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Educational intervention to improve preclinical academic performance: A

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Educational intervention to improve
preclinical academic performance:
A systematic review
Soleiman Ahmady, Nasrin Khajeali1, Farshad Sharifi2,
Website: Zohrehsadat Mirmoghtadaei3,4
www.jehp.net

DOI:
10.4103/jehp.jehp_374_18 Abstract:
INTRODUCTION: One of the major problems of higher education centers is the students’ academic
failure. Increased monitoring, counseling, or remediation may tax the resources of both the program
and the faculty. The present review study gathered evidence highlighted by the experimental studies
on the educational intervention with the purpose of improving preclinical medical performance.
MATERIALS AND METHODS: To achieve the intended studies, databases of PubMed, Web of
Knowledge (Thomson Reuters), Educational Resources and Information Center, and the Scopus were
searched. The inclusion criteria were being an interventional study and assessing the educational
intervention to preclinical academic performance. The study was carried out as a systematic literature
search published between January 1987 and January 2018 . Based on valid tool through the best
evidence medical education review, after assessing the quality of the studies.
RESULTS: Ten studies were enrolled in the review for final evaluation. The Kirkpatrick Model was
Department of Medical employed to analyze and synthesize the included studies.
Education, Shahid
CONCLUSION: Reviewing the conducted studies showed that medical students had positive
Beheshti University
responses and attitudes toward new teaching methods, self‑monitoring skills, and attention
of Medical Sciences,
to physiological needs. The results also indicated that new teaching strategies, attention to
1
Department of Medical
self‑monitoring skills, and sleep hygiene in medical education could positively affect learning in two
Education, Student
domains of Bloom’s Taxonomy.
Research Committee,
Shahid Beheshti University Keywords:
of Medical Sciences, Educational intervention, medical student, new teaching strategies
2
Elderly Health Research
Center, Endocrinology and
Metabolism Population
Sciences Institute, Tehran
Introduction Studying in a medical school requires many
cognitive abilities, a positive attitude, and
University of Medical
Sciences, 3Department
of Medical Education,
Virtual School, Tehran
R esponsive education and accountability
are considered as the main duties of the
universities. Every year, universities admit
an ability to manage the time and respond
to challenges during the training, which is
called self‑management. Medical students
University of Medical new students and graduate some others, so can manage themselves when encountered
Sciences, 4Department of medical schools have the difficult duty of with various kinds of stresses, especially
Medical Education, Virtual when they finish the premedical year and
supporting students for their career. Besides,
University of Medical then continue their preclinical years in
Sciences, Tehran, Iran
this career needs continuous adaptation for
changing knowledge and skill. In addition, different environments. The premedical
Address for students must have other competencies such study is different from the preclinical study
correspondence: as being excellent communicators, leaders, in several aspects including a lot of learning
Dr. Nasrin Khajeali, materials and an increased workload
Department of Medical managers, and team workers.[1‑4]
required to accomplish the courses.[5,6]
Education, Student
Research Committee, This is an open access journal, and articles are
Shahid Beheshti distributed under the terms of the Creative Commons
The transition from premedical to
University of Medical Attribution‑NonCommercial‑ShareAlike 4.0 License, which higher education and preclinical is often
Sciences, Tehran, Iran. allows others to remix, tweak, and build upon the work
E‑mail: nasrinkh2009@ non‑commercially, as long as appropriate credit is given and How to cite this article: Ahmady S, Khajeali N,
yahoo.com the new creations are licensed under the identical terms. Sharifi F, Mirmoghtadaei Z. Educational intervention
to improve preclinical academic performance: A
Received: 11‑11‑2018
systematic review. J Edu Health Promot 2019;8:83.
Accepted: 01‑12‑2018 For reprints contact: [email protected]

