Evaluating The Effectiveness of Gastroenterology e-Module for Undergraduate Medical Students, A Pilot Study From Syria

E-learning is an aspect of the practical application of pedagogy. Most students nd it an entertaining and effective learning method. Also, case-based learning is related to pedagogy and is an interactive and enjoyable experiment for students. In Syrian medical schools, Gastroenterology teaching is depending on traditional teacher-centered style, passively affecting learning outcomes and imposing the search for other up-to-date alternatives. The study aimed to evaluate the effectiveness of a case-based, E-Module of gastroenterology in fullling desired outcomes, and to evaluate students' satisfaction with the e-learning experiment, their self-condence improvement, and their perception of the experiment's obstacles. Methods

The organization recommended shifting to online and E-learning to continue the educational process.
Although e-learning is an old and commonly used method in many countries, it is a rarely-used method in Syria, whether by governmental or private universities, except for the open-learning and virtual university experiments.
Implementing e-learning is considered a practical application of adult learning theory. It allows teachers to act as educational guidance and facilitators instead of the routine teaching role (2,3). Most students nd e-learning an effective and entertaining learning method, but they don't think that it can replace the traditional learning method (4).
Medical e-learning in Syria is limited to some students' initiatives, such as the production or translation of educational videos and uploading them to social networks like YouTube (5). Medical education in Syrian medical schools, either public or private, depends on the traditional style, represented by direct lectures and indoctrination. Students' role is almost always passive. This re ects the need for investigating elearning systematically, as it can later be universally adopted.

Methods:
Our study aimed to design and implement an e-module of gastroenterology for medical undergraduate students, and evaluate its effectiveness in achieving required educational outcomes, and assessing students' satisfaction with e-learning experiment, the improvement of students' self-estimation, and their perception about experiment's obstacles.
A pilot, single-university prospective study involving undergraduate medical students was conducted. We designed an e-module of gastroenterology in a case-based style, approaching a speci c case in each educational unit. Each unit has speci c known educational objectives mentioned at the beginning of the unit. A case scenario related to the unit's subject is presented for discussion, then the unit's contents are outlined as etiology, diagnosis and differential diagnosis, management, and prognosis. The scienti c content was arranged depending on Davidson's Principles and Practice of Medicine 21st ed. and Macleod's Clinical Examination 13th ed. Twelve educational units were designed and divided according to delivery type into 6 synchronous and 6 asynchronous units. Educational units were designed as slides with Microsoft PowerPoint 2016. 26 students were chosen randomly from AlKalamoon university medical school by an announcement through social media. The students were tested by a pretest composed of 25 multiple-choice questions presented by a google form and results were gathered.
Synchronous lectures were introduced within 3 weeks (2 lectures a week) through Google meet with voice and slides sharing, discussing subjects, and answering students' questions about differential diagnosis, diagnostic methods, management, and prognosis for each case.
All lectures (synchronous and asynchronous) were uploaded to the Syrian virtual university's learning management system, so accession to the module can be tracked. Students were able to download lectures and send their questions and notes through email or discussion forums. All students' queries were discussed and answered.
A posttest (different from pretest but similar in di culty and design) was shared with students who completed the course as a google form, and results were gathered. Also, a self-assessment survey based on a ve-point Likert-type scale (6) was lled by students. The survey included 15 questions categorized into 3 groups, each one consisted of 5 questions measuring participant's satisfaction, self-con dence, and experiment obstacles. Each question has 5 answers (strongly agree, agree, neither agree nor disagree, disagree, strongly disagree), and points are given for each answer as (5, 4, 3, 2, 1 point) respectively when the question is positive and in the opposite way when it is negative. Points for the whole survey and each included category were collected. The interpretation of the whole survey's points was as follows (15-35 means bad perception, 36-55 means good perception with a need to improve, and 56-75 means excellent perception), and the interpretation of each category's points was as follows (5-11 means bad perception, 12-18 means good perception with a need to improve, and 19-25 means excellent perception). Statistical analysis was performed using Microsoft Excel 2016 and IBM SPSS Statistics v.20. p-value < 0.05 was considered to evaluate statistical signi cance.

