Factors affecting academic failure in medical students in Iran

Background: Students are considered part of the capital of each country. Several factors can affect their educational status and, as a result, contribute to their academic failure. The current study seeks to investigate the relationship between students’ academic failure and the affecting factors with the Iranian Educational Ranking of Universities. Methods: This is a descriptive cross-sectional study. The required sample size was calculated using Cochran’s formula. A researcher-made questionnaire with 5 parts was used to collect data. Kruskal Wallis and Spearman’s analysis of variance was used for analysis. The significance level was considered as 0.05. Results: A total of 1215 people participated; 13.7% of students had had an academic failure and 2.0% of them were on academic probation. There was a correlation between university RAD rank and academic failure (r = -0.098 and P = 0.0001) as well as student satisfaction (r = 0.264 – P = 0.0001). There was a significant difference between an academic drop and academic grade in three ranks of university (Pv= 0.0001), and, interestingly, having moved from Rank 1 to 3, having academic grade increases, and having academic failure decreases. Conclusion: According to the findings of this study, the higher ranked the college campus is on the RAD scale, the higher the academic failure rate. For annual assessment of universities, it is proposed that assessment of academic failure and grades be used as a benchmark.


Introduction
Students are human capital 1 and future of all countries. 2 Several factors affect students' academic status 3 leading to academic burnout 4 and possibly academic failure. 5 . Academic failure can delay finding a job and lead to frustration, loss of morale, and ultimately result in a large cost. 6,7 According to the definition of the United Nations' Educational, Scientific and Cultural Organization (UNESCO), academic failure means repetition of grades, early dropout, and lower educational quality. 8 Studies have provided different definitions of academic failure, [9][10][11] but all have mentioned educational failure. According to these studies, various criteria such as lower scores, unsatisfactory grade point averages, repeated courses or grades, long education periods, academic probation, being expelled, leaving their programs before the arranged time, and changing disciplines are symptoms of students' academic failure [12][13][14] . Training a medical sciences student is costly [15][16][17] . It should be noted that academic failure and its consequences waste expenditures in this field1. 6,18 Universities vary widely in different regions, 19 and this can be seen in the rankings of medical sciences universities. Ranking medical sciences universities was first carried out in 2000 to assess the capabilities of medical sciences universities, and its criteria were revised over the next years. [20][21] This ranking was conducted by a plan titled "RAD" (Educational Ranking of Universities) in Iranian universities of medical sciences. This ranking focuses on five areas, namely, educational governance, educational development, educational management, qualitative development, and attention to the comprehensive scientific map of Iran. 22 Rank 1 Universities are mother universities; Rank 2 universities are developing universities, and Rank 3 Universities are newly-established universities. 23 However, there is no detailed description of how each university is placed in these three ranks . In the current study, universities were classified according to implicit explanations and available online content of universities, but it should be noted that Rank 1 universities are put in the one-third of the RAD plan ranking; Rank 2 universities are the middle one-third of the RAD plan; and Rank 3 universities are in the lower one-third of RAD plan. 21 The current study sought to investigate relationships of students' academic failure and its factors with ranks of universities.

Material and Methods
The present analytical cross-sectional study was conducted to investigate relationships of students' academic failure and various factors with the RAD rank and type of universities in 2017. A message titled "Recruitment of research colleague" with project details was first posted in the "Abdi research movement" channel of the Telegram application to selected universities, and then the primary researchers who had necessary qualifications in each type of university, were selected for this project. Shahid Beheshti University of Medical Sciences (Rank 1), Mazandaran University of Medical Sciences (Rank 2), and Abadan University of Medical Sciences (Rank 3) were selected to represent the three academic ranks to participate in this study. The sample population of each university was then estimated and the minimum necessary sample for the sampling of each university was determined using Cochran's formula. Ratios of medical, nursing, midwifery, and paramedical students were calculated for each university, and the minimum necessary sample for each discipline was calculated by multiplying sample sizes of universities. The current research used a convenience sampling method where the sample had passed at least one semester. Students had the opportunity to participate in the study and they were excluded in the case of their refusal. After obtaining necessary permits, researchers referred to the hospitals and faculties of the selected university and explained the research objective to students, then collected data without any names after obtaining verbal consent. Data were collected by using a 5-part questionnaire including the following sections: A: Demographic data including age, gender, marital status, height, weight, ABO blood group and Rh, birth order in the family, educational major, year of entering the university, grade point average in high school, grade point average at university, academic degree, number of passed courses, number of failed courses, academic probation status, father's job, mother's job, parents' education levels, economic status, distance from home to university, employment status, and smoking status. Validity and reliability of all questionnaires were evaluated; Cronbach's alpha was r=0.80 for questionnaires "B, C, and D" and r=0.84 for questionnaire "E" (24 and 25). Furthermore, research by Changizi Ashtyani et al. was used for students with average points of less than 15 or at least one probated semester to define academic failure (24).
After data collection, analytical and descriptive statistics were calculated using SPSS 16 and Graph Pad Prism 7 software for analysis. Due to the detection of abnormal distribution of findings by the D' Agostino & Pearson Omnibus test with a significance level of less than 0.0001, a non-parametric test was used for the analysis of variance (Kruskal-Wallis); and the Spearman test was used for evaluating relationships. The significance level was considered to be P<0.05 in the present research.

