Impact of Covid-19 on urogenital online learning through WeChat in China

Background To evaluate the signicance of social media and the impacts of Covid-19 on urogenital continuing education in China through WeChat. Backend database from a Chinese urological online learning platform on account of WeChat named Jiujing before and during Covid-19 pandemic were compared and analyzed. An online questionnaire investigation containing 482 respondents was carried out to evaluate the impact of Covid-19 on urological online learning through WeChat.


Abstract Background
To evaluate the signi cance of social media and the impacts of Covid-19 on urogenital continuing education in China through WeChat.

Methods
Backend database from a Chinese urological online learning platform on account of WeChat named Jiujing before and during Covid-19 pandemic were compared and analyzed. An online questionnaire investigation containing 482 respondents was carried out to evaluate the impact of Covid-19 on urological online learning through WeChat.

Results
During the epidemic of Covid-19, the amounts of national subscribers in Jiujing platform increased by 26.24%, while the constituent ratio of subscribers' quantity from Hubei province decreased although there were 189 new subscribers, and only surgery video section experienced increased constituent ratio of subscribers' concerns. Online investigation indicated that most respondents experienced whittled o ine learning opportunities and boosted online learning demands during Covid-19 pandemic as online learning was more e ciency, and these attitudes were associated with quali cations of the respondents. Surgery videos and academic lectures were the most popular sections. Preferences of the respondents were determined by gender, title, degree and a liation hierarchy.

Conclusions
Even though the Covid-19 pandemic has affected the patterns of online medical education to a certain degree, continuing learning through social media like WeChat is essential and bene cial for urologists. Positional title, a liation hierarchy and education background are supposed to impact their attitudes towards online learning.

Background
The last decade witnessed rapid development of Internet, which has remarkably changed people's lifestyle. In China, WeChat is a popular social application based on either computers or cellphones, which contains multiple functions like text and voice messages, group chats, subscribe to public accounts, and applets [1]. The economic transition in China led to the increasingly structural imbalance of talents, while the number and structure of professional technical talents cannot meet market demands [2]. Meanwhile, the gap between urban and rural areas or among regions in China has caused the shortage and unbalanced distribution of high-quality medical resources, especially the disequilibrium in technological capacities of medical practitioners [3].
The applications of social media in healthcare and its role in scienti c communication provide great opportunities in the urogenital community [4]. Consequently, urologists and andrologists around the world have been using social media for business affairs, academic conferences and health providing [5].
Meanwhile, the development of the new media greatly challenges traditional education mode, which helps break departed imbalance between doctors and patients, or doctors from different areas. Especially, the outbreak of Covid-19 has restricted face-to-face learning and signi cantly promoted transformation of medical continuing education patterns [6].
A group of urologists and andrologists from different cities and a liations in China founded an academic platform on account of WeChat named Jiujing, which is the pronunciation in Chinese Pinyin and means exploring the art of urogenital endoscope. It provides an open accessible and generally shared academic platform, aiming at promoting skills, innovating perceptions and serving the professionals and residents. Since established on December 15th in the year of 2015, nearly 700 messages have been released in Jiujing through WeChat. Over 50 public lectures have been broadcasted online and nearly 8,000 participants have joined 18 chat groups. The platform provides the users with latest literatures express, medical humanity sharing, free online lectures or surgical videos, di cult or special cases discussions and interactions in academic opinions. Urologists, andrologists and related practitioners are encouraged to share their clinical experience, surgical videos or research reports through the platform. Editors from the platform also invite related specialists to give commonweal online lectures and more than 13 thousand listeners have followed the courses. In this way, advanced concepts and ideas are disseminated ignoring barriers of regions and quali cations among the urologists and andrologists.
The pandemic of Covid-19 triggered transitions of online medical learning, in line with this, some structural alterations of the subscribers in Jiujing platform have been noticed. Consequently, we carried out an online questionnaire investigation to explore the impact of Covid-19 on urogenital online learning through WeChat platform.

