Instructional design unlocks the effects of prior knowledge activation in multimedia learning

Instructional design unlocks the effects of prior knowledge activation in multimedia learning | 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 Instructional design unlocks the effects of prior knowledge activation in multimedia learning Andrea Storck, Eva Schönefeld, Michelle Bellstedt, Birte Barbian, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7231966/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Prior knowledge activation (PKA) has long been considered a cornerstone of medical education, yet recent meta-analyses reveal conflicting evidence regarding its effectiveness. This study examined when PKA enhances multimedia learning by investigating the role of different information processing channels outlined in the Cognitive Theory of Multimedia Learning. Methods In a randomized experiment, 151 fourth-year medical students viewed laparoscopic surgery training videos under factorial conditions manipulating PKA (via preperatory anatomical images), visual channel activation (via visual cues), and auditory channel activation (via verbal instructions). Learning outcomes were assessed through landmark identification tasks. Data were analyzed using factorial ANOVA with covariates including baseline prior knowledge and sociodemographics. Results As expected, PKA alone showed no significant effect on learning. However, a new interaction emerged between PKA and auditory channel activation ( η p ² = .04). Students benefited from PKA only when verbal instruction was simultaneously provided during training. Without concurrent verbal instructions, PKA provided no learning advantage and in some cases even slightly hindered learning. Conclusions These findings challenge the widespread assumption that PKA is universally beneficial as a standalone intervention. Instead, PKA effectiveness seem to depend on instructional context, specifically the presence of concurrent verbal instruction. This may involve explicitly referencing activated knowledge during instruction, using narration to scaffold connections that prompt learners to integrate prior understanding with new material. Designing for such alignment seems key to realize the benefits of PKA in multimedia learning environments. Special Education Prior knowledge activation Multimedia learning Cognitive Theory of Multimedia Learning Teacher Instruction Figures Figure 1 Figure 2 Figure 3 INTRODUCTION The promise and paradox of prior knowledge activation For decades, cognitivists and constructivists have positioned students' prior knowledge as a cornerstone of effective education (Roschelle, 2007). The activation of this preexisting knowledge—termed prior knowledge activation (PKA)—has become deeply embedded in educational practice (Wetzels et al., 2011 ; Hattan et al., 2023 ), particularly in medical education where building upon basic science concepts is essential for clinical competence (Roels et al., 2010 ; Schimmelfing & Persky, 2020 ; Heitzmann et al., 2023 ; Darici et al., 2024 ). The theoretical rationale appears straightforward: when learners can connect new information to existing knowledge structures, learning becomes more meaningful, organized, and enduring. However, recent empirical evidence has challenged this seemingly intuitive relationship. A comprehensive meta-analysis by Simonsmeier et al. ( 2022 ) examining 8,776 effect sizes revealed a surprising pattern: while some studies demonstrated positive correlations between prior knowledge and learning gain, many others showed negative correlations. When averaged across all studies, the correlation between prior knowledge and standardized learning gain approached zero ( r = − .059, 95% CI [–.688, .621]), suggesting that the benefits of PKA may be far more conditional than previously assumed. This variability in findings points to a critical gap in our understanding. Rather than asking whether PKA is beneficial, we must ask: Under what conditions does PKA enhance learning, and when might it prove detrimental? The answer to this question has profound implications for educational design, particularly as learning environments become increasingly multimedia-rich, self-regulated and technologically sophisticated (Issa et al., 2011 ). PKA and the Cognitive Theory of Multimedia Learning To address these contradictory findings, we turn to the Cognitive Theory of Multimedia Learning (CTML), which provides a mechanistic framework for understanding how information processing occurs in multimedia environments (Mayer, 2005 ). In brief, CTML posits that learners process new information through two distinct channels: a visual channel for processing images and spatial information, and an auditory channel for processing spoken words. Effective learning occurs when both channels are engaged simultaneously, allowing for the integration of verbal and pictorial models within working memory. Critically, CTML emphasizes that new information must be integrated with existing knowledge stored in long-term memory—essentially, prior knowledge or pre-training effect (Mayer, 2017 ). This integration process may be the key to understanding when and why PKA succeeds or fails. If PKA operates by facilitating the integration of activated prior knowledge with incoming information through these dual channels, then the effectiveness of PKA may depend on how these channels are utilized during instruction. The present study The current study examines the conditions under which PKA enhances multimedia learning by examining the role of different information processing channels outlined in CTML. Drawing on the framework of dual-channel processing (Mayer, 2005 ), we investigate how the auditory and visual channels may differentially influence the relationship between PKA and learning outcomes. For this purpose, we experimentally manipulate the presence of the verbal and/or visual channel during a typical medical multimedia task while measuring the effects of PKA on learning outcomes. By examining the relationship between instructional design and PKA effectiveness, we provide educators with more precise guidance on when and how to implement PKA in multimedia learning contexts. METHODS Study Design This randomized controlled trial employed a 2x2x2 factorial design to investigate the effects of prior knowledge activation and multimedia channel processing on learning outcomes. The study was reviewed by the ethics committee of the university (XXXXX) and deemed not to require formal medical ethics approval (reference: XXXXX). All procedures were carried out in accordance with the Declaration of Helsinki. Participants Fourth-year medical students were recruited in-person during regular classes from January to June 2024 at the XXXXX hospital, affiliated with XXXXX. Informed consent was received from all participants. Participation was voluntary with no incentives offered. Eligible participants were required to have completed the anatomical curriculum as part of their medical training while having no prior laparoscopy training or experience in the regular curriculum. One participant exhibiting implausible response behaviour was excluded from the analysis. Procedure Participants completed the study in-person using tablet devices with headphones in a controlled environment. Students were blinded to the intervention conditions throughout the study. The study procedure began with collection of sociodemographic information and prior knowledge measure (see Supplements), followed by randomization using simple random allocation by the study platform based on three experimental factors: prior knowledge activation (yes vs. no), visual channel activation (yes vs. no), and auditory channel activation (yes vs. no) (Fig. 2 ). Participants assigned to the prior knowledge activation condition completed this intervention before viewing the training material. All participants then watched an instructional training video of laparoscopic robotic prostatectomy (length = 5:37 min), with visual and auditory channel activation interventions applied during the training as assigned by their experimental condition. Following the training video, participants completed image-based questions related to the training content (see Supplements). Total study duration was approximately 30 minutes per participant. Prior knowledge activation. In the prior knowledge activation condition, participants were shown an anatomical image of pelvic anatomy (specifically, a textbook cranial-to-caudal view of the small pelvis from the peritoneum) with relevant structures annotated before they watched the training video. Participants were instructed to recapitulate their preexisting knowledge of the pelvic anatomy. Visual channel activation. Visual channel activation was achieved by