Effect of Gender on Performance of Undergraduate Dental Students at the University of Jordan, Amman

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1 Effect of Gender on Performance of Undergraduate Dental Students at the University of Jordan, Amman Faleh A. Sawair, B.D.S., F.D.S., R.C.S.(Eng.), Ph.D.; Zaid H. Baqain, B.D.S., M.Sc., F.D.S., R.C.S.(Eng.); Iyad Kh. Al-Omari, B.D.S., M.Sc., M.Orth., R.C.S.(Ed.); Fouad K. Wahab, D.D.S., M.Sc., Ph.D.; Lamis D. Rajab, D.D.S., M.Sc., Ph.D. Abstract: The purpose of this study was to see if gender-based differences exist in the performance of dental students at the University of Jordan (UJ), Amman. The retrospective analysis included data from two groups of students: 413 fourth-year dental students (178 males and 275 females) from four consecutive years (2005 through 2008) and 357 fifth-year students (128 males and 229 females) who graduated in the years 2005 to The influence of gender on the results of the fourth-year students in six theoretical and six clinical courses and the cumulative GPAs of the fifth-year students were studied. In both theoretical and clinical fourth-year courses, multivariate analysis of variance (MANOVA) revealed significant main differences in raw scores between the two gender groups. Female students were significantly better in five theoretical courses. In clinical courses, female students outscored male students in pediatric dentistry and prosthodontics, male students outperformed female students in conservative dentistry and orthodontics, and no significant gender differences were seen in oral surgery and fixed prosthodontics. The cumulative GPAs of the female graduated students were significantly higher than those of the male students. The results showed a significant relationship between gender and academic performance of dental students for these classes. The reasons for these findings should be further investigated. Dr. Sawair is Associate Professor, Department of Oral and Maxillofacial Surgery, Oral Medicine, Oral Pathology, and Periodontology; Dr. Baqain is Associate Professor, Department of Oral and Maxillofacial Surgery, Oral Medicine, Oral Pathology, and Periodontology; Dr. Al-Omari is Associate Professor, Department of Paediatric Dentistry and Orthodontics; Dr. Wahab is Professor, Department of Conservative Dentistry; and Dr. Rajab is Professor and Dean all in the Faculty of Dentistry, University of Jordan, Amman. Direct correspondence and requests for reprints to Dr. Faleh Sawair, Faculty of Dentistry, University of Jordan, Amman 11942, Jordan; , ext phone; sawair@ju.edu.jo. Keywords: dental education, gender, undergraduate, dental student, examinations, Jordan, academic achievement Submitted for publication 4/27/09; accepted 7/20/09 Jordan is a Middle Eastern country that has a total population of 5.7 million 37 percent of whom are less than fifteen years of age (2007 estimate). 1 Nearly 39 percent of the citizens live in the capital city of Amman. The primary language is Arabic, and the religion of nearly 93 percent of the people is Islam. The country has given great attention to education; the literacy rate was 92.1 percent in In the 2004 census, nearly 24 percent of adults twenty years of age and older had a university education. 1 The structure of the educational system in Jordan consists of ten years of compulsory primary education followed by two years of secondary education that can either be academic or vocational depending on students achievement in primary school and their preference. Secondary education includes several academic options in which students can enroll: science, arts, information technology, religion, and others. At the end of their secondary education, students have to pass the General Secondary Examination (GSE) in their selected branch to be awarded the General Secondary Education Certificate (GSEC). Thereafter, students apply for universities, competing according to their grades in the GSE; however, vocational education qualifies for community colleges or the job market. 2 The schools of medicine and dentistry are almost always the most competitive for students, requiring the highest grades in the GSE. Since there are only two dental schools in Jordan, the graduates of the entire nation compete for a limited number of seats. Dental education in Jordan is based on five full calendar years (three semesters) to obtain the bachelor s degree. The first three years of the curriculum include general science, basic medical and dental sciences, and preclinical dental courses; the last two years include clinical sciences and clinical training. Before being allowed to practice dentistry in the United States, holders of the Jordanian bachelor s degree in dentistry are usually November 2009 Journal of Dental Education 1313

