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Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 128-132

Text-Messaging to Supplement Classroom Teaching: A Nonrandomized Controlled Trial

1 Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
2 Department of Pediatrics, VMMC & Safdarjung Hospital, New Delhi, India
3 Department of Pediatrics; Department of Medical Education, Maulana Azad Medical College, New Delhi, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Sumaira Khalil
Department of Pediatrics, VMMC & Safdarjung Hospital, New Delhi 110029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mamcjms.mamcjms_26_18

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Introduction Short messaging service (SMS), or text messaging is highly accepted in medical education of health workers and patients. This study was conducted to evaluate if SMS-based supplementation of key messages with conventional classroom teaching compared to conventional teaching results in a better cognitive performance of undergraduate medical students.
Materials and Methods Setting: Department of pediatrics of a public medical college in India. Participants: Ninety-two final-year undergraduate medical students. Study design: Single-center, nonrandomized, controlled trial. Intervention: One batch was given SMS-based key messages in addition to conventional teaching (intervention group, n = 48), as compared to only conventional teaching of the other (control, n = 44) batch. The text messages pertained to five predetermined topics of the teaching session and were sent in the evening of the day the topic was taught. Primary outcome variable: Scores in a multiple-choice question (MCQ)-based test at the end of posting of each batch.
Results A total of 92 final-year MBBS students were enrolled in the study. There was no statistically significant difference between the performance of the study participants in the post-intervention MCQ test in the two groups [mean (standard deviation) scores, 13.4 (1.55) vs. 9.7 (3.49), P > 0.05], even after subgroup analysis for high scorers and low scorers. The total cost of sending the messages was less than Rs. 100.
Conclusion There was no statistically significant effect on cognitive performance following a supplementation of classroom teaching by SMS-based key messages. However, given the low cost of this methodology and the reported high acceptance of this method by students, there is a need for more well-planned studies to confirm these results.

Keywords: E-learning, innovation, medical education, pediatrics, teaching methods

How to cite this article:
Agarwal A, Khalil S, Sethi M, Mishra D. Text-Messaging to Supplement Classroom Teaching: A Nonrandomized Controlled Trial. MAMC J Med Sci 2018;4:128-32

How to cite this URL:
Agarwal A, Khalil S, Sethi M, Mishra D. Text-Messaging to Supplement Classroom Teaching: A Nonrandomized Controlled Trial. MAMC J Med Sci [serial online] 2018 [cited 2020 Nov 24];4:128-32. Available from: https://www.mamcjms.in/text.asp?2018/4/3/128/249024

  Introduction Top

Medical undergraduate teaching in India encompasses tutorials, lectures, hands-on training, besides clinical teaching in the outpatient clinic and inpatient wards.[1] With the advent of e-learning, the paradigm of education has changed for a student, where he can now indulge in structured self-learning; however, these newer modalities have not been used in conjunction with classroom teaching extensively by medical teachers in our setup, especially in the public medical colleges.[2],[3] Among the various newer modalities, the short messaging service (SMS), or text messaging, seems to be most prevalent, handy, and widely used method of communication by the young and old alike.[4] With a mean of 18 SMSs received per day by medical students, it is a electronic modality that needs to be tapped for medical education.[5] Three main areas in which mobile phones are used in education are organization and support of education, learning content, and collaborative learning.[4] Although this has been evaluated and used in the context of effective communication and information dissemination among healthcare providers[6],[7],[8] and patients,[9] it has not been extensively studied as a modality of teaching for medical students. The only previous studies performed are among residents,[10],[11] with only one report on its use in undergraduate students,[12] but that too for assessment purposes. In the context of classroom teaching, brief messages by SMS have been an add-on to the interactive classroom sessions, resulting in better interest and attention in the classroom.[13]

The possible role of mobile phone SMS in teaching–learning of medical students could be an important and low-cost step in undergraduate medical education. Research on smartphone-based educational interventions in graduate medical education is limited.[14] The study performed on nursing student’s to enhance their medication knowledge by SMS reported a significant increase in the medication knowledge score.[15] Another study performed on residents of obstetrical and gynecology reported that learning through text message has much better results on the test questions.[16] Therefore, we conducted this study to evaluate the efficacy of text messaging as an adjunctive tool to classroom teaching for augmenting gain in knowledge of undergraduate medical students.

