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A social network perspective on peer relationship formation of medical undergraduates within

large-scale learning communities
Zhou, Yan; Bos, Nico; Diemers, A.D.; Brouwer, Jasperina

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A social network perspective on peer relationship

formation of medical undergraduates within large-
scale learning communities

Yan Zhou, Nicolaas A. Bos, Agnes D. Diemers & Jasperina Brouwer

To cite this article: Yan Zhou, Nicolaas A. Bos, Agnes D. Diemers & Jasperina Brouwer
(2023) A social network perspective on peer relationship formation of medical undergraduates
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10.1080/10872981.2022.2162253

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MEDICAL EDUCATION ONLINE
2023, VOL. 28, 2162253
https://doi.org/10.1080/10872981.2022.2162253

RESEARCH ARTICLE

A social network perspective on peer relationship formation of medical

undergraduates within large-scale learning communities
a,b b b c
Yan Zhou , Nicolaas A. Bos , Agnes D. Diemers and Jasperina Brouwer
a
Educational Technology, College of Teacher Education, Zhejiang Normal University, Zhejiang, China; bCenter for Education
Development and Research in Health Professions (CEDAR), LEARN, University Medical Center Groningen, University of Groningen,
Groningen, The Netherlands; cEducational Sciences, Faculty Behavioural and Social Sciences, University of Groningen, Groningen, The
Netherlands

ABSTRACT ARTICLE HISTORY

Introduction: Students’ formal networks, which are formed by a formal curriculum design, such Received 5 September 2022
as formally organized study groups within learning communities (LCs), may benefit students’ Revised 8 December 2022
interactions and learning. It is unclear how large-scale LCs contribute to the formation of different Accepted 20 December 2022
informal peer relationships, which refers to student self-organized out-of-class relationships. Two
KEYWORDS
mechanisms can explain relationship formation in LCs. Propinquity within formal networks and Learning community;
homophily of students’ characteristics (nationality, sex, academic performance) may promote informal peer network;
students’ peer relationships. This study explores to what extent the formation of students’ collaboration; social network
informal networks was determined by their formal networks (LCs) while controlling for students’ analysis; undergraduate
characteristics and which mechanisms play an important role. medical education
Methods: With online surveys, data were collected about five informal networks (help-
seeking, collaboration, information sharing, friendship, and learn-from) from 69 first- and
51 second- bachelor year medical students (2890 relationships). Students were divided into
four LCs in the formal curriculum. We compared students’ five informal network structures
between first- and second-year students, domestic and international students, within and
between formal networks. Besides, we used Quadratic Assignment Procedure (QAP)
Regression Analysis in Ucinet to investigate the associations between students’ informal
and formal networks (LCs) and students’ characteristics.
Results: Propinquity (in the same LC) plays a role since students have more informal
connections within LCs than between LCs. Furthermore, it seems to play a greater role
for second-year students than for first-year students. Homophily of nationality is important
in informal networking since students are more likely to connect with others of similar
nationalities.
Conclusion: Students become more connected within the LC when they remain in the same
LC for a longer period. Formal networks enhance the students’ informal interactions within
LCs but seem to restrict the interactions among students from other LCs. International
students need support in order to integrate with domestic students in LCs.

Introduction In the social learning theory Bandura et al. argued

The development of society and the needs of patients
are constantly challenging healthcare and medical edu­
cation. Recently, many countries and universities focus
on competency-driven medical education and consider
local and global healthcare. As Frank et al. [1] men­
tioned, competency-based medical education (CBME)
focuses on both clinical and educational outcomes, it
allows for a highly personalized learning process instead
of a traditional, one-size-fits-all curriculum [2], and
provides a student-centered curriculum approach
[1,3]. In CBME, students’ formal and informal peer
networks are crucial to their learning. However, the
diversity of formal network formations (size, duration)
and student backgrounds leads to unclear results for
various types of informal networks formation.
already more than half a century ago (1969) that
students can learn within a social context, acquiring
new information and behaviours by watching others
[4]. Therefore, peer relationships are closely related to
students’ learning processes and outcomes [5–9]. For
the establishment of peer relationships both formal
and informal networks seem to play an important
role. Some universities consider using Learning
Communities (LCs) to foster CBME implementation
by creating students’ formal networks [10,11, 12–14]
LCs are groups of students who share common aca­
demic goals and attitudes that meet regularly to col­
laborate on classwork, which benefits both their
experience sharing, engagement, and professional
competency development and interpersonal

