Active learning of medical students in Taiwan: A realist evaluation

Active learning of medical students in Taiwan: A realist evaluation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Active learning of medical students in Taiwan: A realist evaluation Chien-Da Huang, Hsu-Min Tseng, Chang-Chyi Jenq, Liang-Shiou Ou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-34476/v2 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Dec, 2020 Read the published version in BMC Medical Education → Version 2 posted 7 You are reading this latest preprint version Show more versions Abstract Background: Active learning is defined as any instructional method that engages students in the learning process. Cultural differences in learning patterns can play an important role in engagement with active learning. We aimed to examine process models of active learning to understand what works, for whom and why. Methods: Forty-eight sixth- and seventh-year medical students with experience of active learning methods were purposively selected to participate in ten group interviews. Interactions around active learning were analysed using a realist evaluation framework to unpack the ‘context-mechanism-outcome’ (CMO) configurations. Results: Three core CMO configurations, including cultural, training and individual domains, were identified. In the cultural context of a strong hierarchical culture, the mechanisms of fear prompted students to be silent (outcome) and dare not give their opinions. In the training context of teacher-student familiarity alongside teachers’ guidance, the mechanisms of learning motivation, self-regulation and enthusiasm were triggered, prompting positive learning outcomes and competencies (outcome). In the individual context of learning how to learn actively at an early stage within the medical learning environment, the mechanisms of internalisation, professional identity and stress resulted in recognising active learning and advanced preparation (outcomes). Conclusions: We identified three CMO configurations of Taiwanese medical students’ active learning. The connections among hierarchical culture, fear, teachers’ guidance, motivation, the medical environment and professional identity have been shown to affect the complex interactions of learning outcomes. Fear derived from a hierarchical culture is a concern as it is a significant and specific contextual factor, often sparking fear with negative outcomes. Educational Philosophy and Theory Internal Medicine Realist evaluation culture active learning hierarchy medical students Background Active learning comprisesan interactive approach to education and training designed to engagelearners as they strive to acquire and understand knowledge[1]. Active learning is grounded in constructivist learning theories [2]whereby learners interacting with their subject matter facilitates the construction and ownership of knowledge. Active learning is also related to adult learning theory [3] which is founded on the principles that effective training should be relevant, engaged, active, and learner-centred. The active learning classroom is one that de-emphasises lectures and other teacher-centred forms of instruction in favour of engaged class environments that are learner-centred. Thus, students are not empty vessels into whom faculty pour knowledge [4, 5].Rather, they read and learn information on their own, with their instructors acting as coaches and mentors [6]. Active learning activities include flipped classroom, problem-based learning (PBL), teamwork, team-based learning (TBL), debates, self-reflection and case-based learning (CBL), that promote students’ engagement and reflection to encourage an exploration around their own attitudes and values, and facilitating their motivation to learn and develop their skills [6-8]. Among these activities, PBL promotes thoughtful engagement, encourages analytical thinking and reasoning to foster the integration and application of knowledge and are designed around well-defined learning objectives [9].In addition, the interactive teaching/learning methods such as TBL and CBL can impart sustainable knowledge and performance change and can lead to high satisfaction among students, as compared with conventional lecture-based classes [10]. However, what we do not know is whether these claims to efficacy are equal across different culture contexts. Culture lies at the very core of how we learn relate to others and think[11].Understanding the deep cultural differences between Western and Eastern societies about learning and development provide us with a deeper clarityaround different motivations for learning. It has been argued that students from Western cultures have a motivationfor learning, which follows some key epistemological themes.By contrast, according to Li, Chinese students today have inherited a Confucianist learning tradition [12]. These different motivations for learning can be explained in term of differences in cultural dimensions: namely collectivist vs individualist cultures. Thus, it is important to examine differences in perception and the role that various dimensions of culture play in developing preferences for active learning between Western and Eastern cultures. Realist methodology attempts to understand how particular mechanisms (usually internal and hidden to the individual) arise within different contexts and lead to a variety of outcomes.In this study, we specifically examine active learning within a Taiwanese medical education setting through the lens ofa realist evaluation by using a ‘context–mechanism–outcome (CMO)’ configuration to explore the complex interactions for the development of a transferable theoretical model of what works, for whom and why. Methods Research design The study used a qualitative approach and data was collected using focus groups (Table 1). The study focused on the perceptions of medical students’ actual experiences of active learning. Further, it examinedboth the process and the factors of active learning on stakeholders’ interpretation and actions, as well as the eventual outcomes of the integrated curriculum. It aimed to understand the interactions between the contextual environment of active learning methods and the mechanisms of stakeholders’ interpretation and action around the active learning.The research was approved by the institutional review board (Chang Gung Medical Foundation Institutional Review Board, CGMF-IRB) with certification of approval (104-9723B). The research process was also regulated and supervised by CGMF-IRB. Participants A total of n=48 participants were recruited, comprising: n=28 (58%) males, including n=24 (58% male) sixth-grade students and n= 24(58% male) seventh-grade students. The participants’ mean ages were 25.08 [24-31] years. Forty-eight sixth- and seventh-year medical students with experiences of active learning methods were purposively selected to participate in ten focus group interviews.The lists of students with experience of active learning in Chang Gung Memorial Hospital (CGMH) Linkou branch were first collected from the clerkship and internship in department of internal medicine, then purposely selected by investigators and invited by telephone.Informed consent was obtained from all participants. Participants were informed of their right to withdraw their consent at any stage of the study without penalty. Each interview lasted approximately one hour. All interviews were audio-recorded, and a small monetary reward (New Taiwan Dollar 500) was given to thank the participants after the interviews. Realist evaluation We used a realist theoretical approach. Realist evaluation was first proposed as a way of understanding the efficacy of complex interventions by Pawson and Tilley’s in their seminal work, ‘Realistic Evaluation’ [13].Realism,[14]is a philosophical viewpoint which suggeststhat material and social worlds are grounded in cause-effect linkages.As such, realist evaluation is used to evaluate the impact by considering the contextual environment in terms of three key connecting elements: contexts, mechanisms and outcomes. This theory-based evaluation approach beginswith a clarification of the ‘intended programme theory’ that elucidates which mechanisms (often hidden, psychological processes) are likely to operate inwhich context and what outcomes are subsequently likely to occur[15]. From this initial ‘intended programme theory’, an investigation into the actual mechanisms, contexts and outcomes was undertaken that enables us to develop an‘actualprogramme theory’. Through this process we understood the widest range of factors that impact on engagement with (for example) active learning. Realist evaluation therefore is a theory-driven approach focused on understanding the mechanism of what works, for whom, in what circumstances and how programmes work (or did not work) in their contextual setting, rather than simply measuring outcomes [13, 14, 16]. Qualitative exploration: We explored qualitatively – via group interviews – learners’ (n=48) perceptions and experiences of active learning.Group interviews took advantage of group dynamics by stimulating conversation among participants [17]. The guiding principle was that the psychological processes help people to identify, reflect on, and clarify their own views and attitudes [18].We used groups as our methodology because of its ability to elicit group and individual responses, as well as to derive information on ‘hidden agendas’, its practical utility, and the availability of institutional expertise [19]. We also included a narrative approach to interviewing to enable us to ground participants’ comments in real experiences [20]. To ensure a wide range of experiences, a purposive sample was used: efforts were made to recruit students and clinical teachers with diverse backgrounds and attitudes (recruitment will announce that ‘all points of view are welcome and encouraged’). Following consent, group interviews wereaudio-taped and conducted by staff and faculty not associated with student evaluation. Both staff and students remained anonymous throughout. Audio-tapeswere later transcribed in their entirety. In addition, the research assistant took field notes during the groups, including observations of group process, and records keywords, sentence fragments, and summaries of basic ideas/concepts. Data analysis Data collection occurred between December 2016 and July 2017.Research assistants (SW, WHC, CYS)did the focus group interviews. Audio-recorded interviews were transcribed verbatim and anonymized.All interview transcripts were entered into the ATLAS software package in Chinese. The data were analysed inductively by 4 researchers (CDH, HMT, CCJ, LSO) and 2 research assistants (WHC, CYS). We used a combination of descriptive, evaluating and causation codes for coding.The research team analysed data with a focus on CMO configurations.All researchers began by analysing the same transcripts in order to develop the initial coding framework. Following this, one researcher (WHC) repeatedly read the transcripts individually and undertook data coding. All data were discussed with the wider team of researchers, who then feedbacked and assisted in developing the coding framework. We moved back and forth between the data sources, the codes, and the realist framework to synthesize relevant aspects of the CMOs [21].In connecting strategy, we look for relationships that connect statements and events into a coherent whole [22].After completing the initial coding of all transcripts for CMOs in Chinese, the excerpts were translated to English. A wider team for English data (including LVM) then identified and clarified the CMO configurations. We summarized the data relevant to each CMO theory in line with the realist framework[13].This analytic process involved all authors in several research meetings in CGMERC, examining each theory for validity to reach a consensus. Results Context 1: Cultural domain: hierarchical culture (Table 2) In the context of hierarchical culture, the mechanisms of fear/boredom came about, prompting students to be silent and dare not to give opinions. This is a significant and specific context in Taiwan sparking fear with negative outcomes. i. Hierarchical culture (top-down criticism) (C) → fear/boredom (M) → dare not give opinions (O) M-Y7 (7B 1:710-711): "...Some [students] dare give their own opinion (M), but then was disapproved [by the teacher] (C), and then he [the disapproved student] stopped giving his opinions afterwards…(O)" F-Y7 (7C 1:692-694): "Sometimes when I [a student] am taking some teachers' classes, I always feel a sense of distance (C). Maybe I feel more stressed. Maybe nobody dares to answer questions (O) when the teacher asks because they are afraid of giving wrong answers...