Knowledge and Perceptions of Medical Students After Using Kahoot! Towards General Pharmacology Practical Sessions at King Abdulaziz University
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Knowledge and Perceptions of Medical Students
After Using Kahoot! Towards General Pharmacology
Practical Sessions at King Abdulaziz University
Fatemah Omar Abdullah Kamel
King Abdulaziz University
Lana Adey Fareed AlShawwa ( lanashawwa@gmail.com )
King Abdulaziz University
Research Article
Keywords: Active learning, Game Based Education, Pharmacology, pharmacokinetics
Posted Date: October 11th, 2021
DOI: https://doi.org/10.21203/rs.3.rs-956795/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License
Page 1/16Abstract
Background
College students often do not study effectively or devote enough time to study and may experience a lot
of stress which negatively affects their learning. Game-based Electronic learning (GbEl) has been shown
to greatly motivate students, encourage learning and improve academic performance. Kahoot! is one
such electronic tool, but its effectiveness in the medical education sector in the Kingdom of Saudi Arabia
has never been evaluated.
Methods
This study aimed to determine the effect of the interactive software, Kahoot!, on the participation and
academic performance of 274 medical students in their general pharmacology practical sessions at the
faculty of medicine at King Abdulaziz University (KAU). The pharmacology sessions were divided into two
groups: control and Kahoot! and after each session, students took ‘pre’ and ‘post-tests’ to assess the
effect on learning. On the final day of the course, students were given a questionnaire to determine their
attitudes and perceptions toward the learning process using Kahoot!.
Results
The results showed that Kahoot! was an effective, enjoyable, and interactive formative tool that increased
student engagement, motivation, and improved academic achievement. Teachers involved in the study
agreed on the advantages of using Kahoot! largely out-weighed disadvantages.
Background
In most medical schools around the world, the teaching of pharmacology is lecture- based where
students are passive listeners receiving a massive amount of knowledge about drugs and prescribing
them medicines, and they are expected to memorize, retain, and interpret the knowledge effectively within
a relatively short period of time (Seth et al., 2010; Chavda et al., 2011; Gillani et al., (2018). This didactic
approach has been widely used for a long time. Unsurprisingly, therefore, it is an accepted notion among
medical students that pharmacology classes are the most tedious and least useful to them (Naeem et al.,
2012; Mustafa et al., 2016).
Integrating practical pharmacology sessions into the curriculum has been an ongoing challenge for
course designers. There is a need to explore effective ways of teaching this challenging subject by
creating a teaching environment conducive to learning and much-needed creative thinking, analytic, and
argumentation skills achievable through interactive teaching methods, as demonstrated by Giorgdze and
Dgebuadze (2017). Interactive learning has been found to encourage student teamwork, enhance
compassion and listening skills, and improve rational decision-making in new situations, all skills
Page 2/16extremely important for medical students in their preparation for becoming competent and caring
healthcare practitioners.
Research suggests that Game-based Electronic learning (GbEl) can greatly improve learners’ motivation
and participation by presenting the content in an interactive, rule-based and competitive manner which
supports the learning process in the cognitive, affective and psychomotor domains (Mitchell and Savill-
Smith, 2004; Boeker et al., 2013). In the area of teaching medical content, several studies have
demonstrated that electronic games could be an effective tool (Kerfoot et al., 2012; Boeker et al., 2013;
Rondon et al., 2013).
This study aims to determine the effect of the interactive electronic gaming software Kahoot!® on the
second-year medical students’ perception and academic performance at the King Abdul Aziz University
(KAU) in Jeddah, Kingdom of Saudi Arabia (KSA) in their general pharmacology practical sessions.
The use of educational games as study aids and their incorporation into curricula have shown improved
students’ attitudes towards learning and enhanced learning outcomes.
There are a variety of modern electronic games that have been successfully used as educational tools in
both schools and at the university level. A systematic review by Shawaqfeh (2015) concluded that
gamification in healthcare education can improve and evaluate the integration of knowledge,
comprehension, and confidence of students. Although some students did not believe that the games
improved their overall grades, the majority of them felt that they were more engaged, prepared, and
confident to face real-life scenarios due to participating in the different educational games.
Kahoot! is a popular educational game that is being used to develop learners’ skills. It is an online game
that can tests students’ knowledge, is free, and simply requires a multimedia tool participation like a cell
phone, laptop, or Chromebook for running the Kahoot! website (Siegle, 2015). Faculty members can
create quizzes in a game-based format using multiple-choice questions. The questions can contain
various multimedia contents, such as pictures or videos (Siegle, 2015) and can be based on real-life
scenarios, thereby approximating practice-oriented learning. There are several studies on the use of
Kahoot! as an educational tool both at the school and university levels.
