Cross-sectional study of attitudes toward online continuing dental education in Libya during the COVID-19 pandemic

During the COVID-19 pandemic, many educational institutions switched to e-learning educational platforms. This approach was essential but raised challenges, particularly in training practitioners for medical emergencies. This approach not only led to global challenges and a need for rapid adaptation, but also raised inequities across countries, with some facing far more technical challenges than others. In Libya, low investment in education technology and unpredictable internet connectivity limited its integration into schools and universities even before the pandemic. The current study reports feedback from an online continuing dental education (CDE) course for dental practitioners that was developed emergently during the pandemic and aimed to address the challenges posed by Libya’s internet environment. Participants were recruited through social media and received an 8-hour online CDE course consisting of three modules. Participants were invited to complete a pre-course demographic/informational survey on a Google form. After passing all modules, students were prompted to complete a post-course survey consisting of 23, five-point Likert scale questions. Respondents included 43 females (74.1%) and 15 males (25.9%). For ~50% of the cohort (n = 32), this was their first online clinical course. 87.9% of post-course participants rated the course as a positive learning experience, while 90.9% agreed their learning outcomes had been achieved. Most participants (97%) agreed the course instructor explained all concepts clearly. In total, 81.8% agreed that the technology effectively supported their learning. Most agreed that a clear demarcation between each course module existed and that the language and depth of the material were adequate. Some students reported technical difficulties, and 33.3% saw repetitions in the modules. However, all post-course respondents said they would recommend the online course to colleagues. Libyan dental practitioners showed high satisfaction levels towards the e-learning process, course content, instructors’ attitudes, and overall e-learning experience despite the inherent e-learning challenges posed in this country.


Introduction
The COVID-19 pandemic caused an exceptional disruption of dental education across the globe [1][2][3] but led to particular challenges in some countries, such as Libya, that did not have established or reliable online infrastructure and availability.In accordance with stay-at-home orders to prevent the spread of the virus, dental schools across the world closed their campuses and moved to online didactic instruction [4][5][6][7].Online teaching platforms were introduced to support graduate dental education and continuing dental education (CDE) for dental practitioners, which included basic science training and theoretical components of clinical dentistry [8,9].In addition, problem-based learning methods incorporating virtual reality elements were applied to endodontic training at the pre-clinical and clinical levels, improving skill development outside the classroom setting [10].These knowledge-based courses provided dental practitioners with the latest research and industry advancements, which could enhance their clinical skills and improve patient care [11].However, the online approach to instruction posed concerns and challenges for Libya's unreliable internet connection and electrical grid, despite online course participants' overall openness to the e-learning experience [12,13].
The abrupt transition to e-learning during the COVID-19 pandemic raised concerns for dental teaching and general higher education, not just in Libya but in many regions of the world [9].Mixed satisfaction with online teaching has been widely observed [6,[14][15][16].Common problems that impair learner satisfaction include a lack of efficiency with online teaching technology, difficulties understanding the concepts taught, and social isolation resulting in limited development of communication skills [11,17,18].For example, many students reported that e-learning during the pandemic contributed to poor engagement and impaired the learning process, in part due to inconsistent internet access [19].Many instructors also felt they lacked adequate technical support for smooth operations despite displaying overall competency in content knowledge [20,21].Despite these challenges, instructors still largely agreed that technology integration was positive [22].A survey of international medical students found that frequent internet access issues and electricity outages interfered with their learning and diminished satisfaction with their courses, with many students reporting that online teaching was unfavorable and did not develop their clinical skills or foster productive discussions [23].Concerns about internet connection also weighed heavily on students' minds in Libya, despite overall satisfaction with the e-learning experience [12,13].In addition to technical limitations, many students and instructors have reported a preference for in-person instruction because it allows them to interact with other students and their teachers and forge better bonds [12,24,25].Likewise, a study of dental students showed that students felt e-learning did not adequately prepare them for examinations or build their practical skills.As a result, many students felt e-learning was only appropriate for theoretical lessons [26].
It has been long established that student satisfaction is tied to grades in learning settings [27].Recent research has found that factors influencing student satisfaction with in-person courses also influence outcomes for online and blended learning programs [28].A study examining blended learning programs found that student engagement, course structure, and instructor presence are tied to both learner satisfaction and educational outcomes [29].Similarly, attitudes to e-learning or blended learning programs are positively correlated with performance on examinations [30].Learner satisfaction does not just apply to individual courses; program performance has also been associated with academic performance and retention [29].These associations are widespread and robust, as one study examining over 10,000 students in 10 countries during the COVID-19 pandemic found that satisfaction with the e-learning format was tied to better student performance [31].
Since learner satisfaction is intrinsically tied to outcomes, it is critical to elucidate what factors influence student satisfaction with e-learning courses.Current research has identified several factors that affect student satisfaction with (1) online learning and (2) hybrid models that mix in-person instruction with e-learning.For example, students' perceptions of e-learning self-efficacy directly correlated with student satisfaction [32].Similarly, teacher involvement, online learning system quality, and service features were considered the strongest factors influencing student attitudes in an international study [31].
While the above literature has contributed substantially to our general understanding of elearning, online courses for dental practitioners in Libya were in their infancy prior to COVID, and there is little information about participant satisfaction and what factors support feasibility in regions without reliable internet connections.The current study reports findings from a course survey as a first step evaluating whether e-learning was a viable option for CDE in Libya.Importantly, we identified key factors in e-learning model design that supported and encouraged participant engagement and, therefore, built foundational methodology for improving e-learning outcomes in internet-challenged regions.Specifically, we investigated dental practitioners' attitudes towards a CDE course during the COVID-19 pandemic in Libya and explored its challenges and successes.Although many individuals in Libya did not make routine cleaning visits during the early days of the pandemic, it was imperative to continue training practitioners for endodontic emergencies [33].We rapidly designed and implemented a series of online CDE courses for dental interns and practitioners in Libya to support training for this critical care.In the current study, we investigated whether specific adaptations to course infrastructure, such as allowing more time to complete the course and complementary lines of communication between teachers and students, improved course satisfaction and willingness to pursue further online learning.

