ABSTRACT

Objective

This study aimed to compare the educational effectiveness of students who continued their anatomy education remotely with that of students who had taken the same course in person the previous year.

Material and Methods

This cross-sectional study included 116 first-year students who took the anatomy course via remote education and 138 second-year students who took the same course in person during the previous academic year. Data collected via an online survey included socio-demographic characteristics, the comprehensibility of the course, participants’ understanding of its importance, and problems encountered. Descriptive statistics are presented as numbers and percentages, and the chi-square test is used to compare categorical variables.

Results

Although the course was taught using the same syllabus, presentation materials, and instructor, the perceived difficulty was 59.4% in the in-person education group and 82.8% in the remote education group (p<0.05). It was determined that 37.1% of students in remote education lacked a personal device (computer or tablet) to access education, 19.8% experienced internet connection problems, and 12.1% lacked a suitable working environment.

Conclusion

Remote education complicates learning in applied courses such as anatomy. The absence of in-person interaction reduced participation, diminished course effectiveness, and hindered the development of professional identity. Infrastructural deficiencies and technological inequalities were also identified as significant barriers. These findings can guide the development of sustainable and inclusive remote education policies.

Introduction

Synchronous (real-time) education refers to instruction conducted online via internet technologies, bringing together students and instructors in different locations. It is a virtual classroom environment. In these virtual classrooms, students can ask the instructor questions and participate in lessons in real time. Asynchronous (non-simultaneous) education refers to students accessing pre-prepared or recorded course materials at their convenience (1, 2).

Remote education is known to offer numerous benefits, such as allowing students to learn outside the classroom and instilling in them a sense of responsibility for independent learning (3, 4). The ability to continuously replay recorded lessons and the opportunity to provide a learning environment where everyone can hear equally well and watch from the same distance, compared with the difficulties experienced in crowded classrooms, are some of the advantages of remote education (1, 4). Moreover, the best-known limitations of remote education are increased failure rates among students who have not acquired responsibility for their learning, greater difficulty communicating with instructors compared with in-person education, and reduced student socialization. The most serious limitation encountered is that students can observe but cannot practice in application-based courses (2, 5). The absence, in remote education, of activities such as collaborative learning experiences, real-time feedback, individual participation in class, and instant information exchange, which are common in classroom and school settings, has the potential to harm educational outcomes (6). These conditions have also required instructors to prepare new course content and develop new teaching methods for practical courses, rather than rely on existing methods (7). Recent global developments have compelled higher education institutions to transition rapidly to mass remote learning models. This sudden and comprehensive transition has made the educational effectiveness and student gains in practice-based courses, such as anatomy, a significant topic of discussion.

Anatomy is the scientific discipline that studies the standard shape and structure of the human body, including the organs that compose it, and the structural and functional relationships among these organs (8, 9). Anatomy education, the foundation of medicine and the health sciences, has been described in numerous studies as a challenging subject to learn (10, 11). Anatomy courses are among the most challenging subjects for students, partly because they are easily forgotten if not reviewed frequently and partly because of the Latin terminology they contain (8).

Therefore, the primary objective of this study is to compare the learning experiences and perceived levels of effectiveness and efficiency of students taking anatomy courses taught by the same instructor using the same curriculum but delivered in person rather than online. The secondary objective is to examine how the teaching method (online or in-person) affects students’ perceptions of their professional identity as future healthcare professionals. It also aims to identify the problems, limitations, and opportunities encountered in online education.

Material and Methods

This cross-sectional study was conducted at Istanbul University-Cerrahpaşa, Vocational School of Health Services between May and June 2021. The study included 254 students who voluntarily participated. Data were collected using a structured online questionnaire. The study population consisted of first-year students who took anatomy remotely during the 2020-2021 academic year, and second-year students who had taken the course in person during the previous year. Although students were enrolled in different associate-degree programs and their distribution was unequal, they all took the anatomy course from the same instructor. Furthermore, the course syllabi and presentations used in both online and in-person education were identical. One hundred and sixteen first-year students took an anatomy course for the first time and attended it online. In contrast, 138 second-year students took the anatomy course in person during their first year (the previous academic year), with the same content and instruction.

