Sociocultural factors affecting first-year medical students' adjustment to a PBL program at an African medical school

doi:10.21203/rs.3.rs-2981284/v1

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Research Article

Sociocultural factors affecting first-year medical students' adjustment to a PBL program at an African medical school

https://doi.org/10.21203/rs.3.rs-2981284/v1

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Journal Publication

published 13 Mar, 2024

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Background

Besides regulatory learning skills, learning also requires students to relate to their social context and negotiate it as they transition and adjust to medical training. As such, there is a need to consider and explore the role of social and cultural aspects in student learning, particularly in problem-based learning, where the learning paradigm is different from what most students have previously experienced. This article explores two significant sociocultural factors contextualized in an African setting that may conflict with effective problem-based learning implementation: the socialization of schooling before medical training and the cultural socialization relating to speaking and silence.

Method

We employed a qualitative case study approach using in-depth interviews with 23 first-year students. Participants ranged in age from 18 to 25 years. All students were bi/multilingual (some spoke three to five languages), with English as the learning language. We conducted an inductive thematic analysis to systematically identify and analyze patterns in the data using the Braun and Clarke framework.

Results

Before medical school, students worked hard to compete for admission to medical school, were primarily taught using a teacher-centered approach, and preferred working independently. At the beginning of medical school, students found it difficult to understand the problem-based learning process, the role of the case, speaking and working effectively in a group, managing a heavy workload, and taking increased responsibility for their learning. By the end of the first semester, most students were managing the workload better, were more comfortable with their peers and facilitators, and appreciated the value of the problem-based learning approach.

Conclusions

In the sub-Saharan African context, sociocultural factors provide another lens for understanding students' learning experiences in a problem-based learning program. Adjustment to problem-based learning requires a conceptual and pedagogic shift towards learner-centered practice, particularly concerning self-direction, the role of the case, and collaborative learning.

first-year medical students

PBL

sociocultural

adjustment

bi/multilingual

The implementation of problem-based learning (PBL) is part of a broader shift toward a constructivist-oriented learning paradigm [1], learner-centered teaching [2], and to some extent, the problem-posing model of education [3] partly intended to confront students' apathy and lack of excitement and motivation about learning during medical school [4]. Learning challenges experienced by medical students have generally been associated with limited regulatory learning skills, such as poor study and critical thinking skills [5], challenges with metacognition and self-regulation [5], and the inability to transition to self-directed learning [6]. However, learning also requires students to relate to their social context [7] and negotiate such a context as they transition and adjust to medical training. As such, there is a need to consider and explore the role of social and cultural aspects in student learning [8–12], particularly in PBL, where the learning paradigm is different from what most students have previously experienced.

Sociocultural theory, emanating from Vygotsky's work, provides a perspective for understanding students' experiences with PBL in medical education beyond regulatory learning skills, in that human cognition and learning are developed through social activities. Thus the "social and cultural context" of human cognitive development is critically important [13 p. 297]. That is, learners do not operate "in a social vacuum but [are] part of a more complex community of practice, one in which they gradually gain access" [12 p. 44]. For Vygotsky, there is a relational ontology between individuals and their world [14]. This situated, embedded relationality implies that any practice "is not ontologically separable from learning and human development, but the very substance of it" [15 p. 50]. Sociocultural theory argues that learning modes, language practices, and relationships of authority will be context-dependent [16] Thus, to determine whether meaningful learning is taking place, it is necessary to account for and acknowledge the specific social and cultural contexts that an individual already inhabits.

Non-Western literature on the sociocultural aspects of PBL implementation generally relates to Asian [10, 17, 18] and Middle-Eastern students [19]. A broad scan of African PBL literature of the past two decades showed that it mostly focuses on implementation [20], student and tutor perception of the PBL process [21–25], and comparisons of student performance in PBL and traditional programs [26, 27], with limited reference to sociocultural factors. The scarcity of African PBL studies addressing sociocultural aspects of PBL thus poses challenges for medical schools seeking to implement PBL in African contexts characterized by multiple languages and subcultures. As Frambach et al. [28 p. 933] argue, PBL is itself a "plural construct", and thus, it is important "to learn from the cultural and situational nuances of educational activities labeled PBL around the world". Considering this claim and the importance of sociocultural contexts and their effect on education, this article explores two significant sociocultural factors contextualized in an African setting that may conflict with effective PBL implementation: the socialization of schooling before medical training and the cultural socialization relating to speaking and silence.

