Problem-based Learning Program Research Articles

Problem-based learning on the WeChat public platform in radiation oncology residency training programs.

This study explored the effectiveness of a Problem-based Learning (PBL) teaching model on the WeChat public platform for radiation oncology residency training programs. The WeChat PBL program was initiated in 2019. The study recruited student participants, on a voluntary basis, who were in their first and second years of standardized training in radiation oncology. We selected classic and trending issues in radiation oncology as the two main teaching topics. Students in the PBL group searched for relevant literature, summarizing PowerPoint presentations or academic speeches on specific issues published on the professional WeChat public platform after an in-depth review by teachers. The final national standardized training examination scores for resident physicians were used to evaluate teaching effectiveness. The graduation scores of the PBL and non-PBL groups were compared, and a stratified analysis was conducted based on the year of participation to assess the teaching effectiveness of this model. Moreover, questionnaires were administered to evaluate students' experiences. Among the 36 students who joined the study in 2019, 16 (44.0%) voluntarily joined the PBL teaching group. Nine students started teaching PBL in their first year of residency, accounting for 47.4% of that year, and seven started in their second year, accounting for 41.2%. The average graduation scores of the PBL group were superior to those of the non-PBL-focused group for the same grade. The rate of high scores among students in the PBL group (56.3%) was higher than that of students in the non-PBL group (25%). Specifically, first-year residents who joined the PBL group had an average score of 92.3 ± 2.2, significantly higher than their non-PBL counterparts, who scored an average of 88.6 ± 4.6, showing a statistically significant advantage (p = 0.042). All students were satisfied with the PBL WeChat teaching and would recommend the PBL WeChat course to others. The PBL residency teaching model on the WeChat platform improved residency scores and garnered student satisfaction.

Emotional Literacy of Elementary School Teachers: A Study on Science Learning with Problem-Based Learning (PBL) and Homogeinity Psycho Cognition (HPC) Program

In the 21st century era, students learn not only to live now but also to live in the future, which is full of dynamics and the surge of globalization. Schools should strive to create a social-emotional environment that supports the development of students' emotional aspects, including by implementing relevant social-emotional learning. Emotional literacy with problem-based learning (PBL) and homogeneity psycho cognition (HPC) learning programs is an unexplored research field in Indonesia, especially in biological science learning in elementary schools and even at higher levels. This research was conducted to explore PBL programs and emotional literacy in depth. This research aims to examine the influence of the PBL learning model with HPC strategies on the emotional literacy of elementary school students in Ambon City. This research is quasi-experimental research, where emotional literacy is the dependent variable and the PBL learning model while HPC strategies is the independent variable. The research results show that there is no difference in emotional literacy between the treatment groups. This means that the implementation of the 2013 curriculum and the Merdeka curriculum in elementary schools have made positive contribution to the learning and emotional environment of elementary school students. Thus, any learning model no longer affects students' emotional literacy. Keywords: emotional literacy, PBL with HPC strategy, emotional environment, elementary schools

Evaluation of Self-Directed Learning Readiness Among Medical Students in Sharjah, the United Arab Emirates.

Self-directed learning (SDL) has become an essential learning principle in medical curricula and a requirement of the professional accreditation standards. It has been advocated that SDL is an effective learning strategy for medical students to develop competence in knowledge acquisition and in promoting life-long learning. Although it has been presumed that problem-based learning (PBL) improves the learner's SDL readiness (SDLR), its effects arestill debatable. This study aimed to investigate the readiness for self-directed learning readiness (SDLR) among undergraduate medical students in problem-based learning (PBL) and non-PBL programs, examining the influence of gender, academic performance, and program year level. This cross-sectional study used a validated instrument, the SDLR instrument (SDLRI), to assess self-directed learning readiness. It consists of 20 items classified into the following four domains: learning motivation (six items), planning and implementation (six items), self-monitoring (four items), and interpersonal communication (four items) based upon a five-point Likert scale. Additionally, demographic data like academic year level, gender, and the student's final grade from the previous semester were collected. Questionnaires were administered to students in their first, third, and fifth (final) academic year across three different medical colleges in the United Arab Emirates (UAE). One of these colleges adopts a hybrid problem-based learning (PBL) approach, while the other two follow non-PBL programs. A total of 386 responses were collected, with 200 students (51.8%) from the hybrid PBL program and 186 students (48.2%) from the non-PBL programs. The overall mean SDLR score was 59.0±18.2. In both programs, the high-achieving students scored SDLR of 64.7±18.0 (n=112), which was statistically significantly higher than the eight medium- and low-achieving students, 57.8±17.2 (n=224). However, the overall SDLR score showed no significant difference in gender or between PBL and non-PBL programs. Although the SDLR increased as PBL students advanced in the program, it decreased in the non-PBL curricula. However, this difference was not statistically significant. The high-achieving students displayed a higher level of SDLR than 10 of the medium- or low-achieving students, regardless of the educational program. This highlights the essential effect of the intrinsic factor for undertaking SDL and implies that students should initiate the process. Moreover, enhancing personal development and SDL educational practices might be effective in improving SDLR if partly implemented in medical programs.

