Comparing two teaching methods based on concept map and lecture on dental students’ knowledge and performance of post-exposure prophylaxis to hepatitis B: A quasi-experimental study

Abstract

BACKGROUND:

Dental students are at high risk of hepatitis B virus (HBV) infection during clinical activities. Therefore, preventive measures are essential after exposure to the HBV. This study aimed to compare the effectiveness of the concept map and the lecture methods on dental students’ knowledge and performance regarding hepatitis B post-exposure prophylaxis (PEP) after possible exposure to the HBV.

MATERIALS AND METHODS:

This quasi-experimental study was conducted on 70 dental students at Shiraz University of Medical Sciences, Iran. Subjects were categorized into two groups, each receiving either the concept map or the traditional lecture methods. After the interventions, dental students’ knowledge and performance were measured by a researcher-made questionnaire.

RESULTS:

The statistical analysis showed significantly higher knowledge and performance in the concept map group compared to the lecture group (P = 0.030 and P = 0.022, respectively). Although both groups’ knowledge and performance decreased after the six-month intervention, the second group who received the lecture method showed more decline in knowledge and performance (P = 0.041 and P < 0.001, respectively).

CONCLUSION:

Both the concept map and lecture methods have proved to be effective ways of improving the knowledge and performance of dental students. However, the present study revealed that the concept method was more effective on dental students’ knowledge and performance regarding preventive measures after exposure to HBV. Thus, the concept map method is recommended for informative and educational purposes.

Introduction

Exposure to blood-borne pathogens poses a critical occupational hazard to dental students during their clinical training. Occupational exposure to patients’ blood and body fluids (BBF) has become a serious health matter for dental students. Among blood-borne pathogens transmitted through the blood, hepatitis B is of primary importance.[1] BBF exposure includes sharp injuries, mucocutaneous contamination, and bites.[2] In addition to the necessity of protective equipment and following the instructions of isolation precautions, familiarity with post-exposure prophylaxis (PEP) strategies is a vital part of the infection prevention program for the safety of dental students.[3] Insufficient knowledge of infection prevention and control (IPC), inadequate experience, inappropriate use of sharp tools, lack of training, neglecting occupational hazards, and inadequate facilities also aggravate the situation.[2,4,5] As a result, to prevent and control infections in hospitals, dental students must receive educational programs. Moreover, necessary facilities must be provided to implement the principles of isolation. Knowledge about infection control and preventive measures after exposure to possible infectious agents and the ability to implement such methods are absolutely critical before any clinical activities. According to the general dentistry curriculum in Iran, dental students attend infection control training in their second year of university. Furthermore, infection control education for dental students is conducted by holding workshops. However, it is mainly performed in the form of a conventional lecture method in a classroom to a large number of students to familiarize them with the basic concepts and materials. It is presented in the conventional lecture method due to a large number of students, inadequate time, and the great extent of educational materials. Dental students are reluctant to apply the training they receive due to a combination of factors such as teaching patterns, the large volume of content, as well as its breadth and dispersion, and the need for more opportunities to put all these pieces of training into practice. Therefore, it is necessary to implement an educational method to overcome the mentioned limitations and turn it into more meaningful learning that allows students to associate acquired material with previous knowledge that serves as an anchor when obtaining new information. Through these connections, the acquired knowledge will be stored in long-term memory. Teaching methods are an essential aspect of teaching and learning, and one of the crucial factors in the learning process involves selecting an appropriate teaching method. Selecting the proper teaching method determines the way learners’ activities are conducted to meet educational goals.[6] The traditional lecture method is one of the common teaching methods used in numerous universities, especially with a large number of students.[7] This method is commonly understood as a teacher-centered mode of instruction that gives full play to the teacher’s leading role and enables the students to obtain more knowledge. However, it is considered passive learning where the teacher is an active participant and the students are passive listeners during the training process. Prioritization and organization of new knowledge are not considered in the lecture method,[8] therefore, appropriate teaching models must be implemented to prevent superficial and short-term learning, so various materials are organized in a specific and logical order and become etched in one’s mind.[9] The concept map method is an active learning technique, and its effectiveness has been confirmed in various studies.[10] The theoretical framework of the concept map teaching method is based on David Ausubel’s theory of meaningful learning. Meaningful learning occurs when the learner interprets, relates, and incorporates new concepts and information with existing knowledge. Novak and Gowin developed the concept map method based on Ausubel’s theory of meaningful learning.[11] A concept map is a diagram or visualization of knowledge of key concepts and their relationships arranged in a hierarchical pattern. The central concept is placed at the top or center of the map, and other concepts are arranged from top to bottom. Lines connect concepts, each labeled with the relationship between the concepts.[12] Therefore, new concepts will be learned meaningfully and maintained longer. Moreover, meaningful learning increases problem-solving and critical-thinking skills.[9] Because dental students are at massive risk of infections during their clinical training years, it is critical to adopt various teaching methods to meet long-term, deep, and meaningful learning. No study has evaluated the effect of different teaching methods, including the concept map, and the lecture methods, on preventive measures after exposure to hepatitis B among dental students. Therefore, this study aimed to compare the effect of the two methods of concept map and lecture on dental students’ knowledge and performance regarding hepatitis B PEP after possible exposure to the hepatitis B virus (HBV).

