Artwork in anatomy education: A way to improve undergraduate students' self‐efficacy and attitude

Anatomy is one of the leading subjects in health science, and students need a strong anatomy background in these fields. Traditional lecturer‐oriented anatomy education is based predominantly on passive learning methods. In recent years, alternative educational methods like hands‐on art and 3D atlas‐based education methods have become more popular as competitive alternatives to traditional approaches. This is a prospective, randomized, longitudinal, interventional study, and a total of 181 undergraduate students participated in this study. A comparative design was used with two groups: Artwork and Atlas. This study aims to evaluate the effectiveness of creative and artistic approaches in improving undergraduate students' attitudes and self‐efficacy toward anatomy courses. A Pearson correlation, an independent t‐test, and a paired t‐test were used to analyze the results. Both groups experienced a negative mean score on the anatomy self‐efficacy scale, suggesting an increase in anatomy self‐efficacy, and showed significant self‐efficacy improvements (p < 0.005). An independent t‐test analysis found no statistically significant difference between the Atlas group and the Artwork group on the anatomy self‐efficacy scales (pretest and posttest) and the anatomy attitudes scale (p > 0.005). Artwork‐based education and learning methods can be used as active learning methods to improve students' self‐efficacy toward anatomy. This method allows learners to employ their creative abilities in order to express their ideas visually, making complex concepts easier to comprehend. It can also help students develop practical, problem‐solving, critical thinking, and teamwork skills. It is cost‐effective and engaging since it does not need any expensive equipment.

primary steps in diagnosing, treating, and caring for patients in clinical settings.It is also a critical component of medical research and development (Molina-Torres et al., 2022).However, learning anatomy can be challenging and complicated due to the complexity of the concepts and terminologies involved; it plays a crucial role in preparing future healthcare providers (Banovac et al., 2023).Healthcare students and medical professionals need to be adequately knowledgeable about anatomy and understand the functions and spatial context of organs before performing any invasive procedures on patients (Roxburgh & Evans, 2021).
Studies have shown that students without basic anatomy knowledge and skills encounter serious difficulties in advanced classes (Ghosh, 2017).
Traditional lecturer-oriented anatomy education is based predominantly on passive learning methods, such as lecture-based instruction, which may not effectively promote active student participation and knowledge retention.In this method, available learning resources are generally limited to textbooks and PowerPoint (Ma et al., 2016).Nowadays, a revised teaching-learning approach known as active learning is implemented to ensure the curriculum remains relevant to the constantly connected and resource-rich world.It involves learners actively participating in the learning process through cooperative or hands-on tasks.
Critical thinking and problem-solving skills are emphasized in this method and can improve student learning in numerous subjects (Bonatto-Costa et al., 2021).Students studying healthcare in the first year may experience challenges with the complexity and volume of anatomy subjects.However, many innovative learning tools, such as three-dimensional models, body donor dissection, and artistic activities, such as drawing and body painting, have been conducted to enhance active learning and improve the quality of education in colleges (Rekhari & Sinnayah, 2018).A few decades ago, medical science schools started teaching multidisciplinary concepts through art and illustrations (Mukunda et al., 2019).In recent years, alternative and innovative educational methods like hands-on art and 3D atlas-based education and learning methods have become more popular as competitive alternatives to traditional approaches (Uribe et al., 2023).Nurses and midwives rely heavily on anatomy knowledge to perform procedures such as injection sites, monitoring vital signs, administering first aid, and performing childbirth and episiotomies.A strong foundation in anatomy can facilitate professional development in these specialized areas and advanced nursing and midwifery practical skills.Moreover, possessing a comprehensive understanding of anatomy can enhance students' self-esteem and confidence when practicing in clinical settings (Satoh et al., 2023).In this study, we consider the significance of active learning methods in improving undergraduate students' attitudes and self-efficacy toward anatomy courses.
Attitude refers to a student's overall evaluation of the subject.
Research shows that healthcare students have positive attitudes about anatomy during their education period.It has been believed that along with self-efficacy, students' perspectives and attitudes toward basic science subjects, such as anatomy, can significantly affect education outcomes (Plaisant et al., 2014).
It has been shown that possessing a positive attitude toward anatomy, coupled with self-efficacy, can significantly impact students' academic performance and professional development in nursing and midwifery.All in all, positive attitudes toward anatomy could develop a comprehensive understanding of fundamental concepts and principles of anatomy.Moreover, students can establish an adequate knowledge base for educational advancement.Along with this, a positive attitude and self-confidence in approaching anatomy significantly impacts performance and learning.Last but not least, maintaining a positive attitude helps individuals overcome challenges, stay motivated, and remain confident when faced with difficult anatomy topics (Acar et al., 2017).
Self-efficacy is the belief in one's capability to manage and take the actions needed to succeed in learning a subject (Woolcock et al., 2016).Self-efficacy has been a leading and also reliable predictor of university student progress since 2000 and is significantly correlated with students' grade point averages and their motivation to learn (Bartimote-Aufflick et al., 2016).Academic self-efficacy determines how well students perceive their capacity to organize and carry out courses of action related to their studies (Tembo & Ngwira, 2016).Throughout history, self-efficacy has been a notable principle in education.The Roman philosopher Lucius Annaeus Seneca outlined the value of cooperative learning in his statement, "Those who teach learn."(Lalit & Piplani, 2019).
The purpose of this study is to assess the efficacy of educational strategies that integrate creative and artistic approaches in improving undergraduate students' attitudes and self-efficacy toward anatomy courses.We hypothesize that creative and artistic approaches can improve students' attitudes and self-efficacy toward anatomy courses.