412 Awardee Talk: Implementing student-centered teaching and learning strategies in undergraduate animal science

Abstract Student-centered teaching and learning strategies enhance active engagement, foster critical thinking, and promote the practical application of knowledge gained from undergraduate animal science courses. The scholarship of teaching and learning (SOTL) has evolved within the animal science community, with a recent focus on adopting evidence-based teaching activities in college classrooms. We discuss documented SOTL approaches utilized in our program for the development of student-centered teaching and learning. In addition to traditional internships and student research projects, capstone projects utilizing a design thinking approach to solving animal industry problems have proven significantly effective. This problem-based learning program enables students to develop industry networks, understand problems within the industry, and develop creative ways to address the problems. Non-conventional and innovative designs of course assignments can foster student interest and enhance learning experiences. For example, by incorporating engaging and novel resources such as animal industry webinars and podcasts as classroom materials, instructors can reinforce course content and captivate students’ attention to the topic. Specifically, students have appreciated the opportunity to learn from experts not available locally at the university. Developing and utilizing real-world case studies exposes students to farm practices and related decision-making. Involving students in competitive team activities like the Dairy Challenge and Academic Quadrathlon contests develops marketable skills for students while training them to implement the knowledge acquired in the classrooms on a commercial farm. Field trips, short courses, and summer schools provide hands-on training opportunities, enhancing students’ exposure to the industry and opportunities after graduation. Students have identified that animal science topics are relevant beyond the classroom walls in everyday life including grocery store and kitchen, as demonstrated by a significant increase in enrollment of non-animal science major students in the animal science courses. The student-centered programs like Cross-training students in data-driven decision support tools help to develop strong day-one competency of graduates through training and networking within and outside the discipline. With the advent of new technologies and tools, training programs surrounding data management and interpretation should integrate systems knowledge across plant science, animal science, and computer science disciplines. These interdisciplinary and cross-disciplinary training activities promote the exchange of ideas while developing systems-level understanding. Furthermore, initiatives like Collaborative Online International Learning (COIL) provide students with exposure to diverse thoughts and situations, broadening their horizons and perspectives. For students not able to participate in study abroad and international programs due to time and financial constraints, COIL delivers cost-effective virtual opportunities to develop global understanding and cultural competency. By incorporating these student-centered teaching and learning strategies, undergraduate animal science programs can effectively prepare students for real-world challenges for the next generation of agriculture leaders.

(Trans)formation of student teachers’ professional identity through problem-based learning in Korea

ABSTRACT The current study explored in what ways a problem-based learning (PBL) programme influenced the (trans)formation of the professional identities of six student teachers of English. The student teachers’ narratives and responses to the questionnaires involved the (re)formed pedagogic meanings and related actions and emotions which constitute their professional identities. Data analysis disclosed that the PBL programme contributed to the formation and/or transformation of the student teachers’ professional identities in a way that led them to specify their desire to be a teacher; (re)form pedagogic meanings; and relate their learning in the PBL programme to other pedagogic activities. Based on the findings, the researcher discusses implications for implementing effective PBL for the construction of student teachers’ professional identities in teacher education programmes.

