Effective Feedback in Medical and Health Science Education, in Malawi: Perceptions and Experiences

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This is especially important for patient safety in health professions education. Feedback only aids learning when used effectively and accepted by its recipients. Most current literature on effective feedback is from western perspectives that we cannot assume will be applicable to all cultures. This study seeks to contribute to discourses relating to feedback effectiveness, exploring concepts of optimizing it in a sub-Saharan healthcare education institution. Methods This qualitative study investigated student and lecturer perceptions and experiences of receiving and delivering feedback at College of Medicine (CoM), Malawi, and how stakeholders felt this influenced self-reported behavioural change in response . Data was collected using semi-structured interviews, with students and lecturers, from across all faculties at CoM, and subsequently analysed sequentially for emerging themes using a grounded theory approach. Results Inductive data analysis resulted in eight interconnected themes: conception of feedback; affective dimension; thirst for feedback; need to achieve; feedback conversations; self-preservation; feedback relationships; students’ ideal feedback which included the desire for pastoral support. Several tensions also emerged from student data: Firstly, a yearning for feedback but experiencing corrective feedback as emotional assaults requiring action for self-preservation. Secondly a preference for receiving affirmative feedback, despite acknowledging that corrective feedback can lead to improved performance. Thirdly, participants valuing dialogue highly as opportunities to seek clarification/understanding/justify themselves, which was deemed less likely with senior faculty whose feedback was paradoxically greatly respected. Whilst students greatly valued feedback from senior faculty, due to cultural respect for hierarchy, they felt less able to engage in the dialogue they desired. Finally, both stakeholder groups equated hard work with success and that critical feedback was perceived as accusations of student laziness. Conclusion ‘Best feedback practices’ articulated by students mostly aligned with western educational discourses but in contrast to international literature students desired lecturers to fulfil pastoral roles rather than simply provide feedback on tasks. Cultural expectations and respect for hierarchy needs to be considered when building evidence-based feedback in a Malawian context. Feedback LMIC Culture low resource Sub-Saharan Africa Figures Figure 1 Background ‘Feedback’ is provision of information on behaviour/activity aimed at improving future performance (Ende, 1983; Sadler, 1989). This study seeks to contribute to discourses relating to the effectiveness of feedback, exploring concepts of optimizing feedback in a sub-Saharan healthcare education institution. Well-delivered feedback can positively influence learning behaviours by bringing actual and desired performances nearer together (McQueen et al., 2016; Norcini, 2010; Nottingham & Henning, 2014;Poulos & Mahony, 2008; Stone, 2014; Weiner et al., 2013). This is especially important regarding issues of patient safety (Bagwandeen & Singaram, 2016; de Beer & Mårtensson, 2015; Hodgson et al., 2021). Feedback is not always effective (Norcini, 2010) only aiding learning when used effectively and accepted by its recipients (Chou et al., 2013; Mubuuke et al., 2016; Murdoch-Eaton & Sargeant, 2012). Several issues affect how learners utilize feedback (Watling et al., 2012) including their own enthusiasm, anxieties and expectations (Eva et al., 2012). Stone (2014) identified how some students find feedback falls short of aims, such as improving future performance (Murdoch-Eaton & Sargeant, 2012; Sadler, 1989; Watling et al., 2012). We sought to understand how, these ideal aims are perceived in Malawi, and could even corrective feedback (i.e. signposting deviance from effective practice and how learner might improve) (Egan, 2002) be rendered more acceptable. Understanding how faculty and students perceive feedback might provide insights for culturally sensitive faculty development and how the credibility of feedback exchanges might be enhanced in the Malawian context. Our study explored feedback practices at College of Medicine (COM), part of the University of Malawi (UNIMA), the only institution training doctors, physiotherapists, pharmacists and medical laboratory scientists in Malawi, which aims to graduate ‘globally competent, locally relevant’ health care professionals (Bandawe, 2005). Despite extensive literature about feedback in health professions education (HPE), most is written from a western viewpoint (Weiner et al., 2013) with a dearth of Sub-Saharan African contributions. Our search strategy uncovered no literature addressing Malawian perceptions of feedback in medical education. Mubuuke et al’s (2017) Ugandan study recognised distinctive social factors, including; language; facilitator communication and participation; gender stereotyping and feedback personalization; and cognitive factors involving perceived tutor ignorance; feedback overload; and unfocussed or contradictory feedback, impacting utilization of feedback by students. These factors along with risks of decoupling feedback from intended learning outcomes (Mubuuke et al., 2017) echo published western concerns (Eva et al., 2012; Poulos & Mahony, 2008). Bleakley et al. (2008) and Wilbur et al. (2019) promote consideration of how to ensure educational practices are culturally appropriate. ‘Accepting that aspirations of higher education (HE) are to improve society and living standards this must be anchored in the culture of that society’ (Matos, 2000). We cannot assume western feedback models will work in a Malawian context. Feedback interactions are social phenomena influenced by culture, which itself may influence perceptions and utilization of feedback (Suhoyo et al., 2014). Cultural barriers to teaching and learning may impede enduring change in behaviour (Weiner et al., 2013). Uncritical application of feedback practices based on western literature exported to other regions, has been critiqued by many (Bleakley et al., 2008; Suhoyo et al., 2014; Wilbur et al., 2019). Defining culture is complex. We valued Boas’ 1930 definition in Monaghan & Just, (2000, p.37). “Culture embraces all the manifestations of social behaviour of a community, the reactions of the individual as affected by the habits of the group in which he lives, and the product of human activities as determined by these habits” These authors argue that culture pervades all areas of society including learnt behaviours, is often subliminally taught, and guides how members feel about and react to workplace, community, tribe or regional situations. Higher Education, has been critiqued as lacking relevance to African struggles or perpetuating processes of colonization and producing Western-influenced graduates, out of touch with their indigenous culture (Bandawe, 2005) and traditionally empirical objectives being disconnected from human or spiritual values (Glasson et al., 2006). The Chewa (Malawi’s, primary ethnic group) (Mcnamara, 2015), word for ‘intelligence’ is nzelu, which incorporates wisdom and social responsibility (Lockett, 2003), and Bandawe (2005) argues that for African higher education to be relevant it should reflect the African philosophy and worldview and promote African identity. Malawi is amongst the world’s poorest, least urbanised countries with an estimated population of 18.6 million and national poverty rate 51.5% (Mcnamara, 2015; World Bank, 2021). Society is collectivist rather than individualistic (Muula & Mfutso-Bengo, 2004) with connectedness or ‘uMunthu’ being central (Bandawe, 2010), influencing social interactions including education (Ntinda, 2017). Malawi is a non-confrontational culture with tendencies towards courtesy bias (Launiala, 2009; Warria, 2018) respect for hierarchy from elders to youth (Lwanda, 2005; Namphande et al., 2017) where opinions of youths are less valued (Porter, 2014). Hofstede (1986) model classified cultural distinctions between countries into four dimensions: Power Distance, Individualism, Uncertainty Avoidance, and Masculinity. Malawi scores highly for power distance and is low on individualism (Hofstede insights, 2021). With such characteristics Suhoyo et al (2014) suggest students are likely to be less independent thus more reliant on teacher direction. Countries scoring low on power distance but highly on individualism have greater equality in student-tutor relationships, more self-driven learning and more student initiated communication (Suhoyo et al., 2014). Morrison et al. (2004), studying students from US and Hong Kong found those with low self-assertiveness and high power- distance were less likely to seek feedback from tutors. Methods Methodology This qualitative study, was deemed appropriate to explore a socially constructed phenomenon such as feedback (Ng et al., 2014; Urquhart, 2013) and was aligned to four research questions 1. What are COM stakeholders’ perceptions and experiences of receiving and giving formal and informal feedback on student performance? 