The socialization of schooling before medical training involves students entering medical training with beliefs about teaching and learning established through a history of high academic achievement. For some students, these beliefs are steeped in a predominantly teacher-centered or 'banking model' of educational orientation, where the teacher is the 'narrator' and students are 'containers' that receive and store information [3]. For instance, most Batswana students (i.e., citizens of Botswana) come from secondary schools where "the pedagogy used never attempted to develop independent thought, group activity or questioning of authority" [29 p. 156]. This model of education leads to passive and non-responsive students, mainly when concepts are unclear, and students are afraid to ask questions [29]

The banking model orientation to schooling can create tension and compete with the self-directed learning required for a PBL curriculum [30, 31]. A PBL curriculum requires students to be strategic, self-regulating learners who assume increased responsibility for their education by planning and executing their learning plan, seeking and evaluating information, assessing their learning, and making the necessary changes [32]. While successful learning requires effort from the teacher and the student, students socialized predominantly through teacher-oriented practice may not value their role in the learning equation [33].

The cultural socialization relating to speaking and silence means that students often bring prior schooling cultural practices and expectations that interfere with efficient learning in PBL, particularly with regard to tutorial groups. Students who prefer to work alone are confronted with a process where small-group learning is at the core of learning, and they need collaborative learning skills of listening, questioning, and claiming their voices in the learning process [2, 34]. While PBL requires students to "show rather assertive behaviors, such as speaking up, asking questions, and challenging the opinions of others" [34 p. 1002], non-Western students may instead demonstrate non-engaging behaviors concerning voice and silence that can inhibit their ability to question and engage in tutorial groups [10]. These practices are counterproductive to the benefits intended to be derived from small-group learning. For instance, amongst Asian students, silence may often be perceived as indicating proper manners or respect in the presence of elders or people of authority [10, 35]. This could be part of the perceived power or authority structures between the teacher and the student [3, 10, 35], students' conception of their identity as learners [10, 35], or limited communicative competence [35].

In the Botswana context, cultural practices and expectations embedded in Setswana identity could initially make Batswana students unable to participate meaningfully in PBL tutorials. This especially relates to silence as a form of communicative behavior [36]. As Bagwasi [36] argues, this interconnectivity between language and culture is reflected in the Setswana belief system, perceptions, behaviors, and speech acts. Central to these factors is the principle of Botho, which is a Setswana word for "respect, good manners, and good character" [29 p. 154]. In the Setswana culture, silence can indicate subordination and politeness in relationships between children and adults and men and women [36]. Children especially are expected to "remain silent in the presence of adults as a sign of subordination, respect, and humility" [36 p. 189].

It is also possible that besides cultural practices and expectations, the culture of schooling regarding the use of English as the primary language of instruction pose challenges for students entering PBL. Although Botswana is a multilingual country with 28 languages, English is the official language of instruction from the second grade of elementary school [37]. English language proficiency, based on the national secondary school exit written examinations, is required for admission to the University of Botswana (UB). Additionally, upon entry to the UB, all students undertake communication and study skills courses to further develop their English language proficiency and help prepare them for university learning.

In most of their pre-medical schooling, students learn in English, with the emphasis generally on English language proficiency through written communication. This can initially pose challenges for students entering PBL, where oral communication is the primary mode of learning in tutorial groups. For instance, students may be self-conscious about speaking, especially when contending with multilingualism in a monolingual classroom. A reason for challenges with oral communication could be the use of code-switching, a culture developed through the years in the school classroom space, where Setswana, the national language, is often employed to complement English [38]. One of the challenges with code-switching is that it may compromise the development of "learners' proficiency and confidence in speaking English" [38 p. 108].

For most Batswana undergraduate medical students, the encounter with PBL could be complicated by the sociocultural and language aspects discussed above. In this article, we report on the findings of a study describing first-year medical students' experiences during the first semester of an undergraduate PBL medical program at an African medical school. We add to PBL literature in the African context that explores how students' experiences could be understood from a sociocultural perspective in addition to the lack of regulatory learning skills. The insights are intended to shape a learning development program for first-year medical students in an African context.

We employed a qualitative case study approach[39, 40] to gain insight into our first-year students' experiences with the problem-based learning program. This allowed us to thoroughly explore our students' experiences while transitioning to a PBL program. This study was conducted at the end of the first semester of their medical training. Ethical approval was granted by the University of Botswana Institutional Review Board (Permit# REF:UBR/IRB/1383). The Study was conducted in accordance with relevant ethical guidelines and regulations.