Teacher’s agency in education for sustainable development: an East-West collaborative Erasmus programme using Q methodology

PurposeThe integration of ESD is a complex problem. It calls for an innovative, student-centred curriculum, as well as professional learning and agency, by which university teachers feel empowered to change their practice and direct their peers and institutions towards ESD. This study aims to explore what university teachers consider to be the most important attitudes in supporting their agency to deliver Education for Sustainable Development (ESD) via a Problem Based Learning (PBL) programme.Design/methodology/approachThis study presents a theoretical framework for professional agency comprising three domains: intrapersonal, action and environmental. A Q methodology is adopted to explore university teachers’ perceptions of the most important environmental factors in supporting their ability to deliver ESD via a problem-based learning (PBL) programme. Twenty-eight participants from six Southeast Asian universities took part in a PBL-based professional development programme designed to improve teachers’ ESD- and PBL-based skills and competencies.FindingsThe results indicate that the participants were confident in their ability to implement PBL and saw PBL as an approach suitable for addressing current educational, professional and societal challenges. This study offers a series of recommendations to help university teachers develop their ESD and PBL practices.Originality/valueAlthough the literature on human agency is extensive, research surrounding teachers’ professional agency in the context of ESD and PBL in higher education is lacking. The present study addresses this gap by capturing individual teachers’ beliefs, perceptions and views and by using Q methodology to examine the subjectivity of study participants.

Problem-based learning and the integration of sustainable development goals

PurposeThis study explores how problem-based learning (PBL) programs can address Sustainable Development Goals (SDGs) via the higher education (HE) curriculum, teaching materials and relevant assessments, supporting learning at scale for HE institutions.Design/methodology/approachEmploying SDGs and their indicators as the coding framework, our two-phase study evaluates the curriculum and teaching materials of seven PBL programs at a leading higher education institution (HEI). The first phase involved a content analysis to assess the degree of sustainability integration in 156 relevant courses. The second phase applied a semi-automated mapping protocol to analyze learning and teaching materials in 120 relevant courses.FindingsThe school aligns with 17 SDGs (100%), covering 94 indicators (55.62%). On average, each program within the school addresses over ten of these goals and incorporates more than 24 associated indicators. However, the study reveals an imbalance in the incorporation of SDGs, with some goals not yet deeply and comprehensively embedded in the curriculum. While there is a substantial focus on sustainability theories, the practical implications of SDGs in emerging countries, particularly through case studies and assessments, require significant enhancement.Practical implicationsMapping SDGs allows HEIs to identify strengths and gaps in SDG integration, thereby improving the PBL approach to enhance student work readiness in sustainability-focused careers.Originality/valueThrough the lens of transformative learning theory, this study provides evidence of SDG integration into PBL curricula. It highlights a mapping methodology that enables HEIs to evaluate their sustainability readiness in curriculum, teaching materials and relevant assessments.

Effects of a Problem-Based Learning Education Program for Occupational Health Nursing Using Smart Learning on Occupational Health Knowledge and Nursing Professionalism.

This study aimed to develop a problem-based learning program for occupational health nursing using smart learning, and to report the program's effects on occupational health knowledge and nursing professionalism. A quasi-experimental study was performed using a non-equivalent control group pre-test-post-test design. An occupational health nursing problem-based learning program using smart learning was developed, and students produced videos containing problem-solving strategies in groups. The experimental and control groups consisted of 34 and 29 participants, respectively. To collect data, an online survey was conducted before and immediately after the intervention. The experimental and control group's mean scores for occupational health knowledge before the intervention were 5.74 and 7.41, respectively. Additionally, the mean scores for nursing professionalism were 3.45 and 3.66. After the intervention, both the knowledge on occupational health and nursing professionalism score improved to 8.26 and 3.64 in the experimental group. This study reported significant improvements after conducting the occupational health nursing education program. These results demonstrate the need to develop a nursing education program for problem-based learning utilizing smart learning. Moreover, filming videos in cooperation with students can improve the effectiveness of education by improving knowledge.

From Being Amotivated to Motivated: Evidence of the Efficacy of Problem-Based Learning in Practical Skills Training