(M)” M-Y7 (7B 1:722-726): "... Some teachers actually ... well, you could feel the sense of distance when he (teacher) is teaching the class (C). He just keeps talking and talking ... talking about what he knows, or talking about what he is professional about. But we (students) feel like we are dying while we are listening (O). Maybe it's because what he talks is too deep or too much, or something else. Or maybe his speaking is quite monotonous... (M)” Context 2: Training domain (Table 3): interaction between teachers and students, teacher-student familiarity and teachers’ guidance In the contexts of interaction between teachers and students, teacher-student familiarity and teachers’ guidance, learning motivation, self-regulation and enthusiasm were triggered, prompting positive learning outcomes and competencies. ii. Good interaction between teachers and students (C) → Motivation is triggered (M) → Students give their opinions (O) F-Y7 (7C 1:694-696): “...About some teachers' teaching methods ... well, he [teacher] would discuss things with you [student] in a friendly way, so that you would speak more (O). He will not confront you directly and say you are wrong (C). He would tell you how to do in a better way, which helps us [students] have more courage to think and to answer (M)." iii. Teachers’/students’ familiarity for active learning (C) → self-regulation and enthusiasm (M) → improved learning outcomes (O) M-Y6 (6D 2:674-676): "Teacher's enthusiasm for delivering knowledge also deeply influence his students in terms of a the tone or attitude (C). These affect students' desire for pursuing knowledge (M) and affect their learning outcome (O)." iv. Teacher's guidance (C) → motivation and enthusiasm (M) → Positive learning competencies (O) M-Y7 (A3 10:168-171): Because this is our first time to encounter this case, we don't know which way would be best to address this.(C) --- It's faster than when you are searching things without any direction"(O). M-Y7 (7A 1:167-176): "...Good teachers would teach us how to solve problems by guiding rather than by directly giving a standard answer which is already in his mind ... some teachers are still able to guide us step by step to the main issues even if we are rambling on and on and on [about our answers] (C). There is a big difference in the motives when we are talking about ‘directly giving the standard answer’ and ‘reaching the standard answer through discussion’ since the processes are very different (M).” Context 3: Individual domain (Table 4). In the context of learning “how to learn actively” early on, in the medical learning environment, the mechanisms of internalization, physician identity and stress resulted in recognizing active learning and advanced preparation. v. Learning "how to learn actively" early on (C) → internalization (M) → recognizing active learning (O) M-Y7 (A1 5:1456-1492): “You just pick up one topic from the general chemistry to do CBL, to train your thinking process (O). You have learned general biology, so you just pick up [one topic] from general biology to train your thinking process. After that, people like us would just be able to understand systems [thinking process] ... would just be able to get connected to the system ... (M) It [the thinking process] didn’t exist in the very beginning (C). M-Y7 (7A 1:105-107): "…Four years ago, passive learning was still dominant in our education. We were required to keep memorising things and take exams (C). And then suddenly we were required to shift to active learning, which actually is not easy (M).” vi. Medical learning environment: External effects (peers, teachers and clinical duty) (C) → professional identity and stress (M) → preparation in advance (O) F-Y6 (6E 3:63-65): "Sometimes somebody would tactically use the reserve psychology on you, saying 'How can you be so useless, of not even knowing this? (C)’ And then you would think, 'How can I lose this game? (M)’ Then you would go and read up on it, until you really understand it (O).” F-Y6 (6B 2:64-67): "But I think, if you think these things are important for taking care of patients, for example ... like how to give nutrients, or give some fluids ... (C) because I think, since we are going to be interns (M), we might need to understand something fundamental or basic ... (O). Discussion: In the age of information explosion, active learning could help everyone to becomelifelong learners and hence be more capable of responding to the rapid changes in the future.In this study, we identified three CMO domains of medical students’ experiences of active learning. For the first: the context of hierarchical culture, the mechanisms of fear/boredom came about, prompting students to be silent, dare not to give opinions. For the second training domain, in the contexts of interaction between teachers and students, teacher-student familiarity and teachers’ guidance, learning motivation, self-regulation and enthusiasm were triggered, prompting positive learning outcomes and competencies. For the third individual domain, in the context of learning “how to learn actively” from early on, and medical learning environment, the mechanisms of internalization, professional identity and stress, resulted in recognized active learning and advanced preparation. These CMOs were synthesized into a process model of active learning. Cultural domain Cultural membership, issues of authority and respect, and language proficiency were identified as having a direct influence on the clinical education process [23].Active learning, such as student-centred and problem-based methods rooted in Western culture, may not be of a truly international nature and its compatibility with non-Western cultures has been challenged [23, 24].Looking at the culture domain, we can see that our society will experience more difficultly with implementing active learning. East Asian education is often referred to as Confucian-heritage education, wherevirtue is achieved primarily bylearning from teachers,imitating their attitudes [25, 26].Confucian culture has undoubtedly been a significant influence on thinking on all aspects of society, unmatched by any other school of thought[27]. It is one of the most frequently cited social factors in healthcare research in East Asian countries[28]and has also significantly influenced the learning styles in medical education in these countries, which need to be questioned and understood within the complex of local cultural influences[29, 30].Students therefore are more likely to limit their individual development by depending purely on the teacherteaching, and their ideas,which inhibits students from doing their own critical thinking. Moreover, students are also influenced by the oriental concept of "respecting teachers" while learning from them. In this study, we use qualitative realist evaluation. The context of a hierarchical cultureis consistent with previous research that report similar findings, including hierarchy interfered with non-Western students’ applicationof PBL [31].Uncertainty, tradition, hierarchy and achievement have often been identified as more prominent in non-Western than in Western cultures[32, 33].In addition, fear and boredomare the mechanism derived from a hierarchical culture. This is a concern as it is a significant and specific context for Taiwan, sparking fear with negative learning outcomes.This suggests a certain incongruity between active learning methods and non-Western cultures. Thus, it complicates the straightforward transfer of active learning to such cultural contexts and the globalization of active learning does not postulate uniform processes and outcomes.Culturally sensitive alternatives might be considered [31]. Trainingdomain The qualities of a good clinical teacher in the context of interaction between teachers and students are important. Sutkin found that excellent clinical teaching, although multifactorial, transcends ordinary teaching and is characterized by inspiring, supporting, actively involving, and communicating with students[34].Research has identified thatmedical students use dual processing to rate the effectiveness of classroom teachers; an interaction between the conscious appraisal of teaching attributes – specifically, the perceived charisma of the teacher – and the subconscious rating of variables that portray stereotypes, such as physical appearance [35].With regard to the interaction between teachers and students, as the context of the effectiveness of excellent teachers, in this study we identified the mechanism of motivation was triggered,resulting in students giving their opinions. In many East Asian cultures schooling primary to secondary education is heavily influenced by a passive learning culture [36, 37], where reproducing teachers’ statements is strongly emphasizedand where teachersrecommended textbooks serve as the main sources of information, there is little opportunity for active learning. However, different learning contexts do not keep East Asian learners from being self-regulated. Awareness of their unique identity leads them to view learning tasks as high-stakes, and to initiate learning strategies that involve self-regulation[36].Thus, the teacher-student’s familiarity of active learning without traditional and teacher-centred education is an important context.andstudents’ self-regulation plays the important role for the mechanism, resulting in positive learning outcomes. The development of active learning relies on teacher's guidance and encouragement. Facilitator’s guidance was a crucial aspect of this process, particularly in situations when students were new to the PBLprocess[38].In a Japanese context of medical education, medical students in Japan have difficulty extracting problems in PBL scenarios without instruction from teachers[39].In fact, exposing Year 1 students to the independent learning environment of PBL without providing them with adequate guidance may, rather than promoting the development of SDL skills, cause them to become severely dependent on tutors, predetermined learning objectives and on rote learning in order to ‘survive’[40, 41]. Individual domain In the context of learning “how to learn actively” from early on, the mechanism of internalization results in recognizing active learning.The lack of readiness of active learning strategies that require self-regulation is problematic in East Asian medical students [36].They expect their teachers to instruct, and themselves to be instructed or “spoon-fed”[25].In a Japanese study, medical students consistently rely on teachers’ explanatory lectures and have low motivation to study after a pilot progress test [42].Student maturity has also been identified as an important factor for active participation [43].Thus, the learning context of "how to learn actively" from early on promotes internalization of active learning. This may cause them to view learning tasks as high-stakes, and lead to the recognition of active learning strategies. In the context of the medical learning environment, the mechanisms of physician identity and stress result in studying ahead of time, particularly in the context of clinical setting where they may experience questions testing their knowledge from seniors. External pressure comes from peers, teachers and clinical responsibilities. They learn to think, act and feel like doctors by gradually taking up meaningful activities in the clinical context which help them to prepare for lifelong learning[44].During this process, they will become full members of a