supplementing the training video with modeling examples that showed the attentional focus of the surgeon during the procedure through additional visual cues as described in Darici et al. ( 2023 ). This intervention was aimed to increase attention to the visual scene. Auditory channel activation. Auditory channel activation involved providing recorded verbal explanations from the surgeon who verbalized the procedure and scene descriptions, which participants could hear during the training video. For example, the surgeon described specific actions such as, “I’m beginning with the dissection of the anterior peritoneum to expose the bladder,” or “Here, I’m using the bipolar forceps to control the dorsal venous complex”. Measurements Measurements included sociodemographic variables of age (free-text response) and gender (man/woman/non-binary), along ten single-choice items related to prior knowledge in pelvic anatomy (Cronbach's α = .165). The primary learning outcome was assessed through a landmark identification task consisting of 14 single-choice (1 of 5) image-based items related to the training content, which were summarized ( α = .655) and normalized to 0-100%. Statistical analysis Statistical analyses and visualizations were performed using R (R Core Team, 2020). Code in the Supplements. A factorial ANCOVA was conducted with the three experimental conditions as fixed effects, landmark identification score as dependent, and gender, age, and prior knowledge as covariates. The results were double-checked with a multiple linear regression model. Effect sizes were reported as partial eta-squared ( η p ²), interpreted according to Cohen's conventions: η p ² = 0.01 (small effects), η p ² = 0.06 (medium effects), and η p ² = 0.14 (large effects). RESULTS Participants We included N = 151 fourth-year medical students ( Mean age = 26 years ± 4 [ Standard Deviation ], 93 females, 57 males, 1 non-binary). A post-hoc power analysis indicates an acceptable power (1 – β = 0.75) to detect the hypothesized interaction effects with medium effect sizes ( η p 2 = .04). While the majority of participants had minimal to no prior experience in robotic surgery, all had successfully completed required anatomy modules. Prior knowledge activation alone does not improve learning First, an ANCOVA was conducted to examine the main effects of prior knowledge activation, visual channel activation, and auditory channel activation on post-training score, while controlling for participant age, gender, and prior knowledge scores (Table 1 ). Table 1 Main effects of variables on post-training score (ANCOVA) Group Post-training score M ± SE (%) Significantly different? p Prior knowledge activation no 54 ± .025 .084 ns yes 57 ± .024 Visual channel activation no 56 ± .024 .612 ns yes 54 ± .024 Auditory channel activation no 47 ± .026 < .001 *** yes 62 ± .023 Notes. M = mean, SE = standard error; ns = not significant; *** = p < 0.001; Covariates appearing in the model are evaluated at the following values: age = 26.54, gender = 1.35, knowledge = 0.37 Prior knowledge activation. We could not show an effect of prior knowledge activation on post-training scores, F (1, 145) = 3.06, p = .084. While students who completed the anatomical review before watching the training video achieved slightly higher scores ( M = 57%, SE = 2.4) than those who did not ( M = 53%, SE = 2.5), this 4-percentage-point difference was statistically insignificant. Visual channel activation. We found no effect of visual channel activation on post-training scores, F (1, 145) = 0.26, p = .612. Surprisingly, participants who received no additional visual cues ( M = 58%, SE = 2.5) scored slightly better than those exposed to cueing ( M = 53%, SE = 2.5). However, this difference was not statistically significant, suggesting that visual enhancements alone do not facilitate learning in this context. Auditory channel activation. A strong main effect was observed for auditory channel activation, F (1, 145) = 21.11, p < .001. Students who received spoken explanations from the surgeon during the training scored substantially better ( M = 62%, SE = 2.3) than those who did not ( M = 48%, SE = 2.5). This 14-percent score gain reflects a large effect size ( η p ² = 0.19), underscoring the critical role of verbal guidance in supporting learning in complex procedural domains. Multiple linear regression analysis corroborated these findings, revealing that auditory channel activation was the strongest predictor of post-training score ( β = 0.392, p < 0.001), while prior knowledge activation ( β = 0.092, p = .316) and visual channel activation ( β = -0.047, p = .601) were not significant. Verbal instruction enables the benefits of prior knowledge activation Importantly, a significant interaction was found between PKA and auditory channel activation, F (1, 145) = 6.59, p = .012, ηp ² = .04, indicating that the effectiveness of PKA was moderated by the presence of verbal instruction. As visualized in Fig. 3 , students benefited from PKA only when auditory channel activation was also present (right panel). In the absence of verbal explanation, PKA did not improve performance and, in some cases, slightly hindered it. In contrast, no significant interaction was observed between prior knowledge activation and visual channel activation ( p = .311), nor between visual and auditory channel activation ( p = .314), suggesting that the observed effects were primarily driven by the auditory channel. DISCUSSION This study addressed a critical gap in our understanding of when prior knowledge activation (PKA) is beneficial to learning by examining its effects through the lens of the Cognitive Theory of Multimedia Learning (CTML). Our findings reveal two key insights: first, PKA alone did not demonstrate a significant effect on learning outcomes, and second, PKA's effectiveness was moderated by the instructional design, specifically the presence of verbal instructions during training—an effect which has received little attention to date. In the discussion that follows, we examine these effects and explore their broader significance for multimedia learning design and educational practice. The absence of standalone PKA effects The finding that PKA alone failed to improve learning performance requires careful consideration of several possible explanations. One potential explanation is that our method did not successfully activate prior knowledge. However, we consider this unlikely given the moderation effect observed between PKA and auditory channel activation. A second possibility is that while PKA was activate, the activated prior knowledge itself is irrelevant to students in this learning context. We argue against this explanation as well, since the anatomical content of the pelvis directly corresponds to the structures needed to identify during the laparoscopic procedure. In addition, we observed a positive correlation ( r = .21, p = .016) between students' baseline prior knowledge in anatomy and post-training performance, independent of activation status, suggesting that prior knowledge in anatomy does theoretically contribute to learning in laparoscopic surgery. The most plausible explanation is that prior knowledge, even if activated and relevant, is not inherently beneficial and depends on determinants of the training environment. Thus, additional elements of the instructional environment are influencing relevant and activated prior knowledge to translate into improved learning outcomes. This suggests a shift from the prior knowledge towards the training context, which has been mostly neglected in research, and leads directly to our second key finding. PKA effects depend on the multimedia design Our most significant finding is that PKA was only effective when combined with verbal instructions during training, as evidenced by the significant interaction between these two factors. This suggests that the instructional content acts as a cognitive bridge between students’ activated prior knowledge and new learning material. The interpretation is straightforward: the effectiveness of PKA depends on instructional elements present during the training phase, specifically the instructional design and verbal explanations provided by the instructor. When PKA was combined with verbal instruction, students achieved significantly higher learning outcomes, suggesting these two elements are intertwined in the learning process. Students appear to integrate their activated prior knowledge with the concurrent instructional design, creating a synergistic effect that enhances learning beyond what either component achieves alone (Hailikari et al., 2008 ; Sweller & Marrienboer, 2019; Bittermann et al., 2023 ; Wang et al., 2024 ). For example, in a laparoscopic surgery training session, medical students might first