A Response to Assessing the Role of Internal Motivation and Extrinsic Factors on Online Undergraduate Medical Teaching in a Resource-Poor Setting During Covid-19 Pandemic in North India: An Observational Study [Letter]

Dear editor

I read, with great interest, the article by Dhingra et al¹ that assesses the role of medical students’ motivation and extrinsic factors on online teaching during the Covid-19 pandemic at a medical school in North India. Although the study is set in a specific context, as a medical student in the UK who has experienced online teaching, I can relate to the topic.

The study refers to three issues in respect of online teaching faced by students at a medical school in India relating to limited internet connectivity and students’ socio-economic status and household environment. Similarly, in Pakistan, a low-income country, internet connectivity issues and lack of faculty training and institutional support have been mentioned as being the key challenges in respect of online medical education during the pandemic.²

Although the authors¹ conclude that students’ household environment and socio-economic status hampered their motivation to attend online classes during the pandemic, these variables are not clearly defined or operationalized as has been done in some other studies.³ The authors also do not evaluate how students’ socio-economic status affects ownership of smart devices, access to internet and data.

This study uses online questionnaires, but poor internet connectivity in rural areas may have lowered the response rate. A combination of paper-based and online surveys³ could have been used to address this issue. The sample¹ only included 1st, 2nd and 3rd year medical students, which limits generalizability of the results. Many studies have reported significant differences in student perception of online learning between students in pre-clinical (1 to 3) and clinical years (4 to 6),^3,4 and highlighted limits of online learning in the clinical years.⁵ Another limitation is that this study¹ is based at a single and relatively new medical school in North India, which further reduces its generalizability.

According to the study,¹ students attending online classes from rural areas experience poorer internet connectivity. However, the sample is not stratified to control for this potentially confounding factor in the assessment of association between student motivation and internet connectivity. The authors recommend that the government should improve digital infrastructure to facilitate internet connectivity but do not outline the steps medical schools and the government could take to motivate students to attend online classes, for example, providing laptops, data and financial assistance and upgrading IT systems/platforms.³

The authors state that various factors limiting student motivation to attend online teaching should be considered for the desired student-led learning as mandated by competency-based medical education.¹ I agree with their overarching conclusion that the amalgamation of online and traditional teaching should be used for educating medical students. It may be desirable to introduce such a hybrid teaching model in conjunction with Problem-Based-Learning (PBL) or Team-Based-Learning (TBL) approaches.⁵

In conclusion, despite its limitations this study raises many important issues which are relevant not only in resource-poor settings but also for richer countries such as the UK, where poor internet connection and family distraction have been found to be the commonly perceived barriers to access online teaching.⁵