Students ’ Perception of Educational Environment of Medical Colleges in Bangladesh

Background: Students’ perceptions of their educational environment are a useful basis for modifying and improving the quality of educational environment. Educational environment is one of the most important factors determining the success of an effective curriculum. The quality of educational environment has been identified to be crucial for effective learning. Identifying the weakness of educational environment and understanding how students perceive the environment will help the institute to facilitate learning and to achieve better learning outcome. Objective: To explore students’ perceptions of their educational environment and to find out gender differences in perception. Methods: It was a cross sectional descriptive study. Dundee Ready Education Environment Measure (DREEM) inventory was administered to 1903 medical students (studying in 3rd, 4th and 5th year MBBS course) in 15 medical colleges of Bangladesh adopting purposive sampling. Results: The total mean score for all students was found positive (110/200). Students’ perceptions of learning was positive (28/48), perceptions of teachers was moving in right direction (24/44), students academic self perception was positive (19.5/32). Students’ perceptions of atmosphere was expressed as many issues need to change (24/48) and social self perceptions was not a nice place (14/28). Female students’ perceptions were significantly higher than male students. Conclusion: Remedial measure should be needed in the subscales of students’ perceptions of atmosphere and social self perceptions for further improvement. Findings from this study may give guideline to curricular planner and faculties/administrators of medical college for further improvement of educational environment.

the environment 3 .Positive environment and positive learning outcome appears to go together 1 .For higher quality of learning it is required to enrich learning environment by identifying the weakness of environment.So more importance should be given to the perception of students' to improve the educational environment as perceptions are associated positively with learning outcomes, learning approach and attitude toward studying 5 .
The undergraduate MBBS curriculum in our country is still in the traditional mode.Generally it is teacher centred, discipline based, information gathering and hospital based with no options or elective modules.The main part of the curriculum consists of lecture, tutorial, practical and ward teaching classes with a limited number of problem based session.The learning task is to reproduce the subject matter in the final examination.
In 2002, a new comprehensive curriculum was introduced for undergraduate medical education.Educational innovation, such as a new curriculum was about introducing .and implementing changes but unfortunately it is also a fact that both students and faculty the a found curriculum stressful to implement 6 .However no study has been yet done to assess student's perception of educational environment.In order to manage changes successfully it is thus necessary to obtain regular evaluation and feedback, as it is only through information obtained in this way alteration can be made, mistakes corrected and momentum maintained.
Inventories measuring learning environment in medical education are widely being used.In the present study DREEM (Dundee Ready Education Environment Measure) was used.It is a reliable and validated instrument that identifies specific problem areas within an institution for different components of educational environment 7 .As DREEM is a unique inventory to measure educational environment so, the present study was intended to find out perceptions of educational environment using this inventory.This study also intends to identify and compare the perceptions of educational environment between male and female students and attempt was also made to identify problem areas in educational environment.

Methods:
The DREEM (Dundee Ready Education Environment Measure) is a validated inventory with proven high reliability that has been used in various countries around the world to assess the educational environment of health professional/ medical institute 6 .The inventory consists of 50 items and each item scored on a five-point likert scale with 4 = Strongly Agree, 3 = Agree, 2 = Unsure, 1 = Disagree and 0 = Strongly Disagree.Nine of the 50 items (4. 8, 9, 17, 25, 35, 39, 48, 50)  were negative and scored in reverse so that a higher score indicates a more positive reading 7 .
The DREEM questionnaire was administered to 1903 medical students' of clinical phase (3 rd , 4 th and 5 th year) of 15 medical colleges.The questionnaire was administered at the end of a scheduled lecture class on different occasions.Before administration, the questionnaire of the class was addressed regarding the purpose and different aspects of questionnaire for providing appropriate information, stressing the anonymity of the participants and the fact that the data could not be tracked to individual participants.It was also explained that the data would be used for quality assurance as well as for research purpose and requested the students' cooperation, making it clear that participants would be entirely on volunteer basis.After distribution they were allowed 20 minutes to fill up the questionnaire and then the completed questionnaire were returned back in the same class.
The inventory yielded two types of information: mean total score for 50 items or each of its 5 subscales and individual item mean scores for each of the 50 item.
The 50-item DREEM has a maximum score of 200 indicating the ideal educational environment as perceived by the students 8 .A score of 0 is the minimum and would be a very worrying result for any medical educator and a score of 100 will be viewed with considerable ambivalence by the students and needs to be improved.Items that have a mean score of 3.5 or over are real positive points.Any item with a mean of 2 or less should be examined more closely as they indicate problem areas 8 .Items with a mean between 2 and 3 are aspects of the climate that could be enhanced.Score for categorized domains, total score and each item were both expressed as mean and percent value.Data were analyzed using the statistical package SPSS (11.5 version) and independent sample t-test were used to determine statistically significant difference (p<0.05).

