Impact of Previous Anatomy Coursework on Student Online Discussion Forum Engagement

Abstract

Background

Peer teaching through online discussion forums (ODFs) has the potential to engage and meet the needs of novice and experienced anatomy learners in the medical and health professions. Exploring ODF engagement patterns of learners with and without anatomy coursework can generate insights to effectively support students with different learning needs.

Purpose

To explore cognitive levels of engagement and social participatory learning roles of students with and without anatomy coursework when using student-led ODFs.

Method

This is a mixed-methods study of first-year occupational therapy students who engaged in peer learning on anatomy ODFs. A descriptive qualitative approach was used to conduct directed content analysis of the text-based posts of seven anatomy ODFs. Posts were categorized into social participatory learning roles and Bloom’s cognitive level of learning. Engagement patterns were defined as frequency of posts and cognitive level represented.

Findings

Of 96 students included in the study, 67 (70%) had anatomy coursework. The proportion of students who contributed to the ODFs (X² (1, n = 96) = 0.03, p = 0.54) and their engagement did not differ between groups (Mann–Whitney U = 753.50, p = 0.08). The ODF posts of students with previous anatomy coursework were more often classified as information providers (n = 120 posts, 47%), while the posts by students without anatomy coursework were most frequently initiators (n = 76 posts, 44%).

Conclusion

Students with and without anatomy backgrounds contributed to ODFs using a similar level of engagement but different social participatory roles. This work highlights the importance of supporting different peer-learning roles in anatomy ODFs.

Introduction

Foundational knowledge in human anatomy is important for occupational therapy practice [1]. An understanding of anatomy equips occupational therapists (OTs) to accurately assess clients’ needs and implement effective interventions, aiding them in resuming their daily roles, habits, and routines [2]. Lack of foundational anatomy knowledge may lead to an increase in practice errors and lower-quality patient care [3, 4]. Additionally, anatomy knowledge is essential for effective communication and collaboration with other health professionals within the interdisciplinary team [5]. Hence, student OTs require an understanding of anatomy to provide high-quality, effective care for their clients.

Students enter occupational therapy programs with a wide range of academic backgrounds. Some have previous education in health or kinesiology, while others have degrees in the arts or humanities, with no formal anatomy education [2]. Although studies show that academic outcomes of student OTs with and without prior anatomy coursework do not differ [6, 7], the process of achieving equivocal outcomes may differ. Students with previous anatomy coursework appear to benefit from an established degree of baseline knowledge. They have a head start in identifying the study strategies that work well for their anatomy learning needs [8, 9]. They also feel less overwhelmed and have better time management than their peers who do not have previous anatomy coursework [8, 10]. These findings help explain why students without previous anatomy coursework need time to “catch up” with their peers [6, 9]. As a result, instructors are faced with a disparate class of anatomy learners at the start of the term.

Among pedagogical approaches used in gross anatomy education [11], peer teaching has the potential to engage and meet the needs of both novice and experienced learners. Peer teaching can involve learners at the same academic level or tutor and tutees from different academic levels [12]. In anatomy occupational therapy education, peer teaching has been shown to benefit both tutors and tutees [13, 14]. The time spent preparing materials and the experience of teaching a peer can enhance tutor academic performance [13]. Tutee academic outcomes are also positive. Academic outcomes of physical and occupational therapy students who were taught by peers were similar to those who were taught by instructors [14]. Lastly, reciprocal peer teaching in gross anatomy has been shown to increase active learning and student engagement in cadaveric-based laboratory instruction [15]. Reciprocal peer teaching is an approach during which the tutor and tutee may switch roles during the learning experience.

Implementing peer teaching in the classroom can take on different forms. One method of implementing reciprocal peer teaching is the use of student-led online discussion forums (ODFs). Student-led ODFs allow students to post and respond to each other’s inquiries about anatomy course content. Green et al. (2014) found such forums to be effective when included as part of the course grade [16]. Student engagement and frequency of posts are shown to positively correlate with anatomy final grades [16, 17]. In Green et al.’s studies, the frequency of ODF posts was used to measure student engagement [16]; however, this does not consider the different roles and cognitive levels of learning involved in these posts [18, 19].

