Mobile learning in dentistry: usage habits, attitudes and perceptions of undergraduate students

The Effectiveness of Technology-Enhanced Learning in Prosthodontic Education: A Systematic Review

OBJECTIVE

To compare the effectiveness of technology-enhanced learning (TEL) with traditional learning in prosthodontic education.

METHODS

The protocol was registered before commencement [CRD42023390277]. The search was conducted to identify randomized controlled trials (RCTs) focused on comparative assessment of TEL and traditional learning in prosthodontic education up to 6 June 2024. A comprehensive search strategy was formulated, encompassing multiple electronic databases. Screening, data extraction and risk of bias assessment using the Cochrane tool (RoB 2) were performed. Educational outcomes were evaluated by Kirkpatrick's four-level evaluation model.

RESULTS

Of 2830 records identified, 14 RCTs were included. All the trials were judged at high risk of bias or had some concerns. The included studies assessed the short-term benefits of various TEL approaches, including e-learning, blended learning, video demonstration specialized self-evaluation software and virtual reality simulation in prosthodontic education for undergraduates. Promising results were found in individual studies, particularly in terms of perceived learning conditions with problem-based learning (PBL) and self-reported understanding and confidence when using video demonstrations. Most studies reported comparable outcomes to traditional learning in practical skills assessments, while the results regarding the acquisition of theoretical knowledge through the incorporation of TEL approaches were contradictory. One study reported promising results in perceived learning conditions with the PBL approach, as well as improved self-reported understanding and confidence with the use of video demonstrations. Furthermore, there was a limited number of studies assessing the effect of TEL approaches on students' behaviour.

CONCLUSION

There is a lack of high-quality evidence to support the adoption of TEL approaches in prosthodontics. However, the incorporation of virtual reality simulation has demonstrated promising results, particularly in improving practical clinical skills.

Dental students in an orthodontic course flipped classroom: A semi-experimental study on knowledge, practice, attitude, and satisfaction

OBJECTIVE

The purpose of this study was to determine the students' attitudes before and after the flipped classroom, and the effectiveness of this method to promote the students' lateral cephalograms tracing abilities, students' satisfaction and their final exam scores.

MATERIALS AND METHODS

This is a single-group quasi-experimental research conducted on dental students of Shiraz University of Medical Sciences (SUMS), Iran in 2019. The intervention was carried out in a blended learning approach with the flipped classroom model. Thirty-five fourth-year dental students participated in a flipped classroom held during a semester for the lateral cephalograms tracing course. The students were provided with the educational materials before the class time through multimedia learning tools and the class time was devoted to discussions. The students were asked to fill out four questionnaires (pretest/posttest attitudes, pretest/posttest self-assessments of theoretical knowledge and practical skills in cephalograms, posttest of satisfaction from quality of the course, and posttest of students' views about effectiveness of blended learning tools) and final exam scores of students.

RESULTS

Students' attitudes toward e-Learning were improved after the flipped classroom and the quality of this method was acceptable to the students (p < .001). Their self-assessment of theoretical knowledge and practical skills were promoted (p < .001). While all blended learning tools averaged more than the cut-off-point, short lecture (5.11 ± 0.98) and live feedback (4.98 ± 1.07) were considered to be the most efficient interactive tools.

CONCLUSION

It seems that the flipped classroom has a positive effect on increasing students' knowledge, attitude, and satisfaction. In general, this method of learning seems to be favored by dental students.

CLINICAL SIGNIFICANCE

The findings showed that blended learning had a positive effect on increasing knowledge, performance, and satisfaction among dental students. Therefore, blended learning as a reliable method might be used in training dental students.

WhatsApp as a Tool in Blended Learning in Dental Education

Background and Objective

Dental education is unique, with clinical/practical learning much different from other professionals. In dentistry, students are exposed much earlier in their curriculum to patients, performing procedures under direct/indirect supervision. Hence, the present review attempted to assess the standing position of dentistry in blended learning worldwide.

