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The Medical Education Environment at the University of Nairobi, Kenya: An assessment with the DREEM tool.

Daniel Ojuka, Faith Bonareri, Beth Githambo, Michael Wambua

Department of Surgery, University of Nairobi, Kenya 

Correspondences to: Daniel Ojuka, Email: danielojuka@gmail.com



The supportive learning environment can enhance impartation of knowledge and skills.


To assess the learning environment at the School of Medicine of the University of Nairobi using the Dundee Ready Educational Environment Measure (DREEM) tool.

Materials and methods

A cross-sectional survey was carried out among the medical students during their clinical years to get their perceptions about the learning environment in the School of Medicine of the University of Nairobi. The DREEM tool was used during the survey. Data were entered and analyzed in SPSS version-19. Comparisons were performed using ANOVA. A p-value ≤ 0.05 was considered statistically significant.


We got 619 response from 800 tools distributed (77.4%). The total mean score of DREEM was 93.3 /200. This is 46.7% score in the overall indicating poor perception of the learning environment. Year 4 was the class with most poor perception with a p-value less than 0.05. 


The DREEM score indicates numerous problems with perception of learning and social support being the areas requiring the most improvement. Though teachers are knowledgeable, students are wary of their ability to transfer knowledge and skills.


Key words: learning environment, DREEM, medical students.

Ann Afr Surg. ****; **(*):***


Conflicts of Interest: None

Funding: None

© 2020 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.


The educational environment consists of, among other factors, documented curriculum and perception of teacher-student interaction in and out of class (1). The anticipation of and experiences by students concerning these factors can either motivate or demotivate students in their learning approaches and learning styles, crucial to these being how the learner is engaged (2). 

The learning environment as perceived by students determines  their behavior and aspiration  (3). Learning  environment is one of the factors that affects quality that can be measured and actions taken to improve, correct or change the environment in order to improve the quality of education (3,4).  DREEM is a culturally non-specific tool that has proven applicable in many culture and language. It has been validated to be good for measuring the learning environment among medical students (5,6).  It has been used to determine the weaknesses or strengths of  institutions’ learning environments, to make comparative analyses of students’ perceptions within and between different cohorts  and might  identify  academic achievers (7).

To our knowledge no study using the DREEM tool or any other tool to determine students’ perceptions of learning environment has been carried out in Kenya or in the University of Nairobi; therefore, this study was undertaken.


Materials and Methods

This was a cross-sectional survey among third to sixth years at the School of Medicine of the University of Nairobi. Ethical approval was obtained from Kenyatta National Hospital-University of Nairobi Ethics and Research Committee (P55/01/2019). We used the DREEM tool to gauge the student’s perception of the educational environment.

DREEM contains 50 statements relating to a range of topics directly relevant to the medical educational environment, scored on a five-point Likert scale ranging from zero to four (4: strongly agree; 3: agree; 2: have no idea; 1: disagree; 0: strongly disagree). The 50 items have a maximum score of 200. However, 9 of the 50 (8,12,15,16,21,23,34,39,45) were given reverse score, i.e., 0 = strongly agree (SA) and 4 = strongly disagree (SD), so that a higher score would indicate more positive responses. The inventory encompasses five subscales: (1) students’ perceptions of learning (SPL) – 12 items; (2) students’ perceptions of teachers (SPT) – 11 items; (3) students’ academic self- perceptions (SASP) – 8 items; (4) students’ perceptions of atmosphere (SPA) – 12 items; and (5) students’ social self- perceptions (SSSP) – 7 items.

The students who agreed to participate consented in writing. The tool was completed during class and returned at the end of class after explanation from one of the research assistants. Data collection for DREEM consisted of paper-based demographics that included year of study and gender.

Data analyses were done using SPSS version 19. Analysis was on the overall score out of 200, subscale score (SPL-48, SPT-44, SASP-32, SPA-48, SSSP-28) and individual score (0-4). Overall score of 0 – 50 is interpreted as extremely poor, 51 – 100 plenty of problems, 101 – 150 more positive than negative and 151 – 200 as excellent. 

Individual items with a mean score of ≥3.5 are particularly strong areas, items with a mean score of ≤2.0 need attention, and items with mean scores between 2 and 3 are areas of the educational environment that could be improved. Cronbach alpha was calculated for internal validity of the DREEM tool within out context.  Kaiser Meyer Olkin test was performed for sampling adequacy. Comparison of mean by t-test was performed using student-t test and ANOVA. Statistical significance was taken as p value <0.05.


