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Table of Contents
Year : 2019  |  Volume : 24  |  Issue : 1  |  Page : 9-17

High Internet awareness and proficiency among medical undergraduates in Nigeria: A likely tool to enhance e-learning/instruction in Internal Medicine

1 Department of Internal Medicine, University of Nigeria, Ituku Ozalla Campus, Enugu, Nigeria
2 Department of Paediatric Surgery, Faculty of Medical Sciences, University of Nigeria, Ituku Ozalla Campus, Enugu, Nigeria

Date of Web Publication1-Aug-2019

Correspondence Address:
Dr. Christian I Okafor
Department of Internal Medicine, University of Nigeria, Ituku Ozalla Campus, Enugu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_1_19

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Background/Objective: The emergence of the Internet several decades ago has brought global revolution in a lot of processes even among developing nations, including educational processes. We assessed the familiarity of the medical students with Internet tools and their preparedness with integrating e-learning into Internal Medicine teaching methods. Materials and Methods: A cross-sectional survey of two graduating medical classes of College of Medicine, using structured self-administered questionnaire, was carried out. The survey assessed the knowledge, utility, and application of Internet tools in medical education using five-point Likert scale. Results: A total of 227 (75%) of the cohort of 292 students responded, comprising 150 (66.1%) males and 77 (33.9%) females. The median age was 24 years (Interquartile range, 23–26 years). Of these, 219 (96.5%) owned Internet-enabled devices, whereas 104 (46.2%) had formal training on the use of computers. Two hundred and twenty-two (97.8%) could access the Internet, with Google and Twitter accounts being the highest and the least used tools, respectively. Two hundred and twenty five (99%; mean rating 4.5 on a scale of 5) indicated that Internet tools were useful in teaching Internal Medicine, specifically in the areas of lectures, assignments, and interaction with experts globally. The key benefits were utility as a regular self-assessment tool and flexible learning schedule (mean rating, 4.0, respectively). Overall, 213 (93.8%) suggested that the use of Internet tools and e-learning should be incorporated into the traditional method of teaching. Challenges with its use included cost of accessing the Internet (n = 126; 55.5%), lack of facility with adequate technology (n = 115; 50.7%), and availability of Internet (n = 96; 42.3%). Conclusion: Undergraduate medical students in our setting are familiar with the Internet and its potential utility for learning and undergraduate teaching of Internal Medicine.

Keywords: Internal medicine, Internet, medical, undergraduates

How to cite this article:
Ekenze OS, Okafor CI, Ekenze SO. High Internet awareness and proficiency among medical undergraduates in Nigeria: A likely tool to enhance e-learning/instruction in Internal Medicine. Int J Med Health Dev 2019;24:9-17

How to cite this URL:
Ekenze OS, Okafor CI, Ekenze SO. High Internet awareness and proficiency among medical undergraduates in Nigeria: A likely tool to enhance e-learning/instruction in Internal Medicine. Int J Med Health Dev [serial online] 2019 [cited 2023 Jun 5];24:9-17. Available from: https://www.ijmhdev.com/text.asp?2019/24/1/9/263541

  Introduction Top

The increasing use of the Internet and the demand for globalization in medical education have led to gradual shift in medical teaching from the traditional classroom face-to-face method to a blend of both the traditional method and electronic learning (e-learning).[1] The need for medical students to be computer literate and the incorporation of e-learning methods into training in Internal Medicine may enhance continuous learning, improve access to learning, and encourage self-directed learning, with more flexible and student-centered training programs.[1],[2],[3] It may also boost real-time teaching and video streaming demonstrating elicitation of clinical signs or medical bedside procedures.[1],[2] E-learning has been shown to facilitate access to resources and services, as well as exchanges and collaborations.[4] Clinical e-learning tools are poised to become more commonplace[5] and are found to be comparable with the traditional methods in the outcome of learning measures[6],[7] and students’ ratings.[8] In addition, there is no demand for the student and the faculty to be physically present at the same time. E-learning is innovative, flexible, and convenient and increases students’ satisfaction and attention.[3],[9] Its incorporation into clinical skills however requires specific skill acquisition, addressing concerns about privacy and the lack of facilities with adequate technology.[5],[10] Integrating e-learning with the traditional methods of teaching is expected to engender collaborative learning and access to resources while maintaining physical interaction between faculty and students.[11]