Study setting and context

The Bachelor of Medicine Bachelor of Surgery (MBBS) program at the University of Botswana Faculty of Medicine (UB FoM) is a five-year undergraduate program. The UB FoM MBBS is a system-based, hybrid PBL program. One or two weekly clinical cases drive the learning for each week [41]. The program uses the Maastricht seven-jump process [42, 43] to facilitate the PBL small-group tutorials. PBL tutorials are complemented by other learning events such as self-directed learning, plenaries, bio-practicals, clinical placement, clinical and communication skills sessions, and resource sessions [41]. The plenaries are intended opportunities for clarifying complex concepts and addressing students' questions from various learning events [44]

The UB FoM MBBS program is not a direct entry program. Students are admitted through a highly competitive process after a year in a Bachelor of Science (BSc) or pre-med program or upon completion of the A-level program. The first two years focus on biomedical sciences, public health, basic clinical and communication skills, and weekly clinical placements [41]. In the first semester, students complete Foundations of Medicine (SoM 201), Cardio-Respiratory Systems (SoM 202), and Gastrointestinal and Urinary Systems (SoM 203). Anatomy is introduced from SoM 202 when students start to focus on specific systems. The study was motivated by two of the research team members' concerns about students' poor integration of concepts, a lack of depth in their responses to questions requiring higher-order thinking, poor learning skills, and challenges with the PBL process, overall. We formed a multidisciplinary team to explore (i) our students' experiences in transitioning from the predominantly teacher-centered BSc program to the learner-centered PBL program, and (ii) how sociocultural factors of our context could be affecting our student adjustment. Our shared belief was that such an understanding could enable us to develop processes to better support our students' transition.

Study team

The research team (four male and six female members) consisted of biomedical scientists and educationists at master's and PhD levels, medical and public health specialists, and a fifth-year medical student. Most team members were educated in the same teacher-centered public school system as most of our medical students. All but one of the researchers are bi/multilingual and may share similar learning experiences as bi/multilingual learners. Four study team members were actively teaching in the first year; three were also PBL facilitators at the time of data collection. In order to address power-relation issues in this study, none of the teachers interviewed participants. Instead, the research team engaged a native English-speaking, paid consultant educationist, who was experienced in qualitative research, to interview participants. Although five team members had experience with PBL as facilitators and/or previously as students, we lacked a shared understanding of our students' experiences in transitioning to a PBL program during the first year of medical training.

Study participants

One of the investigators, who was not involved in teaching the students, invited all 51 first-year medical students (26 male, 25 female) in the cohort to participate in the study after a face-to-face class session. The interviewer followed up with interested students via phone calls and emails to set interview appointments. Twenty-four students agreed to participate, and all of them completed the study. One of the interviews was discarded as the recording was not usable, resulting in 23 interviews (from 11 male and 12 female students). Our sample size was within the recommendations by Morse [45] and Creswell and Creswell [46], who suggested a minimum of six and five to twenty-five participants, respectively. Alternatively, saturation, when no more new information is generated [45], may be used to determine the sample size.

The 23 students, ranged in age from 18 to 25 years. Fourteen came from the BSc program, seven from the pre-med program, and one student came both from A-levels and pre-med. Three international students had previously attended private senior secondary schools, while all the local students had attended public senior secondary schools. Although all students use English as the language of instruction, all were bi/multilingual (some spoke three to five languages). Students reported that they mainly communicated in English with their peers, especially when the peers did not speak the native language and code-switched between English and the vernacular Setswana language. Most students stayed on campus (n = 15), a few (n = 2) stayed off campus, and for the rest (n = 5), no data on their residential status were provided.

Data collection

The research team engaged the consultant with whom they designed the study and interview questions. She collected data through non-participant observations and three batches of in-depth semi-structured interviews based on students' availability. Interviewing in batches allowed us to pause and review the data. Observations and interviews were conducted at the medical school building on the UB campus. The findings of the non-participant observations contributed to the development of the interview questions. The interviewer explained the study and allowed all participants to review and sign the consent form. Participants were notified that they could withdraw from the study at any time without penalty. Interviews generally lasted 90 minutes, were audio-recorded, transcribed verbatim, and checked against the audio to ensure accuracy. Each interview was allocated a code, e.g., G3S6, to identify the batch and the student. There were three focus areas for our questions, as shown in Table 1.

Table 1

Focus areas of questions for students' interviews
Focus area	Focus of the question
Focus area 1	Demographic information: academic background, some of the reasons for wanting to study medicine, and general experiences thus far with the MBBS program
Focus area 2	Overall impressions of the PBL process at this point in their studies
Focus area 3	Impression of PBL tutorials, including preparation, feedback, and challenging aspects

Data analysis

We conducted an inductive thematic analysis to systematically identify and analyze patterns in the data using the Braun and Clarke framework [47–49]. We each read and re-read three transcripts for familiarization, generated initial codes through open coding, and met to discuss the codes, and reached a consensus [47, 48]. Subsequently, team members each read and coded at least two transcripts, while one team member read all the transcripts and consolidated the coding from the rest of the team. Next, we collated the various codes into potential themes and checked the codes to ensure that they were relevant to the theme and consistent with each other, checking themes for coherence. Then we named and defined the themes. The consultant was not part of the data analysis, interpretation, or manuscript writing.

In this section, we present our findings describing students' experiences as they journeyed through the first semester of medical school. We focus on students' experiences just before medical school, at the beginning of medical school (during the first semester), and at the end of the first semester.

