## 5 Discussion
Consequently, although MR Quest 3 shows the highest post-learning score mean (7.95), the ceiling effect likely limits the detection of additional improvements in knowledge. Furthermore, statistical analysis of the learning gains (post-pre) does not reveal significant differences between methods, reinforcing the notion that the ceiling effect may have masked any further potential improvements in knowledge for participants using MR Quest 3. In conclusion, while MR Quest 3 demonstrates the highest post-learning knowledge scores, as well as the highest medians and means, the ceiling effect may have influenced the results, potentially limiting the ability to capture further improvements in knowledge. Nonetheless, these findings highlight the effectiveness of the method compared to others. In any case, to address this limitation, future studies could consider increasing the number of questions in the questionnaire to allow for a greater scoring range, which would provide more capacity to capture further knowledge improvements and reduce the potential for a ceiling effect. All four of the learning methods were effective in increasing knowledge (post-scores), regardless of gender or age. However, the role of gender in learning outcomes and preferences remains a debated issue. The findings of this study align with the broader, mixed results reported in the literature. Numerous studies have explored gender differences in learning outcomes and preferences within immersive environments like VR, AR, and MR, yet no consensus has been reached. For instance, some research indicates gender-based disparities in attitudes and performance. Studies in VR environments, found men reporting more positive attitudes [27] or outperforming women in specific tasks [28]. Similarly, in AR-based studies, differences in spatial abilities and preferences have been observed, with some results favoring men in terms of spatial abilities [29] and others favoring women with regarding preferences [30; 31]. Conversely, other research highlights the absence of significant gender differences in performance within both VR (e.g., [32; 33]) and AR environments (e.g., [34]), as well as in AR acceptance [35]. Furthermore, studies in MR contexts, such as [PERSON] et al. [36], have consistently reported no significant impact of gender on academic performance. The inconsistent findings across these studies suggest that the influence of gender may be context-dependent, varying with the specific tasks, technologies, and educational settings involved. Our results contribute to this ongoing discourse by examining gender as a potential factor influencing learning outcomes and preferences. Considering the complexity and variability of previous findings, further research is needed to better understand the relationship between gender and the use of immersive technologies in educational settings, aiming to achieve gender equality in outcomes. Usability has been widely recognized as a key factor in enhancing educational effectiveness [37]. [PERSON] et al. [38] suggest that user-friendly systems allow learners to focus more deeply on the content. In our study, patients evaluated their experience on the Short-UEQ questionnaire as excellent, with scores placing our applications within the top 10% across all three benchmarked UEQ variables [22]. These findings suggest that the MR and the ARapplications effectively support patients in concentrating on learning about carbohydrate content in different foods. However, when comparing the three applications two by two (Table 5), the MR with Quest 3 and the AR applications provide significantly better ratings than the MR application with Quest 2. When comparing AR and MR with Quest 3, no statistically significant differences are observed, but patients rated the MR experience with Quest 3 better. With regard to the correlations (Table 9), it is worth mentioning that the number of significant correlations differs when using the entire sample compared to analyzing the correlations within the three experimental groups.