Evolution of Universal Human Values Among Medical Students in India—A Cross-Sectional Study

Abstract

Objective

The purpose of higher education, particularly in the medical fields, is to serve humanity, and reflect on core values such as compassion, care, and empathy. This study examines how medical students uphold moral values as they progress through their education, addressing a research gap in the Indian context.

Methods

After obtaining Institutional Ethics Committee approval, a cross-sectional survey was conducted using a self-administered Google questionnaire. Content validity was ensured through consultations with 5 experts, and reliability was confirmed with a Cronbach's alpha coefficient of .75. Data were collected from medical students in India using snowball sampling and analyzed using median, interquartile range, chi-squared test, Pearson correlation coefficient, and multiple regression analysis. The sample size was set at 518, taking into account the nonresponders.

Results

Of 1500 invites, 526 students responded, which corresponds to a response rate of 35.06%. Reliability analysis revealed a high internal consistency (α = .927), and the data were suitable for factor analysis (Kaiser–Meyer–Olkin = 0.929). Principal component analysis identified three factors: Authority and Materialism, Enjoyment and Adventure, and Ethics and altruism, which explained 56% of the variance. Significant gender differences in Ethics and altruism were found. Correlation analysis revealed moderate positive relationships between authority and materialism and both enjoyment and adventure and ethics and altruism. Multiple regression showed that authority and materialism significantly impacts ethics and altruism (β = 0.684, p < .001), whereas enjoyment and adventure had a nonsignificant influence. Women performed better than men in ethics and altruism. This finding is discussed taking into account the unequal gender distribution.

Conclusion

The study shows that medical students prioritize ethics and altruism over authority and materialism, with enjoyment and adventure playing a balancing role. The significant influence of authority and materialism on ethics and altruism suggests that competitive and materialistic values influence ethical priorities. Understanding how different factors impact values and well-being can guide educators and policymakers in fostering ethical practices and supporting student resilience.

Introduction

The primary goal of higher education and a crucial aspect of the medical profession is to serve humanity. ¹ Medical professionals are meant to embody compassion, empathy, and care. Education is crucial in fostering virtues like self-control, selflessness, accountability, and helpfulness.^2,3 However, the current crisis of human values that society is experiencing affects the medical field as well. Among the reasons for this crisis are urbanization, a highly competitive environment, and a commercial outlook on life. ⁴

The rigorous patient interactions, long working hours, heavy workloads, and lack of support often cause students pursuing medical training to suffer from extreme stress and burnout. This stress can negatively impact patient care, faculty relationships, cynicism, and even attrition from the field. Many students demonstrate resilience by adhering to the core values ​of the medical profession in the face of these challenges. Knowing how these pressures impact the development and prioritization of moral values during training is critical to promoting the personal and professional development of future healthcare providers. ⁵

Previous research, such as like Ardenghi et al noted gender-based differences, such as men medical students scoring higher on self-centered orientations, and emphasized differences in personal values between medical and nursing students. This emphasizes the significance of investigating the formation of values within the particular setting of medical education. ⁶ Students’ professional development is significantly impacted by the difficult experiences of moral dilemmas during clinical practice. These conundrums frequently entail resolving conflicting morals, handling outside demands, and forming their professional identities. In order to develop strategies that assist students in developing moral resilience and confidence, it is critical to comprehend these challenges. ⁶ Although previous research highlights the significance of moral principles and the necessity of maintaining them, little is known about how these principles change as students advance through their medical education. Since it is frequently believed that moral principles may deteriorate as students move into later training years, it is essential to investigate this development. This study examines how moral values change as students advance through their academic careers and whether year-to-year variations have an impact on these values within the particular sociocultural context of Indian students. ⁷

While the existing literature emphasizes the importance of moral values and the need for them to maintain them, there is limited research on how these values develop over the course of students’ medical education. It is often assumed that moral values may decline over the later years of education, making it important to examine this progression. This study examines the development of moral values over the course of their academic careers and examines whether seasonal fluctuations influence these values in the unique sociocultural context of Indian students.