A cross-sectional study conducted by Ismail and Mohammad (2017) involving 113 first-year medical
students in Malaysia to explore the advantages of gamification through Kahoot! platform for formative
assessment in medical education found that Kahoot! sessions motivated students to study, focus on the
important concepts and reflect on what they had learned. They concluded that it was a promising
formative assessment tool in medical education and recommended health professions educators include
it into their teaching and learning activities, particularly for formative assessment.
A study conducted by Curto et al. (2019) on a sample of 68 secondary school students (aged 12 to 16
years old) evaluating the use of Kahoot! in mathematics, biology and geology and physics and chemistry
reported that students became more confident and engaged in meaningful learning activities when the
Page 3/16classroom environment became more interactive with Kahoot!. The online questionnaires created by the
teachers with Kahoot! for which the students could get immediate feedback for each answer allowed the
teachers to be informed of the degree of learning achieved by students and the statistics of the data
almost immediately. Overall, the results on the benefits on the learning process were very positive and
helped to examine the potential of further use of online questionnaires in the classrooms.
Felszeghy et al. (2019) examined the effect of using Kahoot! in histology teaching at medical and dental
school classes at the University of Eastern Finland. The participation in Kahoot! by 160 students was
successful and resulted in learning gains. 77.5% (124/160) of students indicated that gamification
increased their motivation to learn. The gaming approach also helped students overcome individual
difficulties (139/160) and set up collaboration (107/160). Also, gamification promoted interest (109/160)
and the respondents found the immediate feedback on their answers in the game to be a positive feature
(146/160).
In KSA, gaming has also been used successfully as an educational tool; wherein many studies have
shown its effectiveness in improving student learning (Al-Zahrani, 2015; Alqurashi et al., 2016). However,
most of the studies have been done in schools. Alqurashi et al. (2016) identified three factors that
significantly influenced middle school students in KSA towards gaming: competition, discovery, and
knowledge. Sulphey (2017) and Albarakati (2019) evaluated the possibility of utilizing GbEl in dealing
with the issues of student engagement and motivation in the higher education sector in KSA, with
Sulphey (2017) concluding that GbEl would be an excellent aid to engage students more effectively and
help to transform the higher education sector and that it would bypass the traditional “teacher-centred
approach” in teaching.
To the author’s best knowledge, no previous research has been conducted evaluating the effectiveness of
Kahoot! in the medical education sector in KSA, which makes this cross-sectional study the first study of
its type.
Methods
Playing Kahoot!
To create a Kahoot! game, instructors logged in to the Kahoot! website (https:// getKahoot!.com). After
choosing the Kahoot! option, the instructors could create questions related to the specific pharmacology
topic using the available features, after which they received an automatically-generated code. Using their
laptop or smartphones, students accessed the game by using the Kahoot! application or by browsing the
website, www.Kahoot!.it. The students entered the code that appeared on the screen and registered their
names. Once the Kahoot! game started, students earned points based on correct answers and speedy
responses.
Research methodology and procedures
Page 4/16All 274 second-year undergraduate female medical students at the faculty of medicine (FOM) at KAU,
Jeddah, Saudi Arabia, participated. Data was collected across the second semester (period from January
2020 till May 2020) during four one-hour long pharmacology practical sessions (routes of drug
administration, pharmacokinetics (PK)I, and PKII, and drug-drug interactions). All the sessions were
taught to all the students in the same usual didactic method in their usual classrooms, which had an
internet connection, and the students had their own electronic devices.
The test sessions (Kahoot!) were the sessions on routes of drug administration and drug-drug
interactions. The control sessions were the sessions on PKI and PKII.
A short ten-question test, the “pre-test”, designed to test the student knowledge level of the particular
session material, was given to all students before each session, whereby they had ten minutes to answer
the questions on their devices.
To formulate the Kahoot! quizzes, two faculty members corroborated on formulating questions in
accordance with the sessions’ student learning objectives and entering them into the Kahoot! template.
One session (on dosage forms) was utilized as a pilot study to validate the quiz.
In the Kahoot! test sessions, after the session was over, the Kahoot! quiz projected on a large screen was
administered to the whole class. When playing the quiz, the question along with the answers were shown
on the large screen and the students had to pick the answer they believed was the correct one. The screen
showed a count-down timer as well as the number of students that answered. To get a high score, the
students had to answer correctly as well as fast. After each question, a distribution of the students’
answers was shown on the screen which showed the level of the students’ understanding of the material
taught in the session and opened up the opportunity to elaborate on the question and answers. After all,
the Kahoot! quiz questions were completed by the class, the same ten-question test administered before
the session, now referred to as the “post-test”, was given to the class to re-take on their devices.
