Student Perspectives on E-Learning in a Malaysian Medical College One Year into the COVID-19 Pandemic: A Cross-Sectional Study

Background: During the coronavirus disease 2019 (COVID-19) pandemic, most in-person classes in Newcastle University Medicine Malaysia (NUMed) were replaced with e-learning. Our study aims to explore students’ e-learning experiences and its perceived benefits and challenges during the pandemic. Methods: 285 students recruited via convenience sampling participated in this cross-sectional study. Participants completed a self-administered online questionnaire on sociodemographic factors and experiences with e-learning. Descriptive statistics and Spearman’s correlation tests were used to analyze the data. Results: Most students used laptops (n=275, 96.5%) for e-learning and owned at least two electronic devices (n=245, 86%). Over half our students (n=148, 51.9%) reported no change to theoretical knowledge, while about three-quarters (n=213, 74.7%) perceived practical skills to have worsened. Students preferred paper-based exams (n=170, 59.6%) and objectively formatted online exams (n=193, 67.7%). Since transitioning to e-learning, the majority of students (n=207, 72.6%) reported difficulties studying online and were unsatisfied with their academic performance (n=166, 58.2%). Students preferred e-learning due to the lower risk of contracting COVID-19 (n=256, 89.8%), the convenience of online classes (n=244, 85.6%) and flexible schedules (n=219, 76.8%). However, the lack of patient contact (n=236, 82.8%), lecturer and peer interaction (n=234, 82.1%), and unreliable internet (n=201, 70.5%) made e-learning challenging. Students’ experiences were generally affected by multiple factors encompassing personal, lecturer, and environmental aspects. Conclusion: E-learning during the COVID-19 pandemic has negatively impacted students’ practical skills and performance satisfaction. Therefore, the university should look towards addressing e-learning constraints and providing adequate support to improve students’ educational experiences in the ongoing pandemic.


Introduction
When Malaysia's Movement Control Order (MCO) was announced in March 2020 as a measure to combat the spread of the coronavirus disease 2019 (COVID-19) pandemic, Newcastle University Medicine Malaysia (NUMed) immediately suspended inperson classes and adopted an online approach for teaching.The complete switch to e-learning was implemented across all teaching programmes in the institution, using a variety of platforms.E-learning has been widely used as a digital web-based educational approach which aims to enhance students' learning through an interactive, personalized, and enjoyable learnercentred environment. 1Despite being conducted in a completely different setting from traditional in-person education, studies have shown that e-learning can be as effective as classroom teaching. 2,3Current research has shown that e-learning is generally welcomed by students due to its flexibility and convenience, although many aspects make its implementation challenging. 2,4,5For healthcare students, there is the added difficulty of replicating patient interaction and patient care in an online setting. 6,7These are crucial elements of training medical students' clinical skills, which form a core requirement of their education in terms of assessments, and will inevitably shape their careers as future healthcare workers.
With strict lockdowns and physical distancing measures in place, limited in-person sessions on campus, and disrupted hospital attachments in the last one and a half academic years, most of the teaching in NUMed is still being delivered online.As such, there is concern over the effectiveness and satisfaction with elearning amongst our students, and how this affects their overall academic performance.Hence, this study aims to explore students' perceptions on the impact, benefits, and challenges of e-learning during the COVID-19 pandemic.

Study Design and Participants
We conducted a cross-sectional study, using a convenience sampling technique via a self-administered online survey.The survey (attached as Supplementary Material) was designed with Google Forms and distributed via an embedded link in an invitation email to all students registered with NUMed for the 2020/2021 academic year.This comprised of students on the following programmes: Bachelor of Medicine, Bachelor of Surgery (MBBS) (Year 1 to 5), Biomedical Science (BMS) (Year 1 & 2), and Foundation in Biological and Biomedical Sciences course.The data was collected between July 12th, 2021 and August 12th, 2021 of which the link was accessible to students for submission of their responses during this period.
The questionnaire consisted of sections on sociodemographic factors and students' experiences with e-learning.This included items where students were asked to report their technology use, e-learning exposure, and perceptions of their experiences over the last academic year (2020/2021).8][9] All the students who were studying at NUMed campus in the academic year 2020/2021 were eligible to participate as they were the first batch of students who have completed a full year of study with the e-learning adjustments undertaken by the university since the pandemic was first declared.Students who were taking a year off or had undergone an intercalation programme in another campus were not invited to the study.A total of 285 students responded to the questionnaire, amounting to a response rate of 40% of overall student population of 725 students.
Before dissemination, the survey was pretested with a sample of students, to ensure clarity in interpretation of the questionnaire.