Material and Methods

A self-administered Google questionnaire on the “Evolution of Universal Human Values Among Medical Students” was used to conduct a cross-sectional survey following approval from the Institutional Ethics Committee (SRMIEC-ST0923-724). The survey's questions followed the checklist for reporting online surveys’ results (CHERRIES). Taking into account a number of variables based on Schwartz's Theory of Basic Human Values, the questions were created to assess a variety of human values, such as self-direction, stimulation, success, harmony, self-discipline, and benevolence. Changes were inferred based on the variations among year groups. ⁸ The reporting of this study conforms to the STROBE statement (https://www.equator-network.org/reporting-guidelines/strobe/) (Appendix1). ⁹

To ensure content validity, five teachers with expertise in the construct being measured were consulted. They were certified in universal human values ​(UHV) through the All-India Council for Technical Education Level 1 course and had experience in medical education. From 1 (not relevant) to 4 (very relevant), each item was rated based on how relevant it was to the construct. The calculated item-level content validity index (I-CVI) was 0–8. Cronbach's alpha coefficient, which measures response reliability, yielded a value of 0.75, indicating satisfactory internal consistency. In order to uncover unclear questions or errors in the questionnaire, a pilot test was also carried out with 50 participants who were not part of the final sample. After IEC approval, data were collected by distributing a Google questionnaire to Indian medical students

Inclusion criteria:

Medical students enrolled in Indian medical colleges from the first professional year to the third professional year.

Exclusion criteria:

Interns who had completed a mandatory rotational medical internship or a mandatory rotational residential internship.

Students who declined to participate in the study.

Snowball sampling was used to encourage participants to recommend other potential participants within their networks. Google Forms was used to create the survey and WhatsApp was used to distribute the link.^10,11 IP restrictions and timestamp validation prevented multiple entries and participation was completely voluntary. Written informed consent was obtained from respondents prior to participation. Once a participant received the link, they were given one week to respond. If no response was received, a reminder was sent via WhatsApp. After waiting another week without a response, the participant was not contacted further. Data collection was done from June to August 2024.

A total of 25 questions were created, which were divided into several sections. For these sections, information about respondents was first collected, including gender, year of study, place of residence, and socioeconomic status. A 5-point Likert scale was used to answer the questions, with 1 indicating complete disagreement and 5 indicating complete agreement. According to the following criteria, participants were asked to select the answers that best reflected their opinions: 1 = strongly disagree: you completely oppose the statement, believing it never reflects your opinion in any situation; 2 = disagree—mostly disagree with the statement, with rare exceptions; 3 = neutral—neither agree nor disagree with the statement, or agree about 50% of the time; 4 = agree—mostly agree with the statement, with rare exceptions and 5 = strongly agree—you completely agree with the statement and think that it accurately reflects your opinion at all times (see Appendix-2; for survey questionnaire).

After a thorough review, the responses were grouped by percentage and frequency. JASP Team (2023) JASP (version 0.16) was used to analyze the data. ¹² To examine possible relationships between contextual variables, the chi-square test was used. In addition, correlations between principal components were determined using multiple regression and Pearson correlation coefficient. The sample size was calculated using the Yamane formula.

$$n=\frac{N}{1=N(e^2)}$$

(2)

Where n = desired sample size.

N = total number of populations.

e = level of precision fixed at 0.05.

It is estimated that 91 927 medical students are enrolled in courses across India (P). ¹³ Using this value (P), the calculated sample size was 398.26. To account for a 30%, increase due to potential nonrespondents, the total sample size was adjusted to 517.738, which was rounded to 518 students (Figure 1).

Figure 1.

STOBE flow diagram.

Results

A total of 526 students out of 1500 invites responded, resulting in a response rate of 35.06%. Data saturation was reached as no new themes or significant variations were observed after analyzing the responses from the final 526 participants. Reliability analysis showed a high internal consistency with an alpha coefficient of .927. The Kaiser–Meyer–Olkin measure was 0.929, indicating suitability for factor analysis. Bartlett's test of sphericity was significant (χ² = 4295.988, P < .001), confirming that the variables are not completely independent. Principal component analysis (PCA) was employed to reduce the dimensionality of the data. According to the analysis, the first component correlates with items 1–5, the second component with items 6–11, and the third component with the remaining 14 items. The analysis identified three key factors that collectively explain 56% of the total variation in the data: authority and materialism, which accounts for the largest share at 30%; enjoyment and adventure, contributing 15%; and ethics and altruism, which explains 11%, with authority and materialism emerging as the most influential factor. Among the students who replied, 336 were women (63.87%) and 90 were men (17.11%). Three hundred sixty-eight (69%) of them were students living in hostels, while 158 (30%) were day scholars. Private colleges accounted for 478 (90-87%) and Government colleges for 48 (9-19%). One hundred thirty (24.92%) of the 526 students who replied were MBBS first-year students, followed by 132 (25.09%) second-years, 137 (26.04%) third-years, and 126 (23.95%) fourth-years. A total of 109 students (20.72%) chose not to reveal their socioeconomic status. Twelve (2.63%) were from low socioeconomic status, 214 (51.31%) were from middle socioeconomic status, and 191 (45.58%) were from high socioeconomic status. No adjustments were made for potential confounders such as socioeconomic status or place of stay, and continuous variables were not categorized in this analysis. In general, responses to questions about human values were positive, with means above 3, with the exception of “I like the sense of authority and power to command others.”

