The Association Between Preclinical Medical Students’ Perceptions of the Anatomy Education Environment and Their Learning Approaches

Abstract

This study aimed to measure medical students’ perceptions of the anatomy education environment and determine its association with their learning approaches. First- and second-year undergraduate medical students (N = 234) completed the Anatomy Education Environment Measurement Inventory and the Approaches and Study Skills Inventory for Students. Results revealed that the students’ perceptions of all the factors in the anatomy education environment were positive except for two areas—the anatomy learning resources and quality of histology learning facilities. The majority of students in the first year (62.3%) and second year (43.7%) adopted a deep learning approach. There was no significant association between most of the factors in the anatomy education environment and the students’ learning approaches, except for the students’ intrinsic interest in learning anatomy factor (p = 0.032). The anatomy education environment was positive for the medical students, and there was a prevalence of a deep learning approach among them. However, most of the factors in the anatomy education environment did not influence the students’ learning approach. Given that the students’ learning approach is a multifactorial construct, investigating the relationship between these two variables in longitudinal time points would provide better insight into the association between the anatomy educational climate and students’ learning approaches.

Introduction

Anatomy is one of the essential basic science subjects in medical curricula. Adequate anatomical knowledge is important for safe and effective clinical practice [1, 2]. It facilitates students’ understanding of mechanisms underlying key clinical features of diseases, performance of relevant and accurate physical examination, interpretation of radiological images, and formulation of differential diagnoses [3, 4]. For the past two decades, medical curricula have undergone significant changes integrating basic science subjects with clinical science subjects [5]. As a result, the contact hours for teaching anatomy in medical schools were reduced [6]. One possible consequence that has been indicated by several studies is declining anatomy knowledge among medical students and medical graduates [7–9]. In light of the changes in the medical curricula, several studies had suggested utilizing multiple teaching modalities via different approaches to engage the learner and promote learning human anatomy in the modern-day medical curriculum [10, 11]. Implementing various approaches that could ensure the attainment of optimum anatomy knowledge among medical students is important. One of the approaches could involve designing a positive anatomy education environment.

The term “education environment” is often viewed as synonymous with learning environment, learning climate, and learning atmosphere [12, 13]. Gruppen et al. [12] refer to educational environment of health professions as the “social interactions, organizational culture and structures, and physical and virtual spaces that surround and shape the learners’ experiences, perceptions, and learning.” The education environment in health profession education encompasses organizational culture and practice (e.g., regulations and policies), curriculum (e.g., learning outcomes and assessment), individual learners (e.g., resilience and personal goal direction), educators (e.g., educators’ behavior and teaching techniques), social relationships (e.g., between learners, learner-to-faculty/staff, and learner-to-patient), physical surroundings (e.g., campus buildings, anatomy laboratories, and simulation facilities), and virtual spaces that include the electronic learning environment for online learning [12, 14, 15]. Assessing the educational environment is imperative because it has been proven to influence the quality of life, learning behavior, and academic performance of medical students [13, 16, 17]. Moreover, evaluation of the educational environment would provide essential input to faculty members and the higher administration of medical institutions regarding ways to provide high-quality education and training to students [13].

One of the approaches for assessing the education environment is by evaluating students’ perceptions of the environment using questionnaires. There are several validated questionnaires that measure medical students’ perceptions of the education environment, namely the Dundee Ready Education Environment Measure (DREEM), medical school learning environment survey (MSLES), and medical school’s environment questionnaire (MSEQ) [15]. However, these instruments measure the general medical education environment and do not assess several factors that are important in anatomy education, such as teaching modalities and tools that are unique to anatomy curricula, which include cadaveric specimens, prosected specimens, plastinated specimens, and histological glass slides [10, 18]. To address this drawback, Hadie et al. [18] developed a validated instrument with good psychometric properties known as the Anatomy Education Environment Measurement Inventory (AEEMI) that can specifically measure the anatomy education environment. The AEEMI can be used to identify aspects of the anatomy education environment of an institution that need to be improved in order to facilitate student learning anatomy.

