CIMJ THE

CEBU INSTITUTE OF MEDICINE JOURNAL

2020 June-December | Vol. 2

OUTLOOK AND INNOVATION IN

MEDICAL EDUCATION The 2020 research of the Cebu Institute of Medicine Journal forms part of the faculty’s renewed push to highlight the importance of research in medical education.

THE CEBU INSTITUTE OF MEDICINE JOURNAL

RESEARCH COMMITTEE C H AI R

Maria Philina P. Villamor, M.D. COR E M EM B E R S

Michael James C. Busa, M.D. Ma. Teresa Cañete, M.D. Hester Gail. Y. Lim, M.D. Adrian Christopher A. Lu, M.D. Corazon T. Meneses, M.D., MSHPEd Neil Wayne C. Salces, M.D. M ANAGI NG EDI TO R

Marie Rose B. Arong, Ph.D.

Design and Illustration by: Alyssa Selanova

FOREWORD

The first time I read two research protocols of the third year medical students related to medical education for IRB approval I was impressed and pleased that finally the students have in one way or another showed the importance of their medical education in the institution. For me, this is a reflection that some of our students in the higher year have developed self-efficacy as learners. When the school shifted to problem-based learning, I did an evaluation of the program and made some necessary improvement through the years. The almost 100% passing rate in the performance of our graduates in the Physician Licensure Examination (PLE) has negated the necessity to do research on PBL. Recently we introduced and required the students to practiced interdependent cooperative learning among the PBL tutorial group members and has made the creation of the group concept map to be submitted after each PBL small group discussion. The student is to create his own concept map based on his assigned topic given by the group leader and in the SGD, they share, improve, and create the group concept map. The making of concept map as a learning tool was discussed during the orientation week. The making of one is not compulsory then. One of the research protocols was to determine the KSA of the students about concept mapping. The other one was on the preference of medical textbook versus medical e-book. Though we have two faculty who are MHPEd, and others are finishing their respective masteral degree; I am confident that sooner than latter the faculty shall also follow through and submit their research on medical education to continuously monitor and improve the quality of medical education at CIM. We are at the midst of the pandemic and all must try their best to adopt to the so called New Normal. How the way of the new normal on outcome-based education with blended flexible learning will impact the learning of our students is a wealth for research on medical education. So, let us do what needs to be done.

DR. CORAZON MENESES Medical Education Unit Head

CONTENT

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A SURVEY OF CIM STUDENTS’ SATISFACTION WITH LIBRARY RESOURCES AND SERVICES | Cayabyab,M, Angeles JM, Booc JL, Castro A, Estanislao E, Garcia D, Larcena AT, Niere RP, Tansingco N, Yu, CE

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CIM STUDENTS’ KNOWLEDGE, SATISFACTION, AND EXPECTATIONS ON THE EXPERIMENTAL RESEARCH FACILITIES AND EQUIPMENT OF CEBU INSTITUTE OF MEDICINE| Bajarias MLL, Berame ID, Chu-Santos CAR., Dagondon MM, Daguplo NFG, Espejo JJP, Odi JAFD, Rubia DJA, Singco PJY, Tan SMU

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EFFECT OF GAP YEAR PRIOR TO MEDICAL SCHOOL ON STRESS COPING MECHANISMS OF CIM MEDICAL STUDENTS | Atilano MA, Erazo RT, Esplanada A, Lingatong CA, Lomaad DJ, Matuco JN, Nuñez V, Redula S, Sanchez FJ, Tibon MA

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EXPLORING THE LINK BETWEEN NEGATIVE EMOTIONAL STATE OF DEPRESSION WITH MENTAL HEALTH LITERACY AMONG FIRST YEAR TO THIRD YEAR STUDENTS OF CEBU INSTITUTE OF MEDICINE | Yulo PAL, La Rosa AKD, Colasito TM, Lagamon TE, Amatorio MAC, Congrehilla LB, Limbaga LPA, Mendoza AD, Oku M and Echor OO

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FACTORS AFFECTING THE PURSUANCE OF PROFESSIONAL MEDICAL CAREERS AT THE PRIMARY HEALTH CARE LEVEL AMONG CIM STUDENTS | Araneta NLL, Bomediano MJR, Curan JKD, Lao PGI, Rabaya AJN, Isabel B, Ricardo R, Rosales NVO, Ting APC, Uymatiao EES, Villar SRD

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PERCEIVED STRESS LEVELS AND COPING MECHANISMS OF SECOND YEAR CIM MEDICAL STUDENTS AFTER EXAMINATIONS | Salva W, Balero J, Ababa R, Busmeon C, Concepcion K, Ho T, Isidto V, Pandoro A, Resuelo K, Urgel V

THE CEBU INSTITUTE OF MEDICINE JOURNAL

The Cebu Institute of Medicine Journal (CIMJ), the official research publication of Cebu Institute of Medicine is an-open access journal; distribution, and sharing of this publication is highly encouraged.

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A SURVEY OF CIM STUDENTS’ SATISFACTION WITH LIBRARY RESOURCES AND SERVICES Angeles JM, Booc JL, Castro A, Cayabyab M, Estanislao E, Garcia D, Larcena AT, Niere RP, Tansingco N, Yu CE

ABSTRACT Introduction: Libraries are service oriented organizations established for the provision of relevant information resources for its users. They are essential educational instruments for the education and research of medical students. Objective: This study aimed to determine the satisfaction of CIM students with their school library, using the LibQUAL + questionnaire developed by the Association of Research Libraries. Methods: A descriptive cross-sectional approach was used. Questionnaires were given to all First, Second, and Third Year students of Cebu Institute of Medicine. From the data, two gap scores, the service adequacy score, and service superiority score, were computed from each dimension of the library services, with higher scores correlating to better library satisfaction. Results: The results revealed that majority of the students use the library weekly, mostly for studying. However, majority of the students also use non-library sources on a daily basis. Furthermore, the results showed negative adequacy gap scores as well as Superiority Gap scores on all three dimensions: affect of service, information control, and library as a place. The aspects of the library with the lowest score, hence, the areas that need the most improvement pertain to the non-existent library website. The website’s limitations prevent students from locating resources on their own and accessing library electronic resources inside the classrooms. The results also point to a lack of community space for group activities. Finally, the respondents gave a fair rating on their overall satisfaction level with the school library resources and services. Conclusion: In conclusion, although there is a discrepancy between the scores on the specific dimensions of library service and the general questions about the overall satisfaction of the respondents, it is clear that there are areas in the school library that the respondents deem inadequate. Keywords: CIM Students, Superiority Gap, LibQUAL, adequacy gap, information control

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INTRODUCTION A library is defined as “a collection of resources in a variety of formats that is organized by information professionals or other experts who provide convenient physical, digital, bibliographic, or intellectual access and offer targeted services and programs with the mission of educating, informing, or entertaining a variety of audiences and the goal of stimulating individual learning and advancing society as a whole.”1 Academic libraries encompass research libraries, baccalaureate, masters and doctoral degree granting institutions, junior and community colleges, and distance learning programs of higher education. The major function of an academic library is to assist members of their communities in achieving the core competencies of information literacy, which include identifying an information need, accessing needed information, evaluating, managing, and applying information, and understanding the legal, social, and ethical aspects of information use.1 Although academic libraries have components that are specific to their own institution, they are often bound by a common mission, such as that of the American Association of School Librarians (AASL) and Association for Educational Communications and Technology (AECT), which is “to ensure that students and staff are effective users of ideas and information.”2 An academic library is an invalu-

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able tool for medical schools due to the constant evolution of medical knowledge and research. Traditionally, the study and practice of medicine has been based on the quantity of factual information, which has resulted in various “garbage can” models in clinical decision-making, that is, the physician’s successful decision making is dependent on his ability to memorize a large number of facts. In order to remedy this, a problem-solving approach was developed with the purpose of teaching medical students how to seek information rather than memorizing facts. This approach to medical education has led to new demands for learning information management skills, and thus a new role for medical libraries. Rather than serving as a passive storehouse of books and journals, medical libraries have become dynamic organizations with an emphasis on information management.3 Thus, libraries need to provide adequate and reliable resources to help students retrieve information from an updated database of journals, articles, health search engines, and e-books. These resources should be available throughout the entirety of medical school, so future physicians can master the skill of integrating their medical knowledge into practice.4 One of the major challenges faced by medical libraries is societal change, specifically the rapid advancements in technology that may threaten the role libraries play in medical institutions. For example, in a 2012 to 2015 study

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conducted by Gregory & Poole, a cross-institutional analysis of eight medical school libraries in the United States was used to ascertain the exact role of library resources in the lives of its medical students.5 Not surprisingly, one of the most sought-after resources is fast wireless Internet connection. Today, most students use smart phones, which provide them with the fastest way of obtaining the information they need, and allow them to bypass physically visiting a library.5 In addition, changes in scholarly communication, including the role of journals, economic models of publishing, and open science, are among the biggest challenges to libraries.6 Despite these challenges, the medical library assumes increasing importance in the lives of medical students and health practitioners. Its role evolves with medicine. It is not merely a repository of information but a purveyor of information, helping future and practicing physicians alike develop information seeking skills and providing access to a wide selection of resources that aid them in their studies, clinical decision-making, and research. This highlights the importance of evaluating the quality of medical library services to ensure that the service it provides is relevant and one way to do this is by measuring users’ satisfaction. Yang noted that user satisfaction is based on the degree of perceived quality that meets users’ expectations; therefore, library management

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should periodically evaluate the services they provide to their users.7 It is the only way to assess users’ needs and expectations as far as the services of a library are concerned. Periodic survey studies need to be done to evaluate all the existing resources and services since necessary measures can be taken to address any dissatisfaction that users may have with its services.7 Historically, the managements of libraries have not included user satisfaction of the library services offered. However, improving service quality based on user feedback is likely to satisfy future customers and reduce future complaints. Thus, quality services provided will lead to ensuring the success and sustainability of library operations, and to retaining existing users and attracting new ones. Recent literature has documented a number of techniques and models used to measure service quality.8 The SERVQUAL model, developed by Parasuraman et al., may be the most popular and can be used to measure service quality in a variety of settings. It is based on consumer perceptions of quality, which emerge from the gap between performance and expectations. As performance exceeds expectations, quality increases, and as performance decreases relative to expectations, quality decreases.9 Thus, performance-to-expectations “gaps” on attributes that evaluate the quality of a service form the theoretical foundation of the SERVQUAL technology. The Association of Research Libraries, in

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collaboration with Texas A&M University, developed the library-measuring model of LibQUAL+.8 It has become a standardized model for assessing and measuring service quality of libraries.10

OBJECTIVES The study aimed to determine the user satisfaction among 1st year to 3rd year CIM students who use the CIM Library. Specifically: (1) to determine the library usage patterns of the 1st year to 3rd year CIM medical students in terms of frequency and purpose of use, (2) to ascertain the library user satisfaction rate among 3rd year CIM medical students based on the availability of information sources needed for learning and research, the library as a place that provides an appropriate environment for its services, and the library staff assistance, and (3) to determine the areas of the library that need improvement.

