1. Introduction
In the 21st century, technology is advancing faster than ever. The younger generation, including college students especially those in medical sciences, are in contact with highly advanced digital equipment, challenging educators to integrate digital technology in education to improve the learning outcomes (O’connor and Andrews, 2015; Risling, 2017). Digital education has become popular for health professions education (Shachar and Neumann, 2003; Choules, 2007; Car et al., 2019). It can be defined as the use of digital technology for teaching and learning. Digital education uses a variety of teaching and learning approaches, including the transformation of simple texts from a paper-based format to a digital format (e.g. portable document format) and the interactive use of sophisticated digital technologies (e.g. video conference, virtual reality) (Car et al., 2019). Most students and healthcare professionals have reported the use of digital technologies in their studies or routine clinical practice (Curran et al., 2017).
Simulation-based medical education in different disciplines (e.g. Medicine, Nursing and Midwifery) has been well recognized and applied for many years. Medical students are required to show an acceptable level of competency. For example, most dental procedures such as cavity preparation, endodontic therapy, and oral surgical interventions are irreversible, and learning these skills only by examining the patient is not an ideal practice. For this reason, simulations of interventions in university laboratories are essential for learning psychomotor skills before going to a real clinic with real patients. In this regard, new technologies can provide tremendous help with the theoretical and practical education of medical students. Among these technologies, multimedia e-books and Augmented Reality (AR) are more common. An e-book is a book available in digital form, consisting of text, images, or both, and can be read on smartphones, tablets, computers or electronic readers. The evidence suggests that students who use e-books also occasionally use traditional printed books. However, there seems to be disagreement about whether the use of e-books is a time-efficient way of learning (Tosun, 2014; Engbrecht, 2018). Some studies have reported that some readers may perceive that e-books take longer to read than printed books (Millar, 2015). A major advantage of e-books is that they have aid to navigation within the text. Navigation is essential in e-books to increase their usage. Having a page with interactive content, links between pages and clear titles improves the user experience (Matraf et al., 2017). E-books ensure that study materials be available for all students, not only for those with the financial ability to purchase a printed book or have access to library books. Access to relevant materials is important for the curriculum in a flipped classroom to ask students to pre-read materials before attending sessions (Eaton, 2017). It has been shown that students support the use of e-books in education for its complementation not for replacing the current practice (Pickering, 2015).
Another technology that has been developed is AR. The AR is the simulation of a three-dimensional environment created using hardware and software that provides users with a realistic experience and the ability to interact. This concept has been developed since the 1960s and has experienced significant improvement since then (Farronato et al., 2019). The key factor in using AR is the development of portable personal computers. The AR was developed after virtual reality because it requires more complex technological specifications, although it is simpler to realize than virtual reality. The reason is that it improves the existing environment by adding virtual elements rather than replacing it with a completely new environment. However, it faces real-world dynamics that are generally difficult to control and often unpredictable (Bugarić, 2013). Arguably, the AR concept has been widely used in the arts, game industry, architecture, daily life, industrial design, navigation, automotive industry, archeology, and other areas. Great efforts have been made to apply AR technology in biomedical sciences (Wang et al., 2014; Suenaga et al., 2015).
The increasingly rapid improvements in the current digital system have attracted the attention for the development of educational models for medical students using either multimedia e-books, interactive e-books, or web-based AR technology. Accordingly, this systematic review aims to investigate the effectiveness of multimedia e-books and AR in the learning process of health sciences students. The question is “How does the use of multimedia e-books and AR affect the knowledge and skills of health sciences students?” 

2. Materials and Methods 
Review protocol 
This systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher et al., 2009) on relavent articles published from 2010 to 2021.

Literature search
Relevant articles were searched in Sciencedirect, ERIC, ProQuest, PubMed, and Wiley Online Library, with a publication period from 2010 to 2021. The search keywords were based on the MeSH terms for health studies. The used keywords were “Effectiveness” OR “Effect” OR “Impact” OR “Evaluation” AND “Multimedia e-book” OR “e-book” OR “Digital book” OR “Augmented Reality” AND “Education” OR “Simulation” OR “Practice” AND “Medical student” OR “Dentistry” OR “Physiotherapy” OR “Nursing students” OR “Midwifery student” OR “Trainer” OR “Surgery” OR “Public health”.