Several studies have explored the different means of facilitating students’ learning, including promoting students’ adoption of an effective learning approach [19, 20]. Learning approaches refer to students’ intentions in relation to their studying and learning, and also their learning processes [21, 22]. Newble and Entwistle [23] identified three main approaches to learning: deep, surface, and strategic learning. The deep learning approach relates to students’ motivation and interest in the learning subject or task; where, effort is intentionally invested in understanding the learning materials and correlating it with previous knowledge and experiences. The surface learning approach is described as studying with an intention simply to fulfil the course requirements by utilizing only minimal time and effort, for example, rote memorization and replication of the learning material. The strategic learning approach reflects the adoption of any strategies that can help students achieve their ultimate learning goal; students who adopt this learning approach focus on assessments and are motivated by achievements of high grades [23, 24].

Medical students who are overwhelmed by excessive workload in a limited time frame reportedly tend to adopt a surface learning approach [20, 25]. Several studies showed that both medical and health students perceive neuroanatomy, head and neck, and pelvis as difficult topics compared to other anatomy topics, and related this perception to the high volume of material involving intricate details and difficulty in visualization of the structures [26–28]. A study conducted by Bergman et al. [29] found that second- and third-year medical students perceived anatomy as boring, which was associated with the need to memorize a large amount of anatomical information without much understanding and direct clinical application. These students’ descriptions of their learning process appeared to be related to the surface learning approach. Previous studies indicated that surface learning approach correlated negatively with examination success, whereas deep and strategic learning approaches correlated with success in higher education examinations [19, 20, 30]. Thus, anatomy educators need to encourage students to adopt deep and strategic learning approaches to foster students’ understanding of their anatomy learning content and better academic performance.

Several individual factors have been found to enhance students’ adoption of the deep learning approach, namely intrinsic motivation, resilience, and self-confidence [19, 31, 32]. In addition, contextual factors such as students’ perceptions of the learning environment had also been reported to influence the students learning approach. Recent studies involving subjects other than anatomy showed that students’ positive perceptions of the teaching–learning environment were related to the deep learning approach, and students’ negative perceptions were related to the surface learning approach [33, 34]. Students’ satisfaction with the quality of a specific course was found to encourage students’ adoption of the deep learning approach [34]. Further, students’ positive perceptions of several contextual factors, such as teaching for understanding, constructive feedback, and appropriate assessment, have been found to influence students’ adoption of the deep and strategic learning approaches [34–36]. Hence, the adoption of learning approaches that could lead to better academic performance might be encouraged by optimizing the education environment, for example, by improving teaching methodology and providing appropriate assessments.

Although many studies have explored the learning approaches adopted by students and their association with the educational environment, there is limited research on this association in the context of anatomy education in a modern and transformed medical curricula that utilize integrated and system-based curricula characterized by reduced anatomy teaching contact hours. Furthermore, current anatomy teachings have changed by adopting multiple pedagogical resources, for example, cadaver dissection, prosections, medical imaging, computer-assisted learning, and plastic models, via various approaches such as problem-based learning, team-based learning, and flipped classroom [10, 37–39]. Additionally, in this study, we used AEEMI, a validated instrument that can specifically measure the anatomy education environment [18]. This study was executed to provide answers to the question and to ascertain whether a positive anatomy education environment could encourage the development of productive learning approaches, which would consequently lead to better academic performances. Therefore, this study aimed to (1) determine medical students’ perceptions of the anatomy education environment; (2) determine the learning approach most adopted in learning anatomy; and (3) investigate the association between students’ perceptions of the anatomy education environment and their adopted learning approach.

Materials and Methods

Study Design and Selection Criteria

A cross-sectional study was conducted from January to February 2019 in the School of Medical Sciences, Universiti Sains Malaysia (USM), Health Campus, Kubang Kerian, Kelantan. The study subjects were the preclinical year students of the 2018/2019 academic session. The participants were invited based on these two eligibility criteria: (i) the participant must be a preclinical year medical student; and (ii) the age must be between 18 and 25 years old. International and repeat students were excluded from the study.

