Education for Health

: 2008  |  Volume : 21  |  Issue : 2  |  Page : 116-

Perceptions of Problem-Based Learning (PBL) Group Effectiveness in a Socially-Culturally Diverse Medical Student Population

VS Singaram1, DHJM Dolmans2, N Lachman3, CPM van der Vleuten2,  
1 Nelson R Mandela School of Medicine, School of Undergraduate Medical Education, University of KwaZulu Natal, Durban, South Africa
2 University of Maastricht, Department of Educational Development, Maastricht, The Netherlands
3 Durban University of Technology, Durban, South Africa

Correspondence Address:
V S Singaram
Clusterbox 24238, Broadlands, Mount Edgecombe,4156,KwaZulu Natal, Durban
South Africa


Introduction: A key aspect of the success of a PBL curriculum is the effective implementation of its small group tutorials. Diversity among students participating in tutorials may affect the effectiveness of the tutorials and may require different implementation strategies. Aims: To determine how students from diverse backgrounds perceive the effectiveness of the processes and content of the PBL tutorials. This study also aims to explore the relationship between students«SQ» perceptions of their PBL tutorials and their gender, age, language, prior educational training, and secondary schooling. Materials/Methods: Data were survey results from 244 first-year student-respondents at the Nelson Mandela School of Medicine at the University of KwaZulu-Natal in South Africa. Exploratory factor analysis was conducted to verify scale constructs in the questionnaire. Relationships between independent and dependent variables were investigated in an analysis of variance. Results: The average scores for the items measured varied between 3.3 and 3.8 (scale value 1 indicated negative regard and 5 indicated positive regard). Among process measures, approximately two-thirds of students felt that learning in a group was neither frustrating nor stressful and that they enjoyed learning how to work with students from different social and cultural backgrounds. Among content measures, 80% of the students felt that they learned to work successfully with students from different social and cultural groups and 77% felt that they benefited from the input of other group members. Mean ratings on these measures did not vary with students«SQ» gender, age, first language, prior educational training, and the types of schools they had previously attended. Discussion and Conclusion: Medical students of the University of KwaZulu-Natal, regardless of their backgrounds, generally have positive perceptions of small group learning. These findings support previous studies in highlighting the role that small group tutorials can play in overcoming cultural barriers and promoting unity and collaborative learning within diverse student groups.

How to cite this article:
Singaram V S, Dolmans D, Lachman N, van der Vleuten C. Perceptions of Problem-Based Learning (PBL) Group Effectiveness in a Socially-Culturally Diverse Medical Student Population.Educ Health 2008;21:116-116

How to cite this URL:
Singaram V S, Dolmans D, Lachman N, van der Vleuten C. Perceptions of Problem-Based Learning (PBL) Group Effectiveness in a Socially-Culturally Diverse Medical Student Population. Educ Health [serial online] 2008 [cited 2022 Oct 6 ];21:116-116
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One of the key contributors to the success of a PBL curriculum is the effective implementation of the small group tutorial. Although many studies have evaluated the effectiveness of PBL approaches, the majority were conducted in an environment where students came from similar educational backgrounds and shared a common first language (Connolly & Seneque, 1999). It is important to confirm the findings of previous studies in different environments as it will expand our understanding of both context-specific and general aspects of the PBL process (Nieminen et al., 2006). Adding more studies to the literature on the small group processes in diverse learning environments could also help us understand “why some groups work well and some do not” (Miflin, 2004).

Current literature that documents the transition from monocultural to multicultural classrooms (e.g. South Africa) focuses on the challenges that arise within diverse communities. These challenges are attributed to the historic barriers between population groups as was the case in apartheid South Africa (Connolly & Seneque, 1999). There is a need to change the mindset and add more studies like those of Holen (2000) and McLean et al. (2006) that emphasize the social benefits of the small group tutorial in PBL. It is anticipated that this study could support the findings of these studies hence highlighting the collaborative learning principles of PBL. In addition, understanding in more detail the association between diversity and socio-cultural influences on small group work could shed more light on the positive, beneficial richness of diversity as opposed to the challenges it presents as illustrated in the studies below.

