Evaluation of Effectiveness of an Online Self-directed Learning Programme in Biochemistry for First-year Medical Undergraduate Students: A Quasi-experimental Study

1. Professor, Department of Biochemistry, Father Muller Medical College, Mangaluru, Karnataka, India. 2. Professor, Department of Biochemistry, Father Muller Medical College, Mangaluru, Karnataka, India. 3. Professor, Department of Biochemistry, Father Muller Medical College, Mangaluru, Karnataka, India.

Abstract

Introduction: Self-directed Learning (SDL) has been suggested as a principle of adult learning to promote lifelong learning abilities among students. Though SDL is not a new concept, there is a lack of uniform implementation across the institutions in India. The Competency-based Medical Education (CBME) proposed by the National Medical Commission in 2019 has emphasised SDL for medical students.

Aim: To evaluate the effectiveness of an online, case-based SDL activity in Biochemistry for the first-year MBBS students.

Materials and Methods: This was a quasi-experimental study conducted at Father Muller Medical College, Mangaluru, Karnataka, India from May to July 2021. A purposive sampling technique was used, and 138 first-year MBBS students were enrolled for the research. The topic of lipid metabolism was chosen for SDL. Parallel to the online didactic lectures, a case-based, team-based, online SDL was implemented. Students were provided with case scenarios and were instructed to discuss the case scenarios and find answers to the accompanying questions in allotted groups for 15 days. A three-hour session was held for the presentation of the SDL, followed by a post-test and reflections of students. The data were analysed using Statistical Package for Social Sciences (SPSS) version 25.0. The significance of the difference in pretest and post-test scores was assessed by paired t-test, and the level of significance was set at a p-value <0.05. Qualitative data were subjected to descriptive statistics, and thematic analysis of reflections was conducted.

Results: The average post-test score of the participants was significantly higher by 99.3% compared to the pretest score (p-value <0.001). On average, 108 out of 138 (78.2%) agreed (agree/strongly agree) that SDL helped them to achieve the learning objectives,115 (83.3%) agreed that SDL helped them to develop as lifelong learners, 115 (83.3%) agreed that SDL helped them to develop as a health professional, and 83 (60.1%) agreed that enjoyed learning in online mode. The inclination of 110 (79.7%) students to have more SDL sessions in the future shows a behavioural change in favour of SDL. Time constraints and internet connectivity were the main challenges.

Conclusion: SDL was effective and was received positively by the majority of the students. It is the need of the hour to develop lifelong learning and critical thinking among medical students and to make learning interesting with the use of case scenarios. Future research should assess the intermediate and long-term outcomes of case-based SDL on learning, behavioural changes, and its impact on patient care and the health of society.

Competency, Critical thinking, Group dynamics, Lifelong learning, Self-learning

The SDL has been defined by Knowles MS as “A process in which a learner takes the initiative, diagnoses their learning needs, creates learning goals, identifies resources for learning, applies appropriate learning strategies, and evaluates their learning outcomes” (1). Though SDL is not a new concept, there was a lack of uniform implementation across the institutions (2),(3). In SDL, the learner is fully responsible for achieving the learning goals, identifying resources, thinking, and discussing with peers and facilitators. This method of learning is proposed to develop lifelong learning skills among medical students (3),(4). SDL comprises personal attributes of a learner such as self-efficacy, intrinsic motivation, self-assessments, beliefs, learning styles, and ability to set goals and involves the application of critical thinking, self-management, social, communication, research, and analytical skills (5),(6),(7). As the learner takes the initiative and controls the direction of learning in SDL, it is not synonymous with “self-learning,” and the locus of control is “internal” with regard to the learner rather than the “external” as in the case of traditional methods of teaching-learning (7).

Implementation of SDL in the medical course is a challenging task due to lack of preparedness by faculties and students, requirement for various resources, lack of adaptability from teacher-centered didactic lectures to a more learner-centered method, hesitation, and resistance from faculty to change from the role of teacher to facilitator (2),(3),(4). The online mode has its own inherent limitations (7),(8),(9).

Compared to the didactic lectures, SDL drives the learners to build self-learning skills, develop higher-order thinking, learn with peers, and work as a team in a learner-centered active process (3),(5). There is a paucity of studies on the implementation of SDL and evaluation of its effectiveness in the Indian context, especially in the subject of Biochemistry. SDL in an online environment may assist in supporting student learning and performance when direct physical/offline access between teachers and students is not possible, in situations such as the Coronavirus Disease-2019 (COVID-19) pandemic. Most of the didactic teaching sessions were held online as the students were physically away from the institution during the COVID-19 pandemic.

Therefore, the aim of this study was to assess the effectiveness of an online, case-based SDL program of Biochemistry for first-year medical undergraduate students.

Material and Methods

This quasi-experimental study was conducted at Father Muller Medical College, Mangaluru, Karnataka, India over a period of three months, from May to July 2021, involving first-year MBBS students. This research was conducted after obtaining approval from the Institutional Ethics Committee (approval no. FMIEC/CCM/349/2021) and with voluntary, informed consent from the study participants.

