E-learning-based medical education during COVID19 pandemic From Medical students' View Points


 Background

Most universities around the world have replaced e-learning with face-to-face methods after Covid-19 Pandemic. The present study evaluates the students' viewpoints about the dimensions of e-learning during the COVID-19 pandemic.
Methods

This is a survey study aimed at investigating e-learning experiences of 550 students of Shiraz University of Medical Sciences(SUMS) during the time Coronavirus pandemic. To data collection, a research-made questionnaire was employed, and the data were analyzed using one sample T-test, Independent T-test, ANOVA, and MANOVA.
Results

The results demonstrated that the students had satisfactory e-learning experiences and the average dimensions of e-learning were: Technological facilities(M = 4.29 ± 1.13),Technical support (M = 4.00 ± 1.08), e-Content quality(3.84 ± 1.05), Asynchronous education (M = 3.73 ± 1.20), Teacher-learner interaction(3.63 ± 1.32) and Synchronous education(M = 3.59 ± 1.31)Respectively. Most important factor was the interaction and feedback between teacher and students. Students' views on the components of e-learning were related to their age, access to electronic devices, and their computer skills significantly.
Conclusion

It seems that e-Learning can be a relatively good alternative to face-to-face training, but the teacher-student interaction is the main element in the greater effectiveness of this method.

Sometimes the positive or negative attitudes students have towards e-learning are universal. For example, it is widely believed that the negative attitudes of university lecturers towards technology-based education can indirectly cause technology-based education resistance among students which, in turn, lead to a series of challenges for the students (6). Sometimes it is not the e-contents, per se, that produce challenges for students, but failure of teacher-student and student-peer communication that negatively in uences students' productivity in e-learning (7). As Chapman and Mahlk (2004) point out, latest educational technology does not necessarily enhance instruction or students' participation (8). Also Daniels et al. (2019) indicate that the way e-learning materials are presented to students has a signi cant effect on the effectiveness of the lesson being taught (9). Sometimes lack of time management and absence of selfregulation are reported as major factors affecting students' e-learning experience (10). According to Pedrotti and Nistor (2019), not informing students as to when to access the contents means leaving it up to the students who, especially in fully presented on-line courses and due to time constraint and lack of effort regulation strategies, fail to strategically plan their e-learning activities during the course (11).
Pedagogically concerned, heightened cognitive load, as a result of teachers' ineffective teaching methods, is another challenge repeatedly reported by students (12). Cognitive load theory (CLT) offers a general framework of learning and its association with working memory as well as long-term memory within an elearning environment (13). Extraneous or ineffective cognitive load presents students with unnecessary information that inhibit their ability to process new information and to create long-term memories (14). As Uppal (2017) indicates, e-learning works only if teachers know how their students learn (15).
Apart from human factors, another challenge that impedes e-learning is technological facilities. Not only at schools and universities, but also at home settings, many students are deprived of access to foundational technology services, software, and hardware to fully explore opportunities that computer-based teaching provides to them (16). Although it is assumed that in the 21st century we might or should not face such challenges anymore, in most developing countries, bandwidth and connectivity issues still cause a perennial hurdle for synchronous and asynchronous e-learning/teaching (17). Even cost of buying Internet packages might be a major concern for many students studying in such countries (16). This has even aggravated undoubtedly during current Coronavirus pandemic that almost all courses are presented online. In terms of Infrastructure, for example, in one study conducted by Koh et al., majority of Malaysian medical students possessed smart devices with medical apps and had reportedly positive feelings regarding the effectiveness of those apps (18). Notably, Wi-Fi and 3G internet services were provided to all them in both university and hospital settings. However, in another study, Masika et al., reported that sub-optimal internet coverage cost of apps, lack of access to smart devices, and limited device memory were the major challenges of using mobile devices and apps for medical education in Kenya (19).
Globally reported, many students have had to receive their course contents in a virtual mode due to their schools' closure during the pandemic (20). This rapid adjustment to the current global phenomenon has necessitated not only teachers but also students to adapt themselves to this new trend of homeschooling system; in other words, they have been pushed to learn new digital skills and new learning and teaching strategies in a short run. As a result, any observations about the way the coronavirus pandemic is affecting e-learning should be the concern for many researchers at this stage. While online learning might be available during Coronavirus pandemic, it is unlikely to be as effective as face-to-face teaching; those with less resources will disproportionately be disadvantaged due to many reasons including lack of preparation to attend online classes, technical issues and concerns, weak/interrupted internet signals during live lectures, lack of face-to-face interaction, lack of time management, and many more. Even before Coronavirus pandemic, little literature was available on the effectiveness of asynchronous and synchronous e-learning in medical universities and previous studies show that perceived e-learning challenges have to do more to improve technological facilities and the kind of Learning Management System (LMS) which is used in a particular school (21). Therefore, this study could be a signi cant contribution to knowledge in this area if we mean to understand the perceptions of students regarding to e-learning-attributable inhibiting factors. Furthermore, e-learning is a relatively new innovation in the design of educational facilities at medical universities in Iran, especially during Coronavirus pandemic during which the fast pace of transition from face-to-face classes to distance education mode could not fully prepare the o cials and university authorities to evolve their digital tools to ensure uninterrupted educational delivery to every one of the students. Mainly, this study aimed to identify SUMS medical students' views of e-learning-based medical education during Coronavirus pandemic; and To see if there are any differences regarding the students' general views and their age, gender, residence, digital and computer literacy, type of digital device used, their prior e-learning experience, and degree of study.

