BMJ OpenIntern, [email protected] - Omar N. Kotb year medical student, Faculty of Medicine,...

For peer review only

Perception and use of massive open online courses among medical students of a developing country: multicenter

cross-sectional study

Journal: BMJ Open

Manuscript ID: bmjopen-2014-006804

Article Type: Research

Date Submitted by the Author: 01-Oct-2014

Complete List of Authors: Aboshady, Omar; Faculty of Medicine, Menoufia University, 6th Year Medical Student Radwan, Ahmed; Faculty of Medicine, Menoufia University, 6th Year

Medical Student Eltaweel, Asmaa; Faculty of Medicine, Alexandria University, 6th Year Medical Student Azzam, Ahmed; Faculty of Medicine, Al-Azhar University in Cairo, 6th Year Medical Student Aboelnaga, Amr; Faculty of Medicine, Tanta University, 5th Year Medical Student Hashem, Heba; Faculty of Medicine, Beni Suef University, 6th Year Medical Student Darwish, Salma; Faculty of Medicine, Suez Canal University, 4th Year Medical Student Salah, Rehab; Faculty of Medicine, Benha University, Intern

Kotb, Omar; Faculty of Medicine, Assiut University, 5th Year Medical Student Afifi, Ahmed; Faculty of Medicine, Ain Shams University, 4th Year Medical Student Noaman, Aya; Faculty of Medicine, Cairo University, 5th Year Medical Student Salem, Dalal; Faculty of Medicine, Cairo University, 6th Year Medical Student Hassouna, Ahmed; Faculty of Medicine, Ain Shams University, MD, Department of Cardiothoracic Surgery

<b>Primary Subject

Heading</b>: Medical education and training

Secondary Subject Heading: Medical education and training

Keywords: Computer-Assisted Instruction , Medical Education , Distance Education , MOOCs, Egypt

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Title Page

Title

Perception and use of massive open online courses among medical students of a

developing country: multicenter cross-sectional study

Authors

- Omar Aboshady

� 6th year medical student, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt.

� [email protected]

- Ahmed E. Radwan



- Asmaa R. Eltaweel

� 6th year medical student, Faculty of Medicine, Alexandria University, Alexandria, Egypt.


- Ahmed Azzam

� 6th year medical student, Faculty of Medicine, Al-Azhar University in Cairo, Cairo, Egypt.


- Amr A. Aboelnaga

� 5th year medical student, Faculty of Medicine, Tanta University, Tanta, Egypt.


- Heba A. Hashem

� 6th year medical student, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt.


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- Salma Y. Darwish

� 3rd year medical student, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.


- Rehab Salah

� Intern, Faculty of Medicine, Benha University, Benha, Egypt.


- Omar N. Kotb

� 5th year medical student, Faculty of Medicine, Assiut University, Assiut, Egypt.


- Ahmed M. Afifi

� 3rd year medical student, Faculty of Medicine, Ain Shams University, Cairo, Egypt.


- Aya M. Noaman

� 5th year medical student, Faculty of Medicine, Cairo University, Cairo, Egypt.


- Dalal S. Salem



- Ahmed Hassouna

� MD, Department of Cardiothoracic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt.


Corresponding author:

Omar Ali Aboshady

6th year medical student,

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Faculty of Medicine, Menoufia University.

Address: 20 Sadat School St, Shanawan, Shebin El-kom, Menoufia, Egypt.

Tel: +2-048-2282698 / +2- 01010747627

E-mail: [email protected]

Fax: +2-048-2326810

Postal code: 32718

Key Words:

Computer-Assisted Instruction (MeSH terms); Medical Education (MeSH terms); Distance Education

(MeSH terms); MOOCs; Egypt.

Word Count:

- Title: 18 words (114 characters)

- Abstract: 294 words

- Text: 3335 words

- Number of figures and tables: 5

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ABSTRACT

Objectives: To primarily assess the prevalence of awareness and use of massive open online courses

(MOOCs) among medical undergraduates in Egypt as a developing country, besides identifying the

limitations and satisfaction of using these courses.

Design: A multi-center, cross-sectional study using a web-based, pilot-tested and self-administered

questionnaire.

Settings: Ten randomly selected medical schools in Egypt.

Participants: Randomly selected 2700 undergraduate medical students with an equal allocation of

participants in each university and each study year.

Primary and secondary outcomes measures: The primary outcome measures were the percentages of

students who knew about MOOCs, students who enrolled and students who obtained a certificate.

Secondary outcome measures included the limitations and satisfaction of using MOOCs through 5-

point Likert scale questions.

Results: Of 2527 eligible students, 2106 filled the questionnaire (response rate 83.3%). Of these

students, 456 (21.7%) knew the term MOOCs or websites providing these courses. Out of the latter,

136 students (29.8%) had enrolled in at least one course, but only 25 (18.4%) of them completed

courses earning certificates. Clinical years’ students showed significantly higher rates of knowledge

(P= .009) and enrollment (P< .001) than academic year students. The primary reasons for incompletion

of courses included lack of time (105; 77.2%) and slow internet speed (73; 53.7%). Of the 25 students

who completed courses, 21 (84%) were satisfied with the overall experience. However, there was less

satisfaction regarding student-instructor (8; 32%) and student-student (5; 20%) interactions.

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Conclusions: Approximately one-fifth of Egyptian medical undergraduates have heard about MOOCs

with only about 6.5% actively enrolled in courses. However, students who actively participated showed

a positive attitude toward the experience, but better time management skills and faster internet

connection speeds are required. Further studies are needed to address the enrolled students for a better

understanding of their experience.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

- This study is the first to assess the actual prevalence awareness and use of MOOCs in Egypt and in

the medical field.

- This study included a large representing sample of ten Egyptian institutions covering nearly the entire

geographic area of Egypt.

- Data obtained from students in all six undergraduate years.

- There were relatively low returned number of participants who enrolled and who had certificates,

which makes analysis of limitations and satisfactions less reliable.

- The study results can not be generaziable to all developing countries.

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INTRODUCTION

Massive open online courses (MOOCs) have been recently proposed as a disruptive innovation with

high expectations to solve challenges facing higher education.1 The idea behind MOOCs is to offer

world-class education to a (massive) number of students around the globe with internet access (online)

for little or no fees (open). The courses consist of prerecorded video lectures, computer-graded tests and

discussion forums to talk over course materials or to get help.2 These courses have gained immense

popularity over a short period, attracting millions of participants and crossing the barriers of location,

gender, race and social status; making 2012 the year of MOOCs according to NewYork journal.3

Coursera, the largest MOOCs provider, in its lastest infograph in October 2013 showed an

extraordinary growth reaching more than 100 institutional partners, more than 500 courses and more

than 5 million students.4

In medical education, the number of related MOOCs is steadily increasing. In a recent study in

2014, it was found that 98 free courses were offered during 2013 in the fields of health and medicine

with an average length of 6.7 weeks.5 These courses were introduced as a possible solution that may

help solving great challenges facing medical education nowdays.6 These challenges including the issues

of quality, costs and the ability to deliver education to enough students who will cover the health care

system’s needs.7 There are uprising discussions to determine which roles MOOCs can play in the

medical field. Despite that, there is still limited information about how medical students perceive such

courses, especially in the developing countries where high-quality learning is often scarce.

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Although there is a great hope that MOOCs can play a role in solving developing countries’ lack of

high quality education, the current demographic data reveal that most of the MOOCs’ participants are

from the developed countries with very low participation rates from low-income countries, especially in

Africa.4 These low rates were thought to be due to various complicated conditions, such as lack of

access to digital technologies, linguistic and cultural barriers and low computer skills.8 In addition, lack

of awareness of the presence of this newly introduced concept may be considered another problem.

To our knowledge, there are no available cross-sectional studies that assessed the actual prevalence

of awareness and use of MOOCs among medical communities in the developing countries, including

Egypt. Our study primarily aims to assess the prevalence of awareness and use of these courses among

Egyptian undergraduate medical students, as an example of a developing country. Second, the study

will assess the limitations that prevent students to enroll and complete courses, besides assessing the

satisfaction level of using MOOCs to better understand of the role these courses in medical education.

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METHODOLOGY

This is a multi-center, cross-sectional study utilizing a structured, web-based, pilot-tested and self-

administered questionnaire. The study was ethically approved by the institutional review board at

Faculty of Medicine, Menoufia University, Egypt.

Study Population and Sample

Our target population was undergraduate medical students in Egypt enrolled in 19 medical schools

for the academic year 2013/14. We randomly selected ten medical schools to be our study settings.

These were Ain Shams, Al-Azhar medical school in Cairo, Alexandria, Assiut, Benha, Beni Suef,

Cairo, Menoufia, Suez Canal, and Tanta medical schools.

Students in these schools are enrolled in a six-year MBBCh program, in which the first three years

are called academic years and the last three years are called clinical years. According to a confidence

interval (CI) of 99%, margin of error 3%, and response distribution of 50%; 1784 students were

required to represent the study population. We used a stratified simple random technique to select our

sample with an equal allocation of participants in each university and each study year. Accordingly,

using the registered students’ names lists, we randomly selected 270 students from each faculty (45 for

each study year) for a total of 2700 participants. We excluded non-Egyptians students and those who

changed their enrollment school at the time of data collection.

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Data collection

We invited the selected participants via e-mail and social media websites to complete our survey

using a unique code for each participant during the period of March–April 2014. We used an online

survey program to administer the questionnaire (SurveyGizmo; Boulder, Colorado, US). Students who

did not have access to the internet at the time of data collection were allowed to record their responses

using a self-administered paper version of the questionnaire. We sent up to five reminder messages for

participants to complete the survey. The participants were informed about the study aims in the cover

letter, and they voluntarily consented to participate with no incentives.

Questionnaire Development

The study questionnaire was developed by the research team through group discussions after an

extensive literature review. The draft was then reviewed by two experts in the fields of medical

education and Biostatistics. We used the final draft in a pilot testing on 175 students in all participating

medical schools. Detailed feedback about the format, clarity and completion time were collected and

we made minor changes in response to participants’ comments. We did not include the pilot responses

in our analysis.

The questionnaire was in Arabic, the participants’ native language, and it comprised 29 questions in

four sections using branching logic function (Figure 1). The first section addressed study aims, consent

and participants’ personal information. This section was followed by a main question asking about their

knowledge about MOOCs. Based on this answer, participants were directed to different sections.

Students who knew about MOOCs were asked how they heard about it and their state of enrollment. If

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the participant was not enrolled in any course, he/she was asked about the limitations, and then the

questionnaire ends.

Enrolled students were directed to the next section, which assessed their perspectives and experience

with MOOCs. For students who gained certificates, further questions were asked regarding their level

of satisfaction as well as any obstacles they might have faced. Finally, four questions were addressed to

assess students’ opinion about integration of MOOCs in the medical field.

Most of the questions were single answer multiple-choice questions. However, there were three

multi-select check-box questions. For assessment of limitations, satisfaction and opinions, a 5-point

Likert scale between 1 (strongly agree/satisfied) and 5 (strongly disagree/unsatisfied) was used.

Statistical analysis:

Results were presented as numbers and perecentages with confidence interval at 99%. The

significance of the association between qualitative variables of interest was analyzed using Chi-square

test or Fisher’s exact test, as indicated. In order to focus on clear opinions, the 5-point Likert scale of

limitations, satisfaction and opinions were collapsed into 3 categories (agree/satisfied, neutral, and

disagree/unsatisfied). Class year was recoded as a dichotomous variable in order to compare results for

students in academic versus clinical education. The acknowledgment of the importance of getting a

certificate before enrollment was also recoded as a dichotomous variable (important/very important

versus limited importance/not important) in order to test the significance of association between the

primarily reported importance of acquiring a certificate and the actual possession of the certificate by

McNemar test. All tests were bilateral and a P value of 0.01 was the limit of statistical significance.

Statistical analysis was performed using the IBM SPSS statistical software package version 22.

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RESULTS

Respondent characteristics

Of 2700 total participants, 62 (2.3%) were excluded being non-Egyptians or having changed their

enrollment school, in addition to 111 (4.1%) students’ whose contact information could not be reached

with final eligible 2527 students. During the data collection phase, 2357 (93.3%) online questionnaire

invitations and 170 (6.7%) paper versions were sent out. Out of these distributed questionnaires, 2016

responses were received (response rate 83.3%). Table 1 show participants’ demographics regarding

school, class and gender.

Knowledge about MOOCs

We found that 456 (21.7% [99% CI, 19.4%–24%]) students had heard about MOOCs or websites

providing such courses. There was no statistically significant difference in knowledge between males

and females (43.6% vs 56.4%, 99 CI, P = .8). However, clinical year students had higher rates of

knowledge than students in the academic years (P< .001) (Table 1). Additionally, there was no

difference between medical schools in students’ knowledge about MOOCs (P=.04).

After clarifying the concept of MOOCs to students who did not know about it, 1342 (81.3% [99%

CI, 78.8%–83.8%]) students showed an interest to participate with a significant difference among

different medical schools (P< .001).

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Table 1. Participants’ demographics and their state of knowledge, enrollment and certificate

attainment.

Knowledge about MOOCs P

value

Enrollment in courses P

value

Certificate Attainment P

value Total (%)

(n=2106)

Yes (%)

(n=456)

No (%)

(n=1650)

Total

(n=456)

Yes (%)

(n=136)

No (%)

(n=320)

Total

(n=136)

Yes (%)

(n=25)

No (%)

(n=111)

Faculty Ain Shams 207

(9.8%)

38

(18.4%)

169

(81.6 %)

P=

.04

38 13

(34.2%)

25

(65.8%)

P=

.13

13 3

(23.1%)

10

(76.9%)

P=

.02

Al-Azhar 216

(10.3%)

42

(19.4%)

174

(80.6%)

42 11

(26.2%)

31

(73.8%)

11 1

(9.1%)

10

(90.9%)

Alexandria 222

(10.5%)

48

(21.6%)

174

(78.4%)

48 19

(39.6%)

29

(60.4%)

19 4

(21.1%)

15

(78.9%)

Assuit 180

(8.5%)

33

(18.3%)

147

(81.7%)

33 6

(18.2%)

27

(81.8%)

6 2

(33.3%)

4

(66.7%)

Benha 205

(9.7%)

57

(27.8%)

148

(72.2%)

57 16

(28.1%)

41

(71.9%)

16 0

(0.0%)

16

(100.0%)

Beni Suef 220

(10.4%)

38

(17.3%)

182

(82.7%)

38 6

(15.8%)

32

(84.2%)

6 0

(0.0%)

6

(100.0%)

Cairo 188

(8.9%)

39

(20.7%)

149

(79.3%)

39 12

(30.8%)

27

(69.2%)

12 2

(16.7%)

10

(83.3%)

Menoufia 248

(11.8%)

53

(21.4%)

195

(78.6%)

53 22

(41.5%)

31

(58.5%)

22 10

(45.5%)

12

(54.5%)

Suez

Canal

199

(9.4%)

59

(29.6%)

140

(70.4%)

59 20

(33.9%)

39

(66.1%)

20 2

(10.0%)

18

(90.0%)

Tanta 221

(10.5%)

49

(22.2%)

172

(77.8%)

49 11

(22.4%)

38

(77.6%)

11 1

(9.1%)

10

(90.9%)

Class Academic

1076

(51.2%)

176

(16.4%)

900

(82.6%)

P<

.001

176 40

(22.7%)

136

(77.3%)

P=

.01

40 4

(10.0%)

36

(90.0%)

P=

.1 Clinical 1024

(48.8%)

280

(27.3%)

744

(72.7%)

280 96

(34.3%)

184

(65.7%)

96 21

(21.9%)

75

(78.1%)

Gender Male

926

(44.1%)

199

(21.4%)

730

(78.6%)

P=

.83

199 71

(35.7%)

128

(64.3%)

P=

.02

71 17

(23.9%)

54

(76.1%)

P=

.08 Female 1174

(55.9%)

257

(21.8%)

920

(78.2%)

257 65

(25.3%)

192

(74.7%)

65 8

(12.3%)

57

(87.7%)

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Enrollment and certificate attainment

Of those who knew about MOOCs, 136 (29.8% [99% CI, 24.3%–35.3%]) were enrolled in at least

one course. Most students (125; 91.9%) registered in 1–5 courses, while only 113 (83.1%) student

reported watching at least one video lecture. Home (109; 99%) was the first place where they watched

these videos. There was no statistically significant difference in enrollment state between males and

females (52.2% vs 47.8%, 99% CI, P= .016). However, there was a significant difference between

students’ class and their enrollment (P=.009) (Table 1). Coursera was the most commonly used website

(99; 72.8%), followed by Edx (14; 10.3%).