Methods
Data acquisition and descriptive analysis from WeChat platform Data of the subscribers in Jiujing platform were obtained from the backend database of WeChat Media Platform (https://mp.weixin.qq.com/). General information of the subscribers including gender, age, region and language were collected. Distributions of the subscribers' regions and clicks volumes of each section in the platform before (data by the end of 2019) or during (data by the end of 2020) the epidemic of Covid-19 were compared.
Online survey on urogenital learning through WeChat during Covid-19 pandemic The online survey titled "The effect of WeChat platform on urogenital learning during the Covid-19 pandemic" was carried out through the online questionnaire instrument WENJUANXIN (https://www.wjx.cn/), which is a platform for professional online surveying, evaluation, and voting in China [7]. The electronic questionnaires containing 11 choice questions (10 single choices and 1 multiple choice) were sent to the followers of Jiujing, and the investigation was performed from February 27 to March 9, 2021. General information questions included gender (item 1), title (item 2), degree (item 3), hierarchy of a liation (item 4), whether from teaching hospital (item 5), whether frontline staff against Covid-19 (item 6). The attitudinal questions included in uence of Covid-19 on face-to-face learning opportunities (item 7) and online learning demands (item 8), e ciency comparison between face-to-face and online learning (item 9), whether bene ting from online learning (item 10), the most bene cial sections (item 11, multiple choice).

Statistical analysis
Data were presented as numbers with percentages (n, %). Descriptive analysis of the data from WeChat Media Platform was performed with Microsoft Excel (2019 edition). Logistic regression analysis and chi-square test of the investigation data were analyzed using the online software SPSSAU (version 20.0, retrieved from https://www.spssau.com) [8]. The *p-value < 0.05 or **p-value < 0.01 were considered statistically signi cant.

Impacts of Covid-19 pandemic on distributions and preferences of the subscribers in Jiujing platform
According to the backend database from WeChat, by the end of 2020, about 22000 individuals have followed the account with total quantity of views approaching 2.4 million. The distribution of languages used by the subscribers were Chinese (98.81%), English (1.01%) and other (0.18%). Approximately 84.88% of the subscribers were male, and 74.68% of them were 26 to 45 years old.
Impacts of Covid-19 pandemic on urogenital face-to-face and online learning through WeChat platform A total of 482 valid questionnaires were received and the general information of the respondents is presented in Table 1. Most of the respondents experienced whittled face-to-face learning opportunities (364/482, 75.52%) and increased online learning demands (413/482, 85.68%) during Covid-19 pandemic.
Among the personal characteristics, differences of the respondents' positional titles remarkably impacted their choices (Table 2). With the ascending of quali cation, signi cantly more respondents suffered decreased face-to-face learning opportunities (64.29% of primary physicians, 74.05% of attending physicians, 80.37% of assistant director physicians, 79.69% of director physicians), and regarded face-to-face learning as the more effective learning manner (25.71% of primary physicians, 30.81% of attending physicians, 39.88% of assistant director physicians, 43.75% of director physicians).

Impacts of personal characteristics on online learning preferences through WeChat platform
In accordance with the backend database of Jiujing platform, the online investigation also indicated that surgery videos (450/482, 93.36%) and academic lectures (425/482, 88.17%) were the most popular sections ( Fig. 2A). As in Table 3, logistic regression analysis showed that a liation hierarchy signi cantly in uenced the respondents' preferences in surgery videos and literature express, and titles of the respondents remarkably impacted their preferences in medical humanities and literature express. Additionally, degree and gender respectively affected their favors in online interactions and case reports. With the upgrading of a liation hierarchy, preferences in surgery videos and literature express accordingly depleted (Fig. 2B). As illustrated in Fig. 2C, respondents with intermediate positional titles (attending physician and assistant director physician) were more interested in medical humanities and literature express. Meanwhile, respondents with bachelor degree (128/225, 56.89%) accounted for the majority who were favor of online interactions (Fig. 2D).