Materials and Methods

Study design and setting

The present study was conducted from January 2022 to July 2022 in the Faculty of Dentistry, Shiraz University of Medical Sciences. It is a quasi-experimental and parallel-group research design, including pre-test, post-test, and follow-up. Seventy dental students in their fifth year of university majoring in clinical dentistry at Shiraz University of Medical Sciences were selected by the census method. The students’ consent was considered as the inclusion criteria of this research. And not participating in educational intervention programs or failing to fill out the questionnaires at each stage of the study was defined as the exclusion criteria. All the students completed the infection control training course in the second year, and none of them had previously participated in the concept map educational courses. Students who met the inclusion criteria were divided into two intervention groups; the concept map method (group 1: n = 350) and the lecture method (group 2: n = 35). The participants were selected by a two-stage random sampling method. The first stage involved stratified random sampling, and the second was systematic random sampling.

Data collection tool and technique

The participants were divided into two groups. The first group participated in a 4-h workshop training method and got familiar with the basics of the concept map design method. Then, the students put it into practice and had a practical experience concerning a common topic under supervision. For the first group, PEP for occupational HBV-related topics was presented in a 3-h training program based on the CDC protocols (Centers for Disease Control and Prevention) and the Iranian Ministry of Health guidance. At the end of the training session, the students were asked to illustrate a concept map of what they had been taught and deliver it to the project managers within a week. All the concept maps were assessed and returned to the participants, along with corrective feedback. The same content was presented to the second group in two 2-h sessions using the lecture method. The same educational programs were implemented to ensure consistency, including lesson plans and the lecturer; the education development office of dentistry approved both lesson plans. One week after the intervention, both groups’ knowledge and self-reported performance were evaluated with a questionnaire. Again, to assess the effectiveness and memorability of the training, knowledge and self-reported performance were evaluated with a questionnaire after six months. A self-reported performance evaluation was also performed for the students who had occupational exposure to HBV. Both groups’ knowledge and performance of PEP for HBV were measured by a researcher-made questionnaire, filled out by the participants without assistance, one week after the interventions and six months later. The questionnaire was designed with the cooperation of several specialists, including community medicine specialists, dental public health specialists, infectious disease specialists, and hospital IPC experts. It is based on the latest CDC protocols regarding preventive measures after exposure to HBV, as well as the Iranian Ministry of Health for infectious diseases prevention.[13,14] The questionnaire consists of a series of questions for the purpose of gathering information about respondents’ demographic characteristics, previous training related to PEP guidelines, and hepatitis B vaccination status, and 46 close-ended questions concerning nine categories, different scenarios of HBV infections in patients, and the students’ occupational exposure to HBV. Ten infectious disease specialists confirmed the content validity of the questionnaire, and a test-retest with a two-week interval on 15 participants in their sixth year of university majoring in clinical dentistry was used to evaluate its reliability (r = 0. 89, P = 0.03). The interviewer assigned a scale of 1 or 0 to the answers; 1 mark was given for every correct answer, and 0 mark was given for incorrect or unanswered. Then, the final score was obtained by summing up the scores of all 46 questions. Also, the answer to the self-reported performance questions and the instructions for the PEP actions was assigned a score of one and the performance of other actions was assigned a score of zero (score range 0–46).

Statistical analysis

Collected data were analyzed using the SPSS software (SPSS Statistics for Windows, Version 24. Chicago: SPSS Inc). The Chi-squared test was applied to assess the homogeneity of groups regarding gender, previous information about PEP for HBV, hepatitis B vaccination status, hepatitis B immunity confirmation, and history of sharp injuries. An independent t-test was used to determine age homogeneity. The result of the Kolmogorov–Smirnov test confirmed the normality assumption, implying the scores of knowledge and performance were distributed normally. The repeated measures analysis of variance (ANOVA) test was applied to compare the level of the student’s knowledge and performance six months after the intervention. The P value is less than 0.05, which is considered to be statistically significant.

Ethical considerations

This study was approved by the education department office of dentistry and has achieved the code of ethics from Shiraz University of Medical Sciences under registration number IR.SUMS.DENTAL.REC.1401.002. An informed consent form was received from all the students who met the inclusion criteria to provide them with the objectives they needed to know.