Eligibility criteria
Eligibility criteria for the selection of studies for review were determined based on the PICOS guidelines (Table 1).

The population consisted of all students in health sciences, such as dentistry, medicine, nursing & midwifery, public health, and physiotherapy. Two types of educational technologies were identified as interventions to support learning activities: Multimedia e-books and AR. Regarding study design and comparisons, Randomized controlled Trial (RCT), quasy experimental, and qualitative studies indicated the positive and negative effects of the use of educational technologies (multimedia e-books and AR) on student learning, and those published in English were included in the review. Studies that did not examine the use of AR or e-books, those with unavailable full-texts, literature reviews or systemic reviews, books, conference proceedings, reports, thesis, research and development, case studies, or clinical guidelines were excluded from this review. 

Risk of bias
The risk of bias was assessed by two authors independently using the Cochrane Collaboration’s risk of bias assessment tool (Higgins et al., 2019). Discrepancies were resolved by discussion or reference to the third author. The following domains were assessed: (1) Random sequence generation, (2) Allocation concealment, (3) Blinding of participants and personnel, (4) Blinding of outcome assessment, (5) Incomplete outcome data, (6) Selective outcome reporting, and (7) Other bias (biases due to funding or conflict of interest). Each potential source of bias was graded as low, high, or unclear; only studies with low risk of bias included in the current review. Each judgment was supported by a quote from the relevant study.

Quality assessment
For quality assessments of selected studies, we used Joanna Briggs Institute (JBI) checklist for randomized clinical trials (Tufanaru et al., 2017), the JBI checklist for cohort studies (Moola et al., 2017), the JBI checklist for (non-randomized) experimental studies (Tufanaru et al., 2017), and the JBI checklist for qualitative research (Lockwood et al., 2015). The data were excluded if they did not meet ≥3 criteria. Table 2 shows the quality assessment results for Randomized Clinical Trials (RCTs). For other studies, the results were not included due to the word limit.

Extraction and analysis
Titles and abstracts of studies were screened independently by two authors. Screening for duplicates was carried out using the Mendeley Desktop. Substantive information was extracted from each article and entered into a table in MS Word. Data extraction was carried out carefully. The specifcations of reviwed studies including the author’s name, study design, participants, intervention/focus, study method, and main findings are presented in Table 3.

Data synthesis was carried out using a synthesis matrix including e-books and AR. 

3. Results
The initial search yielded 493 articles. After removing duplicates, 356 remained, of which 271 removed after screening titles and abstracts. The remaining 85 articles were checked for eligibility, which led to the exclusion of 74 articles. Finally, 11 articles met the inclusion criteria. PRISMA flowchart for literature search is shown in Figure 1.

Characteristics of studies
Most of the included studies (n=5) had quasi-experimental designs (Stirling and Birt, 2014; Wu et al., 2018; Liu, Chou and Lee, 2020; Mladenovic et al., 2020; Zafar and Zachar, 2020). Four articles were RCTs (Bogomolova et al., 2020; Moro, Stromberga and Birt, 2020; Chang et al., 2021; Liao et al., 2021), and two articles were qualitative and prospective (Price and Cartledge, 2019; Mladenovic et al., 2020). A total of 616 students and teachers participated in the studies which were published from 2013 to 2021 and conducted in seven different countries, including Australia (n=3), Taiwan (n=3), China (n=1), England (n=1), Netherlands, (n=1), Serbia (n=1), and Brazil (n=1). 
In general, this review study was conducted on studies assessing the effects of multimedia e-books and AR technology on the learning and teaching process or simulation. The use of e-books in several studies was for improving the ability to teach Evidence-Based Medicine (EBM) (Liao et al., 2021), anatomy (Stirling and Birt, 2014), community health nursing practice (Wu et al., 2018), pediatric acute care (Price and Cartledge, 2019), electrocardiogram (Liu, et al., 2020), and sexual harassment prevention knowledge (Chang et al., 2021). Regarding the AR, several studies used it for simulation of teaching local anesthesia in pediatrics (Mladenovic et al., 2020), local anesthesia of inferior alveolar nerve block (Mladenovic et al., 2020), perception of head and neck anatomy in dentistry (Zafar and Zachar, 2020), medical and health sciences (Moro et al., 2020), and general anatomy (Bogomolova et al., 2020).