Students' experiences just before medical school

The students' journey to medical school started before enrolment in medical school. In general, the participants described their learning experiences before medical school in terms of consistent hard work and high academic achievement: "I had to work really hard to know that I find myself a slot" (G3S2). The high academic achievement was complemented by a competitive process of achieving admission into the BSc/pre-med program and then medical school: "I did my first year as pre-med before I came here. […] we were in pre-med; we were competing to get into this side [medical school]. […] I was focused more on competing to get to this side" (G3S6).

In describing their prior learning experiences, participants chiefly characterized them in terms of the 'banking model' or teacher-centered approach. They described the teacher as the primary source of knowledge and themselves as recipients of the knowledge. This continued during the first year of university (BSc/pre-med), where they relied on listening to detailed lectures, receiving notes, and revising past examination papers: "But you kind of are [spoon-fed] in BSc. They give you everything, examples, and whatnot. All you have to do is just study on what they taught you. [...] they literally teach you everything you need to know" (G3S8). However, some students tended to learn with minimal effort, relying on their intellect and retention ability: "Yeah, I didn't study a lot" (G1S5); or, as another student noted: "I didn't have to study frequently at all" (G2S1).

Students' experiences at the beginning of medical school (during the first semester)

Participants described the MBBS learning environment as unfamiliar and initially very challenging compared to their prior BSc/pre-med learning experience. It took many students time to understand the PBL process, as one student noted:

But problem-based learning, […] I honestly just didn't know what it was. I was still getting to learn what it was about because there are steps to how to do PBL […]. At first, […] I just didn't know how or what we were supposed to do. Once I got to see […] what I was supposed to do and how I got to learn, and how it's related to our plenaries and stuff like that, then it made more sense, and then it was better (G3S8).

Four aspects of the PBL learning environment that students initially found unfamiliar and challenging are described below. These are learning from an integrated PBL case, collaborative learning, substantial workload, and responsibility for learning.

Learning from an integrated PBL case

Initially, students found learning from a case to be challenging as it required an integrated, holistic approach (drawing from multiple disciplines), unlike the more familiar disciplinary silo structure of BSc/pre-med. However, the situation improved as facilitators coached students by providing scaffolding structures for approaching cases: "The facilitator would say, 'Think about the anatomy, think about the physiology, think about the public health' […] it helped. It triggered the transition" (G1S4). In addition, all students indicated brainstorming (including developing objectives) as the most problematic aspects of the PBL process, as indicated by one student:

I don't know if we were doing right or not doing right […]. I think until the end of the semester, we still have difficulty knowing exactly how we should write our problem and how they expect the brainstorming or the objectives we get from the brainstorming. But how the brainstorming should exactly be like and the problem, that's [where] we had confusions (G3S1).

Another unfamiliar aspect of learning from a PBL case was learning the normal functions from the abnormal functions or 'normal from the abnormal'. Although students are presented with medical cases, some students understood the connection of learning the 'normal from the abnormal': "I think the case is more of pathology or abnormal state […]. Its aim is to make sure you know the normal state so that you can see how the abnormal comes from it […]" (G1S3). Another student noted: "If you're dealing with a patient who has a problem with the intestines, you get to realize that I really need to know how the normal digestive system works" (G3S2). Some students did not seem to understand the connection of learning the 'normal from the abnormal': "We don't know what exactly we are supposed to do. Are we supposed to do both normal and abnormal?" (G3S1). Even students who understood the connection acknowledged that, at times, it was challenging to learn from the abnormal when you do not know enough about the disease: "Getting to derive something normal from a disease which you don't know about is quite challenging" (G1S3). Overall, the students described learning from the abnormal as not being problematic once they have more experience: "I don't find it difficult [to relate normal physiology to pathophysiology]. I like relating things" (G1S2).

As they settled into the program at the end of the first six-week block, most students experienced the introduction of anatomy in the second block as a challenge. They used expressions such as 'struggling'', being 'bad with anatomy', and 'not knowing how to go about things'. The students observed that anatomy entailed considerable detail: "Then we went to SOM 202 [...]. I have problems with anatomy [...]. I'm somehow finding it difficult to pay attention to those little details. Yes, because with anatomy, it's all about knowing those little details" (G2S1). As such, the students acknowledged the need for a different approach to anatomy compared to studying physiology: "I studied anatomy like I was studying physiology. I will just read. But I had to be able to do it from the model or from the book, […] okay, fine, this is here. It's this, and it's here" (G3S1). However, unlike in physiology, there is a need for students to visualize body parts using models or their own bodies:

So afterward, I was able even to use myself as a model. I will look and say, 'Okay, this is what I have. This is this.' And then I think it was quite good […]. I don't feel I look stupid, but everybody will be like, 'What's that girl doing?' And I'm busy naming parts and saying stuff (G3S1).