The null hypothesis was rejected at the five percent significance level by the t-test, which revealed P-values greater than .05 for 24 statements. While PCA components 1 (authority and materialism) and 2 (enjoyment and adventure) did not show any differences between men and women students, PCA Component 3 (ethics and altruism) did reveal a significant difference. The three components were compared using the student's t-test; PCA1, 2, and 3 revealed no discernible differences between government and private college students, day scholars or those residing in hostels, socioeconomic status, or academic year.

The Friedman Test results indicate that students’ median ranks for value-based dimensions differ significantly from one another. With a median rank of 4 out of 25, ethics and altruism were found to be the most significant dimension. Enjoyment and adventure came next, with a median rank of 4.0. Materialism and authority came in third with a median rank of 3–4 (Table 1). These differences are statistically significant at the 1% level, as confirmed by the chi-square value of 125.462 and the P-value of less than .001.

Table 1.

Friedman test for significant differences in median among value-based dimensions.

Factors of job description	Median	Chi-square value	P-value
Authority and materialism	3.4	125.462	< .001**
Enjoyment and adventure	4.0
Ethics and altruism	4.25

Note. ** Denotes significant at 1% level.

The value-based aspects show varied degrees of positive relationships, according to the correlation analysis. There is a moderately positive correlation between authority and materialism and both enjoyment and adventure and ethics and altruism, as indicated by the correlation coefficients of 0.478 and 0.289, respectively. The correlation coefficient, on the other hand, between enjoyment and adventure and ethics and altruism is 0.666, suggesting a strong positive relationship (Table 2).

Table 2.

Karl Pearson correlation coefficient between factors among value-based dimensions.

Factors of job description	Authority and materialism	Enjoyment and adventure	Ethics and altruism
Authority and materialism	1.000	0.478	0.289
Enjoyment and adventure	-	1.000	0.666
Ethics and altruism	-	-	1.000

As the most influential factor (t = 14.12, P < .001), the multiple regression analysis reveals that authority and materialism have a significant and positive impact on ethics and altruism (Table 3). This is demonstrated by the unstandardized coefficient of 1.542 and the standardized coefficient (Beta) of 0.684. On the other hand, there is a marginally negative correlation between enjoyment and adventure and ethics and altruism (t = −0.793, P = .428), with an unstandardized coefficient of −0.098 and a standardized coefficient (Beta) of −0.038, as well as no statistical significance. Statistical significance is demonstrated by the constant term of 22.37, which denotes the expected value of ethics and altruism when both predictors are zero (t = 8.912, P < .001) (Table 3).

Table 3.

Variables in the multiple regression analysis on the component ethics and altruism.

Variables	Unstandardized coefficient (B)	SE of B	Standardized coefficient (Beta)	t-value	P-value
Constant	22.37	2.51	-	8.912	< .001
Authority and materialism	1.542	0.109	0.684	14.12	< .001
Enjoyment and adventure	−0.098	0.123	−0.038	−0.793	0.428

Note. ** Denotes significant at 1% level.

Discussion

PCA was used in this study to determine three key elements pertaining to medical students’ human values. These factors include PC1 (authority and materialism), which is linked to hedonism, power, and achievement; PC2 (enjoyment and adventure), which is linked to stimulation and self-direction; and PC3 (ethics and altruism), which is linked to universalism, ethics, tradition, benevolence conformity, and security. Ethics and altruism were ranked as the top priorities by the respondents. PCA revealed no significant distinctions or patterns in the data when comparing groups based on college type (government vs private), living arrangements (day scholars vs hostels residents), socioeconomic status. The study found no significant improvement or decline in moral values across the academic years. There was no observed attrition or betterment of human values among students, suggesting that values may remain stable during their academic years. This stability could be attributed to students entering higher education with well-formed human values shaped by prior upbringing and schooling, leaving little room for significant change. Additionally, the lack of diversity in academic experiences, such as uniform exposure to clinical rotations and lectures, may limit opportunities for value transformation. Furthermore, the absence of personal life experiences outside the academic environment, coupled with relatively lower levels of stress or burnout, may reduce the likelihood of significant shifts in values. Structured reinforcement through UHV courses, faculty support, and role modeling practiced in our medical school might have also played a role in absence of significant differences across academic years.

