Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Virtual Reality (VR) is a technology that allows the user to explore and manipulate computer-generated real or artificial three-dimensional (3D) multimedia sensory environments in real time to gain practical knowledge that can be used in clinical practice. Objective: The aim of this systematic review was to evaluate the effectiveness of virtual reality (VR) for educating health professions and improving their knowledge, cognitive skills, attitudes and satisfaction. Methods: We performed a systematic review of the effectiveness of virtual reality in pre- and post-registration health professions education following the gold standard Cochrane methodology. We searched seven databases from the year 1990 up to August 2017. No language restrictions were applied. We included randomized controlled trials and cluster-randomized trials. We independently selected studies, extracted data and assessed risk of bias, then compared the information in pairs. We contacted study authors for additional information if necessary. All pooled analyses were based on random-effects models. We used the GRADE approach to rate the quality of the body of evidence. Results: Thirty-one studies (N = 2407) were included. Meta-analysis of eight trials found that VR slightly improves post-intervention knowledge scores when compared with traditional learning (SMD = 0.44, 95% CI: 0.18, 0.69, I2 = 49%, N = 603) or to other types of digital education such as online or digital education (SMD = 0.43, 95% CI: 0.07, 0.79, I2 = 78%, N = 608, low certainty evidence). Another meta-analysis of four trials found that VR improves health professions cognitive skills when compared with traditional learning (SMD = 1.12, 95% CI: 0.81, 1.43, I2 = 0%, N = 235). Two studies compared VR to other forms of digital education on skills, favoring the VR group (SMD = 0.50, 95% CI: 0.32, 0.69, I2 = 0%, N = 467, moderate effect size, low certainty evidence). The findings for attitudes and satisfaction were mixed and inconclusive. No studies reported patient-related outcomes, behavior change or unintended/adverse effects of the VR. Overall, the certainty of evidence according to the GRADE criteria ranged from low to moderate. We downgraded our certainty of the evidence primarily because of the risk of bias and/or inconsistency. Conclusions: We found evidence suggesting that virtual reality improves post-intervention knowledge and skills outcomes of health professions when compared to traditional education or other types of digital education such as online or offline digital education. The findings on other outcomes are limited. Future research should evaluate more on the effectiveness of immersive and interactive forms of VR and evaluate other outcomes such as attitude, satisfaction, cost-effectiveness and clinical practice or behavior change.

Background: Effective communication skills are essential in diagnosis and treatment processes and in building the doctor-patient relationship. Objective: Our aim was to evaluate the effectiveness of digital education in medical students for communication skills development. Broadly, we assessed whether digital education could improve the quality of future doctors’ communication skills. Methods: We performed a systematic review and searched seven electronic databases and two trial registries for randomized controlled trials (RCTs) and cluster RCTs (cRCTs) published between January 1990 and September 2018. Two reviewers independently screened the citations, extracted data from the included studies, and assessed the risk of bias. We also assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations assessment (GRADE). Results: We included 12 studies with 2101 medical students, of which 10 were RCTs and two were cRCTs. The digital education included online modules, virtual patient simulations, and video-assisted oral feedback. The control groups included didactic lectures, oral feedback, standard curriculum, role play, and no intervention as well as less interactive forms of digital education. The overall risk of bias was high, and the quality of evidence ranged from moderate to very low. For skills outcome, meta-analysis of three studies comparing digital education to traditional learning showed no statistically significant difference in postintervention skills scores between the groups (standardized mean difference [SMD]=–0.19; 95% CI –0.9 to 0.52; I2=86%, N=3 studies [304 students]; small effect size; low-quality evidence). Similarly, a meta-analysis of four studies comparing the effectiveness of blended digital education (ie, online or offline digital education plus traditional learning) and traditional learning showed no statistically significant difference in postintervention skills between the groups (SMD=0.15; 95% CI –0.26 to 0.56; I2=86%; N=4 studies [762 students]; small effect size; low-quality evidence). The additional meta-analysis of four studies comparing more interactive and less interactive forms of digital education also showed little or no difference in postintervention skills scores between the two groups (SMD=0.12; 95% CI: –0.09 to 0.33; I2=40%; N=4 studies [893 students]; small effect size; moderate-quality evidence). For knowledge outcome, two studies comparing the effectiveness of blended online digital education and traditional learning reported no difference in postintervention knowledge scores between the groups (SMD=0.18; 95% CI: –0.2 to 0.55; I2=61%; N=2 studies [292 students]; small effect size; low-quality evidence). The findings on attitudes, satisfaction, and patient-related outcomes were limited or mixed. None of the included studies reported adverse outcomes or economic evaluation of the interventions. Conclusions: We found low-quality evidence showing that digital education is as effective as traditional learning in medical students’ communication skills training. Blended digital education seems to be at least as effective as and potentially more effective than traditional learning for communication skills and knowledge. We also found no difference in postintervention skills between more and less interactive forms of digital education. There is a need for further research to evaluate the effectiveness of other forms of digital education such as virtual reality, serious gaming, and mobile learning on medical students’ attitude, satisfaction, and patient-related outcomes as well as the adverse effects and cost-effectiveness of digital education.