Result

Seventy dental students in their fifth year of university, aged between 20 and 33 years old (P = 0.128), participated in the study and stayed in during the study. The mean age of group 1 and group 2 was 24.00 ± 2.66 and 23.30 ± 1.55, respectively. Table 1 indicates the demographic characteristics of the two groups. No significant difference was found between the two groups regarding the mentioned characteristics (P > 0.0.5). Among the first group, 20 individuals (80%) reported vaccination against hepatitis B; however, the number reached 31 (88.6%) in the second group (P = 0.324). According to the findings, 23 individuals (85.2%) in the first group and 23 individuals (74.2%) in the second group showed higher than 10 mIU/ml antibody titers (P = 0.462).

Table 1.

Demographic data of dental students in two groups

Variables	Concept map (n=35)	Lecture (n=35)	P
Age (year)	24.00±2.66	23.30±1.55	0.128*
Sex
Male	16 (45.7)	17 (48.6)
Female	19 (54.3)	18 (51.4)	0.811**
History of previous PEP training
Yes	21 (60.0)	25 (71.4)
No	14 (40.0)	10 (28.6)	0.314**
Familiarity with PEP guidelines regarding HBV
Yes	20 (57.1)	19 (54.3)
No	15 (42.9)	16 (45.7)	0.810**
History of vaccination against HBV
Yes	28 (80)	31 (88.6)
No	7 (20.0)	4 (11.4)	0.324**
Immunity confirmation After vaccination against HBV
Yes	23 (85.2)	23 (74.2)
No	5 (17.9)	8 (25.8)	0.462**
Previous history of sharp injuries
Yes	17 (48.6)	20 (57.1)
No	18 (51.4)	15 (42.9)	0.473**

Data are presented as mean±standard deviation or number (percentage). *Independent t-test. **Chi-square test

Table 2 shows the mean scores of dental students’ knowledge regarding hepatitis B PEP. According to the analysis, there was no statistically significant difference in the mean knowledge scores in the two groups before the intervention (P = 0.476). Examining the results of Box’s test of equality of variances (P = 0.324) for both research variables showed that the condition of homogeneity of variance and covariance was well met for all variables. The assumption of equal variances was also confirmed using Levene’s test of equality of variances (P = 0.428, 0.318, and 0.346, respectively). The equality of covariances of the dependent variable was carried out using Mauchly’s sphericity test for the one-factor analysis of variance. Since Mauchly’s sphericity test was greater than 0.05 (P value = 0.262), the assumption of homogeneity of variances was accepted, therefore covariance analysis was used. The mean scores of the two groups showed a significant increase one week after the end of the intervention (groups 1: P value <0.001, and group 2: P value = 0.035). According to the statistical report, the mean score of the first group was more significant than the second group. However, there has been a change in the mean scores, six months after the interventions (groups 1: P value <0.001, and group 2: P value = 0.003).

Table 2.

Comparison of dental students’ knowledge and performance between two groups

Variables	Concept map (n=35)	Lecture (n=35)	P
Knowledge
Before intervention	21.63±6.97	22.86±7.37	0.476
After intervention	30.29±8.77	26.48±4.63	0.030
Mean change	8.66±11.03	3.76±9.78
P*	<0.001	0.035
6 months after the intervention	27.54±7.39	24.52±3.96	0.041
Mean change	-2.74±2.67	-1.97±3.72
P**	<0.001	0.003
Performance
Before intervention	16.23±0.88	15.91±1.09	0.198
After intervention	22.97±1.25	22.08±1.85	0.022
Mean change	6.78±0.82	6.17±1.45
P*	<0.001	<0.001
6 months after the intervention	19.29±1.13	17.89±1.57	<0.001
Mean change	-3.69±0.93	-4.20±1.57
P**	<0.001	<0.001

Data are presented as mean±standard deviation. *Difference between post-intervention and pre-intervention. **Difference between after the intervention and 6 months after

The mean performance scores in both groups also showed a similar pattern, indicating no statistically significant difference between the mean scores of the two groups before the intervention (P = 0.198). However, there has been an increase in the mean performance scores after the intervention, indicating a more significant increase in group 1 compared to group 2 (P = 0.022). Similar to the knowledge, both groups showed a decrease six months after. Table 2 shows a greater decrease in group 2 compared to group 1 (P < 0.001). During the follow-up period, six individuals (17.1%) from group 1 and four individuals (11.4%) from group 2 expressed that they had sharp injuries during practical clinical training. However, the mean performance score of the two groups showed to be entirely in accordance with the PEP guidelines after six months.

