Social media as a learning tool in anatomy education from the perspective of medical and dental students

The traditional approach to anatomy teaching is still the most common. Recently, there has been a demand for methods that make students more active and open to communication and cooperation, and are well integrated with technology. Our aim in this study was to determine the social media usage characteristics and anatomy learning experiences of medical and dentistry students, and their expectations about learning via social media. A questionnaire was prepared and distributed to faculties of Medicine and Dentistry in 10 different universities in Türkiye via Google forms. The questionnaire was voluntarily answered by 762 students. Frequency, exploratory factor and confirmatory factor analyses were applied to the data acquired, and a structural equation modeling (SEM) approach was used. The results showed that 54.3% of the students spent more than 90 min/day on social media; 96.5% of the participants preferred to follow anatomical content pages on social media (acpSM) administered by an academic. They stated that the instant responses from acpSM's admin had a positive effect on motivation to learning (4.08 ± 0.89, mean ± SD, on 5‐point Likert‐type scale). The SEM revealed a statistically significant correlation between the students' learning motivation and the sufficiency and suitability of acpSM content (p < 0.010). Thus, medical and dental students are eager to learn anatomy via social media. However, they found acpSM to be insufficient in quality and quantity and wanted future content to be administered by academics. An acpSM optimized for content sufficiency and suitability increased students' learning motivation.

of Medicine and Dentistry in 10 different universities in Türkiye via Google forms.
The questionnaire was voluntarily answered by 762 students. Frequency, exploratory factor and confirmatory factor analyses were applied to the data acquired, and a structural equation modeling (SEM) approach was used. The results showed that 54.3% of the students spent more than 90 min/day on social media; 96.5% of the participants preferred to follow anatomical content pages on social media (acpSM) administered by an academic. They stated that the instant responses from acpSM's admin had a positive effect on motivation to learning (4.08 ± 0.89, mean ± SD, on 5-point Likert-type scale). The SEM revealed a statistically significant correlation between the students' learning motivation and the sufficiency and suitability of acpSM content (p < 0.010). Thus, medical and dental students are eager to learn anatomy via social media. However, they found acpSM to be insufficient in quality and quantity and wanted future content to be administered by academics. An acpSM optimized for content sufficiency and suitability increased students' learning motivation.

K E Y W O R D S
anatomy education, generation Z, learning tool, medical education, millennials, social media, undergraduate medical education 1 | INTRODUCTION Anatomy is one of the cornerstones of medical education (McLachlan & Patten, 2006;Tubbs, 2022). Cadaver-based practice lessons are important in classical anatomy teaching. The development of technology has introduced many innovative educational approaches in anatomy, especially during the last few decades (Evans & Pawlina, 2022). Nevertheless, the anatomy community has not reached consensus on an ideal anatomy education method that could provide an alternative to the traditional approach (Ortadeveci et al., 2022a). In December 2019, while the anatomy community was struggling to develop an educational model that would meet the expectations of Generation Z, the COVID-19 pandemic broke out.
The pandemic disrupted face-to-face training and dissection courses all over the world, and remote training became necessary in many scientific fields (Tschernig et al., 2022). This also affected anatomy education and reduced the hours available for dissection, the basis of classical anatomy teaching (McNamara & Nolan, 2022). The disruption created an opportunity to try alternative and innovative learning approaches (Xiao & Evans, 2022). It has accelerated the integration of technology into anatomy education by compressing years, even decades, of development into a very short time (Evans & Pawlina, 2022).
Before 2000, during the Web 1.0 era, information and communication technologies consisted of websites of which the content could be designed only by the admins (Cheston et al., 2013). At the turn of the century, the incipient evolution of digital media facilitated access internet technologies. It has become faster, cheaper, and easier to access anatomical images such as photographs, drawings, virtual reconstructions, and illustrations, which are parts of digital media (Hennessy & Smith, 2020). Gradually, anatomical digital media products began to be used and shared on social media platforms such as Facebook, Twitter, Instagram, and YouTube. These educational contents on social media received positive feedback from students (Hennessy & Smith, 2020).
Currently, social media has a very important place in people's daily lives. The number of social media users, which was approximately two billion globally (29% of total world population) in 2015, reached 4.7 billion (59% of total population) in July 2022 (https:// wearesocial.com/). Social media has an active role in shaping the aptitudes, attitudes, expectations, and learning styles of the young population born after 2000, known as millennials (Dilullo et al., 2011).
Higher education lecturers who included social media in their teaching practices have reported positive outcomes for students (Ali, 2016;Donlan, 2014). Indeed, the opportunities for diversity and flexibility provided by social media make it a suitable platform for meeting the needs of both instructors and students (Marsland & Lazarus, 2018). Social media has been integrated into higher education in many academic disciplines such as literature, marketing, and social sciences, and the pace of integration is increasing (Hamadi et al., 2022). However, in practice-based disciplines such as medicine and engineering, the integration is relatively slow. Keenan et al. (2018) reported that 94% of medical students use at least one social media platform to support their learning (Keenan et al., 2018). It has been suggested that social media provides a new way of enabling educators to connect and interact with medical students (Choo et al., 2015). While some studies indicate improved performance outcomes for learners who engage with social media, others have shown it has no such effect (Hennessy et al., 2016;Richardson et al., 2016).
Our aim in this study was to determine the value of social media in anatomy education for medical and dentistry students, and to reveal their opinions and expectations. We also investigated the effects of increasing the sufficiency and suitability of anatomical content pages in social media (acpSM) on the learning motivation of the students.

