The use of ARS in medical education is a new experience for many medical schools, including those in Iraq. The introduction of the ARS use has promoted the use of technology in education and enhanced the concept of interactive learning. Although there is an abundance of studies evaluating the use of ARS in Western culture, it is important that contextualized studies are done. It is imperative to understand both student and tutor perceptions, and the impact on using such a technology, both from the view of the dynamics of the group and from student results. This study provides an early evaluation of this novel experience.
The results of the survey collectively demonstrate a positive preference and advantages of ARS use in all the four domains. ARS use was perceived as liked, preferred, wanted, entertained, and advantageous. Furthermore, students’ responses revealed that the ARS helped them to better understand the topic and stimulated them to further discussion and thinking. FGD analysis revealed that students liked the ARS mostly because it stimulated them to think more deeply. Questions in education are often used by teachers to stimulate building knowledge and critical thinking skills [27, 28]. When the questions are embedded within a lecture, this becomes an invitation to think more deeply about the content of the lecture. This is a first step of the thinking process followed by additional stimulation from the shared responses of the audience and comparing answers. Such answer comparisons are a natural form of learning [29, 30]. Students like to compare themselves and their responses to the classroom responses. This generates a second round of thinking, reviewing and comparing, especially when the responses are diverse. Depending on the setting of the group activity, this could be led by the course instructor for further interactive discussion and shared learning. Question 5 in the students’ survey, “The ARS stimulated me to study and review the topic more after the lecture”, addresses this point specifically. Two thirds of the students agreed or strongly agreed on this effect. This reflects the extended positive effect of the ARS use on continuing learning beyond the session. Motivation increases persistence in achieving learning goals .
The advantages in the domains of attendance, engagement, and memory were evident. Survey results showed perception of improving focus and attracting to attend the educational activity (lecture). Most students found the ARS helpful in participating and interacting in the lecture without embarrassment. Nelson  reported five out of six studies he reviewed favored learner interactions in ARS lectures. Facilitating sharing input helps increase the interaction. The students also found the system stimulating to prepare for the lecture and discuss the topic with their instructor and colleagues. Hassanin et al. reported that the ARS use encouraged students to discuss the topic with peer, in addition to improving engagement and attendance . Attention and interaction of learners may have long term consequences on memory . Focus and attention are indicators of engagement in the educational activity which is an essential component of adult interactive learning.
The use of technology and learning preferences domain was addressed by both the survey and FGD. The potential issue with the use of new technology difficulties did not seem to be an obstacle in the use of the ARS. On the contrary, most of the students found it stimulating to use technology in learning. The use of technology by student continues to grow worldwide, with students reporting they use desktop computers, interactive whiteboards, smart phones, and tablets . The positive perception and openness to use technology in education is an important factor in the introduction of more technology in education with expanding the use and application.
The use of ARS technology provides excitement to learners . This can lead to the possibility that the other features of the ARS use were liked because of other factors eg, entertainment rather than real positive perception of the features. The Technology Acceptance Model (TAM) provides some explanation of the technology use behavior and intention by associating it with the attitude toward technology and ease of use . This uncertainty needs further exploration.
There is clear evidence from the study of the multiple advantages of the ARS use as perceived by the students. As a new electronic tool, the ARS was attractive to the students. Entertaining tools and activities may influence the entire activity to the positive side . Another factor that might have contributed is the novelty of the experience to the students and the medical school. Students expressed excitement to use this technology as the first medical school in the country of Iraq. The course organizer and moderator expressed similar excitement.
The disadvantages of using the ARS reported from the FGD were much fewer than the advantages. The two main disadvantages that were reported are “time consumed” and “repetition” of the question posting process. The extra time needed for the ARS use and its questions is a known issue and disadvantage . Interestingly, the instructor did not believe that using ARS affected the amount of lecture content that was delivered.
The instructor’s perception was generally positive to all the questions of the survey except the two technical questions. Educators using technology often complain about the extra time needed to use technology. But, this extra time to learn the new technology can be evaluated against the length or term of the technology use as well as with the importance of the technology. Technology acceptance and use by teachers has been the focus of prior research, eg the Technology Acceptance Model (TAM) was developed to explain the influential factors and mechanisms of technology use, including in classrooms . It is, therefore, important to consider all factors that influence the adoption of the technology considered for use.
The course had one instructor which limits the data available for evaluation. Alternative way of evaluating the perception was to conduct personal interview that may provide in-depth perception input. However, the course was expected to be delivered by more than one instructor but ended up completed by one instructor for reasons out of the study control.
The instructor was very motivated and enthusiastic which may not reflect the average medical educator’s attitude and availability. According to Sharma and Srivastava, teachers who are willing to adopt new tools are motivated in adopting new teaching approaches . Teachers often resist using new technologies in their classrooms because of the challenges of the new experience . Instructors of courses that are planning to introduce the use of ARS should be prepared to spend initial extra time to learn how to use the technology. With the current level of technology use in all aspects of life and the wide exposure of people to it, learning ARS technology is not long nor difficult. Easy students’ learning and adjustment to technology and the use of the ARS was observed in other studies [39, 43].
The study evaluated one instructor’s perception through a written survey. More instructors’ perception, if available, would be more accurate. In addition, qualitative personal interview might provide more detailed and accurate input from the instructor.
Another limitation is the short-term use of the ARS and the lack of long term follow up. Long-term outcomes and knowledge retention were not embedded into this study due to time limitations but would be useful to study in the future. The scope of this study allows to focus on learning, understanding and short-term application of information. Larger and long-term studies can be designed to evaluate higher level of learning and knowledge retention.