clinical community of practice and collaborate in daily activities [45, 46].Learners who are new to a clinical setting with external pressure from peers, teachers and clinicalresponsibilities are in an active struggle to manage themselves as they are in the process of constructing their professional identities in the clinical training context [47, 48].This helps process helps them to develop a new identity, first as a medical trainee and ultimately as a medical professional.Physician identity formation as a unique medical professional in the clinical setting led to the perception that the medical students as physicians had to allow patients to ask them about any wide-ranging medical problems[45]. Immersion in a responsible individual role, which promotes physician identity formation in the clinical setting, causes medical students to view learning tasks as high-stakes, and to initiate learning strategies in an active learning manner[36]. Medical students need to feel like a valuable member of the clinical team, by thinking, acting and feeling like a future doctor.Therefore, helping them to engage in effective active learning in a clinical setting begins with helping them to understand what learning is and what effective learning strategies are in a clinical setting. Finally, it helps learners create a professional identity they want to develop, resulting in promoting life long learning. Limitations There are several limitations in this study. The research was conducted in a single medical institution in Taiwan by analyzing as a homogenous group, therefore there all the relevantCMO configurations for Asian culture and medical schools may not have been identified. However, our CMO configurations identify important patterns that are shared with similar institutions, cultures and contexts and offer wider relevance.We just collected qualitative data, so limited ability to make statements about the 'academic' outcome/merit of active learning. Our participants had variable exposures to all forms of active learning methods, such as PBL, CBL, and TBL and therefore we cannot assume that our findings apply to all forms of active learning, which were not exhaustively studied. We referred to TBL, CBL and PBL as key approaches to active learning. However, the emphasis of each of these is different in the extent to which they are learner or tutor-driven, the roles expected of the learners, the degree of peer learning and the roles required of the teacher. Finally, there are many factors affecting the quality of active learning methods, especially the facilitator role and tutorial structure. Further study on teachers’ perceptions is warranted. Conclusion Our realist analysis is useful for practice, revealing complex interactions in the learning environments and in learners’ work. We identified three key CMO domains of medical students’ experiences of active learning, including cultural, training, and individual domains. The connections between hierarchical culturewith fear/boredom; teachers’ guidance with motivation; and the clinical environment with professional identity have been identified as affecting learning outcomes. The CMO configurationsidentified around active learning can help improve the sustainability of learned skills. Fear derived from hierarchical culture is a concern in Asian contextthat requires further investigation as it significantly impacts on learning producing negative outcomes in the learning environments and in learners’ work. Abbreviations: CMO: context-mechanism-outcome PBL: problem-based learning TBL: team-based learning CBL: case-based learning CGMF-IRB: Chang Gung Medical Foundation Institutional Review Board CGMH: Chang Gung Memorial Hospital C: context M: mechanism O: outcome Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Chang Gung Memorial Hospital and Chang Gung University Institutional Review Board (IRB No. 104-9723B).The consent we obtained from study participants was written. Consent to publish No individual’s data is included in this study. Availability of data and materials The data are kept at the Chang Gung Medical Education Research Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan. Any questions or requests regarding the data can be addressed to Chien-Da Huang ( [email protected] ). Competing interests The authors declare that they have no competing interests. Funding This study was supported by Chang Gung Memorial Hospital, Taiwan [CDRPG 3F0051]. The role of the funderis the teaching hospital of the study participants from Chang Gung University College of Medicine. Authors’ contributions CDH contributed to development of study, analysis and interpretation of data, writing, reviewing and finalizing the manuscript.HMTparticipated in study conceptualization, analysed data, and revised the manuscript.CCJ and LSO contributed to the conception and design of the study, interpretation of data, active learning education, and revised the manuscript.All authors have read and approved the finial version of the manuscript. Acknowledgements We wish to express our gratitude to Professor Lynn Monrouxe (The University of Sydney, Cumberland Campus, Australia), Professor Jan Illing and Dr. Amelia Kehoe (Newcastle University, UK) for their reviews and comments on earlier versions of this manuscript and to Ms. Eve Huang from CG-MERC who translated the data from Mandarin to English.We thank the research assistants Siva Wang (SW), Wen-Huei Chang (WHC) and Chia-Yi Sheng (CYS) who participated in this study. Authors’ information Chang Gung Medical Education Research Center 1 , Department of Medical Education 2 , Thoracic Medicine 3 , Nephrology 4 , and Pediatrics 5 , Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taipei, Taiwan; Chang Gung University;Department of Health Care Management 6 , Chang Gung University, Chang Gung University, College of Medicine, Taipei, Taiwan. References We can teach the way we were taught, or we can teach the way people learn . In . : Sierra Training Associates, Inc.; 2007. Shepard LA: The role of assessment in a learning culture . Educ Res 2000, 29 (7):4-14. Knowles M: Andragogy in Action . San Francisco: Jossey-Bass; 1984. Graffam B: Active learning in medical education: strategies for beginning implementation . Med Teach 2007, 29 (1):38-42. Dori YD, Belcher J: How does technology-enabled active learning affect undergraduate students’ understanding of electromagnetism concepts? The Journal of the Learning Sciences 2005, 14 (2):243-279. McLaughlin JE, Roth MT, Glatt DM, Gharkholonarehe N, Davidson CA, Griffin LM, Esserman DA, Mumper RJ: The flipped classroom: a course redesign to foster learning and engagement in a health professions school . Acad Med 2014, 89 (2):236-243. Freeman S, O'Connor E, Parks JW, Cunningham M, Hurley D, Haak D, Dirks C, Wenderoth MP: Prescribed active learning increases performance in introductory biology . CBE life sciences education 2007, 6 (2):132-139. Kumar V, Gadbury-Amyot CC: A case-based and team-based learning model in oral and maxillofacial radiology . J Dent Educ 2012, 76 (3):330-337. Vernon DT, Blake RL: Does problem-based learning work? A meta-analysis of evaluative research . Acad Med 1993, 68 (7):550-563. Smits PB, Verbeek JH, de Buisonje CD: Problem based learning in continuing medical education: a review of controlled evaluation studies . BMJ 2002, 324 (7330):153-156. Nisbett RE, Peng K, Choi I, Norenzayan A: Culture and systems of thought: holistic versus analytic cognition . Psychological review 2001, 108 (2):291-310. Li J, Li QL, Li J, Chen ML, Xie HF, Li YP, Chen X: Comparison of three problem-based learning conditions (real patients, digital and paper) with lecture-based learning in a dermatology course: a prospective randomized study from China . Med Teach 2013, 35 (2):e963-970. Pawson R, Tilley N: Realistic Evaluation . London: Sage; 1997. Wong G, Greenhalgh T, Westhorp G, Pawson R: Realist methods in medical education research: what are they and what can they contribute? Med Educ 2012, 46 (1):89-96. Westhrop G: Realist impact evaluation: an introduction . In . : Methods Lab, Overseas Development Institute (ODI), the Australian Department of Foreign Affairs and Trade (DFAT) and BetterEvaluation; 2012 September: 1-12. Wong ELY, Yeoh EK, Chau PYK, Yam CHK, Cheung AWL, Fung H: How shall we examine and learn about public-private partnerships (PPPs) in the health sector? Realist evaluation of PPPs in Hong Kong . Social Science and Medicine 2015, 147 :261-269. Freeman T: 'Best practice' in focus group research: making sense of different views . J Adv Nurs 2006, 56 (5):491-497. Stalmeijer RE, McNaughton N, Van Mook WN: Using focus groups in medical education research: AMEE Guide No. 91 . Med Teach 2014, 36 (11):923-939. Lie D, Shapiro J, Pardee S, Najm W: A focus Group Study of Medical Students' Views of an Integrated Complementary and Alternative Medicine (CAM) Curriculum: Students Teaching Teachers . Med Educ Online 2008, 13 (3):1-13. Riessman C: Narrative methods for the human sciences . Thousand Oaks, CA: Sage Publications; 2008. Saldana J: The coding manual for qualitative researchers . London: Sage; 2013. Miles MB, Huberman AM, Saldana J: Qualitative data analysis: a methods sourcebook : Thousands Oak (CA): Sage.; 2014. Ladyshewsky R: East meets West: The influence of language and culture in clinical education . Aust J Physiother 1996, 42 (4):287-294. Bleakley A, Brice J, Bligh J: Thinking the post-colonial in medical education . Med Educ 2008, 42 (3):266-270. Ho DYF, Peng SQ, Chan SFF: Authority and learning in confu- cian–heritage education . In: Multiple competencies and self-regulated learning: implications for multicultural education. edn. Edited by C.Y. C, Salili F, Hong YY. North Carolina: Information Age Publishing, Inc.; 2001: 29-48. Tweed RG, Lehman DR: Learning considered within a cultural context. Confucian and Socratic approaches . Am Psychol 2002, 57 (2):89-99. Guo Z: Chinese Confucian culture and the medical ethical tradition . J Med Ethics 1995, 21 (4):239-246. Koh EK, Koh CK: Caring for older adults: the parables in Confucian texts . Nurs Sci Q 2008, 21 (4):365-368. Chen LC, Reich MR, J. R: Medical Education in East Asia: Past and Future : Indiana University Press; 2017. Chiavaroli N, Huang CD, Monrouxe L: Chapter 16 Learning Medicine with, from and through the Humanities . In: Understanding Medical Education. 3rd edn. Edited by Swanwick T, Forrest K, O'Brien BC. Hoboken, NJ: Wiley-Blackwell; 2019. Frambach JM, Driessen EW, Chan LC, van der Vleuten CP: Rethinking the globalisation of problem-based learning: how culture challenges self-directed learning . Med Educ 2012, 46 (8):738-747. Al Kadri HM, Al-Moamary MS, Magzoub ME, Roberts C, C.P.M. vdV: Students’ perceptions of the impact of assessment on approaches to learning: a comparison between two medical schools with similar curricula . Int J Med Educ 2011(2):22-52. Leung DYP: Examining the cul- tural specificity of approaches to learning in universi- ties in Hong Kong and Sydney . J Cross Cult Psychol 2008, 39 (3):251-266. Sutkin G, Wagner E, Harris I, Schiffer R: What makes a good clinical teacher in medicine? A review of the literature . Acad Med 2008, 83 (5):452-466. Rannelli L, Coderre S, Paget M, Woloschuk W, Wright B, McLaughlin K: How do medical students form impressions of the effectiveness of classroom teachers? Med Educ 2014, 48 (8):831-837. Matsuyama Y, Nakaya M, Okazaki H, Leppink J, van der Vleuten C: Contextual attributes promote or hinder self-regulated learning: A qualitative study contrasting rural physicians with undergraduate learners in Japan . Med Teach 2018, 40 (3):285-295. Nisbett RE: The geography of thought: how Asians and Westerners think differently and why . In . , edn. New York (NY): Free Press.; 2003: p.xxii. Anderson V, Reid K: Students' perception of a problem-based learning scenario in dental nurse education . Eur J Dent Educ 2012, 16 (4):218-223. Yoshioka T, Suganuma T, Tang AC, Matsushita S, Manno S, Kozu T: Facilitation of problem finding among first year medical school students undergoing problem-based learning . Teach Learn Med 2005, 17 (2):136-141. Miflin BM, Campbell CB, Price DA: A conceptual framework to guide the development of self-directed, lifelong learning in problem-based medical curricula . Med Educ 2000, 34 (4):299-306. Miflin BM, Campbell CB, Price DA: A lesson from the introduction of a problem-based, graduate entry course: the effects of different views of self-direction . Med Educ 1999, 33 (11):801-807. Matsuyama Y, Muijtjens AM, Kikukawa M, Stalmeijer R, Murakami R, Ishikawa S, Okazaki H: A first report of East Asian students' perception of progress testing: a focus group study . BMC Med Educ 2016, 16 (1):245. White C, Bradley E, Martindale J, Roy P, Patel K, Yoon M, Worden MK: Why are medical students 'checking out' of active learning in a new curriculum? Med Educ 2014, 48 (3):315-324. Berkhout JJ, Helmich E, Teunissen PW, van der Vleuten CPM, Jaarsma ADC: Context matters when striving to promote active and lifelong learning in medical education . Med Educ 2018, 52 (1):34-44. Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y: Reframing medical education to support professional identity formation . Acad Med 2014, 89 (11):1446-1451. Weaver R, Peters K, Koch J, Wilson I: 'Part of the team': professional identity and social exclusivity in medical students . Med Educ 2011, 45 (12):1220-1229. Denson JL, Jensen A, Saag HS, Wang B, Fang Y, Horwitz LI, Evans L, Sherman SE: Association Between End-of-Rotation Resident Transition in Care and Mortality Among Hospitalized Patients . JAMA 2016, 316 (21):2204-2213. Bernabeo EC, Holtman MC, Ginsburg S, Rosenbaum JR, Holmboe ES: Lost in transition: the experience and impact of frequent changes in the inpatient learning environment . Acad Med 2011, 86 (5):591-598. Tables Table 1: Focus group interview guide for medical students Opening Question 1. Tell us what active learning means to you. Introductory Question 2. What sections of the integrated curriculum do you feel are the mostly related to your understanding of active learning and why? Transition question 3. Think back to your experiences in the integrated curriculum. To what extent has this has improved your active learning? Which aspects? How? Why? Tell me about a specific situation to help me understand. Key Questions 4. How would you compare the rigor of active learning (CBL, TBL, and PBL) with passive learning (other didactic lectures)? (Workload?) 5. What is your role in the active learning process? 6. In which ways did the process of active learning pose barriers to your learning? Tell me about a specific situation to help me understand. 7. What was the most challenging part of active learning in terms of planning and preparation? Expectations? Tell me about a specific situation to help me understand. 8. How can we improve active learning across the curriculum? End Question 9. Do you have any other comments about the active learning in curriculum? Table 2. Context 1: Cultural domain: hierarchical culture Context Mechanism Outcomes Hierarchical culture (top-down criticism) Fear Boredom Dare not give opinions Table 3. Context 2: Training domain: interaction between teachers and students, teacher-student familiarity and teachers’ guidance Context Mechanism Outcomes Good interaction between teachers and students Motivation Students give their opinions Teachers’/students’ familiarity for active learning Self-regulation Improved learning outcomes Teachers’ guidance Enthusiasm Motivation Positive learning competencies Table 4. Context 3: Individual domain: Context Mechanism Outcomes Learning "how to learn actively" from early on Internalization Recognizing active learning Medical environment: External effects (peers, teachers, and clinical duty) Physician identity Stress Preparation in advance Cite Share Download PDF Status: Published Journal Publication published 03 Dec, 2020 Read the published version in BMC Medical Education → Version 2 posted Editorial decision: Accept 18 Nov, 2020 Review # 1 received at journal 11 Nov, 2020 Reviewers invited by journal 04 Nov, 2020 Reviewer # 1 agreed at journal 04 Nov, 2020 Editor assigned by journal 01 Oct, 2020 Submission checks completed at journal 30 Sep, 2020 Editor invited by journal 30 Sep, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Active learning is grounded in constructivist learning theories [2]whereby learners interacting with their subject matter facilitates the construction and ownership of knowledge. Active learning is also related to adult learning theory [3] which is founded on the principles that effective training should be relevant, engaged, active, and learner-centred. The active learning classroom is one that de-emphasises lectures and other teacher-centred forms of instruction in favour of engaged class environments that are learner-centred. Thus, students are not empty vessels into whom faculty pour knowledge [4, 5].Rather, they read and learn information on their own, with their instructors acting as coaches and mentors [6].\u003c/p\u003e\n\u003cp\u003eActive learning activities include flipped classroom, problem-based learning (PBL), teamwork, team-based learning (TBL), debates, self-reflection and case-based learning (CBL), that promote students\u0026rsquo; engagement and reflection to encourage an exploration around their own attitudes and values, and facilitating their motivation to learn and develop their skills [6-8]. Among these activities, PBL promotes thoughtful engagement, encourages analytical thinking and reasoning to foster the integration and application of knowledge and are designed around well-defined learning objectives [9].In addition, the interactive teaching/learning methods such as TBL and CBL can impart sustainable knowledge and performance change and can lead to high satisfaction among students, as compared with conventional lecture-based classes [10]. However, what we do not know is whether these claims to efficacy are equal across different culture contexts.\u003c/p\u003e\n\u003cp\u003eCulture lies at the very core of how we learn relate to others and think[11].Understanding the deep cultural differences between Western and Eastern societies about learning and development provide us with a deeper clarityaround different motivations for learning. It has been argued that students from Western cultures have a motivationfor learning, which follows some key epistemological themes.By contrast, according to Li, Chinese students today have inherited a Confucianist learning tradition [12]. These different motivations for learning can be explained in term of differences in cultural dimensions: namely collectivist vs individualist cultures. Thus, it is important to examine differences in perception and the role that various dimensions of culture play in developing preferences for active learning between Western and Eastern cultures.\u003c/p\u003e\n\u003cp\u003eRealist methodology attempts to understand how particular mechanisms (usually internal and hidden to the individual) arise within different contexts and lead to a variety of outcomes.In this study, we specifically examine active learning within a Taiwanese medical education setting through the lens ofa realist evaluation by using a \u0026lsquo;context\u0026ndash;mechanism\u0026ndash;outcome (CMO)\u0026rsquo; configuration to explore the complex interactions for the development of a transferable theoretical model of what works, for whom and why.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eResearch design\u003c/p\u003e\n\u003cp\u003eThe study used a qualitative approach and data was collected using focus groups (Table 1). The study focused on the perceptions of medical students\u0026rsquo; actual experiences of active learning. Further, it examinedboth the process and the factors of active learning on stakeholders\u0026rsquo; interpretation and actions, as well as the eventual outcomes of the integrated curriculum. It aimed to understand the interactions between the contextual environment of active learning methods and the mechanisms of stakeholders\u0026rsquo; interpretation and action around the active learning.The research was approved by the institutional review board (Chang Gung Medical Foundation Institutional Review Board, CGMF-IRB) with certification of approval (104-9723B). The research process was also regulated and supervised by CGMF-IRB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of n=48 participants were recruited, comprising: n=28 (58%) males, including n=24 (58% male) sixth-grade students and n= 24(58% male) seventh-grade students. The participants\u0026rsquo; mean ages were 25.08 [24-31] years. Forty-eight sixth- and seventh-year medical students with experiences of active learning methods were purposively selected to participate in ten focus group interviews.The lists of students with experience of active learning in Chang Gung Memorial Hospital (CGMH) Linkou branch were first collected from the clerkship and internship in department of internal medicine, then purposely selected by investigators and invited by telephone.Informed consent was obtained from all participants. Participants were informed of their right to withdraw their consent at any stage of the study without penalty. Each interview lasted approximately one hour. All interviews were audio-recorded, and a small monetary reward (New Taiwan Dollar 500) was given to thank the participants after the interviews.\u003c/p\u003e\n\u003cp\u003eRealist evaluation\u003c/p\u003e\n\u003cp\u003eWe used a realist theoretical approach. Realist evaluation was first proposed as a way of understanding the efficacy of complex interventions by Pawson and Tilley\u0026rsquo;s in their seminal work, \u0026lsquo;Realistic Evaluation\u0026rsquo; [13].Realism,[14]is a philosophical viewpoint which suggeststhat material and social worlds are grounded in cause-effect linkages.As such, realist evaluation is used to evaluate the impact by considering the contextual environment in terms of three key connecting elements: contexts, mechanisms and outcomes. This theory-based evaluation approach beginswith a clarification of the \u0026lsquo;intended programme theory\u0026rsquo; that elucidates which \u003cu\u003emechanisms\u003c/u\u003e(often hidden, psychological processes) are likely to operate inwhich \u003cu\u003econtext\u003c/u\u003e and what \u003cu\u003eoutcomes\u003c/u\u003eare subsequently likely to occur[15]. From this initial \u0026lsquo;intended programme theory\u0026rsquo;, an investigation into the actual mechanisms, contexts and outcomes was undertaken that enables us to develop an\u0026lsquo;actualprogramme theory\u0026rsquo;. Through this process we understood the widest range of factors that impact on engagement with (for example) active learning. Realist evaluation therefore is a theory-driven approach focused on understanding the mechanism of what works, for whom, in what circumstances and how programmes work (or did not work) in their contextual setting, rather than simply measuring outcomes [13, 14, 16].\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative exploration:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe explored qualitatively \u0026ndash; via group interviews \u0026ndash; learners\u0026rsquo; (n=48) perceptions and experiences of active learning.Group interviews took advantage of group dynamics by stimulating conversation among participants [17]. The guiding principle was that the psychological processes help people to identify, reflect on, and clarify their own views and attitudes [18].We used groups as our methodology because of its ability to elicit group and individual responses, as well as to derive information on \u0026lsquo;hidden agendas\u0026rsquo;, its practical utility, and the availability of institutional expertise [19]. We also included a narrative approach to interviewing to enable us to ground participants\u0026rsquo; comments in real experiences [20]. To ensure a wide range of experiences, a purposive sample was used: efforts were made to recruit students and clinical teachers with diverse backgrounds and attitudes (recruitment will announce that \u0026lsquo;all points of view are welcome and encouraged\u0026rsquo;). Following consent, group interviews wereaudio-taped and conducted by staff and faculty not associated with student evaluation. Both staff and students remained anonymous throughout. Audio-tapeswere later transcribed in their entirety. In addition, the research assistant took field notes during the groups, including observations of group process, and records keywords, sentence fragments, and summaries of basic ideas/concepts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection occurred between December 2016 and July 2017.Research assistants (SW, WHC, CYS)did the focus group interviews. Audio-recorded interviews were transcribed verbatim and anonymized.All interview transcripts were entered into the ATLAS software package in Chinese.