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 Table of Contents  
Year : 2021  |  Volume : 6  |  Issue : 2  |  Page : 150-155

Learning approaches adopted by Indian medical students during distance learning: The revised two-factor study process questionnaire

Department of Pathology, Army College of Medical Sciences and Base Hospital, New Delhi, India

Date of Submission12-Oct-2020
Date of Decision18-Dec-2020
Date of Acceptance31-Dec-2020
Date of Web Publication24-Aug-2021

Correspondence Address:
Dr. Sharmila Dudani
7/41, Vikram Vihar, 3rd Floor, Lajpat Nagar-4, New Delhi - 110 024
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjhs.bjhs_104_20

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CONTEXT: Student approaches to learning are a significant determinant of success in the medical profession.
AIM: This study assesses the study processes utilized by undergraduates in a medical college in North India.
SETTINGS AND DESIGN: Cross-sectional, questionnaire-based study.
METHODOLOGY: The study process questionnaire by Biggs et al. was adapted to Google forms and administered to 313 medical students. Individual domain scores assessing deep-motive, deep-strategy, surface-motive, and surface-strategy approaches were obtained. Other variables measured included gender, year of training, whether the student found online distance learning useful, and students' perceptions of their academic performance compared to their peers.
STATISTICAL ANALYSIS USED: The association between the categorical variables was assessed using a Chi-square test. The continuous measures were compared using a t-test or Mann–Whitney U-test. One-way ANOVA or Kruskal–Wallis test was applied for multiple groups.
RESULTS: Deep approach to learning was the most popular overall (66.1%). Females significantly favored deep approaches compared to males. There was no association between the year of training and the study process. The deep approach was associated with better academic performance. Online learning was significantly favored by females, students with a deep learning approach, and better academic performance.
CONCLUSIONS: Gender and academic performance are associated with the study process adopted by medical students. An understanding of the learning methods used by students is helpful in training well-rounded health-care professionals.

Keywords: Curriculum, learning, medical students, revised two-factor study process questionnaire, undergraduate medical education

How to cite this article:
Bhuria M, Mangalesh S, Dudani S, Malik A. Learning approaches adopted by Indian medical students during distance learning: The revised two-factor study process questionnaire. BLDE Univ J Health Sci 2021;6:150-5

How to cite this URL:
Bhuria M, Mangalesh S, Dudani S, Malik A. Learning approaches adopted by Indian medical students during distance learning: The revised two-factor study process questionnaire. BLDE Univ J Health Sci [serial online] 2021 [cited 2023 Jun 3];6:150-5. Available from: https://www.bldeujournalhs.in/text.asp?2021/6/2/150/324515

Medical education is the foundation of the health-care system. There is an ever-increasing demand for doctors to cater to the need of the population. Present-day medical graduates are expected to be thorough in medical knowledge and versatile, socially responsible individuals who are well-equipped for clinical practice. There is a considerable emphasis in recent times on a holistic system of education focused on ensuring competence.[1],[2]

The coronavirus disease-2019 (COVID-19) pandemic has had a considerable impact on the educational system, leading to the closure of medical schools across the world, with a transition from traditional teaching methods to online distance-learning platforms.[3],[4] This change has been sudden and abrupt leading, leading to a host of problems for medical students and educators. Although modern means of disseminating knowledge enable access to specialized material beyond textbooks, medical students face the immediate challenges of reduced clinical exposure and face-to-face patient and teacher interaction.[5]

Medical education is often expensive and challenging, with medical students being considerably more stressed than their peers.[6],[7] Rigorous training schedules comprising postcourse assessments, professional examinations, and clinical assessments are followed to ensure that young professionals can manage patients with excellent standards. Attitudes to learning and the process adopted to assimilate knowledge are of paramount importance to succeed in medicine. Studies have identified deep and surface domains in learning and established sub-domains of motivation and strategy, which have implications on the strategies used by students in their curriculum.[8] Practical learning strategies that allow for deep understanding and long-term retention have also been increasingly studied, but their implementation is lacking in formal education.[9] Holistic learning methods are essential for coping with academic challenges, compounded further due to the challenges faced in present times.