In diverse student populations factors such as gender, language, prior educational training experiences, and age become important considerations when assessing the small group’s effectiveness (Duek, 2000). Cross-cultural learning situations can be problematic in PBL curricula, as students’ backgrounds and cultures influence motivation and the cognitive aspects of the small group tutorial (Carlo et al., 2003). Cultural and linguistic differences between students can lead some to avoid actively participating, which can lead to dysfunctional tutorial groups (Hendry et al., 2003; Gill et al., 2004). Hence, the cultural influences on the functioning of the small group in PBL cannot be overlooked (McLean et al., 2006).

This study investigates how students from diverse backgrounds perceive the effectiveness of the process and content of PBL small group tutorials. The content construct (CC) refers to the group’s cognitive activities, which includes the knowledge of individual students and the collective knowledge of the group. The process construct (PC) refers to how group members work and function together (Duek, 2000). It is envisaged that this study could highlight important aspects that both students and faculty need to be aware of in diverse settings, where students come from multicultural, multilingual, different socio-economic and educational backgrounds. This awareness could heighten group effectiveness and prevent misconceptions regarding the diverse dysfunctional tutorial group. It would also encourage the implementation of appropriate strategies to prevent avoidable problems in group functioning, perhaps by taking particular approaches to orienting students or in helping them adjust to the PBL environment.


To determine how students from different backgrounds perceive the group effectiveness of PBL tutorials.

To explore the relationship between gender, language, prior educational training, age and secondary school background on students' perceptions about the group effectiveness in PBL tutorials.



The Nelson R. Mandela School of Medicine (NRMSM) changed its traditional curriculum to a five-year PBL curriculum in 2001. The curriculum is not subject–based, but instead consists of integrated themes designed around cases or problems. The first three years of training consist of these themes with a clinical methods course starting in the third year. In the fourth and fifth year, students rotate through the clinical disciplines (i.e. Medicine, Obstetrics and Gynaecology, Family Medicine, Surgery, Paediatrics and Psychiatry). PBL small group tutorials, composed of 10 to 12 students, are held twice a week to discuss relevant cases.

In addition to PBL, affirmative action policies were implemented at the NRMSM. These policies aim to address the needs of the developing multicultural society and to overcome racial and social imbalances created by historical segregations. This has produced a diverse student population that consists of students who have different first languages (approximately 13 different languages) and a range of prior educational training experiences, ages, and schooling backgrounds. School backgrounds refer to the type of secondary schools, i.e. public or private, that differ in terms of resources, infrastructure, and methodologies. Prior educational training refers to students who might have had one or more years of undergraduate or postgraduate experience studying another field before applying for Medicine. The students in this study are referred to as ‘mature’ students whilst ‘matriculants’ refers to students who enter medicine directly after completing matric in secondary schooling. Recognizing the heterogeneity of the student population, students are not randomly assigned to the tutorial groups but rather mixed based on their backgrounds in an attempt to balance the diverse experiences in the group. These groupings are changed by the faculty for every theme. This study was conducted at the end of the first semester of the first year of study, when each student had completed three themes.


Questionnaires were handed out in the last teaching sessions of the first semesters of 2004 and 2005. After excluding 26 questionnaires due to missing information, the final response rate was 62.4% (49.7% for 2004; 75.1% for 2005). Hence analyses were performed on responses from 244 first-year medical students from two consecutive calendar years (2004/5).


A questionnaire was developed to explore students' perceptions of small group tutorial effectiveness and learning in a PBL environment. Items were formulated relating to the process of working in a group (process construct) and content learned (content construct). Examples of items included were “learning in a group was not frustrating and stressful” and “members in my group shared information freely.” Students were asked to indicate to what extent they disagreed or agreed with each statement. Reponses were recorded on a 5-point Likert scale (1= ‘strongly disagree’ to 5 ‘strongly agree’). Although anonymous surveys were used, the students’ demographic information was collected i.e. gender, language, prior educational training, age, and school background.


