ORIGINAL PERCEPTION OF EQUIVALENCE OF ONLINE CLASSES TO FACE TO FACE CLASSES AMONG DENTAL AND MEDICAL UNDERGRADUATE STUDENTS OF GANDAKI MEDICAL COLLEGE, NEPAL

Background : Online learning has become a common mode of delivering education in Covid-19 era and our institute is not an exception. The objective of this study was to examine the perception of our students regarding the equivalence of online and face to face learning. Methods: This questionnaire based online study was conducted at Gandaki Medical College, Pokhara among all the medical and dental undergraduate students with a sample size calculated as 180. The students’ perception in terms of general equivalence, flexibility, level of interaction, knowledge gained, and ease of online courses were collected. The data was entered in SPSS 20 and descriptive statistics was performed. The correlation between the variables was done using Spearman’s correlation analysis. Results: The total participants in this study were 187. Online learning wasn’t perceived to be equivalent to face-to-face learning in general (2.82±1.10). Online class was perceived to be more flexible (4.49± 1.10), to provide less opportunity to interact with instructor and peers (3.17±1.13), and to gain less knowledge (3.36± 1.27). However, both were perceived to be relatively similar in terms of ease (3.79±0.8). The comparatively less interaction was correlated to less knowledge gained through online classes (r value = 0.67, P<0.01). Conclusions: The result of this study suggests that the students didn’t find the online learning to be equivalent to face-to-face learning and the online learning experience can be correlated with interactive sessions.


INTRODUCTION
Nationwide restriction imposed to control the spread of COVID-19, had a major impact on every aspect of life including medical education. 1 Online learning had become a common option to continue delivering the medical education. 2 Online learning was seen to be an applicable and effective teaching modality and was accepted by the medical undergraduates. 3,4 Recent meta-analysis showed the learning outcome of online learning is comparable to face-to-face learning, leading the transition in teaching method to online teaching. 1,5 In 21 st century, Medical education has undergone a paradigm shift with application of web based learning, however none of the medical schools had integrated e-learning in Nepal before Covid-19. 6 The flexibility makes online learning an attractive option for time-crunched, place-bound students. However, greater amounts of flexibility may also be associated with less interaction with instructors and peers. 7,8 We adopted online classes as an alternative, though we were not accustomed to this new modality of teaching. Online elearning has its own common challenges faced by faculties and students in developing countries; however, the current scenario should be taken as an opportunity to integrate e-learning in medical education. For implementation of online learning in medical education, the evaluation of the perception of students towards it, is equally important. 9 In this context, we conducted this study to determine the perceptions of students towards general equivalence, comparative interaction, comparative flexibility, comparative knowledge gain and comparative ease of online learning verses face to face learning.

