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Determination and Comparison of the Factors Related to Effective Blended Learning in Medical Sciences from the Viewpoints of Instructors and Learners

Introduction According to rapid growth of innovation in use of technologies in education and learning, blended learning has become an effective method in the student’s education. The purpose of this study was to extract the factors related to effective blended learning and compare the viewpoints of students and instructors in this regard. Methods Mixed method model was used in this study. A content analysis approach was employed in the qualitative phase of the study. Seven faculty members and eight master’s students of medical sciences selected through purposive sampling participated in the qualitative phase. Individual semi-structured interviews were conducted for data collection. In the quantitative phase, appropriate and relevant items were designed based on the main concepts of theoretical and practical definitions that were extracted in the qualitative phase. Results The results of the qualitative phase were 5 categories and 40 subcategories, including student’s capabilities, teacher merits, technological aspects, pedagogic topics and supportive environment. Discussion The results of the questionnaire analysis showed no significant difference in student capabilities and supportive environment between the viewpoints of students and faculty members while there were significant differences in other categories. Although new technologies have offered promising opportunities, they do not result in effective education. The results of the present study suggest that a major revision in student and instructor admission and provision of required technical facilities can promote the status of this type of education. On the other hand, instructor empowerment programs in this field can enhance the effectiveness of virtual education.


Background
The most important mission of education in medical sciences is to train competent and capable individuals who possess the required knowledge, attitude, and skills to preserve and enhance public health. In this regard, along with the goals of sustainable development, medical education plays a key role in improving the students' knowledge for decision making in the future and developing a global perspective through effective education that is proportional to the evolution. 1,2 This area, as part of the higher education that is responsible for providing students with a massive volume of knowledge, attitude, and skills for acquiring professional competencies, 3 is obliged to employ modern methods because public health improvement depends on high-quality education. Moreover, the ultimate goal of human resources planning in the health sector is to train efficient and high-quality manpower. 4 Blended learning is a relatively new term while its concept has been prevailing in areas such as virtual education for decades. 5 In general, the term "blended learning" refers to the third generation of distance education defined as a method to maximize the benefits of face-to-face education and multiple learning technologies. 6 In this approach, in addition to regular classes, some electronic classes are also held during a semester, and the students are not forced to be present at a definite place at a definite time and can interact with their instructors and other learners via the Internet. 7 Providing pure online education to a heterogeneous group of learners with different intellectual and experience backgrounds may not be effective enough. The aim of blended learning is to create opportunities for students to use both the real and virtual environments to enhance their learning. 8 This method is used to optimize the results of learning and costeffectiveness. 9 Since blended learning has the benefits of traditional and virtual education, it is an appropriate method for achieving the training-learning objectives in medical education. The blended learning have been used to develop competencies in medical sciences. 10 The results of the studies conducted by research institutes and universities like Stanford and Tennessee suggest that blended learning has priority over traditional approaches regarding the mechanisms; Moreover, blended learning not only is capable to transferring the learning material more effectively but also is a more effective educational method. 11 The design and implementation of blended learning in medical fields in Iran showed that this type of education can be cost-effective and recommended to implement. Results of the studies also showed that the learners were more significantly satisfied with learning through blended method than the traditional education (face-to-face). Therefore, by considering the valuable position of blended education in increasing the satisfaction and success of learners in medical courses, employing this approach included among the development programs for medical education from 2017.
The term "effectiveness" was first used in the field of management and different viewpoints and frameworks were presented for it. Effectiveness is usually defined as the degree to which the desired objectives are achieved. 12 In general, effective education is achievement of multiple objectives and priorities in the form of a value system, so achievement of goals in terms of cost and time is optimal and satisfy learners and teachers. 13 In the process of education, teaching and learning are interrelated. Although teaching is a teacher's activity, but the result of learning depends on the student. Effective education is based on participation and cooperation. 14 Therefore, effectiveness should be assessed based on the viewpoints of the students and instructors to produce comprehensive results. Although some researchers have investigated blended learning and its problems and barriers, we found no studies that compared the viewpoints of the stakeholders in this regard. Therefore, we decided to extract the factors related to effective blended learning and compare the viewpoints of students and instructors in this regard.
The research questions were as follows: 1. What are the most important factors related to effective blended learning from the viewpoints of students? 2. What are the most important factors related to effective blended learning from the viewpoints of instructors? 3. Is there a significant difference between the viewpoints of students and instructors regarding factors related to effective blended learning?