Inclusion criteria: All consenting first-year MBBS students of the institution who were able to attend the online didactic lectures and SDL were included in the study.

Exclusion criteria: Incompletely filled details and students who were not willing to be part of a team were excluded from the study.

Purposive sampling was utilised to recruit the study subjects. Out of the total 148 students who attended the didactic lectures on lipid metabolism and participated in the SDL, 138 students voluntarily consented to be part of the research. Therefore, 138 participants were included in this research. However, all 148 students participated in the SDL and benefited from the program.

Implementation of SDL: As per the undergraduate curriculum provided by the National Medical Council, 5% of the total teaching-learning hours were allocated for the discussion of SDL topics (10). The faculty of the Department of Biochemistry generated several SDL topics from the chapter on lipid metabolism, involving clinical implications and higher-order thinking. Both didactic lectures and SDL sessions were held online. The didactic lectures on lipid metabolism were scheduled online according to the institution’s teaching program, aligning with the competencies specified by the National Medical Council (10). Case scenarios provided for SDL were not discussed in the didactic lectures.

In the initial class on lipid metabolism, the facilitators explained the SDL method and administered a pretest to the students. Five case scenarios related to lipid metabolism (primary carnitine deficiency, medium-chain acyl-CoA dehydrogenase deficiency, Gaucher’s disease, familial 11hypercholesterolemia, and type I dyslipoproteinemia) were provided to the students. These case scenarios were accompanied by questions on probable diagnosis, biochemical and genetic basis, reasoning for clinical manifestations, and laboratory tests.

The students were divided into 15 batches. They were asked to search for learning resources, work individually and as a group to formulate answers for the questions in the provided case scenarios. There was regular student-student and student-facilitator communication online.

The facilitators compiled the cases, briefed the students on the SDL process, guided them in SDL whenever requested, moderated the presentation session, clarified the learners’ doubts, and finally provided the students with learning material containing key answers and explanations for the cases.

Assessment of SDL: During this synchronous SDL presentation session, a member who was picked by the group presented the learning achieved (in the form of answers to the questions related to the case scenarios) as a PowerPoint presentation on an online platform. The facilitators moderated this three-hour session. Due to time constraints, one group was picked for the presentation of a case, with two other teams picked for reacting and providing inputs. Finally, participation of all groups was ensured. The facilitators only gave their inputs on the learning achieved and provided required clarifications.

The assessment of reaction and learning was done using the Kirkpatrick model at two levels (11). Reactions: Level 1 of the Kirkpatrick model assessed the reactions of learners. Themes identified from the responses to open-ended questions included exploring resources, the learning process, basic-clinical correlation, higher-order thinking, teamwork and communication, creativity, confidence, time allotted, and the role of facilitators. Detailed thematic analysis is presented in (Table/Fig 1).

Responses of learners to “what could have been done better?” included more time allotted for learning, more interactions in the team, the opportunity for more students to do presentations, having a debate, expecting more inputs from facilitators, and involving a greater number of facilitators. Access to the internet and network availability, online interactions not being as effective as offline/physical, time constraints, and personal issues were also detailed in (Table/Fig 1).

Additionally, a five-point Likert Scale with options of “Strongly Disagree”, “Disagree”, “Neutral”, “Agree”, and “Strongly Agree” was used for statements on achieving learning objectives, lifelong learning and the physician of the future, professionalism, involvement in learning, and feedback on the online mode of learning.

Learning was assessed by a pretest and post-test with 15 multiple-choice questions of higher order thinking (reasoning, diagnosis, calculation, biochemical, and molecular basis). There were 15 multiple-choice questions in the pretest/post-test, and each question carried one mark. Students were graded based on performance in the pretest and post-test as follows: excellent (> 90% score), very good (76-90% score), good (61-75% score), satisfactory (51-60% score), average (41-50% score), and below average (< /=40% score).

The percentage change in the post-test was calculated using the following formula:

Percentage change in post-test=(Difference in the number of students who answered the question correctly in pretest and post-test/Number of students who answered the question correctly in pretest)×100.

Statistical Analysis

The data was analysed using SPSS version 25.0. The scores of students in the pretest and post-test were expressed as mean±SD. The significance of the difference scores was assessed by paired t-test. The comparison of the percentage of students who answered correctly in the pretest and post-test for each question and the reflections were presented as descriptive statistics. The reactions were subjected to thematic analysis.