| Participants of the study and ethical approval
The questionnaire used in the current study was completed by 762 students. These participants were medical and dental students from 10 different universities in Türkiye. The study was approved by the Local Non-invasive Clinical Research Ethics Committee (Decree no. 62). After official permissions were obtained from the universities included in the research, the questionnaires were delivered to the participants via Google Forms. The survey link was sent to the students along with an informative text. Only volunteer students participated in the survey. Participation in this study had no effect on the students' academic performance or grades.

| The questionnaire
The questionnaire had four parts. The first part comprised questions regarding demographic information such as age, gender, and faculty/ university. The second part contained 12 multiple-choice questions aimed at determining the characteristics of social media use. The third part presented 5-point Likert-type propositions (1 = totally disagree to 5 = totally agree) adapted from previous studies (Ortadeveci et al., 2022a(Ortadeveci et al., , 2022bWalker & Fraser, 2005)

| Statistical analyses
The results were investigated by frequency analysis, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA). A structural equation modeling (SEM) approach was then used to investigate the relationships among the factors revealed.
SEM makes it possible to model the relationships among many dependent and independent variables. It has frequently been used for complex multivariate research problems in recent years to obtain a systematic and comprehensive result in a single process. Simply, SEM is a type of multiple and combined regression analysis (Çelik & Yılmaz, 2016). IBM ® SPSS Statistics 22 was used for statistical analysis.

| Demographics and data about social media usage
Among the participants in the current study, 59.9% were female and 40.1% were male. The age of 89.9% of the students was under 23.
While 69.6% of the participants were medical students, 30.4% were dentistry students.
Overall, 61.2% of the participants stated that they had three or more social media accounts. Most of them reported spending more than 90 min/day on social media (23.6% 91-120 min, 30.7% 120-+ min). Most of their social media use (72.3%) was in the evening, between 18:00 and 23:59 h. The most popular time intervals for listening to offline lectures from the faculty were 12.00-17.59 h (40.6%) or 18.00-23.59 h (37.9%). Among all social media platforms, 60.7% of the students spent the most time on Instagram. While 70.2% of the students followed at least one acpSM, 29.8% did not follow any; 96.5% stated that they would prefer to follow acpSM administered by an academic/specialist. Participants stated that they searched social media mainly for information about neuroanatomy (51.5%). They pointed to Wikipedia (38.7%) and YouTube (37.2%) as the most reliable sources of information.

