**INTRODUCTION**

The relationship between medical student absenteeism and class performance has received little attention. Educational researchers have focused mainly, on the effect of absence on test scores; those results have demonstrated a negative correlation between absenteeism and test scores.^{1-4} However, the correlation was minimal. For example, Riggs and Blanco2 reported a correlation coefficient (r) value of (-0.1738).

The content of the Medical Pharmacology course is tightly structured and hierarchical, and lecture-based clarifications of fundamental phenomenon are vital for more advanced understanding. Also, pharmacology facts demand comprehensive understanding, which depend on motivation and enthusiasm for the subject. Therefore, students who attend lectures may be more interested in the subject matter and hence, will study the content in more depth. Finally, studying large groups of students will provide an improved chance to analyze potential relationships between absenteeism and test scores.

The aim of this study was to determine whether there is a relationship between lecture absenteeism and performance in medical pharmacology as measured by the end-of-semester examination.

**MATERIALS AND METHODS**

**Participants**

All of the students in the fourth year of the medical curriculum, during the two academic years 2002-2003 and 2003-2004, who had enrolled in the medical pharmacology course, were selected for this study.

Data on 214 students [117 and 97 students for academic years 2002-2003 (class 2005) and 2003-2004 (class 2006), respectively] were recorded during four semesters (fall and spring for the two years). Each semester consisted of three 50-minute lectures per week for 15 weeks. The 30-weeks of lectures covered the entire medical pharmacology course.

**Procedures**

Lecture topics were guided by authoritative textbooks (i.e., B. Katzung 2001 and Goodman & Gilman 2001). The four-lecturers had extensive experience teaching the course, and three of them have received the best teacher award in basic sciences. Multiple choice question examinations (MCQs) were created based on material presented in the lectures; each exam consisted of 130 MCQs.

The academic achievement data in this study were based on the results of the comprehensive exam at the end of the semester.

Using a new sign-up sheet for every lecture session, attendants signed their own names only. As part of the college policy, the students were regularly encouraged to attend, but with no reward or penalty for attendance or absence, respectively. However, names of students absent more than seven times (out of 45 lectures: less than 15%) were sent to the vice-dean before the final exam, for possible alerting of advisors.

Evaluations of academic achievement as presented by test scores and records of attendance were obtained for all students, and those with incomplete data (22, 17, 11, and 5 for the four semesters, respectively) were excluded.

Although that many factors (i.e., the student grade point average and the performance in other courses) can influence the performance on the medical pharmacology examinations, the current study was interested mainly in absenteeism. Therefore, it investigated the relationship between absenteeism and scores in two classes of medical students during their enrollment in the pharmacology course and the factors investigated were grades, absenteeism and the rate of absenteeism.

For each class, the absenteeism and test's scores were studied in two semesters: fall and spring. In order to examine if there were differences between those with low absenteeism and those with high absenteeism, students in every semester were divided into two groups: Group-I with 0-15% absenteeism during the semester period and group-II with more than 15% absenteeism during the same period,

and the results were compared. Student test scores were ranked in a decreasing way, and the upper 15% and the lower 15% were defined as good and poor performance, respectively. The percentage of absenteeism between good and poor performance was compared using an unpaired t-test.

**Statistical Analysis**

Data were analyzed by the SPSS statistical package (version 10.0). Where appropriate, the results are expressed as a mean with 95% confidence intervals or mean + standard deviation or standard error of the mean. In each class, test scores and the percentage of absenteeism for fall and spring semesters were assessed by the paired t-test; and the relation between these factors was determined by linear regression.

**RESULTS**

**Absenteeism**

At the end of semester, absenteeism was assessed by examining the percentage of absence for every student. The mean percentage of absenteeism during the observed period showed no statistical difference among the four semesters or between the two classes (Table 1). However, there was a significant correlation between the fall and spring absenteeism in each class. The correlations (r) were 0.6824 (p less than 0.0001) and 0.7425 (p less than 0.0001) for classes 2005 and 2006, respectively.

**Exam Performance **

To examine the effect of absenteeism on exam grades, this study looked at student scores for four exams in two different classes. The mean test scores during the observed period showed no statistical difference among the four semesters or between the two classes (Table 1). However, there was a significant correlation between the fall and spring test scores in the two classes. The correlations (r) were 0.668 (p less than 0.0001) and 0.7826 (p less than 0.0001) for classes 2005 and 2006, respectively.

