Instagram as a Learning Tool in Neurology: A Prospective Study


 Background: Since the beginning of the Covid-19 pandemic, there were remarkable changes in people’s lifestyle with a tendency to spend more time on social media rendering its platforms essential in all fields. This study was designed to look at the potential role of Instagram as a learning tool in neurology among Saint Joseph University (Beirut, Lebanon) medical students.Methods: This prospective study was spread over the period of 3 months, between the 10th of October and the 10th of December 2020. The target population was the medical students at Saint Joseph University (Beirut, Lebanon) in their 3rd to 7th academic year. The purpose was to evaluate the impact of the Instagram page called “La Synapse” on the students’ answers to ten neurology multiple choice questions (MCQs) before and after their exposure to the page’s content. The evaluation was done through a questionnaire conceived on Google Forms that also covered demographical characteristics, social media usage for educational purposes and their feedback post-exposure. In addition, we intended to evaluate the students’ opinion on using social media as a learning tool. The results were analyzed by comparing the pre-exposure and post-exposure data.Results: A total of 180 students were enrolled in the pre-exposure questionnaire (40% of the entire population) and 107 (59.44%) out of the initial group participated in the post-exposure questionnaire. Most students (81%) already used social media for educational purposes with YouTube being the most popular (51%). After exposure, 95% said to have profited from the experience but the junior students benefited more than the seniors. “Mnemonics” were the most practical learning strategy (44%) according to the participants. Regarding the MCQs, an improvement was found in seven out of the ten questions, with three having a statistically significant upswing (p < 0,05).Conclusions: The Instagram page “La Synapse” was an efficient tool for transmitting neurological information to medical students. These results should encourage the development of future prospective studies to better explore the role of social media in medical education.


Background
Covid-19 pandemic and con nement caused remarkable changes in people's lifestyle with a tendency to spend additional time in front of screens (1). The use of social media (SM) contributes to this screen time, besides gaming and web browsing, essentially for adolescents and adults under the age of 25 (2). Social media platforms gained popularity ever since they were released back in 1995 with "Classmates Online Inc." because of their fast evolution and adaptation to match their users' needs. These platforms became a necessity in almost every domain to keep up with a world in perpetual evolution.
In the eld of medicine, social media have many uses such as exchanging information in conferences (3) or to earn CME credits (4). They were also proven to be an important recruiting technique when the target population was far from reach or when the study conducted was of the observational type (5). Additionally, they are used by hospitals to promote new equipment and technologies acquired resulting in a more trustful medical staff-patient relationship (6) and nally they are used as tools for spreading awareness (i.e., cancer screening, chronic diseases, Covid-related information).
In the academic eld, many conducted studies looked at the impact of social media on medical education and their use as a learning tool, but most of them fell in the descriptive and feedback-based categories (7) hence the need to further investigate these two subjects.
According to medical students, the most popular SM used as learning tools are YouTube followed by Facebook then Twitter (8). On the other hand, a study published in 2017 by the American College of Radiology explored the pros and cons of common social media platforms when used as an educational medium. A very positive feedback was given to Instagram for two main reasons: rst, the caption's upper limit of 2200 characters (vs. 140 for Twitter) promoted a more explicit explanation and second, because of the ability to post a sequence of pictures, each with an independent caption, but all arranged as an album (9). In addition, Instagram has the advantage of having a detailed built-in analytics system.
Lately, we witnessed a cultural shift favoring it over Facebook (10). These reasons contributed to choosing Instagram as the social media for the current study in order to evaluate its effect as a learning tool in neurology among our institution's medical students. In addition, we intended to evaluate the students' opinion on using social media as a learning tool.

