From March 2020, an unprecedented lockdown was implemented in India, in tune with the rest of the world, as the ravaging COVID-19 pandemic brought the entire dynamics of the world to a grinding halt, raking up the case and death tolls, plummeting economies and confining many lives within four walls. Naturally, there was shift in the role of medical teachers towards patient care and the community, instead of teaching the medical students [1].
However, as the pandemic was set for a protracted course, the medical education could not be put on hold indefinitely and alternate avenues had to be sought for. Prior to COVID-19, most of the medical education used to be done in a physical classroom basis. However, the most effective preventive strategy for COVID-19, the social distancing, disallows students from gathering in lecture halls or small rooms for group teaching [2,3].
As the pandemic and subsequent lockdown stopped the physical classroom teaching, the only process for continuation of any form of education left was online. Thus, online education was adopted in a priority basis in educational institutes across India, although major hurdles such as lack of training, infrastructure and lack of awareness of the various online teaching modalities were identified [4]. Medical education in India was not an exception to this sudden drive for online education, and in light of present scenario it is imperative to explore this matter further.
The topic of online education in medical fields has already been a topic of interest for many authors due to its potential and the wide and ever increasing range of technologies available, and the need to frame guidelines [5]. In the Indian context too, various studies in pre COVID times have suggested addition of more technology and online resources in medical teaching in India [6]. Later studies on this matter in pre COVID times also indicated that it was generally accepted by teachers and students when it was considered to be implemented alongside traditional teaching [7].
With the COVID-19 pandemic spreading across the world and shutting down of classrooms, it was recommended to use online teaching in medical and dental fields, and its various advantages were noted, with emphasis on student centered learning [8]. Pei L and Wu H in their meta-analysis in 2019 have also supported the idea of online education in medical field, along with emphasis on further study to evaluate digital learning materials and student’s perspectives amid many other matters [9].
A study by Saiad S et al., in 2020 from India also suggested further exploration of the online education, and expressed the idea that online education can become main stream in the future, and attempted to frame out good medical teaching practices, prioritising training, building infrastructures and guidelines [10]. Other studies also indicated further exploring the matter of online education [11,12].
As the online teaching has gained importance in becoming a necessity in these times, and for the fact that the field is relatively new with always changing technologies, newer studies are necessary, especially to explore the context in Indian framework and to explore the matter from the perspective of the students. The aim of the present study was to assess the perception of first year MBBS students about the online education and assessment during the lockdown period of two months.
Materials and Methods
A descriptive cross-sectional study was designed, in which an online survey was used to assess the student’s perception regarding various aspects of online education and assessment during the lockdown due to COVID-19 pandemic. Data collection through the online survey was done from 29th August to 9th September 2020, after two months period of online education.
Inclusion criteria: First year MBBS students of North Bengal Medical College who undertook two months online education, and prior to pandemic were taught offline.
Exclusion criteria: Those who partially completed the survey, didn’t give consent for the study and didnt participate in the voluntary survey were excluded from the study.
Following COVID-19 Pandemic and subsequent lockdowns, provisions for regular online medical education were arranged for first year MBBS students through the Department of Anatomy in North Bengal Medical College.
In the initial phase, various modalities of E-Learning were explored, such as self-directed learning (Digital study materials shared with the students who study it themselves), online live classes (live classes were arranged online which were attended by the students at a specific time) and Hybrid E-Learning (DEMs shared with students for their study, along with OI with teachers to clarify any doubts). Hybrid E-Learning Method was accepted for the Department of Anatomy. According to the accepted method, the procedure of DEM sharing and OI took place in a Digital Information Sharing Platform (DISP).
Operational definition of the same for the context of this particular study is described herein.
Digital Education Material (DEM): Any digital file or information that can be utilised for the purpose of education is a DEM. The definition of DEM included but was not limited to narrated PowerPoint Presentations, Youtube Videos made by the faculties themselves, Images from textbooks, handwritten notes and typed explanations, voice and video clips, links to external websites and web based classes etc.
Digital Information Sharing Platform (DISP): Any internet based platform with which digital study material can be shared with the students, can be utilised as the DISP. Potential DISP for academic purposes could be instant messanging services such as whatsapp, telegram etc; email services such as Gmail, rediffmail; and social media such as facebook. Among these whatsapp was chosen for its widespread usage, ease of use and privacy; and versatility of type of materials that could be shared in it.
For the purpose of online education, first an academic group was created in WhatsApp where all departmental faculties were present as group admins, and the students of first year MBBS were present as members. They had access to the group through their smartphone or WhatsApp Web. This group was the framework for the sharing of various DEMs according to a time schedule framed by the department and shared with the students.