CONTACT Nicolaas A. Bos n.a.bos@umcg.nl Wenckebach Institute for Education and Training, University of Groningen, University Medical
Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
Supplemental data for this article can be accessed online at https://doi.org/10.1080/10872981.2022.2162253.
© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2 Y. ZHOU ET AL.
relationships [13,15,16]. The formal networks, which
are usually organized by the faculty, offer a pre-struc­
tured environment where students do not have
a choice with whom they collaborate. In addition to
the formation of formal peer relationships, students
will freely establish relationships with their peers out
of class [17–20]. These are the so-called informal peer
networks.
It is known that formal networks influence infor­
mal peer relationships formation to some extent.
However, the diversity of formal networks forma­
tions and informal networks reveal conflicting
results. On the one hand, formal networks benefit
students establishing their informal relationships
[6,19,21]. For instance, Champaloux et al. (2016)
showed that small groups positively impacts peer
selections for social interactions after class [20]. On
the other hand, the small formal groups may not
fulfill students’ social interactions, such as informa­
tion sharing, so they prefer to form informal rela­
tionships with others out of formal networks [18,22–
24]. Besides, formal networks may have different
effects on different informal networks. Brouwer
et al. (2018) found that students prefer to collaborate
with others belonging to the same freshmen LC but
this was not shown in friendship and help-seeking
networks [24]. Thus, it is necessary to consider dif­
ferent types of informal networks (i.e., collaboration,
information sharing) when investigating informal
networks formation within the formal context
of LCs.
As social interactions occur, several types of social
relationships emerge. According to previous studies,
five types of social relationships appear to be most
relevant to the development of medical students’
competencies: (1) ‘study-related support’ (students
seek help from others) [23,25–27]; (2) ‘collaboration’
(students collaboration with others for assignments
or academic tasks) [24,28]; (3) ‘friendship’ [22,29,30];
(4) ‘information-sharing’ (students acquire or share
information with others) [22,31]; and (5) ‘learn-from’
(students’ role model) [25,29]. Different peer rela­
tionships seem to be related, but research findings
are ambiguous in this respect [23,24,28,29]. For
instance, Stadtfeld et al. (2019) found that friendship
and studying-together networks overlap and coe­
volve. This means that students are more willing to
study or collaborate with their friends [23]. However,
Zander et al. (2018) found that relationships between
informal networks are not mutually associated [28].
Students who were initially more integrated with
academic support networks became more integrated
with social support networks over time, but not vice
versa. Besides, it should be noticed that previous
studies either included small (less than ten people)
[18,20,21,25] to middle scaled (around 30 to 50 stu­
dents) [18,28,30] formally structured groups when
investigating informal networks. Few studies consid­
ered large scale formally structured organizations
(i.e., LC more than 100 students) but not in medical
education.,34
Besides the fact that group-size seems to affect
peer network formation, also time may be an influen­
cing factor on networks formation, although also in
this respect the results seem to be ambiguous [22].
Some researchers found that the effect of the formally
structured group on social and educational experi­
ence relationships intensified over time [19,20],
whereas Hommes et al. (2014) found that the effect
of formal network fades over time [22]. It is unclear
how the effect of formal networks on informal net­
works varies between students with varying lengths of
access to formal networks.
From social network research, it is well-known
that two mechanisms can play a role in informal
relationships’ formation [29,32]. The first mechanism
is propinquity [33–35], which refers to the phenom­
enon that people are more likely to connect with
others when they are physically close with each
other [36]. The propinquity can be caused by formal
networks, such as LCs, which may lead to more
informal interactions within LCs rather than between
LCs. Translating the findings of Borgatti and Cross
(2003) to the educational context, students might
seek information on the one hand, from an expert,
but, on the other hand, go for ‘low costs’ and ask
someone who is more available. Brouwer et al. (2018)
showed indeed that social sciences’ students do not
seek information from someone who is considered as
an expert (a high-achieving student), but from
a similar-achieving friend, which might be more con­
venient [8,28,37]. The second mechanism is homo­
phily [35], which refers to the common finding that
people are more likely to connect to each other based
on similarities in their personal characteristics, such
as academic performance, nationality
[18,23,24,35,38]. For instance, in an ethnically diverse
environment, students are more likely to connect
with others according to similar nationality, ethnic
background, or speaking language [39–41]. An
homophily effect in terms of nationality may lead to
boundaries between domestic students and interna­
tional students and network segregation
[30,39,41,42]. This is supported by previous studies
which found that international students seem to have
difficulties with connecting to domestic students both
in and out of class [39–41]. Students may select each
other based on the similarity of their background and
this may create network segregation rather than the
diversity for which educational designers often aim
when they form their formal networks [24].
The existing body of knowledge about formal and
informal networks is mostly derived from research in
different higher education settings, but not so much