Figure 1 shows the mean percentage of occurrence for grades for the four exams that were analyzed. In relation to test scores, the scholastic rating method was as follows: A+: 95-100, A: 90-94, B+: 85-89, B: 80-84, C+: 75-79, C: 70-74, D+: 65-69, D: 60-64, and F: less than 60. For each exam, higher attendance was associated with better grades. Students whose attendance was more than 85% earned substantially, higher grades than did students whose attendance was less than 85%. Practically, significant differences were observed for all passing-grades with the largest differences are for the A+, A, B+, B, and C+ grades (Figure 1). On the other hand, results showed that the percentage of failure in students of Group-II (more than 15% absenteeism) was significantly higher when compared to the percentage of failure in students of Group-I (less than 15% absenteeism) (Figure 1). For example, 13 of the 14 students of class 2006 who failed the fall-semester's examination were in Group-II. Surprisingly, 11 out of the 13 students had failed the spring-semester's examination as well.

When the students were ranked according to their test scores, the uppermost 15% and the lowest 15% were designated good and poor performance, respectively. The percentage of absenteeism was significantly higher in the poor performance students in the four semesters included in the study (Table 2). In order to determine the correlation between being absent from lectures and test scores, the subset of the samples that had no missing values were studied. A simple correlation and a regression analysis, using the test scores as the criterion variable and the percentage of absenteeism from the same semester as the predictor variable, were conducted. Table 2 presents the results of these correlations and regressions. The analysis indicated a significant (p less than 0.01) negative association between test scores and percentage of absenteeism from the same semester (Table 3). The correlation coefficients (r) ranged from -0.383 to -0.495, indicating weak, but consistent relationship.

**DISCUSSION**

This study addressed the issue of whether absenteeism from lecture would have an effect upon one measure of academic performance: the test scores in our medical pharmacology course. Statistical analyses were applied to the absenteeism data and test scores in order to discover if there were significant patterns of change over time from fall to spring semester and/or from class of students to another. The analysis showed that neither the percentage of absenteeism, nor the test scores varied from semester to semester or from class to class. Those data validated further analysis by demonstrating an established and prevailing phenomenon and not an occasional or temporary one, at least, during the two-years of the observation period.

Results indicate that absenteeism was highly and negatively related to test scores. Test scores were significantly better for students whose absenteeism was low, than for students whose absenteeism was high. The effect was not only statistically significant, but was also conspicuous, especially for the higher grades. On the other hand, the number of failures among students with more than 15% absenteeism was significantly higher than among those students with less than 15% absenteeism (7:6, 10:1, 13:1, and 14:2 for the four semesters, respectively). This finding is consistent with and more established than Dhaliwal’s finding of 6:4 for the ophthalmology exam.^{3}

Students who performed poorly (the lowest 15% of the students) were having a nearly two-fold absentee rate (180%) compared to the students who performed well (the uppermost 15% of the students). It is possible that students who performed poorly have weak motivation to attend lectures and less enthusiasm to learn. Therefore, it is important to identify those students early in the course by monitoring their attendance and encourage them to improve their attendance and thereby, enhance their performance.

Finally, the results of this study demonstrate that absenteeism from lecture has a negative effect on

performance of students on medical pharmacology examinations. Previous studies by Riggs and Blanco^{2} and Dhaliwal^{3} showed a negative correlation between lecture absenteeism and obstetrics and gynecology and ophthalmology examinations, respectively. However, the correlation in the current study is stronger than the correlation in the previous publications. This finding may suggest a weaker role for the other factors that affect test scores in medical pharmacology. Also, the substantial difficulty of the pharmacology material requires great efforts by the lecturer for explanations and simplifications; so that, the lectures will increase the students' understanding of the textbook material. Consequently, the student who fails to attend lectures will develop less understanding of the topic and will not perform as well in the course.

**CONCLUSIONS**

The evidence presented here suggests that student's absenteeism has a profound effect upon her/his performance and should be considered seriously when explaining student course achievement.

**REFERENCES**

- Flournoy, D.J. and Hyde, R.M. The relationship of lecture attendance and course grade for second-year medical students.
*Journal Oklahoma State Medical Association*. 1984; 77(1): 20-22.

- Riggs, J.W. and Blanco, J.D. Is there a relation between student lecture attendance and clinical science subject examination score?
*Obstetrics and Gynecology*. 1994; 84(2): 311-313.

- Dhaliwal, U. Absenteeism and under-achievement in final year medical students.
*The National Medical Journal of India*. 2003; 16(1): 34-37.

- Khan, H.U., Khattak, A.M., Mahsud, I.U., Munir, A., Ali, S., Khan, M.H., Saleem, M. and Shah, S.H. Impact of class attendance upon examination results of students in basic medical sciences.
*Journal of Ayub Medical College, Abbottabad*. 2003; 15(2): 56-58.