METHODS
This cross-sectional study was conducted among medical and dental undergraduates of Gandaki Medical College from 20 th September to 20 th November 2020. Ethical approval from Institutional Review committee of Gandaki Medical College was obtained (Reference number 91/077/78). Using the formula n = [z 2 * p * (1 -p) / e 2 ] / [1 + (z 2 * p * (1 -p) / (e 2 * N))]; confidence level at 95% (z-score=1.96), population proportion at 50% and the margin of error at 6%, the sample size was calculated to be 180. The current total number of medical and dental undergraduates in this institute was 551.
A questionnaire, adapted from previous study, was prepared in google form after obtaining permission from the author. 7 The adapted questionnaire was pretested to test its' reliability and validity. The pretesting was done among 30 final year medical students and Cronbach alpha value of 0.9 was obtained. Students enrolled in Dental and Medicine undergraduate programme in Gandaki Medical College, were included in this study and students from other medical institutes and from other disciplines were excluded. The email address and phone numbers of all the medical and dental undergraduates were generated from the Administrative office, Gandaki Medical College. The link to the questionnaire was attached in social networking application (viber application) and was sent to the students. The sampling was done using random sampling technique. A consent form was attached as a first page and the participant who agreed to be a part of this study responded to questionnaire. The questionnaire consisted of 2 parts: the first part included the demographic data and the second part consisted of questions on their perceptions comparing the online and face to face classes in terms of equivalence, flexibility, level of interaction, knowledge gained, and ease of online courses compared to face-to-face courses. 7 The perception of participants regarding the equivalence of online classes to face to face classes was measured using four item rated on seven point Likert scale.
A mean score less than 4 suggested that the students perceived that the online classes were not equivalent to face-to-face class in general and a mean score more than 4 indicated a perception that online classes were equivalent to face to face classes in general.
Seven items rated on a seven-point Likert-type scale (strongly disagree to strongly agree) was used to measure the perception of students regarding relative flexibility of online.
A mean score less than 4 suggested that the students perceived that the online classes were less flexible than face-to face classes and a mean score more than 4 indicated a perception that online classes were more flexible.
Ten-item rated in seven-point Likert-type scale was used to evaluate perception of students regarding the level of interaction with their peers and instructor in online classes.
A mean score less than 4 indicated a less self perceived interactions in online classes versus face-to-face classes and a mean score more than 4 indicated more self perceived interaction. A six-item rated with seven-point likert-type scale was used to compare the self perceived gain of knowledge in online courses versus face-to-face course.
A mean score less than 4 indicated a less self perceived gain in knowledge in online classes than in face-to-face classes; a higher mean score indicated a perception that one learned more in online classes. The five-item scale rated on a seven-point Likert-type scale measured self perceived ease of online class relative to face-to face classes.
A mean score less than 4 indicated a perception that online classes were harder than face-to-face classes; a higher mean score indicated a perception that online classes were easier. The data was collected over a period of 2 months (September 20 to November 20, 2020). The data was entered in SPSS 20 and descriptive statistics was performed. The correlation between the students' perception on general equivalence, relative flexibility, relative interaction, relative knowledge gain and relative ease of online learning was done using Spearman's correlation bivariate analysis. The level of significance was set at the level of P<0.01.