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Synthesizing evidence from randomized controlled trials of digital health education poses some challenges. These include a lack of clear categorization of digital health education in the literature, overarching term with constantly evolving concepts, pedagogies, or theories as well as a multitude of methods, features, technologies, or delivery settings. Digital Health Education collaboration was established to evaluate the evidence on digital education for health professions; inform policymakers, educators and students; and ultimately change the way in which these professions learn and are taught. The aim of this paper is to present the overarching methodology that we use to synthesize the evidence across our digital health education reviews, and to discuss challenges related to the process. For our research, we followed Cochrane recommendations for the conduct of systematic reviews; all reviews are reporting according to PRISMA guidance. This included assembling experts in various digital health education fields, identifying gaps in the evidence base, formulating focused research questions, aims and outcome measures, choosing appropriate search terms and databases, defining inclusion and exclusion criteria, running the searches jointly with librarians and information specialists, managing abstracts, retrieving full text versions of papers, extracting and storing large datasets, critically appraising the quality of studies, analyzing data, discussing findings, drawing meaningful conclusions, and drafting research papers. The approach we used for synthesizing evidence from digital health education trials is commonly regarded as the most rigorous benchmark for conducting systematic reviews. While we acknowledge the presence of certain biases ingrained in the process, we have clearly highlighted and minimized those biases by strictly adhering to scientific rigor, methodological integrity and standard operating procedures. This paper should be a valuable asset for researchers and methodologists undertaking systematic reviews in this area.

Our aims were to evaluate critically the evidence from systematic reviews as well as narrative reviews of the effects of melatonin (MLT) on health and to identify the potential mechanisms of action involved. An umbrella review of the evidence across systematic reviews and narrative reviews of endogenous and exogenous (supplementation) MLT was undertaken. The Oxman checklist for assessing the methodological quality of the included systematic reviews was utilised. The following databases were searched: MEDLINE, EMBASE, Web of Science, CENTRAL, PsycINFO and CINAHL. In addition, reference lists were screened. We included reviews of the effects of MLT on any type of health-related outcome measure. Altogether, 195 reviews met the inclusion criteria. Most were of low methodological quality (mean -4.5, standard deviation 6.7). Of those, 164 did not pool the data and were synthesised narratively (qualitatively) whereas the remaining 31 used meta-analytic techniques and were synthesised quantitatively. Seven meta-analyses were significant with P values less than 0.001 under the random-effects model. These pertained to sleep latency, pre-operative anxiety, prevention of agitation and risk of breast cancer. There is an abundance of reviews evaluating the effects of exogenous and endogenous MLT on health. In general, MLT has been shown to be associated with a wide variety of health outcomes in clinically and methodologically heterogeneous populations. Many reviews stressed the need for more high-quality randomised clinical trials to reduce the existing uncertainties.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Globally, online and local area network-based (LAN) digital education (ODE) has grown in popularity. Blended learning is the use of ODE along with traditional learning. Studies have shown the increasing potential of these technologies in training medical doctors yet the evidence for its effectiveness and cost-effectiveness is unclear. Objective: This review evaluated the effectiveness of online and LAN-based digital education (ODE) in improving medical doctors’ knowledge, skills, attitude, satisfaction (primary outcomes), practice or behavior change, patient outcomes and cost-effectiveness (secondary outcomes). Methods: We searched seven electronic databases for randomized controlled trials (RCTs), cluster-randomized trials (cRCTs), and quasi-randomized trials from January 1990 to March 2017. Two review authors independently extracted data and assessed the risk of bias. Due to high heterogeneity in terms of populations, interventions, comparators and outcomes, we were unable to conduct the pre-planned meta-analyses. Instead we have presented the findings narratively. When possible, we present outcomes using standardized mean difference (SMD) for continuous