Educational environment is a strong predictor of student learning [1]. It comprises multifactorial elements, such as content of instruction, learning outcomes, type of curriculum, teaching methods, and strategies, learning facilities, teachers’ competencies, behavior and guidance; and peer support, that influence student motivation and ability to learn [2]. Volatility in educational systems has indirectly influenced the components of educational environments. In keeping with the development of technology, mobile learning (m-learning) and distance learning have emerged as a new generation of learning methods that require digital literacy from learners and instructors for efficient learning [3]. Nowadays, the educational environment is not only confined to spatial learning, but has extended to social learning situations, where intercultural adaptation and social equity are being emphasized to cater to globalization in learning [4,5]. In addition, social tolerance has been identified as a contributing factor to the psychological well-being of learners, which in turn determines the success of learning in a professional and intercultural educational environment [6]. Hence, social-psychological indices have been imparted as one of the educational environment factors that should be continually monitored to ensure provision of a positive educational environment [7].
In a similar manner, anatomy education has undergone a significant evolution in various aspects of its curriculum [8,9]. As a pillar of medical education, teaching and learning in anatomy must withstand and adapt to changes in the ecosystem of medical training [10]. Within the past two decades, the literature on anatomy education has documented various forms of technology-enhanced and educational theory-based teaching innovations to either replace or supplement traditional teaching methods (i.e., cadaveric dissections, didactic lectures, and demonstration) [11-15]. Many factors underpinned the changes in teaching methods for anatomy, which emerged since 1979 after a revamp in the medical curriculum in Malaysia [16]. For instance, the requirement for medical students to learn new medical topics in an integrated medical curriculum has resulted in a reduction of anatomy syllabus and teaching hours [17]. Nevertheless, such changes in the anatomy education system have attracted a certain degree of attention among anatomists regarding the effectivity of learning due to the increasing concern on the incompetency of anatomy knowledge and related skills among medical graduates [18,19]. This issue has been linked to clinical errors in judgment and medicolegal litigations [20]. Notwithstanding the growing assertion of insufficient knowledge on anatomy among medical students and graduates, empirical evidence has appeared to support that such a claim is lacking [21]. Likewise, previous scholars argued that the components of the educational environment are obsolete despite robust academic discussion on changes in anatomy curricula and teaching methods [22]. In fact, debate among anatomy educators on the most effective teaching methods in anatomy and extent of teaching the subject in the medical curriculum has been long-standing [10.21.23]. Addressing these issues requires appropriate curriculum evaluation, whereby feedback from various stakeholders, such as medical students, should be measured to ensure empirically-based action for improvement.
With the global implementation of outcome-based education in medical training, added flexibility in teaching, and assessment methods is expected from anatomy educators, which thus requires a rapid and high adaptability to the system. An important point to be noted is that students take ownership of learning and are free to utilize any learning resources in the process [24]. Alternatively, lecturers are mere facilitators of learning, who may need to play many roles at once to ensure a smooth and efficient learning process [25]. Based on this premise, measuring students’ perception of anatomy education environment – as a feedback mechanism – is imperative for the improvement of teaching and learning of anatomy. However, to ensure accurate measurement of students’ perception of the educational environment, using a valid, and reliable tool, which is suitable within the context of anatomy education is important.
In line with such a requirement, Hadie et al. [26] developed an instrument known as the Anatomy Education Environment Measurement Inventory (AEEMI), which plays a central role in the objective of the study for several reasons. First, it helps to establish students’ perceptions of factors pertaining to educational climate that influence anatomy learning. Second, the six factors of the AEEMI, namely, students’ perception of anatomy as a subject, anatomy teachers, importance of knowledge about the subject, anatomy learning resources, self-effort in learning anatomy, and quality of histology learning facilities, are aligned with issues raised in the literature on anatomy [27-32]. Third, the AEEMI contains low-inference items of educational environment and thereby ensure accurate rating on the students’ part, which is based on experience and observation rather than opinion [33]. Several studies indicated that low-inference items in an inventory could measure users’ perceptions objectively compared with high-inference items, which capture subjective feelings and reactions [34-36]. Hence, measurement using the AEEMI will address any problems that need improvement or point out issues that are rectifiable when the objective is measurable.
The AEEMI is an instrument that measures the perception medical students regarding the educational climate specific to anatomy as a subject. Hadie et al. [26] developed the AEEMI through the Delphi technique and involved anatomists and medical educators from various countries. A validation of the inventory was conducted on pre-clinical year students in a Malaysian public medical school, where a six-factor and 25-item framework was proposed as the best-fit model for the AEEMI. The validated instrument measures the perception of students regarding anatomy as a subject, teachers, importance of knowledge on anatomy, learning resources, self-effort in learning, and quality of histology learning facilities. A five-point Likert-type scale is used to rate of agreement with the items ranging from 1 = strongly disagree to 5 = strongly agree [26]. Although the tool was demonstrated to have good content, response process, and construct validity, Hadie et al. [26] raised their concerns on the generalizability of the AEEMI items because several important items were omitted during the validation process on the basis of statistical consideration. To ensure the trustworthiness of results obtained from the measurement using the inventory, further validation is required at a global scale to take into account the variability that may exist among institutions. Hence, the study aimed to critically examine the construct validity of the AEEMI across institutions and cohorts of students.
In a broad sense, construct validity implies the accurateness of inferences made by a measurement, such that it can measure what it intends to measure [37]. Construct validity comprises five aspects, namely, content validity (i.e., items in the instrument represent the intended factor), response process validity (i.e., users of the instrument can understand the items), internal structure validity (i.e., results are replicable in a different measurement when the same inventory is used), and relationship with other variables (i.e., results correlate with those using other tools), and consequence validity (i.e., impact of the measurement) [38]. Although evidence for the validity of the AEEMI has been established in a single-center study, a cross-validation of the instrument will ensure the selection of a robust pool of items and therefore represent the global scenario of the anatomy education environment. The AEEMI will not only be valid and reliable, but also a universal inventory at least in the Malaysian context. A universal, valid, and reliable tool will ensure a successful benchmarking process of the anatomy curriculum, which in turn will enable the improvement of the curriculum. Hence, the study intended to critically evaluate the construct validity of the AEEMI across public and private medical schools in Malaysia and propose a universal framework of the AEEMI. This study aimed to answer the following research questions: (1) What is the best-fit universal model for the AEEMI? and (2) What is the internal consistency reliability of the AEEMI when administered to medical students at different phases of training across public and private medical schools in Malaysia? To answer these questions, the study hypothesized that (1) the AEEMI will demonstrate a good model fit that is universal and (2) it would show a high level of internal consistency reliability across cohorts.