Efficacy of Blended Learning Techniques in Medical and Dental Education: Students’ Opinions in Relation to Their Habits as Internet Consumers

Abstract

The success of blended learning programmes, based on digital tools, depends on several factors that significantly influence students’ performance, of which demographics (gender and age group) are the most common. Other factors play an important role too. Among these, we focused on the students’ general attitude towards the digital environment and the importance they attach to it in their daily activities. We investigated a sample of five hundred fifty-one students from four Medical Universities in Romania, mostly females (76.2%), from years 1 and 2 of study (63.7%) and aged between 18 and 20 years (53.9%), and we recorded their general opinion about the effectiveness of four types of teaching tools and the intensity of using Internet services in their daily activities. We conducted univariate (hypothesis testing) and multivariate (two-step clustering) analyses of the recorded responses, and we found that the students’ general behaviour as the users of Internet services significantly influences their choices for certain teaching tools over others. Students who prefer classic oral presentations and PowerPoint presentations are predominantly females, aged between 18 and 20, who use Internet services mainly for communication. Students who prefer educational videos are also mainly females, evenly distributed by age groups; they enjoy using multimedia resources during learning and use Internet services for communication, information or entertainment. Students who prefer the use of online documentary sources are evenly distributed by gender and are over 20 years of age; they also enjoy using multimedia resources during learning and use Internet services mainly for communication and information. The obtained results show that, to optimally combine the teaching tools used in blended learning, it is useful to assess in advance the attitude towards the digital environment of the students to whom it is addressed.

1. Introduction

At present, most subjects in medical education are predominantly based on traditional teaching techniques. These techniques are obviously valuable, their efficacy being proved by years and years of practice, but at present, they have to deal with new challenges. A great challenge is the technological advance, which has deeply changed the life of modern human beings. It has facilitated the work in many fields of activity and, more importantly, has radically changed the concept of information, the tools through which it is transmitted and the ways of access to it. Thus, a series of new tools for presenting and transmitting knowledge have emerged, and they can and must be integrated into modern education.

On the other hand, technological progress has entailed major changes in the conceptions and abilities of individuals in general and particularly the younger generation. The students of today are no longer the students of 10 years ago. Referred under the name of Generation Z, the youngest generation of students admitted to medical schools have particular brand new skills, directly related to the advances in technology. They are “digital natives”, familiar with technology since childhood, with advanced multitasking skills and avowed followers of independent and active visual, tactile and kinaesthetic learning techniques [1,2], based on practical activities and less on theoretical lectures [3,4].

These students find it natural to become informed, communicate and learn using IT-based tools that 10 years ago did not exist at all or were used only in scientific environments. Therefore, teaching methods must be adapted to their expectations; the traditional approach is no longer enough to keep them interested and stimulate their pleasure in learning. The solution, as proven by decades of research, is to change the learners’ role from passive to active [5] and to provide them with new learning tools, available due to technological advances.

1.1. General Background

The scientific literature reveals a major concern about current educational challenges and possibilities for improvement, investigating the potential for using blended learning techniques. Objective data about the efficacy of such techniques encourage universities and course coordinators to consider autonomous learning and to create the appropriate institutional framework in which blended learning techniques can be incorporated into the curricula of medical faculties [6].

Blended learning mixes different learning styles and environments, combining the traditional classroom with modern computer-assisted and multimedia methods [7,8]. Therefore, these techniques allow for improved collaboration, flexibility, interest and mobility of students [9,10]. They combine face-to-face and online teaching and learning activities, both synchronous (real-time) and asynchronous (taking place at different locations and times for each participant) [11,12].

Standard components [13] of a blended learning system include e-learning systems (teaching/learning based on the use of computers), computer-based training (through digital multimedia learning programmes), web-based training (continuing education courses via the Internet), content management system (CMS)/learning management system (LMS)/learning platforms/learning content management system (LCMS) (software applications installed on a web server supporting the delivery and use of learning materials and tools for online cooperation and user administration—e-teaching.org), video conferencing systems, massive open online courses (MOOCs) and so on.

The implementation of blended learning techniques accelerated during the COVID-19 pandemic period. There are different strategies to facilitate the transition from traditional face-to-face learning to online instruction, one example being the DLCPA strategy based on the integration of five components: discover, learn, practice, collaborate, assess [14]. This strategy, developed in the pandemic context, has generally had a positive impact on students and teachers, the difficulties reported being primarily technical (stability of the Internet connection) or subjective (lack of experience of teachers in using videoconferencing systems). Most students were satisfied with the DLCPA strategy, as were the teachers, who declared their willingness to learn how to use such tools and appreciated their ability to improve interaction with students.

The scientific literature offers many successful examples of blended learning programmes implemented in different areas of the medical curricula; their analysis highlights the main features to be fulfilled by such attempts, as well as the possible difficulties and drawbacks.

The most relevant example of the effectiveness of blended learning techniques in teaching preclinical subjects is anatomy. In this case, studies usually report high levels of satisfaction and engagement, improved self-assessment skills and better student outcomes than in conventionally taught courses [15]. The success, consisting in good perceptions of the students about blended learning and good outcomes at the exams, is obtained by emphasizing the value of student interaction in the online environment [16] and by adapting the online teaching to the feedback received and to the real learning needs of students [17].

Similar results, expressed through a significant increase in the theoretical and practical knowledge of students due to blended learning techniques, were reported in other medical specialties as well: anaesthesia [18], orthopaedics [19], family medicine [20], pedodontics [21], pharmacology [22,23], radiology [24,25,26], first aid courses [27], advanced endoscopy, emergency urology, emergency gynaecology, facial plastic surgery, ultrasound and finger amputation management [28], nursing [29,30], drug safety [17], dental medicine [6], trauma and military medicine [31], and the list goes on.

The students who followed blended learning programmes obtained better results in all types of exams compared with those who followed traditional programmes. They have improved skills in problem solving, critical thinking and decision making and are better in solving clinical scenarios or case scenarios [20,32,33]. They acquire better clinical judgement skills, highly demanded in medical practice [34]. Similar results are reported in the case of post-graduate programmes as well [28]; therefore, the participants’ age does not affect the efficacy of blended learning programmes.

In a systematic review, Coyne et al. [35] identified the basic attributes that contribute to the development of an effective blended learning model applicable to any medical field: the connection between theory and practice and learning autonomy. Blended learning techniques allow the use of different learning styles and repeated viewing of educational materials, improving the level of theoretical knowledge and practical skills, and are preferred by students over classic oral presentations because of their flexibility.

