E-learning in medical education during COVID-19 pandemic: Experiences of a research course at Kenya Medical Training College

doi:10.21203/rs.3.rs-846149/v1

Download PDF

Research Article

E-learning in medical education during COVID-19 pandemic: Experiences of a research course at Kenya Medical Training College

https://doi.org/10.21203/rs.3.rs-846149/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 30 Nov, 2021

Read the published version in BMC Medical Education →

You are reading this latest preprint version

Background

E-learning has been widely adopted as a teaching and learning approach in medical education internationally but its adoption in low- and middle-income countries is still at an infantile stage. The use of e-learning may help to overcome some of the barriers to access to quality education and provide flexible, low-cost, user-centred, and easily updated learning. Research can inform improvement in health care, but strategies to develop research skills among health practitioners are complex and require well-designed training. To address the need for research education, we developed and implemented an e-learning course on patient safety research for students enrolled for higher diploma courses at the Kenya Medical Training College (KMTC). In this paper, we report our experience teaching the online research course in resource-constrained settings to enable other medical educators, students and institutions in similar settings to understand approaches to incorporating e-learning interventions.

Methods

The eLearning research course is hosted on the Colleges’ Moodle Learning Management System (LMS). All higher diploma students admitted to the college in the 2020/21 academic year were enrolled on the course. The research course was delivered over 60 hours, but the course materials (text, videos, images, discussion forums, downloadable content) remain accessible to students throughout the academic year. A pretest, posttest, peer-graded assessment and course evaluation were administered on the e-learning platform. The students were expected to conduct individual research projects after the training.

Results

A total of 933 students undertaking 44 higher diploma courses in 11 campuses of KMTC were enrolled in the course. There was a significant increase in the mean knowledge level of students: scores for pretest (Mean = 56.5%, SD = 14.3) and posttest (Mean = 67.8%, SD = 8.9); t (122) = 7.85, p < .001. Student and faculty experience was generally positive. The challenges included infrastructure and technological skills. The standardization of material and team-teaching improved efficiency, effectiveness and inter-faculty discourse on inter-professional collaboration in research.

Conclusion

Our results suggest that e-learning can be used to teach research but there is a need for technological investment and institutional e-readiness.

Educational Philosophy and Theory

E-learning

medical education

COVID-19

Electronic learning (e-learning) refers to the use of information, communication and technology (ICT) interventions to deliver, support and enhance learning and teaching[1]. The adoption of e-learning in Higher Education is supported by the adult learning, cognitive, behavioural and constructivist theories[2, 3]. The e-learning approach is popular in medical education because it transcends the boundaries of time and space whilst promoting student-centred, self-directed and collaborative learning[3, 4]. It also allows students to create new educational experiences and exercise flexibility in the sequence and pace of learning. However, there is a need for academic leadership to determine when and how to implement e-learning successfully to achieve educational and institutional goals[1, 4].

For medical training institutions in resource-limited settings, the adoption of e-learning may present both opportunities and challenges[5]. The adoption of e-learning in institutions of higher learning in Kenya is low and characterised by inadequate ICT infrastructure and insufficient skills among faculty[6]. This approach increases the potential for student engagement, fosters cost savings and makes it possible to disseminate the expertise and experience of the limited faculty to a large audience[4]. E-learning can be used as a tool for increasing educational opportunities for students in low- and middle-income countries[7]. The impediments include the need for technological investment and incompatibility with existing learning management systems. At the very least, the e-learning platform should enable educators to teach and monitor learning and perform assessments[5]. It also requires the availability of faculty with information technology skills, library services, research repositories, and video conferencing to a sufficient degree to meet the needs of the learners[1, 8].

Kenya Medical Training College (KMTC) trains middle-level health care providers at certificate, diploma and higher diploma levels. Each academic year, the college admits approximately 900 students into different higher diploma programs. The college has conventionally used face-to-face and blended pedagogical approaches in training medical professionals. However, on March 11, 2020, the World Health Organization declared COVID-19 a pandemic[9], and the college unexpectedly transitioned to online learning through the Moodle e-learning platform. The college adopted this strategy to mitigate the spread of the disease and comply with government-imposed restrictions on the pandemic. This paper discusses how the college offered the research course to students while highlighting the theoretical underpinnings and the lessons learnt. Our experiences during this period can provide important insights into new and innovative ways of delivering medical training.