Sample Size

There is a scarcity of data reporting the outcomes of these objectives, and hence, we were unable to calculate the sample size for objective 1 (to determine the medical student’s perception of six factors in the anatomy education environment) and objective 2 (to determine the predominant learning approach). The sample size calculation for objective 3 (to determine the association between medical students’ perception of the six factors of the anatomy education environment and their learning approaches) was performed using the Power and Sample Size Calculation Software version 3.1.2 (PS software, Vanderbilt University, Nashville, Tennessee) [40]. Type 1 error (α) and power of study (1-β) were set at 0.05 and 0.80, respectively. The largest sample size was obtained for calculation to determine the association between medical students’ perception of the anatomy education environment and the learning approach (surface approach). Smith et al. [41] reported a P0 of 16%, and P1 was expected to be 31%. The total sample size obtained was 248 participants. Anticipating 20% dropouts due to incomplete response, the corrected sample size was 298 participants.

Participant Recruitment

As the total number of preclinical year students was less than the calculated sample size, no sampling method was applied for this study. All students who fulfilled the eligibility criteria were invited to attend a briefing session where they were informed about the purpose, methodology, participants’ criteria, potential risk, benefits of participation, participants’ confidentiality, and consent of the study. During the briefing session, their eligibility for participation was assessed, and written consent was obtained from eligible volunteered participants. The briefing session and data collection process were conducted by a non-academic researcher, a master’s student, to minimize the sense of obligation to participate in the study [42]. A total of 235 students consented to participate in the study.

Study Procedure

The study was carried out in the second semester of the academic year to ensure that the students have had adequate exposure to the anatomy teaching and learning activities in the School of Medical Sciences, USM. The study was conducted at the beginning of the second semester as to ensure that it would not interrupt any university events, student extracurricular activities, examination, and self-study periods, which commonly occurred at the middle and end of semester. The Anatomy Education Environment Measurement Inventory and Approaches and Study Skills Inventory for Students were distributed in a lecture hall immediately after the briefing session. The students were advised to think about the anatomy curriculum as a whole during completion of the questionnaires. The time to complete the questionnaires ranged between 10 and 15 min. The students were informed that their responses would be anonymous, and their confidentiality would be preserved as much as possible. The participants were also requested to provide their sociodemographic data (i.e., age, sex, race, and year of study) and were reminded to be truthful and forthcoming.

Research Instruments

Anatomy Education Environment Measurement Inventory

The AEEMI is a validated self-administered questionnaire that measures students’ perceptions of the anatomy education environment [18]. Responses to each item are based on a five-point Likert scale ranging from 1 to 5 that represents strongly disagree, disagree, not sure, agree, or strongly agree, respectively. There are six factors under AEEMI that study the perceptions of students toward the anatomy education environment: students’ perceptions of anatomy teachers, importance of anatomy knowledge, students’ intrinsic interest in learning anatomy, anatomy learning resources, students’ effort to learn anatomy, and quality of histology learning facilities [18]. There is a total of 25 items that represent the 6 factors in AEEMI. The scoring of each factor in AEEMI was done by calculating the mean for each factor. The three outcomes or interpretation from each factor were area of concern (score of 1.00–2.99), area for improvement (score of 3.00–3.99), and positive area (score of 4.00–5.00) [18].

In terms of its validity evidence, the inventory was found to have good construct validity, satisfactory content evidence, good response process evidence, and acceptable to high internal consistency, with the Raykov composite reliability estimates of the six factors in the range 0.604–0.876. Hence, AEEMI was proven to have good psychometric properties, and thus plausible for assessing the anatomy education environment in Malaysia [18].

Approaches and Study Skills Inventory for Students

The Approaches and Study Skills Inventory for Students (ASSIST) was derived from the Approaches to Studying Inventory (ASI) designed by the University of Lancaster in the late 1970s [22, 43]. The questionnaire assesses the relative strengths of students’ learning approaches in three main dimensions—deep, surface, and strategic. ASSIST was developed by the Centre for Research on Learning and Instruction at the University of Edinburgh in 1997 [43].

The original ASSIST is composed of 52 items. It was proven to have consistent psychometric findings with good validity and reliability; however, due to its long inventory construct, there was the tendency of participants losing interest in completing it [44, 45]. In this study, the short version of ASSIST that comprised eighteen items was utilized, and respondents rated the statements using a five-point Likert scale from 1 to 5 that represented disagree, disagree somewhat, unsure, agree somewhat, and agree [44]. The short ASSIST inventory has satisfactory psychometric properties and was structured with three scales (constructs): the deep, strategic, and surface learning approaches. Each scale was represented by six items (subscales). The scale scores were calculated by summing up all the relevant item scores; with a scale score range of 6–30. The highest score of these three scales indicates the predominant learning approach [44, 45]. Students who adopted more than one learning approach in this study were excluded from the analysis [46].