This study assessed the study-process utilized by the students of a medical college in North India to identify the frequency of deep and surface strategies to learning using a standardized questionnaire. Associations with other variables such as gender, academic performance, and receptivity to online learning were also assessed.

  Methodology Top

This was a cross-sectional study conducted at a medical college in Northern India, among 400 medical students of the institute, from the 1st to 4th years of medical training. A standardized study process questionnaire with 20 items was adapted to Google Forms® and circulated electronically to the study participants. Response collection was conducted for 10 days, from 2nd to 12th September 2020. Ethical approval was obtained from the institutional ethics committee before the study (Reg. No. IEC/08/2020/39). Informed consent was taken along with the questionnaire responses, and confidentiality issues were explained to participants. Incomplete responses and responses from intern batches were excluded.

The study process questionnaire by Biggs et al., which was revised in 2001, measures two-factors revised two-factor study process questionnaire (R-SPQ-2F) and consists of 20 items evaluating the deep and surface learning approaches.[8] Each approach is assigned ten items on the questionnaire. The surface and deep scales are subdivided into two subscales of five items, representing strategies, and motivations underlying the learning approaches. Hence, four scores, namely deep-motive (dm), surface-motive (sm), deep-strategy (ds), and surface-strategy (ss) are obtained. Items 1, 5, 9, 13, and 17 evaluate the dm approach. Items 2, 6, 10, 14, and 18 evaluate ds, items 3, 7, 11, 15, and 19 evaluate sm approach, and items 4, 8, 12, 16, and 20 evaluate ss approach.

A 5-point Likert scale was used, where 1 = never true for me or only rarely true for me; 2 = only sometimes true for me; 3 = true for me around 50% of the time; 4 = true for me very frequently; and 5 = always true for me or almost always true for me. The total score for each of the four subscales hence ranged from 5 to 25. Demographic parameters such as age and gender were recorded. Some other questions included whether the students found online learning modalities beneficial to them, whether the student believed that they might pass their upcoming exams, and where they would place themselves in comparison to their peers (upper, middle, and lower 1/3rd) in their class.

Statistical analysis was performed using IBM SPSS for Windows version 21.0 (Armonk, NY, USA: IBM Corp). Continuous variables are expressed as mean with standard deviation or medians with interquartile range (IQR). Association between the categorical variables was assessed using a Chi-square test. Normality was assessed using the Shapiro–Wilk test. Homogeneity of variances was assessed using Levene's test. Continuous measures were compared using a t-test or Mann–Whitney U-test as appropriate. One-way ANOVA or Kruskal–Wallis test was applied to compare multiple groups. All P < 0.05 were considered statistically significant.

  Results Top

A total of 313 out of 400 students responded, giving a response rate of 78.25%. The study consisted of 171 (54.6%) male and 142 (45.4%) female respondents. Out of 313, 84 (26.8%) were from the Ist year, 100 (31.9%) from the IInd year, 57 (18.2%) from the IIIrd year, and 72 (23.0%) from the IVth year of training. A total of 173 (55.3%) students said that online classes are beneficial to them. About 90 (28.7%) felt that they would not pass their upcoming examinations. For perceived academic position among their peers, 39 (12.46%) placed themselves in the lower 1/3rd, 69 (22.04%) in the upper 1/3rd, and 205 (65.49%) in the middle 1/3rd.

