Heliyon 8 (2022) e08984

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Heliyon
journal homepage: www.cell.com/heliyon

Research article

The university students’ viewpoints on e-learning system during COVID-19

pandemic: the case of Iran☆
Arash Salahshouri a, Kaveh Eslami b, Hatam Boostani c, Mansour Zahiri d, Simin Jahani e,
Reza Arjmand f, Akbar Babaei Heydarabadi a, Behzad Fouladi Dehaghi g, h, *
a
Department of Health Education and Health Promotion, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
b
Clinical Pharmacy Department, School of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
c
Department of Psychiatry, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
d
Department of Healthcare Services Management, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
e
Department of Nursing, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
f
Department of Parasitology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
g
Environmental Technologies Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
h
Department of Occupational Health, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: The outbreak of COVID-19 closed educational institutions and universities. The aim of this study was to explain
Virtual the strengths and weaknesses of the e-learning system in Iranian universities of medical sciences in the COVID-19
Training pandemic. This is a qualitative study that was conducted with students enrolled in Iranian medical universities.
Strengths
Data was collected through an open-ended electronic questionnaire based on the interview guide and was
Weaknesses
Medical student
analyzed through content analysis.
122 students from 46 medical universities participated in this study. 122 questionnaires from 46 universities of
medical sciences were completed. From a total of 54 codes extracted from the results, seven (strengths/positive
experiences) and six (weaknesses/challenges) themes were extracted, each of which had several subsets. E-
learning has both visible and hidden layers in terms of advantages and disadvantages. The e-learning system is an
essential tool to continue education during the COVID-19 pandemic. Most students believe that e-learning was a
great complement to prevent academic failure, but it cannot replicate the same efficiency of face-to-face training.

1. Introduction not implemented in many academic institutions before the COVID-19

pandemic. Universities that had previously implemented innovative
In late 2019, the new coronavirus (SARS-CoV-2) became a pandemic e-learning programs could use them in this emergency situation. There-
in the world (Dehaghi et al., 2020a; World Health Organization, 2020). fore, due to the nature of the training process, which requires face-to-face
The impact of the pandemic depends on the number of cases, trans- interaction; the closure of educational and academic institutions in the
missibility and severity of its clinical symptoms (Zhang et al., 2020). In COVID-19 pandemic led to an unprecedented impact on the education
this regard, airborne transmission of this disease occurs by respiratory services system. In order to compensate for the disruption of the educa-
droplets, so that COVID-19 patients can be asymptomatic or with tion process, new decisions were needed. In this regard, advanced tech-
symptoms of mild to severe disease, which causes acute respiratory nologies and learning education system (LMS) for educating and
distress syndrome (Alsrhani et al., 2020; Jamshidnezhad et al., 2021). evaluating students, provided an alternative approach for teachers and
Almost all countries, including Iran, tried to prevent the spread of this policy makers to use information technology to continue the education
infectious disease by applying crisis management through strategies such process while applying the constraints caused by the pandemic (Sahu,
as using face mask, physical distance (2 m), imposing traffic restrictions 2020). E-learning methods can include offline or online learning activ-
and shutting down all activities (Dehaghi et al., 2020b; Sj€ odin et al., ities. In addition, this form of learning can provide e-learning from the
2020). E-learning programs have been around for many years but were basic conversion of face-to-face content to digital format to the more

☆
This article is a part of the Medical Education during the COVID-19 pandemic Special issue.
* Corresponding author.
E-mail address: [email protected] (B.F. Dehaghi).

