Pakistani Medical Students ’ Attitudes towards Communication Skills Learning : A Correlation of Demographic and Education-Related Characteristics

This study intends to inspect medical students’ attitudes regarding the learning of communication skills and to inspect the relationship of Pakistani undergraduate medical students’ attitudes towards the learning of communication skills with demographic and education-related characteristics (gender, age, residence and parents’ occupation). The population of the research was the 5th professional, undergraduate medical students of Pakistani medical colleges. Samples were taken from four Pakistani public medical colleges. Data for this research has been collected through the use of already designed communication skills attitude scale by Rees et al. A pilot study was conducted for checking reliability and validity of CSAS and on the basis of findings of pilot study. Some modifications have also been done in CSAS of Rees et al. Data has been analyzed through SPSS version 20. Results of this research have shown that Pakistani medical students carry both positive and negative attitudes towards learning of communication skills.


Introduction
Communication skills refer to process of conveying ideas, thoughts, needs and one's belief with clarity.These can be used in a vast range of situations.In medical education communication skills play a vital role and are very important for the development of a good doctor-patient relationship [1].Krech and Crutchfield [2] viewed attitude as a person's positive or negative response towards a certain person, idea, object or situation and they influenced the individual's selection of action.Attitudes of students of medical profession towards training of communication skills are very good indicators of the importance of medical profession placed upon them.Attitudes may affect communication behaviors in clinical settings [3].Attitudes of students of medical profession towards the learning of communication skills depend on several factors like communicative abilities, age and experience [4].Some studies proposed that different demographic variables such as ethnicity, language and gender influenced the attitudes of students of medical discipline in learning skills of communication [5].

Literature Review
Previously, several researchers studied medical students' attitudes towards communication skills learning and doctor-patient communication.Rees and Garrud [6] conducted a study for the establishment of medical students' response regarding communication skills learning.Findings of their research have shown that medical students carry positive attitudes towards communication skills learning.Authors also found that age, previous educational background and communication capabilities influenced the medical students' attitudes toward the learning of communication skills.Female medical students were found more positive towards learning communication skills [7]- [10].
Kaufmann et al.'s study also showed that as compared with the 4 th year students, students of the 1 st and 2 nd year have more positive attitudes [7].Demonstration of positive attitude by junior students was again found by Cleland et al. [11].They conducted a research for assessing the medical students' attitudes for learning of skills of communication and for validating CSAS' use among a different set of population.Authors concluded through findings of research that the 1 st year students of medical degree possessed more positive attitudes as compared to the 2 nd and 3 rd year's students.Female students, again, had prominent mean positive attitude score than males and males had lesser mean negative attitude score as compared to females.They felt that their clinical and communication skills were not proficient.Findings supported the use of CSAS as a suitable tool.Khashab's study to determine the attitudes of medical students of Alexandria to the learning of skills of communication also found a relationship of attitudes with education-related and demographic characteristics [12].Unlike previous studies, this research showed dominantly positive attitude among the students of the 5 th year class towards communication skills as compared to the 4 th year's students.It was found that occupations of parents also affected the students' behavior towards skills of communication like students whose parents had medical profession showed considerably low negative response in contrast to students whose parents were not doctors.
Personality traits also influence students' attitudes towards learning communication skills as Molinvevo and Torrubia (2013) found in their study involving the first year and second year students [13].Findings showed that students with higher aggression showed worse attitudes.Skills programs also influence attitudes of students as Liddell and Davidson's study [14] showed more positive attitudes of medical students after a Consulting Skills Program.
To conclude, most of the studies except few were conducted in English language speaking countries.As compared to English language speaking countries less work has been done in other countries where English is used as the second language.In Pakistan, English is used as an official language in patriarchal culture [15] [16], which affects students' attitudes towards learning communication skills.In medical education here, students' attitudes are not explored.This research work is the first work for investigation of medical students' attitudes towards learning and teaching of skills of communication in Pakistan.This research intended to answer five research questions.

Aims and Objectives
This research intended to investigate the medical students' attitudes towards the learning of communication skills.Further, it explored the correlation of medical students' attitudes with demographic and education-related characteristics (gender, doctor-parents, medium of instructions and residence area).

Research Questions
1) What are the Pakistani medical students' attitudes towards learning of communication skills?
2) What type of correlation does exist between gender differences and Pakistani medical students' attitudes towards learning of communication skills?3) What type of correlation does exist between parents' occupation differences and Pakistani medical students' attitudes towards learning of communication skills?4) What type of correlation does exist between residence area differences and Pakistani medical students' attitudes towards learning of communication skills?5) What type of correlation does exist between medium of instruction differences and Pakistani medical students' attitudes towards learning of communication skills?

