PERCEPTION OF ONLINE LECTURES AMONG UNDERGRADUATE MEDICAL , DENTAL AND NURSING STUDENTS DURING COVID-19 PANDEMIC : A CROSS-SECTIONAL STUDY AT A TERTIARY TEACHING HOSPITAL

1* 1 2 1 3 Deependra P. Sarraf , Gajendra P. Rauniar , Basant K. Karn , Ramayan P. Kushwaha , Shashi Keshwar Received : 27 May, 2021 Accepted : 12 August, 2021 Published : 04 November 2021 ISSN: 2542-2758 (Print) 2542-2804 (Online) 1527 Birat Journal of Health Sciences Vol.6/No.2/Issue 15/May-Aug., 2021 Original Research Ar cle


Introduc on
The COVID-19 pandemic significantly affected medical educa on and has forced educators to switch to online teaching-learning ac vi es worldwide. Online teachinglearning ac vi es has ensured the safe delivery of the lectures to the students.

Objec ve
To assess the percep on of students towards online lectures and to analyze the perceived barriers to online learning in our context during the COVID-19 lockdown period.

Methodology
A cross-sec onal online descrip ve study was conducted among undergraduate students at a ter ary teaching college in Eastern Nepal during September-November 2020. The link of the Google form consis ng of the semistructured ques onnaire was sent to the students through email. Descrip ve sta s cs frequency and percentage were calculated using Microso Excel 2010. The study was approved by the Ins tu onal Review Commi ee (IRC/2069/20).

Result
A total of 211 students par cipated in the study. Mean age of the students was 20.5±1.5 years. Out of 211, 130 (61.61%) students used smart phones to a end online lectures and 176 (83.41%) students had not a ended any online classes before the COVID-19 pandemic. The most common perceived advantage of the online lectures was availability of recorded lectures (186, 88.15%) whereas reduced interac on (179, 84.83%) was the most common disadvantage. More than half (126, 59.72%) of the students disagreed/strongly disagreed that online lectures are more effec ve than tradi onal face-to-face lectures.

INTRODUCTION
The COVID-19 pandemic has transi oned the world and 1 significantly affected the medical educa on. The medical ins tu ons switched almost overnight to online teaching- 2 learning mode. Online teaching-learning mode is one of the fastest growing trend in the educa onal uses of internet 3 technology. However, there are some challenges regarding online teaching, which includes teaching in isola on, lack of communica on, ignoring learners learning speed, inaccessibility to the students who live in geographically remote areas not having internet facility and who do not have laptop or smartphone. Dropout rates have been shown 4 to be greater in online learning environments. B.P. Koirala Ins tute of Health Sciences (BPKIHS) is a ter ary teaching medical college located in Eastern Nepal. Na onwide lockdown called on March 24, 2020 due to COVID-19 pandemic led to disrup on of theory and prac cal classes and clinical pos ngs of undergraduate students in all 5 the medical colleges across the country. In response to the ongoing crisis of the pandemic and situa onal demand, online teaching-learning ac vi es for various academic th programs were started at BPKIHS on 26 April 2020. The undergraduate curriculum of BPKIHS does not contain online teaching-learning ac vi es as a mode of delivering educa on. Most of the faculty are not yet trained on online teaching-learning ac vi es at BPKIHS. Ul mately, it is the acceptance of online lectures among students that helps in reaping the benefits of online classes. Despite the increasing amount of reliance on online teaching, informa on about the percep on of students toward online teaching-learning ac vi es is scarce in our context. It would be interes ng to explore whether the students are enjoying online lectures, prefer any modifica ons or want to go back to conven onal face-to-face learning altogether. We aimed to assess the percep on of students towards online lectures and to analyze the perceived barriers to online learning in our context during the COVID-19 lockdown period.

