Study on the effectiveness of online classes for undergraduate medical and dental students of Gandaki Medical College during COVID 19 pandemic period in Nepal

Introduction: Pandemic situation of COVID 19 had an impact on medical education globally leading to cancellation of lectures, laboratory exercises, clinical postings and exams. To continue with the academic program, the online classes are started in different academic streams in large scale. This came with challenges and new learning opportunities for medical students and potential to adopt some changes. The objective of this study is to find out the effectiveness of online classes for medical and dental students of Gandaki Medical College (GMC) during COVID 19 pandemic period in Nepal with questionnaire based survey distributed to the students attending the online classes.


INTRODUCTION
Online class can be defined as a course conducted over internet through a learning management system in which students can view their course syllabus and academic progress, as well as communicate with batch mates and the class facilitator. 1 COVID 19 had an impact on medical education globally leading to cancellation of lectures, laboratory exercises, clinical postings and exams. 2 Online classes are not popular in Nepal amongst undergraduate health care professional students. With the COVID 19 pandemic situation, considering the social distancing the traditional class room classes are closed in Nepal. To continue with the academic program, online classes are started in different academic streams in large scale. We also started with online classes for medical and dental students at Gandaki Medical College (GMC), for the theoretical portion of the curriculum. This came with Study on the effectiveness of online classes for undergraduate medical and dental students of Gandaki Medical College during COVID 19 pandemic period in Nepal ABSTRACT challenges to the medical education, new learning opportunities for medical students and potential to adopt some changes. 3 The use of e-learning via the internet has steadily increased amongst health care professionals worldwide. Many studies have been conducted to study the effectiveness of e-learning globally, which has shown some positive effects of e-learning as compared with the tradition learning. [4][5][6] During this COVID 19 pandemic situation, online classes for health care professionals are running steadily and in larger extent. In Gandaki Medical College, WiFi facilities and computer with internet facilities has been set for faculties to conduct the online classes if they wish to take from the institute. This study aims to find out the effectiveness of online classes for medical and dental students of GMC during COVID 19 pandemic period in Nepal with a survey with questionnaires distributed to the students attending the online classes. From this study, we expect to make some guidelines to improve the online classes being conducted to make the sessions more students oriented and effective. It can also suggest if the online classes can be continued even after the COVID 19 pandemic is over and we are back to our normal schedule.

MATERIALS AND METHOD
This is a descriptive cross sectional questionnaire based online survey. The duration of study was from June 2020 to July 2020. The questionnaire was prepared on Google form. The questionnaire were distributed to the undergraduate medical and dental students of Gandaki Medical College (GMC), Pokhara, Nepal through email or viber or facebook messenger whichever feasible. The sample size was calculated by considering 70% of students rating online education as effective. 7 The formula Z 2 pq/L 2 was used, where Z is 95% of confidence interval which is 1.96, p is prevalence which was assumed to be 70% considering 70% of positive response, q was taken as 1-p, L is permissive error which was taken as 10% of prevalence.
The sample came to be 165. Amplifying the sample size by 10% for processing errors and another 10% for non-response errors, the final sample size was 198.The contact details of the students were collected from the administration of the college. The questionnaire for the survey was framed by the principal investigator. The validity of the questionnaire was verified by pre-testing the questionnaire and reviewing by two groups. The reviewers in group I were DP and ND, who are familiar taking online classes to these groups of students. The reviewers in group II were IP and JR who are experts on question construction. The questionnaire was pretested randomly amongst 10% of the total sample size which was 20 students. After receiving the feedbacks from the pre-test and groups of experts, the questionnaires were modified. The questionnaire were sent to all students presently studying Bachelor of Medicine Bachelor of Surgery (MBBS) and Bachelor of Dental Surgery (BDS) at GMC, which is 551 students, we expected to receive the required number of responses. revision of online classes once they are back to regular classroom classes after the pandemic situation and only few 57(27.30%) suggested to continue the online classes even after the pandemic situation comes under control. The comparison of distractions, effectiveness of online classes and interaction in online classes was done amongst classes with one to 50 and 51 to 100 number of students in order to see if the number of students affects these variables (Table 1 and 2). It showed that the number of students did not affect the distractions in online classes and effectiveness of online classes(p=0.638).The online classes with one to 51 number of students showed good interactions as compared to classes with 51 to 100 number of students (p<0.01). Similar comparison was done between MBBS and BDS students to see any differences in effectiveness of online classes (Table 3). There was no differences seen in the effectiveness in online classes between these two streams (p=0.414).

DISCUSSION
In this study, 98.10% of the responded are attending online classes during this pandemic situation. This is relatively high in a developing country like Nepal where only 56% of the total population have access to internet and only 13 % of the schools can run online classes. 8,9 This comparably large number of attendance in online classes could be attributed to the fact that most of the medical students in Nepal are expected to have smart phones, personal computers and access to internet and most of the students in this survey are from urban areas Kaski (35.90%) and Kathmandu (14.80%). Those students who could not attend the classes were from remote areas of the country having problem to access the internet. 10 A study done amongst Jordanian and Saudi Arabia students and teachers showed that technological factor is one of the instrumental factor in affecting the effectiveness of online education. 11 Similar technological problems with connectivity were faced by students of Ghana during online education in a study done by Henaku. 12 In our study, the online classes of 31.60% of students were disturbed by electricity problem and 11.50% of the respondents rated internet connectivity as bad. These technological factors were relatively more in survey done by Subedi et al 13 in nursing students of Nepal. They reported more than half of the students (63.2%) had disturbances in online classes due to electricity problem and 63.6% due to internet problem. These variations could be attributed to the geographical distribution of the students attending the online classes in these two studies.
Similarly the level of understanding of the content covered in the online classes were rated as moderate by 76.6% of respondents which is comparable to in the study of Subedi S et al 13 which was 64.5%. Only 29% of respondents had maximum level of understating. This could be because the medical education is theoretical, practical and clinical training. During this pandemic period the students are attending only theoretical classes. The lagging of the integration of theoretical, practical and clinical portion of the curriculum could have hampered the level of understanding.
In this survey, 58.4% of the students recommended that the teachers need training on how to take online classes. The teachers of Nepal are trained to traditional class room classes. They maintain attention of the students by moving around in the podium; maintaining eye contact and encouraging student's participation. 14 The barriers for the online teaching can be minimized if the teachers are trained for online education system. In medical education, it won't be possible to cover the entire curriculum on online basis. The theoretical portion of the curriculum when covered parallel with the practical/ clinical portion will enhance the understanding of the students. Online teaching education if integrated with traditional classroom lectures for selected topics could be beneficial to the students.
This study was limited to a single medical college and only two streams of health education were covered. Similar study can be extended to different medical and dental colleges of Nepal and students of various health education streams could be included to give an overall scenario which will help to make guidelines for the online classes and make it more effective.

CONCLUSION
The study concludes that good number of students were participating in online classes in medical and dental streams at Gandaki Medical College. The students faced problem in internet connectivity due to electricity cut down. The level of understanding during online classes of majority of students was moderate. The students will need revision of some of the topics covered during the online classes once they are back to regular traditional classes.