2. What is the impact of these perceptions on the self-assessed utilization of feedback to improve performance? 3. What aspects of culture and social hierarchy influence acceptance and utilization of feedback by COM students? 4. What other factors influence acceptance and utilization of feedback to improve student performance? Ethical approval was granted by College of Medicine Research Ethics Committee (COMREC), University of Malawi and University of Dundee. Methods Data was collected via one-hour semi-structured interviews with two sets of stakeholders, students and faculty, purposively sampled from across all faculties at COM, in order to optimize capture of diverse experiences, thereby improving transferability within CoM (Côté & Turgeon, 2005; Kitto et al., 2008; Stalmeijer et al., 2014). Whilst recognising this small study is not generalisable, we hope to achieve phenomenological nods from readers and institutions beyond COM perceiving relevance to wider sub-Saharan Africa. In total nine interviews were conducted. Interview data was recorded, transcribed and analysed sequentially for emerging themes, influencing further interview questioning, and allowing identification of data saturation. Data Analysis Data was analysed utilising techniques derived from grounded theory (Wenrich et al., 2015). Inductive analysis was done manually, initially using open coding followed by an iterative process of categorizing into themes (Heath & Cowley, 2004). Iterative practices of memo writing, diagram drawing and constant comparison were utilised, as concepts developed and a theoretical framework became apparent (Côté & Turgeon, 2005; Heath & Cowley, 2004; Watling & Lingard, 2012). This allowed emerging themes, patterns and insights to be realised (Cleland, 2015). As insider-researchers, reflexivity was required (Urquhart, 2013) acknowledging how insider researcher perspectives may result in more balanced constructivist accounts (Unluer, 2012). To minimise bias (Côté & Turgeon, 2005; Kitto et al., 2008; Mubuuke et al., 2016) and enhance triangulation (Thurmond 2001), a portion of data were also analysed by the second and third authors, a Malawian and a UK researcher. Results Inductive data analysis resulted in eight interconnected themes: conception of feedback; affective dimensions; thirst for feedback; need to achieve; feedback conversations; self-preservation; feedback relationships; students’ ideal feedback which included the desire for pastoral support, as demonstrated in the conceptual map (Fig. 1 ). A few exemplar verbatim quotes are offered to illuminate each of the themes derived. Theme 1: Conception of Feedback Student and faculty participants construed feedback using a deficit model, believing it would only be given when knowledge was lacking. Students associated feedback with poor performance, social and emotional difficulties, not a normal part of learning. ‘…he talked a few things where I didn’t do well and I would have done better’ SL2 Theme 2: Affective Dimension Students reported strong emotions such as anxiety and fear regarding feedback. ‘I was afraid …. “what are they going to say about me?”’ SL2 Students expressed a psychological need for encouragement provided by affirmative feedback, relating it to building confidence and motivation to persevere. ‘medicine is so stressing… it needs… encouragement, … someone who … takes care of your feelings… the psychosocial aspect’ SL3 ‘someone once said I am a very good doctor… I still have that … despite whatever is coming’ SL 3. Some students experienced corrective feedback as an emotional hit linked to sense of failure. ‘people who are not used to negative comments … don’t easily pick themselves up when they fall down.’ SL3 Harshly-delivered feedback was poorly received by students leading to demotivation (SL4, DL4), sense of worthlessness (SL2), and confusion (SL4). ‘’I’d respond in an emotional way and it also has a psychological impact on me … its quite hard to receive feedback in a harsh way’ SL4 Theme 3: Thirst for Feedback Students desired more regular insights into their performance and external motivation. ‘I’d still go for this… very negative feedback than no feedback at all’ SL3 Most faculty concurred that students exhibited feedback-seeking behaviour, seeking guidance and improved performance. Two students perceived it as nurture without which students suffered emotional neglect. ‘…maybe you have even lost some students because they didn’t get feedback quite early … they didn’t get any motivation and they gave up’ SL4 Theme 4: Need to Achieve Most stakeholders aligned hard work with success. All student participants aimed for success through hard work rather than deeper subject understanding, repeatedly referring to feedback motivating hard work, without which they believed they might fail. ‘you have to work extra hard not to fail’ SL3. ‘ it would just push me to say … “I need to do more. I’m not doing enough”. Despite I though …. I’m understanding things’ SL2. This need to succeed put pressure on some students who felt that lecturers had unrealistic expectations. ‘students have to study …. to eat and rest whatsoever … that becomes difficult in terms of time management’ SL2 Theme 5: Feedback Conversations Dialogic feedback positively impacted utilisation, allowing students to justify themselves, disagree or seek clarification, improving understanding. ‘we talked, he listened to me and I listened to him and I still hold on to what he said…. He’s one of the people that has made me reach far so I still remember that one (be)cause… we reached a consensus’ SL1 Students valued being regarded as individuals especially if lecturers asked ‘why’ a student hadn’t succeeded and explored non-academic challenges students faced. ‘but maybe someone ... is not eating or whatsoever… But if someone came …and say … “you didn’t do well on this one, what is the problem?” then that person will be able to open up.’ SL2 Dialogue was inhibited by significant lecturer-student power-dynamics, critical lecturers or harsh tone of delivery. ‘giving them respect you just tend to be passive … even if they tell you to ask questions, you wouldn’t ask because you are giving the person respect’. SL4 Theme 6: Need for Self-preservation Self-preservation emerged as important. Students felt best able to learn when they felt valued and their perspective was heard. Students being given ‘a voice’ enhanced self-reported utilisation of feedback. ‘[dialogue] gives you a platform to justify yourself’ SL1 ‘you need someone who … takes care of your feelings’ SL3 When receiving corrective feedback all students expressed the need for a platform to disagree in order to defend themselves. ‘when you receive that [critical] feedback obviously as a human you have to sit back and sometimes get frustrated, you complain…’ SL3 Power-dynamics inhibited students being able to justify themselves or challenge feedback. All students desired to be valued as individuals and SL4 expressed this acknowledgement motivated him, especially the lecturer expressing concern for their performance or personal struggles. ‘he started asking me about my family background, people I associate with, my life in college and he gave me advice saying “you know what? We all pass through the same things”’ SL1 Theme 7: Feedback Relationships Most students perceived student-teacher relationships influenced their response to feedback, valuing time spent with the lecturer. If a lecturer identified with the student’s difficulties this impacted positively, however if the student felt a disconnect or power-dynamic between themselves and the lecturer, it had a negative impact. ‘if it’s… someone you don’t associate with … you perceive it differently from someone maybe a certain lecturer whom you chat to now and then’ SL2 Seniority and age Some students would passively accept feedback from a very senior lecturer. There was a tension between the cultural inability to respond to senior tutors and the great respect for their feedback. ‘when you get feedback from a senior …you cannot confront the feedback… I think our culture makes us accept even things that we don’t think we have done’ SL 4 ‘there is some sort of hierarchy ... I think the level of the person who is telling you the feedback still matters … we sub-consciously …. respect what someone who’s up there is saying’ SL4 . Two students expressed a generational disconnect from lecturers ‘like they don’t understand us the youth, you know you can’t you even fail to explain this yourself to them. They feel like we are, the generation lost…’ SL1 Most students believed younger lecturers understood their perspective and could dialogue with them. This facilitated questioning and defending themselves. Conversely, SL3 noted feedback from younger lecturers was taken less seriously than from older. ‘because the age difference is not much, some people take them [younger lecturers] for granted’ SL3 Critical lecturers were perceived as unapproachable (SL1), so students didn’t seek clarification, leading to poor understanding. Gender Three students noted that female lecturers were nurturing ‘like a mother’ (SL1 &3) i.e. engaged in friendly dialogue, and ask why a student is struggling. ‘the females are more of mothers; they address you sometimes as part of their children’ SL3 Male lecturers were perceived as giving less feedback, less often, without dialogue, but