2 asked to obtain certification from an accredited dental school in the United States that they have completed a minimum of two years of clinical training, but they can pursue a master s or Ph.D. degree without additional requirements in the United Kingdom. In 2007, females in Jordan comprised slightly less than half of the population (48.5 percent). 1 However, more females than males are enrolling in Jordanian universities. 3 In the academic year , 64.7 percent of the students at the University of Jordan (UJ), the largest and oldest university in the country, were females compared to 58.5 percent in the year The growing proportion of females is more dramatic when only first-year students were considered: nearly 70 percent in the academic year at the UJ were females. 3 The gender distribution at the School of Dentistry at the UJ also has a majority of female dental students. For example, in the academic year , 75.4 percent of the dental students were females. 4 The potential role gender plays when studying students academic performance is becoming increasingly more important. While research has found that female medical students did better than male students in examinations, 5-8 the question concerning gender differences in the performance on dental examinations is yet unresolved. While some studies have shown that males performed better than females, 9-11 other researchers reported no gender difference in the performance of dental students. In light of the inconsistent findings and the lack of similar studies in our region, our study was carried out to investigate if gender has an influence on the performance of dental students at the UJ. Methods The sample consisted of two groups of students. The first group included fourth-year dental students at the UJ who were examined in several dentistry courses between 2005 and Data from six fullyear courses (conservative dentistry, fixed prosthodontics, removable prosthodontics, oral surgery, pediatric dentistry, and orthodontics) that have both theoretical and practical (clinical) elements were included in the analyses. The students performance in the theoretical and clinical parts of the courses were analyzed separately to explore if there were gender differences in these academic outcomes. The scores included in the analyses were determined as follows. In the theoretical courses, the students took three online computer-based tests that consisted of single best answer questions. The students overall raw score of maximally 100 was determined by adding the scores in two midterm examinations (maximally twenty-five points each) and in the final examination (maximally fifty points). In the practical courses, the final raw score of 100 is the sum of sixty possible points for the clinical requirements completed throughout the year and forty points in a final clinical examination that includes case management questions and presentation. Ultimately, these raw score points are converted into the relative scoring system, which is based on letter grades (A, B+, B, C+, C, D+, D, F). The final letter grade is the one officially used, and it is determined relative to the distribution of scores achieved by all students in the class. Currently, no strict rules at UJ are being followed by instructors when converting the raw scores into letter grades; therefore, raw scores will be given more weight in this study. The second group of students included in this study consisted of fifth-year students who graduated in the years 2005 to The dental school cumulative grade point averages (GPAs) upon graduation for male and female students were compared. The cumulative GPA at UJ is out of 4.0 points and is categorized into excellent (3.65 to 4.0), very good (3.0 to 3.64), good (2.50 to 2.99), satisfactory (2.0 to 2.49), and weak (<2.0). Access to the students grades was granted by the registrar of the university. The data were analyzed with SPSS Version 16 (SPSS, Chicago, IL, USA). Multivariate analysis of variance (MANOVA) was used to compare the raw scores of fourth-year male and female students on the six theoretical and six clinical courses. The Wilks statistic was used to determine significance of each effect. Follow-up univariate ANOVAs were generated for each significant effect. The cumulative fifth-year GPAs were calculated, and student s t-tests were used to test whether male and female students differed significantly. The gender differences in the distribution of the letter grades in each theoretical or practical course for fourth-year students and the GPA grades for graduating fifth-year students were tested using chi-square tests. The gender of the students who obtained the ten highest and lowest cumulative GPA values was recorded, and chi-square tests were used to determine statistical significance. Results were considered significant if p-values were less than or equal to Journal of Dental Education Volume 73, Number 11