Results
In all, 1215 subjects participated (570 people from the Rank 1 university, 356 people from the Rank 2 university, and 289 people from the Rank 3 university). Regarding demographics, 756 students (61.7%) were female, and the average age of all participants was 20.22± 2.62 years. Very few students (74; 6.3%) were married. Blood types of A-and O-had the highest prevalence. A total of 365 students (30.2%) were smokers and most participants were the first-born children. Mean weight and height were 64.89± 13.49 and 169.35± 8.50, respectively and most had acceptable body mass indexes (BMIs). A total of 507 students (42.0%) were referred to the counseling center of the university for counseling. An average point of less than 15 accounted for about 1 percent of average points at high schools, while this range accounted for 158 students (13.09%) of average points at universities. Most students had parents with academic degrees and they entered universities immediately after pre-university and were native to provinces of their education. The average response to research questions was 89.4% (Table 1).
According to student satisfaction with academic majors, 96.7% of medical students, 73.8% of nursing and midwifery students, and 62.4% of paramedical students were satisfied with their majors, with a total student satisfaction score of 24.95±4.33. Satisfaction had the highest direct relationship with interest in majors, motivation for continuing education, and parent education, but inverse relationships with major, university rank, and time lag between preuniversity and university (Table 2). Most students had a moderate focus on studying. They liked a free and flexible study method and considered they spent less than an hour per day for study. Most (716) used the Internet for more than 6 hours per day, but 807 students (66.6%) used the internet for their lessons for less than 2 hours. About half lived in dormitories, and 84 students (7.0%) used quotas other than regional quotas. Most students had an intense or moderate interest in their majors and were interested in the continuation of their education and had chosen their majors due to personal interest, but only 282 students (39.7%) "always" or "often" attended classrooms. About half of students found it difficult to access supervisors and advisors. More than half of students considered their specialized courses to be "good" or "excellent", and most reported excellent college education quality. Regarding other factors influencing dropout, 99.1% were responsible (Table 3).
In terms of preventive factors of students' academic failure in all three academic ranks, three options, namely, the educational quality of faculty, the use of expert professors, and improved facilities in dormitories, had the highest impact. on factors preventing students' educational dropout at 98.4 % responsiveness (Table 4).
According to the current study, 166 students (13.7%) experienced academic failure and 2.0% were on probation. In all, 441 students (36.8%) were native to provinces of their education study, and their total score was 25.21±4.33. A total of 82 (17.6%) nursing and midwifery students, 53 (15.1%) medical students, and 31 (8.3%) paramedical students had academic failure ( Table 5). The difference in academic failure and grade point average was significant at three university ranks according to the Kruskal-Wallis test. The average point increased and the academic failure was reduced by moving from Rank 1 to 3. A total of 75 students (45.12%) were referred to counseling centers.
According to the investigation of factors of students' academic achievement, the highest impacts were seen in student motivation, student self-confidence, and interest in the continuation of education at all three ranks; the mean score of factors related to the learner dimension was 6.55±17.65 (out of 25 points), 8.40 ± 27.04 (out of 40) for the educator dimension, 5.46± 17.03 (out of 25) for the educational environment facilities, 2.97± 9.57 (out of 15) for the family dimension, and 4.26± 13.33 (out of 20 points) for the socioeconomic dimension. In all, 97.5% of students answered about the factors affecting their academic achievement (Table 6).