In this study, two separate survey forms were used. These were sent electronically via Google Forms. Each form had multiple-choice questions that were the same for all participants within a group but different across groups. Everyone taking part was informed about the study on the first page. This information emphasised that responses would be kept anonymous and that the data would be used only for research purposes. Completion and submission of the survey constituted informed consent. To ensure the reliability of the feedback, students were asked not to provide their names. The survey questions were designed to compare remote and in-person anatomy education, measure how well students understood the course and how important they perceived it to be, and identify problems students experienced. The questionnaire used in this study was developed by adapting items from previously published questionnaires related to remote learning and anatomy education and by incorporating our students’ feedback on remote learning courses. The questionnaire contains items related to the perceived effectiveness and adequacy of the anatomy course, students’ perceptions of their professional identity as future health professionals, and the problems they experience during distance learning.

This study was approved by the Clinical Research Ethics Committee of University of Health Sciences Türkiye, İstanbul Training and Research Hospital (decision number: 2842, date: 21.05.2021).

Statistical Analysis

IBM SPSS Statistics software (version 21.2; Armonk, NY: IBM Corp.) was used for data analysis. The distribution of responses to Likert-type questions was evaluated using descriptive statistics (frequency and percentage) and multiple-choice questions were analyzed using frequency analysis. The chi-square (χ²) test was applied to evaluate the relationship between categorical variables. The Shapiro-Wilk and Kolmogorov-Smirnov tests were used to assess whether the data were normally distributed. The statistical significance level was set at p<0.05.

Results

Demographic and academic characteristics of the students included in the study are summarized in Table 1. These data were analyzed to ensure the comparability of the two groups in terms of gender, department, and employment status.

The majority of the participants were female (79.9%), and most were enrolled in programs related to dental health, radiotherapy, and medical imaging. In addition, approximately half of the students were working either full-time or part-time while pursuing their education.

Findings comparing the opinions of students who received anatomy education remotely and in person are presented in Table 2.

Statistically significant differences were found between the two groups with respect to perceptions of course sufficiency, the necessity of including anatomy in the second-year curriculum, and feelings of professional identity (p<0.05).

For instance, 60.1% of second-year students (in-person) considered the first-year anatomy course sufficient, whereas this rate was 46.6% among first-year students (remote). Similarly, nearly half of the in-person students (47.1%) believed anatomy should continue in the second year, compared with only 23.3% of the remote learners. Moreover, while 89.9% of students who received in-person education stated that anatomy made them feel like healthcare professionals, this rate dropped to 64.7% among those who received remote education.

In addition to the overall comparisons, the specific views of second-year students who previously received in-person anatomy education are summarized in Table 3. For example, 53.6% of these students reported that the information learned in anatomy classes is easily forgotten, and 49.3% indicated that the main reason for this is the subject’s memorization-based nature. Furthermore, 63.0% of the students believed that the anatomy classes they attended would be beneficial for their professional practice after graduation.

Table 4 details the perceptions and experiences of first-year students who received remote anatomy education, including their communication with instructors, class participation, and technological access. For example, 68.1% of the students reported that they could easily communicate with the instructor during remote learning, and 69.0% stated that they were able to express their thoughts freely. However, 47.4% believed that remote learning reduced the effectiveness of teamwork.

The 35.3% of students regularly attended courses, whereas 6.0% reported that they were unable to attend them at all. The most common reasons cited for inability to attend were lack of a personal device (37.1%) and lack of an internet connection (25.0%); other reasons included an unsuitable study environment (12.1%), connection problems (19.8%), and employment outside the home (6.0%).

In general, most students (84.5%) attended anatomy classes at home; the proportion who considered the remote learning environment suitable was equal to the proportion who did not (44.8%). The most common reasons cited for the learning environment being unsuitable for listening to lectures were environmental noise (48.6%) and the presence of other people (36.9%). Furthermore, 73.3% of the first-year students participating in the study believed that remote learning was less effective than in-person education.