Only 25 students (18.4% [99% CI, 9.8%–26.9%]) completed courses and attained one certificate or

more with 81.6% dropout rate. Interestingly, more than half of students who earned certificates (13;

52% [99% CI, 26.3%–77.7%]) have verified them from the universities that proposed the courses. The

vast majority of enrolled students assumed that getting a certificate is important to them (32 [23.5%]

very important, 37 [27.2%] important, 50 [36.8%] important to some extent, and 17 [12.5%] not

important). Out of the 69 students who assumed that getting a certificate is important before enrollment

(important/very important), 17 were finally certified (24.6%); compared to only 8 certified students out

of the 67 who were not concerned with having certificates (important to some extent/not important;

11.9%); P< .001.

Ways of knowledge and students’ motivations

To assess how students knew about MOOCs and what were their motivations, two multi-select

questions were addressed. Social media was the main way through which 206 (45.2%) students knew

about MOOCs, while knowledge through a friend was the second (184; 40.4%). Using web-search

engines (87; 19.1%) was in the third place, followed by extracurricular activities (46; 10.1%). MOOCs

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providers’ advertisements played a very small role (27; 5.9%) in reaching students as did medical

schools’ official websites (15; 3.3%). Notably, there was no association between the ways through

which student learned about MOOCs and their enrollment. Nevertheless, students who knew through

extracurricular activities were found to enroll more frequently (P= .005).

Concerning students’ motives, most students reported that their main motivation was “to learn new

things” followed by “to help me studying medicine” (Figure 2). Interestingly, the students who enrolled

aiming to have a certificate or to help them in obtaining a future job were significantly more likely to

complete the courses (P= .001) and (P= .008), respectively.

MOOCs and Medicine

By asking the enrolled students (n=136) about their experience and attitude toward medical MOOCs,

103 (75.7% [99% CI,66.2%–85.2%]) declared participation in at least one medical course. Of them, 24

students (17.6% [99% CI, 7.9%–27.3%]) had completed medical courses and earned certificates.

Regarding their medical MOOCs experience, 102 (75%) students agreed that MOOCs helped them in

developing their theoretical background about the topic discussed. However, there was less agreement

(68; 50%) on the role of MOOCs in developing their practical skills. Most students (89; 86.4%) agreed

that MOOCs help in studying medicine, while 83 (61%) believed that MOOCs will help them in getting

a better future job opportunity.

Limitations of MOOCs

Our study reported two types of limitations: enrollment and completion. Students who knew about

MOOCs, but did not enroll in any courses (n=320) were asked about their enrollment limitations. The

majority of students (226; 70.4%) agreed that lack of time was the main limitation, while 147 (45.9%)

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agreed that slow internet speed was another cause (Figure 3). Regarding completion limitations, the

enrolled students (n=136) were asked to assess the limitations that made them drop out of courses.

Similar to the enrollment limitations, it was obvious that lack of time (105; 77.2%) and slow internet

speed (73; 53.7%) were the main obstacles. While lack of technology access, computer literacy,

language difficulty and culture conflicts had less agreement on their roles as limitations (Figure

3). Only 16 (11.8%) students agreed that the scientific content was difficult. In addition, 93 (68.4%)

students disagreed that “low content than expected” is to be a limitation.

For further assessment of the internet speed, we asked the enrolled students to rate their internet

speed. Sixty students (44.1%) reported that the speed was reasonable while 55 (40.4%) reported slow

speed and only 21 (15.4%) had a higher connection speed. When we compared the students’ evaluation

of internet speed and if they watched video lectures or not, we did not find a significant association (P=

.69).

Students’ satisfaction of MOOCs

The 25 students who obtained certificates were asked to report their opinions about each part of the

MOOCs experience. The results showed that most students (21; 84%) were satisfied with the overall

experience, including video lectures (18; 70%), exams and assignments (16; 64%), quality of the

presented materials (21; 84%), and the technology used (20; 80%). However, there was less satisfaction

regarding student–student (5; 20%) and student–instructor (8; 32%) interactions (Figure 4).

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DISCUSSION

Available information about MOOCs participants is data obtained from course-end demographics,

which usually reports heterogeneous populations of different age groups and educational levels from

different countries globally. These data show that most MOOCs’ users are well-educated males with

low participation from developing countries and undergraduates.9-11

To our knowledge, this study is the

first in the medical field and in one of the developing countries to use a cross-sectional study design in

a homogeneous population for assessment of prevalence and uptake of such courses among

undergraduate medical students.

Knowledge and Enrollment

Our results show a funnel-shaped participation pattern, with 22.7 % of the respondents knowing

about MOOCs and 6.5% actually enrolled. Moreover, only 5.4% watched videos and 1.2% obtained

certificates. Although there are no similar cross-sectional studies with which our results can be

compared, the knowledge of about one-fifth of the Egyptian medical students about MOOCs is

considered promising in a developing country that depends mainly on regular education. Additionally,

these courses are still new and there was little role of MOOCs providers’ advertisements for reaching

students beside that there is no any medical MOOC which is given by an Egyptian institution till now.

Social media and personal experience transfer among friends played a vital role in the spreading of the

MOOCs’ idea, raising students’ awareness to this level. This is in line with the uprising role of social

media websites in medical students’ life with more than 90% of medical students in the US using social

media.12

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Notably, it was obvious that there is a disproportion between knowledge about MOOCs and

enrollment with only one-third of students having the awareness registered in courses. The students

reported lack of time and low internet speed as the main limitations. From these enrolled students,

18.4% (23.3% for medical courses) completed courses and earned certificates. These completion rates

are higher than the reported average completion rates in the course demographics. In 2013, The

Chronicle of Higher Education suggested an average of 7.5% completion rate 13, while a recent study in

2014 reported a rate of about 6.5%.14 This may be explained by the reported importance of certificates

for students to add to their resumes hoping for better future chances. It was interesting to note that

about half of them paid money to verify their certificates, although there is no academic credit for

undergraduates for any MOOCs from any medical school in the US 15 and Egypt till now.

Although there was no association between gender and students’ knowledge or enrollment, class had

a significant association. Clinical year students were found to have higher knowledge and enrollment

rates. This may be due to the high stress and pressures experienced by first years medical students

adapting new systems with little time available for extracurricular activities.16 In contrast, final year

students were reported to have less stress 16-18

with more attention to their career plans by searching for

new learning channels to increase their competitiveness.

MOOCs and Medicine

Of the enrolled students, 75.7% participated in at least one medical course with 23.3% completion

rate. They strongly agreed that these courses helped them develop theoretical background about the

topics discussed with less agreement on their role in developing their clinical skills. This raises

questions about the effectiveness of MOOCs with the current lecture-based teaching style in covering

the different aspects of medical education, including its clinical part, which needs student–patient

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interaction. However, in the new evolving era of online learning, a question arises: “why to waste

precious class time on a lecture?” Students may watch the instructor’s lecture remotely in their homes

and utilize class time for learning clinical skills.19 Most of the current opinions expect a complementary

role of MOOCs in undergraduate education with an increasing role in educating those students after

their graduation in continuing medical education.15

MOOCs limitations in Egypt

Lack of time and slow internet speed were the two main limitations reported for causing low

MOOCs enrollment and course completion rates. MOOCs, being a self-learning educational system,

require a considerable amount of time to choose courses, watch videos, take exams and interact through

discussions. This imposes burden on students, leading to the need of increased commitments beside

their busy regular medical education. Time management, either in the design of courses or from

participants, is critically needed to enhance their performance and increase completion rates.

Low internet speed is a commonly reported problem facing online education in developing

countries.20 This problem prolongs the time needed to watch high-quality videos or to download course

content, rendering students less adherent and more susceptible to dropout. The main solution to this

problem is enhancing the internet infrastructure in Egypt. Liyanagunawardena et al. suggested allowing

lower resolution versions of the videos as an alternative solution to help engaging students with limited

bandwidth.8 Interestingly, we did not find computer literacy, language or culture as barriers, although it

was expected that they would represent problems in Egypt, being a developing country.

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MOOCs experience satisfaction

Encouragingly, most of the participants who completed MOOCs (n= 25) were satisfied with the

overall experience. However, there was an obvious dissatisfaction regarding student–student and

student–instructor interactions. This problem is in pervasive in online education in general, with a lack

of face-to-face interaction leading to some feelings of isolation and disconnectedness, which are

thought to be two main factors in dropout rates.21 Some MOOCs providers such as Coursera support

efforts beside the usual discussion forums for overcoming this point. These include more peer

assessments, social media groups, Google hangouts and real in-person Meetups. Despite that, more

involvement of participants is still needed to ensure the full psychological presence.

Study strengths and limitations

The strength of our study is that it included participants from all study years in 10 institutions,

covering nearly the entire geographic area of Egypt with high confidence interval (99%) and high

response rate (83.3%). However, our main limitation was the relatively low returned number of

participants who enrolled (n=136) and who had certificates (n=25), which makes analysis of limitations

and satisfactions less reliable. However, these results are important as a first start to make an evidence

about the real prevalence of MOOCs in Egypt to help the future studies to bluid upon and take more

representative samples to the students who knew about MOOCs for a better understanding of their

experience.

Conclusions:

Approximately one-fifth of undergraduate medical students in Egypt have heard about MOOCs.

Students who actively participated showed a positive attitude toward the experience, but better time

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management skills and faster internet connection speeds are required. Furthor studies are needed to

address the enrolled students to assess their experience in large representative samples. In addition,

more efforts are needed to be done to raise the awareness of students of such courses as most of

students who did not hear about MOOCs, showed interest to participate.

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STATEMENTS:

Acknowledgements: The authors deeply acknowledge Hadeer Alsayed, Islam Shedeed (Menoufia

University), Zyad Abdelaziz, Dina Maklad, Ahmed Gebreil, Mahmoud Medhat (Alexandria university),

Mohammed Alhendy, Aya Sobhy, Omar Azzam (Al-Azhar University in Cairo), Hassan Aboul Nour,

Sara Elganzory (Tanta university), Mohamed Eid, Aya Talaat, Mohamed Emad (Beni Suef university),

Mohamed Abdelzaheer, Ahmed Abdelhamed, Ahmed Saleh (Suez Canal university), Ahmed Zain,

Khaled Ghaleb, Yossri Mohamed (Benha university), Ahmed Alaa, Mohamed Gamal (Assuit

university), Marina Nashed, Ibrahim Abdelmone'm (Ain Shams university), Bassant Abdelazeim,

Ramadan Zaky (Cairo university) for their assistance in data collection. None of them received

compensation for their assistance.

Contributors: Aboshady, Radwan and Hassouna were responsible for the conception and design of the

study. Aboshady and Radwan coordinated the study and managed the data collection. Aboshady,

Radwan, Eltaweel, Azzam, Aboelnaga, Darwish, Hashem, Salah, Kotb, Afifi, Noaman and Salem

collected the data. Hassouna did the analyses, Aboshady, Radwan, Hassouna, Eltaweel, Kotb and

Aboelnaga contributed to interpretation of the findings. Aboshady, Eltaweel and Azzam wrote the first

draft of the manuscript while Radwan, Hassouna, Aboelnaga, Kotb, Hashem, Salah, Darwish, Salem,

Afifi and Noaman made a critical revision of the manuscript for important intellectual content. All

authors approved the final version of the manuscript.

Funding: All funding required was provided by Aboshady and Radwan on their own expenses.

support for this project.

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Competing interests: None.

Ethics approval: Institutional Review Board at Menoufia University, Faculty of Medicine, Egypt.

Data sharing statement: No additional data are available.

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REFERENCES

1. Gooding I, Klaas B, Yager JD, Kanchanaraksa S. Massive Open Online Courses in Public Health.

Front Public Health 2013;1 doi: 10.3389/fpubh.2013.00059

2. Hoy MB. MOOCs 101: an introduction to massive open online courses. Med Ref Serv Q

2014;33(1):85-91 doi: 10.1080/02763869.2014.866490.

3. Pappano L. The Year of the MOOC. The New York Times 2013.

4. A Triple Milestone: 107 Partners, 532 Courses, 5.2 Million Students and Counting! Coursera Blog:

Coursera 2013.

5. Liyanagunawardena TR, Williams SA. Massive open online courses on health and medicine: review.

J Med Internet Res 2014;16:e191. doi:10.2196/jmir.3439

6. Mehta NB, Hull AL, Young JB, Stoller JK. Just imagine: new paradigms for medical education.

Acad Med 2013;88(10):1418-23 doi:0.1097/ACM.0b013e3182a36a07.

7. Cooke M, Irby DM, O'Brien BC. Educating physicians: a call for reform of medical school and

residency: John Wiley & Sons, 2010; 25(2): 193–195

8. Liyanagunawardena T, Williams S, Adams A. The impact and reach of MOOCs:a developing

countries’ perspective. eLearning Papers 2013(33)

9. Emanuel EJ. Online education: MOOCs taken by educated few. Nature 2013;503(7476):342-42 doi:

10.1038/503342a.

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10. Group ME. MOOCs @ Edinburgh 2013: Report #1: the University of Edinburgh, 2013.

11. Huhn C. UW‐Madison Massive Open Online Courses (MOOCs): Preliminary Participant

Demographics: Academic Planning and Institutional Research, 2013.

12. Bosslet GT, Torke AM, Hickman SE, Terry CL, Helft PR. The patient-doctor relationship and

online social networks: results of a national survey. J Gen Intern Med 2011;26(10):1168-74 doi:

10.1007/s11606-011-1761-2|.

13. Kolowich S. The professors who make the MOOCs. The Chronicle of Higher Education 2013;25

14. Jordan K. Initial trends in enrolment and completion of massive open online courses. The

International Review of Research in Open and Distance Learning 2014;15(1)

15. Harder B. Are MOOCs the future of medical education? Bmj 2013;346:f2666 doi:

10.1136/bmj.f2666|.

16. Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: a cross-sectional

study. Med Educ 2005;39(6):594-604 doi: 10.1111/j.1365-2929.2005.02176.x.

17. Guthrie E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress and burnout

in medical students: a five-year prospective longitudinal study. J R Soc Med 1998;91(5):237-43

18. Bassols AM, Okabayashi LS, Silva AB, et al. First- and last-year medical students: is there a

difference in the prevalence and intensity of anxiety and depressive symptoms? Rev Bras Psiquiatr

(Sao Paulo, Brazil : 1999) 2014;0:0

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19. Frehywot S, Vovides Y, Talib Z, et al. E-learning in medical education in resource constrained low-

and middle-income countries. Hum Resour Health 2013;11(1):4 doi: 10.1186/1478-4491-11-4.