Study design and participants
The study was performed according to the reporting of observational studies using epidemiology (STROBE) guidelines [34,35].The study protocol and course were reviewed and approved by the Libyan Society of Endodontology.The recruitment process for our study specifically targeted Libyan practicing dentists.The course announcement was strategically disseminated on social media platforms, including the Libyan Society of Endodontology Facebook page, for a 3-week period.The inclusion criterion was a graduate dental degree; this criterion targeted general dental practitioners, interns, and endodontic specialists.The exclusion criterion was absence of a graduate dental degree; no individuals still in their primary dental training qualified for enrollment in the course or surveys.No inclusion or exclusion criteria were applied regarding the age or gender of recruited dental practitioners; practitioners of any age and gender were welcome to participate.A total of 120 participants showed interest by filling out the pre-registration form, with 91 completing the registration and enrollment process.

Course design
This course was built, in part, on e-learning principles laid out in a previous study, which implemented a similar online learning approach in an inverted virtual faculty development program [36].The course was delivered on an online Moodle platform during the COVID-19 pandemic.It consisted of three modules, each with specific learning objectives related to different cognitive aspects of clinical practice in treating endodontic emergencies, and was delivered through videos, quizzes, and discussion.The course was designed to accommodate the challenges and limitations of online teaching in Libya.Specifically, while course content could have been covered in three days, the course was offered over a 10-day period; this flexible schedule accommodated participants' needs, especially in cases of internet or electricityrelated difficulties.It was complemented by a WhatsApp group that engaged all participants, enabling swift communication.Within this group, the two facilitators, both experts in endodontics, were easily accessible to address any queries, provide assistance, and closely track participants who faced challenges with timely submissions or required extra time, particularly those who joined the course late or experienced internet or electricity-related difficulties.Course completion was achieved by scoring 60% or higher on each quiz module.For scores less than 60%, participants were prompted to review the content material, retake the quiz, and resubmit their answers.
While hands-on training is critical in dentistry, the primary contribution of this online continuing education training was for practitioners who already had basic training to be brought up to date on the latest techniques and management that would improve outcomes for endodontic emergencies.Importantly, there was no other mode of training during the pandemic, and this specialty training was particularly critical during a time when medical burdens often fell on individuals who were not fully trained in the area they were treating, due to redeployment [37].
To motivate course completion, participants received certificates for completing the course.A score of 60% or more on each quiz was required to receive the certificate and Continuing Education credit.If a participant scored less than 60%, they were allowed to go back, study the material again, retake the quizzes, and submit answers again.In addition, participants were required to complete the pre-course questionnaire before accessing the first module.For the post-course questionnaire, we were unable to enforce mandatory participation, resulting in some missing responses.

