The Impact of E-Learning in Postgraduate Health Education: Experience from Palestine

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1 The Impact of E-Learning in Postgraduate Health Education: Experience from Palestine Malik Zaben*, Ahmad Abu Tayeh*, Maher Khdour*, Adel Shtiwi, Mahdi Abu Salameh*, * Sajeda Ajawi*, Kholoud Hardan*, Asma Imam*, Anis El-hajeh*, Colin Green* *Team of members of staff at the International Medical Education Trust2000-Palestine (IMET2000-Pal). Abstract Background Health education becomes widely disseminated via the revolution in information technology (IT). To prepare healthcare professionals for their changing roles, a revolution in education is needed. This need is as important in Palestine as anywhere else, especially in a society where economic resources are limited, yet the culture of educational excellence is strong. E-learning, videoconferencing, telemedicine, and website resources are increasingly recognized as cost and time-effective learning modalities. In Palestine, and before we introduced the modality of e-leaning to promote health education, we undertook this survey to explore the healthcare professionals perceptions of e- learning as a mode of educational delivery. We also aimed to address their needs in terms of continuing health education and tele- medicine. Methods and study settings A 16-item questionnaire was used to seek the health professionals ( including doctors, dentists, nurses and pharmacists) opinions and knowledge about modalities they use to maintain and update their postgraduate health education, as well as to consult them about what they need to develop that practice. 612 health professionals from the main seven counties of Palestine have responded to our survey. Results According to this study, e-learning was highly needed as stated by the majority of respondents (61.3%). The highest percentage was among Medical Doctors/ Specialists at 71.6%. In agreement, e-learning resources have been used by 52.5% of the respondents to solve health care problems on daily basis. In addition, more than half of the respondents (55.5%) expressed their desire to participate in online discussion forums in an attempt to booster their knowledge. On the other hand, 29.5% of health professionals have indicated limited internet and e-services as major limitations to their continuing health education; this is further reflected by the small percentage (18.5%) of participants who used e-learning in their postgraduate education. Conclusion A centre of excellence that provides e- learning and telemedicine services beside a well programmed continuing health education process are highly needed to meet the health professions educational desires and wishes in Palestine. In response to this, the International Medical Education trust- UK has taken the initiative to get this project come into scene. Key Words: IMET2000-Pal, Continuing health education, e- learning, Palestinian health professionals, postgraduate education.

2 Introduction Electronic learning (E-learning) is defined as the use of Internet technologies to enhance knowledge and performance. E-learning technologies has been reported to offer learners control over content, learning sequence, pace of learning, time, and often media, allowing them to tailor their experiences to meet their personal learning objectives (Ruiz, Mintzer et al. 2006). Continuing health sciences education have witnessed an increasing activity in the development of e- learning modules, particularly with flexibility of this modality in terms of time and place of its use (Chang, Hsiao Sheen et al. 2008; Ruf, Berner et al. 2008; Taylor, Abbott et al. 2008). While advanced Internet technology in health care learning is well established in developed countries, it has started to be widely adopted in many developing countries (Latifi, Latifi et al. 2009). The international medical education trust-palestine (IMET2000-Pal) has been established as centre of excellence to provide health professionals in Palestine with e- learning facilities to enable them to pursue their postgraduate continuing education. The IMET2000-Pal aims to provide a matrix of continuous medical education (CME) and encourage a culture of lifelong learning, by establishing a telemedicine network throughout Palestine and providing learning, educational and continuous training resources which transcend factional interests and physical or geographical barriers to access, as well as to create new learning tools for undergraduates, postgraduates and for continuous education for all healthcare professions. In a well structured plan to work on and achieve the above objectives, we, in this study, reviewed the current medical education practice modalities and obtained the needed information to plan for e-learning continuing health education services in Palestine. Methods and Study Design Subjects & Settings Our subjects were all medical doctors, dentists, pharmacists, nurses and other allied health workers in West Bank and Jerusalem. 618 respondents were interviewed face to face by field workers who were trained prior to the study, during a training session which included a comprehensive explanation of the aims and objects of the study, and the importance of not jeopardizing the quality of data collection in any case. The actual study was preceded by a pilot study which was conducted on a sample of 20 respondents. That pilot study aimed to identify indicators that may cause a misconception, the respondents interest in participating and the time needed to complete the interview. Study design The questionnaire was designed by the team of the IMET team. Data Entry & Analysis The data collection process was conducted by field workers who made face to face interviews with the target groups. Data collection was conducted between the periods of November 4th November 18 th, That was followed by the data editing and coding process, where open questions were post coded by the in office editors. The post coding process is important for transforming open questions into close-ended questions, which makes it easier for data analysis purposes. Then by using a special data

