Medical Students’ Perceptions at Dow University of Health Sciences using Dundee Ready Education Environment Measure Inventory

Objectives: To assess medical students’ perceptions regarding learning, teachers, academics, atmosphere at campus and social self-perceptions at Dow University of Health Sciences using Dundee Ready Education Environment Measure (DREEM) Inventory. Method: This cross-sectional observational study was conducted from March 1st, 2022 to September 30th, 2022. All medical students at Dow University of Health Sciences were offered to participate. All students were given the choice to respond to DREEM questionnaire via online Form or printed copy anonymously. The DREEM Inventory measures five domains of students’ perceptions of a given institution. Comparison of responses between different years and institution was carried out by χ2 test. Means scores were compared by Student’s t-test and ANOVA, p-value of ≤.05 was taken as significant. Results: Total of 1054 out of 1750 (60.23%) students submitted fully completed forms and were included, out of these 632 (60.0%) belonged to Dow Medical College & 422 (40.0%) belonged to Dow International Medical College. The mean ±SD of total score of DREEM by DMC students was 100.07 ±31.46 and that of DIMC was 100.52 ±32.73. According to DREEM Global scoring both colleges scores fell into category of “many problems”. Analysis according to domains showed that maximum score was given to 2nd domain of their “perception regarding teachers” and minimum score was allocated to 5th domain regarding “social self-perceptions”. Conclusion: Overall Students perceived environment at DUHS as “many problems” category. This needs to be investigated for betterment of Educational Environment (EE) at campus.


INTRODUCTION
Educational Environment (EE) at campus is an important factor in students' learning and development.These include many factors, e.g., curriculum, teachers' attitudes, self-perception, campus environment and social perceptions etc. Curriculum is defined as the process of learning during the period of student educational process and the document is planned according to the goals of institution. 1 This process includes not only the syllabus, but the overall factors mentioned above.Assessment of the needs of targeted learners is one of the primary objectives of curriculum development.Curriculum should meet the needs of its learners; it is either inefficient or ineffective if it fails to meet this goal.The feedback refers to the information described by the students for the performance in each activity that is intended to guide their future performance in the course they taught. 2,3Medical programs offer a systems-based curriculum in which learning is integrated and there is a system to assess the strength and weakness of the curricula by a mechanism called Dundee Ready Education Environment Measure (DREEM) inventory.The DREEM Inventory has been validated with high reliability in many countries to assess the educational environment of health professional/medical schools and has been translated to Spanish too. 4 Dow University started developing the integrated curricula in 2009 and implemented it in 2011.Up to now six batches have passed out with this curriculum. 5The new curricula is designed to have both horizontal and vertical integration in all subjects taught during the course of MBBS.Assessment of education environment by an inventory is a healthy tool to determine the effectiveness of curriculum.One study carried out in 2013 in DUHS for assessment of educational environment showed total mean score of 57.2%, at that time Sind Medical College was also affiliated with DUHS. 6Much time has passed and there is need to reassess the students' perception of educational environment again.It is therefore important to identify the elements operating in institution and students' perception about them to form foundations for modifications that would augment students' understandings in relation to curriculum teaching goals.This exercise will help to identify Medical Students' Perceptions at Dow University of Health Sciences (DUHS) using Dundee Ready Education Environment Measure (DREEM) Inventory and will thus help to improve it for better teaching and learning.

METHODS
This cross-sectional Observational study was conducted between March 1 st , 2022 to September 30 th , 2022.Study was conducted simultaneously in two medical colleges, Dow Medical College (DMC) & Dow International Medical College (DIMC) that are affiliated with Dow University of Health Sciences (DUHS).All students at both colleges were offered to participate.Study Instrument: DREEM questionnaire is a 50-items questionnaire where each item is scored using a 5-point Likert scale between 0 to 4 (4 = very much agree; 3 = agree; 2 = not sure; 1 = disagree; 0 = strongly disagree).Reverse coding is required for 9 items (4, 8, 9, 17, 25, 35, 39, 48, and 50 [meaning that 4 = strongly disagree; 3 = disagree; 2 = not sure; 1 = agree; 0 = very much agree]). 7he total scale consists of 5 domains: from all academic years were offered the chance to fill in proforma anonymously.Both online Google forms and their printed hard copies were created and were offered to students for participation by any method they choose.Online forms were forwarded by WhatsApp/Email using the college student database of mass email server after permission form relevant principals.Information regarding URL of online form was also displayed after lectures in classes and questionnaire along with a respondent information sheet, was handed to all students present in the class (each semester separately) after routine lectures.The information sheet included a short introduction to the objectives of the study and of DREEM.Since it was anonymous, a separate consent Form was not collected.If questionnaires were returned filled, consent was implicit; if questionnaires were returned blank, non-consent was considered.The data was handled and stored in accordance with the tenets of the Declaration of Helsinki (1964, seventh revision in 2013). 9The submitted forms were then entered/imported in SPSS for analysis.Data Analysis: The DREEM Inventory measures five domains or subscales of students' perceptions of a given institution.These include students' perceptions regarding learning, teachers, academic self-perception, atmosphere at campus and social self-perceptions.Total environment score and scores for the five domains or subscales were calculated.Comparison of responses between different years and institution was carried out by χ 2 test.Means scores were compared by Students' t-test and ANOVA, p-value of ≤.05 was considered significant.