Discussion

The use of remote education models in higher education has made educational effectiveness, particularly in applied health sciences courses such as anatomy, a fundamental research issue. This study differs from many previous reports on anatomy education in several respects. Both remote and in-person groups received the same curriculum and materials from the same instructor, minimizing differences attributable to teachers or course designs. Furthermore, the sample consisted of students enrolled in vocational health services programs, who play an important role in routine health services but are infrequently mentioned in the literature. Finally, our study evaluates the advantages and challenges of online anatomy education from a broad perspective, not only regarding the effectiveness of the course but also regarding students’ perceptions of professional identity and their access to devices, internet connectivity, and suitable working environments. The most significant finding of our study is that, despite sharing the same course, subject, instructor, and materials, the rate of learning difficulties was 59.4% among second-year students who received in-person education, compared with 82.8% among first-year students who received remote education (p<0.001).

A study on anatomy and physiology education supports our findings (12). In this study, even with in-person education, 59.6% of students reported difficulty learning the course, which closely matches the 59.4% observed in our study’s formal education group. In the same study, 48.8% of students reported that they did not consider anatomy lessons necessary, and 67.4% that they would not choose them as an elective course (12).

According to a study by Kürtüncü and Aylin (13), 76.4% of students believe that remote learning is insufficient for practice-based courses. The 79.9% of the students participating in our study believe that associate-degree education should include cadaveric anatomy or laboratory training. Studies by Sahu (14) and Wang et al. (15) report that it is not appropriate to deliver practical courses through remote education. Other studies suggest that remote education can contribute to theoretical knowledge, whereas in-person education is necessary for practical skills. It is important for students to practice analyzing and integrating the information obtained (16, 17). These findings indicate that students recognize the importance of practical courses, which are essential to education, and that they have concerns about the practical aspects of remote learning.

Among participants in our study, 60.1% of second-year students and 46.6% of first-year students considered the anatomy course sufficient in their first year; however, the proportion of undecided respondents was higher among first-year students. A statistically significant difference was found between the responses of the two groups (p=0.016). This indicates that students who took the course remotely did not fully grasp the importance of the anatomy course, did not consider the information available to them adequate, and did not master the subject matter. Responses to the question “Is remote anatomy education an alternative solution?” also support this finding (p=0.011). Indeed, the percentage of first-year students with no experience comparing remote and formal education who responded “I don’t know” (21.6%) was higher than the percentage of second-year students with formal education experience who responded “I don’t know” (12.3%) confirming this lack of experience and indecision.

In work environments, schools, and universities, individuals socialize and interact constantly with their colleagues and friends. In group settings, individuals exchange ideas more frequently and actively attempt to understand others’ thoughts and teachings (18, 19). Bernard et al. (20) examined the effect of three types of interaction (student-student, student-instructor, and student-material) on student achievement using meta-analytic methods. The study found that all three types of interaction had positive effects; student-instructor interaction, in particular, had stronger effects than the other two. Cheng and Chau’s (18) study reported that the lack of social communication among students in remote education and the reduced sense of community could contribute to poorer academic performance by diminishing students’ social interactions. In the study by Keskin and Kaya (17), 36.0% of students reported that remote education reduced teamwork by directing them toward individual work. Similar to these studies, 68.1% of first-year students in our study stated that they could easily communicate with the instructor in remote anatomy education; 69.0% stated that they could easily express their thoughts; and 47.4% believed that remote anatomy education increased individual work and reduced teamwork.

Our study revealed the decisive role of formal and remote education in students’ awareness of the professional necessity of the course. The clearest evidence of this lack of awareness is the responses to the question: “Should the anatomy course be included in the second-year curriculum?” Second-year students with formal educational experience who understand the importance of the course support this idea at a rate of 47.1%. By comparison, 50.0% of first-year students who take the course remotely and struggle to develop this awareness answered “No”. This difference in perception between the two groups is statistically significant (p<0.001) and parallels findings in the literature (12). These findings strongly support the notion that remote learning leads not only to a deficiency in students’ learning of the course content but also to a deficiency in their understanding of why that course is essential for their profession.

The 67.7% of the students in our study believed that anatomy should not be an elective course, and 65.0% stated that they would take the course if it were an elective. Again, there were statistically significant differences between first- and second-year students for these responses (p<0.001 and p=0.004). Moreover, in these responses, we observe that second-year students who received in-person education in their first year make more accurate judgments.