Another student described going to the lab with peers to use models: "We had booked a lab at the same time. They also wanted to go to the lab for the models. When we got there because we were a group, we started talking, discussing, discussing" (G2S1).

Students also suggested the need for an orientation to learning anatomy: "[…] just a way of saying, no this is anatomy, towards the left and right, just categorize these like this, and it will be much easier to think that way, not random bones and things, nerves all of it" (G1S1). The orientation included how to use the atlas, as one student recounted:

She did help me. Because, at first, I was like, 'How am I going to study this big thing, the atlas?' Then she just told me that the lab sheets, she gave us those to help us go through the atlas and it really helps. And it really helped me during the practical that we had because most of the stuff that was there was in those, in the lab sheets (G1S6).

Collaborative learning

The PBL curriculum is designed with collaborative learning as one of its core tenets. Almost all students described their preference as working alone and their initial reluctance to work in groups: "I'm old school […], I prefer to work alone" (G1S2). Another said:

I'm very much of a loner. I enjoy studying alone […], the person I can rely on most is myself. So, I do it my way […]. And it was working until I got here. So, I have to try and change, adapt, and I think I'll get there (G1S5).

Initially, before students got used to one another and the PBL process, there tended to be silence in the tutorials, as the students found participating challenging. As one student noted, the challenge was, "Not being used to being in groups and discussing" (G3S4), or, as another observed: "For the first block we were just new. We were not yet comfortable" (G1S9). The lack of willingness to participate was worse for students who considered themselves 'introverted': "I prefer to listen and stay quiet, so having to speak was a challenge. I'm overcoming it. As a person, I have to motivate myself to speak up" (G1S4). Initially, some students were concerned about embarrassing themselves and appearing 'stupid' among their peers: "We didn't know each other. Maybe if you say something, they will laugh" (G1S6); or, as another said: "When we are in a group where people are always above you [perform better than you], you feel you are low and it affects your contribution" (G1S9). Similarly, some students were unwilling to risk embarrassment in front of the facilitator: "If you ask, the facilitator will think this person hasn't read or something" (G3S2); or, as another student noted: "Yeah, some people may say it is about respect [for the facilitator]" (G1S4).

For some students, the silence was also about the inability to frame questions properly: "I don't think I'm good at […] structuring my questions. [...] I can't really simplify or make people understand what I'm, what do I really need to understand" (G2S6). The student further explained that English being a second language at times interfered with communication: "Some people just think they are not good at communicating. The language itself, English, is not the mother tongue so it can be a challenge. We just don't know how to express or to say some of the things" (G2S6).

The students described some unproductive behaviors in the tutorial sessions during the early stages of medical school, including trying to 'outdo' one another in terms of responses without necessarily making meaningful contributions. Indeed, the data showed that sometimes peers were overly competitive, interrupting one another and not listening to one another, but merely being quiet long enough for the peer to stop talking so that they could say something. Students also did not generally challenge one another's thinking, partly because some students did not know how to receive feedback:

I don't know if it's all the time, but […] most of the time, we don't listen to each other. […] It's more of me saying what I have to score marks. […] it's not about me saying what I have so that people can understand. So, it will just be like, 'Okay, fine, let him finish so that I can say my point and score my marks and go home.' I think that's all it is to it, and you don't actually listen together. Because, even if you make a mistake or you say something that is not right, people can't realize it. […] But I said something wrong, nobody is going to say anything (G3S1).

As the semester progressed and the tutorial group became more cohesive, the students described a change in both the silence and the dynamics of the group: "The silence has changed a lot […] as time goes on you become open, you have created a bond" (G1S9). Or, as another student noted: "It [the silence in the group] has changed, it has really changed. You start knowing how to treat each other. So we start to talk" (G1S6). By the end of the semester, nearly all the students were comfortable in their groups. As one noted: "I like my group. I've seen that they are very good people" (G1S3). In addition, they described the benefit of the tutorial group as providing opportunities to test their understanding of content and the best place to ask questions:

I like it when we exchange ideas […]. I'll have a different take on a certain topic or a different understanding, and then someone will come up with a different view. So we kind of exchange views. So, you learn also in the process (G1S4).

Most students credited the small size of the tutorial group to creating comfort with peers and the facilitator, making it easier to participate than in the plenaries: "I don't usually ask questions in class, more especially when we're in plenaries […] when we are the whole class. But, in PBL I do ask questions because there is just a few […] of us" (G2S3). Furthermore, many students commented on how empathy had developed within their groups as they got to know each other: "You start knowing how to treat each other […] this one is sensitive, so we end here, this one I can go a bit further" (G1S6). Or, as another student said: "We don't want to intimidate each other. I wouldn't say 'I think you're wrong', because I feel he or she will be offended or intimidated" (G1S7).