3 entry program, the computer sets checks and controls that avoid the data entry personnel from entering wrong codes when possible, as well as enables them to skip questions automatically when needed. Finally, after all questionnaires were entered, initial frequency tables were done to the variables and examined to try to detect any data errors or out layers. If an error was detected, the whole questionnaire was re-entered. At that stage the questionnaires were analyzed using Access 2000 software. This program is characterized by the possibility of working in an Arabic language version on the computer screen, limiting data entry errors to the minimal, with the ability of checking the rational sequence in the questionnaire data Moreover, 10% of the questionnaires were double entered to make sure that the data entry quality is up to the standards. After the completion of the previous stages and making sure of the questionnaires accuracy, the data analysis process was conducted. The data was converted from Access2000 program into the statistical program SPSS, using Stat-Transfare program that assures that the data transformation is complete and accurate as well. As shown below the sample was representative of the various health care professionals, involving those who work in hospitals and private clinics or centres in the West Bank and Jerusalem. Results Our target was to meet and ask various health professionals in Palestine including, physicians (24.0%), dentists (25.3%), pharmacists (25.3%), nurses(22.2%) and allied health workers. The majority (63%) practiced their profession for up to 9 years, and (65.9%) of those respondents has BSc degree (Figure 1). Figure 1: The sample distribution based on the profession. Around half of respondents work in hospitals (46.1%). The rest of them worked in private clinics, universities, health care centers, private pharmacies, pharmaceutical companies and other places. After we defined e-learning as a planned teaching/learning experience that uses a wide spectrum of technologies, mainly internet or computer-based, to reach learners, we asked in the questionnaire about the need for e-learning. According to this study, e-learning was highly needed as stated by the majority of respondents (61.3%). The highest percentage was among Medical Doctors/ Specialists (71.6%), those with MSc degrees (77.5%) and those who have less than 5 years of practice. The majority of respondents (62.6%) did prefer all types of e-learning methods. However, power point presentation and questions was the most preferred method of e-learning as indicated by 81.0% of respondents, followed by on-line articles (79.2%) then videoconferences (76.1%). Midwives, those with PhD degrees and those with 5-9 years of practice indicated that power point was the

4 most preferred type (89.5%, 82.9% and 89.5%) (Figure 2). Figure 2: Views about E-learning by healthcare professionals. Only one third of respondents said they had used e-library (33.3%). More males were involved in e-library than females; (37.1%) versus (26.9%). Medical Doctors/ Specialists, those with MSc degree and those with less than 5 years of practice showed highest percentages: 42.8%, 35.9% and 40.9%, respectively. As we aim to provide e-learning to those who need it we enquired about the obstacles facing those who use e- learning, and respondents indicated the impact of time limitation, internet access and computer use as three main obstacles facing them in using e- learning methods. Specifically, time limitation was the major obstacle (53.7%), followed by internet access (29.5%) then computer use (23.0%). Pharmacists, PhDs and those with years of practice were the highest (64.9%, 56.1% and 60.8% respectively).

5 Figure 3: Preferred methods of E- learning by respondents. We sought in this study information regarding the current practice and the use of e-learning, aiming to organize and improve what is available, as well as adding more services, in keeping with the respondents feel needed. The majority of respondents 65.8% stated that they read medical /health science journals. Dentists, MSc and years of practice have highest percentages. On the other hand, 89.3% of all respondents expressed their interest in medical/health science journals if made available for them. Dentists, BSc and those with less than 5 years of practice showed highest percentages. More than half of participant (53.9 %) mentioned hard copy as their preferred form for reading articles, while (40.9%) preferred soft copy. Dentists, MSc and years of practice have highest percentages in hard copy preference. Almost half of respondents wanted the medical journals to be either in English (45%) or in both English and Arabic (44.5%). The percentage was higher for females who prefer both languages, while more males preferred English only. Medical Doctors/ Specialist were more interested in English, while Midwives were more interested in both languages. Those with less than 5 years of practice were more interested in English while they were the least interested in Arabic. According to respondents, the activities they participated in during the last year varied. Attending lectures was the most practiced activity (44.2%), while attending workshops was the second most practiced activity (38.9%), followed by conferences (37.8%), e-learning (18.5%), in-service training 12.0% and on-line courses which was reported as the least practiced activity with a percentage of 8.7%. The percentage of males who attended lectures, workshops is slightly higher than females, but it is much higher when it comes to conferences and e-learning. The percentage of females who did not participate in any

