Number of Citations: 0

Submitted: 29 February 2024
Accepted: 5 February 2025
Published online: 1 July, TAPS 2025, 10(3), 15-25
https://doi.org/10.29060/TAPS.2025-10-3/OA3259

Zaw Phyo¹, Titi Savitri Prihatiningsih², Ye Phyo Aung¹ & Tun Tun Naing¹

¹Department of Medical Education, Defence Services Medical Academy, Yangon, Myanmar; ²Public Health and Nursing Universitas Gadjah Mada, Yogyakarta, Indonesia

Abstract

Introduction: The effective implementation of changes in medical school curricula requires modifications to assessments alongside teaching strategies. The World Federation for Medical Education emphasises the need for assessment policies to align with educational outcomes. In Myanmar, the Defence Services Medical Academy (DSMA) has adopted an outcome-based curriculum since 2017, but the standard setting in assessments remains pending. This study explores concerns and challenges for enhancing assessment practices.

Methods: An explanatory sequential design was used. For a quantitative approach, 36 assessment committee members were surveyed using questionnaires, and pre-and post-test analyses were conducted using SPSS Statistics Version 25. Qualitatively, eight committee members were selected through purposive sampling for in-depth interviews using interpretative methodology with thematic analysis by MAXQDA Software 2022.

Results: It shows that most committee members acknowledge the advantages of standard settings, such as improved teaching and learning defect identification, staff knowledge application, enhanced educational programs, and personal contributions to education quality. Half of the committee members expressed concerns about the increased workload and administrative burden, while another half-supported standard-setting implementation. They all appreciate the integration of standard setting in the outcome-based curriculum, recognising its positive impact on student quality and accreditation standards. Challenges include limited human resources, resistance to change, time-consuming, and an increased workload.

Conclusion: Committee members suggested that targeted interventions are needed to improve awareness, collaboration, and successful implementation. These should consider perspectives, enhance understanding, define roles, and address resources and resistance. This will optimise standard setting, ensure educational quality, and meet accreditation standards.

Keywords:           Assessment, Standard Setting, Integrated Curriculum, Awareness, Perception, Attitude, Lifelong Learning

Practice Highlights

• Members of the committee think that having standards in DSMA’s curriculum is essential for raising the quality of students and the school’s standards.
• Most members know how important it is to set standards, especially for pass/fail exams, and stress how important it is to consider culture and institutional factors.
• Setting standards is thought to help with aligning the curriculum, giving students relevant tests, and meeting accreditation requirements.
• For implementation to go well, all stakeholders must be involved, the process must be in line with real evaluation principles, and teachers must continue to learn and grow.
• Not enough resources, resistance to change, limited time, and more work to do are problems that need solutions based on educational ideas.

I. INTRODUCTION

In the last 30 years, there have been many suggestions for changing the curriculum, but only a few medical schools have made significant changes (Supe & Burdick, 2006). Without altering assessments, modifying curricula or teaching strategies will be ineffective. In the global standards for quality improvement area of the World Federation for Medical Education (WFME), there are clear rules about primary medical education in chapter 3.1 of Assessment Policy and System:

“An assessment policy with a centralised system that guides and supports its implementation will entail using multiple summative and formative methods to acquire the knowledge, clinical skills, and behaviors needed to be a doctor. The policy and the system should be responsive to the school’s mission, specified educational outcomes, available resources, and the context” (World Federation for Medical Education, 2020).

In current Medical Education, with competency-based education becoming more popular, healthcare educational institutions and assessment bodies are being looked at more closely than ever before to make sure they are fair, transparent, and defensible when setting the expected level of performance and rating students’ performance to make decisions about their next steps (Lane et al., 2020). With competency-based assessment, the way the test is done must align with what the student has learned (Crespo et al., 2010).

Regularly setting, keeping, and evaluating assessment standards is essential in medical education. It is not an exact science to set standards. Most educational test validity arguments focus on how well the test matches the curriculum and how valuable the test’s content is (Barman, 2008).

