Flipped classroom combined with human anatomy web-based learning system shows promising effects in anatomy education

Flipped classroom assisted by Rain Classroom for anatomy practical classes: Challenges and opportunities of anatomy education

Anatomy practical classes are an essential part of learning human anatomy. The flipped classroom teaching model has been used in medical education in recent years. However, its precise impacts on anatomical knowledge acquisition and learning outcomes remain controversial. With the development of information technology, new educational tools, such as Rain Classroom, have recently attracted much interest. The Rain Classroom is an application that can easily connect students and teachers through smartphones or computers. However, whether and how to apply it to the flipped classroom in anatomy practical classes needs to be evaluated. In this study, we designed a teaching model of flipped classroom assisted by Rain Classroom and carried it out in anatomy practical classes at our university. Results showed that the final exam scores of the experimental group were significantly improved, compared with the control group (p < 0.01); the final exam score was significantly correlated with both the pre-class quiz score (p < 0.05) and the in-class quiz score (p < 0.001). Student satisfaction was measured by a questionnaire on a Likert scale of 1-5. All the mean scores were greater than 4.5, indicating that most students had positive attitudes toward this teaching model. The present study suggests that the Rain Classroom helps support students throughout the learning processes of the flipped classroom, and the model of flipped classroom assisted by Rain Classroom could improve students' learning efficiency and ultimately increase their exam performance in anatomy practical classes.

Improving student learning and performance through a continuous flipped anatomy teaching model

The flipped classroom teaching model has been widely used in anatomy education to embrace a blended learning strategy. However, the impact that a continuous flipped classroom teaching model exerts on student learning of human topographic anatomy remains unclear. To address this question, student learning experience and performance were compared between third-year undergraduate students who participated in a continuous flipped anatomy classroom teaching since their first year (n = 65, experimental group) and those under the flipped anatomy teaching model only in their third year (n = 45, control group). A five-point Likert scale learning and teaching survey was conducted to evaluate students' perceptions of the flipped classroom model. Students under a continuous flipped classroom teaching model rated significantly higher on the impact of the flipped model on learning difficult anatomy concepts than the control group (*p = 0.0346). The rating on independent learning remained not statistically different between the two groups, although a trend difference was detected (p = 0.0604). Analysis of learning performance revealed that the experimental group significantly outperformed the control group when answering questions focusing on regional anatomy (*p = 0.0207). No significant difference was identified in students' marks of case-based studies between the two groups. In summary, the results of this study indicate that the flipped classroom model implemented over a long term continues to advance students' learning experience and performance in anatomy, indicating a "dose" effect on active learning. The findings of this study will assist the best practices of the flipped anatomy classroom and develop evidence-informed approaches to advance anatomy education in the future.

Flipped Classrooms in Medical Education: Improving Learning Outcomes and Engaging Students in Critical Thinking Skills

The flipped classroom (FC) model involves students independently acquiring knowledge before in-person class sessions, during which they engage in active discussions and problem-solving. Various methods to implement FC are quizzes, e-content, case-based learning, problem-based learning, and reading assignments. The advantages of the FC approach included improved student preparation, active participation, and the promotion of critical thinking skills. Some disadvantages identified are technical problems like internet connection, improper planning and preparation, which increases teacher workload, and lack of self-motivation. This review underscores the potential of the FC approach to improve medical education by promoting independent learning, active participation, and deeper understanding. Consideration of factors such as curriculum design, faculty development, technological infrastructure, and student readiness is vital for successfully implementing the FC model. Balancing self-directed study with meaningful face-to-face interactions remains crucial to harnessing the full benefits of this innovative approach. By leveraging technology and student-centered methods, medical educators can create an enriched learning experience that positively influences future healthcare professionals.

The Role of E-Content Development in Medical Teaching: How Far Have We Come?

With the advancements in technology, medical educators are now able to create and deliver content to students through digital platforms. Electronic content (e-content) development has allowed educators to incorporate multimedia, animations, simulations, and interactive elements which support verbal instruction, such as improved expression and comprehension, into their teaching materials. E-content development is a relatively new field, but it is growing very rapidly. Recent findings have indicated that the e-learning sector will likely experience a huge surge in the upcoming years. The Indian government has launched various initiatives for e-content development in medical education. E-content development has great potential and can be used in various learning scenarios. While it initially gained popularity in higher education, it has since been applied to many other sectors, including healthcare. It allows educators to create highly engaging learning experiences that are accessible by all students. Challenges in e-content development include availability of the internet, creating content that is engaging and relevant to a wide range of learners, and access. Still, it is expected that the use of e-content in medical teaching will continue to increase in the future. The future of e-content development in medical teaching is likely to see continued growth and innovation as technology advances and more educators and learners recognize the benefits of online and digital resources.