Results

108 out of 138 (78.2%) agreed (agree/strongly agree) that SDL helped them to achieve the learning objectives,115 (83.3%) agreed that SDL helped them to develop as lifelong learners, 115 (83.3%) agreed that SDL helped them to develop as a health professional, and 83 (60.1%) agreed that enjoyed learning in online mode. The inclination of 110 (79%) students for having more SDL sessions in the future shows a behavioural change in favour of SDL. When students were asked to reflect on the online mode of SDL compared to offline and other methods of teaching and learning, 78 (56.5%) either agreed or strongly agreed that the online mode of SDL is feasible. Feedback on whether the “online mode of SDL is as effective as offline” showed that 54 (39.1%) agreed or strongly agreed, 43 (31.1%) disagreed or strongly disagreed, and 41 (29.7%) showed neutral stance. 73 agreed or strongly agreed that online SDL is a better option compared to other online teaching learning methods (like didactic lectures/small group discussion) (Table/Fig 2).

Learning: As shown in (Table/Fig 3), the average post-test score of the participants was significantly higher compared to the pretest (p-value <0.001). When assessing the number of students who answered the questions correctly in the pretest and post-test, for each question, the number was higher in the post-test than in the pretest. Grading of students based on the score showed that the number of students in the “excellent,” “very good,” and “good” categories was zero in the pretest, while 52.9% of the students (73 out of 138) were in these categories in the post-test (Table/Fig 4). On average, the number of students who answered correctly increased by 99.3% in the post-test compared to the pretest (Table/Fig 5).

Discussion

Online, case-based SDL received positive reactions from the majority of the students, and they showed a favourable attitude toward more such sessions of SDL in the future. The effectiveness of SDL was evident through significantly improved learning of the topic of lipid metabolism, as demonstrated by the pretest/post-test results.

The learners’ reactions demonstrated their perception of SDL as a method for in-depth learning and resource exploration, promoting confidence, creativity, teamwork, coordination, and basic science-clinical correlation, despite challenges, mainly related to internet connectivity. Previously, Hill M et al., used a team-based SDL method in Microbiology for first-year medical undergraduates and observed a positive response from students and faculty regarding its implementation (6). Similar observations of positive reactions from learners have been reported in previous studies (2),(4).

It was observed that the majority of the students either “strongly agreed” or “agreed” that SDL helped them achieve the learning objectives, identify appropriate learning resources, correlate basic science with clinical practice, develop as lifelong learners, work in a team, develop professionally, create a good learning environment, and enjoy learning. Notably, 87% of the study participants agreed or strongly agreed that SDL is more interactive and learner-centered than didactic lectures, and 85.5% agreed or strongly agreed that SDL promotes higher-order thinking. Similar observations favouring SDL were seen in previous studies (2),(4),(6). However, there are research studies reporting that didactic lectures are more effective in gaining knowledge than SDL (8).

The comparison of pretest and post-scores indicates improved knowledge among the students regarding inborn disorders of lipid metabolism. The observation that 53% (73 out of 138) of students scored in the grades of “good to excellent” (>60% score) in the post-test, compared to no students in these categories in the pretest, indicates significant learning that took place through SDL. Previous authors have reported similar observations of improved test scores after SDL (2),(12).

SDL in the subject of Biochemistry has been rarely reported by researchers, and present study had the unique distinction of using five case scenarios with questions requiring higher-order thinking. A previous study by Agrawal P and Verma N reported using a case on “Heme Degradation and Jaundice” to allow students to set the learning objectives in groups of 30 students each, with contact sessions over a period of five days followed by discussion of the topic in small group teaching sessions (13). The authors observed that the overall performance of the students regarding core and clinical aspects of the topic improved considerably after the discussion (13).

The enthusiastic participation of students in SDL, with lots of positive inputs, encourages us to undertake more SDL programs in the future. This study had the uniqueness of using an online mode for SDL in a situation where only online teaching and learning were possible due to the prevailing lockdown imposed in the country. The learners set their learning objectives themselves, searched for learning sources on their own, and derived the required details from these resources. Facilitators were in the background, observing the activity and intervening only to coordinate the group activities. SDL, as a philosophy of adult learning and as the process of building a lifelong learner in medical undergraduates, was facilitated by us.

Limitation(s)

The major limitation was the time constraints involved in allowing all the groups to present all five cases, as the only option in the current context of the COVID-19 pandemic was the online platform. However, attempts to overcome these limitations were made by arranging a presentation session, trying to involve as many students as possible during the presentations, and having frequent interactions with them online. Although efforts were made to safeguard all principles of SDL, some directions had to be given to the students, and a few interventions were required as they were in the process of evolving as “self-directed learners”.

Conclusion

Online, case-based SDL was effectively implemented for the topic of lipid metabolism in the subject of Biochemistry. Learners showed positive reactions and demonstrated improved learning. SDL is the need of the hour to create interest in learning among medical students and to develop lifelong learners. In the present context of medical education, “teachers” need to take the position of “facilitators” to develop competent physicians of the future.

DOI and Others

DOI: 10.7860/JCDR/2024/65819.19056

Date of Submission: Jun 06, 2023
Date of Peer Review: Aug 27, 2023
Date of Acceptance: Dec 09, 2023
Date of Publishing: Feb 01, 2024

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. NA

PLAGIARISM CHECKING METHODS:
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EMENDATIONS: 6