METHODS A cross-sectional study design by means of a survey was used in this study to determine the user satisfaction among 1st year to 3rd year CIM students who use the CIM Library. The questionnaires were handed out to respondents in their individual SGD rooms and in the Microbiology/Pathol-

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ogy laboratory, within the premises of the Cebu Institute of Medicine, during the SGD and laboratory sessions, respectively. The subject of this study was limited to all the 1st year to 3rd year students of the Cebu Institute of Medicine currently enrolled in the academic year 2017-2018. It does not include the faculty, library personnel, staff of the administration and the hospital, and visitors using the library but not enrolled in CIM. The study was conducted at a time convenient for the participants. A consent form was provided, and the questionnaires were distributed per year level and collected immediately after completion. The collected data were encoded using Excel for analysis. The study used the LibQual +TM survey form, a rigorously tested instrument that measures library users’ minimum, perceived, and desired levels of service quality across three dimensions: affect of service, information control, and library as a place. The survey has a total of 22 core questions; each dimension includes a number of subquestions. On the survey form, the questions are intermixed.11 Each item is rated in three parts, namely the minimum, desired, and perceived service levels, with the score of 1 being the lowest rating, and 9 being the highest. The minimum service level corresponds to the minimum level of service that the user finds acceptable, the desired service rating is the number that represents the level of service that the

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user personally wants, and the perceived service level represents the level of service that the user believes the library currently provides.12 The Information Control dimension (eight questions) relates to whether the users are able to find the required information in the library in the format of their choosing, in an independent and autonomous way. The affect of service dimension (nine questions), is the human dimension of service quality. These questions relate to user interactions with, and the general helpfulness and competence of, the library staff. The library as a place dimension (five questions) deals with the physical environment of the library as a place for individual study, group work, and inspiration.13 The 22 core questions, which measure the three dimensions, are augmented by the comments provided by the users in the space provided at the end of the survey form.13 It also provided for the assessment of library user’s usage pattern. The data were interpreted by means of gap scores. There are two gap scores provided by the survey. First, the service superiority gap score is calculated by subtracting the desired score from the perceived score on any given question. The second gap score is the service adequacy gap score, which is calculated by subtracting the minimum score from the perceived score. Both scores could either be negative or positive depending on which score is higher. The higher the service superiority and service ade-

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quacy scores, the better the library’s performance. The space between desired and minimum scores is called the “zone of tolerance.”13 The data were also presented in a graphical manner through a radar chart and bar graphs for convenient interpretation. The averages of the collected were visualized into graphs. Radar charts are a helpful way to summarize the 22 questions and the 3 scales (minimum, desired, and perceived). Microsoft Excel was utilized to create a radar chart. To create a radar chart, score from the individual surveys were combined to form one set of aggregate survey data. The scores were taken as minimum, desired, and perceived mean scores for the service superiority and service adequacy gaps. Areas between each of the mean scores on the radar chart are color-coded to highlight the differences. The process was repeated for each individual item, and the mean scores were mapped on a single line and the areas between the scores were highlighted, then these lines were laid out like spokes on a wheel. Questions from each of the 3 dimensions were grouped together. On the radar chart, differences were highlighted in color: red indicates areas where the perceived score was less than the minimum score, yellow indicates that perceived scores were less than the desired scores, and green highlights areas where perceived scores were greater than the desired scores.13

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Bar charts provided another way to look at the aggregate survey data. On each chart, the zone of tolerance was shaded in gray and the adequacy gap was supposed to appear as an orange bar, which will show whether a perceived score goes beyond, within, or below the zone of tolerance.13 Using these methods, areas where users are satisfied and unsatisfied were identified and a conclusion was formulated.

RESULTS AND DISCUSSION About 300 respondents or more than half of the population of 1st to 3rd year CIM students took part in answering the survey. As they had the option to skip items that they feel are irrelevant to them, numerous items yielded an inconsistent number of responses. Classifying the overall responses into each year level was not possible because there were a considerable number of respondents who did not enter their year level. So, the discussion is solely based on the collective responses of all the respondents regardless of their demographic background. Analysis of the results depicted in Figure 1 reveal that across all dimensions of service quality analyzed: affect of service (AS), information control (IC), and library as place (LP), the CIM library fails to meet the minimum and desired levels of expectation, as portrayed by the red areas transected by all the question items.

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Figure 1. Cebu Institute of Medicine (CIM) Library (2018), Service Quality (All Dimensions)

Firstly, for the AS aspect, majority of respondents rated the service level less than desired, and some less than the minimum. AS measures the responsiveness, assurance, empathy, and reliability of the library employees.14 AS question 5, representing the availability of employees who have the knowledge to answer users’ questions, has the least negative adequacy gap (adequacy gap = -0.058). This means that this aspect of AS was perceived as closest to the minimum expected level. AS question 6, representing how well employees deal with users in a caring fashion, show the greatest negative adequacy gap (adequacy gap = -0.758) among the AS questions, meaning perceived service performance in this aspect is significantly below minimum expectation relative to the others, and thus requires the most improvement. For the IC aspect of service, across all 8 IC questions, the CIM Library also rated less than desired and/or less than the minimum levels of expectation. IC measures how users are able to interact with the library and

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includes the ease of navigation, modern equipment, scope, timeliness and convenience, and self-reliance.14 IC question 7, representing the accessibility of information for independent use, has the least negative adequacy gap (adequacy gap = -0.273). This means that this aspect of AS was perceived as closest to the minimum expected level. IC question 1, representing the accessibility of electronic resources, shows the greatest negative adequacy gap (adequacy gap = -1.165) and therefore requires the most improvement. Furthermore, the LP aspect of service was assessed through five (5) questions, which include whether the library provides adequate space for group and individual activities, and its conduciveness for learning. Among the five questions, the respondents rated the CIM library less than the desired and/or less than the minimum levels of expectation. Among the 5 LP questions, question 1, which determined whether the library creates an atmosphere conducive for learning had the least negative adequacy gap (adequacy gap = -0.58). It is thus perceived to be closest to the minimum expected level. On the other hand, question 5, which ascertained whether the library provides adequate space for group activities, garnered the highest negative adequacy gap (adequacy gap = -1.48). Hence, this area requires the most improvement. Overall, among the twenty-two (22) questions that covered the three

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dimensions assessed, the three items with the least negative adequacy gap were all from the AS aspect of library service. These include the following questions in decreasing order of adequacy gap: question 5, which reflected whether the employees have the knowledge to answer user questions (adequacy gap = -0.06); question 1, which ascertained whether the employees instill confidence in users (adequacy gap = -0.09); and question 4. which determined the employees' readiness to respond to users' questions (adequacy gap = -0.12). It can therefore be inferred that these three areas under the AS aspect, and among the three dimensions, were perceived by the respondents to be the closest to the minimum level of expectation. Meanwhile, the three items with the highest negative adequacy gap came from the IC and LP dimensions. Question 5 under the LP dimension, which assessed whether the library provides adequate community space for group activities, had the highest negative adequacy gap of -1.48. The next top two items were both from the IC dimension, including question 1, which reflected the user's accessibility to electronic resources from their own homes or classrooms had an adequacy gap of -1.17, and question 2, which sought out the existence of a library Web site allowing users to locate information on their own had an adequacy gap of -1.12. Consequently, these three areas need the most improvement.

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Presented in another way, the perceived scores of the CIM Library on the three dimensions were below the minimum service level expected by the respondents. As shown in the Figure 2, none of the perceived scores (red dots) were inside the Zone of Tolerance (gray area) for each dimension.

Figure 2. Summary of the mean perceived scores (red dots) and its relation to the Zone of Tolerance (gray area).

This means that the library has negative Adequacy Gap and Superiority Gap scores for every dimension and an overall adequacy gap score of -0.59. Thus, based on the perception of the respondents, the library, in terms of its availability of information, its environment, as well as its personnel service, is inadequate. Among the three dimensions, the affect of service scored the highest Adequacy Gap score, while the library as a place scored lowest. Responses to questions about general satisfaction are slightly more encouraging. The data listed on Table 1 describe how the library serves CIM students. The mean scores describe the degree to which the respondents

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agree with the statements, on a scale 1-9, with lower scores indicating that the respondent strongly disagrees, and higher scores indicating that the respondent strongly agrees with the statement. The last statement asked the respondents to give an overall rating on the quality of the library service on a scale of 1 to 9, with 9 indicating an extremely good rating. Overall, across the first 6 statements, there was little variation of the mean score (Mean: 6.38; SD = 0.25), providing a good measure that this data is in fact mostly reliable (no outliers with normal distribution). The mean scores show that most respondents are satisfied with the way they are treated in the library and found that the library enables them to be more efficient thus helping their academic progress. The library also improved the respondent’s information skills by providing trustworthy information and resources. Significantly, the respondents agree to the greatest level when asked if they are satisfied with the way in which they are treated at the library, and the least when they were asked if they are satisfied with the library support for learning and/or research needs. Finally, the overall mean service quality rating was fair, at 6.46/9 from all respondents. This data indicates that the CIM students “somewhat agree” that the library is useful, meets the student’s needs, and provides adequate service. The mean scores for this set of questions are more satisfac-

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Table 1. Mean scores of the perceived general satisfaction.

tory than the ones that measured the service adequacy and gap scores. This may be attributed to some other factors not assessed by the questionnaire that might contribute to user satisfaction, or it might be somewhat related to some comments about the first part of the questionnaire being difficult to answer, since it is a more complex form of the usual Likert scale. This merits further investigation. Library Usage Pattern

Figure 3 shows the library usage pattern of 1st-3rd year CIM students and its comparison with their non-library resource usage pattern. As shown in the graph, majority of the students (40.5%; n=118) use

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Figure 3. Library and non-library usage patterns of 1st-3rd year CIM students.

the library on a weekly basis than on a daily basis (20.82%; n=61). Fifteen percent only use it quarterly and only 4.4% of the respondents never use the library. This shows that most students use the library at least several times per week, which is indicative of the utility of the library in medical schools. However, whether the fact that fewer

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students use it daily than weekly implies inadequacy of the library service or not, is beyond the scope of this study. In contrast, majority of the respondents use non-library information gateways on a daily basis (56.2%; n=167), as compared to less frequent occasions. This might reflect a preference for faster and easier access of information through technology and the internet, but this also indicates more students get information from possibly unreliable sources using the internet.15 The library can use this information to consider making its technological facilities compatible with the students’ needs so that they can have more convenient access to reliable biomedical information. In addition, as shown in Figure 4, most students use the library for studying purposes (45.5%). This somehow reflects the main purpose of this part of the school. With the PBL system of the institution, students are given more time for self-studying, thus, the library may play a major role in helping the system work more effectively.

Figure 4. Purposes for using the CIM Library.

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The administration may consider deploying more strategies to help the students foster good study habits such as providing more books, resources, and a place more conducive for studying. Significantly, the 2nd most common reason for using the library is to make outputs for clinics. This is noteworthy since even though only the 2nd and 3rd years do this, the data still showed a high frequency. The library might consider creating a space solely for making clinics output, where students discuss their cases without disturbing other students. Qualitative Data: Respondents’ Comments and Suggestions

There were 182 additional comments made by the respondents. The top three main concerns of the respondents, constituting most of the comments made, include the library space, its internet services, and the physical environment of the library. First, most respondents mentioned that there should be more space to be used for studying and doing research as well as a separate space where groups can get together and discuss and make projects. It was also noted that plenty of students wanted to use the library but there are not enough tables and chairs. They also wanted more individual cubicles for studying, more air-conditioned rooms, and a place to rest and sleep. A substantial number wanted a faster and better internet connection for the Wi-Fi and computers. This would help in studying, doing research, and find-

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ing books, articles, or journals not found in the library. In addition, it was frequently noted that the library can get too crowded and noisy at times. They noticed that noisy students are rarely reprimanded. In some of the rooms, the street can be heard outside which can be very noisy. Other comments include longer business hours, especially during bimonthly and final exams weeks, more comfortable and cleaner tables and chairs, more charging stations, more pigeon holes for bags, and updated books and articles, and some comments about the library personnel being not so courteous. The common theme in the majority of these comments is about the LP dimension. This coincides with the results discussed earlier, which found that the LP dimension had the least satisfaction scores. This indicates that the LP dimension should be a priority when improving library services. On the other hand, not all comments were critical. A few people said that the library staff members were helpful. Some respondents found the amenities in the library useful, such as the couch provided for reading magazines and journals and the individual cubicles for studying. Others felt that the library satisfactorily provides the necessary information to aid their studies.