paradoxically its scarcity made it more valuable. Theme 8: Students’ Ideal Feedback Students expressed preferences for motivating feedback, in private, personal, verbal feedback conversations with affirmative feedback before corrective feedback, and time to reflect on feedback. Students wanted to be asked their opinions, to seek clarification, and if necessary challenge feedback. Some students needed lecturers to explore student’s non-academic challenges. Table 1 is a summary of students’ expressed feedback preferences. Content Personal Specific Affirmative then Corrective Critique not critical Lecturer asks Qs about non-academic challenges Includes advice on way forward Informs of expectations Not comparative Delivery Private Two way conversation – students can seek clarification Students given a ‘voice’ – free to challenge feedback, justify themselves, express challenges Friendly tone of voice Psychologically supportive: Motivating, encouraging, nurturing Regular Includes time to reflect Table 1 . Collation of CoM students’ ideal feedback experiences and conceptions Discussion CoM students valued both affirmative and corrective feedback but preferred praise, which encouraged and built their confidence, equipping them to then receive and accept corrective feedback. Participants expressed a psychological need for encouragement but reported this alone did not alter performance. Corrective feedback seemed to change behaviour, most often expressed as the motivation to work harder in keeping with Boehler et al. ( 2006 ) who found corrective feedback improved performance, whilst praise improved student satisfaction. Here we face a dilemma where culturally students experience critique as criticism especially when provided by senior faculty who command their respect. Students also expressed a ‘generation gap’ (i.e. a divide separating beliefs, values and behaviours across generations) (Hayes, 2021 ; Josephine & Jones, 2022 ) leading to a disconnect and perception that older lecturers were critical, which negatively impacted feedback utilisation. However older lecturers were automatically revered in keeping with hierarchical culture and perceived as experienced and more credible. Paradoxically, this power-dynamic also inhibited a sense of mutual respect, which, although arguably counter-cultural, students sought to help them cope with critique. This echoes Josephine and Jones ( 2022 ) findings that hierarchy in the Indonesian medical education environment, could hinder learning opportunities. Students exhibited feedback seeking behaviour and a thirst for feedback, essential for success in keeping with the concept of ‘lifeblood of learning’ (Rowntree, 1987 ). Some considered failed students who did not receive feedback and subsequently left the programme, as ‘lost’ (almost like a bereavement). They professed a paucity of feedback leading to ‘learning without purpose’ or even neglect, in keeping with Ende ( 1983 ). Emotional reactions to feedback should be considered (Bing-You et al., 2017 ). Students engage in a ‘cost-benefit’ analysis weighing up the need to protect their ‘self’ (the cost) against potential learning (the benefit) in seeking feedback (Bok et al., 2013 ). Although CoM students desired feedback they expressed negative emotions linked to it, including depression and anxiety, echoing Eva et al.'s ( 2012 ) suggestion that it aligns with the stages of grief, which could endure beyond the event. This may reflect how faculty and students are sometimes not separating ‘self’ from task in feedback interactions (Ende, 1983 ) leading to a perceived personal attack or judgement (Boud & Molloy, 2013 ) rather than constructive criticism aimed at improving their performance. At odds with the desire for feedback, the data implied students sought to preserve their ‘sense of self’ including being valued as a person by their lecturers, to have a voice; to defend themselves and learn to cope with feedback. The emotional dimensions of feedback, and feedback-relationships may be underestimated and poorly understood (Jones, 2014 ). Clynes and Raftery ( 2008 ) recommend constructive feedback that is sensitive to students’ emotions, since it can be disappointing. A clear plan on how to move forward is needed since feedback utilisation may be hindered if the student does not understand (or value) it (Clynes & Raftery, 2008 ; Killingback et al., 2019 ) Feedback can provide emotional or even pastoral support especially as junior students adjust to University culture (Dixon, 2015 ; Poulos & Mahony, 2008 ). Data suggested students actually desired faculty to demonstrate ‘uMunthu’ (‘connectedness’ or ‘humanity’) by exploring non-academic challenges and pastoral issues when giving feedback. Since students expressed how negative emotions hindered their ability to process feedback, in this relational culture, addressing ways to improve the student-teacher relationship may improve students’ engagement. Student participants repeatedly referred to the importance of dialogue in feedback, in keeping with the international literature. Clynes & Raftery's (2008) literature review highlights the importance of interaction. Hodgson et al. ( 2021 ) found SA students sought dialogue over one-way flow of information. Data suggested dialogue allowed study participants to defend themselves, seek clarification or even disagree, whilst fostering a sense of nurture. Students bemoaned a paucity of feedback-dialogue, resonating with Nicol’s ( 2010 ) ‘transmission view’ of feedback and sometimes leaving learners wanting clearer guidance. Students need sufficient time for clarification (Clynes & Raftery, 2008 ). Both stakeholder samples recognised how allowing more time for discussion, critique, challenge and exploration could reap many learning benefits for students. Students expressed how relationships with feedback-givers affected their ability to accept and respond to feedback. ‘Good’ relationships with lecturers enabled participants to open up during feedback interactions and relational issues such as power dynamics, critical language, and harsh delivery, inhibited dialogue. Respondents reported some correlation between time spent with lecturers and value afforded to feedback, concurring with western literature (Clynes & Raftery, 2008 ; Gillespie, 2002 ). Students felt most able to challenge and discuss feedback with educators closer to their own age and stage. Respondents expressed that younger lecturers, as near peers, could identify with them, increasing trust in their feedback whilst paradoxically valuing feedback from seniors more. Generating conditions for ideal feedback Extrapolating students’ ideal feedback experiences echoed international literature from countries with variously different cultures to Malawi including that feedback is more effective if: delivered appropriately (Clynes & Raftery, 2008 ); in an ‘enabling environment’ (Weaver, 2006 ) is motivational and engaging (Ellery, 2008 ); aimed at problem solving and action. Wilbur et al. ( 2019 ) similarly found Qatari students, from a high power-dynamic Arabic-culture, exhibited feedback preferences seen in Western students. Their study aligns with our findings emphasising importance of considerate approach, privacy and non-comparative, individualised feedback. Some findings were more unique: whilst much of the literature favours impersonal feedback – aimed at performance not the person the data suggested our students wanted to be treated as individuals. Feedback was aligned with a lack of knowledge, which in an achievement driven culture translated to a sense of failure. Students wanted lecturers to explore the challenges faced by students in particular with regard to external non-academic influences such as hunger and financial issues. This conceptualised feedback more with counselling, or parental guidance, than information on actual performance. This desire may simply reflect the unique needs and pressures experienced by disadvantaged students studying highly-regarded degrees e.g. Medicine, in a LIC setting or the desire for improved student-lecturer relationships and ‘uMunthu’ in a collectivist culture. Faculty development on feedback may benefit from including affective factors such as relationship-building skills, which are not usually the focus of such initiatives (Jones, 2014 ), and consideration of local perceptions and behaviours relating to hierarchy on such relationships. Conclusion Much global discourse on HPE is focussing on decolonization of the curriculum, we set out to explore the feedback culture at CoM, with an assumption that western educational practices cannot automatically be applied to the Malawian setting. Unexpectedly, our findings were in many ways aligned with western educational practices. This was especially true regarding ‘best feedback practices’ expressed by students. Despite a culture of courtesy bias, students had a thirst for feedback. Within the hierarchical and non-confrontational culture, students still wished to be ‘given a voice’. They desired dialogue, to be involved in the process and given a chance to justify themselves whilst maintaining their self-esteem. Feedback ideally included affirmation to psychologically prepare the student to accept corrective feedback. The influence of hierarchy caused a paradox. Students valued feedback from senior faculty more, due to respect for hierarchy, but couldn’t engage in dialogue for the same reason. So whilst acknowledging the influences of their culture, the students desired feedback delivery to be, on some occasions, counter-cultural e.g. desiring respectful tone from an elder. Opening up discourses to reduce learner-teacher interactions based upon hierarchy, rather than learning, may be beneficial. A unique finding that did not align with western literature included the desire for lecturers to show ‘uMunthu’, exploring non-academic issues when interacting in feedback dialogue, offering a pastoral role rather than simply a delivery of facts. This may reflect the culture, but also the LMIC setting and unique challenges (e.g. hunger) these students face. In order to improve health professions’ students’ performance, the recommended feedback practices should be based on evidence from within the relevant context and culture. 