Methods
Part 1 -Planning of the study and sample population: This prospective study was spread over the period of 3 months, between the 10th of October 2020 and the 10th of December 2020. The purpose was to look at the impact of exposing the medical students to the Instagram page called "La Synapse" through the administration of two questionnaires (cf supplementary le) separated by a two and a half months long period (before and after exposure).
The initial step was to recruit the biggest number of medical students at Saint Joseph University in Beirut (Lebanon) in their 3rd to 7th academic year by broadcasting a WhatsApp text message to their class administrative groups. The message comprised two links: the rst, leading to the pre-exposure questionnaire and the second leading to the Instagram page "La Synapse" for them to follow. A reminder text message was sent afterwards for ve consecutive days.
The chosen population included all medical students at Saint Joseph University (USJ) starting from 3rd year of medical school at USJ (equivalent to the nal year of premed) to the 7th year (which is the 4th year of medical school, MedIV) who own an Instagram account. The reason behind that choice was the fact that in the French curriculum, neuroanatomy and neurophysiology are introduced in second year whereas neuropathology is initiated in the third.
The pre-exposure questionnaire was conceived on Google Forms and had three main sections: the rst studying the demography of the population, the second focusing on the students' SM usage for educational purposes and the third consisting of ten multiple choice questions (MCQs) that helped draw a baseline level of their knowledge in neurology.
It is important to mention that ten students (two from each academic year) were randomly chosen prior to administrating of the pre-exposure questionnaire to participate to a pilot study in order to get their feedback regarding the level of di culty and formulation of the MCQs.
The second step consisted of exposing the participants (for a duration of two and a half months) to a series of Instagram posts (including stories) shared by "La Synapse". These posts incorporated the answers to the MCQs in addition to supplementary information in the eld of neurology: anatomy, pathology, pathophysiology, therapeutics, and clinical vignettes.
The third step consisted of a post-exposure questionnaire made on Google Forms and shared via a WhatsApp text message to the administrative groups coupled to a daily reminder for the duration of ve days. This questionnaire targeted students who already answered the initial questionnaire and had followed the Instagram page. It had three main sections: the population's demography, the participants' feedback regarding the content of the Instagram page and the same neurology MCQs as presented in the rst questionnaire.
Of note that the initial recruiting technique was supposed to be done for all participants at once based on a questionnaire to be lled in class to limit the information bias and the students' access to search engines. Unfortunately, due to the Covid-19 pandemic, the governmental policies, and the university's restrictions, this was not applicable and both questionnaires were broadcasted via WhatsApp.
This study was approved by the ethics committee of Saint Joseph University -Beirut (number Tfem 2020/12). All methods were performed in accordance with our institution guidelines and all participants gave their consent prior to answering the rst questionnaire. Results were analyzed anonymously. The Instagram page "La Synapse": This Instagram page was created for the sole purpose of this study. Its name was inspired from the actual role of a synapse in any living organism which is transmission of information.
A hashtag (#KeepTheInformationFlowing) was created too, and allowed, with the help of Instagram analytics, to keep track of the interaction between the students and the page.
Using the help of Instagram Analytics, every post was provided with the following data: a "Reach" (which is the number of accounts who have seen a post), "Impressions" (which is the number of times a post has been seen without taking into account the pro le of the user. I.e., a single account looking at the same post thrice will generate 1 Reach and 3 Impressions), the number of times a post has been saved and nally the number of times the post was sent via direct message (DM) by any participant to another.
Two posts were published every week at 1:00 pm to maximize interaction (11). Moreover, "Stories" were published once a week and allowed students to answer questions and suggest new themes for the following weeks.

Part 2 -Statistical analysis:
The results were analyzed by comparing the pre-exposure and post-exposure data. Chi square statistics were used to test the hypotheses with a con dence interval of 95%. A comparison between the pre-exposure and postexposure MCQs was made to determine the change in proportion of right answers.
In case of a statistically signi cative improvement in results (p < 0.05), factors that would theoretically affect the participants' choices in the pre-exposure questionnaire (such as the gender, the academic year, and the prior use of social media as a learning tool) were studied one at a time to evaluate their in uence on the chosen answers. This was done to isolate the effect of the Instagram posts on the chosen answers.
Another table was then made based on the pre-exposure and post-exposure MCQs and was distributed according to the participants' academic year; this table helped comparing the performances between the different classes and determine which one had the highest pro t from the intervention.
Finally, using Instagram Analytics, a table was generated to represent the interaction between the participants and the posts related to the MCQs' topics: this table contained the featured learning strategy, the number of Reaches, Impressions, saves and DMs. It facilitated studying the correlation between a higher number of views and better results as well as the effectiveness of each learning strategy.