Discussion
According to the 47th China Statistical Report on Internet Development (data available at http://www.cnnic.net.cn/hlwfzyj/hlwxzbg/hlwtjbg/202102/P020210203334633480104.pdf), by the end of 2020, the amount of online education users in China has increased 109 million compared with that in the year of 2019. The Covid-19 pandemic is forcing medical educators to re-evaluate how to educates learners of all levels [9]. Travel restrictions have brought about a preference towards online meetings in urogenital associations despite the irreplaceability of the face-to-face manner [10]. Therefore, continuing education in the time of social distancing aroused our attentions to social media such as Twitter, which have been widely used in education and conferences sharing among global urogenital communities [11]. Urogenital online learning was inevitably forced to rapidly adapt to the Covid-19 situation, urologists as well as andrologists adopted web-based platforms to develop virtual education programs to ll the gap [12]. Young and junior physicians need to learn more, while expert and senior specialists want to show more, so they get together and communicate online through social media, especially in the era of Covid-19.
As one of the most popular social media applications in China, WeChat has been playing an import role in medical education [13]. According to the backend database of Jiujing, one of the most well-known WeChat public platforms in Chinese urogenital community, online learning through WeChat became more fervent during the Covid-19 pandemic. Afterwards, we conducted an online questionnaire survey to explore the signi cances and determinants of urogenital online learning though WeChat during the Covid-19 pandemic. As expected, the majority of the respondents experienced decreased face-to-face learning opportunities during the Covid-19 pandemic and consequently triggered increased online learning demands. It was reassuring that most urologists and andrologists have bene ted from online learning including those who have directly participated in the battle against Covid-19. However, compared with veteran senior physicians (director physicians), online learning was signi cantly more bene cial for the juniors (primary and attending physicians).
A systematic review indicated that Internet and software-based platforms for surgical training was as effective as other methods of training, but technical and infrastructural resources might be a major challenge for implementing online learning [14,15]. Understanding various demands of the users with different backgrounds is particularly important when building an online learning platform. Whether from teaching hospital or working as frontline staffs against Covid-19 had no effect on the attitudes of the respondents. Given that medical students used to be engaged and motivated when being taught with a video-feedback and visual manner [16], surgery videos and academic lectures were the most popular sections in either Jiujing platform or questionnaire survey. Consistent with a previous study, the subscribers tended to pay more attention to surgical videos sections, which resulted from the decreased quantity of operations during the Covid-19 epidemic [12]. Since most users of social medias are young adults, the decreased quantity of operations is supposed to cause decreased practice opportunities especially for the inexperienced surgeons. However, the imbalance of learning resources owing to regional discrepancy has led to different attitudes towards online education [17]. Investigated bene ts from surgery videos and literature express sections decreased with the hierarchical ascending of respondents' a liations. As surgery videos and literature resources were less accessible for the physicians from grass-root hospitals, urologists and andrologists in these institutions might bene t more from online learning than that in provincial or national hospitals.
With the rapid development of medical science, online learning from literature is a complementary and essential way to update knowledge for continuing education [18]. Compared to natural science courses, dreary teaching style and limited attention are placed on medical humanities in Chinese medical education system although it has some merits: meeting basic needs, early exposure and mandatory [19]. When faced with the tension between doctors and patients, we are required to optimize our professional knowledge as well as humanistic care. Our study uncovered that online learning of literature and medical humanities were considered signi cantly bene cial among attending doctors and assistant director physicians, who usually took the main responsibilities to communicate with the patients in Chinese hospitals.
In order to meet the huge demand for doctors while ensure a basic minimum of quality, medical education in China used to be classi ed into different program durations: associate with 3 years (licensed assistant doctors), bachelor with 5 years (licensed general practitioner), master with 3 more years (licensed residency) and doctor with another 3 more years (licensed specialist physicians) [20,21]. In the earlier years, medical undergraduates in China got access to work as licensed doctors in hospitals without systematic education and training as specialist physicians, so they obtained specialty knowledge in urology and andrology mainly relied on self-learning and communication with colleagues. It is no wonder that in our investigation, bene ts from online interaction were associated with the degree of respondents: urologists and andrologists with a bachelor degree exhibited the most enthusiasms. A previous systematic review and meta-analysis revealed that face-to-face learning was no better than online learning in undergraduate medical education, but online learning had advantages to enhance undergraduates' knowledge and skills [22].
Admittedly, our work existed some limitations. There are some other WeChat platforms for urogenital online learning in China, but consistent and comparable backend data of these platforms have not been obtained and included. On the other hand, the online questionnaires were randomly given out through WeChat and collected from the target respondents. All these factors modestly restricted the representativeness of the data.

Conclusions
Even though the outbreak of Covid-19 has affected the patterns of urogenital online continuing education to a certain degree, and long-term impact of the pandemic on medical education remains unknown, urologists and andrologists in China have been applying what they had learned from the platform and shared their gains through the WeChat platform. The present work also promoted that when establishing a urogenital online education platform, the