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CONCLUSION Care must be taken in interpreting the results of the study. There could be many extraneous factors that can contribute to user satisfaction, as evidenced by the somewhat discordant results between the service adequacy scores and the general satisfaction scores. One tool, no matter how rigorously tested, may not be sufficient to consider such factors. Although the overall results were unsatisfactory, respondent demographics, learning preferences, knowledge about library services, time spent in the library, and even the ability to understand the questionnaire may be possible factors that need to be further explored. Furthermore, this study only provides a snapshot of user satisfaction which could easily change with time. Furthers studies done longitudinally are warranted, particularly those that identify and integrate these factors as much as possible, in order to paint a more meaningful picture of the adequacy of the library services. On the other hand, one could not overlook the considerable indications of inadequacy of the CIM Library. The fact that the LP dimension had the worst service adequacy score and also got the greatest number of negative comments is a reliable indicator that more efforts should be focused on improving this area, notably the need of a space for group discussions and projects. The results also showed the prime importance that the students

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place on having access to information in a faster and more convenient manner, mainly through electronic means. This underlies the need for the library to keep up with the technological advancements of this information age if it wants to effectively serve its users or perhaps increase its usage rate. As pointed out earlier, the affect of service dimension had the best overall score, however the respondents felt that the personnel do not adequately deal with the users in a more caring fashion. This suggests that library personnel are more than just administrators of the library but also, they are an extension of the services that the library provides and having a caring staff could improve the overall library experience. Overall, by using the LibQUAL+ questionnaire, the study was able assess the user satisfaction in various aspects of the CIM Library services. The consistency in the results makes the questionnaire a reliable one. Although some respondents had difficulty answering the questionnaire owing to its more complex format, they were able to provide strong indications of the strengths and weaknesses of the library and provide suggestions on how to improve its services. The study also revealed that the CIM Library plays a dynamic and integral role in the education in the education of the CIM students.

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LibGuides: Definition of a Library: General Definition. American Library Association. http://libguides.ala.org/library-definition. Accessed December 26, 2017. Latrobe K. School Libraries - History, Goals and Purposes, Materials and Equipment http://education.stateuniversity.com/pages/2396/ School-Li-braries.html. Accessed December 26 2017. Braude RM. Role of libraries in medical education. Bull N Y Acad Med.1989; Jul-Aug; 65(6):704–738. Eldredge JD, Heskett KM, Henner T, et al. Current practices in library/informatics instruction in academic libraries serving medical schools in the western United States: a three-phase action research study. BMC Med Educ.2013;13(119). https://doi.org/10.1186/14726920-13-119 Gregory G & Poole C. 2016. A day in the life: how medical students use library resources. Illinois Library Association.2016;34(6). The 21st Century Medical Librarian: More Vital than Ever. NEJM Library Hub. http://libraryhub.nejm.org/article-hub/2017/06/21st-century-medical-librarian-vital-ever/. Accessed December 26 2017. Yang ZYL. Customer satisfaction with interlibrary loan service—deliverEdocs, Journal of Interlibrary Loan, Document Delivery & Information Supply.2004;14(4):79-94, DOI: 10.1300/J110v14n04_07 Veasna U & Nimol C. Effect of LibQUAL dimensions on library user satisfaction: evidence from Cambodia. Journal of Business Administration and Management Sciences Research.2015;4(7):152-165. Asubonteng P, McCleary KJ & Swan JE. SERVQUAL revisited: a critical review of service quality. J. Serv. Mark. 1996;10:62-81 Blixrud JC. Evaluating library service quality: use of LibQUAL+TM”, unpublished manuscript. Association of Research Libraries. Learn About LibQUAL+® Presentation. LibQUAL+®. http://www.libqual.org/about/about_sur vey/tools. Accessed November 20 2017. LibGuides: LibQUAL+ 2017: Kings College London Library Guides. http://lib guides.kcl.ac.uk/librarysurvey. Accessed November 20 2017. Green D & Kyrillidou M. LibQUAL+® Chart ing Library Service Quality: Procedures Manual. Association of Research Libraries. http://www.libqual.org/documents/LibQual/pub lications/2011_ProceduresManual.pdf. Accessed November 20 2017. Jones S & Kayongo J. Identifying student and faculty needs through LibQUAL™+: an analysis of qualitative survey comments.College & Research Libraries. 2008;69(6):493-509. https://doi.org/10.5860/crl.69.6.493 Kothari M and Moolani S. Reliability of “Google” for obtaining medical information. US National Library of Medicine National Institutes of Health. https://www.ncbi.nlm.nih. gov/pmc/articles/PMC4448244/ Accessed 7 2018.

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CIM STUDENTS’ KNOWLEDGE, SATISFACTION, AND EXPECTATIONS ON THE EXPERIMENTAL RESEARCH FACILITIES AND EQUIPMENT OF CEBU INSTITUTE OF MEDICINE Bajarias MLL, Berame ID, Chu-Santos CAR., Dagondon MM, Daguplo NFG, Espejo JJP, Odi JAFD, Rubia DJA, Singco PJY, Tan SMU

ABSTRACT Introduction: It is vital for medical schools to provide excellent research facilities and equipment to its students. In CIM, the experimental research facilities and equipment are frequently cited as in need of improvement. This has a potential impact on the research productivity and attitudes of medical students toward research. The researchers believe that student participation is important in the feedback process regarding this issue. Such quality assurance will benefit the students and it may also shed light on the real situation of the research education in the Philippines. Objective: To determine the knowledge, satisfaction and expectations of CIM students of school year 2019-2020 on the experimental research facilities and equipment of Cebu Institute of Medicine. Methods: This study is a descriptive study. Collection of data from 129 PBL-2 and 143 PBL-3 CIM students of A.Y. 2019-2020 was done through a 37 item online questionnaire. Participation is voluntary. Results and Discussion: The results showed that, overall, CIM students agree that they know most of the experimental research facilities and equipment of CIM (mean = 3.91, sd = 0.637). In terms of overall satisfaction of these facilities and equipment, CIM students are neutral (mean = 2.77, sd = 0.74), however, many have low satisfaction rating specifically in terms of availability (41.2%), variety (47.4%) and quality (29.8%). Most CIM students have “less than expected” expectations of the experimental research facilities and equipment of CIM (53.7%). Conclusion: Majority of CIM students agree to know most of the experimental research facilities and equipment of CIM. Overall, CIM students are neutral towards their satisfaction on these facilities and equipment but more are dissatisfied in the specific aspects of availability, variety, and quality. Lastly, majority of CIM students found these facilities and equipment less than what they’ve expected. Keywords: CIM Students, Knowledge, Satisfaction, Expectations, Experimental Research Facilities and Equipment

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ORIGINAL RESEARCH

INTRODUCTION Evidenced based medical practices have already become the standard for patient care. It is through various researches that significant advancements in medical science and patient care have come to fruition. The continuity of such advancements depends on the unrelenting and unhindered quest for medical innovation. Research education and opportunities during medical school teach future physicians the skills required to critically evaluate the medical literature, to collaborate for further medical knowledge, and to provide context to the application of research findings to medical practice.1 A role of paramount importance for all medical schools is to provide quality research education to all medical students. This responsibility entails not only the foundation of an excellent curriculum but also the adequate allocation of quality services, including the provision of excellent research facilities and equipment. In an ideal setting, a quality research education demands a quality research environment and a quality research environment requires quality research facilities and equipment. An excellent research environment is basically a major requirement for research success. The challenge of cultivating and preserving an excellent research environment for medical students lies ultimately in the hands of the medical schools. The Cebu Institute of Medicine

ORIGINAL RESEARCH

(CIM) facilities for experimental research have been frequently cited by students as in need of improvement. This is particularly evident during the implementation of the basic medical research protocols in the second year of medical school. Students mostly complete their experimentation and data analysis in the laboratories of other institutions. CIM has to network with other institutions for outsourcing of other lacking experimental research equipment. Some of the mostly sought equipment includes a RotaVap evaporator, spectrophotometer, micropipettes, incubators, dissecting microscopes and commonly used chemicals such as ethanol, methanol and the like. This lack of quality experimental research facilities and equipment in CIM caught the attention of the researchers because of its potential impact on the research productivity and attitudes of medical students toward future research projects. This observation is supported by the study of Tiu AC, et al, who recommended that CIM needs to invest in the improvement of infrastructure, software, IT systems, and other equipment to support basic and applied biomedical research.2 This was based on their finding that the state of facilities is one of the dimensions driving the satisfaction of medical students and graduates on the research education course of CIM. However, this said dimension only ranked fourth out of six with an explained 3.19% variance in their study.2

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The research education course in CIM also known as Biomedical Research (BMR), consists of two years of basic health research methodology with implementation and one year of applied health research project. Research proposals and protocols involving non-human subjects are developed and submitted during the first year. Implementation of the said research protocols are completed and presented in second year. In the third year, the students begin to do applied health research employing human participants. All of these research activities are undertaken under the guidance of a research adviser. During the fourth year of medical school, there are no formal research education activities but the principles of research application are reiterated using EBM and their clinical work.2 Currently, there is only one published study evaluating research education courses in the Philippines. Tiu et al. identified six dimensions that were important according to the CIM medical students and graduates in their satisfaction of the research education course in CIM.2 The six dimensions are the following: a) curriculum, expertise of instructors, social skills, b) problem-solving skills and instructor-student rapport, c) Classroom management, d) facilities, e) publishing and conducting research, and f) instructor’s availability. Exploratory factor analysis was conducted on the dimensions identified as determinants that drive satisfaction of the research

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education course among the medical students and recent graduates. One their findings stated that the dimension on facilities ranked fourth out of six dimensions driving the satisfaction of medical students and graduates on the research education course of CIM. This dimension explained 3.19% variance in their study.2 Oliver and deSarbo defined student satisfaction as the subjective evaluation of the students to the learning experiences and outcomes while in an educational institution.3 It is the result of the students’ educational experience, services and facilities. Satisfaction is said to correlate with student loyalty.4 According to Navarro’s study on North American students, there is a strong correlation between the level of student satisfaction and loyalty at the college. Dimensions which influenced student satisfaction included teaching quality, administration of the program, and support from teaching staff.5 The simplest way to measure satisfaction, according to Hamner and Organ, is to ask questions as to how a facet of an object that needs proper definition gives them satisfaction.7 A factor that determines student satisfaction is their expectation on the service provision. In fact, satisfaction comes as a result of the difference between the expectation and the outcome. Yet, despite studies on the matter, satisfaction is a complex phenomenon and several factors may affect the perceived attitude of stu-

ORIGINAL RESEARCH

dents to such facilities but that is beyond this study’s scope.6 A study done on satisfaction with the use of USU Library conducted by Samosir and Zumi used a survey method questionnaire that utilized descriptive statistics. The study showed that reliability, responsiveness, assurance, empathy and direct evidence were factors that contributed to overall service quality and all simultaneously affected student satisfaction.7 Furthermore, Napitupulu D, et al. cites Sukandi’s conclusion that there is a positive relationship between facilities provided by the institution on student satisfaction.8

OBJECTIVES This study aimed to determine the knowledge, satisfaction and expectations of CIM students of school year 2019-2020 on the experimental research facilities and equipment of CIM. Specifically: (1) to measure the knowledge of CIM students of school year 2019-2020 on the experimental research facilities and equipment of CIM, (2) to measure the level of satisfaction of CIM students of school year 2019-2020 on the experimental research facilities and equipment of CIM, in terms of availability, variety, access, usability, and quality, and (3) to determine the level of expectations of CIM students of school year 2019-2020 on the experimental research facilities and equipment of

ORIGINAL RESEARCH

CIM.