specifically in medical education. With the increasing
use of formal groups in medical education (e.g., small
group, learning community) and the diversity of stu­
dents’ backgrounds, we need to develop an in-depth
understanding of the association between formal net­
works and informal peer networks formation.
Additionally, since medical education programs are
focusing more on collaborative learning but also
more on self-study in recent years [43,44], it is rele­
vant to consider different types of informal networks.
In this study, we considered five informal networks
(ask help, collaboration, share-information, friend­
ship, and learn-from networks), which were demon­
strated to relate to learning in previous studies
[18,23,24,45], rather than two or three as been
included usually [23,29]. Currently, we do not know
how specifically medical students build different
types of informal networks, the contribution of their
characteristics (such as sex, nationality) and how
large-scale formal networks influence these. Thus, in
this study, we will investigate the impact of the for­
mal network (LC) on the formation of five informal
networks of medical students during the first two
academic years. Considering the internationalization
of medical education, we also compare informal con­
nections between and within domestic and interna­
tional medical students in our study. Based on the
results, we provide suggestions to curriculum
designers and administrators in medical schools to
improve the learning process.
Thus, our research questions are:
(1) What are the differences of structures between
the five informal peer networks (study-related
support, collaboration, share-information,
friendship, and learn-from networks)?
(2) To what extent was the formation of students’
informal networks determined by their formal
networks (LCs)?
(3) To what extent are background characteristics
(sex, nationality, academic performance) and
formal networks (LCs) linked to informal net­
works? To what extent are the five informal
networks linked with each other?
Methods
Research setting
This study was conducted at a medical school in the
Netherlands. To improve connections and collabora­
tive learning, the medical school adopted four the­
matic learning communities (LCs): Sustainable Care
(SC), Intramural Care (IC), Global Health (GH), and
Molecular Medicine (MM). Each TLC has its own
profile, content, task activities, learning materials,
and assessments. The four LCs were considered as
formal networks in this study. The LCs share a basic
MEDICAL EDUCATION ONLINE 3
programme (same curriculum design and learning
material) and have their LC specific task programme
(different curriculum design and learning material).
Each LC contains around 100 students. All students
were full-time students and want to earn their degree
at our medical school. LC SC and IC contain only
domestic students and are taught in Dutch. LC GH
and MM contain both domestic and international
students and are taught in English. Students are
assigned to one of the four LCs at the beginning of
the first-year according to their interests and lan­
guage preference. They stay in the same LCs for the
first two and a half years of their three-year bachelor
programme. Students within the same LC are allo­
cated randomly into small tutor groups (of 10 stu­
dents) every half-semester to facilitate propinquity
(formal network influence). In tutor groups, students
study and collaborate with others from the same LC.
Tutor groups meet twice every week and are guided
by trained faculty (tutors).
Ethical approval
Ethical approval was obtained from the Ethical
Review Board of the Netherlands Association of
Medical Education (NVMO), dossier number
2019.4.9. The participation of students was voluntary
and they consented to participate before answering
the questions.
Data collection and participants
First-year (N = 69, 16.4% of total first-year students)
and second-year (N = 51, 13.0% of total second-year
students) students participated in this study. For their
characteristics see Table 1. The data were collected, at
the end of the 2018/2019 academic year, through two
approaches. First, we used an online questionnaire
through Qualtrics to collect data about students’
informal networks. The questionnaire contained
questions related to five informal networks: study-
related support, collaboration, friendship, share-
information, and learn-from (Table S1) [22,23,27].
The online questionnaire was distributed by email
to all first- and second-year students in our medical
school. After clicking the informed consent, we asked
students to fill in fellow students’ names who they
had regularly contacted in the past year out of class.
Participants could list up to 35 fellow students. These
fellow students’ names automatically appeared in the
following questions related to informal networks so
that students did not need to fill in their peers’ names
again. They only need to click yes if they thought this
student is the answer to the question.
We collected data about formal networks (LCs) and
individual data (sex, nationality (domestic or interna­
tional), written test scores) from the administration of
4 Y. ZHOU ET AL.
Table 1. Demographics of the participants.
Characteristics of participants (N=120)
First year (BA1819)
LC
Sustainable Care (SC)
Intramural care (IC)
Global Health (GH)
Molecular Medicine (MM)
Female (%)
Domestic (%)
English-speaking LC (%)
Written test score average (SD)
the medical school (see also Table 1). In this study, we
used the written test score as the grading system to
present students’ academic performance, which is
a curriculum-dependent test assessing medical knowl­
edge. The four LCs used the same test questions so
that we were able to compare students’ academic per­
formance between four LCs. The range of test scores is
from 0 to 10. The written test is performed by the
students around five times every semester and we
calculated the average score of all the taken tests.
Data analysis
Social network analysis (SNA) techniques were used to
investigate the impact of the formal peer network and
individual characteristics on informal peer networks.
Data transformation
In this study, all informal networks and characteris­
tics were transformed into dyadic variables. We used
matrices to present the informal relationships and the
relationship of characteristics between students. If
students indicated the informal relationship, we
assigned the value of ‘1’ in the matrix, otherwise the
value of ‘0’ was assigned. Categorical variables (i.e.,
LC) or binary variables (i.e., sex, nationality (domes­
tic or international), the language used in LC) were
transformed by valuing ‘1’ if both individuals in the
dyad were in the same category or valuing of ‘0’
otherwise. Continuous variables (i.e., written test
scores) entered the models as absolute differences
between individuals. In this case, the smaller the
difference, the greater the similarity (homophily) in
the dyad.
Whole network structures
To investigate the differences between the five infor­
mal peer networks for first- and second-year students
in terms of network structures, we described and
compared different informal networks’ constructions
by calculating density, clustering coefficient, degree
centrality, and reciprocity. The density refers to the
Second year (BA1718)
69 51
15 4
15 20
19 12
20 15
58 (84%) 39 (76%)
44 (64%) 42 (82%)
39 (57%) 27 (53%)
6.323 (0.101) 6.061 (0.150)
proportion of the number of actual connections of
possible connections in a network [46]. It indicates
the association occurring between any pair of ran­
domly selected students. The clustering coefficient
presents the degree to which students in the network
tend to cluster together [47]. It reflects the extent to
which a network has areas of high and low density. If
the clustering coefficient is much higher than the
overall density, it indicates that some individuals are
clustering in the entire network. Centrality is the
construct we used to quantify the relatedness to
other students in the social networks [48]. Degree
centrality calculates the importance according to the
number of links held by each student. It includes in-
degree (number of inbound links) and out-degree
(number of outbound links) [49]. The network level
centrality presents the degree of inequality or differ­
ence in a network as a percentage of that in a perfect
star network of the same size [50]. High centrality
refers to the power of individuals with some indivi­
duals as the most influential or that they dominate
the entire network. Reciprocity presents the likeli­
hood of individuals reciprocating relations. It takes
the number of reciprocated connections of students
divided by the total number of connections [46].
The influence of students’ characteristics on their
informal networks formation
To explore to what extent the formation of informal
networks was determined by students’ characteristics,
we calculate the E-I index concerning the nationality
and sex. The E-I (external-internal) index measures
the similarity of connected students by comparing the
number of connections of students with the same and
different characteristics [46]. It presents the similarity
of students and their peers. In this study, we categor­
ized students according to their characteristics (i.e.,
sex, nationality (domestic or international), formal
group (LC)). To explore to what extent the formation
of informal networks was determined by their formal
networks (LCs), we calculated E-I index concerning
the LCs and language used in LCs of five informal
 MEDICAL EDUCATION ONLINE 5

