Perceptions and Experience of Medical Students Regarding E-learning during COVID-19 Lockdown: A Cross-sectional Study

1. Assistant Professor, Department of Pulmonary Medicine, Shri Lal Bahadur Shastri Medical College and Hospital, Mandi, Himachal Pradesh, India. 2. Vice Chancellor, Atal Medical and Research University Campus, Shri Lal Bahadur Medical College and Hospital, Mandi, Himachal Pradesh, India. 3. Associate Professor, Department of Pulmonary Medicine, Government Medical College and Hospital, Chandigarh, Punjab, India. 4. Professor and Head, Department of Internal Medicine, Shri Lal Bahadur Shastri Medical College and Hospital, Mandi, Himachal Pradesh, India.

Abstract

Introduction: Medical education has been adversely affected during Coronavirus Disease-19 (COVID-19) pandemic. Imparting medical education through e-platforms exclusively was a novel experience both for students and teachers. Even though online classes have been ongoing since almost one and half year, not much data on perception and experience about e-learning among medical students is available from India.

Aim: To evaluate perceptions, experiences and challenges faced by medical students regarding e-learning during lockdown period owing to COVID-19 along with their future preferences.

Materials and Methods: The present study was a questionnaire based cross-sectional survey regarding use of e-learning during COVID-19 pandemic among 340 Bachelor of Medicine and Bachelor of Surgery (MBBS) and Bachelor of Science Nursing (BSc-NUR) students. It was conducted in the Department of Pulmonary Medicine at Shri Lal Bahadur Shastri Medical College and Hospital Mandi, Himachal Pradesh, India from May 2021 to July 2021. Students perceptions’ of e-learning were assessed using the validated Technology Acceptance Model (TAM) model and responses were measured on 5-point Likert scale. Quantitative data was expressed by mean and standard deviation and significant level of differences between means were tested by Student’s t-test (unpaired). Proportions were compared by Chi-square test or Fisher’s-exact test. A p-value of <0.05 was considered statistically significant.

Results: Out of 400 students, 340 responded of which 225 were females. Of the total 340 students, (n=333; 97.9%) respondents, had an idea of e-learning and more than half (n=188; 55.3%) had used any type of e-learning platform prior to onset of COVID-19. More number of MBBS students had used e-learning than BSc-NUR students (55% v/s 41%; p=0.033). Cell phone was the most common device (n=324; 95.3%) used. The quick sharing of material (n=258; 76%) and flexibility (n=233; 68.5%) were top rated benefits of e-learning. The key disadvantages were suboptimal practical training (n=222; 65.3%) and lack of face-to-face interactions (n=146; 43%). Majority of students voted for traditional learning (n=156; 45.9%) closely followed by blended learning (n=140; 41.2%).

Conclusion: The students had an overall positive attitude towards e-learning and wanted to continue e-learning alongside traditional teaching i.e., blended learning. Exploration of merits and barriers to e-learning during pandemic can act as a guide to implement blended learning in medical curriculum for enhanced teaching/learning experience.

Alternative learning, E-platforms, Hybrid learning, Online classes, Pandemic

Coronavirus Disease-2019 (COVID-19), a highly infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), was declared as pandemic by World Health Organisation (WHO) on 31^st March, 2020 (1). In view of lack of specific treatment/vaccine for the disease, measures like social distancing, wearing masks and repeated hand washing were implemented worldwide to stop the human to human transmission (2). On similar lines, lockdowns were announced across 107 countries including India that led to closure of all public places including medical institutions across the country which adversely affected teaching and learning activities for a considerably long period (3),(4). In a survey on 440 medical students in 33 United Kingdom (UK) medical schools, it was found that 77.3% respondents had their electives cancelled and 43% of assistant placements were postponed (5).

New modes and tools of delivering education were discovered which helped to continue and impart learning in these unprecedented times. E-learning supposedly turned out to be the powerful medium to mitigate gaps in learning (6). Medical universities like Harvard and Yale considered e-learning as a reasonable alternative during pandemic (7). In a quantitative survey, 65.21% healthcare professionals perceived that e-learning played a major role in minimising the impact of pandemic on medical education (8). Research by Dost S et al., on 2721 medical students across 39 medical schools in the UK also pointed out that integration of technology can enhance teaching/learning experience coupled with benefit of flexibility of time and space (9). Ba?czek M et al., echoed similar benefits of e-learning in a study among polish medical students during COVID-19 lockdown (10).