Standards are an expression of values, so the ways to set them are systematic ways to gather people’s opinions on values, make agreements, and show that agreement as a single score on a test (Norcini, 2003). “Standard Setting” is a process used to make precise lines between things like “pass” and “fail” or “honors,” “proficient,” and “needs improvement.” Setting standards is “central to giving meaning to test results and, as such, is at the heart of validity arguments” (Wiliam, 1996).

There are two primary methods in which standards are set: (1) criterion-referenced or absolute methods, in which standards setting is not based on test results, and (2) norm-referenced or relative methods, in which setting standards is based on test results. No golden rule exists (Cohen-Schotanus & Van Der Vleuten, 2010).  In health professions education, it can be challenging to develop credible, defendable, and acceptable passing or cut-off scores for exams (Norcini & Guille, 2002).

In Myanmar, there are currently no private medical schools, although there are five public medical schools and one military medical school (Defence Services Medical Academy). Myanmar medical schools have used traditional lecture-based teaching methods, and many eminent physicians have emerged from teacher-centered educational programs (Myint, 2020).

Defence Services Medical Academy (DSMA), listed in the World Directory of Medical Schools, was founded in Mingalardon, Yangon, on November 19, 1992 (Naing et al., 2022). Since 2017, DSMA has been the first medical school in Myanmar to implement an outcome-based, integrated curriculum. According to the Dundee three circle models, the graduates of DSMA are supposed to be scholars and scientists, as well as practitioners and practitioners professionals (Harden et al., 1999).  The new DSMA curriculum is meant to encourage students to keep learning and give them more responsibility for their learning. It is presently focusing on meeting the criteria of WFME accreditation.

In DSMA, the assessment methods (written, practical, oral, and structured and unstructured observations) include accurate and standardised patients, objective structured clinical examination, patient management problems or simulations, etc. The assessments include continuous assessment, formative assessment, and summative assessment. However, there is no Standard Setting in DSMA, and it will be implemented soon (after training standard setting experts) to set the required basic minimum standards.

Even though accrediting organisations advise medical schools in general what the curriculum should cover and how it should be tested, most medical schools decide how and what to test (Epstein, 2007). There are five ways to figure out how valuable a method of assessment is: reliability (how accurate and repeatable the measurement is), validity (whether the assessment measures what it says it measures), impact on future learning and practice, acceptability to students and teachers, and costs (Van Der Vleuten, 1996). Therefore, the Assessment Committee’s DSMA meetings establish the process and procedures for conducting assessments throughout the undergraduate medical program. The Assessment committee must collect and evaluate feedback regularly, and faculty feedback revealed issues with the assessment process in DSMA.

 For a successful, acceptable, and feasible assessment to implement an outcome-based, integrated curriculum, it is essential to explore how students, faculty, and assessment committee members perceive the implication of the standard setting for the assessment. Therefore, this study investigated what the Assessment Committee members think about setting standards in medical education and the most significant problems.

II. METHODS

A. Research Design

Figure 1 shows explanatory sequential mixed methods design (also called a two-phase model (Creswell & Clark, 2017)): Quantitative followed by qualitative was used to explore the views, opinions, beliefs, and feelings of the assessment committee members (Ivankova & Stick, 2007). For the quantitative, all assessment committee members were asked using questionnaires (Likert scale), and qualitatively, Individual In-depth Interviews (IDI) were asked of the selected assessment committee members.

Figure 1. Explanatory sequential mixed methods design

The main benefit of mixed methods research is that they make a potent mix when quantitative and qualitative data are combined (Miles & Huberman, 1994). In addition, a “complex” image of a social phenomenon might be created, for instance, by evaluating both the quantitative and qualitative aspects of a study’s results (Greene, 2006).

B. Data Collection

For Phase 1 (Quantitative): The survey consists of four parts: (1) Collecting demographic information; (2) Investigating people’s perception of standard-setting procedures; (3) Examining attitudes towards these procedures; and (4) Evaluating these procedures using five-point Likert scale items ranging from 5 (strongly agree) to 1 (strongly disagree).