activate their prior knowledge about abdominal anatomy through a brief review of organ positions and relationships. However, this prior knowledge activation only becomes effective when the surgeon-instructor verbally connects these concepts during the laparoscopic procedure, saying: " Remember the liver's position relative to the gallbladder that you just described? Notice how on this laparoscopic view, we're seeing that same relationship, but from this unusual angle—the liver edge is now this bright structure blocking our view of the gallbladder ." Without this verbal bridging, students may struggle to translate their three-dimensional anatomical knowledge to the magnified laparoscopic perspective. This congruency effect can also be interpreted through the framework of CTML, where prior knowledge stored in long-term memory serves as a foundation for integrating incoming sensory stimuli (Johnson et al., 2015 ; Almasseri & AlHojailan, 2019 ). Auditory channel activation appears to provide the necessary scaffolding that allows students to prime their activated prior knowledge towards the incoming information. This coupling may facilitate students' ability to focus on relevant information during training (Cook, 2006 ; Arslan-Ari, 2018 ), thereby overcoming the inherent limitations of working memory capacity (Schweppe & Rummer, 2014 ). While the importance of integrating verbal and visual channels is well established within CTML, the interaction between activated prior knowledge activation and verbal instruction has not, to our knowledge, been directly tested in experimental studies. Importantly, this effect helps to (partly) explain the conflicting evidence reported in the meta-analysis by Simonsmeier et al. ( 2022 ), who found highly variable effects of PKA across studies. It suggests that such inconsistencies may arise not from the ineffectiveness of PKA itself, but from variations in how well instructional designs support the integration of activated knowledge through verbal guidance. For example, anatomy studies that simply asked medical students to "review the hepatobiliary system" before a laparoscopic surgery observation likely showed minimal effects, while contingent studies where surgeons explicitly referenced anatomical landmarks during the procedure ( "This is the hepatocystic triangle you studied in gross anatomy, but notice how the inflammation has distorted the normal relationships" ) would demonstrate stronger learning gains. This effect also extends the understanding of the pre-training effect described by Mayer and colleagues (2017), suggesting that pre-training without proper re-articulation or reference to activated knowledge during the main instructional phase may not be as effective as previously assumed. A surgical skills course might have students recall their knowledge of tissue planes and fascial layers before learning laparoscopic dissection techniques. However, if the instructor never verbally connects these concepts during the hands-on training —"The tissue plane you identified in cadaver lab creates this exact dissection line we're following with the electrocautery" —the anatomical pre-training becomes an isolated activity rather than a foundation for developing surgical judgment. This has important implications for instructional design, indicating that PKA interventions should be coupled with explicit connections during training rather than implemented as standalone preparatory activities. However, it is important to consider that this interaction effect may be influenced by learners' pre-existing knowledge levels. As described in the expertise-reversal effect (Kalyuga, 2009 ), PKA may have diminished or even opposite effects for expert learners who already possess high levels of prior knowledge. Future research will examine how this interaction between PKA and verbal instruction varies across different levels of learner expertise to provide more nuanced guidance for educational practice. Implications for educational theory and practice These findings have implications for both educational theory and practical instructional design. From a theoretical perspective, our results challenge the widespread assumption that PKA is universally beneficial when implemented as a standalone intervention. Instead, they support a more nuanced, conditional view of PKA effectiveness that emphasizes the critical importance of instructional context. This shifts the research focus from whether to use PKA to how PKA should be integrated with other instructional elements to maximize its benefits. For educational practitioners, particularly in medical education and other complex procedural domains, these findings suggest that PKA interventions should be systematically coupled with instruction that references and builds upon the activated knowledge. Simply asking students to review relevant prior knowledge before instruction may be insufficient—instructors must actively connect this activated knowledge to the learning content through verbal explanations during training. This has immediate practical applications for curriculum design, suggesting that pre-training activities should be followed by instructor-led sessions that explicitly link prior knowledge to new material rather than assuming students will make these connections independently (Thomas et al., 2022 ; Otto et al., 2024 ; Barbian et al., 2025 ). From a practical standpoint, educators should consider redesigning PKA interventions to include explicit verbal connections during instruction rather than treating knowledge activation as a separate preparatory phase. This may be particularly important in complex learning domains where students must integrate multiple sources of information while managing high cognitive load (Young et al., 2014 ). The synergistic effect we observed between PKA and verbal instruction suggests that optimal learning environments should coordinate these elements rather than implementing them in isolation. Limitations and future directions Several limitations constrain the generalizability of our findings and point toward important avenues for future research. First, there is a risk of contextual specificity, as our study exclusively examined laparoscopic surgical imagery within a medical education setting. The extent to which our findings regarding the interaction between PKA and verbal instruction generalize to other domains remains to be established. Different subject areas may exhibit varying relationships between PKA and instructional modalities due to differences in content complexity, visual-spatial demands, and knowledge structures. Similarly, our study utilized verbal instructions from a single instructor, which raises questions about the consistency of these effects across different teaching approaches, expertise levels, and instructional approaches. The specific way our instructor integrated verbal explanations with visual content may have unique characteristics that contributed to the observed interaction effect. Future research should examine whether the PKA-verbal instruction interaction holds across multiple instructors with varying pedagogical approaches and communication styles to establish the robustness of this relationship. A third limitation concerns our understanding of the underlying mechanisms driving these effects. While we demonstrated that PKA and verbal instruction interact to enhance learning, this study did not investigate which specific elements of the training facilitated the learning process. Moreover, it remains unclear which particular components of the PKA intervention interacted with the verbal instructions and through what cognitive processes this interaction occurred. Future research employing more fine-grained analysis methods, such as eye-tracking or think-aloud protocols, could illuminate the specific cognitive mechanisms underlying this interaction. Finally, our study design presents a theoretical limitation related to CTML itself. According to the theory, there are inherent connections between spoken words and the visual channel, which may confound the effects we attributed specifically to auditory channel activation. The verbal instructions in our study necessarily referred to and directed attention to visual elements, making it difficult to isolate pure auditory processing effects from integrated audio-visual processing. Future research might explore ways to more cleanly separate the activation of different processing channels, perhaps through carefully designed stimuli that minimize cross-modal references or through neuroimaging approaches that can track channel-specific activation patterns. Conclusion The current study addressed a critical question in educational research: when is prior knowledge activation beneficial for learning? Our findings reveal that PKA is beneficial only when co-activated with the auditory channel through teacher instructions, providing new insight into the conditions under which PKA should be implemented in educational settings. This discovery sheds light on when and how PKA should be used in education, with implications for both educational theory and practice. Declarations We hereby confirm that approval has been received from the ethics board (“Ethik Kommission Westfalen-Lippe”, Ref: 2023-631-f-N). We also confirm that all participants gave informed consent to participate in the study. Acknowledgements: We thank all the students for participating in this study. Conflicts of interest: The authors declare no conflicts of interest. AI disclosure: Claude v. 4 Sonnet has been used for language editing. All content and ideas remain the original work of the authors, with AI assistance to improve linguistic clarity. References Almasseri, M., & AlHojailan, M. I. (2019). How flipped learning based on the cognitive theory of multimedia learning affects students' academic achievements. Journal of Computer Assisted Learning, 35 (6), 769–781. https://doi.org/10.1111/jcal.12386 Arslan‐Ari, I. (2018). Learning from instructional animations: How does prior knowledge mediate the effect of visual cues? 