© 2019 Journal of Education and Health Promotion | Published by Wolters Kluwer - Medknow 1
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Ahmady, et al.: Educational intervention to improve preclinical academic performance

experienced as challenging and difficult by the students. the outcome of educational intervention in preclinical
The main concern is to help 1st‑year students become academic performance.
familiar with what it means to be a self‑managed
and independent learner. Time management is Materials and Methods
particularly difficult for students to learn. First‑year
students have poor classroom participation and need This systematic review was conducted on all the
to adopt a new style of learning.[7] Another important educational interventional studies in preclinical
issue is the new “Millennial Student.” Students are medical courses from January 1987 to January 2018.
required to have skills to manage their daily life. The methods of presenting including determination
They are determined and those who are dependent of the study problem, data collection, analysis, and
on technology and their support system.[8] Therefore, interpretation of the findings were performed based on
teaching 1st‑year students has more challenges than the Preferred Reporting Items for Systematic Reviews
that of senior students. There is consequently a need and Meta‑Analyses reporting system. To achieve the
to develop academic literacy, not only as an adjunct intended studies, published articles in databases such
“skill” but also through engagement in learning in the as PubMed, Web of Knowledge  (Thomson Reuters),
process of academic disciplines. Fisher (1995) discuss Educational Resources and Information Center, and the
that students need to acquire not only the explicit Scopus were searched. No time limitation was set for
knowledge (as in the content of the curriculum) but searching the resources. For comprehensiveness of the
also the tacit knowledge (e.g., learning to understand search, the following keywords were used in the abstract,
and interpret the values, beliefs, or social practices title, and keyword sections: “academic performance,”
of a particular community of scholars). [9] The “academic failure,” “academic achievement,” “drop
preclinical study is integral for clinical year training out,” “academic engagement,” “learning disorder,”
because medical students are supposed to apply and “medical student,” “struggle student,” and “problem
implement their knowledge during clinical practice. learner.” Hand searching was also carried out in Medical
Therefore, we aimed to identify the intervention and Teacher and Medical Education journals. Besides,
learning behavior of medical students during the first reference lists of all the papers meeting the quality
preclinical year for these students faced more academic criteria were reviewed identifying and selecting the
difficulties and began to develop poor grades during relevant papers. The most prominent authors in this
the 1st year of preclinical training. The increase in poor area were contacted with a request for “gray literature:”
academic performance was more apparent in their conference proceedings, unpublished studies, internal
clinical years. Therefore by identifying interventions reports, etc., and the obtained data were included
to improve academic performance, we can decrease in the study. The inclusion criteria for the articles
poor academic performance in clinical years.[5] were as follows: being an educational interventional
study and assessing the academic performance of the
There is a good deal of evidence indicating that improving undergraduate medical students without any language
preclinical academic performance can decrease dropout or time limitation from January 1987 to January 2018.
rates and improve academic success until graduation. Besides, the exclusion criteria for the search were being
Accordingly, there is a pressing need to integrate secondary research or observational study design
evidence and evaluation of the outcome regarding and not being a preclinical medical student. All the
preclinical academic interventions to guide medical databases were searched by one reviewer, and Endnote
teachers to choose the best educational intervention to X8 was used for data management. The articles were
improve academic performance in preclinical phase in imported into Endnote X8 to remove the duplicate data
the future. before importing the data into Excel. The imported
data were the list of authors, titles, journals, and years
To the best of the researchers’ knowledge, this is the of publishing. The titles and abstracts were screened by
first systematic review in this research area. The present two independent researchers to determine the potentially
review study attempted to focus on the preclinical relevant articles. The full‑text version of the study was
intervention to improve the academic performance of subsequently reviewed if the study appeared to meet
the students in medical programs.   The necessity of this the selection criteria or if there was any doubt regarding
work lies in the fact that this intervention is a relatively the study’s eligibility. Moreover, a third independent
a deep and systematic examination of the results of researcher was requested to resolve any disagreements.
educational intervention in medical education can
improve the medical teachers’ insights into the subject To increase the validity and reliability of the study,
under consideration. Consequently, the present study the articles were examined in terms of quality by two
was carried out to synthesize the findings based on the separate researchers. Each article entering the study
experimental works and to offer a deeper insight into was examined in terms of methodological quality using
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Ahmady, et al.: Educational intervention to improve preclinical academic performance