networks. The range of the E-I index is from −1 (all
ties are internal to the group) to + 1 (all ties are
external to the group) [50]. When the E-I index is
less than 0, students tend to connect with others who
have similar characteristics or are in the same formal
groups.
Correlation among informal networks and
influence factors
To investigate the associations between background
characteristics (sex, nationality, academic perfor­
mance), formal networks (LCs) and informal net­
works, and the associations among five informal
networks, Quadratic Assignment Procedure (QAP)
Correlation was used to analyze the statistical associa­
tion between independent variables [46].
Independent variables include five informal networks
(study-related support, collaboration, share-informa­
tion, friendship, and learn-from networks) and their
characteristics (i.e., sex, nationality (domestic or
international), LC, written test score, language used
in LCs).
All analyses were performed by using the UCINET
6.690 software package [46]. In addition, we used the
Netdraw software package to visualize networks [46].
Figures describe the networks based on the
characteristics.
was almost similar. The clustering coefficient of
informal networks differed between informal net­
works and also differed between first- and second-
year students. We saw the highest clustering in the
first-year students’ friendship networks. In general,
first-year students showed more clustered networks
than second-year students. Figure S1 and Figure S2
reveal this more intuitively.
Collaboration network showed much less centrali­
zation at the network level than the other four infor­
mal networks. High centrality refers to some
individuals who are the most influential or dominate
the entire network. Our result shows that collabora­
tion is maybe more divided across all the students.
This may be due to the random distribution of small
groups in LCs. Students were able to collaborate with
different fellow students in small groups over time. In
general, all informal networks of second-year stu­
dents were less centralized than first-year students.
The reciprocity of friendship of first-year students
was the highest. Literature shows that friendships
are often based on mutual trustworthy relationships
[26], it may explain the high reciprocity of friendship.
The reciprocity of collaboration of second-year stu­
dents was higher than first-year students. It may
reflect the positive influence of peer relationships in
the formal collaborative curriculum on informal col­
laboration networks.