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Adapting prior knowledge activation: Mobilisation, perspective taking, and learners' prior knowledge. Computers in Human Behavior, 27 (1), 16–21. https://doi.org/10.1016/j.chb.2010.05.004 Young, J. Q., Van Merrienboer, J., Durning, S., & Ten Cate, O. (2014). Cognitive load theory: Implications for medical education: AMEE Guide No. 86. Medical Teacher, 36 (5), 371–384. https://doi.org/10.3109/0142159X.2014.889290 Additional Declarations The authors declare no competing interests. Supplementary Files SUPPLEMENTS.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7231966","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":491848524,"identity":"d9e74e68-a0c4-4139-ae1b-5c8b947b9feb","order_by":0,"name":"Andrea Storck","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Storck","suffix":""},{"id":491848525,"identity":"a95bb136-f0e3-41ff-8f1f-e10862b6283e","order_by":1,"name":"Eva Schönefeld","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Eva","middleName":"","lastName":"Schönefeld","suffix":""},{"id":491848526,"identity":"6fe1de6b-62ed-47ce-8673-246bc78a2453","order_by":2,"name":"Michelle Bellstedt","email":"","orcid":"https://orcid.org/0009-0001-3445-7928","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Michelle","middleName":"","lastName":"Bellstedt","suffix":""},{"id":491848527,"identity":"ba9b9596-3216-438e-ba9c-b06139080db5","order_by":3,"name":"Birte Barbian","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Birte","middleName":"","lastName":"Barbian","suffix":""},{"id":491848528,"identity":"f4969ead-5b4f-4a35-b90f-a18380587f25","order_by":4,"name":"Martin Janssen","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Janssen","suffix":""},{"id":491848529,"identity":"72f7ce11-5a83-472a-8c64-e7cfc0286a59","order_by":5,"name":"Konstantin E. Seifert","email":"","orcid":"https://orcid.org/0000-0002-9109-9004","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Konstantin","middleName":"E.","lastName":"Seifert","suffix":""},{"id":491848530,"identity":"8173219e-29cb-4d01-8042-2d7c97bdba91","order_by":6,"name":"Dogus Darici","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYDCCAyBkYMPAwIwsykNYSxpCCw8xWoDgMJoF+LTwHT/78MCPgvOJ29kZWDfzVNyxt2fvfcDwpgK3Fskz6QYHewxuJ+5sZmC7zXPmWWIPz3EDxjlncGsxOJAGdBVQy4bD/N9u87YdTuCRSGNg5m3Do+X8M5CWc0AtQFt4/x2255F/BtTyD4+WG2BbDkC1NBxm7JFgA2ppwOOXG88YgH5JNgZpuTnn2OHEnjNpDAfnHMOthe98GvOHH3/sZDecP8B2403NYXv29mOMD97U4NaCHRwgVcMoGAWjYBSMAlQAANKGVNr0v77OAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-2375-8792","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Dogus","middleName":"","lastName":"Darici","suffix":""}],"badges":[],"createdAt":"2025-07-28 09:10:50","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7231966/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7231966/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88061656,"identity":"53775913-b409-4c00-8492-3b005aa9294c","added_by":"auto","created_at":"2025-08-01 02:02:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":431215,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCognitive theory of multimedia learning framework with experimental manipulations.\u003c/em\u003e\u003cbr\u003e\nThe diagram illustrates the flow of information from multimedia presentation through sensory and working memory into long-term memory, adapted from Mayer's Cognitive Theory of Multimedia Learning. Information is presented as spoken words and pictures, entering the auditory and visual sensory channels, respectively. These inputs are processed in working memory as verbal and pictorial models, which are then integrated with prior knowledge in long-term memory. The green labels indicate the three variables that were experimentally manipulated in the current study: auditory activation, visual activation, and prior knowledge activation. These manipulations were designed to examine their individual and interactive effects on learning outcomes.\u003c/p\u003e","description":"","filename":"Screenshot20250728at11.13.27.png","url":"https://assets-eu.researchsquare.com/files/rs-7231966/v1/c7d31222f1306fbaa58acfcc.png"},{"id":88062427,"identity":"e1392815-40e5-4359-bcb7-0697b45dcc76","added_by":"auto","created_at":"2025-08-01 02:18:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1993448,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eOverview of the experimental design. \u003c/em\u003eThe design includes three factors: prior knowledge activation, visual channel activation, and auditory channel activation. Within each group, visual channel activation was manipulated by overlaying a visual cue onto the training video, and auditory channel activation was manipulated by adding expert narration.\u003c/p\u003e","description":"","filename":"Screenshot20250728at11.13.38.png","url":"https://assets-eu.researchsquare.com/files/rs-7231966/v1/7be5cc850bcb059910e8adfa.png"},{"id":88062208,"identity":"61361716-5085-408c-9506-bbbd3fa681ab","added_by":"auto","created_at":"2025-08-01 02:10:48","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":476521,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eNormalized post-training score as a function of prior knowledge activation and modality-specific channel activation (visual vs. auditory).\u003cbr\u003e\n \u003c/em\u003eBar plots show mean post-training score (%) with individual participant scores (dots) and 95% Confidence Intervals. The left panel depicts the effect of activating the \u003cstrong\u003evisual channel\u003c/strong\u003e (no = orange, yes = blue), while the right panel shows the effect of activating the \u003cstrong\u003eauditory channel\u003c/strong\u003e. Within each panel, performance is stratified by whether \u003cstrong\u003eprior knowledge\u003c/strong\u003ewas activated (no vs. yes). Activating the auditory channel in conjunction with prior knowledge yielded the highest performance gains. In contrast, visual channel activation showed minimal performance differences across prior knowledge conditions.\u003c/p\u003e","description":"","filename":"Screenshot20250728at11.13.48.png","url":"https://assets-eu.researchsquare.com/files/rs-7231966/v1/5b69298edb32a126435505d4.png"},{"id":88063034,"identity":"ef643b81-dea9-4e2e-9f2f-6ec3d70a4d59","added_by":"auto","created_at":"2025-08-01 02:26:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3927875,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231966/v1/2b053d32-8261-41f3-89d1-ebff4ea261ac.pdf"},{"id":88062426,"identity":"b2a7f69a-18b1-4285-adb2-63612c27c663","added_by":"auto","created_at":"2025-08-01 02:18:48","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":812674,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMENTS.docx","url":"https://assets-eu.researchsquare.com/files/rs-7231966/v1/3324e183ab234fedf078f327.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eInstructional design unlocks the effects of prior knowledge activation in multimedia learning\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003e\u003cb\u003eThe promise and paradox of prior knowledge activation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFor decades, cognitivists and constructivists have positioned students' prior knowledge as a cornerstone of effective education (Roschelle, 2007). The activation of this preexisting knowledge—termed prior knowledge activation (PKA)—has become deeply embedded in educational practice (Wetzels et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Hattan et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), particularly in medical education where building upon basic science concepts is essential for clinical competence (Roels et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Schimmelfing \u0026amp; Persky, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Heitzmann et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Darici et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The theoretical rationale appears straightforward: when learners can connect new information to existing knowledge structures, learning becomes more meaningful, organized, and enduring.