Students engage in a variety of different social roles while sharing and receiving support from each other on ODFs. Several different classifications of student ODF social participatory roles have been generated using social network analyses [19]. Among these classifications is Ouyang and Chang’s (2019) work that focuses on the relationship between social roles and cognitive engagement [20]. They found that active learners contributed to higher cognitive engagement while those on the periphery demonstrated lower cognitive engagement. Learners in roles such as leader, starter, and influencer demonstrated higher levels of knowledge inquiry and construction; however, leaders were the only group of learners that had consistently high participation. Starters and influencers had low to medium participation.

Therefore, a comprehensive examination of student engagement on ODFs includes frequency of posts, cognitive level of engagement, and social participatory roles. Examining these aspects of engagement on reciprocal peer-learning ODFs may improve understanding of how learners seek, provide, and receive help. Further, comparison of engagement of students with and without anatomy coursework may generate insights on how to optimize peer learning on ODFs to support students with different learning needs. Therefore, this study aims to comprehensively evaluate engagement of student OTs with and without previous anatomy coursework while learning anatomy on student-led ODFs.

Method

This is a mixed-methods study of student OTs who engaged in reciprocal peer learning on student-led ODFs in a musculoskeletal foundations course at the University of Toronto Master of Science in Occupational Therapy (MScOT) program. A descriptive qualitative approach was used to conduct directed content analysis of ODF text-based posts to identify the level of cognitive learning and student roles. Following, frequency of these categorical data was analyzed quantitatively to compare engagement and social participatory roles between groups.

Participants in this study were student OTs in the entry cohort of the University of Toronto 2021–2023 MScOT program. All learners in this cohort enrolled in the Musculoskeletal Foundations for Occupational Therapy Practice course were eligible for inclusion in this study. Students who completed an undergraduate or graduate degree in anatomy or were concurrently enrolled in any post-secondary anatomy or kinesiology course(s) were excluded (n = 0). Students who withdrew from the MScOT program were also excluded (n = 1). Student OTs were recruited at the end of the term by a research team member that was not part of the teaching team to obtain consent to release their course assessments and grades for research. Students self-reported whether they had taken one or more post-secondary courses in human musculoskeletal anatomy. Their responses were cross-referenced with their reported entry degree at the time of their application to the program. Approval for this study was obtained from the [de-identified institution] Research Ethics Board (Approval #41315), and informed consent was received from the students who participated.

While taking the Musculoskeletal Foundations for Occupational Therapy Practice course, student OTs engaged in seven student-led anatomy ODFs that accompanied seven online anatomy self-learning modules on the following topics: musculoskeletal terminology; upper limb (UL) bones and joints; UL proximal muscles; UL distal muscles; UL nerves and blood supply; trunk and back muscles; and lower limb muscles and nerves. Engagement on the ODFs, class participation, and lab attendance contributed 5% of the final course grade.

Directed content analysis was used to systematically examine text-based data to categorize ODF posts into pre-determined (i.e., deductive) definitions of cognitive level of engagement (see Table 1) and social participatory roles (see Table 2) [21]. Engagement was defined as frequency of posts and Bloom’s cognitive level of learning from lower- to higher-order thinking: remember, understand, apply, analyze, evaluate, and create [18]. Each level of Bloom’s Taxonomy was assigned a value between 1 and 6 in ascending order; 1 was assigned to remember and 6 was assigned to create. Posts that were administrative (e.g., thank you posts) were assigned 0 points. Next, informed by Ouyang and Chang’s classification [20], social participatory roles were refined and defined through consensus by the research team after iterative independent coding of the student roles observed in these data. The social participatory role categories were classified as follows: initiator, validator, information provider, and contributor. A codebook with operational definitions of each level of Bloom’s taxonomy (see Table 1) and types of social participatory role (see Table 2) was developed by the researchers after independently coding the posts of two anatomy modules. The frequency of posts in each category of Bloom’s cognitive level of learning and social participatory roles was recorded. The content of each student post was reviewed and assigned the highest Bloom’s level represented in the text and one social participatory role ranking. Four researchers analyzed the posts, with consensus and disagreements handled through group comparison and discussion.

Table 1.