Ethical Considerations

This study procedure was approved by the Human Research Ethics Committee (JEPeM) of USM (JEPeM USM Code:-USM/JEPEM/19100625). The participants were considered a vulnerable population because some researchers had a direct teaching role in the participants’ academic program. Hence, the participants may be vulnerable to coercion. The students might also feel pressured to participate in the research to protect their academic achievement. They may assume that their decision to be involved would affect their marks, services that they received, and relationship with researchers who were also their lecturers.

To address these issues, several safeguard measures were performed. First, researchers directly involved in the students’ academic program were not involved in the recruitment of the students. Second, the briefing session was conducted by a postgraduate student who was not involved in any students’ academic activities. Third, the voluntary nature of the participation was strongly emphasized during the briefing session, and participants were reassured that their disinvolvement in the research would not affect their course marks or services. Fourth, other aspects regarding the participants’ risk, confidentiality, privacy, and methods of refusal and withdrawal were illuminated. Lastly, a Research Information Sheet containing information about the study was provided to the participants.

Statistical Analysis

Data collected from the completed questionnaires was organized and analyzed utilizing IBM SPSS Software Version 25 (SPSS Inc., Chicago, IL) [47]. Descriptive statistics were applied for sociodemographic background information, which consisted of gender, race, and year of study. All data were scrutinized and perused thoroughly for any errors or missing values. Prior to the applied statistical analysis for the variables, assumptions were properly met, and the level of significance (α) was set at 0.05. Chi-square/Fisher’s exact test was applied to investigate the association between the medical students’ perceptions of the anatomy education environment and their learning approaches.

Results

Out of 300 medical students, 235 students gave their consent (116 first-year and 119 s-year students) to take part in this study. All of the participants returned the questionnaires except for one participant from the second year. Thus, the response rate of this study was 99.6%. The year of study of the participants was approximately equally represented, with 116 (49.6%) students in the first year and 118 (50.4%) in the second year. The participants’ ages ranged from 20 to 24 years old, and most were females (73.5%). A total of 195 (83.3%) of the students were Malay, 23 (9.8%) were Chinese, 14 (6.0%) were Indian, and 2 (0.9%) from other racial backgrounds.

Students’ Perceptions of Anatomy Education Environment

Table 1 represents the medical students’ perceptions of the anatomy education environment, measured based on the six factors in AEEMI. The students perceived anatomy teachers (100%), the importance of anatomy knowledge (86.8%), their intrinsic interest in learning anatomy (59.4%), and their effort to learn anatomy (63.2%) as positive areas. However, 52.6% of the participants perceived anatomy learning resources as an area for improvement and 65% perceived the quality of histology learning facilities as an area of concern (Table 1).

Table 1.

Students’ perceptions of anatomy education environment (n = 234)

Factors in AEEMI Outcome	n (%)
1. Students’ perceptions of anatomy teachers
Area of concern	0 (0.0)
Area for improvement	0 (0.0)
Positive area	234 (100.0)
2. Students’ perceptions of the importance of anatomy knowledge
Area of concern	4 (1.7)
Area for improvement	27 (11.5)
Positive area	203 (86.8)
3. Students’ perceptions of their intrinsic interest in learning anatomy
Area of concern	10 (4.3)
Area for improvement	85 (36.3)
Positive area	139 (59.4)
4. Students’ perceptions of anatomy learning resources
Area of concern	20 (12.8)
Area for improvement	123 (52.6)
Positive area	81 (34.6)
5. Students’ perceptions of their effort to learn anatomy
Area of concern	7 (3.0)
Area for improvement	79 (33.8)
Positive area	148 (63.2)
6. Students’ perceptions of the quality of histology learning facilities
Area of concern	152 (65.0)
Area for improvement	28 (12.0)
Positive area	54 (23.0)

Table 2 presents the mean scores (SD) for the individual items of each factor of the AEEMI. The three highest mean scores were reported for the individual items “anatomy teachers are knowledgeable” (4.85 ± 0.385), “anatomy teachers are friendly” (4.76 ± 0.447), and “anatomy teachers are enthusiastic to teach” (4.71 ± 0.531). The two lowest mean scores were reported for the items “prosected/cadaveric specimens are accessible” (2.67 ± 1.138) and “quality of the microscopes for histology classes is poor” (2.73 ± 1.158).

