Developing the e-learning module
The Reproductive Health (RH) part of the PH course constitutes about 15% of the curriculum and is four weeks long. It includes sections on Maternal and Child Health, the Family planning program in Egypt, as well as indicators to measure health. In the traditional setting this part is given in 7 grand lectures, 8 tutorials and 4 site visits (in total 38 hours of teaching). Additionally, the students are instructed to read the comprehensive text book on the subject.
The open source Course Management System (CMS) "Moodle" was utilized to develop an e-Learning course covering the RH part of PH curriculum. The e-Learning course contains 4 modules: Measurement of health (10 lessons), Maternal health program (17 lessons), the Family planning program (4 lessons), and Child health care (14 lessons). Each lesson is estimated to take one hour each and is followed by a lesson quiz with multiple choice questions (MCQ) and extended matching questions. All e-Learning material was based on the required course textbook and the intended learning outcomes (ILO's). However, to facilitate learning the original material was complemented by new visuals, animations and other interactive materials. The Course Management System environment also offers student-student as well as student-teacher communication via a chat room (open 24 hours), forum discussions, and the possibility to send messages between the users as well as faculty members.
Deadlines for completion of each module were set by the course facilitators. Completion of the course took on average five weeks. Course facilitators (two senior and one junior staff member) spent approximately 20-25 hours a week participating with all students in online discussion forums and answering questions.
E-learning course assessment
Each lesson of the e-Learning course is followed by a number of MCQ and matching questions with a 70% passing grade requirement to move on to the next lesson. Additionally, each module of the e-Learning course starts with a pre-quiz and ends with a post-quiz. Quizzes include 20 MCQ and matching questions, which appear at random, from all lessons of the module. Students are allowed one attempt for the pre-quiz and five attempts for the post-quiz. The final score for the module is based on the average of the five post-quizzes.
Polls about the different sections were developed to assess satisfaction with the module content and instructional design. Additionally, behavior/attitude-based assessments were also done based on contributions to the on-line discussion forums. A final questionnaire was developed to assess attitudes and perceptions towards e-learning in comparison to the traditional lectures.
Study design and participants
This prospective interventional study included two student groups. "Group 1" includes students who volunteered to use the e-Learning course. This group was assessed by online post-modules' quizzes as mentioned above and a final online exam. "Group 2" were those who received the traditional lecturing approach only. The whole class (including both groups) was a highly motivated group of students whose grades, according to university records, were high. Initial paper instructions were given to the first group of students on how to use the on-line system, methods of assessments and deadlines.
The study used a prospective design, were students attending the DOPHCM round were invited at the 1st week of the round to the e-learning module on a voluntary basis. Over three rounds a total of 171 students participated in the e-learning module.
The students enrolled in the e-Learning course were also invited (by email and phone) to three focus group discussions. In the focus groups, the students discussed what they enjoyed most and if they found any limitations or difficulties during the course. The students who did not volunteer to use the system were also invited (by email and phone from their peers using the e-learning system) to similar group discussions where they gave insights to the reasons of non-participation.
At the end of each round, a random sample of students from group 1 and group 2, were asked to complete two questionnaires; the first was the RH knowledge questionnaire, and the second a Course Experience Questionnaire (CEQ) adapted from Ramsden 1991 and Ramsden 2003 [13, 14]. A total of 295 students completed the RH questionnaire (140 taking the e-Learning course and 155 non-participants in the e-Learning course) and 200 students completed the CEQ (97 from the e-Learning course and 103 non-participants in the e-Learning course). A third questionnaire was introduced to 106 students who did not use the e-learning course to detect reasons for non-participation.
1- Students participating in the e-learning module were assessed by the pre and post quizzes as well as by the final online quiz. Online quizzes consisted of a range of MCQ and extended matching questions, covering the sections addressed in each module. All quizzes were timed and since questions appeared randomly for each student, it was not possible for students to share answers.
2- The CEQ reflects students' opinion concerning the learning process from students' perspectives.
3- The RH knowledge questionnaire was a paper based questionnaire introduced to students during their final week of the PH course. Students were asked to fill it anonymously indicating if they participated in the e-learning course or not.
The RH knowledge questionnaire and online quizzes were specifically developed to cover the intended learning outcomes of all areas of the RH part of the PH course. Content validity was determined by a senior member of the PH staff. Then the final e-learning course was pilot-tested before allowing the volunteering students to register in the course.
Data manipulation, scoring, and analysis
Questions on the CEQ were grouped into five categories, namely;
The Good Teaching Scale (GTS)which contains 6 questions covering practices such as giving feedback to the students on their progress, explaining things, and making the course interesting.
The Clear Goals and Standards Scale (CGS), contains 4 questions and measures the clarity of course goals and the expected standards of students attending the course.
The Appropriate Assessment Scale (AAS)contains 3 statements that attempt to measure the students' perceptions of the course assessments.
The Appropriate Workload Scale (AWS), which contains 4 questions aimed to measure the student's perception of the amount of work needed for the course.
The Generic Skills Scale (GSS)containing 6 questions takes into account the extent to which the course adds to the generic skills of the students e.g. decision and problem solving skills and capacity for self learning.
All questions were rated on a 5 point Likert scale from strongly disagree with a score of 1 to strongly agree with a score of 5. Scores for each scale were added and mean scores were reported
Questions on the RH knowledge questionnaire were scored as incorrect or correct and a final total score was calculated. At the end of the RH questionnaire, students were asked to evaluate the ease of the questions on a 3 point Likert scale (easy, moderate and difficult).
The Statistical Program for Social Sciences (SPSS) version 15 was used for data analysis. Analysis included simple frequencies and descriptive analysis (Mean and Standard Deviations). Statistical tests of significance used were the Chi Square test, the Paired t-test and the Student's t-test, as appropriate. A P - value < 0.05 was considered significant.
The focus groups
All meetings were recorded and transcribed manually. After transcription, responses from each meeting were subjected to content analysis which permitted category or theme creation based on frequency of participants' responses.
The study was approved by the Public Health Department Council, Faculty of Medicine - Cairo University. All assessment questionnaires were collected in an anonymous and voluntary manner. Data of students participating in the e-learning course was preserved confidentially throughout the study in accordance with the Declaration of Helsinki.