RESULTS
The total of 187 dental and medicine undergraduate students participated in this study. Among 187 participants, 179 were females (58.3%), 77 were males (41.2%), and 1 (0.5%) preferred not to reveal the gender. The age of the participants ranged from18 to 28 (mean age: 21.28 with SD = 1.63). The participants included were: 39 first year students, 37 second year students, 55 third year students, 35 fourth year students and 21 final year students. All the participants had attended the online classes conducted by the institute.
Online learning, was not perceived as equivalent as face-toface learning in general, was perceived more flexible, was perceived to provide less opportunity to interact with instructor and peers, and to gain less knowledge as the mean score of items for each was 2.82±1.10, 4.49± 1.10, 3.17±1.13 and 3.36± 1.27 respectively. However, both were perceived to be relatively similar in terms of ease (3.79±0.8).The Table 1-5 showed the frequency and percentage of students' response to items on equivalence, level of interaction flexibility, knowledge gained and ease of online classes in comparison to face to face classes respectively.      The correlation between the students' perception on general equivalence, relative flexibility, relative interaction, relative knowledge gain and relative ease of online learning done using spearman's correlation test is shown in Table 6. DISCUSSION In our study, students' perceived comparatively more flexibility in study time, study location, designing own study agenda, organizing own study materials and flexibility in terms of deadlines (overall mean 4.49± 1.10). They even perceived online learning to be easy to fit into their schedule and allowed them to work at their own pace. This finding was consistent with previous findings and was only perceived advantage of online learning. 1,7,8,10 Online education can enhance students' educational learning experience, support development, ease time limitation, overcome geographical limitations and offer greater flexibility. 10 In contrast to previous findings, online class wasn't perceived to be equivalent to face-to-face courses in general (2.82±1.10) suggesting that the online classes were unable to provide satisfactory experiences for most students included in this study. 4,11 Although the study respondents did not perceive online courses to be generally equivalent to face-to-face courses, they also did not perceive them easier (mean 3.79±0.8), a finding similar to Platt et al. 7 In a comparative study by Wiecha et al, improvement in educational performance among students learning online exceeded that of face to face learning suggesting at least equivalence, if not superiority, of the online method. Moreover, medical students were equally satisfied and online education was acceptable. 11 Similarly in another study, synchronized online classes were well-accepted by the medical students and most of the preclinical students even preferred online learning for the upcoming academic years. 4 The perceived overall equivalence of online and face to face learning has been seen to increase with previous experience with online learning and with the number of online courses taken. 7,12 In our study, students' had the perception of comparatively less interaction with tutor and peers (overall mean 3.17±1.13), which was consistent with previous study. 7,8,[13][14][15] Lack of or difficulty in interaction may be common even in the face to face lectures in large classroom and can be exacerbated in the online environment. 15 The root cause of this learning experience might include lack of previous experience of online teaching, lack of training to engage students, lack of formal training for online assessment and lack of awareness of the strategies to incorporate quizzes, polls, and mini assignments in the online teaching in order to keep the students engaged and making the lectures more interactive. 16,17 A course designed for effective students' engagement including the seven principles for good practice in undergraduate education has been seen to be successful in the online learning environment. These principles states that the good instructional practice encourages contact between student and teacher, develops cooperation among students, encourages active learning, provides prompt feedback, emphasizes timely completion of assigned task, communicates the high expectations, and respects diverse talents and ways of learning. 18 Traditional Lecture classes may be useful, in face to face classes, but may not facilitate engagement and interactions with tutor and peers in online environment. 14 Failure to actively engage students promote distractions from the home environment and the current state of heightened anxiety and uncertainty likely made it even harder to maintain engagement. 15 The students' engagement had been shown to be encouraged and promoted through online student response systems incorporating methods such as online real time polls, quizzes or small group discussion through breakout rooms and even monitoring a chat feed. 1,19 Several other innovative teaching methods such as flipped classroom model, pre-recorded minilectures provided beforehand, micro-learning pedagogy, online question and answer sessions, clinical procedures and clinical examination videos and assessment in the form of multiple choice questions/case scenario-based questions has also been advocated to engage the students online. 20,21 Consistent to previous finding, students' perception of comparatively less interaction was positively correlated to perception of comparatively less gain in knowledge. 7 In our study, students' experienced less gain in knowledge which was consistent with previous finding. 7 In contrast, the learning outcome of online learning has been seen to be comparable to face-to-face learning. 5,22 Inês C. Moreira et al showed that e-learning can provide relevant knowledge gains. 22 The study by Platt et al found that the students with less exposure to online courses perceived online learning environments as less conducive to learning and suggested that the previous experience with online courses affected the student perceptions of knowledge gained. 7 Even if the students are exposed to the interactive lecture with the faculty, they may feel isolated from their peers, and remain in a state of distracting anxiety, thus reducing cognitive domain. 15 Rhim et al in a review article provided five guidelines for designing online curriculum in the medical education context which recommended embracing experiential learning such as flipped classroom, accommodating both synchronous and asynchronous online learning to create a social presence as well as provide time for reflection, facilitating interactions among peers and facilitator through small group discussion in breakout rooms, promoting practice opportunities through online platforms in certain patient cases, and promoting a learning community to maintain a sense of a learning community even in an online environment. The adoption of online learning with application of these guidelines in the medical school may supplement the traditional medical education or even provide additional benefits in the new normal after the COVID-19 pandemic. 23 This study has its own limitation of sample population being from single institution. Hence, the result of this study lacks generalizability.

CONCLUSION
The perception of students, who will be taking the online class, should be taken into consideration. The result of this study suggests that the students didn't find the online learning to be equivalent to face-to-face learning and the effective online learning experience is dependent on interactive sessions.

ACKNOWLEDGEMENT
We would like to thank Dr Ishwori Sharma Paudel, Professor in Department of Community Medicine, for his support in carrying out statistical analysis and interpretation of result.