Substantial workload

The students described the workload as substantial, requiring many hours of studying: "The amount of material we covered in 201, ah, it amounts to the whole of BSc [laughing]. I tell you, that was the whole of BSc" (G2S4). They described the workload as overwhelming and stressful, using expressions such as "it's really stressful" (G1S5), "I was stressed out. I was really stressed out" (G2S1), "a lot of pressure" (G3S2), and "I was too pressured. Actually, at first, I was so freaked" (G2S3). Some students were disappointed that their marks did not match the effort they put into studying, although the low grades did not dissuade students from hard work, as hard work was needed to 'maintain' grades and ensure that their grades did not worsen. The students also expressed concern that the medical school took up so much time that there was little time left for anything else: "It's just a whole lot of material that you have to do in a short space. So, that on its own really puts pressure on us. We really don't have time for anything other than books" (G2S3).

Responsibility for learning

The students discussed having to assume increased responsibility for their learning and having to be self-disciplined, self-directed, and self-reliant:

So here, you have to self-motivate […]. You don't get motivation from your lecturers […]. So, you get to have self-responsibility, drive your own things, make your own life timetable, know what to do at what time […]. I just learned, like, self-responsibility (G3S2).

Plenaries in the MBBS program provided "an overview of the topic, and then you have to do most of the reading at home" (G2S3) to cover the necessary objectives. The students had to do a considerable amount of independent learning:

[…] usually, in the lectures, we don't get deep into stuff […], we only go shallow. So, PBL helps us, […] we do come up with some learning objectives related to the biomedical lectures and the PBL. So, we go research on that, and we'd be […] learning deeper (G2S7).

As the teacher is no longer the sole knowledge authority, successful learning requires focus and good study habits. In addition, learning effort is critical, as "it's no longer about how smart you are. The level of intelligence got you here, but the work you put in makes you stay here" (G2S2). Furthermore, most students reported changing their study strategies to accommodate the workload, for example, by increasing study time and adhering to a schedule.

Students' experiences at the end of the semester

Towards the end of the semester, most students were settling into the program, and all reported enjoying the program despite the workload and challenges. At this point, most had a clearer understanding of the PBL process and appreciated the value of the PBL approach.

Views on the enjoyment of the program

Despite the substantial workload, achieving lower marks than in BSc, and the unfamiliarity of the PBL approach, all students reported enjoying the program: "Despite the marks I get, I'll say, yes [laughs] I think I like the challenge mostly. […] And the people I'm always with, they make it more enjoyable" (G1S5). A few, however, described liking the challenge and pressure of medical school: "[…] I'm enjoying the pressure more than anything else [laughing]" (G3S1). Some also enjoyed learning something new every day: "Apart from the fact that medicine is interesting on its own, every day is a learning curve for you. You grasp almost a new concept all the time" (G2S5). In addition, clinical placements added to the enjoyment of the program in that they exposed students to how life would be as a doctor: "Every Wednesday, we go there [clinical placement], so [it is] always exciting. Just the fact that we get to […] see first-hand what we're supposed to be doing" (G3S3).

Views on the benefits of PBL

The students also appreciated and recognized some benefits of PBL. Even those who did not like the PBL approach acknowledged that the opportunity to speak and present among peers was an advantage: "Well, for me, it [PBL] hasn't contributed that much […] except that maybe I can talk to people, something that I didn't do in the past. […] That's all, I think, the positive part of it" (G1S5). Furthermore, being confident enough to speak in a group suggests that they had to learn and understand what they were presenting: "If I'm able to voice it out here, it means I learned a whole lot about it" (G3S3). Another benefit that was highlighted related to independent learning and coming back to share with peers:

I think PBL is really helpful […] considering that you go out on your own, you research. […] Sometimes you just go an extra mile in PBL, and going that extra mile, it kind of lightens up, it shows things to you […]. And now having to be with people around you and they introduce stuff that you didn't know, or the stuff that you skipped, and there they explain that. […] So, it's really interesting (G2S1).

Appreciating the value of the PBL approach

As the first semester ended, most students described a better understanding of the PBL process and recognized that the case and tutorials were at the core of the learning process. They realized that in attending the plenaries and practical sessions, and utilizing the objectives from the block guide and the case for self-study, they were equally preparing for the feedback tutorial, tests, and examinations:

At first, it was a little bit tough because […] we didn't have the strategy to make sure that there is an organization between the PBL, the lectures, and your studying. So, these days we managed to try and organize so that […] it becomes easier. […] I realized that […] the PBL is not like it's something separate […] it's related to the material for the lectures in the content for objectives for that week. So, when I realized that, I just take these objectives that we are given in PBL, I make sure it's part of my revision. I no longer see there is PBL, there is revision, no. When I'm doing PBL, I'm revising, and I'm also doing […] part of the lectures. I think it's a cornerstone (G1S9).