In the control sessions, after the session was over, no Kahoot! quiz was administered to the class, but the
“post-test” was given to the class to re-take on their devices.
“Pre” and “post-test” scores for both Kahoot! and control sessions were collected for analysis.
At the end of the course and after all four general practical pharmacology sessions, a final exam was
administered, encompassing all material covered in the study sessions. As well, an eleven-item
questionnaire was given to the students on the last day of the course to determine their attitudes and
perceptions towards electronic game-based learning with Kahoot! in general pharmacology practical
sessions. Moreover, the questionnaire intended to establish whether Kahoot! reinforced knowledge and
had a positive effect on classroom dynamics or not. For descriptive statistics, Likert-item responses were
used with potential rankings ranging from 5 (strongly agree) to 1 (strongly disagree) as shown in Table 1.
Additional qualitative data were collected from focus group discussions after each session with four
faculty members who had shown particular interest in Kahoot! on the perceived advantages and
Page 5/16disadvantages of Kahoot!
Table 1
Students’ Satisfaction Questionnaire Toward Kahoot!
Items Strongly Disagree Not Agree Strongly
disagree sure agree
1 2 3 4 5
1. Kahoot! was an effective learning tool
for me.
2. Kahoot! improved my analytical skills.
3. Kahoot! improved my ability to retain
information.
4. Kahoot! improved my attendance and
participation in lectures.
5. Kahoot! should be utilized in other basic
medical sciences.
6. Kahoot! addresses lecture objectives.
7. Playing Kahoot! quizzes was a fun. I
always looked forward to playing it.
8. I would like to share this technology with
friends and other students.
9. The Kahoot! game was a distraction.
10. Kahoot! motivates me to learn more.
11. I feel prepared for tests and quizzes
after using Kahoot!.
Statistical Analysis
The quantitative data were entered into Statistical Package for the Social Sciences (SPSS, v. 26.0,
Chicago, USA). For statistical data analysis, the paired-comparisons t-test was used to compare the mean
scores between “pre” and “post-test”. Hence, it allowed recognizing the magnitude of change in test
scores.
The Mann-Whitney test was used to compare the average participation (summative and final exams)
grade between the sessions that utilized Kahoot! method and those did not (pThematic analysis of conversation was used to analyse the focus group discussion results.
Results
Reliability and validity test
Cronbach's Alpha value was used to determine the reliability of the questionnaire. The validity test was
used to evaluate the validity of each item and measure the satisfaction level. As seen in Table 2, the
questionnaire was reliable and all items highly correlated with their intention to measure as evidenced by
the validity tests except for item 11.
Table 2
Reliability and Validity of The Questionnaire
Items Overall Cronbach's
scale Alpha
1. Kahoot! was an effective learning tool for me. r 0.836** 0.893
2. Kahoot! motivates me to learn more. r 0.832**
3. Kahoot! improved my analytical skills. r 0.755**
4. Kahoot! improved my ability to retain information. r 0.782**
5. I am prepared for tests and quizzes after using Kahoot! r 0.700**
6. Kahoot! addresses lecture objectives. r 0.760**
7. Kahoot! improved my attendance and participation in lectures. r 0.803**
8. Kahoot! should be utilized in other basic medical sciences. r 0.668**
9. I would like to share this technology with friends and other r 0.780**
students.
10. Playing the Kahoot! quizzes were fun. I always looked forward r 0.759**
to playing it.
11. The Kahoot! game was a distraction. r 0.244
Students’ Perception Toward Kahoot!
The students’ perception towards Kahoot! was largely positive.
Page 7/16Table 3
Results of Students’ Satisfaction Questionnaire Toward Kahoot!
Items Percentage (%)
Strongly Disagree Not Agree Strongly
disagree sure agree
1. Kahoot! was an effective learning tool 7.2 5.6 17.4 26.7 43.1
for me.
2. Kahoot! improved my analytical skills. 9.2 11.8 23.1 29.2 26.7
3. Kahoot! improved my ability to retain 5.1 8.2 16.9 29.2 40.5
information.
4. Kahoot! improved my attendance and 9.2 9.7 20.0 19.0 42.1
participation in lectures.
5. Kahoot! should be utilized in other basic 8.7 7.7 17.4 24.1 42.1
medical sciences.