There are studies regarding the efficacy of almost all didactic tools involved in blended learning approaches. Some authors [22] combined e-learning courses with clinical presentation stages of structured clinical examinations of real patients and active learning techniques, as team-based learning and game-based learning [23], and reported positive feedback from students. The active learning practices were also explored in association with the delivery of course material [36], and it was concluded that the students use more frequently such learning strategies when watching lectures in real time then in the case when they receive pre-recorded course materials. Gamification-based blended learning strategies are more effective than face-to-face learning [37], being associated with increased engagement, team communication and responsibility, as well as reduced fatigue and stress. The benefits of video sequences with integrated explanatory comments in demonstrating standard clinical procedures are also agreed to by the students, who prefer to use them individually but in combination with patient demonstrations and presentation of standardised clinical examination protocols [21,26]. Long video segments are contraindicated, and technical issues should be avoided. Shorey et al. [30] developed a learning environment based on role-play exercises and highlighted the importance of effective communication skills. A similar approach was used by Hinneburg et al. [33]; they reported instead that role-play exercises were not enough for understanding the relevant topics and accompanied them by a theoretical introduction based on statistical elements for the preparation of the tasks.

Difficulties or neutral results are reported as well. Among these, we can mention the following: difficulties in adapting to blended learning techniques for students accustomed to traditional teaching [38] or with insufficient self-directed learning skills [39] (can be solved by organizing special training sessions), poor performance in improving the patient counselling skills [40], limited time available for preparation of teaching materials [31], lack of multidisciplinary team-based training [31] and high costs of delivery (can be reduced as such tools are widely implemented) [27].

It is obvious that designing successfully blended learning programmes is not an easy task. The integration of technology is a necessity but must be carefully planned to ensure an optimal, efficient and safe learning environment for students [1]. If implemented haphazardly, the transition of university education to blended learning techniques can undermine teachers’ confidence in such approach, limit academic freedom and lead to a lack of alignment of objectives between the different managerial levels of the university when administrative structures are not prepared for crisis situations [41]. From an institutional perspective, it is necessary to introduce changes in current government policies to readjust standards and requirements and adapt them to dynamically changing educational environments [39].

1.2. Our Research

In this context, the present study proposes a deeper investigation of the success chances of blended learning programmes for medicine and dental medicine students and their influencing factors.

Most of the papers mentioned above obtained the reported conclusions regarding the success features of blended learning programmes through quantitative studies in which the results of interviews taken from students on with what they agree and with what they do not agree in these methods are analysed comparatively to traditional teaching methods. The results are usually reported at the level of the entire group of students and separately on their demographic characteristics (genders and age groups) and are eventually accompanied by the comparative study of the results obtained at exams after attending traditional teaching programmes and modern blended learning programmes.

We diversified the analysed teaching tools involved in blended learning programmes, by choosing four of them instead of two (similar to most other authors): classic oral presentations, PowerPoint presentations, educational videos and online documentary sources. The novelty and the strength of our approach consists in the analysis we carried out, which is also significantly refined. We started by comparing the students answers according to their demographic features (gender and age group), but we deepened the analysis by taking into consideration another features too, not investigated so far in the literature (according to our knowledge): the students’ general behaviour as users of digital technologies and Internet services. We chose this multivariate approach because the success of a blended learning programme based on digital tools depends not only on the demographic characteristics of the students to whom it is addressed but should also be significantly influenced by their psychological background and, particularly, by their attitude towards the digital environment and the importance they attach to it in their daily activities, not necessarily related to learning. A learner who generally accepts digital resources and finds them useful not only for entertainment but also for making various daily activities quicker or easier should naturally also accept the blended learning style which, although at first glance may seem more impersonal, places the emphasis on autonomy, flexibility and empowerment. The results we obtained are useful for any teacher interested in switching its didactic programme to a blended approach, allowing him or her to understand better the reasons for which such an initiative can lead to a success or failure, according to the behavioural habits of the targeted students.

2. Materials and Methods

Participants: In order to obtain a representative sample, we invited in this study students at Medicine and Dental Medicine from all main Romanian Universities and all years of study. They are the target beneficiaries of educational strategies, and it is important to know their opinions about different teaching tools and to understand the objective reasons which lead them to such opinions. Such knowledge is mandatory to customize efficiently the teaching process in order to make it more suitable to the students’ real needs and expectations and to help them to learn easier and better. We managed to collect the opinions of five hundred fifty-one students at Dental Medicine or General Medicine, belonging to all years of study, from four main Universities in Romania (Iasi, Craiova, Timisoara and Cluj-Napoca). The sample size is satisfying, because it was validated according to the formula for a finite population, where the margin of error is 5%, the confidence level is 95%, and the population size equals 63,216 of Romanian students enrolled in 2020–2021 at Faculties of Health and Social Assistance. Based on the sample size calculation, our study required a minimum of 382 participants.

Data collection: Students were invited to complete anonymously online a 17-item questionnaire in which they expressed their general opinion on the usefulness of using multimedia resources in the learning process and their comparative views regarding specific features of four types of instructional materials used in university education: classic oral presentations, PowerPoint presentations, educational videos and online documentary sources (Appendix A). The features surveyed and quantified for each teaching tool were efficacy (utility, value and completeness), scientific rigor, capacity for synthesis, clarity and ability to arouse the interest. The questionnaire was presented and explained separately to each subject, along with the research goals. The students were asked to specify their level of agreement for each item on a 5-unit Likert scale (1 = total disagreement, 5 = total agreement); responses were centralised by calculating overall agreement scores for each of the investigated teaching tools (RMT = agreement score for the classic oral presentations, RMP = agreement score for the PowerPoint presentations, RMF = agreement score for the educational videos and RMO = agreement score for the online documentary sources). Furthermore, in order to characterise the extent to which students generally agree to use digital resources, they were proposed four distinct categories of activities that can be carried out using Internet services (information, communication, entertainment and domestic facilities), which they were asked to rank in order of preference (Appendix A).