Results
RQ 1: What are the differences of structures between
the five informal peer networks (study-related sup­
port, collaboration, share-information, friendship,
and learn-from networks)?
Whole network structures comparison
Considering the network structure, Table 2 shows the
network density, cluster coefficient, centralization,
and reciprocity of five informal networks. The density
was almost similar in all networks of both first-
and second-year students. This suggests that the
degree of interconnectivity of all informal networks
Informal networks formation concerning
students’ nationality and sex
Table 3 shows the E-I index of informal networks
concerning students’ characteristics. We found that
the E-I indexes regarding nationality (domestic or
international) of all informal networks are always
lower than −0.50. When the E-I index is lower than
0, connections tend to be within the same nationality.
The lower the E-I index, the more connection within
the same nationality. It reveals that international stu­
dents preferred to connect with other international
students and domestic students preferred to connect
with other domestic students. Second-year students
had more study-related support and collaboration
connections with others of different nationalities

Table 2. Descriptive statistics of network density, cluster coefficient, and centralization.

Study-related support Collaboration Friendship Share information Learn from
First-year Second-year First-year Second-year First-year Second-year First-year Second-year First-year Second-year
Network density 0.006 0.006 0.005 0.007 0.007 0.006 0.006 0.006 0.008 0.007
Clustering coefficient 0.090 0.060 0.053 0.067 0.107 0.052 0.071 0.039 0.057 0.027
Centralization
Degree (Out) 7.68% 3.47% 4.90% 1.86% 10.68% 2.82% 10.64% 9.93% 14.36% 10.30%
Degree (In) 1.29% 0.42% 1.28% 0.26% 2.14% 0.41% 1.40% 1.43% 2.15% 1.27%
Reciprocity 0.064 0.040 0.044 0.052 0.086 0.040 0.068 0.031 0.056 0.019
6 Y. ZHOU ET AL.

Table 3. E-I index of informal networks concerning students’ characteristics.

E-I Index Study-related support Collaboration Friendship Share information Learn from
First- Second- First- Second- First- Second- First- Second- First- Second-
Attributes year year year year year year year year year year
LC −0.511 −0.686 −0.775 −0.917 −0.500 −0.580 −0.549 −0.659 −0.607 −0.761
Sex −0.557 −0.511 −0.486 −0.534 −0.485 −0.551 −0.527 −0.516 −0.374 −0.547
Nationality −0.720 −0.701 −0.695 −0.606 −0.596 −0.783 −0.600 −0.695 −0.579 −0.799
(domestic or
international)
Language −0.842 −0.839 −0.944 −0.938 −0.854 −0.761 −0.859 −0.812 −0.925 −0.874

than first-year students, but less friendship, share
information, and learn from connections with others
of different nationalities. Besides, as Figure S1 and
Figure S2 show, most connections across English
taught and Dutch taught LCs were established by
domestic students. Besides, students were more likely
to connect with others of the same sex (E-I index <0,
see Table 3). Except for the learn-from network, first-
year and second-year students presented similarly on
the E-I index for informal networks formation.
showed a similar E-I index of first-year and second-
year students’ networks. In other words, second-year
students seem not to establish more friendship ties
within LCs than first-year students. In
addition, second-year students showed slightly higher
E-I indexes regarding language than first-year stu­
dents. This means that even though the second-year
students preferred to connect with fellow students
within LCs, connections between English taught and
Dutch taught LCs were slightly more than among the
first-year students.

