Students' Perception of Quality of Medical Education in a Medical

© 2016 Indian Journal of Public Health | Published by Wolters Kluwer - Medknow

Students’ Perception of Quality of Medical Education in a Medical College in West Bengal, India

Dipta Kanti MukhopadhyayAssociate Professor, Department of Community Medicine, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India

Abstract

Background: Students’ perceived quality of educational service is an important fi eld of educational research. Objectives: To identify the gaps in the quality of educational services as perceived by students in a medical college in West Bengal, India. Materials and Methods: In a cross-sectional study, educational quality was measured using validated SERVQUAL instrument between two randomly selected groups of undergraduate medical students (n = 179). This fi ve-point Likert scale questionnaire measured the expectation and perception of students on 26 items under fi ve dimensions of quality of educational services, viz., tangible (physical facilities, equipment, and appearance of personnel), reliability (accuracy and consistency of a department in providing educational services), responsiveness (eagerness to help and commitment), assurance (ability of teaching departments to earn students’ confi dence), and empathy (ability to communicate care and understanding). Dimension-wise difference in the mean scores for expectation and perception was calculated and was considered as quality gaps in educational services. Results: Signifi cant negative quality gaps were noted in all fi ve dimensions. The highest gap was found in tangible (-1.67) followed by empathy (-1.64) although the mean score of perceived quality in the dimension of empathy was the lowest (2.53). This indicates the need for improvement in physical facilities as well as behavior of teachers and staff toward students. The smallest gap was noted in the dimension of assurance (-1.29), which indicates the students’ overall confi dence in teaching departments regarding their management or content expertise. Conclusion: These fi ndings underscore students’ aspiration for the overall improvement of educational services that can be taken into consideration during development planning.

Keywords: Medical education, quality, SERVQUAL, students’ perception

Introduction

Medical education is primarily meant to serve medical students although the ultimate goal is to ensure quality health care to the community. The Medical Council of India, universities, colleges, teachers, students, and the community are the stakeholders of medical education in

Corresponding Author: Dr. Dipta Kanti Mukhopadhyay,Lokepur, Near NCC Offi ce, Bankura - 722 102, West Bengal, India.E-mail: [email protected]

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India. Collaboration of these stakeholders is necessary for improvement of the quality of medical education, particularly in a country, which produces around 50,000 qualifi ed doctors per year.1 The perception and expectation of stakeholders are crucial for collaboration. However, in India, there is little opportunity to consider the views of students and the community during planning and implementation of medical education. Educational service quality emphasizing the students’ view is an important fi eld of educational research. It is not only related to students’ performance but also can be a useful

Cite this article as: Mukhopadhyay DK. Students’ perception of quality of medical education in a medical college in west Bengal, India. Indian J Public Health 2016;60:4-9.

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5Mukhopadhyay: Students’ perceived quality of medical education

Indian Journal of Public Health, Volume 60, Issue 1, January-March, 2016

basis for improving the quality of the educational service itself.2,3

Perceived quality is the judgment about excellence of a service from the point of view of the expectations of people using that service.4 SERVQUAL, a multiple item scale with established validity and reliability, has been used to measure the service quality as a gap between consumer perception and expectation of services in different settings including higher education although students cannot be seen as “consumers” in the same way as a person who buys a commodity in a shop.5-7

Studies highlighting the issue of students’ perceived quality gaps in medical education, which might sensitize policy makers and administrators to their needs, are reported from other countries but are scarce in India.8-10

The objective of this study was to determine the quality gaps within educational services as perceived by the medical students using an instrument based on the SERVQUAL model in a Medical College in West Bengal, India.

Materials and Methods

Study design and durationA cross-sectional descriptive study was conducted in Bankura Sammilani (B.S.) Medical College, Bankura in West Bengal from May 2010 to April 2011.

Development and validation of questionnaireThe instrument (SERVQUAL) was modified for adaptation in the present setting to measure the students’ perceptions and expectations of the service quality of medical education along fi ve dimensions: Tangible (physical facilities, equipment, and appearance of personnel), reliability (accuracy and consistency of a department in educational service provision), responsiveness (eagerness to help and commitment), assurance (ability of teaching departments to earn students’ confidence in a professional manner), and empathy (ability to communicate care and understanding).5 Based on the theoretical construct of the instrument, four focus group discussions were conducted with students who were not selected in the study to identify items of educational quality under the abovementioned constructs. Similarly, in-depth interviews with 15 medical teachers having a formal training in medical education technology

were conducted to identify items on essential quality of medical education. The items proposed by the students and teachers were reviewed and a harmonized version of the questionnaire was developed with 41 items. Through the Delphi technique, with the help of seven medical education specialists, a fi nal version of the questionnaire with 26 items was prepared. Using the instrument, the students were asked to rate their perception about the quality of educational services in a fi ve-point Likert scale (very good, good, moderate, poor, and very poor). They were also asked to rate their level of expectation on each item in a fi ve-point Likert scale (very important, important, moderate, less important, and least important). Each item was scored from 1 to 5 with very poor/least important as 1 and very good/very important as 5 and others in between. In each dimension, the score of individual items was added up and the sum was divided by the number of items in that dimension to get a mean score. The mean score of each dimension of the study population was calculated in both the perceived and expected services of education.