METHODS This is a descriptive study on the knowledge, satisfaction and expectation of the selected population of CIM students on the experimental research facilities and equipment of CIM done through an online survey questionnaire. The study was done online due to quarantine protocols for the COVID-19 pandemic. All 192 CIM PBL-2 and 146 CIM PBL-3 students of the current academic year 2019-2020 who have undergone or is undergoing the research course in Cebu Institute of Medicine with a total of 338 students, were included in this study. The 10 CIM students who are the proponents of this study were excluded. Data were collected using a 37 item self-made online questionnaire. No pilot study was done. Data gathered were consolidated and were subjected to appropriate data analysis. This study utilized a 37 item self-made online questionnaire using a Likert Scale in Google Forms as this was convenient for the respondents considering the impact of the COVID-19 pandemic. This study utilized descriptive analysis on the data gathered. Quantitative data analysis was carried out to code the reply to each question of the questionnaire into an ordinal scale of 1-5. A statistician was tapped to perform analysis on the data using SPSS

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(Social Packages for the Social Sciences) software. The frequency at which certain responses appear is represented as percentages, and illustrated using charts. Central tendencies were calculated using the mode for specific items and mean for overall knowledge and satisfaction.

RESULTS AND DISCUSSION The purpose of this study is to determine the knowledge, satisfaction and expectations of CIM students on the experimental research facilities and equipment of CIM. Out of the 338 student population only 272 respondents (80.47%) participated in this study with 176 females and 96 males. The data gathered are from the 129 PBL-2 and 143 PBL-3 students of CIM of the academic year 2019-2020.

Figure 1. Knowledge of CIM students on the Experimental Research Facilities of Cebu Institute of Medicine

Presented in Figure 1 above is the knowledge of CIM students on the different experimental research facilities of CIM. Three out of five identified experimental research facilities, namely the Microbiology/Pathology/Parasitology Laboratory, Histology

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Laboratory and Biochemistry/Human Nutrition Laboratory each received a highest frequency rating of “Strongly Agree” with the following percentages: 56.3%, 60.3% and 48.2%, respectively. Even though the rating “Strongly Agree” did not reached a consensus (>50%) of the respondents’ responses (only 48.2% ) on their knowledge of the Biochemistry/Human Nutrition Laboratory, a closer examination of the diverging bar in Figure 1 shows that majority of CIM students agree and strongly agree that they know of its existence. These results mean that majority of CIM students strongly agree that they know the existence of these three experimental research facilities. On the other hand, the remaining 2 experimental research facilities, namely the Physiology Power Laboratory and ironically, the Research Laboratory were only rated with a highest frequency rating of “Unsure” garnering 29% and 32%, respectively. Both ratings did not reach a consensus (>50%) of the responses suggesting that CIM students are divided on their knowledge of the existence of the said experimental research facilities. Figure 2 shows that most CIM students have a high rating of their knowledge on the majority of the listed experimental research equipment in CIM. Each of these following experimental research equipment (with their respective percentages) received a highest frequency rating of “Strongly Agree”: light microscope

ORIGINAL RESEARCH

*Soxhlet Extractor

Figure 2. Knowledge of CIM students on the Experimental Research Equipment of Cebu Institute of Medicine

(66.9%), test tubes (58.8%), beakers/flasks (58.8%), slides (58.1%), alcohol lamp (57.7%), glass rod (56.3%), graduated cylinder (55.1%), Petri dishes (54%), funnel (50.7%), mortar and pestle (44.5%), incubator (40.4%) and pipettes (37.1%). Triple Beam Balance received a highest frequency rating of “Agree” with a percentage of 32%. These items account for 13 of the 18 listed experimental research equipment commonly used in basic medical research in CIM with 9 of them each reaching a consensus (>50%) of the responses. There are also 5 experimental research equipment in which each

ORIGINAL RESEARCH

received a highest frequency rating of “Unsure.” These include: PowerLab machine (43.4%), spectrophotometer (42.3%), Soxhlet Extractor (46.3%), analytical balance (35.7%) and rotary evaporator (26.1%). Each of these ratings did not reach a consensus (>50%) of the responses which means that CIM students are divided on their knowledge of the existence of these 5 experimental research equipment. Some of these items were also among the list of experimental research equipment observed to be mostly outsourced by the students from other institutions. This implies that CIM students’ knowledge of the existence of

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these items might have been a contributing factor behind their outsourcing activities.

research facilities and equipment. This is quite alarming considering the fact that all medical students especially those who have undergone or who are undergoing medical research course in CIM are somehow expected to have knowledge of these experimental research facilities and equipment commonly used in biomedical research.

Figure 3. Overall Knowledge of CIM students on the Experimental Research Facilities and Equipmentof Cebu Institute of Medicine.

In order to determine the overall knowledge of CIM students on the experimental research facilities and equipment of CIM, Figure 3 shows the distribution of responses. The respondents reported a mean of 3.91, with a standard deviation of 0.637 which categorizes as “Agree.” This means that CIM students agree that they know the existence of the experimental research facilities and equipment of CIM. Closer examination of the histogram also shows that the distribution of data is skewed to the left which suggests that majority of the respondents are rating high on their knowledge of the experimental research facilities and equipment of CIM. It is also important to note that there are still a small percentage of CIM students who rated low on their knowledge of CIM’s existing experimental

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Figure 4. CIM students Source of Knowledge on the Experimental Research Facilities and Equipmentof Cebu Institute of Medicine.

In Figure 4, majority of CIM students are made aware of the experimental research facilities and equipment of CIM by asking school staff (74.6%), followed by word of mouth from previous researchers (65.1%), from research coordinator (50%), not aware until information from this rese arch (14.3%), and information posted in school (7.7%). These results reflect that knowledge on the existence of the different experimental research facilities and equipment of CIM are mostly derived from the students’ own active inquiry and not much from the school’s effort of active information dissemination about these experimental research facilities and equipment. This may be one of the contributing factors

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why some of CIM students did not know or were unsure of the existence of some experimental research facilities and equipment of CIM.

31.6 % and 37.3%, respectively, each not reaching a consensus (>50%) of responses. These results translate to the low satisfaction of CIM students on the experimental research facilities and equipment of CIM in terms of availability, variety and quality; and a high satisfaction in terms of access and usability.

Figure 5. CIM students Satisfaction on the Experimental Research Facilities and Equipment of Cebu Institute of Medicine.

Another objective of this study is to determine the satisfaction of CIM students on the experimental research facilities and equipment of CIM. Shown in Figure 5, are the respondents’ satisfaction in terms of availability, variety, access, usability and quality. In terms of availability, variety and quality, the rating with the highest frequency in each item is “Dissatisfied” with the following percentages: availability (41.2%), variety (47.4%) and quality (29.8%). Although each three aspects did not reach a consensus (>50%) of the responses, when examined more closely the diverging bars shows that more CIM students have low satisfaction ratings of the experimental research facilities and equipment of CIM in these three dimensions. However, in terms of access and usability, the rating with the highest frequency in each item is “Satisfied” receiving

ORIGINAL RESEARCH

Figure 6. CIM students Overall Satisfaction on the Experimental Research Facilities and Equipmentof Cebu Institute of Medicine.

In terms of overall satisfaction of CIM students towards the experimental research facilities and equipment of CIM, as depicted in Figure 6, the respondents reported to be “Neutral” with a mean of 2.77 and standard deviation of 0.74. The lack of consensus of responses on the specific areas of satisfaction affected this overall rating. The distribution of data, however, suggests that a little bit more respondents are rating low satisfaction than people rating high satisfaction. According to Tiu AC, et. al., the dimension on facilities is one of the dimen-

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sions driving the satisfaction of medical students on the research education course of CIM. This suggests the results of this study on satisfaction have a bearing on the satisfaction of the students on the research education course of CIM.2

comes as a result of the difference between the expectation and the outcome.6 This could mean that CIM students’ level of expectations is a factor that might have affected their level of satisfaction on the experimental research facilities and equipment of CIM.

CONCLUSION

Figure 7. CIM students Expectations on the Experimental Research Facilities and Equipment of Cebu Institute of Medicine

Presented in Figure 7 is the level of expectations of CIM students on the experimental research facilities and equipment of CIM. Majority of the students have a level of expectation “Less than Expected” (53.7%), followed by “Much Less than Expected” (25.4%), “Matched Expectations”(19.9%) and “Exceeded Expectations”(1.1%). These results mean that the experimental research facilities and equipment of CIM are less than what CIM students have expected. CIM students per se have higher expectations on the experimental research facilities and equipment of CIM given that CIM is a PAASCU Level III medical school. A factor that determines student satisfaction is their expectation on the service provision.6 In fact, satisfaction

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Majority of the students agree that they know most of the research facilities and equipment of CIM. The facilities students found to be unsure of include: the Physiology Power Laboratory and Research Laboratory; while in terms of equipment are the following: analytical balance, Soxhlet extractor, rotary evaporator, PowerLab machine and spectrophotometer. Their knowledge is mostly based on asking school staff and least on information posted in school. In terms of satisfaction, majority of CIM students are satisfied with the access and usability of the research facilities and equipment of CIM, but are dissatisfied with its availability, quality and variety. The students overall satisfaction on these research facilities and equipment is neutral. Lastly, majority of the students found the research facilities and equipment of CIM less than what they have expected.

ORIGINAL RESEARCH

REFERENCES 1. 2.

3.

4.

5.

6. 7. 8.

