Evaluation of technology‐based learning by dental students during the pandemic outbreak of Corona virus disease 2019

Abstract Introduction Although technology‐based learning (TB‐learning) has been accepted as an efficient educational tool in the field of dentistry, evaluation of TB‐learning in non‐prepared situations such as pandemics has not been fully investigated. This study aimed to evaluate different aspects of TB‐learning among undergraduate dental students during the pandemic outbreak of COVID‐19. Materials and methods Dental students in selected Iraqi universities (University of Baghdad, University of Sulaimani, and Dijlah University College) were invited to join the study. A questionnaire was created using a Google platform and answered by students. Satisfaction and attitude toward TB‐learning plus total evaluation scores for lecturers were examined. Results A total of 832 out of 1800 dental students participated in the study. The majority of participants have basic (40.7%) and intermediate (47.5%) computer skills and more than half of them lack any experience in TB‐learning. The overall satisfaction and positive attitude toward TB‐learning was less than 50%. Students at final grade, with advanced computer skills and TB‐learning experience showed higher satisfaction (OR: 3.031, 2.876, 3.644, respectively) and a more positive attitude (OR: 3.172, 3.035, 3.477, respectively) toward TB‐learning than those at earlier grades. Total evaluation scores for lecturers were higher among females (11.5± 5.8) than males (9.9± 7.2) as well as among participants at final grade (14.0± 6.2), with advanced computer skills (13.8± 6.1), and TB‐learning experience (16.2± 6.0). Conclusions Dental students demonstrated low‐moderate satisfaction and positive attitude toward TB‐learning and the quality of material presented to them. Integrating TB‐learning into the dental education curriculum is an essential step in enhancing the acceptance of TB‐learning in the future.


Introduction
In December 2019, coronavirus disease 2019 (COVID-19) was recognized as an acute respiratory infectious disease in Wuhan city, China. Later, on 11 February 2020, COVID-19 was announced by the World Health Organization (WHO) as a pandemic with high mortality and morbidity rates 1,2 . The mechanism of spreading the virus is mainly dependent on direct contact and airborne droplets, even from asymptomatic carriers, and the rate of transmission is highly increased in crowded places such as universities 1 . Therefore, drastic measures, mainly focusing on restricting social gatherings, were taken at international and national levels to reduce the risk of transmission 3 . Accordingly, strict recommendations were suggested by The United Nations Educational, Scientific and Cultural Organization (UNESCO), Office of the United Nations High Commissioner for Human Rights (OHCHR), the International Federation of the Red Cross and Red Crescent Societies (IFRC), and WHO 4,5 . These organizations urged countries to provide Accepted Article education settings that would be well prepared, acceptable, adaptable and accessible to all at schools and universities following temporary closures during pandemic disasters. The intention was to promote distant online learning and various delivery strategies [4][5][6][7] .
Technology-based learning (TB-learning) is a learning approach that relies on incorporation of information and communication technologies such as visual media, digitalized content, interactive video tools, graphs, or web-based interaction to suit the learning style of students and enhance their ability to interact with the learning process, regardless of time and place 8 . It is broadly applied as an efficient learning and training tool in the medical sciences, including dental education [9][10][11][12][13] . In terms of pedagogical impact, TB-learning has the potential to shift the educational process towards an active learner environment compared to the passive role in the conventional classroom environment 14 . Distance learning has been shown to have a positive influence on students' learning outcomes such as learning satisfaction 15 . In this context, social media including WhatsApp and other applications such as Google class, Edmodo and Zoom can be valuable tools in conveying online learning 16 . Furthermore, it has been shown that a combination of the distance TB-learning and conventional styles brought optimum student performance and satisfaction 17 . However, several pros and cons of TB-learning have been reported in literature that raise questions regarding whether it is superior to or even as effective as conventional classroom learning. Additionally, emergence of abrupt circumstances that make distance learning to be very challenging might lead to inequality among individuals 18 . The evaluation of distance TB-learning in the non-prepared environment of transition from the conventional classroom learning style during unexpected circumstances such as pandemic disease has yet to be investigated.
In light of COVID-19 infection-control recommendations, the emergency operations center and health authorities in Iraq have decided to temporarily close all the educational institutions and implement distance TB-learning as an indispensable alternative educational tool. Therefore, a questionnaire-based survey was conducted to evaluate the satisfaction of undergraduate dental students in selected Iraqi universities towards different aspects of TB-learning during the pandemic outbreak of COVID-19.

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This article is protected by copyright. All rights reserved This study was a questionnaire-based online survey to evaluate TB-learning experience among dental students in selected Iraqi universities (University of Baghdad, University of Sulaimani, and Dijlah University College). The questionnaire was created using a Google platform, then the link was sent to the students via their email accounts for them to complete the questionnaire anonymously. This study was approved by the local ethics committee in the Department of Periodontics, College of Dentistry, University of Baghdad in accordance with the Helsinki declaration for human researches. Consent was obtained from each student by including a welcome message that explained the purpose of this study and a consent statement at the beginning of the questionnaire. This study followed the guidelines of the STROBE statement for writing observational studies 19 .

