Online learning during the COVID-19 pandemic: A qualitative study among final year medical students at the University of Zambia

Introduction

With the rise of the COVID-19 global pandemic, many learning institutions across the world had to shut down to slow the spread of the disease; an estimate of at least 1.5 billion children and youth were affected by the closures.¹ To minimize interference in academic activities, online teaching and learning platforms were introduced in several countries with high levels of digital penetration.² To curb the spread of the COVID-19 pandemic, the government in Zambia, through the Higher Education Authority, closed all the institutions. This prompted the University of Zambia (UNZA) to employ online teaching and learning via Moodle and ASTRIA to mitigate the impact of COVID-19 on academic activities.³ Moodle is a widely used, open-source learning platform that comes without a cost and enables educators to create interactive online courses. At the same time, ASTRIA is a paid service that provides several different management systems for the students and educators.⁴ Some lecturers used other platforms such as ZOOM, Google Meet and WhatsApp according to their preferences. This transition was made for all the programs offered at UNZA, including the Bachelor of Medicine and Surgery.

Online learning, also called virtual or e-learning, is the acquisition of knowledge through digital technologies and media, typically by accessing the internet or any electronically enabled learning.⁵ Online learning is variable among medical schools, and is more common in basic sciences than in clinical clerkship years. In clinical years, however, it has been used to increase the effectiveness of conventional face-to-face methods as it has its limitations.⁶ The discipline of medicine is about saving lives whilst upholding patient safety, and any significant alterations in how it is taught call for intensive consideration. Most of the activities and teaching in medical training are practical-based⁷ and require physical interaction with the patients, laboratories and theatres. This underscores the importance of social interactions in the constructivist learning theory, which is the philosophical underpinning principle of experiential learning.⁸ The UNZA had never taught medical students on a full-time digital platform. This meant that students needed to adapt to the new mandatory digital methods, including final year medical students who were soon to be interns and attending to patients as the first health professionals the patients would encounter in many hospitals in the country. Online teaching and learning were introduced at a time when the country was faced with challenges regarding consistent electricity supply countrywide. Some communities faced up to 15 hours of load shedding per day of electricity, with some parts of the country, such as rural areas, experiencing poor internet connectivity.⁹ During load shedding periods, the affected areas had no electricity supply from the country’s only power supply institution, meaning a total blackout.

In an integrative review conducted by O’Doherty et al., prior studies highlighted significant barriers to online learning that include: time constraints, attributed lack of incentives to engage in online education, deficits in technical skills, inadequate infrastructure like technology and quality of services, lack of institutional strategies and support as well as negative attitudes of the people involved.¹⁰ Some of the suggested solutions to these identified barriers include adopting digital tools that could free up some time, collaborating with relevant stakeholders and departments with the adoption of new approaches, as well as maintaining a positive attitude among all team players.

This study aimed to explore the experiences of final year UNZA medical students as they transitioned to online learning to complete their medical training program and highlight the barriers and facilitators.

Methods

We used a descriptive qualitative approach to understand the experiences, barriers and facilitators of online learning among final year medical students for 2020 at the UNZA during the COVID-19 pandemic lockdown. Thus this study was imbedded within the interpretivism paradigm in trying to explore the perceived barriers and facilitators for the students’ online learning during the lockdown as the underlying philosophical approach because reality is deemed to be socially constructed.¹¹ Since online learning is a fairly new concept in this setting, we adopted the individual facet of technology acceptance model (TAM) which has been used in other studies to show user acceptance of the technology based on the perceived usefulness and perceived ease of use.¹²

Results

The demographic characteristics of the participants are presented in Table 1 below.

The ages varied between 24 and 29, with all participants being single and unemployed. There were four female and ten male participants. The participants represented five of Zambia's ten provinces, including Copperbelt, Eastern, Central, Southern and Lusaka.

We considered the broad themes that affected the effectiveness of online learning during the COVID-19 lockdown: online learning perceptions, barriers and facilitators to online learning. Under these themes, we established sub-themes to provide a deeper understanding. Table 2 below shows the summary of the themes.

Theme 1: Online learning perceptions

The participants' perceptions are discussed under three sub-themes: simplicity, scheduling, and self-directed learning or skills development. Overall, the participants' perceptions of online learning were generally positive, as some expressed their approval of this method, commending the University’s initiative of switching to online learning during the lockdown to facilitate the continuity of their studies.

