Does an Attendance-Credit Increase Medical Students’ Attendance in In-class Lectures and Performance in Pharmacology and What is the Correlation Between Class Attendance and Performance on Pharmacology Exams?

K Raj Paudel¹, R Panta², L Diaz¹, G Johnson¹, S Thapa¹

Affiliations:
¹Trinity Medical Sciences University School of Medicine, St Vincent and the Grenadines
²Physiology, Department of Clinical and Applied Science Education at the University of the Incarnate Word School of Osteopathic Medicine, USA

Corresponding Author
Keshab Raj Paudel, MD
Trinity Medical Sciences University- School of Medicine
Ratho Mill, St Vincent and the Grenadines
Email: [email protected]

DOI:

Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.

©2022 The Authors. Caribbean Medical Journal published by Trinidad & Tobago Medical Association.

ABSTRACT

Objectives
This study aimed to find out the effect of an attendance-credit on class attendance and performance on Pharmacology exams, and analyze a correlation between class attendance and performance on Pharmacology exams.

Methods
A total of 182 students from a period of two years, January 2017 to December 2018, were enrolled in the study. Ethical clearance was obtained from the institutional review board. Attendance of the first group of students was credited whereas the attendance of the second group of students was not credited. Lecture materials were made available and downloadable to the students from the beginning of the semester until the end of final exams, irrespective of their class attendance. Assessment items were single response multiple-choice questions built around clinical vignettes. Pearson correlation and Chi-Square (χ²) tests were used as tests of significance. The level of significance was considered at P-value ≤0.05.

Results
Eighty seven percent (87%) of students attended more than 70% of lectures when class attendance was credited whereas only 44% of students attended more than 70% of lectures when the attendance was not credited. The average of ‘credited class attendance’ was 87% vs 61% for ‘non-credited class attendance’ (P<0.001). The correlation between academic score and ‘credited class attendance’ was significant (r= 0.240, df= 90, r for df 90 at P=0.05 is 0.205), and the correlation between academic score and ‘non-credited class attendance’ was stronger (r= 0.368, df= 88, r for df 80 at P=0.01 is 0.283) than for credited attendance.

Conclusion
Provided that lecture materials are available and downloadable from the beginning until the end of the semester to the medical students, an attendance-credit, an external motivation, increased the class attendance significantly in the lectures. However, it did not increase the performance on Pharmacology exams accordingly.  The class attendance had a significantly positive correlation with the performance on Pharmacology exams. So, present study concludes that students who attend the lectures irrespective of the external motivation perform significantly higher on the exams, and it has a strong positive linear correlation.

INTRODUCTION
Medical students’ attendance in class activities is important for their academic success.¹ However, increasing absenteeism of students in medical schools is common globally besides strict attendance policies.² Students’ attendance in the lectures helps understand the basic concepts in clinical scenarios, promote social interaction among the students, enhance communication skills and adapt in new learning environment. It also exhibits students’ positive attitude, professionalism and dedication towards medical education which play important role in students’ future success in medical education.³ Even before the Corona virus disease-19 (COVID-19) pandemic, the easy availability of online resource materials has largely reduced the classroom attendance in medical colleges⁴ and has caused the lack of interest to attend the lectures to prepare for assessments.⁵ Nevertheless, previous studies have indicated that even if students have access to recorded online lectures⁶ and other online and commercially programmed resources, poor class attendance of the lectures may lead to failure of students if they rely completely on the online resources without having prepared the authentic materials provided by the medical educators at medical universities.^7-9 Furthermore, students who attend lectures regularly are highly successful academically and are enthusiastic to apply their knowledge clinically; whereas, students who fail to attend lectures regularly lag behind academically and often have poor grades, which affects their academic progress negatively.^7-9

Due to COVID-19 pandemic, many medical universities have resorted to online platforms to continue medical education. However, the success of online medical education is yet to be measured and evaluated on a larger scale. Provided that the lecture materials are easily available to the students, the importance of class attendance in theory classes may be a debatable topic among medical educators, even if we have findings in the literature favoring and mandating class attendance.⁸ In the in-class lectures, the attendance of students is dependent on both external and internal factors namely affecting extrinsic and intrinsic motivation.^9-10 Students who are intrinsically motivated apply a deep study approach and may attend the lectures regularly and consistently.¹⁰ Providing credit to the class attendance is one extrinsic motivational factor which may increase attendance and performance on the exams, and it may help distinguish the performance of students on the exams between intrinsically and extrinsically motivated students. So, we hypothesized that an attendance-credit as an external motivating factor increases both class attendance and performance on Pharmacology exams. Thus, the present study aimed to evaluate the effect of an attendance-credit on class attendance and performance on Pharmacology exams, along with a study of a correlation between class attendance and performance on Pharmacology exams of medical students who were in pre-clinical years.

