Blended Learning Effectiveness: Improving Japanese Medical Laboratory Science Students’ Identification of Parasite Eggs

Parasitic infections are declining in Japan, resulting in fewer hours of parasitology instruction in medical laboratory science and medical schools. However, there are growing concerns that the parasite identification skills of medical laboratory technologists and the diagnostic skills of physicians may be compromised as a result. Effective teaching methods are required to improve the identification of parasites in pre-graduate education. We therefore adopted a new teaching method: the blended learning method, in 2018. This method combined the e-learning and jigsaw methods, which had already been implemented separately in 2017. This study aimed to evaluate the pedagogical effectiveness of this blended learning approach compared to that of 2017 in teaching parasitology practice to students enrolled in the Department of Medical Laboratory Science. The results show that the median score for the practical test was 83.3 points for the blended learning lessons, which was not significantly different from the scores for jigsaw or e-learning lessons. However, blended learning had the lowest percentage of failures on the practical test, at 10.7%. Additionally, the microscopic image test results indicate a significant memory retention effect. From the questionnaire results, 94.7% of the students were satisfied with their practice. In conclusion, the blended learning did not significantly improve parasite identification skills, but it may reduce the number of failures, suggesting a knowledge retention effect and a high level of satisfaction with this practice.


Background
In Japan, education on clinically meaningful parasites is provided mainly to students of medicine, pharmacy, and medical laboratory science (Kobayashi & Ikeda, 2015;Sekine, 2022).Although parasites (such as the Japanese indigenous lymphatic filaria, Schistosoma japonicum, and malaria parasites) have been eradicated, parasitic diseases have not disappeared (Tada, 2008;Kasai, Nakatani, Takeuchi, & Crump, 2007).The number of hours spent on parasitology education has been reduced in medical school recently, and there are concerns that physicians' diagnostic skills may be deteriorating (The Japanese Society of Parasitology Board of Education, 2015).Similarly, parasitology education in universities is undervalued in Western countries (Acholonu, 2003;Bruschi, 2009).On the contrary, parasitic diseases are expected to increase in the future (Palmieri, Elswaifi, & Fried, 2011).China has been working on parasitology education using various teaching methods (Peng, Zhang, Wang, & Chen, 2012); therefore, parasitic disease education in Japan needs to be improved owing to its subtropical climate and international status (Kobayashi & Ikeda, 2015).

Aim and Research Hypothesis
Against the abovementioned background, we considered that new teaching methods are required to improve the identification skills of parasites in pre-graduate education.The use of digital technologies (David, 2017;Jabbar, Gasser, & Lodge, 2016) and the usefulness of the jigsaw method (Colosi & Zales, 1998) have already been shown.Hence, we conducted a parasitology practice using e-learning and jigsaw methods for medical laboratory science students to evaluate their performance in 2017 (Kobayashi, Kosuge, & Akazawa, 2023).Based on the results, we designed a blended learning approach.Blended learning is a method that combines e-learning and face-to-face classes (Caner, 2012).It is more effective than non-blended learning (Liu et al., 2016).However, the pedagogical effects of blended learning incorporating cooperative learning in parasitology practice have yet to be clarified.Therefore, this study aimed to evaluate the pedagogical effects of blended learning and identify its improvements.In this study, blended learning consisted of preparatory learning through e-learning (internalization), and collaborative learning through the jigsaw method (externalization).We hypothesized that blended learning would improve the identification skills of parasite eggs (including larvae and protozoa), compared to either the e-learning or jigsaw method alone.

Method
This was a non-randomized, comparative study that compared the performance of the blended learning lessons (from 2018) with the e-learning and jigsaw lessons (from 2017) in parasitology classes.In this blended learning study, students prepared with e-learning materials in addition to the textbook, and they then practiced using the jigsaw method.