Traditional mode of medical education has remained the major method of educational instructions across many disciplines and institutions in many developing countries.[12] Inadequate number of teaching staff coupled with large number of students on a background of inadequate and/or overstretched facilities, obviously, impacts negatively on academic instructions as discussions and interaction between students and teachers are highly restricted.[12],[13] Hence, the use of Internet tools may provide efficient means of overcoming these challenges.[12],[13],[14] Despite the putative benefits of e-learning, it is still less used particularly in developing countries,[3] but among medical students such as in Nnewi, South East Nigeria, Anyaoku et al.,[15] showed high rates of daily Internet access (72%) and medical information search (82%). Medical students use the Internet for different activities but recent studies now suggest that learning-related activities are on the increase even up to 100% in Abraka, Delta State, Nigeria.[16],[17] The evaluation of the knowledge base and the use of Internet tools among medical students in our medical school are therefore very important in establishing the required framework for integrating e-learning into the traditional teaching of Internal Medicine to improve learning and its outcomes.

The study, therefore, assessed the familiarity of the medical students with Internet tools and their preparedness with integrating e-learning into their Internal Medicine learning methods.

  Materials and Methods Top

Undergraduate medical training at the University of Nigeria started in 1970. It is undertaken over a 6-year period. Clinical clerkship commences in the third year and gets completed in the final year. During this period, the students are taught by the faculty in the classrooms and by the consultant physicians and residents in the specialist medical clinics, ward rounds, and the weekly interdisciplinary academic programs. Evaluation and assessment of the students is continuous and is carried out by periodic examinations and scoring of relevant procedures in the students Internal Medicine procedure book. Presently, no Internet-based tutoring/teaching method(s) or assessment with the use of social media, search tools, or simulations during Internal Medicine clerkship is available. However, PowerPoint tools and electronic pictures are presently used for teaching and assessment.

To assess the familiarity of the medical students with Internet tools and their preparedness with integrating e-learning into their medical learning methods, consecutive students of the 2013 and 2014 graduating classes were surveyed after they completed their lectures and their last posting in Internal Medicine using a pretested self-administered questionnaire [Appendix A]. Approximately 150 students were present in each class. The survey was distributed hand to hand to individual students after explaining the objective of the study, voluntary nature of the survey, and confidentiality of the procedure. Consenting students undertook the survey. Completed questionnaires were collected back within 24h.

The key sections of the survey included (1) demographics of the students and their familiarity with the Internet, (2) assessment of the traditional method of teaching, and (3) evaluation of the utility of Internet tools in overall medical education and undergraduate Internal Medicine training. The exposure to the Internet and the use of Internet tools, assessment of traditional method of teaching, and the utility of Internet tools in medical education and Internal Medicine training were assessed quantitatively using appropriate five-point Likert scale, where 1 indicated a very poor ability or very low usage, whereas 5 indicated an excellent ability or a very high usage. The other responses were evaluated qualitatively.

Minimum sample size needed for analysis was determined using the formula for sample size estimation for proportion in survey type of studies: N = (zα/2)[2]p (1 – p) × D/E,[2] where zα (at 95% confidence interval) = 1.96, E = margin of error at ±8% (usually approximately 10% of p = 0.08),[18] proportion (p) was assumed at 80% (0.8), and D = design effect (D = 1). Total sample size was therefore calculated to be 96.04 (approximately 96); however, all the students who were willing to participate were given the opportunity (i.e., 292 students).

Data analysis was carried out with the Statistical Package for the Social Sciences (SPSS, IBM Corporation, Amonk, New York, USA) software, version 20. Results were expressed as simple frequencies, mean values, and median values. Test of differences in mean was carried out using t-test, whereas test of association for categorical variables was carried out using chi-square test. P value of <0.05 was regarded as being significant.

  Results Top

A total of 227 (75%) students of the 292 responded. The respondents comprised 150 (66.1%) males and 77 (33.9%) females. Their median age was 24 years (Interquartile range, 23–26 years).

