Learning Medical Terminology in Risk Factors for Cardiovascular Diseases Using Concept Mapping: Case University of Medicine

Medical English language has developed quickly over the past few years. Concept mapping (CM) is an effective tool in teaching and learning, however ,this strategy has not been evaluated among medical terminology (MT) in risk factors for cardiovascular diseases (CVD).The purpose of this study is to introduce concept mapping to improve learning medical terminology in risk factors for card iovascular diseases course, different skills and also to determine if concept mapping increases medical learners' capability to correct ly interpret medical terminology in risk factors for cardiovascular diseases. Participants were fourth year medical learners (n=100) from the university of medicine Algiers in Algeria; they were randomly d ivided into two groups of (50), one group attending the traditional programme, the other the innovative programme. Learner performance was controlled using written knowledge tests. The Learners also evaluated the suitability o f the learn ing process using a 7-item survey. The results of this study showed that the learners gave ext remely positive rat ings for the innovative course. So concept mapping is a strategy that can help medical learners, with their efforts towards meaningful learning and to enhance their different reasoning and learning skills, as well as their deeper understanding of medical terminology in risk factors for cardiovascular diseases.


Introduction
The language of med icine is mainly developed fro m Greek and Latin [6,70]. Medical termino logy is used in international language, and it is also necessary for effective oral co mmun ication skills with other medical personnel. Anyone who works in a healthcare setting benefits by the capability to read, understand and interpret the medical terms used in reports, abbreviations and health records [68]. It is similar to studying a foreign language, in other words, there are rules and systems which must be applied and memo rizat ion plays a remarkable part in its mastery. The mean ings of medical terms change with different beginnings and endings. Additionally, med ical terms can contain multip le root words, prefixes and suffixes and combin ing vowels. So new medical terms had to be formed [17,23]. To understand the meaning of medical words, it is important to learn how to dissect them into their basic elements. A physician must be very precise when dictating and interpreting a medical term. According to Wilner and Feinstein-Whittaker [68] if a letter or word is misused or unintentionally changes, the result could be unnecessary tests and appointments. Hence, an unnecessary treatment or an incorrect diagnosis, prevention, prediction and management could take place. In particular, Gy lys & Masters [31] and Lysanets & Bieliaieva [40] showed that the rules which specify how the mult itude of roots, prefixes, and suffixes can be combined are generally based in Lat in. Medical terminology in risk factors for cardiovascular diseases (MT of RF fo r CVD) prepares learners with language skills necessary for learning effective oral co mmun ication skills [68], independent use of health and medical reference materials. It includes the study of med ical terms and med ical abbreviat ions, symbols, and Greek and Latin word part mean ings taught within the context of med ical terminology in risk factors for cardiovascular diseases. Learners have the opportunity to acquire skills in interpreting medical records and commun ications completely and logically. Learn ing scientific language and med ical terminology in risk factors for cardiovascular diseases continue to be challenging for many learners because of its intrinsic co mplexity, volu me of specific and general terminology, advanced in high technologies and many fields of sciences which include the same terminology for different applicat ions. In order to more effectively learn and apply the language of science, we propose the use of concept mapping [51]. Concept mapping is a technique that encourages learners to learn in a mean ingful learning and preserve prior and new knowledge because it engages complex cognitive structures within the brain . So meaningful learning refers to the acquisition and application of new data, information and knowledge by an individual and its interrelationship with existing relevant knowledge mental structures [46,65,48]. The use of concept maps has spread since it was first described in the 1960s and later supported by Novak and Go win [43] and also has been used to collect and analyze data in research with reference to teaching and learning [20].