Implementation Summary
The participants were first-year students in the Department of Medical Technology at Kitasato Junior College of Health and Hygienic Sciences (Niigata Prefecture, Japan).The students in the blended learning ( 2018), e-learning (2017), and jigsaw (2017) classes were all different individuals; no participant attended more than one of the aforementioned classes.Students are required to take this practice to graduate and thus all new students complied in their first year.

Blended Learning Class
Eighty-four students participated in the practice, of which 75 were analyzed.The practice period was January 2018 (additional surveys were conducted in May 2018 and April 2019), and the practice time was 15 hours (10 sessions of 90 minutes each).The practice was the observation of parasite eggs (26 species in total, including larvae and protozoa), and two teachers were in charge during the sessions.The primary outcome was the percentage of correct answers on a practical test (12 specimens in total), in which students made their own specimens and identified parasites using a microscope.The secondary outcome was the percentage of correct answers on the microscopic image test (20 questions in total).The exploratory outcome was longitudinal changes in microscopic image test scores (conducted three times) and questionnaire responses.

E-Learning and Jigsaw Classes
All 66 students who participated in the practice were included in the analysis (Kobayashi et al., 2023).The practice was divided into e-learning (n = 33) and jigsaw (n = 33) classes.Each class had one teacher in charge.The practice period was January 2017 (additional surveys were conducted in May 2017 and April 2018).The practice's location, time, content, and assessment items were identical to those of the blended learning class.

Ethical Considerations
We informed the 84 students taking the parasitology course in 2018 about the practice's procedure, their grades, and the use of the questionnaire results in our study; 75 participants submitted completed informed consent forms.This study was approved by the Kitasato Junior College of Health and Hygienic Sciences Ethics Review Committee.Additionally, all 66 participants in 2017 consented to participating in the study (Kobayashi et al., 2023).

Sample Size and Power
The sample size in this study had limitations.The blended learning class comprised 75 students.For the practical test score, we assumed that students in the blended learning class would answer one question more correctly than the jigsaw or e-learning class.However, the statistical power of the Wilcoxon rank sum test at a significance level (α) of 0.05 was 0.51 and 0.45 for comparisons with the jigsaw and e-learning classrooms, respectively.

Practical Worksheet
Before the day of the practice, students recorded their preparation on a worksheet.The preparation included questions on how the infection was transmitted, how to test, the morphological characteristics of eggs, and answers to a quiz on egg photo.The teachers reviewed the results of everyone's preparation before the practice commenced.Students recorded all of their observations during the practice on a worksheet.Shail (2019).In addition, we deduce that the students retained more memory than other parasites with respect to the parasites on which the students were experts in the jigsaw activity.

Micros
Blended learning increases learner satisfaction even when scores do not improve significantly (Sadeghi, Sedaghat, & Shaahmadi, 2014).Our questionnaire results indicated that the total number of positive responses was high (approximately ≥ 90%) in each category related to satisfaction, worksheet materials, teachers, and self-assessment.Therefore, we considered the practice itself a success.
Alternatively, the reasons why the results contradicted the hypothesis and improvements in teaching methods in blended learning were considered as follows: regarding e-learning, the questionnaire results showed that approximately 83% of the students engaged in preparation for each practice.Preparation is a useful tool to reduce the cognitive load in practice, and to improve learning effectiveness (O'Brien & Cameron, 2008).
Especially in practices where observation is the focus, preparation of what one should look for before the actual practice helps eliminate any anxiety during the practice (Jones & Edwards, 2010).Additionally, the repetition and feedback of gamification materials have a memory retention effect (Krishnamurthy et al., 2022).For this reason, preparation through e-learning materials is essential.We therefore hold the considered view that the jigsaw method should be improved for blended learning.