Ownership of computer or Internet-enabled devices

Most of the participants (219, 96.5%) owned Internet-enabled devices. Personal laptop computer was owned by most (183, 80.6%). Other devices were Android-operated devices such as phones (99, 43.6%), tablets (51, 22.5%), iPhones (28, 12.3%), and others (23, 10.1%) [Figure 1].
Figure 1: Types of devices owned distributed by gender (P values were based on chi-square analyses comparing the genders

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The rate of ownership of the devices did not significantly differ between the genders (97.4% in females vs. 96.6% in males; χ2(1) = 0.097; P = 0.755); however, a difference was observed when distributed by the year of graduation (99.1% among the 2013 class vs. 94.6% among the 2014 class; χ2(1) = 3.872; P = 0.049).

Internet access and proficiency among the students

A total of 222 (97.8%) students could access the Internet and owned various Internet accounts with Google (222, 97.8%) having the highest ownership, whereas Twitter (75, 33%) was the least owned [Table 1]. Knowledge regarding the use of computer and Internet was acquired through formal training (49.3%), self-directed instructions (39.8%), and from peers (10.9%).
Table 1: Participants’ ownership of Internet accounts

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The mean duration of access to Internet between male and female respondents did not differ significantly (7.4 ± 3.1 vs. 7.0 ± 3.1 years; P = 0.409). Google and e-mail-related accounts have the longest duration of ownership (7.2 ± 3.0 years), whereas Twitter accounts have the least (3.4 ± 2.5 years). Two hundred and two (89%) participants undertook Internet-based medical search, of which 60 (26.4%) did so daily, whereas 83 (36.6%) did the same weekly. Forty-two (18.5%) and 11 (4.8%) participants engaged in Internet-based medical searches monthly and quarterly, respectively. Medscape (121, 53.3%), Wikipedia (34, 15%), and e-medicine (19, 8.4%) were the more commonly visited sites.

Two hundred and thirteen students (93.8%) were aware of Internet-based activities in the university. Excluding course registration, most of the Internet-based school activities were carried out for nonacademic reasons [Figure 2].
Figure 2: Usage of Internet for school-based training requirements

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Assessment of traditional method of teaching

A total of 106 (46.7%) and 107 (47.1%) respondents, respectively, considered the ability of the traditional method of teaching in delivering a particular course content and imparting knowledge as average [Table 2].
Table 2: Mean rating of usefulness of traditional teaching methods by the students

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Some of the challenges of traditional method of teaching observed by respondents were insufficient time (39, 17.2%), deficient illustrations (12, 5.3%), poor interaction between students and faculty (30, 13.2%), poor learning environment (21, 9.2%), and crowded classrooms and lectures (11, 4.9%). Provision of better learning environment with information communication technology facilities, use of audiovisuals, increase in lecture time, and more cordial relationship between student and faculty were some of the ways proffered to overcome these challenges.

Evaluation of Internet tools in teaching Internal Medicine

Two hundred and twenty-five (99%) respondents positively considered Internet tools as useful in medical education. A total of 124 (54.6%) and 118 (52%) respondents strongly agreed that Internet tools would increase the value of education and should be used with traditional method to enhance learning, respectively [Table 3].
Table 3: Mean rating of usefulness of Internet tools in Internal Medicine education

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A total of 213 (93.8%) students positively recommended that e-learning should be integrated with the traditional teaching method. The respondents stated that such integration will enhance real-time communication, connecting and facilitating collaboration with experts worldwide, and enhance creativity. They also noted that such tools should be used in lectures, assignments, and video streaming of medical procedures and images of peculiar medical conditions.

