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Usefullness of an Internet-based thematic learning network: Comparison of

effectiveness with traditional teaching
María Jesús Coma del Corral a; José Cordero Guevara a; Pedro Abáigar Luquin a; Horacio J. Peña b; Juan
José Mateos Otero c
a
Research Unit, Hospital General Yagüe, Burgos, Spain b University of Palermo, Buenos Aires, R., Argentina
c
Universities and Research General Director, Junta de Castilla y León, Valladolid, Spain

Online Publication Date: 01 March 2006

To cite this Article Corral, María Jesús Coma del, Guevara, José Cordero, Luquin, Pedro Abáigar, Peña, Horacio J. and Otero, Juan
José Mateos(2006)'Usefullness of an Internet-based thematic learning network: Comparison of effectiveness with traditional
teaching',Informatics for Health and Social Care,31:1,59 — 66
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 Medical Informatics and the Internet in Medicine
March 2006; 31(1): 59 – 66

Usefullness of an Internet-based thematic learning network:

Comparison of effectiveness with traditional teaching

MARÍA JESÚS COMA DEL CORRAL1, JOSÉ CORDERO GUEVARA1,

PEDRO ABÁIGAR LUQUIN1, HORACIO J. PEÑA2 &
JUAN JOSÉ MATEOS OTERO3
1
Research Unit, Hospital General Yagüe, Burgos, Spain 2University of Palermo, Buenos Aires, R.,
Argentina 3Universities and Research General Director, Junta de Castilla y León, Valladolid, Spain
Downloaded By: [Stanford University] At: 12:54 22 October 2008

(Received July 2005; accepted January 2006)

Abstract
UniNet is an Internet-based thematic network for a virtual community of users (VCU). It supports one
multidisciplinary community of doctoral students, who receive most of the courses on the network. The
evident advantages of distance learning by Internet, in terms of costs, comfort, etc., require a previous
evaluation of the system, focusing on the learning outcomes of the student. The aim was to evaluate the
real learning of the students of doctorate courses, by comparing the effectiveness of distance learning in
UniNet with traditional classroom-based teaching. Five doctorate courses were taught simultaneously to
two independent groups of students in two ways: one, through the UniNet Network, and the other in a
traditional classroom. The academic knowledge of students was evaluated at the beginning and end of
each course. The difference in score was considered as a knowledge increase. The comparison was made
using Student’s t-test for independent groups. There were no significant statistical differences in the
outcomes of the two groups of students. This suggests that both teaching systems were equivalent in
increasing the knowledge of the students. Both educational methods, the traditional system and the
online system in a thematic network, are effective and similar for increasing knowledge.

Keywords: Distance learning, distance education, continuing medical education, association learning,
computer communication networks, Internet

1. Introduction
The development of online education has provoked questions on the quality of the learning
[1]. Online courses could help people, who live or work off-campus, to have Continuing
Medical Education. Therefore, distance learning could be a good alternative for health care
professionals.
UniNet (http://www.uninet.edu) is a University Network of Thematic Telematic Integrated
Services for Virtual Users Communities [2]. UniNet network is like a knowledge virtual
city, focusing the integration telematic resources in a permanent network, which has been
designed for scientific work and is independent of commercial and institutional business.

Correspondence: Marı́a Jesús Coma del Corral, Unidad de Investigación, Hospital General Yagüe, 09005 Burgos, Spain.
Tel: þ34-610620180. Fax: þ34-947281612. E-mail: mjcoma@uninet.edu

ISSN 1463-9238 print/ISSN 1464-5238 online Ó 2006 Taylor & Francis

DOI: 10.1080/14639230600598026
 60 M. J. Coma del Corral et al.