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Newcomer Feedback Seeking. A Comparison of the United States and Hong Kong. Appl Psychol, 53 (1), 1–22. https://doi.org/10.1111/j.1464-0597.2004.00158.x Mubuuke AG, Louw AJN, Van Schalkwyk S. Cognitive and Social Factors Influencing Students׳ Response and Utilization of Facilitator Feedback in a Problem Based Learning Context. Health Professions Educ. 2017;3(2):85–98. https://doi.org/10.1016/j.hpe.2016.09.003 . Murdoch-Eaton D, Sargeant J. Maturational differences in undergraduate medical students’ perceptions about feedback. Med Educ. 2012;46(7):711–21. https://doi.org/10.1111/j.1365-2923.2012.04291.x . Muula AS, Mfutso-Bengo JM. Important but neglected ethical and cultural considerations in the fight against HIV/AIDS in Malawi. Nurs Ethics. 2004;11(5):479–88. https://doi.org/10.1191/0969733004ne726oa . Namphande P, Clarke L, Farren S, McCully A. Education for democratic citizenship in Malawian secondary schools: balancing student voice and adult privilege. 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In: Brown EL, editor. Global Perspectives On Gender And Sexuality In Education: Raising Awareness, Fostering Equity, Advancing Justice. Information Age Publishing; 2017. pp. 239–56. Porter C. Turning old problems into new problems: The role of young citizens in improving accountability in education in Malawi and Kenya. Compare. 2014;44(3):356–78. https://doi.org/10.1080/03057925.2013.778535 . Poulos A, Mahony MJ. Effectiveness of feedback: The students’ perspective. Assess Evaluation High Educ. 2008;33(2):143–54. https://doi.org/10.1080/02602930601127869 . Rowntree D. (1987). Assessing students: How shall we know them? (2nd ed.). Kogan. Sadler DR. Formative assessment and the design of instructional systems. Instr Sci. 1989;18:119–44. https://link.springer.com/article/10.1007/BF00117714 . Stalmeijer RE, McNaughton N, Van Mook WNKA. Using focus groups in medical education research: AMEE Guide 91. Med Teach. 2014;36(11):923–39. https://doi.org/10.3109/0142159X.2014.917165 . Stone A. Online assessment: What influences students to engage with feedback? Clin Teacher. 2014;11(4):284–9. https://doi.org/10.1111/tct.12158 . Suhoyo Y, Van Hell EA, Prihatiningsih TS, Kuks JBM, Cohen-Schotanus J. Exploring cultural differences in feedback processes and perceived instructiveness during clerkships: Replicating a Dutch study in Indonesia. Med Teach. 2014;36(3):223–9. https://doi.org/10.3109/0142159X.2013.853117 . Thurmond VA. The point of triangulation. J Nurs Scholarsh. 2001;33(3):253–8. https://doi.org/10.1111/j.1547-5069.2001.00253.x . Unluer S. Being an insider researcher while conducting case study research. Qualitative Rep. 2012;17(29). https://doi.org/10.46743/2160-3715/2012.1752 . Urquhart C. Grounded Theory for Qualitative Research: A Practical Guide. 1st ed. Ltd: SAGE; 2013. https://doi.org/10.4135/9781526402196 . Warria A. Girls’ innocence and futures stolen: The cultural practice of sexual cleansing in Malawi. Child Youth Serv Rev. 2018;91:298–303. https://doi.org/10.1016/j.childyouth.2018.06.011 . Watling C, Driessen E, van der Vleuten C, Lingard L. Learning from clinical work: The roles of learning cues and credibility judgements. Med Educ. 2012;46(2):192–200. https://doi.org/10.1111/j.1365-2923.2011.04126.x . Watling C, Lingard L. Grounded theory in medical education research: AMEE Guide 70. Med Teach. 2012;34(10):850–61. https://doi.org/10.3109/0142159X.2012.704439 . Weaver MR. Do students value feedback? Student perceptions of tutors’ written responses. Assess Evaluation High Educ. 2006;31(3):379–94. https://doi.org/10.1080/02602930500353061 . Weiner S, Totten V, Jacquet G, Douglass K, Birnbaumer D, Promes S, Martin I. Effective teaching and feedback skills for international emergency medicine train the trainers programs. J Emerg Med. 2013;45(5):718–25. https://doi.org/10.1016/j.jemermed.2013.04.040 . Wenrich MD, Jackson MB, Maestas RR, Wolfhagen IHAP, Scherpbier AJJ. From cheerleader to coach: The developmental progression of bedside teachers in giving feedback to early learners. Acad Med. 2015;90:S91–7. https://doi.org/10.1097/ACM.0000000000000901 . 11 Association of American Medical Colleges Medical Education Meeting. Wilbur K, BenSmail N, Ahkter S. Student feedback experiences in a cross-border medical education curriculum. Int J Med Educ. 2019;10:98–105. https://doi.org/10.5116/ijme.5ce1.149f . World Bank. (2021). The World Bank in Malawi: Overview . https://www.worldbank.org/en/country/malawi/overview Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5867708","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":407651007,"identity":"4feb981c-1d1b-4f0e-8ef8-741fec4e2e8f","order_by":0,"name":"Emma Thomson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYFACHgjFz8PARqQONqgWyR6StRicIVYLv3zvwUc3/tjkGZ85Y/bgwx8Gef4G7jQJfFok2/iSjXPb0orNzvaYG85sYzCccYB3G14tBsd4zKRzGw4nbjsPZPA2MDBuYODddgOfFnuQlpw/hxM39wMZf/4w2BPUYsAG0sJ2OHEDb4+ZNDAEEglqkTiWYwzyS+KMM8fKJHvbJJJnHObd/gOfFv7mM4aPc/7YJPb3JG+T+PHHxra/vXezAT4tGLYyMDCTon4UjIJRMApGAVYAACRMRKS9LE4jAAAAAElFTkSuQmCC","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Emma","middleName":"","lastName":"Thomson","suffix":""},{"id":407651009,"identity":"79b8801b-f937-43f0-80ca-f1814615bbfe","order_by":1,"name":"Tuntufye Mwambyale","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Tuntufye","middleName":"","lastName":"Mwambyale","suffix":""},{"id":407651011,"identity":"eae68603-5251-4729-9748-7290c2d2c790","order_by":2,"name":"Linda Jones","email":"","orcid":"","institution":"University of Dundee","correspondingAuthor":false,"prefix":"","firstName":"Linda","middleName":"","lastName":"Jones","suffix":""}],"badges":[],"createdAt":"2025-01-20 16:53:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5867708/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5867708/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":75312188,"identity":"2608e103-0561-491c-9508-4ff9d02592c1","added_by":"auto","created_at":"2025-02-03 09:12:33","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":42716,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual map of eight inter-related themes\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5867708/v1/aefa056f2be19cd8b520a773.jpg"},{"id":77589896,"identity":"08bd78f9-7e1c-4442-a758-63682c78ce26","added_by":"auto","created_at":"2025-03-03 11:08:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":651084,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5867708/v1/7b73fe16-b353-462d-a449-56eb3cb7962b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effective Feedback in Medical and Health Science Education, in Malawi: Perceptions and Experiences","fulltext":[{"header":"Background","content":"\u003cp\u003e‘Feedback’ is provision of information on behaviour/activity aimed at improving future performance (Ende, 1983; Sadler, 1989). This study seeks to contribute to discourses relating to the effectiveness of feedback, exploring concepts of optimizing feedback in a sub-Saharan healthcare education institution.\u003c/p\u003e\n\u003cp\u003eWell-delivered feedback can positively influence learning behaviours by bringing actual and desired performances nearer together (McQueen et al., 2016; Norcini, 2010; Nottingham \u0026amp; Henning, 2014;Poulos \u0026amp; Mahony, 2008; Stone, 2014; Weiner et al., 2013). This is especially important regarding issues of patient safety (Bagwandeen \u0026amp; Singaram, 2016; de Beer \u0026amp; Mårtensson, 2015; Hodgson et al., 2021). Feedback is not always effective (Norcini, 2010) only aiding learning when used effectively and accepted by its recipients (Chou et al., 2013; Mubuuke et al., 2016; Murdoch-Eaton \u0026amp; Sargeant, 2012). Several issues affect how learners utilize feedback (Watling et al., 2012) including their own enthusiasm, anxieties and expectations (Eva et al., 2012).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStone (2014) \u0026nbsp;identified how some students find feedback falls short of aims, such as \u0026nbsp;improving future performance (Murdoch-Eaton \u0026amp; Sargeant, 2012; Sadler, 1989; Watling et al., 2012).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe sought to understand how, these ideal aims are perceived in Malawi, and could even corrective feedback (i.e. signposting deviance from effective practice and how learner might improve) (Egan, 2002) be rendered more acceptable. Understanding how faculty and students perceive feedback might provide insights for culturally sensitive faculty development and how the credibility of feedback exchanges might be enhanced in the Malawian context.