Questionnaire: The questionnaire was adapted and developed starting from the models already existent in the scientific literature [42,43,44,45]. Its validity and reliability were assessed using several methods (expert opinion, item analysis, Kaiser–Meyer–Olkin coefficient, Bartlett test and factor analysis); the Cronbach’s alpha reliability coefficients were 0.970 (the items concerning classic oral presentations), 0.955 (the items concerning PowerPoint presentations), 0.959 (the items concerning educational videos) and 0.965 (the items concerning domestic facilities). On these bases, the questionnaire was considered suitable for being applied in our study.

Variables: The study’s variables were the students’ answers to the questionnaire and their agreement scores for the 4 teaching tools investigated, which were analysed comparatively by gender, age group and preference for using Internet services.

Statistical analysis: The data from the questionnaire were recorded in a data file in SPSS 29.0 (SPSS Inc., Chicago, IL, USA) for Windows. The answers to each item were characterized through frequency distributions and contingency tables. The numerical variables were characterized through descriptive statistics (mean, standard deviation, range and median). The comparisons between samples were performed using the chi-squared test for categorical data and the Mann–Whitney and Kruskal–Wallis tests for quantitative data, according to the results of Shapiro–Wilks tests of normality. We considered the p ≤ 0.05 value as statistically significant (*) and the p ≤ 0.01 value as statistically highly significant (**). In order to investigate the internal connections between the items used to characterize the four didactic tools, we used two-step clustering; the number of clusters was calculated automatically, using the Schwarz’s Bayesian criterion (BIC) and a maximal limit of 15 clusters.

Ethical statement: Participation in our study was voluntary. The subjects were informed about this study and the content of the questionnaire, and they agreed to provide the informed consent. The questionnaires were filled anonymously in order to protect the subjects’ intimacy and obtain objective answers as much as possible. This study was approved by the Ethical Committee of “Grigore T. Popa” University of Medicine and Pharmacy of Iasi, Romania (decision no. 21/16.11.2020).

3. Results

Three-quarters of the students are females (76.2%); most of them are in years 1 and 2 of study (63.7%) and are aged between 18 and 20 years (53.9%), with a mean age of 21.78 ± 3.736 years. Students who have no previous higher education account for 90%, and about one-third come from families where at least one parent has a higher education. The general characteristics of the group are presented in

Table 1. General characteristics of the study group.

		n	%
Sex	male	131	23.8
	female	420	76.2
Age group	18–20 years	297	53.9
	21–24 years	158	28.7
	over 25 years	96	17.4
University	UMF “Grigore T. Popa”, Iași	356	64.6
	UMF, Craiova	108	19.6
	UMF ”Victor Babeș”, Timișoara	80	14.5
	UMF ”Iuliu Hațieganu”, Cluj Napoca	7	1.3
Previously graduated from university studies	yes	55	10.0
	no	496	90.0
Parents’ level of education	University	232	42.1
	High school	298	54.1
	Pre-high school	21	3.8
Total		551	100.0

.

3.1. Students’ Opinions towards the 4 Teaching Tools—Univariate Analysis

The analysis of the students’ opinion scores on the four teaching tools, compared according to the proposed criteria, shows the following (

Table 2. Opinion scores for the 4 teaching tools—univariate analysis.

	RMT m ± SD	RMP m ± SD	RMF m ± SD	RMO m ± SD
Sex
Male	3.81 ± 1.047	3.27 ± 0.880	3.49 ± 0.984	3.37 ± 0.995
Female	4.09 ± 0.853	3.47 ± 0.809	3.63 ± 0.851	3.30 ± 0.923
	p = 0.010 *†	p = 0.022 *†	p = 0.121 †	p = 0.567 †
Age group
18–20 years	4.16 ± 0.840	3.45 ± 0.828	3.49 ± 0.892	3.16 ± 0.956
21–24 years	3.84 ± 0.973	3.34 ± 0.888	3.67 ± 0.865	3.38 ± 0.887
over 25 years	3.91 ± 0.951	3.46 ± 0.730	3.84 ± 0.849	3.71 ± 0.859
	p = 0.001 **‡	p = 0.357 ‡	p = 0.002 **‡	p = 0.000 **‡
Use the Internet mainly for information:
The least important	3.66 ± 1.221	3.36 ± 0.974	3.59 ± 0.880	3.37 ± 1.012
Slightly important	4.17 ± 0.743	3.37 ± 0.897	3.47 ± 0.928	3.13 ± 0.960
Important	4.02 ± 0.871	3.32 ± 0.779	3.51 ± 0.874	3.14 ± 0.889
Most important	3.95 ± 1.016	3.57 ± 0.802	3.81 ± 0.835	3.67 ± 0.882
	p = 0.329 ‡	p = 0.031 *‡	p = 0.003 **‡	p = 0.000 **‡
Use the Internet mainly for communication:
The least important	4.60 ± 0.659	3.34 ± 0.889	3.21 ± 1.030	2.91 ± 1.308
Slightly important	3.56 ± 1.076	3.30 ± 0.902	3.45 ± 0.975	3.18 ± 0.972
Important	3.88 ± 0.937	3.36 ± 0.807	3.62 ± 0.889	3.41 ± 0.975
Most important	4.16 ± 0.832	3.47 ± 0.826	3.62 ± 0.866	3.31 ± 0.911
	p = 0.000 **‡	p = 0.248 ‡	p = 0.408 ‡	p = 0.324 ‡
Use the Internet mainly for entertainment:
The least important	4.07 ± 0.799	3.47 ± 0.688	3.62 ± 0.779	3.42 ± 0.819
Slightly important	4.00 ± 0.969	3.38 ± 0.865	3.70 ± 0.845	3.36 ± 0.965
Important	4.09 ± 0.801	3.38 ± 0.839	3.45 ± 0.934	3.13 ± 0.902
Most important	3.96 ± 0.987	3.48 ± 0.817	3.67 ± 0.871	3.47 ± 0.953
	p = 0.873 ‡	p = 0.691 ‡	p = 0.053 ‡	p = 0.009 **‡
Use the Internet mainly for domestic facilities:
The least important	4.06 ± 0.857	3.39 ± 0.895	3.60 ± 0.928	3.21 ± 1.002
Slightly important	4.10 ± 0.846	3.33 ± 0.739	3.46 ± 0.857	3.29 ± 0.860
Important	3.86 ± 1.026	3.53 ± 0.725	3.68 ± 0.777	3.52 ± 0.813
Most important	3.78 ± 1.181	3.75 ± 0.794	3.98 ± 0.795	3.79 ± 0.840
	p = 0.277 ‡	p = 0.028 *‡	p = 0.009 **‡	p = 0.000 **‡

^† Mann–Whitney test; ^‡ Kruskal–Wallis test; * p < 0.05 statistically significant; ** p < 0.01 statistically highly significant.