Results:
Total respondent were 1903, among them 940 were male 963 were female student.
Table I Shows the DREEM domain and total maximum score, mean score and percentage of score in all respondents.Students' perceptions of learning was 27.86/ 48 (56%) i.e. more positive perception, students' perceptions of teachers was 24.36/44 (55%) i.e. moving in right direction, students' academic self perceptions was 19.51/32 (61%) i.e. feeling more on positive side, students perceptions of atmosphere was 24.34/48 (50%) i.e. there are many issues need to change and students social self perception was 14.37/28 (50%) i.e. not a nice place.Highest score was found in domain 3 and lowest in domain 4 and 5. Total DREEM mean score was 110/200 and when percentage was done it was 55% and it can be expressed Table III shows significant difference in perception between male and female students regarding individual items, subscale and total DREEM mean score.Item wise comparison shows that female scored high in most items.Among them significant difference were found in 17 items.
Only in four items male students scored high than female i.e. teachers ridicule them, they are confident about their passing, they feel they are prepared for their future profession and they have good friends in the college.
Subscales comparison shows that female students scored significantly high than male about perception of learning, teachers and atmosphere.Total DREEM mean score also significantly high in female than male students.

Discussion:
This cross sectional descriptive study was done with a view to determine medical students' perceptions of educational environment in fifteen medical colleges of Bangladesh.Self administered structured questionnaire was used to collect data and DREEM inventory was used for this purpose.
The overall DREEM score for all students were found positive (110/200, 55%).There was no accepted agreement on what is an acceptable DREEM inventory score from published literature.Our total score is consistent with that of others 3 but some others 5, 9, 10 found low (102, 107) total score.On the other hand higher total score (117, 118) was found by other investigators 11,12 in India and Turkey.
The DREEM domains are likely to be independent variables and may be less of an environment measure but more of a measure of the overall motivation and learning attitude of the individual.Five subscales or domains of DREEM were interpreted, which define the weakness or strength of educational environment.When we interpret 8 the five domain it can be stated that all students agreed a more positive approach regarding their perception of learning, moving in right direction for perception of teachers, feeling more on the positive side for their academic self perception, there are many issues which need to change for the perception of atmosphere and social self perceptions were not a nice place.In this study highest score was found in students' academic self perception and lowest score in students' perceptions of atmosphere and social self perceptions.Our findings regarding perceptions of five domains are consistent with others 3,10 .Whereas some others 9,13 found lowest score in students' academic self perceptions and in students perceptions of learning and atmosphere.In another study others 12 found highest score in students' perceptions of teachers and lowest score in students' perceptions of atmosphere.
Gender wise comparison showed higher score in female (112.7/200)students' than male (108/200) and the difference was highly significant.Same observation was made by others 3 but some others 11 found no difference in perception between male and female students and some investigators 5 found lower score in female than male students.Female students perception was high may be due to the fact that they are more satisfed with learning, teaching and atmosphere of environment than male.
The DREEM can be used to pinpoint more specific strengths and weaknesses within the educational environment 7 .Less (<2) score in individual item might be due to our curriculum content overload, teachers attitude towards student, stressful environment and too much formative assessment system.It is very well known that the atmosphere actually represents the real educational environment for learning of students and thus the dynamism of curriculum may influence atmosphere of learning 12 .The ineffective hidden curriculum in our course might be an important factor to explain the relatively low score in students' perception of atmosphere and social self perception.It has shown that hidden curriculum is associated with social and the physical environment and might be more effective than the manifest curriculum 12 .
Teaching learning must be promoted as a scholarly endeavor 3 .An educational climate that foster and rewards educational leadership, innovation and excellence in teaching is required in Bangladesh.Remedial measure should be taken to intervene the perceived problems for some items especially in the subscales of students' social self perceptions and perception of atmosphere respectively.We need to implement student centred learning, more practical oriented session in future to improve our environment.Consideration may be given to staff development, creation of cooperative and congenial teacher-students' relationship in near future for improvement.If we incorporate creative/ elective component in our curriculum we can reduce stress during the course.To improve their social perception issues may be addressed in future are-non threatening environment, good social and academic support, pleasant accommodation, less class time, more opportunity for self learning and scope of practice of informal curriculum.

Conclusion:
As the learning environment affects students' motivation and achievement 4 , it is important to get feedback from the students' on how they are experiencing their learning environment on a regular basis.The results obtained in this study were thus can be used to guide strategic planning and the institutional focus of available resources.Consequently contents of curriculum, teaching methods, teachers' behavior with students', the atmosphere during lecture/tutorial/ward teaching, the social and academic environment, support system during stress, commitment of the institute with students', favorable accommodation for students have come out to be the main intervention areas for the further development of our educational environment.

Table - I
Subscale and total DREEM mean and percentage score in all students (n=1903) SPL=students perception of learning, SPT= Student's Perceptions of Teachers, SASP= Student's Academic Self-Perceptions, SPA= Student's Perceptions of Atmosphere, SSSP= Student's Social Self Perceptions.as more positive.

Table - III
Item and domain mean score shows significant difference between male and female students'.