Table 2.

The mean scores for the individual items in each factor of AEEMI (n = 234)

Factors in AEEMI Items (item number)	Mean (SD)
1. Students’ perceptions of anatomy teachers
Anatomy teachers are knowledgeable (1)	4.85 (0.385)
Anatomy teachers are available to help students (13)	4.55 (0.607)
Anatomy teachers are enthusiastic to teach (14)	4.71 (0.531)
Anatomy teachers are friendly (2)	4.76 (0.447)
Anatomy teachers are well prepared (20)	4.68 (0.545)
Anatomy teachers are good role models for learning anatomy (17)	4.60 (0.629)
Anatomy teachers are approachable (25)	0.573)
2. Students’ perceptions of the importance of anatomy knowledge
My anatomy knowledge helps me to understand other medical subjects (22)	4.59 (0.610)
The anatomy topics prepare me for clinical years (3)	4.54 (0.587)
I can apply my anatomical knowledge in clinical years (15)	4.22 (0.741)
The anatomy topics are relevant to future profession (21)	4.54 (0.601)
Learning anatomy prepared me to be a good doctor (4)	4.59 (0.610)
Relevant anatomy topics are reemphasized in clinical years (11)	4.03 (0.807)
Anatomy subject gives me a feeling of becoming a doctor (24)	0.715)
3. Students’ perceptions of their intrinsic interest in learning anatomy
Learning anatomy is fun (16)	4.17 (0.800)
I am confident in answering anatomy questions well (5)	3.42 (0.778)
Anatomy is an interesting subject (23)	4.35 (0.746)
4. Students’ perceptions of anatomy learning resources
Anatomy practical sessions are well organized (10)	4.10 (0.763)
Prosected/cadaveric specimens are accessible (6)	2.67 (1.138)
Learning facilities are well maintained (19)	3.81 (0.878)
5. Students’ perceptions of their efforts to learn anatomy
I utilize anatomy museum to learn anatomy (7)	3.62 (1.017)
I use anatomy models/specimens to learn anatomy (12)	4.22 (0.807)
Anatomy examinations help me to identify my weaknesses in anatomy knowledge (8)	0.740)
6. Students’ perceptions of the quality of histology learning facilities
Quality of the microscopes for histology classes is poor (18)	2.73 (1.158)
Poor quality of histology slides (9)	2.74 (1.042)

Learning Approaches

As shown in Table 3, the majority of students favored a deep learning approach (52.5%). The percentage of students who adopted the strategic learning approach was 34.2% and the surface approach was 13.3%. Thirty-eight students adopted multiple learning approaches; thus, they were removed from further analysis, resulting in a total of 196 participants [46]. A comparison of learning approaches between first- and second-year students revealed a significant difference between the two groups. A greater proportion of second-year students (40.8%) adopted the strategic approach compared to first-year students (26.9%).

Table 3.

Predominant learning approach

Learning approach	Overall (n = 196)	Year 1 (n = 93)	Year 2 (n = 103)	χ2	*p-value
	n (%)	n (%)	n (%)
1. Deep	103 (52.5)	58 (62.3)	45 (43.7)	6.85	0.033a
2. Strategic	67 (34.2)	25 (26.9)	42 (40.8)
3. Surface	26 (13.3)	10 (10.8)	16 (15.5)

*p < 0.05

^aχ² test

Association Between Students’ Perceptions of Anatomy Education Environment and Learning Approaches

The findings revealed that the students’ perceptions of most of the anatomy education environment factors did not have any significant association with their learning approaches. Table 4 shows that a significant association only existed between the students’ perceptions of their intrinsic interest in learning anatomy and their learning approaches (p = 0.032). On the contrary, an association test could not be performed with the students’ perceptions of the anatomy teacher factor, as all the participants perceived this factor as a positive area.