Research Design
Present research followed quantitative approach.It has been used for maximizing the objectivity, reliability and generalizability of findings.It attributed to the use of surveys to collect data that correspond to research questions of interest [17].Cross-sectional survey research design provided help in gathering information about the current behaviors, attitudes and beliefs in a population at a single point in time [18] [19].

Method of Data Collection
Population of this study was the 5 th year medical students studying in public medical colleges of province Punjab, Pakistan.Convenience (non-probability) sampling technique was adopted to select a sample of 400, the In this research a cross-sectional survey questionnaire was used to collect data about people's experiences of a particular initiative or event and for determining the relationship between two variables [18].A questionnaire permits collection of data from a much larger population [19].A standardised questionnaire to measure students' attitudes towards communication skills developed by Rees et al. [5] was adapted.Original Communication Skills Attitude Scale (CSAS) consists of 26 items with two subscales: the first subscale consists of 13 items that represent positive attitudes and the second subscale consists of 13 items that represent negative attitudes towards learning of communication skills.A pilot study was carried out with twenty medical students.On the basis of findings of pilot study, five items (4, 12, 15, 16 and 26) were excluded because these items showed less reliability in Pakistani context.Further modified version of item 8 of CSAS questionnaire by Marambe et al. [20], i.e. "It's too much trouble to attend sessions on communication skills" was included in order to remove ambiguity.Questionnaire of this research consisted of 21 items (1,2,3,5,6,7,8,9,10,11,13,14,17,18,19,20,21,22,23, 24 and 25) with two subscales.Ten items represented positive attitudes towards communication skills learning and remaining eleven items represented negative attitudes towards communication skills.Items were escorted by 5-point Likert scale ranging from strongly disagrees to strongly agree.Measured value of Cranach's α was 0.710.

Method of Data Analysis
The SPSS version 20 was used for statistical analysis.Descriptive statistics were used to identify the demographic and education-related characteristics of the total sample.The association of the dependent variables (PAS and NAS scores) with the independent variables (gender, doctor parent, medium of instruction at intermediate level and residential area) was determined.Pearson's value for the association of attitudes and other variables was measured (P 0.05).Multivariate statistics were used to determine correlation between independent and dependent variables.

Demographic and Education-Related Characteristics
Results showed that 57% of 400 students were female while 43% male, 23% have doctor parents whereas 77% were not, 30.7% students belonged to rural areas while 69% to urban areas, Medium of instructions of 77.5% of medical students was English while of 22.5% was Urdu up to intermediate level (HSSC) as shown in Table 1.

Medical Students' Attitudes towards Communication Skills Learning
Results of PAS items revealed that majority of students agreed that communication skills are essential, lasting and fascinating skills.Bulk of students thought that communication skills assisted in respecting their patients and colleagues.Majority of students agreed that communication skills supported in the learning of medicine and group work as described in Table 2.
Results of NAS items showed that barely students thought that communication skills' learning is not important for them and they don't need excellent communication skills.Some students thought that communication  skills learning is an easy task and it's tough to take communication skills classes.Bulk of students also thought that they can pass examinations with poor communication skills.Huge mass of students felt hesitation in confessing their communication skill problems.Students also confessed that they can't give proper time for communication skill's learning as shown in Table 2. Hence, it has been concluded that majority of students agreed that "In order to be a good doctor I must have good communication skills".This was validated by disagreement of an immense majority with the statements that "I can't see the point in learning communication skills" and I don't need good communication skills to be a doctor".Therefore, Pakistani undergraduate medical students have more positive attitudes towards the learning of communication skills.

Gender and Attitudes
Findings of this research have shown that scores of Pakistani medical students for PAS ranged from 9 to 45 (Median = 37.5, SD = 5.695).Mean PAS score (SD) of Female students was 40.13 (6.005) and of Male students was 40.15 (6.315).Pearson value for relationship between PAS scores and gender was 0.977, this indicate that there is no significant relationship between gender and PAS scores as shown in Table 3.On the other hand NAS scores ranged from 20 to 48 (mean = 32.21).Mean NAS score (SD) of Female students was 32.71 (6.1) and of Male students was 31.46 (5.0).Pearson value for relationship between NAS scores and gender was 0.134, this indicate that there was no significant relationship between gender and NAS scores and changes in one variable were not correlated with changes in the second variable as shown in Table 3.Thus, unlike previous studies [7]- [10], this study exhibited no relation in gender and students' attitudes towards communication skills.