We got 77.4% response rate (619/800).  The highest number of responses (32.1%) was obtained from fourth years. The gender response rates were: Females 50.2% and males 49.8% (Table 2).

The Cronbach α was 0.882 while the Kaiser-Meyer-Olkin 0.904 (p-value= <0.001). Indicating sample size was adequate and high internal validity. The mean score was 93.3/200 (46.7%), implying that generally we have numerous problems.

Click to view Table 1

Click to view Figure 1

Looking at the subscale scores, it is only year V that seems to have overall and specific area like SPL, SPT, and SSAP seen as moving towards positive. Additionally, year III has positive on SPT and year VI positive on SSAP (Figure 1).  The student perception on learning subscale is an area that requires attention as the only statement that scored above 2 was “I am clear about the learning objectives of the course”.

Click to view Figure 2

Only one item is above 2. All items in Figure 2 require action.

Analysis of variance revealed there were significant differences in the scores across the clinical years in all questions except 47 (p-value =0.772) and 48 (p-value =0.072), all other questions had p-value less than 0.05. The differences in gender were only significant for questions 13 (p-value=0.006), 22(p-value-0.022), 44 (p-value 0.009) and 47(p-value =0.012).

    1. Students’ perception of teachers

Click to view Figure 3

Across this subscale, only statement 2 had mean above 3.0.  Those areas that require action include every item statement where the score was less than 2 (Figure 3).

One-way analysis of variance indicate that mean for year IV were significantly difference from other classes in all the areas (p values as follows Questions 2=0.004, 6=0.014, 8=<0.001, 9=<0.001, 18=0.012, 19=<0.001,32=0.014,37=0.040,39=<0.001, 40=<0.001 and 50=0.001)

The score by females was significantly different from males on question 19, and 32 with p value of 0.007 and 0.014, respectively.


   2.Students’ academic self-perception

Click to view Figure 4

Majority of areas in academic self-perception needs attention except two areas statement 10 and 45 (Figure 4). In ANOVA, the higher the class was one was likely to agree with item 5 with p-value of 0.027, while they disagreed with items 10, 21, 26, 27 and 41 with p values of <0.001 for all of them.

The females disagreed with items 5, 10, 21 and 27 with p values of 0.038, 0.005, <0.001 and <0.001 respectively.


Students’ perception of atmosphere

Click to view Figure 5

There are five areas that could be improvement-statements 23,30,33,34 and 36 and the rest needs improvement (Figure 5).

In ANOVA there was significant difference in means for class with year IV disagreeing with statement 11, 12,23,30,34,35,42,43 and 49 and agreeing statement 17 with p values of <0.001, <0.001,0.041, <0.001,0.008,0.003,0.001,0.011, <0.001 and 0.002 respectively. 

The females also agreed with statement 17, p-value of 0.001. The females disagreed with statement 11,12, 42 and 49 with p value of 0.005, <0.001,0.020 and 0.001 respectively.


  3.Students’ social self-perception

Click to view Table 2

The worst area is that of support for student with a mean of less than 1 (Table 2). In ANOVA, females agreed with Item 4, and disagreed significantly with item 14 and 46 with p values of 0.006, 0.011 and <0.001, respectively. All classes disagreed, though more of year IV disagreed significantly with statement 3 ,14 ,29 and 46, agreed with statement 4 with p values of <0.001, 0.008, <0.001, <0.001 and 0.009 respectively.


The Dundee Ready Education Environment Measure (DREEM) instrument was developed and validated for use in any culture and country(6). It has been used to measure the educational environment, identify problem areas in an education program, get baseline before curriculum reform and determine student reaction to curriculum reform and as a tool for monitoring improvement (8,9). In this study, it was used for assessing student’s perception of the learning environment and possible problem areas in the education program.