20. Angelino LM, Williams FK, Natvig D. Strategies to Engage Online Students and Reduce Attrition

Rates. Journal of Educators Online 2007;4(2):n2

21. Prober CG, Heath C. Lecture halls without lectures--a proposal for medical education. N Engl J

Med 2012;366(18):1657-9 doi: 10.1056/NEJMp1202451.

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Fig. 1: Questionnaire branching logic questions and the number of responders to each one.

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0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

Lack of Time Low Internet

Speed

Difficulty of

Language

Lack of

Technology

Access

Computer

Literacy

Beliefs Conflict

Fig. 2: Students’ motives for enrollment in MOOCs reported by 136 students.

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3%

10%

12%

13%

46%

70%

20%

11%

32%

16%

17%

14%

63%

73%

44%

64%

34%

11%

0% 20% 40% 60% 80% 100%

Beliefs Conflict

Lack of Technology

Access

Difficulty of Language

Computer Literacy

Low Internet Speed

Lack of Time

Enrollment Limitations

n= ��#

3%

12%

14%

10%

54%

77%

8%

11%

23%

8%

10%

13%

82%

74%

62%

79%

35%

10%

0% 20% 40% 60% 80% 100%

Completion limitations

n= �6$

Agree

Neutral

Disagree

Fig. 3: Enrollment and completion limitations.

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Fig. 4: Student satisfaction regarding each part of MOOCs experience.

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STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies

Item

No Recommendation

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract

(done)

(b) Provide in the abstract an informative and balanced summary of what was done

and what was found (done)

Introduction

Background/rationale 2 Explain the scientific background and rationale for the investigation being reported

(done)

Objectives 3 State specific objectives, including any prespecified hypotheses (done)

Methods

Study design 4 Present key elements of study design early in the paper (done)

Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment,

exposure, follow-up, and data collection (done)

Participants 6 (a) Give the eligibility criteria, and the sources and methods of selection of

participants (done)

Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect

modifiers. Give diagnostic criteria, if applicable (done)

Data sources/

measurement

8* For each variable of interest, give sources of data and details of methods of

assessment (measurement). Describe comparability of assessment methods if there is

more than one group (Not applicable)

Bias 9 Describe any efforts to address potential sources of bias (done)

Study size 10 Explain how the study size was arrived at (done)

Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable,

describe which groupings were chosen and why (done)

Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding

(done)

(b) Describe any methods used to examine subgroups and interactions (done)

(c) Explain how missing data were addressed (Not applicable)

(d) If applicable, describe analytical methods taking account of sampling strategy

(Not applicable)

(e) Describe any sensitivity analyses (Not applicable)

Results

Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially

eligible, examined for eligibility, confirmed eligible, included in the study,

completing follow-up, and analysed (done)

(b) Give reasons for non-participation at each stage

(c) Consider use of a flow diagram (done)

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and

information on exposures and potential confounders

(b) Indicate number of participants with missing data for each variable of interest

(done)

Outcome data 15* Report numbers of outcome events or summary measures(done)

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and

their precision (eg, 95% confidence interval). Make clear which confounders were

adjusted for and why they were included (done)

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(b) Report category boundaries when continuous variables were categorized (Not

applicable)

(c) If relevant, consider translating estimates of relative risk into absolute risk for a

meaningful time period (Not applicable)

Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and

sensitivity analyses(Not applicable)

Discussion

Key results 18 Summarise key results with reference to study objectives (done)

Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or

imprecision. Discuss both direction and magnitude of any potential bias (done)

Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations,

multiplicity of analyses, results from similar studies, and other relevant evidence

(done)

Generalisability 21 Discuss the generalisability (external validity) of the study results (done)

Other information

Funding 22 Give the source of funding and the role of the funders for the present study and, if

applicable, for the original study on which the present article is based (Not

applicable)

*Give information separately for exposed and unexposed groups.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and

published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely

available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is

available at www.strobe-statement.org.

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Journal: BMJ Open

Manuscript ID: bmjopen-2014-006804.R1


Date Submitted by the Author: 20-Nov-2014




<b>Primary Subject







jopen.bmj.com

/B

MJ O


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Title Page

Title



Authors

- Omar A. Aboshady



- Ahmed E. Radwan



- Asmaa R. Eltaweel

� 6th year medical student, Faculty of Medicine, Alexandria University,Alexandria, Egypt.


- Ahmed Azzam



- Amr A. Aboelnaga



- Heba A. Hashem

� 6thyear medical student, Faculty of Medicine, BeniSuef University, BeniSuef, Egypt.


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- Salma Y. Darwish



- Rehab Salah



- Omar N. Kotb



- Ahmed M. Afifi



- Aya M. Noaman



- Dalal S. Salem

� 6thyear medical student, Faculty of Medicine, Cairo University, Cairo, Egypt.


- Ahmed Hassouna




Omar AliAboshady


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Tel:+2-048-2282698 / +2-01010747627

E-mail:[email protected]

Fax:+2-048-2326810

Postal code:32718

Key Words:



Word Count:



- Text: 3340 words


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ABSTRACT




Design:A multi-center, cross-sectionalstudy using a web-based,pilot-tested and self-administered

questionnaire.

Settings: Ten out of 19 randomly selected medical schools in Egypt by simple random sampling

technique.










courses earning certificates. Clinical years`students showed significantly higher rates of knowledge (P=

.009) and enrolment (P< .001) than academic year students. The primary reasons for incompletion of

courses included lack of time (105; 77.2%) and slow internet speed (73; 53.7%). Of the 25 students

who completed courses, 21 (84%) were satisfied with the overall experience. However, there was less

satisfaction regarding student-instructor (8; 32%) and student-student (5; 20%) interactions.

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with only about 6.5% actively enrolled in courses.However, students who actively participated showed





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- This study is the first to assess the actual prevalence of awareness and use of MOOCs among medical

students in Egypt.




- There was relatively low returned number of participants who enrolled and who had certificates,


- The study results cannot be generalizable to all developing countries.

INTRODUCTION

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high expectations to solve challenges facing higher education.1 The idea behind MOOCs is to offer



discussion forums to discuss course materials or to get help.2 These courses have gained immense

popularity over a short period, attracting millions of participants and crossing the barriers of location,

gender, race and social status; making 2012 the year of MOOCs according to New York Times.3

Coursera, the largest MOOCs provider, in its latest infograph in October 2013 showed an extraordinary

growth reaching more than 100 institutional partners, more than 500 courses and more than five million

students.4

In medical education, the number of related MOOCs is steadily increasing. In a recent study in 2014,

it was found that 98 free courses were offered during 2013 in the fields of health and medicine with an

average length of 6.7 weeks.5 These courses were introduced as a possible solution that may help

solving great challenges facing medical education.6 These challenges include the issues of quality, cost

and the ability to deliver education to adequate number of students who will cover the health care

system`s needs.7 Nowdays, there are ongoing discussions aiming to determine the role of MOOCs in

medical education. However, information about how medical students perceive such courses is still

limited, especially in developing countries where high-quality learning is often scarce.

Although MOOCs are considered as a hope to provide developing countries with education of high

quality, the current demographic data reveal that most of the MOOCs` participants are from developed

countries with very low participation rates from low-income countries, especially in Africa.4 Low

participation rate was thought to be due to various complicated conditions, such as lack of access to

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digital technologies, linguistic and cultural barriers and poor computer skills.8 In addition, lack of

awareness of the presence of this newly introduced concept may be considered as another problem.





will assess the limitations that hinder students from enrolment and completing the courses, besides

assessing the satisfaction level of using MOOCs to better understanding of the role these courses in

medical education.

METHODOLOGY


administered questionnaire. The institutional review board at Faculty of Medicine, Menoufia

University, Egypt, ethically approved the study.

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Our target population was undergraduate medical students in Egypt enroled in 19 medical schools for

the academic year 2013/14. We selected ten out of the 19 medical schools to be our study settings using

simple random sampling technique. The sample included Ain Shams, Al-Azhar medical school in

Cairo, Alexandria, Assiut, Benha, BeniSuef, Cairo, Menoufia, Suez Canal and Tanta medical schools.

Students in these schools are enroled in a six-year MBBCh program, in which the first three years are

called academic years and the last three years are called clinical years. According to 99% confidence

interval (CI), 3% margin of error and 50% response distribution; 1784 students were required to

represent the study population. We used a stratified simple random technique to select our sample with

an equal allocation of participants in each university and each study year. Accordingly, using the

registered students`names lists, we randomly selected 270 students from each faculty (45 for each study

year) for a total of 2700 participants. We excluded non-Egyptians students and those who changed their

enrolment school at the time of data collection.

Data collection

We invited the selected participants via e-mail and social media websites to take our survey using a

unique code for each participant during the period of March–April 2014. We used an online survey

program to administer the questionnaire (Survey Gizmo; Boulder, Colorado, US). Students who did not

have access to the internet at the time of data collection were allowed to record their responses using a

self-administered paper version of the questionnaire. We sent up to five reminder messages for



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medical schools. Detailed feedback about the format, clarity and completion time was collected and we

made minor changes in response toparticipants`comments. We did not include the pilot responses in our

analysis.

The questionnaire was in Arabic, the participants`native language, and it comprised 29 questions in

four sections using branching logic function (Figure 1). The first section addressed study aims, consent

and participants` personal information. This section was followed by a main question asking about their

knowledge about MOOCs. Based on this answer, participants were directed to different sections.

Students who knew about MOOCs were asked how they heard about it and their state of enrolment. If

the participant was not enrolled in any course, he/she was asked about the limitations, and then the

questionnaire ends.




assess students`opinion about integration of MOOCs in the medical field.


multi-select check-box questions. For assessment of limitations, satisfaction and opinions, a five-point

Likert scale between one (strongly agree/satisfied) and five (strongly disagree/unsatisfied) was used.

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Results were presented as numbers and percentages with confidence interval at 99%. The significance

of the association between qualitative variables of interest was analyzed using Chi-square test or

Fisher`s exact test, as indicated. In order to focus on clear opinions, the five-point Likert scale of

limitations, satisfaction and opinions were collapsed into three categories (agree/satisfied, neutral and



certificate before enrolment was also recoded as a dichotomous variable (important/very important

versus limited importance/not important) in order to test the significance of association between the


McNemar test. All tests were bilateral and a P value of 0.01 was the limit of statistical significance.

Statistical analysis was performed using the IBM SPSS statistical software package version 22.

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RESULTS



enrolment school, in addition to 111 (4.1%) students` whose contact information could not be reached

with final eligible 2527 students. During the data collection phase, 2357 (93.3%) online questionnaire


responses were received (response rate 83.3%). Table 1 showes participants`demographics regarding


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and females (43.6% vs. 56.4%, 99 CI, P = .8). However, clinical years` students had higher rates of


difference between medical schools in students` knowledge about MOOCs (P=.04).

After informing the students who did not know about MOOCs that this system provides scientific

courses in different disciplines by specialists from top universities worldwide for no or low fees

through the internet, 1342 (81.3% [99% CI, 78.8%–83.8%]) students showed an interest to participate

with a significant difference among different medical schools (P< .001).


attainment.


value


value


value Total (%)

(n=2106)

Yes (%)

(n=456)

No (%)

(n=1650)

Total

(n=456)

Yes (%)

(n=136)

No (%)

(n=320)

Total

(n=136)

Yes (%)

(n=25)

No (%)

(n=111)


(9.8%)

38

(18.4%)

169

(81.6 %)

P=

.04

38 13

(34.2%)

25

(65.8%)

P=

.13

13 3

(23.1%)

10

(76.9%)

P=

.02

Al-Azhar 216

(10.3%)

42

(19.4%)

174

(80.6%)

42 11

(26.2%)

31

(73.8%)

11 1

(9.1%)

10

(90.9%)

Alexandria 222

(10.5%)

48

(21.6%)

174

(78.4%)

48 19

(39.6%)

29

(60.4%)

19 4

(21.1%)

15

(78.9%)

Assuit 180

(8.5%)

33

(18.3%)

147

(81.7%)

33 6

(18.2%)

27

(81.8%)

6 2

(33.3%)

4

(66.7%)

Benha 205

(9.7%)

57

(27.8%)

148

(72.2%)

57 16

(28.1%)

41

(71.9%)

16 0

(0.0%)

16

(100.0%)

Beni Suef 220

(10.4%)

38

(17.3%)

182

(82.7%)

38 6

(15.8%)

32

(84.2%)

6 0

(0.0%)

6

(100.0%)

Cairo 188

(8.9%)

39

(20.7%)

149

(79.3%)

39 12

(30.8%)

27

(69.2%)

12 2

(16.7%)

10

(83.3%)

Menoufia 248

(11.8%)

53

(21.4%)

195

(78.6%)

53 22

(41.5%)

31

(58.5%)

22 10

(45.5%)

12

(54.5%)

Suez

Canal

199

(9.4%)

59

(29.6%)

140

(70.4%)

59 20

(33.9%)

39

(66.1%)

20 2

(10.0%)

18

(90.0%)

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Tanta 221

(10.5%)

49

(22.2%)

172

(77.8%)

49 11

(22.4%)

38

(77.6%)

11 1

(9.1%)

10

(90.9%)

Class Academic

1076

(51.2%)

176

(16.4%)

900

(82.6%)

P<

.001

176 40

(22.7%)

136

(77.3%)

P=

.01

40 4

(10.0%)

36

(90.0%)

P=

.1 Clinical 1024

(48.8%)

280

(27.3%)

744

(72.7%)

280 96

(34.3%)

184

(65.7%)

96 21

(21.9%)

75

(78.1%)

Gender Male

926

(44.1%)

199

(21.4%)

730

(78.6%)

P=

.83

199 71

(35.7%)

128

(64.3%)

P=

.02

71 17

(23.9%)

54

(76.1%)

P=

.08 Female 1174

(55.9%)

257

(21.8%)

920

(78.2%)

257 65

(25.3%)

192

(74.7%)

65 8

(12.3%)

57

(87.7%)

Enrolment and certificate attainment

Of those who knew about MOOCs, 136 (29.8% [99% CI,24.3%–35.3%]) were enroled in at least one

course. Most students (125; 91.9%) registered in 1–5 courses, while only 113 (83.1%) students reported

watching at least one video lecture. Home (109; 99%) was the first place where they watched these

videos. There was no statistically significant difference in enrolment state between males and females

(52.2% vs. 47.8%, 99% CI, P= .016). However, there was a significant difference between students`

class and their enrolment (P=.009) (Table 1). Coursera was the most commonly used website (99;

72.8%), followed by Edx (14; 10.3%).



52% [99% CI,26.3%–77.7%]) have verified them from the universities that proposed the courses. The

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very important, 37 [27.2%] important, 50 [36.8%] important to some extent and 17 [12.5%] not

important). Out of the 69 students who assumed that getting a certificate is important before enrolment



11.9%); P< .001.

Ways of knowledge and students`motivations


questions were addressed. Social media was the main way through which 206 (45.2%) students knew

about MOOCs, while knowledge through a friend was the second (184; 40.4%). Using web-search

engines (87; 19.1%) got the third place, followed by extracurricular activities (46; 10.1%). MOOCs

providers` advertisements played a very small role (27; 5.9%) in reaching students as did medical

schools` official websites (15; 3.3%). Notably, there was no association between the ways through

which students learned about MOOCs and their enrolment. Nevertheless, students who knew through

extracurricular activities were found to enrol more frequently (P= .005).

Concerning students` motives, most students reported that their main motivation was “to learn new



complete the courses (P= .001) and (P= .008), respectively.

MOOCs and Medicine


103 (75.7% [99% CI, 66.2%–85.2%]) declared participation in at least one medical course. Of them, 24

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that MOOCs help in studying medicine, while 83 (61%) believed that MOOCs will help them in getting

a better future job opportunity.