https://doi.org/10.1016/j.heliyon.2022.e08984
Received 21 December 2021; Received in revised form 3 February 2022; Accepted 15 February 2022
2405-8440/© 2022 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A. Salahshouri et al. Heliyon 8 (2022) e08984

sophisticated deployment of digital technologies (e.g., mobile education, threatening conditions. Distance learning is not and cannot be the same
virtual patients, and virtual reality). Instructors conducted e-learning as planned online education. Due to the rapid shift of educational de-
with several types of e-learning software such as Adobe connect, livery to distance learning in the spring of 2020, Hodges et al., high-
sky-room, etc. to provide students with the highest access to educational lighted that: “The main goal in this situation is not to re-create a strong
content in pandemic conditions (Kumar et al., 2020). educational ecosystem, but to provide temporary access to educational
In Iran, as in other countries, educational institutions and universities support in a way that is quick to set up and reliably available in an
were closed by the government following the outbreak of COVID-19. emergency or crisis” (Hodges et al., 2020). Considering that there were
However, the ministry of education directed all educational institutions limited studies to determine the problems of the e-learning system, the
and universities to have LMS for creating online classes so that there aim of this study was to determine the strengths and weaknesses of
would be no disruption in teaching and learning (Shah et al., 2020). e-learning in Iranian universities of medical sciences in the COVID-19
Several studies have shown the importance and effectiveness of the pandemic from the students’ point of view.
e-learning system (Co et al., 2021a; Huynh, 2017; Navimipour and Zar-
eie, 2015). Despite the advantages of e-learning, there are limitations 2. Materials and methods
such as lack of interaction between learner and teacher (teachers and
students, faculty and students) (Davis et al., 2019). With regard to this 2.1. Study design
approach in teaching in Iran, both students and professors face problems
in e-learning. This was a qualitative study of contractual (inductive) content anal-
ysis using semi-structured interviews with the students of medical uni-
1.1. Literature review versities in Iran which was conducted between March 2020–August 2020
to explain the strengths and weaknesses of e-learning.
Any information system needs the use of the system by users for its
success (Almaiah, 2018). Therefore, in the field of e-learning system, 2.2. Study population
student acceptance of e-learning is considered as one of the main ele-
ments for success in e-learning. Several studies have addressed the issues Purposeful sampling with maximum variety was performed to select
of e-learning in many countries around the world. Almaiah et al., used the participants. Therefore, a heterogeneous group of students with a
technology acceptance model and the innovation and diffusion theory wide range of underlying characteristics (gender, age, educational field
model to examine the critical factors influencing the use of the Malaysian of study) were selected from governmental medical universities. Which
student e-learning system. The results showed that comparative advan- were similarly closed-up with the outbreak of COVID-19.
tages, observability, flexibility, perceived adaptability, complexity and
enjoyment of the mind are factors that play an important role in students' 2.3. Selection criteria
decision to use the e-learning system in Malaysia (Almaiah et al., 2016).
Salloum et al., showed that four factors (innovation, quality, trust and Medical students aged 18 years or older participated in the study. The
knowledge sharing) were observed to better achieve e-learning system inclusion criteria were giving consent to participate in the study; and