Study settings
This study was conducted at Sakarya University, Faculty of Health Science, Türkiye, which includes students in the nursing and midwifery program.The participants were first-year students enrolled in this study.The study protocol was approved by the Social and Humanities Ethics Committee of the University of Sakarya by the number E-61923333-050.99-175496.This study is also registered on Clini calTr ials.gov under registration number NCT05868031.

Study design
This prospective, randomized, longitudinal, interventional study was completed within 14 weeks at the University of Sakarya.The study utilized a comparative design with two groups: an Atlas group (ATG) and an Artwork group (ARG).Atlas-based education is a recognized active learning approach.A medical atlas is a compilation of visual representations that detail the parts, organs, and systems of the human body.Students are encouraged to engage with these visual resources effectively in active learning environments.
Atlas-based teaching encourages learners to develop a comprehensive and deeper understanding of the subject matter.
Instead of passive methods like lectures or reading textbooks, it encourages students to think deeply and analyze information.It is particularly useful in fields like anatomy, where complex structures must be visualized and understood (Mukhopadhyay, 2022).
Additionally, for other groups, we chose artwork-based active learning, known for its cost-effectiveness, reliability, and fostering a greater sense of student engagement and contribution to the learning process.The study consisted of first-year students enrolled in the midwifery and nursing program at Sakarya University, students who have not previously taken an anatomy course, and individuals who expressed willingness to participate in the research.Exclusion criteria for the study included students who declined to participate in the study and individuals who had previous experience in anatomy courses.All in all, comparative analysis provided a more comprehensive understanding of how these methods affect students' attitudes and self-efficacy.In this regard, both groups filled out the Anatomy attitude scale in the first session.As well, we asked participants to complete the anatomy self-efficacy scale in both pretest and posttest forms in the first and last sessions.

Data collection
Among 250 first-year students in the faculty of health science, 181 midwifery and nursery students actively participated in this study.| 69 HADAVIBAVILI and İLÇIOĞLU out a self-report questionnaire, which was prepared based on literature references and included information regarding their age, sex, and field of study.In addition, both groups of students were also required to fill out the anatomy attitude scale immediately after the first session.We also asked students to complete the anatomy selfefficacy scale in both pre-and posttest forms.
Anatomy attitude scale (Bahçeci, 2006): It measures students' attitudes toward anatomy, which refer to their opinions, beliefs, and feelings related to the subject on a 5-point Likert scale, with a minimum score of 24 and a maximum score of 120.An opinion is a judgment or evaluation of a subject formed by a person's experiences, knowledge, and perspective.On the scale, students will provide

Researcher involvement
The researcher responsible for distributing and collecting the questionnaires did not participate in teaching anatomy to the students.This indicates that the researcher remained independent of the teaching process to avoid bias.

