Performance and preference of problem-based learning (PBL) and lecture-based classes among medical students of Nepal

Background: PBL (problem based learning) is new active learning educational strategy that has been extensively tested and used in recent years. Patan Academy of Health Sciences (PAHS) is one of medical schools from Nepal, a Low Income Country (LIC) implementing PBL for undergraduate medical education. This study aims to compare PAHS students' understanding and knowledge retention when taught through PBL and lecture-based classes and compare students' perceptions of PBL and lectures in medical education. Methods: This is a cross-sectional study of medical students of a PBL based medical school in Nepal, a non-Western low-income country. Ethical approval was given by the institutional research committee of the Patan Academy of Health Sciences. Understanding and knowledge retention was assessed with 50 vignette-based multiple-choice questions, half of which were taught through PBL sessions, and the remaining half were taught in didactic lectures during basic science years of medical school. A separate pre-validated perception questionnaire was used to assess students' preferences regarding PBL and lectures. Results: Out of 107 students, 99 participated in the understanding and knowledge retention questionnaires and 107 completed perception questionnaires. Understanding and knowledge retention of students was found to be the same for topics taught by PBL and lectures, with median scores of 17 and s16, respectively. PBL were mostly preferred for the physiology (59.81%), pathology (51.40%) and pharmacology (53.27%) concepts, and lectures were mostly preferred for the anatomy (78.50%), biochemistry (45.79%), and microbiology (42.99%) topics. Students wanted the same concepts to be taught through both PBL and lectures, especially for anatomy. Conclusions: Understanding and knowledge retention is the same for topics taught by either PBL or lectures during the basic science years of undergraduate medical education. Students prefer PBL for physiology, pathology, and pharmacology-related concepts, conventional didactic lecture for physiology and microbiology, and a combination of lecture and PBL sessions for anatomy.


Introduction
Sir William Osler, referred to as the father of modern medicine, emphasized teachers' role in helping students to observe and reason.He recommended for teachers to abolish the traditional lecture method of instruction. 1 PBL (problem-based learning) is a newer active learning educational strategy that has been extensively tested and used in recent years. 2 PBL is an integral part of teaching in the undergraduate medical education of several medical schools around the globe, including the Patan Academy of Health Sciences (PAHS), a government medical school of a non-Western LIC (lowincome country), Nepal. 2 The PBL process was pioneered by Barrows and Tamblyn at the medical school of McMaster University in Canada in the 1960s. 3Students like PBL because it is student-focused, allows active learning, and leads to better understanding and retention of knowledge. 4,5udents take more interest and responsibility for learning, look for resources like research articles, journals, internet, textbooks, etc. and themselves resolve the contextual problems given in PBL. 6PBL enhances content knowledge and simultaneously fosters the development of communication, collaboration, problem-solving, critical thinking, and selfdirected learning. 7,8PBL emphasizes lifelong learning by developing the potential to determine goals, locate appropriate resources, and assume responsibility for what one needs to know. 9It helps students for long-term knowledge retention and improves competency as physicians after graduation. 10,11[14] PBL encourages students to ask questions, search references, and think of logical answers.On the other hand, PBL is resource-intensive and requires more physical space, computer resources, and more staff to facilitate PBL sessions. 15tudents also report uncertainty, information overload, and inability to determine the required depth and relevance of information available. 15This study aims to compare students' understanding and knowledge retention of topics taught through PBL and lectures, and also compare students' perception of PBL and traditional lectures, among the first two batches of medical students of PAHS who passed in 2016 and 2017.The data was collected before they graduated from PAHS.