acceptance among students (Salloum et al., 2019). medical student with experience in e-learning during or before the
The use of e-learning among users is a challenge for many universities COVID-19 pandemic. The exclusion criterion was the student without
in all countries, but it is likely to be a concern in developed countries for access to internet.
their students' willingness to accept and use e-learning. Eltahir showed
that the challenges of adopting an e-learning system in developing 2.4. Sample size
countries are still real due to the problem of getting access to these
technologies (Eltahir, 2019). Aung and Khaing, stated that the lack of A total of 122 students from various profession (nursing, rehabilita-
knowledge of information technology (IT), poor network infrastructure tion, paramedical, health, pharmacy, dentistry and medicine) in different
and poor content development are the main challenges of accepting the educational levels participated in the study and answered the semi-
e-learning system in developing countries (Aung & S.S., 2016). A study in structured electronic questionnaire based on the interview guide.
Pakistan found that system features, Internet experience, and computer
self-efficacy were the most important issues that prevented the successful 2.5. Data collection procedures
adoption of the e-learning system (Kanwal and Rehman, 2017). Another
study identified three main challenges to e-learning: inadequate IT In the present study, in order to collect the data, a semi-structured
infrastructure, lack of technical skills, and financial constraints (Tarus electronic questionnaire based on the interview guide was used and
et al., 2015). A study by Kisanga and Ireson found that inadequate was placed in the university official website. Then, by introducing the
technical support and lack of IT skills are the main obstacles that prevent questionnaire link, students' opinions were received. A total of 122
the successful implementation of existing e-learning projects (Kisanga questionnaires (open-ended) were received from 46 governmental
and Ireson, 2015). In a study during the COVID-19 outbreak the level of medical universities across the country. The students were asked to enter
psychosocial stress in 110 medical students was evaluated. The results their student ID, so that it could be controlled that only medical students
showed a high level of stress (in all aspects) in the case group compared have completed the questionnaire. The data collection process was
to the control group. Also, academic performance during the COVID-19 completed within four months. No personally identifiable information
pandemic among medical students declined (Co et al., 2021c). Also, Co was obtained from the participants.
et al., in another study, reported that teaching technical skills, including After studying the participants' answers due to the ambiguity of some
surgery, through web-based training during the COVID-19 pandemic in of the answers as well as the questions created in the minds of the re-
medical students was no different from face-to-face training. In such a searchers, the interviews were repeated with 31 participants. The semi-
way that even after the end of the COVID-19 outbreak, this educational structured interviews continued until data saturation.
system can be used beside other training methods (Co et al., 2021b).
Hodges et al., differentiated between online education and emergency 2.6. Data analysis
distance education, indicating that the first model relies on informed and
advanced design - often six to nine months of planning. Distance edu- The interview data were entered into Microsoft Word (57 pages) and
cation, on the other hand, is a temporary and sudden shift towards then were entered into MAXQDA 10 software. The data was analyzed
educational delivery due to crisis such as the weather, war, or health using the Graneheim and Lundman approach (Graneheim and Lundman,