To implement this transition from face-to-face to e-learning, the college organized the faculty into two teams. The first team was responsible for organizing teaching and learning activities, while the second monitored learner participation and provided student support. Both teams comprised multidisciplinary faculty members, administrators and heads of departments. We also engaged the communications, ICT and library departments to enhance lecturer and student support. A coordinators’ WhatsApp group was established to facilitate real-time deliberations and supplement existing communication channels. As this was a large class of 933 students, communication between teachers and students was achieved through multiple channels such as phone, email and tools provided on the e-learning platform.

The first team, which was responsible for learning activities, uploaded teaching material for each lesson on the Moodle-based learning management system of the college (hereafter referred to as the ‘e-learning platform’). For each research lesson, we provided text-based content, pre-recorded videos, downloadable resources and assessment quizzes. The communications department guided the recording and production of teaching videos. Also, lecturers broadcasted live classroom sessions for each lesson through the Zoom video conferencing software. These sessions were recorded and later uploaded to the e-learning platform to ensure access by students who were unable to join the live sessions. We designed learning in this manner to enhance synchronous, asynchronous and self-paced learning among the students. All the content on the eLearning platform was made available to students for the entire academic year.

We tracked activity completion in each session and administered two modes of formative assessment: pretest and peer-graded assignment and a summative posttest. The pretest was diagnostic and focused on establishing how well students understood the subject matter. Also, it served as a road map for material to be covered and gave students an indication of the depth of knowledge required. Pretests can help judge students' understanding of prerequisite knowledge and determine existing gaps, which can help direct teaching[10]. However, the teaching team did not have adequate time to review the pretest and adjust their approach accordingly. The role of the peer-graded assessment was to encourage deep learning among students and equip them with self-assessment skills. The teaching team trained students on how to conduct a peer assessment. Also, a grading rubric was provided to students to standardize the assessment. We assessed the first two levels of learning on the Kirkpatrick model for evaluation of training in the course evaluation at the end of the training.

A total of 933 students from 11 KMTC campuses, who had joined 44 higher diploma programs, were enrolled in the course. Of these, 49.1% were female, and 50.1% were male. All the students were already practising health professionals in various disciplines.

The facilitating team consisted of 22 research lecturers who met virtually and standardized the research teaching material. Besides teaching, lecturers participated and guided students in discussion forums on the e-learning platform. Each lecturer was allocated between 4 to 6 hours of teaching time for their preferred thematic area. The diversity of lecturers who facilitated this course brought a wealth of research experience. Also, this arrangement required fewer lecturers as compared with face-to-face teaching, whereby students are taught as per their speciality in different departments and campuses. The face-to-face arrangement that had been previously used to teach this course would have required 44 lecturers, each taking 60 hours. Standardization of learning material and team-teaching also improved efficiency, effectiveness and interprofessional collaboration in research. We observed that students were able to log in to the platform and participate in discussion forums or watch videos at their own pace (asynchronous learning). Also, they were able to attend live video conferencing sessions and engage in the chats with immediate feedback (synchronous learning).

Our records show that 65% (n = 613) of students attempted the pretest, but only 53% (323) answered all questions. The mean student performance for the pretest was 56.3% (sd 14.5). Also, we provided a posttest at the end of the module, but only 62% (579) of students accessed it. The mean performance for this test was 68% (sd 8.3), and only 266 students answered all questions. These tests were synchronous and required student to access the e-learning platform at the same time which created a surge in traffic. These events put a significant strain on the bandwidth of the e-learning platform and possibly made it difficult for students to access and complete the two tests. We filtered students who had answered all questions in both tests and performed a paired t-test to compare their pretest and posttest scores. The results showed that there was a significant increase in the knowledge level: scores for pre-test (Mean = 56.5%, SD = 14.3) and post-test (Mean = 67.8%, SD = 8.9); t (122) = 7.85, p < .001.

This course was planned within a short time and with limited resources. We experienced infrastructural challenges such as limitations in internet bandwidth, which often contributed to slow speeds on the e-learning platform, especially during synchronous activities such as tests. Unstable internet and power interruption in the homes of faculty and students also affected access to live sessions. Members of faculty and students were operating from their homes, most of which are in remote areas. The following is a comment from a student who faced technical challenges while doing the posttest exam.