Study design and participants
This study is a cross-sectional study performed in Nepal, a non-Western low-income country, among medical students of PAHS, where the hybrid PBL method is used during basic science years.All of the selected two batches of PAHS medical students were included in this study with their written informed consent.Students who did not give consent, students among the researcher team of this study, and students who participated in the pilot survey of questionnaires developed for this research were excluded from the study.The developed questionnaires were administered to 15 students who were randomly selected in the pilot study to establish the validity and feasibility.They were asked in detail about the questionnaire and any suggestions for revisions or editing needed.The pilot survey did not undergo any statistical comparisons.Only a few grammatical corrections were made after review and feedback from the pilot study.Subsequently, the final study was conducted on March 2014.Ethical approval was given by the Institutional Research Committee (IRC) of PAHS (IRC-PAHS) and research was carried out per relevant guidelines and regulations. 16ols: validation, implementation, and analysis Multiple-choice questions (MCQ) were used to assess understanding and knowledge retention, whereas a separate questionnaire was used to assess the preference for PBL and lectures. 25The MCQ questionnaire for the assessment of understanding and knowledge retention had 50 vignette-based MCQs, half of which were from topics taught through PBL, and the remaining half were from topics taught through lectures.These MCQs were developed and validated by the students with the help of research advisors.The MCQ scores were converted into percentages and interpreted in terms of percentage: <60% = very low, 60-70% = low, 70-80% = moderate, 80-90% = high and 90-100% = very high.The perception questionnaire was compiled and discussed in the student research group and reviewed by the research advisors to establish content validity.It was administered to the 15 students to establish the face validity and feasibility.

REVISED Amendments from Version 2
As suggested by the peer reviewer.
-The date has been mentioned.
-We rewrote some parts of the "Perception of students" topic in the results section of the manuscript ensuring that the Likert scale questionnaire results are appropriately emphasized.
Any further responses from the reviewers can be found at the end of the article The perception questionnaire had 30 questions to be answered on a forced Likert scale, ranging from one (strongly agree) to four (strongly disagree).Students were allowed to explain or give opinions qualitatively in some questions of the perception questionnaire.Data entry and editing were done in an MS Excel spreadsheet and analyzed in the SPSS 13.0 software for Windows.Descriptive statistics (mean and percentage) and inferential statistics were used to compare perceptions.A p-value less than 0.05 was taken as a statistically significant result.

Basic characteristics and information
Out of 107 students, 99 completed the understanding and knowledge retention questionnaires. 25The mean age of the participants was 22 years.In total, 59.6% of respondents were male and 40 (40.4%) were female.The majority (67/99, i.e. 67.7%) of respondents have completed their schooling at a private school and 32 (32.3%) completed their schooling at a public school.About half (49.5%) were living in urban areas, while 24 (24.2%) and 26 (26.3%) were from semi-urban and rural areas, respectively.The majority (91, i.e. 91.9%) of the respondents were from a 10 + 2 high school science background, while only 8 (8.1%) were from 10 + 3 health sciences background.

Understanding and knowledge retention of students
The normality test showed that the marks obtained by participants on topics taught via PBL and topics taught via lecture were not normally distributed (Shapiro-Wilk p-value = 0.015 for lectures and 0.024 for PBL).Thus, the median score was computed, which was 16 for lectures and 17 for PBL, as shown in Table 1.

Perception of students
The perception scale was internally consistent as the coefficient alpha of the perception questionnaire was 0.893.The perception questionnaire answered on a forced Likert scale, ranging from one (strongly agree) to four (strongly disagree) showed that students mostly preferred physiology, pathology, and pharmacology-related concepts through PBL, whereas they preferred anatomy, biochemistry, and microbiology-related topics through lectures.Some students wanted to be taught via both PBL and lectures, especially for anatomy subjects (Table 2).