For Phase 2 (Qualitative): An in-depth interview (IDI) with semi-structured questions was used to collect the data. The researcher made an interview guide, which helped shape the interview and get detailed comments from the assessment committee members. The IDIs lasted 30-45 minutes, and the researcher informed participants that their names and information would be kept private.

The researcher performed all the interviews in the participants’ local language (Myanmar). The IDI explored the themes of the conceptual framework. A video recording was made for continuous recording in a quiet, private section of the medical education department office. The researcher conducted open discussions with the assessment committee members and kept them confidential, especially the students. Each interviewer uses a different set of questions (10–12), and the sessions last between 45 and 60 minutes. The researcher kept doing interviews until it became clear that the stories, themes, and problems had been covered to saturation point. The researchers utilised constructivist reflexivity throughout the entire study procedure, as advised by Alvesson and Sköldberg (2017).

C. Sampling Procedure

In DSMA, there are 38 members of the assessment committee. The assessment committee comprises three groups: Discussant members, voting members, and secretariat.

For Phase 1 (Quantitative): All the assessment committee members of DSMA were recruited. Among the 38 eligible persons who met eligibility, approximately 95% of the population (36 participants) responded to the evaluation survey.

For Phase 2 (Qualitative): By using the purposes sampling methods, individual in-depth interviews (IDIs) with semi-structured questions were given to the selected eight members of the assessment committee who are information-rich persons (two discussant Members, five voting members, and one secretariat) to find out what they thought, what they had done, and how they did it.

D. Data Analysis

The survey data was stored in an Excel file and processed using SPSS software (version 25). Descriptive analysis explored assessment committee members’ perceptions, attitudes, and practices.

The MAXQDA 2022 program extracted themes and sub-themes (Côté & Turgeon, 2005). The recorded interviews were transcribed to do content analysis. First, the data were summarised, proofread, and translated into English. Second, for the data analysis, themes, sub-themes, and clusters were identified (Cresswell, 2012). Finally, conceptualisation and explanation throughout the later stages led to the development of concrete abstracts. Analytic coding was done while reading the transcripts, and emerging issues were thought to be included in the thematic statements.

E. Ethical Considerations

The study was done according to the guidelines published by the Ethical and Research Committee of DSMA. Participation in this study is entirely voluntary.

F. Informed Consent

Before conducting the study, informed verbal consent was obtained for respondents’ autonomy to participate in this study.

III. RESULTS

Quantitatively, thirty-seven questions were asked about each participant’s background, knowledge, perception, attitude, and practices regarding the standard-setting. The survey received responses from 36 participants. The data supporting this study’s findings are openly available in the Figshare repository, https://doi.org/10.6084/m9.figshare.25657875.v1 (Phyo et al., 2024).

A. Demographic Characteristics

According to an analysis of the committee’s demography (see Table 1), two-thirds of the members were older than 25, and males dominated. Faculty members (64%) were primarily doctoral holders on the evaluation committee. More than ten years of teaching experience can be found among half of the assessment committee members.

Table 1. Personal background information of the assessment committee members

B. Awareness of Standard Setting

In Table 2, most assessment committee members believe that DSMA has been implementing a standard setting in the assessment process, but it is still in the process of being fully implemented. However, 75% know the purpose behind establishing standard settings in DSMA. Furthermore, faculty members are debating whether DSMA is a precise standard-setting approach for standardisation and how DSMA intends to implement whatever assessment model.