Research Design
A descriptive survey study was conducted in March 2020 on the students' perception of e-learning experiences during the semester coincided with Coronavirus pandemic.

Population of the Study
The target population of this study was all SUMS students in various disciplines. SUMS is a public medical sciences university located in Shiraz, Iran. It is ranked as one of Iran's top medical universities and it includes 11 main schools dealing with various academic medical elds. As to the exposure to e-learning, Prior to the COVID-19 Pandemic, e-learning was used to a very limited extent in medical education, Therefore, the experience of pure e-learning was an unprecedented experience for SUMS students. The sample size of this study was determined to include 507 participants by means of Krejcie and Morgan's Table (22), and simple random sampling was applied to collect the data.

Research Instrument
To achieve the objectives of this study, a self-devised questionnaire was used. In order to design the questionnaire considering wide diversity of perceptions regarding students' e-learning experiences, an online focus group of heterogeneous sample was made consisting of 5 students studying at different SUMS schools and 5 SUMS faculty members.
With the permission of the participants, the focus group was video-recorded, and all the comments were then drafted, and conclusions were drawn by the researchers of this study.
Twenty six items were then extracted and presented in the Likert format of six items ranging from strongly agree (6) down to strongly disagree (1). The questionnaire was included 2 parts; part one comprised of demographic parameters such as gender, age, residence, digital and computer literacy, eld of study, and their degree level (Continuous Bachelor and Discontinuous Bachelor degrees, Master's, PhD degrees, and professional doctorate degree (Doctor of Medicine, Dentistry, and Pharmacy). Part two of the questionnaire was designed based on semantic and content linkages of all items in the questionnaire. Five questions evaluated technological facilities; 4 questions were related to technical support; 4 questions targeted asynchronous learning, 4 questions targeted synchronous online classes; 3 questions identi ed the quality of e-contents made by faculty members, and 6 questions evaluated teacher-student interactions. In addition, four short questions measure students' general feelings towards e-learning. The cut-off point score for each item was considered 3.5 equivalent to 50% which meant that the average above 3.5 for each component denoted students' satisfaction.