Data collection and course evaluation
Study goals addressed by data collection.The current study was conducted at a time when there is already dense literature addressing certain questions and conclusions about effectiveness of online learning, but it was not intended to achieve the goal of evaluating a full learning model, such as Kirkpatrick's model [38].In particular, given the urgency of its implementation, it was not an appropriate platform for a standard research design, which would have delayed life-saving treatment during the pandemic.The goal of our study was not to test learning; rather, the information collected in this study was intended primarily to evaluate attitudes toward e-learning in a region where e-learning faces significant logistical challenges and skepticism of participants about feasibility.Before designing a study to assess learning, it is necessary to first understand if others are willing to use this method and model of learning (reaction, level 1 of Kirkpatrick's model).If feasibility and willingness to learn this way are lacking, as previous studies of e-learning in internet-limited regions indicated, it would not be worth developing the courses further.The primary goal of the current study was to determine if the adjustments in flexibility and accessibility in the course design used would lead to more positive outcomes.It is not sound methodology to test a model where the methods are uncertain-this study assessed the feasibility of the methods used, not the outcomes.
Pre-course survey.Participants were asked to complete a pre-course demographic and informational survey on a Google form and submit their answers before starting the course modules.The pre-course survey was developed internally and consisted of nine closed-ended questions regarding demographics (gender, employment), endodontic emergencies, dental practices during COVID-19, the frequency of attendance of similar previous courses, and knowledge of recommended guidelines for safe dental practice during the pandemic.
Post-course survey.After passing all modules, participants were prompted to complete a post-course survey, also developed internally, consisting of 23 five-point Likert scale questions, wherein a score of 1 denoted "strongly disagree," and 5 represented "strongly agree."Questions addressed the participants' satisfaction with the course content, technology, and instructor.A single open-ended question regarding feedback on the course was also included.
Survey design.Both the pre-course and the post-course surveys were self-made by the authors to address e-learning needs for endodontic emergency care in Libya during the pandemic.Because this was the first time this particular need had been encountered, the survey was tailored specifically to evaluate the novel adaptations made to the online course.Due to the urgent nature of course implementation, it was not possible to run pilot studies on the surveys.However, we ran reliability statistics on the Likert scale portion of the post-course survey (the majority of this survey) and this yielded a Cronbach's Alpha internal consistency score of 0.81, surpassing the acceptable thresholds of both 0.70 for early-stage research and 0.80 for applied research [39] In addition, survey questions, both open-ended and Likert format, closely resembled previously published course surveys [40].

Ethics statements
The study was approved by the Libyan Society of Endodontology.Informed consent was obtained from all participants verbally through online meetings.Written consent was not required as no clinical data were collected.Verbal consent was documented through audio recordings and notes taken by the researcher.The consent process was thoroughly explained to the participants.All were informed of the study's purpose, procedure, and potential risks and benefits.The participants voluntarily agreed to participate in the study after confirming their understanding of the information provided.Participants' confidentiality and privacy were maintained throughout the study, and data were collected and analyzed anonymously.The Libyan Society of Endodontology reviewed and approved the study protocol before initiation.

Statistical analysis
Data were analyzed using SPSS (statistical package for social science) version 26.0 (SPSS Inc., Chicago, IL, USA).Qualitative data were recorded as percentages "n (%)."To evaluate the internal consistency of the post-course survey, we used Fisher's Exact Test to ask if there was a significant association between learning outcome Likert ratings and three questions relating to attitude toward the online course.Specifically, we looked at interaction between "learning outcome of the course on dental practice" with the following three questions: "preference for running the course online," "desire to take another course," and "would recommend this course to other colleagues."Since three tests were done, we used a Bonferroni correction for multiple comparisons requiring p�0.05/3 or 0.017 for significance.