No	Question	Answers	Total (n=36)
			Frequency	Percentage
1	Does DSMA have a standard Setting in the MBBS Programme?	Yes	23	63.9
		No	11	30.6
		Uncertain	2	5.6
2	Who Is the most Responsible person in the Implementation standard setting within DSMA?	Rector	9	25.0
		Assessment Committee	6	16.7
		All Staff	20	55.6
		Uncertain	1	2.8
3	Why did DSMA introduce a Standard setting?	Rector’s foresight and planning	8	22.2
		Requirement of MMCAC guideline	27	75.0
		Uncertain	1	2.8
4	How many types of standard settings?	One	6	16.7
		Two	22	61.1
		Three	8	22.2
5	The assessment system of the DSMA is designed by applying a ready-made model like programmatic assessment.	Yes	12	33.3
		No	12	33.3
		Uncertain	12	33.3
6	Does DSMA have an exact standard-setting method to standardise the assessment system?	Yes	17	47.2
		No	10	27.8
		Uncertain	9	25.0

Table 2. Awareness of standard setting

Table 3. Perception, attitude, and practice towards standard setting

The attitudes section indicates lower ratings (2.0–3.0) with worries about increasing workload (59% agreement) and administrative burden (56% agreement), revealing resistance or uncertainty among some staff members towards the practical implications of standard setting. They also feel that implementing standards creates an uncomfortable academic environment, but 81% think the standard-setting process is successful (4.0 ± 0.7).

The high mean scores (4.0–4.4) and agreement percentages (up to 88%) in sections on perceptions and practices indicate strong support for standard setting among respondents. This suggests a recognition of its value in improving educational quality.

The data suggests that standard settings are supported, but there’s a need for more engagement and clear communication about its processes. Apprehension about workload and administrative tasks may stem from a lack of understanding or poor implementation strategies. Institutions could benefit from transparent, inclusive, and efficient management of standard-setting processes, including regular updates, training sessions, and support systems. A balanced approach is needed to address apprehensions and ensure positive outcomes for educational quality and student success.

D. Thematic Analysis Outcomes

The participants were Assessment Committee Members (n=8) from the Assessment Committee of the DSMA who were involved in developing the Standard setting for the Assessment.  The data collected from IDIs were organised into five themes and 19 sub-themes in Figure 2.

Figure 2. Showing the main themes and sub-themes

1) Perceptions of the assessment committee members: The assessment committee members expressed appreciation for the incorporation of standard setting in the Outcome-based Integrated curriculum at our university. Most committee members showed enthusiasm for using this method, which they believed was fitting for assessing students in this program. Additionally, the committee aimed to enhance the assessment techniques used in the Outcome-based Integrated curriculum. They were convinced that implementing standard settings would improve student and DSMA quality.

“An outcome-based integrated curriculum has replaced DSMA’s old curriculum. The product of an outcome-based curriculum is not produced. So, we must prepare for that product to be assessed using the standard setting. It is a transitional period for our DSMA from the old curriculum to the outcome-based curriculum. So, the state holders and teachers from DSMA must understand the standard setting. We must set the standard for the assessment of DSMA, but slowly and steadily.”

(Participant 1)

“If the integrated curriculum is changed and outcomes are improved, the quality of the university will improve. Local or international qualifications will be enhanced, not only by students but also by the quality of the DSMA.” 

(Participant 3)

2) Understanding of standard settings: It was evident that members emphasised the importance of standard setting, particularly in the context of Pass/Fail exams for students. Furthermore, committee members demonstrated knowledge regarding various types of standard setting. They were able to identify the most suitable method for DSMA, taking into consideration factors such as cultural context and institutional requirements.

“The standard setting is a method designed to determine a student’s pass or fail scores, and it is also a technique for determining whether students will pass or fail a test.”

(Participant 4)

“DSMA has to set standards for the assessment according to our culture, values, and conditions. We have taken the standard setting of another prestigious university as a reference. It is not suitable to apply the ready-made model.”

(Participant 1)

3) Benefits of implementing standard settings: The assessment committee members recognised Standard Settings are essential for effective curriculum alignment, meaningful student assessment, and accreditation. DSMA can demonstrate its commitment to delivering high-quality education and meeting accreditation standards by aligning the curriculum, teaching practices, and assessments through Standard Settings. The committee members believe Standard Settings play a crucial role in enhancing the quality of education DSMA provides.