Dekker FW. Science education in medical curriculum: teaching science or training scientists? J Int Assoc Med Sci Educ. 2011;21: 258–60. Tiu A, Capuyan M, Gamallo F, et al. Dimensions driving satisfaction of medical students and recent graduates of a research education course of Cebu Institute of Medicine. Journal of Association of Philippine Medical Colleges. 2017. Salinda Weerasinghe IM , Lalitha R, Fernando S. Students’ satisfaction in higher education literature review. American Journal of Educational Research. 2017;5(5):533-539.doi: 10.12691/education-5-5-9 Aldemir C & Gülcan Y. Student satisfaction in higher education: a Turkish case. Higher Education Management and Policy. 2004;16(2):109-122.doi: 10.1787/hemp-v16-art19-en Navarro MM, Iglesias MP & Torres PR. A new management element for universities: satisfaction with the offered courses. International Journal of Educational Management.2005;19(6) :505-526. Hamner W & Organ D. Organized Behavior: An Applied Psychological Approach. Dallas, TX: Business Publications. Inc, 1978. Naidoo AA. The effect of service quality on student satisfaction using USU library. Library: Journal of Library and Information Studies. 2005;1(1):28-36. Napitupulu D, et al. Analysis of student satisfaction toward quality of service facility. IOP Conf. Series: Journal of Physics: Conf. Series. 2018. doi :10.1088/1742-6596/954/1/012019

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EFFECT OF GAP YEAR PRIOR TO MEDICAL SCHOOL ON STRESS COPING MECHANISMS OF CIM MEDICAL STUDENTS Atilano MA, Erazo RT, Esplanada A, Lingatong CA, Lomaad DJ, Matuco JN, Nuñez V, Redula S, Sanchez FJ, Tibon MA

ABSTRACT Introduction: The experience of distress during medical training is a well-known issue and much effort has been made to examine its effects on the students’ mental health, and to initiate preventive programs. Different types of coping mechanisms may have been the subject of different research, but little is known about the relative efficacy of taking a gap year in handling academic stress better among medical students. Objective: To determine and compare the coping mechanisms of students who had a gap year and those who did not have a gap year. Methods: This study is a correlation analysis. The collection of data was done through an online questionnaire. Data was gathered from a study population of bonafide first to third year medical students of CIM who voluntarily participated in this study. The data collection tool used was the Brief COPE which included 28 questions designed to explore the 14 different strategies of coping. The questionnaire took 15 minutes to complete. Results: The results showed that out of 248 respondents, 56% had a gap year while 44% did not have a gap year. Among the gap year students, 71% had an occupation while 29% did not. The 14 different coping mechanisms from the two populations were ranked according to frequency based on the summated scores for each mechanism. The top 5 most frequently used coping mechanisms in both populations were that of approach coping, which is associated with better emotional response. Out of the 14 coping styles assessed, only the acceptance coping strategy varied significantly in terms of frequency. Conclusion: There was no significant difference in the coping mechanisms used between students who had a gap year and those without. However, with the more frequent use of acceptance as a coping style in gap year students, taking a gap year may have an indication on stress management. Keywords: Gap year, coping mechanisms, academic stress

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ORIGINAL RESEARCH

INTRODUCTION The experience of distress during medical training is a well-known issue and much effort has been made to examine those effects on the students’ mental health and to initiate preventive programs. To verify the assumption that medical training contributes to the deterioration of mental health, Brazeau et al.1 compared matriculating medical students with age-matched college graduates from the general population. They found that medical students at the beginning of their studies were of better mental health compared to the controls, suggesting that the training process may contribute to an increase in psychological morbidity. These findings are confirmed by Kötter et al.2 in an ongoing longitudinal study, which compared freshmen of medical training with students of other courses of studies in terms of mental health and also reported no differences at baseline In order to address the impending risk of developing mental health problems during training and in later professional life, health promotion and prevention programs have become prevalent in medical schools. Burnout amongst health professionals is characterized by “various degrees of emotional exhaustion, depersonalization and a low sense of personal accomplishment.”3 Symptoms of burnout are prevalent from the outset of medical training, with multi-institutional studies indicating that at least 50% of

ORIGINAL RESEARCH

medical students may meet burnout criteria at some point during their studies.4 Strategies at individual, and structural or organizational levels have all reported clinically meaningful reductions in burnout amongst doctors. Such strategies include the: promotion of healthier lifestyle choices and social activities in medical training; provision of psychosocial support; web-based interventions; guidance to support positive attribution styles during the teaching process; and elective courses for learning relaxation techniques. Different types of coping mechanisms may have been the subject of different research, but little is known about the relative efficacy of taking a gap year in handling academic stress better among medical students. There are no current statistics that show the average age of first year medical students in the Philippines. This could have shown an estimate of the proportion of students who took a year or more off before going to medicine proper.7 There are a variety of reasons why students might defer their entry into medical school and take a “gap year” including: unsuccessful initial application, travel, working to save money, gaining further work experience, or to get a high score in their entrance examinations. Brown et al suggested that the greatest reason is that “young people feel the need to take a breather before going on to higher education.”5 According to Brown et al, there appears to be overwhelming support for a gap year

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before entering medical school from those students who have taken one and nearly half of those students who did not. In answer to their research question “Do students who have taken a gap year feel that this was advantageous compared to students who did not have a gap year?”, the answer is a very clear yes. The majority of students taking a gap year believed that they had benefited greatly by increasing in maturity and independence. Some of them felt that their gap year also helped them to make friends and settle into university life.5 Although there are many positive and beneficial reasons for taking a gap year before starting medical studies, there are also some reasons why it might be considered unadvisable. Gap years may be considered inadvisable for a number of reasons: perhaps some feel that students may change their minds during their gap year and then not take up their places at Medical School, while others may find it unsettling or challenging to return to the routine of studying and leave the course before completion.5 In Brown’s study, the concerns that it might be difficult to settle back into academia are clearly unfounded with minimal difference found between the two groups.5 The benefits of greater maturity, independence, life experience and improved social interactions associated with taking a gap year may be seen for some as to outweigh some of the more negative perceptions. In order to determine if taking a

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gap year/s or not make a significant difference in a medical student’s ability and strategies in coping with the demands in medical school, the present study aims at comparing two groupsCIM medical students who took a gap year/s before entering medical school and those who proceeded directly from their pre-medical courses and how effectively they cope with stress in their current year in Cebu Institute of Medicine.

OBJECTIVE To determine and compare the coping mechanisms of students who had a gap year and those who did not have a gap year.

METHODS The researchers used a correlational study design. This design allowed the study to compare the coping mechanisms for stress of Cebu Institute of Medicine (CIM) students with and without a gap year using the Brief COPE tool, which is an open access and a brief form of a previously validated tool called COPE inventory, which was proven to be a useful health-related research. The addition of asking the student whether he/she has taken a gap year, and if he/she had an occupation during the gap year was also included in the questionnaire

ORIGINAL RESEARCH

(Appendix B). The study was done in CIM, F. Ramos Street, Cebu City. Bonafide medical students of CIM of PBL I, II and III of any age and participated. Students who withdrew or are not bonafide medical students of CIM and students who did not give their informed consent to take part in the study, were not included. The data collection tool used for this study is the Brief COPE (Appendix B) which includes 28 questions scored from one (“I haven’t been doing this at all”) to four (“I’ve been doing this a lot”).6 The questions were designed to explore 14 different strategies of coping: active coping, planning, positive reframing, acceptance, humor, religion, use of emotional support, use of instrumental support, self-distraction, denial, venting, substance use, behavioral disengagement, and self blame (Appendix C).7 Socio-demographic variables that will be included and asked along with the Brief COPE questionnaire will be age, gender, year level, identification of being a gap year or non-gap year student, and previous occupation during their gap year. The research survey was conducted last April 2020 using an online questionnaire which was distributed to the respondents through their batch presidents and group leaders who forwarded it to their respective batch mates. Included in the first part of the questionnaire was an informed consent to participate in the study. This was followed by a set of instructions on how to answer the questionnaire.

ORIGINAL RESEARCH

Respondents were given 15 minutes to answer. The data gathering process lasted for 8 weeks. The coping styles of each group, gap year students and non-gap year students, were determined by their responses from the Brief COPE survey. The mean of each of the summated scores of the 14 coping strategies were then determined and ranked from the highest to the lowest. The Welch t-test was used to determine if there was a significant difference between the coping strategies of the 2 populations. Participation of the survey was voluntary. Respondents were informed about the aims of the study. Informed consent was obtained. Respondents were assured of the confidentiality of their answers. However, all the year levels of the respondent were included. Data collected during and after the study are stored for future references and possible follow up studies.

RESULTS AND DISCUSSION A total of 248 respondents participated in this study with 139 gap year students (56%) and 109 non-gap year students (44%). Of the 139 gap year students, 98 students (71%) had an occupation during their gap year while 41 students (29%) did not have an occupation. The data gathered are from the PBL I, II, and III student population of the Cebu Institute of Medicine.

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Figure 1. Coping strategies of gap year students of CIM (n=139) and non-gap year students of CIM (n=109)

Figure 1 shows the comparison in the frequency of the coping strategies used between the gap year and non-gap year student populations. Figure 2 and Figure 3 show the different coping strategies of the two populations ranked from the most to the least frequently used based on the mean of the summated scores of each coping strategy. As shown in Figure 2, the top 5 most frequently used coping styles for gap year students are Acceptance (6.748), Self-distraction (6.388), Positive Reframing (6.359), Use of emotional support (6.245) and Planning (6.209). Figure 3 shows that the top 5 most frequently used coping styles for non-gap year students are Self-distraction (6.633), Acceptance (6.422), Positive Reframing (6.339), Planning (6.284) and Active coping (6.028). These findings suggest that both student populations generally use Approach coping styles characterized by the use of Acceptance, Positive Re-

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Figure 2. The coping strategies of gap year students of CIM (n=139)

Figure 3. The coping strategies of non-gap year students of CIM (n=109)

framing, Use of emotional support, Planning and Active Coping strategies,8 which is associated with better response to adversity and emotional response.9 However, Self-distraction, an Avoidant coping strategy, is used frequently by both populations,8 being ranked as the most frequently used coping strategy in non-gap year stu-

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dents and the second most frequently used coping style in gap year students. Avoidant coping is shown to be less effective in managing anxiety.9 Out of the 14 coping styles assessed by the Brief COPE survey, only the Acceptance coping strategy varied significantly between both groups in terms of frequency with a p-value of 0.05. Thus, it can be implied that gap year students tend to use Acceptance as a coping strategy more often when compared to non-gap year students. From this, it can be inferred that gap-year students tend to accept the reality of the stressors encountered in medical school more readily when compared to non gap-year students which indicates that there is a positive influence in taking a gap year.5 This correlates with various studies that expound on the benefits of taking a gap year. The results, however, failed to find any significant difference in the use of the remaining thirteen coping styles between the gap year and non-gap year students. Two implications may be drawn from this. First, taking a gap-year does not influence the frequency of using the remaining thirteen coping styles which may imply that despite its influence on stress management, as purported in various studies, it is not a major determinant. This correlates with the study conducted by Parker et al that there is not much difference between gap year and non gap-year students.31 Second, the results may have been influenced by

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the sampled population which then influenced the data. Majority of the study’s respondents were students of PBL II and III. Perhaps by these levels, exposure to the same environment for a long period of time had caused the students to adapt to stressors in similar ways.

CONCLUSION

Although there have been studies that have shown that students who took a gap year gain more personal perspective and growth in maturity, this present study has shown that the method and frequency of coping mechanisms between students who took a gap year did not differ greatly from those of their peers who went straight into medical school. However, it has been shown that gap year students more frequently use Acceptance as a coping style more when compared to non gap year students. This may be an indication that taking a gap year may have an effect on how students manage stress.

REFERENCES 1.

2.

Brazeau CM, Shanafelt T, Durning SJ, Massie FS, Eacker A, Moutier C, Satele DV, Sloan JA, Dyrbye LN. Distress among matriculating medical students relative to the general population. Acad Med. 2014;89(11):1520–1525. Kotter T, Tautphaus Y, Scherer M, Voltmer E. Health-promoting factors in medical students and students of science, technology, engineering, and mathematics: design and baseline results of a comparative longitudinal study.

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3. 4.

5.

6. 7. 8. 9.

