Impact of COVID-19 pandemic on Paediatric Residency Training Programme in Sudan: Challenges and the Way Forward


 Background: The clinical education and hands-on training are affected by the disruption of formal health care delivery and the emergency need to adapt the new rapidly evolving Covid 19 pandemic .Here we aim to determine the impact of COVID-19 paediatric on residency program training in Sudan.Methods: This study was carried out in the period from December 2020 – January 2021. A designed questionnaire was distributed using Google form, 186 trainees responded. Results: The study included 186 trainees of whom 152 (83.5%) females and 30(16.5%) males. Of whom 15 (8.2%) acquired infection with Covid 19. Comparing the work load and teaching opportunities in the year 2019 to 2020 it was very clear that there is decrease in working load and training opportunities during Covid 19 pandemic. Almost all trainees fully agreed that their training was severely affected during Covid 19 pandemic locked down. Trainees raised the issue of being stressed by transmitting the infection to their families and the working environments.Conclusion: The undue effect of the COVID-19 pandemic on residency paediatric training is well documented. Different innovative alternative teaching methods must be implemented to maintain quality of education, and research.


Introduction
Covid-19 is the fastest evolving and most horri c pandemic in the recent global history. It is perhaps the most daunting challenge humanity has faced since World War. 1 The WHO declared coronavirus disease 2019 (COVID-19) a global pandemic on 11 March 2020 and Sudan was one of the most exposed countries in Africa, Khartoum (the capital) was the most affected region. 2 The rst case in Sudan was reported on 13 March 2020, and up to 28/ April 2021 there are 33,104 positive Covid 19 cases and 2,349 deaths. 3 The government of Sudan has implemented preventive measures during the coronavirus disease pandemic, such as partial lockdown, contact monitoring, risk communication, social distance, and isolation to prevent the spread of Covid 19 virus. 4 These measures had its impact on health system and on training and education in general. We believe that COVID-19 pandemic has signi cantly impacted the pediatric residency education and training, and profoundly changed the daily practice in Sudan. A number of operational changes, including modi ed clinical and didactic training policies, have been implemented to mitigate the spread of COVID-19 worldwide. 5 The mitigation measures 6 also advised reduction of doctor and patient contact. A direct consequence of this measure is the postponement of outpatient's clinic appointments, resulting in a decline in clinical exposure. The academic medical institutions confronted with a unique set of challenges with respect to ensuring the safety and well-being of resident versus providing service to patients and continue training program quality.
In this study we aim to study the impact of Covid 19 pandemic on pediatric residency training program and to compare training opportunities before(2019) and during(2020) Covid 19 pandemic in Sudan. We as well address the trainees' perception towards training and working environment during Covid 19 pandemic.

Methods
This is a comparative, cross sectional facility based study. This study was conducted during the period from January to February 2021. It was led at the SMSB including ve paediatric training centres: Omdurman, Bahri, Soba, Khartoum and Wad Medani. The study population were nal-year trainees, who completed 4 years training according to the updated Paediatric and child health residency program curriculum (2020). Sampling: Using a designed questionnaire, which was distributed to pediatric trainees in training using Google form. One hundred and eighty six responded with a response rate of 62%. The questionnaire consist of questions related to training opportunities before and after Covid 19 pandemic and its impact on training.

Statistical analysis
Data were analyzed using SPSS software version 23.0. Regarding descriptive statistics, categorical variables are presented as numbers and percentages. The recorded patient visits in 2019 and 2020 were compared using Pearson's chi-square or Fisher's exact tests for categorical variables. A p value of < 0.05 was considered statistically signi cant.

Demographic data
The study included 152 (83.5%) females and 30(16.5%) males. The ve group for discussion included 30 candidates, 5-7 in each group, of whom 20(66.7%) were females and 10(33.3%) were males. The majority 57.7% of trainees in the year 2019 tend to cover ward on call three to four times per months compared to 11.9% in the year 2020( gure2 ) Sixty percent of trainees in the year 2019 cover emergency department on call four times per month compared to 8.2% in the year 2020 ( gure3) Patients' exposure (encounter) Almost half (50.3% )of trainees in the year 2019 used to be exposed to more than 30 patients in the inpatient ward per month, while in the year 2020 the majority 50.5% exposed to less than 10 patients per month. ( gure4) 42.2% of trainees in the year 2019 were exposed to more than 50 patients in the outpatient department per month while in the year 2020 the majority 64.2% exposed to less than 20 patients per month. ( gure5) 44.5% of trainees in the year 2019 were exposed to more than 50 patients in the emergency department per month while in the year 2020 the majority 50.5% exposed to less than 10 patients per month. ( gure6)

Unit activities / Didactic teaching
In the year 2019 the majority 170(93.4%) of trainees had grand round twice a week compared to 32(17.6%) in 2020, this is similar to other activities such as discharge clinic, teaching activities (Tutorial/seminar/case presentation / radiology sessions/ journal club ...etc.) and research work activities. Table 1 Year 2019 Year 2020 In discussion groups almost all trainees fully agreed that their training was severely affected during Covid 19 pandemic locked down.

Discussion
The impact of Covid 19 virus on children has been comparatively mild despite its overwhelming effects on adult populations globally. Among the affected children, most have mild symptoms and some are even asymptomatic (7,8,9) The Chinese Centre for Disease Control and Prevention has reported that among ~70,000 cases, <1% were aged <10 years. 10 However measures taken to alleviate the spread of Covid 19 virus have transformed the current setting of paediatric practice and have thus impacted on our patients as well as our paediatric residency training. Several researchers worldwide claim the need to enhance medical training programs and comprehensive continuing medical education with an emphasis on skills and competencies development. 11 In this study it was very obvious that encounters with inpatients are decreased and outpatient encounters are nearly absent which will de nitely led to decrease in the opportunities to counsel on preventive health and managing chronic disease. These competencies are very important to be acquired by trainees if we take into consideration that in Sudan non-communicable diseases are increasing dramatically, at the same time, the burden of chronic and endemic infections disease remains considerable. 12 In our set up and maybe other resource limited countries measures to adapt with these special situation and challenges during Covid 19 pandemic are extremely enormous due to poor infrastructure, inadequacy and fragility of the health systems. 13  The COVID-19 pandemic has affected research activities to a great extent as reported in this study. As a direct consequence of lockdown measures and the closure of most university research facilities, all research activities unrelated to COVID-19 have been paused this was similarly reported in the literature. 21 As the majority of trainees in this study had access to internet and smart phones this will help establishing online training activities. There is a need to support training with technology-enhanced learning methods and active learning strategies that requires strategic support. Stakeholders need to take action in order to develop and implement innovative methods for medical training taking into consideration the current new norms and the setup in Sudan.

Conclusion
In order to continue training and to preserve the quality of the certi cate it's important that the program will adapt an innovative teaching and training methods using advanced technology, simulation and online teaching. Availability of data and materials The dataset used and analysed during the current study is available from the corresponding author on reasonable request.
Ethics approval and consent to participate Ethical approval was obtained from Research and Ethical Committee at SMSB.
All methods are carried out in accordance with relevant guidelines and regulations. All the participants voluntarily participated in this study and provided written informed consent.

Consent for publication
Not applicable Number of patients seen at Emergency department per week in the year2019 compared to 2020