  Materials and Methods Top


This single-center, nonrandomized, controlled trial was conducted in the department of pediatrics in a tertiary-level public hospital attached to a medical college from February 1, 2016 to May 31, 2016. Approval was taken from Institutional Ethical Committee (IEC), and informed written consent (after providing IEC-mandated limited information) was taken from all students before enrollment in the study. The full details of the study methodology were conveyed to the participants only at the end of the study.

Each year medical undergraduate student intake (250) is divided into five equal batches on the basis of first alphabet of their names. Each batch is posted to the department of pediatrics for a period of 7 weeks in the 8th to 9th semester. Of these, two consecutive batches posted to the department were approached for inclusion in the study on the first day of the posting. Students not having access to a cellular phone were excluded. The first batch of students posted to the department was labeled as Control (conventional classroom teaching only) group and the next batch as Intervention (conventional classroom teaching with SMS) group.


Five faculty members (one senior professor, two professors, and two assistant professors) were coopted for the purpose of the study. One topic by each of these was selected for the purpose of the study, and they were requested to teach it in the same way (content, teaching–learning methods, and teaching aids) for both the batches. None of the study investigators were included among these, nor were the study methodology or group allocation revealed to the teachers prior to completion of the study.

The students in the Control group were taught the five selected topics by the respective teachers, along with conveying of five key points at the end of each teaching session. The Intervention group (the next batch of students posted to the department) were similarly taught and conveyed the same Summary points. In addition, they received a text message containing the Summary points for that lecture on the evening of the same day, containing the five key points from that day’s topic. Services of a commercial bulk SMS-sending portal were used for sending the messages. Thus, each student received a total of five text messages, corresponding to the five lectures.


An attrition period of 5 weeks was given to the students in each batch, as they were posted with us for only 7 weeks, after which they were tested on the same five topics by a multiple-choice question (MCQ) test. A question bank of 40 single response type MCQs (eight from each of the five topics) was created based on the key messages. Out of this question bank, 20 randomly selected MCQs (by random number generation, four from each of the five topics) were included in the two MCQ test papers of 15-min duration with a maximum score of 20 (there was no negative marking). One set each was used for the intervention and the control group. Scores of this test were not included in the standard formative evaluation at the end of the posting (ward-leaving examination). The students of the intervention group were not informed in advance that the MCQ test will be based on the key messages sent by SMS.

There was no plan to check whether students actually read the SMSs sent as part of the study intervention. All students enrolled in the study were assessed in the allotted groups. Students missing any or all the classes were not excluded. Those not appearing in the MCQ-based examination were excluded as trial deviates. The evaluating team was blinded to the group they were evaluating.

Statistical analyses

The data were entered in an anonymized format in Excel sheets. Descriptive statistics were derived using MS Excel program. Normality of the data was checked with online descriptive statistics (http://www.xuru.org), and comparisons were performed using the free online calculator at Simple Interactive Statistical Analysis (http://www.quantitativeskills.com/sisa/statistics/t-test.php).

Comparison of MCQ scores between the two groups as a whole was performed using the Student t test. Data of students of both the groups were also divided in three equal-sized subgroups each based on their average examination scores in the previous semesters and were labeled as high scorers, medium scorers, and low scorers. Average MCQ scores of the high scorers and low scorers from both the Intervention and Control groups were also compared with their corresponding group using the Student t test. Categorical variables were compared using the Chi-square test. A value of P less than 0.05 was considered significant.

  Results Top

The two batches posted to the department of pediatrics included a total of 100 students, but only 93 attended the postings in the 8th semester (due to detentions etc. in previous semesters). As one girl refused consent, 92 final-year MBBS students (58 males, mean age 22.1 years) were enrolled in the study [[Figure 1]]. The baseline participant characteristics, namely, mean age (22.34 vs. 21.87 years), sex distribution (30 vs. 28 males), and the average scores in the previous summative examinations (61.96% vs. 63.19%) were similar for the two groups.
Figure 1 Flow of participants in the study

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The performance of the study participants in the postintervention MCQ test is shown in [[Table 1]]. There was no statistically significant difference between the performances of students in the two groups in the MCQ test. A subgroup analysis was conducted to determine whether text messaging selectively helps the poorly performing or better performing students.
Table 1 Past scores and performance in the MCQ test among students of each group

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The total cost of sending the five messages to all 48 students was Indian National Rupee (INR) 91.20. The bulk-messaging software provided successful delivery reports for all the participants.