RQ 2: To what extent was the formation of informal

networks determined by their formal networks (LCs)?
Informal networks formation concerning formal
networks (four LCs)
To see whether students have more informal connec­
tions within LCs than between LCs, we calculated the
E-I index concerning the LCs and language used in
LCs of five informal networks (see Table 3). We
found that the E-I indexes concerning LC of all
informal networks were always lower than −0.50,
which suggests that students had more informal con­
nections with peers who came from the same LC than
from different LCs. Besides, we noticed that
E-I indexes concerning language are lower than
E-I indexes concerning LC, close to −1, which
means that although students had some connections
across LCs, most of them occurred within two
English LCs or within two Dutch LCs.
Informal networks formation concerning formal
networks (differences between first- and
second-year students)
In addition, the E-I indexes concerning LC of second-
year students are lower than those of first-year stu­
dents, which suggests that second-year students gen­
erally had more connections within LCs than first-
year students. Figure S1 and Figure S2 reveal this
more intuitively. The friendship network, however,
RQ 3: To what extent are background characteristics
(sex, nationality (domestic or international), aca­
demic performance) and formal networks (LCs)
linked to informal networks? To what extent are the
five informal networks linked with each other?
Correlation among informal networks and
influence factors
To explore the association between five informal net­
works, and the association between informal net­
works and background characteristics and formal
networks (LCs), we did a QAP correlation analysis
[46]. We found moderate to strong positive correla­
tions between the five networks (study-related sup­
port, collaboration, share-information, friendship,
and learn-from networks) for both first-
and second-year students. The collaboration net­
works of second-year students were more strongly
correlated with other networks than those of first-
year students. It reflects that second-year students’
other informal peer networks (study-related support,
friendship, share-information, and learn-from net­
works) are more influenced by collaboration net­
works than first-year students. In contrast,
background characteristics and formal networks
showed very weak correlations with the five informal
networks. Furthermore, the correlation between
background characteristics and informal networks
was stronger in the cohort of first-year students
 MEDICAL EDUCATION ONLINE 7

than in the cohort of second-year students (see
Table 4).
Discussion
This study uses the social network analysis method to
present the effect of the formal peer network (LC) on
informal peer network formation (study-related sup­
port, collaboration, share-information, friendship,
and learn-from networks) considering student char­
acteristics (i.e., nationality, sex and academic perfor­
mance). We first investigated the differences between
the five informal peer networks for first- and second-
year, domestic and international medical students in
terms of network structures. Then we inquired to
what extent the formation of students’ informal net­
works was determined by their formal networks
(LCs) and students’ background characteristics (sex,
nationality, academic performance), and to what
extent the five informal networks are linked with
each other.
The result of QAP correlation analysis supports
the literature showing the association between the
five informal networks(study-related support, colla­
boration, share-information, friendship, and learn-
from networks), and the relationship between char­
acteristics(i.e., nationality, sex, academic perfor­
mance, formal networks (LC) and informal
networks [22,23,39–41]. Propinquity (stay in the
same LC) plays a role since students have more
informal connections within LCs than between LCs,
which is consistent with previous findings [18,20].
Formal networks (LC) enhance the possibility of
informal relationship formation since students may
easily know each other and start to form informal
relationships [20]. Besides, we found that the five
informal peer networks, such as friendship and
share information, are positively correlated with
each other. It may mean that when students collabo­
rate, they are also likely to become friends, seeking
academic help, sharing information and learn from
each other [23,51]. Background characteristics (sex,
nationality, academic performance) are only weakly
related to informal networks, and the similarity of
characteristics is hardly associated with the formation
of informal networks in contrast to other studies who
found that homophily can be important in informal
networking [35,52].
Furthermore, we explored the differences of infor­
mal networks considering the influence of formal
networks and the length of students were in the
same LC. It contributes to clarifying the role of
lengths of access to formal networks and personal
characteristics in informal peer relationships. Our
finding that the social and educational experience
relationships are more clustered when they stay
longer in the college system is consistent with earlier
research [19,20,29] but contradicts the findings of
Hommes et al. (2014) who found that the formal
network’s influence on friendship and information
sharing network fades over time [22]. In the long­
itudinal study of Hommes, the formal networks were

Table 4. QAP correlations between networks and students’ characteristics.