Data Analysis
In this study, the data were analyzed using IBM SPSS Statistics Version 27, primarily through use of descriptive statistics for frequencies and percentages.Spearman's correlation test was used to identify correlation between students' e-learning experiences, the effects of e-learning, and academic performance.These variables were measured on a 5-point Likert scale from "1 = Strongly Disagree" through to "5 = Strongly Agree" and "1 = Never" to "5 = Always".A p-value of <0.05 was considered statistically significant.

Ethics
Ethical approval was granted by the NUMed Research Ethics Committee and the Newcastle Institutional Review Board (Ref: 13518/2020).Informed consent was gained from the students prior to their participation in this survey, and all responses collected were anonymized to maintain individual confidentiality.

Results
Our findings showed that from the total of 285 NUMed students who participated in the study, 81 (28.4%) were males and 204 (71.6%) females.The median age of the students was 22 ± 2 years.Most of the participants (n=239, 83.9%) were medical students, with two-thirds of the students being Malaysian (n=229, 66.7%).At the time of the survey, two-thirds of the students (n=190, 66.7%) were living in their hometowns, and the majority (n=258, 90.5%) were staying with family or friends.A total of 171 students (60%) had received at least one dose of the COVID-19 vaccine at the time of the survey.
The most popular electronic devices used for e-learning were laptops (n=275, 96.5%)More than half the students utilized tablets (n=159, 55.8%) and most students owned two or more electronic devices (n=245, 86%).A total of 263 respondents (92.2%) perceived their Information Technology (IT) proficiency level as good to proficient.For internet access, the majority of students (n=272, 95.4%) reported predominant use of broadband with 214 participants (96.1%) describing the quality of their internet service as ranging from acceptable to excellent (Table 1).had no prior experience with e-learning before the COVID-19 pandemic.Since transitioning to e-learning, almost threequarters of students (n=207, 72.6%) reported difficulties studying online which include unreliable internet, technical problems, lack of self-discipline, poor learning environment, etc (Table 3).As a result of e-learning, students generally perceived that their practical skills have worsened, whilst their theoretical knowledge remains unchanged.(Figure 1).Alongside these, more than half (n=166, 58.2%) of the students reported feeling unsatisfied with their overall academic performance after switching to e-learning.Most students still preferred paper-based exams (n=170, 59.6%) to online-based exams and two-thirds of the students preferred objectively formatted online exams (n=193, 67.7%) over a subjective format.The lower risk of contracting COVID-19 (n=256, 89.8%), the convenience of attending classes from home (n=244, 85.6%) and the flexible schedules (n=219, 76.8%) are benefits of e-learning during the pandemic that students have chosen (Table 4).The majority of students also found the access to online materials (n=193, 67.7%) and the comfortable or conducive study environment (n=143, 50.2%) to be beneficial as well.Conversely, the most common constraints of e-learning according to students were the lack of patient interaction (n=236, 82.8%), as well as reduced interactions with lecturers and peers (n=234, 82.1%).Technological factors such as unreliable internet (n=201, 70.5%) and technical problems i.e., incompatible devices, power outage, etc. (n=195, 68.4%), in addition to personal factors like lack of self-discipline (n=191, 67%) and social isolation (n=190, 66.7%) were also reported by most students.
Multiple factors which were related to our students' e-learning experience are presented in Table 4. From the analysis using Spearman's correlation test, our study shows that students were facing difficulties with studying online and were unsatisfied with their academic performances due to various challenges faced during the COVID-19 pandemic.These included issues such as the inability to adjust to e-learning, feeling incapable of studying subjects online, as well as the lack of motivation and technical skills.Students who had difficulties studying online reported problems in terms of experiences with lecturers also.Particularly, this was when communication was poor, leading to a lack of clear direction from the lecturers (r=-0.331,p<0.001), when resources or skills for online teaching were lacking amongst them (r=0.273,p=<0.001), and when they were not technology-friendly (r=-0.137,p=<0.021).The results show that frequent fluctuations in lecture timings (r=-0.238,p=<0.000)affected these students as well.Conversely, environmental factors such as non-conducive learning environments, technical issues, unreliable internet or power disruptions, lack of infrastructure, and resources to support online teaching also have an impact on online learning and academic performance satisfaction.