| Questionnaire results
The evaluations in the questionnaire ranged from 1 = totally disagree to 5 = totally agree. The average result for the statement "acpSM contribute to learning anatomy" was 3.43 ± 0.95 (mean ± SD). The average of the answers for the statement "anatomical information I come across while surfing social media increases the permanence of learning" was 3.46 ± 0.96. In general, the students thought that obtaining instant answers to their questions from the acpSM administrator had a positive effect on their learning desires (4.08 ± 0.89). In contrast, the number of students who did not wish to see anatomical content on social media remained very low (1.90 ± 1.08). The average of the answers to the statement "the number of acpSM is sufficient" was quite low (2.13 ± 0.84). Students generally held that creating an official acpSM in the faculty at which they studied would support their anatomy education (3.93 ± 0.96). Many students responded positively to the statement that the pandemic had increased their duration of social media use (4.13 ± 0.97). However, this increase was not reflected in the desire to learn via social media at the same rate (2.97 ± 1.16). All propositions and the corresponding results in this part of the questionnaire are presented in A 3-factor set obtained from the EFA explained 84% of the total data structure. These factors were named learning motivation, sufficiency, and suitability. CFA was used to confirm the structures revealed by EFA (Figure 4). The proposed model was shown to be consistent with standard consistency criteria ( Table 1) To the question "What are the advantages of acpSM for you?" 264 answers were received. Many students listed the features of acpSM as "time saver, quick and easy access to information, reminder/repetitor, anti-forgetting." Many of them also stated that it provides a "reminder/stimulus to leave the phone and study." To the question "What are the disadvantages and limitations of acpSM?" 230 answers were received. The most common ones were "distraction caused by other content on social media, problems about reliability of information, insufficient number of acpSMs, low-quality images and lack of 3D." Some students also stated that they did not want to see educational content on social media. The most prominent answers for open-ended questions are listed in Table 2.
The question "What are your general thoughts on anatomical content producers on social media" was answered by 233 participants. Answers such as "supportive for lessons, beneficial, should be improved, the number of acpSM should be increased" came to the fore. In addition, some participants stated that social media contents directed to a general audience are more readily understandable.
F I G U R E 1 Mean results (± SD) of students' responses to 5-point Likert-type propositions assessing the reliability, sufficiency, and preferability of acpSM. acpSM, anatomical content pages on social media.

| Classical lectures versus alternative approaches
In modern education, classical lectures are criticized for not being student-centered and not enabling students to construct knowledge by encouraging methods that enable them to use higher level cognitive skills (Bligh & Cameron, 2000). Classical lectures are important for anatomy education, but alternative and blended approaches have become more prominent during the last few decades (Taylor et al., 2022;Zammit et al., 2022). As a result, anatomy lectures have occupied less time in many courses (Evans, 2022). Because of the attainments during the Covid-19 pandemic, most Australian universities have indicated that they will not offer on campus lectures in 2021 (Kinash et al., 2021). In anatomy education, students proved able to handle online learning and are more inclined to give up theoretical face-to-face teaching rather than the practical part (Boulos, 2022; Ortadeveci et al., 2022b).

| Is classroom the best place for education?
It is expected that digital resources and learning models offering personalized learning flexibility and more effective preparative learning opportunities will be important in future anatomy education (Krishnamurthy et al., 2022;Xiao & Evans, 2022). While lectures and instructors are still useful for inspiring students in a new subject area, explaining key or challenging concepts, presenting engaging discourse, and framing and contextualizing the topic, whether the classroom is the best place for this is a matter for debate (Evans, 2022). Is the classroom the place where students can feel as comfortable, socially free, eager to learn, and open to cooperation as they do on social media? Social media was found to have most of these qualities and is one of the most powerful alternatives for filling the gap left by theoretical lectures. Social media facilitates active interaction and collaboration by enabling instant communication (Hennessy & Smith, 2020).
It allows everyone to express themselves freely and to create unique individual styles that make it easy and fun to use as a learning tool (Dumpit & Fernandez, 2017). These qualities of social media overlap F I G U R E 3 Mean results (± SD) of students' responses to 5-point Likert-type propositions assessing the effects of acpSM on learning motivation. acpSM, anatomical content pages on social media. F I G U R E 2 Mean results (± SD) of students' responses to 5-point Likert-type propositions assessing the suitability of acpSM and its effects on student autonomy. acpSM, anatomical content pages on social media.
with the expectations of student-centered lectures in modern education.