Study samples
The characteristics of the study cohort are summarized in Table 1.A total of 120 dentists registered for the course, with 91 responses submitted (58: pre-course questionnaire; 33: postcourse questionnaire).Pre-course respondents included a significantly higher number of females (n = 43; 74.1%) than males (n = 15; 25.9%).Regarding the experience level of the study samples, 51 (87.9%) were general dental practitioners, 6 were endodontists (10.4%), and 1 participant was an intern (1.7%).Of the participants, 32 (55.2%) were attending an online clinical training course for the first time, 20 (34.5%) stated that they had attended similar courses previously, and 6 (10.3%) stated that they attended similar clinical courses on a regular basis.

Perception of E-learning
A total of 33 respondents provided feedback on perceived benefits of the learning modules.Of these, 16 (87.9%)rated the online course as a positive learning experience, with 18 (90.9%)agreeing that the learning outcomes were clearly met.Moreover, 24 (93.9%) agreed that the course instructor was competent, (87.9%) helpful, (93.9%) encouraged participation, and (97.0%) explained all concepts clearly.Regarding the participant-reported effectiveness of the e-learning module, 14 (81.8%) agreed that the technology could effectively support their learning, with 15 (84.8%) rating the flow of the course as appropriate.Most participants (n = 25, 75.8%) felt equally engaged in all course modules, and 31 (94.0%) agreed that a clear demarcation existed between each module.A total of 32 (97.0%) thought the course language was easy to understand, and 26 (78.8%) believed that the course depth was adequate.A total of 26 participants believed the course content to be of sufficient depth, compared to 22 (66.7%)who stated that the course was too challenging.Only 11 participants (33.3%) thought that the course module showed repetition, with 31 (93.9%) in agreement regarding the relevancy of the session activity and 26 (78.7%) of the effectiveness of the quiz (Table 3).Open-ended feedback was generally positive, although one participant mentioned experiencing technical difficulties with instructional videos.

Overall E-learning experience ratings
Of the post-course respondents, a higher number (n = 25; 75.8%) stated a preference for the online course compared to an on-site equivalent (n = 8; 24.2%).A total of 32 (97%) agreed that they would retake the course online compared to on-site, and 1 (3%) was neutral to the course.All post-course survey participants (100%) stated that they would recommend the course to other colleagues (Table 4).

Internal consistency of learning outcome ratings and attitude toward online course
There was a trend toward interaction between Likert ratings of learning outcome and "preference for running the course online" (p = 0.039).There were significant interactions between learning outcome and "desire to take another course" (p = 0.007) and between learning outcome and "would recommend this course to other colleagues" (p = 0.017) (Table 5).

