Features of this study
The use of AR methodology and female students of a Sports and Science University who are training to become Japanese health and physical education teacher as subjects, and the fact that each phase of development of the cervical cancer education program process was performed based on their participation shows that the study is original.
This study provides appropriate educational material contents (input) and the description (output) of the student reports which can aid the training of Japanese health and physical education teachers who are in a social situation where it is difficult to provide cervical cancer education. This shows how much the content is transformed if the curriculum is structured. AR focuses on collaborative problem solving aimed at creating new wisdom [23]. In this study, we showed what kind of educational content should be provided (input) and the predictability of how students will be transformed (output). Thus, we provided basic materials that can contribute to improving the reproducibility of future programs.
The review and revision of the teaching material, which is the input part of the program in this study, was conducted with the involvement of many participants. The AR organized those involved in first-, second-, and third-person and focuses on engaging others through areas of mutual interest [24]. In this study, the main instructor is distinguished as a university instructor (first person), a student as a recipient of the program (second person), and an expert who closely examines appropriate educational content (third person). Until now, health education in Japan has been based on the teaching guidelines established by the government (Ministry of Education, Culture, Sports, Science, and Technology), and was guided by teachers. However, when specialized content such as cancer education is included, there is a restriction as only university teachers can teach it in the teacher training course. Thus, this study showed the process of developing an educational program while seeking the knowledge of experts and evaluating students’ responses to handling new learning content.
Appropriate cervical cancer education content
The contents shown in the prototype version in this study were primary, secondary, and tertiary prevention measures including coexistence with cancer survivors that have been made a column, and are common to Japanese cancer teaching materials [25, 26]. However, in the revised content, 'message from cervical cancer survivors' was deleted and placed as a column intended for 'the prevention of cervical cancer'. The messages from students, university lecturers, and gynecologists are predicated on the aim to transform female university students' behavior towards the prevention of cervical cancer, including acquiring HPV vaccination and undergoing screening, and to communicate that men are also person concerned. Cancer education for Japanese students focuses on proper awareness of cancer and proper understanding of cancer survivors. In cancer education for children, it was reported that after cancer prevention classes, the percentage of those who chose ‘people who overused cigarettes and alcohol’ as their image of cancer survivors was significantly higher [11].
There is also the possibility that improving cancer prevention awareness for those who equate a lung cancer patient to a smoker [27], and raising issues of cancer stigma [28], will nurture prejudices against cancer patients. In light of this, this study structured the cervical cancer education program to instigate behavioral changes in female university students, and reflect their intentions to use their knowledge to guide cancer education as teachers in the future. To optimize this program, it may be necessary to devise teaching methods, such as inviting cancer survivors as external instructors.
In the Japanese health and physical education teacher training course, knowledge of cancer can be taught in subjects such as public health and health education. However, from the results of the review of the prototype version of the teaching materials of this study, the gynecologists pointed out that cancer risk factors based on epidemiology studies and the limitations of population-based screening, including public health findings, are questionable. It is clear that Japanese cancer risk factors are smoking, infection, physical inactivity, and inadequate intake of vegetables and fruits [29]. In addition, effective guidelines for cervical cancer screening have also been developed, and they recommend that women aged 20 years and over get examined every other year [13]. On the other hand, there are limitations to providing generalized evidence on cancer prevention to the specific group of university students who are the subjects of this study, and caution is required.
The content of the educational materials on cervical cancer that was developed in this study is not merely evidence-based knowledge. The revised version of the teaching material content contains illustrations of the brushes used for cervical cancer screening and clothing to put on when going for the screening. It also has a column describing students’ experiences of the medical examination (Figure 2) [30]. It has been found that women in Japan and the rest of the world, psychologically resist screening with the use of internal examination tables [31, 32]. As such, female university students are vaguely aware of this and may be surprised when faced with the examination table. However, at the time of developing the educational materials, none of the teaching materials explained the specific contents of cervical cancer screening for students. The increase in the number of items related to screening in the revised version of the teaching material content may be the result of those study subjects who have experienced the screening strongly demanding that the content be enhanced.
The value of this program to the health and physical education teacher training course
In this study, we analyzed the content of the students’ reports and confirmed a certain number of statements about the deepening of knowledge and awareness of cervical cancer after the developed program was implemented. In addition, the extraction of the ‘preparation for action’ category confirmed that the subjects had a desire to convey the knowledge they had learned to others. Although the subjects were students training to become teachers of health and physical education, as current students, they would like to convey the acquired knowledge to their immediate families and friends, and as teachers to child students in the future. Such a change of consciousness that leads to peer education is because women form the majority of health volunteers who disseminate information on health in Japan [33]. These health volunteers have been working well with families and residents while playing a role in maintaining and fostering social capital such as community-based trust and networks [34]. Though there are differences between all 47 prefectures, the pass rate for the teacher recruitment test in Japan in the summer of 2019 was about two to 20 times for junior high school health and physical education, and five to 60 times for high school health and physical education [35]. This shows it is not easy to be hired as a health and physical education teacher. In addition, the percentage of female teachers in Japan is almost the lowest among the Organization for Economic Co-operation and Development countries [36]. As such, even if one obtains a license for teaching health and physical education, the opportunities for using it may be limited. Even under such circumstances, Japanese women have been reported to be able to improve their Quality of Life as full-time housewives [37] and to have a positive effect on others, especially their families. The ripple effect of providing the cervical cancer education program to female university students is significant.
Three categories were extracted in the content analysis of the student report descriptions. Among them, ‘preparation for action’ is a category that was derived from ‘improvement of awareness’ and ‘improvement of knowledge level’. The human mindset and the desire to convey to others when something valuable is learned are explained by social cognitive theory [38]. The Learning Partner Model, which incorporates this, shows the potential for cancer knowledge to spread to others [39, 40]. The concept of the learning pyramid, which shows that active learning has the greatest effect on conveying learning to others, is also shown [41]. Therefore, it is worthwhile to investigate the learning effect and the possibility of its diffusion in the future.
Limitations and challenges
This study has several limitations. First, it is not clear what parts of the teaching material development and cancer lectures, which are the input of this study, were used in the students; reports. Second, this study used the AR methodology and the subjects are only female university students in Tokyo, Japan. In addition, there may be subject bias. The Hawthorne effect, which feels more promising as a subject of the research per se, causes behavioral changes and eventually leads to favorable results [42]. Third, the most of participants in this study were female university students, and it is unclear from this study whether the results can be applied to male university students. To generalize the usefulness of the teaching materials developed in this study, it is necessary to compare the results with those of the validation conducted at a coeducational general university, which is being conducted in parallel with this study. Forth, the educational materials developed do not include recommendations for HPV vaccination for the prevention of cervical cancer. This was due to public overreaction to adverse reactions to the vaccine in Japan at the time of development. This is because boards of education and others avoided addressing the HPV vaccine issue in cancer education. However, active vaccination recommendations are scheduled to resume after April 2022. From now on, HPV vaccination recommendations can be handled in education.
On the other hand, this study also has some strengths. We used AR in this study. The results of the study showed aspects of Community-Based Participatory Research (CBPR) [43], as there is bidirectional learning and acquisition of knowledge between researchers and the community - in the case of this study, the student population. For this reason, this study has the potential to lead to students being empowered and to knowledge dissemination activities. While paying attention to the interpretation of the results based on the limitations of this study described above, it is necessary to accumulate practices of cervical cancer education programs through education for female university students. Therefore, it is needed to plan to compare the effectiveness of this material and educational program using a literacy scale to compare behavior change (e.g., cancer screening uptake rates) among groups of students with and without peer education.