, Figure 1):

The gender comparative study of the questionnaire responses shows that females agree to a large extent with the benefits of classic oral presentations, with a significantly higher score than males (p = 0.010), and also with the benefits of PowerPoint presentations, while males agree only to a medium extent with the latter tool (p = 0.022). Females also tend to agree significantly more than males with the benefits of educational videos, while males agree slightly more with the benefits of online documentary sources.

Students’ opinions about the qualities of investigated teaching tools are statistically significant different between the three age groups identified. Students aged 18–20 years prefer classic oral presentations first, followed by educational videos, PowerPoint presentations and lastly online documentary sources. The order shifts slightly in the other age groups—students aged 21–24, but also those over 25, rank classic oral presentations and educational videos first, followed by online documentary sources and PowerPoint presentations last.

Unlike other studies, we refined our analysis by investigating other criteria too and providing additional results.

Learners who use the Internet mainly for information agree almost equally with the benefits of all four blended learning tools. The average agreement score recorded for classic oral presentations is comparable to the similar scores observed for students who are not very interested in Internet information. The average agreement scores for PowerPoint presentations, educational videos and online documentary sources are significantly higher than the scores recorded for the other categories of students who are not very interested in Internet information.

Students who use the Internet mainly for communication are most likely to agree only with the benefits of classic oral presentations and educational videos, the other two tools being only moderately acceptable. Classic oral presentations have the average agreement score significantly higher than the scores observed for students who rank Internet communication the second and third, but lower than that of students who rank communication last in the top preferences. The average agreement scores for PowerPoint presentations, educational videos and online documentary sources are not significantly different from the scores calculated for students who are not very interested in Internet communication services.

Students who use the Internet mainly for entertainment largely agree with the benefits of classic oral presentations and educational videos, and to a lesser extent with the benefits of the other two tools. The average agreement score for online documentary sources is the only one significantly higher than that for students who rank Internet entertainment in the second and third places, being similar to the score observed for students who rank Internet entertainment the last.

Students who use the Internet mainly for domestic facilities largely agree with the benefits of all four proposed blended learning tools. Classic oral presentations have a lower average agreement score but not statistically significant compared to the similar scores observed for students who do not use the Internet for domestic facilities. The average agreement scores for PowerPoint presentations, educational videos and online documentary sources are all significantly higher than for students who do not use the Internet for domestic facilities.

3.2. Students’ Opinions towards the Four Teaching Tools—Multivariate Analysis

We performed the classification of the questionnaire items (the 16 items evaluating the benefits of the four blended learning tools), using the two-step clustering technique, in order to identify the significant predictors among them and their internal connections.

The evaluation of the classic oral presentations according to the sixteen items led to the identification of three clusters, the largest one covering 41.0% of the students, the next 37.9%, and the smallest 21.1%. The most important predictor among the 16 items investigated was item 15a: Methods that best help to understand the concepts presented (predictor importance PI = 1.00), followed by item 9a: Clearest way of explaining concepts (PI = 0.98), item 7a: Methods that provide essential information (PI = 0.95), item 14a: Methods that stimulate interest best (PI = 0.95), item 13a: Methods that capture attention best (PI = 0.95), item 16a: Methods that make it easier to learn the concepts presented (PI = 0.92), item 8a: Methods that provide the most accurate information (PI = 0.85) and item 3a: Most useful methods (PI = 0.80); the other items had importance coefficients PI < 0.80.

The first cluster identified comprises 37.9% of the students, who strongly agree with the advantages of classic oral presentations. The second cluster (41.0% of cases) contains students who agree to a medium to high extent with the advantages of these methods, and the third and smallest cluster (21.1%) contains students with unfavourable opinions, who agree only to a low to medium extent with the advantages of these methods.

The evaluation of PowerPoint presentations according to the sixteen items in the survey led to the identification of four clusters, the largest of which covered 37.4% of students, and the smallest 14.5% of students. The most important predictor among the 16 investigated was also item 15b: Methods that best help to understand the concepts presented (predictor importance PI = 1.00), followed by item 13b: Methods that capture attention best (PI = 0.90), item 14b: Methods that stimulate interest best (PI = 0.86), item 16b: Methods that make it easier to learn the concepts presented (PI = 0.86) and item 9b: Clearest way of explaining concepts (PI = 0.83); the other items had importance coefficients PI < 0.80.

The first cluster identified (25.6% of cases) contains the students with the most favourable opinions—who overwhelmingly agree with the benefits of PowerPoint presentations. The second, smaller, cluster (14.5% of cases) contains students who agree to a large extent with the advantages of these methods. The third cluster (37.4% of cases) contains students who agree to a medium extent, and the fourth cluster (22.5% of cases) contains students who agree only to a small extent with the advantages of PowerPoint presentations.

The evaluation of the educational videos according to the sixteen items led to the identification of four clusters, two larger ones, each comprising about one-third of the students, and two smaller ones. The most important predictor among the 16 investigated was also item 15c: Methods that best help to understand the concepts presented (importance of predictor PI = 1.00), followed by item 6c: Methods that provide the most expert knowledge (PI = 0.86), item 16c: Methods that make it easier to learn the concepts presented (PI = 0.83) and item 7c: Methods that provide essential information (PI = 0.80); the other items had importance coefficients PI < 0.80.

The first cluster identified (32.1% of cases) contains students who strongly agree with the benefits of educational videos. The second cluster (18.7% of cases) contains students who agree to a high extent with the advantages of educational videos. The third cluster, comparable in size to the first (33.6%), contains students who agree to a medium extent with the advantages of educational videos, and the last cluster (15.6% of cases) contains students with unfavourable opinions, who agree only to a low extent with the advantages of educational videos.

The evaluation of online documentary sources according to the sixteen items led to the identification of two clusters of approximately equal sizes. The most important predictor among the 16 items investigated was item 7d: Methods that provide essential information (predictor importance PI = 1.00), followed by item 6d: Methods that provide most expert knowledge (PI = 0.93), item 12d: Most complete way of explaining concepts (PI = 0.90), item 15d: Methods that best help to understand the concepts presented (PI = 0.90), item 4d: Most valuable methods (PI = 0.89), item 3d: Most useful methods (PI = 0.85), item 9d: Clearest way of explaining concepts (PI = 0.84), item 8d: Methods that provide the most accurate information (PI = 0.83) and item 11d: Most detailed way of explaining concepts (PI = 0.83); the other items had importance coefficients PI < 0.80.