6. Kahoot! addresses lecture objectives. 5.6 4.1 21.5 29.7 39.0
7. Playing Kahoot! quizzes were a fun. I 9.2 2.1 14.9 20.5 53.3
always looked forward to playing it.
8. I would like to share this technology with 8.2 5.1 15.9 24.6 46.2
friends and other students.
9. The Kahoot! game was a distraction. 35.9 22.1 21.5 8.2 12.3
10. Kahoot! motivated me to learn more. 8.7 7.2 20.0 26.2 37.9
11. I feel prepared for tests and quizzes 20.0 23.6 28.7 13.8 13.8
after using Kahoot!
Effect of Kahoot! on test performance
Table 4 shows the differences in mean improvement scores between “pre” and “post-tests” with Kahoot!
versus the control sessions, whereby the mean for improvement was statistically greater with Kahoot!
Page 8/16Table 4
Differences in mean improvement scores between Kahoot! versus control sessions
Parameter Mean N Std. Deviation p-value
Kahoot! Drug-Drug Session Improvement 26.56 192 24.37 0.001
Control Session: PK1 Improvement 14.19 192 31.49
Kahoot! Drug-Drug Session Improvement 26.23 183 23.85 0.001
Control Session: PK2 Improvement 12.39 183 49.59
Kahoot! Route of Drug Administration Improvement 33.89 179 25.04 0.001
Control session: PK1 Improvement 14.53 179 32
Kahoot! Route of Drug Administration Improvement 33.89 179 25.04 0.001
Control session: PK2 Improvement 12.1 179 49.68
P-value considered statistically significant at ≤0.05.
Final Exam Results
There was a statistically significant difference in the final exam difficulty indexes between topics covered
through Kahoot! vs. control sessions.
Focus group discussion findings
The findings concerning the importance of Kahoot! in a classroom and the pros and cons of the
application as perceived by the faculty members involved in the group discussion are shown below in
Table 5.
Page 9/16Table 5
– Focus group discussion findings
Question Response
How important is it to play - ‘It helps learners share knowledge.’
Kahoot! in a classroom?
- ‘Learners support each other’s thinking processes.’
- Getting the answer wrong is the most effective way of learning
through Kahoot!’
- ‘The quizzes have emphasized what learners are not good at; they are
designed to demonstrate that being wrong is how you learn.’
State the Positives of - ‘If the time given to answering questions was extended, this could help
Kahoot! develop high order thinking.’
- ‘They could be a stepping-stone to a deeper understanding.’
- ‘No fear of answering incorrectly.’’
- ‘Encourage interest in a new topic.’
- ‘Repetition and recall are how Kahoot! can create and consolidate
learning.’
- The motivation arises from beating scores.
“detailed report on Kahoot! session easily measures learning impact for
each student”
State the Negatives of - Can’t be applied on cognitive questions (case scenario).
Kahoot!
- Internet access (poor signal and technical problems).
Discussion
In this study, Kahoot! created a learning experience that was largely described as “fun” and contributed to
useful classroom engagement dynamics (in terms of improved participation and motivation to learn
more. 64.1% of participants agreed that Kahoot! motivated them to learn more and 61.1% believed that it
improved their attendance and participation in class. Prensky and Thiagarajan, 2007; Perrotta et al., 2013;
Erhel and Jamet, 2013; Ismail and Mohammad, 2017; and Ismail et al., 2019 all reported that game-based
learning was more effective and motivational than traditional ways to promote learning. This difference
can be due to the interactive nature of game-based learning involving and stimulating students to learn
through active engagement (Jaganathan, 2014; Ismail and Mohammad, 2017; Ismail et al., 2019).
Moreover, this study supported what Plump and LaRosa (2017) suggested that Kahoot! helped students
to actively engage in their learning activities without it being a distraction.
Formative assessment, or ‘assessment for learning, is defined as “the assessment that provides feedback
throughout teaching” (Boston, 2002; Taras, 2005; Ismail et al., 2019). Recently, formative assessment has
Page 10/16taken on a greater role in the educational field, including medical education (Garrison and Ehringhaus,
2007; Black and Wiliam, 2010; Ismail and Mohammad, 2017). Johns, 2015; Ismail and Mohammad,
2017; Ismail et al., 2019 have shown that students’ learning is enhanced from greater interaction and
communication with their teachers and colleagues when they receive immediate feedback. Therefore, the
importance of designing appropriate assessment tools that yield feedback on the understanding of
students becomes a necessity very much. Properly designed game-based learning materials can help to
achieve this purpose and several studies, such as Yien et al. (2011), Wang and Lieberoth (2016), and
Ismail and Mohammad (2017), have shown the effectiveness of game-based learning in comparison with
traditional learning methods. The results of this study also showed a significant improvement in the
scores of students in the ‘post-tests’ versus ‘pre-tests’ in all Kahoot! sessions compared to control
sessions. The detailed student performance reports were made available to the teachers during the
Kahoot! sessions allowed the teachers to perceive incomplete levels of understanding and opened up
valuable feedback and more extensive discussions of the question and answers. This allowed immediate
correction of misunderstandings related to the subject matter and facilitated the learning process to
retain knowledge as supported by the students’ final exam results. This distinguishes Kahoot! from other
formative assessment methods and has also been reported in the work of Ismail et al. (2019).