Statistical analysis
Pearson correlation analysis was conducted to assess the relationship between the anatomy attitude total scale score and posttest anatomy self-efficacy in both ATG and ARG.Using Pearson correlation analysis is appropriate for examining linear relationships between continuous variables based on the strength and direction of their linear relationship.It allows us to quantitatively measure the degree of association between these variables, identifying whether participants exhibiting more positive attitudes toward anatomy also demonstrate higher levels of self-efficacy.An independent t-test was conducted to compare the means of two groups (ARG vs. ATG) on continuous variables such as scores on the anatomy self-efficacy scale or the anatomy attitude scale.A paired t-test was conducted to assess changes in anatomy self-efficiency pretest and posttest within each group over time.Continuous variables with normal and abnormal distributions were reported as mean ± standard deviation (SD).The significance level of p ≤ 0.05 was considered, and all statistical analysis was performed using SPSS version 26 software (IBM Corporation, Armonk, NY, USA).

RE SULTS
In total, 181 undergraduate students were included in the study.
Study participants were aged 17-23, with an average age of 19.03 ± 1.11 years.Approximately 58% of students were aged between 19 and 20 years.In our study, the gender distribution was 13.3% male and 86.7% female.This study involved 70.7% of nursing students and the rest were midwifery students.The majority of students prefer to study at university in the faculty of health science voluntarily.In Table 1, we present some sociodemographic characteristics of the study participants.
In Table 2, we present the paired sample test analysis result between pretest and posttest scale of anatomy self-efficacy in both intervention groups.Both groups experienced a negative mean score on the anatomy self-efficacy scale, suggesting an increase in anatomy self-efficacy.As well, in both groups, the p-values of 0.000 suggest that the interventions in the ATG and ARG had a significant impact on improving self-efficacy.
According to the anatomy self-efficacy scale, the pre-test mean scores are very similar for the ATG and ARG, respectively, with TA B L E 1 Sociodemographic characteristics of the participants.The overall mean score for the pretest is 71.39 ± 9.48.This suggests that initially, both groups had similar levels of self-efficacy in anatomy.

Characteristics
There was a significant increase in the mean scores of both groups in the posttest.The ATG achieved a mean score of 89.20 ± 5.81, while the ARG had a mean score of 89.08 ± 6.58.The overall mean score for the posttest is 89.14 ± 6.16.These higher scores indicate a substantial improvement in self-efficacy levels for both groups after the active learning intervention.Table 4 shows a correlation between anatomy attitude total scale score and posttest anatomy self-efficacy in ATG and ARG.In the ATG, there was a strong positive correlation between anatomy attitudes and anatomy self-efficacy (r = 0.642, p < 0.05).As well, in the ARG, a strong positive correlation was observed between anatomy attitudes and anatomy self-efficacy (r = 0.693, p < 0.05).
According to these findings, individuals with more positive attitudes toward anatomy tend to have higher levels of self-efficacy.
Consequently, higher levels of anatomy self-efficacy could result in increasing confidence in understanding and applying anatomical knowledge.

