2024 Volume 47 Issue 3 Pages 708-712
In 2020, the coronavirus disease 2019 (COVID-19) pandemic made social distancing compulsory. In patient lectures by hepatitis B patients (Patient Lectures)—a humanity education initiative that had traditionally been delivered face-to-face to assembled students—it was necessary to divide the students into two groups, one that attended the Patient Lectures in person (face-to-face group) and another that assembled in a separate room to view the delivered lecture simultaneously and remotely via a teleconferencing platform (remote group). To investigate possible changes in students’ awareness of hepatitis B patients before (pre-) and after (post-) the lecture that year, the face-to-face and remote-attendance groups were analyzed separately. The participants were 203 fourth-year students belonging to the Faculty of Pharmaceutical Sciences at Japan’s Setsunan University, whose pre-clinical education curriculum prior to pharmacy practice experience included a Patient Lecture. The students were divided into two groups based on their student-ID numbers. Survey questionnaires were completed anonymously before and after the Patient Lecture. The students’ awareness of hepatitis B patients’ experience changed significantly after attending the Patient Lectures; this change was similar in both the face-to-face and remote-attendance groups. Regarding the possibility of hepatitis B virus infection, the remote group selected fewer answers implying strong convictions than did the face-to-face group, and both groups perceived several issues incorrectly. Although slight differences were observed between the two groups, the changes before and after the lectures were similar, indicating that humanity-education lectures are worthwhile not only when delivered in face-to-face contexts but also when delivered and viewed remotely within a class setting.
The Model Core Curriculum for Pharmacy Education includes the following specific behavioral objective: “To always keep viewpoints of patients/consumers and maintain the attitude of a healthcare professional.” Lectures in which students hear directly from patients are essential in allowing them to understand and consider patients’ viewpoints. At the Faculty of Pharmaceutical Sciences, Setsunan University, Japan, before pharmacy practice experience, a lecture is delivered to students during year four by hepatitis B patients with the aim of offering students greater insight into patients’ problems and suffering and teaching them about the spread of the hepatitis B virus (HBV). In analyzing the Patient Lectures’ educational impact, we have found that they cultivate sympathy for patients and enhance students’ awareness of hepatitis B patients.1) However, the coronavirus disease 2019 (COVID-19) pandemic in 2020 required lecture formats to be changed in healthcare education worldwide and made face-to-face lectures difficult.2,3) Patient Lectures at Setsunan University were delivered face-to-face with the patient addressing one group in person, while simultaneously addressing students assembled in another room through a remote interface to facilitate social distancing. We were interested in exploring how the differences between face-to-face and remote delivery might have influenced the results. Courteille et al. reported that medical students’ and residents’ knowledge retention was the same for virtual patient-based training and a video-recorded standard lecture.4)
In this study, we evaluated how students’ HBV knowledge and awareness of hepatitis B patients’ experiences changed before and after Patient Lectures, while considering the different lecture-delivery modes (i.e., face-to-face or remote attendance), and discuss the importance of implementing these lectures even when social distancing is necessary.
The Patients’ Lecture was conducted for fourth-year students at the Faculty of Pharmaceutical Sciences, Setsunan University, Japan, as part of the pre-clinical education curriculum before pharmacy-practice experience. The lecture was given with the hepatitis B suit legal counsel and plaintiff corps nationwide. The lecture program was as follows: a lawyer delivered a lecture on mass vaccination and HBV infection in Japan, and this was followed by a lecture delivered by two patients and a question-and-answer session between students and the lawyer or patients. The patients talked about the process of disease recognition, their daily physical condition, relationships with their families, balancing work and medical treatments, taking medication, and their relationship with their pharmacists. Following the lecture, students listed their thoughts anonymously on paper and hand them to the speaker. A booklet containing a patient’s memoir, “Do You Remember This Scene?”5), and information about hepatitis B were given to the students to encourage self-study. The students also completed a short test about hepatitis B, drugs, and medical treatment, and they considered clinical patients’ cases. In 2020, this lecture was delivered in two ways: face-to-face (face-to-face lecture group, 102 students) and a simultaneous lecture delivered through a remote interface to students assembled in another room (remote group, 101 students). Students were divided into two groups according to their student ID numbers. A faculty member was present in each room to oversee measures aimed at ensuring physical distancing among the students to prevent the spread of COVID-19.