The data from both year-cohorts of students were combined and analysed together using SPSS version 11.5 (SPSS Inc, Chicago, Ill, USA). Exploratory factor analysis was conducted to verify the items in the questionnaire relating to the constructs described above. Cronbach’s alphas were calculated for each of the factors to inspect internal consistency. The students’ perceptions for each construct and individual items were identified as the dependent variables in this study whilst the independent variables were gender, language, age, prior educational training, and school background. Full ANOVA tests were conducted to find associations between the independent variables and the dependent variables. A p value of less then 0.05 was considered significant. Effect sizes (Cohen's d) were calculated for the main effects (Cohen, 1987). An effect size below 0.20 is considered small, between 0.20 and 0.50 medium, and above 0.50 as large.


Table 1 outlines the demographic profile of the respondent sample. Nearly 60% of students were female, 82% were age 21 and younger, and for more than two-thirds of the students the first language was not English.

Table 1: Student Profile

In the next section the factor analysis will be presented, followed by the descriptive statistics of the results of each of the research questions outlined earlier.

Factor Analysis

A two-factor solution was found (Eigen values >1), with items 6 to12 loaded on the first factor and items 1 to 5 loaded on the second factor. The content construct (first factor) had a 49.56% variance and an alpha coefficient of 0.90. The process construct (second factor) had 12.72% variance and an alpha coefficient of 0.80. Apparently, the two underlying factors were represented in the questionnaire and the reliability of the scales was appropriate.

Descriptive Statistics

Table 2 outlines the average scores for the 13 items measuring students' perceptions of small group tutorial effectiveness which varied between 3.3 and 3.8 (scale 1-5). The standard deviations (SD) varied between 0.9 and 1.3 (n=244). In the process construct the students felt most strongly that learning in a group was not frustrating and stressful (Q4) whilst in the content construct, learning to work successfully with students from different social and cultural groups (Q7) had the highest mean.

Table 2: Perceptions of PBL Group Effectiveness (1= ‘strongly disagree’ to 5 ‘strongly agree’)

Table 3 illustrates findings related to the second research question which investigated the relationship of gender, language, prior educational training, age, and school background with students' perceptions about the group effectiveness in PBL tutorials. No significant main effects were found between the mean ratings of the perceptions of students within the gender, language, prior educational training, age, and school categories in the different constructs for group effectiveness. There were also no significant higher order interactions (not reported in the table) that could have masked significant main effects.

The effect sizes point to small effects, except for the age effect on the content construct, with a medium effect size.

Table 3: The Influence Of Student Background On Perceptions About The Content And Process Constructs Of Group Effectiveness?

Discussion and Conclusion

This study investigated perceptions of the process and content of small group tutorials used in a PBL-oriented curriculum within a socio-culturally diverse medical student population. Students participating in this study came from a variety of cultural, school and educational backgrounds, spoke different first languages, and were of different ages. This study found that students’ perceptions were overall positive about the group effectiveness of the PBL tutorial in both constructs.

Learning to work successfully with students from different social and cultural groups had the highest average rating in the content construct (Q7). In addition, the majority of the students felt that they shared information freely and benefited from the input of other members. This is most encouraging for the students’ professional development and future relationships especially within the South African context. These findings are similar to McLean et al. (2006), Bollinger (2003), Whitla et al. (2003), Holen (2000), Duek (2000) and Connolly and Seneque (1999), who highlight the social and affective advantages of the small group tutorial. As students learn to gather and deal with new knowledge in relation to patient problems, their working with others help them to develop attributes necessary for effective collaboration and self-directed learning (Miflin, 2004). Furthermore, students felt that learning and group work helped them to understand areas of the course material that they had difficulty with. These findings highlight the underlying collaborative learning principles of PBL and that the tutorial group work in PBL is intended to have a positive effect on learning (Dolmans et al., 2001; Dolmans et al., 2005). Similar to the findings of McLean et al. (2006) students in this study generally felt positive about learning to be tolerant in group sessions. Students also perceived that they were becoming more perceptive and sensitive to the needs of others during group work.

