Print this page Email this page Users Online: 307 | Click here to view old website
Home About us Editorial Board Search Current Issue Archives Submit Article Author Instructions Contact Us Login 

 Table of Contents  
Year : 2007  |  Volume : 20  |  Issue : 3  |  Page : 129

Introduction of Regular Formative Assessment to Enhance Learnning for Clinical Students at Muhimbili University College, Tanzania

Muhimbili University College, Dar es Salaam, Tanzania

Date of Submission29-Oct-2007
Date of Web Publication24-Nov-2007

Correspondence Address:
C A Mkony
P O Box 65001, Dar es Salaam
Login to access the Email id

Source of Support: None, Conflict of Interest: None

PMID: 18080965

Rights and PermissionsRights and Permissions

Objective: To determine if undertaking regular Formative Assessment (FA) in the setting of our medical school enhanced the students' learning experience.
Methods: An FA intervention was designed and implemented with clinical students during their clerkship in the academic year 2003/04. FA was administered as structured verbal comments on daily clinical case presentations. Evaluation of the intervention included pre- and post-surveys exploring the perceptions of students and teachers on the quality of the learning experience. Focus group discussions with students and with teachers were held at the start and conclusion of the intervention to identify strengths and weaknesses of FA.
Findings: All participating teachers perceived that students were interested in learning before the intervention. Teachers who perceived that students achieved the set learning objectives increased from 0% before to 28% after the intervention. Most teachers (71%) and students (86%) perceived FA to enrich students' learning experience. Students appreciated the positive change in teachers' attitudes during the FA intervention. Both students and teachers recommended that FA become a regular and routine activity.
Conclusions: Students and teachers viewed FA as a positive, feasible intervention. They thought it enriched the learning process and recommended it be a routine learning activity.

Keywords: Formative assessment, learning, student-teacher relationship, curriculum Innovation

How to cite this article:
Mkony C A, Mbembati N A, Hamudu N A, Pallangyo K. Introduction of Regular Formative Assessment to Enhance Learnning for Clinical Students at Muhimbili University College, Tanzania. Educ Health 2007;20:129

How to cite this URL:
Mkony C A, Mbembati N A, Hamudu N A, Pallangyo K. Introduction of Regular Formative Assessment to Enhance Learnning for Clinical Students at Muhimbili University College, Tanzania. Educ Health [serial online] 2007 [cited 2023 Jan 28];20:129. Available from:


The School of Medicine at Muhimbili is the oldest and largest medical training institution in Tanzania, dating back to 1963. In studies performed by the school in 2001/2002, former students reported a need to improve relations between teachers and students. Teachers conveyed a negative attitude towards students and students interpreted this as teachers who were out to fail them, which led to mutual mistrust. Unfortunately, the graduates who become teachers continue to perpetuate this cycle.

We adopted Formative Assessment (FA) to cultivate an environment of mutual respect and understanding. In FA, students receive immediate feedback on their performance, utilizing a positive approach and language to provide guidance (Gronlund, 2003). With FA, teachers and students can identify actions to improve learning (Velan et al., 2002; Dow, 2003; Burge & Lancaster, 2004; Olson & McDonald, 2004). Students find FA useful (Hill et al., 1994; Chur-Hansen, 2000; Dow, 2003), and studies support the usefulness of FA in learning (Velan et al, 2002; Henly 2003; Ker et al., 2003; Olson & McDonald, 2004).

This paper describes our implementation and evaluation of a structured formative assessment pilot program.

Description of the Intervention

The FA program provided all students with the opportunity to practice case presentation and receive immediate, constructive suggestions from faculty members. Teachers adopted positive attitudes towards students and used positive language during the clinical case presentation and discussion. During the daily FA intervention, in each of three clinical units of each of four departments, one student was assigned a patient by the teacher to clerk. The other (7-8) students read about the condition and prepared for discussion.

During a 90-minute session the index student presented the patient and others contributed. The teacher gave the student verbal feedback on his/her performance, based on specified criteria. Twelve sessions were planned daily affecting the entire class for one academic year.


This was a pre/post intervention study with 98 fourth-year medical students doing clerkships in Medicine, Surgery, Pediatrics and Obstetrics/Gynecology, which were the main clerkships for the penultimate academic year in 2003/2004.

Twenty-four randomly selected teachers (six each) from the four departments implemented the intervention. Faculty members received an honorarium to teach outside their normal teaching commitment. Students completed a ten-item questionnaire and teachers completed a seven-item questionnaire. Responses were anonymous and on a Likert scale from 1(strongly disagree) to 5 (strongly agree).

Four groups of eight students each, randomly selected from gender clusters, and ten teachers, randomly selected from the 24 in department clusters, took part in separate focus groups both before and after the intervention. A trained interviewer with no connection to the study conducted the groups.

The data were analyzed using EPI Info 6 and the themes were extracted from the transcriptions gained from the focus groups.


Sixty-two (63%) students returned the pre-questionnaires and 75 (77%) returned the post-questionnaires. All teachers completed both questionnaires. Of planned sessions, 15% were missed and rescheduled on weekends, while 5% were missed altogether.

Table 1 presents student responses, indicating a favorable perception of the FA intervention. On average there was a 50% increase in the favorable ratings given to the statements after the intervention. Table 2 summarizes the results for teachers.

Table 1. Comparison of student perceptions of teacher attitude, student-teacher relationship or aspects of FA before and during the intervention

Overall the responses indicated a more positive perception after the intervention. The improvement in ratings averaged 55%. Most teachers (71%) indicated that FA consisted of an intensity of teaching that was reasonable and sustainable.