The first cluster identified (53.5% of cases) contains students who agree with the advantages of online documentary sources to a great or very great extent. The second cluster (46.5%) contains students who agree only to a small or medium extent with their benefits.

In the next step of our analysis, we characterized in depth the previously identified clusters according to the criteria we initially established: gender, age group, opinions about the autonomous use of multimedia resources in the learning process and general preferences for using the four categories of Internet services we defined. The obtained results are presented in

Table 3. Comparative study of clusters identified for advantages of classic oral presentations.

General Idea: Classic Oral Presentations Help Best to Understand the Concepts Presented, Being a Clear Way of Explanation, Providing Essential Information, Stimulating Interest and Capturing Attention Best, Helping to Make Learning Easier, Providing the Most Correct Information and Therefore Being the Most Useful.
		Cluster 1—agreement to a very high extent n (%)	Cluster 2—agreement to a high and average extent n (%)	Cluster 3—agreement to a low to average extent n (%)	p-value
Sex					0.035 *
	Male	40 (19.1)	54 (23.9)	37 (31.9)
	Female	169 (80.9)	172 (76.1)	79 (68.1)
Age group					0.018 *
	18–20 years	129 (61.7)	119 (52.7)	49 (42.2)
	21–24 years	48 (23.0)	68 (30.1)	42 (36.2)
	over 25 years	32 (15.3)	39 (17.3)	25 (21.6)
Level of openness to autonomous use of multimedia resources in learning:					0.000 **
	1—total disagreement	16 (7.7)	3 (1.3)	1 (0.9)
	2—partial disagreement	53 (25.4)	19 (8.4)	11 (9.5)
	3—neutral	85 (40.7)	97 (42.9)	39 (33.6)
	4—partial agreement	30 (14.4)	61 (27.0)	25 (21.6)
	5—total agreement	25 (12.0)	46 (20.4)	40 (34.5)
Internet services mainly used for information (on a scale of 1 to 4):					0.378
	1—most important	71 (34.0)	68 (30.1)	41 (35.3)
	2—important	78 (37.3)	87 (38.5)	49 (42.2)
	3—less important	54 (25.8)	64 (28.3)	20 (17.2)
	4—least important	6 (2.9)	7 (3.1)	6 (5.2)
Internet services mainly used for communication (on a scale of 1 to 4):					0.000 **
	1—most important	145 (69.4)	136 (60.2)	53 (45.7)
	2—important	50 (23.9)	64 (28.3)	40 (34.5)
	3—less important	10 (4.8)	25 (11.1)	23 (19.8)
	4—least important	4 (1.9)	1 (0.4)	-
Internet services mainly used for entertainment (on a scale of 1 to 4):					0.542
	1—most important	70 (33.5)	68 (30.1)	45 (38.8)
	2—important	71 (34.0)	86 (38.1)	33 (28.4)
	3—less important	53 (25.4)	61 (27.0)	30 (25.9)
	4—least important	15 (7.2)	11 (4.9)	8 (6.9)
Internet services mainly used for domestic facilities (on a scale of 1 to 4):					0.021 *
	1—most important	12 (5.7)	12 (5.3)	11 (9.5)
	2—important	32 (15.3)	31 (13.7)	26 (22.4)
	3—less important	66 (31.6)	49 (21.7)	28 (24.1)
	4—least important	99 (47.4)	134 (59.3)	51 (44.0)
Total		209 (100.0)	226 (100.0)	116 (100.0)

Pearson’s chi-squared test; * p < 0.05 statistically significant; ** p < 0.01 highly statistically significant.

,

Table 4. Comparative study of clusters identified for the benefits of PowerPoint presentations.

General Idea: PowerPoint Presentations Best Help to Understand the Concepts Presented, Capture Attention and Stimulate Interest Best, Helping to Make Learning Easier and Being the Clearest Way to Explain Concepts.
		Cluster 1—agreement to a very high extent n (%)	Cluster 2—agreement to a high extent n (%)	Cluster 3—agreement to an average extent n (%)	Cluster 4—agreement to a low extent n (%)	p-value
Sex						0.071
	Male	27 (19.1)	19 (23.8)	45 (21.8)	40 (32.3)
	Female	114 (80.9)	61 (76.3)	161 (78.2)	84 (67.7)
Age group						0.090
	18–20 years	83 (58.9)	35 (43.8)	117 (56.8)	62 (50.0)
	21–24 years	38 (27.0)	24 (30.0)	52 (25.2)	44 (35.5)
	over 25 years	20 (14.2)	21 (26.3)	37 (18.0)	18 (14.5)
Level of openness to autonomous use of multimedia resources in learning:						0.000 **
	1—total disagreement	6 (4.3)	3 (3.8)	6 (2.9)	5 (4.0)
	2—partial disagreement	21 (14.9)	5 (6.3)	33 (16.0)	24 (19.4)
	3—neutral	35 (24.8)	38 (47.5)	93 (45.1)	55 (44.4)
	4—partial agreement	29 (20.6)	23 (28.7)	38 (18.4)	26 (21.0)
	5—total agreement	50 (35.5)	11 (13.8)	36 (17.5)	14 (11.3)
Internet services mainly used for information (on a scale of 1 to 4):						0.201
	1—most important	53 (37.6)	30 (37.5)	68 (33.0)	29 (23.4)
	2—important	45 (31.9)	32 (40.0)	86 (41.7)	51 (41.1)
	3—less important	37 (26.2)	17 (21.3)	46 (22.3)	38 (30.6)
	4—least important	6 (4.3)	1 (1.3)	6 (2.9)	6 (4.8)
Internet services mainly used for communication (on a scale of 1 to 4):						0.355
	1—most important	94 (66.7)	47 (58.8)	128 (62.1)	65 (52.4)
	2—important	31 (22.0)	27 (33.8)	55 (26.7)	41 (33.1)
	3—less important	14 (9.9)	5 (6.3)	22 (10.7)	17 (13.7)
	4—least important	2 (1.4)	1 (1.3)	1 (0.5)	1 (0.8)
Internet services mainly used for entertainment (on a scale of 1 to 4):						0.381
	1—most important	54 (38.3)	24 (30.0)	71 (34.5)	34 (27.4)
	2—important	47 (33.3)	24 (30.0)	75 (36.4)	44 (35.5)
	3—less important	33 (23.4)	28 (35.0)	45 (21.8)	38 (30.6)
	4—least important	7 (5.0)	4 (5.0)	15 (7.3)	8 (6.5)
Internet services mainly used for domestic facilities (on a scale of 1 to 4):						0.000 **
	1—most important	13 (9.2)	6 (7.5)	14 (6.8)	2 (1.6)
	2—important	20 (14.2)	19 (23.8)	39 (18.9)	11 (8.9)
	3—less important	27 (19.1)	19 (23.8)	66 (32.0)	31 (25.0)
	4—least important	81 (57.4)	36 (45.0)	87 (42.2)	80 (64.5)
Total		141 (100.0)	80 (100.0)	206 (100.0)	124 (100.0)

