INTRODUCTION

The outbreak of COVID-19 in January 2020 has rapidly transformed into a pandemic after the World Health Organization’s classification. The public health emergency has motivated the implementation of social distancing measures and prohibition of non-essential services¹, followed by universities that suspended in-person activities aiming at reducing students’ mobility and, consequently. restricting disease transmission². In medical schools, the migration to e-learning platforms was almost immediate and an alternative to adapt medical education from the traditional format to virtual scenarios^3),(4.

Although technology may represent an alternative to continuing knowledge⁵, the lack of solid evidence that it may be as effective as in-person teaching methodology for medical students brought concerns with regard to their personal and professional development^6)-(8, and this challenge still needs clarification during the ongoing pandemic, as a second wave strikes Europe and North America. Therefore, medical students, more specifically those attending the last years of undergraduate medical school, suffer more anxiety, because they are at a crucial moment to obtain which cannot be obtained in a similar fashion through digital platforms.

However, the same clinical scenario is the most at-risk place for acquiring COVID-19 and several strategies should be proposed in the attempt to overcome prejudices due to the lack of clinical training in this group of students. The virtual discussion of real clinical-case scenarios and elective disciplines that improve the training in critical situations (telemedicine¹⁰), as well as volunteer activities, have been fundamental as a response to many health sectors¹¹. Volunteering may be seen as an altruistic attitude, or an opportunity to learn from the situation, but in the presence of a pandemic, there might be other reasons^12),(13 and medical courses should be aware of them. Given that, we sought to identify the factors associated with choosing a volunteering activity among medical students attending the last years of medical school during the COVID-19 pandemic.

METHODS

RESULTS

Of 350 invitations, 125 (35.8%) responded and were included in the analysis. Response rates varied: 24.8% from the MS4, 37.6% from MS5 and 37.6% from the MS6. No incomplete responses were found. Table 1 shows the sociodemographic characteristics and the questionnaire responses by volunteers and non-volunteers. Among the participants, 79 were females (63.2%) and 46 (36.8%) males. All participants had access to the Internet and 102 (81.6%) used a notebook, 10 (8%) used a desktop computer and 13 (10.4%) used smartphones and tablets. Sixty-five (52%) students were volunteers and the distribution of the activities were (more than one type of activity could be chosen): 56 worked with telemedicine, 16 worked with the Expeditionary Health team, 8 worked by taking medical night calls and 7 performed external activities. Among the volunteers, most of them were MS-5/6 (66.15%); however, less than half of this medical class were volunteers - among the MS-4s, 70.97% were volunteers.

About the time spent on social media during a day, 24 (19.2%) students accessed them for less than 120 minutes, 72 (57.6%) spent between 120 and 360 minutes and 29 (23.2%) more than 360 minutes. On the other hand, 80 (64.5%) spent less than 120 minutes using the e-learning platforms.

Compared to MS5-MS6 students, MS-4s participation as volunteers was significantly lower (χ²=5.94; p=0.01), as well as MS with higher family income (χ²=8.96; p=0.03) and students that considered themselves more satisfied with previous theoretical and practical preparation (χ²=9.28; p=0.02) (Table 1).

When students were asked about their capability during theoretical and practical preparation for a public health emergency, 98 (78.4%) considered themselves as not sufficient and 97 (77.6%) did not feel capable to attending or dealing with an emergency in a global health situation, such as COVID-19.

Before the pandemic, 50.4% of the respondents considered important the teaching technologies (eg. e-learning). However, during the pandemic, the exclusive use of e-learning for theoretical activities and clinical case discussions were considered not sufficient for 70.4% of students about their professional qualification.

Univariate and multivariate analysis to the associated factors with volunteering were described in Table 2. After logistic regression, it was found that MS-5/6s were less associated with volunteering (OR, 0.21; 95% CI, 0.06-0.66), family income with 5.1-10 minimal wages more associated with volunteering (OR, 2.32; 95% CI, 0.94-6.42). Exposure to social media platforms between 120-360 minutes in social media platforms (OR, 0.1; 95%CI, 0.02-0.42) and over 360 minutes (OR=0.16[0.03-0.76]) reduced the risk for volunteering. Interestingly, MS that considered themselves able to face a pandemic situation (OR 4.91; 95%CI, 1.49-16.2) and that presented e-learning modules before pandemic (OR=16.46[1.35-200.32]) were risk factors for being volunteers (Table 2).

DISCUSSION

This study has identified factors associated with volunteer activities among medical students attending the last years of undergraduate school during the COVID-19 pandemic. Students attending the 4^th year of the medical course, students with family income between 5-10 minimum wages, and students who felt more confident and capable to face the pandemic were more prone to be volunteers. Students that more often used social media networks showed a low probability of being volunteers.