Results
1 -Pre-exposure questionnaire: 1A -Demography: In total, 180 students out of 456 (39.47%) answered the rst questionnaire and were enrolled in the study; 89 (49%) of them were males and 91 (51%) females. Their distribution according to academic year is shown in gure 1.

1B -Social Media usage:
Out of the 180 participants, 146 (81.1%) already used social media for educational purposes. These 146 individuals were then asked questions regarding the frequency of usage (Fig. 2), the platforms they used (Fig. 3) and nally about their favorite social media (Fig. 4). Results are exposed in the corresponding gures.
All participants were asked to express their opinion regarding social media: 127 (70.6%) were in favor of using the Instagram platform as a learning tool whereas the rest were not and thought it was a form of distraction.
Concerning their knowledge on ethical restrictions related to using social media as a learning tool in medicine, 59.4% claimed having no information on the topic.
Students had also to pick a level of agreement to multiple statements (Table 1) regarding the importance of social media for communication between colleagues and the necessity of having more similar platforms in the upcoming years. The participants' answers to each of the 10 MCQs were divided into correct and incorrect answers, their distribution is shown in Table 2. 1D -Factors in uencing the choice of answers for the pre-exposure MCQs: 1D.1 -The prior use of social media as a learning tool: Table 3 shows the effect of a prior use of social media on the participants' answers in the pre-exposure questionnaire. There was no statistically signi cant difference in responses related to gender.
1D.3 -The academic year: Details of answers related to each academic year are displayed in Table 4. We can conclude that 6 out of 10 MCQs  Participants were rst asked to pick their favorite learning strategy amongst the ones used by "La Synapse": mnemonics came in rst place (44%) followed by clinical vignettes (32%), word-image associations (17%) then stories (7%).
Three "yes or no questions" were then asked to see whether the page helped them learn new information, recall previously acquired knowledge and nally to assess the need of similar platforms for the future. All three questions came back with a 95-97.2% positive feedback. 2C -Post-exposure MCQs: The participants' answers to each of the 10 MCQs were divided into correct and incorrect answers and are shown in Table 5. On the other hand, a distribution of the answers was displayed according to the academic year in order to compare the performances across class levels. Results are shown in Table 6.

-Instagram Analytics:
The gathered data by Instagram Analytics is shown in Table 7