Pearson’s chi-squared test; ** p < 0.01 highly statistically significant.

,

Table 5. Comparative study of clusters identified for the benefits of educational videos.

General Idea: Educational Videos Best Help to Understand the Concepts Presented and Provide the most Background Knowledge, Making Learning Easier and Providing Essential Information.
		Cluster 1—agreement to a very high extent n (%)	Cluster 2—agreement to a high extent n (%)	Cluster 3—agreement to an average extent n (%)	Cluster 4—agreement to a low extent n (%)	p-value
Sex						0.656
	Male	40 (22.6)	23 (22.3)	43 (23.2)	25 (29.1)
	Female	137 (77.4)	80 (77.7)	142 (76.8)	61 (70.9)
Age group						0.054
	18–20 years	91 (51.4)	43 (41.7)	111 (60.0)	52 (60.5)
	21–24 years	50 (28.2)	38 (36.9)	46 (24.9)	24 (27.9)
	over 25 years	36 (20.3)	22 (21.4)	28 (15.1)	10 (11.6)
Level of openness to autonomous use of multimedia resources in learning:						0.000 **
	1—total disagreement	8 (4.5)	-	7 (3.8)	5 (5.8)
	2—partial disagreement	10 (5.6)	18 (17.5)	32 (17.3)	23 (26.7)
	3—neutral	53 (29.9)	47 (45.6)	83 (44.9)	38 (44.2)
	4—partial agreement	39 (22.0)	30 (29.1)	38 (20.5)	9 (10.5)
	5—total agreement	67 (37.9)	8 (7.8)	25 (13.5)	11 (12.8)
Internet services mainly used for information (on a scale of 1 to 4):						0.075
	1—most important	75 (42.4)	32 (31.1)	50 (27.0)	23 (26.7)
	2—important	55 (31.1)	43 (41.7)	84 (45.4)	32 (37.2)
	3—less important	42 (23.7)	24 (23.3)	44 (23.8)	28 (32.6)
	4—least important	5 (2.8)	4 (3.9)	7 (3.8)	3 (3.5)
Internet services mainly used for communication (on a scale of 1 to 4):						0.481
	1—most important	107 (60.5)	63 (61.2)	115 (62.2)	49 (57.0)
	2—important	54 (30.5)	25 (24.3)	52 (28.1)	23 (26.7)
	3—less important	15 (8.5)	15 (14.6)	15 (8.1)	13 (15.1)
	4—least important	1 (0.6)	-	3 (1.6)	1 (1.2)
Internet services mainly used for entertainment (on a scale of 1 to 4):						0.395
	1—most important	68 (38.4)	29 (28.2)	62 (33.5)	24 (27.9)
	2—important	50 (28.2)	35 (34.0)	68 (36.8)	37 (43.0)
	3—less important	47 (26.6)	32 (31.1)	46 (24.9)	19 (22.1)
	4—least important	12 (6.8)	7 (6.8)	9 (4.9)	6 (7.0)
Internet services mainly used for domestic facilities (on a scale of 1 to 4):						0.072
	1—most important	17 (9.6)	6 (5.8)	9 (4.9)	3 (3.5)
	2—important	27 (15.3)	17 (16.5)	34 (18.4)	11 (12.8)
	3—less important	32 (18.1)	26 (25.2)	58 (31.4)	27 (31.4)
	4—least important	101 (57.1)	54 (52.4)	84 (45.4)	45 (52.3)
Total		177 (100.0)	103 (100.0)	185 (100.0)	86 (100.0)

Pearson’s chi-squared test; ** p < 0.01 highly statistically significant.

and

Table 6. Comparative study of clusters identified for the benefits of online documentary sources.

General Idea: Online Documentary Sources Provide Essential Information and the Most Expert Knowledge, Being the Most Complete Way of Explaining Notions, Which Best Helps to Understand Them, Being a Valuable, Useful, Clear Method, Providing the Most Accurate and Detailed Information.
		Cluster 1—agreement to a high or very high extent n (%)	Cluster 2—agreement to a low or average extentn (%)	p-value
Sex				0.862
	Male	71 (24.1)	60 (23.4)
	Female	224 (75.9)	196 (76.6)
Age group				0.000 **
	18–20 years	138 (46.8)	159 (62.1)
	21–24 years	91 (30.8)	67 (26.2)
	over 25 years	66 (22.4)	30 (11.7)
Level of openness to autonomous use of multimedia resources in learning:				0.000 **
	1—total disagreement	4 (1.4)	16 (6.3)
	2—partial disagreement	24 (8.1)	59 (23.0)
	3—neutral	99 (33.6)	122 (47.7)
	4—partial agreement	77 (26.1)	39 (15.2)
	5—total agreement	91 (30.8)	20 (7.8)
Internet services mainly used for information (on a scale of 1 to 4):				0.000 **
	1—most important	125 (42.4)	55 (21.5)
	2—important	93 (31.5)	121 (47.3)
	3—less important	67 (22.7)	71 (27.7)
	4—least important	10 (3.4)	9 (3.5)
Internet services mainly used for communication (on a scale of 1 to 4):				0.199
	1—most important	179 (60.7)	155 (60.5)
	2—important	89 (30.2)	65 (25.4)
	3—less important	24 (8.1)	34 (13.3)
	4—least important	3 (1.0)	2 (0.8)
Internet services mainly used for entertainment (on a scale of 1 to 4):				0.101
	1—most important	102 (34.6)	81 (31.6)
	2—important	90 (30.5)	100 (39.1)
	3—less important	80 (27.1)	64 (25.0)
	4—least important	23 (7.8)	11 (4.3)
Internet services mainly used for domestic facilities (on a scale of 1 to 4)):				0.065
	1—most important	24 (8.1)	11 (4.3)
	2—important	55 (18.6)	34 (13.3)
	3—less important	74 (25.1)	69 (27.0)
	4—least important	142 (48.1)	142 (55.5)
Total		295 (100.0)	256 (100.0)

Pearson’s chi-squared test; ** p < 0.01 highly statistically significant.

and actually highlight the intrinsic reasons for which the students make their choices of one teaching tool over the others.