DISCUSS ION
The anatomy course is one of the basic foundations of studying medicine and other health sciences fields at the undergraduate level.A number of factors make teaching anatomy in undergraduate courses challenging, including struggling to adapt to university education curriculum, shortening of education period, retaining knowledge from anatomy courses without laboratory components, difficulties understanding Latin terminology, emotional stress in students, and limited body donor resources (Gripshi et al., 2022).A dissection course can be both exciting and stressful for students.In some cases, students experience emotional stress when using surgical instruments such as a scalpel to dissect the anatomical structures of someone who looks like a family member or friend, which significantly impacts their relationships in the future (Hildebrandt, 2016).Some students also consider ethical and moral aspects related to the use of human materials in teaching (McLachlan et al., 2004).A study conducted by Moxham (2019) indicates that, overall, students approach dissection in a curious and interested manner.In addition, the number of potential concerns reduced significantly after the first dissection session.The study also reported a relatively low incidence of anxiety and repulsive feelings.Furthermore, the study results showed that emotional reactions, including death anxiety, decreased as students gained more dissection experience (Moxham et al., 2019).The limited resource of donor body education is also considered a significant challenge in teaching anatomy; however, according to literature, this can be improved by using innovative digitally based education techniques and reducing the need for human body education as well as eliminating ethical and moral concerns (McMenamin et al., 2018).A variety of factors can make human anatomy difficult for students.According to a study conducted by Lieu et al. (2018), the peripheral nervous system is regarded as the most challenging to study because of its complicated structure-function TA B L E 3 Score distribution of anatomy self-efficacy and anatomy attitudes between Atlas and Artwork groups.relationships and the difficulty in visualizing it.The cardiovascular and skeletal systems were perceived by students as less challenging to learn due to their prior exposure and ease of visualization.As a result of these findings, instructional strategies can be developed and altered to address the difficulties students face when learning about difficult organ systems (Lieu et al., 2018).Along with this, undergraduates tend to underestimate the importance of anatomy education in safe practice, as they have preconceived perceptions about anatomy.
Many students perceive anatomy as a theoretical subject with limited application, which might explain why it is not recognized as an essential component of effective healthcare education (Huang et al., 2022).
A relevant anatomy education should be emphasized by anatomy professors with enough experience in anatomy education and practical experience to help students develop their skills as healthcare providers (Shaffer, 2016).This study examined two different active learning methods, Atlas-based education, and hands-on artwork production along with traditional lecturer-oriented education method, to assess their effectiveness in improving first-year undergraduate students' at- them with the confidence to apply their anatomical knowledge effectively in their healthcare careers.This holistic approach enhances students' learning experiences by providing them with a sense of purpose and application to their anatomical studies.In a study conducted by Tembo and Ngwira (2016), there was a significant association between high self-efficacy beliefs and active and logical learning strategies.According to these findings, self-efficacy correlates positively with active learning strategies educators use during education (Tembo & Ngwira, 2016).According to Han et al. (2015), the majority of students believe that peer-assisted learning enhances their knowledge, attitudes, and skills in anatomy (Han et al., 2015).In 2016, Entezari et al. found that students enjoy active learning, which improves their attitude toward the outcomes of their studying.Instructors also benefit from these strategies, which increase their enthusiasm and keep them more engaged with their students (Entezari & Javdan, 2016).
Based on our findings, both the ATG and the ARG expressed similar levels of self-efficacy on the pretest scale, as indicated by nearly the same mean scores on the anatomy self-efficacy scale.However, after the implementation of the interventions, both groups experienced a significant increase in self-efficacy scores, as reflected in the higher mean scores in the posttest.This suggests that both active learning emphasized that students should not simply memorize anatomical structures but also understand spatial relationships during anatomy study (Kusumaningtyas et al., 2020).
Atlas-based education method focuses on visual learning and aims to provide students with a comprehensive and easy understanding of anatomical details.The study conducted by Bains and Kaliski (2020) showed that Atlas-based educational programs are valued by students and have the potential to increase their self-efficacy in anatomy (Bains & Kaliski, 2020).Despite this, Park et al. (2019) found that while the 3D atlas may be helpful in quickly identifying anatomical structures, it is not very useful for acquiring deep anatomical knowledge or memorizing their locations.It is also possible to use the 3D atlas in anatomy education if used properly since most students find them useful (Park et al., 2019).
Another study conducted by Langfield et al. (2018) also showed that providing supplementary 3D atlas-based education had no impact on learning and self-efficacy toward anatomy (Langfield et al., 2018).
There has been a close connection between art, illustration, and anatomy for centuries in history books and this is evidenced by Leonardo da Vinci's anatomical drawings and Leopoldo Marcantonio Caldani textbook (Porzionato et al., 2012).Artwork-based education method was considered to engage students in a more active and creative manner, allowing them to develop a deeper understanding of the subject matter.By visualizing and creating the anatomical structures themselves, the students were able to retain the information better and apply it in a practical context.An artwork called "A Powerful Aid to Modern Medical Education" was introduced by Wang (2020).
According to Wang, art is not just about teaching observation skills, but also it can improve empathy, discipline in study, flexibility in education groups, conflict resolution, and teamwork (Wang, 2020).A study by Johnston et al. (2015) highlights the importance of active learning in anatomy and practical laboratory exercises in first-year nursing students.Authors claimed that hands-on and artwork learning activities are cost-effective, reliable, and suited to all learning types.
The use of active learning methods can improve nursing students' attitudes toward anatomy courses (Johnston et al., 2015).Another study conducted by Bell and Evans (2014) found that there is a significant association between art and medical science based on students' feedback.Moreover, it showed that art could positively develop clinical observational skills through analyzing art in medical education.This study also concludes that art-based approaches to teaching observational skills in medical science and other healthcare curricula could be worthwhile (Bell & Evans, 2014).
All in all, according to our results, both Atlas-based education and Artwork-based education methods are effective in anatomy education.
Atlas-based resources and virtual tools promote visual representations and ease of understanding, whereas hands-on artwork production encourages students to engage in learning more actively.Incorporating these active learning methods alongside traditional teaching methods can enhance student attitudes, self-efficacy, and overall engagement with anatomy.In limited body donor resource labs, students' innovative artworks can be used to educate and enhance future students' creativity.Along with this, educators can provide future healthcare professionals with a more effective learning experience by incorporating artwork into undergraduate anatomy education.