“It is beneficial for constructive alignment. So, we adopted and prepared the standard setting for assessing DSMA for accreditation. It is also essential for the teaching and learning process and method. We can check the teaching and learning process, and if errors occur, we can fix them and circle again for the following year.”

(Participant 1)

“I think the outcomes that come out improve not only the student’s quality but also the DSMA’s quality. If the integrated curriculum is changed and outcomes are improved, the quality of the university will improve. Local or international qualifications will be enhanced, not only by students but also by the quality of the DSMA.”

(Participant 3)

4) Roles and responsibilities while implementing standard setting in DSMA: The Assessment Committee members recognised the critical roles and responsibilities of implementing standard setting. They emphasised the need for an inclusive approach involving all stakeholders. Furthermore, they highlighted the importance of aligning standard setting with authentic assessment principles and providing continuous professional development for faculty members. By considering these factors, the committee members aimed to enhance the quality of assessment and promote meaningful learning outcomes for students.

“The standard setting must be built with support; all teachers at DSMA are responsible for it because only the medical education department knows about the standard setting, which is ineffective. Teachers in all departments, including professors, must know about the standard setting. That’s why all the teachers at the university need to understand when setting standards.”

(Participant 2)

“The assessment committee is in charge of the standard setting in DSMA, including the medical education committee, the curriculum committee, the quality assurance committee, the assessment committee, etc. The assessment committee can emphasise its role and responsibility, including implementing the standard setting. Thus, it is more reasonable and practical.”

(Participant 6)

5) Challenges and weaknesses of implementing the standard-setting: The Assessment committee members identified several challenges in implementing standard setting. These challenges include limited human resources, resistance to change, time-consuming processes, and increased workload. Understanding these challenges through the lens of educational theories can guide the development of strategies to address them effectively and ensure the successful implementation of standard-setting practices.

“Human resources are our main weakness. There are very few human resources in DSMA to apply the standard setting. Time-consuming is another area for improvement.”

(Participant 1)

“Most importantly, students don’t know what a “standard” setting is, and some teachers don’t know either. They need to know what a “standard” setting is.”

(Participant 7)

IV. DISCUSSION

The outcomes from the study at the Defence Service Medical Academy (DSMA) assessment committee shed light on essential aspects of standard-setting in medical education. In institutions like DSMA, which implement the outcome-based integrated curriculum, medical students must remember what they learned in their preclinical training to make sound clinical decisions based on reliable scientific principles (Lazić et al., 2006). In medical education, it is crucial to establish, maintain, and frequently review assessment criteria (Senanayake & Mettananda, 2005).

The study revealed a predominantly male composition within the assessment committee, highlighting the need for diversity and expertise among committee members. While increasing the diversity of academic medical leadership to address the underrepresentation of minorities and women in medicine has been proposed, there has been limited investigation into this topic (Meadows et al., 2023).  Encouraging diversity can contribute to robust discussions and decision-making processes related to standard-setting. While committee members demonstrate a solid grasp of standard-setting, the results indicate a requirement for continual education to translate this knowledge into practical application (Norcini & McKinley, 2007). Therefore, targeted interventions and professional development programs must enhance their knowledge and awareness.

Committee members show favorable attitudes towards standard-setting, but there is a discrepancy between their perceptions and actual practices. Implementing open communication strategies consistent with Downing’s (2005) emphasis on the value of clarity in assessment practices could close this gap. Moreover, the lack of active participation in the implementation process may indicate a more significant engagement problem within academic committees (Van der Vleuten et al., 2010).

The study highlights issues that align with existing literature on medical education reform, citing resource limitations and reluctance to change as typical obstacles to adopting innovative instructional approaches (Swing, 2007). The committee’s alignment with constructivist and cognitive theories advocates for a transition to more interactive and participatory learning methods, which a parallel change in evaluation methods should accompany (Harden & Crosby, 2000). Committee members emphasised the need for an inclusive approach involving all stakeholders and aligning standard-setting with authentic assessment principles, resonating with sociocultural theories emphasising social interaction and collaboration in the learning process.