Discussion
This study showed that students mostly liked being taught by both PBL and lectures.PBL was preferred for physiology, pathology, and pharmacology-related concepts, lectures were preferred for biochemistry and microbiology-related topics, and a combination of both for anatomy.Overall, the respondents wanted to be taught the same concepts via both PBL and lectures for anatomy.A meta-analysis by Nandi et al. compared the newer PBL curriculum and the conventional lecture-based mode of teaching undergraduate medical students.They concluded that a combination of both the conventional lecture-based and more recent PBL curricula would provide the most effective training for undergraduate medical students. 17However, their findings were not subject-specific.
This study showed understanding and knowledge retention of students remained the same for topics taught by PBL compared to topics taught by lecture.There was no statistical difference in the median score obtained for PBL and lectures for the understanding and knowledge retention questionnaire (17 and 16, respectively).However, most other studies show better understanding and knowledge retention with PBL than with lectures.A study by Albanese et al. showed that the PBL students score higher than the students in traditional courses.They also concluded that the reason for higher scores in PBL are the learning competencies, problem-solving, self-assessment techniques, data gathering, behavioral science, etc. of PBL students. 18Similarly, a study from Pakistan showed the mean score in the group exposed to PBL was 3.2 AE 0.8, while those attending lecture-based classes was 2.7 AE 0.8 (p = 0.0001). 19Another study on mathematics students from Slovenia found that students exposed to PBL were better at solving more complex problems. 20is study involved students taught through PBL in the first and second year of medical school i.e. basic science years, and showed equivalent results compared to lectures.However, another study on PAHS students showed that PBL imparts long-term knowledge retention through students' active participation. 21Wun et al. have also found that PBL started in the initial years of medical school is associated with more active participation, interaction, and collaboration among students, and PBL students score higher too. 22Another study on nursing students found that all students with higher or lower grades showed a significant increase in scores among students in the PBL group.Still, only students with higher grades showed a notable increase in scores among students in the lecture group.Learning motivation was also significantly higher in the PBL group (t = 2.608, p = 0.012). 23few of the respondents qualitatively reported in this study that some students in the PBL group worked harder than other members of the same group to prepare and participate in discussions.They also found the time allocated for each topic was not sufficient at times.Silva et al. reported that teamwork and the time involved can limit PBL learning. 24According to Wood, major disadvantages to this process involve the tutor facilitation and utilization of excessive resources. 15

Conclusion
Students' understanding and knowledge retention is the same for topics taught by PBL compared to topics taught by conventional didactic lecture.PBL is preferred for physiology, pathology, and pharmacology-related concepts.In contrast, traditional lectures were preferred for biochemistry and microbiology-related topics, and a combination of lecture and PBL sessions were preferred for anatomy during the basic science years of undergraduate medical education.Students prefer community-based programs and lecture sessions delivered by a group of faculty members for CHS.In contrast, they prefer a bedside teaching and hospital ward-based teaching methodology for ICM rather than lectures and PBL.

Data availability
Underlying data Figshare: Raw data and Questionnaire of research "Performance and Preference of Problem-Based Learning (PBL) and Lecture-Based Classes Among Medical Students of Nepal."https://doi.org/10.6084/m9.figshare.17286902.v1. 23is project contains the following underlying data:

Ashlesha Chaudhary
Nepal Medical College and Teaching Hospital,, Kathmandu, Nepal The article is well written.The methodology is sound, and the results are clearly presented.The statistical analysis appears appropriate and detailed.The authors have addressed key aspects of student preferences and learning outcomes, providing valuable insights for curriculum development and teaching practices.Overall, I recommend accepting this article for publication.

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.

Mamata Chimmalgi
Department of Anatomy, Sree Gokulam Medical College and Research Foundation, Trivandrum, Kerala, India I have seen the remarks of the authors for the queries.They are all satisfactory and hence the same can be accepted for indexing with no further suggestions from me.Best wishes for the authors.

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Version 2
Reviewer Report 29 April 2022 https://doi.org/10.5256/f1000research.133438.r136042 © 2022 Maharjan B. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Babu Raja Maharjan
Department of Biochemistry, School of Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal Some revision have been made in the manuscript following my previous comments.However following two comments have not been addressed.
1.When was MCQs and questionnaire administered for this study?
The outcome of MCQs score will depend on whether they are administered immediately or a long time after the completion of basic science.In the discussion itself authors have mentioned the dichotomous result on knowledge retention from the literature.Stating administered time of MCQs will also will help authors to justify their indifference in knowledge retention between PBL and lecture.
2. What about Likert scale questionnaire result?
In the preference questionnaire, there are Likert scale questionnaire for PBL and lecture.But its result is not mentioned.Why?

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Yes

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of
It is not stated when the questionnaire and MCQ test was administered.Recall bias will be there if it is administered a long time after the completion of basic science years where PBL is being implemented.This in turn will affect the measurement of performance by MCQ score and preference of PBL/Lecture for various subjects.Therefore, it should be clearly mentioned as the limitation of the study and current finding is based on students preference and performance of PBL measured after ?? time period.
Furthermore, the drawing of comparative inference on the preference of subjects for either PBL or Lecture is inappropriate.Questionnaire that was used in the study independently asked the preference of subjects for PBL and Lecture to the participants hence inference cannot be drawn if a certain subject has been preferred more or less for PBL over lecture.With the given study design, valid inference that can be drawn will be just the preference of various subjects to PBL and the preference of different subjects to Lecture but not comparison between PBL and lecture for a subject as mentioned in discussion and conclusion.
In discussion section, all of a sudden there is presentation of qualitative findings while it was neither mentioned in method section or result section.This needs to be consistent.