Effectiveness of using multimedia e-books in learning
Liao et al. (2021) evaluated the impact of using multimedia e-books by simMAGIC software for teachers as their supporting material for teaching EBM. An evaluation was carried out at the end of each session using the Fresno test. Their results showed the success of online e-books in increasing the effectiveness of teaching EBM, satisfaction, teaching quality, teaching methods, and most importantly, students’ interest in learning EBM.
In another study, multimedia e-books showed positive results in learning anatomy. The impact of using this e-book was also seen in students’ laboratory exam results, which significantly increased their performance (Stirling and Birt, 2014). A similar increase was also found in another study conducted in Taiwan which used e-books in learning ECG. Students using e-books were more motivated to study because the learning materials were complete and interactive (Liu et al., 2020). The application of e-books in the community health nursing practice, e-books could increase students’ attention, motivation, participation, and satisfaction (Wu et al., 2018).


Effectiveness of AR in learning
Most AR technologies were used in simulating learning processes, such as the administration of local anesthetics in pediatric patients (Mladenovic et al., 2020) and dental care (Zafar and Zachar, 2020). The results of studies regarding the simulation of learning by AR technology showed improved understanding and correct performance of procedures and reduced stress in students. However, the students believed that learning by AR should be combined with traditional cadaver learning. AR was also used in learning anatomy and physiology (Bogomolova et al., 2020; Moro et al., 2020). The results showed that the use of AR in learning anatomy and physiology could significantly improve students’ understanding and help them in the next practices. 

Comparing multimedia e-books and AR with other methods
Several studies have compared the effects of using e-books and AR with the effects of other methods or technologies. One study compared the impact of e-books with that of videos and brochures. The results showed that e-books were better able to increase student satisfaction in learning and further improve their abilities in independent learning, but there was no significant difference between the two methods (Liu et al., 2020). Another study compared the use of mobile-based AR with Microsoft Hololens, and the results showed no significant difference between them. However, a difference was observed in dizziness when Hololens was used (Moro et al., 2020). 