Discussion
According to the results of this study, the higher the university rank , the higher the academic failure rate. The prevalence of academic failure is notable in academic ranks, and the academic educational failure in better ranks conveys the message that there are problems in  9 Students with better ranks choose universities with better ranks. Furthermore, universities with better ranks allocate higher budgets for education. The academic failure of these universities could lead to two hypotheses, 1) universities with better types were stricter than lower-type universities, leading to student failure, or 2) universities with better types had lower educational qualifications. According to the Ministry of Health policy reports on the accreditation of educational systems, universities with better types had almost the same position in educational accreditation. 22 Therefore, the researchers' second hypothesis was less likely to occur and the hypothesis that universities with better types are stricter than lower-type universities leading to student failure to get more power. As in previous studies, there was an inverse relationship between academic failure and female gender in the present research, 10 but it was inconsistent with studies by Tagharrobi et al., and Hoseini et al. on the greater incidence of academic failure in females. 26,27 Academic failure also had an inverse relationship with age, but no

Direct Correlation (r-spearman) Reverse correlation (r-spearman)
Interest to the field of study (0.445) field of study (-0  relationship was seen with marriage. 10 It should be noted that, unlike previous studies, there was no relationship between academic failure and other demographic characteristics such as economic status of family members or parents' education, degrees, or jobs. 24,[28][29][30] Distances between students' homes and universities and time lag between high school and the university had no relationship with academic failure, contrary to studies by Dehbozorgi et al. and Vanhanen and Janhonen. 31,32 About 1 percent of high school students had average points of below 15, while 13% of university students averaged points below 15. Furthermore, the average point of above 18 at high schools dropped by almost 71 percent at universities. Unlike other studies, there was no relationship between academic failure with university or high school average points. 11,24 Satisfaction with academic majors had an inverse relationship with university types; in other words, universities with better types showed students had lower satisfaction with their major; and this difference was significant. Furthermore, academic majors had a significant impact on satisfaction with major, meaning that by moving from medicine to nursing, midwifery, and paramedics, the satisfaction with major was reduced, and this was consistent with the previous studies. 13,[33][34][35] According to studies on relationships of the academic failure with determinants of academic failure (Table 5), it was found that concentration in the classroom is the single most important and simple factor in preventing academic failure. Increasing the order in the research can also reduce students' academic failure. This was confirmed by the previous studies. 27,[34][35][36] Among determinants of preventing academic failure in terms of students' views, improved educational quality of universities and colleges and recruitment of experienced professors along with improving facilities of universities and faculties can be effective in preventing this, but it is necessary to pay attention to determinants of academic achievement in addition to determinants of academic failure. From students' perspectives, all three factors with the greatest impact on academic achievement were reliant on students. Creating an appropriate educational environment can help to prevent academic failure, but the current study found that students considered motivation and high self-confidence for the continuation of study as effective factors in their academic achievement.

Conclusion
The findings of the current research were very broad and practical, but the most important finding was an inverse relationship of the university RAD rank type with students' academic failure and satisfaction with their majors because students' academic failure in a better university type wastes more capital cost. Based on the findings of the current research, the self-discipline among students who attend better-ranked universities had a higher significant effect on students' performance; and satisfaction with majors could support researchers' perspectives in this study. The current research was not a conclusion to studies on academic failure at medical universities because academic failure is a variable subject dependent on many factors. Therefore, based on researchers' experiences in the current study, it is suggested to evaluate the academic failure and average points as criteria for annual evaluation of universities to prevent the loss of human capital by better management.
It should be noted that it was difficult to conduct this study because there was little inter-university cooperation and the issue of registering research separately at each university was a deterrent that postponed the research and delayed its implementation. It is suggested to create a comprehensive system for inter-university studies to conduct more high-quality studies with a larger network of researchers.

Competing interests
We did not have any conflict of interest with any organization or individual in this study.

Authors contribution's
All authors contributed to this article and met the standard criteria for authorship. All authors contributed to the writing of the various sections. There is no contributor whose name is not included in the article.