Sample size
The targeted sample was dental students in all grades from the three selected universities (1800 students). Calculation of the sample size was performed according to the following formulas: Sample Size = (Distribution of 50%) / ((Margin of Error% / Confidence Level Score)2) Confidence level= 1.96 (for confidence level of 95%), margin of error= 0.05.
True Sample = (Sample Size X Population) / (Sample Size + Population -1) According to the results, the required sample was 306 subjects which was then multiplied by 4 to allow a 25% response rate 20 . Thus, the final sample size was 1224 which represented the number of students who had received the questionnaire after randomly selecting these accounts using a simple randomization method.

Design of the questionnaire and score calculation
The questionnaire was designed and drafted depending on already published questionnaires in the English language and no attempt was made to translate it to native language 8 . The questions were split into two sections. The first section dealt with demographic data on the participants, including age, gender, grade, computer skill level, and experience level in TB-learning. The second section consisted of evaluation questions and was subdivided into three parts. The first part (questions #1 to #8) was dedicated to "TB-learning satisfaction", while the second part (questions #9 to #17) was designed to evaluate participants' "attitude towards TB-learning". The third part was aimed at "evaluating the lecturers" (questions #18 to #24) and the possible answers were presented on a Likert scale. Elements of the questionnaire are illustrated in table 1.

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This article is protected by copyright. All rights reserved As the questionnaire's design obliged the participants to answer all the questions, the returned electronic forms were all completed.

Statistical analysis
The data were not evenly distributed; therefore, nonparametric analyses were used for comparing different variables. For part I and II, Chi-square test was used because the data were expressed as frequency. In addition, the association of different bi-and multivariant variables with positive answers (Yes) for these parts was determined by calculating the odd ratio (OR) at 95% confidence interval (CI). Analysis of Likert-based questions (third part) was performed by using the Mann-Whitney U test and Kruskal-Wallis test followed by post-hoc analysis. All statistical methods were performed by using GraphPad Prism (Version 8.4.0, USA). The statistical significance level was set at p< 0.05.

Results
Eight hundred and thirty-two students (357 male and 475 female) with mean age of 20.95±1.65 years (ranging from 17 to 26 years) participated in the study. The number of respondents represented 68% of the calculated sample size (1224), which was considered as a satisfactory response rate. The percentages of students at the different grades of dental education were as follows: grade 1= 20.8%, grade 2 = 10.3%, grade 3 = 23.1%, grade 4=28.4% and grade 5=17.4%. The overall proportions of positive and negative responses to each question in parts I and II of the questionnaire are shown in Figure 1. The majority of participants had basic (40.7%) and intermediate (47.5%) computer skills and more than half of them lacked any experience in TB-learning, while only 7.6% of participants were experienced in TB-learning (Table 2).
TB-learning evaluation (Part I of the questionnaire) varied among the participants; there was a statistically significant difference between males and females (p< 0.001), with a higher proportion of females expressing satisfaction with TB-learning (OR 1.238). Furthermore, students who had progressed further in their education showed increased satisfaction with TBlearning (p< 0.001). Both computer skills and TB-learning experience were shown to have a statistically significant impact on overall TB-learning evaluation (p< 0.001 for both). The higher the computer skills and TB-learning experience, the greater the satisfaction (Table 3).
Likewise, there was a statistically significant difference in overall attitude toward TB-learning amongst participants (part II of the questionnaire). Females were more appreciative than males of TB-learning (p< 0.001, OR 1.338). Students' grade level was also shown to have a significant

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This article is protected by copyright. All rights reserved effect on attitude toward TB-learning (p< 0.001). Moreover, there were statistically significant differences between students with different computer skills (p< 0.001) and TB-learning experience (p< 0.001). Those with higher computer skills showed greater appreciation of TBlearning. Similarly, the more experience of TB-learning, the more positive the attitude towards TB-learning ( Table 4).
Evaluation of lecturers by students was another aspect examined in this study (Part III of the questionnaire). Gender was shown to have a statistically significant effect on the overall evaluation of lecturers by students (p<0.003), with females giving higher evaluations (11.5± 5.8) than males (9.9± 7.2). Furthermore, student's grade level was shown to have a statistically significant impact on the evaluation of lecturers by the students. The higher the grade, the higher the total evaluation score for lecturers. Finally, variations in computer skills and TB-learning experience were shown to have a statistically significant effect on the students' total evaluation scores for lecturers (Table 5).

