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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.
- Ahmed E. Radwan
� 6th year medical student, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt.
- 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
� 6th year medical student, Faculty of Medicine, Cairo University, Cairo, Egypt.
- 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
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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
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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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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.R1
Article Type: Research
Date Submitted by the Author: 20-Nov-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 A. Aboshady
� 6th year medical student, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt.
- Ahmed E. Radwan
� 6th year medical student, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt.
- 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
� 6thyear medical student, Faculty of Medicine, BeniSuef University, BeniSuef, 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
� 6thyear medical student, Faculty of Medicine, Cairo University, Cairo, Egypt.
- Ahmed Hassouna
� MD, Department of Cardiothoracic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
Corresponding author:
Omar AliAboshady
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: 297 words
- Text: 3340 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-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.
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 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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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.
STRENGTHS AND LIMITATIONS OF THIS STUDY
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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.
- 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 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 to all developing countries.
INTRODUCTION
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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 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.
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 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
This is a multi-center, cross-sectional study utilizing a structured, web-based, pilot-tested and self-
administered questionnaire. The institutional review board at Faculty of Medicine, Menoufia
University, Egypt, ethically approved the study.
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Study Population and Sample
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
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.
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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 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.
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 five-point
Likert scale between one (strongly agree/satisfied) and five (strongly disagree/unsatisfied) was used.
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Statistical analysis:
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
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 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
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
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.
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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 years` 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 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).
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%)
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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%).
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
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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 enrolment
(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%) 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
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
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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: enrolment and completion. Students who knew about
MOOCs, but did not enrol in any courses (n=320) were asked about their enrolment limitations. The
majority of students (226; 70.4%) agreed that lack of time was the main limitation, while 147 (45.9%)
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 enrolment 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).
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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).
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 Enrolment
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
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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
Notably, it was obvious that there is a disproportion between knowledge about MOOCs and
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
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
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 enrolment 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 besides
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.
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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.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 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.
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 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:
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
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,
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 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),
Mohamed Abdelzaheer, Ahmed Abdelhamed, Ahmed Saleh (Suez Canal university), Ahmed Zain,
KhaledGhaleb, Yossri Mohamed (Benha university), Ahmed Alaa, Mohamed Gamal (Assuit
university), Marina Nashed, Ibrahim Abdelmone'm (Ain Shams university), BassantAbdelazeim,
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
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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.
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.
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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.
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:
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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.
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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
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
Perception and use of massive open online courses among medical students of a
developing country: multicenter cross-sectional study
Authors
- Omar A. Aboshady
� 6th year medical student, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt.
- Ahmed E. Radwan
� 6th year medical student, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt.
- 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
� 6thyear medical student, Faculty of Medicine, BeniSuef University, BeniSuef, 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
� 6thyear medical student, Faculty of Medicine, Cairo University, Cairo, Egypt.
- Ahmed Hassouna
� MD, Department of Cardiothoracic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
Corresponding author:
Omar AliAboshady
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: 297 words
- Text: 3340 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-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.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’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.
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 of awareness and use of MOOCs among medical
students in Egypt.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 werewas 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 notcannot be generaziablegeneralizable 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 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
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 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.
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 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
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, Egyptinstitutional review board at Faculty of Medicine,
Menoufia University, Egypt, ethically approved the study.
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 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.
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 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.
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’ 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 5five-point
Likert scale between 1 one (strongly agree/satisfied) and 5five (strongly disagree/unsatisfied) was used.
Statistical analysis:
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
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’ 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.
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% vsvs. 56.4%, 99 CI, P = .8). However, clinical years` 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’ 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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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%) 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%).
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’ 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
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
By asking the enrolled students (n=136) about their experience and attitude toward medical MOOCs,
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.
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
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majority of students (226; 70.4%) agreed that lack of time was the main limitation, while 147 (45.9%)
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) 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
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’ 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’ 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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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 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
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 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 besides
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
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
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 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.
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
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:
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. FurthorFurther 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 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),
Mohamed Abdelzaheer, Ahmed Abdelhamed, Ahmed Saleh (Suez Canal university), Ahmed Zain,
KhaledGhaleb, Yossri Mohamed (Benha university), Ahmed Alaa, Mohamed Gamal (Assuit
university), Marina Nashed, Ibrahim Abdelmone'm (Ain Shams university), BassantAbdelazeim,
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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10. Group ME. MOOCs @ Edinburgh 2013: Report #1: the University of Edinburgh, 2013.
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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
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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
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17. Guthrie E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress and burnout
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difference in the prevalence and intensity of anxiety and depressive symptoms? Rev Bras Psiquiatr
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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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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
Perception and use of massive open online courses among medical students of a
developing country: multicenter cross-sectional study
(b) Provide in the abstract an informative and balanced summary of what was done
and what was found (Done) (page 4-5)
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported
(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)
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment,
exposure, follow-up, and data collection (Done) (page 9-10)
Participants 6 (a) Give the eligibility criteria, and the sources and methods of selection of
participants (Done) (page 9, last paragraph)
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect
modifiers. Give diagnostic criteria, if applicable (Not applicable)
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 (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)
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable,
describe which groupings were chosen and why (Done) (page 11)
Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding
(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)
(d) If applicable, describe analytical methods taking account of sampling strategy
(Done) (page 9,11)
(e) Describe any sensitivity analyses (Not done)
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) (page 13)
(b) Give reasons for non-participation at each stage (Not done)
(c) Consider use of a flow diagram (Done) (Figure 1)
Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and
information on exposures and potential confounders (Done) (Table 1)
(b) Indicate number of participants with missing data for each variable of interest
(Not Done) (No missing data)
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Outcome data 15* Report numbers of outcome events or summary measures (Done) (page 13-14)
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) (page 13-17)
(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) (page 18)
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)
(page 21)
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations,
multiplicity of analyses, results from similar studies, and other relevant evidence
(Done) (page 18-21)
Generalisability 21 Discuss the generalisability (external validity) of the study results (Done) (page 6,
21)
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) (No external funding)
*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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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.R2
Article Type: Research
Date Submitted by the Author: 02-Dec-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: multi-centre cross-sectional study
Authors
- OmarA. Aboshady
� 6th year medical student, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt.