2
A. Salahshouri et al. Heliyon 8 (2022) e08984

2004). This approach involves the step by step writing down the in- e-learning; early experience; lack of comprehensive regulations and
terviews and studying them several times to get a general view; then protocols in e-learning; insufficient familiarity with e-learning; and bar-
dividing the text into summarized semantic units; Abstract semantic units riers to access and coordination (Tables 2 and 3).
summarized and tagged by codes; Separation of codes in sub-themes by
comparing them based on their similarities and differences and setting
themes as an indicator of the hidden content of the text (Graneheim and 3.1. Strengths and experiences
Lundman, 2004). When all of the data was encrypted and the categories
were created, the authors evaluated each category for saturation. All 1 Desirable education and information:
steps of interviewing, typing interviews transcriptions and encryption The first main category in the field of strengths is "desirable education
were done in Persian. To ensure the accuracy of this study, the integrated and information" which is divided into two sub-categories "prepara-
criteria for quality research reporting (COREQ) were followed. Grane- tion, compilation and communication of virtual education regulations
heim and Lundman criteria were also used for data robustness. Partici- and instructions" and "timely education and information in the field of
pants were selected with different experiences, ages and genders. Much e-learning by managers ". Setting virtual content standards, devel-
effort was made in selecting semantic units, summarizing and abstracting oping guidelines for e-learning, approving by regulations and
them, and selecting topics and themes. Whenever there was a disagree- communicating them to faculty members, administrators, faculties,
ment, the authors discussed it in order to reach an agreement. Table 1 students, and the support team through formal correspondence and
presents the sociodemographic characteristics of the study participants. holding classes and workshops are some of the most important
strengths mentioned.
2.7. Confirmation of ethics and consent to participate in the study As one student has said: "The University very quickly drafted the uni-
versity's e-learning regulations and communicated it to the faculties and
The study was started after the approval of the present study in the faculty through the administrators. This was perhaps the turning point in
our education process".
research committee of Ahvaz Jundishapur University of Medical Sciences
and after receiving the code of ethics committee on research with human Ali said: "The University provided the latest virtual content preparation
information to the faculties very quickly and several courses in the field of
(IR. AJUMS. REC.1399.542). All participants were fully informed about
the study purpose and method and signed the consent form to participate electronic content production and how it works ".
2 Supporting and accompanying managers in the implementation of
voluntarily based on the Declaration of Helsinki.
virtual education programs:
This category itself consists of two subcategories "Support and
3. Results
Encouragement for the Development of Virtual Education" and
"Support and Cooperation of Managers in the Development of Virtual
A total of 122 students from 46 medical universities participated in
Education". Analysis of participants' experiences indicates that the
this study, which was 68% of the response rate compared to all univer-
support, support and encouragement of university and college offi-
sities in the country (67 universities). A total of 122 questionnaires
cials are effective factors in the development and implementation of
(open-ended) from 46 universities of medical sciences were completed.
e-learning programs. This support is achieved through the support of
Qualitative data analysis was performed in two main areas including
officials for virtualization decisions or material and spiritual
strengths/positive experiences and weaknesses/challenges. From the
encouragement of users (faculty and students) and executives, as well
participants' statements, it was found that strengths/positive experiences
as empowering them on issues related to virtual education.
had seven categories (including desirable education and information;
Zahra said: "The university supervisors supported all of our virtualization
support and accompaniment of managers in the implementation of vir-
decisions and they were the first to participate in the virtual learning ses-
tual education programs; cooperation and coordination inter and intra
sions and workshops".
sectors; responsibility, availability and full-time responding re-
Another student said: "The Managers very well encouraged faculty to
sponsibility; evaluating, monitoring and providing feedback on an
provide and deliver virtual educational content".
ongoing basis; having capable and specialized e-learning staff; and
3 Cooperation and coordination inter and intra sectors
enjoying and prioritizing e-learning). Also, weaknesses/challenges had
This category is divided into three sub-categories: the existence of
six categories including: common attitudes, beliefs and attitudes towards
specialized e-learning committees and working groups at the uni-
versity level; Cooperation of managers in providing e-learning facil-
Table 1. Sociodemographic characteristics of the study participants.
ities and infrastructure; and the cooperation and coordination of
managers at different levels in the virtual development of the uni-
Gender Frequency (%) versity. Based on the analysis of the results, the existence of
Male 52 (42.6) communication between different departments as well as the align-
Female 70 (57.3) ment of all different departments at the university and Ministry of
Age: Median years Health in order to develop e-learning has been reminded as a positive
18–23 25 (20.5) experience by the participants.
24 97 (79.5) Reza said: "The collaboration between the information technology (IT)
School of and education development center (EDC) departments of the university
Medicine 35 (28.6) with students and faculty was very effective in the development of e-
Pharmacy 5 (4) learning. This was a privilege that exists in fewer universities".
Dentistry 5 (4) A student collaborating with EDC said: "The presence of a specialized
Health 15 (12.3) virtual education team and a virtual committee in EDC with the mem-
Nursing 37 (30.3)
bership of senior educational administrators helped us a lot in the devel-
opment of virtual infrastructure".
Rehabilitation 15 (12.3)
4 Responsibility, availability and full time responding responsibility
Paramedical 10 (8.2)
Accountability as well as full time accountability of university ad-
Former experience of E-learning
ministrators and educational experts in the field of virtual education
Yes 15 (12.3)
to the educational problems of students have been mentioned as a
No 107 (87.7)
strength and a positive experience by the participants.

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A. Salahshouri et al. Heliyon 8 (2022) e08984

Table 2. Code, subcategory and category of strengths and positive experiences of e-learning development.