Method
The mixed method model, which combines both qualitative and quantitative approaches, was used in this study. By using the mixed method, research strong aspects of quantitative and qualitative methods can be utilized and its limitations can be minimized. [15][16][17][18] Particularly, complexity of social facts is eliminated by bringing different methods together than observing and discussing them, which hereby contributes to the better understanding of the fact. 15 In this study sequential exploratory mixed method was employed, further described in (Figure 1).

Qualitative Phase
In an exploratory design, qualitative data is first collected and analyzed, and themes are used to drive the development of a quantitative instrument to further explore the research problem. 16,18,19 As a result of this design, three stages of analyses are conducted: after the primary qualitative phase, the secondary quantitative phase use and then, at the integration phase two strands of data and extends connects to create initial qualitative exploratory findings. 16 This article reports on the final integration phase of the research. A content analysis approach was employed in the qualitative phase of the study. Qualitative content analysis is an approach for Subjective interpretation of the textual data through the processes of systematic categorization, coding, and themes or known patterns design. 20 In the content analysis approach, categories are directly extracted from the textual data to help the researcher achieves a deeper perception of the phenomenon. 21 The reason that this approach was applied in this study was to explore the meaning, priorities, attitudes and perception of the students and instructors of effective blended learning through analyzing their verbal messages.

Participants
The sampling was purposeful. Seven faculty members of Medical Sciences universities of IRAN with at least two consecutive years of experience in the blended learning system and eight master's students of medical sciences selected through purposive sampling participated in the qualitative phase. The inclusion criteria were experience of teaching or learning in the virtual education system, availability, and willingness to participate in the study.

Data Collection and Analysis
Individual semi-structured interviews were conducted for data collection. After obtaining of informed consent from the participant, the interviews begun with unstructured questions, some probe questions were also in the interview protocol to ensure interviewees' perceptions regarding concept of factors related to effective blended learning in medical sciences. Each interview lasted for 30-45 min. All interviews were recorded then transcribed for analysis. The introductory questions were "What do you think about blended learning and how it should be held?" "What do you think about the challenges of blended learning?" and "What are executable solutions to improve this educational method considering the prevailing context?" According to the participants' answers, probing questions were also asked during the interview. The seven-step Colaizzi's method was applied for data analysis, including familiarization with the data by reading important findings and developing empathy with the participants to extract significant statements, formulating meanings for the extracted sentences, categorizing identified meanings and clusters, referring to the original statements and comparing the data, describing the phenomenon under investigation, and finally returning the description to the participants for verification of results. These steps were followed by coding and extraction of themes and sub-themes. 22 Interviewing continued, until the data from the interviews was being consistently duplicated. There appeared to be saturation of data as no new information was gained from the last interviews. The MAXQDA version 12 was used for data analysis.

Trustworthiness of Qualitative Data
Numerous frameworks have been developed to evaluate the rigor or assess the trustworthiness of qualitative data 23,24 and strategies for establishing credibility, transferability, dependability, and Confirm ability. In this study, the credibility of the qualitative findings was ensured by using member check and immersion techniques as well as ongoing engagement of the researchers with the data and also participation in similar congresses. Then, in order to complete the data and examine the transferability of the findings, the people who had the experience of conducting qualitative research were asked (peer check) to review the initial interviews, coding and categories. To increase the reliability of the data, the longterm work with the research subject, the observers' review and controlling the findings with the participants in terms of the extent of reflecting their experiences were used. The principles of confidentiality of information and informed consent for interviewing and recording the conversations were observed as well. The right to withdraw from research at any time was one of the ethical considerations that were observed, too.