Discussion
The study was designed prior to the Covid-19 pandemic with a goal to explore the impact of an Instagram page on neurology education in premed and medical students. The results will be discussed in terms of their importance but also relevance, especially after the shift of the major part of the medical education to online teaching.
Lately, it became very important to nd attractive and interesting ways of transmitting medical knowledge while encouraging students, stimulating their metacognition, and keeping them constantly motivated. First, let us start by reviewing the response rates for the pre and post page exposure evaluations. These were respectively 40 % then 60 % (of the initial group) and were overall satisfying and representative of the targeted population.
Despite the change of lifestyle due to the pandemic and the 22 % positivity rate for Covid among our students during the same period, we were able to motivate them to participate in the questionnaires and to follow "La Synapse". Since the factor "academic year" affected 6 out of the 10 MCQs in the pre-exposure questionnaire and 5 in the post-exposure questionnaire, it would be interesting to compare the results of Table 4 and 6 in order to evaluate the improvement in performance according to each class level: in Table 4 (pre-exposure), the 7th year students had the highest scores on almost all the questions except for question 2 (neuro bromatosis type 2) and question 8 (diagnosis of Guillain-Barré) where the 3rd year students did better. These results re ect the "traditional" learning curve followed by medical students through their journey in medical school: in the earlier years, the main interest is focused on the details of semiology and pathophysiology (hence their results on questions 2 and 8) whereas at a later stage, the focus shifts towards the main clinical features, treatments, and guidelines (hence the perfect score on question 1 for the 7th year students).
In Table 6 (post-exposure), we also nd the highest scores being those of the 7th years' but what was interesting was the progress of knowledge among the younger classes (3rd and 4th years) related to topics that are out of their comfort zone; for instance, a 21% improvement occurred in question 1 (treatment of status epilepticus) in the youngest class (Table 8). In fact, this satis es the main goal of our study: facilitating teaching and improving knowledge of neurological emergencies management in a pleasant setting.
Overall, the Instagram posts generated improvements in all classes but at different degrees: the junior students gained more than the seniors, and that could be the consequence of a heavier workload once medical students start their hospital rotations resulting in less social media time, or due to the shift of the information selection process as students advance in their medical studies.
It is also important to note that question 8 (diagnosis of Guillain-Barré Syndrome or GBS) got the lowest results in both pre (23.4%) and post-exposure (22.4%) questionnaires. The persistence of low scores could be explained by the level of complexity of the question, the di culty of the diagnosis or the poor exposure on the Instagram page (question 8 got the lowest "Reach" and "Impressions" numbers - Table 8).
Either way, the necessity of mentioning this condition even more during the medical curriculum is essential to spread awareness especially for the older classes who are going through their rst clinical rotations in these critical Covid-19 times (12).
Part 2: 2A -The use of social media as a learning tool among medical students: Social media has been growing in popularity especially among the younger generation enrolling in medical school: the number of prior users and their frequency of usage is superposable to those of Saudi Arabia (8): around 80% of students already used social media for their education prior to the study and more than half of them claimed a daily usage.
Concerning the platforms' popularity, YouTube was the favorite with 33% which is similar to the study conducted by Al Suraihy et al. (8) and the one in King Saud University (13) followed by Instagram (25%) and Google+ (17%).
The main difference between the results generated by this study and the one from Al Suraihy et al. (8) is the popularity of Facebook: 17% v/s 2% in the current study. This could be the result of a shift in preferences of the younger generation lately with a tendency to go towards trendier applications (10) such as YouTube and Instagram to satisfy their needs or due to cultural or social preferences. 2B -Ethical implications related to social media use as a learning tool: Regarding the ethical restrictions related to using social media as a learning tool, more than half of the study population (59%) was not aware of them. This could be secondary to a lack of awareness on this subject: Instagram, like many other social platforms is not subject to thorough peer-review (14) therefore using it as part of the medical eld is tied to ethical obligations in order not to break the Doctors' Oath: the patients' anonymity should always be preserved while discussing clinical cases (15). On the other hand, the interactions with patients should always be professional in order not to affect the doctor-patient balance (16) and nally the accidental defamation of a colleague or a con ict of interest could have social and legal repercussions.
2C -Students' feedback on the Instagram page "La Synapse": Concerning the section dedicated to the learning strategies, mnemonics were the most popular (44%) and most effective among our medical students. This technique helps not only with learning, but also with recalling and consolidating information (17).
On the other hand, the least popular used learning strategy were the MCQs in the Instagram stories (7%). To further support this statement, Instagram Stories generated the lowest number of Reaches and Impressions and lead to relatively poor improvements in results. This might have been caused by the limited exposure or viewing time (24 hours period) for participants.
Finally, by comparing the participants' feedback in the pre and post-exposure questionnaires, we nd a 12.3% increase in the need of similar platforms for the future. This was obtained by combining the answers "strongly agree" and "agree" from Table 1 -hypothesis 3 and the post-exposure feedback questionnaire results (95%). More platforms would further facilitate the communication between students, help disseminate evidence on trending and rapidly changing subjects (18), share scholarly information especially in visually rich specialties (19) and measure the public interest towards one's academic accomplishments (20).

-Limitations:
Concerning the logistic limitations discussed earlier, the main setback was the students' easy access to search engines while answering the MCQs; to limit this information bias, we sent a text message with the questionnaires to motivate the participants. We respected anonymity knowing that some statistical power will be lost. Identifying and tracking the participants would have allowed us to trace the individual progress instead of comparing the results generated by two independent series but we opted for the latter one to have a more objective analysis.

Conclusions
Social media became an essential part of today's world, not only because of the perpetual technological advances, but also because of the imposed "virtual" life that came along the Covid-19 pandemic. Nowadays, all elds are making the best out of this tool to create a communication net to spread information within the community and this is being applied to the medical eld as well.
As we previously mentioned, our page appellation was inspired from the role of a synapse in any living organism, and it is crucial to retain that this ow of information would never go through without a pre-synaptic neuron, ready to transmit, and a receptive post-synaptic neuron, ready to be stimulated. This study has shown that the Instagram page "La Synapse" was an e cient and promising tool to transmit neurological information to medical students. It     Favorite SM used for educational purposes.

Supplementary Files
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