The investigation of the degree of amotivation and subsequent intervention towards the motivation of undergraduate vocational and technical education (VTE) students has not received the same amount of attention as other disciplines. Despite the negative impact of a lack of volitional drive on students' practical skills learning, there is scarcity of literature on amotivation among VTE undergraduate students. This study aimed to demonstrate the effectiveness of problem-based learning (PBL) in transitioning undergraduate students from a state of being amotivated to motivated. The study utilized a quasi-experimental research design and selected 168 students in their penultimate and final years majoring in agricultural education, business education, computer education, home economics, and industrial technical education who met the study's inclusion criteria. The intervention consisted of eight weeks of treatment and four weeks of follow-up meetings. An existing academic motivation scale was adapted for use, and data was collected through a self-report questionnaire. Data analysis was conducted using independent sample t-tests, and paired sample t-tests. The findings revealed that the level of amotivation among the students was high, and PBL had a significant impact on transitioning VTE students from being amotivated to motivated in the treatment group compared to those in the control group. Furthermore, the positive gains were maintained by the treatment group at follow-up. The study suggests that a PBL program can effectively address students' lack of volitional drive to engage in academic activities among undergraduate students majoring in agricultural education, business education, computer education, home economics, and industrial technical in Nigeria.

The Response of Higher-Achieving South African Learners from Poverty to an Extracurricular Mathematics-guided Problem-based Learning Programme

Problem-based learning (PBL) has the potential to enhance both cognitive and affective engagement but has been criticised for being unsuitable for learners with low levels of knowledge and skills, such as South African learners from poor backgrounds. In such cases, guided problem-based learning (GPBL), which includes direct instruction and teacher prompting, may be more effective. However, little is known about the extent to which GPBL can replicate the cognitive and affective benefits of PBL for such learners in the context of middle-school mathematics problem-solving. It is also not clear what the optimal granularity of teacher prompting should be within GPBL. To address these issues, this instrumental case study was conducted with 26 higher-achieving Grade 8 and 9 learners from schools serving poor communities. These learners participated in a GPBL week-long extracurricular holiday mathematics programme in which they were guided to use trigonometry to determine the maximum height reached by a water rocket. Data were collected through video recordings, field notes, written work, and audio-recorded group discussions, and were coded using the multidimensional problem-solving (MPS) framework to identify cognitive and affective behaviors. The learners’ affective responses suggested general positivity towards effortful problem-solving. Their cognitive responses suggested successful engagement in some, but not all, aspects of problem-solving. Although fine-grained prompting did not promote exploratory discussion, it was found to be necessary to guide productive mathematical activity. Medium-grained prompting, which did lead to exploratory discussion, did not appear to be directly productive, although it did appear to enhance learners’ receptivity to subsequent fine-grained prompting.

Promoting self-directed learning skills in a first-year problem-based university program with a self-development intervention

ABSTRACT This study investigated whether an intervention aimed at self-development would stimulate the self-directed learning skills of university students within a problem-based learning program. In a randomized controlled trial study, 408 first-year psychology students were randomly assigned to an experimental or control condition. During their courses, all students received the problem-based program, including feedback from their tutors on professional behaviour and study skills. Students in the experimental group also received an extra self-development intervention including two sessions with a mentor, during which students were asked to reflect on personal learning goals. At the beginning and end of the year, students’ self-directed learning skills were measured with two questionnaires. Over the year, students in the experimental group showed a larger increase in their self-control, in their ability to monitor improvement during task performance, and in their ability to evaluate process and outcome after task execution. Also, their willingness to invest study effort had not decreased, in contrast to students in the control group. These findings show that a relatively simple intervention making students reflect more on their self-development can have a significant effect on a number of relevant self-directed learning skills, even when added to a problem-based learning university program that is already focused on stimulating self-directed learning.

Relationship between Learning Approaches and Students’ Preferences for Online Learning

Objectives: The objective of this study is to enhance the quality of medical education by exploring the learning approaches of students and their relationship with the student’s preference for online learning in a Problem-Based Learning (PBL) Program. Subjects and Methods: The study was a descriptive, cross-sectional one; the target population included a random sample of students in the 1st, 2nd and 3rd years (n = 300). The study was conducted at the Faculty of Medicine, Suez Canal University in Ismailia, Egypt during the academic year 2021-2022. The instrument used for data collection is named “a Two-Factor Study Process Questionnaire (R-SPQ-2F)” (Arabic Version). Results: In this study, the students mostly adopt deep learning strategies (72.3%) compared to superficial learning strategies (27.7%). The current study shows that females mostly adopt deep learning strategies (75.8%) compared to males who adopted deep learning strategies (68.7%). The results of the correlation test in the current study show that learning approaches significantly correlated with gender and skills, also only computer skills and year were significantly correlated with the preferences of the students of distance learning. We conducted a correlation analysis with the subscales of the questionnaire with the preference of the students of distance learning. The only significant one is the first item of the questionnaire. Conclusion: In conclusion, the results of this research show that students in a PBL school adopt a deep learning approach. Older students with good computer skills prefer online learning to face-to-face learning more than younger ones do. In addition, students prefer online learning to increase their satisfaction in their time of studying, and there is a significant relationship between their computer skills and the learning approach.