It is a voluntary and altruistic work of scientific cooperation between many professionals. The
project is universal, thematic, linguistic, and geographically open to all types of scientists
and professionals who belong to Virtual Users Communities. UniNet resources include web
services, mailing lists, webnews, discussion boards, databases, and text-conference networks
using Internet standard protocols. The objective is to promote Internet resources, in a simple
way, to interested scientists and students. UniNet carries out several teaching activities,
including clinical pathology sessions around the world, courses on continuing medical
education, doctorate and masters programs, virtual congresses, medical journals, and
electronic books [3].
For the provision of continuing education to health professionals, many authors point out
that the online educational system should be based on several applications reproducing, in the
best way, traditional education [4]. Low-cost and effective Telematics applications, including
CD-ROMs, chats, conferences, and classrooms based on a website, are frequently used [5].
Our system, at UniNet Network, is mainly using Web pages, mailing lists, discussion boards,
and text-conferencing.
As many people have verified, real-time interactive distance learning based on the
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availability of the Internet is viable [6]. An online course can be as effective as other education
methods, and it may be more interactive and dynamic [7]. Students can submit comments or
questions directly to the teaching staff and go beyond the course content as they learn how to
search and take advantage of the information resources available on the Internet. The online
classes can help provide opportunities for methods of communication that are not
traditionally nurtured in traditional classroom settings [8].
The development of online education has prompted questions on the quality of the
learning. Until now, most investigations on distance learning were focused on determining
the quality of the courses, student satisfaction, improved knowledge, agreement, adherence,
the characteristic of the participants, student expectations, or how the participants eval-
uated the content of the courses, reasons for selecting the distance learning group, or the
participants’ experience of internet tools [7,9], teacher and student satisfaction, adjustment to
the expectations, material and personal costs, learner outcomes [10 – 13], etc.
However, the real learning capability of educational systems based on Internet, has not
been well established. There are few investigation studies that really compare the level of
knowledge acquired between an online system, based on the Internet, and the traditional
classroom system.
Distance learning needs a rigorous evaluation on its capability as an educational
instrument, a diagnosis on its effectiveness, and documentation of its pedagogic advantages.
We hypothesize that the online system could be as useful as a traditional one, as regards
the increase in knowledge. The focus is on how the technology of the Internet enables the
learning process. The objective of this work is to evaluate the teaching capability of the
UniNet network using only simple Internet tools, versus the traditional educational system
based on the classroom, by comparing student academic outcomes.

2. Material and methods

This study evaluated five courses of the Doctoral Program ‘Introduction to Research in
Medicine and Surgery’ which the University of Valladolid has supported at The General
Yagüe Hospital, in Burgos since 1994 (http://doctorado.uninet.edu). These courses have
academic validity, and all students must have a Degree to be admitted. Four students were
pharmacists, and 104 were physicians.
 An Internet-based thematic learning network 61

The courses are entitled ‘Biology of Inflammation’, ‘Research Methodology’, ‘Micro-

biology Updates’, ‘Clinical Toxicology’ and ‘Physiopathology of Inflammation’. Each course
has three credits (30 lecturer hours).
The courses were distributed simultaneously in two different ways. The first was given in
the classroom and the second online by Internet at UniNet Network. The teachers of this
study were not selected. Each course had different teachers, the same ones who taught the
course traditionally in the preceding years.
The students freely chose each course and mode of education. The students who followed
the online learning were previously trained on Internet tools, apart from those students who
already had enough knowledge on the Internet. Every course was given over 3 weeks,
simultaneously, on Monday, Tuesday, and Wednesday. The students who carried out the
course through the Internet did not attend classes, and most of them were many kilometres
away. The students who carried out a ‘mixed system of teaching’ were excluded from the
study. The Internet educational contents were protected by passwords. When the traditional
class ended, the same teacher started the online class. The distance online students received
the same contents and at the same time as their colleagues in the traditional learning.
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The traditional method consisted of a lecture by the teacher in the classroom, aided by
slides, blackboard, etc., followed by a dialogue.
The online system is based on Web and text-conferencing (chat). The teacher, helped by
the UniNet technical staff, used the Web to transmit the teaching materials, figures, tables, or
slides. At the start, the students opened their browser and text-conferencing tool (chat). While
the students read the educational material placed on the Web, the teacher discussed the
subjects with the students by text-conference. All the dialogues transmitted by text-
conference were logged and placed on the website to read or consult later. Afterwards, a
discussion board and the course mailing lists were used for announcements, comments, etc.
Figure 1 shows the schematic representation of the procedure.
The evaluations were made by examinations at the beginning and end of each course.
Only the students with initial and final evaluations were included in this study. Each student
filled in a form, with 20 questions with four or five answer choices on the subject of each

Figure 1. Schematic of telematic educational resources for distance learning in UniNet.