Category Subcategory Codes

Desirable education and Preparation, compilation and  Defining in-campus virtual content standards
information communication of virtual  Preparing and compiling the necessary guidelines regarding e-learning
education regulations and  Approving the regulations of virtual education and notify it to the faculty
guidelines members
 Timely follow-up in preparing an educational package for using the virtual
system for students
Timely training and information  Timely and regular information to the faculties by the university administrators
in the field of e-learning by  Fast performance in providing the latest virtual content preparation information
managers  Timely information and continuous guidance of managers
 Holding online electronic content production courses for faculty
 Holding workshops to work with the Navid system and solving faculty problems
 Informed faculty in a timely manner
 Provide timely training to the support team
Support and accompaniment of Support and encourage the  Full support of the deans of the faculties for the virtualization decisions of the
managers in the implementation development of e-learning Vice Chancellor for Education
of virtual education programs  Support managers for virtualization and production of electronic content
 Support and encouragement in the form of promises and promises to prepare
and provide virtual educational content
 Material and spiritual support for the implementation of virtual education
programs
 Encourage faculty to produce standard content
 Encourage educational assistants from successful faculty in virtual education
 Organizing various virtual training courses to empower teachers
 Close interaction of administrators with professors and students and
encouraging them to use virtual learning facilities and systems
Support and cooperation of  Support and cooperation of managers in the discussion of virtualization of
managers in the development of university affiliates
virtual education  Accompanying managers in the implementation of e-learning programs
 Membership of staff and environmental education managers in virtual
education working groups
 Being active in approving and implementing e-learning regulations
 Managers take the lead in using virtual learning systems and software
 Production of at least one electronic content by 70% of educational
administrators
 Comprehensive cooperation with students and faculty in holding virtual classes
 Continuous participation of managers in meetings related to the development of
e-learning
Cooperation and coordination Cooperation of managers in  Cooperation of managers in providing online training software
inter and intra sectors providing e-learning facilities and  Providing the necessary platform for e-learning by managers
infrastructure  Utilizing the maximum capacity of faculty facilities for e-learning
Responsibility, availability and Availability of managers and  24-hour and online access of students to educational administrators
full time responding responsibility experts  Full-time availability of system support experts for guidance and response
Evaluating, monitoring and Continuous evaluation and  Supervising the production of educational content for practical and internship
providing feedback on an ongoing monitoring of the production of courses
basis produced content  Supervising the educational content of theory courses
 Regular evaluation of the quantity and quality of content provided in the Navid
system
 Diligently pursue the improvement of quantitative and qualitative content
Availability of capable and Availability of specialized and  Availability of an active expert in the field of electronic content production
specialized e-learning staff skilled personnel and experts in  Availability of experienced IT experts familiar with working with virtual
the field of e-learning education systems
 Availability of software, hardware and network experts
 Availability of skilled experts in solving system problems
 Availability of expert and compassionate experts in the IT department of the
university
 Availability of e-learning expert active in the field of educational design
 Availability of e-learning expert, medical informatics and information
technology in the university
Enjoying and prioritizing e- Prioritize e-learning  Priority in multimedia production
learning  Decisive decision of managers to start virtual education at the beginning of
quarantine
 Take timely actions to expedite the use of e-learning
 Understanding the priority of e-learning
 All managers agree on the need for professors to use virtual programs
 Prioritizing e-learning in university programs
 Managers' emphasis on implementing virtual education

Ehsan said: "Some support managers and experts answered our questions 5 Evaluating, monitoring and providing feedback on an ongoing basis
24 h a day, even during off-hours. Many of them were really responsible. It Based on data analysis, reporting, monitoring and continuous moni-
helped a lot to solve system problems and make e-learning more effective." toring of faculty/students' performance and educational problems;
Mahdi said: "It was great that managers responded through various means Continuous evaluation and monitoring of the production of content
of communication such as WhatsApp, SMS, email, etc. This helped a lot". produced by the faculty members in both theoretical and practical