Is the work clearly and accurately presented and does it cite the current literature?
Yes Abstract is structured and draws attention to the aims of the study and the correctly conclusions.

○
Introduction segment enumerates the merits and challenges of PBL and proceeds to list the aims of this study in that context.

○
Methods segment elaborates on inclusion and exclusion criteria; developing MCQ questionnaire and perception questionnaire; establishing validation of the questionnaire; implementation and analysis.However, time intervals between the T/L methods and the administration of the questionnaire may be added to understand whether immediate learning or long-term retention were being studied -although the discussion segment mentions another study at PAHS addressing the long term retention, the method followed in the current study is missing.

○
In the Results segment, inference drawn regarding the performance may be included under 'understanding and knowledge retention of students' before proceeding to the results -e.g.'learning outcome following PBL was similar to lecture' or 'students performance following PBL was comparable to performance following didactic lecture'….…○ Regarding perception of students -both in results and in discussion segments, other parameters assessed by the perception questionnaire -unless deliberately omitted -may be included.

○
Conclusion segment effectively and correctly sums up the findings.

○
Under References, is there a need to add the last reference by the authors (no.25), when the same are shared under data availability?
○ Overall, a well-written, clear and concise article.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Yes

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?Yes Are all the source data underlying the results available to ensure full reproducibility?
They have to add rationale of study the introduction.Introduction need to be written in sequence.

Methodology
Authors have to mention duration of study How the reliability of questionnaires was established.
Authors may mention what guidelines and regulations were followed.They may mention number and date IRC.
Authors may mention briefly how MCQ were validated and clarify which group of students validated the MCQs and whether these were excluded rom the study.
In one sentence brief about students research group whether of same batches or others.
In raw data sheet in several cells data is missing; nothing is mentioned in the data analysis about this.

SD is missing in age.
Explain 10+2 and 10+3 schooling as everyone is not aware of this.

Discussion
Authors have to explain why there is difference in results in this study and other similar study conducted in PAHS.
Authors have to mention the limitations of study and include their recommendations in conclusion.

Others
Authors have to improve language of the article; mention conflict of interest and source of funding if any.

Competing Interests: I have no competing interest
The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.com Expertise: Medical Education, Psychiatry I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.Reviewer Report 25 October 2023 https://doi.org/10.5256/f1000research.156930.r212106© 2023 Chimmalgi M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Table 2 .
Subject preference to be taught using problem-based learning (PBL) and lectures (N = 107).
Note: For multiple response items, respondents were allowed to select PBL or lecture or both.

Table 1 .
Multiple choice question (MCQ) median score by two teaching methods at Patan Academy of Health Sciences, Nepal.The perception questionnaire also showed that neither PBL nor lectures were preferred for Community Health Science (CHS) and Introduction to Clinical Medicine (ICM), where many opted not to respond.Regarding CHS, students mentioned they learn public/community health better in community postings and lecture sessions with a group of faculty members as a part of Community-Based Learning Education (CBLE).Regarding ICM they prefer it on hospital wards and bedside teaching.

Open Peer Review Current Peer Review Status: Version 3
23tended dataFigshare: Raw data and Questionnaire of research "Performance and Preference of Problem-Based Learning (PBL) and Lecture-Based Classes Among Medical Students of Nepal."https://doi.org/10.6084/m9.figshare.17286902.v1.23 • Raw Data of PBL Research.xls• Descriptive Analysis of PBL Research.dochttps://doi.org/10.5256/f1000research.156930.r255160© 2024 Chaudhary A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility?
Saroj Adhikari Yadav et al. in their article 'Performance and preference of problem-based learning (PBL) and lecture-based classes among medical students of Nepal' have compared the learning outcome following PBL and didactic lecture and assessed preference of the students regarding the two methods.The article is written adhering to IMRAD structure and elaborates the findings of a cross sectional study conducted in PAHS in Nepal.