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BMC Med Educ. 2014;14:134. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory manual (3rd ed.). Mountain View, CA: Consulting Psychologists Press 1996. Prinz P, Hertrich K, Hirschfelder U, De Zwaan M. Burnout, depression and depersonalisation – psychological factors and coping strategies in dental and medical students. GMS Z Med Ausbild. 2012;29. 7 Paterson-Brown L, Paterson-Brown F, Simon E, Loudon J, Henderson-Howat S, Robertson J, et al. The influence of a ‘gap year’ on medical students. J Educ Train Stud. 2015;3(4):49-56. http://dx.doi.org/10.11114/jets.v3i4.810. 30 NovoPsych Australia: NovoPsych PtyLtd; 2018. Brief Cope. 2018. https://novo psych.com.au/ Accessed June 5 2020. Carver C. You want to measure coping but your protocol’s Too Long: Consider the Brief COPE. Int J Behav Med. 1997 Mar; 4(1):92-100. Carver CS, Scheier MF, Weintraub JK. Assessing coping strategies: a theoretically based approach. J Pers Soc Psychol. 1989 Feb;56(2):267–83. Parker PD, Thoemmes F, Duineveld JJ, Salmela-Aro K. I wish I had (not) taken a gap-year? the psychological and attainment outcomes of different post-school pathways. Dev Psychol. 2015 Mar;51(3):323-33

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ORIGINAL RESEARCH

EXPLORING THE LINK BETWEEN NEGATIVE EMOTIONAL STATE OF DEPRESSION WITH MENTAL HEALTH LITERACY AMONG FIRST YEAR TO THIRD YEAR STUDENTS OF CEBU INSTITUTE OF MEDICINE Yulo PAL, La Rosa AKD, Colasito TM, Lagamon TE, Amatorio MAC, Congrehilla LB, Limbaga LPA, Mendoza AD, Oku M and Echor OO

ABSTRACT Introduction: Mental health literacy encompasses knowledge on identifying different mental disorders and ways in dealing with them. Adequate mental health literacy is key in developing help-seeking behaviors when mental disorders such as depression arise, allowing at-risk populations such as medical students to receive proper care and attention at the soonest possible time. Objective: To identify the relationship between negative emotional state of depression with mental health literacy among First Year to Third Year CIM students. Methods: This study is a cross-sectional survey. Data was gathered from First year to Third year CIM students, with ages ranging from 20 to 35 years old. The study population constituted the first year to third year CIM students who voluntarily participated in this study. There was a total of 454 out of 522 students, with each level consisting of: 1st year – 162 students (Male=59; Female=103), 2nd year – 178 students (Male=66; Female=103), 3rd year – 123 (Male=46; Female=77). The number of male and female respondents are not equal in number since the population of CIM students comprised of more females than males. Data collection was done through two sets of self-administered questionnaires. The first questionnaire contained 7 items which were designed to measure the negative emotional state of depression. The second questionnaire contained 35 items which were designed to measure one’s knowledge about mental health. Results: The results showed a significant relationship between Negative Emotional State of Depression and Mental Health Literacy with a p-value of 0.047. Also, results showed an odds ratio of 1.01 indicating that for every 1 unit increase in the Mental Health Literacy Scale score, the odds of having normal DASS-21 scores (no negative emotional state of depression) is increased by 1%. Furthermore, there is an increasing percentage of students that scored adequately on the Mental Health Literacy Scale as the year level progressed. Among the CIM students, 38% have no negative emotional state of depression while 11% of the population have extremely severe negative emotional state of depression. Conclusion: The more adequate the student’s mental health literacy becomes, the more normal the emotional states are regardless of gender. Also, the more the students are exposed to mental disorders by way of curriculum and exposure in the higher year levels, the better their mental health literacy becomes. Keywords: Depression, DASS-21, Negative Emotional State, Mental Health Literacy, Mental Health Literacy Scale, Medical Students

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INTRODUCTION The life of a medical student could be overwhelming and challenging. Twenty Four hours in a day would not be enough in accomplishing certain tasks. Balancing priorities is one of the greatest challenge, such as finishing all the readings to get satisfactory grades while trying to get enough sleep. It could also be as simple as having few hours spent to de-stress or spend it with your family and friends while not worrying about the things you need to study. The goal of medical education is to produce physicians who are knowledgeable, skillful and professional in their respective fields. The medical school curriculum has been developed to attain all these qualities. In addition, the CIM not only aims to yield good results in terms of academics but also produce physicians with a heart, a physician who is willing to serve with compassion. However, the great demands of attaining these goals could have negative effects on such students. It was found that some aspects of training may have unintended negative effects on medical students' mental and emotional health that can ultimately undermine the aforementioned values.1 The overwhelming burden of information in medical school leaves a minimal opportunity to relax and recreate and will sometimes leads to serious sleep deprivation.2 It constitutes various stressors which may cause im-

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paired judgment, reduced concentration, loss of self-esteem, increased anxiety and depression.3 In addition, a study conducted last 2003 among Thai Medical students found out that academic problems were found to be the major cause of distress among students brought about by test or exams. In the same study, it was found that stress levels reported were highest among 3rd year students.4 Thus, the great demands of being a medical student could predispose one to a lot of stress, anxiety, and depression. Change in appetite, sleeping less, reduced concentration, indecisiveness, restlessness, feelings of worthlessness, guilt or hopelessness, and thoughts of self-harm or suicide further characterize depression.5 In 2004, the Department of Health (DOH) reported 4.5 million cases of depression in the Philippines with only 30 among 90 cases seek help.6 In 2011, Philippines had the highest number of depressed people in Southeast Asia according to World Health Organization. Mental illness is the third most common form of disability in the country, next to visual and hearing disabilities according to the National Statistics.7 It is essential to take note of the effects of stress, which could further lead to depression, since it could greatly affect one’s mental well-being. The WHO emphasized suicide as a major health problem with 75 percent of global incidents occurring in lowand middle-income countries like the

ORIGINAL RESEARCH

Philippines. According to the Philippines Statistics Authority, suicide rate in the country increased from 1984 to 2005. In 2012, a total of 2,558 Filipinos committed suicide, 2009 males and 549 females.6 In 2015, Global Burden of Disease Study reported that 3.3 million Filipinos suffer from depressive disorders, with suicide rates in 2.5 males and 1.7 females per 100 000 of the Filipino population according to the National Center for Mental Health. Most suicides are among males in their 20s.7 Due to the prominent rates of Filipinos suffering from depressive disorder and suicidal cases, as well as medical students suffering from stress and anxiety which could predispose them to depression, it is essential to focus on the mental well-being of the said individuals. Improved mental health literacy will facilitate the early recognition of mental illness and providing appropriate treatment.8 Mental health literacy is the knowledge about different mental disorders, its risk factors, and how to self-treat. It also includes the ability to recognize specific disorders and different attitudes that promote the recognition of mental health problems. In addition, it encompasses having the intention to seek help and belief about intervention and prevention of mental health disorders.9 In line with the promotion of awareness regarding mental health of Filipinos, Mental Health Act, RA 11036, was signed on June 20, 2018.10

ORIGINAL RESEARCH

OBJECTIVES To identify the relationship between the level of the negative emotional state of depression with the mental health literacy among First Year to Third Year CIM students.

METHODS The study is a cross-sectional study exploring the link between negative emotional state of depression and mental health literacy among First Year to Third Year CIM students. The independent variables are year level, gender, and mental health literacy and the dependent variable is the negative emotional state of depression. Regression analysis was used to determine if year level, gender and/or mental health literacy predicts the emotional state of depression. Moreover, significant relationship was investigated in terms of the scores in MHLS and the depression subset of the DASS-21. All participants were current medical students of Cebu Institute of Medicine S.Y. 2018-2019 ages 20 and above. Year levels were limited to first year, second year, and third year only. Furthermore, informed consent was sought from all participants prior to testing and individual test results were made available to all those who participated in the research. The study excluded fourth year medical students since their exposure to the psychiatric department could contribute to the

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confounding variables. Also, participants who have had a pre-medical undergraduate course of AB or BS Psychology were not included in this study because they have prior exposure to the questionnaires to be administered in our study which would cause bias in their responses. The current total population of CIM is 522 students. However, 68 students were not included in this study. These are the researchers (10), the participants who had a pre-medical course of AB or BS Psychology (9), those whose questionnaires were void (11), and those who decided not to participate in the study (38). Thus, the total study population is 454 comprising of first year to third year students in CIM who answered the questionnaires completely and voluntarily. In total, the study involved 454 students (Male=171; Female=283) which comprises of 86.97% of the first to third year population of CIM. This sample size is significant because based on previous researches on mental health literacy they used at least 60% of the total population. An example of such a study is entitled “Mental health literacy in an educational elite - an online survey among university students” wherein they used 61% of the total population as their sample size.11 With approval from the Dean of the institution and in coordination with the schedules set by the PBL coordinators of the different year levels included in the study, cluster sampling was

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used to gather the students of the CIM as the participants of the study. Questionnaires containing the DASS-21 and MHLS were distributed to the First, Second, and Third year student participants on their scheduled lectures, and they were asked to answer the questionnaires were accomplished within 10 minutes. Informed consent forms as well as participant data sheet and a briefer were attached to the questionnaires for the participants to fill out and sign prior to answering the questionnaire. The entire data gathering process run for 2 weeks. Depression, Anxiety, Stress Scale - 21 Items (DASS-21) Depression subset The DASS-21 is a set of three self-report scales designed to measure the negative emotional states of depression, anxiety and stress. The DASS-21 was constructed not merely as another set of scales to measure conventionally defined emotional states, but to further the process of defining, understanding, and measuring the ubiquitous and clinically significant emotional states usually described as depression, anxiety, and stress. The DASS-21 should thus meet the requirements of both researchers and scientist-professional clinicians. The DASS-21 is based on a dimensional rather than a categorical conception of psychological disorder. The assumption on which the DASS-21 development was based (and which was confirmed by the research data) is that the differences between the de-

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pression, the anxiety, and the stress experienced by normal subjects and the clinically disturbed, are essentially differences of degree. The DASS-21 therefore has no direct implications for the allocation of patients to discrete diagnostic categories postulated in classificatory systems such as the Diagnostic and Statistical Manual (DSM) of Mental Disorders and International Classifications of Diseases (ICD). Simply put, the DASS-21 merely measures the emotional states of depression, anxiety, and stress and does not fulfill any diagnostic criteria. However, recommended cutoffs for conventional severity labels (normal, moderate, severe) are given in the DASS-21 Manual. Lastly, only the Depression scale (14 questions) will be used for the study. The depression subscale contains 14 items and subjects are asked to use 4-point severity/frequency scales to rate the extent to which they have experienced each state over the past week. The items in the DASS-21 is scored from 0 to 3, 0 which is equivalent to the response “did not apply to me at all” and 3 equivalents to the response “applied to me very much or most of the time”. The points for the items in the depression subset are added up together and multiplied by 2 to obtain the final score. Mental Health Literacy Scale (MHLS) The scale is formulated by Dr. Matt O’ Connor and Dr. Leanne Casey. It includes a total of 35 items which

ORIGINAL RESEARCH

consists 3 parts namely, Part 1: ability to recognize disorders and knowledge of professional help available; Part 2: knowledge of where to seek information, appropriate help-seeking behavior, and stigma about mental illnesses; Part 3: discrimination towards people suffering from mental illnesses. Some items were modified as per advice from the original authors to fit into the current mental health demographics in the Philippines. The responses of the MHLS are given with specific equivalents. The four-point scale is given a score of 1 to 4 for options very unlikely/helpful to very likely/helpful, and the five-point scale is given a score of 1 to 5 for options strongly disagree/very unwilling to strongly agree/very willing accordingly. Reverse scoring is applied to items 12, 15, and 20-28. The equivalent scores for the responses shall be added together with a minimum of 35 points and maximum of 160 points, with scores =98 as adequate. This study mainly focused on the relationship between negative emotional state of depression and the level of adequacy of mental health literacy. This study only measured the negative emotional state experienced by the respondent within the past week, thus, not diagnosing or identifying those with Depression disorder. Aside from mental health literacy, gender and year level were also correlated with negative emotional state of depression as to see if these factors can have an

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effect on such. However, the relationship between gender and year level with mental health literacy was beyond the scope of the study. Other external factors affecting negative emotional states such as socioeconomic factors, religion, etc. are beyond the scope of the study. CIM students were approached after their scheduled lectures wherein the nature, objective, and mechanics of the study were discussed. They were given ample time for clarifying questions. The students were then invited to participate in the study. Voluntary nature of participation will be stressed. Anonymity of respondents was maintained by non-collection of personal identification information such as name, address nor contact numbers. The informed consent was attached to the questionnaire thus; the returning of the filled questionnaire was a sufficient evidence of their voluntary informed consent to participate in the study. Participants were asked to write the number of their questionnaire and affix the date of their participation on the informed consent. Confidentiality of subject responses were maintained at all times. Filled questionnaires were stored in a secured place with access only by the members of the investigating group. The questionnaire did not have any names thus, data analysis will be conducted on completely anonymized information. Each question-

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naire had an assigned code so that the study participants have the option to inquire about their results. All print data were properly disposed by paper shredder and all electronic data was deleted after the completed paper was disseminated for future publication.