Limitations
There are some limitations to this study.There were only 181 participants in this study, which limits its generalizability to other student populations and institutions.Additionally, participants may interpret self-report questionnaires subjectively or submit biased responses.
Although the study compared two active learning methods, the absence of a traditional lecture-based control group makes it difficult to isolate the specific effects of the interventions.The students in our study were eager to participate in an active learning group, so we suggest that more studies be conducted with control groups in order to determine if active learning is more effective.The study was also conducted over a period of 14 weeks.The sustainability of the results could be better understood over a longer period of time.

FU N D I N G I N FO R M ATI O N
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Participants were divided into two groups based on students' preferences.In fact, they had the option of choosing the Atlas-based method or the artwork-based method as their active learning approach.Students made the choice based on their individual learning styles and preferences.In this preference option, students felt a sense of responsibility and investment in their education.As a result, motivation and engagement can be increased, which can positively impact their self-efficacy.Moreover, students are more likely to work with peers who share similar interests and learning styles when they select their groups based on their preferences.The result can be a supportive, collaborative learning environment in which students share ideas, encourage one another and provide assistance to one another.As a result of peer support, students can improve their selfefficacy through acknowledgment, constructive criticism and reinforcement through social interaction.An enrollment CONSORT flow diagram is shown in Figure 1.Traditional lecturer-oriented teaching was used for both groups.The two groups only differed by the additional active learning method.The ATG was provided with a selection of illustrations from online interactive 3D atlases.They were encouraged to use them as a resource to aid their studies throughout the semester.The ARG was tasked with preparing anatomical models by drawing or creating them by hand.A few examples of students' artwork are presented in Figures 2-4.The students were asked to fill F I G U R E 1 Enrollment CONSORT flow diagram.
their perspectives or assessments about anatomy-related topics based on their analyses or opinions.Cultural, social, and educational factors can influence students' opinions.Participants' beliefs are reflected in the scale, indicating their underlying beliefs concerning certain aspects or principles of anatomy.Feelings refer to emotions and attitudes toward a subject.A person's feelings can be shaped by emotions such as enthusiasm, hesitation, or indifference.In the scale context, participants' feelings could emerge as emotions related to their anatomy experiences, indicating their emotional preferences.According to a Likert scale, participants rate a series of statements related to anatomy on a scale of 1-5.Individual attitude scores are determined by the sum of their scores for each item.