Understanding Middle School Students’ Self-Efficacy and Performance in a Technology-Enriched Problem-Based Learning Program: A Learning Analytics Approach

Teachers interested in implementing problem-based learning (PBL) in classrooms encounter many challenges. Research suggests learning analytics (LA) can provide insights into students’ problem-solving process and offer teachers valuable information about when to provide necessary scaffolding. Yet, LA research in K-12 is lacking. There is also a need to explore how K-12 students’ self-efficacy may impact their problem-solving performance and learning behaviors. This study examined 418 middle school students’ self-efficacy, their learning performance and behavioral patterns after using a multimedia-enriched PBL program, and explore the relationships among these factors. Using a mixed-methods design, this study showed students’ different levels of self-efficacy were correlated with their success rates in solving problems. Students with higher self-efficacy used more appropriate tools at the appropriate times than students with lower self-efficacy. Students’ different levels of content knowledge also play a role in how students determine when and what tools to use to facilitate their problem-solving.

Understanding U.S. secondary computer science teachers’ challenges and needs

ABSTRACT Background and Context Based on issues arising around how to best prepare CS teachers and the constantly changing nature of the CS education content, curriculum, and instructional methods, it is crucial to examine the needs of secondary CS teachers. Objective The primary purpose of this study was to identify secondary computer science (CS) teachers’ needs and make recommendations for future CS education research and practices in the U.S. Method Using a mixed-method research design, the data were collected from Computer Science Teachers Association (CSTA)’s email listserv member discussions (n = 1,706 from 482 unique members), questionnaire responses from 222 secondary CS teachers, and semi-structured interviews with eight CS teachers in the US. Findings Updating curriculum resources was an important ongoing need for secondary CS teachers. Curriculum resources, materials to assess students learning, and embedding the principles of computational thinking into curriculum were reported as major needs for secondary teachers. Teachers also reported that they need to learn more about student-centered teaching strategies (e.g. problem-based learning and pair programming) and guide students’ learning using scaffolding and team-management strategies. The findings suggest that teachers perceived the need for administrators’, parents’, and other CS teachers’ support. Having an online community for teachers was critical to address their curricular and pedagogical needs. Furthermore, increasing student enrollment and interest in CS was critical for the future of CS education. Implications The findings of this research have implications for creating professional development plans and support that can address secondary CS teachers’ needs in the US.

Effects of electronic fetal monitoring simulation with problem-based learning on nursing students' performance confidence, clinical judgment, and knowledge.

This study aimed to determine the effects of an electronic fetal monitoring simulation with problem-based learning (EFM SPBL) program based on the Clinical Judgment Model. Third-year nursing students were randomly allocated to the control (n = 46) or experimental groups (n = 46). The control group participated in the conventional clinical practice, while the experimental group participated in the EFM SPBL program. The students completed a structured questionnaire on Google surveys. Nursing performance confidence (t = 10.72, p < .001) and clinical judgment (t = 2.53, p = .015) increased significantly in the experimental group. This study recognized improvement in students' clinical judgment in the context of learning transfer. A standardized SPBL with various cases is recommended.

Capacity Building for Food Safety Practices in Fish Farmers in Bangladesh: A Problem-Based Learning Approach