A Chi-square test was used to test for the associations between the categorical variables. Females were more likely to find online classes beneficial. The majority of IInd, IIIrd, and IVth year students found online classes helpful (69.0%, 61.4%, and 55.6%, respectively), in contrast with Ist year students (34.5%) who were significantly less likely to find online classes beneficial. Students who believed they were in the lower 1/3rd of their class and would not pass their upcoming examinations were less likely to find online classes beneficial. The results are summarized in [Table 1].
Table 1: Association of categorical variables with student perceptions on whether online classes would be beneficial to them

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The overall median (IQR) scores of the four parts of the SPQ-2F were dm 17.0 (5.0); ds 16.0 (5.0); sm 12.0 (5.0); and ss 15.0 (6.0). The overall deep approach score was 32.0 (9.0), and the surface approach score was 28.0 (9.5). Out of 313 participants, 207 (66.1%) preferred a deep learning approach, and 106 (33.9%) preferred the surface approach. The SPQ-2F scores for each year of training from Ist to IVth are represented in [Figure 1]. No statistically significant differences in the scores were observed between the students in different years of training.
Figure 1: Median revised two-factor study process questionnaire scores for students across different years of training

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On average, females had higher dm scores and lower sm and ss scores. The results are summarized in [Table 2].
Table 2: Gender differences in revised study process questionnaire two-factors scores

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Student perceptions about their class position were also associated with SPQ-2F scores, with the upper 1/3rd group showing higher dm and ds scores and the lower 1/3rd showing higher sm and ss scores. The results are summarized in [Table 3].
Table 3: Revised study process questionnaire two-factors scores among students that placed themselves in the upper, middle, or lower 1/3rd of their class compared to their peers

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Students who felt online classes were not beneficial had significantly lower dm and ds scores and higher sm scores [Table 4].
Table 4: Revised study process questionnaire two-factors scores among student groups that felt online classes would or would not be beneficial to them

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  Discussion Top

The R-SPQ-2F is a questionnaire developed by Biggs et al. intended for the use by teachers to both evaluate their teaching methods and the learning attitudes of their students.[8] Among the four domains, deep learners tend to analyze new information by association with preexisting knowledge and building on concepts. This includes actively reading extra information on a topic of interest or testing oneself till the topic is understood fully. Since this method is based on logical step-by-step understanding and retention of concepts, it allows for long-term retention and application in solving unfamiliar problems.[10] Surface learning is associated with memorization and reproduction of the information for an examination, which leads to superficial retention of knowledge.[11] A surface learner classically tries to do as little work as possible to pass the course. The surface and deep components are further divided into motivational and strategic subparts.[8] The motive component is centered around personal fulfillment and the strategic component around meeting specific goals and targets.

This study found significant gender differences in learning strategies and receptivity to online modalities to learning. Female students were about two times more likely to find online classes beneficial [Table 1]. It was also observed that female medical students were significantly more inclined toward deep approaches to learning than toward sms and strategies [Table 2]. In contrast, male students had significantly higher scores on surface approaches, with a more strategic and goal-oriented approach. To our knowledge, this study is the first instance of the R-SPQ-2F being used to describe gender differences in a medical student population. Mixed findings have been reported in other studies employing different questionnaires.[12],[13],[14],[15]

Our findings suggest that there may be inherent differences in learning attitudes in males and females. While working to maximize grades for the explicit purpose of passing a course is the primary focus of a surface learner, there may be no meaningful benefit to this approach, especially in the medical field. Surface approaches to learning are akin to the efficient use of space and time. Surface learning was more common among males in this study, suggesting that narrow personal targets and rote learning were more prevalent in this group.[8] While the surface approach is arguably the most strategic and intuitive means to succeed in the present education system, this is a cause for concern.