RESULTS
A total of 1054 students returned/submitted fully completed forms and were included in the study, out of these 632 (60.0%) belonged to DMC & 422 (40.0%) belonged to DIMC.In DMC 459 (72.6%) were females & 173 (27.4%) were males, while in DIMC 256 (60.7%) were females & 166 (39.3%) were males.The year-wise distribution of students who responded is detailed in Table-I.
The mean ±SD of total score of DREEM by DMC students was 100.07 ±31.46 and that of DIMC was 100.52 ±32.73, there was no significant difference in scores given by students of two colleges regarding curriculum [t (1052) = -.222;p = .824].According to DREEM Global scoring both colleges scores fell into category of "many problems".Year wise distribution of means of DREEM Global scores showed that in both colleges' year one, two and three responses were in category "more positive than negative" but year four & five responses were in category "many problems".Year wise mean DREEM Global scores are given in Table-I.Students DREEM scores according to gender showed that males gave higher scores as compared to females (101.72 ±32.2 vs 99.56 ±31.8), but the difference was not statistically significant [t (1052) = 1.03; p =.306].

Table-II
Minimum scores were given by 4 th year students, while maximum scores were given by 1 st year students.Inter-class difference of scores was assessed by oneway ANOVA test which showed significant differences in scores between classes except that between 2 nd and 3 rd years, details are given in Table-III and Fig. 1.DREEM score analysis according to its domains by medical students of DUHS showed that maximum score was given to 2 nd domain of their perception regarding teachers and minimum score was allocated to 5 th domain regarding social self-perceptions.Details of all 50 items' mean scores according to five domains is detailed in Table-IV.

DISCUSSION
In our study the mean of total score of DREEM by DMC students was 100.07 and that of DIMC was 100.52, both these values fall into category of 'many problems'.In our study the highest mean scores for the DREEM inventory were recorded for the first year while minimum scores were given by 4 th year students.][12] The students' perception can be used to initiate change and improvement in EE of the institute.Evaluation of EE should be part of educational practices by any institute. 13,14A study showed that when learners feedback was incorporated into curriculum, the learners' satisfaction level improved significantly. 15We need to ensure that the environment is as conducive as possible to learning, thus reducing the risk of academic underachievement.Our results showed that it is essential for faculty members and course managers to make more efforts toward observing principles of instructional designs, to create an appropriate educational environment, and to reduce deficits to provide a better learning environment with more facilities and supportive systems for the students.
In a study from Peshawar, Pakistan comparison were done between pre-clinical and clinical students regarding educational environment and they did not find any difference in opinion. 11[17][18] 8 This trend was also observed in our study where highest scores were given by 1 st year which gradually decreased to lowest for 4 th year, but 5 th year students scored slightly better than 4 th year students.Same effect was also seen in another study which also showed that the scores given by 1 st year were highest and lowest by final year students.In many studies that used DREEM for EE, it was found that Q3 (There is a good support system for students who get stressed) was found to be most problematic.This was followed by Q27 (I am able to memorize all I need), Q4 (I am too tired to enjoy the course), Q9 (Teachers are authoritarian), Q25 (The teaching overemphasizes factual learning), Q42 (The enjoyment outweighs the stress of the course), and Q48 (The teaching is too teacher oriented). 21The items of concern in our study were 3, 4, 5,7, 9, 12, 13, 14,  16, 21, 22, 24, 25, 27, 28, 30, 32, 36, 41, 42, 43, 44, 45 &  48.Out of these Q3 (There is a good support system for students who get stressed), Q9 (The teachers are authoritarian), Q12 (This college is well timetabled) need urgent redressal by institute administration.In comparison with some other institutes where Q17 (Cheating is a problem in the school) and Q39 (The teachers get angry in the class) were not identified as issues in our study and DUHS is managing these items amenably.
Five items that got highest scores in our study in descending order are Q10 (I am confident about my passing this year; 2.57 ±1.23), Q15 (I have good friends in this college; 2.56 ±1.38), 17 (Cheating is a problem in this college; 2.47 ±1.35), Q2 (The teachers are knowledgeable; 2.45 ±1.25) & Q18 (The clinicians have good communications skills with patients; 2.35 ±1.10).Students' self-opinion regarding their passing is a good omen more over students also highly ranked teachers' knowledge and clinicians' good communications skills with patients.Also, in students' opinion cheating is not a problem in DUHS.
Five items that got lowest scores in ascending order were Q3 (There is a good support system for students who get stressed; 1.34 ±1.29), Q4 (I am too tired to enjoy the course; 1.62 ±1.24), Q12 (This college is well timetabled; 1.65 ±1.34), Q14 (I am rarely bored on this program; 1.65 ±1.26) & Q42 (The enjoyment outweighs the stress of the program; 1.71 ±1.30).
University management needs to address the low scoring domains for better student experience in university that will also increase their interest in education.
Limitations: It was conducted in only one university.

CONCLUSION
Students perceived EE in DUHS as "many problems".Some negative aspects were also revealed, e.g., lack of support for students who are stressed, more tried to enjoy course, poor timetable and getting bored.These facts need looking into for betterment of EE.A change in attitudes and approach by teachers and administration will mitigate the deficiencies pointed out by students and will help to provide better EE for students thus helping them to become very competent professionals.

Table - I
: Year wise distribution of students who responded as per their college affiliation.

Table -
IV: Mean scores of 50 items and five domains of Dundee Ready Educational Environment Measure (DREEM) from 1054 medical students of DUHS.
Our results were similar to study conducted in India in which global scores were