4
A. Salahshouri et al. Heliyon 8 (2022) e08984

courses and internships; Also, monitoring the performance of the Covid 19 pandemic, and waiting until the universities reopen; compensa-
experts of the e-learning unit and the faculties by the managers and tory classes".
supervisors of the e-learning unit were among the important and 3 Early experience
effective factors in the proper implementation of e-learning. Given that virtual education has begun its first days in the country, it
Fatemeh said: "In my opinion, the evaluation and monitoring of students' is associated with many issues. As some participants do not inter-
e-learning activities by faculty members is effective in improving the quality nalize the role of technology in traditional education; much more
of e-learning". pressure on professors by managers and students due to high demand;
6 Availability of capable and specialized e-learning staff and cited little experience in conducting online training courses as
It is clear that one of the basic requirements for the proper imple- effective barriers to the development of e-learning.
mentation of e-learning is availability of capable and specialized Sadra said: "In some faculties, conventional education still plays a leading
human resources. In this regard, universities that had a history of role, in fact, the need to change the mode of education has not yet been
graduate education in the field of e-learning or had the conditions for accepted by some students".
hiring technical manpower, announced that due to the employment 4 Lack of comprehensive regulations and protocols in the field of E-
of capable and specialized managers in the field of e-learning; Exis- learning
tence of specialized and capable faculty members; And employing
specialized experts in the field of e-learning are more prepared for the Some participants stated the lack of comprehensive regulations on
development of e-learning. measuring the quality and quantity of e-learning; Lack of standards in the
A Member of EDC said: "We have trained several master's degree students field of content development and how to evaluate professors and students
in e-learning and we have hired some of them. Therefore, we had enough are important challenges of e-learning.
specialized staff to implement e-learning.
Amir said: "We had a lot of experts and technicians in the fields of soft- A student said: "There is no single guideline for performance appraisal or
ware, hardware, networking, e-content production, and familiarity with e- content development. For example, one person uploads a pdf file as a
learning systems who were very capable of implementing e-learning". session and another uploads a PowerPoint file".
7 Enjoying and prioritizing e-learning 5 Insufficient familiarity with virtual education
One of the factors that the participants considered as a factor in the Based on the analysis of participants experiences, unfamiliarity with
development of e-learning was the interest, belief, enjoying and virtual education and how to evaluate the quality of virtual activities,
prioritizing e-learning and efforts to launch its fields, as well as as well as unfamiliarity of some students and professors as the most
removing barriers and problems of systems and software. Participants important elements of the educational system with virtual education
also mentioned the priority of virtual education for educational ad- software are other challenges in developing virtual education. Other
ministrators and senior university administrators as an important participants also mentioned the lack of familiarity of experts and
factor in this regard. managers with the basic principles of e-learning.
A student said: "The attitude of the university administrators towards e- Hossein said: "Many students are unfamiliar with online education soft-
learning was very positive. In fact, it can be said that they were determined ware. So effective education is almost impossible for everyone".
in the development of e-learning and made a lot of efforts to eliminate 6 Barriers in access to coordination
obstacles and problems in systems and software. To some extent, it can be Cooperation and support of managers has an important role in
said "After the fight against corona eradication, virtualization of education developing and improving the activities of an organization, and if this
was a priority for our managers' programs." support is not provided and there is no cooperation between man-
agers of different departments, the activities of that organization will
3.2. Weaknesses and challenges be disrupted. In this regard, some participants considered the lack of
proper communication and cooperation between educational ad-
1. Limitations of service clients and e-learning infrastructure ministrators and information technology, as well as the lack of
The first major category in terms of weaknesses and challenges is cooperation of some group managers in pursuing students' virtual
“Limitations of service clients and e-learning infrastructure", such as problems as an important challenge in the field of virtual education.
barriers and limitations in hiring specialized manpower, Lack of One of participants said: "There is no proper communication and coop-
specialized and experienced staff in the field of virtual education, eration between university administrators and administrators of the uni-
Weakness of e-learning facilities and infrastructure. versity's virtual education department. I do not know why, but this
Hoda said: "Weak electronic infrastructure, lack of evaluation infra- challenge has shown its impact on the development of virtualization. Some
structure in Navid system; the impossibility of using the Navid system in participants also stated that professors' difficult access to educational ad-
teaching practical courses as well as the shortcomings of the system in ministrators and students and vice versa is a major challenge in the
holding the exams correctly were among the challenges of universities in development of virtual education in universities."
holding online classes and developing virtual education". Bahram said: "We have difficulty accessing educational administrators;
Hadi said: "At our university, the Internet infrastructure for e-learning is we have no way to offer them our suggestions, so they make virtualization
very weak". Farzad said: "Navid system, which is used as the main system decisions regardless of the suggestions."
of virtual education in our university and most universities in the country,
does not have a suitable infrastructure for evaluating the quality of virtual 4. Discussion
education, it is not suitable for evaluating students' activities, more
usability". The present study evaluated the strengths and weaknesses of e-
2 Common tendencies, beliefs and views towards e-learning learning in universities of medical sciences during the COVID-19
Concern and distrust of some students about the quality of e-learning; pandemic in Iran from the students’ point of view. The outbreak of
Lack of interest of managers in virtual education; and users' resistance COVID-19 has led to the sudden suspension of all educational in-
to e-learning was one of the challenges mentioned by some of the stitutions. In such challenging time, teachers used e-learning tools to
participants. continue the process of educating students. In the present study, various
Shahin said: "It can be said that our main problem in the development of e- questions were asked from the students of medical universities to assess
learning is the concern of managers and their disbelief in the quality of e- their views on strengths and weaknesses of e-learning system. The
learning. Users' resistance to e-learning is a major challenge, with some importance of evaluating e-learning platforms has been discussed in
professors and students refusing to attend classes in person, even during the many studies (Frehywot et al., 2013; Huynh, 2017). The findings of these