\u003c/p\u003e\n\u003cp\u003eOur study explored feedback practices at College of Medicine (COM), part of the University of Malawi (UNIMA), the only institution training doctors, physiotherapists, pharmacists and medical laboratory scientists in Malawi, which aims to graduate ‘globally competent, locally relevant’ health care professionals (Bandawe, 2005).\u003c/p\u003e\n\u003cp\u003eDespite extensive literature about feedback in health professions education (HPE), most is written from a western viewpoint (Weiner et al., 2013) with a dearth of Sub-Saharan African contributions. Our search strategy uncovered no literature addressing Malawian perceptions of feedback in medical education. Mubuuke et al’s (2017) Ugandan study recognised distinctive social factors, including; language; facilitator communication and participation; gender stereotyping and feedback personalization; and cognitive factors involving perceived tutor ignorance; feedback overload; and unfocussed or contradictory feedback, impacting utilization of feedback by students. These factors along with risks of decoupling feedback from intended learning outcomes (Mubuuke et al., 2017) echo published western concerns \u0026nbsp;(Eva et al., 2012; Poulos \u0026amp; Mahony, 2008).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBleakley et al. (2008) and Wilbur et al. (2019)\u0026nbsp; promote consideration of how to ensure educational practices are culturally appropriate. ‘Accepting that aspirations of higher education (HE) are to improve society and living standards this must be anchored in the culture of that society’ (Matos, 2000). We cannot assume western feedback models will work in a Malawian context. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFeedback interactions are social phenomena influenced by culture, which itself may influence perceptions and utilization of feedback (Suhoyo et al., 2014). Cultural barriers to teaching and learning may impede enduring change in behaviour (Weiner et al., 2013). Uncritical application of feedback practices based on western literature exported to other regions, has been critiqued by many (Bleakley et al., 2008; Suhoyo et al., 2014; Wilbur et al., 2019).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDefining culture is complex. \u0026nbsp;We valued Boas’ 1930 \u0026nbsp;definition in \u0026nbsp; Monaghan \u0026amp; Just, (2000, p.37).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Culture embraces all the manifestations of social behaviour of a community, the reactions of the individual as affected by the habits of the group in which he lives, and the product of human activities as determined by these habits”\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese authors argue that culture pervades all areas of society including learnt behaviours, is often subliminally taught, and guides how members feel about and react to workplace, community, tribe or regional situations.\u003c/p\u003e\n\u003cp\u003eHigher Education, has been critiqued as lacking relevance to African struggles or perpetuating processes of colonization and producing Western-influenced graduates, out of touch with their indigenous culture (Bandawe, 2005) and traditionally empirical objectives being disconnected from human or spiritual values (Glasson et al., 2006). The \u0026nbsp;Chewa (Malawi’s, primary ethnic group) (Mcnamara, 2015), word for ‘intelligence’ is nzelu, which incorporates wisdom and social responsibility (Lockett, 2003), and Bandawe (2005) argues that for African higher education to be relevant it should reflect the African philosophy and worldview and promote African identity. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMalawi is amongst the world’s poorest, least urbanised countries with an estimated population of 18.6 million and national poverty rate 51.5% (Mcnamara, 2015; World Bank, 2021). Society is collectivist rather than individualistic (Muula \u0026amp; Mfutso-Bengo, 2004) with connectedness or ‘uMunthu’ being central (Bandawe, 2010), influencing social interactions including education (Ntinda, 2017). Malawi is a non-confrontational culture with tendencies towards courtesy bias (Launiala, 2009; Warria, 2018) respect for hierarchy from elders to youth (Lwanda, 2005; Namphande et al., 2017) where opinions of youths are less valued (Porter, 2014).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHofstede (1986) model classified cultural distinctions between countries into four dimensions: Power Distance, Individualism, Uncertainty Avoidance, and Masculinity. Malawi scores highly for power distance and is low on individualism (Hofstede insights, 2021). With such characteristics Suhoyo et al (2014) suggest students are likely to be less independent thus more reliant on teacher direction. \u0026nbsp;Countries scoring low on power distance but highly on individualism have greater equality in student-tutor relationships, more self-driven learning and more student initiated communication (Suhoyo et al., 2014). \u0026nbsp; Morrison et al. (2004), studying students from US and Hong Kong found those with low self-assertiveness and high power- distance were less likely to seek feedback from tutors.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eMethodology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis qualitative study, was deemed appropriate to explore a socially constructed phenomenon such as feedback (Ng et al., 2014; Urquhart, 2013)\u0026nbsp; and was aligned to four research questions\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1. What are COM stakeholders’ perceptions and experiences of receiving and giving formal and informal feedback on student performance?\u003c/p\u003e\n\u003cp\u003e2. What is the impact of these perceptions on the self-assessed utilization of feedback to improve performance?\u003c/p\u003e\n\u003cp\u003e3. What aspects of culture and social hierarchy influence acceptance and utilization of feedback by COM students?\u003c/p\u003e\n\u003cp\u003e4. What other factors influence acceptance and utilization of feedback to improve student performance?\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by College of Medicine Research Ethics Committee (COMREC), University of Malawi and University of Dundee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was collected via one-hour semi-structured interviews \u0026nbsp;with two sets of stakeholders, students and faculty, purposively sampled from across all faculties at COM, in order to optimize capture of diverse experiences, thereby improving transferability within CoM (Côté \u0026amp; Turgeon, 2005; Kitto et al., 2008; Stalmeijer et al., 2014). Whilst recognising this small study is not generalisable, we hope to achieve phenomenological nods from readers and institutions beyond COM perceiving relevance to wider sub-Saharan Africa. In total nine interviews were conducted.\u003c/p\u003e\n\u003cp\u003eInterview data was recorded, transcribed and analysed sequentially for emerging themes, influencing further interview questioning, and allowing identification of data saturation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was analysed utilising techniques derived from grounded theory (Wenrich et al., 2015). Inductive analysis was done manually, initially using open coding followed by an iterative process of categorizing into themes (Heath \u0026amp; Cowley, 2004). Iterative practices of memo writing, diagram drawing and constant comparison were utilised, as concepts developed and a theoretical framework became apparent (Côté \u0026amp; Turgeon, 2005; Heath \u0026amp; Cowley, 2004; Watling \u0026amp; Lingard, 2012). This allowed emerging themes, patterns and insights to be realised (Cleland, 2015).\u003c/p\u003e\n\u003cp\u003eAs insider-researchers, reflexivity was required (Urquhart, 2013) acknowledging how insider researcher perspectives may result in more balanced constructivist accounts (Unluer, 2012). To minimise bias (Côté \u0026amp; Turgeon, 2005; Kitto et al., 2008; Mubuuke et al., 2016) and enhance triangulation (Thurmond 2001), a portion of data were also analysed by the second and third authors, a Malawian and a UK researcher.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eInductive data analysis resulted in eight interconnected themes: conception of feedback; affective dimensions; thirst for feedback; need to achieve; feedback conversations; self-preservation; feedback relationships; students\u0026rsquo; ideal feedback which included the desire for pastoral support, as demonstrated in the conceptual map (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). A few exemplar verbatim quotes are offered to illuminate each of the themes derived.\u003c/p\u003e\n\u003ch3\u003eTheme 1: Conception of Feedback\u003c/h3\u003e\n\u003cp\u003eStudent and faculty participants construed feedback using a deficit model, believing it would only be given when knowledge was lacking. Students associated feedback with poor performance, social and emotional difficulties, not a normal part of learning.