QuestionnaireThis study was conducted with the approval of the Setsunan University Ethical Review Committee for Medical and Health Research Involving Human Subjects (Approval No.: 2017-086). The subjects (203 students) attended the Patient Lecture in December 2020. We explained to the students that the survey results would not affect their grades, assured them of their anonymity, and advised them that submission of the questionnaire would be regarded as indicative of their consent to participate in the research. Questionnaire surveys were conducted immediately before (pre-) and after (post-) the lecture, and the questionnaires were collected on site in each room. The questionnaires were anonymous, and each respondent’s pre- and post-lecture surveys were linked using arbitrary numbers on the questionnaires. The questionnaire content was prepared following Yotsuyanagi et al.’s6) report entitled “Perception of Hepatitis and Hepatitis Patients by Healthcare Professionals.” The participants ranked items relating to HBV knowledge as either “agree,” “disagree,” or “not sure.” Regarding their impressions of hepatitis B patients and the possibility of HBV infection, the choices were “agree,” “somewhat agree,” “somewhat disagree,” “disagree,” and “not sure.”
Statistical AnalysisResponses were valid only if both the pre- and post-lecture questionnaires had been completed. Percentages were calculated by dividing the number of respondents who selected each option by the number of valid respondents in each lecture group (face-to-face and remote groups). Statistical analysis was performed using JMP Pro 15 (SAS Institute Inc., Japan), and a significance level of p < 0.05 was taken to indicate statistical significance. The knowledge-content choices were used as a nominal scale. The Bowker test was used for pre- and post-lecture changes. The Chi-square test was used to analyze differences between the face-to-face and remote groups, and Fisher’s exact test was used when the expected frequency was five or less. The patient-image and HBV-infection choices were scored excluding “Not sure” as follows: agree = 4, somewhat agree = 3, somewhat disagree = 2, and disagree = 1 point. We used Wilcoxon’s signed rank test to analyze pre- and post-lecture differences. A higher post- than pre-lecture score was considered a positive-rank change, and a lower score was a negative-rank change. The Mann–Whitney U test was used to analyze differences between the face-to-face and remote groups for each question.
Table 1 lists the HBV knowledge content questions. For item 1-1, 41 and 50% of students in the face-to-face and remote groups, respectively, answered “not sure” before the lecture; after the lecture, however, over 97% of the students correctly answered “agree.” The pre- and post-lecture comparisons showed a significant increase in correct responses after the lecture, and no difference was observed between the face-to-face and remote groups. After the lecture, the number of “not sure” responses decreased for all items in both groups.
| Questionnaire item | Answer | Face-to-face | Remote | Face-to-face vs. remote p-value | |||||
|---|---|---|---|---|---|---|---|---|---|
| Pre (%) | Post (%) | Pre-post p-value (n) | Pre (%) | Post (%) | Pre-post p-value (n) | Pre | Post | ||
| 1-1. The reuse of syringes and needles during mass vaccinations caused hepatitis B viral infection in Japan | Agree | 50.5 | 97.9 | <0.001* (97) | 42.0 | 99.0 | <0.001* (101) | 0.451 | 0.241 |
| Disagree | 8.2 | 0.0 | 8.0 | 1.0 | |||||
| Not sure | 41.2 | 2.1 | 51.0 | 0.0 | |||||
| 1-2. Vaccination efficacy against HBV | Agree | 84.5 | 96.9 | 0.006* (97) | 89.0 | 97.0 | 0.029* (101) | 0.681 | 0.838 |
| Disagree | 4.1 | 2.1 | 3.0 | 3.0 | |||||
| Not sure | 11.3 | 1.0 | 9.0 | 0.0 | |||||
| 1-3. HBV infection can be identified by a blood test | Agree | 65.7 | 98.0 | <0.001* (99) | 74.0 | 100.0 | <0.001** (101) | 0.674 | 0.246 |
| Disagree | 1.0 | 0.0 | 1.0 | 0.0 | |||||
| Not sure | 33.3 | 2.0 | 26.0 | 0.0 | |||||
n: Total number of respondents. Bowker’s test *: p < 0.05, Fisher’s exact test **: p < 0.05.