  Discussion Top

In this nonrandomized controlled trial on 92 final-year MBBS students, conducted at a public-sector medical college in India, we observed no statistically significant difference in cognitive performance at the end of the study period, as estimated by an MCQ test between the group in which SMS of key messages was sent along with conventional classroom teaching vs. conventional classroom teaching alone. Analysis of high-performing and low-performing students separately also did not show any difference in the MCQ scores.

Previous studies have shown uniformly high acceptance of SMS-based educational inputs by the users.[6],[7],[8] However, the previous studies performed on SMS use have only been conducted on nursing students,[15] family medicine,[10] and gynecology residents.[16] In a randomized controlled trial, 63 family medicine residents completed the pre-tests and post-tests. The intervention group’s score improved from 55% of questions answered correctly to 64%; the control group improved from 56% to 61%. Although these pretest/posttest changes each were statistically significant, the difference in improvement between the two groups was not. Therefore, they concluded that the use of electronically generated educational messages as initially developed did not increase resident knowledge based on examination scores,[10] a result similar to the present study. The study conducted among gynecology residents showed better acceptance and better learning with the SMS method as compared to learning by textbook.[6] Having been performed in residents, both studies lacked comparison of text messaging with conventional face-to-face teaching. Sichani et al.[18] also reported statistically significant difference between SMS learning method and lecture method in the medication test scores of medical students, but evaluation of the satisfaction showed that 78.7% of participants were not satisfied.

We could not find any previous English-language published studies conducted on undergraduate medical students. Spiller et al.[12] have shared their experience of using SMS to support the undergraduate medical student experience, but the four case studies reported primarily address use of SMS for assessment of competence, as a mobile-enabled log book, enrolling patient-volunteers for objective structured clinical examination, and collecting whole class assessment and feedback. Use of this modality in pediatric residents showed good acceptability by residents, although impact on learning was not assessed.[11]

The study had a few limitations. It was a single-institution-based study with convenient sample size limited by the size of the batch under study. The design was nonrandomized, which was to obviate the possibility of sharing of the SMS in case the first batch was randomized as the Intervention group. The MCQs were not psychometrically validated but were discussed with the concerned teachers regarding the difficulty level. Although we confirmed that all participants in the study group received the SMS, there was no mechanism to confirm that all of them read it or revised it before the MCQ test. The number of text messages sent (for five topics only) was to obviate the students getting used to the messages and not reading them, a possibility expressed in a previous similar study.[10] The number of MCQs was kept at a manageable 20 MCQs to prevent fatigue of the students. Difficulties in conducting controlled trials in the field of medical education have previously also been highlighted.[17] The major strength of the study was the controlled study design, large number of study participants, use of same faculty for the teaching of the same topics for both the groups, and enrollment of students from the same semester.This nonrandomized study of medical undergraduates did not show a statistically significant effect on the cognitive performance following a supplementation of classroom teaching by SMS-based key messages. This could be attributed to that students were taught by lecture method over the entire academic years, so they were not familiar to SMS-based learning.[18] However, given that this SMS-based intervention was low cost and considering that literature shows a high acceptability of this modality by users, further testing of SMS-based transmission of curricular content for medical undergraduates in various settings is suggested so as to act as an adjunct to didactic lecture and allow for asynchronous trainee learning.


