Needs assessment in surgical undergraduate teaching in a South Asian cohort; implications for cultural adaptations

doi:10.21203/rs.3.rs-4948360/v1

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Needs assessment in surgical undergraduate teaching in a South Asian cohort; implications for cultural adaptations

https://doi.org/10.21203/rs.3.rs-4948360/v1

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Introduction

Student-centered learning has been accepted and adopted globally and the evidence for this is mainly derived from Western populations. Research in the recent past has identified the conflicts of implementing these concepts across different cultures.

Method

A needs assessment was carried out amongst a cohort of medical undergraduates regarding their lack of active participation in general learning activities and small group discussions using an anonymous online questionnaire.

Results

Majority of the students were in agreement that the active participation of medical students (54%) in learning activities and that their personal involvement during classes (61%) was inadequate. Deficiency in language skills (34%), anxiety to make mistakes in public (46%), and reluctance to address the teachers directly (41%) were the leading reasons for the lack of participation. Several structural, resource, and time-related local factors were identified as reasons for poor contributions to small group discussions. The student population was more interested in conceptual learning than assessment-oriented teaching.

Conclusion

Socio-cultural and personality-related anxieties such as addressing the teachers and making mistakes in front of peers were the leading causes for the lack of active participation. Deficiencies in English language skills contributed. Although novel learning methods have been shown to be effective in higher education there may be a need for cultural adaptations or student orientation prior to their implementation for the best results. More research in this area is needed.

needs analysis

South Asia

higher education

Medical education

cultural adaptations

Higher education has undergone a significant transformation over the past few decades from a traditional teaching environment to a one that promotes self-motivated learning coupled with deep understanding. Globally, there have been much evidence-based interventions to convert the teacher-centered delivery and assessment of knowledge to a more student centered knowledge construction with fair and objective assessment. However, there are social, cultural and economic constraints, which challenge the progression to such an idealistic setting. Needs assessment has been recognized as a formal requirement in planning curriculum or organizational policy (1). In the context of education, it is a process by which the policy makers identify the learning or training needs of a target student population based on the expected competencies, student perceptions of the learning activity plus the practical aspects of delivering and achieving the learning objectives (2). Needs have been classified as perceived needs, expressed needs, normative needs (defined by experts), and comparative needs (3). However, a needs assessment should achieve a fine balance between addressing narrow personalized perceived needs versus wider professional expectations in medical education as some areas of learning may not appear to be directly required in the short term but will be beneficial during the practice of medicine in the long run (4).

The Sri Lankan higher education system is a state funded free for all system from primary to tertiary level. The limited numbers of positions for medical sciences in state universities, which are offered in order of merit, have resulted in highly competitive examinations (5). The entry to preferred state funded schools have also shaped the entire education system to be assessment oriented. It is quite a challenge for the students coming from such a competitive assessment-based education system to adapt to a self-learning environment in higher education. Also, most Sri Lankan state schools conduct education in the native language while medical education is exclusively conducted in English. Gogus and Arikan have described a similar observation in Turkey due to a similar competitive exam-oriented education in secondary and primary level (6). However overall lack of learning habits when students transform from school education to university level has been addressed by authors from different corners of the world.

As a developing economy, countries like Sri Lanka are facing other challenges in higher education. Training of teachers armed with knowledge and skills to identify needs, facilitate learning and carry put assessment in a constructively aligned manner is lacking. Providing training to teachers in higher education on novel concepts and methods is pertinent to change the culture in higher education institutions. Access to information technology and education material allowing students to self-educate is costly. Cultural aspects also influence how an individual learns (7). In more conservative communities where questioning figures of authority is discouraged, there is a hindrance to adapt to a learning environment.

Needs analysis plays a pivotal role in designing a higher education curriculum (2). Identifying the requirements of a target population allows a teacher in higher education to adopt and adapt his or her teaching methods. Although theories and evidence for teaching and learning are in abundance direct application of these to a particular population will be challenged by multiple factors. Especially in a background where most research in higher education comes from more resource abundant western populations, their application will require careful consideration of the learner perspective as well (8).

The objective of this article is to present a needs assessment done in a resource limited setting and to discuss the importance of such practice prior to implementing teaching and learning techniques in different settings.