 62 M. J. Coma del Corral et al.

course, which was previously prepared by the teachers. There was one only exception, the
course on the Physiopathology of Inflammation: the initial evaluation of this course
consisted of 35 questions with short answers and, in the final exam, a multiple-choice
questionnaire.
All the students had the same time to answer the questionnaire. The distance students
were connected online by text-conference while they were filling in the form, which had
been sent to them by e-mail or by direct client-to-client (DCC) file-transfer protocol on
Internet.
All the tests were evaluated by an expert on the teaching method, in blind form on the
method of learning. Personal identification in the exams was not required, but a code was
used to identify and match up the initial and final evaluation of each student. The academic
evaluation was made using other procedures and outwith this study.
The exams were evaluated using the following method: the number of correct answers was
taken into account, adding one point for each correct one. The resulting number was reduced
by multiplying the total number of the incorrect answers by 0.2 or 0.3 (depending on whether
the question had four or five options). After this, the final result was divided by the number of
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questions. This allowed us to find the academic level of each student, at the beginning and
end of each course, expressed as a percentage.
The variation of score obtained by the students between the beginning and the end of
each course (initial and final score of each student) was considered as a knowledge increase.
The comparison of the increase in knowledge between each group was made using
Student’s t-test for independent groups, after the statement of conditions for it. The level of
initial knowledge of each student before each course was considered for adjusting the proper
comparison of increased knowledge between the groups, using covariance analysis.

3. Results
A total of 108 exams were evaluated, 78 from traditional classroom students and 30 by
distance learning. Each student studied one or several courses and therefore took one or more
exams.
The course ‘Biology of Inflammation’ was the first course. This was evaluated in
13 students, 11 traditional classroom students, and two by distance learning. In the course
‘Clinical Toxicology’, which had 19 students, 12 traditional students and seven online
students were evaluated. In the course ‘Research Methodology’, the evaluation was carried
out for 33 students: 25 traditional students and eight online students. The course
‘Microbiology Updates’ was evaluated with 21 students: 13 traditional and eight online.
The course ‘Physiopathology of Inflammation’ was evaluated with 22, 17 traditional students
and five online students, as can be seen in the following tables.
Table I shows the results of the evaluations of knowledge before each course in the different
student groups. There were statistically significant differences between the initial evaluation of
students opting for classroom teaching and the online ones. This suggests that the students
who selected online teaching had a better baseline knowledge on the subject than the students
who chose the traditional option.
We have analysed the level of previous knowledge of each course, and observed that the
basal state was comparable in four of the five courses, between both groups. The exception
was the course ‘Research Methodology’ where online students had a higher knowledge than
the traditional students, and the difference was statistically significant.
Table II shows the mean percentage increases in academic knowledge in each group of
students.
 An Internet-based thematic learning network 63
Table I. Initial score by course.

Mode

Traditional Internet
Course Mean + SD (N) Mean + SD (N) P

Biology of Inflammation 19.73 + 8.30 (N ¼ 11) 14 + 2.83 (N ¼ 2) 0.369

Clinical Toxicology
Research Methodology
Microbiology Updates
Physiopathology of Inflammation
Overall
36.83 + 12.11 (N ¼ 12) 34.86 + 18.31 ( N ¼ 7) 0.779
27.04 + 15.12 (N ¼ 25) 84.13 + 8.37 (N ¼ 8) 50.001*
30.31 + 23.21 (N ¼ 13) 18.50 + 16.68 (N ¼ 8) 0.227
21.47 + 8.74 (N ¼ 17) 16.60 + 4.04 (N ¼ 5) 0.247
26.85 + 15.24 (N ¼ 78) 39.20 + 31.10 (N ¼ 30) 0.045*

*Significant.