MATERIALS AND METHODS
A total of 182 students from a period of two years, January 2017 to December 2018, were enrolled in the study. Ethical clearance was obtained from institutional review board of Trinity Medical Sciences University (TMSU). Students were enrolled in the study when they were in their third academic semester and were instructed by the same professor with more than 8 years of teaching experience. A professor lectured 45 Pharmacology didactic lectures in a traditional pedagogy, using PowerPoint slides and a projector, and the lectures were recorded using Panopto. All the PowerPoint slides and the recorded lectures were made available to all the students till the end of their academic semesters, irrespective of their class attendance. The first group of students (Spring, Summer and Fall 2017) were given an attendance-credit of 10 points (credited attendance) calibrated as per their percentage of attendance during their whole semesters. Following the subsequent year, attendance of the second group (Spring, Summer, and Fall 2018) of students was not credited (non-credited attendance). An attendance record sheet was circulated in prior to each lecture and was collected after completion of the lecture. Students were given three formative assessments and one summative assessment. Assessment items were single response multiple-choice questions built around clinical vignettes with one best answer and four distracters and were prepared by the same professor who lectured the topics. Only the concepts covered in the lecture materials were tested on the exams.  Assessments were delivered by using ExamSoft. Academic scores in percentages were correlated with class attendance in percentages. Pearson correlation test was used to find the correlation between the scores and class attendance, and Chi-Square (χ²) test was used to compare the categorical data. P-value ≤0.05 was considered to be significant.

RESULTS
Provided that all the class materials and recorded videos were available to the students throughout the semesters irrespective of class attendance, the non-credited class attendance was 61%±31.95% (mean±SD) vs 87%±17.16% for credited class attendance with significant statistical difference, and the scores on the exams were 76%±11.89 vs 76±10.86%, respectively (table 1 and figure 1). Eighty-seven percent (87%) of students attended more than 70% of lectures when class attendance was credited, whereas only 44% of students attended more than 70% of lectures when attendance was not credited (figure 1). Figure 2 shows a linear relationship between attendance (credited and non-credited) and performance on Pharmacology exams. However, there was no commensurate increase in performance when there was an increase in class attendance in credited attendance (table1, figure 2). The correlation between academic score and ‘credited class attendance’ was significant (r= 0.240, df= 90, r for df 90 at P=0.05 is 0.205) (figure 3), and the correlation between academic score and ‘non-credited class attendance’ was highly significant (r= 0.368, df= 88, r for df 80 at P=0.01 is 0.283) (figure 4). So, the results showed a stronger correlation between class attendance and performance on the exams when the attendance was not credited than for credited attendance and performance.

Table 1 – Students’ attendance and performance on Pharmacology exams

Figure 1 – Comparison between credited and non-credited class attendance, χ² test

Figure 2 – Relationship between class attendance and score on Pharmacology exams (mean values are plotted)

Figure 3 – Correlation between academic score and class attendance (credited), Pearson correlation test, r= 0.240, df= 90, r for df 90 at P=0.05 is 0.205

Figure 4 – Correlation between academic score and class attendance (non-credited), Pearson correlation test, r= 0.368, df= 88, r for df 80 at P=0.01 is 0.283

DISCUSSION
The present study was set to find out the effect of an attendance credit on class attendance, the performance of students on Pharmacology exams and a correlation between class attendance and performance on the exams. Results of the study showed that significantly (P<0.05, figure 1) a low number of students- the mean class attendance for non-credited attendance was 61% vs 87% for credited attendance, (table 1)- attended class lectures when attendance was not credited, provided that lecture materials and recorded lecture videos were accessible to the students. Also, 87% of students attended more than 70% of lectures when class attendance was credited whereas only 44% of students attended the same when attendance was not credited (figure 1). These findings suggest that external motivation in the form of an attendance-credit increases class attendance, which may play an important role to facilitate learning environment by incorporating group discussions and interactive sessions. In this study, the reasons why students were less interested to attend the in-class lectures were not explored. However, based on the findings, it can be postulated that the easy availability of the same lecture materials and recorded lectures might have decreased the class attendance when class attendance was not credited, and this postulation is in agreement with previous findings of a study.⁷