3 Results The fourth-year study group consisted of a total of 413 students, of whom 275 (66.6 percent) were female and 138 (33.4 percent) were male. The number of students per year ranged between ninety and 130, and the yearly female-male ratio did not differ significantly from year to year, being around 2:1. A total of 357 students graduated between 2005 and 2008, with 229 students (64.1 percent) being female and 128 (35.9 percent) being male. The number of graduated students per year ranged from seventy-nine to 100 (mean=89 students). Results from MANOVA analysis of the theoretical fourth-year courses revealed a significant main effect for gender, Wilks λ=0.968, F(6, 406)=2.23, p= Follow-up univariate ANOVAs revealed significantly higher mean scores for female students relative to male students in all six theoretical courses except orthodontics (Table 1). When letter grades were considered, female students had significantly higher letter grades in all courses except orthodontics and fixed prosthodontics. In clinical courses, MANOVA revealed significant main differences in raw scores between the two gender groups, Wilks λ=0.875, F(6, 406)=11.64, p< The results of the follow-up univariate ANOVAs showed less consistent effect of gender on the performance in different courses (Table 2). Male students had significantly better raw scores in conservative dentistry and in orthodontics; female students achieved significantly higher scores in removable prosthodontics and pediatric dentistry; and the two gender groups did not differ significantly in their scores in oral surgery and fixed prosthodontics. When the raw scores were converted to letter grades (Table 2), female students also showed significantly better results in fixed prosthodontics, but the significant difference between the two gender groups in orthodontics was lost. The overall results of the graduated fifth-year students in the years 2005 to 2008 are presented in Table 3. Female students had significantly higher average cumulative GPAs compared to males. A slightly higher percentage of male students had excellent grades upon graduation, but they had Table 1. Average grades of male (n=138) and female (n=275) students in six theoretical dentistry courses Raw Scores Letter Grade Course Name Gender Mean ±SD P value* <C C/C+ B/B+ A P value** Conservative Male 68.9 ± % 37.0% 41.3% 7.2% Dentistry Female 70.6 ± % 34.5% 41.5% 16.0% 0.02 Total 70.0 ± % 35.4% 41.4% 13.1% Fixed Male 70.3 ± % 39.4% 37.2% 10.9% Prosthodontics Female 72.3 ± % 32.6% 45.7% 12.3% 0.30 Total 71.6 ± % 34.9% 42.9% 11.9% Removable Male 65.1 ± % 40.0% 43.7% 5.9% Prosthodontics Female 66.7 ± % 36.2% 45.7% 12.7% 0.05 Total 66.1 ± % 37.5% 45.0% 10.5% Oral Surgery Male 71.9 ± % 41.3% 50.0% 7.2% Female 73.6 ± % 29.7% 50.7% 18.1% Total 73.1 ± % 33.6% 50.5% 14.5% Pediatric Male 73.4 ± % 43.7% 42.2% 7.4% Dentistry Female 76.2 ± % 29.5% 51.4% 15.1% Total 75.3 ± % 34.1% 48.4% 12.6% Orthodontics Male 64.1 ± % 42.8% 44.2% 9.4% Female 65.4 ± % 32.8% 47.8% 12.0% 0.14 Total 64.9 ± % 36.2% 46.6% 11.2% *P value of follow-up univariate ANOVAs **P value of chi-square test (df=3) November 2009 Journal of Dental Education 1315

4 Table 2. Average grades of male (n=138) and female (n=275) students in six practical dentistry courses Raw Scores Letter Grade Course Name Gender Mean ±SD P value* <C C/C+ B/B+ A P value** Conservative Male 72.8 ± % 30.2% 50.0% 19.0% Dentistry Female 70.7 ± % 43.0% 41.9% 11.9% 0.01 Total 71.5 ± % 38.9% 44.4% 14.1% Fixed Male 64.5 ± % 29.1% 41.8% 17.9% Prosthodontics Female 65.2 ± % 31.7% 52.9% 11.2% Total 65.0 ± % 30.8% 49.3% 13.3% Removable Male 69.6 ± % 52.6% 33.3% 5.9% Prosthodontics Female 72.9 ±7.1 < % 32.5% 50.2% 12.6% <0.001 Total 71.8 ± % 39.1% 44.7% 10.4% Oral Surgery Male 84.7 ± % 64.7% 12.5% Female 85.2 ± % 68.2% 14.1% 0.46 Total 85.0 ± % 67.1% 13.6% Pediatric Male 73.0 ± % 61.1% 20.0% 7.4% Dentistry Female 79.6 ±9.9 < % 31.1% 50.2% 14.6% <0.001 Total 77.6 ± % 40.1% 41.1% 12.4% Orthodontics Male 67.1 ± % 36.5% 49.6% 8.0% Female 65.2 ± % 42.9% 38.9% 8.0% 0.14 Total 65.8 ± % 40.8% 42.5% 8.0% *P value of follow-up univariate ANOVAs **P value of chi-square test (df=3) also higher percentages of acceptable and good grades, while female students had higher percentage of very good grades; these variations were close to statistical significance (p=0.06, df =3). When the lower and upper two grades were combined, significant differences were noted: 49.8 percent of females had very good or excellent grades compared to 37.5 percent for males (p=0.03, df=1). Although more graduated female students were within the highest 10 GPA values group compared to males, this difference was not statistically significant. In contrast, significantly more male students were within the lowest 10 GPA values group compared to female students (Table 3). Discussion At the UJ, females outnumber males in all schools except medicine and engineering, where they total around 40 percent of registered students. 4 A higher percentage of female students are enrolling in the dental school at UJ than in other countries such as the United States. 