Constructing different types of concept maps related to med ical terminology in risk factors for cardiovascular diseases are especially useful in learn ing abstract, general concepts, specific concepts, abbreviations and conceptual topics in which there are mult iple ways to interpret abstract relationships between concepts [65]. Concept mapping allo ws learners to draw their deeper understanding of key ideas and demonstrates their perception of relationships among them [43,46]. Concept mapp ing is a powerful strategy that can assist you to create a v isual representat ion of co mp lex data, in format ion and knowledge. These graph ic representat ions of kno wledge structures include majo r concepts, princip les and termino logy. Following Novak and Cañas [49,50] who defined concept as a perceived regularity in events or objects, or records of events or objects, and propositions as statements about some object or event in the universe, either naturally constructed. According to Pinto and Zeitz [55] concept mapping facilitated the learner's talent to organize info rmation, assessed existing knowledge gains, developed perceptions into new and prior knowledge and transferred knowledge to new experiences. In med ical education, meaningfu l learn ing is now recognized as a major goal amongst med ical educators [55]. Therefore, concept maps have the potential to develop meaningful learning within medical education. However, although mean ingful learning through concept mapping can be significant and stimulating, it is often difficult for teachers to move away fro m rote learning to mean ingful learning [45,32]. In their 1978 analysis Ausubel et al., concept maps pro moted a new way of thinking and learn ing known as constructivist epistemology [2] which was based on the idea that individuals constructed their own knowledge over time based on what they already knew. Both teachers and learners can benefit fro m the use of concept maps since the maps can assist in identifying and organizing the key concepts on which a learning task was based [43].
Moreover, a concept map can be thought as a visual summary of prior, cu rrent and new knowledge. In a particular develop ment of the method, however, on the other hand, Kinchin et al. [36] have shown how it can be used to an instrument of measurement the cognitive structures that the mapper kept in mind to describe a particular topic. In general, the analysis of concept maps can detect typologies of gross knowledge structures indicative of different patterns of understanding [34].
This study aims to provide an introduction and a literature review of concept mapping as an instructional pedagogy in different sciences, and then discusses implications for medical terminology in risk factors for CVD as tool to improve meaningful learning of the essential concepts that includes the ability to find and use appropriate learning resources and finally summarizes the findings and concludes by arguing that concept mapping has the potential to imp rove the learners' capability to learn mean ingfully and resourcefully in context of med ical terminology in any given situation in their careers.

Materials and Methods
The language of medicine is a specialized vocabulary used by health care providers. Deeper understanding and continuing the concepts in medicine by medical learners are among the most serious challenges they face in their careers in the future. Concept mapping is a technique that is assisting learners to construct their own useful mental structure in med ical terminology of risk factors for cardiovascular diseases.

Data Collected and Procedures
Participants were fourth year med ical learners (n =100) fro m the Un iversity of med icine Algiers in Algeria; they were randomly d ivided into two groups of 50, one group attending the traditional programme, the other the innovative programme. Learner performance was measured using written knowledge tests (with a maximu m score of 20). The learners also evaluated the relevance of the learning process using a 7-item survey. Learners were encouraged to construct their own visual representations of concept maps in medical terminology. During the application activit ies, teacher (instructors and experts) accessed each individual's and team's map drawing to guide learner critical thinking, problem solving, mean ingful learning, deeper understanding. Learners could also type responses back to the teacher. Time was reserved at the end of class to examine various solutions yielded by individuals and teams. Th roughout the interrogation, the teacher exh ibits each individual's and team's map drawing using sheets of paper or any software to assess their prior, new knowledge and assist them to create new knowledge in any given situation in med ical terminology using different types, levels and propositions of concept maps.