Simplicity

The first sub-theme we considered under this core theme was simplicity, where most participants stated to have been able to understand the presentations delivered as both lectures and notes with ease. When asked what they thought about the material that was provided online, one participant said:

Not only was the material said to have been uploaded for easy accessibility, but the content was also excellent and sufficient according to the requirements of the students, as stated by participant 8 quoted below:

However, not all participants were satisfied by the lecture notes provided online; some expressed their disapproval of online learning, implicitly stating the need for further explanation of the lecture notes administered to them:

Scheduling

The lessons were delivered by sending lecture notes to the students to study at their convenience, and then they were assessed on this material. The assessment was done physically following the uploading of notes, thus combining traditional ways of evaluation with virtual methods of teaching. This was attested by the response below:

Lectures were also delivered online in real-time, with interactions between the students and lecturers made possible by the Zoom platform.

Furthermore, as part of the training, the medical students were also assessed online through an assignment that required to be downloaded, answered and uploaded to complete the task.

Self-directed learning

Self-directed learning (SDL), a strategy in which learners take responsibility for their learning, was yet another sub-theme that emerged, highlighting the participants’ willingness to augment their online learning. With medical training being a hands-on program, students need to learn certain skills to aid in patient management. A couple of examples are highlighted below how students were able to use their initiative to facilitate their learning:

Theme 2: Barriers

Online learning had challenges; students and lecturers faced various difficulties with this method of sharing knowledge, such as the inability to navigate around the platform. We grouped the barriers encountered by the participants into four sub-themes: quality of internet and access, power outages, lack of patient-student interaction and lack of learning space at home. These barriers were beyond the students’ control and could not be easily overcome.

Quality of internet and access

Internet connectivity in the country depends on the network provider one subscribes to and the geographical location. The most prominent of these factors is the geographical location, where certain areas of the country struggle with internet connectivity more than others. Moreover, one needs to pay for internet access by buying data bundles to enable them to access online platforms. The University of Zambia offers internet access within the school premises through Wi-Fi routers; however, with the school’s closure, the students had to fend for themselves to have internet access because they were no longer on campus.

While others struggled with internet connectivity, a few had challenges with access to the internet as they occasionally could not afford to purchase data bundles. These students would then be forced to abscond classes and either watch the lecture video if it was recorded or just read the lecture notes if and when they are made available. Some participants stated not to have always been able to afford data bundles to access online lectures.

Power outages

Zambia was experiencing load shedding in many regions to prevent excessive load on the main generating electric plant. With specific areas experiencing electricity power cuts for as long as 8 hours daily, such were the conditions that the final year medical students had to learn under as they were not exempted from these power cuts.

Lack of patient-student interaction

Traditionally, clinical students learn most of their skills in the hospital wards, where they can interact with patients. Through these interactions, medical students are therefore able to practice therapeutic and diagnostic procedures as well as counselling patients. Virtual education resulted in the cessation of student-patient interactions, which affected the students.

With medical training being a hands-on program, the best place to train medical students remains at the patient’s bedside; despite being able to read various textbooks and presentations, a medical student's skills are best developed at the bedside through practical participation. Students need to learn specific skills to aid in patient management. The impact on the acquisition of skills that the lack of patient-student interaction brought was highlighted as follows:

To balance the practical aspect of the training with the theoretical one, some participants proposed methods in which students could do their theory work online and still find time to go to the ward for their practical training or even make use of the skills lab:

Lack of learning space at home

In most homes, dependents are expected to help their guardians with chores that are usually routine and executed at specific time frames. With the medical students being sent home, they had to perform these chores as per custom. Furthermore, some houses’ setups have noisy environments or are too crowded to be impeccable for studying or attending online lectures. Moreover, none of them had designated places to enable participants adequately attend to their academic responsibilities. This was considered to be interfering with the learning process of some of the participants.

Learning from home proved to be a barrier for most of the participants. When asked how the living arrangements fitted in with online learning, p3 and p12 had this to say:

Theme 3: Facilitators

Three sub-themes emerged from the final core theme considered: self-paced learning schedules, support systems and prospects of completing school. These sub-themes expressed the factors that helped enhance the students’ learning experience.

Self-paced learning schedules

All participants regarded online learning as advantageous because they could easily refer back to the content given either during recorded lectures or in PowerPoint presentations. The participants revealed the following:

Support systems

The support systems of the students during this period were explored. Most respondents said they had not received any support from the University. In contrast, others considered the availability of lecturers during this period as a means of support from the University. Some of the participants’ verbatim regarding support from the University are highlighted below:

Others, however, allude to the support from colleagues as one of the facilitators.

Prospects of completing school

Being at the verge of completing their undergraduate training and facing the closure of physical attendance of school, the medical students were fully receptive to the progression of lessons virtually.

Discussion

The study explored the experiences of final year medical students at the UNZA doing online learning during the COVID-19 pandemic. Online learning was delivered in a scheduled and simplified manner. However, there was unreliable internet connectivity and access, power outages and diminished patient-student interaction. Notwithstanding, positive online learning experiences were identified as self-paced learning, support systems and the thought of graduating from medical school.