Knowledge acquisition efficacy of a remote flipped classroom on learning about removable partial dentures

PURPOSE

Coronavirus disease 2019 has forced the use of remote education worldwide. In 2020, the authors conducted a fully digitized, remote flipped (RF) classroom focusing on removable partial dentures. This study aimed to evaluate the learning outcomes of the RF classroom and compare these with those of the on-site classroom.

METHODS

The fourth-year dental students in 2017-2019 attended on-site flipped classroom (OF; n=70) or on-site lecture classroom (OL; n=67), and those in 2020 (n=58) attended the RF classroom. Lecture videos and text were provided online in the OF and RF groups, while only the text was given to the OL group. Individual and group tests were conducted to assess knowledge acquisition one week after all the classes ended. A one-way analysis of variance following Tukey's test was performed to compare individual/group test scores among the OF, OL, and RF groups. Multilevel linear regression analysis was performed to identify the factors associated with an increase in each test score.

RESULTS

The mean individual test scores in the RF and OF groups were significantly higher than in the OL group (P<0.01). The mean group test score in the RF group was significantly higher than in the OF and OL groups (P<0.001). The multilevel analysis identified remote and flipped classroom styles in the individual test, and the remote style in the group test, as significant effective factors in learning (P<0.05).

CONCLUSIONS

These results suggest that the RF classroom is more effective than the on-site lecture in knowledge acquisition in undergraduate prosthodontic education.

Application of Blended Learning to Veterinary Gross Anatomy Practical Sessions: Students' Perceptions of Their Learning Experience and Academic Outcomes

The use of blended learning strategies is increasingly common in health sciences, including veterinary medicine; however, there are very few descriptions of these methods being applied to practicals. We describe here the application of blended learning based on the implementation of flipped classrooms with collaborative learning and gamification to the 2020-2021 veterinary medicine gross anatomy practicals at CEU Cardenal Herrera University (Spain). Students prepared for the sessions by pre-viewing videos and taking a quiz before the start. The sessions were conducted in small groups where students learned through collaborative work and reviewed their learning with a card game. A small but significant increase was observed when comparing the scores of practical exams of the locomotor apparatus with those of 2018-2019 (6.79 ± 2.22 vs. 6.38 ± 2.24, p < 0.05), while the scores were similar (7.76 ± 1.99 vs. 7.64 ± 1.92) for the organ system exams. Students' responses in a satisfaction survey were mostly positive (>80%) regarding the motivating and learning-facilitating effect of this educational method. Our work shows that the application of blended learning in anatomy practicals based on a flipped classroom and with elements of gamification and collaborative work can be an effective way to improve the learning experience of students.

Flipped Classroom to Facilitate Deeper Learning in Veterinary Undergraduate Students: An Educational Change Pilot Study Limited to the Imaging Module Bones

In a flipped classroom, learners study at home and do the 'homework' in class. This approach respects the limitations of memory and allows more interaction between learners. The overall vision is self-paced activities for learners with decreased boredom and greater task value, which should facilitate deeper learning. To implement a flipped classroom, a bumpy incremental change process characterized by periods of relative stillness punctuated by the acceleration of pace was planned. All veterinary undergraduate students used an existing eLearning platform to access relevant text and selected image examples before class. Only for the randomly selected students in the flipped classroom (FC) was this content amended with purposeful audio content and concrete tasks. Further, FC learners discussed their opinions in an online class forum. To measure the educational change, a pre- and post-class formative test and a standardized questionnaire for students in the FC versus in the traditional classroom (TC) were performed. To assess engagement, students were invited to measure all learning activities, categorized into attendance, or self-study. The educational change project resulted in more commitment and less resistance from teachers. The FC consisted of 20 students, while the TC had 40. The mean pre-class scores difference between FC students and TC students was +1.7/20 points, and the mean post-class scores difference was +3/20 points. The chance of answering item 10 of the formative test (describe site of the fracture) correctly was about seven times higher for FC compared to TC learners (OR = 6.96; p = 0.002). The questionnaire revealed more satisfaction and greater task value in the FC compared to TC (p = 0.048). FC students invested 21 h into the course on average, while TC students invested 16 h. The results of this pilot agree with previous reports: A transparent process was helpful to initiate mainly positive interactions between teachers and students. Higher scores, higher chance to give the correct answer, greater task value, and more positive emotions are observed in the FC compared to the TC. Higher measures of learning time are not expected to affect exam results but indicate more engagement.