Materials and Methods

E-learning modality was at its primitive stage as food for thought among educational task force committees, with only a handful of developed and developing countries equipped with it. During this pandemic, "WhatsApp" became a savior, as it was a widely used educational device among dental teachers and students. Furthermore, it was easily applicable in places where there was difficulty in obtaining regular internet bandwidth, especially in remote/rural areas. It is noteworthy that blended learning/e-learning, when complemented with the conventional teaching method, upskill critical thinking and problem-solving capabilities. Blended learning or virtual reality education should be made feasible without disparity, worldwide. Mind training, both students and staff in hybrid e-learning, is the need of the hour not only to keep pace with digitalized dentistry but to prepare the students to face real-world situations.

Conclusion

The sustainability of dental education should be rethought by dental schools with "Complimented Digital learning" wherever feasible, not only to cope with current trends but also to face unforeseen future challenges.

Smartphone Applications in Dentistry: A Scoping Review

This scoping review aims to investigate the latest literature concerning the use of smartphone applications (apps) in the prevention, management, and monitoring of oral diseases. Smartphone applications are software programs that are designed to run on smartphones. Nowadays, smartphones are regularly used by people of all ages, and mobile health apps (MHAs) represent an important means of spreading information related to oral health, which is the state of the mouth and teeth, including the gums and other tissues. Several apps have been designed to promote prevention, diagnosis, and therapeutic adherence monitoring. This scoping review considered randomized clinical trials, cross-sectional studies, before-after (pre-post) studies with no control group, and observational studies. Once the inclusion and exclusion criteria had been defined, a preliminary confined search was performed on PubMed and Scopus; key terms from the collected articles were selected to design a search strategy, and then a search of all the included articles' reference lists was run for further research. Studies were excluded if they did not fulfill the inclusion criteria. The preferred reporting items for scoping reviews (PRISMA-ScR) consensus was followed. The risk of bias was evaluated by providing a qualitative analysis of the clinical studies via the National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment of Controlled Intervention Studies, Observational Cohort Studies, and Cross-Sectional Studies (NHLBI, NIH). A total of 21 studies were included in this review. As it is clear from the studies selected, the literature indicates that MHAs are effective in improving oral hygiene in adolescents and children and reducing the dental plaque index, including in patients undergoing orthodontic treatment. MHAs are also able to reduce the symptoms of patients affected by obstructive sleep apnea-hypopnea syndrome (OSAHS) and improve the swallowing-related quality of life of elderly patients. MHAs are furthermore recommended to decrease dental anxiety among patients, both during dental procedures and the post-operative period. MHAs are useful to spread knowledge about traumatic dental injuries among non-oral health professionals and to monitor dental erosion and awake bruxism. MHAs' clinical outcomes might have been influenced by the demographic features of the subjects involved. Further studies considering a longer follow-up period and larger samples are needed. In conclusion, MHAs can be considered a useful tool to monitor oral disease and increase patients' quality of life related to oral health.

Evaluation of Atlas-Based Mobile Application in Undergraduate Teaching in Oral Histopathology

The utilization of mobile devices in education is a growing trend in various subjects. We developed the Dental and Maxillofacial Development Teaching Atlas App, and applied it to the learning process of oral histopathology. The aim of the current study was to investigate the educational effects of atlas-based mobile-assisted teaching in the field of dental medicine, and to suggest relevant improvements. The Dental and Maxillofacial Development Teaching Atlas App encompasses a wide range of atlases. It harbors various features, such as terminology definitions, student communications, and teacher-student interactions. By conducting questionnaires (70 students) and a quiz (68 students), we obtained students' feedback, to evaluate the effects and application prospects of the WeChat applet. The questionnaire results indicate that students experienced a high level of satisfaction and support. Additionally, students participated in the quiz, with the experimental group exhibiting significantly higher average scores than the control group. The fill-in-the-blank questions, image recognition questions, and the total score all demonstrated statistically significant differences, while the terminology definition questions did not. The Dental and Maxillofacial Development Teaching Atlas App facilitates students' utilization of fragmented time for learning, and demonstrates positive effects in enhancing students' learning interests and proactiveness. It also holds promising potential for applications in other disciplines in the field of dental education.