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026hellip;he talked a few things where I didn\u0026rsquo;t do well and I would have done better\u0026rsquo; SL2\u003c/em\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme 2: Affective Dimension\u003c/h2\u003e\n \u003cp\u003eStudents reported strong emotions such as anxiety and fear regarding feedback.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;I was afraid \u0026hellip;. \u0026ldquo;what are they going to say about me?\u0026rdquo;\u0026rsquo; SL2\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eStudents expressed a psychological need for encouragement provided by affirmative feedback, relating it to building confidence and motivation to persevere.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;medicine is so stressing\u0026hellip; it needs\u0026hellip; encouragement, \u0026hellip; someone who \u0026hellip; takes care of your feelings\u0026hellip; the psychosocial aspect\u0026rsquo; SL3\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;someone once said I am a very good doctor\u0026hellip; I still have that \u0026hellip; despite whatever is coming\u0026rsquo;\u003c/em\u003e SL 3.\u003c/p\u003e\n \u003cp\u003eSome students experienced corrective feedback as an emotional hit linked to sense of failure.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;people who are not used to negative comments \u0026hellip; don\u0026rsquo;t easily pick themselves up when they fall down.\u0026rsquo; SL3\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eHarshly-delivered feedback was poorly received by students leading to demotivation (SL4, DL4), sense of worthlessness (SL2), and confusion (SL4).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026rsquo;I\u0026rsquo;d respond in an emotional way and it also has a psychological impact on me \u0026hellip; its quite hard to receive feedback in a harsh way\u0026rsquo; SL4\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eTheme 3: Thirst for Feedback\u003c/h3\u003e\n\u003cp\u003eStudents desired more regular insights into their performance and external motivation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I\u0026rsquo;d still go for this\u0026hellip; very negative feedback than no feedback at all\u0026rsquo; SL3\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost faculty concurred that students exhibited feedback-seeking behaviour, seeking guidance and improved performance. Two students perceived it as nurture without which students suffered emotional neglect.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026hellip;maybe you have even lost some students because they didn\u0026rsquo;t get feedback quite early \u0026hellip; they didn\u0026rsquo;t get any motivation and they gave up\u0026rsquo; SL4\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 4: Need to Achieve\u003c/h3\u003e\n\u003cp\u003eMost stakeholders aligned hard work with success. All student participants aimed for success through hard work rather than deeper subject understanding, repeatedly referring to feedback motivating hard work, without which they believed they might fail.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;you have to work extra hard not to fail\u0026rsquo; SL3.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;\u003cem\u003eit would just push me to say \u0026hellip; \u0026ldquo;I need to do more. I\u0026rsquo;m not doing enough\u0026rdquo;. Despite I though \u0026hellip;. I\u0026rsquo;m understanding things\u0026rsquo;\u003c/em\u003e SL2.\u003c/p\u003e\n\u003cp\u003eThis need to succeed put pressure on some students who felt that lecturers had unrealistic expectations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;students have to study \u0026hellip;. to eat and rest whatsoever \u0026hellip; that becomes difficult in terms of time management\u0026rsquo; SL2\u003c/em\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme 5: Feedback Conversations\u003c/h2\u003e\n \u003cp\u003eDialogic feedback positively impacted utilisation, allowing students to justify themselves, disagree or seek clarification, improving understanding.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;we talked, he listened to me and I listened to him and I still hold on to what he said\u0026hellip;. He\u0026rsquo;s one of the people that has made me reach far so I still remember that one (be)cause\u0026hellip; we reached a consensus\u0026rsquo; SL1\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eStudents valued being regarded as individuals especially if lecturers asked \u0026lsquo;why\u0026rsquo; a student hadn\u0026rsquo;t succeeded and explored non-academic challenges students faced.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;but maybe someone ... is not eating or whatsoever\u0026hellip; But if someone came \u0026hellip;and say \u0026hellip; \u0026ldquo;you didn\u0026rsquo;t do well on this one, what is the problem?\u0026rdquo; then that person will be able to open up.\u0026rsquo; SL2\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eDialogue was inhibited by significant lecturer-student power-dynamics, critical lecturers or harsh tone of delivery.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;giving them respect you just tend to be passive \u0026hellip; even if they tell you to ask questions, you wouldn\u0026rsquo;t ask because you are giving the person respect\u0026rsquo;. SL4\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme 6: Need for Self-preservation\u003c/h2\u003e\n \u003cp\u003eSelf-preservation emerged as important. Students felt best able to learn when they felt valued and their perspective was heard. Students being given \u0026lsquo;a voice\u0026rsquo; enhanced self-reported utilisation of feedback.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;[dialogue] gives you a platform to justify yourself\u0026rsquo; SL1\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;you need someone who \u0026hellip; takes care of your feelings\u0026rsquo; SL3\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eWhen receiving corrective feedback all students expressed the need for a platform to disagree in order to defend themselves.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;when you receive that [critical] feedback obviously as a human you have to sit back and sometimes get frustrated, you complain\u0026hellip;\u0026rsquo; SL3\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003ePower-dynamics inhibited students being able to justify themselves or challenge feedback.\u003c/p\u003e\n \u003cp\u003eAll students desired to be valued as individuals and SL4 expressed this acknowledgement motivated him, especially the lecturer expressing concern for their performance or personal struggles.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;he started asking me about my family background, people I associate with, my life in college and he gave me advice saying \u0026ldquo;you know what? We all pass through the same things\u0026rdquo;\u0026rsquo; SL1\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme 7: Feedback Relationships\u003c/h2\u003e\n \u003cp\u003eMost students perceived student-teacher relationships influenced their response to feedback, valuing time spent with the lecturer. If a lecturer identified with the student\u0026rsquo;s difficulties this impacted positively, however if the student felt a disconnect or power-dynamic between themselves and the lecturer, it had a negative impact.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;if it\u0026rsquo;s\u0026hellip; someone you don\u0026rsquo;t associate with \u0026hellip; you perceive it differently from someone maybe a certain lecturer whom you chat to now and then\u0026rsquo; SL2\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eSeniority and age\u003c/h2\u003e\n \u003cp\u003eSome students would passively accept feedback from a very senior lecturer. There was a tension between the cultural inability to respond to senior tutors and the great respect for their feedback.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;when you get feedback from a senior \u0026hellip;you cannot confront the feedback\u0026hellip; I think our culture makes us accept even things that we don\u0026rsquo;t think we have done\u0026rsquo; SL 4\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;there is some sort of hierarchy ... I think the level of the person who is telling you the feedback still matters \u0026hellip; we sub-consciously \u0026hellip;. respect what someone who\u0026rsquo;s up there is saying\u0026rsquo; SL4\u003c/em\u003e.\u003c/p\u003e\n \u003cp\u003eTwo students expressed a generational disconnect from lecturers\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;like they don\u0026rsquo;t understand us the youth, you know you can\u0026rsquo;t you even fail to explain this yourself to them. They feel like we are, the generation lost\u0026hellip;\u0026rsquo; SL1\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eMost students believed younger lecturers understood their perspective and could dialogue with them. This facilitated questioning and defending themselves. Conversely, SL3 noted feedback from younger lecturers was taken less seriously than from older.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;because the age difference is not much, some people take them [younger lecturers] for granted\u0026rsquo; SL3\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eCritical lecturers were perceived as unapproachable (SL1), so students didn\u0026rsquo;t seek clarification, leading to poor understanding.