Results of a needs assessment, that was carried out amongst final year medical students at a state owned Sri Lankan University, to assess student perceived needs in several aspects of learning were analyzed. A convenient sampling method was chosen for the assessment, with students following professorial surgical appointments between January and July 2022. The objective was to recognize the student perspective on solutions for several issues observed during learning activities. A lack of student participation in discussions, lack of questioning after a learning activity and lack of self-motivated learning were observed during the final year clinical engagement. All instructors observed poor performance during pre-designated small group discussions with lack of active student participation and inadequate preparation. Self-administered on-line forms were distributed amongst students with questions structured to assess how students perceived the observed issues. Two questioners were distributed, one each for identifying learning needs and one to assess student perspective on restructuring the ‘small group discussion’ learning activity. The assessment was a part of routine teaching activities aimed at quality improvement.

The questioner to obtain student perspective on restructuring the small group discussion learning activity was distributed amongst three clinical groups (98 students) of final year medical students and was responded by 91 with a response rate of 93%. Out of the total respondents, only 7.7% had the understanding that the small group discussions were aimed at covering aspects that were not covered at lectures. While 45.3% thought it was a discussion based on already covered knowledge, a 45% believed it to be a form of revision. Only 52% enjoyed participating for the learning activity, 10% has clearly shown displeasure. Although 83.5% has stated that they prepare for the learning activity the consistent complaint of the teachers was that the students were poorly prepared. A 74% majority had pointed out that their clinical work schedules get disturbed due to the ‘small group’ discussion sessions on topics unrelated to their current clinical appointment and 82% had indicated that they might prefer if the discussions were scheduled to be relevant to the current clinical appointment.

The questioner on the issues pertaining lack of student involvement in clinical learning activities was distributed amongst 98 final year medical students and the response rate was 82.6%. Of the total, 56% were in agreement that the medical students are reluctant be involved in academic discussions while 60% agreed that their personal agreement was not satisfactory (Figs. 1 & 2). Over one third (34.3%) of the respondents identified a deficiency in spoken English language skills as the reason for poor involvement while 45.7% indicated that they were afraid to make mistakes in-front of their peers. Anxiety to directly address the teachers was identified by 41.3% of the respondents as another reason for the lack of involvement in discussions. In the assessment of the preferred type of learning, 65% of the students indicated that they prefer to learn concepts and understand the subject matter as opposed to a 25.7% who preferred assessment oriented learning (Fig. 3). Only 13.7% had indicated that they disliked reading standard textbooks as reference material and of those who disliked, 90% indicated lack of time as the constraint.

In the comments submitted most have highlighted the lack of a structured guidance on what and what not to study. The general attitude in the comments was towards a request for closer guidance and task oriented teaching activities rather than learning activities.

The medical curriculum in Sri Lanka has gone through various changes over the years to its current form (9). In most instances the curriculum was adopted based on an existing system mainly from the West. The secondary and primary education system in Sri Lanka has undergone less reform compared to the tertiary level. The Medical curriculum was converted to a modular system where student centered learning plays a bigger role. The students who are acclimatized to a highly competitive teacher based education system during the secondary education, find it difficult to adapt to the University education. Gogus and Arikan also made a similar observation in the education system in Turkey (6). Only 10% of the students identifying the objective of the small group discussion in our analysis demonstrate deficiencies in the process. In adult education, students need to identify the requirement of each learning activities and the system should be designed to provide such insight. According to Knowles theory, the adult learner will be motivated only if the activity is useful (10). In a background where the student is unaware of the importance of the activity, poor preparation by the participants and only 52% indicating that they enjoyed the activity is somewhat justified.

The social and cultural upbringing of the target population also affects how knowledge or skill training is perceived (11). A significant proportion of students indicating that they were reluctant to directly speak with the lecturers is a crucial observation that needs urgent attention. In an adult learning environment, discussions with the teachers is a mandatory part of learning.

As Hofstede’s described, five dimensions of culture viz: power distance, uncertainty avoidance, individualism, gender roles, and spatial orientation for rewards have a profound influence on the educational system (12)(13). The South Asian culture in general does not encourage questing authority and instill a high level of ‘respect’ to elders and teachers (power distance). Students brought up in such environments may be reluctant to engage in conversation with the teachers freely as the primary and secondary education doesn’t encourage this behavior either. Marambe et al in a study conducted amongst Sri Lankan undergraduates reported the students’ idea of an ideal student is ‘a person who respects teachers’ (14)(5). Nguyen et al similarly observed that in South-East Asian communities (Confucian heritage), the students rarely question the teacher which led to an authoritarian behavior amongst teachers (7).