Tutorials in anatomy education of medical students during the COVID-19 pandemic - An evaluation of its effectiveness

Anatomy has traditionally been taught through prosected specimens and the use of models and other techniques. During the COVID-19 period, this was replaced by tutorials, where students came to college to continue taking practical sessions. The study comprised four components. The first component consisted of demographic data. The second component consisted of questions concerning students' satisfaction with the tutorials. The third component included questions for Year 2 medical students only because they had tried both the new and old systems. The fourth component included the results for the Year 2 medical students. The study included 102 medical students. The number of tutorials each week and the duration of each tutorial were considered successful, since 47 (46.1%) and 44 (43.1%) students approved, respectively. The students were comfortable with understanding the information from PowerPoint presentations; 41 (40.2%) agreed with this statement. Moreover, 44 students (43.1%) agreed about the ability to recall material after the tutorial and the interaction it allowed them with the doctors. Overall, all the questions proved that the tutorials were of great value to the students during the COVID-19 period. Although COVID-19 limited anatomy teaching, tutorials were seen as a light at the end of the tunnel pending the end of the COVID-19 period.

Achievement of learning outcomes in non-traditional (online) versus traditional (face-to-face) anatomy teaching in medical schools: A mixed method systematic review

In recent years, the logistical challenges posed by the Covid-19 pandemic have prompted medical educators teaching gross anatomy to explore an expanded use of online instructional modalities. There is concern that this shift to online anatomy education in medical schools could affect long-term learning outcomes for future healthcare providers. In this systematic review, the educational effectiveness of online anatomy teaching is compared with traditional ("face-to-face") teaching methods, specifically in terms of students' academic performance and satisfaction. A search of four databases identified and screened 162 studies. Subsequently, 31 studies were analyzed, including both (a) teaching outcome measures (test scores) and (b) student satisfaction ratings. Authors chose studies, extracted data, assessed quality and examined risk of bias. Nineteen studies compared students' academic performances between online and face-to-face teaching methods. Twenty-six studies measured students' levels of satisfaction in both teaching methods. Both qualitative and quantitative analyses of the data revealed comparable academic performances with no statistical difference between the two teaching methods, but a higher level of satisfaction with face-to-face teaching. The findings confirm that students can learn from online teaching but are more satisfied with face-to-face teaching. The authors conclude that online teaching cannot replace traditional teaching and there is no preference for one type of modality over the other. Therefore, a multi-modal learning approach combining online with face-to-face educational modalities for medical students could be efficient and successful.

How Virtual Animal Anatomy facilitated a successful transition to online instruction and supported student learning during the coronavirus pandemic

Anatomy faculty with cadaver-based laboratory courses were presented with a significant challenge in March 2020 to create equivalent learning experiences without cadaveric access. The undergraduate domestic animal anatomy course at the Colorado State University was halfway into a 16-week semester when COVID-19 lockdown orders and the transition to remote instruction began. The new course curriculum was critically evaluated using student surveys and course outcome data. Most students (92.5%) agreed that the transition to online learning was a success; however, students who valued face-to-face lectures prior to March were less likely to perceive the transition as a success. Qualitative and quantitative analyses of survey results suggest that the resources perceived as most helpful for the transition to online learning were not the same as those that helped facilitate animal anatomy learning. Most students (92.5%) agreed that the Virtual Animal Anatomy (VAA) helped them learn anatomy, and 82.2% indicated that the VAA was a valuable resource following the transition to online learning. Additional resources associated with transition success included course instructors, weekly quizzes, written descriptions of anatomical structures and open laboratory sessions. In contrast, those resources associated with facilitating learning included guided quizzes and asynchronous lecture recordings. These findings suggest that the VAA can support online anatomy learning when used in conjunction with other best practices for online teaching.