The overall score was 93.3 /200, which implies perception of a very poor learning environment with of plenty of problems. Similar findings  have been reported by various studies(10–13). Majority of these were in the Asian and Arab world. Factors associated with low scores in these studies were a traditional curriculum as compared to modern type that includes problem-based learning or system-based learning(11,14). The more senior classes were more likely to give lower scores (10,13,15)  in environments where teachers are perceived to be authoritarian (10).  Majority of the surveys usually get the average of between 101-150, meaning more positive than negative  as was described in a systematic review of DREEM studies  by Chan et al(16). Few studies score higher than 150 according to that systematic review, and those that scored high were those with small to moderate sized classes(17) and those who had placement in general practice or community hospitals (18).


The medical school is a habitat whose principal inhabitants are obviously its students for whose education, training and welfare the institution exists, it’s very raison d’être(19). It is for this reason that how students perceive the learning environment is key to those who run and work within the institution. A deeper look at this complex environment, both in the subscale and individual items, reveal the depth of the problems.


The student perception of learning (SPL) domain had only one question (I am clear about the learning objectives of the course) scoring above 2. The only year that scored most items above two was year V. The reason could be that they are divided in smaller groups that deal with a particular discipline before moving to the next.  They may therefore perceive this as a more friendly micro-environment created in this space. The most affected are the fourth years who seem to be finding the clinical years and teachers hostile to them. This is similar to the study by Hasan and Gupta in Iran and Roff in comparing Nigeria and Nepal where most scores were low in earlier years,

increase, then decline again (10,20).  There is emphasis of factual learning, superfluous teacher-centered learning where lecturers just read through the slides as well as overemphasis on exam scores. This is similar to the studies in Iran(21) and Sri Lanka(22)  and contrasting to the study by Abraham in India(23) .  A study has indicated that students in traditional medical curricula often perceived learning as being too teacher centered, dogmatic and with an over emphasis on ‘‘rote memorization’’(24).


Student perception of teachers (SPT) domain had 21.73/44 (49.3%) which is above all other domains this study with just over half of the items being above two but one above three. The students acknowledge that their teachers are knowledgeable but may lack the critical skill in delivery of the subjects. They also criticize teachers as being unavailable, irritable, authoritarian, and having difficulty in interacting with patients and giving feedback to students. Teachers being irritable, sarcastic and authoritarian has long been noted by Abraham in India(23) and Menaka in Sri-Lanka(22) as well as Hasan and Gupta in Iran(10). This has been postulated to be due to pressure of work and increased work load which might be eased by even distribution of work(10).


In the Student’s perception of atmosphere (SPA) domain, majority of the items 7 out of 12 were below two, indicating serious problems. It includes lack of following of the schedule, tension in classes and wards due to the character of the teachers with students expressing social discomfort, inability to clarify doubts in class due to tongue lashing from teachers, cheating by other students and lack of interpersonal cohesiveness. These factors enhance low confidence among student in the environment and coupled with heterogeneity (male-female, Kenyan-non-Kenyan, age), of the student population, bring about inadequate bonding patterns. It is also enhanced by hectic student schedules, authoritarian or uninvolved teaching styles.  Hasan and Gupta(10) as well as Hassan et al found similar issues  in Iran and Sudan respectively(10,25). These should be explored in remedial measures because they lead to failure due to factors other than the academic ability of the students.

In the students’ academic self-perception (SASP) domain, sixth years seem more confident than the rest. Increased confidence among seniors has been noticed in the studies in Asia(21,22).

One of the poorly scored domains was SSP, mainly because of the lack of social support during stressful periods as has been indicated in the SPA domain above. This could arise because of lack of teacher’s interaction and involvement in student life. The involvement may be due to the teacher’s workload among other things. So strong was this lack of support and the teacher’s role in increasing stress that some felt the school of medicine participates in destroying and not building the life and career of students.   The stress in medical school may be  attributed to exams anxiety, lack of leisure time and inadequate resources as indicated by studies from Australia(26), and Europe(27).

Limitations of this study include: It is a single center study, timing of the study in that it was given four weeks before exams and the increased stress associated with exams could have led to more complaints and participant bias.




This study indicates that students in the University of Nairobi are critical of the general climate of the school and the quality of teaching, especially in areas regarding class participation and provision of clear learning objectives. The students also perceive their courses as being tutor centered, un-balanced curriculum, difficulty with timetabling of teaching, knowledgeable teachers who do not provide feedback in appropriate manner and overly concerned with the marks obtained and not clinical skills learned. These findings should encourage reflection by the schools in Kenya to relook into the learning environment of medical education so as to improve it.


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