Doctor Parents and Attitude towards Communication Skills
Findings of this research have also shown that mean PAS score (SD) of students who have doctor parent was 40.13 (4.765) and of those who did not have doctor parent was 30.84 (3.426).Pearson value for relationship between PAS scores and doctor parents was 0.095, this indicate a significant relationship between students who have doctor parent and who did not towards positive attitudes and changes in doctor parents were correlated with changes in PAS scores.There was a significant difference between student who had doctor parent and who did not have towards positive attitudes as shown in Table 3 as was found in previous study [12].Whereas mean NAS score (SD) of student who had doctor parent was 32.93 (5.7) and of those who didn't was 31.99 (5.8).
Pearson value for relationship between NAS scores and doctor parents was 0.338; this indicate no significant relationship between students who had doctor parent and who didn't towards negative attitudes and changes in doctor parents were not correlated with changes in NAS scores as shown in Table 3.
Table 3. Pakistani Medical students' attitudes and demographic and education-related characteristics.

Residence Area and Attitude towards Communication Skills
As shown in Table 3 mean PAS score (SD) of rural area students was 39.00 (7.463) and of urban area was 40.72 (5.353).Pearson value for relationship between PAS scores and residential area was 0.127; this means that there was a weak relationship between PAS scores and residential area of students and changes in residential area were not correlated with changes in PAS scores.While mean NAS score (SD) of rural area students was 34.23 (6.2) and of urban area was 31.31(5.35).Pearson value for relationship between NAS scores and residential area was 0.001; this indicated a relationship between NAS scores and residential area of students and changes in residential area were correlated with changes in NAS scores as shown in Table 3.

Medium of Instruction and Attitude towards Communication Skills
Results have shown that mean PAS score (SD) of medical students with Urdu medium instructional background was 38.56 (7.973) and of English was 40.59 (5.405).Pearson value for relationship between PAS scores and medium of instruction was 0.049; this means that there was a strong relationship between PAS scores and Premedical admission medium of instructions (Class-1 to 12) and changes in medium of instruction were correlated with changes in PAS scores as shown in Table 3. Whereas mean NAS score (SD) of medical students with Urdu medium instructional background was 32.73 (5.48) and of English was 32.06 (5.8).Pearson value for relationship between NAS scores and medium of instruction was 0.489; this means that there was no relationship between NAS scores and medium of instruction of students and changes in medium of instruction were not correlated with changes in NAS scores as shown in Table 3.

Conclusions
Attitudes of medical students towards training of communication skills are very good indicators of the importance of responsibilities placed on them with regard to medical profession.Attitudes may affect communication behaviors in clinical settings.Attitudes of students of medical profession towards the learning of communication skills depend on several factors like communicative abilities, age and experience.Some studies proposed that different demographic variables such as ethnicity, language and gender influenced the attitudes of students of medical discipline in learning skills of communication.Much work has been carried out in English speaking countries while no work has been done in Pakistan on association of medical students' attitude with the learning and teaching of communication skills.It has been concluded from findings of this research that majority of students agree that they need good communication skills in order to be a good doctor.This was validated by disagreement of an immense majority with the statements negating the significance of learning communication skills for doctors.Therefore, Pakistani undergraduate medical students have more positive attitudes towards the learning of communication skills.It has also been concluded from the correlation of dependent variable (PAS) and four independent variables that occupation and medium of instruction of students' parent have a significant effect on medical students' attitudes towards communication.Results also infer that students with doctor parents has more positive attitude towards communication skills learning as compared to those who do not have doctor parents.Pre-medical admission English medium students have more positive attitudes as compared to Urdu (national language) medium students.Findings of correlation of dependent variable (NAS) and four independent variables has shown that only residence area has significant effects on attitudes towards communication.Urban area students showed more positive attitude towards communication skills learning as compared to rural area student towards communication skills learning.Deficiencies of statistical association between the majority of the demographic and education-related characteristics and NAS or PAS scores may be due to rise in development and globalization.
It is recommended that planners of medical education in Pakistan should take steps for strengthening the medical students' communication skills training through practical communication skills workshops.Further, communication skills should be taught throughout the five-year undergraduate degree.Furthermore, research is recommended for verification and resulting of a guide line for medical education planners in Pakistan.

Table 1 .
Demographic and education-related characteristics.

Table 2 .
Percentages of student's scores towards PAS and NAS.