Validity and Reliability of Questionnaire
The validity of the questionnaire was assessed by calculating the Content Validity Ratio (CVR), Means the necessity of each item, and the Content Validity Index(CVI) with three sub index (Relevance, Clarity and Simplicity). To this end, ten experts in the elds of medical education, e-learning, medical sciences, and English Language reviewed the questionnaire items. Based on expert opinions, the CVR was between 70-100% for each items and total mean of CVR = 93.8%. Also, for CVI, the simplicity and clarity sub index for each question was between 70-100% and the relevance for each question was between 80-100%. total mean of CVI for simplicity = 95.3%, Clarity = 96.9% and Relevance = 97.3%. In addition, the face validity of the questionnaire was also checked. Following this, eight questions were modi ed in terms of grammar and eloquence.
The reliability of the questionnaire was also measured by sending the initial version of the questionnaire to 40 medical students. Using Cronbach's alpha for analysis, we found that the reliability of the questionnaire with 26 items was high (97.5%). Reliability was also calculated for each component. collection began. This study was conducted in June, 2020, and while collecting the data, we were still in quarantine as a result of Coronavirus pandemic. Therefore, to collect the data, an online survey was designed. The link was sent to all SUMS students through WhatsApp social media groups that faculty members had created to be in touch with their students.
Privacy and anonymity of the participants and con dentiality of data were granted, and informed consent was obtained from the participants.

Data Analysis
The data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA) for windows (version 24). Demographic characteristics of the participants were calculated by descriptive statistics (frequency and percentage of frequency). The data were also analyzed by One Sample T-test, Independent T-test, MANOVA, and ANOVA.

Results
As shown in Table 1, the demographic and pro le information of those 507 students who responded to the online survey indicates that 343 (67.7%) were females and 164 (32.3%) were males. The highest percentage of the respondents, 207 (40.8%), was studying at a continuous Bachelor degree, followed by 193 (38.1%) professional doctorate degree, 79 (15.6%) discontinuous Bachelor students, 16 (3.2%) PhD, and nally 12 (2.4%) Master's students. Four hundred (78.9%) participants aged between 18-24 years old; 107 (21.1%) aged above 24, and the mean age average of the participants was 26.8 ± 23.7. There were 222 (43.8%) who were living in their hometowns at the time of quarantine and 258 (56.2%) resided at the campus. Regarding the students' digital and computer literacy, the results showed that 287 (56.6%) participants had low to average digital and computer literacy, while 368 (72.6%) had a su cient digital and computer literacy and had the knowledge and ability to e ciently use computers and related technology. Out of all the participants, 368 (72.6%) had a personal laptop to use for their online studies, 139 (27.4%) had only their mobile phones or occasionally had access to friends' or family members' computers and laptops. There were 125 (24.7%) participants who had experienced e-learning prior to Covid-19, and 382 (75.3%) had had no experience (Table 1). signi cantly showed an average above the cut-off point (Minimum Score) except for the component of Synchronous education (P = 0.14). (Table 2) Also the mean and standard deviation for the participants' responses to each items are illustrated in Table 3. As the table shows, the overall mean score of all items in the questionnaire regarding the medical students' views towards e-learning education was satisfactory (3.87 ± 1.52). , (Table 3)  Considering the age factor, the students were divided into two groups including 18 to 24 years and above 24. In Table 4, the results of the independent samples t-test showed a signi cant difference in the overall mean of the students' responses to the questionnaire items with respect to the age factor (P = 0.027). That is, the greater the age, the more satisfaction the students experienced regarding e-learning education except for synchronous classes (P = 0.98), technological facilities (P = 0.39), and support (P = .08) components in which no signi cant difference was identi ed (Table 4). In terms of gender, the results of the independent samples t-test indicate no signi cance difference between the male and female students' e-learning experience (P > 0.05) in neither the overall mean nor the subcomponents. Likewise, no signi cant difference was seen in terms of the students' residence.
Students' computer skills were questioned in three levels: low, to some extent, and Su cient Skills. None of the students were in the low skills category. However, a signi cant difference was observed in both the overall mean and the mean of each e-learning component in terms of students' computer skills. In other words, students with better computer skills scored better on e-learning components , (Table 5) The results of Table 6 also showed a signi cant difference between the overall mean score of those who had access to PCs or laptops compared to those who had only their mobile phones (P = 0.002). This difference was signi cant in terms of all the e-learning components ( Table 6)  We evaluated the relationship between the students' degree (Undergraduate and Postgraduate student) and their views of e-learning education. The results show that the Postgraduate student scored e-learning components higher than Undergraduate students signi cantly MSc students (P = 0.001), and PhD students (P = 0.03).
Since the investigated components in the present study were in fact different facets of e-learning education, an interaction between them was assumed and, therefore, MANOVA was used. For running MANOVA, at rst, four indices including Pillai's Trace, Hotelling's Trace, Roy's Largest Root, and Wilkes Lambda index were checked to ensure that the assumptions for conducting a MANOVA were not violated. The ndings con rmed the interaction between the variables in the present study (P = 0.000). , (Table 8) As it can be seen in Table 8 desirability of e-learning education. (Table 9). In terms of responses to short questions, the results show that 322 (67%) of students thought online education was interesting; however, 302 students (60%) preferred using blended learning in the future after eradication the COVID-19 pandemic, 356(75%) believed lack of physical presence of the teacher sensed throughout the semester; likewise, 410 students (80%) reported missing the peer -peer interaction they used to have in the traditional learning environment.