\u003c/p\u003e\n\u003cp\u003eThe data were analysed inductively by 4 researchers (CDH, HMT, CCJ, LSO) and 2 research assistants (WHC, CYS). We used a combination of descriptive, evaluating and causation codes for coding.The research team analysed data with a focus on CMO configurations.All researchers began by analysing the same transcripts in order to develop the initial coding framework. Following this, one researcher (WHC) repeatedly read the transcripts individually and undertook data coding. All data were discussed with the wider team of researchers, who then feedbacked and assisted in developing the coding framework. We moved back and forth between the data sources, the codes, and the realist framework to synthesize relevant aspects of the CMOs [21].In connecting strategy, we look for relationships that connect statements and events into a coherent whole [22].After completing the initial coding of all transcripts for CMOs in Chinese, the excerpts were translated to English. A wider team for English data (including LVM) then identified and clarified the CMO configurations. We summarized the data relevant to each CMO theory in line with the realist framework[13].This analytic process involved all authors in several research meetings in CGMERC, examining each theory for validity to reach a consensus.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContext 1: Cultural domain: hierarchical culture (Table 2)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the context of hierarchical culture, the mechanisms of fear/boredom came about, prompting students to be silent and dare not to give opinions. This is a significant and specific context in Taiwan sparking fear with negative outcomes.\u003c/p\u003e\n\u003cp\u003ei. Hierarchical culture (top-down criticism) (C) \u0026rarr; fear/boredom (M) \u0026rarr; dare not give opinions (O)\u003c/p\u003e\n\u003cp\u003eM-Y7 (7B 1:710-711): \"...Some [students] dare give their own opinion (M), but then was disapproved [by the teacher] (C), and then he [the disapproved student] stopped giving his opinions afterwards\u0026hellip;(O)\"\u003c/p\u003e\n\u003cp\u003eF-Y7 (7C 1:692-694): \"Sometimes when I [a student] am taking some teachers' classes, I always feel a sense of distance (C). Maybe I feel more stressed. Maybe nobody dares to answer questions (O) when the teacher asks because they are afraid of giving wrong answers...(M)\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eM-Y7 (7B 1:722-726): \"... Some teachers actually ... well, you could feel the sense of distance when he (teacher) is teaching the class (C). He just keeps talking and talking ... talking about what he knows, or talking about what he is professional about. But we (students) feel like we are dying while we are listening (O). Maybe it's because what he talks is too deep or too much, or something else. Or maybe his speaking is quite monotonous... (M)\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContext 2: Training domain (Table 3): interaction between teachers and students, teacher-student familiarity and teachers\u0026rsquo; guidance\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the contexts of interaction between teachers and students, teacher-student familiarity and teachers\u0026rsquo; guidance, learning motivation, self-regulation and enthusiasm were triggered, prompting positive learning outcomes and competencies.\u003c/p\u003e\n\u003cp\u003eii. Good interaction between teachers and students (C) \u0026rarr; Motivation is triggered (M) \u0026rarr; Students give their opinions (O)\u003c/p\u003e\n\u003cp\u003eF-Y7 (7C 1:694-696): \u0026ldquo;...About some teachers' teaching methods ... well, he [teacher] would discuss things with you [student] in a friendly way, so that you would speak more (O). He will not confront you directly and say you are wrong (C). He would tell you how to do in a better way, which helps us [students] have more courage to think and to answer (M).\"\u003c/p\u003e\n\u003cp\u003eiii. Teachers\u0026rsquo;/students\u0026rsquo; familiarity for active learning (C) \u0026rarr; self-regulation and enthusiasm (M) \u0026rarr; improved learning outcomes (O)\u003c/p\u003e\n\u003cp\u003eM-Y6 (6D 2:674-676): \"Teacher's enthusiasm for delivering knowledge also deeply influence his students in terms of a the tone or attitude (C). These affect students' desire for pursuing knowledge (M) and affect their learning outcome (O).\"\u003c/p\u003e\n\u003cp\u003eiv. Teacher's guidance (C) \u0026rarr; motivation and enthusiasm (M) \u0026rarr; Positive learning competencies (O)\u003c/p\u003e\n\u003cp\u003eM-Y7 (A3 10:168-171): Because this is our first time to encounter this case, we don't know which way would be best to address this.(C) --- It's faster than when you are searching things without any direction\"(O).\u003c/p\u003e\n\u003cp\u003eM-Y7 (7A 1:167-176): \"...Good teachers would teach us how to solve problems by guiding rather than by directly giving a standard answer which is already in his mind ... some teachers are still able to guide us step by step to the main issues even if we are rambling on and on and on [about our answers] (C). There is a big difference in the motives when we are talking about \u0026lsquo;directly giving the standard answer\u0026rsquo; and \u0026lsquo;reaching the standard answer through discussion\u0026rsquo; since the processes are very different (M).\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContext 3: Individual domain (Table 4).\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the context of learning \u0026ldquo;how to learn actively\u0026rdquo; early on, in the medical learning environment, the mechanisms of internalization, physician identity and stress resulted in recognizing active learning and advanced preparation.\u003c/p\u003e\n\u003cp\u003ev. Learning \"how to learn actively\" early on (C) \u0026rarr; internalization (M) \u0026rarr; recognizing active learning (O)\u003c/p\u003e\n\u003cp\u003eM-Y7 (A1 5:1456-1492): \u0026ldquo;You just pick up one topic from the general chemistry to do CBL, to train your thinking process (O). You have learned general biology, so you just pick up [one topic] from general biology to train your thinking process. After that, people like us would just be able to understand systems [thinking process] ... would just be able to get connected to the system ... (M) It [the thinking process] didn\u0026rsquo;t exist in the very beginning (C).\u003c/p\u003e\n\u003cp\u003eM-Y7 (7A 1:105-107): \"\u0026hellip;Four years ago, passive learning was still dominant in our education. We were required to keep memorising things and take exams (C). And then suddenly we were required to shift to active learning, which actually is not easy (M).\u0026rdquo;\u003c/p\u003e\n\u003cp\u003evi. Medical learning environment: External effects (peers, teachers and clinical duty) (C) \u0026rarr; professional identity and stress (M) \u0026rarr; preparation in advance (O)\u003c/p\u003e\n\u003cp\u003eF-Y6 (6E 3:63-65): \"Sometimes somebody would tactically use the reserve psychology on you, saying 'How can you be so useless, of not even knowing this? (C)\u0026rsquo; And then you would think, 'How can I lose this game? (M)\u0026rsquo; Then you would go and read up on it, until you really understand it (O).\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eF-Y6 (6B 2:64-67): \"But I think, if you think these things are important for taking care of patients, for example ... like how to give nutrients, or give some fluids ... (C) because I think, since we are going to be interns (M), we might need to understand something fundamental or basic ... (O).\u003c/p\u003e"},{"header":"Discussion:","content":"\u003cp\u003eIn the age of information explosion, active learning could help everyone to becomelifelong learners and hence be more capable of responding to the rapid changes in the future.In this study, we identified three CMO domains of medical students\u0026rsquo; experiences of active learning. For the first: the context of hierarchical culture, the mechanisms of fear/boredom came about, prompting students to be silent, dare not to give opinions. For the second training domain, in the contexts of interaction between teachers and students, teacher-student familiarity and teachers\u0026rsquo; guidance, learning motivation, self-regulation and enthusiasm were triggered, prompting positive learning outcomes and competencies. For the third individual domain, in the context of learning \u0026ldquo;how to learn actively\u0026rdquo; from early on, and medical learning environment, the mechanisms of internalization, professional identity and stress, resulted in recognized active learning and advanced preparation. These CMOs were synthesized into a process model of active learning.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCultural domain\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCultural membership, issues of authority and respect, and language proficiency were identified as having a direct influence on the clinical education process [23].Active learning, such as student-centred and problem-based methods rooted in Western culture, may not be of a truly international nature and its compatibility with non-Western cultures has been challenged [23, 24].Looking at the culture domain, we can see that our society will experience more difficultly with implementing active learning. East Asian education is often referred to as Confucian-heritage education, wherevirtue is achieved primarily bylearning from teachers,imitating their attitudes [25, 26].Confucian culture has undoubtedly been a significant influence on thinking on all aspects of society, unmatched by any other school of thought[27]. It is one of the most frequently cited social factors in healthcare research in East Asian countries[28]and has also significantly influenced the learning styles in medical education in these countries, which need to be questioned and understood within the complex of local cultural influences[29, 30].Students therefore are more likely to limit their individual development by depending purely on the teacherteaching, and their ideas,which inhibits students from doing their own critical thinking. Moreover, students are also influenced by the oriental concept of \"respecting teachers\" while learning from them.\u003c/p\u003e\n\u003cp\u003eIn this study, we use qualitative realist evaluation. The context of a hierarchical cultureis consistent with previous research that report similar findings, including hierarchy interfered with non-Western students\u0026rsquo; applicationof PBL [31].Uncertainty, tradition, hierarchy and achievement have often been identified as more prominent in non-Western than in Western cultures[32, 33].In addition, fear and boredomare the mechanism derived from a hierarchical culture. This is a concern as it is a significant and specific context for Taiwan, sparking fear with negative learning outcomes.This suggests a certain incongruity between active learning methods and non-Western cultures. Thus, it complicates the straightforward transfer of active learning to such cultural contexts and the globalization of active learning does not postulate uniform processes and outcomes.Culturally sensitive alternatives might be considered [31].