The students were in constant correspondence with the teachers through the group for any queries they might have, and were free to contact any teacher personally for any confusion in their study or revision. The communication and interaction took place between the students and teachers via whatsapp text messages, voice messages, and video and audio calls to ensure proper understanding.
The students were also regularly assessed through OAs done through multiple choice questions framed out in Google Forms, the link to which were sent to them through the Academic WhatsApp group. Time limit was fixed for each test and the system was locked after the stipulated time. The results were tabulated and declared on the next day through whatsapp, the queries of the students were also answered in that platform.
After two months of online education and assessment from 29th June 2020 to 29th August 2020 following the described methods, the perception of the students regarding online education and assessment was evaluated through a survey. The questionnaire for the survey was framed by the authors. Questionnaire was checked by a group of experts in this field. Face and content value of the questionnaire were judged by them. Then the digital version of the questionnaire was created in google form and the link of which was shared to the students for their voluntary participation from 29th August 2020 to 4th September 2020. The link to participate in the survey was sent to the students in their batch whatsapp group along with a description. Participation was entirely voluntary and optional.
The survey questions that the participant’s answers were divided in the following major group:
Details of the students such as gender, type of internet and device used
Queries on the student perception of DEM
Queries on student perception of OI
Queries on student perception of OA
Comparison of online education with offline
Comparison of online examination with offline
The details of the questionnaire can be found in the [Annexure 1].
Regarding DEMs, OI and OA, students were presented with questions that contained a statement, and four option to choose from a rating scale using modified Likart Scale: strongly agree, agree, disagree and strongly disagree.
If the students choose to strongly agree or agree, they were considered to be in agreement with the statement and for the other options, viz., disagree and strongly disagree, they were taken to be in disagreement.
Regarding the comparison of online vs offline mode of education and assessment, the students were presented with questions where they were to choose between online mode of education, offline mode of education, or both, and the respective choices were noted and duly tabulated.
Statistical Analysis
Data collected through google form was exported into google sheets first and then transferred to Microsoft Excel 2016 for further analysis of percentage of each group. Results were expressed in frequency and percentage.
Results
A total 95 students out of 200 had opted to participate in the survey. There were 54 males (57%) and 41 females (43%) in the survey. Most students (n=90, 94.7%) appeared to be using their smartphones and most (n=78, 82%) were reliant on mobile internet [Table/Fig-1].
Summarising the participating demographic and modalities of accessing the online education (n=95).
| Total students of 1st MBBS course | Number of students who participated in the study n (%) | Type of internet connection used by the students n (%) | Type of device used by the students n (%) |
|---|
| 200 | Total | Males | Females | Mobile internet | Broadband | Both | Mobile phone | Laptop | Tablet |
| 95 (47.5%) | 54 (27.0%) | 41 (20.5%) | 78 (82.1%) | 5 (5.26%) | 12 (12.63%) | 90 (94.74%) | 5 (5.26%) | 0 (0) |
Digital Education Material (DEM)
There was variable opinion of the students regarding the effectiveness of the DEMs, with most agreeing that the DEMs are relevant (83.2%) and informative (80.7%) [Table/Fig-2].
Student perception of Digital Education Material (DEM) (n=95).
| Category of response | Strongly agree n (%) | Agree n (%) | Disagree n (%) | Strongly disagree n (%) |
|---|
| Relevancy | 11 (11.57) | 68 (71.57) | 13 (13.68) | 3 (3.15) |
| Informative | 16 (16.84) | 61 (64.21) | 13 (13.68) | 5 (5.26) |
| Ease of understanding | 5 (5.26) | 46 (48.42) | 32 (33.68) | 12 (12.63) |
| Easily revisable | 4 (4.21) | 40 (42.10) | 35 (36.84) | 16 (16.84) |
| Fulfillment of learning objective | 8 (8.42) | 43 (45.26) | 33 (34.74) | 11 (11.57) |
Online Interaction (OI)
Regarding OI, a similar diverging trend was observed with most students agreeing that the OI with the teachers being prompt (77.9%), relevant (71.6%), informative (84.2%) and helpful for understanding (64.2%) but only 46.8% of them considered that OI was fulfilling their learning experience [Table/Fig-3].