Discussion
Although a random sample of 507 students sought out to participate in this study, the ndings and conclusions are limited in their generalizability because they were derived from only one medical university in Iran and most speci cally the data were collected at the unusual time of COVID-19 pandemic, when results of any research is signi cantly overshadowed by the disease. Furthermore, because of the university closure, the data were collected only electronically, so perhaps students who did not have access to Internet could not ll out the questionnaire despite the likelihood of their having negative views regarding e-learning education. With these caveats in mind, results have demonstrated that SUMS students had a positive elearning experience during the lockdown. This nding parallels another research carried out during the lockdown. Hyseni Duraku and Hoxha (2020) reported that although students faced challenges in terms of lack of attention in online classes due to various reasons, generally, they had a positive feeling towards elearning because not only did e-learning draw their attention psychologically away from the pandemic, but also learning wise, they had more time for lessons and interactions with the professors (23). Our result is contradictory to the study conducted in Pakistan College of Medicine and Dentistry since it showed that the majority of Pakistani students had a negative feeling towards e-learning and were more inclined towards face-to-face learning in the future; most importantly, they felt e-learning had little impact on their learning during the pandemic (24). Considering medical students' e-learning experience literature prior to COVID-19, the results are mixed with a greater number of medical studies reporting students' positive feelings towards e-learning (25)(26)(27). This study, however, revealed that SUMS students were dissatis ed with online synchronous classes perhaps because not all students could access synchronous classes reliably due to their geographical zone insu cient bandwidth, peer-to-peer tra c, and poor video streaming services (28).
In our study, lack of interaction with the professors was also mentioned as one of the reasons why students were dissatis ed with synchronous classes. As to asynchronous classes, many studies reported that students preferred asynchronous classes over live class sessions as in the latter teachers do not have time to answer their questions and do not have the required skills to properly handle online classes (29)(30)(31). This dissatisfaction can be attributed to what Sims (1999) states regarding the types of interactivity a synchronous session requires to be successful : learner-teacher interaction, learner-learner interaction, learner-content interaction and learner-interface interaction (32).
As to the age factor, this study showed that older students were more satis ed with e-learning. This piece of nding is not in line with the result of the study conducted by Fleming, Becker, and Newton (2017) in which it was reported that age was not a signi cant factor in uencing both satisfaction with e-learning and the future use intentions (33) Another study carried out by Dabaj (2009) also reported similar nding (34). This result is interesting because it seems that younger generation is supposed to be more digital literate and more competent with e-learning; however, it seems that in our study, experience and wisdom acquired by age had a more contributing role in e-learning acceptance especially at the time of the over-night shift to virtual learning due to COVID-19 pandemic. McSporran and Young (2001) reported that because mature female students out preform at scheduling their learning and function better at communicating online, they are more motivated towards distance learning (35) taking gender into account, this nding is partly inconsistent with our result because we could not nd any signi cant relationship between students' gender and their e-learning experience. This is supported by a study conducted in Malaysia (36).
However, our nding revealed that students' computer and digital literacy played a signi cant part in their elearning experience. This nding parallels previous research in this area stating students' digital literacy as a prerequisite for learning effectively in a blended learning environment (37)(38) However, Concannon et al. (2005) have a different viewpoint as they believe that this is not the students' digital literacy that should be the main concern, but it is their attitude towards e-learning that matters the most. In their study, they reported that even the least digital literate students had a positive attitude towards e-learning and, as a result, none of them stated di culties with using technologies (39). In contrast, Mohammadyari and Singh (2015) believe that digital literacy is not merely about having the computer knowledge; it is, instead, one of many other literacies people need, in the 21st century, to understand and comprehend various types of information (38).