METHODOLOGY
Study design and se ng: A web-based descrip ve crosssec onal study was conducted among undergraduate students at BPKIHS between September-November, 2020. The undergraduate medical, dental and nursing students st nd who were studying in 1 and 2 year, who were a ending the online lectures conducted during the lockdown and who gave their consent were enrolled in the study. Postgraduate students were not included in the study. Sample size calcula on: The study considered 95% confidence interval (CI) and 90% power to es mate the sample size. In a study by Gupta et al,76.9% students agreed 6 that the online class is distrac ng. Therefore, Prevalence (p)=76.9 Complement of p (q)=100 -p=23.1 Z=1.96 at 95% Confidence Interval L= 10% of p at 90% power=7.69 2 2 n=z *p*q/L =115 A er adding 10% in calculated sample size, the final sample size was 127. Data collec on tool: A semi-structured ques onnaire was developed from previously used surveys on percep on of students toward online learning and modified appropriately [6][7][8][9] to suit our study par cipants and context. It consisted of three sec ons: (A) basic sociodemographic [age, gender, academic stream, academic year of study, residence, na onality],(B) Computer skills and accessibility to computer and internet (5 items having single response), (C) advantages and disadvantages of online lectures (2 items having mul ple response), (D) Percep on of online lectures (5 items), (E) Perceived barriers to online lecture (1 item having mul ple response). The items on percep on of online lectures were accompanied by 5 point Likert scale ("Strongly agree", "Agree", "Neutral", "Disagree" and "Strongly disagree"). The ques onnaire was revised several mes by three subject experts and the research team to ensure face and content validity. The ques onnaire was then pilot tested in 13 respondents for its acceptability and consistency. Data from the pilot study were not included in the final analysis. Internal consistency was determined by the Cronbach's 10 alpha (α = 0.63) and was found to be in acceptable range. Data collec on technique: Convenience sampling technique was used to collect the data. Link of the Google Form (docs. google.com/forms) containing the ques onnaire was sent anonymously to the par cipants via email. The first page of the link contained a brief introduc on to the study's objec ves, eligibility criteria, declara on of confiden ality and anonymity and informed consent. The study par cipa on was purely voluntary. The consent was implied by comple on of the ques onnaire. They were also informed that all opinions provided by them would be kept confiden al. The study was approved by the Ins tu onal Review Commi ee (IRC/2069/20). Sta s cal Analysis: The filled ques onnaires were extracted from the Google Forms and exported to Microso Excel 2010. Descrip ve sta s cs like frequency, percentage and standard devia on were calculated and the data were presented as tables and graphs.

RESULTS
A total of 211 students par cipated in the study. The gender distribu on was almost equal. The age of the students ranged from 17 to 31 years. Mean age of the students was 20.5 ± 1.5 years with 115 (54.5%) in the age group of 17-25years. One hundred and thirty eight (65.40%) students had urban residency and 180 (85.31%) were from Nepal. One hundred thirty four (63.51%) students were studying Bachelor of Medicine and Bachelor of Surgery (MBBS) and 122 (57.81%) were in the first year of the academic course (Table 1). One hundred and eighty three (86.73%) students stated that they had internet access at home and 130 (61.61%) students agreed that the status of their internet connec on was usually sa sfactory. One hundred and seventy six (83.41%) students had not a ended any online classes before the COVID-19 pandemic. Out of 211, 130 (61.61%) students used smartphones to a end the online classes. In addi on, 111 (52.61%) students used to spend 3-5 hours per day on their mobile or laptop for study purposes (Table 2). The most common perceived advantages of the online lectures was availability of recorded lectures (186, 88.15%) followed by learning at own pace (131, 62.09%) and ability to stay at home (130, 61.61%). Similarly reduced interac on with the teacher (179, 84.83%) was the commonest disadvantage followed by distrac ve (154, 72.99%) and poor learning condi ons at home (117, 55.45%) (Figure 1). Out of 211, 126 (59.72%) students disagreed/strongly disagreed that online lectures are more effec ve than tradi onal face-to-face lectures in terms of increasing knowledge. Ninety-five (45.03%) students disagreed that they ac vely par cipate during online lectures compared to the tradi onal face-to-face lectures. Only 20 (9.48%) agreed that they can interact more during online lectures compared to the tradi onal face-to-face lecture. Similarly, 131 (62.08%) students agreed that they feel isolated during online lectures compared to the tradi onal face-to-face lecture. However, only 64 (30.33%) students responded that they enjoyed online lectures. Sixty-five (30.8%) students agreed that when colleges fully reopen, online lectures should remain part of teaching and learning ac vity in our college (Table 3). Technical and internet problems (92.42%) were the most common perceived barriers to online learning in our context ( Figure 3).