“I did not finish my posttest exam yesterday as the system had malfunctioned due to technical issues. I only attempted 20 questions before this problem arose.” [Student on the course]

The lack of adequate technological skills was initially a challenge for faculty and students, but this improved as the course progressed. Also, early in the course, we found out that our videoconferencing option (Google Meet) could not meet the needs of such a large class, therefore, we explored several alternatives (Livestream on Google, Big Blue Button, Zoom). Through collaboration, we were able to find a suitable solution.

We asked students to rate the value of the course using a numeric-rating scale of zero to ten, with zero indicating an extremely low rating and ten indicating an extremely high rating. We also asked students to rate the quality of the course on an alpha-numeric scale of zero to six, with zero indicating an extremely low rating and six indicating an extremely high rating. Despite the challenges, the use of e-learning to teach research received positive students’ feedback with a high level of satisfaction and engagement with e-learning activities (Figs. 1 and 2).

The students involved in this course were grateful for the wealth of material and perspectives they acquired in this course.

“On my side, every topic is useful to me because l will implement the knowledge l have acquired to write my research, which every step learnt is important.” [Student on the course]

‘’It was a great learning experience from the first to the last session....and all sessions were equally useful I guess it’s because I had very little knowledge on research” [Student on the course]

Faculty experienced constraints such as insufficient technical skills, time constraints on already overloaded staff, the need for incentives and discomfort with the sudden requirement to share content online, including privacy concerns. These were overcome through a team approach and faculty feedback was generally positive:

‘It has been a great learning experience…let’s all celebrate this milestone in the history of KMTC…we have contributed to the success (of the research course) …thanks to the team leadership’ [Lecturer on the course]

‘That was a great team, and I am glad to be part of it’ [Lecturer on the course]

‘The organization and coordination skills were admirable…’ [Lecturer on the course]

We did not document the costs of the implementation - substantial costs are incurred in providing skilled personnel to provide e-learning support, learning design support, the production of e-learning materials and the infrastructure. A summative written report that highlighted the challenges, experiences and recommendations was shared with the college administration.

The effectiveness of the e-learning approach varies from context to context. It often requires sustained learner motivation, digital literacy and significant investment by the host institution[10]. In this course, we provided a mix of synchronous and asynchronous learning opportunities to 933 students. This approach is considered an essential factor for the success of e-learning[10]. The flexibility in time, location and distance allowed students and facilitators who were off campus to engage with the training. The e-learning approach fostered a collaborative learning environment where students and lecturers from different specialities worked together to meet the challenges of the COVID-19 pandemic. The teaching faculty realized lower time commitment and benefited from the standardized course delivery. Other studies have shown that well-structured e-learning programs canfrehy[7] free faculty time. After completing the e-learning course on various aspects of research, students’ knowledge, readiness and confidence to conduct a research project increased. Other studies have given comparable results shown that the use of e-learning in medical education enhances knowledge acquisition, especially for topics that are considered complex (such as research)[11].

Positive aspects of student experience included perceptions of increased knowledge on research and readiness to conduct research. Faculty also expressed positive experiences, such as interdisciplinary teamwork, increased efficiency and effectiveness in course delivery, and reduced time demands. Lectures who engage in e-learning are likely to realize an improvement in technological skills[12]. However, the technical challenges experienced in this online course underscore the need for strong institutional support, as highlighted in other literature[1]. To promote e-learning, there is a need to improve institutional readiness and support – e.g., ICT support, developing skills of lecturers, access to computers, increase bandwidth, find a videoconferencing solution. There is also a need to build the skills of faculty and address faculty concerns[1, 13].

The generalizability of the results is limited because we only included students from Kenya Medical Training College. However, we minimized the potential for selection bias by including all higher diploma courses on all campuses. Also, student participation in the research course was mandatory. We did not assess the impact on students with disabilities, and we did not collect data on the costs of training - this evidence would be helpful to develop a robust understanding of the potential gains of e-learning.

To overcome weaknesses of this study, we are currently designing a randomized controlled trial in which we will investigate the effectiveness of an e-learning research course in an intervention group, compared to a control group that uses the traditional face to face mode of teaching and learning.

In our experience, the use of e-learning for teaching research has been feasible and successful. Critical thinking, creativity, collaboration, communication, technological investment and institutional readiness are required in the successful adoption of e-learning for such large classes. There is a need to ensure that its integration takes into consideration the local context and accounts for the specific needs of learners and faculty. Other educators and researchers might find this experience useful. Future studies could investigate the long-term effects of the course on the research practices of the students.