Discussion
Although dentistry is a practice-based specialty, the incorporation of e-learning into dental education is now widespread.A paradigm shift towards online teaching occurred worldwide following the outbreak of the COVID-19 pandemic, including CDE [41][42][43][44][45][46][47].This transition in learning was a new experience for both educators and learners [48,49].The current study was designed to assess the feasibility and success of e-learning on CDE in Libya.This study's findings highlight how the concept of virtual learning was novel amongst Libyan dental practitioners, with the majority reporting it as their first experience of an online course.The satisfaction levels of the included participants were relatively high, and feedback was positive; 100% of respondents in the post-course survey said they would recommend the course to other colleagues and 97% reported a desire to take another online course.The specific course design, targeted to the challenges posed by Libya's online infrastructure, appeared to contribute to the easy adoption and acceptance of the e-learning courses since most of the participants provided positive feedback for the overall experience.During the initial COVID-19 period, clinicians were eager for further online courses to boost their knowledge but there were no data on approach or feasibility in regions where internet connectivity was not reliable.The course evaluated in the current study was designed to address these challenges to the extent possible without previously established platforms for doing so.Specifically, the course extended over 10 days instead of 3 days, providing flexibility for all participants to access all educational materials and overcome the frequent internet disconnections.This flexibility was critical, as infrastructural issues like these are tied to decreased learner engagement and satisfaction [23].Moreover, the presence of the facilitators in the WhatsApp group removed doubt when an activity or test was unclear and increased the attendees' satisfaction.In this program, a strong majority felt that the course instructor was competent (93.9%), helpful (87.9%), and encouraged active participation (93.9%).This is critical, as instructor engagement is strongly correlated to learner satisfaction in other studies [29,31].Moreover, the use of asynchronous and synchronous discussion forums was reported by learners in one study as critical for engagement [10].Future programs should be similarly adaptive to technological issues in order to avoid dissatisfaction with e-learning.
An additional advantage of online learning for this specific region and population was that knowledge could be accessed for low cost, time, and effort [50,51].A relatively large number of participants taking the online course required long journeys to attend the on-site course, making the course accessible to some who might not have attended CDE otherwise.In previous studies investigating the perspective of the participating dentists and instructors, 63.2% preferred e-learning compared to face-to-face teaching [52].In the current study 75.8% preferred the online to the in-person format; in this particular case, the accessibility challenges with inperson courses in Libya may have played a role in this strong preference, in addition to the other adaptations we made.
During preparation, there were challenges with poor internet connections, difficulties in communicating remotely, and the inability to identify a suitable e-learning platform.In previous studies, difficulties in concentration during online training and the inability to deliver online tasks or assignments were two major reasons cited for the preference for face-to-face training [53,54].The absence of a face-to-face connection during e-learning is also thought to contribute to professional isolation [55].In contrast, responses regarding the e-learning module showed that a plurality of participants (81.8%) thought that the technology implemented in the program facilitated their learning, with no respondents reporting that it did not.However, one participant reported technical issues viewing instructional videos in the open-ended comments section at the end of the survey.This example of technical difficulties impacting the overall learning experience mirrors the overall international experience with e-learning and is a potential point of refinement for this program and others [23,47].
Several previous studies have examined the impact of e-learning on the development of clinical skills and outcomes, compared to traditional learning, in dental workers [56][57][58].In these studies, attendees stated a lack of confidence in their ability to handle patients as a result of online learning [53,59].Conversely, e-learning was shown to encourage general dental practitioners to participate in clinical training, with up to 65% reporting positive benefits [60].These differences may be due to the different modes of learning between preclinical and clinical years.As an example, a computer-assisted design manufacturing (CAD/CAM) learning software for preclinical prosthodontics exercises received positive feedback when implemented [61].A variety of factors, including attitude, online teaching expertise, learning environment, and the quality of online content may account for these discrepancies [27,[62][63][64][65][66][67][68].In addition, economic, cultural, and political issues can impact learner attitudes and perceptions of their education environment [66][67][68][69][70][71].However, the program implemented in this study was largely deemed effective by participants, with the majority (90.9%) feeling that learning objectives were met and no respondents disagreeing that the course was an effective learning experience.Similarly, a high degree of engagement was reported by attendees, with 75.8% agreeing that they felt engaged across all modules.

Strengths and limitations of this study
While the current study focused on the demands and constraints of learning during the COVID-19 pandemic, the findings in this study provided an opportunity to expedite online learning tool development for the post-COVID-19 era.The pandemic drove a steep learning curve for online teaching methods that will benefit the future of online education.The findings in the current study identified factors leading to the success of online course implementation in infrastructure-, internet-and electricity-challenged regions across the world by showing that extended time for completion and inclusion of discussion groups are key factors influencing (1) willingness to participate in online courses and (2) ability to successfully complete such courses.The challenges addressed by our course design were not themselves related to the pandemic and, thus, are fully applicable to courses beyond the pandemic.
The findings of this study highlight new opportunities for e-learning classes within the Libyan CDE sector.However, some limitations should be noted.(1) The internally developed survey used in this study had to be developed rapidly and in parallel with the emergent demand for the online course.As a result, there was no time to run this specific survey through a pilot stage.However, the questions closely resembled previously published surveys of this nature [40] and the measure of survey internal consistency was shown to be rigorous (Cronbach's Alpha = 0.81 and significant within-construct consistency).( 2) During the delivery of this course, the pre-course questionnaire was obligatory, but the post-course questionnaire was optional, leading to a drop-off in responses.As a result, the sample size was small, with 25 responders lost to follow-up between pre-and post-questionnaires.There is thus a possibility of response bias toward those who felt more engaged in the course.It is noteworthy that this study was completed at a time when many research programs around the world were shut down completely, so it is a strength that this study was completed, even if a certain percentage of participants were lost to follow-up.(3) The large proportion of high-performing individuals in the sample taking the survey could have led to a volunteer bias.
Below, we suggest recommendations for future research practice based on what we learned from the strengths and limitations of the current study.