6 activity is higher than those of males. Medical Doctors/ Specialists, MSC and those with less than 5 years of practice were the highest in attending lectures, while dentists, those with diploma and those with years of practice were the highest in attending workshops. Findings regarding the sources used by respondents to solve health care problems, indicated that discussion with colleagues is the most common source (60.3%), followed respectively by text book (56.2%) and internet search (52.5%), while journals was reported as the least source used. The percentage of females who use discussion with colleagues and those who use internet search is higher than males in both cases, while it is less than males in cases of using text books and journals. Medical doctors/ specialist, PhD and years of practice were the highest. More than half of the respondents (55.5%) expressed their desire to participate in online discussion forums while (33.2%) said they might do. Males showed more interest in online discussion forums than females: (56.5%) versus (53.5%) said they would like to participate, while (31.4%) versus (36.3%) said they might do. Midwives, Phds and those with years of practice showed most interest. We noticed the above results reflect the need for an organized health education, to meet the desires of those who participate in the study, as well as to create an atmosphere rich in medical recourses, readily available when needed, especially when facing a medical problem. Majority of respondents (62.6%) preferred periodic lectures (face to face) and (46.3%) of them preferred special web sites as ways to get continues health education. Only (27.2%) of them mentioned on-line discussion, and (20.1%) of them said the use of test to check comprehension. Females showed less interest than males in web sites and online discussions, while they showed more interest in periodic lectures (face to face) and tests to check comprehension. Medical doctors/ specialists, MSc and those with 15 years of practice or more showed the highest percentages. Most of respondents (70.5%) said they would like to have credit hours for the continuous health education activities they participate in. More females showed interest in having credit hours than males: (73.1%) versus (69%). Midwives, Phds and those with 5-9 years of practice showed the highest percentages in the interest of having credit hours for CHE activities they participate in. The survey clearly indicates that e-learning is highly needed as a mode of medical education in Palestine. A major proportion of the respondents particularly those with years of practice said they read medical / health journals, while only one third said they used e-library. Our survey revealed that the impact of time, internet access and computer use as three main obstacles facing them in using e-learning methods. On the other hand, a majority expressed their interest in medical journals if made available to them. Among different modes of medical education, we noted that e-learning and on-line courses were the least practiced among our respondents, while attending lectures, workshops and conferences came on the top of the list. There is a clear need and desire for more organized continuous medical education and particularly e-learning in Palestine.

7 Discussion The results of this study show that for health professionals in Palestine, e- learning has been indicated as an important modality in enhancing knowledge as lecture-based learning. This is especially of interest since the study was conducted in a group of health professionals distributed evenly among the different health subspecialties - including dentists, medical doctors, nurses and pharmacists- and those who have been practicing for long periods of time with presumably fewer computer skills. Interestingly, time limitation, limited internet access and computer skills have been identified as a major barriers preventing health professionals in Palestine to use e-learning in their education, rather than a lack of interest in this modality. This study is the first to demonstrate that e-learning is highly needed by health professionals in Palestine. At the same time, it is the first study in the country that explores the opinions, the desires and the needs of this group of professionals. The results of this study are of great help for those who are interested in setting a continuing heath education program in developing countries including Palestine where economic resources are limited, yet the culture of educational excellence is strong. While this study has enabled us to identify the needs of the health education system in Palestine, it has guided us in planning our projects in an attempt to further develop this program. At the time we have started delivering our e-learning programs both in medical and nursing education; we are planning to get the dame program started in pharmacy and dental education. We will then move to study the effectiveness of different forms of e-learning and also the persistence of obtained knowledge over time. Acknowledgements The researchers would like to thank the International Medical Education Trust2000 for sponsoring the study and Alpha International for Research, Polling and Informatics for their help in data analyses. References 1. Chang, W. Y., S. T. Hsiao Sheen, et al. (2008). "Developing an E- learning education programme for staff nurses: processes and outcomes." Nurse Educ Today 28(7): Latifi, R., R. Latifi, et al. (2009). ""Initiate-Build-Operate-Transfer"- A Strategy for Establishing Sustainable Telemedicine Programs in Developing Countries: Initial Lessons from the Balkans." Telemed J E Health. 3. Ruf, D., M. M. Berner, et al. (2008). "[E-Learning--an important contribution to general medical training and continuing education?]." Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 51(9): Ruiz, J. G., M. J. Mintzer, et al. (2006). "The impact of E-learning in medical education." Acad Med 81(3): Taylor, L., P. A. Abbott, et al. (2008). "E-learning for health-care workforce development." Yearb Med Inform: 83-7.