RESULTS Mental Health Literacy score For the first-year students, among the males, only 27 (45.76%) scored adequately, while 32 (54.24%) scored inadequately indicating that there are more first year males who have inadequate mental health literacy scores. Among the females, 65 (63.11%) scored adequately, while 38 (36.89%) scored inadequately indicating that there are more first year females who have adequate mental health literacy scores. For the second year students, among the males, 40 (60.61%) scored adequately; while among the females, 75 (72.82%) scored adequately indicating that there are more participants who scored adequately for both genders. For the third years, among the males, 28 (60.87%) scored adequately; while among the females, 61 (79.22%) scored adequately indicating that there are more participants who scored adequately for both genders. In total as seen in Figure 1, there are 92 (56.79%) first year stu-

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not achieved an adequate mental health literacy score. On the other hand, Table 1 shows the number of participants who scored normal, mild, moderate, severe, and extremely severe categorized by year level and gender. For the first years, among the males, most of the participants scored normal, 19 (32.20%), and mild, 19 (32.20%), while among the females, most of the participants scored normal, 36 (34.95%) and moderate, 27 (26.21%). This is also noted for both genders in second year wherein most of the males scored normal, 30 (45.45%) and moderate, 18 (27.27%) and most of the females scored normal, 40 (38.83%), and moderate, 27 (26.21%). For the third years, the same ap-

dents who scored adequately, 115 (68.05%) second year students that scored adequately, and 89 (72.36%) third year students that scored adequately. The figure shows an increasing trend in mental health literacy as the year level goes higher. Lastly, there are a total of 296 (65.19%) CIM students who are considered to have adequate mental health literacy, while there is a total of 158 (34.80%) CIM students who have

Figure 1. Level of Mental Health Literacy of each year level.

Table 1. . Levels of the Negative Emotional State of Depression among different year levels and gender.

Depression Subset Score First Year

Second Year

Third Year

162 (35.7%)

169 (37.2%)

123 (27.1%)

Male

Female

Male

Female

Male

Female

Normal

19

36

30

40

14

33

172

Mild

19

18

6

14

8

9

74

Moderate

9

27

18

27

13

14

108

Severe

5

10

5

12

4

15

51

Extremely Severe

7

12

7

10

7

6

49

59

103

66

103

46

77

454

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plies for the males wherein mostly scored normal, 14 (30.43%) and moderate, 13 (28.26%). However, most of the females scored normal, 33 (42.86%) severe, 15 (19.48%) and moderate, 14 (18.18%). In total, as seen in Figure 2, most of the first years scored normal, 55 (33.95%) mild, 37 (22.84%) and moderate 36 (22.22%); while most of the second years scored normal, 70 (41.42%) and moderate, 45 (26.63%); and most of the third years

Figure 2. Levels of Negative Emotional State of Depression of each year level.

also scored normal, 47 (38.21%) and moderate, 27 (21.95%). Lastly, most of the CIM students scored normal, 172 (37.89%) and moderate, 108 (23.79%). The ordered logistic regression was used in the study to predict the effect of ordinal level of dependent variables with independent variables. The ordinal dependent variables are different levels of Negative Emotional State of depression (ie. Normal, Mild, Moderate, Severe, Extremely Severe) which were correlated with the independent variables namely, Mental Health Literacy, Gender, and Year Level. Among the three independent variables, only Mental health literacy, with a p-value of 0.047, has a significant effect on the Negative Emotional State of Depression. Both Gender and Year Level have p-values greater than

Table 2. Ordered Logistic Regression of Mental Health Literacy, Gender, Year Level, and Negative Emotional State of Depression with a significant p-value of 0.05.

Ordered Logistic Regression Table Predictor

Coef

Const(1) Const(2)

-2.332 -1.663

0.923 0.920

-2.530 -1.810

0.012 0.071

Const(3) Const(4)

-0.559 0.291

0.918 0.921

-0.610 0.320

0.543 0.752

0.015

0.007

1.990

0.047

1.010

1.000

1.030

2

0.075

0.177

0.420

0.671

1.080

0.760

1.530

YEAR LEVEL 2

0.046

0.200

0.230

0.819

1.050

0.710

1.550

3

-0.107

0.218

-0.490

0.621

0.900

0.590

1.380

MENTAL HEALTH LITERACY GENDER

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SE Coef

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Z

P

Odds Ratio

95% CI Lower Upper

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0.05, thus showing no correlation. Furthermore, the Odds ratio of 1.01 indicates that the respondents are more likely to be normal or have no negative emotional state of depression. Also, for every 1 unit increase in the score of Mental Health Literacy, the odds of having no negative emotional state of depression is increased by 1%.

DISCUSSION

This study aimed to identify the relationship between the Negative Emotional State of Depression and the Mental Health Literacy among the first to third year students of Cebu Institute of Medicine. The results showed a significant relationship between Negative Emotional State of Depression and Mental Health Literacy, thus rejecting the null hypothesis. This was assessed by utilizing Ordered Logistic Regression, where the scores of Mental Health Literacy based on the MHLS were correlated to the different levels of Negative Emotional State of Depression, which were also based on the DASS-21 scores. Furthermore, results showed an odds ratio of 1.01, which indicates that for every 1 unit increase in the MHLS score, the odds of having normal DASS-21 scores or no negative emotional state of depression is increased by 1%. This indicates that the more adequate the mental health literacy is, the less likely in having a negative

ORIGINAL RESEARCH

emotional state of depression. This association was also exemplified Jorm’s study which explains the relationship between mental health literacy and severity of depression.12 This study primarily defined mental health literacy as being able to recognize different mental health disorders and the ability to seek proper health care, which explains how an individual with adequate mental health literacy may have fewer depressive symptoms.12 In contrast, a person with poor mental health literacy, indicating that the individual is not able to recognize psychiatric symptoms and seek help for it, may experience more depressive symptoms.12 The results suggest that improving mental health literacy seem to be an essential intervention in lowering down depression rates.12,13 This would include teaching individuals how to recognize psychiatric symptoms, as well as educating on how, where, and when to seek help for a professional. One avenue for this would be to engage students in mental health literacy programs that enhances understanding of mental health issues and teaches them the correct attitudes and behaviors in seeking help. Programs like this are covered in the Mental Health First Aid course which is known in some countries that aims to improve their mental health literacy rates. As covered in the study, these programs may especially be useful for the medical students in CIM. Another interesting finding was that in majority of both males and

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females, the top two levels of depression scores were normal and moderate across year levels. However, in the female population of third year students, severe depression ranked second. A possible explanation as to why there is a deviance in the third-year population may be due to the increased stress in this particular year level.4 In applying it to the curriculum of third year students in CIM, more school demands may be due to the fact the students have clinics on top of academics. This can also be due to the schedule where third year students should be within the school premises for at least 11 hours, comprising of lectures, small group learning, and clinics. Proper time management such as excelling in academics through maximizing free time to study can be really challenging in this situation. Although stress was not measured in the study, this may have contributed to the negative emotional state of depression of the respondents. However, this study did not show any significant relationship between gender and negative emotional state of depression. Gender, as to being female, did not have any effect on the level of negative emotional state of depression among CIM students. Although a study by Fernanda stated that female gender, along with other factors such as location of school and scholarship, are factors that may predispose medical students to anxiety and depression.14 It has been repeat-

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edly shown that women are at greater risk of major depressive disorder (MDD) than men, as the female-to-male (F:M) prevalence ratio of the disorder has been widely accepted to be approximately 2:1. However, this may artifactually reflect a greater tendency of women to seek help or over-report depressive symptoms than men.1 Furthermore, women may be more apt to dwell on their stress and turn transient negative emotions into severe depressive symptoms, whereas men tend to minimize their depressive mood engaging in more active behaviors.15 In comparing between genders, another result in the study showed that there were more females that scored adequately on the Mental Health Literacy scale in proportion to the males. This is similar to the study done by Wong, which stated that female gender showed a higher mental health literacy and awareness as compared to the male gender especially in post-secondary students.16 This may due to the fact that females have greater tendencies to seek mental health care.1 Although the study did not aim explore the relationship between gender and mental health literacy, this descriptive statistic poses an interesting case. This may imply that male CIM students should be given priority when mental health interventions are applied. Although compared in proportion, it should also be taken into consideration that the female population in this study outnumber the

ORIGINAL RESEARCH

male population. In addition, the comparison of Mental Health Literacy scores in the study among year levels showed an increasing average score of mental health literacy from 121.28 of first year, 124.80 of the second years and lastly 125.53 of the third years showing that the adequacy of mental health literacy improves as the year level in medical school increased. This indicates an increasing percentage of students that scored adequately on the Mental Health Literacy Scale as the year level progressed. This is similar to the study of Lam in 2014 wherein it was reported that 70% of higher education students were able to recognize depression.17 Also a study by Cheslock in 2005, stated that third year medical students may accurately diagnose mental disorders because of their experiences during their medical field rotations, or with individuals who have mental disorders. On the other hand, low identification rates of depression in lower year levels could be due to having less personal experiences of depressive mood. It could also be due to the lack of mental health education designed for this specific year level. Another possible explanation is that younger individuals misinterpret depressive symptoms as other health problems and show negative attitude toward help-seeking behaviors. Also, lower year level medical students may not have been able to identify the disorders due to lack of professional experiences and exposure to individu-

ORIGINAL RESEARCH

als who present with these symptoms as well as lack of psychiatric education.18 Additionally, Lauber et al. found that individuals who had exposures to those who have a mental illness, particularly depression, are better in recognizing depression as a disorder compared to others.19 Although the relationship between year level and mental health literacy score was not explored, these results propose another approach on addressing depressive emotional states considering that improving mental health literacy can significantly impact level of one’s negative emotional state of depression. This could be done by starting early mental health interventions as soon as the individual steps into medical school, be it through the form of seminars, lectures or regular mandated guidance counselor visits. This would not only improve the mental health literacy of earlier year levels, but also the overall mental health literacy of the school, followed by improvement in the overall levels of negative emotional state of depression among CIM

students. CONCLUSION The study was conducted to identify whether a relationship exists between negative emotional state of depression and mental health literacy among first year to third year CIM students. Negative emotional state of depression was measured using depres-

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sion subset of DASS-21 which only included 7 items. Other variables such as gender and year level were also considered. Out of 522 CIM students, only 454 responded. Those who were not included are those with BS Psychology degree and members of the research group. Some students opted not to participate in the study, and forms with incomplete data were marked as void and were not included. Using ordered logistic regression, results of the study showed that there is a significant relationship (p0.05) with the DASS-21 score, indicating that gender and year level do not affect the level of the negative emotional state of Depression. Furthermore, results showed that the level of Mental Health Literacy among CIM students was shown to be more adequate as the year level progresses. This relationship could be attributed to increased academic knowledge and clinical exposure. For instance, Psychiatry Module is part of the Second Year Level curriculum, and Third Year students have the application of this module to some patients they encounter during clinics. In addi-

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tion, the results indicated that only 11% of the population showed extremely severe level of negative emotional state of depression. Majority of CIM students in all year levels have no negative emotional state depression based from the Depression subset scores of the DASS-21. It can therefore be concluded that the more adequate the student’s mental health literacy becomes, the more normal the emotional states are regardless of gender. Also, it can safely be inferred that the more the students are exposed to mental disorders by way of curriculum and exposure in the higher year levels, the better their mental health literacy becomes.