We acknowledge the help of Drs. Monika Juneja, Seema Kapoor, Mukta Mantan, Ashish Jain, and Raghvendra Singh in assisting us in the conduct of the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Medical Council of India. Regulations on graduate medical education. 1997 (amended). Available at: http://www.mciindia.org/Rules-and-Regulation/GME_REGULATIONS.pdf. [Last accessed on September 15, 2018].  Back to cited text no. 1
Dhir SK, Verma D, Batta M, Mishra D. E-learning in medical education in India. Indian Pediatr 2017;54:871-7.  Back to cited text no. 2
Vyas R, Albright S, Walker D, Zachariah A, Lee MY. Clinical training at remote sites using mobile technology: An India-USA partnership. Distance Educ 2010;31:211-26.  Back to cited text no. 3
Sandars J. Mobile phones in undergraduate medical education: The tide is beginning to flow. Available at: http://connection.ebscohost.com/c/articles/23175511/mobile-phones-undergraduate-medical-education-tide-beginning-flow. [Last accessed on September 15, 2018].  Back to cited text no. 4
Mahmoodabad SS, Mazloomy BA, Nadrian H, Moshiri O, Yavari MT. Survey of ownership and use of mobile phones among medical science students in Yazd. Pak J Biol Sci 2009;12:1430-3.  Back to cited text no. 5
Alipour S, Jannat F, Hosseini L. Teaching breast cancer screening via text messages as part of continuing education for working nurses: A case-control study. Asian Pac J Cancer Prev 2014;15:5607-9.  Back to cited text no. 6
Richardson A, Littrell OM, Challman S, Stein P. Using text messaging in an undergraduate nursing course. J Nurs Educ 2011;50:99-104.  Back to cited text no. 7
Chen Y, Yang K, Jing T, Tian J, Shen X, Xie C et al. Use of text messages to communicate clinical recommendations to health workers in rural China: A cluster-randomized trial. Bull World Health Organ 2014;92:474-81.  Back to cited text no. 8
Deng X, Ye L, Wang Y, Zhu T. A cross-sectional study to assess the feasibility of a short message service to improve adherence of outpatients undergoing sedation gastrointestinal endoscopy in the People’s Republic of China. Patient Prefer Adherence 2014;8:1293-7.  Back to cited text no. 9
Mount HR, Zakrajsek T, Huffman M, Deffenbacher B, Gallagher K, Skinker B et al. Text messaging to improve resident knowledge: A randomized controlled trial. Fam Med 2015;47:37-42.  Back to cited text no. 10
Adamson GT, Draper LR, Broom MA. Text4P eds Feasibility of an educational text-messaging program for pediatrics residents. J Grad Med Educ 2014;6:746-9.  Back to cited text no. 11
Spiller J, Smith S, Skinner J. SMS: Students, mobile and support: Four case studies using SMS to support the undergraduate medical student experience. Paper presented at Computer Assisted Assessment Conference, 2012. Available at: http://caaconference.co.uk/pastConferences/2012/caa2012_submission_9.pdf. [Last accessed on September 15, 2018].  Back to cited text no. 12
Short SS, Lin AC, Merianos DJ, Burke RV, Upperman JS. Smartphones, trainees and mobile education: Implications for graduate medical education. J Grad Med Educ 2014;6:199-202.  Back to cited text no. 13
Ozdalga E, Ozdalga A, Ahuja N. The smartphone in medicine: A review of current and potential use among physicians and students. J Med Internet Res 2012;14:e128.  Back to cited text no. 14
Chuang YH, Tsao CW. Enhancing nursing students’ medication knowledge: The effect of learning materials delivered by short message service. Comput Educ 2013;61:16-75.  Back to cited text no. 15
Alipour S, Moini A, Jafari-Adli S, Gharaie N, Mansouri K. Comparison of teaching about breast cancer via mobile or traditional learning methods in gynecology residents. Asian Pac J Cancer Prev 2012;13:4593-5.  Back to cited text no. 16
Sullivan GM. Getting off the “Gold Standard”: Randomized controlled trials and education research. J Grad Med Educ 2011;3:285–9.  Back to cited text no. 17
Sichani MM, Mobarakeh SR, Omid A. The effect of distance learning via SMS on academic achievement and satisfaction of medical students. J Educ Health Promot 2018;7:29.  Back to cited text no. 18


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1 Use of Mobile Phones to Aid Learning in Medical Undergraduate
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Indian Pediatrics. 2020; 57(3): 273
[Pubmed] | [DOI]


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