Concept Maps in Medical Terminology of Risk Factors for Cardiovascular Diseases
Obviously, based on different researches, one strategy that can lead to meaningful learn ing is concept mapping. In particular, Novak and Cañas [52] suggested that the starting point should be a domain that is familiar to the learners and that this is best constructed as a focus question. In this way, in order to have skilled physicians, there is a need to prepare medical learners in ways to become life-long and meaningful learners in MT of RF for CVD. So the first step in constructing a concept map is find ing a domain of knowledge. Then the learner also should define a context in which the map will be constructed. In this way, a focus question that specifies a particular problem or a question should be considered. This will show the context and the hierarchical structure of the concept maps. And the last step will be the determination of general and specific key concepts that apply to the domain knowledge and classify them fro m most general at the top to lower general at the bottom. By the same taken, the most specific, lower general concepts are placed either. Ho wever, Cañas et al. [16] noted variations in the degree of freedo m that learners have in developing a concept map. During the application activities, learners are able to externalize their original knowledge and incorporate it with new one for rearranging and internalizing both the old and new knowledge [27,18].
Through these application activities, learners were directed to build many different concept maps related to med ical terminology in RF for CVD in which they needed to use 20 concepts pulled fro m topics directed in the fundamental module and the process of learning and teaching and showed how they relate to one another with different types of levels such as one level (figure 1), t wo levels, mult iple levels, network levels and interdisciplinary levels (figures 2, 3). They could use any of the chosen topics as their beginning topic for the concept maps, such as ischaemia and arrhythmia , which they were just given for their individuals and groups concept maps. They were given a large p iece of paper, such as fro m a flip chart, and were ordered they could add more sheets of paper if needed (figures 1, 2, 3). Following, Betty [7]; Betsy [8]; Carol [15] and Gy lys & Masters [31] learners were also ordered they could add any additional topics from the module, but at a minimu m, they needed to use the 20 concepts and learners were given 90 minutes to work. By the end of these application activities using several concept maps which consist of different types related to MT in RF for CVD, learners beco ming familiar with med ical terminology in CVD is like learn ing a new language, however, you can figure out the mean ing of many different words just by analyzing the word parts using different concept mapping process demonstrates what learners see as important concepts and how they relate these concepts.   Table 1. Procedure of application activities using concept maps in medical terminology of risk factors for cardiovascular diseases Outcomes Criteria of skills T opics Learners will be able to: determine, decipher, recognize, analyze, name prior and new medical terms using word analysis and through several application activities of concept maps in medical terminology of risk factors for cardiovascular diseases 1) Organization prior knowledge; 2) Links and resources different concepts; 3) Foster different skills such as meaningful learning, self-directed learning, critical thinking and problem solving; 4) Create new medical terms

Concept Maps as a Teacher Tool in Medical Terminology of Risk Factors for Cardiovascular Diseases
According to Gylys and Masters [31] who showed, for example, arrhyth mia and dysrhythmia these two medical terms connecting to the abnormal rhyth m of the heart rate are very similar in their meanings, but they have extremely important differences. As you have taught, the prefix (a-) means without, absence of, and the prefix (dys-) means bad, abnormal, painfu l and difficu lt. Then look closely at the word roots. They are not similar. The medical term arrhythmia (condition of without rhythm) has an additional (r). To remember which medical term is spelt with two (rs), it might help to think of the expression (without rhyme or reason). A condition of arrhythmia is a heartbeat (without rhyme or reason), whereas a condition of dysrhythmia is a heartbeat with an abnormal rhythm. Arrhythmia is used much more often than dysrhythmia. Moreover, learners need this med ical terminology because the heart is the most important organ in the body and essential to the continued functioning of the body. Following, Betty [7]; Betsy [8] and Carol [15] illustrated an example of a concept map that described the structure of MT in RF for CVD using different topics and application activit ies directed in the fundamental module (figure 2, table 1), the concepts are represented in a hierarchical style. Overall, med ical learners had more co mments that concept mapping application activ ities were helpful fo r immediate feedback and exam preparat ion and fewer co mments about maps being more busy work and difficult challenges.