Within the process construct, students felt most strongly that learning in a group was not frustrating or stressful. This finding seems to indicate that first-year students’ common initial concerns and anxieties about adapting to PBL were allayed as students became familiar with the PBL process (O’Hanlon, 1995; McLean, 2006). Furthermore, it is interesting to note that, although in the majority, students did not feel as strongly that working in a group was better than working alone. In addition, some students found learning in a group time-consuming, frustrating and stressful. This could be attributed to the cultural forces that foster competition and compliance in previous school environments (Duek, 2000). This finding also reminds educators to pay attention to the changing and developing needs of students so that an appropriate balance of individual and collective needs can be achieved (Barrows & Tamblyn, 1980) especially in the educational analysis of the dysfunctional PBL group. This needs to be explored further in future studies.

No statistically significant associations were found between the language, age, and prior educational training experience of students and their perceptions of the content and process constructs of group effectiveness. This unexpected finding may be attributed to the small sample size studies, but the effects sizes were rather small too. It seems more likely that the absence of group differences is the appropriate explanation for these findings. In addition, the mixed groups (described earlier) which assist in decreasing the impact of diverse background differences in group learning may also have contributed to this finding. However, we found that English second language students felt more positive about the content and process construct of group effectiveness than English first language students, albeit not significant. This may be attributed to the language constraints experienced by some of the English second language students (Connolly & Seneque, 1999). This finding highlights their reliance on group learning to help them to improve their understanding of the subject matter they had difficulties with. The willing nature of students to share information and the co-operation between the different social and cultural groups was also appreciated more by the English second language students. This positive attribute of PBL may be contributing to the increased throughput rate at NRMSM since the implementation of PBL in 2001 as per NRMSM faculty undergraduate records.

Contrary to the findings of Carlo et al. (2003) who found differences between male and female students’ perceptions about factors influencing the success of PBL tutorial groups, this study found no significant differences between males and females in both constructs of group effectiveness. Perhaps this is due to the higher number of female students enrolled in medicine at NRMSM as per current faculty records. Hence, unlike the increased pressure to succeed felt by females in the UAE (Carlo et al., 2003), the scenario at NRMSM in South Africa is more equitable for males and females.

This study supports previous findings that highlight the expanding role of the small group tutorial in diverse populations (McLean et al., 2006). It highlights some of the positive benefits of diversity. This study found that the small group tutorial learning format encourages students to overcome social and cultural barriers and become more tolerant with each other. This is most encouraging as it is important for students to learn to function effectively in a team, especially in multicultural societies. This finding suggests that small group work in PBL plays a role in developing medical professionalism in undergraduate medical students. It also sets the tone for developing team work skills which are essential for medical professionals who are expected to be effective role players in multidisciplinary health care teams.

In future studies more attention should be directed toward the students who responded negatively to group work. These negative responses indicate that not all students prefer group work and perhaps justify the need for more continuous PBL orientation throughout the academic year. It is also important to analyze the opinions of non-responders. Further research in this area will provide deeper insight into dysfunctional groups. Also noting the subjectivity and limitations of self-reporting as a research instrument (Carlo et al., 2003), further qualitative research would validate if self-reported behavior and observed behavior are similar in diverse student populations. It can also provide insight into whether a large group size (10-12) influences students’ perceptions of group work. It is also suggested that future studies assess the link between students’ perceptions of PBL small group work and their academic achievement.


R. Hoogenboom from the University of Maastricht and T. Esterhuizen from the University of KwaZulu-Natal for statistical analysis.

Source of Funding

National Research Foundation (South Africa).

Ethical Approval

The head of the school had given approval for carrying out this study. Student participation in this study was voluntary. This study has no consequences on student assessment and did not prejudice student learning.


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