11,12 In 2004, females comprised 42.2 percent of dental school admissions in the United States compared to 64.8 percent in UJ in the same year. 15 However, the fact that women are now the majority on college campuses is not unique to Jordan; in the United States, the percentage of all undergraduates who were male had dropped from 44 percent in to 42 percent in The desire for social status, prestige, and high income are the usual motives for Jordanian students who excel in the GSE to choose medicine, dentistry, pharmacy, or engineering, in that order, when they apply to university. It is possible that Jordanian women find dentistry more acceptable culturally than medicine and engineering, believing they will be able to balance more effectively their personal and professional lives. Therefore, it is essential to study and tackle issues that may restrict the career options of Jordanian females and to encourage males to pursue college education, including dentistry; perhaps these issues are best addressed as early as elementary and secondary schools. Admission to Jordanian universities depends on the outcome of the GSE only. Given the enrollment 1316 Journal of Dental Education Volume 73, Number 11

5 Table 3. Fifth-year students results for 2005 through 2008 Highest 10 Lowest 10 Out of 4.0 Grades GPA values GPA values (P=0.02)* (P=0.06)** (P=0.70)*** (P=0.02)*** Acceptable Good Very Good Excellent Gender N (%) Mean ±SD N (%) N (%) N (%) N (%) N (%) N (%) Male 128 (35.9%) 2.91 ± (14.1%) 62 (48.4%) 41 (32.0%) 7 (5.5%) 16 (12.5%) 25 (19.5%) Female 229 (64.1%) 3.0 ± (7.9%) 97 (42.4%) 103 (45.0%) 11 (4.8%) 32 (14.0%) 24 (10.5%) Total 357 (100%) 2.97 ± (10.1%) 159 (44.5%) 144 (40.3%) 18 (5.0%) 48 (13.5%) 49 (13.7%) Acceptable: GPA , Good: GPA , Very good: GPA , Excellent: GPA *P value of student s t-test (df=1) **P value of chi-square test (df=3) ***P value of chi-square test (df=1) numbers at the UJ, it is obvious that female students perform better on this examination than do male students. Analyses of the academic performance of male and female dental students also demonstrated a mostly superior performance of females in university education. The reason for this difference is not clear; one consideration could be that achieving higher grades in GSE and enrolling in universities might increase female students chances to enter the labor market. Jordanian females currently form only 14.7 percent of the Jordanian working population. 1 Women who do not finish secondary school or have a university degree find fewer work opportunities in Jordan compared with men, who can choose other alternatives such as military service, construction, transportation, commerce, and technical professions. It is possible that young Jordanian females are aware of this low representation and therefore take these examinations as a challenge in a conservative society with a high literacy rate. This could explain our observation that female dental students work harder and are less likely to miss lectures than their male peers. They are also more likely to seek and receive support from staff. In the United States, there is no consensus on the causes of the gender gap in undergraduate enrollment and bachelor s degree attainment; possible reasons have been reported to fall into three major categories: economic incentives, school effects, and social-psychological factors. 16 A few studies 9-14 have looked at gender differences in the achievement of dental students, and most of these were done in the United States. No data have been published by any other dental or medical schools in the Arab or Muslim worlds. Previous results have ranged from no difference to males doing marginally better Interestingly, no previous studies have looked at gender variations in performance of dental students in theoretical versus clinical subdivisions of dentistry courses. In our study, female dental students outperformed their male counterparts in theoretical courses, but their performance was inconsistent in clinical or practical courses. The latter is independent of the amount of time spent studying, but involves patient management and performance of manual skills that may not be associated with gender. Males were reported to demonstrate greater spatial abilities than females, particularly in speed of mentally manipulating objects or forms such as speeded rotation ability, kinesthetic ability (rapid left-right object discriminations), and spatial orientation ability. 17 This gender difference in spatial abilities could explain the outperformance of males in clinical orthodontics, which mainly involve exercises in wire bending to form different three-dimensional shapes, and in clinical conservative dentistry, in which students are asked to prepare cavities of different designs and on different teeth and surfaces sometimes with indirect working methods through dental mirrors. Although it is difficult to explain the gender difference favoring female students in removable prosthodontics, the possibility that female students are more willing and patient in treating children 18 may explain in part their better performance in clinical pediatric dentistry. As practical courses constitute less than one-third of the credit hours in the dental curriculum at the UJ, females showed better-quality performance in the cumulative overall results of graduated students. Although the results in the theoretical courses are unlikely to be due to examiner bias because the examinations are machine-marked and unadjusted, November 2009 Journal of Dental Education 1317