Concept Maps as a Learner Tool in Medical Terminology of Risk Factors for Cardiovascular Diseases
These application activit ies were organized during the last lecture of the module; two lectures after the learners completed a mu ltiple choice with 100 questions test on all aspects of the MT of RF for CVD. The participants were Algerian learners (n=100), studying in the field of med ical education, pharmacy and dental surgery from the university of medicine A lgiers, A lgeria. All of them, at the time of the study, were fourth year learners and were randomly chosen to participate in this study. The learners were randomly divided into two groups. Group one (n=50) was taught to use concept maps to learn medical terminology related to risk factors for CVD, while group two (n=50) was taught by traditional approaches.
The methodology used to assess the level of the learning process in the MT in RF for CVD module is composed of four steps as follows:

First step: A deeper understanding
Learners were introduced to the knowledge of MT in RF for CVD and concept mapping and its practical applications fro m theoretical, p ractical, clinical and laboratory reasoning and through several examp les during their class sessions.

Second step: Constructing concept maps
Afterwards, a question-answer session. Then, the learners were asked to prepare a concept map of their understanding of MT in RF for CVD module. For their assistance with the activities, learners were asked to use a variety of questions, for example: What is an MT in RF for CVD? Where are they used? How they are developed? Why are they important? How they are fo rmed? How they are deciphered? and the learners were given 30 minutes to construct their own maps on paper or using any software. The built concept maps were then gathered and classified depending on learners' origin and level of prior experience.
Third step: Assessment of the learning process using a 7-item survey The learners also evaluated the suitability of the learning process using a 7-item survey. Each group was attributed with facilitators (Instructors and experts) fro m all the three departments: medicine, pharmacy and dental surgery for coordination and to guide the learners for making their distributed topics related concept maps. All the concept maps prepared by the individuals and small groups were judged by senior faculty members of other discip lines. Prior knowledge about the topics was already informed to all the judges.
Finally, the fourth step: Learners assessed using the rubric of criteria Learners assessed all the maps as individuals and groups based on the given criteria such as 1). Abilities to organize their prior and new knowledge; 2). Connect and resource different concepts; 3). Foster skills such as meaningful learning, self-d irected learn ing, critical thin king and problem solving skills; 4). Capabilities to construct new medical terms with their meanings.
Following, Dzuganova [21]; Betty [7]; Betsy [8]; Carol [15]; Dong et al. [22] and Draren i [24] represented a map of the structure of electrocardiogram (figure 3, ECG/ EKG). In figure 3 above illustrated an example of a concept map that described the structure of electrocardiogram using different topics and application activit ies directed in the fundamental module, the concepts are represented in a hierarchical style. of course, fro m the map, as findings shown that the experimental group boosted importantly more than control group to create new medical terms fro m the word parts connected with the electrocardiogram, to explain, pronounce and spell the word parts used to create new med ical terms for the electrocardiogram and to decipher ,dissect and describe common med ical terms used for symptoms, diseases, disorders, procedures ,treatments, prediction, prevention, management and devices connected with the cardiovascular diseases. In addition, Betsy [8] and Caro l [15] indicated the huge essential of differentiating between medical terms in CVD, for examp le, echocardiography and electrocardiography are both tools of measuring heart function. The two medical terms are similar enough in construction and in mean ing to be confusing. Let the wo rd parts supply the clue of informat ion that helps learners to identify and give a mean ing of new medical terms. Remember that one hears an echo, and thus, echocardiography is the procedure that uses ultrasound (US) technology to make measurements of heart function. Learning med ical terminology in risk factors for CVD is like to learn a foreign language. We summed up that using an expert concept mapping as an advanced organizer progresses knowledge organization [1,2] and integration as well as enhancing deeper understanding, meaningful learning and self-directed learning of medical terms in risk factors for cardiovascular diseases.