| Social media as a learning tool
In the current study, we characterized social media usage by medical and dental students in Türkiye, and their opinions and expectations about the use of social media in anatomy education. The results show that students are eager to learn anatomy via social media, but acpSM are insufficient in quality and number and should be improved, the reliability of information on acpSM is quite low, and these deficiencies should be remedied by institutions/academics. The results also revealed that increasing the suitability and sufficiency of acpSM content has a positive effect on the learning motivation of the students.
The average daily social media usage time around the world is 2 h 29 m. For people aged 16-24, similar to the participants of our study, this usage time is 3 h 8 m for women and 2 h 38 m for men. Internet F I G U R E 4 Exploratory factor analysis, revealing a three-factor set that explained 84% of the total data structure. These factors were named learning motivation, sufficiency, and suitability.

Consistency criteria
Well consistency Acceptable consistency Value of model Consistency response to the open-ended questions, it gives reminders (triggers) to take a break from social media and start studying. In addition, anatomical information can easily be forgotten because of its distinctive terminology. Knowledge of anatomy among postgraduate obstetrics and gynecology trainees is not sufficient (Koppes et al., 2022). Encountering anatomical information on social media can help not only undergraduate but also to postgraduate students to remember critical structures.

T A B L E 2
Major responses to open-ended questions about the advantages and disadvantages of acpSM.

| Using social media in higher education
Social media platforms designed by a university can help students to access academic support, deliver feedback in a less confrontational environment, and engage students in discussion and professional development opportunities, which more traditional approaches to education can lack (Arnbjörnsson, 2014). In effect, social media can support online communities of practice by facilitating communication and providing a platform for members to share and access learning resources (Guckian et al., 2019). If social media were used to bring faculty members and students together and enable them to share feedback with each other, its efficiency would increase drastically (Cheston et al., 2013).
In some countries, social media is actively used in anatomy education (Chytas, 2019). Currently, some pages on social media are available for producing and sharing anatomical content or bringing anatomists and students together so they can communicate comfortably (Jaffar, 2014;Pickering & Bickerdike, 2017). In examples of trainings in medical education with the inclusion of social media, communication between students and instructors was so advanced that it continued even into the evenings and weekends. According to the literature, social media use in anatomy education provides a supportive environment in which students can ask questions easily and share their concerns (Border et al., 2019). Some features of social media such as instant communication, public availability, and easy access to anatomical contents make it advantageous (Hennessy & Smith, 2020). When social media was incorporated into medical education, it had a positive effect on outcomes such as learner satisfaction, knowledge, attitudes, and professional skill development (Cheston et al., 2013). Similarly, in this study, students stated that learning the answers to anatomical questions instantly from acpSM administrators would contribute to their motivation. In addition, it has been widely accepted that social media serves as a time saver in the learning process.