CRISP method with flipped classroom approach in ECG teaching of arrhythmia for trainee nurses: a randomized controlled study

BACKGROUND

This study aimed to explored the effects of the Cardiac Rhythm Identification for Simple People (CRISP) method with flipped classroom approach for arrhythmia interpretation in electrocardiogram (ECG) by trainee nurses.

METHODS

A total of 120 trainee nurses were enrolled and randomly divided into the experimental group and the control group using lecture-based learning method. We observed the effects of the two methods in ECG interpretation training and investigated the students' attitudes toward the teaching practices.

RESULTS

After training, the ECG test scores in the experimental group were significantly higher than that of the control group. Six months later, the ECG test scores of the experimental group was still higher. Self-learning enthusiasm, understanding of teaching content, satisfaction of teaching mode, satisfaction of teaching effectiveness, and interest in learning ECG were significantly higher in the experimental group.

CONCLUSION

CRISP method with flipped classroom approach is a new and effective mode worth trying in ECG teaching for trainee nurses.

The effect of flipped classroom in multiple clinical skills training for clinical interns on Objective Structured Clinical Examinations (OSCE)

AIMS

The flipped classroom (FC) is a hybrid approach, combining online learning and face-to-face classroom activities. To comprehensively evaluate the role of the Flipped Classroom (FC) model in clinical skills teaching of medical interns and investigate the acceptance and recognition of FC and Objective Structured Clinical Examinations (OSCE).

METHODS

In the teaching of clinical skills, the students were further grouped into two groups- A and B (A = 37, B = 42), using a computer-based random digital method. group A adopted the traditional classroom (TC) model, and group B adopted the FC model. OSCE was used to assess the clinical skills of the two groups of interns. Two independent sample t-test was used to analyze the difference of participant's demographic data and OSCE scores between the two different teaching model. We sent FC questionnaires to group A and OSCE questionnaires to groups A and B.

RESULTS

The score of OSCE in group B was higher than that in group A (P = 0.024), especially in the heart physical examination (P < 0.050), lung physical examination (P < 0.050), and abdominal physical examination (P < 0.050). The result of the FC questionnaires showed that regarding online courses, most students in group B thought watching videos was a good way to prepare for class (97.6%), For offline courses, most medical interns said that it enhanced their learning ability (88.1%), and they could accept this form of teaching (85.7%). As for the form of OSCE questionnaires, most people in group A and B said that they knew more about this form of assessment (81.0%), that it truly reflected the clinical ability (82.3%).

CONCLUSIONS

FC model has shown good results in clinical skills training, while FC and OSCE can be further promoted in future teaching and assessment.

Flipped anatomy classroom integrating multimodal digital resources shows positive influence upon students' experience and learning performance

Anatomy is shifting toward a greater focus on adopting digital delivery. To advance digital and authentic learning in anatomy, a flipped classroom model integrating multimodal digital resources and a multimedia group assignment was designed and implemented for first-year neuroanatomy and third-year regional anatomy curricula. A five-point Likert scale learning and teaching survey was conducted for a total of 145 undergraduate health science students to evaluate students' perception of the flipped classroom model and digital resources. This study revealed that over two-thirds of participants strongly agreed or agreed that the flipped classroom model helped their independent learning and understanding of difficult anatomy concepts. The response showed students consistently enjoyed their experience of using multimodal digital anatomy resources. Both first-year (75%) and third-year (88%) students strongly agreed or agreed that digital tools are very valuable and interactive for studying anatomy. Most students strongly agreed or agreed that digital anatomy tools increased their learning experience (~80%) and confidence (> 70%). The third-year students rated the value of digital anatomy tools significantly higher than the first-year students (p = 0.0038). A taxonomy-based assessment strategy revealed that the third-year students, but not the first-year, demonstrated improved performance in assessments relating to clinical application (p = 0.045). In summary, a flipped anatomy classroom integrating multimodal digital approaches exerted positive impact upon learning experience of both junior and senior students, the latter of whom demonstrated improved learning performance. This study extends the pedagogy innovation of flipped classroom teaching, which will advance future anatomy curriculum development, pertinent to post-pandemic education.