Availability of data

The dataset is available from the corresponding author on reasonable request to the head of institution

Ethics approval and consent to participate

A waiver on ethics review was granted by the institutional review committee of KMTC since this was routine data.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author contributions

FG, NM, WG implemented the training program, collected data and analysed it as part of routine training processes. All authors have participated in data interpretation. FG drafted the manuscript. All authors have critically reviewed the manuscript and revised the manuscript, as well as approved the final version for publication.

Funding

There was no funding received.

Acknowledgements

We would like to thank Felistus Muinde -Deputy Principal Academics KMTC Nairobi campus for her support in coordination of the program. We also that all the lecturers and students who took part in the course.

ICT Information, Communication and Technology

KMTC Kenya Medical Training College

KENET Kenya Education Network Trust

O’Doherty D, Dromey M, Lougheed J, Hannigan A, Last J, McGrath D. Barriers and solutions to online learning in medical education – an integrative review. BMC Medical Education 2018 18:1. 2018;18:1–11. doi:10.1186/S12909-018-1240-0.
Huynh R. The Role of E-Learning in Medical Education. Academic Medicine. 2017;92:430. doi:10.1097/ACM.0000000000001596.
Evgeniou E, Loizou P. The theoretical base of e-learning and its role in surgical education. Journal of Surgical Education. 2012;69:665–9.
Zehry K, Halder N, Theodosiou L. E-Learning in medical education in the United Kingdom. Procedia - Social and Behavioral Sciences. 2011;15:3163–7.
Pei L, Wu H. Does online learning work better than offline learning in undergraduate medical education? A systematic review and meta-analysis. https://doi.org/101080/1087298120191666538. 2019;24. doi:10.1080/10872981.2019.1666538.
Makokha GL, Mutisya DN. Status of E-Learning in Public Universities in Kenya. International Review of Research in Open and Distributed Learning. 17.
Frehywot S, Vovides Y, Talib Z, Mikhail N, Ross H, Wohltjen H, et al. E-learning in medical education in resource constrained low- and middle-income countries. Human Resources for Health 2013 11:1. 2013;11:1–15. doi:10.1186/1478-4491-11-4.
Masic I. E-Learning as New Method of Medical Education. Acta Informatica Medica. 2008;16:102. doi:10.5455/AIM.2008.16.102-117.
Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. Acta bio-medica: Atenei Parmensis. 2020;91:157–60. doi:10.23750/abm.v91i1.9397.
Ruggeri K, Farrington C, Brayne C. A Global Model for Effective Use and Evaluation of e-Learning in Health. Telemedicine Journal and e-Health. 2013;19:312. doi:10.1089/TMJ.2012.0175.
Gaupp R, Körner M, Fabry G. Effects of a case-based interactive e-learning course on knowledge and attitudes about patient safety: a quasi-experimental study with third-year medical students. BMC Medical Education 2016 16:1. 2016;16:1–8. doi:10.1186/S12909-016-0691-4.
Zalat MM, Hamed MS, Bolbol SA. The experiences, challenges, and acceptance of e-learning as a tool for teaching during the COVID-19 pandemic among university medical staff. PLOS ONE. 2021;16:e0248758. doi:10.1371/JOURNAL.PONE.0248758.
Roddy C, Amiet DL, Chung J, Holt C, Shaw L, McKenzie S, et al. Applying Best Practice Online Learning, Teaching, and Support to Intensive Online Environments: An Integrative Review. Frontiers in Education. 2017;0:59.

No competing interests reported.

Download PDF

Journal Publication

published 30 Nov, 2021

Read the published version in BMC Medical Education →

Editorial decision: Major revision
10 Oct, 2021
Reviews received at journal
07 Oct, 2021
Reviewers agreed at journal
07 Oct, 2021
Reviewers invited by journal
04 Oct, 2021
Editor assigned by journal
04 Oct, 2021
Editor invited by journal
04 Oct, 2021
Submission checks completed at journal
04 Oct, 2021
First submitted to journal
25 Aug, 2021

You are reading this latest preprint version

E-learning in medical education during COVID-19 pandemic: Experiences of a research course at Kenya Medical Training College

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Results

Discussion

Limitations

Conclusion

Declarations

Abbreviations

References

Additional Declarations

Status:

Journal Publication

Version 1