Bloom’s cognitive engagement of learning—codebook and definitions

Bloom’s cognitive engagement level	Definition	Example post
Level 0	Does not achieve Level 1 (“remember”)	“Thank you so much for your explanation!”
Level 1: Remember	Refers to the retention of specific, discrete pieces of information like facts and definitions (terminology) or methodology. Student demonstrates retrieval, recognition (identify), repeat, or recalling (memorize) of information	“I was also confused about this, especially since the question mentioned it was the ‘lateral third’ of the clavicle, which I thought aligned more with the cords of the brachial plexus. Hope someone can provide some clarity!”
Level 2: Understand	Demonstrated by paraphrasing a concept in their own words, classifying/organizing items into groups, comparing and contrasting items with other similar entities, or explaining a principle to others. Student classifies, explains and expresses (describing), interprets, exemplifies, summarizes, distinguishes or compares; explains categories, theories, principles, and models or procedures (steps, process)	“I was also wondering something similar. So, for my own clarification, can a person lose feeling in the C8 dermatome and yet still have feeling from the radial nerve? I gathered from class that the radial nerve is dependent on the C8 dermatome - is that correct?”
Level 3: Apply	Students begin to incorporate knowledge into their existing cognitive schemas. Students try to incorporate new knowledge into existing knowledge or demonstrates applying skills/knowledge from class outside of the class context, considering objective cause and effect. Students demonstrate inferring, predicting, using, and implementing knowledge; relates information to conceptual knowledge of categories, theories, principles, and models or procedures (technique, process)	“Just in reviewing the section of the module discussing peripheral nerve injuries of the brachial plexus, I wanted to know if anyone has found any information regarding what types of treatment an OT would provide for these cases? Would it largely consist of working on ways to correct these postures or strengthen these atrophied muscles somehow? Or more focused on alternative ways the client could perform their daily tasks?”
Level 4: Analyze	Student uses critical thinking skills to apply knowledge to a novel (actual or perceived) situation. Breaking down information into its component parts; determining how different components relate to each other and to the overall structure/purpose. Considering implications of the knowledge. Student demonstrates judgement, critiquing, predicting, interpreting, researching, or integrating information from other sources; analysis of class information; organizing information	“I was at the gym today and of course I was thinking about my joint movements and muscle actions the entire time during my workouts. I was performing a wide-grip pull up (palms face away from me and holding on to a bar overhead, with hands wide apart so that you look like a Y). When I am at the top of the pull up, does gravity want abduction of the glenohumeral joint motion? Additionally, I believe the direction in which the scapula would rotate would be superior rotation. I hope someone can confirm this!”
Level 5: Evaluate	Making judgements (critical thinking) based on criteria (e.g., using information learned in class to make a judgement about something unrelated to class). Student demonstrates confirming and critiquing information; checking or validating information; cross-discipline connections; self-assessment, knowledge of various learning skills and techniques	“I took some time to research the ‘stomach vacuum’ technique, and beyond YouTube, TikTok videos, and bodybuilding forums, there is little to no clinical/credible research for its validity. Certainly, it appears that body builders and those who already have a low body fat percentage will likely be able to see a decrease in waist circumference and an increase in thoracic circumference if they work out their TA. However, this exercise is one that should not be recommended to populations outside of the body building community. Certainly, those who wish to have a smaller waist could be referred to a registered dietitian, lifestyle coach, and personal trainer to begin lifestyle changes to aid in their effort toward a healthier mind and body.”
Level 6: Create	Putting elements together to form a novel, coherent whole or make an original product. Synthesizing information from different sources to create a clinical question or answer

Table 2.

Social participatory roles—codebook and definitions

Role	Definition	Example post
Initiators	Asking questions and seeking explanations to stimulate discussion	“Can anyone elaborate on the role of the deltoid muscle in shoulder movement? I find it intriguing and would love to hear different perspectives.”
Validators	Provide positive feedback, encouragement, and express gratitude in response to posts	“Great explanation! Your insights about the nervous system’s impact on hand function were really helpful. Thanks for sharing!”
Information provider	Offer factual information and answers, supporting discussions with visual, auditory, kinesthetics, resource-based content	“Here’s a link to an informative video illustrating the biomechanics of the knee joint, which might help in understanding its relevance to occupational therapy.”
Contributor	Actively share new thoughts, ideas, everyday examples, personal stories, and engage in reflective discussions	“I recently encountered a case where understanding the specific anatomy of the hand was crucial in developing a customized splint. Has anyone else had a similar experience?”