The effect of repetition- and scenario-based repetition strategies on anatomy course achievement, classroom engagement and online learning attitude

Anatomy is known to be the oldest and most fundamental branch among medical sciences. That is the reason why it is given at the beginning of medical education to form the basis for other medical sciences. Students who newly begin medical education need to spare plenty of time outside the course hours to study Anatomy which involves different and a lot of terminology. In this study, online repetitions were done outside the class using the repetition (classical presentation) and scenario-based repetition methods and the knowledge levels, course engagement statuses and online learning attitudes of the students were compared quantitatively and qualitatively between the groups.The study was conducted with 162 medical school year 2 students. These 162 students were randomized to experimental and control groups. The data were obtained with "Anatomy Achievement Test (AAT)", "Classroom Engagement Inventory (CEI)" and "Medical School Students' Attitudes Towards Online Learning Scale (MSSATOLS)". After administering the experimental procedure to the students who were randomized to the experimental and control groups, focus group interviews were held with 16 students from the experimental group, 8 who received the highest scores and 8 who received the lowest scores from the data collecting instruments. The collected research data determined that the affective engagement (AE) and the anatomy achievement test (AAT) performed pre- and post-study were higher in the group in which the scenario-based repetition strategy was applied. AAT pre-test (mean = 27.16) and post-test (mean = 27.15) scores of the repetition group were very close to each other. However, the AAT post-test (mean = 32.33) average of the scenario-based repetition group was above the mean pre-test scores (mean = 26.79) (p < .05). Similarly, the mean AE pre-test (mean = 17.79) and post-test (mean = 17.91) scores of only the repetition group were very close to one another. However, the AE post-test (mean = 19.46) mean score of the scenario-based repetition group was above the mean pre-test score (mean = 17.82) (p < .05). In summary, pre-test and post-test scores changed the anatomy achievement and affective engagement scores, and this change was in favour of experimental group and increasing the post-test scores.The responses given to the questions in the scales and the impressions obtained from qualitative interviews indicated that the students did not find adequate the lectures given in the form of presentations alone and thought that various methods and primarily scenario-based education should be used as part of anatomy education to be able to establish a good connection with clinical sciences and Anatomy education should be provided not only at the beginning of the medical education but also in the following years.

Study on the Reporting Quality of Randomized Controlled Trials of Flipped Classroom in Medical Education

BACKGROUND

With the deepening of medical education reform, the flipped classroom has become a commonly used teaching method. Many randomized controlled trials (RCTs) have shown that flipped classroom combined with problem-based learning (PBL) improves many students' abilities. It remains unclear whether the design and reports of these RCTs comply with specifications. The aim of this study was to provide a systematic assessment of the quality of RCTs investigating the effectiveness of flipped classroom teaching in medical education.

METHOD

Two investigators searched PUBMED and EMBASE and analyzed 15 filtered RCTs addressing flipped classroom in medical education, published between January 1, 2016 and December 31, 2021. The overall reporting quality was assessed using the overall quality score (OQS) according to the 2010 CONSORT statement.

RESULTS

The search revealed 15 RCTs closely related to flipped classrooms. After analysis, it appeared that least half of them made no mention of half of the OQS items in the CONSORT 2010 statement. Since the flipped classroom is an emerging teaching method, all the retrieved articles were published after 2016. Furthermore, a number of issues that we considered very important were not adequately addressed in the RCT reports.

DISCUSSION

Although the CONSORT 2010 statement was issued 12 years ago, the quality and content of many RCTs are not satisfactory. Our findings suggest that authors need to make more effort to meet the CONSORT statement requirements. This article is protected by copyright. All rights reserved.

Flipped Classroom versus Traditional Didactic Classroom in Medical Teaching: A Comparative Study

Background

The effective and efficient delivery of healthcare services that the National Medical Commission (NMC), India desires from Indian Medical Graduate (IMG) can only be fulfilled if the learner’s participation is extensive. Flipped classroom (FC) may promote enhanced as well as meaningful learning and critical thinking in students. By implementing this method trend can be changed from a teacher-centered approach to a student-centered approach, thus teaching-learning becomes more effective and interesting. It promotes learning and thinking helping the students in diagnosis and formulating appropriate management of patients during the clinical years of medical teaching of MBBS (Bachelor of Medicine and Bachelor of Surgery) and thereafter.

Aim

To compare FC and traditional didactic classroom (TDC) teaching for first-year MBBS students.

Objectives

-To evaluate FC method teaching for first-year MBBS students.