Table 4.

The association between students’ perceptions of anatomy education environment with learning approaches (n = 196)

Factors in AEEMI Outcome	Learning approach, n (%)			χ2 (df)	*p-value
	Deep (n = 103)	Strategic (n = 67)	Surface (n = 26)
1. Students’ perceptions of anatomy teachers
Area of concern	-	-	-	-	-
Area for improvement	-	-	-
Positive area	103 (100.0)	67 (100.0)	26 (100.0)
2. Students’ perceptions of the importance of anatomy knowledge
Area of concern	2 (1.9)	0 (0.0)	0(0.0)	-	0.868b
Area for improvement	13 (12.6)	7 (10.4)	3 (11.5)
Positive area	88 (85.5)	60 (89.6)	23 (88.5)
3. Students’ perceptions of their intrinsic interest in learning anatomy
Area of concern	7 (6.8)	0 (0.0)	2 (7.7)	-	0.032b
Area for improvement	41 (39.8)	20 (29.9)	12 (46.3)
Positive area	55 (53.4)	47 (70.1)	12 (46.0)
4. Students’ perceptions of anatomy learning resources
Area of concern	13 (12.6)	8 (11.9)	3 (11.5)	2.10 (4)	0.717a
Area for improvement	52 (50.5)	52 (50.5)	17 (65.4)
Positive area	38 (36.9)	22 (32.8)	6 (23.1)
5. Students’ perceptions of their effort to learn anatomy
Area of concern	1 (1.0)	1 (1.5)	1 (3.8)	-	0.368b
Area for improvement	41 (39.8)	19 (28.4)	9 (34.7)
Positive area	61 (59.2)	47 (70.1)	16 (61.5)
6. Students’ perceptions of the quality of histology learning facilities
Area of concern	72 (69.9)	37 (55.2)	16 (61.5)	5.50 (4)	0.240a
Area for improvement	13 (12.6)	10 (14.9)	2 (7.7)
Positive area	18 (17.5)	20 (29.9)	2 (7.7)

*p < 0.05

^aχ² test p-value

^bFisher’s exact test

Discussion

This study explored the association between USM medical students’ perceptions of the anatomy education environment in the School of Medical Sciences and their preferred learning approaches. This evaluation is important as such analysis is still scarce in the anatomy education context especially in a modern and transformed medical curriculum. Moreover, this information is needed to provide an environment where quality student learning can occur in the anatomy education environment, as several studies claimed that anatomical knowledge had declined among medical students [41, 48]. This study identified three major findings. Our first finding is that students perceived most of the factors in the anatomy education environment as positive areas except for anatomy learning resources and quality of histology learning facilities factors, which were perceived as areas for improvement and areas of concern, respectively. Second, the predominant learning approach adopted by students was the deep learning approach. Lastly, students’ perceptions of their intrinsic interest in learning anatomy was the only AEEMI factor that had a significant association with students’ preferred learning approach.

In the current study, four out of the six factors in AEEMI were highly rated by the students. The majority of the students perceived anatomy teachers, importance of anatomy knowledge, their intrinsic interest in learning anatomy, and their effort to learn anatomy as positive areas. This could indicate the strength of the anatomy education environment in the School of Medical Sciences, USM. The items that received the highest scores were “anatomy teachers are knowledgeable,” “anatomy teachers are friendly,” and “anatomy teachers are enthusiastic to teach,” which are items under the anatomy teachers factor. This finding is similar to that of a previous study by Yusoff et al. [49] who used DREEM to evaluate the medical students’ perceptions of the general medical education environment in the same institution. Yusoff et al. [49] documented that the first-year medical students assigned the highest score to “the teachers are knowledgeable,” an item under the teacher factor. These findings provide further insight into the role of teachers’ content and pedagogical knowledge (i.e., being knowledgeable in the field and teaching) and motivational orientation (i.e., being enthusiastic and showing interest in teaching) in students’ perceived learning support [50, 51]. Rowe et al. [52] also reported that students had attributed their learning success to their perceived supportive relationships with lecturers. Taken together, it is evident that the teacher factor contributes to a positive educational environment. In another study, Palmgren et al. [53] found that the score of first-year students’ perceptions of the educational environment was the highest compared to those of the senior students. Nevertheless, they proposed that the high score could partly be due to individual factors as first-year students had high expectations of the educational environment, owing to their enthusiasm to begin their studies in a university and to experience independent adult life [53].