Expectation and perception questionnaires in the fi ve-point Likert scale were pilot tested among 100 students outside the study population representing two year groups. Five principal constructs, similar to theoretical constructs were yielded on principal component analysis with varimax (variance maximization) rotation in both the expectation and perception scales having a minimum loading of 0.34 [Tables 1 and 2]. The extraction method used based on eigenvalue greater than 1. All the items except item no. 9 showed maximum loading in the concerned theoretical dimensions. Item no. 9, though theoretically considered in the reliability dimension, showed higher factor loading in the responsiveness dimension.

After redistribution of items based on principal component analysis, dimension-wise internal reliability were examined with Cronbach’s alpha. In the expectation scale, values of Cronbach’s α were 0.78, 0.76, 0.78, 0.82, and 0.86 for tangible, reliability, responsiveness, assurance, and empathy, respectively [Table 1]. Similarly, as noted in Table 2, all fi ve dimensions of the perception questionnaire were found to be internally reliable (Cronbach’s α was 0.75, 0.83, 0.85, 0.69, and 0.74 for tangible, reliability, responsiveness, assurance, and empathy, respectively).


6 Mukhopadhyay: Students’ perceived quality of medical education


Test-retest validity was examined in a small group of students (n = 25) with a washout period of 2 weeks and weighted kappa value for each item was above 0.8.

The validation of questionnaire establishes that the questionnaire was internally consistent, reliable, and valid in the present sociocultural setting.

Study subjects and method of data collectionIn this study, two year groups with 199 enrolled undergraduate medical students were selected randomly out of fi ve year groups. In small group teaching classes, after taking written informed consent, the anonymous self-administered questionnaires were distributed among students. They were requested to submit the fi lled up questionnaires in a box kept in the classroom. Absentees were recorded from the attendance register and they were retrieved in three consecutive visits.

Medical teachers attached to the institution with an experience of 5 years and above were also requested to express their expectation and perception of the quality of medical education in the same questionnaire.

In both the expectation and perception scales, dimension-wise mean score was calculated. The difference between the mean score in the expectation and perception scales in each dimension was considered as “quality gap” and Wilcoxon signed-rank test was applied to check whether the differences were signifi cant or not.

Ethics: The study obtained clearance from the Institutional Ethics Committee of the concerned medical education institute.

Results

The total number of enrolled students in the selected classes was 199. In the present study, 179 (89.9%) students participated, out of whom 33.3% were females. Among the study subjects, 50.5% were 3rd Professional Part I students and the rest were from the 2nd Professional Bachelor of Medicine, Bachelor of Surgery (MBBS).

ExpectationProvision of handouts after class (item no. 9 under “reliability”), out-of-class consultation (item no. 18 under “responsiveness”), and of giving anonymous suggestion to departments (item no. 23 under Empathy) were considered as of moderate importance by the students with score less than 4 [annexure 1]. The remaining 23 items having scored more than 4 indicated that they were considered as important by the students. All fi ve dimensions of quality as per SERVQUAL concept were regarded as important (score ≥4) by the students. There was no signifi cant difference in expectation by gender or class.

PerceptionIn eight items such as neat and professional appearance of teachers, clarity of teaching materials, developing clear concept by attending class, regular classes, timeliness in teachers, easy accessibility of teachers as well academic heads and adequate preparedness of the teacher for the class (item no. 1, 7, 8, 10, 12, 13, 14, and 21 as shown in Annexure 1), the quality of existing services was perceived as moderate (score 3-4) by the students, whereas in the remaining 18 items the services were perceived as of poor (score 2-3) or very poor quality