Our study reported two types of limitations: enrolment and completion. Students who knew about

MOOCs, but did not enrol in any courses (n=320) were asked about their enrolment limitations. The




Similar to the enrolment limitations, it was obvious that lack of time (105; 77.2%) and slow internet






speed. Sixty students (44.1%) reported that the speed was reasonable, while 55 (40.4%) reported slow

speed and only 21 (15.4%) had a higher connection speed. When we compared the students` evaluation

of internet speed and if they watched video lectures or not, we did not find a significant association (P=

.69).

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Students` satisfaction of MOOCs




presented materials (21; 84%) and the technology used (20; 80%). However, there was less satisfaction


DISCUSSION



different countries globally. These data show that most MOOCs` users are well-educated males with

low participation from developing countries and undergraduates.9-11

To our knowledge, this study is the

first in the medical field and in one of the developing countries to use a cross-sectional study design in

a homogeneous population for assessment of prevalence and uptake of such courses among


Knowledge and Enrolment



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these courses are still new and there was little role of MOOCs providers`advertisements for reaching

students beside that there is no any medical MOOC which is given by an Egyptian institution till now.

Social media and personal experience transfer among friends played a vital role in the spreading of the

MOOCs` idea, raising students` awareness to this level. This is in line with the uprising role of social

media websites in medical students` life with more than 90% of medical students in the US using social

media.12


enrolment with only one-third of students having the awareness registered in courses. The students

reported lack of time and low internet speed as the main limitations. Out of these enrolled students,

18.4% (23.3% for medical courses) completed courses and earned certificates. These completion rates

are higher than the reported average completion rates in the course demographics. In 2013, The

Chronicle of Higher Education suggested an average of 7.5% completion rate 13, while a recent study in

2014 reported a rate of about 6.5%.14 This may be explained by the reported importance of certificates

for students to add to their resumes hoping for better future chances. It was interesting to note that

about half of them paid to verify their certificates, although there is no academic credit for

undergraduates for any MOOCs from any medical school in the US 15 and Egypt until now.

Although there was no association between gender and students` knowledge or enrolment, class had

a significant association. Clinical year students were found to have higher knowledge and enrolment

rates. This may be due to the high stress and pressures experienced by first years` medical students

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adapting new systems with little time available for extracurricular activities.16 In contrast, final year

students were reported to have less stress 16-18

with more attention to their career plans by searching for

new learning channels to increase their competitiveness.

MOOCs and Medicine







precious class time on a lecture?” Students may watch the instructor`s lecture remotely in their homes

and utilize class time for learning clinical skills.19 Most of the current opinions expect a complementary

role of MOOCs in undergraduate education with an increasing role in educating those students after

their graduation in continuing medical education.15



MOOCs enrolment and course completion rates. MOOCs, being a self-learning educational system,


discussions. This imposes burden on students, leading to the need of increased commitments besides



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bandwidth.8 Interestingly, we did not find computer literacy, language or culture as barriers, although it

was expected that they would represent problems in Egypt, being a developing country.MOOCs

experience satisfaction



student–instructor interactions. This problem is common in online education in general, with a lack of

face-to-face interaction leading to some feelings of isolation and disconnectedness, which are thought

to be two main factors in dropout rates.21 Some MOOCs providers such as Coursera support efforts

beside the usual discussion forums for overcoming this point. These include more peer assessments,

social media groups, Google hangouts and real in-person Meetups. Despite that, more involvement of

participants is still needed to ensure the full psychological presence.






and satisfactions less reliable. However, these results are important as a first start to make evidence

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about the real prevalence of MOOCs in Egypt to help the future studies to build upon and take samples

that are representative to the students who knew about MOOCs for a better understanding of their

experience.

Conclusions:



management skills and faster internet connection speeds are required. Further studies are needed to

address the enrolled students to assess their experience in large representative samples. In addition,



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STATEMENTS:

Acknowledgements: The authors deeply acknowledge HadeerAlsayed, Islam Shedeed (Menoufia

University), ZyadAbdelaziz,Dina Maklad, Ahmed Gebreil, Mahmoud Medhat (Alexandria university),

Mohammed Alhendy, AyaSobhy, Omar Azzam (Al-Azhar University in Cairo), Hassan AboulNour,

Sara Elganzory (Tanta university), Mohamed Eid, AyaTalaat, Mohamed Emad (BeniSuef university),


KhaledGhaleb, Yossri Mohamed (Benha university), Ahmed Alaa, Mohamed Gamal (Assuit

university), Marina Nashed, Ibrahim Abdelmone'm (Ain Shams university), BassantAbdelazeim,







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REFERENCES




2014;33(1):85-91 doi: 10.1080/02763869.2014.866490.

3. Pappano L. The Year of the MOOC.The New York Times 2013.


Coursera 2013.





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7. Cooke M, Irby DM, O`Brien BC. Educating physicians: a call for reform of medical school and



countries` perspective. eLearning Papers 2013(33)


10.1038/503342a.






10.1007/s11606-011-1761-2|.





10.1136/bmj.f2666|.



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Med 2012;366(18):1657-9 doi: 10.1056/NEJMp1202451.

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1

Title Page

Title



Authors

- Omar A. Aboshady



- Ahmed E. Radwan



- Asmaa R. Eltaweel



- Ahmed Azzam



- Amr A. Aboelnaga



- Heba A. Hashem



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2

- Salma Y. Darwish

� 3rd

year medical student, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.


- Rehab Salah



- Omar N. Kotb



- Ahmed M. Afifi

� 3rd

year medical student, Faculty of Medicine, Ain Shams University, Cairo, Egypt.


- Aya M. Noaman



- Dalal S. Salem



- Ahmed Hassouna




Omar AliAboshady

6th

year medical student,

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Tel:+2-048-2282698 / +2-01010747627


Fax:+2-048-2326810

Postal code:32718

Key Words:



Word Count:



- Text: 3340 words


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ABSTRACT




Design:A multi-center, cross-sectionalstudy using a web-based,pilot-tested and self-administered

questionnaire.


technique.Ten randomly selected medical schools in Egypt.










courses earning certificates. Clinical years’years`students showed significantly higher rates of

knowledge (P= .009) and enrollmentenrolment (P< .001) than academic year students. The primary

reasons for incompletion of courses included lack of time (105; 77.2%) and slow internet speed (73;

53.7%). Of the 25 students who completed courses, 21 (84%) were satisfied with the overall

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experience. However, there was less satisfaction regarding student-instructor (8; 32%) and student-

student (5; 20%) interactions.


with only about 6.5% actively enrolled in courses.However, students who actively participated showed




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students in Egypt.in Egypt and in the medical field.




- There werewas relatively low returned number of participants who enrolled and who had certificates,


- The study results can notcannot be generaziablegeneralizable to all developing countries.

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INTRODUCTION


high expectations to solve challenges facing higher education.1

The idea behind MOOCs is to offer



discussion forums to discuss talk over course materials or to get help.2

These courses have gained

immense popularity over a short period, attracting millions of participants and crossing the barriers of

location, gender, race and social status; making 2012 the year of MOOCs according to New York

TimesNewYork journal.3

Coursera, the largest MOOCs provider, in its lastestlatest infographinfograph

in October 2013 showed an extraordinary growth reaching more than 100 institutional partners, more

than 500 courses and more than 5five million students.4



average length of 6.7 weeks.5

These courses were introduced as a possible solution that may help

solving great challenges facing medical education nowdays.6 These challenges includeincluding the

issues of quality, costs and the ability to deliver education to enough adequate number of students who

will cover the health care system’s system`s needs.7

Nowdays, there are ongoing discussions aiming to

determine the role of MOOCs in medical educationThere are uprising discussions to determine which

roles MOOCs can play in the medical field.. However, information about how medical students

perceive such courses is still limited, especially in the developing countries where high-quality learning

is often scarce.

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Although there is a great hope that MOOCs can play a role in solving developing countries’ lack of

high quality educationMOOCs are considered as a hope to provide developing countries with education

of high quality, ,the current demographic data reveal that most of the MOOCs’ MOOCs` participants

are from the developed countries with very low participation rates from low-income countries,

especially in Africa.4

These lLow participation rates wererate was thought to be due to various

complicated conditions, such as lack of access to digital technologies, linguistic and cultural barriers

and low poor computer skills.8 In addition, lack of awareness of the presence of this newly introduced

concept may be considered as another problem.





will assess the limitations that prevent students to enroll and completehinder students from enrolment

and completing the courses, besides assessing the satisfaction level of using MOOCs to better

understanding of the role these courses in medical education.

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METHODOLOGY


administered questionnaire. The study was ethically approved by the institutional review board at

Faculty of Medicine, Menoufia University, Egyptinstitutional review board at Faculty of Medicine,

Menoufia University, Egypt, ethically approved the study.


Our target population was undergraduate medical students in Egypt enrolled in 19 medical schools

for the academic year 2013/14. We randomly selected ten out of the 19 medical schools to be our study

settings using simple random sampling technique. The se weresample included Ain Shams, Al-Azhar

medical school in Cairo, Alexandria, Assiut, Benha, BeniSuef, Cairo, Menoufia, Suez Canal and Tanta

medical schools.

Students in these schools are enrolled in a six-year MBBCh program, in which the first three years

are called academic years and the last three years are called clinical years. According to 99%

confidence interval (CI), 3% margin of error and 50% response distribution; 1784 students were

required to represent the study population. According to a confidence interval (CI) of 99%, margin of

error 3%, and response distribution of 50%; 1784 students were required to represent the study

populatioWe used a stratified simple random technique to select our sample with an equal allocation of

participants in each university and each study year. Accordingly, using the registered students’

students`names lists, we randomly selected 270 students from each faculty (45 for each study year) for

a total of 2700 participants. We excluded non-Egyptians students and those who changed their

enrollment school at the time of data collection.

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Data collection

We invited the selected participants via e-mail and social media websites to complete take our survey

using a unique code for each participant during the period of March–April 2014. We used an online

survey program to administer the questionnaire (SurveyGizmoSurvey Gizmo; Boulder, Colorado, US).

Students who did not have access to the internet at the time of data collection were allowed to record

their responses using a self-administered paper version of the questionnaire. We sent up to five

reminder messages for participants to complete the survey. The participants were informed about the

study aims in the cover letter, and they voluntarily consented to participate with no incentives.





medical schools. Detailed feedback about the format, clarity and completion time werefeedback about

the format, clarity and completion time was collected and we made minor changes in response

toparticipants’ participants`comments. We did not include the pilot responses in our analysis.

The questionnaire was in Arabic, the participants’ participants`native language, and it comprised 29

questions in four sections using branching logic function (Figure 1). The first section addressed study

aims, consent and participants’ participants` personal information. This section was followed by a main

question asking about their knowledge about MOOCs. Based on this answer, participants were directed

to different sections. Students who knew about MOOCs were asked how they heard about it and their

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state of enrollmentenrolment. If the participant was not enrolled in any course, he/she was asked about

the limitations, and then the questionnaire ends.




assess students’ students`opinion about integration of MOOCs in the medical field.


multi-select check-box questions. For assessment of limitations, satisfaction and opinions, a 5five-point

Likert scale between 1 one (strongly agree/satisfied) and 5five (strongly disagree/unsatisfied) was used.


Results were presented as numbers and perecentagespercentages with confidence interval at 99%. The

significance of the association between qualitative variables of interest was analyzed using Chi-square

test or Fisher’s Fisher`s exact test, as indicated. In order to focus on clear opinions, the 5-five-point

Likert scale of limitations, satisfaction and opinions were collapsed into 3three categories

(agree/satisfied, neutral and disagree/unsatisfied). Class year was recoded as a dichotomous variable in

order to compare results for students in academic versus clinical education. The acknowledgment of the

importance of getting a certificate before enrollment was also recoded as a dichotomous variable

(important/very important versus limited importance/not important) in order to test the significance of

association between the primarily reported importance of acquiring a certificate and the actual

possession of the certificate by McNemar test. All tests were bilateral and a P value of 0.01 was the

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limit of statistical significance. Statistical analysis was performed using the IBM SPSS statistical

software package version 22.

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RESULTS



enrollment school, in addition to 111 (4.1%) students’ students` whose contact information could not be

reached with final eligible 2527 students. During the data collection phase, 2357 (93.3%) online

questionnaire invitations and 170 (6.7%) paper versions were sent out. Out of these distributed

questionnaires, 2016 responses were received (response rate 83.3%). Table 1 showes participants’

participants`demographics regarding school, class and gender.




and females (43.6% vsvs. 56.4%, 99 CI, P = .8). However, clinical years` students had higher rates of


difference between medical schools in students’ students` knowledge about MOOCs (P=.04).

After clarifying the concept of MOOCs to students who did not know about itAfter informing the

students who did not know about MOOCs that this system provides scientific courses in different

disciplines by specialists from top universities worldwide for no or low fees through the internet, 1342

(81.3% [99% CI, 78.8%–83.8%]) students showed an interest to participate with a significant difference

among different medical schools (P< .001).

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attainment.


value


value


value Total (%)

(n=2106)

Yes (%)

(n=456)

No (%)

(n=1650)

Total

(n=456)

Yes (%)

(n=136)

No (%)

(n=320)

Total

(n=136)

Yes (%)

(n=25)

No (%)

(n=111)


(9.8%)

38

(18.4%)

169

(81.6 %)

P=

.04

38 13

(34.2%)

25

(65.8%)

P=

.13

13 3

(23.1%)

10

(76.9%)

P=

.02

Al-Azhar 216

(10.3%)

42

(19.4%)

174

(80.6%)

42 11

(26.2%)

31

(73.8%)

11 1

(9.1%)

10

(90.9%)

Alexandria 222

(10.5%)

48

(21.6%)

174

(78.4%)

48 19

(39.6%)

29

(60.4%)

19 4

(21.1%)

15

(78.9%)

Assuit 180

(8.5%)

33

(18.3%)

147

(81.7%)

33 6

(18.2%)

27

(81.8%)

6 2

(33.3%)

4

(66.7%)

Benha 205

(9.7%)

57

(27.8%)

148

(72.2%)

57 16

(28.1%)

41

(71.9%)

16 0

(0.0%)

16

(100.0%)

Beni Suef 220

(10.4%)

38

(17.3%)

182

(82.7%)

38 6

(15.8%)

32

(84.2%)

6 0

(0.0%)

6

(100.0%)

Cairo 188

(8.9%)

39

(20.7%)

149

(79.3%)

39 12

(30.8%)

27

(69.2%)

12 2

(16.7%)

10

(83.3%)

Menoufia 248

(11.8%)

53

(21.4%)

195

(78.6%)

53 22

(41.5%)

31

(58.5%)

22 10

(45.5%)

12

(54.5%)

Suez

Canal

199

(9.4%)

59

(29.6%)

140

(70.4%)

59 20

(33.9%)

39

(66.1%)

20 2

(10.0%)

18

(90.0%)

Tanta 221

(10.5%)

49

(22.2%)

172

(77.8%)

49 11

(22.4%)

38

(77.6%)

11 1

(9.1%)

10

(90.9%)

Class Academic

1076

(51.2%)

176

(16.4%)

900

(82.6%)

P<

.001

176 40

(22.7%)

136

(77.3%)

P=

.01

40 4

(10.0%)

36

(90.0%)

P=

.1 Clinical 1024

(48.8%)

280

(27.3%)

744

(72.7%)

280 96

(34.3%)

184

(65.7%)

96 21

(21.9%)

75

(78.1%)

Gender Male

926

(44.1%)

199

(21.4%)

730

(78.6%)

P=

.83

199 71

(35.7%)

128

(64.3%)

P=

.02

71 17

(23.9%)

54

(76.1%)

P=

.08 Female 1174

(55.9%)

257

(21.8%)

920

(78.2%)

257 65

(25.3%)

192

(74.7%)

65 8

(12.3%)

57

(87.7%)

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Enrollment and certificate attainment

Of those who knew about MOOCs, 136 (29.8% [99% CI,24.3%–35.3%]) were enrolled in at least

one course. Most students (125; 91.9%) registered in 1–5 courses, while only 113 (83.1%) students

reported watching at least one video lecture. Home (109; 99%) was the first place where they watched

these videos. There was no statistically significant difference in enrollment state between males and

females (52.2% vsvs. 47.8%, 99% CI, P= .016). However, there was a significant difference between

students’ students` class and their enrollment (P=.009) (Table 1). Coursera was the most commonly

used website (99; 72.8%), followed by Edx (14; 10.3%).