-To compare effectiveness of FC and TDC teaching for first-year MBBS students.

-To evaluate perception of students toward FC teaching method.

Methodology

The study was conducted after getting approval from the Institutional Ethics Committee. Total of 100 students volunteered to participate in the study after providing informed consent. Two groups based on pseudo randomization were created and subjected to the FC method and TDC method in module A and crossover of groups was done in module B. Both groups were subjected to post-test after intervention in modules. Feedback was obtained from students on their perception toward the FC method.

Results

There was a statistically significant difference (p<0.05) in post-test scores of both FC groups in both modules (FC Method: 14.77 ± 2.16 and 11.26 ± 1.76 vs TDC Method: 12.16 ± 2.05 and 10.03 ± 2.57). Overall positive feedback was received for FC method of teaching compared to TDC method.

Conclusions

Considering responses and results of the assessment, it can be concluded that the FC approach is beneficial for students. It enhances the learning of students. Perception of students toward medical teaching can be greatly improved. It helps students achieve better results in their learning. With larger sample size studies, this result of FC method being a better learning tool will gather more strength.

Implementation of flipped classroom combined with case-based learning: A promising and effective teaching modality in undergraduate pathology education

The popularity of flipped classroom (FC) is growing in medical education. However, the application of FC in pathology teaching has not been well explored. This study assessed the efficacy of FC combined with case-based learning (CBL) in undergraduate pathology education via comparison with a traditional lecture-based classroom (LBC).A total of 117 third-year students were enrolled and assigned to the FC group (n = 59) or LBC group (n = 58) with demographic matches. Two sections in the pathology textbook (cardiovascular and respiratory system diseases) were chosen for the teaching content. Students in the FC group were required to study the preprovided course materials pre-class, followed by clinical case-based interactive group discussion in-class. Students in the LBC group were encouraged to preview and attended a didactic lecture in class. Post-class quizzes and Likert questionnaires were performed to investigate the efficacy and possible advantages of CBL-based FC over LBC.The scores of the 2 groups in the mid-term examination of pathology before interventions were comparable. However, students in the FC group gained significantly higher scores in the post-quizzes than those in the LBC group, especially the scores regarding the questions of clinical case analysis. In the questionnaires, more students considered CBL-based FC to be beneficial to learning motivation, knowledge comprehension, critical thinking, patient management and teamwork than LBC. In addition, more students agreed that the FC model increased pre-class burden than LBC, rather than in-class pressure.CBL-based FC modality has promising effects on undergraduate pathology education and may be a better choice than traditional LBC. Further optimizations are needed to implement this novel approach in pathology and other medicine curricula.

Enhancing the effectiveness of flipped classroom in health science education: a state-of-the-art review

BACKGROUND

In a flipped classroom, students acquire knowledge before class and deepen and apply this knowledge during class. This way, lower-order learning goals are achieved before class and higher-order skills are reached during class. This study aims to provide an overview of the factors that contribute to the effectiveness of the flipped classroom and how these factors can be stimulated. The effectiveness of the flipped classroom is conceptualized in this study as test scores, the achievement of higher learning goals, and student perceptions.

METHODS

A state-of-the-art review was conducted. The databases MEDLINE, PsycINFO, PubMed, Web of Science, and Scopus were consulted. The timeframe is 2016 till 2020. The studies were qualitatively analyzed according to the grounded theory method.

RESULTS

After screening the studies based on the inclusion-and exclusion criteria, 88 studies were included in this review. The qualitative analysis of these studies revealed six main factors that affect the effectiveness of the flipped classroom: student characteristics, teacher characteristics, implementation, task characteristics, out-of-class activities, and in-class activities. Mediating factors are, amongst other factors, the learner's level of self-regulated learning, teacher's role and motivation, assessment approach, and guidance during self-study by means of prompts or feedback. These factors can be positively stimulated by structuring the learning process and focusing the teacher training on competencies and learning-and teaching approaches that are essential for the flipped classroom.

CONCLUSION

This paper provides insight into the factors that contribute to the effectiveness of the flipped classroom and how these factors could be stimulated. In order to stimulate the effectiveness of the flipped classroom, the positively and negatively affecting factors and mediating factors should be taken into account in the design of the flipped classroom. The interventions mentioned in this paper could also be used to enhance the effectiveness.