Student perception of online interaction (OI) (n=95).
| Category of response | Promptness n (%) | Relevant and to the point n (%) | Informative n (%) | Helped in understanding n (%) | Effectively fulfilled learning objective n (%) |
|---|
| Strongly agree | 15 (15.80) | Agree: 77.9% | 13 (13.70) | Agree: 71.6% | 13 (13.70) | Agree: 84.2% | 11 (11.60) | Agree: 64.2% | 10 (10.52) | Agree: 46.8% |
| Agree | 59 (62.10) | 55 (57.90) | 67 (70.52) | 50 (52.36) | 35 (36.90) |
| Disagree | 18 (18.90) | Disagree 22.1% | 25 26.30) | Disagree 28.4% | 13 (13.70) | Disagree 15.8% | 29 (30.52) | Disagree 35.8% | 41 43.20) | Disagree 53.2% |
| Strongly disagree | 3 (3.20) | 2 (2.10) | 2 (2.10) | 5 (5.30) | 9 (9.50) |
Online Assessment (OA)
Regarding OA majority of the students agreed regarding all the parameters posed in the query, except 55% of students disagreed that OA was harder [Table/Fig-4].
Student perception of online assessment (OA) (n=95).
| Category of response | An (%) | Bn (%) | Cn (%) | Dn (%) | En (%) | Fn (%) | Gn (%) | Hn (%) | In (%) | Jn (%) |
|---|
| Strongly agree | 12 (12.63) | 9 (9.47) | 18 (18.94) | 20 (21.05) | 12 (12.63) | 9 (9.47) | 12 12.63) | 4 (4.21) | 10 (10.52) | 11 (11.57) |
| Agree | 54 (56.84) | 66 (69.47) | 65 (68.42) | 56 (58.94) | 54 (56.84) | 44 (46.31) | 31 (32.63) | 61 (64.21) | 55 (57.89) | 47 (49.47) |
| Disagree | 23 (24.21) | 16 (16.84) | 10 (10.52) | 16 (16.84) | 20 (21.05) | 27 (28.42) | 42 (44.21) | 24 (25.26) | 24 (25.26) | 25 (26.31) |
| Strongly disagree | 6 (6.31) | 4 (4.21) | 2 (2.10) | 3 (3.15) | 9 (9.47) | 15 (15.78) | 10 (10.52) | 6 (6.31) | 6 (6.31) | 12 (12.63) |
A: All questions are within the scope of digital study materials shared
B: Online Assessments helped in time management
C: Assessment questions were unambiguous, clear and to the point
D: Assessment was challenging and tested knowledge and understanding
E: Assessment was fair and objective
F: Assessment was effective way of assessment
G: Assessment online was harder than regular
H: Expected scoring was possible to be achieved in Online Assessment
I: Felt confident in taking online examination
J: Online Assessment was comfortable
The details are shared in the respective table.
Comparison of Online Education and Offline Education [Table/Fig-5]
Comparison of online education and offline education (n=95)
| Education | Relevance (Classes and materials stick to the point n (%) | Informativeness (Amount of info shared) n (%) | Ease of understanding and comprehension n (%) | Better and complete understanding (n (%) | Retention is better n (%) | Convenient n (%) | Revision easier n (%) | Prefer which mode n (%) |
|---|
| Online education | 14,15% | 27, 28% | 9, 9% | 9, 9% | 16, 17% | 27, 28% | 27, 28% | 9, 9% |
| Offline education | 58, 61% | 51, 54% | 74, 78% | 79, 83% | 68, 72% | 60, 63% | 57, 60% | 74, 78% |
| Both Education/No difference | 23, 24% | 17, 18% | 12, 13% | 7, 7% | 11, 12% | 8, 8% | 11, 12% | 12, 13% |
It was seen that majority of the students preferred offline method of education. The same trend can be seen in the matter of examinations where the students seemed to prefer the offline examination even though most expressed their opinion that it was easier to score in online examinations.
Comparison of online vs offline mode of examination [Table/Fig-6]
Comparison of online vs offline mode of examination (n=95).
| Examination | More difficult | More comfortable | Easier to score in | Prefer which type of exam |
|---|
| Online exam | 32, 34% | 36, 38% | 77, 81% | 27, 28% |
| Offline exam | 46, 48% | 46, 48% | 12, 13% | 51, 54% |
| Both/No difference | 17, 18% | 13, 14% | 6, 6% | 17, 18% |
It appeared that in spite of recognising that online examination was easier to score in (81%), the students mostly preferred offline examination (54%) and 18% preferred both. About 28% preferred online examinations and almost half of them (48%) felt more comfortable with offline examination.
Discussion
Online teaching has been increasing ever since internet came into place, and it’s potential was already being assessed in the fields of higher studies [11]. However, its presence was never as widespread and important as it has become during this pandemic. As COVID-19 closed the door of the physical classroom in every institute across the world, and left everyone to improvise, often on a short notice and with little resources and know how, Online Education remained as the only possible way of education in this situation, becoming a necessity in a very short period of time [12].