Utilizing an organizational development framework as a road map for creating a technology-driven agile curriculum in predoctoral dental education

The landscape of dental education is undergoing a paradigm shift from both the learner's and teacher's perspectives. Evolving technologies, including artificial intelligence, virtual reality, augmented reality, and mixed reality, are providing synergistic opportunities to create new and exciting educational platforms. The evolution of these platforms will likely play a significant role in dental education. This is especially true in the wake of calamities like the COVID-19 pandemic during which educational activities had to be shutdown or moved online. This experience demonstrated that it is prudent to develop curricula that are both agile and efficient via creating hybrid courses that provide effective learning experiences regardless of the mode of delivery. Although there is growing interest in incorporating technology into dental education, there are few examples of how to actually manage the implementation of technology into the curriculum. In this paper, we provide a road map for incorporating technology into the dental curriculum to create agility and discuss challenges and possible solutions.

Learning outcomes of a mobile application for dental infection control education

PURPOSE/OBJECTIVES

This study aimed to apply and verify the effectiveness of a mobile-based dental infection control education application to enable students majoring in dental hygiene to learning dental infection control education without time and space constraints.

METHODS

This study used a nonequivalent control group pretest-posttest design to examine differences in learning outcomes between an experimental group that learned through the mobile application and a control group that learned with handouts. The Infection Prevention and Control Mobile Application (IPC App) and handouts were developed by referring to the Center for Disease Control's (CDC) guidelines for Infection Prevention and Control in Dental Settings. Both the experimental and control groups were guided to perform self-regulated learning, where they independently led and managed their learning for two weeks. The study was conducted at the D university college with 42 students from the second grade in the Department of Dental Hygiene from August to October 2021. Differences in knowledge, self-efficacy, and summative evaluation were analyzed using an independent sample t-test and repeated measures analysis of variance (p < 0.05).

RESULTS

The findings confirmed that the experimental group who learned through the IPC mobile application had improved their knowledge and indicated a higher summative evaluation than the control group that learned via learning documents (p < 0.05).

CONCLUSIONS

Owing to the high accessibility and repeatability of the learning content, the mobile application recommended in this study may serve as an effective self-directed learning tool for students to gain knowledge on the standard precautions for dental infection control.

Mobile application as a learning tool for improving dental students' knowledge regarding dental trauma

INTRODUCTION

Current evidence suggests an important knowledge gain of health sciences' students and professionals with mobile devices (m-learning). This study aimed to verify whether different strategies of teaching (traditional lecture classroom, m-learning and association of both methods) would present greater efficacy in knowledge improvement regarding dental trauma in primary dentition.

MATERIALS AND METHODS

An action research study using a participatory approach was conducted with 36 undergraduate Brazilian dental students. A structured questionnaire composed of six clinical cases of traumatic injuries was initially applied to all students (pre-test). Participants were then randomly distributed into three experimental groups: TC-students who had access exclusively to traditional lecture classroom; APP-access exclusively to the mobile application; and TC-APP-access to both approaches. The traditional and technological methods had evidence-based content and visual resources of the subject. After interventions, all students responded to the same previous questionnaire (post-test). Wilcoxon and Kruskal-Wallis tests were performed for statistical analysis.

RESULTS

All tested groups obtained statistically significant improvement between their pre-test and post-test scores, for both diagnosis and treatment of dental trauma (p < .005). Nonetheless, no intergroup differences were observed amongst the scores of pre- and post-test for diagnosis (p = .159) and treatment (p = .206).

CONCLUSION

All teaching approaches applied obtained similar knowledge improvement of undergraduate dental students regarding traumatic injuries in primary teeth.

Insight on the influence of technology-enhanced learning in orthodontics' education: A systematic review

OBJECTIVES

Technology-enhanced learning (TEL) provides a pliable and current way to present orthodontic curriculum material to students. This review aimed to assess the effectiveness of TEL compared with traditional learning methods in the field of orthodontics.

MATERIALS AND METHODS

The search comprised randomised controlled trials (RCTs) related to orthodontics' interactive learning from the following databases: PubMed, Scopus, CENTRAL, Psyclnfo, ERIC, Web of Science, Dissertations and Theses Global. Two authors performed the screening, data extraction and assessed risk of bias using the Cochrane tool (Rob 2) blindly and in duplicate. Kirkpatrick's 4-level evaluation model was used to evaluate educational outcomes.

RESULTS

A total of 3131 records were identified of which 11 RCT were included. On level 1 (Reaction), students had a positive attitude towards TEL. On level 2 (Learning), included studies did not report any significant knowledge improvement when TEL was compared with traditional learning strategies. One study assessed level 3 (Behaviour), where students felt that flipped classroom learning created feelings of greater confidence. On level 4 (Results), most studies suggested that TEL tools are as equally effective in imparting information as traditional tools and recommended that both methods should be considered in teaching students.