\u003c/p\u003e\u003cp\u003eHowever, recent empirical evidence has challenged this seemingly intuitive relationship. A comprehensive meta-analysis by Simonsmeier et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) examining 8,776 effect sizes revealed a surprising pattern: while some studies demonstrated positive correlations between prior knowledge and learning gain, many others showed negative correlations. When averaged across all studies, the correlation between prior knowledge and standardized learning gain approached zero (\u003cem\u003er\u003c/em\u003e = − .059, 95% \u003cem\u003eCI\u003c/em\u003e [–.688, .621]), suggesting that the benefits of PKA may be far more conditional than previously assumed.\u003c/p\u003e\u003cp\u003eThis variability in findings points to a critical gap in our understanding. Rather than asking whether PKA is beneficial, we must ask: \u003cem\u003eUnder what conditions does PKA enhance learning, and when might it prove detrimental?\u003c/em\u003e The answer to this question has profound implications for educational design, particularly as learning environments become increasingly multimedia-rich, self-regulated and technologically sophisticated (Issa et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003ePKA and the\u003c/b\u003e \u003cb\u003eCognitive Theory of Multimedia Learning\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo address these contradictory findings, we turn to the \u003cem\u003eCognitive Theory of Multimedia Learning\u003c/em\u003e (CTML), which provides a mechanistic framework for understanding \u003cem\u003ehow\u003c/em\u003e information processing occurs in multimedia environments (Mayer, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). In brief, CTML posits that learners process new information through two distinct channels: a visual channel for processing images and spatial information, and an auditory channel for processing spoken words. Effective learning occurs when both channels are engaged simultaneously, allowing for the integration of verbal and pictorial models within working memory.\u003c/p\u003e\u003cp\u003eCritically, CTML emphasizes that new information must be integrated with existing knowledge stored in long-term memory—essentially, prior knowledge or \u003cem\u003epre-training effect\u003c/em\u003e (Mayer, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This integration process may be the key to understanding when and why PKA succeeds or fails. If PKA operates by facilitating the integration of activated prior knowledge with incoming information through these dual channels, then the effectiveness of PKA may depend on how these channels are utilized during instruction.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe present study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe current study examines the conditions under which PKA enhances multimedia learning by examining the role of different information processing channels outlined in CTML. Drawing on the framework of dual-channel processing (Mayer, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2005\u003c/span\u003e), we investigate how the auditory and visual channels may differentially influence the relationship between PKA and learning outcomes.\u003c/p\u003e\u003cp\u003e For this purpose, we experimentally manipulate the presence of the verbal and/or visual channel during a typical medical multimedia task while measuring the effects of PKA on learning outcomes. By examining the relationship between instructional design and PKA effectiveness, we provide educators with more precise guidance on when and how to implement PKA in multimedia learning contexts.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis randomized controlled trial employed a 2x2x2 factorial design to investigate the effects of prior knowledge activation and multimedia channel processing on learning outcomes. The study was reviewed by the ethics committee of the university (XXXXX) and deemed not to require formal medical ethics approval (reference: XXXXX). All procedures were carried out in accordance with the Declaration of Helsinki.\u003c/p\u003e\u003cb\u003eParticipants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFourth-year medical students were recruited in-person during regular classes from January to June 2024 at the XXXXX hospital, affiliated with XXXXX. Informed consent was received from all participants. Participation was voluntary with no incentives offered. Eligible participants were required to have completed the anatomical curriculum as part of their medical training while having no prior laparoscopy training or experience in the regular curriculum. One participant exhibiting implausible response behaviour was excluded from the analysis.\u003c/p\u003e\u003cb\u003eProcedure\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants completed the study in-person using tablet devices with headphones in a controlled environment. Students were blinded to the intervention conditions throughout the study.\u003c/p\u003e\u003cp\u003eThe study procedure began with collection of sociodemographic information and prior knowledge measure (see Supplements), followed by randomization using \u003cem\u003esimple random allocation\u003c/em\u003e by the study platform based on three experimental factors: prior knowledge activation (yes vs. no), visual channel activation (yes vs. no), and auditory channel activation (yes vs. no) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Participants assigned to the prior knowledge activation condition completed this intervention before viewing the training material. All participants then watched an instructional training video of laparoscopic robotic prostatectomy (length = 5:37 min), with visual and auditory channel activation interventions applied during the training as assigned by their experimental condition. Following the training video, participants completed image-based questions related to the training content (see Supplements). Total study duration was approximately 30 minutes per participant.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePrior knowledge activation.\u003c/em\u003e In the prior knowledge activation condition, participants were shown an anatomical image of pelvic anatomy (specifically, a textbook cranial-to-caudal view of the small pelvis from the peritoneum) with relevant structures annotated before they watched the training video. Participants were instructed to recapitulate their preexisting knowledge of the pelvic anatomy.\u003c/p\u003e\u003cp\u003e\u003cem\u003eVisual channel activation.\u003c/em\u003e Visual channel activation was achieved by supplementing the training video with modeling examples that showed the attentional focus of the surgeon during the procedure through additional visual cues as described in Darici et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This intervention was aimed to increase attention to the visual scene.\u003c/p\u003e\u003cp\u003e\u003cem\u003eAuditory channel activation.\u003c/em\u003e Auditory channel activation involved providing recorded verbal explanations from the surgeon who verbalized the procedure and scene descriptions, which participants could hear during the training video. For example, the surgeon described specific actions such as, \u003cem\u003e“I’m beginning with the dissection of the anterior peritoneum to expose the bladder,”\u003c/em\u003e or \u003cem\u003e“Here, I’m using the bipolar forceps to control the dorsal venous complex”.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMeasurements\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMeasurements included sociodemographic variables of age (free-text response) and gender (man/woman/non-binary), along ten single-choice items related to prior knowledge in pelvic anatomy (Cronbach's \u003cem\u003eα\u003c/em\u003e = .165). The primary learning outcome was assessed through a landmark identification task consisting of 14 single-choice (1 of 5) image-based items related to the training content, which were summarized (\u003cem\u003eα\u003c/em\u003e = .655) and normalized to 0-100%.