Results:
Out of 26 students who answered the pretest, only 13 continued to attend the online lectures, download documents (tracked by LMS), and ll the posttest and survey. So that the nal sample was 13 students included 3 males and 10 females, 11 from the fth academic year, 1 from the fourth year, and 1 from the sixth year. Most of the participants had already received education in gastroenterology during medical school years (23 out of 26), and most had been involved previously in e-learning experiments (16 out of 26).
The 26 students' average degree of the pretest was 38.77%. Table 1 and Fig. 1 compare the results of preand post-test of the 13 students. The results of the posttest were further analyzed, comparing the answers of students about subjects related to synchronous lectures with those related to asynchronous ones, right answers were 66.7% of synchronous lectures vs. 66.8% of asynchronous ones. The p-value was statistically not signi cant (0.48).
Regarding the assessment survey, Cronbach's alpha coe cient was calculated to ensure internal consistency for the whole survey and each category included in it (Table 2). The whole survey 0.82 The best response of students was about the improvement of their self-con dence following the elearning experiment, while the worst perception was about the experiment's obstacles (Table 3 and Table  4). Discussion: Rapid technology evolutions led to the release of new learning patterns. E-learning is an interactive activity that aims to deliver knowledge, skills, and attitudes to the learner through direct and indirect ways using information and communication technology (7). The importance of e-learning lies in solving the problem of informative explosion and widening the learning opportunities to include overseas people, also it provides exibility and a more systematic approach to learning (3). We aimed to design and evaluate an e-learning based course in gastroenterology for medical students in Syria.
Most participants in our study were female students, re ecting the increased desire to explore new learning methods in females. Although most participants had past education in GI diseases, the degrees of the pretest were relatively low (16 to 60%), which re ects the poor curriculum presented to students in medical school. Most students in the study had experience in e-learning during the COVID-19 pandemic and universities lockdown in 2020.
When we started the course, one-half of the students went off the study. Some of those show discomfort with the bad internet connection or the unsuitable timing of synchronous lectures.
Comparing the results between pretest and posttest, we noted good improvement in students' knowledge. The mean degree of participants was 41.5% in pretest, rising to 66.8% in post-test with a statistically signi cant difference. This refers to the e-module effectiveness in improving the level of students' knowledge and information.
Comparing results of synchronous and asynchronous lectures showed no difference. We can conclude that students' participation in synchronous lectures did not add a bene t to downloading and reading lectures, with further asynchronous discussion with the tutor.
When students are asked to evaluate their participation in the course through the nal survey, we can conclude the following: The internal consistency was good for the whole questionnaire and knowledge improvement category, still acceptable for the self-con dence category, but poor for the obstacles category which means that some questions in the last one need to be modi ed (8).
Most students felt improvement in knowledge.
Most participants felt e-learning is more exible and gives more time management ability.
One-half of participants felt that e-learning is more entertaining while one-third found traditional one is better.
More than 50% of participants believed that medicine is hard to be learned remotely.
Self-con dence was improved after the e-learning experiment, this was re ected by the feeling of knowledge improvement, feeling able to solve NBE questions, and the improvement of GI symptoms approach by most participants.
Less than one-half of students felt more tendency to GI specialty after the course.
Regarding e-learning obstacles, most of the participants found e-learning less expensive and didn't feel upset about bad internet connections or technological di culties.
Comparing our study with other studies shows similar results, for example, the systematic review of Barteit et al (9) showed good results of e-learning in low-income countries (like Syria). Participants' satisfaction after course completion was good also in the study of Borakati (10). Dost et al (11) found out that the best impression was about e-learning exibility and the most important obstacle was the family distraction and the bad internet connection, while the best bene t in our study was the improvement in self-con dence and the major obstacle was the absence of direct contact. Unlike our results, Khasawneh et al (12) found that e-learning didn't improve the level of knowledge.

Conclusion:
We concluded that e-learning plays an important role in improving the level of knowledge, with no difference between synchronous and asynchronous methods. Most of the participants express good satisfaction with the improvement of their knowledge and self-con dence. The major barrier is the absence of direct contact in e-learning, while the effect of other di culties regarding internet connection and technical issues was neglected. Ethical approval was given by ethics committee of Syrian virtual university. Informed consent was obtained and signed by each participant before starting the course.

Consent for publication
Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Figure 1 Comparison of pre-and post-test results