Participants

Each academic year, first-year medical students at the University of Valencia are divided into four groups. All of them must take a subject on human musculoskeletal anatomy in the first semester. The syllabus of this subject is identical for the four groups, and the distribution, calendar and evaluation of the contents are previously agreed upon by all the professors responsible for the subject. Out of those four groups, two groups of first-year medical students participated in this study during the 2022–2023 academic year, one with 76 enrolled students (the unidirectional intervention group) and another with 83 (the interactive intervention group). There were no differences between the groups in terms of gender composition, age distribution or access conditions to medical studies. Both interventions were based on the contents of upper limb anatomy in the human musculoskeletal anatomy subject.

Ethical Approval

Approval for this study was obtained from the university Consulting Committee on Teaching Innovation Proposals, with approval number/ID UV-SFPIE_PID-2078036.

Types of InterventionsUnidirectional Material

Online lessons focused on a specific aspect of the first-year anatomy course: the osteology and myology of the upper limb. The contents underwent a thorough review by different professors from the Department of Anatomy, who deemed it interesting and of high quality.

Lessons took the form of a website, created with eXeLearning [20], an open-source tool designed for the development of online educational content. To objectively assess the success of this intervention, the resulting HTML code was supplemented with the website traffic statistics tools of Google Analytics [21] (Fig. 1). Online lessons contained new original anatomical images, distributed under a CC BY-NC-ND license. They were generated from photographs of real structures, obtained from a careful dissection specifically conducted for this project. Additionally, new illustrations were created by an anatomical illustrator.

Fig. 1

Main page of the project’s Google Analytics account, showing the web analytics variables corresponding to the unidirectional website engagement results

A link (www.uv.es/sanzuda) was provided to the 76 students enrolled in the target group via e-mail, a week before the final exam of the anatomy course, to ensure those students would be actively studying the subject. It was assumed that, anxious about the proximity of the exam, students would more likely turn to material provided by the course’s teaching team as a study aid, and if they found it useful, they would share it with their classmates. The e-mail was sent by the professor responsible for the project, who was a member of the Department of Anatomy but did not have any teaching or scoring responsibilities in the target group. This was done in order to avoid biases in the degree of use of the material, due to the students having the impression that the material provided was somehow mandatory study or that it was more likely to be asked in the exam of the subject. The e-mail explicitly informed the students that their grades would not be influenced whatsoever by their use or the lack of use of the provided material.

Interactive Intervention

Interactive resources were developed as an Instagram profile, @eldeanato (Fig. 2). The profile was overseen by a teacher from the Department of Anatomy, with a link to his professional profile included in the profile header. Instagram posts were based on anatomical illustrations and new photographs of dissections, with a description of the images and allusive quotes from literary works, songs or movies, in all the official teaching languages of the institution. Image captions included an announcement about the creation of a questionnaire during the following days, encouraging viewers to study the course contents related to the image. Questionnaires and images were uploaded to the profile coinciding with the cadaveric dissection practical sessions dedicated to the regions shown in those same images, so that students could interact with it in parallel to the upper limb anatomy classes. Quizzes were carried out weekly and were made using the questionnaire sticker of Instagram stories (Fig. 3).

Fig. 2

Instagram profile @eldeanato, with number of followers, number of posts and highlighted stories as of June 1, 2024

Fig. 3

Instagram profile @eldeanato. Example of one of the questionnaires, with one of the newly created dissection images

Although the profile was kept public, the teacher managing it especially publicized the creation of the account among the 83 students of the group he was teaching that year. These 83 students were again explicitly told that their grades would not be influenced whatsoever by their amount of engagement with the profile. Nevertheless, given that, by its very nature, the interactive intervention required greater involvement, more time dedication and closer interaction with the students than the unidirectional intervention, and that its content was less in-depth and of a more playful nature, with a less obvious relationship with the content to be assessed in the exam, it was considered more appropriate in this case that the responsible professor would be the one in charge of teaching anatomy to the group.

Photographic Materials

All photographic materials used on these innovation projects were taken and processed by the teaching team responsible for the anatomy courses, from the cadaveric dissections used for the prosection practical classes. To maintain anonymity, precautions were taken in the publication of all photographic images to prevent the identification of the donors. Facial features, tattoos, and any other identifying characteristics were concealed. The cadaveric material came from donors who during their lifetime had signed a consent form for the donation of their bodies for educational or research purposes to the Department of Anatomy and Human Embryology of the University of Valencia. The donation process adhered to the recommendations of the Spanish Anatomical Society [22].

Satisfaction Questionnaires

The level of satisfaction of the students with both interventions, unidirectional and interactive, was subjectively assessed by means of an online survey, created using Google Forms. Both surveys were made up of four items, which measured the students’ use of the tool, the appeal of the intervention and the students’ perception of knowledge acquisition and motivating effects (Table 1). Both satisfaction surveys were very similar. Each was specifically given to the students in the group corresponding to each of the two interventions, immediately after the final exam of the Musculoskeletal Anatomy course, before publishing their grades so that they would not bias the students’ perception of knowledge gain. In this way, the students could globally assess whether they had gained knowledge with the intervention, once they had studied the complete syllabus for the exam, with all the tools at their disposal. Both questionnaires had four items, answered yes/no or scored using a five-point Likert scale (1, not at all; 2, slightly; 3, moderately; 4, very; 5, extremely).

Table 1 Satisfaction surveysWeb Analytics ToolsGoogle Analytics

The level of engagement of students with the unidirectional material was assessed using Google Analytics, a widely used and freely available web analytics service provided by Google. Google Analytics offers aggregated information of web usage data, such as the geographical origin of the website users, the duration of their session, the time spent by the user on each page, pages accessed per session or the bounce rate (the percentage of users who visit only the homepage without further exploring the website contents). Google Analytics has been previously used in a few recent studies to measure the effectiveness of educational innovation interventions in health sciences [23, 24], although none of them was related to anatomy courses.

In order to implement Google Analytics, its Java Script tracking code was added to every page of the website generated by eXeLearning. This code loads specific tracking files from the Google web servers which send web usage data to the Google Analytics user account (Fig. 1).

Instagram Engagement Metrics

There are several methods available to measure engagement on Instagram. Conventional approaches involve metrics such as the number of followers, the number of “likes” per post or the number of views of a story. However, these measures have limitations and may not always correlate with meaningful user engagement. For instance, a follower may not revisit the profile after following it or quickly scroll through stories without thoroughly reading them.

In our study, a more reliable method was used to measure engagement: the percentage of answers to the questionnaires in the stories. Calculating the number of questionnaire answers as a percentage of the total story views indicates users who not only viewed the story but also took the time to understand the question and provide an answer. In this regard, the percentage of answers to the questionnaires offers similar insights, but in the opposite direction, to the bounce rate provided by Google Analytics.

In order to make the two interventions, the Instagram profile and the online lessons, more comparable, both were limited to the same block of lessons, the ones about upper limb anatomy. To this end, although the Instagram profile remained active after the upper limb anatomy classes had finished, the percentages of answers to the Instagram questionnaires were calculated only on the quizzes related to this block of lessons. These questionnaires were published during the same weeks in which the students attended the theoretical and practical classes about upper limb anatomy.

Approval for this study was obtained from the university Consulting Committee on Teaching Innovation Proposals, with approval number/ID UV-SFPIE_PID-2078036.