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A. Salahshouri et al. Heliyon 8 (2022) e08984

Table 3. Code, subcategory and category of weaknesses and challenges of e-learning development.

Category Subcategory Codes

Limitations of service clients and Lack of specialized and  Lack of medical IT specialist staff in the virtual education unit
e-learning infrastructure experienced staff in the field of  Lack of experts in content production problems
virtual education  Lack of technical and educational technology expert to produce content
 Few people are familiar with content development software
 Lack of engineers fluent in designing and developing training systems
 Lack of fluent and capable experts in the field of virtual education
 Lack of trained and law-abiding experts in the field of e-learning
 Inadequacy of the number of experts with the workload
Common tendencies, beliefs and Users' non-compliance to virtual  Early non-compliance of users to virtual learning by students
views towards e-learning learning  Managers' concern about the quality of virtual education
 Lack of eagerness to follow of general education instructors to hold classes online
Early experience little experience in the field of e-  Refusal to change the training model by some managers with experience
learning  Surprise caused by the large number of applicants for virtual education
 Double pressure on professors by managers in the early days
 Less experience in holding training courses online
Lack of comprehensive regulations Lack of evaluation regulations  Lack of standard guidelines for measuring the quality and quantity of e-learning
and protocols in the field of E-  Lack of a national standard protocol in the field of e-learning
learning  Lack of unit virtual education regulations in the field of educational content
Insufficient familiarity with Experts, managers, teachers and  Lack of familiarity of managers and educational experts with virtual education
virtual education students are not familiar with  Lack of familiarity of managers with the basic principles of virtual education
virtual education  Insufficient familiarity of professors and students in the field of e-learning
 Lack of familiarity and lack of mastery of virtual education by some professors
 Lack of familiarity of professors with how to evaluate the quality of virtual activities
 Insufficient familiarity of professors and students with virtual education software
Barriers in access to coordination Weak cooperation and support of  Lack of proper communication and cooperation between educational and information
managers Limited access to technology managers
professors, students and education  Lack of cooperation of some group managers in following up on students' virtual problems
administrators  Difficult access to students to coordinate online classes by faculty members
 Difficult access to education for students to inform online classes
 Restriction in students' access to faculty and educational administrators