Table 2. Comparison of teacher perceptions of student attitude, and aspects of FA before and during the intervention

The student pre-focus group report indicated high teacher commitment in most clinical teaching units. Students praised those teachers, for their sensitivity, friendliness and empathy in academic interaction with students. However, students also reported that teachers in some departments were unfriendly, non-empathetic and intimidating. Teachers who were harsh and unduly critical during clinical case presentations made students nervous and anxious, rendering the learning experience ineffectively. Some students compared the teaching ward round in some units with a battlefield situation, making them seek excuses to avoid the ward round. Students reported that some departments had low teacher commitment to teaching, leading to numerous missed scheduled sessions.

In the post-intervention focus group discussion, students expressed that the FA intervention, by bringing students and teachers regularly together in an atmosphere in which teachers consciously endeavored to treat students considerately and respectfully, provided an improvement in relations and promoted mutual understanding and respect. Students started feeling at ease with their teachers, appreciated the unaccustomed friendliness and found the feedback given after the case presentation very helpful.

Students made recommendations for improvement of the FA intervention, including recommending three instead of five clinical sessions per week allowing time for other learning activities. They preferred being allowed to present the case from start to finish with minimal interruption by the teacher and they preferred fellow students to have the first chance to query them on their presentation.

Teachers in their pre-focus groups recognized the existence in the standard setting of an unfavorable atmosphere between students and teachers, including a tendency to bully and embarrass students in front of their peers and patients. However, teachers also expressed that unprepared students de-motivated their teachers. They thought that the students’ level of responsibility, initiative and enthusiasm in their learning needed to be raised.

In the post-intervention focus group, teachers perceived that during the FA exercise a friendly atmosphere with minimal tension prevailed. Students were more relaxed, freer to participate in discussion, they asked questions, and generally performed better during summative assessment. Teachers primarily adopted the role of facilitators. Teachers were concerned that the FA sessions took them away from other activities. They, too, felt three sessions would be effective for student learning. Teachers appreciated the effectiveness of giving immediate feedback to students and emphasizing what had been done well by the student. Furthermore, teachers said that FA should be a regular academic activity.


This study found marked positive changes in students’ and teachers’ perceptions of issues related to learning and student assessment as well as the attitude of each towards the other following the FA intervention. The experiences were positive and both students and teachers thought it should become a regular academic activity.

In andragogy (adult learning), as opposed to pedagogy (teaching children), the emphasis is on learner participation, which requires an environment conducive to learning. Teachers were encouraged to avoid the natural tendency to direct attention at what the student does not (yet) know and to seek to build on what the student already knows, using positive language communication, or what has been termed ‘vocabularies of hope” (Ludema, 1999).

However, the study had limitations. Students and faculty may have responded favorably due to the novelty of the intervention and to being part of a research study. The faculty had a monetary incentive to participate. Unfortunately, due to ongoing rehabilitation of the teaching hospital, it has not been practical to continue with the program at present in a formal manner. Fortunately, the seed of change has been planted and the benefits of the intervention are evident in the school’s daily routine teaching-learning activities.

FA was successfully introduced for clinical students and well-appreciated by teachers and students, who thought it enriched the learning process. They suggested that it should be a routine activity. Student-teacher interaction improved during the intervention, and plans are underway at the school to make FA a routine activity.


We acknowledge the pivotal role of the Foundation for the Advancement of Medical Education and Research (FAIMER) for the Institute Fellowship training in which one of the authors (CAM) participated and which led to the conception and implementation of the study. We wish to thank the MUCHS administration for approving financial support for the study, the bulk of which was spent on honoraria for the teachers conducting the clinical case presentations. We also wish to acknowledge the Swedish International Development Agency, Swedish Agency for Research Cooperation (Sida-SAREC), the source of the funds through research support to the college.


BURGE, S.M. & LANCASTER, T. (2004). Assessment in undergraduate dermatology. Clinical Experimental Dermatology 29: 441–446.

CHUR-HANSEN, A. (2000). Medical students’ essay-writing skills: criteria-based self-and tutor-evaluation and the role of language background. Medical Education 34: 194-198.

DOW, R.B. (2003). The introduction of web-based formative assessment in medical science-an action research.

GRONLUND, N.E., (2003) Assessment of student achievement, Seventh edition, Allyn and Bacon, Boston.

HENLY, D.C. (2003). Use of web-based formative assessment to support student learning. European Journal of Dental Education 7:116-122.

HILL, D.A., GUINEA, A.I. & MCCARTHEY, W.H. (1994). Formative assessment: a student perspective. Medical Education 28: 394-399.

KER, J., MOLE, L., & BRADLEY P. (2003). Early introduction to interprofessional learning: a simulated ward environment. Medical Education 37: 248-255.

LUDEMA, J.D. (1999). From Deficit Discourse to Vocabularies of Hope: The Power of Appreciation. In Appreciative Inquiry: Rethinking human organization toward a positive theory of change. Ed. Dianna Whitney, Therese Yaeger, 265-287. Champaign,IL: Stipes Publishing Company.

OLSON, B.L. & Mc DONALD, J.L. (2004). Influence of online formative assessment upon student learning in biomedical science courses. Journal of Dental Education 68: 656–659.

VELAN, G.M., KUMAR, R.K., DIEGIELEWSKI, M. & WAKEFIELD, D. (2002). Web-based self-assessment in Pathology with Questionmark Perception. Pathology 34: 282-284.


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article

 Article Access Statistics
    PDF Downloaded189    
    Comments [Add]    

Recommend this journal