Does peer education increase academic achievement in first year students? A mixed-method study

Research on the impact of peer education (PE) on learning outcomes has produced inconclusive results, partly due to the methodology employed in such studies. There is a necessity to design blind, controlled studies. Further, quantitative approaches to evaluating PE may not provide a complete picture of the impact of PE on learning outcomes. The aim of the study was to determine the effect of peer education on students' academic achievement and to explain students' lived experience of participating in a PE program. The study employed an exploratory, sequential mixed-method design and occurred in two distinct and consecutive phases. The first phase consisted of a cluster-controlled, double-blind educational trial; the second, of a qualitative conventional content analysis. Data was collected during the second semester from February to July 2015 from undergraduate students. Analysis of the preand post-tests has been performed to evaluate the program among those enrolled in nursing and midwifery (intervention groups) and anaesthesia nursing (control group) in physiology and anatomy courses. PE resulted in significant differences in the physiology post-test scores and the anatomy post-test scores in favour of midwifery and nursing students respectively (intervention groups). Statistically significant improvement was not achieved based on formal academic exams. Themes were identified by analysing the content of qualitative feedback, with “facilitated learning” being the main theme emerging from the data. The PE program promoted learning based on the facilitator-based examination (based on post-test scores). However, PE did not improve learning in blinded condition in the current study (formal academic exam). INTRODUCTION Peer education (PE) is an impressive and rapidly developing educational method to enhance student learning, especially in the fields of nursing education (Stone, Cooper, & Cant, 2013) and medical education (Burgess & Nestel, 2014). PE is defined as “people of similar social groupings who are not professional teachers helping each other to learn and learning themselves by teaching” (Tzu-Chieh et al., 2011). Students instruct fellow students, and face new experiences and a challenging role (Sobral, 2002; Srivastava et al., 2015) while taking part in an experience that is different from typical teachercentred learning strategies (Mirhaghi, Karimi-Moonaghi, Sharafi, & EmamiZeydi, 2015). Studies have shown that students perceive the peer tutoring sessions favourably and show their passion to continue PE as part of other courses (Glynn, MacFarlane, Kelly, Cantillon, & Murphy, 2006; Lake, 1999; Srivastava et al., 2015). Additionally, as a learner-centred approach, PE is wellreceived by students because it provides a great opportunity for them to fully Does peer education increase academic achievement 90 participate in an educational program (Outhred & Chester, 2010; Sevenhuysen et al., 2013). While studies highlight students’ positive perceptions of PE, the impact on learning outcomes is inconclusive (Secomb, 2008). Peer education has been positively associated with an increase in students’ confidence, self-awareness (Ramm, Thomson, & Jackson, 2015; Secomb, 2008; Stone et al., 2013), and with insignificant changes in students` learning and level of bonding with the instructor. Several studies have found that peer tutorials may have a positive effect on students’ outcomes in post-tutorial physiology examination scores (Glynn et al., 2006; Jackson & Evans, 2012; Kibble, 2009) as well as in anatomy courses (Manyama et al., 2016; Weyrich et al., 2008). Anatomy and physiology courses have been regarded as the most challenging courses in the undergraduate program, and have been subject to several studies. Some remarkable additional effects from PE have included alleviating the faculty teaching burden, preparing students to be role models, developing teaching skills, helping students acquire skills for their future roles as instructors (Ten Cate & Durning, 2007) and a positive social learning experience (Ramm et al., 2015). Finally, studies have indicated that PE has reasonable and pragmatic implications for clinical education despite statistically non-significant results (Benè & Bergus, 2014; Secomb, 2008; Stone et al., 2013). In addition, the evaluation of PE has primarily relied on written examinations due to the fact that peer assessment questionnaires have not been fully developed or sufficiently validated (Speyer, Pilz, Van Der Kruis, & Brunings, 2011). Ten Cate and Durning indicated that a low level of evidence exists on the efficacy of PE (2007). Furthermore, the efficacy studies that have been completed are detracted from by their poor methodological quality (Ten Cate & Durning, 2007). Peer education is often led by instructors, leading to these instructors playing a significant role. This confounding variable violates the requirements for study validity, and