Table 2 lists the questions regarding the students’ perceptions of hepatitis B patients. In a comparison of the pre- and post-lecture responses to the questions, 10 items in the face-to-face lecture group and 11 items in the remote group significantly changed to “agree” after the lecture, and 10 of the 11 items were the same in the remote and face-to-face groups (items 2-1, 2-2, 2-9, 2-10, 2-17, 2-18, 2-19, 2-21, 2-22, and 2-23). Seven items in the face-to-face group and eight items in the remote group significantly changed to “disagree” after the lecture, and six of the items were the same in both groups (items 2-3, 2-4, 2-5, 2-6, 2-8, and 2-14). A comparison of the face-to-face and remote groups’ pre-lecture answers showed a difference only for item 2-11. After the lecture, there were differences for items 2-3 and 2-14. The percentages of all responses are shown in supplementary Figs. S1 (face-to-face group) and S2 (remote group). After the lecture, the number of “not sure” responses decreased for most items in both groups. Before the lecture, responses to item 2-11 differed between the face-to-face and remote groups; fewer students in the face-to-face group than in the remote group selected “agree” or “somewhat agree.” After the lecture, for items 2-3 and 2-14, the numbers of “disagree” responses were higher in the face-to-face group than in the remote group.
| Sub number. Questionnaire item | Face-to-face | Remote | Face-to-face vs. remote p-value | |
|---|---|---|---|---|
| Pre-post p-value (n) | Pre-post p-value (n) | Pre | Post | |
| 2-1. Have a horrible disease | <0.001a) (94) | 0.009a) (98) | 0.825 | 0.620 |
| 2-2. Have an incurable disease | <0.001a) (93) | <0.001a) (92) | 0.508 | 0.858 |
| 2-3. Feel fear of infection when near patients | <0.001b) (93) | 0.009b) (96) | 0.846 | 0.034* |
| 2-4. Unpleasant to partake in meals with patients | <0.001b) (97) | 0.015b) (96) | 0.724 | 0.052 |
| 2-5. Undesirable to be partner of a patient | <0.001b) (92) | <0.001b) (95) | 0.451 | 0.296 |
| 2-6. Would prefer not to associate with patients | <0.001b) (94) | 0.003b) (95) | 0.412 | 0.380 |
| 2-7. Tell other people to avoid spread of the infection | 0.180 (91) | 0.049b) (89) | 0.082 | 0.413 |
| 2-8. Tell others about infected individuals | 0.037b) (86) | 0.004b) (88) | 0.762 | 0.774 |
| 2-9. Feel sympathy for patients suffering from discrimination | <0.001a) (84) | <0.001a) (83) | 0.547 | 0.745 |
| 2-10. Feel sympathy for patients suffering from prejudice | <0.001a) (87) | <0.001a) (84) | 0.455 | 0.791 |
| 2-11. Infected by having sexual intercourse | 0.166 (84) | 0.788 (75) | 0.017* | 0.614 |
| 2-12. Infected through family | 0.137 (83) | 0.234 (75) | 0.093 | 0.584 |
| 2-13. Drinking alcohol is prohibited | 0.022b) (71) | 1.000 (73) | 0.996 | 0.070 |
| 2-14. Sports are prohibited | <0.001b) (79) | <0.001b) (81) | 0.506 | 0.031* |
| 2-15. Lead a comfortable life on a great subsidy | 0.382 (75) | 0.049b) (66) | 0.181 | 0.723 |
| 2-16. Capable of living socially with less subjective symptoms | 0.610 (73) | 0.031a) (70) | 0.461 | 0.474 |
| 2-17. Hard to maintain health | <0.001a) (72) | 0.004a) (70) | 0.481 | 0.519 |
| 2-18. Hard to work and to do housekeeping | <0.001a) (73) | <0.001a) (75) | 0.214 | 0.589 |
| 2-19. Become a burden to other family members in the same household | 0.002a) (75) | 0.006a) (70) | 0.190 | 0.251 |
| 2-20. Hard to obtain or retain life insurance | 0.911 (71) | 0.736 (58) | 0.904 | 0.168 |
| 2-21. Difficult to receive regular outpatient care | <0.001a) (86) | <0.001a) (82) | 0.623 | 0.869 |
| 2-22. High medical costs for treatment | 0.010a) (83) | <0.001a) (81) | 0.964 | 0.147 |
| 2-23. May be under strained/stressful circumstances | <0.001a) (79) | <0.001a) (72) | 0.584 | 0.536 |
n: Total number of respondents. Wilcoxon signed-rank test: p < 0.05 [a): positive-rank, b): negative-rank (post–pre)]. The Mann–Whitney U test revealed significant differences between the face-to-face and remote groups (* p < 0.05).