An interruption of the educational process of the medical curriculum was expected to happen during the COVID-19 pandemic¹¹, as we were not prepared to deal with a situation like that from a public health standpoint and the resources provided to students by the institutions were tested during this unprecedented period. During this survey, an attempt was made to identify medical students willing to be volunteers during a healthcare emergency situation, and we found that few students felt prepared regarding their abilities and previous experiences¹³, and many thought that the lack of full medical training would compromise their assistance to patients, even under supervision^14),(15. It was possible to observe during this pandemic, the unraveling of the scenarios in a virtual environment and how damage to the medical education could be minimized- that is, the fact that the e-learning structure was not completely prepared for what was coming¹⁶.

However, facing COVID-19 can have a positive impact promoted by medical students¹⁷. In Switzerland, students supervised by medical tutors in a critical-care scenario have demonstrated that the medical students felt motivated to work and learn, and the experience was considered feasible and safe ⁽¹⁸. In Brazil and United States¹⁹, medical students were submitted to a compulsory interruption of their clinical rotations and did not have a central role when facing this crisis, if one remembers that these countries had the largest death tolls worldwide²⁰. This can be a controversial discussion, and there are pros and cons to both opinions on exposing a medical student to a pandemic situation.

The MS-4 have their first exposure to patient care¹⁴, and faced the interruption of outpatient and inpatient clinical rotations^22),(23. Volunteering can be a positive stimulus as the student can consider the unpredictability of the scenario, without knowing when they are coming back to the “normal” routine. This experience can motivate them to have contact with clinical experiences²⁴; however, they showed less interest in volunteering than MS-5 and MS-6, and it is possible that the latter group considered the longer duration of the pandemic and having to undergo a transition to become physicians with less practical training. In addition, the unpredictability of the end of the medical course due to the pandemic²¹, as previous studies have shown that medical students may feel psychologically stress before the residency selection process²⁵. Many countries, such as United Kingdom and United States, are changing the residency process to a virtual format and the new scenario can add stress to the process²⁶.

During the COVID-19 pandemic, the use of social media has disseminated a great amount of information, and this certainly contributed to misinformation and fake news²⁷. This trend may have impacted on the interest to be a volunteer; we have found that spending longer periods on social media decreased the interest to be a volunteer, and this can be explained by the fact that wrong information can generate high levels of stress and fear/uncertainty^27),(28. Social media exposure (SME) may cause misinformation and this can affect the mental health of users²⁹ and compromise their willingness to participate in other activities during a crisis. Humanitarian crises may have consequences on the mental health of survivors²⁹ and usually, the most affected population live in low‐ and middle‐income countries (LMICs)^30),(31, such as Brazil.

Many health determinants, such as family income, may impact on the risk and outcomes caused by SARS-CoV-2³². For individuals with a low socioeconomic level, social distancing may be more difficult, due to overcrowded housing and difficulty to maintain jobs with the home-office modality during the pandemic³³. Such evidence may be related to difficulties that low-income students had to struggle with; many could not face the challenge of staying in the city where they were attending their medical school as the economic crisis was affecting many families; it is known that economic consequences secondary to restrictive measures have caused a global increase in unemployment rates³⁴.

Students that felt prepared to face a global health emergency were more prone to be volunteers, and literature has shown that attitudes and previous knowledge may influence the student’s decision to volunteer³⁵. A Canadian study analyzed factors and attitudes of medical students who chose to volunteer during the influenza pandemic and reported that a previous volunteering experience was a strong predictor of being available to collaborate in that circumstance³⁶. Other variables, such as age and gender³⁶ may also be related to volunteering; however, our study did not identify these associations.

Our study has some limitations, which include the non-response bias inherent to its survey design and the sample that may be biased by self-selection, as the sample size was not calculated. If responders were more interested in being a volunteer than those that did not respond, then our results would be overly optimistic about the factors associated to participation in volunteer activities. Secondly, the impact of a higher risk of severe illness caused by Covid-19 infection was not directly measured among the responders. Another one is that all the students who answered the survey came from a single university located in the same country, which does not allow us to generalize our results.

The strengths of our study include the fact that it was conducted in a country that represents the third place regarding the number of cases and the second in death rates caused by COVID-19 and that has faced the collapse of the public health system in many cities around its national territory. Our response rate was satisfactory and compatible with other surveys.

COVID-19 pandemic has led our society to reshape itself and medical schools have undergone modifications aiming to face this pandemic. Medical students were questioned about their role during this pandemic period. It was concluded that half of our sample participated in volunteer activities during the COVID-19 pandemic and a previous, confident attitude towards a public health emergency increased the odds of working as a volunteer.

CONCLUSION

COVID-19 pandemic has led our society to reshape itself and medical schools have undergone modifications aiming to face this pandemic. Medical students were questioned about their role during this pandemic period. It was concluded that half of our sample participated in volunteer activities during the COVID-19 pandemic and a previous, confident attitude towards a public health emergency increased the odds of working as a volunteer. It is possible that the volunteer activities performed by medical students, with a high-quality training, during this pandemic might change the public health system care, especially in low-and-middle income countries, facilitating access to the service and care of patients with lower clinical complexity.