1. Background
English, as a global language, plays a pivotal role in advancing knowledge and technology (1). Academicians, especially those in fields such as medicine, must achieve proficiency in English to accomplish career milestones. Autonomous learning, wherein students take responsibility for their educational processes, is critical in acquiring a foreign language (2, 3). Moreover, learning autonomy not only enhances students’ engagement but also promotes the development of critical thinking skills, which are indispensable in the medical field (4). Autonomous learners are better prepared to meet the complex demands of their academic and professional careers (5).
Cognitive, affective, biological, and socio-cultural factors influence the learning process and, consequently, medical students' TOEFL scores (6). Self-efficacy, defined by Bandura as "people's judgments of their capabilities," is a crucial determinant of academic motivation, learning, and achievement (7). Studies indicate that higher self-efficacy correlates with superior academic outcomes, including language proficiency (8). Specifically, students with high self-efficacy tend to use effective reading strategies, a vital component of TOEFL success (9).
Medical students frequently encounter significant stress, including burnout, depression, anxiety, and suicidal ideation (10). Research has demonstrated that self-efficacy can mitigate these adverse effects (11). Additionally, autonomous learning has been found to reduce stress and foster resilience (12, 13). Many medical graduates must take international examinations such as TOEFL or IELTS to pursue advanced studies or career opportunities abroad (14).
2. Objectives
Given the limited research on the interplay between learner autonomy, self-efficacy, and medical students' TOEFL reading comprehension (15-18), this study aimed to investigate these factors and their impact on students' attitudes and academic performance. The findings may inform strategies to enhance these factors and improve medical students’ overall well-being.
3. Methods
3.1. Design and Settings
This quantitative and qualitative research, utilizing a mixed-method design, was conducted at Urmia University of Medical Sciences.
3.2. Participants and Sampling
Sixty medical students (interns and residents) at the Urmia Medical University Language Center were randomly selected to participate in the study. All participants provided informed consent and were confirmed to have a homogeneous English proficiency level, as assessed by the Oxford Proficiency Test. The sample included 30% third-year students and 70% residents, with a gender ratio of 41 females to 19 males. The participants' ages ranged from 22 to 30 years, with an average age of 25.5 years.
3.3. Instruments
Learner autonomy was assessed using Zhang and Li's 21-item questionnaire (19), while self-efficacy was measured with Smith and Betz's 25-item scale (20). TOEFL reading comprehension scores were also collected. Additionally, semi-structured interviews were conducted with 10 medical students to gather in-depth insights into the relationship between self-efficacy, autonomy, and TOEFL reading achievement. To ensure credibility, participants reviewed and confirmed the accuracy of their responses. For dependability, 20% of the results were re-checked by two colleagues, resulting in an inter-rater reliability score of 0.95.
3.4. Data Collection Methods
Data collection (January–February 2023) adhered to ethical guidelines. Participants anonymously provided information regarding their age and TOEFL course duration. Interviews were conducted in Farsi, translated to ensure accuracy, and subsequently analyzed thematically. Quantitative data, gathered via face-to-face meetings and online platforms such as Skype or Google Meet, was analyzed using Pearson correlation. Data saturation was achieved after two months.
The method chosen for the interview analysis was a qualitative approach using thematic analysis, reported in the form of themes, sub-themes, and extracts from the semi-structured interviews. Thematic analysis, a method for identifying, analyzing, and reporting patterns (themes) within data (21), involved familiarization, coding, theme generation, and reviewing, followed by the classification of themes. The researcher thoroughly analyzed transcripts for patterns and trends, ensuring the credibility and dependability of the interviews. Both credibility and dependability of the interview data were explicitly addressed and reported.
3.5. Data Analysis
Data were analyzed using SPSS (version 20). Descriptive statistics (mean and standard deviation) were used to summarize the data, while inferential tests were employed to examine the hypothesis. Normality was assessed using the Shapiro-Wilk and Kolmogorov-Smirnov tests. Kendall's Tau and Spearman tests were applied to determine the relationship between clinical competence and self-directed learning. A 95% confidence level and a significance level of 0.05 were used in all analyses.
4. Results
A total of 60 students participated in the study, with the majority being female (68.3%). The mean age of the participants was 22.6 ± 2.05 years, with an age range of 19 to 29 years. The descriptive statistics of scores obtained from the OPT revealed a mean of 39.87 ± 2.05 (Table 1).