Challenges to the use of Internet tools in Internal Medicine teaching

Some challenges documented by the respondents on the use of Internet tools include cost of accessing the Internet (n = 126; 55.5%), lack of facility with adequate technology (n = 115; 50.7%), and availability of Internet network (n = 96; 42.3%). Other challenges noted were lack of knowledge on the use of these tools (n = 55; 24.2%) and willingness of faculty to adapt to these new teaching methods (n = 25; 11%). Most of the respondents did not think demands on time (n = 16; 7%), privacy concerns (n = 9; 4%), and abuse of the teaching method (n = 23; 10.1%) were the challenges to integrating Internet tools in learning. Improved training on the use of Internet tools (n = 135; 59.5%), better availability, reducing cost of Internet (n = 205; 90.3%), and encouraging faculty to use these tools (n = 101; 44.5%) were the solutions proffered by the respondents in overcoming some of these challenges.

  Discussion Top

This study noted a changing trend in the ownership of computers and other Internet-enabled devices and good familiarity with the use of Internet among the respondents, comparable with reports from both developing and developed countries.[15],[17],[19],[20],[21],[22] This in effect brings out the importance of communication in any society, and the Nigerian society is not left out of the attempt to catch up with modern communication trends. More female respondents owned personal computers, which were Internet enabled in the this survey, comparable to previous observations.[10] This may not be unconnected to the social structure of most societies where female gender tends to receive more attention in terms of gifts and training requirements, parental protection of the girl child, and peer influence.[23] Although many of the respondents had Internet-enabled devices and could access the Internet, most of them, however, did not engage in medical-related searches regularly as about a quarter and a third of the respondents engaged in medical searches daily and weekly, respectively. This may be explained by the poor availability and affordability of high-speed Internet in developing countries.[10] Such nonavailability of high-speed broadband Internet may hamper the use of synchronous and asynchronous online communications for lectures. Improper awareness may also be contributory as well as a source of acquisition of knowledge on the use of computer and Internet generally.

Fewer of the respondents, compared to earlier studies conducted in developing countries, had formal computer training[10] and most of them used the Internet tools for social networking and other nonacademic purposes. Samuel et al.[20] also observed that few of their participants used the computer for learning purposes; similar to findings in Ghana,[24] India,[25] and Malaysia,[26] where use of Internet among students rated highly for chatting and entertainment as against the findings by Anunobi[22] in Nigeria. This finding in our study may be related to the fact that most of the academic work conducted in the university was by the traditional face-to-face method of classroom teaching or instruction. Inclusion of formal computer training in the course of medical school curriculum may improve the students’ proficiency and also equip them for e-learning and improved academic performances,[26],[27] though it may also influence their academic performances negatively.[24],[28]

Most of the respondents indicated that the traditional method of teaching though good had some challenges. It was particularly deficient in imparting knowledge and without clearly defined assessment goals. These may have contributed to the overall poor rating of this method of teaching, and the respondents reported that it did not prepare them well to practice medicine. Albarrak et al.,[29] in a study among Saudi medical students, noted that traditional learning was deficient comparatively in teaching, supervision, and course organization.

This report indicates that the medical students believed that Internet tools could be made useful in medical education and that they could be incorporated with the traditional method of teaching to enhance learning. This is comparable to other studies, which observed that a combination of traditional learning and e-learning can be made more effective in teaching medical students and that e-learning should be blended into the traditional face-to-face method.[30],[31],[32] Such blending of both methods of teaching will assist in developing skills, strengthen collaboration, add benefits in clinical discussion and case demonstrations, review rare conditions, conduct assignments, and enhance learning from experts that are teaching from other centers. These will lead to enhanced learning and better achievement of course learning objectives, especially as the Internet harbors a vast volume of academic resources that students can access easily.[20],[32]

The high cost of accessing Internet and the willingness of faculty to adapt to the technology were some of the challenges of incorporating e-learning. The high cost and the unavailability of high-speed broadband Internet in the developing countries have been noted as reasons for low usage of the Internet among medical students in these areas for learning purposes.[10] Efforts geared at reducing the cost of high-speed broadband Internet, training on the use of these tools for learning, and encouraging faculty to incorporate e-learning into the medical school training were proffered as ways to overcome the challenges of incorporating e-learning into the medical school curriculum. This was similar to the finding by Selzer et al.[5] who noted that incorporation of technology into clinical encounters involved special skills, which should be an integral part of medical training.