6 the effect of examiner bias is hard to rule out in the clinical evaluations. Academic success has been found to be a significant predictor of postgraduate achievement. 19 Unexpectedly, women comprise only around onethird of the academic staff currently working at the UJ dental school; the ratio is even lower in the UJ at large. Although women comprise nearly two-thirds of the teaching assistants (TA) working in 2008, they are less than one-quarter (24.7 percent, 317/1285) of the whole academic staff. 4 TAs at the UJ are usually top graduates and are offered scholarships to pursue postgraduate studies abroad, mainly in the United States and United Kingdom. However, a significant number of Jordanian females find it difficult to travel abroad unaccompanied to follow postgraduate education that qualifies them to become academic staff on returning. There is evidence that this attitude is changing at the UJ; the proportion of newly appointed female staff is growing. While females represented only 6.9 percent of the full professors in the year 2008, they constituted 12.6 percent of associate professors and 21.1 percent of assistant professors. 2 In addition, one-third of faculties have female deans. Although Jordanian female dentists have equal work opportunities compared to their male counterparts, all women in the profession of dentistry are essentially striving for a balance between their profession and family commitments. 20 Jordanian female dentists are challenged by professional competition, the increased cost of business management, and acquiring the latest materials and equipments. It is our observation that generally Jordanian female dentists prefer to work as assistant dental practitioners or in community dental services rather than having their own dental practice. To commit more time to parenting, they seek part-time posts with fewer working hours; therefore, their work opportunities are more restricted than those of their male colleagues. For cultural reasons and family commitments, women dentists usually decline to work in rural places or distant areas from their homes when offered jobs by the ministry of health. The requirements for maternity leave or break to care for children make it extremely difficult to maintain their jobs, particularly in the private sector. As in other countries, 20 those who take long career breaks may find it difficult to return to dentistry for reasons such as lack of confidence, lack of updated knowledge, and family commitments. In Jordan, there are no Keeping in Touch and Getting Back to Practice courses 20 that can help female dentists return to practice following career breaks. Conclusions Jordanian female dental students outperform males in dentistry courses. The reasons for these findings should be investigated. The results of this study could also be used to attract more attention to study variations in skills between male and female dental students in practical courses. Finding ways to help new female dental graduates join the dentistry practice, to facilitate their return to the profession after career breaks, and to facilitate female postgraduate education is equally essential. REFERENCES 1. Department of Statistics, The Hashemite Kingdom of Jordan. At: htm. Accessed: April 20, Ministry of Education, The Hashemite Kingdom of Jordan. At: Accessed: July 4, Ministry of Higher Education, The Hashemite Kingdom of Jordan. At: aspx. Accessed: August 30, Documentation Section, Department of Media and Public Relations, University of Jordan. At: Figures/Forms/AllItems.aspx. Accessed: July 14, Haq I, Higham J, Morris R, Dacre J. Effect of ethnicity and gender on performance in undergraduate medical examinations. Med Educ 2005;39(11): McDonough CM, Horgan A, Codd MB, Casey PR. Gender differences in the results of the final medical examination at University College Dublin. Med Educ 2000;34(1): Krueger PM. Do women medical students outperform men in obstetrics and gynecology? Acad Med 1998;73(1): Fabrega H Jr, Ulrich R, Keshavan M. Gender differences in how medical students learn to rate psychopathology. J Nerv Ment Dis 1994;182(8): Potter RH. Application of a structural relationship model to gender-related student performance. J Dent Educ 1986;50(9): Coy K, McDougall H, Sneed M. Issues regarding practical validity and gender bias of the Perceptual Abilities Test (PAT). J Dent Educ 2003;67(1): Fields HW, Fields AM, Beck FM. The impact of gender on high-stakes dental evaluations. J Dent Educ 2003;67(6): Stewart CM, Bates RE Jr, Smith GE, Young L. Impact of gender on dental state licensure examination performance. J Dent Educ 2006;70(5): Casada JP, Cailleteau JG, Seals ML. Predicting performance on a dental board licensure examination. J Dent Educ 1996;60(9): Graham JW. Comparison of males and females in the dental admission testing program. J Dent Educ 1976;40(12): Journal of Dental Education Volume 73, Number 11

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