Impact of COVID-19 on medical education in different income countries: a scoping review of the literature

Figures & data

Table 1. World Bank Group country classifications by income levels for 2021–2022

Group	Income (GNI per capita in current US dollars, using Atlas method exchange rates)
Low-income	<1045
Low-middle-income	1046–4095
Upper-middle-income	4096–12,695
High-income	>12,695

Source: World Bank Group, 2021.

Figure 1. PRISMA flowchart

Table 2. Summary Table of Included Studies x = Information not available or not applicable to study

Author(s)	Title	Year of Publication	Country of Study	World Bank Income Classification of Country	Design of Study	Number of Participants	Aim(s) of Study	Data Collection Duration	Key Findings
Bączek et al [13]	Students’ perception of online learning during the COVID-19 pandemic	2021	Poland	High-income	Survey study	804participants	To analyse medical students’ perception of online learning during the COVID-19 pandemic.	4 weeks and 3 days	Main advantages of online learning: ability to stay at home (69%), continuous access to online materials (69%), learning at own pace (64%) and comfortable surroundings (54%). Main disadvantages of online learning: lack of interaction with patients (70%) and technical problems with IT equipment (54%). No statistical difference between face-to-face and online learning in relation to increasing knowledge. E-learning is less effective than face-to-face learning in increasing skills and social competencies. 73% of students found online learning enjoyable.
Choi et al [5]	The Impact of the COVID-19 Pandemic on Final Year Medical Students in the United Kingdom: A National Survey	2020	UK	High-income	Survey study	444 participants	To identify the impact of COVID-19 on final year medical students’ examinations and placements in the UK and how it might impact on their confidence and preparedness going into their first year of foundation training.	x	38.4% of participants had their final OSCEs cancelled (43% had already completed these exams before restrictions were imposed). 18.6% had simulated patients or OSCE stations requiring patient contact cancelled. 55.9% reported no change to written examinations while 26.8% completed them online remotely. 9.8% reported cancellations. Students’ confidence for starting foundation training was significantly affected by the impact of COVID-19 on student assistantships only.
Compton et al [14]	Medical students’ preference for returning to the clinical setting during the COVID-19 pandemic	2020	Singapore	High-income	Survey study	179 participants	To assess medical students’ preference for re-entering the clinical setting during the COVID-19 pandemic and to explore personal and environmental characteristics associated with that preference.	9 days	One third of participants preferred not to return to the clinical setting due to COVID-19. Two-thirds of participants wanted to return to clinical placement. Reasons for this included improving clinical capacity.
De Ponti et al [15]	Pre-graduation medical training including virtual reality during COVID-19 pandemic: a report on students’ perception	2020	Italy	High-income	Survey study	115 participants	To assess medical students’ perception of online training including simulated clinical scenarios during the COVID-19 pandemic.	x	90% of participants evaluated virtual reality training positively. 77% thought virtual reality training was realistic for initial clinical assessment. 94% thought virtual reality training was realistic for diagnostic activity. 28% found online access difficult due to technical issues.
Dost et al [16]	Perceptions of medical students towards online teaching during the COVID-19 pandemic: a national cross-sectional survey of 2721 UK medical students	2020	UK	High-income	Cross-sectional, online national survey study	2721 participants	To investigate perceptions of medical students on the role of online teaching in facilitating medical education during the COVID-19 pandemic.	1 week	Overall, students did not find online teaching to be engaging or enjoyable. They also did not find it as effective as face-to-face teaching. 76% felt online teaching did not successfully replace clinical teaching via direct patient contact. 82% felt they could not learn practical clinical skills through online teaching. Main advantages of online learning were saving time on travelling (19.82%), flexibility (19.52%) and allowing students to learn at their own pace (18.63%). Main barriers to online learning were family distraction (26.76%) and poor internet connection (21.53%).
Elzainy et al [17]	Experience of e-learning and online assessment during the COVID-19 pandemic at the College of Medicine, Qassim University	2020	Saudi Arabia	High-income	Cross-sectional study	250 participants (pre-clinical phase)	To explore the impact of e-learning and assessment on the performance of students and faculty, and the challenges to their sustainability.	65 days	78% of students either strongly agreed or agreed that e-learning compensated for face-to-face teaching. 40% either strongly agreed or agreed that staff had enough experience in e-learning requirements while 30% either strongly disagreed or disagreed on the same issue. 68% either strongly agreed or agreed that interaction during the online sessions was satisfactory. 60% either strongly agreed or agreed that online assessment is effective to test knowledge.