Studies show that social media is an easy and enjoyable learning
tool that encourages open participation and collaboration (Dumpit & Fernandez, 2017). Hennessy et al. (2016) used Twitter in neuroanatomy education and observed that even though it did not increase the students' examination scores it facilitated communication, relieved anxiety, and raised morale (Hennessy et al., 2016). In the current study, students stated that acpSM increased their learning motivation, contributed to their learning process and academic success, and made their knowledge more permanent.
In the present study, students were eager to see anatomical content on social media. They expect that acpSM will be improved in quality/number if managed by academics. They also stated that the pandemic increased their social media usage time. However, there was no corresponding increase in students' desire to learn from social media. This could be because quality and number of acpSM are insufficient. If acpSM are improved to a level that meets expectations about quality and number, students will have an increased desire to learn from social media. Indeed, our study also showed that improving the sufficiency and suitability of acpSM could evoke a significant increase in students' learning motivation. As expected by students, acpSM should be managed by academics so that reliable information can be accessed. When new forms of education integrated with technology are used, there are skills that need to be developed by both students and instructors (Babacan & DogruYuvarlakbas, 2022). In their relationship with social media, the harmony achieved by academics lags far behind that of students. This could lead students to support each other in online platforms and to move away from learning styles that do not reflect their own needs (Border et al., 2019). Increasing the number of acpSM administered by anatomists could prevent this development.
Some students in the current study did not wish to see anatomical contents on social media. This indicates that students' attitudes towards technology are not all the same, as also observed in previous studies. While some students are more inclined to learn via technology-integrated methods, others find themselves more comfortable with classical methods in which learning takes place only in the physical classroom (Prensky, 2009). Some stated that they spent time on social media to relax and get away from the stress related to lessons, so naturally they do not want to see lesson-related content on social media.
4.5 | How can social media be used more effectively in anatomy education?
All these examples show that students' social communication and learning styles are becoming increasingly divergent. Social media undoubtedly has an important place in the lives of new generations. It would be wise for anatomy curriculum makers to consider this, although it is challenging to keep up with its evolution (Cheston et al., 2013). Some innovations in the teaching system can make the learning process more comfortable for students.
According to the model suggested by the current study, increasing the quality of acpSM content will promote students' learning motivation. In today's technological environment, students with greater learning motivation can easily access the information they need. Anatomy professionals are important for improving the quality and sufficiency of acpSM. Students also firmly agreed that acpSM administrators should be experts in anatomy. Anatomy departments in universities can set up official social media pages for this purpose.
These accounts will make it easier for students to access reliable information, high-quality contents, and images. By sharing anatomical structures, clinical examples, and variations in parallel with the curriculum, such official acpSMs can increase students' interest in the topic.
Furthermore, students can be more motivated by organizing intra-class, intra-faculty, and inter-faculty competitions through these social media accounts.
These accounts will make it simpler for many students who are shy or uncomfortable in public interactions or face-to-face conversations to communicate with their teachers. As a result, this generation's approach to education, which encompasses both traditionalist and innovative students, will reach out to appeal to both groups.
The ability to create content for social media will require some additional training and education for anatomists. To address this, teams of social media specialists and anatomy experts should be created. These groups should first identify the content and scope of anatomy education via social media. The features identified should be announced to national anatomical societies in congresses, seminars, workshops, and other organizations.

| Limitations of this study
The current work has some limitations. Students study in different faculties and follow different acpSMs. Some of the participating students' lecturers (regardless of the institution) could have acpSMs. Differences in the quality of these accounts could have affected the questionnaire answers. Similar studies with a control group of students could provide more reliable data.

| CONCLUSIONS
Today, the anatomy community is debating whether face-to-face anatomy education is dead. Studies show that although practical lessons still seem to be alive, lacking a strong enough alternative, it would not be wrong to say that the theoretical part is now at its last gasp.
If the attainments during the pandemic period can be interpreted constructively, today's anatomists can turn the pandemic to advantage by designing the anatomy education of the future appropriately.
It seems that for the near future, classical practical lessons based on cadaver and three-dimensional real-like plastic materials will remain in anatomy teaching, with some technological adjustments. For the theoretical part, the prospects are quite different. Considering the developing distance-education systems and the increase in anatomical content on social media, it is not difficult to foresee a decreasing demand for, and interest in, face-to-face theoretical anatomy education among students. If anatomists do not want to teach theoretical lessons to empty lecture halls, then national and international anatomy curricula, especially their theoretical parts, must acquire a form that students can access regardless of time and place. Social media seems to be cut out for this. It is possible that in the not-too-distant future, students who want to learn anatomy will acquire theoretical knowledge of the topic on social media from a well-known anatomist, and then attend practice classes to consolidate their understanding and improve their 3D perception using cadavers.
Unquestionably, social media is significant in our daily lives.
National anatomy societies should immediately organize workshops on how to use social media and other technologies in anatomy teaching, and to plan future anatomy education.

ACKNOWLEDGMENTS
The authors wish to thank Yasin Emre Oguz (Ph.D.) for statistical guidance and Numan Aydin and Gozem Celfis for providing language help to the presented study. Portions of this work were presented in a different form as oral presentations "The XX. Congress International Federation of Associations of Anatomists-IFAA (5-7 August 2022, Istanbul; Türkiye)." This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.