Concept Maps as an Assessment Tool in Medical Terminology of Risk Factors for Cardiovascular Diseases
After the learning and practicing phases, learners fro m both of group one and group two were asked to construct their own concept maps as individuals and groups in an hour using different applicat ion activities with different maps to resolve the most problemat ic with medical terms in CVD. Learners need prio r and new knowledge of how the med ical terms are formed. At the first stage, the topics selected were distributed to the small groups and details of the topics were discussed between facilitators (instructors and experts) and learners. Also, learners completed mu ltip le choice knowledge tests which each test contained 20 questions, and questions were based on the topic given to each group. The organizing stage included a deeper analysis of the medical terms problem related to the topic. The data, informat ion and knowledge were listed out and integrated with the planning stage. For example, the basic electrocardiogram concepts were connected to the clinical problems in lin kage stage. Revising of the existing knowledge and try to obtain insights to new knowledge were done in revising and finalizing stage. There was also exchange of information and ideas amongst the learners. these application activit ies exhib ited that concept mapping is an ideal pedagogy for mean ingful learn ing in MT of RF for CVD. Learning in a mean ingful way means that med ical learners, residents, and practicing physicians actively look for ways to associate new informat ion and experience with what they already know, necessarily creating an organized knowledge driving to the development of adaptive expertise in medical pract ice. In the same manner, in the clinical field, Cutrer et al. [14] found that resident physicians who used concept maps as an advanced by organizing performed better on an assessment measure than the control group and concluded that concept maps improve knowledge organizat ion. This finding also consistent with the study of Santos et al. [64] highlighted that knowledge organization was the main purpose of applying CMs in co mputer science. In this regard, concept mapping is a strategy that is serving learners to construct their own skilled mental structure in creating medical terms in future and to be independent, mean ingful and self-d irected learners in any given situation in their careers in the future. At the second stage, learners in group one and two were also required to organize a feedback survey at the end of the course. The survey was contained of a 7-item which were established by the teachers (table 2). It was found that the learners who used the concept maps to learn and teach MT of RF fo r CVD performed better than those who did not use the concept maps in providing arguments when deciphering the med ical terms. Feedback was acquired fro m learners about their perception, usefulness, understanding and overall impact fro m a 7-item, following, Susan [61] who referred that all items were rated on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Would you continue to use concept maps to solve problem in medical terminology in risk factors for cardiovascular diseases in the future Recording from learners' responses: SD strongly disagree, D disagree, N neutral, A agree, SA strongly agree. The answers were recorded on a typical five-level Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral (neither Agree nor disagree), 4= agree, 5 = strongly agree). ( ): Numbers in parentheses indicate the number of learners answers

Results and Discussion
The findings of using concept maps as individuals and groups have provided a meaningful learn ing tool, crit ical thinking and problem-solving skills necessary to pull together the relevant and related concepts in medical terminology in risk factors for CVD in any given context in the future (appendices). These findings are consistent with learners' responses and previous studies [44,4,13,39,24,25].

Results
The results signalled that the concept maps could facilitate learners' ill-structured problem solving related to MT of RF for CVD which facilitates effective oral communicat ion skills and correspondence between physicians across borders and from different parts of the world (appendix 2). The learners' responses to the satisfaction survey seemed that most of them agreed that CM encouraged them to learn and understand medical terminology in RF for CVD course, also included and demonstrated the inter-relat ionships among topics content of CVD module (appendix 1). Furthermo re, most of the learners confirmed that CM motivated them to learn and to think independently and critically so to become more self-directed learn ing, meaningful learning and crit ical thinking (85%). While (92%) felt that concept maps made them a crit ical thinker as it motivated effect ive oral communicat ion skills, also this is what has been proved by Atay and Karabacak [4] who argued that the experimental group had developed better crit ical thinking skills than the control group. This was supported by Chabeli [13]; Ku mar [37] and Kaddoura [39] who found in their study that learners had extremely positive opinion regarding using concept maps and they have expressed that if they are taught to use concept maps fro m the first year, it will be one of the best methods to learn. Most of the learners (80%) believed that concept maps were helpful to recognize the word parts used to create new medical terms and on other hands, to enhance their deeper understanding of the topic in MT of RF for CVD [24,25]. A mongst all 100 learners (90%), strongly felt that concept maps were helpfu l to organize prior knowledge and create new knowledge to learn medical terminology using word parts associated with the RF for CVD and (93%) learners strongly agreed that concept maps were helpful to solve complex problem in learning MT in RF for CVD and will be ab le to communicate clearly about their patients. However, a considerable majority of learners (100%) showed that they would continue using concept maps to solve more comp lex problems in learning medical terminology in the future because learners look at it as like speaking a foreign language and is vital to prevent errors at all stages of care diagnosis, prevention, management and treat ment. according to qualitative analysis (table 2), majority of learners extremely accepted concept maps as a helpful tool to foster meaningful, self-d irected learn ing, advance critical thin king and problem solving skills. Finally, difficult challenges to learn and to teach at the starting and time consuming are the two problems in using this technique in learn ing and teaching MT in RF for CVD, nonetheless, the overwhelming majority of the learners extremely signalled to continue using it.