surveys will help to shape strategies to improve the e-learning system. achievements. Students are dissatisfied with the institutional facilities,
The challenge of limited scientific resources in developing countries and and they stressed that relevant training is needed to make effective use of
due to the growing need for health care providers, the importance of the electronic system. The results of this study indicate that students have
using e-learning system has been considered (Kumar et al., 2020; Olum a less positive perception of distance education in the university.
et al., 2020). The results of descriptive analysis show that the desired Therefore, to achieve a positive attitude and create a high level of
education and information were expressed by the participants as the satisfaction among students, it is necessary to address the weaknesses of
most important strength by the development of regulations and related the authorities in the e-learning processes. Another challenge of
instructions. The participants also stated that the support and encour- e-learning is that not all activities work well online and this should be
agement of university and college officials are effective factors in the taken into account when designing activities. A recent study by Romano
development and implementation of e-learning programs. Other et al., highlighted the impact of e-learning on ophthalmology education
strengths expressed by the students include 24-hour support for the during the COVID-19 outbreak. They stated that restrictions on
e-learning system, continuous evaluation, monitoring and feedback, the COVID-19 have a detrimental effect on medical graduate students
presence of capable and specialized e-learning staff, and an interest in (Romano et al., 2020). The results of the present study showed that
and prioritizing e-learning. According to the participants, comfort in students have the ability to use mobile phones and computers efficiently,
communicating with the e-learning platform and feeling relaxed during have a positive relationship with the impact of e-learning system, they
e-learning were mentioned as other strengths. The results of the present were not satisfied with the available facilities and emphasize the
study showed that with proper knowledge of the strengths and weak- importance of education to become effective users. These findings are
nesses of e-learning, it is possible to provide a better educational envi- consistent with previous reports that students and teachers who use so-
ronment for students by making appropriate changes. Therefore, moving cial media more often have significant potential to cope with the
educational activities to an online format can include many benefits such e-learning system challenges (Kimura et al., 2018; Romano et al., 2020).
as freedom from time and place limitations, scalability, interaction, and Another study by Chang et al., in China showed that teachers are not
quality control. Also, data analysis indicates that the role of teachers in ready to accept the online education system. During the survey, they
attracting students' attention and focus in e-learning is very important. found that some faculty members have little knowledge of computer
From the participants' point of view, the weaknesses and challenges of technology, and they prefer face-to-face interaction with students (Chang
e-learning were the limitations of the specialized human resources in the and Fang, 2020). Abbasi et al., studied medical students' perceptions of
field of e-learning infrastructure, reluctance and negative view toward e-learning system, they concluded that although medical students are
e-learning, mandatory use of this method due to circumstances, lack of satisfied by e-learning but they concluded that this approach is not quite
appropriate executive instructions and unfamiliarity with this educa- effective in technical and clinical skills (Abbasi et al., 2020). Similar
tional system and also lack of facilities and equipment were expressed. findings were obtained in the present study.
Therefore, most students believe that e-learning system is not equivalent One of the limitations of this study was the small number of re-
to face-to-face education and this system is not able to improve learning spondents. However, a longitudinal survey is needed to better identify

6
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Data will be made available on request. Navimipour, N.J., Zareie, B., 2015. A model for assessing the impact of e-learning systems
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Declaration of interests statement 2020. Medical education and E-learning during COVID-19 pandemic: awareness,
attitudes, preferences, and barriers among undergraduate medicine and nursing
students at makerere university, Uganda. J. Med. Educ. Curric. Dev. 7,
The authors declare no conflict of interest. 2382120520973212.
Romano, M.R., Ferrara, M., Rocha-de-Lossada, C., Angi, M., Govetto, A.,
Additional information Mastropasqua, R., Romano, V., 2020. Active e-learning in ophthalmology through
live webinars: back to the theatre. Eye 1–2.
Sahu, P., 2020. Closure of universities due to coronavirus disease 2019 (COVID-19):
No additional information is available for this paper. impact on education and mental health of students and academic staff. Cureus 12 (4),
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Shah, S., Diwan, S., Kohan, L., Rosenblum, D., Gharibo, C., Soin, A., Provenzano, D., 2020.
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