Most of the literature on e-learning during pandemic has been generated from western studies (5),(9),(10). With difference in infrastructural facilities as well as access, knowledge and awareness about these teaching modes, the results from these studies may not be applicable to Indian settings. Hence, this study was conducted to evaluate the experience, perceptions and challenges faced by medical students regarding e-learning during lockdown period owing to COVID-19.

Material and Methods

The present study was a questionnaire-based cross-sectional observational study conducted in the Department of Pulmonary Medicine at Shri Lal Bahadur Shastri Medical College and Hospital (SLBS GMCH), Mandi, Himachal Pradesh, India from May 2021 to July 2021. The confidentiality and anonymity of participants was maintained. The study was approved by Institutional Ethics Committee (IEC) (letter no. 50).

Inclusion criteria: The study population included all students in second year (batch of 120), third year (batch of 100) and final year (batch of 100) undergraduate medical students (MBBS) as well as second year (batch of 40) and third year (batch of 40) BSc-NUR students, who gave consent to participate in this study.

Exclusion criteria: Students in first year of MBBS and BSc NUR who joined the course in 2021 were excluded as they had no experience of online classes. Those students who refused to participate were also excluded. Moreover, survey forms with incomplete information were not included in analysis.

Sample size: A total of 400 students were enrolled in the study. Forty students did not gave consent to participate in the study. In addition, 20 participants provided incomplete information. Therefore, a total of 340 participants were available for final analysis. Similar sample size was taken in previously published studies also (9),(11),(12).

Data Collection Tools

Questionnaire was developed by two investigators (MB and SK) comprising of 30 questions divided into four sections. The proforma included questions regarding perceptions towards e-learning from validated Technology Acceptance Model (TAM) model which was used in previously published studies also (10),(13),(14),(15). Pilot study was done and tested on 20 students (10 MBBS and 10 BSc-NUR) and modifications were done after incorporating suggestions from respondents. The questionnaire was finalised after inputs from senior medical faculty involved in medical education.

The type of questions included were as follows:

Initial three questions were Yes/No type, open ended and Multiple Choice Question (MCQ) type with multiple correct options. Questions 4-7 and 25-28 were MCQ type. Questions from 8-24 and 29 were 5-point Likert scale response type ranging from strongly disagree to strongly agree and last question was open end type. The yes/no type questions were scored as 0 for unattempted, 1 for no and 2 for yes as responses. For MCQ type, unmarked options were scored as 0 and marked options as 1. The questions regarding perceptions were analysed using 5-point Likert scale with scores 1 to 5 ranging from strongly disagrees to strongly agree. Median scores >2.5 indicated acceptance and below 2.5 indicated refusal. The internal validity of questionnaire was calculated by Cronbach’s alpha coefficient which was 0.89. The open questions were largely pertaining to personal, demographic details and relevant information was added in the text. The last question was an open ended type inviting feedback/suggestions from students to improve learning/teaching experience which is elaborated in the results and discussion.

Each student was given a well-structured questionnaire pertaining to his/her experience and perceptions about e-learning during COVID-19 times when campus teaching was suspended for almost a year. The questionnaire was pertaining to four major parameters.

I. Personal information and demographic details (First part).
II. Knowledge and practices of e-learning before and after lockdown period (seven questions). Live classes were suspended in the institution from March 2020 to March 2021 which was taken as lockdown period where teaching activities were conducted primarily through online classes.
III. Students’ perception of e-learning was measured by four sub constructs (15 questions); perceived usefulness, perceived self-efficacy, perceived ease of use, perceived attitude and intention to use. The questions were based on validated TAM model for exploring factors that affect students’ acceptance and use of e-learning as a teaching tool (14).
IV. Experiences of institutional online classes during lockdown period including various facilitating and hindering factors for satisfactory experience and future preferences (eight questions).

Statistical Analysis

Data was recorded on a Microsoft (MS) excel sheet and analysed using Statistical Package for the Social Sciences (SPSS) trial version 20.0 (Chicago, IL). Quantitative data was expressed by mean and standard deviation and significant level of differences between means were tested by Student’s t-test (unpaired). Proportions were compared by Chi-square test or Fisher’s-exact test. A p-value of <0.05 was considered statistically significant.