Table 1.Descriptive Statistics of OPT scores
| Variables | N | Mean (Age) | Minimum - Maximum | Mean ± SD | Variance |
|---|---|---|---|---|---|
| Gender | |||||
| Male | 19 | 22.07 | 32 - 43 | 39.11 ± 2.36 | 4.21 |
| Female | 41 | 22.04 | 31 - 42 | 38.97 ± 2.12 | 4.09 |
| Valid N (list wise) | 60 | 22.06 | 31.04 - 42.03 | 39.87 ± 2.05 | 4.17 |
The descriptive statistics of scores obtained from self-efficacy, autonomy, and the reading section of the TOEFL are presented in Table 2, with means of 96.1 ± 9.96, 70 ± 16.07, and 22.01 ± 1.64, respectively.
Table 2.Descriptive Statistics of Self-efficacy, Autonomy and Reading Scores
| Variables | Mean ± SD | N |
|---|---|---|
| Reading | 22.0167 ± 1.64153 | 60 |
| Self-efficacy | 96.1500 ± 9.96745 | 60 |
| Learner autonomy | 70.0167 ± 16.07450 | 60 |
According to Table 3, the Pearson correlation value is 0.797 with a significance value of .000 (P-value = 0.05). It can be concluded that there is a positive average relationship between medical students’ self-efficacy and their TOEFL reading test performance. The R-squared value equals 0.64, indicating that students’ self-efficacy level can predict their TOEFL reading score by up to 64 percent. To address the second question, the relationship between medical students’ autonomy and their TOEFL reading comprehension was calculated (Table 4).
Table 3.Correlation Between Self-efficacy and TOEFL Reading Test
| Variables | Self-efficacy | TOEFL Reading Test |
|---|---|---|
| Self-efficacy | ||
| Pearson correlation | 1 | 0.797 |
| Sig. (2-tailed) | 0.000 | |
| N | 60 | 60 |
| TOEFL reading test | ||
| Pearson correlation | 0.797 | 1 |
| Sig. (2-tailed) | 0.000 | |
| N | 60 | 60 |
Table 4.Correlation Between Autonomy and TOEFL Reading Test
| Variables | TOEFL Reading Test | Autonomy |
|---|---|---|
| TOEFL reading test | ||
| Pearson correlation | 1 | 0.311 |
| Sig. (2-tailed) | 0.691 | |
| N | 60 | 60 |
| Autonomy | ||
| Pearson correlation | 0.311 | 1 |
| Sig. (2-tailed) | 0.691 | |
| N | 60 | 60 |
Table 4 reveals that the Pearson correlation is 0.311 with a significance value of .691 (P-value = 0.05). It can be concluded that there is no significant relationship between medical students’ autonomy and their TOEFL reading comprehension. The qualitative phase involved analyzing semi-structured interviews, with the first question focusing on understanding the strategies medical students use to enhance their self-efficacy while preparing for the TOEFL reading comprehension test. All 10 interviewees identified strategies such as familiarizing themselves with the test format, practicing regularly, and employing effective reading techniques. The first two strategies, along with vocabulary building, were the most frequently mentioned and contributed to data saturation. Extract 1 highlights how regular practice was crucial in building self-efficacy:
- Extract 1: Regular practice, starting with easier passages and gradually increasing difficulty, was crucial for improving my TOEFL reading skills and confidence.
Another student emphasized the importance of developing effective reading strategies, as shown in Extract 2:
- Extract 2: Developing effective reading strategies like skimming, scanning, and summarizing helped me efficiently understand TOEFL reading passages and boost my confidence.
In Extract 3, the focus shifts to vocabulary enhancement as a key self-efficacy strategy:
- Extract 3: Enhancing my vocabulary knowledge through regular learning of new words was crucial for increasing my self-efficacy.
The other question of the interview was related to the concept of autonomy. The question was as follows:
How do you think having a sense of autonomy affects your motivation and engagement in passing the TOEFL reading comprehension test?
Medical students emphasized the importance of autonomy in TOEFL reading practice, citing enhanced critical thinking, engagement, and self-regulation as key benefits. However, they rated self-efficacy as even more crucial. Qualitative findings aligned with these quantitative results.
However, many interviewees noted that while autonomy is important, it was not as crucial as self-efficacy. Extract 4 provides insight into this perspective:
- Extract 4: Autonomy allowed me to choose personalized study methods, increasing my engagement.