Franklin et al [18]	How the Covid-19 Pandemic Impacted Medical Education During the Last Year of Medical School: A Class Survey	2021	USA	High-income	Cross-sectional, mixed method survey	63 participants	To get a better understanding of how the COVID-19 pandemic impacted fourth-year medical students’ learning, after a complete changeover from in-person to remote learning.	6 days	57% indicated that their sub-speciality was impacted by COVID-19. 35% of students were satisfied with use of their e-learning platform. Students did not find tele-education and e-learning as effective as traditional medical education.
Haley et al [19]	The Negative Impact of COVID-19 on Medical Education amongst Medical Students Interested in Plastic Surgery: A Cross-sectional Survey Study	2021	USA	High-income	Cross-sectional study	130 participants	To investigate how medical students interested in plastic surgery were impacted by COVID-19-associated curriculum changes.	1 month	91% of students attended schools that offered online courses and 46% still had in-person rotations with restricted schedules. 80% believed that the pandemic had a negative impact on their medical education. 94% felt that their medical schools were ‘’fairly supportive’’ of their psychosocial wellbeing during COVID-19.
Harries et al [4]	Effects of the COVID-19 pandemic on medical students: a multicenter quantitative study	2021	USA	High-income	Cross-sectional survey study	741 participants	To investigate the educational and psychological effects of the pandemic on US medical students and their reactions to the Association of American Medical Colleges (AAMC) recommendation to pause all student clinical rotations with in-patient care, in order to inform medical education policy.	35 days	74.7% of students felt the pandemic had significantly disrupted their medical education. 61.3% believed they should continue with their normal clinical rotations during the pandemic. 61.4% felt COVID-19 had disrupted their skill development to prepare for residency. 72.7% felt medical schools were doing their best to help students adjust.
Kim et al [20]	How medical education survives and evolves during COVID-19: Our experience and future direction	2020	South Korea	High-income	Survey study	362 participants	(1) To assess the experience of running a medical school curriculum during COVID-19 by moving all classes online and minimising face-to-face contact. (2) To investigate student satisfaction, problems, achievements and perspectives on the future in relation to COVID-19.	x	Students were generally satisfied with the online course. Students had a higher preference for online lectures (63%) compared to offline lectures (29%), while professors preferred offline lectures (77.3%) over online lectures (31.9%). 84.3% of students wanted to maintain online courses after the pandemic. Among them, 45.5% wanted to combine offline and online classes while 38.8% wanted most lectures to be maintained online. 47.7% of professors wanted to maintain online lectures while 52.3% wanted to return to offline lectures.
Loda et al [21]	Medical education in times of COVID-19: German students’ expectations – A cross-sectional study	2020	Germany	High-income	Cross-sectional survey study	372 participants	To investigate the teaching- and learning-related stressors and expectations of medical students in Germany during the COVID-19 pandemic.	3 weeks	Students reported being afraid of losing a semester due to COVID-19. Students reported general uncertainty and scarcity of information as the greatest stressors, followed by worries regarding examinations, practical years and training terms abroad. 71% wanted their teachers to be willing to enhance digital competencies and 66.4% expected teachers to be lenient about examinations.
Motte-Signoret et al [22]	Perception of medical education by learners and teachers during the COVID-19 pandemic: a cross-sectional survey of online teaching	2021	France	High-income	Cross-sectional survey study	80 participants	To investigate how online teaching was perceived by both teachers and learners during the COVID-19 pandemic, in order to help determine how to adapt curricula over the coming years.	2 months	85.5% of students agreed that online teaching was an appropriate teaching method during the pandemic. Approximately 70% of students and 69% of teachers felt that they have not received or provided training of an equivalent level and quality as expected. Approximately 15% of students and 38.5% of teachers felt that an online curriculum should continue after the pandemic.