By contrast, the medical students reported dissatisfaction with the anatomy learning resources and quality of the histological learning facilities in the School of Medical Sciences. These students have limited opportunity to use cadaveric specimens, plastinated specimens, and virtual microscopy for their learning, as these tools are limited and reserved for demonstration purposes by the lecturers. Hence, the students learn and revise anatomy by using plastic anatomical models, anatomical textbooks, online materials, and optical microscopy. This finding supports the fact that medical students prefer access to various forms of learning materials for anatomy learning, such as cadaveric specimens, three-dimensional visualizer tools, and computer-assisted learning, as these tools are reported to be effective in enhancing the students’ understanding of spatial association between human body structures [54–56]. Chang Chan et al. [57] had recommended low- and middle-income countries with limited resources to implement anatomy teaching in a combination of complementary strategies which include lectures, a learning management system, and practical classes that utilize prosected specimens, radiological imaging, and computer-assisted learning. Institutions that adopted a multimodal approach of anatomy teaching had attained students’ positive perceptions, greater student engagement, and improved assessment outcomes [37, 39]. With regard to histological learning facilities, virtual microscopy incorporated into various teaching approaches, such as team-based learning, case-based learning, and peer teaching, had shown to enhance learner engagement and result in better student performance [58, 59]. Scrutinizing the aforementioned achievements, a multimodal teaching approach is worth serious consideration to improve our institution’s anatomy education environment.

In terms of learning approach, the majority of the first-year medical students in this study were found to adopt a deep learning approach. This result is in line with a previous study conducted by Ward [25] that attributed it to students’ devotion to achieving a meaningful understanding of their coursework. According to Feeley and Biggerstaff [20], apart from students’ perceptions of the learning environment, psychological factors, such as low anxiety levels and students’ perceptions of having enough time to understand the coursework, may also encourage the adoption of a deep learning approach. This might be the case with the first-year students in this study who did not have to undergo a professional exam at the end of their first year. On the other hand, the predominant learning approaches adopted by second-year medical students were deep and strategic approaches. Interestingly, a greater proportion of second-year students adopted the strategic approach compared to first-year students. This was probably due to the second-year students’ responses to pressures of assessment, as they must pass a professional exam at the end of second year [41]. The second-year students might also have acknowledged the need to differentiate and scrutinize the essential anatomy learning content from the vast amount of facts [20]. The adoption of a deep and strategic learning approach by the majority of the students in this study is perhaps aligned with their perceptions of the anatomy education environment, whereby they perceived the anatomy education environment in general as positive and they had high intrinsic interest in learning anatomy. In fact, this study had shown that students’ perceptions of their intrinsic interest in learning anatomy was significantly associated with students’ adopted learning approaches. Our result supports previous research by Holmes [60], who reported that students’ approach to learning is influenced by their level of interest. Holmes [60] documented that students who had an interest in a topic tend to utilize a deep approach, while those who are lacking in interest tend to utilize a surface approach.

The present study revealed that all of the students had positive perceptions of the anatomy teachers, and a majority of them adopted the deep learning approach. Based on these findings, we postulate some form of relationship between students’ positive perceptions of the anatomy teachers and their adoption of a deep learning approach. Previous studies have shown that academics who are supportive and enthusiastic to teach influence the adoption of a deep learning approach among students [34, 35]. For instance, Karagiannopoulou and Milienos [35] concluded that tutors’ efforts to consolidate psychology students’ understanding during teaching and their enthusiasm and support toward promoting students’ learning were the strongest predictors for the deep learning approach. This was corroborated by the findings of Postareff et al. [34] that showed a relationship between increased adoption of a deep learning approach among natural sciences students with their positive perceptions of teaching for understanding. Thus, we anticipate that the anatomy teachers factor, which overlies items that obtained the highest scores in this study, could contribute to the adoption of a deep learning approach among the students. Hence, future studies should rigorously examine the relationship between teachers’ competencies and teaching behaviors with students’ learning approaches.