52% [99% CI,26.3%–77.7%]) have verified them from the universities that proposed the courses. The


very important, 37 [27.2%] important, 50 [36.8%] important to some extent, and 17 [12.5%] not

important). Out of the 69 students who assumed that getting a certificate is important before enrollment



11.9%); P< .001.

Ways of knowledge and students’ students`motivations


questions were addressed. Social media was the main way through which 206 (45.2%) students

knewstudents knew about MOOCs, while knowledge through a friend was the second (184; 40.4%).

Using web-search engines (87; 19.1%) was ingot the third place, followed by extracurricular activities

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(46; 10.1%). MOOCs providers’ providers` advertisements played a very small role (27; 5.9%) in

reaching students as did medical schools’ schools` official websites (15; 3.3%). Notably, there was no

association between the ways through which students learned about MOOCs and their enrollment.

Nevertheless, students who knew through extracurricular activities were found to enroll more

frequently (P= .005).

Concerning students’ students` motives, most students reported that their main motivation was “to

learn new things” followed by “to help me studying medicine” (Figure 2). Interestingly, the students

who enrolled aiming to have a certificate or to help them in obtaining a future job were significantly

more likely to complete the courses (P= .001) and (P= .008), respectively.

MOOCs and Medicine


103 (75.7% [99% CI,66.2, 66.2%–85.2%]) declared participation in at least one medical course. Of

them, 24 students (17.6% [99% CI, 7.9%–27.3%]) had completed medical courses and earned

certificates. Regarding their medical MOOCs experience, 102 (75%) students agreed that MOOCs

helped them in developing their theoretical background about the topic discussed. However, there was

less agreement (68; 50%) on the role of MOOCs in developing their practical skills. Most students (89;

86.4%) agreed that MOOCs help in studying medicine, while 83 (61%) believed that MOOCs will help

them in getting a better future job opportunity.


Our study reported two types of limitations: enrollment and completion. Students who knew about

MOOCs, but did not enroll in any courses (n=320) were asked about their enrollment limitations. The

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Similar to the enrollment limitations, it was obvious that lack of time (105; 77.2%) and slow internet







speed and only 21 (15.4%) had) had a higher connection speed. When we compared the students’

students` evaluation of internet speed and if they watched video lectures or not, we did not find a

significant association (P= .69).

Students’ Students` satisfaction of MOOCs




presented materials (21; 84%), and the technology used (20; 80%). However, there was less satisfaction


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DISCUSSION



different countries globally. These data show that most MOOCs’ MOOCs` users are well-educated

males with low participation from developing countries and undergraduates.9-11

To our knowledge, this

study is the first in the medical field and in one of the developing countries to use a cross-sectional

study design in a homogeneous population for assessment of prevalence and uptake of such courses

among undergraduate medical students.

Knowledge and Enrollment






these courses are still new and there was little role of MOOCs providers’ providers`advertisements for

reaching students beside that there is no any medical MOOC which is given by an Egyptian institution

till now. Social media and personal experience transfer among friends played a vital role in the

spreading of the MOOCs’ MOOCs` idea, raising students’ students` awareness to this level. This is in

line with the uprising role of social media websites in medical students’ students` life with more than

90% of medical students in the US using social media.12

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enrollment with only one-third of students having the awareness registered in courses. The students

reported lack of time and low internet speed as the main limitations. From Out of these enrolled

students, 18.4% (23.3% for medical courses) completed courses and earned certificates. These

completion rates are higher than the reported average completion rates in the course demographics. In

2013, The Chronicle of Higher Education suggested an average of 7.5% completion rate 13

, while a

recent study in 2014 reported a rate of about 6.5%.14

This may be explained by the reported importance

of certificates for students to add to their resumes hoping for better future chances. It was interesting to

note that about half of them paid money to verify their certificates, although there is no academic credit

for undergraduates for any MOOCs from any medical school in the US 15

and Egypt tilluntil now.

Although there was no association between gender and students’ students` knowledge or enrollment,

class had a significant association. Clinical year students were found to have higher knowledge and

enrollment rates. This may be due to the high stress and pressures experienced by first yearsyears`

medical students adapting new systems with little time available for extracurricular activities.16

In

contrast, final year students were reported to have less stress 16-18

with more attention to their career

plans by searching for new learning channels to increase their competitiveness.

MOOCs and Medicine






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precious class time on a lecture?” Students may watch the instructor’s instructor`s lecture remotely in

their homes and utilize class time for learning clinical skills.19

Most of the current opinions expect a

complementary role of MOOCs in undergraduate education with an increasing role in educating those

students after their graduation in continuing medical education.15



MOOCs enrollment and course completion rates. MOOCs, being a self-learning educational system,


discussions. This imposes burden on students, leading to the need of increased commitments besides




countries.20

This problem prolongs the time needed to watch high-quality videos or to download course




bandwidth.8

InterestinglyIinterestingly, we did not find computer literacy, language or culture as

barriers, although it was expected that they would represent problems in Egypt, being a developing

country.

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MOOCs experience satisfaction



student–instructor interactions. This problem is in pervasivecommon in online education in general,

with a lack of face-to-face interaction leading to some feelings of isolation and disconnectedness, which

are thought to be two main factors in dropout rates.21

Some MOOCs providers such as Coursera support

efforts beside the usual discussion forums for overcoming this point. These include more peer

assessments, social media groups, Google hangouts and real in-person Meetups. Despite that, more

involvement of participants is still needed to ensure the full psychological presence.






and satisfactions less reliable. However, these results are important as a first start to make an

evidenceevidence about the real prevalence of MOOCs in Egypt to help the future studies to bluidbuild

upon and take more representative samplessamples that are representative to the students who knew

about MOOCs for a better understanding of their experience.

Conclusions:



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management skills and faster internet connection speeds are required. FurthorFurther studies are needed

to address the enrolled students to assess their experience in large representative samples. In addition,



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STATEMENTS:

Acknowledgements: The authors deeply acknowledge HadeerAlsayed, Islam Shedeed (Menoufia

University), ZyadAbdelaziz,Dina Maklad, Ahmed Gebreil, Mahmoud Medhat (Alexandria university),

Mohammed Alhendy, AyaSobhy, Omar Azzam (Al-Azhar University in Cairo), Hassan AboulNour,

Sara Elganzory (Tanta university), Mohamed Eid, AyaTalaat, Mohamed Emad (BeniSuef university),


KhaledGhaleb, Yossri Mohamed (Benha university), Ahmed Alaa, Mohamed Gamal (Assuit

university), Marina Nashed, Ibrahim Abdelmone'm (Ain Shams university), BassantAbdelazeim,













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REFERENCES




2014;33(1):85-91 doi: 10.1080/02763869.2014.866490.



Coursera 2013.





7. Cooke M, Irby DM, O'Brien O`Brien BC. Educating physicians: a call for reform of medical school

and residency: John Wiley & Sons, 2010; 25(2): 193–195


countries’ countries` perspective. eLearning Papers 2013(33)


10.1038/503342a.

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10.1007/s11606-011-1761-2|.





10.1136/bmj.f2666|.








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Med 2012;366(18):1657-9 doi: 10.1056/NEJMp1202451.

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167x202mm (300 x 300 DPI)

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243x145mm (300 x 300 DPI)

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186x105mm (300 x 300 DPI)

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161x118mm (300 x 300 DPI)

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Item

No Recommendation





and what was found (Done) (page 4-5)

Introduction


(Done) (page 7-8)

Objectives 3 State specific objectives, including any prespecified hypotheses (Done) (page 8,

last paragraph)

Methods

Study design 4 Present key elements of study design early in the paper (Done) (page 9, first

paragraph)


exposure, follow-up, and data collection (Done) (page 9-10)


participants (Done) (page 9, last paragraph)


modifiers. Give diagnostic criteria, if applicable (Not applicable)

Data sources/

measurement



more than one group (Done) (page 11)

Bias 9 Describe any efforts to address potential sources of bias (Not done)

Study size 10 Explain how the study size was arrived at (Done) (page 9)


describe which groupings were chosen and why (Done) (page 11)


(Done) (page 11)

(b) Describe any methods used to examine subgroups and interactions (Not

applicable)

(c) Explain how missing data were addressed (Not applicable) (no missing data)


(Done) (page 9,11)

(e) Describe any sensitivity analyses (Not done)

Results



completing follow-up, and analysed (Done) (page 13)

(b) Give reasons for non-participation at each stage (Not done)

(c) Consider use of a flow diagram (Done) (Figure 1)


information on exposures and potential confounders (Done) (Table 1)


(Not Done) (No missing data)

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Outcome data 15* Report numbers of outcome events or summary measures (Done) (page 13-14)



adjusted for and why they were included (Done) (page 13-17)


applicable)




sensitivity analyses (Not applicable)

Discussion

Key results 18 Summarise key results with reference to study objectives (Done) (page 18)


imprecision. Discuss both direction and magnitude of any potential bias (Done)

(page 21)



(Done) (page 18-21)

Generalisability 21 Discuss the generalisability (external validity) of the study results (Done) (page 6,

21)

Other information



applicable) (No external funding)







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Journal: BMJ Open

Manuscript ID: bmjopen-2014-006804.R2


Date Submitted by the Author: 02-Dec-2014




<b>Primary Subject







jopen.bmj.com

/B

MJ O


ownloaded from



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Title Page

Title


developing country: multi-centre cross-sectional study

Authors

- OmarA. Aboshady



- Ahmed E. Radwan



- Asmaa R. Eltaweel

� 6th year medical student, Faculty of Medicine, Alexandria University, Alexandria, Egypt.


- Ahmed Azzam

� 6th year medical student, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.


- Amr A. Aboelnaga



- Heba A. Hashem

� 6th year medical student, Faculty of Medicine, Beni Suef University, BeniSuef, Egypt.


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- Salma Y. Darwish



- Rehab Salah



- Omar N. Kotb



- Ahmed M. Afifi



- Aya M. Noaman



- Dalal S. Salem



- Ahmed Hassouna



Corresponding author

Omar Ali Aboshady

6th year medical student, Faculty of Medicine, Menoufia University.

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Tel:+2-048-2282698 / +2-01010747627


Fax:+2-048-2326810

Postal code:32718

Key Words

Computer-assisted Instruction (MeSH terms); Medical Education (MeSH terms); Distance Education


Word Count



- Text: 3815 words


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ABSTRACT

Objectives: To assess the prevalence of awareness and use of massive open online courses (MOOCs)

among medical undergraduates in Egypt as a developing country, as well as identifying the limitations

and satisfaction of using these courses.

Design: A multi-centre, cross-sectionalstudy using a web-based, pilot-tested and self-administered

questionnaire.

Settings: Ten out of 19 randomly selected medical schools in Egypt.

Participants: 2700 undergraduate medical students were randomly selected, with an equal allocation of


Primary and secondary outcomes measures: Primary outcome measures were the percentages of

students who knew about MOOCs, students who enrolled, and students who obtained a certificate.

Secondary outcome measures included the limitations and satisfaction of using MOOCs through five-


Results: Of 2527 eligible students, 2106 completed the questionnaire (response rate 83.3%). Of these


136 (29.8%) students had enrolled in at least one course, but only 25 (18.4%) of them had completed

courses earning certificates. Clinical years’ students showed significantly higher rates of knowledge

(P= .009) and enrolment (P< .001) than academic years’ students. The primary reasons for the failure

of completion of courses included lack of time (105; 77.2%) and slow Internet speed (73; 53.7%).

Regarding the 25 students who completed courses, 21 (84%) were satisfied with the overall experience.

However, there was less satisfaction regarding student-instructor (8; 32%) and student-student (5; 20%)

interactions.

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Conclusions: About one-fifth of Egyptian medical undergraduates have heard about MOOCs with only

about 6.5% actively enrolled in courses. Students who actively participated showed a positive attitude

towards the experience, but better time-management skills and faster Internet connection speeds are

required. Further studies are needed to survey the enrolled students for a better understanding of their

experience.

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- This study is the first to assess the prevalence of awareness and use of MOOCs among medical

students in Egypt.

- This study includes a large representative sample of ten Egyptian institutions covering nearly the

entire geographic area of Egypt.

- Data are obtained from students in all six undergraduate years.

- There was a relatively low number of respondents who enrolled or successfully completed a MOOC,

which makes the analysis of limitations and satisfaction less reliable.

- The study results cannot be generalised to all developing countries.

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INTRODUCTION

Massive open online courses (MOOCs) have recently been proposed as a disruptive innovation, with

high expectations to meet challenges facing higher education.1 The idea behind MOOCs is to offer

world-class education to a (massive) number of students around the globe with Internet access (online)

for little, or no fees (open). The courses consist of pre-recorded video lectures, computer-graded tests

and discussion forums to review course materials or to get help.2 These courses have gained immense

popularity over a short period of time, attracting millions of participants and crossing the barriers of

location, gender, race and social status; making 2012 the year of MOOCs according to the New York

Times.3 In its latest infograph in October 2013, Coursera (which is the largest MOOCs provider)

demonstrated an extraordinary growth, reaching more than 100 institutional partners, offering more

than 500 courses and enrolling more than five million students.4

In medical education, the number of related MOOCs is steadily increasing. In a recent study, it was

found that 98 free courses were offered during 2013 in the fields of health and medicine with an

average length of 6.7 weeks.5 These courses were introduced as a possible solution to the great

challenges facing medical education.6 These challenges include the issue of quality, cost and the ability

to deliver education to an adequate number of students to cover the health care system’s needs.7

Nowadays, there are ongoing discussions aimed at determining the role of MOOCs in medical

education. However,information about how medical students perceive such courses is still limited,

especially in developing countries where high-quality learning is often scarce.

MOOCs are considered as a solution to providing developing countries with high-quality education.

However, the current demographic data reveals that most of the MOOCs’ participants are from

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developed countries, with very low participation rates from low-income countries, especially in Africa.4

This low participation rate was thought to be due to various complicated conditions, such as the lack of

access to digital technology, linguistic and cultural barriers, and poor computer skills.8 In addition, the

lack of awareness of this newly-introduced concept may be considered to be another problem.

To our knowledge, there are no available cross-sectional studies that have assessed the awareness

and use of MOOCs among medical communities in developing countries, including Egypt. Our study

primarily aims to assess the prevalence of awareness and use of these courses among undergraduate

medical students in Egypt, as an example of a developing country. Secondly, our study aims to assess

the limitations that hinder students from enrolling in and completing the courses, as well as assessing

the satisfaction level of using MOOCs to better understand the role these courses play in medical

education.

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METHODOLOGY

This is a multi-centre, cross-sectional study using a structured, web-based, pilot-tested and self-

administered questionnaire. The institutional review board at Faculty of Medicine, Menoufia



Our target population was undergraduate medical students across Egypt, enrolled in 19 medical

schools during the 2013-14 academic year. We selected ten out of the 19 medical schools to be our

study settings using a simple random sampling technique. Selected institutions included Ain Shams, Al-

Azhar medical school in Cairo, and Alexandria, Assiut, Benha, BeniSuef, Cairo, Menoufia, Suez Canal

and Tanta medical schools.