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eGender\u003c/h2\u003e\n \u003cp\u003eThree students noted that female lecturers were nurturing \u0026lsquo;like a mother\u0026rsquo; (SL1 \u0026amp;3) i.e. engaged in friendly dialogue, and ask why a student is struggling.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;the females are more of mothers; they address you sometimes as part of their children\u0026rsquo; SL3\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eMale lecturers were perceived as giving less feedback, less often, without dialogue, but paradoxically its scarcity made it more valuable.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme 8: Students\u0026rsquo; Ideal Feedback\u003c/h2\u003e\n \u003cp\u003eStudents expressed preferences for motivating feedback, in private, personal, verbal feedback conversations with affirmative feedback before corrective feedback, and time to reflect on feedback. Students wanted to be asked their opinions, to seek clarification, and if necessary challenge feedback. Some students needed lecturers to explore student\u0026rsquo;s non-academic challenges.\u003c/p\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1 is a summary of students\u0026rsquo; expressed feedback preferences.\u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"8\"\u003e\n \u003cp\u003eContent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersonal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpecific\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAffirmative then Corrective\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCritique not critical\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLecturer asks Qs about non-academic challenges\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncludes advice on way forward\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInforms of expectations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot comparative\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"7\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelivery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwo way conversation \u0026ndash; students can seek clarification\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudents given a \u0026lsquo;voice\u0026rsquo; \u0026ndash; free to challenge feedback, justify themselves, express challenges\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFriendly tone of voice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePsychologically supportive: Motivating, encouraging, nurturing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegular\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncludes time to reflect\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. \u003cstrong\u003eCollation of CoM students\u0026rsquo; ideal feedback experiences and conceptions\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eCoM students valued both affirmative and corrective feedback but preferred praise, which encouraged and built their confidence, equipping them to then receive and accept corrective feedback. Participants expressed a psychological need for encouragement but reported this alone did not alter performance.\u003c/p\u003e \u003cp\u003eCorrective feedback seemed to change behaviour, most often expressed as the motivation to work harder in keeping with Boehler et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) who found corrective feedback improved performance, whilst praise improved student satisfaction. Here we face a dilemma where culturally students experience critique as criticism especially when provided by senior faculty who command their respect.\u003c/p\u003e \u003cp\u003eStudents also expressed a \u0026lsquo;generation gap\u0026rsquo; (i.e. a divide separating beliefs, values and behaviours across generations) (Hayes, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Josephine \u0026amp; Jones, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) leading to a disconnect and perception that older lecturers were critical, which negatively impacted feedback utilisation. However older lecturers were automatically revered in keeping with hierarchical culture and perceived as experienced and more credible. Paradoxically, this power-dynamic also inhibited a sense of mutual respect, which, although arguably counter-cultural, students sought to help them cope with critique. This echoes Josephine and Jones (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) findings that hierarchy in the Indonesian medical education environment, could hinder learning opportunities.\u003c/p\u003e \u003cp\u003eStudents exhibited feedback seeking behaviour and a thirst for feedback, essential for success in keeping with the concept of \u0026lsquo;lifeblood of learning\u0026rsquo; (Rowntree, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e1987\u003c/span\u003e). Some considered failed students who did not receive feedback and subsequently left the programme, as \u0026lsquo;lost\u0026rsquo; (almost like a bereavement). They professed a paucity of feedback leading to \u0026lsquo;learning without purpose\u0026rsquo; or even neglect, in keeping with Ende (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1983\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEmotional reactions to feedback should be considered (Bing-You et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Students engage in a \u0026lsquo;cost-benefit\u0026rsquo; analysis weighing up the need to protect their \u0026lsquo;self\u0026rsquo; (the cost) against potential learning (the benefit) in seeking feedback (Bok et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Although CoM students desired feedback they expressed negative emotions linked to it, including depression and anxiety, echoing Eva et al.'s (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) suggestion that it aligns with the stages of grief, which could endure beyond the event. This may reflect how faculty and students are sometimes not separating \u0026lsquo;self\u0026rsquo; from task in feedback interactions (Ende, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1983\u003c/span\u003e) leading to a perceived personal attack or judgement (Boud \u0026amp; Molloy, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) rather than constructive criticism aimed at improving their performance.\u003c/p\u003e \u003cp\u003eAt odds with the desire for feedback, the data implied students sought to preserve their \u0026lsquo;sense of self\u0026rsquo; including being valued as a person by their lecturers, to have a voice; to defend themselves and learn to cope with feedback. The emotional dimensions of feedback, and feedback-relationships may be underestimated and poorly understood (Jones, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eClynes and Raftery (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) recommend constructive feedback that is sensitive to students\u0026rsquo; emotions, since it can be disappointing. A clear plan on how to move forward is needed since feedback utilisation may be hindered if the student does not understand (or value) it (Clynes \u0026amp; Raftery, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Killingback et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) Feedback can provide emotional or even pastoral support especially as junior students adjust to University culture (Dixon, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Poulos \u0026amp; Mahony, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Data suggested students actually desired faculty to demonstrate \u0026lsquo;uMunthu\u0026rsquo; (\u0026lsquo;connectedness\u0026rsquo; or \u0026lsquo;humanity\u0026rsquo;) by exploring non-academic challenges and pastoral issues when giving feedback. Since students expressed how negative emotions hindered their ability to process feedback, in this relational culture, addressing ways to improve the student-teacher relationship may improve students\u0026rsquo; engagement.\u003c/p\u003e \u003cp\u003eStudent participants repeatedly referred to the importance of dialogue in feedback, in keeping with the international literature. Clynes \u0026amp; Raftery's (2008) literature review highlights the importance of interaction. Hodgson et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) found SA students sought dialogue over one-way flow of information. Data suggested dialogue allowed study participants to defend themselves, seek clarification or even disagree, whilst fostering a sense of nurture. Students bemoaned a paucity of feedback-dialogue, resonating with Nicol\u0026rsquo;s (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) \u0026lsquo;transmission view\u0026rsquo; of feedback and sometimes leaving learners wanting clearer guidance. Students need sufficient time for clarification (Clynes \u0026amp; Raftery, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Both stakeholder samples recognised how allowing more time for discussion, critique, challenge and exploration could reap many learning benefits for students.\u003c/p\u003e \u003cp\u003eStudents expressed how relationships with feedback-givers affected their ability to accept and respond to feedback. \u0026lsquo;Good\u0026rsquo; relationships with lecturers enabled participants to open up during feedback interactions and relational issues such as power dynamics, critical language, and harsh delivery, inhibited dialogue.