E-learning as a teaching tool of medical education can offer an effective alternative to the traditional on-site education format and help to solve the problem of shortage of health care providers and educators [6, 11, 12]. Hugenholtzet al. found that E-learning is just as effective in enhancing knowledge as lecture-based learning [13]. Moreover E-learning was found to be associated with cost reduction compared to traditional methods of education [14]. However, access to communication technologies and secure internet capacity together with poor infrastructure and institute experiences of performing E-learning are major hurdles to overcome in ensuring the success of E-learning [15, 16]. Additionally, lack of technical skills and insufficient computer skills were the barriers that can inhibit educator’s willingness or ability to engage with the development or delivery of E- learning [17, 18].
The COVID-19 outbreak has forced medical schools to suspend campus learning in order to curb the spread of the virus. Currently, medicals schools in Sudan are closed due to the COVID-19 health threat. In such situations, E-learning is the best solution that provides an online interactive learning environment for medical students without getting much affected during COVID-19 outbreak. In the developed world, many academic institutions have begun to adapt to the pandemic and are using E-learning. However,in limited-resource countries, like Sudan, shifting towards E-learning requires many adjustments to be made in order to make sure the E-learning is held in a proper manner, as best as possible.
In our study setting, FMUG undergraduate medical students have no exposure to E-learning. Recently, the Medical Education Development Center-University of Gezira offers On-line E-learning for a master’s degree in health professional education. In our limited resource setting, factors that can influence success or failure of E- learning programme are not well documented. It is known that students’ willingness and acceptance to use E-learning is a major factor in the success of e-learning system. Furthermore, a better understanding of the students’ requirements will help the decision maker to adopt E-learning successfully. Therefore, study of the perceptions of medical students at FMUG regards E-learning may help the success of the adoption of E-learning in our poor resource setting.
As far as we know, this is the first study concerning medical students’ perception twords E-learning during the COVID-19 outbreak in Sudan. A predesigned online-based questionnaire was used for data collection was developed through literature search. We strived to avoid non-response bias by using neutral wording. Additionally the content accuracy and internal validity of the survey items were finalized with multidisciplinary input from the study investigators. The survey questionnaire was also tested on 10 medical students to ensure questions were clearly articulated and the responses options are relevant. In order to assess the perception of medical students on the effect of the COVID-19 pandemic in education we used 4 point Likert scale to force the students to form an opinion i.e. no neutral opinion. We were unable to distributing the questionnaire to all medical students because the survey was conducted during COVID-19 lockdown and potential participants are hard to access. Therefore participants were invited to share the survey link via social media platforms with other medical students through a snowball sampling method. Survey data are limited by reliance on self reporting, and are potentially biased by non-responders. Our study sample was small, and these data should therefore be considered preliminary.
Compared with High income countries, the use of information and communications technology (ICT) in education programs in limited resource nations is relatively limited. Nevertheless, in recent years, there has been growing interest in the use of ICT in educational settings in developing countries. The use of ICT in undergraduate medical education in Africa lags behind that in other regions [19]. Access to technology among university students varies greatly across the African continent, so it would stand to reason that there are also disparities when it comes to accessing E-Learning tools. Technical issues, including connectivity and communications infrastructure, cost of accessing the infrastructure that is in place and lack of adequate number of competent academic staff are considered as the most significant factors in restricting E-learning in Sudan [20]. Recently, Sudan has increasingly used ICT in higher education institutions [21].
In our study, approximately two-thirds of respondents reported that good quality internet connection is too expensive for them and the affordable bandwidth is limited, which often contributed to slow speed of download and low quality of videos or visual outputs. Moreover, in remote rural areas telecommunication signal is quite hampered. The poor internet connectivity as a barrier for E-learning in medical education has been reported from another low income country context [22]. A previous study from India reported that 82 out of 201 of the planned E-learning sessions were canceled due to technical reasons (20 %) or no availability of the presenter at the host end (80 %) [23]. Therefore, in the context of low and middle income countries especially in Africa, E-learning resources should not be restricted to the Internet only and internet resources should be available in low-graphic or text‐only versions to minimise download times.
In this study, only one-third of the students have access to computers. This figure is low and comparable to studies carried out in Sub Saharan African countries [24, 25]. The majority of the surveyed medical students have smartphones with reasonable facilities. Smartphones were reported as the main mobile device used for E-learning in African higher education institutions [16]. A pervious study conducted at Central University College in Ghana showed that mobile learning enhanced collaboration between lecturers and students [26]. Moreover, smartphone E-learning applications have been effectively providing e-learning resource for resident physicians in rural areas [27]. Therefore, E-learning software that is user-friendly and easy to operate with a smartphone is needed in our setting. Just like any other technology, mobile devices have limitations especially within Africa and other developing regions. Previous studies from African countries showed that most of the students operating learning management system on mobile phones reported that using mobile devices was very slow especially in loading pages because it needed a large memory, which was lacking in most phones owned by students [28, 29].
We found 24 % of our study population being hostile to accept E-learning because they are unaware of the effectiveness of E-learning compared to the face-face teaching style and are unfamiliar with E-learning systems. Therefore, knowledge on effectiveness of E-learning among medical students is extremely important in our limited resource setting. It has been reported that the lack of face-to-face communication with lecturers and students during E-learning sessions contributed to a poor environment for professional communication and the exchange of learning experiences [14]. Similarly, we found that lack of face-to-face interaction was considered as an inhibitory factor for E-learning implementation by 15 % of our study population. Therefore, faculty administrators should develop strategies for increasing and ensuring higher levels of students’ engagement in and during E-learning.
After summarizing the response of students to the open questions, we found that 42.4 % of the respondents were worried that E-learning may need specific preparations. Further study is needed to further investigate what factors considered to make them worried about this topic. If lack of understanding of how the E-learning software runs, it means that the information technology staff must be educating/socializing in more detail to a more limited and specific group. There is also fear among our study population about the methods for online assessment and time flexibility in case of technical problems.
Medical students at the clerk level and those from outside Sudan were more likely to agree to start E-learning and attend the session and exams (p-value < 0.05). This could be because students from outside Sudan (Gulf countries) have access to a good quality internet connection. Further study is still needed to further investigate the critical success factors that influence E-learning acceptance among medical students.
The findings of this study were presented to the faculty assembly and decision was made to implement E-learning for some courses as a pilot project. Future study comparing students’ expectations prior to the commencement of the programme and the success of the programme is required.
The study has several limitations. The small sample size from a single medical school in central Sudan limits the generalizability of our results and the data should be interpreted with caution. Moreover, the sample may not be representative of all medical students as there is a potential for selection bias in distributing via the internet as medical students with access to the internet during the study period were more likely to participate in the study. In this study, data were collected at only one point in time (cross-sectional design) and the researcher could not manipulate the variables. Therefore, longitudinal research is required to enhance the understanding of correlation and interrelationships among variables.