Students in these schools were enrolled in a six-year MBBCh program, in which the first three years

are called academic years and the last three years are called clinical years. To achieve a 99%

confidence interval (CI), 3% margin of error and 50% response distribution,1784 students were

required to represent the study population. We used a stratified simple random technique to select our

sample with an equal allocation of participants in each university and each study year. Accordingly,

using the registered students’ names lists, we randomly selected 270 students from each faculty (45 for

each study year) for a total of 2700 participants. We excluded non-Egyptian students and those who

changed their enrolment school at the time of data collection.

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Data Collection

Selected participants were invited by email and social media websites to participate in our survey

using a unique code for each participant during the period of March–April 2014. In each university, a

team of data collectors was recruited (two active members from each class), which were led by a local

study coordinator (LSC). This team received standardised training on how to approach selected

students either online or offline. Each LSC was responsible for obtaining the students lists for each

class through official channels. The two principle investigators selected the students randomly from

these lists according to the planned sampling technique. Initially, participants from two universities

were invited using their official emails. However, there was very low response rate as many students do

not check their emails regularly, which is partially explained by the fact that this email service was not

introduced into Egyptian universities until recently. Therefore, we shifted our data collection plan to the

use of social media websites (mainly Facebook). The majority of Egyptian medical students have

Facebook accounts, and each class has a Facebook group, including all students of that class, for study-

related discussions. The two data collectors of each class were responsible for obtaining the personal

account of each selected student. To confirm that the collected account belonged to the selected student,

a personal message was sent first to this account to confirm his or her personal details. After receiving

the confirmation, a Facebook message was sent containing a cover letter with the study’s aims, the

participant’s special code and a link to the online questionnaire. The student was to first fill out a

voluntary consent form after reading the study aims and instructions. We sent up to five reminder

messages to participants, prompting them to complete the survey. If we did not get a response in two to

three weeks, non-responders were approached in lecture rooms and training sessions to ask them to

complete the questionnaire. If any of them informed us of a lack of Internet access, and if the

respondent agreed to partricipate, a paper version of the questionnaire (same questions and format as

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the online version) was provided for immediate completion. LSC were responsible for entering the data

into our online system. We used an online survey program to administer the questionnaire (Survey

Gizmo; Boulder, Colorado, U.S.).




education and biostatistics. The questionnaire was then piloted on 175 students, from all participating

medical schools. Detailed feedback about the format, clarity and completion time was collected and

used to make minor changes. We did not include the pilot responses in our analysis.

The questionnaire was in Arabic, the participants’ native language, and it included 29 questions in

four sections using a branching logic function (Figure 1). The first section addressed study aims,

consent and participants’ personal information. This section was followed by a main question asking if

the student had heard about the new open online educational system (MOOCs) provided in websites

like Coursra, Edx, Udacity and FutureLearn, among others. Based on his or her answer, the participant

was directed to different sections. Students who knew about MOOCs were asked how they heard about

it and their state of enrolment. If the participant was not enrolled in any course, respondents were asked

about the limitations to their use, and then the questionnaire ended.

Enrolled students were directed to the next section, which assessed their perspectives and

experiences with MOOCs. For students who gained certificates, further questions were asked regarding

their level of satisfaction as well as any obstacles they might have faced. Finally, four questions were

asked to assess students’ opinions about the integration of MOOCs into the medical field.

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Most of the questions were in a single-answer multiple-choice format. However, there were three

multi-selection check-box questions. For the assessment of limitations, satisfaction and opinions, a five-

point Likert scale between one (strongly agree/satisfied) and five (strongly disagree/unsatisfied) was

used.

Statistical Analysis

Results were presented as numbers and percentages with the confidence interval at 99%. The

significance of the association between qualitative variables of interest was analysed using chi-square

or Fisher`s exact tests, as indicated. To focus on clear opinions, the five-point Likert scale of

limitations, satisfaction and opinions was collapsed into three categories (agree/satisfied, neutral and



certificate before enrolment was also recoded as a dichotomous variable (important/very important

versus limited importance/not important). This was to test the significance of association between the


McNemar test. All tests were bilateral and a P value of 0.01 was used as the limit of statistical

significance. Statistical analysis was performed using the IBM SPSS statistical software package

version 22.

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RESULTS

Respondent Characteristics

Of 2700 total participants, 62 (2.3%) were excluded for being non-Egyptians or having changed their

enrolment school, in addition to 111 (4.1%) students who could not be reached, resulting in a final

eligible cohort of 2527 students. During the data collection phase, 2357 (93.3%) online questionnaire


responses were received (response rate 83.3%). Table 1 shows participants’ demographics regarding





and females (43.6% vs. 56.4%, 99 CI, P = .8). However, clinical years’ students had higher rates of


difference between medical schools in the students’ knowledge about MOOCs (P=.04).


courses in different disciplines given by specialists from top universities worldwide for no or low fees

through the Internet, 1342 (81.3% [99% CI, 78.8%–83.8%]) students showed an interest in

participating with a significant difference among different medical schools (P< .001).

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Table 1. Participant demographics and their state of knowledge, enrolment and certificate attainment.


value

Enrolment in courses P

value


value Total (%)

(n=2106)

Yes (%)

(n=456)

No (%)

(n=1650)

Total

(n=456)

Yes (%)

(n=136)

No (%)

(n=320)

Total

(n=136)

Yes (%)

(n=25)

No (%)

(n=111)


(9.8%)

38

(18.4%)

169

(81.6 %)

P=

.04

38 13

(34.2%)

25

(65.8%)

P=

.13

13 3

(23.1%)

10

(76.9%)

P=

.02

Al-Azhar 216

(10.3%)

42

(19.4%)

174

(80.6%)

42 11

(26.2%)

31

(73.8%)

11 1

(9.1%)

10

(90.9%)

Alexandria 222

(10.5%)

48

(21.6%)

174

(78.4%)

48 19

(39.6%)

29

(60.4%)

19 4

(21.1%)

15

(78.9%)

Assuit 180

(8.5%)

33

(18.3%)

147

(81.7%)

33 6

(18.2%)

27

(81.8%)

6 2

(33.3%)

4

(66.7%)

Benha 205

(9.7%)

57

(27.8%)

148

(72.2%)

57 16

(28.1%)

41

(71.9%)

16 0

(0.0%)

16

(100.0%)

BeniSuef 220

(10.4%)

38

(17.3%)

182

(82.7%)

38 6

(15.8%)

32

(84.2%)

6 0

(0.0%)

6

(100.0%)

Cairo 188

(8.9%)

39

(20.7%)

149

(79.3%)

39 12

(30.8%)

27

(69.2%)

12 2

(16.7%)

10

(83.3%)

Menoufia 248

(11.8%)

53

(21.4%)

195

(78.6%)

53 22

(41.5%)

31

(58.5%)

22 10

(45.5%)

12

(54.5%)

Suez

Canal

199

(9.4%)

59

(29.6%)

140

(70.4%)

59 20

(33.9%)

39

(66.1%)

20 2

(10.0%)

18

(90.0%)

Tanta 221

(10.5%)

49

(22.2%)

172

(77.8%)

49 11

(22.4%)

38

(77.6%)

11 1

(9.1%)

10

(90.9%)

Class Academic

1076

(51.2%)

176

(16.4%)

900

(82.6%)

P<

.001

176 40

(22.7%)

136

(77.3%)

P=

.01

40 4

(10.0%)

36

(90.0%)

P=

.1 Clinical 1024

(48.8%)

280

(27.3%)

744

(72.7%)

280 96

(34.3%)

184

(65.7%)

96 21

(21.9%)

75

(78.1%)

Gender Male

926

(44.1%)

199

(21.4%)

730

(78.6%)

P=

.83

199 71

(35.7%)

128

(64.3%)

P=

.02

71 17

(23.9%)

54

(76.1%)

P=

.08 Female 1174

(55.9%)

257

(21.8%)

920

(78.2%)

257 65

(25.3%)

192

(74.7%)

65 8

(12.3%)

57

(87.7%)

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Enrolment and Certificate Attainment

Of those who knew about MOOCs, 136 (29.8% [99% CI,24.3%–35.3%]) were enrolled in at least

one course. Most students (125; 91.9%) registered in 1–5 courses, with 113 (83.1%) students reporting

having watched at least one video lecture. Home (109; 99%) was the primary place where they watched

these videos. There was no statistically significant difference in enrolment between males and females

(52.2% vs. 47.8%, 99% CI, P= .016). However, there was a significant difference between students’

class and their enrolment (P=.009) (Table 1). Coursera was the most commonly used website (99;

72.8%), followed by Edx (14; 10.3%).


more with an 81.6% dropout rate. Interestingly, more than half of students who earned certificates (13;

52% [99% CI,26.3%–77.7%]) have used the signature track to obtain verified certificates from the

universities that offered the courses. The vast majority of enrolled students stated that getting a

certificate was important to them (32 [23.5%] very important, 37 [27.2%] important, 50 [36.8%]

important to some extent, and 17 [12.5%] not important). Out of the 69 students who assumed that

getting a certificate is important before enrolment (important/very important), 17(24.6%) were finally

certified, as compared to only 8(11.6%) certified students out of the 67 who were not concerned to

receive a certificate at the time of enrolment (important to some extent/not important; 11.9%); P< .001.

Ways of Knowledge and Students’ Motivations

To assess how students found out about MOOCs and what their motivations were, two multi-

selection questions were asked. Social media was the primary way through which 206 (45.2%) students

were introduced to MOOCs, while knowledge through a friend was the second (184; 40.4%). Web-

search engines (87; 19.1%) took the third place, followed by extracurricular activities (46; 10.1%).

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MOOCs providers’ advertisements played a very small role (27; 5.9%) in reaching students as did the

official websites of medical schools (15; 3.3%). Notably, there was no association between the method

through which students learnt about MOOCs and their enrolment. Nevertheless, students who were

introduced through extracurricular activities were found to enrol more frequently (P= .005).


things” followed by “to help me study medicine” (Figure 2). Interestingly, the students who enrolled


complete the courses (P= .001 and P= .008, respectively).

MOOCs and Medicine







that MOOCs helped in studying medicine, while 83 (61%) believed that MOOCs will help them in

securing a more desirable, better job opportunity in the future.




majority of students (226; 70.4%) agreed that a lack of time was the main limitation, while 147 (45.9%)

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agreed that slow Internet speed was another cause (Figure 3). Enrolled students (n=136) were asked to

assess the limitations that made them drop out of courses. Similar to the enrolment limitations, lack of

time (105; 77.2%) and slow Internet speed (73; 53.7%) were the main obstacles. Lack of technology

access, computer literacy, language difficulty and culture conflicts were less frequently selected as a

limiting factor to completion of the course (Figure 3). Only 16 (11.8%) students agreed that the

scientific content was difficult for them to comprehend. In addition, 93 (68.4%) students disagreed that

“lower content than expected” wasa limitation.

For further assessment of Internet speed, we asked the enrolled students to rate their Internet speed.

Sixty students (44.1%) reported that the speed was reasonable, while 55 (40.4%) reported slow speed,

and only 21 (15.4%) had a high connection speed. When we compared the students’ evaluation of

Internet speed and whetherthey watched video lectures, we did not find a significant association (P=

.69).

Students’Satisfaction of MOOCs






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DISCUSSION

Available information regarding MOOCs participants is primarily data obtained from course-end

demographics, which usually demonstrate aheterogeneous population of varying age groups,

educational levels and countries globally. These data show that most MOOCs’ users are well-educated

males with low participation from developing countries and undergraduates.9-11

To our knowledge, this

study is the first in the medical field and a developing country to use a cross-sectional study design in a

homogeneous population for the assessment of prevalence and uptake of such courses among



Our results demonstratea funnel-shaped participation pattern, with 22.7 % of the respondents

knowing about MOOCs and 6.5% actually enrolled. Moreover, only 5.4% watched the offered video

lectures and 1.2% obtained certificates of completion. Although there are no similar cross-sectional

studies with which our results can be compared, the knowledge that approximately one-fifth of the

Egyptian medical students are familiar withMOOCs is considered promising in a developing country

that depends mainly on traditional education. Additionally, these courses are still new, and MOOCs

providers’ advertisements had little effect in reaching students. Also, there was no medical MOOC

offered by an Egyptian institution until now. Social media and the sharing of personal experiences

among friends played a vital role in the spread of the MOOCs, raising students’ awareness to its current

level. This is in line with the increasing role of social media websites in medical students’ lives, with

more than 90% of medical students in the U.S. using social media.12

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Notably, it was obvious that there was a gap between knowledge of MOOCs and enrolment in them,

with only one-third of students who knew about MOOCs actually registering in courses. Students

reported a lack of time and low Internet speed as the main limitations for MOOC use. Out of these

students, 18.4% (23.3% when looking at those enrolled in a medical course) completed the courses and

earned certificates. These completion rates are higher than the reported average completion rates in the

course demographics. In 2013, The Chronicle of Higher Education suggested an average of 7.5%

completion rate 13, while a recent study in 2014 reported a rate of about 6.5%.

14 This may be explained

by the importance reported by students that obtaining certificates has in terms of adding to their

resumes in the hope of improving future employment opportunities. It is interesting to note that about

half of them paid to verify their certificates, although there is no academic credit for undergraduates for

any MOOCs from any medical school in the U.S.15 and Egypt at this time.

Although there was no association between gender and students’ knowledge or enrolment, class year

had a significant association. Clinical years’ students were found to have higher knowledge and

enrolment rates. This may be due to the high level of stress and pressures experienced by early-year

medical students adapting to new academic systems with little time available for extracurricular

activities.16 In contrast, students in their final years were reported to have less stress

16-18 with more

concern about their career plans, and searching for new learning channels to increase their

competitiveness.

MOOCs and Medicine

Of the enrolled students, 75.7% participated in at least one medical course with a 23.3% completion

rate. They strongly agreed that these courses helped them to develop theoretical backgrounds on the


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the different aspects of medical education, including its clinical part, which requires student–patient

interaction. However, in the new and evolving era of online learning, the question of why waste

precious class time on a lecture? arises. Students may watch the instructor’s lecture remotely in their

homes and useclass time for learning clinical skills.19 Most current opinions anticipate a

complementary role for MOOCs in undergraduate education, with an increasing role in educating those

students after their graduation in continuing medical education.15

MOOCs Limitations in Egypt

Lack of time and slow Internet speed were the two main limitations reported for causing low


requires a considerable amount of time to choose courses, watch videos, take exams and interact

through discussions. This imposes a significant time burden on students, leading to the need for an

increased commitment beyond their busy regular medical education. Time management, either in the

design of courses or from participants, is critical to the enhancement of their performance and increased

completion rates.

Low Internet speed is a commonly reported problem facing online education in developing



problem is enhancing the Internet infrastructure in Egypt. Liyanagunawardena et al. suggested allowing


bandwidth.8Interestingly, we did not find computer literacy, language or culture as barriers, although it

was expected that they would represent problems in Egypt, being a developing country.

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MOOCs Experience Satisfaction





to be two main factors affecting dropout rates.21 Some MOOCs providers, such as Coursera, support

efforts beyond the usual discussion forums to help overcome this issue. These efforts include more peer

assessments, social media involvment, Google+ hangouts and real in-person meet-ups. Despite that,

more involvement of participants is needed to ensure the full psychological presence.