Results

Demographic characteristics: Overall response rate was 85% (MBBS= 82.5%; BSc-NUR= 90%). The age of participants ranged from 18 to 25 years. The mean age was 20.5 years. Out of the total 340 participants, 264 were MBBS students, 72 were BSc-NUR students and 1.2% (n=4) students did not specify the course. Females outnumbered males in the ratio of 2:1 (Table/Fig 1). Majority of participants were residents of Himachal Pradesh (n=266) followed by Rajasthan (n-22) and Kerala (n=18). The rest belonged to places as follows: Delhi (n=11), Haryana (n=7), Punjab (n=4), Telangana and Chandigarh (n=2 each), Uttar Pradesh, Uttarakhand, Maharashtra and Tamil Nadu (n=1 each). Four students did not mention their place of residence.

Knowledge about e-learning prior to COVID-19 lockdown: Majority of the participants (n=333, 97.9%) had some level of knowledge about e-learning. Majority of students (n=258; 75.9%) thought that online learning is same as e-learning. Almost half of them (n=188, 55.3%) had used any type of e-learning platform prior to onset of COVID-19. Its use was more common among MBBS than BSc-NUR students (55% v/s 41%; p=0.033). Mobile phone was the most common mode of e-learning (95.3%; n=324) followed by laptop (14.1%; n=48). The question regarding use of devices was a MCQ type and responses were not mutually exclusive (Table/Fig 1).

E-learning during COVID-19 lockdown: Google-meet was the most common online platform (n=300; 88.2%) used for online teaching by the students followed by Zoom (n=213; 62.6%) (MCQ type question). There was no difference in the usage of Google-meet between MBBS students and BSc-NUR students (91.6% v/s 87.5%. p=0.40). The platforms were mainly used for online lectures (n=238; 70%) and online tests (n=206; 60.6%)

Perceptions about e-learning among the students: Perception of students about e-learning was evaluated using 15 questions based on 5-point Likert scale. The responses for each question were calculated and analysed separately. Ability to take tests and submit assignments electronically (mean 3.79), to study at any location (mean 3.78) and ability of interactive communication (3.73) were the top 3 ranked perceptions that influenced the overall perception. Details are given in (Table/Fig 2).

Mean score of the participant’s perception was 3.29±0.65. On statistical terms, 145 (42.6%) subjects had a mean score above 3.40 indicating positive perception for e-learning. Moreover, there was no difference in the mean score between MBBS and BSc-NUR students (MBBS mean score 3.30±0.67 v/s BSc-NUR mean score 3.20±0.53; p=0.18).

Experience of Institutional Online Classes during Lockdown

Advantages and disadvantages: Ability for easy and quick sharing of educational material and flexibility in time and space were among the most common advantages of e-learning perceived by 75.9% (n=258) and 68.5% (n=233) of the participants, respectively. The key disadvantages of e-learning were suboptimal practical training (65.3%, n=222) and lack of face-to-face interactions (43%, n=146). Details are given in (Table/Fig 3).

Challenges faced by the students: Poor internet signal (57.1%, n=194) was the topmost challenge reported by respondents while attending institutional online classes. A 144 (42.4%) of students felt that they had low motivation to use e-platforms while others reported lack of conducive atmosphere at home (55.9%, n=190) and distraction issues while using media apps (63.2%, n=215) which hampered their learning. A significant number of students (49.7%, n=169) reported health issues like headache and fatigue while using digital platforms for duration longer than their usual routine. A 57.1% (n=194) students admitted that they copied assignments and evaluation process was not upto the mark (63%, n=214) which hindered their preparation for future examinations.

Overall attitude towards e-learning: Overall, students had a positive attitude towards usage of e-learning. They felt that it was underutilised in medical education and would use it to assist learning in future. Though traditional teaching remained the favourite, a significant number liked the idea of hybrid education or blended learning. However, exclusive online learning was advocated by 30 (8.8%) of the participants only (Table/Fig 4). One question pertaining to use of e-learning in module teaching was dropped from analysis as majority of participants did not attempt the question.

Feedback/Suggestions by students: The last question in the proforma was an open ended question inviting feedback/suggestions to improve online teaching/learning experience and is shown in (Table/Fig 5).