Table 1: Rotated factor structure and domain-wise Cronbach’s

alpha for expectation scale

Item No. Components

Assurance Empathy Reliability Responsiveness Tangible

E1 0.139 0.690

E2 0.106 0.216 0.159 0.721

E3 0.292 0.157 0.774

E4 .130 0.750

E5 .203 0.640 .212

E6 .251 .165 0.556 .175 .102

E7 .330 .243 0.441 .179 .235

E8 .214 0.618 −.154

E9 .347 .148 0.389 .246

E10 0.705

E11 .137 0.521 .439 .120

E12 .187 0.593 .269

E13 .346 .159 .189 0.556 .200

E14 .375 0.625

E15 .142 .227 .176 0.629 .107

E16 .122 0.691 .134

E17 .201 .314 0.488

E18 .363 .250 .276 0.468 .131

E19 0.735 .197 .138 .149

E20 0.751 .101 .218

E21 0.767 .115 .152 .215

E22 0.641 .151 .117 .210 .216

E23 .106 0.720 .137 .244

E24 .157 0.852 .192

E25 .170 0.817 .223

E26 0.796 .152 .205 .241

Cronbach’s

alpha

0.82 0.86 0.76 0.78 0.78

Extraction Method: Principal Component Analysis (loading less than 0.1 were

omitted), Rotation Method: Varimax with Kaiser Normalization.




(score <2). Assurance was the only dimension where the perceived quality of services was moderate. In the remaining four dimensions, the mean scores were less than 3 and more than 2, which indicated that those services were perceived as poor. Signifi cant difference by gender or class was also not found in perception.

Quality gapIn all fi ve dimensions, expectation of students exceeded their perceived quality of existing educational services [Table 3]. Highest gap was found in the dimension of tangible (−1.67) indicative of physical facilities, equipment, and appearance of the personnel followed by the dimension of “empathy” (−1.64), the ability to communicate care and understanding of students. The lowest gap was found in Assurance dimension (−1.28), which means the ability to earn students’ confi dence. Highest quality gaps (two or more) were found in four items (No. 23, 4, 3, and 2) out of which three items were from the “tangible” dimension.

Annexure 1: Questionnaire Sl. no. QualitiesTangible1. Neat and professional appearance of faculty

members2. Comfortable physical facilities in class rooms3. Materials and educational equipment being up-

to-date4. Attractive audiovisual teaching toolsReliability5. Provision of correction of tasks by faculty6.. Conducting evaluation regularly and

communicating results7. Understandability of presented educational

materials in the class8. Class attendance for a clear understanding of

the subject9. Provision of handouts after each class10. Taking classes regularly as per schedule11. Easy accessibility of reference learning materials12. Fulfi lling the responsibilities of the faculty in

promised timeResponsiveness13. Easy accessibility of faculty members in need 14. Easy accessibility of HOD†/Dean in need15. Introducing suitable reference to students for

reading16. Considering students’ view and suggestion in

scheduling classes17. Energy and eagerness of faculty in classes18. Provision of extra time for educational

consultation with facultyAssurance19. Facilitating discussion and interaction in class20. Accessibility of teachers outside class21. Faculty members’ adequate preparedness for

class22. Students prepared adequately for the next level

of educationEmpathy23. Provision of anonymous suggestion to the

departments24. Dignifi ed treatment of students by teachers25. Dignifi ed treatment of students by staff26. Flexibility of teachers to fulfi ll the individual

student’s need†HOD: Head of the Department

Table 2: Rotated factor structure and domain-wise Cronbach’s

alpha of perception scale

Item No. Component

Responsiveness Reliability Empathy Tangible Assurance

P1 .316 .164 0.527 .179

P2 .248 .135 0.759

P3 .181 .157 0.757 .114

P4 .148 0.772

P5 0.854 .110 .190

P6 .208 0.624 .237 .441

P7 0.658 .301 .126

P8 .305 0.699 .200

P9 0.339 .172 .154 .113

P10 .257 0.684 .130 .114 .195

P11 .302 0.559 .188 .242

P12 .471 0.576 .152 .208

P13 0.651 .241 .289 .169

P14 0.658 .254 .219 .173

P15 0.723 .143 .114 .139

P16 0.557 .384 .176 −.192

P17 0.548 .475 .301 .132

P18 0.544 .387 .337 −.134 .190

P19 .387 .150 .399 .137 0.423

P20 .338 .383 0.487

P21 .192 .269 .119 0.611

P22 .203 .416 .209 0.472

P23 0.608 .218 .207

P24 .195 .248 0.744 .215

P25 .213 0.792

P26 .249 .234 0.662 .184

Cronbach’s

alpha

0.85 0.83 0.74 0.75 0.69

Extraction Method: Principal Component Analysis (loading less than 0.1 were

omitted), Rotation Method: Varimax with Kaiser Normalization.

Twenty teachers filled up the questionnaire. They considered all items (item no. 5, 16, and 22) and all


8 Mukhopadhyay: Students’ perceived quality of medical education


dimensions in the expectation scale as important (average score ≥4). In 11 items of the perception scale, the existing services were considered as moderate to poor (average score 2-3) and in rest items the services were considered as good to moderate (average score 3-4). According to the teachers, signifi cant negative quality gap persisted in all SERVQUAL dimensions (P < 0.001), the highest being in tangible (−1.64) followed by empathy (−1.53).