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTrainingdomain\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe qualities of a good clinical teacher in the context of interaction between teachers and students are important. Sutkin found that excellent clinical teaching, although multifactorial, transcends ordinary teaching and is characterized by inspiring, supporting, actively involving, and communicating with students[34].Research has identified thatmedical students use dual processing to rate the effectiveness of classroom teachers; an interaction between the conscious appraisal of teaching attributes \u0026ndash; specifically, the perceived charisma of the teacher \u0026ndash; and the subconscious rating of variables that portray stereotypes, such as physical appearance [35].With regard to the interaction between teachers and students, as the context of the effectiveness of excellent teachers, in this study we identified the mechanism of motivation was triggered,resulting in students giving their opinions.\u003c/p\u003e\n\u003cp\u003eIn many East Asian cultures schooling primary to secondary education is heavily influenced by a passive learning culture [36, 37], where reproducing teachers\u0026rsquo; statements is strongly emphasizedand where teachersrecommended textbooks serve as the main sources of information, there is little opportunity for active learning. However, different learning contexts do not keep East Asian learners from being self-regulated. Awareness of their unique identity leads them to view learning tasks as high-stakes, and to initiate learning strategies that involve self-regulation[36].Thus, the teacher-student\u0026rsquo;s familiarity of active learning without traditional and teacher-centred education is an important context.andstudents\u0026rsquo; self-regulation plays the important role for the mechanism, resulting in positive learning outcomes.\u003c/p\u003e\n\u003cp\u003eThe development of active learning relies on teacher's guidance and encouragement. Facilitator\u0026rsquo;s guidance was a crucial aspect of this process, particularly in situations when students were new to the PBLprocess[38].In a Japanese context of medical education, medical students in Japan have difficulty extracting problems in PBL scenarios without instruction from teachers[39].In fact, exposing Year 1 students to the independent learning environment of PBL without providing them with adequate guidance may, rather than promoting the development of SDL skills, cause them to become severely dependent on tutors, predetermined learning objectives and on rote learning in order to \u0026lsquo;survive\u0026rsquo;[40, 41].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIndividual domain\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the context of learning \u0026ldquo;how to learn actively\u0026rdquo; from early on, the mechanism of internalization results in recognizing active learning.The lack of readiness of active learning strategies that require self-regulation is problematic in East Asian medical students [36].They expect their teachers to instruct, and themselves to be instructed or \u0026ldquo;spoon-fed\u0026rdquo;[25].In a Japanese study, medical students consistently rely on teachers\u0026rsquo; explanatory lectures and have low motivation to study after a pilot progress test [42].Student maturity has also been identified as an important factor for active participation [43].Thus, the learning context of \"how to learn actively\" from early on promotes internalization of active learning. This may cause them to view learning tasks as high-stakes, and lead to the recognition of active learning strategies.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; In the context of the medical learning environment, the mechanisms of physician identity and stress result in studying ahead of time, particularly in the context of clinical setting where they may experience questions testing their knowledge from seniors. External pressure comes from peers, teachers and clinical responsibilities. They learn to think, act and feel like doctors by gradually taking up meaningful activities in the clinical context which help them to prepare for lifelong learning[44].During this process, they will become full members of a clinical community of practice and collaborate in daily activities [45, 46].Learners who are new to a clinical setting with external pressure from peers, teachers and clinicalresponsibilities are in an active struggle to manage themselves as they are in the process of constructing their professional identities in the clinical training context [47, 48].This helps process helps them to develop a new identity, first as a medical trainee and ultimately as a medical professional.Physician identity formation as a unique medical professional in the clinical setting led to the perception that the medical students as physicians had to allow patients to ask them about any wide-ranging medical problems[45]. Immersion in a responsible individual role, which promotes physician identity formation in the clinical setting, causes medical students to view learning tasks as high-stakes, and to initiate learning strategies in an active learning manner[36].\u003c/p\u003e\n\u003cp\u003eMedical students need to feel like a valuable member of the clinical team, by thinking, acting and feeling like a future doctor.Therefore, helping them to engage in effective active learning in a clinical setting begins with helping them to understand what learning is and what effective learning strategies are in a clinical setting. Finally, it helps learners create a professional identity they want to develop, resulting in promoting life long learning.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThere are several limitations in this study. The research was conducted in a single medical institution in Taiwan by analyzing as a homogenous group, therefore there all the relevantCMO configurations for Asian culture and medical schools may not have been identified. However, our CMO configurations identify important patterns that are shared with similar institutions, cultures and contexts and offer wider relevance.We just collected qualitative data, so limited ability to make statements about the 'academic' outcome/merit of active learning. Our participants had variable exposures to all forms of active learning methods, such as PBL, CBL, and TBL and therefore we cannot assume that our findings apply to all forms of active learning, which were not exhaustively studied. We referred to TBL, CBL and PBL as key approaches to active learning. However, the emphasis of each of these is different in the extent to which they are learner or tutor-driven, the roles expected of the learners, the degree of peer learning and the roles required of the teacher. Finally, there are many factors affecting the quality of active learning methods, especially the facilitator role and tutorial structure. Further study on teachers\u0026rsquo; perceptions is warranted.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur realist analysis is useful for practice, revealing complex interactions in the learning environments and in learners\u0026rsquo; work. We identified three key CMO domains of medical students\u0026rsquo; experiences of active learning, including cultural, training, and individual domains. The connections between hierarchical culturewith fear/boredom; teachers\u0026rsquo; guidance with motivation; and the clinical environment with professional identity have been identified as affecting learning outcomes. The CMO configurationsidentified around active learning can help improve the sustainability of learned skills. Fear derived from hierarchical culture is a concern in Asian contextthat requires further investigation as it significantly impacts on learning producing negative outcomes in the learning environments and in learners\u0026rsquo; work.\u003c/p\u003e"},{"header":"Abbreviations:","content":"\u003cp\u003eCMO: context-mechanism-outcome\u003c/p\u003e\n\u003cp\u003ePBL: problem-based learning\u003c/p\u003e\n\u003cp\u003eTBL: team-based learning\u003c/p\u003e\n\u003cp\u003eCBL: case-based learning\u003c/p\u003e\n\u003cp\u003eCGMF-IRB: Chang Gung Medical Foundation Institutional Review Board\u003c/p\u003e\n\u003cp\u003eCGMH: Chang Gung Memorial Hospital\u003c/p\u003e\n\u003cp\u003eC: context\u003c/p\u003e\n\u003cp\u003eM: mechanism\u003c/p\u003e\n\u003cp\u003eO: outcome\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Chang Gung Memorial Hospital and Chang Gung University Institutional Review Board (IRB No. 104-9723B).The consent we obtained from study participants was written.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNo individual\u0026rsquo;s data is included in this study.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe data are kept at the Chang Gung Medical Education Research Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan. Any questions or requests regarding the data can be addressed to Chien-Da Huang ([email protected]).\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis study was supported by Chang Gung Memorial Hospital, Taiwan [CDRPG 3F0051]. The role of the funderis the teaching hospital of the study participants from Chang Gung University College of Medicine.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions \u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eCDH contributed to development of study, analysis and interpretation of data, writing, reviewing and finalizing the manuscript.HMTparticipated in study conceptualization, analysed data, and revised the manuscript.CCJ and LSO contributed to the conception and design of the study, interpretation of data, active learning education, and revised the manuscript.All authors have read and approved the finial version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWe wish to express our gratitude to Professor Lynn Monrouxe (The University of Sydney, Cumberland Campus, Australia), Professor Jan Illing and Dr. Amelia Kehoe (Newcastle University, UK) for their reviews and comments on earlier versions of this manuscript and to Ms. Eve Huang from CG-MERC who translated the data from Mandarin to English.We thank the research assistants Siva Wang (SW), Wen-Huei Chang (WHC) and Chia-Yi Sheng (CYS) who participated in this study.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eChang Gung Medical Education Research Center\u003csup\u003e1\u003c/sup\u003e, Department of Medical Education\u003csup\u003e2\u003c/sup\u003e, Thoracic Medicine\u003csup\u003e3\u003c/sup\u003e, Nephrology\u003csup\u003e4\u003c/sup\u003e, and Pediatrics\u003csup\u003e5\u003c/sup\u003e, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taipei, Taiwan; Chang Gung University;Department of Health Care Management\u003csup\u003e6\u003c/sup\u003e, Chang Gung University, Chang Gung University, College of Medicine, Taipei, Taiwan.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u003cstrong\u003eWe can teach the way we were taught, or we can teach the way people learn\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e: Sierra Training Associates, Inc.; 2007.\u003c/li\u003e\n\u003cli\u003eShepard LA: \u003cstrong\u003eThe role of assessment in a learning culture\u003c/strong\u003e. \u003cem\u003eEduc Res \u003c/em\u003e2000, \u003cstrong\u003e29\u003c/strong\u003e(7):4-14.\u003c/li\u003e\n\u003cli\u003eKnowles M: \u003cstrong\u003eAndragogy in Action\u003c/strong\u003e. San Francisco: Jossey-Bass; 1984.\u003c/li\u003e\n\u003cli\u003eGraffam B: \u003cstrong\u003eActive learning in medical education: strategies for beginning implementation\u003c/strong\u003e. \u003cem\u003eMed Teach \u003c/em\u003e2007, \u003cstrong\u003e29\u003c/strong\u003e(1):38-42.\u003c/li\u003e\n\u003cli\u003eDori YD, Belcher J: \u003cstrong\u003eHow does technology-enabled active learning affect undergraduate students\u0026rsquo; understanding of electromagnetism concepts?\u003c/strong\u003e\u003cem\u003eThe Journal of the Learning Sciences \u003c/em\u003e2005, \u003cstrong\u003e14\u003c/strong\u003e(2):243-279.\u003c/li\u003e\n\u003cli\u003eMcLaughlin JE, Roth MT, Glatt DM, Gharkholonarehe N, Davidson CA, Griffin LM, Esserman DA, Mumper RJ: \u003cstrong\u003eThe flipped classroom: a course redesign to foster learning and engagement in a health professions school\u003c/strong\u003e. \u003cem\u003eAcad Med \u003c/em\u003e2014, \u003cstrong\u003e89\u003c/strong\u003e(2):236-243.