Quantitative Phase
In the quantitative phase, appropriate and relevant items were designed based on the main concepts of theoretical and practical definitions that were extracted in the qualitative phase and preliminary questionnaire was developed in 40 items in five general categories. The validity and reliability of questionnaire was assessed. The face validity, content validity index (CVI) and ratio (CVR) of the questionnaire was examined by 10 students and 10 faculty members and their comments were applied to the questionnaire after they were reviewed by the research team. In the next step, to Compilation of the final version, the questionnaire was assessed by a number of e-learning experts in a face-to-face session, and their comments were reviewed by research team. Finally, the final version of the questionnaire was prepared that contained 40 items in 5 general categories related to effective-blended learning. The final questionnaire included students' capabilities (four questions), teacher merits (11 questions), technological aspects (9 questions), pedagogic topics (11 questions), and supportive environment (5 questions). The questions of each category were scored on a 5-point Likert scale from very low (1 point) to very high (5 points). The minimum score of questionnaire was 40 and maximum was 200. The Cronbach's alpha was calculated to assess the reliability of the questionnaire, which was 0.91 for faculty members and 0.86 for students. The questionnaire was forwarded to 105 faculty members and students through email to prioritize effective blended learning indexes that 24 faculty members and 63 students (total=98) completed the questionnaire (Response rate: 93.3%). For data analysis, the total score of each category was divided by the number of questions, and a mean score was calculated. SPSS version 21 was applied for analysis, using descriptive (mean, and standard deviation) and analytical (independent t test) statistics.
For ethical considerations, the objectives and protocol of the study were explained to the participants and informed consent was obtained from all of them. The participants were assured that participation was voluntary, they could withdraw from the study at any time, and the audio files confidential and anonymous.

Results
The mean age of students and professors participated in the study was 29.31±5.2 and 41.6±4.8 years, respectively. Fifty-two percent of students and 44% of professors were female. The results of the qualitative and quantitative phase are presented in the following.

Qualitative Phase Results
The aim of the qualitative phase was to determine the factors affecting effective-blended learning and to compare the viewpoints of faculty members and students in this regard. The results of this phase in five categories and 40 subcategories are presented in (Table 1).

Student Capabilities
According to the interviewees, student capabilities were an important indicator of effective-blended learning, which includes metacognitive skills like creativity, critical thinking, self-direction, etc., in addition to cognitive skills. According to participant number 10, "Blended learning requires personal maturity, critical thinking, creativity, and self-education." Moreover, one of the faculty members (participant number 7) said, Both the student and the teachers should have the minimum information and computer literacy. In addition, their personality is also a key determinant of developing a constructive interaction and effective learning.

Teacher Merits
Teacher merits were another category. Participant number 12 said "Our faculty members neither have the literacy in such areas nor are they familiar with ethics of this environment. So how can they deliver effective education?"

Technological Aspects
Another category that emerged in the qualitative phase was technological aspects, including the cyberspace and electronic content. Participant number 52 said, If the educational content isn't easy to access, high quality, and up-to-date, education will not be effective. Blended learning should develop with technological advances and the learning system should be a lovely environment.

Pedagogic Topics
Another category was pedagogic topics, which included the subcategories of team working, effective evaluation, organize content, etc. According to participant number 41, "Pedagogic topics are important in every teaching-learning process, and they are much greater importance in blended learning."

Supportive Environment
According to the participants, a supportive environment could enhance effective-blended learning. This means that, deeper connection and e-monitoring produce a Compatible environment that is interesting for the learners and instructors to embark on teaching and learning. Participant number 36 said "The students are entitled to educate in a tension-free environment with the maximum relationship with the instructor without discrimination and commotion."

Quantitative Phase Results
Normality of data was assessed by the Kolmogorov-Smirnov test and regarding the normal distribution of data, parametric tests were used. The total mean score of questionnaire for teachers was 148.4± 7.74 and for students was 164.1±9.68 that was significant. The results revealed that no significant difference in student capabilities and supportive environment between the viewpoints of students and faculty members while there were significant differences in other categories ( Table 2).
In the student's capabilities category, metacognitive skills were the most important factor related to blended learning according to faculty members (90%) and students (85.9%). In the category of teacher merits, the faculty members pointed to information literacy (90%) and the students cited content expertise (100%) as the most important subcategories. In the category of technological aspects, the interactive virtual environment was the most important determinant of effective-blended learning according to faculty members (90%) and students (92.3%). Faculty members (100%) and students (96.2%) believed that student progress monitoring was the most important  (Table 3).