Nishimura et al [23]	Impact of the COVID-19 Pandemic on the Psychological Distress of Medical Students in Japan: Cross-sectional Survey Study	2021	Japan	High-income	Cross-sectional survey study	473 participants	To provide details on how medical students have been affected by the pandemic in Japan.	1 week	29.8% of students were concerned about the shift to online teaching, mostly because they thought online teaching would be ineffective compared to face-to-face teaching. 25.6% were concerned about effects on their future career. 49.7% were concerned about their relationships with teachers. Those who had concerns had higher odds of having generalised anxiety and being depressed.
Paton et al [24]	Medical Student Experience During the COVID-19 Pandemic: A Qualitative Study	2020	USA	High-income	Qualitative, descriptive study	11 participants	To learn the perspectives of medical students at a single institution regarding the impact of COVID-19 on their education, identify common challenges that they faced, and gather recommendations to approach medical education during similar national or global crises in the future.	10 days	Most students reported that the interruption in clinical rotations negatively affected their education. Reasons for this negative effect included loss of clinical training, access to preceptors, career planning and missing critical clinical electives and opportunities. Students reported they were learning about the form and function of the healthcare system which could not be taught in a classroom setting.
Shahrvini et al [25]	Pre-clinical remote undergraduate medical education during the COVID-19 pandemic: a survey study	2021	USA	High-income	Survey study	104 participants	To better understand the effects of the complete transition to remote learning during the COVID-19 pandemic on pre-clinical students.	x	Overall, students felt that online learning had negatively affected teaching quality and their ability to participate. Only 25.5% still felt connected to the medical school or classmates. Anxiety and isolation were reported. 56.7% felt their preparation for exams was negatively affected. 43.3% felt unprepared to begin clerkships.
Torda et al [26]	How COVID-19 has pushed us into a medical education revolution	2020	Australia	High-income	Literature review	x	To highlight the way in which COVID-19 has changed medical education.	x	The transition from face-to-face to online teaching was relatively easy for lectures and small group teaching. However, it was more difficult for practical science classes and clinical skills teaching. Senior year medical students were paired with a junior medical officer so they received training with clinical teams and could alleviate pressure on junior medical staff. Campus-based examinations were put online. OSCEs were not possible so other online simulated options were investigated.
Rajab et al [27]	Challenges to Online Medical Education During the COVID-19 Pandemic	2020	Saudi Arabia	High-income	Cross-sectional study	177 participants	To analyse the impact of the COVID-19 pandemic on online education at the College of Medicine of Alfaisal University in Riyadh, Saudi Arabia.	March-April 2020	37.4% of medical students and 57.9% of the faculty reported having little or no experience with online teaching before the pandemic. Challenges to online learning include issues regarding in-person communication, assessment, technology tools, experience in online learning, pandemic-related anxiety and stress, learning curve, time management, students’ evaluations of faculty and technophobia.
Vatier et al [28]	Lessons from the impact of COVID-19 on medical educational continuity and practices	2021	France	High-income	Survey study	698 participants	To determine the impact of the COVID-19 outbreak on French undergraduate medical students from Sorbonne University.	41 days	15% of teachers did not do any of their usual teaching duties, 50% maintained less than half of their classes, and 13% gave all scheduled lessons. 6% of students did not follow any lessons, 36% followed less than half of the course and 21% used all resources available. 55% of medical students regretted not having face-to-face teaching and 70% of teachers had this same regret.
Al-Balas et al [29]	Distance learning in clinical medical education amid COVID-19 pandemic in Jordan: current situation, challenges, and perspectives	2020	Jordan	Upper-middle- income	Cross-sectional study	652 participants	To explore the situation of distance e-learning among medical students during their clinical years and to identify possible challenges, limitations, satisfaction and perspectives for this approach to learning.	x	26.77% of students were satisfied with their experience in distance learning, 28.81% felt neutral and 44.42% were dissatisfied with this experience. 55.9% of students reported multiple advantages including time-saving, flexibility and improved interaction with instructors and classmates. 48.3% reported low quality of teaching, 62.1% reported poor interaction with instructors and 69.2% reported internet quality issues.