Purpose: This paper discusses how a problem-based learning (PBL) approach can be used effectively to resolve problems in food safety standards being adopted by fish farmers in Bangladesh. Using the example of a Food and Agriculture Organization (FAO) Food Safety Programme, this paper further highlights the potential of PBL to promote the capabilities needed to train multiple stakeholders, including staff working in local, district, and national organisations, and for local fish farmers to apply the FAO Food Safety Code of Practice in their farms. Design/Methodology/Approach: A qualitative intrinsic case study approach with qualitative content analysis of written reports was adopted to assess and provide an in-depth description of the PBL programme, the potential capabilities developed and the impact(s) of the project. Findings/Results: The PBL approach adopted for training multiple stakeholders was based on the teaching learning theory of social constructivism using a cascade model of training. Drawing on these principles, the training has promoted capacity building in the different levels of the cascade model, empowered fish farmers to change their behaviours, and adopt the FAO Food Safety Code of Practice, and enhanced their business quality and performance as well as food safety control. Moreover, the success of the training programme enabled it to be extended to a further 100,000 fish farms, and the same approach has been adopted in other types of farms, such as poultry and crop farms. Originality/Value: This paper provides a clear understanding how a PBL approach is capable of outscalling capacity building and amplifying sustainable impact by developing collaborative partnerships with different actors in the fishery sector to bring positive changes in communities that they support. Paper Type: Case study.

A Case Study of the Use of Artificial Intelligence in a Problem-Based Learning Program for the Prevention of School Violence

The aim of this study was to develop, implement, and evaluate the use of Artificial Intelligence in the prevention of violence among middle-school students. The sample for this study consisted of 20 first-year middle-school students who participated in theme selection activities in a free semester program as part of their home economics studies. The data for the study consisted of nine class observation logs, four group activity outputs, 30 class results, an online survey, and in-depth interviews with three students. A program called “R.U.OK” was developed by setting problematic situation for school violence prevention linked to the contents of the Home Economics Education(HEE) curriculum. After the program was implemented, the survey on the students’ class satisfaction content elements, with AI-based learning activities and PBL and interest, displayed high points, with an average of 4.0 or higher. Our qualitative analysis produced four significant results. First, students’ concerns about school violence had increased and they showed a change in attitude, having more empathy with friends and more interest in their surroundings. Second, digital and AI literacy had improved, and students’ interest in digital media learning had increased. Third, there had been an improvement in problem-solving ability in terms of being able to think more critically and independently. Fourth, the results also demonstrated that there had been a positive effect on self-direction and an improved capacity for teamwork. This study was significant in demonstrating the effectiveness of a program for the prevention of school violence based on the use of digital technology in the educational environment.

Exploring Approaches for Blended Learning in Life Sciences

Digital tools and platforms offer new solutions to design and conduct university teaching. This case illustrates how such digital solutions may be utilized in problem-based learning programmes within life science educations. Specifically, the case evaluated the use of live-streamed and recorded lectures, the incorporation of digital formative assessment in lectures, and the use of a digital platform to support experimental project work in a research laboratory. We find that digital solutions provide flexibility for both lecturers and students, advantageous options for collecting and sharing information, and for engaging students in their learning process. However, digital tools cannot replace all aspects of traditional in-person teaching, such as social interactions. Rather, when blended with in-person teaching, digital solutions have a large potential for supporting new forms of and approaches to both theoretical and experimental university teaching.

Creating an Interactive Dashboard to Support Middle School Teachers’ Implementation of a Technology-Supported Problem-Based Learning Program

In this design case, we describe our experience of designing and creating a teacher’s dashboard as an accompanying tool to support sixth-grade teachers who implement a technology-supported problem-based learning program on sixth-grade space science in their classrooms. We describe in detail the background of this design case, our motivation to create this teacher’s dashboard, and our iterative design process over a period of five years. Our design process consists of three phases from the idea generation phase to both low- and high-fidelity versions of the prototyping phase to three iterations of the implementation phase. We present our rationales for making various design decisions over the process and our reflections on this design experience including the challenges we have encountered.

Story Telling Problem Based Learning (ST-PBL): A Program for Rural Elderly with Chronic Diseases

Purpose: To measure changes in health knowledge, health attitudes, and health promotion behaviors of the elderly in rural communities after using the Story Telling Problem Based Learning program facilitated by students in a nursing course.Methods: A quasi-experimental study using a non-equivalent control group: 72 students sampled from the nursing discipline were divided into experimental (n=36) and control groups (n=36). The ST-PBL program was provided to the older rural people in the experimental group for six weeks. Results: Data were analyzed using the SPSS/WIN 21.0. After the application of the ST-PBL program, the participants in the experimental group showed a significant increase in health knowledge and health promotion behavior. Conclusion: The participants in the experimental group demonstrated positive changes in health knowledge, health attitudes, and health promotion behaviours. The use of an approach such as the ST-PBL program can promote uptake of self-care behaviors within the elderly with chronic diseases living in rural areas.