CONCLUSION

Technology-enhanced learning techniques might have the potential to enhance educational outcomes in orthodontic education and students seem to enjoy the implementation of technology in the learning process. These educational tools should be used as an adjunct to the traditional didactic classroom, and not as a replacement, due to the challenges encountered with their application.

The Understanding of Medical Informatics among Dental and Medical Students

Background

Current medical care deeply relies on informatics during all stages of patient care, which is significantly enhanced due to its use. The healthcare professional's formation in medical informatics results crucial for their everyday practice. However, healthcare study programs not always provide education about the use of this wide variety of systems, and young professionals find that they need to learn about it over the experience. The aim of this study was to assess the understanding of medical and dental students regarding medical informatics and ICTs.

Materials and Methods

A questionnaire was produced with 3 sections and a total of 24 questions. Students replied to the survey before and after taking the medical informatics course.

Results

A total of 719 students from second year of medical and dental school were recruited for the study between the period of September of 2017-May 2018, September 2018-May 2019, September 2019-May 2020, and September 2020-May 2021. Medical and dental students showed a good level of understanding regarding medical informatics, as well as a good perception of the relevance of ICT learning for the professional practice. Course attendance increased the percentage of students that felt confident of their knowledge about medical informatics. However, most students felt that little or no medical informatics education was lectured at their schools and that the University should adapt the academic program to include it. After taking the course, the student's perception on this matter was improved.

Conclusion

Medical and dental students find medical informatics learning useful for their future professional practice and feel inclined to use it. However, they feel that Universities need to adapt their programs in order to include medical education courses and trainings; partly because they are not completely aware of the use of ICTs that already are established in their courses.

Effect of M-Learning on promoting the awareness of faculty members of the universities of medical sciences of Iran about their employment regulations in 2020

Introduction

New technologies enable universities to incorporate innovative teaching-learning strategies into their curricula. Therefore, this research investigates the effect of mobile learning on promoting the awareness of faculty members of the universities of medical sciences of Iran about their employment regulations.

Materials and methods

The statistical population of this research included all faculty members of Ahvaz Jundishapur University of Medical Sciences in southwestern Iran. One hundred and fourteen people entered the quasi-experimental study through convenience sampling. First, we sent the designed mobile app to them through social networks to install on their phone. We measured their awareness about the app and M-Learning through a researcher-constructed questionnaire.

Results

M-Learning and App was able to increase the awareness of faculty members, which was significant according to their academic rank and work experience. Faculty members who were professor and instructor, as well as those who had e under 5 years or 11-20 years of experience gained more awareness (P = 0.00). It was not significant in other variables. Ninety eight percent of the faculty members considered the technical capabilities of the designed app appropriate. Ninety seven percentage of the faculty members suggested M-Learning for teaching similar subjects in their profession.

Discussion and conclusion

The faculty members had a positive attitude toward this designed educational app and M-Learning. Designing similar mobile training apps can improve their professional performance.

Experiences of international medical students enrolled in Chinese medical institutions towards online teaching during the COVID-19 pandemic

Introduction

. The COVID-19 pandemic has forced the world to pause. One hundred and eighty-eight countries have imposed countrywide school closures, affecting more than 1.5 billion children and youths. The majority of academic leaders are currently encouraging online education to resolve this crisis. This study aimed to investigate international medical students' (IMS) experiences of online teaching during the COVID-19 pandemic.

Methods

Data were collected online using a validated questionnaire and one open-ended question, presented on the Google forms platform. The study attracted responses from 1,107 IMS volunteer participants. IBM SPSS v. 25, GraphPad Prism v. 9, and MindManager v. 2018 were used for data analysis. All variables were subjected to descriptive statistical analysis. The Mann-Whitney U test was used in subgroup analysis and the Kruskal-Wallis test was also applied for year-wise comparisons. Open-ended text responses were analyzed qualitatively, extracting themes by which responses were classified.

Results

Among 1,107 respondents, a total of 67.8% were males, and the majority (63.1%) of the IMS were in the age group of 21-23 years. The results show that more than half of the respondents reported their Internet connection quality as poor to average. Poor Internet connection severely affected IMS online learning experience. Persistent and recurrent issues with Internet access became a significant concern for IMS. Lack of electricity is one of the factors that can contribute to poor learning output and dissatisfaction with online teaching. IMS perceive online medical education as unhelpful in several phases of the training, such as improving their clinical skills, knowledge, and discussion skills.