Alsoufi et al [30]	Impact of the COVID-19 pandemic on medical education: Medical students’ knowledge, attitudes, and practices regarding electronic learning	2020	Libya	Upper-middle- income	Cross-sectional survey study	3348 participants	To provide an overview of the situation experienced by medical students during the COVID-19 pandemic and to determine the knowledge, attitudes, and practices of medical students regarding electronic medical education	May-June 2020	97.1% reported suspended lectures and educational programs, while 86% reported suspended clinical training and laboratory skills training. 35.1% and 29% of students reported that they had access to a good or very good internet connection, respectively. 64.7% disagreed that e-learning could be used easily in Libya. 78.3% found it difficult to participate in e-learning due to financial cost.
Aziz et al [31]	Impact of Covid-19 on education of undergraduate medical students in Pakistan.	2020	Pakistan	Lower-middle-income	Cross-sectional study	765 participants	To assess the impact of COVID-19 on the education of undergraduate medical students in Pakistan.	1 month	96% of students had online classes but 52.8% reported that these were not effective. 69.7% of students were dissatisfied with e-learning. 91.5% reported that they have lost interest in studies. 88% rejected online assessment as an alternative to traditional examinations.
Baticulon et al [32]	Barriers to Online Learning in the Time of COVID-19: A National Survey of Medical Students in the Philippines	2021	Philippines	Lower- middle-income	Cross-sectional study	3870 participants	To identify barriers to online learning from the perspective of medical students in a developing country.	14 days	Only 41% of students were capable of adapting to online learning. 44% reported that their schools were equipped to support online teaching. Common barriers to online learning included difficulty adjusting to a new learning style, having to perform other responsibilities at home, poor communication from educators, lack of physical space and lack of sufficient internet connection.
Daroedono et al [33]	The impact of COVID-19 on medical education: our students perception on the practice of long distance learning	2020	Indonesia	Lower- middle- income	Cross-sectional survey study	545 participants	To measure the impact of COVID-19 on medical education by asking the students’ perception on long distance learning delivered during this pandemic.	2 weeks	The greatest perceived benefits of distance learning by medical students were: location flexibility (87.9%), time flexibility (76.5%), low cost (65.7%) and no specific preparation needed (57.6%). The greatest perceived disadvantages were: being internet signal dependent (80.2%), costs for additional cellular data (79.1%), lack of understanding (77.8%) and lack of concentration (77.6%).
Liu et al [34]	The impact of COVID-19 on medical education: Experiences from one medical university in Taiwan	2021	China	Upper- middle- income	Short communication	x	To present the strategies taken by Taiwanese medical schools to continue in-person medical education on campus when COVID-19 first occurred.	x	Of all strategies introduced in medical universities to combat COVID-19, adjusting classes to a largely online format had the most significant and lasting effect on students. Lack of staff training in using technology, internet instability and lack of motivation and time management skills were all reported disadvantages of online learning. Time flexibility was a reported advantage of online learning.
Nepal et al [35]	Students’ Perspective on Online Medical Education Amidst the COVID-19 Pandemic in Nepal	2020	Nepal	Lower- middle- income	Cross-sectional survey study	226 participants	To analyse medical students’ perspective in Nepal on the newly introduced online medical education system due to COVID-19.	5 days	74.3% of students reported that online classes were poorer than traditional teaching 77.8% would choose traditional teaching over online teaching. 55.8% reported that they did not engage with lessons or reading from e-books before or after online classes.
Oladipo et al [36]	Challenges with medical education in Nigeria in the COVID-19 era	2020	Nigeria	Lower- middle- income	Survey study	72 participants	To study the impact of the COVID-19 pandemic on medical education in Nigeria.	x	75% of students reported that e-learning platforms were not used in their institutions before the pandemic. Due to mandatory closing of schools, 45% of schools continue to provide medical education via online learning. All private institutions could continue education while only a few public institutions could do this. Transition to e-learning took 4-8 weeks, indicating some students had no medical education for up to approximately 8 weeks.
Rafi et al [37]	Concerns and confidences expressed by teaching staff about the shift of medical education to online mode in South India during the COVID 19 pandemic	2020	India	Lower- middle- income	Survey study	51 participants	To investigate the concerns and confidences of medical teaching staff in India regarding the effect of COVID-19 on undergraduate medical education.	1 week	All teachers preferred regular classroom teaching due to better teacher-student interaction. One third of teachers wanted the long-term continuation of online classes. 47% of teachers self-graded the success rate of online classes as 90% or higher and 43% graded it between 71% and 90%.