Discussion
In this study, we explored students' perceptions of e-learning during the COVID-19 pandemic.Across the world, the sudden and rapid shift of education from in-person teaching to an online setting has been met with mixed responses; varying degrees of students' acceptance of and adaptation to e-learning have been reported over the last two years. 2,10,113][14][15] Our study included medical students across all years (Year 1 to 5) in Bachelor of Medicine, Bachelor of Surgery (MBBS), Biomedical Science (BMS) and Foundation programme , being the first study of its kind in the Asia Pacific region.
Despite almost three-quarters of our participants facing difficulties studying online and more than half feeling unsatisfied with their academic performance since switching to e-learning, interestingly, about half the students did not perceive any changes in their theoretical performance.Conversely, threequarters of students reported their practical skills to have deteriorated.The perceived worsening in practical performance is worrying, although not unexpected due to the traditional hands-on training of medical and biomedical science students in the clinical and laboratory settings, respectively.According to Keržič et al., students' experiences and satisfaction with elearning are main factors which contribute to perceive academic performance. 16Other studies amongst healthcare students have shown similar unchanged or negative trends in academic performance with the suspension of in-person teaching as well. 7,17,18th the unprecedented shift to distance-learning in the COVID-19 pandemic, educational institutions have been forced to improvise on the delivery of assessments as well.The data we collected from our students shows that paper-based exams were still preferred over online-based exams.The possible reasons for this could be explained by results from a systematic review by Montenegro-Rueda et al. which summarized some of the challenges to online examinations, including e-proctoring or online invigilation of students; dishonest student behaviour with cheating and plagiarism; lack of training and technological issues, i.e. internet or power outage, privacy issues, etc. 19 However, if exams were to be conducted online, about two-thirds of our students preferred them to be structured in an objective format over a subjective exam.Our study reported similar results with a study by Muthuprasad et al. amongst Indian graduates who preferred objective mode of examination. 20cording to our participants, the most popular chosen benefits of the transition to e-learning in this pandemic were being at a lower risk of contracting COVID-19, followed by the convenience of attending classes from home and the flexible schedules.This concurs with a study by Dhawan et al. on Strengths, Weaknesses, Opportunities and Challenges analysis of e-learning which reported that the "Anywhere-Anytime" flexibility in time and location is thought to be one of its main strengths. 21This is also in line with the findings from Muthuprasad et al. that preference for online education was due to the flexibility and convenience of its nature. 20r data has also shown that the main downside of the virtual setting is the lack of human connection, where the vast majority of students perceived their e-learning experiences to be lacking in interactions with patients, as well as with lecturers and peers.Besides this, issues like unreliable internet and technical problems were widely perceived as limitations amongst our students.Additionally, Dhawan's work proposed weaknesses in the online learning approach to education, including lack of communication with others and technical difficulties. 21With previous research in Malaysia showing technological difficulties to be a barrier to elearning amongst university students, 22 moving forward, this should be an important consideration when planning for a transition of education to an online setting in the future.
Our results reflected that students who faced difficulties studying online also tended to report problems with their experiences with lecturers.Thus, we infer that educators play an important role in improving a student's transition to e-learning.Research conducted amongst other healthcare students in Jordan and Iran have shown similar opinions amongst their students, 23,24 where lecturers' readiness to engage in online learning and the effectiveness of their communication skills are thought to greatly influence the students' e-learning experiences.Hence, as proposed by Turnbull et al., there is a need to provide better training for university staff, allowing a higher level of online competence to be achieved, 25 and in turn, better outcomes for students.

Limitations & Recommendations
The limitations of this study include its cross-sectional design, resulting in only a brief snapshot of the respondents' perceptions towards e-learning.The study results are also limited in their broader interpretation as this is a single-centre study.Furthermore, data collection via a self-reported questionnaire, which was conducted during the students' summer breaks, likely could have led to reporting and recall biases.We also acknowledge that there may have been some element of selection bias in the recruitment of participants since this process was done on a voluntary basis through an email invitation disseminated to all students in NUMed.Thus, students interested in our research topic might have been more likely to respond to this study.
Understanding that our study population was relatively small at a total number of 285, and that students' perceptions of e-learning are subjective, diverse and can evolve over time, we believe that more research into this topic would be beneficial as the use of elearning continues.While universities endeavour to improve their delivery of teaching with and beyond the 'new normal' of the COVID-19 pandemic, longitudinal research and qualitative studies on students' perceptions of e-learning over time could deepen general understanding on this topic for future use in education.