Regarding the possibility of HBV infection (Table 3), the same three items changed significantly to “agree” after the lecture in both groups (items 3-8, 3-9, and 3-12). Ten items changed significantly to “disagree” after the lecture (items 3-1, 3-2, 3-3, 3-4, 3-5, 3-6, 3-7, 3-11, 3-13, and 3-14) in the face-to-face group, and three items (items 3-13, 3-14, and 3-15) did so in the remote group. Of these, two (items 3-13 and 3-14) were the same in both groups. No pre-lecture differences were detected between the two groups; however, post-lecture differences were observed for items 3-2 and 3-6. The percentages of all responses are detailed in supplementary Figs. S3 (face-to-face group) and S4 (remote group). After the lecture, “not sure” responses decreased for most items in both groups. For items 3-2 and 3-6, “disagree” responses were more common in the face-to-face group; students in the remote group tended to answer “disagree” less frequently for questions when there was no actual possibility of infection.
| Sub number. Questionnaire item | Face-to-face | Remote | Face-to-face vs. remote p-value | |
|---|---|---|---|---|
| Pre-post p-value (n) | Pre-post p-value (n) | Pre | Post | |
| 3-1. Talk with an infected person | 0.004b) (92) | 0.874 (92) | 0.988 | 0.100 |
| 3-2. Talk with an infected person who is coughing | <0.001b) (89) | 0.176 (91) | 0.988 | 0.031* |
| 3-3. Shake hands with an infected person | <0.001b) (92) | 0.412 (92) | 0.866 | 0.059 |
| 3-4. Eat a meal served on the same dish as that of an infected person | 0.002b) (89) | 0.560 (84) | 0.909 | 0.080 |
| 3-5. Eat using the same dish as an infected person | 0.050b) (88) | 0.819 (85) | 0.725 | 0.133 |
| 3-6. Take a bath with an infected person | <0.001b) (88) | 0.920 (84) | 0.418 | 0.008* |
| 3-7. Use the same towel as an infected person | <0.001b) (90) | 0.845 (83) | 0.727 | 0.055 |
| 3-8. Use the same toothbrush as an infected person | 0.002a) (89) | <0.001a) (87) | 0.461 | 0.604 |
| 3-9. Use the same razor as an infected person | <0.001a) (89) | <0.001a) (89) | 0.300 | 0.712 |
| 3-10. Use the pierced earrings of an infected person | 0.810 (85) | 0.131 (89) | 0.894 | 0.735 |
| 3-11. Kiss an infected person | 0.006b) (83) | 0.819 (84) | 0.469 | 0.220 |
| 3-12. Have sexual intercourse with an infected person | 0.046a) (85) | 0.009a) (89) | 0.571 | 0.586 |
| 3-13. Sit on a toilet seat bloodstained by an infected person | <0.001b) (89) | <0.001b) (83) | 0.357 | 0.692 |
| 3-14. Be bitten by a mosquito that bit an infected person | <0.001b) (80) | <0.001b) (86) | 0.226 | 0.309 |
| 3-15. Tattooed with tools previously used on (exposed to the blood of) an infected person | 0.516 (88) | 0.013b) (91) | 0.418 | 0.540 |
n: Total number of respondents. Wilcoxon signed-rank test: p < 0.05 [a): positive-rank, b): negative-rank (post–pre)]. The Mann–Whitney U test revealed significant differences between the face-to-face and remote groups (* p < 0.05).