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I G U R E 2 (A) Knitted doll with anatomical position (palms facing forward), (B) knitted uterus during fertilization, (C) pencil crayon skull bone anatomy drawing (anterior view), (D) pencil crayon skull bone anatomy drawing (lateral view).According to the literature, anatomy learning, performance, and overall engagement can be greatly influenced by an individual's attitudes(Moxham et al., 2016).In general, attitudes are classified as low, moderate, and high, with scores ranging from 24 to 55 indicating a low attitude, 56-88 indicating a moderate attitude, and 89-120 indicating a high attitude.A higher score indicates a more positive attitude toward anatomy.Measurement reliability refers to the consistency and stability of results obtained from a scale.The reliability coefficient is calculated using statistical methods, specifically Cronbach's Alpha.This coefficient quantifies how closely the individual items on the scale correlate with each other.A value closer to 1 indicates higher internal consistency, suggesting that the items measure the same underlying trait.A scale's validity is related to its ability to measure what it is intended to assess.Anatomy attitude scale validity refers to the measure capturing students' attitudes toward anatomy.A reliability coefficient of 0.75 is important because it indicates that the scale consistently measures students' attitudes, enhancing credibility and trustworthiness.In this study, Cronbach's Alpha reliability score is 0.819.This suggests the high-reliability coefficient and indicates that the scale is valid and reliable for measuring attitudes.Anatomy self-efficacy scale (Bahçeci & Mustafa, 2008): It is a specialized measurement tool designed to determine an individual's self-efficacy and confidence in the student's anatomy-related knowledge and the ability to apply theory efficiently to practice and real-life situations.According to subdimension analysis, 26 items F I G U R E 3 (A) An anterior view of a coronal cross-section of the cement-made uterus and vagina, (B) drawing of the knee joint, (C) pencil crayon drawing of the cerebral hemisphere.were loaded onto three subdimensions in the self-efficacy scale: "Confidence in anatomical knowledge accumulation," "Awareness of practical skills in anatomy," and "Transformation of theoretical knowledge into life skills in anatomy."The scale provides a quantitative measure, with a minimum score of 26 and a maximum score of 130, and the scale consists of six negative and 20 positive items.There are four levels of self-efficacy on the anatomy self-efficacy scale based on participants' scores: 26-43 points: very low, 44-60 points: low, 61-96 points: moderate, 97-113 points: high, and 114-130 points: very high.Based on a person's score on the scale, these categorizations indicate their level of self-efficacy.In the field of anatomy, a higher score indicates greater self-efficacy.The scale's reliability was calculated as Cronbach's alpha (α) = 0.84.In this study, Cronbach's alpha reliability score is 0.687.This suggests the moderate-reliability coefficient and indicates that the scale is valid and reliable for measuring self-efficacy.
titudes and self-efficacy regarding anatomy.This study examined two different active learning methods, Atlasbased education and hands-on artwork production, to assess their effectiveness in improving first-year undergraduate students' attitudes and self-efficacy regarding anatomy.The results of the study provide new insights into how interventions affect student perceptions regarding anatomy and learning experiences.In this study, a self-report attitude scale was administered to the students in the first session after providing information about anatomy classes and the curriculum's objectives.The results of the self-report attitude scale revealed that the mean score of attitudes among the students was 80.55 ± 11.92, indicating a moderate level of attitudes toward anatomy.Moreover, both groups generally displayed positive attitudes toward anatomy, with the ATG having a slightly more positive attitude than the ARG.These findings suggest that students already possess a positive attitude toward learning anatomy.Consequently, we decided to skip the posttest for the attitude scale.This allowed us to collect data more effectively and minimize potential participant burden and boredom during filling out scales, allowing for more focused research into self-efficacy effects.Due to our results, there is a positive strong correlation between anatomy attitude and self-efficacy.This suggests that interventions to improve students' attitudes toward anatomy would likely result in higher self-efficacy in anatomy.We believe that educators can significantly affect students' attitudes toward anatomy by creating an active learning environment and highlighting anatomy's relevance and significance.Educators can transform anatomy from a theoretical in-class subject into a dynamic, practical field of study through active learning environments that foster engagement and interaction.Clinical applications of anatomy bridge the gap between theoretical knowledge and real-world applications in clinical practice.Students' self-efficacy can be positively impacted by this shift in perspective, empowering and education methods contributed to a positive change in their perception of anatomy and improved students' confidence in their anatomical skills as well as overall engagement in anatomy classes and practical skills.Through Atlas-based education, students developed a deeper understanding of anatomical details, enabling them to master more specialized structures with more confidence.The art-based approach allowed students to actively visualize and construct anatomical structures, giving them a deeper understanding of the subject.Students' overall competence in anatomy was enhanced by these interventions, which grounded theoretical knowledge in practical applications.According to these findings, active learning methods provide an alternative approach to learning anatomical structures and concepts in comparison to traditional lecturer-based teaching.To support our findings, Kusumaningtyas et al. (2020) also introduced an approach modality of active learning methods in anatomy learning, which Score distributions of the pretest and posttest anatomy self-efficacy scale in the Atlas and Artwork groups.

efficacy scale (total post-test) Anatomy self-efficacy scale (total post-test)
The relationship between anatomy attitude total scale score and posttest anatomy self-efficacy in both the Atlas and Artwork groups.