the tools the validity of which had been supported by from the reference lists. Articles were most likely to
the best evidence medical education  (BEME) review have been published in medical education and medical
on education portfolio. The tool was part of the data teacher journals [Figure 1].
extraction sheet and included 11 quality indicators about
the appropriateness of the study design, results, analysis, Results
and conclusions, which were used to examine the
quality of the studies. The tool has been recommended Based on a systematic review of the educational papers
for quantitative, qualitative, and combined‑method published during 1987–2018 on preclinical interventions
research in medical education.[10] The studies that met in medical education, 10 interventional studies were
a minimum of eight quality indicators or those meeting extracted and used to form the basis for answering the
six or seven criteria were categorized as high‑quality research questions. Two approaches were employed to
and medium‑quality, respectively. Furthermore, those conduct the present research review. Half of the articles
studies that met five or fewer criteria were considered were investigated using an experimental approach
as low‑quality studies.[11] For adequately homogeneous through randomization technique. [13‑17] The other
data, for example, studies with similar interventions, half were reviewed applying a quasi‑experimental
comparisons, outcomes, and study design‑standard design. Meanwhile, in these articles, the subjects had
methods for meta‑analysis (Cochrane Handbook) were not been randomly assigned to the test and control
employed. Nonetheless, according to other systematic groups.[18‑22]
reviews in the medical education literature, it is assumed
that the collected data may be extra heterogeneous, Countries under investigation  –  Based on the results,
which makes it improper to be mixed for quantitative India was at the top of the country list in terms of the
statistical meta‑analysis. If so, a qualitative review of number of studies (n = 3) followed by Turkey (n = 2). The
the evidence would be carried out through grouping United States of America, Canada, UK, Germany, and
and reporting studies using the Kirkpatrick hierarchy Croatia were found to have only one article.
introduced by BEME for educational contexts.[12] The
search identified 6305 abstracts. Totally, 480 articles were About population – In terms of professional groups in
selected for further review. The final review included 10 the 10 cited articles, the educational intervention was
articles. The majority of them (n = 9) were identified from used by the preclinical medical students (first‑, second‑,
electronic databases and the balance[1] was identified and third‑year students).
Identification

Records identified through

database researching
(N=13123)

Records after duplicates Records excluded on

Screening

were removed the title/abstract basis

(N=6305) (N=5825)

Full-text articles
assessed for eligibility
Eligibility

(N=480) Full-text articles excluded (N=391):

not-medical students = 86
not undergraduate = 7
not causes=78
not preclinical=177
not primary research=122
Included

Studies included in
quantitative
synthesis (N=10)

Figure 1: Preferred Reporting Items for Systematic Reviews and Meta‑Analyses flowchart

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Ahmady, et al.: Educational intervention to improve preclinical academic performance