Majority of the students indicating that they dislike making mistakes in front of their peers is also worrying. This again has a cultural and a social implication due to the highly competitive early education system where performance is celebrated based on a final aggregate rather than the development of a student over time. A mature learner is expected to be honest and bold to question knowledge. Students coming from an environment of ‘shame and blame’ would find it difficult to adapt to an adult learning environment. Uncertainty avoidance, individualism and gender roles as Hofsted described may play a role in such behavior amongst this cohort of Sri Lankan students.

The availability of resources also influences the delivery and reception of education. When implementing an education system developed elsewhere in to ta resource poor setting this carries a higher weight. In our assessment of the small group discussions, students had indicated that participation in this activity disturbs their current clinical engagement. This may be due to logistical reasons they face during attending these activities. The discussions are arranged at lecture halls at different sites in the hospital depending on the availability and this may result in the students having to spend time to reach the site. Preparation for the topic outside of the current clinical engagement would require them to access reading material on the relevant topic outside of working hours. Being a developing country, access to Internet facilities is limited and costly.

It is encouraging to see that a majority prefers to learn concepts versus memorizing facts to aimed at assessments. This was also highlighted during a previous study done by the author, for online learning during the COVID 19 pandemic in the same student population (15). However conceptual learning requires frequent dialog for the teacher to gauge the level of understanding in the student. With students being reluctant to engage in discussion this task may seem arduous. In a previous study on cross cultural comparison of learning methods by Marambe et al, the existence of a typical Asian learner concept was disputed (14). They also reported that the Sri Lankan students relied less on memorizing and were more interested in the construction of knowledge compared to their South-East Asian counterparts.

Socio-cultural adaptations of learning methods are a crucial area that needs further attention in higher education. In an environment where most of the formulation and research on learning methods are based on western student populations, the direct application of such methods may be ineffective in a contrasting socio-cultural setting (Charlesworth 2008, (7). It will be best if the students are brought up in a student-centered learning environment where construction of knowledge and deep understanding are encouraged. However, in countries like Sri Lanka, due to the scarcity of resources the secondary education has become highly competitive. In communities where the students migrate from such competitive systems into higher education, it will be helpful at least to have an orientation session to introduce the concepts of adult learning at an early stage of the graduate life. Author has initiated such a programme based on the findings of the needs analysis at the institution. A proposal has been also submitted to change the structure of the small group discussion activity to meet the practical difficulties faced by the students and to encourage student participation.

The current widely accepted learning methods in higher education are undoubtedly effective in building a comprehensive graduate. However resistance may be faced during implementation of such methods due to scio-cultural and socio-economic disparities between the target population and the country of origin of such concepts. The current study demonstrated that this Sri Lankan cohort of medical students were engaging less during learning activities due to the anxiety of making mistakes and not willing to address their teachers directly. Both these reasons have a socio-cultural background in the South Asian society. Lack of English language skills and time constraints due to logistic reasons also contributed to their poor participation in small discussion based learning activities. Students are capable of adapting to different learning environments if they are properly guided in the early stages. At present the Sri Lankan higher education system lacks such guidance during the transformation. Teachers may also be required to consider socio-economic factors unique to their locality when designing learning activities to maximize the efficacy. A healthy discussion on cross- cultural adaptation with proper directives is required in the future.

Acknowledgements

I acknowledge the students who provided honest feedback for the needs assessment.

Authors’ contributions

PC was involved in the concept, carrying out the activity, collection of data, analyzing and interpreting the data, writing the manuscript and critically appraising the manuscript.

Funding

No funding was received for this study.

Availability of data and materials

The data is available at https://doi.org/10.6084/m9.figshare.20292459.v1

Ethics approval and consent to participate

Work was carried out in accordance with the Declaration of Helsinki, including, but not limited to the anonymity of participants being guaranteed. Informed consent was provided by all participants.

The study was exempted form a full review and approved by the Ethics Review Committee of the Faculty of Medcine, University of Kelaniya, Sri Lanka (P/134/11/2022).

Competing interests

PC does not declare competing interests.

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No competing interests reported.

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Needs assessment in surgical undergraduate teaching in a South Asian cohort; implications for cultural adaptations

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