highlights the necessity to design blind, controlled trials to ensure more consistent results. In addition, each peer educator has an individualised teaching-learning style that should be adjusted according to the peers being taught and peers` skills, the content of the course material, and the course’s setting and context (Ramm et al., 2015). Several contextual factors (such as confidence level and motivation) impact the learning-teaching process. Studies using a qualitative approach are capable of explaining the impact of these factors on student-related outcomes that are implicitly embedded in an educational process (Ramm et al., 2015; Secomb, 2008). This complex scenario increases the probability that the quantitative approach may provide an incomplete picture in relation to the impact of PE on learning outcomes. OBJECTIVES In light of the inconclusive results from previous studies and methodologically flawed studies, this study aimed to determine the effect of peer education on students’ academic achievement and explain the students’ lived experience during participation in a PE program. METHODS Study design The study employed an exploratory, sequential mixed-method design. The collection and analysis of quantitative data was performed primarily to Zarifnejad, Mirhaghi, and Rajabpoor 91 determine the effect of PE on students` academic achievement. The second, qualitative phase of the study was designed to explain the students’ lived experience of their participation in a PE program (Figure 1). The mixed method approach brings opportunity for in-depth insight, in which the findings of the first quantitative phase can be explained in terms of its humanistic and social aspects. In fact, PE has several effects on students as human subjects, including in the cognitive, psychological, and social domains, so it is worth reaching a comprehensive insight into PE implementation and outcomes in the academic setting by utilising mixed methodologies (Karimi Moonaghi, Dabbaghi, Oskouie, Vehviläinen-Julkunen, & Binaghi, 2010). Figure 1. Explanatory sequential mixed method design. Ethical principles This study was approved by the Ethics Committee of the Mashhad University of Medical Sciences in Iran and the Education Development Centre Review Board (ID: 921530). Each student gave written informed consent to participate in the interviews, which were performed in the nursing and midwifery school and generally took around 45 minutes. The first phase: quantitative A cluster-controlled, blind educational trial was performed in three classrooms in the school of nursing and midwifery of the Mashhad University of Medical Sciences during the second semester of the school year (February to June 2015). Each classroom had fewer than thirty students. Anaesthesia nursing, midwifery, and nursing students voluntarily participated in this study. A convenience sample of three classrooms was selected. Students were organised into three separate classrooms based on their major. All students were in the first year (second semester) of their undergraduate programs. Midwifery students with a physiology course as well as nursing students with an anatomy course were allocated to the intervention group that participated in the PE program, so they received PE in addition to faculty instruction. Anaesthesia nursing students with anatomy and physiology courses were allocated to the control group simultaneously and therefore they received faculty instruction without PE. Anatomy and physiology are both two-credit courses that are required for all majors during the second semester. Prior to intervention, students were fully instructed by the researchers with respect to PE and their roles in the program. Peer-education sessions were held every two weeks during the school year; the content of the courses was divided among volunteer students. Each student was allowed to lecture once during Does peer education increase academic achievement 92 the program in order to broaden participation in the PE program, with four students lecturing in each session. Eight to ten sessions, each lasting 90 to 120 minutes, were held during the program implementation period. Students were not forced to choose any specific kind of teaching style. A faculty member served as a facilitator, organising the time, coordinating the students, and directing all sessions. The faculty member supervised junior students during the sessions to ensure that students perform their role (such as lecturing and group discussion) effectively and reviewed presentations before each session. All students were taught by the same anatomy and physiology teachers, and all anaesthesia, midwifery, and nursing students received equal amounts of faculty instruction. The anatomy and physiology teachers were blinded to all conditions of the PE program. Anaesthesia nursing students were monitored through the entire semester to ensure they did not receive any other extra instructional support. Any anaesthesia nursing student who took part in extracu