The study suggests a complex interplay between seemingly disparate values. A moderately positive correlation between authority and materialism and enjoyment and adventure. Authority and materialism had a moderate correlation with ethics and altruism. There is a strong positive relationship between enjoyment and adventure and ethics and altruism. This suggests that when the importance of adventure and enjoyment rises, so does the emphasis on ethics and altruism.

Borges et al discovered that undergraduate medical students initially valued altruistic factors shifting toward authoritative values over time, in contradiction to our study which showed no significant differences based on the year of study. ¹⁴ A parallel study on nursing students yielded similar findings. ¹⁵ According to a South African study, members of Generation Y exhibit high levels of materialism and entitlement. The values of independence, leisure, and materialism are associated with nonexploitative entitlement, whereas the values of independence and job satisfaction are associated with exploitative entitlement. ¹⁶

According to Ardenghi's research, despite the fact that nursing is a women-dominated field, women students outperformed their men counterparts in terms of ethics and altruism. ¹⁷ This aligns with societal expectations for women to embody altruistic traits. Benevolence universalism, and self-direction are also important motivators for students pursuing healthcare degrees, according to research, with prospective physicians placing a high value on compassionate principles like benevolence. Hedonism, accomplishment, and power were perceived as less significant. A study at NRI Medical College in India used the Moral Foundations Questionnaire to evaluate and compare the moral values of nursing and medical students. The domains of authority, purity, and harm/care were found to differ by gender. While nursing students scored higher on teamwork and deference to authority, medical students scored higher on harm/care and fairness. ¹⁸

Dehghani et al, and Shafakhah et al demonstrate how different elements affect how students develop their professional ethics. These elements encompass both environmental and personal factors. Personal convictions, values, and drive are important, as are outside variables like discipline, teamwork, and cultural perspectives. Gaining insight into these factors can enhance medical care.^19,20 Despite being the least significant, authority and materialism were found to be the most significant contributors to ethics and altruism. Those with a dominant nurturing state make an effort to maintain relationships, are viewed as helpful and altruistic. ²¹ The study by Flore et al, investigated 437 school counselors and discovered a correlation between increased altruism and wellness levels. ²² Enjoyment and adventure can offer relief and balance, while materialism and authority may foster competitive environments. By helping students uphold their ethical commitments, an understanding of these dynamics can help reduce burnout. ²³

People in the conventional stage of moral development tend to prioritize rules and expectations over their own moral convictions, aligning their behavior with the norms and values of their community or social group. ²⁴ The ethical conundrums that final-year medical students encountered during their clinical rotations were examined by Ribiero et al. The four main dimensions of these dilemmas—conflicting values, external constraints, differences between ideal and current selves, and weighing ethical principles—were identified by researchers using thematic analysis and interviews. Pupils had strong, enduring emotional reactions, especially when their behavior contradicted their beliefs. These encounters had a big influence on their professional growth and might have made them more morally courageous or emotionally detached.

There are various limitations to the study. A longitudinal approach, which would follow students throughout their four years of medical school, would provide a more thorough understanding of how values change than the cross-sectional design currently in use. As it is cross-sectional design, it restricts our ability to infer causality. Consequently, while differences in human values were observed, these cannot be directly attributed to the influence of higher education, as other confounding factors may be involved. The study failed to take into account internal elements like competence that can lead to burnout, as well as external elements like relationships and the learning environment. These findings should be the focus of future studies to give a more thorough picture of the ways in which different elements affect the values and general well-being of medical students.

Conclusion

This cross-sectional survey of 526 Indian medical students investigated universal human values, revealing key insights into the values that inform and shape future doctors. The study, employing a Google questionnaire and statistical analyses, identified three principal components: authority and materialism, enjoyment and adventure, and ethics and altruism. Ethics and altruism were found to be the most significant dimension, with authority and materialism also showing a notable positive impact on ethics and altruism.

Interestingly, the study found no significant changes in values across academic years, suggesting values are well-formed prior to higher education. The study emphasizes the importance of a comprehensive understanding of these values for medical education to support students’ ethical development and overall well-being. A longitudinal approach could provide a more thorough understanding of how values.