Nearly 70% of participants agreed that Kahoot! was an effective learning tool. These results are
consistent with the results of many other studies (Wang, 2015; Ismail and Mohammad, 2017).
Wang (2015) reported that Kahoot! helped students focus on specific relevant content, particularly when
a large amount of material was taught in lectures. In addition, students reported that the discussions with
teachers during Kahoot! helped them retain information without needing additional revision sessions
before tests. Our results are consistent with this prospect since there was a statistically significant
difference in the difficulty indexes in the final exam questions between Kahoot! vs. traditional sessions.
An interesting finding in our study, however, was that around 72% of the students disagreed or were not
sure if using Kahoot! prepared them for tests and quizzes. This finding could be explained based on the
fact that Kahoot! could only test the recall questions due to the limited number of characters used to
create questions which made it difficult to formulate questions to discern educational learning as per
Bloom’s taxonomy. However, the questions in our final exam were also recalled questions to match the
Kahoot! quiz and the ‘pre’ and ‘post-tests.’ Another explanation is that students were not aware of the
importance of formative assessment as a tool that could help them identify knowledge gaps and better
prepare them for exams. This finding has alerted our attention to enlighten the students on the use of
formative assessments and their role in their process of exam preparation.
This study was unique in that it was comprised entirely of females (both students and researchers).
Although Adrianson (2001) found no gender differences in the styles of conversation and participation
between males and females in an e-learning environment, Hou (2019) reported that in Kahoot! female
students felt less stressed than males because they could respond to questions at their speed. In
addition, females showed more positive perceptions than males towards the benefits of mobile-assisted
Page 11/16tools in helping them pay greater attention in lectures and understanding class material, building
confidence to study and monitoring their learning, and receiving better scores on exams.
The advantage of Kahoot! as perceived by faculty members during the focus group discussions was that
it endorsed the potential for deeper assessment and interactive learning. The faculty also appreciated
real-time feedback, which provided them with the opportunity to measure learning and tailor their
instruction based on student understanding on quizzes. The disadvantages were possible problems with
internet access and the perceived fact that it could not be applied to formulate practice-based scenarios
or questions requiring cognitive skills. This could be due to the faculty members’ non-familiarity with the
features of Kahoot!
Conclusions And Recommendations
This study has demonstrated that Kahoot! was an effective, enjoyable and interactive formative tool that
increased student engagement and motivation and improved academic achievements.
Therefore, we recommend that medical schools, including ours at KAU, use Kahoot! in lectures, tutorials
and problem-based learning activities for effective formative feedback.
One limitation of this study was that Wi-Fi coverage might have affected internet speed and connectivity
and thus impacted students’ performance. As well, Kahoot! ‘s limited number of possible characters for
creating questions could have impeded teachers’ creativity in formulating more complex questions.
Finally, further future research on how gaming can foster interpersonal skills, teamwork, professionalism,
accepting criticism, verbal and non-verbal communication skills is needed. As well, the use of gaming in
non-cognitive skills assessments needs more research.
Abbreviations
Game based Electronic learning GbEl
King Abdul Aziz University KAU
Kingdom of Saudi Arabia KSA
Faculty of Medicine FOM
Pharmacokinetics I PKI
Pharmacokinetics II PKII
Declarations
Page 12/16Ethics approval and consent to participate
Local ethics committee ( Ethics Committee of Human Research at King Abdulaziz University) ruled that
no formal ethics approval was required in this particular case.
Consent for publication
Not Applicable
Availability of data and materials
Not Applicable
Competing interests
The authors declare that they have no competing interests
Funding
Not Applicable
Authors' contributions
FK conceptualized and designed the study, acquired and interpreted the data, drafted the initial
manuscript, revised the manuscript, and approved the final manuscript. LS contributed to the
conceptualization of the study, revised and approved the final manuscript
Acknowledgments
Not Applicable
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