Study Strengths and Limitations

The strength of our study is that it included participants from all study years in ten institutions,

covering nearly the entire geographic area of Egypt with a high confidence interval (99%) and high


participants who enrolled (n=136) and who had certificates (n=25), which makes the analysis of

limitations and satisfaction of MOOCs less reliable. However, these results provide an important

contribution as a first stepin gathering evidence about the prevalence of perception and use of MOOCs

in Egypt. In addition, these results will facilitate the ability of future studies to build upon our findings

and select samples that are representative of students with prior knowledge of MOOCs, leading to a

better understanding of their experience.

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Conclusions

About one-fifth of in undergraduate medical students Egypt have heard about MOOCs. Students who

actively participated showed a positive attitude towards the experience, but better time management

skills and faster Internet connection speeds are required. Further studies are needed involving enrolled

students in large representative samples, to assess their experiences using MOOCs. In addition, more

effort is needed to raise the awareness among students of such courses, as most students who had not

heard about MOOCs did show interest in participating once they became aware of the courses.

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STATEMENTS

Acknowledgements: The authors acknowledge Hadeer Alsayed, Islam Shedeed (Menoufia

University), Zyad Abdelaziz, Dina Maklad, Ahmed Gebreil, Mahmoud Medhat (Alexandria

University), Mohammed Alhendy, Aya Sobhy, Omar Azzam (Al-Azhar University in Cairo), Hassan

AboulNour, Sara Elganzory (Tanta University), Mohamed Eid, Aya Talaat, Mohamed Emad (Beni

Suef University), Mohamed Abdelzaheer, Ahmed Abdelhamed, Ahmed Saleh (Suez Canal University),

Ahmed Zain, Khaled Ghaleb, Yossri Mohamed (Benha University), Ahmed Alaa, Mohamed Gamal

(Assuit University), Marina Nashed, Ibrahim Abdelmone'm (Ain Shams University), and Bassant

Abdelazeim, Ramadan Zaky (Cairo University) for their highly-valued assistance in data collection. In

addition, we acknowledge Bishoy Gouda (Canada), Susannah L. Bodman (U.S.), Melanie Haines,

Marion Mapham (Australia), Mohamed Aleskandarany (U.K.) and Moahmed Alaa (Egypt) for their

much-appreciated help in the English revision of our paper. None of them received compensation for

their assistance.




collected the data. Hassouna did the analyses;Aboshady, Radwan, Hassouna, Eltaweel, Kotb and





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doi: 10.1038/503342a.

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12. Bosslet GT, Torke AM, Hickman SE, Terry CL, Helft PR. "The patient-doctor relationship and

online social networks: Results of a national survey."J Gen Intern Med 2011;26(10):1168-74 doi:

10.1007/s11606-011-1761-2|.

13. Kolowich S. "The professors who make the MOOCs."The Chronicle of Higher Education 2013;25.

14. Jordan K. "Initial trends in enrolment and completion of massive open online courses."The

International Review of Research in Open and Distance Learning 2014;15(1).

15. Harder B. "Are MOOCs the future of medical education?"Bmj 2013;346:f2666 doi:

10.1136/bmj.f2666|.

16. Dahlin M, Joneborg N, Runeson B. "Stress and depression among medical students: A cross-

sectional study."Med Educ 2005;39(6):594-604 doi: 10.1111/j.1365-2929.2005.02176.x.

17. Guthrie E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. "Psychological stress and

burnout in medical students: A five-year prospective longitudinal study."J R Soc Med 1998;91(5):237-

43.

18. Bassols AM, Okabayashi LS, Silva AB, et al. "First- and last-year medical students: Is there a

difference in the prevalence and intensity of anxiety and depressive symptoms?"Rev Bras Psiquiatr

(Sao Paulo, Brazil : 1999) 2014;0:0.

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19. Frehywot S, Vovides Y, Talib Z, et al. "E-learning in medical education in resource constrained

low- and middle-income countries."Hum Resour Health 2013;11(1):4 doi: 10.1186/1478-4491-11-4.

20. Angelino LM, Williams FK, Natvig D. "Strategies to Engage Online Students and Reduce Attrition

Rates."Journal of Educators Online 2007;4(2):n2.

21. Prober CG, Heath C. "Lecture halls without lectures-a proposal for medical education."N Engl J

Med 2012;366(18):1657-9 doi: 10.1056/NEJMp1202451.

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Title Page

Title



Authors

- Omar A. Aboshady



- Ahmed E. Radwan



- Asmaa R. Eltaweel



- Ahmed Azzam



- Amr A. Aboelnaga



- Heba A. Hashem



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- Salma Y. Darwish



- Rehab Salah



- Omar N. Kotb



- Ahmed M. Afifi



- Aya M. Noaman



- Dalal S. Salem



- Ahmed Hassouna




Omar Ali Aboshady


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Tel: +2-048-2282698 / +2-01010747627

E-mail: [email protected]

Fax: +2-048-2326810

Postal code: 32718

Key Words:



Word Count:


- Abstract: 297 299 words

- Text: 3340 3809 words


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ABSTRACT


(MOOCs) among medical undergraduates in Egypt as a developing country, besides identifyingas well

as identify the limitations and satisfaction of using these courses.

Design:A multi-centercentre, cross-sectional study using a web-based, pilot-tested and self-

administered questionnaire.


technique.

Participants: Randomly selected 2700 undergraduate medical students were randomly selected, with

an equal allocation of participants in each university and each study year.

Primary and secondary outcomes measures: The pPrimary outcome measures were the percentages

of students who knew about MOOCs, students who enrolled and students who obtained a certificate.



Results: Of 2527 eligible students, 2106 filled completed the questionnaire (response rate 83.3%). Of

these students, 456 (21.7%) knew the term MOOCs or websites providing these courses. Out of the

latter, 136 (29.8%) students (29.8%) had enrolled in at least one course, but only 25 (18.4%) of them

had completed courses earning certificates. Clinical years’ students showed significantly higher rates of

knowledge (P= .009) and enrolment (P< .001) than academic years’ students. The primary reasons for

incompletion the failure of completion of courses included lack of time (105; 77.2%) and slow internet

Internet speed (73; 53.7%). Of Regarding the 25 students who completed courses, 21 (84%) were

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satisfied with the overall experience. However, there was less satisfaction regarding student-instructor

(8; 32%) and student-student (5; 20%) interactions.

Conclusions: Approximately About one-fifth of Egyptian medical undergraduates have heard about

MOOCs with only about 6.5% actively enrolled in courses. However, sStudents who actively

participated showed a positive attitude towards the experience, but better time- management skills and

faster internet Internet connection speeds are required. Further studies are needed to address survey the

enrolled students for a better understanding of their experience.

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students in Egypt.

- This study included includes a large representing representative sample of 10ten Egyptian institutions

covering nearly the entire geographic area of Egypt.

- Data are obtained from students in all six undergraduate years.

-

- There was a relatively low number of respondents who enrolled or successfully completed a MOOC,

which makes the analysis of limitations and satisfactions less reliable.

There was relatively low returned number of participants who enrolled and who had certificates, which

makes analysis of limitations and satisfactions less reliable.

- The study results cannot be generalizable generalized to all developing countries.

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INTRODUCTION

Massive open online courses (MOOCs) have been recently proposed as a disruptive innovation, with

high expectations to solve meet challenges facing higher education.1 The idea behind MOOCs is to

offer world-class education to a (massive) number of students around the globe with internet access

(online) for little, or no fees (open). The courses consist of pre-recorded video lectures, computer-

graded tests and discussion forums to discuss review course materials or to get help.2 These courses

have gained immense popularity over a short period of time, attracting millions of participants and

crossing the barriers of location, gender, race and social status; making 2012 the year of MOOCs

according to the New York Times.3 In its latest infograph in October 2013, Coursera which is the

largest MOOCs provider, demonstrated an extraordinary growth, reaching more than 100 institutional

partners, offering more than 500 courses and enrolling more than five million studentsCoursera, the

largest MOOCs provider, in its latest infograph in October 2013 showed an extraordinary growth

reaching more than 100 institutional partners, more than 500 courses and more than five million

students.4



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average length of 6.7 weeks.5 These courses were introduced as a possible solution that may help

solving to solve the great challenges facing medical education.6 These challenges include the issues of

quality, cost and the ability to deliver education to an adequate number of students who will cover the

health care system’s needs.7 Nowadays, there are ongoing discussions aiming to determine aimed at

determining the role of MOOCs in medical education. However, information about how medical

students perceive such courses is still limited, especially in developing countries where high-quality

learning is often scarce.

Although MOOCs are considered as a hope to provide developing countries with high-quality

education of high quality. However, the current demographic data reveal that most of the MOOCs’`

participants are from developed countries, with very low participation rates from low-income countries,

especially in Africa.4 Low participation rate was thought to be due to various complicated conditions,

such as the lack of access to digital technologiestechnology, linguistic and cultural barriers and poor

computer skills.8 In addition, the lack of awareness of the presence of this newly introduced concept

may be considered as another problem.

To our knowledge, there are no available cross-sectional studies that have assessed the actual

prevalence of awareness and use of MOOCs among medical communities in the developing countries,

including Egypt. Our study primarily aims to assess the prevalence of awareness and use of these

courses among Egyptian undergraduate medical students, as an example of a developing country.

Secondly, the our study aims towill assess the limitations that hinder students from enrolment enrolling

in and completing the courses, besides as well as assessing the satisfaction level of using MOOCs to

better understanding of the role these courses in medical education.

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METHODOLOGY

This is a multi-centre, cross-sectional study utilizing using a structured, web-based, pilot-tested and

self-administered questionnaire. The institutional review board at Faculty of Medicine, Menoufia



Our target population was undergraduate medical students in Egypt enroled enrolled in 19 medical

schools for during the 2013-14 academic year 2013/14. We selected ten 10 out of the 19 medical

schools to be our study settings using simple random sampling technique. The sampleSelected

institutions included Ain Shams, Al-Azhar medical school in Cairo, Alexandria, Assiut, Benha,

BeniSuef, Cairo, Menoufia, Suez Canal and Tanta medical schools.

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Students in these schools are enroledwere enrolled in a six-year MBBCh program, in which the first

three years are called academic years and the last three years are called clinical years. According toTo

achieve a 99% confidence interval (CI), 3% margin of error and 50% response distribution; , 1784

students were required to represent the study population. We used a stratified simple random technique

to select our sample with an equal allocation of participants in each university and each study year.

Accordingly, using the registered students`names lists, we randomly selected 270 students from each

faculty (45 for each study year) for a total of 2700 participants. We excluded non-Egyptians students

and those who changed their enrolment school at the time of data collection.

Data collectionCollection

Selected participants were invited by e-mail and social media websites to participate in our survey

using a unique code for each participant during the period of March–April 2014. In each university, a

team of data collectors was recruited (two active members from each class), which were led by a local

study coordinator (LSC). This team received standardized training on how to approach selected

students either online or offline. Each LSC was responsible for obtaining the students’ lists for each

class withthrough official channels. The two principle investigators selected the students randomly

from these lists according to the planned sampling technique. Initially, participants from two

universities were invited using their official emails. However, there was very low response rate as most

many students do not check their emails regularly, which is partially explained by the fact that this

email service was not introduced into Egyptian universities until recently. Therefore, we shifted our

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data collection plan to the use of social media websites (mainly Facebook). The majority of Egyptian

medical students have Facebook accounts, and each class has a Facebook group, including all students

of this class, for study-related discussions. The two data collectors of each class were responsible for

obtaining the personal account of each selected student. To confirm that the collected account

edbelonges to the selected student, a personal message was sent first to this account to confirm his

personal details. After receiving the confirmation, a Facebook message was sent containing a cover

letter with study aims, the participant’s special code and a link for the online questionnaire. The student

was to first fill out a voluntary consent form after reading the study aims and instructions. We sent up

to five reminder messages to participants to complete the survey. If we did not get responses in two to

three weeks, non-responders were approached in lectures’ rooms and training sessions to ask them to

complete the questionnaire. If any of them informed us of a lack of Internet access, a paper version of

the questionnaire (same questions and format as the online version) was provided for immediate

completion, if the respondent agreed to participate. LSC were responsible for entering the data into our

online system. We used an online survey program to administer the questionnaire (Survey Gizmo;

Boulder, Colorado, U.S.).

We invited the selected participants via e-mail and social media websites to take our survey using a

unique code for each participant during the period of March–April 2014. We used an online survey

program to administer the questionnaire (Survey Gizmo; Boulder, Colorado, US). Students who did not

have access to the internet at the time of data collection were allowed to record their responses using a

self-administered paper version of the questionnaire. We sent up to five reminder messages for



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education and Biostatisticsbiostatistics. The questionnaire was then piloted on 175 students, from all

participating medical schools.We used the final draft in a pilot testing on 175 students in all

participating medical schools. Detailed feedback about the format, clarity and completion time was

collected and used to make minor changes.we made minor changes in response

toparticipants`comments. We did not include the pilot responses in our analysis.

The questionnaire was in Arabic, the participants’ native language, and it comprised included 29

questions in four sections using a branching logic function (Figure 1). The first section addressed study

aims, consent and participants`’ personal information. This section was followed by a main question

asking if the student had heard about the new open online educational system (MOOCs) provided in

websites like Coursra, Edx, Udacity and FutureLearn, among others. about their knowledge about

MOOCs. Based on this his answer, the participants wasere directed to different sections. Students who

knew about MOOCs were asked how they heard about it and their state of enrolment. If the participant

was not enrolled in any course, he/sherespondents was were asked about the limitations to their use,

and then the questionnaire endsended.

Enrolled students were directed to the next section, which assessed their perspectives and

experiences with MOOCs. For students who gained certificates, further questions were asked regarding

their level of satisfaction as well as any obstacles they might have faced. Finally, four questions were

addressed asked to assess students’ opinion about integration of MOOCs in the medical field.

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Most of the questions were in a single- answer multiple-choice questionsformat. However, there

were three multi-selection check-box questions. For the assessment of limitations, satisfaction and

opinions, a 5five-point Likert scale between one (strongly agree/satisfied) and five (strongly

disagree/unsatisfied) was used.

Statistical analysisAnalysis:

Results were presented as numbers and percentages with confidence interval at 99%. The significance

of the association between qualitative variables of interest was analyzed using Chichi-square test or

Fisher`s exact tests, as indicated. In order tTo focus on clear opinions, the 5five-point Likert scale of

limitations, satisfaction and opinions were was collapsed into three categories (agree/satisfied, neutral

and disagree/unsatisfied). Class year was recoded as a dichotomous variable in order to compare results

for students in academic versus clinical education. The acknowledgment of the importance of getting a

certificate before enrolment also was also recoded as a dichotomous variable (important/very important

versus limited importance/not important). This was to in order to test the significance of association

between the primarily reported importance of acquiring a certificate and the actual possession of the

certificate by McNemar test. All tests were bilateral and a P value of 0.01 was used as the limit of

statistical significance. Statistical analysis was performed using the IBM SPSS statistical software

package version 22.

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RESULTS

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Respondent Characteristics

Of 2700 total participants, 62 (2.3%) were excluded for being non-Egyptians or having changed their

enrolment school, in addition to 111 (4.1%) students who could not be reached, resulting in final

eligible cohort of 2527 studentsin addition to 111 (4.1%) students` whose contact information could not

be reached with final eligible 2527 students. During the data collection phase, 2357 (93.3%) online

questionnaire invitations and 170 (6.7%) paper versions were sent out. Out of these distributed

questionnaires, 2016 responses were received (response rate 83.3%). Table 1 showes participants’

`demographics regarding school, class and gender.




and females (43.6% vs. 56.4%, 99 CI, P = .8). However, clinical years`’ students had higher rates of


difference between medical schools in students’ knowledge about MOOCs (P=.04).


courses in different disciplines by specialists from top universities worldwide for no or low fees

through the Iinternet, 1342 (81.3% [99% CI, 78.8%–83.8%]) students showed an interest to

participatein participating with a significant difference among different medical schools (P< .001).