\u003c/li\u003e\n\u003cli\u003eFreeman S, O'Connor E, Parks JW, Cunningham M, Hurley D, Haak D, Dirks C, Wenderoth MP: \u003cstrong\u003ePrescribed active learning increases performance in introductory biology\u003c/strong\u003e. \u003cem\u003eCBE life sciences education \u003c/em\u003e2007, \u003cstrong\u003e6\u003c/strong\u003e(2):132-139.\u003c/li\u003e\n\u003cli\u003eKumar V, Gadbury-Amyot CC: \u003cstrong\u003eA case-based and team-based learning model in oral and maxillofacial radiology\u003c/strong\u003e. \u003cem\u003eJ Dent Educ \u003c/em\u003e2012, \u003cstrong\u003e76\u003c/strong\u003e(3):330-337.\u003c/li\u003e\n\u003cli\u003eVernon DT, Blake RL: \u003cstrong\u003eDoes problem-based learning work? A meta-analysis of evaluative research\u003c/strong\u003e. \u003cem\u003eAcad Med \u003c/em\u003e1993, \u003cstrong\u003e68\u003c/strong\u003e(7):550-563.\u003c/li\u003e\n\u003cli\u003eSmits PB, Verbeek JH, de Buisonje CD: \u003cstrong\u003eProblem based learning in continuing medical education: a review of controlled evaluation studies\u003c/strong\u003e. \u003cem\u003eBMJ \u003c/em\u003e2002, \u003cstrong\u003e324\u003c/strong\u003e(7330):153-156.\u003c/li\u003e\n\u003cli\u003eNisbett RE, Peng K, Choi I, Norenzayan A: \u003cstrong\u003eCulture and systems of thought: holistic versus analytic cognition\u003c/strong\u003e. \u003cem\u003ePsychological review \u003c/em\u003e2001, \u003cstrong\u003e108\u003c/strong\u003e(2):291-310.\u003c/li\u003e\n\u003cli\u003eLi J, Li QL, Li J, Chen ML, Xie HF, Li YP, Chen X: \u003cstrong\u003eComparison of three problem-based learning conditions (real patients, digital and paper) with lecture-based learning in a dermatology course: a prospective randomized study from China\u003c/strong\u003e. \u003cem\u003eMed Teach \u003c/em\u003e2013, \u003cstrong\u003e35\u003c/strong\u003e(2):e963-970.\u003c/li\u003e\n\u003cli\u003ePawson R, Tilley N: \u003cstrong\u003eRealistic Evaluation\u003c/strong\u003e. London: Sage; 1997.\u003c/li\u003e\n\u003cli\u003eWong G, Greenhalgh T, Westhorp G, Pawson R: \u003cstrong\u003eRealist methods in medical education research: what are they and what can they contribute?\u003c/strong\u003e\u003cem\u003eMed Educ \u003c/em\u003e2012, \u003cstrong\u003e46\u003c/strong\u003e(1):89-96.\u003c/li\u003e\n\u003cli\u003eWesthrop G: \u003cstrong\u003eRealist impact evaluation: an introduction\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e: Methods Lab, Overseas Development Institute (ODI), the Australian Department of Foreign\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAffairs and Trade (DFAT) and BetterEvaluation; 2012 September: 1-12.\u003c/p\u003e\n\u003col start=\"16\"\u003e\n\u003cli\u003eWong ELY, Yeoh EK, Chau PYK, Yam CHK, Cheung AWL, Fung H: \u003cstrong\u003eHow shall we examine and learn about public-private partnerships (PPPs) in the health sector? Realist evaluation of PPPs in Hong Kong\u003c/strong\u003e. \u003cem\u003eSocial Science and Medicine \u003c/em\u003e2015, \u003cstrong\u003e147\u003c/strong\u003e:261-269.\u003c/li\u003e\n\u003cli\u003eFreeman T: \u003cstrong\u003e'Best practice' in focus group research: making sense of different views\u003c/strong\u003e. \u003cem\u003eJ Adv Nurs \u003c/em\u003e2006, \u003cstrong\u003e56\u003c/strong\u003e(5):491-497.\u003c/li\u003e\n\u003cli\u003eStalmeijer RE, McNaughton N, Van Mook WN: \u003cstrong\u003eUsing focus groups in medical education research: AMEE Guide No. 91\u003c/strong\u003e. \u003cem\u003eMed Teach \u003c/em\u003e2014, \u003cstrong\u003e36\u003c/strong\u003e(11):923-939.\u003c/li\u003e\n\u003cli\u003eLie D, Shapiro J, Pardee S, Najm W: \u003cstrong\u003eA focus Group Study of Medical Students' Views of an Integrated Complementary and Alternative Medicine (CAM) Curriculum: Students Teaching Teachers\u003c/strong\u003e. \u003cem\u003eMed Educ Online \u003c/em\u003e2008, \u003cstrong\u003e13\u003c/strong\u003e(3):1-13.\u003c/li\u003e\n\u003cli\u003eRiessman C: \u003cstrong\u003eNarrative methods for the human sciences\u003c/strong\u003e. Thousand Oaks, CA: Sage Publications; 2008.\u003c/li\u003e\n\u003cli\u003eSaldana J: \u003cstrong\u003eThe coding manual for qualitative researchers\u003c/strong\u003e. London: Sage; 2013.\u003c/li\u003e\n\u003cli\u003eMiles MB, Huberman AM, Saldana J: \u003cstrong\u003eQualitative data analysis: a methods sourcebook\u003c/strong\u003e: Thousands Oak (CA): Sage.; 2014.\u003c/li\u003e\n\u003cli\u003eLadyshewsky R: \u003cstrong\u003eEast meets West: The influence of language and culture in clinical education\u003c/strong\u003e. \u003cem\u003eAust J Physiother \u003c/em\u003e1996, \u003cstrong\u003e42\u003c/strong\u003e(4):287-294.\u003c/li\u003e\n\u003cli\u003eBleakley A, Brice J, Bligh J: \u003cstrong\u003eThinking the post-colonial in medical education\u003c/strong\u003e. \u003cem\u003eMed Educ \u003c/em\u003e2008, \u003cstrong\u003e42\u003c/strong\u003e(3):266-270.\u003c/li\u003e\n\u003cli\u003eHo DYF, Peng SQ, Chan SFF: \u003cstrong\u003eAuthority and learning in confu- cian\u0026ndash;heritage education\u003c/strong\u003e. In: \u003cem\u003eMultiple competencies and self-regulated learning: implications for multicultural education.\u003c/em\u003e edn. Edited by C.Y. C, Salili F, Hong YY. North Carolina: Information Age Publishing, Inc.; 2001: 29-48.\u003c/li\u003e\n\u003cli\u003eTweed RG, Lehman DR: \u003cstrong\u003eLearning considered within a cultural context. Confucian and Socratic approaches\u003c/strong\u003e. \u003cem\u003eAm Psychol \u003c/em\u003e2002, \u003cstrong\u003e57\u003c/strong\u003e(2):89-99.\u003c/li\u003e\n\u003cli\u003eGuo Z: \u003cstrong\u003eChinese Confucian culture and the medical ethical tradition\u003c/strong\u003e. \u003cem\u003eJ Med Ethics \u003c/em\u003e1995, \u003cstrong\u003e21\u003c/strong\u003e(4):239-246.\u003c/li\u003e\n\u003cli\u003eKoh EK, Koh CK: \u003cstrong\u003eCaring for older adults: the parables in Confucian texts\u003c/strong\u003e. \u003cem\u003eNurs Sci Q \u003c/em\u003e2008, \u003cstrong\u003e21\u003c/strong\u003e(4):365-368.\u003c/li\u003e\n\u003cli\u003eChen LC, Reich MR, J. R: \u003cstrong\u003eMedical Education in East Asia: Past and Future\u003c/strong\u003e: Indiana University Press; 2017.\u003c/li\u003e\n\u003cli\u003eChiavaroli N, Huang CD, Monrouxe L: \u003cstrong\u003eChapter 16 Learning Medicine with, from and through the Humanities\u003c/strong\u003e. In: \u003cem\u003eUnderstanding Medical Education.\u003c/em\u003e 3rd edn. Edited by Swanwick T, Forrest K, O'Brien BC. Hoboken, NJ: Wiley-Blackwell; 2019.\u003c/li\u003e\n\u003cli\u003eFrambach JM, Driessen EW, Chan LC, van der Vleuten CP: \u003cstrong\u003eRethinking the globalisation of problem-based learning: how culture challenges self-directed learning\u003c/strong\u003e. \u003cem\u003eMed Educ \u003c/em\u003e2012, \u003cstrong\u003e46\u003c/strong\u003e(8):738-747.\u003c/li\u003e\n\u003cli\u003eAl Kadri HM, Al-Moamary MS, Magzoub ME, Roberts C, C.P.M. vdV: \u003cstrong\u003eStudents\u0026rsquo; perceptions of the impact of assessment on approaches to learning: a comparison between two medical schools with similar curricula\u003c/strong\u003e. \u003cem\u003eInt J Med Educ \u003c/em\u003e2011(2):22-52.\u003c/li\u003e\n\u003cli\u003eLeung DYP: \u003cstrong\u003eExamining the cul- tural specificity of approaches to learning in universi- ties in Hong Kong and Sydney\u003c/strong\u003e.\u003cem\u003e J Cross Cult Psychol \u003c/em\u003e2008, \u003cstrong\u003e39\u003c/strong\u003e(3):251-266.\u003c/li\u003e\n\u003cli\u003eSutkin G, Wagner E, Harris I, Schiffer R: \u003cstrong\u003eWhat makes a good clinical teacher in medicine? A review of the literature\u003c/strong\u003e. \u003cem\u003eAcad Med \u003c/em\u003e2008, \u003cstrong\u003e83\u003c/strong\u003e(5):452-466.\u003c/li\u003e\n\u003cli\u003eRannelli L, Coderre S, Paget M, Woloschuk W, Wright B, McLaughlin K: \u003cstrong\u003eHow do medical students form impressions of the effectiveness of classroom teachers?\u003c/strong\u003e\u003cem\u003eMed Educ \u003c/em\u003e2014, \u003cstrong\u003e48\u003c/strong\u003e(8):831-837.\u003c/li\u003e\n\u003cli\u003eMatsuyama Y, Nakaya M, Okazaki H, Leppink J, van der Vleuten C: \u003cstrong\u003eContextual attributes promote or hinder self-regulated learning: A qualitative study contrasting rural physicians with undergraduate learners in Japan\u003c/strong\u003e. \u003cem\u003eMed Teach \u003c/em\u003e2018, \u003cstrong\u003e40\u003c/strong\u003e(3):285-295.\u003c/li\u003e\n\u003cli\u003eNisbett RE: \u003cstrong\u003eThe geography of thought: how Asians and Westerners think differently and why\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e, edn. New York (NY): Free Press.; 2003: p.xxii.\u003c/li\u003e\n\u003cli\u003eAnderson V, Reid K: \u003cstrong\u003eStudents' perception of a problem-based learning scenario in dental nurse education\u003c/strong\u003e. \u003cem\u003eEur J Dent Educ \u003c/em\u003e2012, \u003cstrong\u003e16\u003c/strong\u003e(4):218-223.\u003c/li\u003e\n\u003cli\u003eYoshioka T, Suganuma T, Tang AC, Matsushita S, Manno S, Kozu T: \u003cstrong\u003eFacilitation of problem finding among first year medical school students undergoing problem-based learning\u003c/strong\u003e. \u003cem\u003eTeach Learn Med \u003c/em\u003e2005, \u003cstrong\u003e17\u003c/strong\u003e(2):136-141.\u003c/li\u003e\n\u003cli\u003eMiflin BM, Campbell CB, Price DA: \u003cstrong\u003eA conceptual framework to guide the development of self-directed, lifelong learning in problem-based medical curricula\u003c/strong\u003e. \u003cem\u003eMed Educ \u003c/em\u003e2000, \u003cstrong\u003e34\u003c/strong\u003e(4):299-306.\u003c/li\u003e\n\u003cli\u003eMiflin BM, Campbell CB, Price DA: \u003cstrong\u003eA lesson from the introduction of a problem-based, graduate entry course: the effects of different views of self-direction\u003c/strong\u003e. \u003cem\u003eMed Educ \u003c/em\u003e1999, \u003cstrong\u003e33\u003c/strong\u003e(11):801-807.\u003c/li\u003e\n\u003cli\u003eMatsuyama Y, Muijtjens AM, Kikukawa M, Stalmeijer R, Murakami R, Ishikawa S, Okazaki H: \u003cstrong\u003eA first report of East Asian students' perception of progress testing: a focus group study\u003c/strong\u003e. \u003cem\u003eBMC Med Educ \u003c/em\u003e2016, \u003cstrong\u003e16\u003c/strong\u003e(1):245.\u003c/li\u003e\n\u003cli\u003eWhite C, Bradley E, Martindale J, Roy P, Patel K, Yoon M, Worden MK: \u003cstrong\u003eWhy are medical students 'checking out' of active learning in a new curriculum?\u003c/strong\u003e\u003cem\u003eMed Educ \u003c/em\u003e2014, \u003cstrong\u003e48\u003c/strong\u003e(3):315-324.\u003c/li\u003e\n\u003cli\u003eBerkhout JJ, Helmich E, Teunissen PW, van der Vleuten CPM, Jaarsma ADC: \u003cstrong\u003eContext matters when striving to promote active and lifelong learning in medical education\u003c/strong\u003e. \u003cem\u003eMed Educ \u003c/em\u003e2018, \u003cstrong\u003e52\u003c/strong\u003e(1):34-44.\u003c/li\u003e\n\u003cli\u003eCruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y: \u003cstrong\u003eReframing medical education to support professional identity formation\u003c/strong\u003e. \u003cem\u003eAcad Med \u003c/em\u003e2014, \u003cstrong\u003e89\u003c/strong\u003e(11):1446-1451.\u003c/li\u003e\n\u003cli\u003eWeaver R, Peters K, Koch J, Wilson I: \u003cstrong\u003e'Part of the team': professional identity and social exclusivity in medical students\u003c/strong\u003e. \u003cem\u003eMed Educ \u003c/em\u003e2011, \u003cstrong\u003e45\u003c/strong\u003e(12):1220-1229.\u003c/li\u003e\n\u003cli\u003eDenson JL, Jensen A, Saag HS, Wang B, Fang Y, Horwitz LI, Evans L, Sherman SE: \u003cstrong\u003eAssociation Between End-of-Rotation Resident Transition in Care and Mortality Among Hospitalized Patients\u003c/strong\u003e. \u003cem\u003eJAMA \u003c/em\u003e2016, \u003cstrong\u003e316\u003c/strong\u003e(21):2204-2213.\u003c/li\u003e\n\u003cli\u003eBernabeo EC, Holtman MC, Ginsburg S, Rosenbaum JR, Holmboe ES: \u003cstrong\u003eLost in transition: the experience and impact of frequent changes in the inpatient learning environment\u003c/strong\u003e. \u003cem\u003eAcad Med \u003c/em\u003e2011, \u003cstrong\u003e86\u003c/strong\u003e(5):591-598.