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FACTORS AFFECTING THE PURSUANCE OF PROFESSIONAL MEDICAL CAREERS AT THE PRIMARY HEALTH CARE LEVEL AMONG CIM STUDENTS Araneta NLL, Bomediano MJR, Curan JKD, Lao PGI, Rabaya AJN, Isabel B, Ricardo R, Rosales NVO, Ting APC, Uymatiao EES, Villar SRD Cebu Institute of Medicine; Email: [email protected]

ABSTRACT Introduction: Inequities in distribution of physicians in the country poses huge problems in primary health care (PHC). Objective: The aim of this study is to determine the factors that affect the pursuance of careers at the PHC level among first to third year medical students of CIM. Methods: This is a descriptive cross- sectional study involving 522 first year to third year medical students. A self-administered questionnaire adapted from validated tools of by Leonardia et al. and Elizabeth et al. was utilized. All of the potential respondents completed and submitted their questionnaires. Results: Data analyzed by logistic regression analysis showed the following factors have no association to the pursuance of a career in PHC: age, gender, knowledge on primary health care, perceived working conditions, living conditions, and career advancement opportunities. On the other hand, factors that significantly affect CIM medical students’ decision to pursue professional medical career in primary health care are their year level, past community work experience, and their perceptions toward the compensation they would get from these careers. Conclusion: A better understanding of students’ career decision-making process through these findings can aid the major stakeholders like schools and branches of government to identify their possible points of intervention and to implement such. Keywords: Primary Health Care, Career, Medical Careers

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INTRODUCTION In a third-world country like the Philippines, a disparity in the exercise of rights and privileges across different socioeconomic strata and cultural backgrounds is evident in various local and national systems. The health care sector is not exempt from this discussion, as inequities in access to health continue to be one of the most pressing problems in the country. A significant contributor to this health care gap is the issue of scarcity and maldistribution of health care workers. While the World Health Organization (WHO) recommends a doctor-to-population ratio of 1:1000, the Philippines has only 3.9 doctors per 10,000 population. Ninety-one percent of these doctors work in hospitals, leaving only 9% to work in non-hospital and primary care settings. Primary health structures like Rural Health Units (RHUs) and Municipal Health Offices (MHOs) — which ideally function as the first points of access to health service — are therefore among the most significantly affected by the lack of health workers. Across the country, there is only one doctor per RHU on average. The phenomenon of urban congestion of physicians is illustrated further by findings of the Philippine Health System Review 2018, which showed that the National Capital Region, the area with the largest urban agglomeration in the Philippines, has the highest level of doctorless RHUs at 13%.1 As primary health care (PHC) empha-

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sizes the essential health care elements of health promotion, preven tion, and control, it has been recognized as the only means of providing practical health care for the growing populations of poor economies. Thus, it becomes pertinent to ask about the state of the Philippines’ mission to achieve this prospect of health for all, and about the barriers which our primary health structures face especially in the context of the workforce problem. This leads to a call to examine the factors that encourage doctors, or deter them, from pursuing professional careers in primary health care. Identifying these factors may be the first step for major stakeholders like schools and the government to make the necessary policies and structural changes that will address this prevalent health care issue and push us closer to universal health care. Leonardia et al. assessed aspects of the workforce problem, specifically the retention rates of the Doctors to the Barrios program.2 It investigated the low number of DTTB enrollees who opt to remain in the LGUs after completion of the program and explored the factors influencing the doctors’ decisions to remain or leave their rural posts. A mixed- method approach was used comprising a self-administered questionnaire and oral interviews with former DTTBs. The literature on the mobility of health workers suggests that an interplay of “push” and “pull” factors influence an individual’s decision to leave or stay in a rural work-

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place. Pull factors are those that attract health workers to urban workplaces and abroad. These include higher financial rewards, improved living conditions, and career advancement. In contrast, push factors, such as professional isolation, poorly resourced facilities, and limited recreational possibilities, can provoke health workers to leave. The assessment revealed that among former DTTBs, the wish to serve rural populations was the most widely cited motivation. In comparison, more than half joined the program due to return of service obligations; a quarter to help rural populations; and some out of an interest in public health. Those who joined the program to return service experienced significantly less satisfaction, while those who joined out of an interest in public health were significantly more satisfied with their rural work.2 The LGU was shown to play a pivotal role in retention and has the most important influence on DTTBs’ decision-making. It becomes apparent that, if LGU support is in place, then the MHO can rely on the availability of utilities, infrastructure, logistics, services, funding, and human resources, thus considerably facilitating the management of the local health system. On the other hand, the lack of LGU support leads to problems regarding personal security; the availability of drugs, medical supplies, health program funds; and even the provision of DTTB benefits. Moreover, once DTTBs

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are absorbed by the LGUs, they become more susceptible to the pressures of local politics.2 Since the administrative transition or devolution of the management of health workers to local politicians with little or no experience in managing health systems, there was an initial decline in morale of health staff and resignation of key personnel. This would explain why some former DTTBs preferred to re-enter the Program and be assigned to another area and to retain their more neutral DOH employee status than to become an LGU employee. DOH support is also important for retention, particularly when DTTBs consider or embark upon absorption. Some of the former DTTBs expressed regret that DOH support waned once they became part of the LGU despite efforts from the DOH to continually contact and invite former DTTBs to CME sessions.2 Another factor playing a prominent role in the decision-making of DTTBs is the financial compensation. While most current DTTBs agree that they are fairly compensated, the views of former DTTBs show that this is not the case after absorption. In addition, family issues considerably influenced retention, as DTTBs mentioned the need to be closer to aged parents. Family expectations put increased pressure on these physicians to maintain a standard of living not found in rural areas. Lastly, it was noted that rural upbringing of physicians was associated with greater willingness to

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engage in rural practice. In contrast, those who graduated from medical schools in the National Capital Region were significantly more critical about their compensation, were significantly less positive about DOH support, and perceived there to be fewer options for leisure in rural areas. This could be because career advancement is a common personal goal, and these physicians do not perceive the linkage with the DOH to be crucial for their immediate and future careers.2

OBJECTIVES To determine the factors that affect the pursuance of professional medical careers at the primary health care level among first year to third year medical students of CIM. Specifically: (1) to determine the profile of the respondents, (2) to determine whether the respondents are considering pursuing professional medical careers at the primary health care level, and (3) to determine if there is a significant effect in the consideration of pursuing careers at the primary health care level among respondents when they are grouped according to various parameters.

METHODS This descriptive cross-sectional study analyzes the population by recording data without manipulating the study environment and comparing

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the different variables at the same time. It describes the attitudes of CIM students toward working in primary health care and examines the different factors affecting their decision to pursue or not to pursue such careers. This study was conducted within the CIM campus, located at F. Ramos Street, Cebu City. It is one of the seven medical schools in the province of Cebu. A total of 522 students were identified from the first year to third year level. Of which, only 503 respondents passed the inclusion criteria, which included medical students of Filipino nationality currently enrolled in and attending the CIM, belonging to year levels 1, 2, and 3. There were 202 respondents from the first-year level, 172 respondents from the second-year level, and 129 respondents from the third-year level. The population of the study covered all first year to third year CIM students passing the inclusion criteria, hence no sampling technique was applied. The data collection tool utilized in this study was a self-administered questionnaire, adapted from the validated tools. The questionnaire was divided into three parts. Part I consisted of the Respondent’s Profile such as year level, age, sex, nationality, past experience with community work or community service, and a question on whether or not the respondent is considering a career in primary health care. Part II contained 20 true-or-false questions on basic primary health con-

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cepts to assess the respondent’s knowledge on primary health care, and Part III was comprised of a total of 39 questions regarding the respondent’s perceptions toward different aspects of careers in primary health care, including compensation, working conditions, living conditions, and career advancement opportunities. The respondents were provided with choices for each item and were given at least 10 minutes to complete answering the tool. The data collection tool was prepared based on the validated questionnaire used by Leonardia, et al.2 Pilot testing was initially done on randomly selected CIM students from first to third year, comprising of 5 students per year level, as recommended by the statistician. This was conducted at CIM on March 10, 2019. Feedback was obtained, and respondents were asked for identification of vagueness, inconsistency, and difficulty of questions. Upon completion, validity of the questionnaire was established, allowing the researchers to proceed with data collection. The researchers determined the qualification for enrollment to the study through the established inclusion and exclusion criteria. The respondents were given an informed consent form, wherein they affixed their signature if they agreed to be part of the study. The form emphasized respondents’ confidentiality, explaining that the respondents’ name would not be asked but pre-assigned

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questionnaire numbers were to be written at the bottom of the form. The purpose of the questionnaire number was solely to facilitate contacting a respondent in the case that the researchers had clarifications to some provided or unprovided answers. Prior to distribution of the tool, the researchers briefly explained to the respondents the background and objectives of the study and gave instructions for answering the different questionnaire parts. For data collection of the first year and third year levels, the researchers distributed the questionnaires in all small group discussion (SGD) rooms after each group’s SGD session. For the second-year students, SGD facilitators helped in the distribution of the questionnaires to their respective SGD groups. The researchers gathered the answered questionnaires thereafter. Once collection was complete, all data were tallied and tabulated on Microsoft Excel for presentation and interpretation. The study involved frequencies and percentage in the description of the profile of respondents and in the determination of whether the respondents are considering pursuing professional medical careers at the primary health care level. The study also involved Logistic Regression Analysis, a statistical method that analyzed a dataset in which one or more independent variables were involved in determining an outcome. The outcome was measured with a dichotomous variable. In this study, the statistical tool

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was used to test if there was a significant effect on the decision to pursue a career in primary health, based on factors such as year level, age, sex, past experience with community work, knowledge on primary health care, and perceptions toward the compensation, working conditions, living conditions, and career advancement opportunities in the primary health. P-values were also calculated for each factor, with a cut-off of 0.05 used to indicate high internal validity. P-values