3.2.1. In-Depth Analysis of Clusters Obtained for Classic Oral Presentations

Statistically significant differences are found in the cluster structure separating students according to their opinions on the advantages of classic oral presentations. Students who strongly agree with the advantages of these methods are mainly females, aged between 18 and 20, and partially disagree with the advantages of the use of multimedia resources in the learning process. Most of them use Internet services mainly for communication, one-third of them use such services for information or entertainment, and only a few of them use the Internet for domestic facilities. A higher proportion of students who agree only to a small to medium extent with the advantages of classic oral presentations are instead males, over 20 years old, who agree with the advantages of the use of multimedia resources in the learning process; slightly higher proportions of them use Internet services mainly for information, entertainment or domestic facilities. Statistically significant differences between the three identified clusters are reported in terms of their gender structure, age groups, degree of using multimedia resources in the learning process and opinions on using Internet services mainly for communication and domestic facilities (Table 3).

3.2.2. In-Depth Analysis of Clusters Obtained for PowerPoint Presentations

Students who strongly agree with the benefits of PowerPoint presentations are also predominantly females and young (aged 18–20), who enjoy using multimedia resources in the learning process. Most of them use Internet services mainly for communication; again, one-third of them use such services mainly for entertainment or information, and almost 10% use the Internet for domestic facilities. Students who agree to a moderate extent with the benefits of PowerPoint presentations are also mostly females, aged 18–20, but only a third of them use multimedia resources for learning. Most of them use Internet services mainly for communication, followed by entertainment, information and domestic facilities sporadically. The percentage of males among the students who like PowerPoint presentations to a lesser extent is increasing, and the age structure is perfectly balanced. They do not enjoy very much using multimedia resources in the learning process; just over half of them use Internet services mainly for communication, about a quarter of them use the Internet for entertainment or information, while domestic facilities are solved through the Internet only in very isolated cases. Statistically significant differences are found only in the degree of using multimedia resources autonomously in the learning process, which decreases as the level of agreement for PowerPoint presentations decreases, and in the use of Internet services for domestic facilities, which varies in the same way (Table 4).

3.2.3. In Depth Analysis of Clusters Obtained for Educational Videos

Students who strongly agree with the benefits of educational videos are more than three-quarters females, evenly distributed by age group, and who enjoy using multimedia resources in the learning process. The main purpose for which Internet services are used is still communication, but a high percentage of students also uses these services for information, followed by entertainment and domestic facilities. Students who agree to a medium or low extent with the benefits of educational videos are mainly young, aged between 18 and 20. Almost half of them are neutral in terms of systematic use of multimedia resources in the learning process. Most of them use Internet services for communication, a third of them use such services for entertainment, a quarter use them for information, and only a few use them for domestic facilities. There are no statistically significant differences between the four clusters according to the criteria investigated, with one exception, namely the agreement with the benefits of the autonomous use of multimedia resources in the learning process, which decreases proportionally with the agreement degree for educational videos (Table 5).

3.2.4. In-Depth Analysis of Clusters Obtained for Online Documentary Sources

Only two clusters were identified that separated students by their degree of agreement with the benefits of the use of online documentary sources. No statistically significant differences were found between them in terms of their gender structure. Students who strongly or very strongly agree with the benefits of the use of online documentary sources are slightly older, they generally enjoy using multimedia resources in the learning process and, although they use Internet services mainly for communication, the second most preferred is information, followed by entertainment and domestic facilities (almost 10%). On the other hand, students who agree to a small or medium extent with the benefits of the use of online documentary sources are young, they do not particularly agree with the benefits of the use of multimedia resources in individual study, and they also use Internet services mainly for communication, followed by entertainment, information (less than a quarter) and domestic facilities (in very isolated cases). Statistically significant differences between the two clusters are found in their age group structure, the degree of using multimedia resources in the learning process and the frequency of the use of Internet services for information (Table 6).

4. Discussion

All investigated students put in the first place among the blended learning tools the classic oral presentations, followed in the second place by educational videos. The females, as well as the younger students (with age between 18–20 years), put in the third place PowerPoint presentations, the online documentary sources being in the last place. The males, as well as the older students (with age over 21 years), prefer online documentary sources over PowerPoint presentations.

Our results are similar somehow to the other findings presented so far in the scientific literature. The literature review performed by Shorey et al. [1] highlights that the students from Generation Z (today’s students) prefer individualized and self-paced learning, in mixed approaches that integrate videos, PowerPoint presentations with integrated vocal records, simulations, discussion boards, online quizzes as well as case studies in the classroom. Extavour et al. [46] did not find significant correlation between the students’ gender, age group and their agreement with the benefits of blended-learning approaches; most participating students found the blended learning approaches to be useful and to facilitate greater flexibility in learning. Instead, Sezer [44] shows that male medical students are more likely to agree with the benefits of e-learning techniques than female medical students, because male students are more prone to use high technology than female students. A study published by Tripodi et al. [47] highlights positive opinions of the students regarding the use of online videos during the learning process; the students find online videos useful for reviewing materials after the class and for exam preparation and, generally speaking, beneficial for their study motivation.

Another issue investigated by us is a personal approach—we were unable to find so far similar research in the scientific literature, even if we think that our approach is necessary and has certain advantages. We identified statistically significant differences in students’ preferences for certain teaching tools over others driven by their overall behaviour as users of digital technologies and Internet services, so the response to our research question is affirmative and justifies it.