After all posts within the seven modules were coded, a summed engagement score was calculated by weighing each post made by a student with the points awarded for its cognitive level. Therefore, students who posted more frequently and at a higher cognitive level achieved the highest summed engagement score. After determining the normality of the data using the Shapiro–Wilk test, a comparison of engagement scores between students with and without anatomy coursework was conducted using Mann–Whitney U tests. The comparison between the proportion of students with and without previous anatomy coursework within each social participatory role was conducted using a two-sided chi-square analysis. Data were coded/ranked using Microsoft Excel and analyzed using the Statistical Package for the Social Sciences v.29 (SPSS) software [22].

Result

Of 130 students in the 2021–2023 MScOT cohort at the University of Toronto, 97 consented to participate in the study. One student withdrew from the program at the time of analysis, leaving 67 (70%) students with prior anatomy coursework and 29 (30%) students without. Demographic information such as gender and age were not collected to maintain anonymity of the students, as there is traditionally a small proportion of male learners in the MScOT program.

Fifty-two (78%) of the 67 students with anatomy coursework and 23 (79%) of the 29 students without anatomy coursework contributed at least one post on any of the seven ODFs. The proportion of students who contributed to the ODFs did not differ between groups (X² (1, n = 96) = 0.03, p = 0.54). The summed engagement scores, as determined by frequency and cognitive level of learning represented in each post, of the entire student cohort are shown in Fig. 1 along with the number of students who achieved each respective score. The median summed engagement score was 6.0 (IQR = 12.0, Min-Max: 0–45). Of the students who contributed at least one ODF post (n = 75), most achieved a summed engagement score between 1 and 25 (Fig. 1). Five students had engagement scores > 25, three of whom did not have previous anatomy coursework. Comparatively, the summed engagement scores did not differ between groups (Mann–Whitney U = 753.50, p = 0.08).

Fig. 1.

Summed engagement score determined by frequency and cognitive level of learning represented in each post

Table 3 contains a summary of the comparison between the number of students and posts within each of the social participatory role categories. Each student may post more than once in each category. Of the 427 ODF posts made by the full cohort of students, the social participatory roles of initiator (31%), validator (22%), and information provider (34%) were relatively similarly represented. The contributor role (14%) was less common. The proportion of students who were initiators (X² (1, n = 96) = 11.44, p < 0.001) and validators (X² (1, n = 96) = 6.30, p = 0.02) was statistically different between groups. There was no difference in the proportion of students who were information providers (X² (1, n = 96) = 4.18, p = 0.06) and contributors (X² (1, n = 96) = 0.076, p = 0.83).

Table 3.

Comparison of ODF social participatory roles

Role	Students with Anatomy Coursework n = 253 posts			Students with No Anatomy Coursework n = 174 posts
	n	%	Min–max	n	%	Min–max
Initiator	55	22	0–6	76	44	0–10
Validator	40	16	0–4	52	30	0–9
Information provider	120	47	0–7	26	15	0–4
Contributor	38	15	0–3	20	11	0–2

The comparison of the percentage of social participatory roles represented in ODF posts between groups is visually displayed in Fig. 2. Proportionately, students with previous anatomy coursework were more often information providers (n = 47, 70%), while students without anatomy coursework were more frequently initiators (n = 23, 79%). Lastly, the number of posts made by students with previous anatomy coursework had the greatest representation in the information provider role (Table 3, n = 120, 47%), offering factual information and resources in response to initiations. The greatest proportion of posts (n = 76, 44%), made by students without anatomy coursework, was representative of an initiator role (Table 3).

Fig. 2.

Percentage comparison of social participatory roles between groups

Discussion

Student engagement in ODFs extends beyond frequency of posts; it also includes cognitive level of engagement and social participatory roles. This study found that the majority (78%) of learners participated in the student-led anatomy ODFs when contributions were included as part of their grade. Learners with and without anatomy coursework did not differ in their level of engagement, as measured by frequency of posts and cognitive level of engagement. However, students with a previous anatomy background more frequently engaged in the ODFs as information providers, while students without an anatomy background were more often initiators. These findings suggest that students work and learn together through peer teaching, but through different roles. Fostering peer learning on ODFs could be enhanced by including strategic tutor-tutee learning opportunities for peers at different academic levels.