The students’ awareness of hepatitis B patients’ experience changed significantly after attending the Patient Lectures; this change was similar in both the face-to-face and remote-attendance groups. Even if patients are unable to attend and deliver the lectures in person, active remote delivery of such lectures benefits students studying holistic medicine.
When asked about their knowledge of HBV before the lecture, several students indicated that they were “not sure,” despite having covered these topics in their junior year. After the lecture, the answers improved significantly in both groups. These findings suggest that students whose knowledge had not been established in the lower grades had consolidated their previous learning through their connections to the patients’ stories. Our study found minimal differences between the face-to-face and remote-attendance groups, implying that the two lecture styles similarly supported student learning. Courteille et al.4) and Chotiyarnwong et al.7) reported no differences in knowledge retention between virtual patient-based training and video-recorded standard lectures, or between traditional lecture-based learning and video-based learning, respectively. Although on-demand lectures are useful as a general lecture style but were not a subject of our study, it is expected that various lecture styles will be used for Patient Lectures in further comparative studies.
Moreover, the students’ answers concerning their impressions of hepatitis B patients changed similarly in the two groups after the lecture. The students did not consider HBV to be a difficult or incurable disease before the lecture. However, after hearing the patients’ stories about their experiences of the disease, they understood more completely that the disease drastically changes lives. The Japanese Ministry of Health, Labor, and Welfare’s notice (Promotion of Education on Hepatitis B at Training Schools and Medical Professional Training Facilities (Request)8)) recommends the “enhancement of education to prevent prejudice and discrimination, etc.” After the lecture, more students selected “agree” regarding whether prejudice and discrimination existed, implying that they recognized that patients are exposed to social prejudice and discrimination due to the disease. In addition, for items concerning physical contact with patients, the Patient Lectures helped the students to reduce their tendency to avoid HBV patients. For items concerning patients’ lives, the number of students who selected “not sure” decreased post-lecture in both groups. Among students who answered “not sure” before the lecture, the number who selected “agree” increased after the lecture (data not shown). We suspect that when students selected “not sure” after the lecture, they also meant that they could not decide or could not say either way. They became aware of the difficulties faced by the patients in their daily lives, and their concern for the patients increased.
Before the lecture, there was a significant difference between the face-to-face and remote groups regarding item 2-11; however, this difference disappeared after the lecture. After the lecture, for items 2-3 and 2-14, despite a significant change toward a negative response in both groups, a significant difference emerged between the face-to-face and remote groups. This result may be attributable to the fact that the number of “disagree” responses was smaller in the remote group than in the face-to-face group. Regarding the possibility of HBV infection, there were significant differences between the face-to-face and remote groups’ responses after the lecture for items 3-2 and 3-6. The percentage of “disagree” responses was lower in the remote group than in the face-to-face group. This finding implies that students in the remote group were less confident about their answers. We suspect that the difference in students’ responses was dependent on whether they had met the patients who delivered the lectures, which may have left a stronger impression on them.
Concerning the possibility of HBV infection, although some items are presumed to carry a high risk of infection, many students in both groups did not give correct answers after the lecture. Therefore, regardless of lecture style, the Patient Lectures should be supplemented with additional information regarding the possibility of HBV infection.
The pharmacy students learned about how hepatitis B has spread in Japan, along with the physical and psychological suffering and living conditions of patients affected by the disease, through Patient Lectures in which patients presented their stories to the students as a narrative. Patient Lectures can support students in their pharmacy practice, enhance their awareness of patients’ perspectives and experiences, and encourage them to reflect on their professionalism as pharmacists in their interactions with patients and society, thus providing a valuable humanistic education opportunity, even when delivered remotely.
We gratefully acknowledge all of those involved in the lecture. We thank the subjects who completed the survey questionnaire and the faculty members who managed the lecture.
The authors declare no conflict of interest.
This article contains supplementary materials.