Similarly, Extract 5 underscores the role of autonomy in fostering critical thinking and self-regulation while also noting its secondary importance compared to self-efficacy:
- Extract 5: Autonomy encouraged independent thinking and critical analysis of TOEFL reading passages, but I believe self-efficacy, which demands more effort, is ultimately more important.
When asked about factors influencing their autonomy and self-efficacy, medical students frequently cited motivation, previous success, and teacher support. These factors played significant roles in shaping their attitudes and behaviors, as exemplified in the following extract:
- Extract 6: Intrinsic motivation, stemming from a genuine interest in learning English and setting personal goals, was crucial in developing my autonomy and self-efficacy.
Students also recognized the importance of previous successes and teacher support in developing autonomy and self-efficacy. These factors, however, may vary individually, as personal experiences and circumstances influence language learning.
5. Discussion
This study aimed to explore the relationships among Iranian medical students' TOEFL reading comprehension scores, self-efficacy, and autonomy. Results showed a significant correlation between self-efficacy and reading performance, but not with autonomy. These findings were supported by both quantitative data and qualitative interviews.
Both quantitative and qualitative data emphasized the greater importance of self-efficacy over autonomy in influencing TOEFL reading performance. High self-efficacy is associated with better self-regulation, effort, and academic achievement, as confirmed by previous research (22). Furthermore, self-efficacy beliefs have a positive relationship with academic achievement, as reported in a meta-analysis conducted by Caprara et al. (23), which provides strong evidence supporting this link. Similarly, Graham and Weiner’s (24) meta-analysis of self-efficacy research in motivational studies also confirmed the positive relationship between efficacy beliefs and academic achievement.
The results of this study align with the findings of Naseri and Ghabanchi (25), who explored the relationship between self-efficacy beliefs, locus of control, and reading comprehension levels among Iranian EFL advanced learners. Their study found positive relationships between self-efficacy, locus of control, and reading comprehension, suggesting that enhancing these factors can improve reading scores. However, these findings contrast with Piran’s study (26), which explored the relationship between self-concept, self-efficacy, and self-esteem with reading comprehension scores.
This study also supports Pajares' (27) assertion that students' inner processes and perceptions about their skills must be considered because they have a significant impact on academic success or failure (28). The results are consistent with social cognitive theory. Self-efficacy has been identified by Bandura (22) as a crucial psychological component of learners' functioning. Learners with high self-efficacy exhibit confidence in their capacity to accomplish tasks successfully. Other scholars (29, 30) have emphasized the importance of one's self-assessment regarding personal abilities. In summary, self-appraisal and self-persuasion rely on sources of efficacy information, such as enactive experiences, which are considered the most significant for efficacy beliefs due to their foundation in personal experience (31).
Regarding the second research question, the study found no significant relationship between autonomy and reading comprehension. This suggests that while independence is valuable, self-efficacy, which requires persistence and energy, is ultimately more crucial for effective task completion. Furthermore, autonomous learners may not always have a positive attitude toward every aspect of their learning (32); yet, these learners have developed reflective and attitudinal skills to overcome temporary motivational setbacks (33). A defense of autonomy posits that effective communication requires complex procedural skills learned through practice. Thus, students with high social autonomy can seamlessly fulfill the discourse-related roles essential for spontaneous communication (34).
The results of the study by Faramarzi et al. (35) revealed no significant relationship between learners’ autonomy and their listening comprehension. However, this result contrasts with findings by Little et al. (36), who reported significant positive correlations between learner autonomy, skill development, and language proficiency.
Based on these findings, syllabus designers should account for learners' individual differences, particularly their orientation toward language learning. Curriculum developers and material producers should collaborate with teachers and learners to create better programs, materials, and tasks that foster autonomy and self-efficacy, ultimately improving medical students' academic outcomes. Additionally, curricula should include both implicit and explicit instruction aimed at enhancing autonomy and self-efficacy within the educational system.
This study's limitations include a small sample size of Iranian medical students from a single institution, potentially restricting the generalizability of its findings. Additionally, the study's focus on reading comprehension, self-efficacy, and autonomy may limit the broader scope of its applicability. Nevertheless, promoting self-efficacy and autonomy can help educators support students in developing critical skills essential for academic success and lifelong learning.
5.1. Conclusions
Higher levels of autonomy and self-efficacy may enable learners to reflect on their language abilities and cultivate a greater eagerness to learn a second language, often perceived as a challenging task for demotivated individuals. Therefore, medical students should actively seek opportunities to enhance their autonomy and self-efficacy to improve their academic achievement.