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses and visualizations were performed using R (R Core Team, 2020). Code in the Supplements. A factorial ANCOVA was conducted with the three experimental conditions as fixed effects, landmark identification score as dependent, and gender, age, and prior knowledge as covariates. The results were double-checked with a multiple linear regression model. Effect sizes were reported as partial eta-squared (\u003cem\u003eη\u003c/em\u003e\u003csub\u003e\u003cem\u003ep\u003c/em\u003e\u003c/sub\u003e²), interpreted according to Cohen's conventions: \u003cem\u003eη\u003c/em\u003e\u003csub\u003e\u003cem\u003ep\u003c/em\u003e\u003c/sub\u003e² = 0.01 (small effects), η\u003csub\u003ep\u003c/sub\u003e² = 0.06 (medium effects), and \u003cem\u003eη\u003c/em\u003e\u003csub\u003e\u003cem\u003ep\u003c/em\u003e\u003c/sub\u003e² = 0.14 (large effects).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cb\u003eParticipants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe included \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;151 fourth-year medical students (\u003cem\u003eMean\u003c/em\u003e\u003csub\u003eage\u003c/sub\u003e = 26 years\u0026thinsp;\u0026plusmn;\u0026thinsp;4 [\u003cem\u003eStandard Deviation\u003c/em\u003e], 93 females, 57 males, 1 non-binary). A post-hoc power analysis indicates an acceptable power (1 \u0026ndash; \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.75) to detect the hypothesized interaction effects with medium effect sizes (\u003cem\u003eη\u003c/em\u003e\u003csub\u003e\u003cem\u003ep\u003c/em\u003e\u003c/sub\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.04). While the majority of participants had minimal to no prior experience in robotic surgery, all had successfully completed required anatomy modules.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrior knowledge activation alone does not improve learning\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFirst, an ANCOVA was conducted to examine the main effects of prior knowledge activation, visual channel activation, and auditory channel activation on post-training score, while controlling for participant age, gender, and prior knowledge scores (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMain effects of variables on post-training score (ANCOVA)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost-training score\u003c/p\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003eSE\u003c/em\u003e (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSignificantly different?\u003c/p\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior knowledge activation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54\u0026thinsp;\u0026plusmn;\u0026thinsp;.025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e.084 \u003cem\u003ens\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57\u0026thinsp;\u0026plusmn;\u0026thinsp;.024\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVisual channel activation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56\u0026thinsp;\u0026plusmn;\u0026thinsp;.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e.612 \u003cem\u003ens\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54\u0026thinsp;\u0026plusmn;\u0026thinsp;.024\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuditory channel activation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47\u0026thinsp;\u0026plusmn;\u0026thinsp;.026\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001 ***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62\u0026thinsp;\u0026plusmn;\u0026thinsp;.023\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eNotes. \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;mean, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;standard error; \u003cem\u003ens\u003c/em\u003e\u0026thinsp;=\u0026thinsp;not significant; *** = \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Covariates appearing in the model are evaluated at the following values: age\u0026thinsp;=\u0026thinsp;26.54, gender\u0026thinsp;=\u0026thinsp;1.35, knowledge\u0026thinsp;=\u0026thinsp;0.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrior knowledge activation.\u003c/b\u003e We could not show an effect of prior knowledge activation on post-training scores, \u003cem\u003eF\u003c/em\u003e(1, 145)\u0026thinsp;=\u0026thinsp;3.06, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.084. While students who completed the anatomical review before watching the training video achieved slightly higher scores (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;57%, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.4) than those who did not (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53%, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.5), this 4-percentage-point difference was statistically insignificant.\u003c/p\u003e\u003cp\u003e\u003cb\u003eVisual channel activation.\u003c/b\u003e We found no effect of visual channel activation on post-training scores, \u003cem\u003eF\u003c/em\u003e(1, 145)\u0026thinsp;=\u0026thinsp;0.26, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.612. Surprisingly, participants who received no additional visual cues (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;58%, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.5) scored slightly better than those exposed to cueing (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53%, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.5). However, this difference was not statistically significant, suggesting that visual enhancements alone do not facilitate learning in this context.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAuditory channel activation.\u003c/b\u003e A strong main effect was observed for auditory channel activation, \u003cem\u003eF\u003c/em\u003e(1, 145)\u0026thinsp;=\u0026thinsp;21.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. Students who received spoken explanations from the surgeon during the training scored substantially better (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;62%, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.3) than those who did not (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;48%, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.5). This 14-percent score gain reflects a large effect size (\u003cem\u003eη\u003c/em\u003e\u003csub\u003ep\u003c/sub\u003e\u0026sup2; = 0.19), underscoring the critical role of verbal guidance in supporting learning in complex procedural domains.\u003c/p\u003e\u003cp\u003eMultiple linear regression analysis corroborated these findings, revealing that auditory channel activation was the strongest predictor of post-training score (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.392, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while prior knowledge activation (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.092, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.316) and visual channel activation (\u003cem\u003eβ\u003c/em\u003e = -0.047, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.601) were not significant.\u003c/p\u003e\u003cp\u003e\u003cb\u003eVerbal instruction enables the benefits of prior knowledge activation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eImportantly, a significant interaction was found between PKA and auditory channel activation, \u003cem\u003eF\u003c/em\u003e(1, 145)\u0026thinsp;=\u0026thinsp;6.59, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.012, \u003cem\u003eηp\u003c/em\u003e\u0026sup2; = .04, indicating that the effectiveness of PKA was moderated by the presence of verbal instruction. As visualized in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, students benefited from PKA only when auditory channel activation was also present (right panel). In the absence of verbal explanation, PKA did not improve performance and, in some cases, slightly hindered it.\u003c/p\u003e\u003cp\u003eIn contrast, no significant interaction was observed between prior knowledge activation and visual channel activation (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.311), nor between visual and auditory channel activation (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.314), suggesting that the observed effects were primarily driven by the auditory channel.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study addressed a critical gap in our understanding of \u003cem\u003ewhen\u003c/em\u003e prior knowledge activation (PKA) is beneficial to learning by examining its effects through the lens of the \u003cem\u003eCognitive Theory of Multimedia Learning\u003c/em\u003e (CTML). Our findings reveal two key insights: first, PKA alone did not demonstrate a significant effect on learning outcomes, and second, PKA's effectiveness was moderated by the instructional design, specifically the presence of verbal instructions during training\u0026mdash;an effect which has received little attention to date. In the discussion that follows, we examine these effects and explore their broader significance for multimedia learning design and educational practice.