Discussion
The emergence of an unexpected pandemic disease imposes obligatory changes on the normal daily activities and lifestyle, including the teaching processes in educational institutes. Such a sudden transition in the teaching mode creates challenges in terms of delivering the required scientific materials to the students. Current reviews have shown that, like qualified dentists, dental students are at high risk of infection as they closely manage patients as part of their academic learning 21,22 . Thus, this study was designed to evaluate different aspects of TB-learning experience amongst dental students in three Iraqi universities.
Previous studies have indicated that although TB-learning is well-accepted among dental students, less than half of the participants expressed positive perceptions of TB-learning 23 .
Similarly, more just over 50% of the participants in the current study were not satisfied with their TB-learning experiences. However, significant variations within different demographic variables were observed. Satisfaction and positive attitude towards TB-learning seem to be positively associated with gender, grade, computer skills, and previous experiences of online learning.
These results were consistent with a previous study conducted among dental students in Croatian universities 8 . In terms of gender, females showed higher satisfaction and a more positive attitude than males towards TB-learning, which is similar to the suggestion by other studies that females are more willing to engage in TB-learning 24,25 . Nevertheless, other studies have rejected the role

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This article is protected by copyright. All rights reserved of gender in relation to acceptance of or positivity towards TB-learning methods 26,27 . These differences could be due to variations in the sample size and assessment methods.
Further, the attitudes of 5 th year students towards TB-learning and technical experience were significantly more positive than among their younger peers 28 . Lack of technical skills is among the leading obstacles that adversely affect the TB-learning process 29 . Responses of dental students in another study have showed that their perception of TB-learning was related to the degree to which they possessed the essential computer skills and permanent access to the internet 30 . These results were in line with the finding by our survey.
Computer and information technology (IT) skills potentially strengthen the connection between individuals and the TB-learning concept. In addition, it enhance their dexterity in using different platforms and applications and vice versa 31 . Although social media can offer effective tools in the TB-learning process, most of the respondents considered social media to be unhelpful. A previous study concluded that the curriculum must be pre-defined and well-structured to ensure the effectiveness of these tools for professional TB-learning 16 , while the failure to meet these requirements could explain the negative responses in our study.
Conflicting results have been previously reported regarding satisfaction with TB-learning, with the drop-out rate among participants being not significantly different from that in face-face settings 32 . Meanwhile, another study has indicated a higher attrition rate for online courses than conventional learning 33 . This could be attributed to overlapping in the timing of online lectures with personal and normal daily activities 34 . However, in general, students' perceptions of satisfaction with TB-learning programs are influenced by several factors, most importantly the quality of the course 35 . Support for this notion was reflected by the participants' emphasis on the need to improve the quality of the given online lectures. Furthermore, most of them agreed that combining TB-learning with classic classroom learning is the best approach to achieve the goals of the educational process. This finding agrees with results obtained from a previous systematic review and meta-analysis 17 and other surveys conducted on medical and dental students 29,36,37 .
However, no significant difference was observed between dental students receiving conventional learning only and those with additional access to TB-learning 38 .
Evaluation of the lecturers showed that the mean attitude of females towards e-lecturers was significantly higher than that of their male counterparts, which is consistent with results from a previous analytic cross-sectional study which suggested that females are more teacher-oriented

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This article is protected by copyright. All rights reserved than males 39 . Also, the mean of e-lecturer evaluation increased significantly in relation to the variables investigated. Creativity, design and aesthetic presentation of the online material, and live interaction with the students are among the lecturer-related factors that positively and significantly affect the success of the online courses 40,41 . Indeed, attitude towards e-lecturers and the quality of the lectures are fundamental factors in judging the success of TB-learning 29 .
Preparation of a lecture delivered through cyberspace is a real challenge to the teachers and IT knowledge and proper infrastructure are paramount requirements 39 in terms of compensating for the lack of physical presence and dynamic interaction of the conventional learning environment.
The sudden transition to TB-learning, with no preparations, negatively affected the performance of the lecturers. In addition, the TB-learning programs were not seriously considered as an integral part in the educational process or their application might have been very limited in many universities. These problems were further aggravated by massive demand for constant use of the web, as indicated by the increase in inbound and outbound traffic, which potentially limited the teachers' ability to offer better-quality presentations that usually require high bandwidth in order to achieve online availability. All the previously mentioned reasons could compromise the quality of online lectures and performance of e-lecturers.
Like other observational studies, this study has inherent limitations whereby only associations with certain variables can be determined but not the cause-effect relationship. Also, the current survey focused on evaluating online lectures for undergraduates only. Thus, assessment of other aspects of distant learning, e.g. webinars, and interactive tutorials, and postgraduate online courses should be considered in the future studies. Furthermore, the results of this study were compared to previous literature studies published in normal situations rather than a crisis period, which could have introduced some bias to the responses, especially regarding depression and anxiety associated with the compulsory social restrictions.

Conclusions
In general, the results of our study showed a low-moderate degree of satisfaction and positive attitude towards TB-learning and the quality of presentation of the scientific material. However, COVID-19 associated events have highlighted the importance of improving IT and computer skills among students and teaching staff members to make them better prepared for similar crises that may happen in the future. This can be achieved by upgrading the curricula at all academic

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This article is protected by copyright. All rights reserved levels to include IT and computer sciences on a broader basis. Also, it is recommended that TBlearning be accredited as a compulsory subject alongside the classical classroom curriculum.

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This article is protected by copyright. All rights reserved

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This article is protected by copyright. All rights reserved