\u003c/p\u003e \u003cp\u003eRespondents reported some correlation between time spent with lecturers and value afforded to feedback, concurring with western literature (Clynes \u0026amp; Raftery, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Gillespie, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). Students felt most able to challenge and discuss feedback with educators closer to their own age and stage. Respondents expressed that younger lecturers, as near peers, could identify with them, increasing trust in their feedback whilst paradoxically valuing feedback from seniors more.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eGenerating conditions for ideal feedback\u003c/h2\u003e \u003cp\u003eExtrapolating students\u0026rsquo; ideal feedback experiences echoed international literature from countries with variously different cultures to Malawi including that feedback is more effective if: delivered appropriately (Clynes \u0026amp; Raftery, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2008\u003c/span\u003e); in an \u0026lsquo;enabling environment\u0026rsquo; (Weaver, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) is motivational and engaging (Ellery, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2008\u003c/span\u003e); aimed at problem solving and action. Wilbur et al. (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) similarly found Qatari students, from a high power-dynamic Arabic-culture, exhibited feedback preferences seen in Western students. Their study aligns with our findings emphasising importance of considerate approach, privacy and non-comparative, individualised feedback.\u003c/p\u003e \u003cp\u003eSome findings were more unique: whilst much of the literature favours impersonal feedback \u0026ndash; aimed at performance not the person the data suggested our students wanted to be treated as individuals. Feedback was aligned with a lack of knowledge, which in an achievement driven culture translated to a sense of failure. Students wanted lecturers to explore the challenges faced by students in particular with regard to external non-academic influences such as hunger and financial issues. This conceptualised feedback more with counselling, or parental guidance, than information on actual performance. This desire may simply reflect the unique needs and pressures experienced by disadvantaged students studying highly-regarded degrees e.g. Medicine, in a LIC setting or the desire for improved student-lecturer relationships and \u0026lsquo;uMunthu\u0026rsquo; in a collectivist culture.\u003c/p\u003e \u003cp\u003eFaculty development on feedback may benefit from including affective factors such as relationship-building skills, which are not usually the focus of such initiatives (Jones, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), and consideration of local perceptions and behaviours relating to hierarchy on such relationships.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMuch global discourse on HPE is focussing on decolonization of the curriculum, we set out to explore the feedback culture at CoM, with an assumption that western educational practices cannot automatically be applied to the Malawian setting.\u003c/p\u003e \u003cp\u003eUnexpectedly, our findings were in many ways aligned with western educational practices. This was especially true regarding \u0026lsquo;best feedback practices\u0026rsquo; expressed by students.\u003c/p\u003e \u003cp\u003eDespite a culture of courtesy bias, students had a thirst for feedback. Within the hierarchical and non-confrontational culture, students still wished to be \u0026lsquo;given a voice\u0026rsquo;. They desired dialogue, to be involved in the process and given a chance to justify themselves whilst maintaining their self-esteem. Feedback ideally included affirmation to psychologically prepare the student to accept corrective feedback. The influence of hierarchy caused a paradox. Students valued feedback from senior faculty more, due to respect for hierarchy, but couldn\u0026rsquo;t engage in dialogue for the same reason.\u003c/p\u003e \u003cp\u003eSo whilst acknowledging the influences of their culture, the students desired feedback delivery to be, on some occasions, counter-cultural e.g. desiring respectful tone from an elder. Opening up discourses to reduce learner-teacher interactions based upon hierarchy, rather than learning, may be beneficial.\u003c/p\u003e \u003cp\u003eA unique finding that did not align with western literature included the desire for lecturers to show \u0026lsquo;uMunthu\u0026rsquo;, exploring non-academic issues when interacting in feedback dialogue, offering a pastoral role rather than simply a delivery of facts. This may reflect the culture, but also the LMIC setting and unique challenges (e.g. hunger) these students face. In order to improve health professions\u0026rsquo; students\u0026rsquo; performance, the recommended feedback practices should be based on evidence from within the relevant context and culture.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eET wrote the main manuscript text. ET, TM and LJ contributed to data analysis. LJ contributed significant edits to the final manuscript. 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(2021). \u003cem\u003eThe World Bank in Malawi: Overview\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.worldbank.org/en/country/malawi/overview\u003c/span\u003e\u003cspan address=\"https://www.worldbank.org/en/country/malawi/overview\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Feedback, LMIC, Culture, low resource, Sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-5867708/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5867708/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWell-delivered feedback can positively influence learning behaviours and bring actual and desired performances closer together. This is especially important for patient safety in health professions education. Feedback only aids learning when used effectively and accepted by its recipients. Most current literature on effective feedback is from western perspectives that we cannot assume will be applicable to all cultures. This study seeks to contribute to discourses relating to feedback effectiveness, exploring concepts of optimizing it in a sub-Saharan healthcare education institution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis qualitative study investigated student and lecturer perceptions and experiences of receiving and delivering feedback at College of Medicine (CoM), Malawi, and how stakeholders felt this influenced self-reported behavioural change in response\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was collected using semi-structured interviews, with students and lecturers, from across all faculties at CoM, and subsequently analysed sequentially for emerging themes using a grounded theory approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInductive data analysis resulted in eight interconnected themes: conception of feedback; affective dimension; thirst for feedback; need to achieve; feedback conversations; self-preservation; feedback relationships; students’ ideal feedback which included the desire for pastoral support. Several tensions also emerged from student data: Firstly, a yearning for feedback but experiencing corrective feedback as emotional assaults requiring action for self-preservation. Secondly a preference for receiving affirmative feedback, despite acknowledging that corrective feedback can lead to improved performance. Thirdly, participants valuing dialogue highly as opportunities to seek clarification/understanding/justify themselves, which was deemed less likely with senior faculty whose feedback was paradoxically greatly respected. Whilst students greatly valued feedback from senior faculty, due to cultural respect for hierarchy, they felt less able to engage in the dialogue they desired. Finally, both stakeholder groups equated hard work with success and that critical feedback was perceived as accusations of student laziness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e‘Best feedback practices’ articulated by students mostly aligned with western educational discourses but in contrast to international literature students desired lecturers to fulfil pastoral roles rather than simply provide feedback on tasks. Cultural expectations and respect for hierarchy needs to be considered when building evidence-based feedback in a Malawian context.\u003c/p\u003e","manuscriptTitle":"Effective Feedback in Medical and Health Science Education, in Malawi: Perceptions and Experiences","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-03 09:12:28","doi":"10.21203/rs.3.rs-5867708/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3f48fa35-cd22-4d59-afc4-fc4f4d4f4922","owner":[],"postedDate":"February 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-11T09:53:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-03 09:12:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5867708","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5867708","identity":"rs-5867708","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}