However, even at the end of the semester, some students still isolated the learning events and they still spoke of 'doing PBL':

We do have objectives on Monday, so most of the times we have two cases. What I'll simply do, I'll take one on Tuesday, and then the other one on Wednesday. So, I don't do PBL at my studying time. […] Mostly on Wednesdays we have clinical placements, so I would go there maybe in the morning, come back around 13:00. Then, from there, I'll take time to do my PBL after lunch at home. I'll just do my PBL then. One case per day (G2S3).

Through this study, we add to PBL literature situated in the African context by exploring how students' experiences could be understood not just from the lack of regulatory learning skills, but also from a sociocultural perspective. We describe first-year medical students' experiences (just before medical school, at the beginning of medical school [during the first three courses], and at the end of the first semester) with an undergraduate PBL medical program at a sub-Saharan African medical school. Just before medical school, students worked hard to compete for admission to medical school, were taught using a teacher-centered approach to learning, and preferred working independently. At the beginning of medical school, students had difficulty understanding the PBL process, the role of the case, speaking and working effectively in a group, managing a heavy workload, and taking increased responsibility for their learning. By the end of the first semester, most students were managing the workload better, were more comfortable with their peers and facilitators, and appreciated the value of the PBL approach.

Just before medical school

Students who had been admitted to the BSc program were high academic achievers. Before and during the first year of the BSc program, the modalities of instruction were similar; that is, mostly teacher-centered [29]. Although concerns have been raised about teacher-centered approaches [29], learning during the BSc program was a continuation of a learning process that had worked well for the students through the years. Based on the study, we suggest that the first year of the BSc program allowed students to operate within a familiar socialization of schooling. The program also did not come into conflict with students' cultural socialization relating to speaking and silence because of the limited use of small groups and in-class discussions. Furthermore, the instructional approach continued to reinforce the teacher as the main source of information, proclivity for competition, and preference for working independently. As such, students managed whatever adjustments were required at BSc and continued to perform well.

At the beginning of the medical school

As previously shown [50], our students experienced a disequilibrium as learning in the PBL program conflicted with their prior experiences and beliefs about the socialization of schooling and cultural socialization relating to speaking and silence. For most, the transition created a tension between wanting to continue as 'spectators' and becoming 'actors', initially oscillating between falling back on what previously worked well and exploring effective strategies for the new environment. This may be due in part to the initial tension between the students' external cultural factors and the values inherent in self-direction and self-regulation as essential components of PBL, as previously reported by other non-Western students [9]; that is, the tension between students' prior beliefs about teaching and learning and PBL.

Some of the students displayed behaviors consistent with poor self-regulated learning. For instance, while some students employed specific practices for managing their learning consistent with self-regulated learning (planning the week and preparing for classes, filling in the gaps during class, and reviewing material after class) [51, 52], some reported not having a specific approach to learning, such as a study schedule. Consistent with previous literature [53, 54], some students also seemed to resist assuming more responsibility for their learning by insisting on the need to be 'taught' or 'given notes'. Also, similar to previous literature [55], some of our students expressed being frustrated that tutors did not immediately take over the conversation to resolve discrepancies in knowledge during the tutorial. Poor self-regulation has been associated with stress and burnout [56], which might help explain our students' expression of being 'pressured', 'stressed', 'pulling me down', and 'freaking out'. The nature of our hybrid PBL program could contribute to the delay in students' transition to self-direction and self-regulation. For example, some weeks have as many as 11 plenaries, and some plenaries have over 50 slides; both of these factors continue to reinforce the teacher as the primary source of information, and thus may encourage students to hold on to their prior socialization of schooling because of its perceived benefits.

Although collaborative learning is at the core of PBL [8, 55], some of our students experienced challenges with voice and silence within small groups. While models of group dynamics [57] may be used to explain voice and silence within small groups, our results suggest that it may also be important to consider sociocultural factors as an additional perspective. Some students expressed the fear of being wrong and embarrassed as reasons for their silence. In the facilitator's presence, silence may however not just be about saving face but also about perceived respect for elders. In the Setswana culture, children are placed at the bottom of the social strata and are socialized not to be heard, but seen through their works, e.g., attaining good grades. Expressions such as "Go balabala ga ngwana ga se botlhale" (A talkative child is not necessarily intelligent; talkativeness does not mean intelligence)", which are commonly applied in our culture and extend beyond children to the general population [36], could pose challenges when students who have traditionally been socialized to be silent are expected to have a voice in the learning process.

Other cultural reasons may also explain the small-group tutorial silence in our study. Whereas in the Western culture it is understood that one may respectfully interrupt a speaker to express a contrary view, in Setswana, interrupting, or "go tsena ganong" (getting into the mouth of the speaker) [36] is viewed as poor manners and disrespectful. This may limit having an active and engaging discussion, and it could thus contribute to some students deferring to talkative students and remaining silent. Silence in tutorial groups may also be a symptom of challenges with self-expression in English [29, 58]. Perhaps it should not be surprising to find some students reporting challenges with self-expression in English because English is not their native language, and they are learning a new and difficult language of medicine. Despite English being the language of instruction through most of their schooling, many of our students often code-switch between English and Setswana, reflecting a common use, if not accepted practice, in our culture, including teaching and learning [59–62].