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe absence of standalone PKA effects\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe finding that PKA alone failed to improve learning performance requires careful consideration of several possible explanations. One potential explanation is that our method did not successfully activate prior knowledge. However, we consider this unlikely given the moderation effect observed between PKA and auditory channel activation.\u003c/p\u003e\u003cp\u003eA second possibility is that while PKA was activate, the activated prior knowledge itself is irrelevant to students in this learning context. We argue against this explanation as well, since the anatomical content of the pelvis directly corresponds to the structures needed to identify during the laparoscopic procedure. In addition, we observed a positive correlation (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.21, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.016) between students' baseline prior knowledge in anatomy and post-training performance, independent of activation status, suggesting that prior knowledge in anatomy does theoretically contribute to learning in laparoscopic surgery.\u003c/p\u003e\u003cp\u003eThe most plausible explanation is that prior knowledge, even if activated and relevant, is not inherently beneficial and depends on determinants of the training environment. Thus, additional elements of the instructional environment are influencing relevant and activated prior knowledge to translate into improved learning outcomes. This suggests a shift from the prior knowledge towards the training context, which has been mostly neglected in research, and leads directly to our second key finding.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePKA effects depend on the multimedia design\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Our most significant finding is that PKA was only effective when combined with verbal instructions during training, as evidenced by the significant interaction between these two factors. This suggests that the instructional content acts as a cognitive bridge between students\u0026rsquo; activated prior knowledge and new learning material.\u003c/p\u003e\u003cp\u003eThe interpretation is straightforward: the effectiveness of PKA depends on instructional elements present during the training phase, specifically the instructional design and verbal explanations provided by the instructor. When PKA was combined with verbal instruction, students achieved significantly higher learning outcomes, suggesting these two elements are intertwined in the learning process. Students appear to integrate their activated prior knowledge with the concurrent instructional design, creating a synergistic effect that enhances learning beyond what either component achieves alone (Hailikari et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Sweller \u0026amp; Marrienboer, 2019; Bittermann et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Wang et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). For example, in a laparoscopic surgery training session, medical students might first activate their prior knowledge about abdominal anatomy through a brief review of organ positions and relationships. However, this prior knowledge activation only becomes effective when the surgeon-instructor verbally connects these concepts during the laparoscopic procedure, saying: \"\u003cem\u003eRemember the liver's position relative to the gallbladder that you just described? Notice how on this laparoscopic view, we're seeing that same relationship, but from this unusual angle\u0026mdash;the liver edge is now this bright structure blocking our view of the gallbladder\u003c/em\u003e.\" Without this verbal bridging, students may struggle to translate their three-dimensional anatomical knowledge to the magnified laparoscopic perspective.\u003c/p\u003e\u003cp\u003eThis congruency effect can also be interpreted through the framework of CTML, where prior knowledge stored in long-term memory serves as a foundation for integrating incoming sensory stimuli (Johnson et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Almasseri \u0026amp; AlHojailan, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Auditory channel activation appears to provide the necessary scaffolding that allows students to prime their activated prior knowledge towards the incoming information. This coupling may facilitate students' ability to focus on relevant information during training (Cook, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Arslan-Ari, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), thereby overcoming the inherent limitations of working memory capacity (Schweppe \u0026amp; Rummer, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). While the importance of integrating verbal and visual channels is well established within CTML, the interaction between activated prior knowledge activation and verbal instruction has not, to our knowledge, been directly tested in experimental studies.\u003c/p\u003e\u003cp\u003eImportantly, this effect helps to (partly) explain the conflicting evidence reported in the meta-analysis by Simonsmeier et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), who found highly variable effects of PKA across studies. It suggests that such inconsistencies may arise not from the ineffectiveness of PKA itself, but from variations in how well instructional designs support the integration of activated knowledge through verbal guidance. For example, anatomy studies that simply asked medical students to \"review the hepatobiliary system\" before a laparoscopic surgery observation likely showed minimal effects, while contingent studies where surgeons explicitly referenced anatomical landmarks during the procedure (\u003cem\u003e\"This is the hepatocystic triangle you studied in gross anatomy, but notice how the inflammation has distorted the normal relationships\"\u003c/em\u003e) would demonstrate stronger learning gains.\u003c/p\u003e\u003cp\u003eThis effect also extends the understanding of the pre-training effect described by Mayer and colleagues (2017), suggesting that pre-training without proper re-articulation or reference to activated knowledge during the main instructional phase may not be as effective as previously assumed. A surgical skills course might have students recall their knowledge of tissue planes and fascial layers before learning laparoscopic dissection techniques. However, if the instructor never verbally connects these concepts during the hands-on training\u003cem\u003e\u0026mdash;\"The tissue plane you identified in cadaver lab creates this exact dissection line we're following with the electrocautery\"\u003c/em\u003e\u0026mdash;the anatomical pre-training becomes an isolated activity rather than a foundation for developing surgical judgment. This has important implications for instructional design, indicating that PKA interventions should be coupled with explicit connections during training rather than implemented as standalone preparatory activities.\u003c/p\u003e\u003cp\u003eHowever, it is important to consider that this interaction effect may be influenced by learners' pre-existing knowledge levels. As described in the expertise-reversal effect (Kalyuga, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), PKA may have diminished or even opposite effects for expert learners who already possess high levels of prior knowledge. Future research will examine how this interaction between PKA and verbal instruction varies across different levels of learner expertise to provide more nuanced guidance for educational practice.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplications for educational theory and practice\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThese findings have implications for both educational theory and practical instructional design. From a theoretical perspective, our results challenge the widespread assumption that PKA is universally beneficial when implemented as a standalone intervention. Instead, they support a more nuanced, conditional view of PKA effectiveness that emphasizes the critical importance of instructional context. This shifts the research focus from whether to use PKA to \u003cem\u003ehow\u003c/em\u003e PKA should be integrated with other instructional elements to maximize its benefits.