Discussion and Limitation
The findings of this study have provided a qualitative (appendix 2 and appendix 3) and a quantitative (table 2, appendix 3 and appendix 4) viewpoint of concluding that CM can be applied in other subject-matter do mains, such as MT in RF for CVD. The results are d ivided into two elements [5,3,30]. The first element is that concept maps are as a useful tool, as they advance learners' meaningful learning, critical thinking, problem solving skills and engagement through individuals and groups CM s discussion. These findings are consistent with previous studies, which have shown that utilizing concept maps in med ical education supplies more opportunities for all learners to actively participate in class application activities, hence developing their capability to identify relationships among the key concepts within a given discipline Rendas et al. [58] ; Hay et al. [34] and Drareni [24,25]. The second element is that concept maps are effective in help ing learners understand the topic matter, therefore clarifying init ial misconceptions [34]. In accordance with previous studies, functioning prior knowledge is an essential condition to help learners learn deeply and meaningfully [34]. On the same manner, this stresses that the role of the teacher in the process of constructing maps is most impo rtant to securing the learners' long-term learning success [30]. These findings were consistent with Ellermann et al. [26]; Sharma [63] and Ku marManoj & Rizwaan [38] who high lighted that CM teaching method is based on meaningful learn ing, and learning occurs when the learners were able to organize and relate the concepts and new informat ion with their mental structures. This was also agreed by Chularut & DeBacker [10] and Yao walak [69] who stated that CM is considered as a good strategy to encourage learners' learning in a higher education setting in the UK, USA and Taiwan. To sum up, most of the experimental learners perceived CM conclusively and teachers documented that the development of concept maps in groups aided learner learning in relation to the contents of MT in RF for CVD and fostered their meaningful learning in several other ways. In this way, effective oral communication skills, critical thin king and problem solving skills as a foundation for other meaningful learn ing activities can be increased and designed. Likewise, Cutrer et al. [14] who assured that using concept maps are a considerable strategy for mean ingful learning. Learners can analysis and arrange existing prior knowledge, organize new knowledge, recognize a new co mponent of a concept or idea, and relate former and create new knowledge in MT of RF for CVD.