  Limitations of the Study Top

The study is limited by the fact that it is a self-reported knowledge and hence may introduce bias. Also the use of these Internet tools in clinical learning has not been applied in our setting; hence, its comparison with the traditional method of teaching in learning outcomes may not be objectively assessed.

  Conclusion Top

The study observed that undergraduate medical students in our environment are familiar with the use of Internet tools and are ready for the gradual incorporation and blending of e-learning into the traditional method of teaching undergraduate Internal Medicine. However, the facilities for such incorporation still remained underdeveloped. The high cost of Internet and its unavailability as well as the willingness of faculty to adapt to the new technology were observed as challenges. Making Internet access to be freely available and having the faculty integrate e-learning resources into their teaching will foster interactions and enhance learning.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  Appendix Top

Questionnaire on undergraduates’ evaluation of the use of Internet tools in teaching Internal Medicine

Section A

  • 1. Age ………………………………….

  • 2. Sex…………………………………..

  • 3. Year of study…………………………

  • 4. Do you own a computer or Internet-enabled device? Yes………No……….

  • 5. If “Yes,” which of these do you own? Computer (desktop, laptop),…Android,…iPhone,…Tablet,…Others.............

  • 6. Did you receive formal training on the operation and use of computer? Yes……No……

  • 7. If “No,” how did you learn the operation and use of computer……………………………………….

  • 8. Is any of your school/training requirements Internet-based (e.g., course registration, payments, accommodation selection, lectures, and assignments). Yes………..No……….

  • 9. If “Yes” please list ………………………………………………………………………………………

  • Please answer the following:

  • 10. What do you do when you access Internet? Tick as many

    • a. Read and send e-mail

    • b. Chat with friends

    • c. Socialize on Facebook

    • d. Follow friends and events on Twitter

    • e. Read topics on medical sites

    • f. Just “browse”

  • 11. Have you ever joined educationally based discussion group on the Internet? Yes……….No……..
    • If “Yes,” how frequent do you do this (tick): …Daily, …Weekly, …Monthly, …Quarterly, …Annually

  • 12. Do you routinely search for facts/information on medical topics on the Internet? Yes…….No……..
    • If “Yes,” how frequent do you do this (tick): …Daily, …Weekly, …Monthly, …Quarterly, …Annually

  • 13. What is your favorite site for medical topics? ..................................................

  • 14. Please rate your overall familiarity with these Internet tools

  • 15. Please rate your overall use of these tools for education/learning

  • 16. Please rate your overall use of these tools for social networking

Section B

Traditional method of teaching/learning

  • 1. Please rate the following aspects of traditional method of teaching in Internal Medicine (tick as appropriate)

  • 2. In your opinion what are the major challenges of the traditional method of teaching in Internal Medicine. Please list two.
    • ……………………………………….

    • ……………………………………….

  • 3. Please list two ways to address or overcome the challenges
    • a. ………………………………………………..

    • b. ………………………………………………..

  • 4. Do you consider your training by the traditional method adequately prepares you to practice medicine?
    • a)Yes…

    • b)No….

Section C

The use of Internet Tools in undergraduate medical education

  • 1. Please rate the following aspects of the use of Internet tools in medical education

  • 2. Which aspects of Internal Medicine training may be applicable with Internet tools (please tick as many)
    • a. Lectures

    • b. Assignments

    • c. Posting video of procedures on the Net

    • d. Posting image of interesting cases on the net and quizzing students about them

    • e. Using Skype or other real-time broadcast to teach and demonstrate procedures

    • f. Encouraging interaction with experts that are not members of local faculty

  • 3. What are the possible challenges in the use of Internet tools for medical education (tick only two)
    • a. Demand on time

    • b. Concern about privacy

    • c. Lack of knowledge and skills on how to use the tools

    • d. Lack of facility with the technology

    • e. Abuse of the procedure

    • f. Some lecturers may find it difficult to adapt to the use

    • g. Cost of accessing the Internet

    • h. Network availability

  • 4. Please indicate possible ways of addressing the challenges (tick as appropriate)
    • a. Increased training on how to use the tools

    • b. Availability and cost

    • c. Encourage use by lecturers

    • d. Others…………………………………

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]

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