Discussion
Blended learning encompasses different components. The results of a study entitled "the Arab union's E-learning Effectiveness evaluation framework" showed that a group of participants only emphasized technological aspects, another group-underlined pedagogic factors, and some participants focused on both. 25 In this study, five categories were identified for effective-blended learning, including students' capabilities, teacher merits, technological aspects, pedagogic aspects and supportive environment. The process of teaching-learning is a knowledge transfer from the teacher to the learner which both play an undeniable role. Information literacy and metacognitive skills were the most important subcategories of student capabilities. Other experimental studies have also shown that in this type of learning, the learner is self-directed and its effectiveness is increased due to control over the time and location of learning. 26,27 The results of some studies indicate that in blended learning, the students have more control over the speed and flow of learning and can achieve their objectives sooner through selecting proper resources and applying metacognitive processes like time management. 28 Moreover, it is important to consider satisfaction and values for measuring the effectiveness of any type of education. 29 In other words, the student satisfaction is associated with increased motivation and commitment to the E-learning program, resulting in educational success and decreased dropout rate. 30 We found that student knowledge is a determinant of effectiveness while there was no evidence of the role of attitude on effectiveness. On the other hand, it has been shown that counselling and teaching study and time management skills to students can enhance the effectiveness of this education system, which is almost consistent with the results indicating the role of metacognitive skills. 31 Instructors and teachers are the second part in the teaching-learning process that play a crucial role in effective learning. 32 Several studies confirm the results of present study. 33,34 Studies claim that the role of instructors in E-learning Stills more prominent than the new technologies. New technologies do not play an important role in student satisfaction. 35 It should be noted that a teacher should have special capabilities to leave a positive effect on the teaching-learning process. Content experience and virtual class management were two important subcategories of teacher merits. Adams believes that these merits improve learning significantly. In a study conducted in South Korea, the experience and expertise of the teachers and their knowledge of the cyberspace were identified as important aspects of the quality of online education. 36 Studies have shown that the teacher's attitude is also a determinant of failure or success because the teacher's beliefs are in close association with teaching behavior and learning objectives; 35 however, this finding was not observed in our study. Regarding technological aspects, several studies have shown a broad spectrum of factors related to blended learning. Evidence reported that in any electronic education, a flexible educational design and standard educational content have a direct effect on the effectiveness and efficiency. 37 However, quality problems regarding provision of education material and modifying and updating the courses are limitations of electronic education. 38 In this category, the subcategories of interactive virtual environment and virtual computing infrastructure had the highest frequency according to teachers and students. Electronic education required an interesting mutual interactive environment. 39 It is obvious that having the basic infrastructures and equipping it regularly along with technological advances are important determinants of quality. 40 Another category that emerged in this study was pedagogic topics, which forms the basis of any type of training. A review of the literature about pedagogy suggests that attention should be paid to the principles of Instructional Design, production of appropriate educational content, effective evaluation, and learning strategies, 41 which is consistent with the results of the present study. According to education experts, pedagogic topics and process evaluation complement each other. 42 However, in the present study, the research units believed that evaluation was less important than other factors, which could be due to the type of learners since they were all adults and practiced self-directed learning, so they did not consider evaluation as an important factor.
The present study showed the significance of virtual feedback system and student progress monitoring. Many researchers have also reported that feedback is an important component of blended learning skills. 43 Osguthorpe and Graham stated that the principle of blended learning was to improve areas such as pedagogy and interactions. 44 Providing prompt constructive feedback enhances the teacher-student cooperation and interaction. 45 The last category of effective education was supportive environment. Among its subcategories, strong guidance and e-monitoring have a greater importance. Bouras believes that in a virtual educational environment, educational objectives are not met if proper guidance is lacking. 46 The information era has created dynamic changes in relationships and the presence of education in this area required electronic mentoring. This finding is consistent with the results of other studies in this field. 47,48

Conclusion
The importance of "learning-teaching process" and the increasing demand for access to education on the one hand and emphasis on the effectiveness of education on the other hand are the challenges experienced by all educational organizations. Education used to be at information transfer level and expressing a series of facts as the necessary knowledge in the field of medical sciences. But in the world of exploding information how fast and to what extend can we really transfer facts with education? Although new technologies have offered promising opportunities, they do not result in effective education. The results of the present study suggest that a major revision in Student and instructor admission and provision of required technical facilities can promote the status of this type of education. On the other hand, instructor empowerment programs in this field can enhance the effectiveness of virtual education. Having a full knowledge of the factors influencing blended learning in medical sciences from the viewpoint of medical students, educational authorities can improve the environmental and organizational conditions to help medical students prevent Learning defects in order to take steps to improve the health of the community.

Data Sharing Statement
The datasets during the current study are not publicly available due to confidentiality of the students' data, but they will be available upon reasonable request.

Ethics and Consent Statement
Ethics approval was obtained from the Tehran University of Medical Sciences. Written informed consents were obtained from all participants.

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