One of the most striking findings of our study emerged in relation to students’ perception of professional identity. When asked, “Does anatomy education make you feel like a healthcare professional?”, 64.7% (n=75) of first-year students enrolled in remote education answered “Yes”. In comparison, this rate rose to 89.9% (n=124) among second-year students with formal educational experience. This difference is statistically significant. Similarly, 63% of second-year students answered “Yes” to the question: “Do you believe that the anatomy course you are taking will be useful in your professional life after graduation?”. In light of these data, remote anatomy education appears to provide less support than formal education for students’ development of their health professional identity and professional self-confidence. This finding is consistent with a study conducted in Brazil that showed that over 70.0% of students were concerned about the future of their professional education and only 24.1% found remote learning effective (21).

In a study by Rizun and Strzelecki (22), university students reported wanting to return to in-person education. In a study by Uzun et al. (23) examining the attitudes of 128 university students toward distance learning, only 15 (11.72%) considered it practical. Similarly, 73.3% of first-year students in our study reported that distance anatomy education was less effective than in-person instruction, whereas 55.1% of students in both classes opposed expansion of distance anatomy education. In the studies conducted by Başer et al. (7) during the pandemic, 46.4% of students reported having a suitable home environment for studying. Additionally, 55.1% of students were unable to attend their lessons regularly due to problems with internet infrastructure and access. In our study, 44.8% of students considered the learning environment was suitable. According to a study by Kürtüncü and Aylin (13) among nursing department students (n=824), only 105 of 516 participants reported that they could follow their classes without problems related to internet access or computers. In a study by Karadağ and Yücel (24) involving 17,939 students from various classes at 163 universities, 37.0% lacked internet access at home, 34.0% lacked a computer or tablet, and 23.0% reported that they could not continue their remote education. According to a report published by Kırşehir Ahi Evran University in 2020 (25), 23.0% of the 2,781 students were unable to attend online classes, and 75.0% of those unable to attend online classes reported internet connection issues. According to the data from our study, 37.1% of the 116 students did not have access to a computer, tablet, or smartphone; 25.0% did not have an internet package; and 19.8% experienced internet connection problems. Based on the studies conducted and our findings, it is evident that internet connectivity and infrastructure problems have not yet been completely resolved in our country, and that the percentage of students without access to a computer, tablet, or smartphone remains high. When equal opportunities in education cannot be fully ensured, courses may not reach their full potential, and instructors may have fewer opportunities to effectively support students. Many studies comparing online and in-person education found no difference in participants’ success at the end of training (26, 27, 28). In fact, according to some studies, remote education is more effective than formal education in terms of participants’ academic success (26, 29, 30). Considering these data, we believe that remote education in our country will again become a debatable issue once the learning environment is more suitable, internet infrastructure and access problems are resolved, and access to technology (e.g., phones, tablets, and computers) is ensured.

Study Limitations

The first major limitation of the study is that the sample consisted exclusively of students from the Health Services Vocational School of a single university, drawn from multiple health-related associate degree programs with unequal group sizes. Consequently, the findings may not be generalizable to other institutions or programs, and unmeasured program-level differences (e.g., baseline academic preparation or career orientation) may have confounded the comparative results. Furthermore, since the data obtained through the questionnaire are based on the students’ subjective statements, the accuracy of the responses may have been affected by individual differences. Another important limitation is that although the survey is based on existing surveys and student feedback, no separate pilot test or formal psychometric analyses (e.g., Cronbach’s alpha or KR-20 for internal consistency) were conducted on the current version of the instrument. Therefore, measurement error and limited generalizability of survey scores cannot be completely disregarded.

Conclusion

This study has revealed that distance learning models used in practical health courses, such as anatomy, may significantly complicate the learning process and negatively impact educational efficiency. Limited in-person interaction and active participation have prevented students from fully grasping the professional importance of the course. Furthermore, infrastructural deficiencies, technological limitations, and educational inequality experienced during this process have been identified as key factors reinforcing these negative outcomes. These digital education models, whose use is expected to increase in the near future, need to be reevaluated and improved in light of the current findings, to make them sustainable and inclusive.