DISCUSSION
The present study aimed to provide an overview of the situa on experienced by the students and to know the percep on of the students towards online lectures delivered to them during the lockdown period due to COVID-19 pandemic. Our study showed that the majority of undergraduate students had nega ve percep on towards online lectures as compared to the tradi onal face-to-face learning. Similar findings were also reported by Koirala et al 11 12 (54.1%) and Abbasi et al (77.4%). More than half (59.72%) of the students disagreed/strongly disagreed that online lectures are more effec ve than tradi onal face-to-face lectures in terms of increasing knowledge. Similar findings 13 were also reported by Adnan et al (67.5%), Muthu prasad 14 15 et al (44.45%) and Sharma et al (63.98%). Tradi onal faceto-face classroom learning is far more effec ve as compared to online learning as there might be limited opportuni es to ask ques ons in the online lectures.
In the present study, majority of the students (45.03%) disagreed that they ac vely par cipate in the online lectures. Significant frac on of students (38.86%) were neutral with respect to the statement "I ac vely par cipate during online lectures compared to the tradi onal face-toface lectures". One of the reasons might be the lack of an interac ve approach when delivering the online lecture to the students as majority of the faculty are not well trained for online teaching-learning methods. More than half of the students disagreed that they can interact more during online lectures compared to the tradi onal face-to-face lecture in our study. This was similar to the report by Chalise 16 et al (64.7%). In contrast, majority (67%) of the respondents rated that the online classes were interac ve in a study by 7 Tuladhar et al. The ra ng of online lectures as more interac ve in other studies might be due to use of interac ve pla orm for online lecture and the faculty might be well trained. Non-interac ve online lectures might lead to demo va on for online learning as students usually ac vely par cipate in academic ac vi es in tradi onal classes due to their face-to-face engagement with facul es and class fellows. Gamifica on can be incorporated to boost 17 the interac vity of online learning. Similarly online quizzes and mul ple choice ques ons can also be incorporated in the online lectures to make it more interac ve and interes ng. Nearly two-third (62.08%) of the students agreed that they felt isolated during online lectures compared to the tradi onal face-to-face lecture in our study. However, Chalise et al had reported that only one-third (35%) of the 16 students felt isolated during online lectures in their study.
The present study showed that majority of the students disagreed/strongly disagreed that they enjoyed online lectures during the COVID-19 pandemic. In contrast, majority of the respondents (73%) rated online learning as 8 enjoyable in a report by Bączek et al. It might be due to their higher internet connec on quality, prior exposure to online learning or trained facul es for online learning modules.
Our study also showed that most of the students (86.79%) had an internet connec on at their home; however, only three-fi h of the students (61.61%) had a sa sfactory internet connec on. It highlights that poor internet connec on might act as the main obstacle for online learning. The students might be discouraged due to poor internet connec on and hence the online teaching-learning ac vity might be less effec ve. Therefore, the medical educators should think about the quality of internet connec on before implemen ng online lectures to the students. Majority of the students (83.41%) in our study had not a ended any online lectures before the COVID-19 pandemic and similar findings were also reported by Gupta A study also found that smartphones have wonderful influence on the educa on as it had easy access to relevant 19 resources through internet. The smartphone is also described as a poten al "learn anywhere" resource for the 20 students. The medical educa onists should consider smartphones as an adjunc ve tool to the conven onal faceto-face classroom teaching and ensure their usage to 21 enhance the learning experiences through online lectures. More than half (52.61%) of the students used to spend three-to-five hours per day on their mobile or laptop for online lectures in the present study. In contrast, Muthuprasad et al had reported that majority (48.86%) of the respondents spent only two-to-four hours in a day for 14 online class. It is good to have small session of online lectures and small break in between two classes to prevent 22 eye straining as too much screen me is harmful for eye. Too much screen me may lead to sleep problems, less me with family and friends, not enough outdoor or physical 23 ac vity, weight problems and mood problems. One of the most important advantages of online teachinglearning is that it has flexibility and hence it enables the students to learn at their own pace and our study findings also supported this. The students in the present study perceived that availability of recorded lectures, learning at their own pace, ability to stay at home and comfortable surroundings were some of the advantages of online lecture. Similarly, ability to stay at home (69%), con nuous access toonline materials (69%), the opportunity to learn at your ownpace (64%) and comfortable surroundings (54%) were advantages of online lectures in a study by Bączek et 8 al. Therefore, availability of the recorded lectures helps the students to learn at their own pace. The posi ves of lecture recordings outweigh the nega ves and its con nued use in 24 higher educa on is recommended by O'Callaghan et al. However, Schnee et al had reported that lower-performing 25 students benefit from a ending