Discussion

The study showed that the students felt quality gaps in all 26 items under fi ve SERVQUAL dimensions. It was evident from the study that students’ perceptions of existing services lagged behind their expectations. Similar fi ndings were noted by Aghamolaei et al., Kebriaei et al., and Mosahab et al. among medical students and students in higher education institutes in Iran, and Chopra et al. and Chua C in higher education institutes in India and Canada, respectively.8,10-13 Negative quality gap in SERVQUAL domains except tangible was reported by Ruby CA while Abili et al. noted negative quality gaps in only three dimensions, namely, tangible, reliability, and empathy.9,14 Ramakrishnan et al. in India found positive quality gap in the responsiveness dimension and negative quality gaps in the rest of the four dimensions.15 Gholami et al. in Iran found negative quality gaps in all dimensions and all but one item.16

Tangible was the domain where students perceived the highest quality gap. It was revealed that students were not happy with the physical facilities, availability of educational aids, audiovisual tools, and appearance of their faculty members. The issue of physical facilities is a matter of real concern in medical teaching institutes in India and other countries.16,17 However, this fi nding differs depending on the setting. In contrast to the present study, Ruby noted positive quality gap in tangible, which means that the perception of students

about physical facilities exceeded their expectations.9 The highest quality gap was reported in the dimension of “responsiveness” in two Iranian studies and “assurance” in a Canadian study.8,9,11

The present study also noted the high negative quality gap in empathy that was in corroboration with Chopra et al. and Ramakrishnan et al. in India.13,15 In the present setting, students perceived that the lowest quality of services was provided in the dimension of empathy even despite their low expectation in this dimension. The lowest perceived quality of service was recorded for the item under this dimension concerning the provision of anonymous suggestions to the department. This perhaps suggests a lack of capacity among college teachers and staff to communicate care and understanding. Awareness of teachers and staff regarding this issue followed by capacity-building can address this dimension of educational services.

Earlier studies in India and Canada noted the lowest negative quality gap in assurance dimension that was similar to the present study.9,13,15 It means that the college and teachers are close to the students’ expectations in enjoying their confi dence. However, Chua, Aghamolaei et al., Kebriaei et al., and Mosahab et al. reported the lowest quality gap in the dimension of reliability.8,10-12

It was encouraging that all the senior teachers including administrators recognized all fi ve SEVQUAL dimension as important in maintaining the quality of educational services.

Negative quality gap in educational service dimensions can be used as a referendum for future planning and allocation of resources at the institutional level.14 Although in the present study, negative quality gaps were found in all fi ve dimensions, a focused approach may be appropriate in our resource-constrained setting to prioritize the issue(s), which are relatively considered to be most important or where the quality gap is maximum. It was encouraging that the quality gaps regarding consistency of and commitment to educational services as well as in earning students’ confi dence were somewhat smaller than in the other dimensions in the current study. Students were mostly dissatisfi ed with the physical facilities and the ways they are treated by the teachers and staff of the college.

This fi nding is specifi c to the study institute and the situation would be different in different institutes. The

Table 3: Domain-wise quality gap in educational services as

perceived by study participants

Domains Expectation

score

Mean ± SD†

Perception

score

Mean ± SD

Mean

gap

P value

Tangible 4.39±0.48 2.72±0.75 −1.67 0.000

Reliability 4.25±0.50 2.89±0.77 −1.36 0.000

Responsiveness 4.26±0.50 2.90±0.91 −1.36 0.000

Assurance 4.28±0.60 3.00±0.75 −1.28 0.000

Empathy 4.17±0.68 2.53±0.86 −1.64 0.000

†SD: Standard deviation




students’ aspiration and perception may differ depending on the background, exposure of the students, and the institutes they were in. Situation in government and private institutes may be perceived differently.

An analysis of the reasons for the observed gaps is the cornerstone of the improvement process and may be considered as a priority issue for further research. It could be suggested that the SERVQUAL model of service quality is applicable in medical education in the Indian sociocultural setting and could provide a useful input in emphasizing the areas of concern in medical teaching institutions, as perceived by students.

AcknowledgementsThe author acknowledges the intellectual inputs of Prof. Janet Grant, Director, Centre for Medical Education in Context (CenMEDIC) and FAIMER Centre for Distance Learning, London, England, Professor Tejinder Singh and Professor Jugesh Chhatwal of CMCL-FAIMER Regional Institute at Christian Medical College, Ludhiana, Punjab, India during different phases of the study and during preparation of the draft.

Financial support and sponsorshipNil.

Confl icts of interestThere are no confl icts of interest.

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Students' Perception of Quality of Medical Education in a Medical