Students demonstrated high levels of engagement on the anatomy ODFs, irrespective of prior anatomy coursework, based on the frequency of posting and the cognitive level of learning. This may have been largely true since the ODFs were part of the students’ contribution grades in the course, which has been suggested elsewhere [16]. When grades are given, students are more motivated to participate in educational activities. For example, in a mixed-methods study by Willoughby et al. (2024), it was found that second- and third-year undergraduate students learning anatomy were primarily motivated to learn by grades, intrinsic factors (e.g., interest), and career factors (e.g., prospects of being accepted into medical school). Of the five components of motivation examined in this study (i.e., intrinsic factors, career, self-determination, self-efficacy, and grades) using a validated scale and follow-up focus groups, grades were identified by students as the greatest motivator for learning [23]. Therefore, there is a strong indication to assign grades to student-led ODFs in the anatomical and medical sciences to enhance student participation and engagement.

Students with and without prior anatomy coursework played different roles when using student-led ODFs in our foundational musculoskeletal anatomy course. That is, students with an anatomy background were often categorized as information providers, providing resources (e.g., YouTube videos, peer-reviewed articles) and answers to questions posed by other students. In contrast, students with no prior anatomy coursework were often categorized as initiators, posting inquiry-based questions about foundational anatomy concepts. Put simply, students with prior anatomy coursework took on the role of tutor, while peers without prior anatomy knowledge were tutees. This peer teaching/tutoring relationship has positive impacts given the previous literature on active learning and peer learning. There is evidence that students in a tutoring role solidify concepts and learning for themselves through peer teaching and active learning [24]. Learning through teaching is an effective approach to learning gross anatomy, with no significant differences seen between instructor-led and peer-led coaching [14]. To foster peer learning among tutors and tutees in the same classroom, future research and curricular development should structure study groups more heterogeneously, featuring students with differing levels of anatomy knowledge and comfort with the content.

Students primarily used anatomy ODFs for inquiry-based learning, a form of active learning where students pose questions, scenarios, and problems to construct knowledge [25]. Evidence supports the effectiveness of inquiry-based learning [26], with a second-order meta-analysis on the effects of inquiry-based learning on learning outcomes finding a medium-level positive effect on learning outcomes (e.g., academic achievement and thinking skill) [27]. Further, Andrini’s (2016) theoretical review highlighted the effectiveness of inquiry-based learning and its ability to enhance student learning outcomes by promoting active participation and critical thinking. Overall, there is a need for and support of consistent integration of inquiry-based learning into anatomy curricula [28]. One solution to support inquiry-based learning in the classroom in the future is through generative artificial intelligence (AI) chatbots (e.g., ChatGPT). This would also align with students’ preferences to ask questions (i.e., initiators) and to share internet-based resources (i.e., information providers) for anatomy learning.

Limitations

While this study features many strengths, there are some acknowledged limitations. For instance, despite using operational definitions to categorize and quantify ODF posts’ level of learning according to Bloom’s taxonomy, there is still some subjectivity associated with this approach. To mitigate the effects of subjectivity, we recognized this and worked with the data via a team of independent researchers from different perspectives (i.e., instructors, students). Our process for categorizing ODF posts according to Bloom’s taxonomy was rigorous in the sense that each reviewer coded all posts and met as a group to discuss all areas of discrepancy. Through this, subjectivity was minimized in every way possible. Lastly, the lack of difference in summed engagement scores between groups should be interpreted with caution due to the relatively small sample of students who did not have anatomy coursework.

Conclusion

In this study, it was found that students with and without an anatomy background in the University of Toronto’s MScOT program both contributed to the course’s student-led ODFs using a similar cognitive level of learning and engagement. However, it was found that these two groups engaged in the ODFs through different roles (e.g., information providers vs. initiators). This work highlights the importance of peer learning in student-led anatomy ODFs. Students with and without anatomy backgrounds in this study contributed to the course’s student-led ODFs using a similar level of engagement. However, students in these two groups engaged in different social participatory roles. This work highlights the importance of supporting different peer-learning roles in anatomy ODFs.

Author Contribution

Erica Dove: project administration, conceptualization, methodology, formal analysis,

supervision, writing—reviewing and editing.

Harjot Shoker: conceptualization, methodology, formal analysis, writing—original draft.

Maria Zainab: conceptualization, methodology, formal analysis, writing—original draft.

Shannon Scherer: data collection, data analysis, reviewing and editing.

Emma Slobozianu: data collection, data analysis, reviewing and editing.

Emily S. Ho: project administration, conceptualization, methodology, formal analysis,

resources, supervision, writing—review and editing.

Data Availability

The data that supported the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Conflict of Interest

The authors declare no competing interests.