Table II. Adjusted difference final – initial score by course.

Mode
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Traditional Internet
Course Mean + SD (N) Mean + SD (N) P

Biology of Inflammation 36.97 + 0.59 (N ¼ 11) 33.16 + 3.23 (N ¼ 2) 0.845

Clinical Toxicology 30.08 + 2.07 (N ¼ 12) 35.71 + 3.56 (N ¼ 7) 0.592
Research Methodology 24.09 + 1.42 (N ¼ 25) 18.22 + 4.45 (N ¼ 8) 0.694
Microbiology Updates 27.55 + 1.65 (N ¼ 13) 23.23 + 2.67 (N ¼ 8) 0.664
Physiopathology of Inflammation 46.64 + 2.86 (N ¼ 17) 59.23 + 9.73 (N ¼ 5) 0.020*
Overall 31.15 + 0.93 (N ¼ 78) 34.51 + 2.42 (N ¼ 30) 0.43

*Significant.

The statistical analysis with a paired Student’s t-test shows that online students learned
more. Previous values were adjusted by covariance analysis to avoid initial differences. If we
examine each course, we note that only the ‘Physiopathology of inflammation’ course has a
significant learning increase by online students. In the rest of courses, there were no statistical
differences in initial and final scores, or in the overall score. This is shown in Figure 2. This
suggests that both traditional and online distance learning systems using an Internet-based
network like UniNet have similar teaching potential.

4. Discussion
In this work, we attempt to compare the capability of distance learning with traditional
classroom-based teaching, focusing on knowledge increases, with standardized conditions
between both methods. When we analysed the level of previous knowledge of the students of
each course, we observed that the basal state was comparable between both distance and
traditional learning groups in four of the five courses. However, in the ‘Research Methodology’
course, online students had more knowledge than the traditional students, and the difference
was statistically significant. This may represent a selection bias, and in this sense, we found that
some of the subjects in this course were about databases, online data access, and electronic
resources for academic work. Statistical analysis considers this event, and an appropriate
adjustment was made for proper comparability between groups. The overall analysis of our
results indicates there are no statistical differences in real learning between the traditional
students and Internet-based distance learning students within UniNet Network. This suggests
that both traditional and online distance learning systems have similar teaching capabilities.
 64 M. J. Coma del Corral et al.
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Figure 2. Initial and final score by traditional versus Internet.

Student performances in online and traditional classroom versions of the same course
have been compared by many authors. Most results show no significant differences between
the two groups of students. Many studies suggest there are no differences in the average on
some tests between the online and traditional students [14,15]. Hersh et al. [10] developed
some courses by streaming audio plus slides for lectures and discussion boards for student
interaction. To compare online with traditional learning, a final examination was taken by the
student. It was found that the performance of distance learning students was superior to that
of on-campus students. However, direct comparison of final examination results is not
definitive for determining which teaching setting is ‘better’, since the student groups were
different, and the amount of time to take the examination was different. Real-time
communication programs were found to be superior for problem discussion and hypothesis
formulation.
Lipman et al. [12] have carried out a prospective, randomized study on educational
outcomes, comparing a traditional classroom course on clinical ethics with the same course
taught by Internet-based discussion. The student understanding of ethical analysis, as mea-
sured by grades of external reviewers on the final paper, was significantly higher in the course
taught via the Internet than in the traditional course. Maki et al. [16] evaluated the online
format and that of traditional teaching in an introductory online psychology course, using a
pre-test, post-test, non-equivalent control group design. They found that the increase in
knowledge was greater for online students. On the other hand, a prospective controlled trial to
evaluate the benefit of access to educational information for surgical rotations of medical
students having access to educational material on a hospital information system was
evaluated. The results did not demonstrate any learning advantage for medical students [15].
However, none of these studies considered the initial knowledge of the students, a reason why
a selection bias cannot be excluded.
 An Internet-based thematic learning network 65