By the end of the semester

Embracing the need for conceptual and pedagogic shift [63, 64] towards PBL as a learner-centered approach, most students replaced what did not work with what worked for the new environment by appreciating the value of the PBL approach, managing the workload better, and being more comfortable in working with their peers and facilitators. Rather than it being a peripheral component, students realized the centrality of the case as driving the learning not just for the PBL tutorials, but for all other learning events. This helped them to manage their workload better because the learning plans they devised were integrated and intentionally inclusive of learning objectives for all learning events. The need to save face was no longer as important; rather, students openly shared their thoughts and asked questions. Most students thus valued the opportunities for independent learning and learning in groups. Nonetheless, a few students were resistant to change as they remained ambivalent about PBL, insisting on being 'taught', thus showing that the change process may not be easy and that different students will change at different times. That is, for most students, the adjustment to the PBL approach was an evolution and not a revolution – a conceptual change process that required time for intellectual development [55] and learning new habits and strategies. As such, students need adequate support and resources to facilitate and enable them to be proactive in learning [55]. The proportion of those who fail because they are struggling with the learner-centered approach but would otherwise thrive in a teacher-centered approach is unclear.

Limitations and future research

Future research using instruments to assess students' beliefs and approaches regarding learning, the measure of self-study hours, self-efficacy, and self-regulation could enhance a holistic understanding of students' experiences. It is further suggested that future research may also look into ways to adequately prepare students for the transition to PBL, thus enabling them to optimize their regulatory competence and meaningfully engage in a PBL curriculum as soon as possible [56, 65]. This could be through programs that focus on PBL ethos and process, the conceptual and pedagogic shift needed to adjust to a PBL program, and how to study in a PBL program using strategies that support regulatory learning [66].

Sociocultural factors may provide another lens for understanding students' experiences of learning in a PBL program. Our findings suggest a need for a conceptual and pedagogic shift towards learner-centered practice as part of the adjustment to PBL, particularly concerning self-direction, the role of the case, and collaborative learning.

Although the early days of a PBL program are challenging to most students [50] as they encounter a learning approach that is quite different from what they were used to, the students in the current study all reported enjoying the program. Initially, some students tried to stick to old methods that had worked in previous learning contexts, and for which they had been rewarded with high grades and accolades [54, 67]. Even at the end of the first semester, some students still had an 'underdeveloped' conception of the role of the case, elevating the role of plenaries over learning from the case. However, by the end of the first semester, most students had acclimatized to the PBL process: they displayed a less competitive attitude, had better understanding of the brainstorming process, and reported feeling generally more comfortable with their medical training. Nonetheless, there is a need for an induction process to better support students' development of regulatory skills and practices needed for adjusting to learning through PBL.

Ethics approval and consent to participate

Ethical approval was granted by the University of Botswana Institutional Review Board (Permit# REF:UBR/IRB/1383). We confirm that all methods were carried out in accordance with relevant ethical guidelines and regulations. Informed consent was obtained from all participants.

Consent for publication

Not applicable

Availability of data and materials

The interviews transcripts are included as a supplement and can also be requested from the corresponding author at [email protected]

Competing interests

The authors declare that they have no conflict of interest.

Funding

This project was in part funded by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant T84HA22125 (Medical Education Partnership Initiative, $10 000 000). The information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the US government.

Authors' contributions

MBK, GGM, MSM, ON, JW, RF, and MK contributed to conceptualizing the research proposal. All authors contributed to the analysis and interpretation of the data. MBK prepared the first draft, and all authors contributed substantially to the ongoing revision of the manuscript. All authors read and approved the final manuscript and take full responsibility for the data presented.

Acknowledgements

We thank our medical librarians (Mr Khutsafalo Kadimo, Ms Dineo Ketshogileng, and Ms Stella Kube) for supporting our literature search.

Authors’ information

¹ Department of Medical Education, University of Botswana, Gaborone, Botswana

²Wits School of Education, University of the Witwatersrand, South Africa

³Department of Biomedical Sciences, University of Botswana, Gaborone, Botswana

⁴Communication and Study Skill Unit, University of Botswana, Gaborone, Botswana

⁵Department of Surgery, University of Botswana, Gaborone, Botswana

Supporting information

Interview Transcripts: G1S1 - G1S9, G2S1 - G2S7, G3S1 – G3S6, G3S8.

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No competing interests reported.

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Sociocultural factors affecting first-year medical students' adjustment to a PBL program at an African medical school

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