Conclusions

During these unprecedented periods, online teaching has allowed medical education to continue. However, IMS are generally dissatisfied with online teaching. Medical students must visualize the human body, so supportive technologies are important to compensate for the lack of clinical practices. Medical institutions may need to invest in faculty training programs and continually adjust to enhance the content of online training and international partnerships. A switch from conventional face-to-face teaching to a fully functional virtual education framework in the medical education field will take time and experience.

Perceptions of dental students towards online education during the COVID-19 pandemic

Purpose

This study evaluated the usage habits, attitudes, and perceptions of undergraduate dental students toward distance (online) learning and identified variables related to those attitudes.

Materials and methods

The study included 1,605 undergraduate dental students who participated voluntarily. The data collection tool consisted of a distance learning attitude scale, a questionnaire on personal information, and open-ended questions. The perceptions of dental students to distance education according to the year and type of dental school they attended were evaluated.

Results

Most students expressed that distance learning in dental courses was not as effective as traditional face-to-face education (59.1%, n=949). While students studying at state universities had a more negative view of distance education, the satisfaction scores of the first-year students were found to be significantly lower than the other students (p<0.05).

Conclusion

Dental students were generally unhappy with the interruption of traditional education caused by COVID-19 and having to continue their education online. However, under the circumstances, they saw it as an advantage allowing them to continue their education and avoid a complete suspension.

Effect of mobile learning on academic achievement and attitude of Sudanese dental students: a preliminary study

BACKGROUND

Despite the great development of smart phone programs and applications, and the wide-spread of these devices among students, their use for the educational purposes remains weak. The study aimed to investigate to what extent utilizing mobile learning as an adjunct to classic classroom lectures affect students' academic achievement and, to assess their attitude toward using mobile application as an instructional method in dental education.

METHODS

A quasi-experimental study was conducted among undergraduate dental students from two Sudanese universities. A total of 67 students who voluntarily agreed to participate were randomly allocated into a control group of 33 and an intervention group of 34 students. Initially, the two groups undertook a pre-test to ensure the standardization of a scale regarding their existing academic knowledge of dental surgery forceps used for tooth extraction. Then the intervention group was provided with a mobile application (Dental Surgical Forceps application version 2.1.0.0), and 3 weeks later a post-test was given for both groups. The attitude of the students toward the effectiveness of mobile learning was as assessed by five-point Likert scale questionnaire. For comparison of the numerical parametric data, a T. test was used, while for non-parametric categorical data a Chi-Squire test was used, with level of statistical significant difference set at P-value of ≤0.05.

RESULTS

The response rate was 91% for the intervention group (31 out of 34 students completed the study), and 78% for the control group (26 out of 33 students completed the study). Statistical significant difference was observed between the pretest and post-test mean scores of the intervention group (P < 0.005), while the differences were not significant among the control group (P > 0.05). Regarding the attitude of the dental students, the mean scores of the sample indicate that the vast majority of the participants (93.5%) showed positive attitude regarding the effectiveness of mobile learning.

CONCLUSIONS

There is a marked difference in the students' scores regarding their knowledge of dental surgical forceps. The students showed positive attitude toward using the mobile application.

Self-Reported Effectiveness of e-Learning Classes during COVID-19 Pandemic: A Nation-Wide Survey of Pakistani Undergraduate Dentistry Students

OBJECTIVES

 The main aim of this study was to determine the undergraduate dental students' self-reported effectiveness of online classes offered by various dental institutes of Pakistan.

MATERIALS AND METHODS

 A cross-sectional study was conducted using an online survey. A pretested and validated questionnaire comprising of 31 questions was circulated among dental students. The study participants were inquired about the perceived level of accessibility of resources and the effectiveness of online teaching. The data was analyzed using SPSS version 24. Mann-Whitney U test and Kruskal-Wallis test were used for statistical analysis at p ≤0.05.