4. Discussion
This systematic review investigated the effects of using multimedia e-books and AR on the knowledge and skills of students in health sciences such as medical, dental, nursing & midwifery, and public health. Among 11 relevant studies, 6 focused on the use of multimedia e-books, and 5 were related to the use of AR. Overall, studies showed that both multimedia e-books and AR could significantly improve the abilities and skills of both teachers and students. The efficacy of multimedia e-books was demonstrated in several studies, whose results showed a reduction in the time required for students to study ECG (Liu et al., 2020). Another study revealed that learning by using e-books had a more lasting effect on long-term memory, and suggested that e-books can be used to increase sexual harassment knowledge and prevention in nursing students (Chang et al., 2021).
Multimedia e-books contain digital information and, compared to traditional books, are much easier to store, have access to, and disseminate their information (Casselden and Pears, 2020). E-books materials can be searched by keywords, and have navigation aid such as links to other materials and the ability to copy and paste the materials. These technological advances further improved the attitudes towards e-books, and led to their growth. From the library’s perspective, e-books provide access to information systems (Ferguson, 2016), support distance and part-time learning modes, can meet the high demand for access to reading lists (Riha and LeMay, 2016), and save space compared to multiple printed copies (Frederick, 2016). One study on the use of e-books in ECG learning found that there was no difference in learning achievement between the group that received e-book materials and the control group (Liu et al., 2020). This may be because both groups had the same level of learning motivation at the beginning of the study. Furthermore, ECG-related education is efficient and helpful for clinical practice; therefore, regardless of the type of learning materials, students themselves need to try to learn as much as possible. The second reason is that learning materials alone do not guarantee the appropriateness of learning achievement; other learning strategies should be included. According to Liberatore (2017), interactive e-books combined with pre-class assignments can improve performance in exams. In Liu et al. (2020)’s study, no preliminary or pre-class assignments were given, and the percentage of students who previewed the ECG-related materials before the class was not monitored. Without the preview of materials, the learning effect of e-books would not be different between experimental and control groups.
The AR is a technology that combines virtual information with the real world. The technical tools it uses include multimedia, 3D modeling, real-time tracking and registration, intelligent interaction, sensing, and more. The principle is to apply computer-generated virtual information, such as text, images, 3D models, music, videos, etc., to the real world after simulation. In this way, the two types of information complement each other and enhance the real world (Chen et al., 2019). The AR can provide broad benefits to education in the health sector. Combining the real world and the digital world that applies the AR provides a valuable experience for students who need continuous skill training in clinical practice with real patients. The limited materials for learning due to the cost of procurement and maintenance is the reason to use AR in the students’ learning process (Dutã et al., 2011). Mladenovic et al. (2019) conducted a study on the use of AR for teaching local anesthesia of anterior superior alveolar nerve in dental students. The result showed decreased performance time in students who used the AR simulator compared to controls. In another study, measuring the effect of AR in students performing local anesthesia, results of Mladenovic et al. showed a reduction in their stress and anxiety levels after the anesthetic procedure compared to pre-procedure results. The authors concluded that, by using AR for teaching local anesthesia, access to anatomical structures in the oral cavity is easy and because of ther user interface, the use of this method provides excellent help in clinical anesthesia (Mladenovic et al., 2020). Another study used AR in studying the structure of human anatomy and physiology. The dynamic exploration of the features of the 3D AR model showed its positive learning effect and created a sense of additional depth in learning (Bogomolova et al., 2020). A study conducted by Moro et al. (2020) showed that AR could act as a useful additional teaching tool. By combining conventional and modern (AR) methods, the learners could feel an increase in their understanding and remembering of the anatomical and physiological structures of the human body.
Several studies indicated the advantages of using multimedia e-books and AR in helping students improve their knowledge. However, a study stated that students did not totally agree with replacing traditional learning methods with e-books as the sole method of learning. Instead, they preferred to use e-books as an adjunct to traditional teaching methods (Stirling & Birt, 2014). In a previous systematic review, students believed that e-books were useful in preparing for the exam and assuring them that they had read everything they needed to know (Folb et al., 2011). In another study, students who used e-books perceived higher learning gains (Price & Cartledge, 2019). A study reported that using e-books for previewing helped to improve understanding of the lecture during class, while with traditional paper handouts and books, it was more difficult to comprehend content, as the only function available was reading the text. In contrast, the students approved the e-book’s challenge tests which helped them self-evaluate their levels of knowledge. They mentioned that the “challenge tests allowed me to immediately examine my level of knowledge”. Further, the prompt feedback and forced jump-back function helped them to quickly locate the page that contained the relevant content, re-read the content, and find the right answer, and they gained a better understanding of the content’ (Liu et al., 2020).
Regarding the variable of knowledge, the results of studies revealed that AR helps students recognize body parts very quickly because the user interface is attractive and can be thoroughly explored. Although the studies did not directly measure the effectiveness of AR on students’ knowledge, it can be found from the increase in students’ performance and satisfaction with performing procedures or lessons in body anatomy. 
According to the studies, both e-books and AR could help students implement practical techniques. Students who received training by the AR simulator were faster at performing anesthetic procedures than those who received training by traditional methods (Mladenovic et al., 2020). The same finding was found in another study that used interactive e-books for learning a practical technique in students. In this study, although students who used the interactive e-books had learning achievement similar to those who received traditional learning materials, they learned more efficiently (Liu et al., 2020).

5. Conclussion
The use of multimedia e-books and AR has more significant effects on the learning process of students in health sciences compared to conventional teaching methods that use textbooks, whiteboards, or lectures. Considering the advantages of these technologies, their inetgration in education, along with traditional methods, can more improve the knowledge and skills of health sciences students. Further research is highly recommended to compare the effectiveness of traditional and digital lerning methods in laboratory practical skills.

Limitations
For conducting a systematic review, all relevant articles need to be collected. We cound not collect all relevant articles due to limited access to other databases that required to sign up to have acces to the full texts of articles. Moreover, we only selected articles published in English. Moroever, we were unable to carry out further analysis (meta-analysis) because the number of articles included in this study did not meet the requirements.

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Health Research Ethics Committee of Health Polytechnic of Jambi, Indonesia (ID: LB.02.06.2.176.2021). 

Funding
This study did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to express their gratitude to the director and president of Jambi University, Indonesia for supporting the implementation of this research.


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