Online anatomy education during COVID 19 pandemic period among pre-clinical medical students: an experience of University of Peradeniya

Objective The objective of this study was to evaluate the perception, attitudes, and barriers faced by students during the online anatomy course. Materials and methods A descriptive cross-sectional study was carried using a questionnaire, based on available feedback questionnaires from the faculty and published questionnaires, pilot tested and finalized. It was distributed via Google-forms to 185 second-year students who had undergone 2 semesters of online teaching. Results A total of 115 Google-forms were received. Females represented 50.9%, with a mean age of 21.9±1.022 years. Smartphones (86%) were mainly used to access online material while mobile data (79.8%) was the commonest method of internet access. Online learning tool usage was: Moodle-98.2% Zoom-94.7% and Youtube-66.7%. Attitudes towards online learning were positive (77.2%) with prior preparation for teaching sessions as high as 97.4% and active participation in the online sessions (81.6%). Majority preferred Moodle for online lectures (81.74%), histology practical sessions (89.57%) and slide projections (82.74%) while for gross practical sessions it was Moodle (80.87%) and Youtube (41.74%). For tutorials (70.44%) and discussions (76.52%) majority preferred Zoom sessions. Of the respondents 57.9% feared lack of direct anatomy learning might have an impact on their clinical skills in future. The major problems of online learning were identified as lack of self-motivation, lack of onsite practicals, and increased screen time. Conclusion Though majority of participants agreed that onsite anatomy teaching and learning cannot be replaced by the online course, the attitude towards it appears to be mostly positive during the COVID-19 pandemic.


Introduction
The COVID 19 infection is a serious global health threat, continuing its spread across the world. It has caused a pandemic with a growing number of cases and considerable mortality rate, infecting more than 90 million people worldwide from the end of 2019 going into 2021. This situation has changed the day to day life of individuals throughout the world. Schools and universities had to be closed and education activities were discontinued as a part of health guidelines to prevent the spread of the disease.
However, education is a must for the betterment of a country and a society and prolonged periods without education will have a bad impact on the future. Therefore, educators and teachers had to use alternative methods of teaching and learning to overcome this issue and as a result internet and webbased teaching and learning came to play a major role in continuing education during the pandemic.
Online teaching is characterized as the use of computer technology to provide technologybased learning. Even though this type of teaching has been there ever since the discovery of the web it always placed a less important role to onsite teaching. However, with the closure of universities and schools around the world, learning management systems and conference platforms quickly became the main method of imparting knowledge to millions of students around the world. Online learning modalities encourage student-centered learning and they are more easily manageable during this Pandemic situation (1). Further, transition to complete online program may be a learning experience for both students and faculty (2).
In Sri Lanka the situation is similar and online learning system has become a compulsory part of the teaching and learning process for higher education. After the sudden closure of universities in the country with the spread of COVID -19, the government of Sri Lanka promoted online and other distance education methods as an alternative solution for continuing higher education.
Unlike developed countries, this was a big challenge for most government universities where mostly education concepts were delivered through onsite teaching methods. For some subjects online platforms were ideal and maybe even better. However, for medical education where they have to take decisions based on experience it was a bigger challenge.
In situations where conclusions are arrived at based on observations, guidance of a lecturer seems essential.
However, Faculty of Medicine, University of Peradeniya has continued the academic program shifting quickly to online teaching preventing major disruption of educating medical graduates. Almost all the batches in the faculty are involved in the online academic program including pre-clinical batches.
Pre-clinical years form the base of the entire medical career of undergraduates and therefore any deficiency in delivering knowledge during this initial period can affect their entire future. First year students with fresh minds and a high degree of enthusiasm are energetic learners and need proper guidance for laying the foundation to their medical careers.
When it comes to pre-clinical years anatomy is one of the main subjects. It is a highly practically oriented subject which requires students to learn by dissecting cadavers, handling bones and looking at microscopic slides. Therefore, the anatomy teachers face a huge challenge in delivering the practical aspects of anatomy to students through online education tools. The aim of this study is to assess the student perception of the current online teaching program, to understand the attitudes of students, their preferences and the barriers faced in learning anatomy via the online platform, with a view to improving the delivery of subject matter to preclinical medical students.