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attainment.


value


value


value Total (%)

(n=2106)

Yes (%)

(n=456)

No (%)

(n=1650)

Total

(n=456)

Yes (%)

(n=136)

No (%)

(n=320)

Total

(n=136)

Yes (%)

(n=25)

No (%)

(n=111)


(9.8%)

38

(18.4%)

169

(81.6 %)

P=

.04

38 13

(34.2%)

25

(65.8%)

P=

.13

13 3

(23.1%)

10

(76.9%)

P=

.02

Al-Azhar 216

(10.3%)

42

(19.4%)

174

(80.6%)

42 11

(26.2%)

31

(73.8%)

11 1

(9.1%)

10

(90.9%)

Alexandria 222

(10.5%)

48

(21.6%)

174

(78.4%)

48 19

(39.6%)

29

(60.4%)

19 4

(21.1%)

15

(78.9%)

Assuit 180

(8.5%)

33

(18.3%)

147

(81.7%)

33 6

(18.2%)

27

(81.8%)

6 2

(33.3%)

4

(66.7%)

Benha 205

(9.7%)

57

(27.8%)

148

(72.2%)

57 16

(28.1%)

41

(71.9%)

16 0

(0.0%)

16

(100.0%)

Beni Suef 220

(10.4%)

38

(17.3%)

182

(82.7%)

38 6

(15.8%)

32

(84.2%)

6 0

(0.0%)

6

(100.0%)

Cairo 188

(8.9%)

39

(20.7%)

149

(79.3%)

39 12

(30.8%)

27

(69.2%)

12 2

(16.7%)

10

(83.3%)

Menoufia 248

(11.8%)

53

(21.4%)

195

(78.6%)

53 22

(41.5%)

31

(58.5%)

22 10

(45.5%)

12

(54.5%)

Suez

Canal

199

(9.4%)

59

(29.6%)

140

(70.4%)

59 20

(33.9%)

39

(66.1%)

20 2

(10.0%)

18

(90.0%)

Tanta 221

(10.5%)

49

(22.2%)

172

(77.8%)

49 11

(22.4%)

38

(77.6%)

11 1

(9.1%)

10

(90.9%)

Class Academic

1076

(51.2%)

176

(16.4%)

900

(82.6%)

P<

.001

176 40

(22.7%)

136

(77.3%)

P=

.01

40 4

(10.0%)

36

(90.0%)

P=

.1 Clinical 1024

(48.8%)

280

(27.3%)

744

(72.7%)

280 96

(34.3%)

184

(65.7%)

96 21

(21.9%)

75

(78.1%)

Gender Male

926

(44.1%)

199

(21.4%)

730

(78.6%)

P=

.83

199 71

(35.7%)

128

(64.3%)

P=

.02

71 17

(23.9%)

54

(76.1%)

P=

.08 Female 1174

(55.9%)

257

(21.8%)

920

(78.2%)

257 65

(25.3%)

192

(74.7%)

65 8

(12.3%)

57

(87.7%)

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Enrolment and certificate Certificate attainmentAttainment

Of those who knew about MOOCs, 136 (29.8% [99% CI,24.3%–35.3%]) were enroled enrolled in at

least one course. Most students (125; 91.9%) registered in 1–5 courses, while onlywith 113 (83.1%)

students reported reporting having watching watched at least one video lecture. Home (109; 99%) was

the first primary place where they watched these videos. There was no statistically significant

difference in enrolment state between males and females (52.2% vs. 47.8%, 99% CI, P= .016).

However, there was a significant difference between students`’ class and their enrolment (P=.009)

(Table 1). Coursera was the most commonly used website (99; 72.8%), followed by Edx (14; 10.3%).


more with an 81.6% dropout rate. Interestingly, more than half of students who earned certificates (13;

52% [99% CI,26.3%–77.7%]) have used the signature track to get verified ied thecertificates m ffrom

the universities that proposed the courses. The vast majority of enrolled students assumed stated that

getting a certificate is was important to them (32 [23.5%] very important, 37 [27.2%] important, 50

[36.8%] important to some extent and 17 [12.5%] not important). Out of the 69 students who assumed

that getting a certificate is important before enrolment (important/very important), 17 (24.6%) were

finally certified (24.6%), as; compared to only 8 (11.6%) certified students out of the 67 who were not

concerned with to receive a certificate at time of enrolmenthaving certificates (important to some

extent/not important; 11.9%); P< .001.

Ways of knowledge and studentsStudents`’ motivationsMotivations

To assess how students knew found out about MOOCs and what were their motivations were, two

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multi-selection questions were addressedasked. Social media was the main primary way through which

206 (45.2%) students knew aboutwere introduced to MOOCs, while knowledge through a friend was

the second (184; 40.4%). Using wWeb-search engines (87; 19.1%) got took the third place, followed by

extracurricular activities (46; 10.1%). MOOCs providers`’ advertisements played a very small role (27;

5.9%) in reaching students as did medical schools`’ official websites (15; 3.3%). Notably, there was no

association between the ways method through which students learned about MOOCs and their

enrolment. Nevertheless, students who knew were introduced through extracurricular activities were

found to enrol more frequently (P= .005).




complete the courses (P= .001) and (P= .008), respectively).

MOOCs and Medicine







that MOOCs help in studying medicine, while 83 (61%) believed that MOOCs will help them in

securinggetting a more desirable better job opportunity in the future job opportunity.


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majority of students (226; 70.4%) agreed that a lack of time was the main limitation, while 147 (45.9%)

agreed that slow internet Internet speed was another cause (Figure 3). Regarding completion

limitations, the eEnrolled students (n=136) were asked to assess the limitations that made them drop out

of courses. Similar to the enrolment limitations, it was obvious that lack of time (105; 77.2%) and slow

Iinternet speed (73; 53.7%) were the main obstacles. Lack of technology access, computer literacy,

language difficulty and culture conflicts were less frequently selected as a limiting factor to completion

of the courseWhile lack of technology access, computer literacy, language difficulty and culture

conflicts had less agreement on their roles as limitations (Figure 3). Only 16 (11.8%) students agreed

that the scientific content was difficult for them to comprehend. In addition, 93 (68.4%) students

disagreed that “lower content than expected” is was to be a limitation.

For further assessment of the iInternet speed, we asked the enrolled students to rate their Iinternet


speed and only 21 (15.4%) had a higher connection speed. When we compared the students’ evaluation

of internet Internet speed and if whether they watched video lectures or not, we did not find a

significant association (P= .69).

Students`’ Ssatisfaction of MOOCs




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DISCUSSION

Available information about regarding MOOCs participants is primarily data obtained from course-

end demographics, which usually reports demonstrate a heterogeneous populations of different varying

age groups and, educational levels from and different countries globally. These data show that most

MOOCs’ users are well-educated males with low participation from developing countries and

undergraduates.9-11

To our knowledge, this study is the first, in the medical field and in one of thea

developing countries country to use a cross-sectional study design in a homogeneous population for the

assessment of prevalence and uptake of such courses among undergraduate medical students.


Our results show demonstrate a funnel-shaped participation pattern, with 22.7 % of the respondents

knowing about MOOCs and 6.5% actually enrolled. Moreover, only 5.4% watched the offered videos

lectures and 1.2% obtained certificates of completion. Although there are no similar cross-sectional

studies with which our results can be compared, the knowledge of about that approximately one-fifth of

the Egyptian medical students about are familiar with MOOCs is considered promising in a developing

country, that depends mainly on regular traditional education. Additionally, these courses are still new,

and MOOCs providers’ advertisements had little effect in reaching students. Also, there is no medical

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MOOC offered by an Egyptian institution until now. Additionally, these courses are still new and there

was little role of MOOCs providers`advertisements for reaching students beside that there is no any

medical MOOC which is given by an Egyptian institution till now. Social media and the sharing of

personal experiences personal experience transfer among friends played a vital role in the spreading of

the MOOCs` idea, raising students’ awareness to this its’ current level. This is in line with the uprising

increasing role of social media websites in medical students’ life, with more than 90% of medical

students in the U.S. using social media.12

Notably, it was obvious that there is was a disproportion gap between knowledge about of MOOCs

and enrolment in them, with only one-third of students who knew about MOOCs having the awareness

registered registering in courses. The sStudents reported a lack of time and low internet Internet speed

as the main limitations for MOOC use. Out of these enrolled students, 18.4% (23.3% when looking at

those enrolled in a medical coursesfor medical courses) completed the courses and earned certificates.

These completion rates are higher than the reported average completion rates in the course

demographics. In 2013, The Chronicle of Higher Education suggested an average of 7.5% completion

rate 13, while a recent study in 2014 reported a rate of about 6.5%.

14 This may be explained by the

reported importance reported by students that obtaining of certificates has in terms of adding for

students to add to their resumes in hopes of improving future employment opportunitieshoping for

better future chances. It was is interesting to note that about half of them paid to verify their certificates,

although there is no academic credit for undergraduates for any MOOCs from any medical school in

the U.S. 15 and Egypt until nowat this time.

Although there was no association between gender and students’ knowledge or enrolment, class had

a significant association. Clinical years’ students were found to have higher knowledge and enrolment

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rates. This may be due to the high level of stress and pressures experienced by first years`’ medical

students adapting to new academic systems with little time available for extracurricular activities.16 In

contrast, final years’ students were reported to have less stress 16-18

with more attention to concern

towards their career plans by searching for new learning channels to increase their competitiveness.

MOOCs and Medicine

Of the enrolled students, 75.7% participated in at least one medical course with a 23.3% completion

rate. They strongly agreed that these courses helped them to develop theoretical backgrounds about the




interaction. However, in the new and evolving era of online learning, a question arises: “why Why to

waste precious class time on a lecture?” Students may watch the instructor’s lecture remotely in their

homes and utilize use class time for learning clinical skills.19 Most of the current opinions expect

anticipate a complementary role of for MOOCs in undergraduate education, with an increasing role in

educating those students after their graduation in continuing medical education.15


Lack of time and slow Iinternet speed were the two main limitations reported for causing low



discussions. This imposes a significant time burden on students, leading to the need of for an increased

commitments besides beyond their busy regular medical education. Time management, either in the

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design of courses or from participants, is critically needed to enhance their performance and increase

completion rates.

Low internet Internet speed is a commonly reported problem facing online education in developing



problem is enhancing the internet Internet infrastructure in Egypt. Liyanagunawardena et al. suggested

allowing lower resolution versions of the videos as an alternative solution to help engaging students

with limited bandwidth.8 Interestingly, we did not find computer literacy, language or culture as

barriers, although it was expected that they would represent problems in Egypt, being a developing

country.

MOOCs Experience Ssatisfaction





to be two main factors in dropout rates.21 Some MOOCs providers, such as Coursera, support efforts

beside beyond the usual discussion forums for to help overcoming overcome this point. These efforts

include more peer assessments, social media groupsinvolvment, Google+ hangouts and real in-person

Meetupsmeet-ups. Despite that, more involvement of participants is still needed to ensure the full

psychological presence.

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Study strengths Strengths and limitationsLimitations


covering nearly the entire geographic area of Egypt with a high confidence interval (99%) and high


participants who enrolled (n=136) and who had certificates (n=25), which makes the analysis of

limitations and satisfactions of MOOCs less reliable. However, these results are provide an important

contribution as a first start step to makein gathering evidence about the real prevalence of perception

and use of MOOCs in Egypt. In addition, these results will facilitate the ability of future studies to build

upon our findings and select samples that are representative of students with prior knowledge of

MOOCs, leading to a better understanding of their experience.

to help the future studies to build upon and take samples that are representative to the students who

knew about MOOCs for a better understanding of their experience.

Conclusions:

Approximately About one-fifth of undergraduate medical students in Egypt have heard about

MOOCs. Students who actively participated showed a positive attitude toward the experience, but

better time management skills and faster internet Internet connection speeds are required. Further

studies are needed involving to address the enrolled students in large representative samples, to assess

their experiences using MOOCs in large representative samples. In addition, more efforts is are needed

to be done to raise the awareness of among students of such courses, as most of students who had

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notdid not heard about MOOCs, did showed interest in participating once they became aware of the

coursesto participate.

STATEMENTS:

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Acknowledgements: The authors deeply acknowledge Hadeer Alsayed, Islam Shedeed (Menoufia

University), Zyad Abdelaziz, Dina Maklad, Ahmed Gebreil, Mahmoud Medhat (Alexandria university),

Mohammed Alhendy, Aya Sobhy, Omar Azzam (Al-Azhar University in Cairo), Hassan Aboul Nour,

Sara Elganzory (Tanta university), Mohamed Eid, Aya Talaat, Mohamed Emad (Beni Suef university),


Khaled Ghaleb, Yossri Mohamed (Benha university), Ahmed Alaa, Mohamed Gamal (Assuit

university), Marina Nashed, Ibrahim Abdelmone'm (Ain Shams university), Bassant Abdelazeim,

Ramadan Zaky (Cairo university) for their assistance in data collection. In addition, we deeply

acknowledge Bishoy Gouda (Canada), Susannah L. Bodman (U.S.), Mohamed Aleskandarany (U.K.)

and Moahmed Alaa (Egypt) for their help in English revision of our paper. None of them received












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REFERENCES




2014;33(1):85-91 doi: 10.1080/02763869.2014.866490.



Coursera 2013.





7. Cooke M, Irby DM, O`Brien BC. Educating physicians: a call for reform of medical school and



countries` perspective. eLearning Papers 2013(33)


10.1038/503342a.

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10.1007/s11606-011-1761-2|.





10.1136/bmj.f2666|.








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Med 2012;366(18):1657-9 doi: 10.1056/NEJMp1202451.

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167x213mm (300 x 300 DPI)

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267x159mm (300 x 300 DPI)

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292x165mm (300 x 300 DPI)

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241x146mm (300 x 300 DPI)

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Item

No Recommendation





and what was found (Done) (page 4-5)

Introduction


(Done) (page 7-8)

Objectives 3 State specific objectives, including any prespecified hypotheses (Done) (page 8,

last paragraph)

Methods

Study design 4 Present key elements of study design early in the paper (Done) (page 9, first

paragraph)


exposure, follow-up, and data collection (Done) (page 9-10)


participants (Done) (page 9, last paragraph)


modifiers. Give diagnostic criteria, if applicable (Not applicable)

Data sources/

measurement



more than one group (Done) (page 11)

Bias 9 Describe any efforts to address potential sources of bias (Not done)

Study size 10 Explain how the study size was arrived at (Done) (page 9)


describe which groupings were chosen and why (Done) (page 11)


(Done) (page 11)

(b) Describe any methods used to examine subgroups and interactions (Not

applicable)

(c) Explain how missing data were addressed (Not applicable) (no missing data)


(Done) (page 9,11)

(e) Describe any sensitivity analyses (Not done)

Results



completing follow-up, and analysed (Done) (page 13)

(b) Give reasons for non-participation at each stage (Not done)

(c) Consider use of a flow diagram (Done) (Figure 1)


information on exposures and potential confounders (Done) (Table 1)


(Not Done) (No missing data)

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Outcome data 15* Report numbers of outcome events or summary measures (Done) (page 13-14)



adjusted for and why they were included (Done) (page 13-17)


applicable)




sensitivity analyses (Not applicable)

Discussion

Key results 18 Summarise key results with reference to study objectives (Done) (page 18)


imprecision. Discuss both direction and magnitude of any potential bias (Done)

(page 21)



(Done) (page 18-21)

Generalisability 21 Discuss the generalisability (external validity) of the study results (Done) (page 6,

21)

Other information



applicable) (No external funding)







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BMJ OpenIntern, [email protected] - Omar N. Kotb year medical student, Faculty of Medicine,...

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