Implications of this study for research practice
This study was intended to capture participant reactions to the first online continuing dental education courses in Libya, building the foundation of technical and infrastructural feasibility needed to design a more comprehensive course evaluation.With this logistically feasible platform now established, future studies can refine the course and replicate and extend the survey findings.There are many elements to learning success and the current study honed in on only very focused, specific factors but, importantly, these were factors that were critical to the context of this particular course [72].Future studies are needed now (1) to evaluate the range of other elements that affect course success, including more direct assessment of learning itself, and (2) to assess the interconnectedness of individual factors in determining this success.
One future research recommendation would be a more comprehensive evaluation of course effectiveness, including direct assessment of participant learning.The current study evaluated only the first level (Reaction) of Kirkpatrick's model of learning evaluation (Kirkpatrick and Kirkpatrick [38]); future studies can now be planned to assess levels 2 and 3 of this model to evaluate course content learning and implications of such learning.For example, level 2 (Learning) could be assessed more directly using pre-and post-tests for course material, and level 3 (Behavior) could be assessed using surveys about how the course has changed clinical practice methods.Follow-up studies with a control group receiving equivalent face-to-face training would permit comparison of the online versus in-person approach to teaching this material.
Another future research recommendation would be to compare, in a non-emergent situation (i.e., not during a pandemic), the course offering with versus without the adjustments made to promote technical/logistical feasibility; this would allow for more direct testing of the role of these adjustments in improving feasibility.Such a study might, to be fair and ethical, use a cross-over design to be certain all participants have access to the material by the end of the study, although one could not directly compare learning within-subject across conditions in this manner.Another research design might entail comparing the same course methods with two different instructors, since learning has been shown to be strongly dependent on the beliefs and attitude of the instructor [73].Collection and analysis of survey data regarding the course instructor's own experience would also be useful in this regard.
Another future research recommendation would be to adjust certain design elements of the current study.For example, in the current study, only the pre-course questionnaire was required to receive the course certificate and continuing education credit.To better motivate participation in the post-course questionnaire, future studies could require both the pre-and post-course questionnaires be completed to receive the course certificate and credit.Studies in larger cohorts would also be beneficial; for this purpose, further increases in motivation, such as monetary incentives, might be included with participation.
Finally, studies at multiple locations are now required to confirm the generalizability of the results to other disciplines, instructors, and participant pools.

Conclusion
In conclusion, the overall satisfaction of Libyan dental practitioners toward (1) the e-learning process, (2) online course content, and (3) instructor's attitude and experience was high for the online course evaluated in this study.Easy access to knowledge, the lack of travel to attend the course, flexibility in the schedule, the ability to retake the course, and the presence of facilitators were cited as major advantages of both e-learning generally and the specific design of this course.A lack of experience with online courses and internet instability were recognized as pre-existing challenges to implementing online CDE, particularly in countries such as Libya.The COVID-19 pandemic has emphasized the need for prompt development of adaptive and effective strategies to make learning accessible and facilitate the transition from faceto-face to remote learning for dental, medical, and paramedical professions.Future studies can now build on the strengths and learn from the limitations of the current work.

Table 3 . Learning outcomes and participants' attitude towards the course instructor and module content (post- course survey).
*For purposes of the table here we have combined counts of "agree and strongly agree" ratings and "disagree and strongly disagree" ratings.https://doi.org/10.1371/journal.pone.0296783.t003