Finally, the central advantage of concept mapping is precisely its relational ach ievement. As described above, concept maps empower relat ional links to be made between pertinent general and specific concepts. In the instructional context, it is insisted that meaningful learn ing best took place by linking new concepts to existing knowledge [41]. Hence, Maas and Leauby [41] stated that concept maps empowered the elements of learning to connect to how cognitive knowledge is developed structurally by the learner. a major disadvantage of concept mapping is that it is limited to relat ions between general and specific concepts. So many issues in MT of RF for CVD require more than a determination of relationships between concepts [28,29] who created a biology network revealed 67 relations used to link about 2,300 concepts and also in a network of about 70 propositions. Also, the difficulty in lin king phrases and lack of carefu lness in concept mapping are already reported by other researchers [12]. On the other hand, Sowa [60]; Kremer, [35] and So wa [61] docu mented that concept maps in the field of art ificial intelligence (AI) community are considered as non-rigorous in methodology, and the maps lack in knowledge representation (KR) formalis ms. This point of crit ique is cited in the works of Kremer [31] and Cañas & Carvalho [41] showed that concept maps and artificial intelligence (AI) or knowledge representation (KR) was not compatible. This is a limitat ion of concept mapping and it has led to the development of a new kind of CM; a CM for interdisciplinary maps that demands identification of relationships between concepts and interdisciplinary perspectives in medical terminology for CVD. Correspondingly, these findings were inconsistent with Oppl and Stary [54] who h igh lighted that the healthcare case demonstrated how mean ingful work-model entit ies evolve in the course of articu lat ion and guide aligned restructuring of work, by showing supporters to ach ieve majo r object ives of prog ressive education and conceptualized a learn ing env iron ment prov iding learn ing facilit ies. A lso, these authors concluded that active exp loring of p roblems boosted analyt ical th in king, creativ ity, pract ical abilit ies, and social capabilities for problem solving, s ince learn ing should also happen in groups so concept maps are an effect ive too l for imp roving learners' capab ility to th ink crit ically and meaningfully.

Conclusions and Recommendations
Concept mapping can be a very powerfu l tool to foster a higher level of crit ical thinking, problem solving, mean ingful and resourceful skills [43,47,67]. The findings of this study have provided a qualitative perspective of accepting that CM can be applied in other domains, such as med ical terminology in risk factors for CVD so we can believe that concept mapping aids learners to grow their deeper knowledge in an accumulat ive process and enhances the required critical thin king, problem solving skills and practical competencies that a medical learner needs in their career in the future. These results are consistent with those found by Novak & Canas [49,50] and Ku mar et al. [37]. Finally, the use of concept maps in learning med ical terminology related to RF for CVD make the idea of the development and the training of learners' independence, since self-d irected learn ing, crit ical thinking and problem solving skills are the essential factors to make mean ingful learning then will be able to construct their own effective o ral co mmunication skills that are necessary between physicians-patients. On the other hand, according to Baig M. et al. [9] stated that concept map is lead ing to retention of learning conceptual knowledge with an improved deeper understanding of the concepts, retention of useful knowledge and improvement in the perfo rmance of medical learners.
Further, this study suggested that a lack of med ical knowledge in technical terms, interpreting enormous health data and communicating effect ively with physicians-patients and other health professionals should address in medical terminology of effective oral communicat ion skills that can be taught to medical learners to increase their clinical, practical and laboratory reasoning skills using more than innovative methods such as CM alone and mixed it with other active learning such as problem-based and team-based learning to enhance their mean ingful learning , critical thinking and problem solving skills. A lso, the findings of this study recommended using other types of CM s such as knowledge concept maps and collaborative concept maps by experts which used to preserve organizational knowledge that have been associated with meaningful learning theory and pro motion of higher order thinking skills [59,19]. Learners should be able to enhance the learning to learn meaningfully and critically.  Learners should be able to develop the learners' graphic capabilities and creativity to organize their prior and new knowledge.  Learners should be able to develop the capability to structure, organize, and create knowledge concept maps.
First session: constructing concept maps based on different med ical resources (texts, medical reports and case studies).
Approach and steps of application activities (90 minutes) Learners are arranged individually to construct their own concept maps and then in s mall groups to create their collaborative concept maps in the classroom. The teacher (with instructors and experts) give the learners a printout of application activities, consisting of a medical terminology text in CVD, entitled medical terminology in risk factors for card iovascular diseases, the steps for co mpleting the activities and many blank sheets of paper to do the activities with software to draw and present their concept ma ps as individuals and groups.
Session to learn how to construct a concept map (16 steps) Learners are arranged indiv idually and then in small groups to create their individual and collaborative concept maps in the classroom according to the following steps : Step 1: Reading The learners read the medical terminology in risk factors for CVD fro m different resources such as texts, reports and case studies (from the fundamental module).