The poor class attendance also reflects low levels of self-motivation which might have been resulted from poor socialization, low self-confidence, improper sleep pattern, etc.¹¹ Additionally, quality of teaching materials, students’ and teacher’s learning attitudes, exam patterns, academic environment of a lecture hall, family environment, and extra-curricular activities also contribute to the poor class attendance.¹² It is noteworthy to mention that consistent class attendance is paramount to ignite new ideas in students’ minds; to develop analytical and critical skills; and to improve academic performance by increasing team-work efficiency, self-confidence, and reasoning ability, which ultimately lead to students’ academic progress and success.¹³ So, based on the findings of the study, it can be suggested that allowance of attendance credit as an external motivation is useful to increase the class attendance of students to overcome the poor attendance problem in medical schools.

In addition to an attendance-credit, other factors that increase the attendance of the students in the class lectures need to be considered and incorporated in the teaching strategy in medical schools. For example, a mandatory requirement of student attendance can be incorporated in the curriculum design which plays central role to increase students’ attendance and involvement in learning activities.⁸ Additionally, the student-focused and interdisciplinary-integrated curriculum is more impactful than traditional teacher-centered curriculum to enhance students’ engagement and interactions in learning environment.^14-15

Despite the increase in the class attendance of the students after the attendance was credited, the performance of the students on the exams did not increase proportionately as it was evident by the finding that the academic score was 76±10.86% when attendance was credited and it was 76±11.89 when the attendance was not credited (table 1). This result indicates that internal motivation is a very important factor for academic success and attending lectures by the students only to fill mandatory requirements and get the attendance-credit does not lead to academic success. However, results showed a significant positive linear correlation between class attendance and performance on the Pharmacology exams (figure 2, 3 and 4) which is noteworthy. So, the important indication of this finding is that the external motivation (an attendance-credit) did not increase the performance commensurately with an increase in class attendance; however, class attendance of intrinsically motivated students is an independent indicator for their academic success.

Findings of the study showed that there was a strong positive linear correlation between class attendance and performance on the exams (figure 3,4). The Pearson’s correlation coefficient (r) between class attendance and performance on the exams was 0.240 (df=90) when the attendance was credited, and it was 0.368 (df=88) when the attendance was not credited. This result demonstrates that when the attendance was not credited the correlation between in-class attendance and performance on the exams was even stronger (figure 4) than the correlation for credited class attendance and performance on the exams.  So, this finding suggests that students who participate in the class lectures without caring for attendance-credit are more intrinsically motivated, and adopt a deeper approach to their learning strategies, leading more academic success.^{10, 16-19} Also, ethnicity, socioeconomic status, cognitive, and psychological determinants may affect the academic success of the students²⁰ and these factors have not been taken into account in the present study.

Limitations of the study include small sample size, single medical school, and failure to assess factors leading to poor class attendance. Such factors include students’ and faculty’s attitude towards learning, and quality of presented materials.¹² In the present study, only class attendance was observed in terms of academic success of students with respect to the grades on Pharmacology exams, and the other aspects of professional and social development after class attendance have not been explored in the study.

CONCLUSION
Attendance-credit, an external motivation, increased the class attendance significantly in the in-class lectures. However, it did not increase the performance on Pharmacology exams in accordance with an increase in class attendance provided that lecture materials and recorded lecture videos were made easily accessible and downloadable to the students from the beginning till the end of the semester. Class attendance had a significantly positive correlation with the performance in Pharmacology. So, present study concludes that students who attend the lectures regularly irrespective of the external motivation perform significantly higher on the Pharmacology exams, and the positive correlation is very robust. Therefore, the findings of the study suggest that the intrinsic motivation of medical students is a very strong factor for academic success.

Ethical Approval statement: Obtained from institutional review board of Trinity Medical Sciences University (TMSU)

Conflict of Interest statement: None

Informed Consent statement: Not Stated

Funding statement: None

Authors Contributions: Conceptualization and initial study design by KRP, data collection and analysis by KRP and RP, manuscript writing and finalization by KRP, RP, ST, GJ, and LD

Acknowledgement: TMSU Students

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