Discussion

The present study aimed to compare the effect of two teaching methods, the concept map method and the traditional lecture method, on dental students’ knowledge and performance regarding hepatitis B PEP after contact with HBV. Findings showed that the knowledge and performance of the two groups increased significantly two weeks and six months after the intervention. According to the results, there is a meaningful relationship between teaching methods and their effect on the student’s knowledge and performance. The concept map method was more effective than the lecture method in spite of the fact that the knowledge scores of both groups showed a decrease six months after the interventions. According to another study conducted by Anand et al., the concept map method was a better learning tool than the traditional lecture method. Students showed significant improvement in knowledge after applying the concept map method.[15,16] Another study aimed to determine the effect of the concept map and lecture methods on learning basic life support in Iranian nursing students. The results showed that nursing students’ awareness in both groups (concept map and lecture) increased after the intervention; however, there was no significant difference between the two methods.[12] Suppose the lecture method, like any other teaching method, is incorporated with students participating in group discussions and practice. In that case, it can be an effective method for improving their knowledge of various topics. The concept map is a visual representation of learners’ interpretation of concepts, and learners have an active role; putting it simply, learners would have a better understanding by being encouraged to notice their errors. It also fosters motivation in students and helps in getting them to take responsibility for learning. Above all, the concept map method has a hierarchical structure that leads to long-term retention because long-term memory is also organized through a hierarchical arrangement of concepts. The concept map teaching method can take the form of graphics and depicts relationships and links between complex concepts. Concept maps, a road to critical thinking, help learners understand better and facilitate creativity.[17] This teaching method connects new information with existing information in a meaningful way.[18,19] In research conducted on psychology students in their third year of university, the concept map method showed a more significant effect on fostering creative and critical thinking than the lecture method. On the contrary, in the lecture method, the students remain inactive by being passive listeners and recipients of the new concepts, which usually come to them like rain showers and lead to the improper storage of information. Consequently, new information is not stored in a hierarchical and meaningful manner which causes difficulties in understanding and retrieving information.[8] Some studies indicated that students are primarily passive participants in the traditional lecture method. In other words, passive students absorb new information without engaging with the information received, like doing exercises or attending group discussions, and they often take notes instead. As a result, the student’s attention is easily diverted; they do not process new information and materials deeply, make connections between the new information received, or draw conclusions based on the main ideas.[20] In the present study, knowledge scores in both groups had decreased six months after; however, it showed a greater decrease in group 2 compared to group 1. In another research, Nicoara et al. researched Romanian students regarding the effectiveness of the concept map method for long-term memorization of anatomy. Findings demonstrated that learning with the concept map method proved efficient, especially regarding long-term memory concerning learning anatomy.[21] The concept map method proved to be effective in another research to explore the effectiveness of concept maps accompanying the text on reading comprehension. The result of this study showed that the concept map method is effective in better understanding and recalling the content presented.[22] Applying learned knowledge is critical in clinical training activities and professional careers after graduation. Therefore, improving deep and long-term learning is an effective and helpful strategy, and it is essential to apply those methods to make learning more effective and profound. Furthermore, according to the current study and other research, the concept map method was an effective teaching method.[15] The findings indicated that students’ knowledge and performance improved after the intervention. Nevertheless, the performance score of those with no exposure to hepatitis B during the follow-up period was higher in the concept map group compared to the lecture group. In both groups, a direct correlation was observed between students’ knowledge and performance, regarding PEP to HBV. In general, the number of studies that have investigated the effect of different educational methods on a group of dental students compared to other groups is limited, and the present study improves our understanding of selecting appropriate teaching methods in improving the knowledge and performance of dental students. The present study confirmed that both teaching methods of the concept map and the traditional lecture method effectively improved students’ knowledge and performance in dentistry. Therefore, it can be concluded that if the traditional lecture method has been implemented perfectly and appropriately, it can still be used as a standard method to increase students’ knowledge and performance in various subjects. In comparison, the concept map as an active and student-oriented method can be effective in better understanding, improving knowledge and performance, long-term memory, and meaningful learning. It should be noted that it is not feasible to generalize this study’s results due to the concept map’s characteristics for teaching any topic. Different types of educational content, time-limit, different educational purposes, and a large number of learners are among the practical limitations of the concept map teaching method, which teachers should consider when designing and choosing the concept map method.

Conclusion

Both the concept map and the lecture map were effective and led to knowledge and performance improvement of dental students regarding preventive measures after contact with hepatitis B. However, the concept map method proved more effective than the classical lecture method. The concept map depicts the relationships between concepts and is an effective tool for organizing content. It facilitates deep and meaningful learning and fosters learning motivation. As a result, student-centered learning strategies, such as concept maps, are recommended alongside the traditional teaching method.

Limitation and recommendation

This study used a researcher-made questionnaire and self-reported data to evaluate the effectiveness of interventions on the student’s performance. Therefore, results must be interpreted with caution. It is suggested to use objective structured clinical exams (OSCE) to evaluate students’ performance better.

Financial support and sponsorship

This study was done with the financial support of Shiraz University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.