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\"\u003e\n\u003ccaption\u003eTable 1:\u003cbr/\u003e Focus group interview guide for medical students\u003c/caption\u003e\n \u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003eOpening Question\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Tell us what active learning means to you.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003eIntroductory Question\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e2.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; What sections of the integrated curriculum do you feel are the mostly related to your understanding of active learning and why?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003eTransition question\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e3.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Think back to your experiences in the integrated curriculum. To what extent has this has improved your active learning? Which aspects? How? Why? Tell me about a specific situation to help me understand.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\"\u003e\n\u003cp\u003e\u003cstrong\u003eKey Questions\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e4.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; How would you compare the rigor of active learning (CBL, TBL, and PBL) with passive learning (other didactic lectures)? (Workload?)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003e5.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; What is your role in the active learning process?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003e6.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; In which ways did the process of active learning pose barriers to your learning? Tell me about a specific situation to help me understand.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003e7.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; What was the most challenging part of active learning in terms of planning and preparation? Expectations? Tell me about a specific situation to help me understand.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003e8.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; How can we improve active learning across the curriculum?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003eEnd Question\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e9.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Do you have any other comments about the active learning in curriculum?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr /\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"100%\"\u003e\n\u003ccaption\u003eTable 2.\u003cbr/\u003e Context 1: Cultural domain: hierarchical culture\u003c/caption\u003e\n \u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003e\u003cstrong\u003eContext\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003e\u003cstrong\u003eMechanism\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003eHierarchical culture (top-down criticism)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003eFear\u003c/p\u003e\n\u003cp\u003eBoredom\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003eDare not give opinions\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\n\n\u003ctable border=\"1\" width=\"100%\"\u003e\n \u003ccaption\u003eTable 3. \u003cbr/\u003eContext 2: Training domain: interaction between teachers and students, teacher-student familiarity and teachers\u0026rsquo; guidance\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003e\u003cstrong\u003eContext\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003e\u003cstrong\u003eMechanism\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003eGood interaction between teachers and students\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003eMotivation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003eStudents give their opinions\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003eTeachers\u0026rsquo;/students\u0026rsquo; familiarity for active learning\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003eSelf-regulation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003eImproved learning outcomes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003eTeachers\u0026rsquo; guidance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003eEnthusiasm\u003c/p\u003e\n\u003cp\u003eMotivation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33%\"\u003e\n\u003cp\u003ePositive learning competencies\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\u003ctable border=\"1\" width=\"100%\"\u003e\n\u003ccaption\u003eTable 4. \u003cbr/\u003eContext 3: Individual domain: \u003c/caption\u003e\n \u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"35%\"\u003e\n\u003cp\u003e\u003cstrong\u003eContext\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003eMechanism\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35%\"\u003e\n\u003cp\u003eLearning \"how to learn actively\" from early on\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eInternalization\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eRecognizing active learning\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35%\"\u003e\n\u003cp\u003eMedical environment: External effects (peers, teachers, and clinical duty)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003ePhysician identity\u003c/p\u003e\n\u003cp\u003eStress\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003ePreparation in advance\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Realist evaluation, culture, active learning, hierarchy, medical students","lastPublishedDoi":"10.21203/rs.3.rs-34476/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-34476/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Background: Active learning is defined as any instructional method that engages students in the learning process. Cultural differences in learning patterns can play an important role in engagement with active learning. We aimed to examine process models of active learning to understand what works, for whom and why.\nMethods: Forty-eight sixth- and seventh-year medical students with experience of active learning methods were purposively selected to participate in ten group interviews. Interactions around active learning were analysed using a realist evaluation framework to unpack the ‘context-mechanism-outcome’ (CMO) configurations.\nResults: Three core CMO configurations, including cultural, training and individual domains, were identified. In the cultural context of a strong hierarchical culture, the mechanisms of fear prompted students to be silent (outcome) and dare not give their opinions. In the training context of teacher-student familiarity alongside teachers’ guidance, the mechanisms of learning motivation, self-regulation and enthusiasm were triggered, prompting positive learning outcomes and competencies (outcome). In the individual context of learning how to learn actively at an early stage within the medical learning environment, the mechanisms of internalisation, professional identity and stress resulted in recognising active learning and advanced preparation (outcomes).\nConclusions: We identified three CMO configurations of Taiwanese medical students’ active learning. The connections among hierarchical culture, fear, teachers’ guidance, motivation, the medical environment and professional identity have been shown to affect the complex interactions of learning outcomes. Fear derived from a hierarchical culture is a concern as it is a significant and specific contextual factor, often sparking fear with negative outcomes.","manuscriptTitle":"Active learning of medical students in Taiwan: A realist evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2020-10-13 20:22:52","doi":"10.21203/rs.3.rs-34476/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-11-19T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-11-12T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nPEER REVIEWER ASSESSMENTS:\n\nOBJECTIVE - Full research articles: is there a clear objective that addresses a testable research question(s) (brief or other article types: is there a clear objective)?\nYes - there is a clear objective\n\nDESIGN - Is the current approach (including controls and analysis protocols) appropriate for the objective?\nYes - the approach is appropriate\n\nEXECUTION - Are the experiments and analyses performed with technical rigor to allow confidence in the results?\nYes - experiments and analyses were performed appropriately\n\nSTATISTICS - Is the use of statistics in the manuscript appropriate?\nN/A - there are no statistics in this study\n\nINTERPRETATION - Is the current interpretation/discussion of the results reasonable and not overstated?\nYes - the author's interpretation is reasonable\n\nOVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically sound? If not, can revisions be made to make the work technically sound?\nYes - current version is technically sound\n\nPEER REVIEWER COMMENTS:\n\nGENERAL COMMENTS:\nThis is well-written and framed article. The authors investigate the process of active learning in Eastern culture using a realistic evaluation. The results give useful perspectives in medical schools in Eastern culture who try to use active methodologies and also give some context-mechanism-outcomes relationships that may be utilized in the difficulties encountered while implementing active methods.\nIt is seen that all previous reviewer concerns were addressed in the article.\n\nREQUESTED REVISIONS:\nIt is seen that all previous reviewer concerns were addressed in the article. Clear and well-written.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **This reviewer has been recruited by a partner organization, Research Square. Reviewers with declared or apparent competing interests are not utilized for these reviews. This reviewer has agreed to publication of their comments online under a Creative Commons Attribution License attributed to Research Square and was paid a small honorarium for completing the review within a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer recommendation.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewersInvited","content":"","date":"2020-11-05T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-11-05T00:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-10-01T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-30T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-30T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-07-08 21:15:49","doi":"10.21203/rs.3.rs-34476/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-09-21T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-09-17T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nIt is clear that all previous editor and reviewer concerns were addressed in this most recent version of the manuscript. For a topic like active learning that has been covered many times in the literature, this manuscript provided a unique perspective grounded in theoretical framework. In a climate where cultural sensitivity and bias are of increasing importance, looking at the effectiveness of active learning through a cultural lens is very timely. While there is the large limitation of being a single site study, I believe the findings and conclusions seem both transferable and generalizeable enough to be meaningful to readers.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-08-28T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-18T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nThe authors investigate interactions for the development of a transferable theoretical model using a realist evaluation tool. The manuscript underlines the learning differences for active learning between eastern and western culture and presents a good work. Further, the manuscript can be shortened in several paragraphs (e.g. results and discussion can be shortened). Overall the manuscript lacks grammatical errors (p14 l.22, p15 l.47) in several paragraphs and must be re-written. * Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. 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