In contrast to other batches, 1st-year medical students, on average, did not perceive online classes to be useful. Students at the outset of their medical training come from different backgrounds, with varied expectations from medical school. Soon after the academic session's commencement, 1st-year students were forced to return home and resume studies from a new online modality. This mismatch between student expectations and the reality of the pandemic perhaps explains the poor receptivity of this group to online classes. Adaptation to medical education in the early days is a known stressor and is a major challenge for 1st-year medical students. Significant differences in approaches to learning were not detected between the students of different years of training. A uniform pattern of learning attitudes exists in both the preclinical and clinical years in this study. Other studies conducted on dental students revealed similar findings.[16],[17]

Study participants ranked themselves compared to their class peers into the upper, middle, and lower thirds based on academic performance. Whether the students believed that they could pass their upcoming examination was also used as a surrogate to measure academic performance. Marks and grade point averages (GPA) could not be used, as summative examinations were still pending. We found a significant relationship between learning approaches and student perceptions about their position in their class [Table 3]. Those who perceived themselves to be in the upper 1/3rd showed higher dm and ds scores. In contrast, the middle and lower 1/3rd groups showed higher sm and ss scores. These findings demonstrate a strong association between academic success and deep-learning approaches. Students who were confident in their academic position and ranked themselves higher also had significantly higher deep learning scores. A similar study among medical students from Saudi Arabia demonstrated that deep-learning approaches were associated with higher GPAs.[18] This finding was also observed in other studies employing different inventories to assess learning strategies.[19],[20]

Students who did not find online classes useful were about three times as likely to be in the lower 1/3rd group, and six times more likely to expect failure in upcoming examinations [Table 1]. Academic performance was associated strongly with student receptivity toward online learning modes, with this group having a more positive outlook toward online learning.

Students who felt online classes were beneficial had significantly higher dm and ds scores and lower sm scores [Table 4]. The surface learning strategy has been described as an attempt to optimize the time consumed working, keep out of trouble with minimal effort, and memorize material selectively to maximize grades.[8] Students who are inherently deep learners have a stronger desire to adapt to online learning modalities, motivated by an intense interest in the subject matter.

Learning styles differ from person to person in alignment with personal goals. Students who are intrinsically motivated and can acknowledge their subject's professional applications tend to adopt a deep approach. Externally motivated individuals, who fear failure, or are driven only to complete the course, are inclined toward the surface approach. An educator's understanding of the learning approaches of students is essential for enabling their long-term success. As the learning approaches are not fixed, the educator can be a significant contributor in making the educational environment conducive to changing approaches by students.

They can play a transformative role in weak medical students' academic life, who may often be trapped in a vicious cycle of poor performance. In the highly competitive medical education environment, a single failure often creates an insurmountable backlog, which makes progress very difficult. With a mentality of scarcity, underperforming medical students may be driven to divert all their effort into superficial learning strategies to avoid failing again. With the fear of failure becoming the sole motive, an undesirable and vicious habit formation occurs. Negative reinforcement as a driving force is not conducive to a deep motivational learning approach and is a cause for concern.[8] Surface or deep traits are not irredeemable or stable and can be modified by the teaching context, for which both teachers and students are joint stakeholders for achieving desired goals.

The new curriculum adopted by the Medical Council of India may, therefore, be a step in the right direction. With a competency-based approach, there is an intensified focus on the acquisition of core knowledge and skills.[21] Emphasis on a more continuous system of performance evaluation and assessments is needed, to shift focus away from an exclusively exam-oriented medical school experience. Reading the subject as a leisure activity should be encouraged, and ample opportunity to achieve this must be provided. Collaborative learning opportunities among students are essential to increase participation and to encourage critical thinking. Online learning modalities, in particular, may now play a significant supplementary role outside the classroom long after the pandemic is over.


This was a cross-sectional study, conducted by electronically circulating the survey to all study participants. Due to the constraints of the ongoing COVID-19 pandemic, in-person response collection was not possible. Assessment of learning approaches in the setting of regular in-person classes is also needed. As no summative assessments had taken place for each batch of medical students in this study, academic performance could not be assessed using test-scores, and self-reported responses were used in their place.

  Conclusions Top

Females prefer the deep approach to learning more than males. Students who adopted a deep learning approach, and had better academic performance, were more likely to find online learning modalities useful. Understanding the learning approach utilized by medical students may prove useful in providing a conducive learning environment for well-rounded health-care professionals for future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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