Improvement of Jigsaw Method for Blended Learning
The jigsaw teaching method is effective in transforming students from passive to active learners (Bhandari, Mehta, Mavai, Singh, & Singhal, 2017).This method performs better than traditional teaching methods that do not motivate students in biology practices where specimens are observed (Baken, Adams, & Rentz, 2020).
However, in this study, all negative opinions were about the jigsaw method.The number of students who could share information within the expert team and explain it to others in the jigsaw group, was 57 (76%).For approximately one in four students, the jigsaw activity was not always a good fit.In particular, 18 students (24%) commented that they did not have enough practice time.These results agree with those reported by Soundariya, Senthilvelou, Teli and Deepika (2021) that the jigsaw method lacks time owing to the complexity of the learning method.Also, similar to the results of our study, approximately 75% of the students had positive opinions about the jigsaw activity (Soundariya et al., 2021).
Additionally, the team acknowledged negative comments for the jigsaw activity, such as "information could not be shared within the team," and "it is easy to make mistakes when students make decisions on their own."Mori (2018) reported that in learning through student interaction, some students could not gain proper understanding through peer interaction alone.In this study, two teachers served as facilitators during the practice, supporting groups that had difficulty detecting eggs.Furthermore, after the jigsaw activity, students were encouraged to reflect within their expert teams, followed by a commentary by the faculty.Of the students, 98.7% acknowledged this support from their teachers, but not all accepted the jigsaw activity.Jigsaw activities in experiments rely strongly on teamwork as well as individual contributions (Williams, Perlis, Gaughan, & Phadtare, 2018).Thus, the effectiveness may vary depending on the expert team members or jigsaw group.Based on the above, further benefits can be expected if three aspects are improved: time allocation, standardization of experts' knowledge level, and fostering teamwork when using the jigsaw method.

Limitations
This study had several limitations.The target students were not randomized, as this comparison of teaching methods was conducted across different years.Therefore, confounding factors may have influenced the results.However, because there were no significant between-class differences in background factors that might affect the results of this study, we did not consider them a heterogeneous group.Adjustment by propensity score using background factors and evaluation by analysis of covariance, were also considered analytical methods.However, it was not used because of the reduced sample size and low model fit.Additionally, we could not obtain accurate access logs because some students were engaged in learning with other students who shared the same device (smartphone, personal computer, or tablet), although they were all registered in the Moodle system.Despite these limitations, this study demonstrated the effectiveness of the blended learning method in parasitology practice, focusing on the identification of microscopic specimens.

Further Research and Prospect
Blended learning can give students confidence in experimental manipulation (Chen et al., 2020).Additionally, students' self-efficacy (I acquired the ability to identify parasite eggs) was ranked highly in this study.To improve instructional design, the ten tips presented by Hege, Tolks, Adler and Härtl (2020) for incorporating blended learning into medical education curricula, are helpful (Hege et al., 2020).Further research is required to determine the best way to combine e-learning with teaching methods (Vallée, Blacher, Cariou, & Sorbets, 2020).
From another perspective; the blended learning can also be used in practices, such as microscopic examination of urine sediment and blood specimens, with the same effect as in the present study.
Currently, there are 100 million patients in each of the three major intestinal helminth infections, which are part of the neglected tropical diseases, in Association of Southeast Asian Nations (ASEAN) countries (Sripa, Leonardo, Hong, Ito, & Brattig, 2022).In addition, there is also concern about the increase in helminth and protozoan infections in urban areas owing to global climate change (Hotez, 2018).We must improve students' parasite identification skills during pre-graduate education so that clinical laboratory technologists' test results do not lead to misdiagnoses.

Conclusions
This study demonstrated the pedagogical effectiveness of blended learning, which combined e-learning and jigsaw methods, in parasitology practice for medical laboratory science students.Test scores for the blended learning class were not significantly different from those for the e-learning or jigsaw classes.However, the practical test results showed a reduction in the percentage of failures, and the microscopic image test results indicated a short-term memory retention effect.The preparation through e-learning should be actively used to enhance blended learning.Additionally, cooperative learning, such as the jigsaw method, can help encourage active participation in practice.Further benefits can be expected if three aspects are improved: time allocation, standardization of experts' knowledge level, and fostering teamwork when using the jigsaw method.To verify the effectiveness of these improvements, further validation is required. Figu
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