Students who use Internet services mainly for information rank the four blended learning tools analysed in the following order: the classic oral presentations come in the first place, followed by educational videos, online documentary sources and PowerPoint presentations. Students who use Internet services mainly for communication or entertainment put also in the first place the classic oral presentations, followed by educational videos in the second place, but they enjoy more PowerPoint presentations than the online documentary sources. The difference is noticeable in the case of students who use the Internet mainly for domestic facilities: they are most fond of educational videos, followed by online documentary sources and, very close behind, classic oral presentations and PowerPoint presentations. On the other hand, the highest scores of agreement for classic oral presentations were observed among students who use the Internet primarily for communication, followed by those interested in entertainment, information and domestic facilities, in that order. The highest scores of agreement for PowerPoint presentations, as well as the highest scores of agreement for educational videos and online documentary sources were observed among students who use the Internet primarily for domestic facilities, followed by those interested in information, entertainment and communication, in that order.

The purpose for which students use Internet services in their daily activities is actually a hint of their level of technical knowledge. Communication and entertainment are the most accessible services on the Internet. Their use does not require advanced technical skills, so it is natural for students who limit themselves to these services to avoid online documentation as a learning tool as much as possible and to put it last in order of preferences. Students who use the Internet primarily for information have more advanced technical skills, and therefore they agree to document themselves online, if necessary. They do not enjoy PowerPoint presentations, which are less spectacular and passive as learning tools. On the other hand, students who use the Internet for domestic facilities have the most advanced technical knowledge; they naturally like teaching methods based on technology (educational videos and online documentary sources), putting PowerPoint presentations and classical methods in the last place. They are also more inclined to be active than passive learners.

The questionnaire proposed to the students to evaluate the efficacy of the investigated teaching tools enlists a series of possible features belonging to the investigated concept: utility (items 2, 3, 4, 15, 16, 17), scientific rigor (items 5, 6, 8, 11, 12), capacity for synthesis (item 7), clarity (items 9, 10) and ability to arouse interest (items 13, 14). The classic oral presentations, as well as the PowerPoint presentations and the educational videos are rated by the students mainly for their utility, while the online documentary sources are rated mainly for their capacity for synthesis and scientific rigor. The next features appreciated by students are clarity and capacity for synthesis (for classic oral presentations), ability to arouse interest (for PowerPoint presentations) and scientific rigor (for educational videos). Our analysis reveals therefore that students agree with the benefits of specific teaching tools based on very pragmatic reasons, which can be used further as hints for their appropriate integration in blended learning programmes.

Our study was also able to extract the main features of students who prefer certain teaching methods. There are actually two broad categories of students: those who prefer the classic teaching style and PowerPoint presentations, and those who prefer educational videos and online documentary sources. Students in the first category are usually females, in the first years of study (aged between 18 and 20), who use the Internet mainly for communication. Those who like the classic teaching style tend to avoid using multimedia resources during learning (are inclined to be passive learners), while those who like PowerPoint presentations are open also in using such resources and being therefore active learners. Students of the second category enjoy using multimedia resources in the learning process as active learners and use the Internet for all the available services, including domestic facilities. Those who like online documentary sources are more mature (over 20 years old), while educational videos are accepted regardless of age.

The novelty of our study is this in-depth approach for the analysis of students’ opinions about the effectiveness of blended learning methods, based on multivariate analysis through data mining techniques. The results we obtained show that students’ preferences for some teaching tools instead of others are by no means random or subjective, being instead the direct consequence of their vision about digital technologies in general, and how they choose to use these technologies, both in the learning process as well as in their daily activities. We believe that the results obtained bring valuable information for the efficient combination of various teaching tools in blended learning programmes, based on objective and quantifiable criteria for characterizing the students to whom they are addressed. The present study has some limitations, which we intend to eliminate in future work: the relatively small number of students interviewed from the Faculty of Medicine (most of the students come from Dental Faculties), the relatively small number of students interviewed from university centres other than Iasi and the limited investigation of elements related to the students’ personal background. Indeed, in our study we focused only on two such elements, namely the students’ preferences for using multimedia resources during the autonomous learning and the degree to which they choose to use digital technologies (i.e., Internet services) in their daily activities. The obtained results are encouraging enough to motivate us to extend this research direction. We believe that the students’ evaluation can be refined by including supplementary elements regarding their psychological profile and their general mentality about learning. Such elements can have certain influences over their choices and therefore over the efficacy of blended learning techniques in terms of the degree of their acceptance among students, and this research direction is also relatively not investigated (a meta-analysis study published in 2023 identified only 22 papers indirectly related to this approach, and not in medical field [48]).

The main beneficiary of the results regarding the efficiency of some teaching methods compared to others is the educational system on all its levels. At the basic level, there are the teachers, who can redesign their courses so as to make them more attractive to students, arouse their interest, motivate them and improve their learning results, by delivering them knowledge in a more accessible form that they feel familiar. Our study shows that it is not enough to focus only on the technical aspects of presenting materials and carrying out online activities, but students’ perceptions of and reactions to such learning environment, as expressed through their performance, should also be taken into account. On the next level, we found the educational institutions (universities), which will improve their percentages of promotability, as well as their position on the educational market, becoming more attractive for candidates. On the last level, there is the entire national education system, which becomes more efficient and offers graduates better preparation for the labour market. All these implications are highly important, and therefore it is obvious that any research in the field is important too.

5. Conclusions

The results reported in our study provide quantitative evidence of the effectiveness of blended learning techniques in medical education, confirming the ideas known in the literature on this topic. There is no doubt that students prefer blended learning techniques and multimedia resources for the flexibility they offer in organising their study periods according to their own pace. Our study, however, presents an original approach, as it documents the idea that students’ choices of learning style have a deeper motivation, being related to the degree to which they generally accept digital technologies, translated by the way they choose to use these techniques in their daily activities. Thus, we have shown not only that there are statistically significant differences between genders and age groups in terms of choices of certain learning tools over others, but also that these choices are equally dependent on a number of additional factors.

The integration of modern technologies is changing the learning environment, both face-to-face and online, with definite but quantifiable effects on the quality of learning, quantified through the learning outcomes and students’ satisfaction with the process. The results provided by our study and other similar studies as well are useful mainly for teachers interested to update their didactic materials according to the demands of the new generations of students but also for the health professions’ educational system on all its levels. On the next level, universities with optimally developed blended-learning programmes become more attractive for candidates and gain upper positions on the educational market. The ultimate beneficiary is, in the long term, the entire national health professions’ educational system, which will better prepare graduates for the labour market. In addition, of course, at last but not least, there are the patients who will be treated by better-prepared physicians with extended knowledge and advanced skills in using modern technologies and digital environments to improve the quality of medical act.