Shehata et al [38]	Medical Education Adaptations Post COVID-19: An Egyptian Reflection	2020	Egypt	Lower- middle- income	2-phase mixed method exploratory study	78 participants	To explore how medical schools in Egypt responded to the COVID-19 pandemic regarding teaching, learning and assessment for undergraduate students.	x	55.1% of faculty evaluated staff level of preparedness for the changes caused by the pandemic as optimum to high. Only 17.9% reported that technology preparedness for this change was high. 67.9% reported that alternative examination methods were used for formative assessment but 75.6% stated that there was an absence of alternative methods for summative assessment.
Tempski et al [39]	Medical students’ perceptions and motivations during the COVID-19 pandemic	2021	Brazil	Upper- middle- income	Survey study	10443 participants	To evaluate the motivation of medical students to be part of health teams to help in the COVID-19 pandemic	3 days	39.7%, 29% and 29% of 1^st /2^nd years, 3^rd/4^th years and 5^th/6^th years respectively, reported that they would prefer to delay their training to fully replace academic activities rather than participating in distance learning. 41.9%, 56.3% and 58.8% of 1^st /2^nd years, 3^rd/4^th years and 5^th/6^th years respectively, reported that they felt able to study their course through distance learning. 37.2%, 48.7% and 40.3% of 1^st /2^nd years, 3^rd/4^th years and 5^th/6^th years respectively, reported that they believed that after the pandemic, only practical elements of the course must be resumed.
Thomas et al [40]	Survey Among Medical Students During COVID-19 Lockdown: The Online Class Dilemma	2020	India	Lower- middle- income	Cross-sectional survey study	1016 participants	To evaluate the attitudes of, and the factors affecting, medical students attending online classes during lockdown.	2 days	Network issues was the most common reason (85.8%) why participants disliked online learning. Learning at leisure was the most common reason (44.5%) why participants liked online learning. 51.7% of participants did not want to continue online classes after the pandemic. 55% favoured traditional classes compared to online classes.
Tuma et al [41]	Students and faculty perception of distance medical education outcomes in resource-constrained system during COVID-19 pandemic. A cross-sectional study	2021	Iraq	Upper- middle- income	Survey study	717 participants	To describe, evaluate and provide pertinent recommendations about interactive distance education in experience and resource-limited medical schools during the COVID-19 pandemic.	x	27% of students and 49% of instructors either agreed or strongly agreed that the expectations and objectives of online learning activities were achieved. 53% of instructors reported that knowledge gain and teaching effectiveness were similar or better than traditional learning. 67% of students reported more difficulties with online learning compared to traditional learning. 67% of students reported fatigue or loss of interest while participating in online learning.
Yu et al [42]	Analysis of factors influencing the network teaching effect of college students in a medical school during the COVID-19 epidemic	2021	China	Upper- middle- income	Cross-sectional survey study	7084 participants	To understand the influencing factors of Chinese college students’ satisfaction with online teaching and psychological pressure associated with learning during the coronavirus epidemic.	1 month	Students from urban areas rated higher than those from rural areas in preparation for their classes, access to information on teaching arrangements and teaching methods, answers to questions and satisfaction with teaching results. The psychological pressure on learning in urban area students was lower than that in rural area students. Satisfaction of female students with teachers’ preparation was higher than that of male students. Students who used computers/tablets as learning tools had higher satisfaction than those who used mobile phones as learning tools.
Gismalla et al [43]	Medical students’ perception towards E-learning during COVID 19 pandemic in a high burden developing country	2021	Sudan	Low-income	Cross-sectional survey study	358 participants	To assess medical students’ perception towards implementing e-learning during COVID-19 and to highlight e-learning implementation in Sudan as an example of a limited-resource setting.	16 days	64% of medical students believe that e-learning is the best solution for medical education during the pandemic. Factors reported against e-learning implementation in Sudan include: limited internet connectivity (38%), limited technical support (24%), unfamiliarity with e-learning systems (22%) and lack of face-to-face interaction (16%).

Figure 2. World Bank Group income classification of countries included in review

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