Discussion

Institutional e-learning had to be made mandatory for the first time during the lockdown although it has also been sparingly utilised in medical field, previously. In this study, majority were female students. Similar findings have been reported by others also (10),(15). The reasons could be that all BSc-NUR students were females and more females opted for participation in the survey. The present study showed that majority of students (97.9%) had some knowledge about e-learning. A study by Olum R et al., revealed that the awareness rates were similarly high in Makerere University in Uganda (96%) (16). However, Alqahtani N et al., reported that in a medical school in Saudi Arabia only 62% of students of health sciences had a concept of e-learning (17). More than 90% of students reported use of smartphones in this study probably due to its multipurpose utility. So, it became obvious that new models of e-learning adopted at institutional level should be compatible with smartphones and or laptops.

The advantages reported by students such as quick sharing of educational material, flexibility of time and space corroborated with findings of Buch AC et al., (18). Lack of face-to-face interactions with patients was the major limiting factor observed in this study. Further, e-learning was perceived to be ineffective in acquiring clinical skills. Similar concerns were reported previously also; both before and during COVID-19 pandemic (10),(19),(20),(21). In this survey, students from both courses had an overall positive outlook towards e-learning as a teaching aid which was in line with other studies conducted during lockdown period (15),(22),(23). However, parallel surveys by Abbasi S et al., from Pakistan and Olum R et al., from Uganda reported contradictory results (11),(16). The plausible reasons for difference in perceptions could be uniqueness of medical curriculum (blend of knowledge acquisition and skill training), sense of familiarity and comfort with traditional teaching methods, awareness and availability of gadgets, infrastructure or internet issues especially in developing nations (17),(21),(24).

The present study emphasised that blended learning was popular among medical students and closely followed traditional teaching as future preference. Similar findings were reported in previous studies from India and other countries (10),(13),(18),(21). Also, blended learning has an advantage of face-to-face interaction coupled with benefits of autonomy and flexibility associated with e-learning. Search of literature showed that when compared to exclusive online learning, traditional teaching is preferred over by a wide margin (8),(9),(15). However, a study showed that digital lectures could be a satisfactory substitute to classroom teaching in the subject of anatomy (25). The comparative review of literature from similar studies in medical students during COVID-19 pandemic has been summarised in (Table/Fig 6) (8),(9),(10),(11),(12),(15),(16),(18),(21),(22),(23),(26),(27).

E–learning has a potential to enrich teaching/learning experience in medical field (24). But, inculcation of e-learning in medical curriculum requires meticulous planning and such surveys can help a great deal in identifying areas that need consideration for satisfactory experience. Evidence from literature showed that students echoed similar feedback/suggestions for successful implementation of e-learning (8),(15),(18),(22). Competency Based Medical Education (CBME) which has been introduced in India for undergraduate level of MBBS course can set the stage for necessary changes to make e-learning/blended teaching an established pedagogic tool. It is learner-centered competency based training that allows vertical and horizontal integration of subjects for better understanding. Learning is divided into four domains (knowledge, skill, attitude, and communication) and five levels of competencies (knows, knows how, shows, shows how and performs). It also aims to boost communication skills (28),(29). There is an urgent need to restructure/modify the curriculum to make the e-learning a viable platform even for regular teaching and training sessions in different disciplines of medical sciences. The suggested framework for e-learning in a teaching institution for implementation of CBME is depicted in (Table/Fig 7) (18),(26),(30).

Limitation(s)

Feedback from teachers regarding use of e-learning during COVID-19 pandemic was not taken in the study. It could have provided a comprehensive analysis of the issue. Further, deficiency in infrastructure and technical support including internet availability could have affected perceptions of students regarding use of e-learning as teaching aid. More surveys with larger sample involving students from other disciplines such as dentistry, physiotherapy, laboratory technology etc., can help in better understanding of scope of e-learning in various disciplines of medical sciences.

Conclusion

E-learning became a popular pedagogical tool to minimise gaps in learning during COVID-19 pandemic. It allows quick sharing of information and gives the advantage of flexibility of time and space. However, students missed face-to-face interactions and felt that practical training was compromised. The students had an overall positive attitude towards e-learning and wanted to continue e-learning alongside traditional teaching i.e., blended learning. It is high time that concrete steps are taken to formally incorporate e-learning in medical curriculum for enriched teaching/learning experience.

DOI and Others

DOI: 10.7860/JCDR/2022/54803.16051

Date of Submission: Jan 07, 2022
Date of Peer Review: Jan 24, 2022
Date of Acceptance: Feb 08, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 12, 2022
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• iThenticate Software: Feb 11, 2022 (19%)

ETYMOLOGY: Author Origin