Step 2: Question-answer discussion The learners were asked to use a variety of questions (questions-answers) related to medical termino logy in risk factors for CVD.
Step 3: Identify a domain of knowledge The learners were asked to determine a do main of knowledge through the fundamental module.
Step 4: Identify the key ideas The learners identify the key ideas (general and specific concepts), directed by key questions written by the teacher and also assisted by the instructors and experts.
Steps 1, 2, 3, 4 and 5: Explain the main concepts The teacher exp lains the main key ideas. While the instructors and experts explain the specific key ideas of the med ical terminology fro m other fields of med ical education.
Steps 1, 2, 3, 4, 5 and 6: Show how to identify the main concepts The Teacher/instructors/experts show how to determine the key concepts and how to construct, classify, identify and organize a list of general and specific concepts.
Steps 7: Identify the key concepts (20) and organize them The learners identify the key concepts (20) and organize them in order of relevance (fro m most general at the top to most specific at the bottom).
Step 8: Place the key concepts The learners place the concepts on a blank sheet of paper according to levels of hierarchic importance (fro m more general to more specific).
Step 9: Beginning of constructing the components of the maps The learners draw labels, lines, joining the concepts using linking phrases.
Steps 8, 9 and 10: Animated by the instructors and experts The teacher shows his/her way of positioning and joining the concepts, aided by the guided, progressive and animated by instructors and experts.
Step 11: Learners add the linking words The learners add the linking words between the general and specific concepts, setting up relationships between them and creating propositions.
Step 12: Animated by the instructors and experts The teacher shows his/her way of adding the key words and phrases and building propositions, assisted by the instructors and experts.
Step 13: Teacher adds cross links The teacher adds cross links that connect the concepts belonging to different h ierarch ical branches of the concept map.
Step 14: Animated by the instructors and experts The teacher shows his/her way of adding the cross links on the map, assisted by the instructors and experts.
Step 15: Animated by the instructors and experts The instructors and experts show his/her manner of constructing knowledge concept maps in MT of RF for CVD using medical terms such as hypertension, arrhythmia and cardiopathy.
Step 16: Assessment of all maps and animated by the teacher, instructors and experts The teacher/instructors/experts proceed to collect the maps created to evaluate them and hands out a copy of the list of key concepts and concept map he or she created based on the text and shown in the PowerPoint presentation.
Second session: session to learn how to construct new types of concept maps such as knowledge concept maps in med ical terminology of risk factors for cardiovascular diseases In this session, the learners practice what they have learned and individually develop a concept map, following the steps set out in the first session. With the help of instructors and experts, learners construct their own other types of CM s such as knowledge CM s and collaborative CM s . These maps display how medical terms in risk factors are derived fro m medical condit ions. Many learners have difficulty with the concept of med ical terminology in risk factors for CVD and also show different medical terms related to diseases, conditions, and procedures related to the cardiovascular diseases (CVD) and heart diseases (HD). These maps also extend the concept of health literacy consider as modifiable risk factors for CVD. Overwhelmingly, the majority of learners need knowledge of how the med ical terms in CVD are formed. Thus, at the end of the second session, learners will be ab le to describe the parts of words used to create med ical terms , analyze med ical terms to determine mean ing ,give the meanings of a beginning set of roots, comb ining forms, suffixes and prefixes, and name the referents of abbreviations; list abbreviations for various medical phrases related to :  Signs and symptoms of the cardiovascular system  Diseases and disorders of the cardiovascular system  Treatments, procedures, and devices of the cardiovascular system  Abbreviations of the cardiovascular system  Risk factors for cardiovascular diseases Finally, these maps provide a meaningful learn ing tool, critical thinking and problem solving skills necessary to pull together the relevant and related concepts in medical terminology in risk factors for CVD in any given context in the future.