\u003c/p\u003e\u003cp\u003eFor educational practitioners, particularly in medical education and other complex procedural domains, these findings suggest that PKA interventions should be systematically coupled with instruction that references and builds upon the activated knowledge. Simply asking students to review relevant prior knowledge before instruction may be insufficient\u0026mdash;instructors must actively connect this activated knowledge to the learning content through verbal explanations during training. This has immediate practical applications for curriculum design, suggesting that pre-training activities should be followed by instructor-led sessions that explicitly link prior knowledge to new material rather than assuming students will make these connections independently (Thomas et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Otto et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Barbian et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e From a practical standpoint, educators should consider redesigning PKA interventions to include explicit verbal connections during instruction rather than treating knowledge activation as a separate preparatory phase. This may be particularly important in complex learning domains where students must integrate multiple sources of information while managing high cognitive load (Young et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The synergistic effect we observed between PKA and verbal instruction suggests that optimal learning environments should coordinate these elements rather than implementing them in isolation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations and future directions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSeveral limitations constrain the generalizability of our findings and point toward important avenues for future research. First, there is a risk of contextual specificity, as our study exclusively examined laparoscopic surgical imagery within a medical education setting. The extent to which our findings regarding the interaction between PKA and verbal instruction generalize to other domains remains to be established. Different subject areas may exhibit varying relationships between PKA and instructional modalities due to differences in content complexity, visual-spatial demands, and knowledge structures.\u003c/p\u003e\u003cp\u003e Similarly, our study utilized verbal instructions from a single instructor, which raises questions about the consistency of these effects across different teaching approaches, expertise levels, and instructional approaches. The specific way our instructor integrated verbal explanations with visual content may have unique characteristics that contributed to the observed interaction effect. Future research should examine whether the PKA-verbal instruction interaction holds across multiple instructors with varying pedagogical approaches and communication styles to establish the robustness of this relationship.\u003c/p\u003e\u003cp\u003eA third limitation concerns our understanding of the underlying mechanisms driving these effects. While we demonstrated that PKA and verbal instruction interact to enhance learning, this study did not investigate which specific elements of the training facilitated the learning process. Moreover, it remains unclear which particular components of the PKA intervention interacted with the verbal instructions and through what cognitive processes this interaction occurred. Future research employing more fine-grained analysis methods, such as eye-tracking or think-aloud protocols, could illuminate the specific cognitive mechanisms underlying this interaction.\u003c/p\u003e\u003cp\u003eFinally, our study design presents a theoretical limitation related to CTML itself. According to the theory, there are inherent connections between spoken words and the visual channel, which may confound the effects we attributed specifically to auditory channel activation. The verbal instructions in our study necessarily referred to and directed attention to visual elements, making it difficult to isolate pure auditory processing effects from integrated audio-visual processing. Future research might explore ways to more cleanly separate the activation of different processing channels, perhaps through carefully designed stimuli that minimize cross-modal references or through neuroimaging approaches that can track channel-specific activation patterns.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe current study addressed a critical question in educational research: when is prior knowledge activation beneficial for learning? Our findings reveal that PKA is beneficial only when co-activated with the auditory channel through teacher instructions, providing new insight into the conditions under which PKA should be implemented in educational settings. This discovery sheds light on \u003cem\u003ewhen\u003c/em\u003e and \u003cem\u003ehow\u003c/em\u003e PKA should be used in education, with implications for both educational theory and practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eWe hereby confirm that approval has been received from the ethics board (\u0026ldquo;Ethik Kommission Westfalen-Lippe\u0026rdquo;, Ref: 2023-631-f-N). We also confirm that all participants gave informed consent to participate in the study.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe thank all the students for participating in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u003c/strong\u003e The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAI disclosure:\u003c/strong\u003e Claude v. 4 Sonnet has been used for language editing. 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Cognitive load theory: Implications for medical education: AMEE Guide No. 86. \u003cem\u003eMedical Teacher, 36\u003c/em\u003e(5), 371\u0026ndash;384. https://doi.org/10.3109/0142159X.2014.889290\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Münster","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Prior knowledge activation, Multimedia learning, Cognitive Theory of Multimedia Learning, Teacher Instruction","lastPublishedDoi":"10.21203/rs.3.rs-7231966/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7231966/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePrior knowledge activation (PKA) has long been considered a cornerstone of medical education, yet recent meta-analyses reveal conflicting evidence regarding its effectiveness. This study examined \u003cem\u003ewhen\u003c/em\u003e PKA enhances multimedia learning by investigating the role of different information processing channels outlined in the Cognitive Theory of Multimedia Learning.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn a randomized experiment, 151 fourth-year medical students viewed laparoscopic surgery training videos under factorial conditions manipulating PKA (via preperatory anatomical images), visual channel activation (via visual cues), and auditory channel activation (via verbal instructions). Learning outcomes were assessed through landmark identification tasks. Data were analyzed using factorial ANOVA with covariates including baseline prior knowledge and sociodemographics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAs expected, PKA alone showed no significant effect on learning. However, a new interaction emerged between PKA and auditory channel activation (\u003cem\u003eη\u003c/em\u003e\u003csub\u003e\u003cem\u003ep\u003c/em\u003e\u003c/sub\u003e\u0026sup2; = .04). Students benefited from PKA only when verbal instruction was simultaneously provided during training. Without concurrent verbal instructions, PKA provided no learning advantage and in some cases even slightly hindered learning.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThese findings challenge the widespread assumption that PKA is universally beneficial as a standalone intervention. Instead, PKA effectiveness seem to depend on instructional context, specifically the presence of concurrent verbal instruction. This may involve explicitly referencing activated knowledge during instruction, using narration to scaffold connections that prompt learners to integrate prior understanding with new material. Designing for such alignment seems key to realize the benefits of PKA in multimedia learning environments.\u003c/p\u003e","manuscriptTitle":"Instructional design unlocks the effects of prior knowledge activation in multimedia learning","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 02:02:44","doi":"10.21203/rs.3.rs-7231966/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f63678c7-6c7a-4435-8678-a398e6658d36","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":52215462,"name":"Special Education"}],"tags":[],"updatedAt":"2025-08-01T02:02:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-01 02:02:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7231966","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7231966","identity":"rs-7231966","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}