to online study during the pandemic. Most notably, these included an increase in flexibility of scheduling (including reduced commute) and the ability to revisit recorded lectures, allowing students to better manage their learning. Students also found the replacement of face-to-face clinical experience with online clinical sessions beneficial in gaining experience with Telehealth. Identifying specific challenges and benefits of online learning is important. This will help educational institutions to take further action to help staff and students mitigate these challenges while capitalising on the potential benefits available.

Strengths and limitations 

Our study demonstrates several key strengths. Firstly, the survey attracted a large response with a total of 413 participants, aged between 18 to 45 years old, studying in all Australian states and territories. This response rate equates to 2.27% of all Australian medical students at the time (18,157 students in 2021) and increases the reliability of our results [22]. 36.8% of survey respondents were students living in Victoria, allowing us to thoroughly investigate the impact on those facing short and longer lockdown lengths.

The results of our study may have been impacted by the timeframe in which responses were collected. Responses of the survey were collected between the 3rd of July 2021 and the 30th of September 2021. In Victoria during 2021, there were four periods of lockdown, resulting in a total of 109 days in lockdown for the year. Many of the responses were recorded within the windows of lockdown five (15th July to 27th July) and lockdown six (5th August to 21st October) of the pandemic. The degree of optimism or pessimism may have influenced the survey responses of Victorian participants who were, yet again, experiencing lockdown. Had survey responses been taken earlier in 2021, not during lockdown, Victorian responses may have reflected differently. Additionally, in 2021, other states and territories entered in and out of lockdowns at numerous time points while the survey was open, which similarly may have affected their reflections on their experience in 2020. Equally, the survey being open during lockdown periods may also be considered a strength as it facilitated the collection of real-time data without the potential dilution caused by hindsight bias.

Selection bias would have also impacted our responses, as survey dissemination was coordinated via GPSN ambassadors. Therefore, Australian medical schools, without a GPSN club including, University of Newcastle and University of Wollongong, were likely to be under-represented by our data.

Conclusion 

Our quantitative results do not demonstrate any significant differences in the experiences of medical students residing in states with shorter lockdown lengths compared to those residing in Victoria with longer lockdown lengths. However, from our qualitative results, it is evident that COVID-19 had both positive and negative impacts on medical students around Australia.

While the transition to online learning presented novel opportunities, it also exacerbated existing stressors. This exploration of medical students’ mental health, financial situation, and education is an important starting point to support these potentially vulnerable students. The findings of this study hold significant implications for the increasing dependence on online learning, not just for the adaptation of medical curricula, but also for other tertiary courses that blend practical and theoretical components. This is particularly relevant given the pressing challenges identified by a shift to online education. These findings can guide all educational institutions, offering insight into the holistic student experience during the transition to online learning, and aiding in the refinement of strategies for optimising remote study environments.

Acknowledgements  

We would like to acknowledge Dr Loai Albarqouni and Alexandra Yeoh (Bond University) for their guidance during this project. This work was supported by GPSN and Bond University.

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Conflicts of interest 

‘The authors have no conflicts of interest to declare.’

Author contribution 

Angeline Kavitha Sathiakumar: Conceptualisation, Methodology, Investigation, Writing – Original Draft, Writing – Review & Editing, Project Administration

Cynthia Nga Yu Leung: Conceptualisation, Formal Analysis, Investigation, Writing – Original Draft, Writing – Review & Editing

Tamarangi Keerthipala: Conceptualisation, Investigation, Writing – Original Draft, Writing – Review & Editing

Rebecca Martin: Conceptualisation, Investigation, Writing – Original Draft, Writing – Review & Editing

Ethics

Ethics approval was given for this project in May 2021 via Bond University Human Research Ethics Committee (BUHREC).  The ethics application number is RM03171.