Variables 1 2 3 4 5 6 7 8 9 10
First-year
1 Study-related support 1.000
2 Collaboration 0.614* 1.000
3 Friendship 0.766* 0.543* 1.000
4 Share information 0.720* 0.594* 0.762* 1.000
5 Learn from 0.578* 0.456* 0.621* 0.617* 1.000
6 LCs 0.078* 0.079* 0.080* 0.079* 0.063* 1.000
7 Nationality (domestic or international) 0.035* 0.027* 0.026* 0.026* 0.018* 0.141* 1.000
8 Sex 0.019* 0.011* 0.014* 0.016* 0.003 −0.002 0.064* 1.000
9 Written test −0.021* −0.016* −0.018* −0.020* −0.015* −0.019* 0.031 −0.047 1.000
10 Language used in LCs 0.056* 0.050* 0.058* 0.055* 0.045* 0.580* 0.246* 0.006 −0.016* 1.000
Second-year
1 Study-related support 1.000
2 Collaboration 0.689* 1.000
3 Friendship 0.737* 0.604* 1.000
4 Share information 0.690* 0.642* 0.770* 1.000
5 Learn from 0.651* 0.572* 0.602* 0.647* 1.000
6 LCs 0.006 0.010* 0.004 0.002 0.010* 1.000
7 Nationality (domestic or international) −0.008 −0.003 −0.004 −0.004 0.005 0.202* 1.000
8 Sex −0.009 −0.003 −0.009 −0.008 −0.002 0.003 0.022 1.000
9 Written test 0.007 0.013* −0.013* 0.012 0.010 0.002 −0.003 −0.024 1.000
10 Language used in LCs 0.015* 0.015* 0.011* 0.009* 0.017* 0.588* 0.316* 0.011 0.003 1.000
Significance levels: *p ≤ 0.05. All variables are at the dyadic level.
8 Y. ZHOU ET AL.
tutorial groups, which included 10 to 12 students in
each group that were followed over time [22]. It was
different from this study which is cross sectional and
involves larger formal networks such as LCs, thus,
more research is needed about the effects of different
group sizes and time on peer relationship formation.
Besides, personal characteristics are more important
for first-year students than second-year students in
informal network formation because they meet each
other for the first time and will contact others accord­
ing to visible attributes [53]. It reflects the importance
of formal networks on their informal networks on
a long-term basis. Therefore, if we want to promote
informal interactions among students with different
characteristics, we can place students in a formal net­
work for a longer time. Although students preferred
to connect with others who are similar to them in
informal networks, the similarity of characteristics
cannot predict the relationship vice versa.
Different from other informal networks, however,
when comparing structure of networks, friendship
networks did not show much-increased internality
(more connections within LC) in second year stu­
dents compared to first year students. In contrast,
students have more collaboration relationships within
LCs than other informal peer relationships. The dif­
ferences in the curriculum design of the four LCs
may be the reason. Students may prefer to collaborate
with others who face similar problems or tasks espe­
cially. Therefore, the differences between LCs may be
also the explanation for the dissimilarity of friendship
and collaboration networks. It slightly differs from
Zander’s finding that students who are more inte­
grated with academic support networks became
more integrated with social support networks over
time [28]. Considering the positive influence of for­
mal networks on informal collaboration and the posi­
tive association between informal peer relationships,
it is worthwhile for medical schools to provide more
opportunities to increase the propinquity (collaborate
in small groups in the formal curriculum), which may
foster the training of excellent team collabora­
tors [54].
Moreover, we explored the differences in informal
networks formation between international and
domestic students. The connections of informal net­
works between domestic and international students
are much less than within domestic students or
within international students, specifically across LCs,
which is consistent with previous studies [30,39,42].
The English taught LCs mixing domestic and inter­
national students did improve informal peer relation­
ships between domestic and international students.
However, most students’ connections between
English and Dutch taught LCs were established by
domestic students. This may be explained by lan­
guage. Since international students are inadequately
able to speak Dutch, especially in the first year, LCs
using English may benefit international students’
communications with domestic students. Extra sup­
port for international students is necessary if we want
to enhance their connections with domestic students,
specifically to domestic students from Dutch LCs.
Strengths, limitations, practical implications
and future research
The first strength of this study is that we investigated
five types of informal networks. These five peer rela­
tionships are different itself. Previous research did
a lot in comparing collaboration, friendship, and
help-seeking, we took learn-from and share-informa­
tion into account as well in this study [23,24,29]. We
were able to explore the relationship between differ­
ent types of informal networks, which adds to the
already existing knowledge. Second, this is one of the
first studies that address the effect of large-scale for­
mal networks in terms of LCs on undergraduate
informal peer networks formation within the medical
field. It contributes to the diversity of literature
regarding the effect of formal networks on informal
peer relationships and to the understanding of the
effect of formally structured organizations on peer
relationships. Third, considering the globalization of
medical education, we investigated the differences
between domestic and international students’ infor­
mal networks formation. Our results may help curri­
culum designers to develop their programme design
in such way that international students have more
opportunities to be involved in different kinds of
informal networks.
We consider three important limitations of our
study. First, this study is a cross-sectional study,
which means that we only captured informal net­
works at one-time point. We were unable to follow
the development of the informal network over time
and we cannot make any inferences about causality
[55]. Future research could consider a longitudinal
social networks study to make it clear how informal
peer relationships develop over time [51]. Second, the
response rate of this study is not that high. Students
who have less contact with others might be less
inclined to take part in such investigations.
However, the distribution of students from different
LCs is relatively balanced. Third, we took
a quantitative approach to address the question to
what extent students are connected. We do not
address the question of why students connect.
Therefore, future research could consider qualitative
research (i.e., interview) or mixed-method research to
investigate how students build their informal net­
works, and try to involve more participants, gaining
insight into the role of formal networks in forming
informal peer relationships within medical curricula.