live lectures. The policy makers should consider these factors during formula on and implementa on of online learning. Reduced interac on with the teacher, easy distrac on by the social media, poor learning condi ons at home and social isola on due to prolonged use of smartphone and laptop were some of the perceived disadvantages of online lectures in our study. Similar findings were also reported by Baczek et al in which lack of interac ons (70%) and technical problems 8 with IT equipment (54%) were the main disadvantages. The students also experienced headache and eye strain during online learning in our study. This finding was also supported by the findings that they used to spend more than three hours daily on screen. Sharma et al had reported similar 15 finding. Interac on between students and facul es is one of the major driving forces for success of online teachinglearning ac vi es. It is essen al to develop and sustain a collabora ve learning space within an e-learning 26 environment to maximize the sa sfac on of the students. Online lectures should engage the students through frequent and meaningful ac vi es that help to keep them focused in the class. It is important to have frequent interac ons to make online classes more effec ve and 27 memorable. Overloading of the online classes was one of the disadvantages perceived by one fi h of the students in the present study. A Chinese study had also documented that back-to-back classes caused high levels of stress among 28 the students. The transforma on from tradi onal face-to-face learning to complete online learning presents several challenges to the 29 students as well to the educa onists. This study found technical and internet problems as the most common perceived barrier to online learning in our context. This was similar to the finding of Olum et al conducted in Uganda among undergraduate students which also iden fied poor internet connec vity (84%) as the most important barriers 30 to e-learning. Online learning requires a reliable and fast internet connec on and the laptop, desktop or smartphone and an uninterrupted electricity supply. The students should also have a sound skill toward computers and informa on technology to learn effec vely from online teachinglearning ac vi es. This ul mately helps them in effec ve me management without facing any difficulty. The students in this study found online learning unsuitable for prac cal and clinical classes and a similar finding was also 31 reported by Khalil et al. Clinical skills and experience and human interac on are two most extremely important requirements for the prac ce of medicine, den stry and 32 nursing. Nothing can replace seeing a pa ent. However, online learning may serve as an efficient resource for learning these clinical skills by integra ng different modali es like virtual simula on technologies and computer-based models of real-life processes. This can provide opportuni es to learn skills in a safe environment. A computer-based virtual pa ent program can be designed and implemented to simulate real-life clinical scenarios. Such programs might be useful for students to learn history taking and physical examina on that encourages diagnos c 33 and therapeu c decision-making among the students. Our study also showed that less than one-third of the students wanted online lectures as a part of teaching and learning ac vity in our college when it fully reopened a er the pandemic. This was consistent with the finding of Ansari et al in which more than 50% agreed that they would 34 recommend it in the future. Our study findings also indicated that we need to review the exis ng medical curriculum and design appropriate content for online lectures. Given the needs of the academic environment where teachinglearning ac vi es can progress in op mal manner, the curriculum has to be frequently revised to improve the 35 quality of medical educa on. It should be be er to introduce online teaching-learning ac vi es gradually along with the regular face-to-face lectures a er the end of COVID-19 pandemic which ul mately may be accepted by the majority of the students; however, it will take some me to achieve frui ul outcomes. There is always much room for improvement as far as online learning goes. It is of utmost importance to provide excellent training and support to both the students and teachers regarding the usage of online teaching-learning ac vi es that helps in increasing their comfort ability.

LIMITATION OF THE STUDY
The present study was performed in a single medical college; therefore, the results may not be generalized to other medical colleges in the country. A substan al number of students also gave "neutral" response to percep on of online lectures. It is likely that our students might not have formed a concrete opinion. We could not explore the role of parents' educa on in facilita ng students' online teachinglearning ac vi es. As the results of the present study are only based on students' percep ons, "with as the results of the present study are besed on only students percep ons" the inclusion of faculty opinions in future studies might help in understa ng the overall impact of online teachinglearning ac vi es on medical educa on.

CONCLUSION
Within the limita ons of the present study, we conclude that the majority of undergraduate students showed a nega ve percep on towards online lectures. The students perceived many challenges during online learning and these factors must be further explored to make online learning acceptable, effec ve and enjoyable. We recommend using a hybrid of online teaching-learning ac vi es and conven onal face-to-face teaching that would be more effec ve. The administrators, facul es, students and policy makers should work in harmony to remove the barriers in online teaching-learning ac vi es.