The primary study findings are that their online learning was delivered in a scheduled and simplified manner, whilst they also had an element of self-directed learning. The notable barriers to this online learning were the variability in internet connectivity and access, power outages, and a lack of patient-student interaction impeding their acquisition of technical skills and a lack of learning space in their homes. On the other hand, highlighted facilitators to online learning include self-paced learning, having to support systems, and the prospects of completing medical school, which motivated them. Online learning provided the best available means for the students to continue their education during the lockdown, as the pandemic kept spreading with poor control globally, thus presenting an indefinite period of spread.¹⁷

The study participants were satisfied with the transition to online learning, commended the course delivery, and felt it was simple and convenient. Earlier studies also show that online learning was welcomed as the best alternative for continued education for the students given the circumstances.¹⁸ However, it was recommended that a combination of online learning and physical attendance in class should be used to maximize the benefits of education.¹⁹ Contrary to this welcomed initiative, a different study reported a general dissatisfaction by the students that led to a disruption of learning.²⁰ It was also previously established that the student’s perception and ability to adapt to their learning environment were essential to achieving learning.^21,22

Online learning was considered a platform that allowed students to set their own pace regarding learning. Our participants stated they were able to refer back to the recordings, and they could replay them as much as they would have loved to gain a deeper understanding. This student-centered advantage of online learning was also reported by Mukhtar et al. in that the students learned asynchronously during the day and also remotely from various locations across the country.²³ Considering that it enabled these students to log in from various geographical locations, this was deemed beneficial to them as they could easily access lectures with great convenience.

One of our participants' negative learning experiences was the inability to develop skills through online learning. Participants felt that the practical aspect of the training was deprived and shattered the possibility of acquiring basic skills and needed supplementation with physical attendance to aid in skills development. Similar findings were reported in China, where some students in one study also thought it was necessary to reteach the topics physically to gain a comprehensive understanding.²⁴ Similarly, Mukhtar et al. in 2020 found online learning inefficient and difficult to maintain academic integrity. Skills could not be taught; there was a lack of student feedback, poor attentiveness, lack of discipline and plagiarism during assessments.²⁵

Another negative online learning experience that the students reported arose from their environment. They reported to have had challenges with internet connectivity, and the poor quality of internet access led to the students failing to log in and being logged out of lectures. This challenge was not unique to our study participants but has also been encountered by students in several other studies.^26–28 According to the World Bank, many African countries already have substandard internet quality of less than 10mbps. With the institution of the COVID-19 lockdown, there was increased traffic on the internet which led to slow internet speeds with reductions of as much as -10%.²⁹ Another challenge was frequent electricity power outages reported by some participants who missed some of the lessons as a result of the power challenges. Similarly, students in India also reported poor network and electricity power cuts as disturbing the online learning process.³⁰ Electricity outages were coupled with the high demand on the electricity industry encountered during the lockdown, which immediately ameliorated with the lifting of the quarantine.³¹

Lack of learning space was yet another highlighted challenge some participants reported. There were various distractions to their learning schedule such as noise, chores and other competing demands. These findings were also reported by Ishita et.al. in 2021, whereby the students would encounter distractions that eventually affected their performance in exams.³² Other studies found mind wandering as one of the distractions to online learning^33–35 but this phenomenon was not reported by any of our study participants.

Furthermore, the students indicated that the absence of interaction with patients for their training during this period was a barrier to adequate learning. For instance, one participant alluded to how he needed to be able to put the theoretical knowledge into practice and be able to appreciate the theory on an actual patient. Singh described the importance of student-patient interaction as it aids in building social intelligence, confidence, communication skills, coming up with differential diagnoses following clinical examination and how the patient is the best teacher for the student than a book would be.³⁶ Another study reports that students were not able to contribute to patient care anymore as a result of the closure.³⁷

Smith reported that some universities offered support for the students to cater for their mental health and financial support. Mental health assistance had always been there for these students, but with the arrival of the pandemic, it was now accessible through video call counselling sessions. More than half of their students had reported deterioration of their mental health during the lockdown. Although there was no financial support from the University that our participants reported, Smith reported a hardship fund that their students acquired from the institutions’ financial support services³⁸ whose idea was also recommended recently by Rainbow and Dorji.³⁹ Our participants considered the availability of lecturers and technical guidance on how to navigate the online platforms as the only support they received from the University.

Conclusion

Despite its potential benefits, online learning cannot completely replace the traditional training of medical students. However, it could be considered supplemental to student clinical placements. As the information communications technology industry develops further, there is hope for future training to have better delivery virtually with better student satisfaction.

Data availability