Online education needs the use of different application systems, as we are doing in the
UniNet Network. Also, others, such as Caton et al. [17] are working on a Virtual Learning
Centre, with thematic telematic integrated resources. As they explain, text conferencing
alone has not been sufficient to deliver an online course. Several educational technologies,
using multimedia, are needed to support an online model. According to Hopper [18],
synchronous online chat-rooms and asynchronous discussion boards are flexible, inexpen-
sive online tools, to facilitate discussion and collaboration. Schoech and Helton [11] have
performed a quantitative analysis and found that the chat-room section students had a more
positive attitude and were more satisfied with the course and the technology than traditional
students.
Like Skorga [19], we have found that online students are more active in the learning process
and participate in the course assignments discussing information more often than the
traditional classroom student. Discussion occurs ‘anytime’ online between students and the
teacher, who must spend more time chatting, responding to student e-mail or discussion
boards. The text-conference network of UniNet is private, and the channels are dedicated
exclusively to the academic activities related to them. The technology makes no difference to
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knowledge increase probably because, among other reasons, the type of interaction used by
the teacher online using text-conferencing, on UniNet Network, as compared with classroom
interaction is not very different.
There are important problems in transferring traditional education courses to virtual
formats. The technological advances provide exciting opportunities for the delivery of
education to those who have not previously been able to access on-campus learning, usually
due to barriers of distance and cost.
We point out that the teachers of this study were not selected, and at the start of this study,
some teachers had limited knowledge and few skills to use the Internet tools to support the
students, and were not very enthusiastic on the possibilities of the Internet. As Russell et al.
[20] have stated that for the success of a groupware, the characteristics of UniNet Network
include a fluid network structure, the presence of a strong network identity and culture of
reciprocity, and the opportunity for new members to learn through passive participation are
required. In accordance with Hersh et al. [10], we think that ‘Distance learning has the
potential to revolutionise education in much the same way as other medical computer
applications are changing health care’.

5. Conclusions
We have verified that real-time interactive distance learning, based on the availability of the
Internet, is viable, and is very promising for providing tele-education to the medical
community. Other reasons such as time, cost, or other factors, are the key to choosing one
system over another.
Education on the Internet, using a combination of several integrated telematic resources,
the main one being the text-conference, as normally used in the UniNet Network, is a valid
and useful method for continuing medical education, and has a similar value to traditional
teaching.

Acknowledgements
To Victoria Santos for the technical support. This project was supported by Grant
(FIS 99/0324) from the Fondo de Investigación Sanitaria, and the European Union FEDER
fund.
 66 M. J. Coma del Corral et al.

References
1. Asselmeyer H. Trends, current developments, and concepts in distance learning and E-learning. International
Journal of Computerized Dentistry 2004;7:145 – 157.
2. Coma del Corral MJ, Martı́n-Alganza A, Hawa Attourah M. Direct communication on the Internet. Uninet: the
university link for Integrate Telematic Services. Revue Neurologique 1998;26:992 – 995. Available from: http://
www.revneurol.com/26154/ia26154.htm (accessed July 2005).
3. Sanchez Ramos MA, Coma del Corral MJ, Moro Rodrı́guez E, Conde Martı́n AF, Vieira e Silva CR, Hernández
Martı́n A. Pat-UniNet: creación y desarrollo de un foro internacional, multilingüe, de diagnóstico en Patologı́a.
Patologı́a 2003;36:149 – 258. Available from: www.pgmacline.es/revpatologia/volumen36/vol36-num2/36-
2n05.htm (accessed July 2005).
4. Curran VR, Hoekman T, Gulliver W, Landells I, Hatcher L. Web-based continuing medical education (I): field
test of a hybrid computer-mediated instructional delivery system. Journal of Continuing Education in the Health
Professions 2000;20:97 – 105.
5. Locatis C, Fontelo P, Sneiderman C, Ackerman M, Uijtdehaage S, Candler C, Stensaas S, Dennis S. Webcasting
videoconferences over IP: a synchronous communication experiment. Journal of the American Medical
Informatics Association 2003;10:150 – 153. Available from: http://www.pubmedcentral.nih.gov/articlerender.
fcgi?tool¼pubmed&pubmedid¼12595404 (accessed July 2005).
6. Woo MK, Ng KH. A model for online interactive remote education for medical physics using the Internet. Journal
Downloaded By: [Stanford University] At: 12:54 22 October 2008