RESULTS

 A total of 1,207 students from all over Pakistan responded. The majority of students was dissatisfied with the institutional learning management system and quality of learning resources available. Students were also dissatisfied with the level of training of teachers for online lectures. The worst rating was reported for questions related to the effectiveness of online classes (average rating: 3.83 and 3.781/5). First-year students reported poor interaction with teachers (p < 0.001) and strongly disagreed with the effectiveness of online classes (mean rating: 4.14 ± 0.935).

CONCLUSIONS

 The results from the present survey showed that dental students of Pakistan unanimously voiced dissatisfaction toward various elements of online teaching sessions. Findings from this survey will aid the academic institutes to establish proficient learning platforms focused on improving students` learning experience.

Smartphone and medical application use among dentists in China

Background

With the development of information technology, an increasing number of healthcare professionals are using smartphones and mobile medical applications (apps) in their clinical practice. The objective of this study was to survey the use of smartphone-based medical apps among dentists in China and determine dentists’ perceptions of such apps.

Methods

All data were collected using anonymous questionnaires. The questionnaires for this cross-sectional study were randomly sent to dentists by email, and 379 dentists responded. Dentists’ demographics and perceptions of WeChat, QQ (the most popular social media apps in China) and other medical apps were assessed; the questionnaire including questions on the purpose, frequency, daily use, and opinion of the apps they used. Questions were answered using a Likert scale (1 = strongly agree, 2 = agree, 3 = not sure, 4 = disagree, and 5 = strongly disagree).

Results

A total of 379 valid responses were received; the respondents had a median age of 33.6 years old (63.3% female). All subjects (100%) owned a smartphone, and all of them installed and used WeChat or QQ in their clinical practice. Only 76% of subjects installed medical apps (other than WeChat and QQ) on their smartphones. Male dentists were more likely to install medical apps than female dentists (p < 0.05). With increasing age, the percentage of dentists who installed medical apps decreased (p < 0.001). The frequency and daily use were higher for WeChat and QQ than for medical apps. Medical apps were positively perceived, with dentists reporting that they recommend these medical apps to their peers (Likert score: 1.67 ± 0.68).

Conclusion

Medical apps were perceived to have a positive impact on clinical practice, education and patient care in dentistry by providing relevant medical information. However, there will still be much room for improvement in the future.

Successful promotion of physical activity among students of medicine through motivational interview and Web-based intervention

Background

Regular physical activity supports healthy behavior and contributes to the reduction of preventable diseases. Students in their social transition period are the ideal groups for interventions. The higher education period, associated with demanding changes and poor time management, results in a low level of physical activity. In this age, social media usually are a suitable channel of communication and multicomponent interventions are the most desirable. It has not been sufficiently investigated how effective a Web-based approach is among university students when it comes to physical activity in the long-term period. We combined a Web-based approach with motivational interviews and tested these two interventions together and separate to assess their impact on improving the physical activity of medical students 1 year after the intervention.

Methods

All 514 first-year students at the Faculty of Medicine in Belgrade were invited to fill in a baseline questionnaire. Also, they underwent measurement of weight, height and waist circumference. After that, students selected a 6 months intervention according to their preference: Intervention through social media (Facebook) (Group 1) or combined with a motivational interview (Group 2). Group 3 consisted of students without any intervention. One year after completion of the 6 months intervention period, all students were invited to a second comprehensive assessment. Analyses were performed employing a wide range of statistical testing, including direct logistic regression, to identify determinants of increased physical activity measured by an average change of Metabolic Equivalent of Task (MET). This outcome measure was defined as the difference between the values at baseline and one year after completion of the 6 months intervention period.

Results

Due to a large number of potential determinants of the change of MET, three logistic regression models considered three groups of independent variables: basic socio-demographic and anthropometric data, intervention and willingness for change, and health status with life choices. The only significant model comprised parameters related to the interventions (p < 0.001). It accurately classified 73.5% of cases. There is a highly significant overall effect for type of intervention (Wald = 19.5, df = 2, p < 0.001) with high odds for the increase of physical activity. Significant relationship between time and type of intervention also existed (F = 7.33, p < 0.001, partial η² = 0.091). The influence of both factors (time and interventions) led to a change (increase) in the dependent variable MET.

Conclusion

Our study confirmed the presence of low-level physical activity among students of medicine and showed that multicomponent interventions have significant potential for positive change. The desirable effects of the Web-based intervention are higher if an additional booster is involved, such as a motivational interview.