variables and risk ratios (RR) for dichotomous variables. In the main review we have presented only comparisons ODE vs self-directed/face-to-face learning and blended learning vs self-directed/face-to-face learning, rest of the comparisons are presented in Multimedia Appendix 1. Results: Ninety-three studies (N = 16,895) were included of which seventy-six studies compared ODE (including blended) vs self-directed/face-to-face learning. Overall the effect of ODE (including blended) on post-intervention knowledge, skills, attitude, satisfaction, practice or behavior change and patient outcomes was inconsistent and ranged mostly from no difference between the groups to higher post-intervention score in the intervention group (small to large effect size, very low to low quality evidence). Twenty-one studies reported higher knowledge score (small to large effect size; very low quality) for the intervention while 20 studies reported no difference in knowledge between the groups. Seven studies reported higher skill score in the intervention (large effect size; low quality) while thirteen studies reported no difference in skill score between the groups. One study reported higher attitude score for the intervention (very low quality), while 4 studies reported no difference in attitude score between the groups. Four studies reported higher post-intervention physician satisfaction with the intervention (large effect size; low quality), while six studies reported no difference in satisfaction between the groups. Eight studies reported higher post-intervention practice or behavior change for the ODE group (small to moderate effect size; low quality) while five studies reported no difference in practice or behavior change between the groups. One study reported higher improvement in patient outcome, while three others reported no difference in patient outcome between the groups. None of the included studies reported any unintended/adverse effects, cost-effectiveness of the interventions. Conclusions: Empiric evidence from majority of the studies reported that ODE and blended learning may be equivalent to self-directed/face-to-face learning for training physicians'. Few other studies demonstrated that ODE and blended learning may significantly improve learning outcomes compared to self-directed/face-to-face learning. The quality of the evidence in these studies was found to be low and very low for knowledge. Given the inconsistent findings, further high quality RCTs are required before evidence of efficacy can be concluded.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Medical schools in low- and middle-income countries are facing a shortage of staff, learning infrastructure as well as access to fast and reliable Internet. Offline digital education may be an alternative solution for these issues allowing medical students to learn at their own time and pace, without the need for a network connection. Objective: The primary objective of this systematic review was to assess the effectiveness of offline digital education compared with traditional learning or a different form of offline digital education in improving knowledge, skills, attitudes, and satisfaction of medical students. The secondary objectives was to assess the cost-effectiveness, changes in accessibility and/or availability of education, and the unintended/adverse-effects of the interventions on students. Methods: We carried out a systematic review of the literature by following the Cochrane methodology. We searched seven major electronic databases from January 1990 to August 2017 for randomized controlled trials (RCTs) or cluster RCTs (cRCTs). Two authors independently screened studies, extracted data and assessed risk of bias. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE). Results: We included 36 studies with 3,325 medical students. Thirty-three of the studies were RCTs and three were cRCTs. The interventions consisted of software programs, Compact Disc Read-Only Memory (CD-ROMs), PowerPoint presentations, computer-based videos and other computer-based interventions. The pooled estimate of 19 studies (1,717 participants) showed equivalent effectiveness between offline digital education and traditional learning groups in terms of students’ post-intervention knowledge scores (standardized mean difference (SMD) = 0.11, 95% confidence interval (CI): -0.11, 0.32, small effect size, low quality evidence). Meta-analysis of four studies found that, compared with traditional learning, offline digital education improved medical students' post-intervention skills (SMD = 1.05, 95% CI: 0.15, 1.95, large effect size, low quality evidence). We are uncertain about the effects of offline digital education on students’ attitudes and satisfaction due to missing or incomplete outcome data. Only four studies estimated the costs of offline digital education; and none reported changes in accessibility and/or availability of education, or adverse-effects. The risk of bias was predominantly high in more than half of the included studies. The overall quality of the evidence was low (for knowledge, skills, attitudes and satisfaction) due to the study limitations and inconsistency across the studies. Conclusions: Our findings suggest that offline digital education is as effective as traditional learning in terms of medical students’ knowledge and more effective than traditional learning in terms of medical students’ skills. However, there is a need to further investigate students’ attitudes and satisfaction with offline digital education as well as its cost-effectiveness, changes in accessibility and/or availability of education, and any unintended/adverse-effects of the interventions.