This study also revealed a signi cant difference between the overall mean score of those who had access to PCs and laptops compared to those who had only their mobile phones to use. This shows that the choice of hardware plays a signi cant role not only in students' e-learning experience in general, but also in all the sub-components of this study, content quality, interaction with teachers, and asynchronous classes, to name a few. From asynchronous classes and content quality point of view, this result might be justi able in that almost all the multimedia contents made during COVID-19 pandemic were not designed and developed for mobile users; they were simply made out of necessity. Therefore, while developing the contents, perhaps teachers did not consider the smaller screen of the mobile phone users and the type and the size of the fonts they were using. Sung, Chang, and Liu (2015) believe that teachers need teacher-development training to improve mobile-enhanced instruction (40). Insu cient preparation on behalf of teachers, according to Frohberg et al. (2009), is one of the major factors in students' learning failure using mobile devices (41).
Although in our study, only about 28% had only their mobile phones for studying and did not have access to any personal computers and laptops., teachers should customize their teaching program to meet the need of majority of students rather than "simply designing their own program around the use of technology" without taking the accessibility of the required devices into account (40). Our results also showed a signi cant difference between the e-learning experience of students who had experienced virtual classes prior to COVID-19 pandemic and those who had not. In other words, those students who had experienced blended learning before had a more positive e-learning experience during the semester presented during the pandemic. Interestingly, this difference was signi cant in terms of all the e-learning components except for the asynchronous classes. This is because only shortly after the pandemic began, SUMS launched NAVID Academic Learning Management System for the multimedia contents to be uploaded by the teachers for the students and this experience was new to all the students studying at SUMS. Therefore, perhaps, unfamiliarity with the system and its different modules might be the reason why there was a signi cant relationship between all the e-learning components except for the Navid system. This result is supported by Sha ei Sarvestani, Mohammadi, Afshin, Raeisy (2019) who reported that students from Virtual School of SUMS reported that using a large number of modules in Navid System has led to increased application complexity (42).
Furthermore, our investigations revealed that the teacher-learner interaction factor and asynchronous learning factor had the greatest impact on the students' desirability of e-learning education, respectively.
The potential of interactivity and the ability to respond contingently to the learner's action has been placed as one of the most important factors in adult learning education (43). In a study conducted by Begum, Ali, and Panda (2020), ndings showed that medical students' Knowledge, interaction, attendance, and engagement in class signi cantly increased following the application of interactive teaching module (44).
In terms of asynchronous e-learning, Hrastinski (2008) reported that because of its exible modus operandi, asynchronous mode of learning has been the most prevalent form of e-learning (45). Perveen (2016), though, reported that in her study, students favored the ideal blend of the two modes of instruction, asynchronous and synchronous, after better technological advancements and speed of the Internet (46).

Conclusion
This study holds clear implications for e-learning based medical education in the future since having insight regarding medical students' views of e-learning could help teachers, course designers, and university authorities to develop general principles and standards through a systematic model to design relevant elearning courses for medical students. Since it is not known when we get back to the traditional, face-toface or blended learning education, the results of this study provide yet more evidence for curriculum designers or instructional coordinators to design and facilitate multimedia-based courses that are tailored to all students, especially those who do not have the opportunities everyone else might have. Our result also highlights the importance of professional content development resources for teachers in order to support them build necessary skills for developing virtual contents and delivering remote teaching, which, in turn, help the students not only develop their academic abilities but also learn more independently at home.

Suggestions For Future Research
Although the ndings of this study showed that medical students had positive views regarding e-learning education, longer experiments with larger samples need to be conducted in the future to further investigate the effectiveness of e-learning medical education, especially under normal circumstances. Furthermore, since teachers are the providers of this education, it is vital to study their viewpoints regarding e-learning.