Conclusion
Overall, e-learning during the COVID-19 pandemic has impacted students negatively in terms of academics, particularly practical skills, and performance satisfaction.Nevertheless, students do perceive benefits of e-learning to include its convenience, flexibility, and safety, especially with the lower risk of contracting COVID-19.Constraints were predominantly focused on the lack of interactions, technological difficulties and personal factors.Generally, difficulties studying online and academic performance satisfaction are affected by personal, lecturer and environmental factors.With the likely incorporation of e-learning into educational systems, the university should strongly consider addressing students' concerns and providing academic support where appropriate to ensure the high quality of the student experience in the online setting as we continue to navigate this pandemic.

Summary -Accelerating Translation
Title: Student Perspectives on E-Learning in a Malaysian Medical College One Year into the COVID-19 Pandemic: A Cross-Sectional Study Main Problems to Solve: The COVID-19 pandemic has affected students' education in Malaysia whereby in-person classes had to be converted into online learning.E-learning is a novel tool in the education, however, its effectiveness in replicating in-person classes still lacks evidence.

Aim of Study:
This study would like to look at students' e-learning experiences and its perceived benefits and challenges during the pandemic.The outcomes might help future students learn more effectively online and rely less on traditional classroom sessions.Additionally, it will better equip the university to handle unforeseen situation such as the COVID-19 in the future.
Methodology: This study was conducted as a cross-sectional, selfadministered online survey using a convenience sampling technique.The study included all students studying in NUMed in the academic year 2020/2021.The survey consists of sections on sociodemographic factors, students experience with e-learning which included items on technology use, e-learning exposure, and perceptions of their experiences over the last academic year.
Results: Overall, students find that their practical skills have been heavily affected due to the switch to online learning.The majority of students have contributed this to lack of interaction with patients, peers, and lecturers.However, students have also benefited from online learning as it gives students flexibility and convenience in learning whilst reducing the risk of contracting COVID-19.

Conclusions:
This study has demonstrated that online education has both positives and negatives effects on students across the medical science programmes during the pandemic.Therefore, the institution should strive to address the drawbacks to enhance the overall educational experience.

Figure 1 .
Figure 1.NUMed Students' Perceptions of Changes to Academic Performance after Transition to E-Learning during Academic Year 2020/2021.

B1. 5 B1. 6 B1. 7 B1. 8 B1. 9 B2. Benefits and constraints of e-learning 1 B2. 1 ☐B2. 2 ☐
Have you ever participated in any type of e-learning before the pandemic?Do you face any difficulties studying online?How has your academic performance changed since you switched to e-learning?Are you satisfied with your overall academic performance?Which type of exam do you prefer?☐ Online based ☐ Paper based ☐ No preference B1.10 Which type of online exam do you prefer?☐ Objective (SBA, MCQ, EMQ) ☐ Subjective (WRISKE, SAP, SAQ) ☐ Both What are the benefits of e-learning during the COVID-19 pandemic?Check all that you consider true.Access to online materials ☐ Flexible schedules (e.g.learning at your own pace) ☐ Convenience (e.g.ability to stay at home, option to request for recording) ☐ Comfortable/conducive environment ☐ Better focus with less distractions ☐ Improved communication/interaction ☐ Lower risk of contracting COVID-19 infection ☐ Others, please specify: ________________________ Original Article Kong SWW, et al.Student Perspectives on E-Learning in a Malaysian Medical College One Year into the COVID-19 Pandemic: A Cross-Sectional Study Int J Med Stud • 2023 | /Jul-Sep | Vol 11 | Issue 3 DOI 10.5195/ijms.2023.1484| ijms.info183 What are the constraints of e-learning during the COVID-19 pandemic?Check all that you consider true.Reduced interaction with lecturers/colleagues ☐ Lack of interactions with patients ☐ Technical problems ☐ Unreliable internet connectivity/power interruption ☐ Poor learning environment at home ☐ Lack of self-discipline ☐ Social isolation ☐ Others, please specify: ________________________ B4.Challenges to e-learning 2

Table 3
. NUMed Students' Perceptions of E-Learning Benefits and Constraints in the 2020/2021 Academic Year (n = 285).Variables n (

Table 4 .
Spearman Correlation Analysis: Student, Lecturer and Environmental Factors related to the E-Learning Experience (Difficulties Studying Online and Academic Performance) by NUMed Student during Academic Year 2020/2021.

4 .
Programme and year of study in Academic Year 2020/2021: Which of the following devices do you own and utilize for your learning?Check all that apply.