The uncertainty of how long this situation remains makes it even more important to study the matter of online teaching, to better harness the potential of internet and available technology for medical education, and it is important to find out the inefficiencies and barriers that remain in existing systems so that they can be modified and brought closer to perfection. This is especially true for India where online education is still in its early stage and suffers from lack of infrastructure [11]. There has been many studies that indicate student perception and satisfaction regarding the education given to be important for the success and acceptance of the said education, and this holds true for online education [13-15]. So, it was imperative for us to assess the perception of the students regarding the present modalities of E-learning.
As it appeared from the results, while the students have overall accepted the DEM, OI with the teachers, and OA; majority of them still preferred the offline mode of education and examination. Since interaction with the teachers was present, lack of traditional classroom socialisation and lack of proper infrastructure could be a reason for such tendencies, as was also noted by Adnan M in a similar study [16]. This trend was also noted in other studies where despite live classes were arranged and students identified positive features of Online Education, about 50% of them still preferred Offline Education [17]. However, even with these shortcomings, other studies done in similar time also supported carrying out online education for medical and dental students [8].
Thus, it is suggested that online education must be further explored and used for medical education. If done properly it can lead to comparable and potentially better results than offline method [9]. Different approaches can be taken to make it better. One study has suggested case based learning for clinical subjects can be useful [8]. Similarly, in anatomy education can be arranged around practical classes and dissection. Alternatively, more novel approaches like online virtual dissection simulation, potentially taking help from virtual reality technologies can improve knowledge and confidence of students as these approaches are shown to improve surgeon confidence in various studies [18,19].
Even without virtual reality, studies from even 1993 have indicated that interactive dissection simulation are as effective in promoting student learning and efficacy as in actual dissection, and are better in videotaped version of the same [20]. With advent of better technologies now, and the idea that once developed such infrastructure would be practically free to distribute; it has potential in revolutionising online education of anatomy.
As the COVID-19 is potentially here to stay for a protracted period, and since by the time it ceases to be a threat there shall already be a system for online education in place, it appears that in the future medical learning in India should go forward with a blended or hybrid mode of online and offline learning, which can give better results [21].
The study therefore indicates that there is ample scope for further exploration and improvement in the matter of online education. This study can help future studies to identify the feasibility and acceptance of different newer methods, adjustment to the existing methods in use, in ways that appeal more to the students. The positive features of present forms of online educations are also noted in this study, which indicate that in future when offline classes would resume, some form of online education or a hybrid of traditional and online modes can still benefit the students in regards to medical education.
This study was done during the unprecedented crisis of COVID-19 pandemic. The nature of the crisis might have influenced the students aversely towards the online mode of education. If online education took place in a normal time, the perception of the students might have been different. Reasons that could negatively affect the student perception during the pandemic were:
There was no previous infrastructure for online learning and the faculties were not trained in online education during their trainee period as most of the conventional teaching in medical field is done offline.
Connectivity and other technological issues
General negative emotion towards the entire Pandemic situation and potentially associating the online education with that.
Limitation(s)
The study could have used a pilot study, which was not possible due to the nature of the pandemic.
A simultaneous control group was absent as no student could be taught offline during the same period.
Conclusion(s)
This study explores the perspective of the students regarding various aspects of online education and assessment. The results indicate that while most students accept online education, interaction and assessment, and can identify various positive points of the same, at the end most of them would still prefer the offline modes if it was not deemed impossible due to the pandemic. This could be reflecting the lack of student to student interaction and group discussion, missing the familiar environment of classroom teaching, and association of the online education to the unpleasant experience of the lockdown; or this could also indicate the need for change in our approach to online education. Possibly newer technologies and virtual resources such as virtual dissection can be utilised that would engage the students better. Alternatively, perhaps the present common approach of arranging online classes at specific time that mimic the traditional classes need to be changed, and the Online medical education can be made into a continuous learning experience through a digital framework where students and faculties can engage more freely and more frequently, removing the barrier of strict formalities and time schedules.
A: All questions are within the scope of digital study materials sharedB: Online Assessments helped in time managementC: Assessment questions were unambiguous, clear and to the pointD: Assessment was challenging and tested knowledge and understandingE: Assessment was fair and objectiveF: Assessment was effective way of assessmentG: Assessment online was harder than regularH: Expected scoring was possible to be achieved in Online AssessmentI: Felt confident in taking online examinationJ: Online Assessment was comfortable