of Medical Internet Research 2003;5:e3. Available from: http://www.jmir.org/2003/1/e3/ (accessed July 2005).
7. Sigulem DM, Morais TB, Cuppari L, Franceschini SC, Priore SE, Camargo KG, Gimenez R, Bernardo V,
Sigulem D. A Web-based distance education course in nutrition in public health: case study. Journal of Medical
Internet Research 2001 Apr – Jun;3(2):E16. Available from: http://www.jmir.org/2001/2/e16/ (accessed July 2005).
8. Riley JB, Austin JW, Holt DW, Searles BE, Darling EM. Internet-based virtual classroom and educational
management software enhance students’ didactic and clinical experiences in perfusion education programs.
Journal of Extra-Corporeal Technology 2004;36:235 – 239.
9. Spallek H, Pilcher E, Lee JY, Schleyer T. Evaluation of web-based dental CE courses. Journal of Dental
Education 2002;66:393 – 404. Available from: http://www.jdentaled.org/cgi/reprint/66/3/393 (accessed July
2005).
10. Hersh W, Junium K, Mailhot M, Tidmarsh P. Implementation and evaluation of a medical informatics distance
education program. Journal of the American Medical Informatics Association 2001;8:570 – 584. Available from:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool¼pubmed&pubmedid¼11687564 (accessed July 2005).
11. Schoech D, Helton D. Qualitative and quantitative analysis of a course taught via classroom and Internet
chatroom. Qualitative Social Work 2002;1:111 – 124.
12. Lipman AJ, Sade RM, Glotzbach AL, Lancaster CJ, Marshall MF. The incremental value of Internet-based
instruction as an adjunct to classroom instruction: a prospective randomized study. Academy of Medicine
2001;76:1060 – 1064.
13. Yom YH. Integration of Internet-based learning and traditional face-to-face learning in an RN-BSN course in
Korea. Computers, Informatics, Nursing 2004;22:145 – 152.
14. Buckley KM. Evaluation of classroom-based, Web-enhanced, and Web-based distance learning nutrition courses
for undergraduate nursing. Journal of Nursing Education 2003;42:367 – 370.
15. Patterson R, Harasym P. Educational Instruction on a hospital information system for Medical students during
their surgical rotations. Journal of the American Medical Informatics Association 2001;8:111 – 116. Available
from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool¼pubmed&pubmedid¼11230379 (accessed July
2005).
16. Maki RH, Maki WS, Patterson M, Whittaker PD. Evaluation of a Web-based introductory psychology course: I.
Learning and satisfaction in on-line versus lecture courses. Behavior Research Methods, Instruments, and
Computers 2000;32:230 – 239.
17. Caton KA, Hersh W, Williams JB. Implementation and evaluation of a virtual learning center for distributed
education. In: Proceedings of the AMIA Symposium; 1999. p 491 – 495. Available from: http://www.amia.org/
pubs/symposia/D005647.HTM (accessed July 2005).
18. Hopper KB. Education, teleconferencing, and distance learning in respiratory care. Respiratory Care
2004;49:410 – 420. Available from: http://www.rcjournal.com/contents/04.04/04.04.0410.pdf (accessed July
2005).
19. Skorga P. Interdisciplinary and distance education in the Delta: the Delta Health Education Partnership. Journal
of Interprofessional Care 2002;16:149 – 157.
20. Russell J, Greenhalgh T, Boynton P, Rigby M. Soft networks for bridging the gap between research and practice:
illuminative evaluation of CHAIN. British Medical Journal 2003;328:1174. Available from: http://www.
pubmedcentral.nih.gov/articlerender.fcgi?tool¼pubmed&pubmedid¼15142924 (accessed July 2005).