Methodology
This descriptive cross-sectional questionnaire based online survey was conducted from January 20 th to February 15 th 2021, among second year students in the Faculty of Medicine, University of Peradeniya.
Participation was completely voluntary and informed consent was taken from each participant.
This survey was conducted to assess the perception, attitudes, and barriers faced by students during the online anatomy course conducted during the pandemic period. A questionnaire was designed using available feedback questionnaires from the faculty and published questionnaires. The questionnaire was pilot tested on 5 final year students and edited accordingly. The finalized questionnaire was built into Googleforms. The consent form and the questionnaire were emailed to 185 second-year students who had undergone 2 semesters of online teaching.
Statistical data analysis was performed by using Microsoft excel and Minitab 17 statistical software.  Kosgallana EW, Jayasankita PN, Jayaweera AK, Supunsara HMG, Adikari SB, Amaratunga HA -Online Anatomy education during COVID 19 pandemic period among pre-clinical Medical Students: An Experience of University of Peradeniya Table 1: Statements used to assess the attitude towards online learning/ teaching in Anatomy.

Out
1) I comfortable in learning Anatomy via online platforms.
2) I feel that online learning in Anatomy should play a complementary role in the future.
3) I feel that Moodle (LMS) is well organized and user friendly for teaching Anatomy. 4) I feel less stressed for online teaching in anatomy compared to onsite teaching. 5) I feel that I have got more time to be with my family because of online teaching. 6) I feel that online teaching is efficient for Anatomy compared to onsite teaching. 7) I feel that online teaching is used effectively for Anatomy during COVID 19 pandemic period.
8) I feel that increased use of online platforms for Anatomy improves standards of Anatomy education.
9) My motivation is high for online teaching in Anatomy compared to onsite teaching.
10) I feel independent during online learning compared to face to face Anatomy learning. 11) I am able to manage my time effectively and easily because of online teaching compared to onsite teaching.
12) I prefer online learning anatomy to onsite methods.
13) I believe that I could reduce my expenses spent on study materials because of online teaching.
14) I have a fear of getting low marks for anatomy because of online learning.
15) I feel that lack of direct anatomy learning will have an impact on my clinical knowledge in future.
16) I feel that onsite learning in anatomy cannot be replaced by online learning.
The percentage of students that mentioned they had prior preparation for teaching sessions was as high as 97.4% and active participation in the online sessions was 81.6%. Student preferences on the delivery mode of different anatomy teaching components are given in table 2.

Issues/ Barriers faced during the online Anatomy course.
With regard to problems faced during the online course, 21.1% complained about the screen size of their device. Only 24.6% of the participants complained of poor internet connection. Respectively 15.8% and 13.2% complained about uncomfortable home environment and diminished freedom at home due to online learning. The time spent on learning via online platforms has significantly increased as expected. Previously only 10.5% engaged more than 4 hours per day to learn via online modes. However, during the pandemic time, it has increased up to 70.2%. Of the participants 49.1% faced health problems or discomfort due to prolonged screen time. Visual symptoms were more common among the respondents (83.9%). According to respondents sleeping difficulties were complained by 36.2% and musculoskeletal related pain by 41.1% of the participants.

Discussion
Due to the COVID 19 infection, physical classroom sessions were suspended by different government regulations and universities had to assume an online based course. This transition was more difficult for disciplines such as anatomy due to its practical COVID-19 pandemic has disrupted face-toface teaching in medical schools all over the world. This study reflects that the Department of Anatomy has successfully transitioned their educational environment to online teaching and assessments. One of the main implications was identified as preclinical students missing the hand on experience during their preclinical years (57.9%). Similar results were reflected by a study by Gaur et al., 2020 (9).
The major problems of online learning were identified as lack of self-motivation (52.6%), loss of peer learning (78.9%) and lack of onsite practicals (74.6%). In a study carried out among medical students in Libya the main problems faced by the participants were financial issues and poor quality of internet connection which were not reported by the majority in our study (10).
As the response rate was 62.16%, the attitudes and perceptions of all students could not be accurately assessed, which can be considered as a limitation of this study. It is further questionable whether this was due to issues with regard to online communication.
Even though online education has proven to be well perceived by the students during the pandemic period educators must be vigilant in identifying problems related to online learning and addressing them when designing and implementing new online anatomy courses for effective online education.