Further, the insignificant association between students’ perceptions of importance of anatomy knowledge, anatomy learning resources, students’ effort to learn anatomy, and quality of histology learning facilities, and their adopted learning approaches—mainly the deep approach—could be due to the students having a disposition to understand for themselves by striving to reach a complete understanding of what they study [34, 61]. Students with a disposition to understand are devoted to their well-developed learning strategies and are alert to changes in the learning context. They display a strong preference toward a deep approach irrespective of the learning context [34, 61]. Apart from that, it is hypothesized that the deep learning approach among the students in this study could have been influenced by the design of the medical curriculum in the School of Medical Sciences, USM, whereby the curriculum is conducted through an integrated problem-based learning (PBL) approach [62]. A study by Dolmans et al. [63] concluded that the PBL method had enhanced the development of a deep learning approach among university students as they are professionally involved in group discussions of relevant problems with enhanced knowledge application and integration.

This study has some limitations. First, the data obtained in this study are self-reported by the students. The actual behaviors of the students that indicate their learning approach were not observed, and these behaviors could differ from the students’ self-perceptions. Second, the learning approach is a dynamic and multidimensional element that could be influenced by various factors not limited to the factors of the anatomy educational environment. Since the learning approach of students can be adjusted according to their learning needs, it would be difficult to conclude the association between the anatomy education environment factors and the students’ learning approach in a single measurement. The students’ judgment while responding to the learning approach assessment might be biased, as they were learning various medical subjects concurrently. As controlling this bias is almost impossible in an integrated medical curriculum, this study could have been of greater value if undertaken in programs that heavily emphasize anatomy as a main curriculum component (e.g., postgraduate program in anatomy). Lastly, the insufficient sample size may not have adequate statistical power to detect significant associations between the students’ perceptions of the anatomical education environment and students’ learning approach. We recommend future studies on longitudinal measurement of anatomy education environment and learning approaches at different time points of the curriculum, as these evaluations would give a better insight into the relationship between these two variables. Including qualitative assessment of students’ experience in learning anatomy (e.g., reflective diary or focus group discussion) would add value to the studies, capturing non-observed variables (i.e., students’ actual learning behavior). These efforts would contribute to more valid and reliable research data.

Conclusions

In conclusion, the first- and second-year medical students in this study perceived the anatomy education environment in general as positive and conducive. The results further indicate that the teacher factor highly contributed to the positive anatomy educational environment. Perceptions relating to anatomy learning resources and the quality of histology learning facilities were not favorable and may be factors that need to be further investigated and rectified. Most of the medical students adopted the deep learning approach. However, the adoption of a learning approach is not influenced by most of the factors in the anatomy education environment, except for the factor of students’ perceptions of their intrinsic interest in learning anatomy. Thus, the importance of instilling students’ interest in anatomy cannot be overstated. A few factors that can enhance students’ interest are diversity in teaching methods and approaches, emphasizing the clinical relevance of anatomy studies and problem-based learning [64, 65]. The reported insignificant association could be due to students having a disposition to understand for themselves, the integrated PBL approach in the medical curriculum, and the insufficient sample size. Investigating the relationship between these two variables in a longitudinal study involving multiple cohorts from multiple institutions is necessary to provide a better understanding of the factors that lead to the adoption of each learning approach and whether the factors could be influenced by the curriculum design and teaching methodology of anatomy.

Author Contribution

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Haziq Hazman Norman and Najib Majdi Yaacob. The first draft of the manuscript was written by all authors. Fazlina Kasim and Siti Nurma Hanim Hadie edited the previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

This study was funded by the Universiti Sains Malaysia under the School of Medical Sciences Postgraduate Studies Development Incentive Fund (Tabung Insentif Pembangunan Pengajian Siswazah PPSP (TIPPS)) 2019.

Availability of Data

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics Approval

This study was approved by the Human Research Ethics Committee (JEPeM) of the Universiti Sains Malaysia (Ethics approval number: JEPeM USM Code:-USM/JEPEM/19100625).

Consent to Participate

Written informed consent was obtained from all individual participants included in the study.

Consent for Publication

Written informed consent was obtained from all individual participants included in this study.

Conflict of Interest

The authors declare no competing interests.