- Ahmed E. Radwan
� 6th year medical student, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt.
- 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
� 5th year medical student, Faculty of Medicine, Tanta University, Tanta, Egypt.
- Heba A. Hashem
� 6th year medical student, Faculty of Medicine, Beni Suef University, BeniSuef, 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
� 6thyear medical student, Faculty of Medicine, Cairo University, Cairo, Egypt.
- Ahmed Hassouna
� MD, Department of Cardiothoracic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
Corresponding author
Omar Ali Aboshady
6th year medical student, Faculty of Medicine, Menoufia University.
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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 (115 characters)
- Abstract: 299 words
- Text: 3815 words
- Number of figures and tables: 5
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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
participants in each university and each study year.
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-
point Likert scale questions.
Results: Of 2527 eligible students, 2106 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 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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STRENGTHS AND LIMITATIONS OF THIS STUDY
- 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
University, Egypt, ethically approved the study.
Study Population and Sample
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.).
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. 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
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 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
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
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
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 shows 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 years’ 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 the 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 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.
Knowledge about MOOCs P
value
Enrolment 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%)
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%).
Only 25 students (18.4% [99% CI, 9.8%–26.9%]) completed courses and attained one certificate or
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).
Concerning students’ motives, most students reported that their main motivation was “to learn new
things” followed by “to help me study 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 helped in studying medicine, while 83 (61%) believed that MOOCs will help them in
securing a more desirable, better job opportunity in the future.
Limitations of MOOCs
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
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
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 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
undergraduate medical students.
Knowledge and Enrolment
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
topics discussed with less agreement on their role in developing their clinical skills. This raises
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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 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
MOOCs enrolment and course completion rates. MOOCs, being a self-learning educational system,
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
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.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
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 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 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
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 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.
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.
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Funding: All funding required was provided by Aboshady and Radwan on their own expenses.
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
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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
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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
Perception and use of massive open online courses among medical students of a
developing country: multicenter cross-sectional study
Authors
- Omar A. Aboshady
� 6th year medical student, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt.
- Ahmed E. Radwan
� 6th year medical student, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt.
- 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
� 6thyear medical student, Faculty of Medicine, BeniSuef University, BeniSuef, 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
� 6thyear medical student, Faculty of Medicine, Cairo University, Cairo, Egypt.
- 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: 297 299 words
- Text: 3340 3809 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 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.
Settings: Ten out of 19 randomly selected medical schools in Egypt by simple random sampling
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.
Secondary outcome measures included the limitations and satisfaction of using MOOCs through 5-
point Likert scale questions.
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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STRENGTHS AND LIMITATIONS OF THIS STUDY
- This study is the first to assess the actual prevalence of awareness and use of MOOCs among medical
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
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
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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
University, Egypt, ethically approved the study.
Study Population and Sample
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
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.
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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 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.
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 years`’ 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 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 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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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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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%).
Only 25 students (18.4% [99% CI, 9.8%–26.9%]) completed courses and attained one certificate or
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).
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
securinggetting a more desirable better job opportunity in the future job opportunity.
Limitations of MOOCs
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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
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. 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 Internet speed and if whether they watched video lectures or not, we did not find a
significant association (P= .69).
Students`’ Ssatisfaction 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
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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).
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.
Knowledge and Enrolment
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
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
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
MOOCs limitations in Egypt
Lack of time and slow Iinternet speed were the two main limitations reported for causing low
MOOCs enrolment 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 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
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 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
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 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 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
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 a 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 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),
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. 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
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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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
Perception and use of massive open online courses among medical students of a
developing country: multicenter cross-sectional study
(b) Provide in the abstract an informative and balanced summary of what was done
and what was found (Done) (page 4-5)
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported
(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)
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment,
exposure, follow-up, and data collection (Done) (page 9-10)
Participants 6 (a) Give the eligibility criteria, and the sources and methods of selection of
participants (Done) (page 9, last paragraph)
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect
modifiers. Give diagnostic criteria, if applicable (Not applicable)
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 (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)
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable,
describe which groupings were chosen and why (Done) (page 11)
Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding
(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)
(d) If applicable, describe analytical methods taking account of sampling strategy
(Done) (page 9,11)
(e) Describe any sensitivity analyses (Not done)
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) (page 13)
(b) Give reasons for non-participation at each stage (Not done)
(c) Consider use of a flow diagram (Done) (Figure 1)
Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and
information on exposures and potential confounders (Done) (Table 1)
(b) Indicate number of participants with missing data for each variable of interest
(Not Done) (No missing data)
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Outcome data 15* Report numbers of outcome events or summary measures (Done) (page 13-14)
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) (page 13-17)
(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) (page 18)
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)
(page 21)
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations,
multiplicity of analyses, results from similar studies, and other relevant evidence
(Done) (page 18-21)
Generalisability 21 Discuss the generalisability (external validity) of the study results (Done) (page 6,
21)
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) (No external funding)
*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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