The findings offer crucial insights into the committee’s perceptions and experiences with standard-setting in the integrated outcome-based curriculum. Aligned with educational theories, these insights underscore the importance of lifelong learning and can guide future research and targeted interventions to continuously enhance standard-setting practices.

V. CONCLUSION

In conclusion, the findings from both the quantitative and qualitative research provide valuable insights into the assessment committee’s knowledge, perceptions, attitudes, and practices regarding standard-setting in medical education at the Defence Service Medical Academy (DSMA). While there is a positive attitude towards the potential benefits of standard-setting, there are also concerns and doubts among some committee members.

The study emphasises the importance of targeted interventions in medical education to improve awareness, address concerns, foster collaboration, and support the successful implementation of standard-setting. The Assessment Committee Members appreciate the incorporation of standard setting in the outcome-based integrated curriculum and recognise its importance during the transitional period. They demonstrate a strong understanding of standard settings, particularly in Pass/Fail exams, and emphasise the need to consider cultural and institutional requirements. Standard settings can enhance curriculum alignment, meaningful student assessment, and accreditation purposes.

The committee members emphasise the roles and responsibilities associated with implementing standard setting, including an inclusive approach, continuous professional development for faculty members, and addressing challenges such as limited human resources, resistance to change, time-consuming processes, and increased workload. Strategies informed by educational theories are needed to improve human resource capacity, provide training on standard setting, and create awareness among students and teachers.

These findings underscore the importance of supporting the assessment committee in their understanding, implementation, and continuous improvement of standard-setting practices. By addressing concerns, providing necessary resources, and promoting collaboration, DSMA can optimise the benefits of standard-setting in medical education and ensure the quality of its educational programs. Incorporating lifelong learning fosters continuous professional development, keeping DSMA at the forefront of educational excellence and adaptability.

Notes on Contributors

Dr. Zaw Phyo contributed significantly to the manuscript development process, including reviewing existing literature, identifying research gaps, and addressing questions and goals. He helped draft and revise the manuscript, emphasising its importance for medical education.

Titi Savitri Prihatiningsih contributed to shaping the research question and framework, ensuring a systematic approach. She applied her expertise in evaluation to refine the research tools and meticulously reviewed the thesis and manuscript for accuracy.

Dr. Ye Phyo Aung engaged in the study’s methodology phase, endorsing the chosen research design, sampling strategies, and data collection techniques, adding valuable insights to the research execution.

Dr. Tun Tun Naing assisted in the meticulous proofreading of the article, ensuring clarity, coherence, and compliance with academic standards.

Ethical Approval

The Ethical Review Committee of the Defence Services Medical Academy,  Yangon, Myanmar, granted ethical approval. (2 / Ethics/ 2021).

Data Availability

The data supporting this study’s findings are openly available in the Figshare repository, https://doi.org/10.6084/m9.figshare.25657875.v1 (Phyo et al., 2024).

Acknowledgment

I would also like to thank the FAIMER Regional Institute of Indonesia for Educational Development and Leadership (FRIENDSHIP) for helping me finish this research project at the Faculty of Medicine, Public Health, and Nursing at Universitas Gadjah Mada (Indonesia).

I would also like to thank my supervisor, the head of the medical education department (DSMA), and my colleagues. Without their help, I would not have been able to survey my research. I am grateful to all the assessment committee members from DSMA, Myanmar, who helped me complete my survey by giving me their valuable opinions and experiences.

Funding

The research was carried out during the study period at the FRIENDSHIP-FAIMER Regional Institute of Indonesia for Educational Development and Leadership. No financing is associated with this publication.

Declaration of Interest

There is no conflict of interest in the current research.

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*Zaw Phyo
No.94, Pyay Road, Mingaladon Township,
Postal code – 1102
Yangon, Myanmar
Phone: 95 92032754
Email: dr.zawphyoo@gmail.com