Fourth, we only consider the association between
informal networks and three objective characteristics
of students (sex, nationality, academic performance)
in this study, but more objective characteristics, for
instance economic and social status, entry perfor­
mance, and subjective characteristics, such as motiva­
tion, self-efficacy, emotions (anxiety, belonging) may
also influence their informal relationships [56–58].
Future studies may shed a light on how other objec­
tive and subjective characteristics influence informal
peer network formation.
Conclusion
This study addresses the effect of formal networks on
students’ informal networks formation within the
medical field. Propinquity plays a role since students
have more informal (collaborative) connections
within LCs than between LCs. Formal networks
(study groups organized by faculty) and various cur­
riculum design in four LCs enhance the informal
interactions within LCs but seem to restrict the inter­
actions among students from other LCs. The LC
seems to play a greater role in the informal peer
network formation for second-year students than
for first-year students. Homophily is important in
informal networking since students are more likely
to connect with others of similar nationalities.
International students need more support to connect
with domestic students, especially between LCs, due
to fewer ties between nationalities than within
nationality.
Acknowledgements
The authors would like to thank all anonymous partici­
pants of the University Medical Center of Groningen for
their participation.
Funding
YZ was supported by a grant of the Chinese Scholarship
Council (No. 201609110118). The funding provided
a fellowship to YZ to do her PhD study in the
Netherlands. The CSC has no influence on the setup of
the study or on the outcomes of the data. Research time of
JB (the last author) is funded by VI.Veni.191S.010.
Authors’ contribution
All the authors have made substantial contributions to the
research: the research design, the data collection, the inter­
pretation of the data, the manuscript writing, and have also
substantively revised it. NB supervised data collection and
YZ organized the data according to the planned analyses
and carried them out, JB supervised especially the statistical
analysis and interpretation. YZ wrote the manuscript. NB,
JB and AD improved data interpretation and revised the
MEDICAL EDUCATION ONLINE 9
manuscript. All authors have read and approved the sub­
mitted the manuscript.
Availability of data and materials
The dataset used and analyzed during this study is available
from the corresponding author upon reasonable request.
Ethics approval
The study was approved by the Ethical Review Board of the
Netherlands Association of Medical Education (NVMO),
dossier number 2019.4.9.
Disclosure statement
No potential conflict of interest was reported by the
author(s).
ORCID
Yan Zhou http://orcid.org/0000-0002-6952-3032
Nicolaas A. Bos http://orcid.org/0000-0002-8649-0455
Agnes D. Diemers http://orcid.org/0000-0001-9024-5543
Jasperina Brouwer http://orcid.org/0000-0002-7332-
9320
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