For methodological quality  –  There were five Students’ skill improvement

high‑quality[13‑17] and five medium‑quality[18‑22] papers. There was no article about the impact of educational
Besides, no low‑quality paper was included in the intervention on students’ skill learning.
present study. All the papers were compared based
on the 11 quality indicators, namely, control of Acquisition and enhancement of student’s
confounding, triangulation, ethical issues, and analysis theoretical knowledge
of the results, conclusions, data collection methods, In all of the studies carried out regarding the effects
prospective, reproducibility, completeness of data, of educational intervention on medical students’
research question(s), and study participants. The most performance, a positive impact was found on their
commonly met indicators were appropriateness of theoretical knowledge. The summary of interventions
perspective, analysis of the results, and conclusions can be stated as follows: the effect of (I) self‑monitoring
of data. Nevertheless, on many occasions, the data exercises on biomedical sciences;[13] (II) concept mapping
collection method  (if the data gathering method was on learning biochemistry;[14]  (III) blending problem
reliable and valid for the research question and context) based learning (PBL) with web technology on learning
was not clear due to insufficient data. Clearly, because physiology;[15] (IV) counseling and advising regarding
of the quantitative nature of the papers in this work, a study skills; [18]  (V) teaching on learning outcomes
low triangulation was expected [Table 1]. by peer educators; [16]  (VI) self‑directed learning on
learning effect;[17,21]  (VII) sleep hygiene education on
Based on the Kirkpatrick outcome levels – The proportion
academic performance;[19]  (VIII) student‑led objective
of papers that evaluated the effect of the educational
tutorial  (SLOT) on academic performance; [20] and
intervention at each Kirkpatrick outcome level is listed
(IX) PBL program enrich with brain/mind learning
in Table 2.
(BML principle).[22]
Changes in knowledge/skills (levels 2B) were reported
in all the papers and only two papers mentioned the Students’ positive attitudes and perceptions
evaluation of the students’ learning transfer into their toward educational interventions
workplace (level 3).[18] Moreover, five articles reported There were five studies regarding the effects of
two or more outcome levels.[13,17,18,20,22] There was no educational interventions on attitudes and perceptions
report regarding the effects on the system/organization about academic achievement in the subjects. Leggett
or patient care outcome as a direct outcome of the et  al. showed a significantly increased self‑efficacy
knowledge, skills, and attitudes developed by the and greater satisfaction with performance respecting
subjects in the educational intervention (level 4). self‑monitoring exercises. [13] Besides, Mysorekar
demonstrated a significant increase in satisfaction
Synthesis of findings scores compared with those of the baseline and after
The outcomes of educational intervention are synthesized the counseling and advice regarding the study skills.[18]
in the following sections based on three categories, Peine et  al. also indicated that the intervention group
namely, (I) improvement in students’ skill; (II) acquisition had a notable increase in learning motivation compared
and enhancement of the students’ theoretical knowledge; with the control group.[17] Sukhlecha reported that the
and  (III) positive attitudes and perceptions of the students in SLOT groups found the support by the peer
students. educator significantly more positive than that evaluated

Table 1: Quality of included studies

Quality indicator Details Indicator met Indicator not met
Research question Is the research question or hypothesis clearly stated? 8 2
Study subjects Is the subject group appropriate for the study being carried out (in terms of the 5 5
number, characteristics, selection, and homogeneity)?
Data collection Are the methods used (qualitative or quantitative) reliable and valid for the research 3 7
methods question and context?
Completeness of data Have the subjects dropped out? Is the attrition rate of less than 50%? Is the 3 7
response rate acceptable (60% or above) for questionnaire‑based studies?
Control of confounding Have multiple factors/variables been removed or accounted for, where possible? 4 5
Analysis of the results Are the statistical or other methods of results analysis used appropriately? 7 3
Conclusions Is it clear that the data justify the obtained conclusions? 8 2
Reproducibility Could the study be repeated by other researchers? 4 6
Prospective Does the study look forwards in time (prospective) rather than backward (retrospective)? 9 1
Ethical issues Were all the relevant ethical issues addressed? 4 6
Triangulation Were the results supported by the data from more than one source? 1 10

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Ahmady, et al.: Educational intervention to improve preclinical academic performance

by those in the control group.[20] In addition, according to changes in attitude has mainly relied on self‑statements
the report by Gulpinar et al., all the subjects stated that by the students.[23]
the PBL program enriched with BML principles was the
best study method.[22] A summary of the main findings In addition, the period of the interventions varied
of several studies is provided in Table 3. form 1 day to even months in the published studies.
Accordingly, a significant issue to be carefully
Discussion investigated in future research is the frequency of
intervention delivery as continuous or repeated
This systematic review aimed at searching, analyzing, interventions and their effects on educational outcomes.
and synthesizing experimental articles conducted on Only in one study which was carried out by Mysorekar,
educational intervention in medical sciences education there were subsequent assessments after 1 and 6 months,
during 1987–2018. To the best of the authors’ knowledge, respectively.[18] However, in other articles mentioned in
this study was the first work of this nature. In general, the this review, there was not any subsequent evaluation. In
application of educational interventions for preclinical many studies, the interval between pretest and posttest
medical students was few and only 10 articles were found was very short. This may have led to bias, meaning
during the period of searching in this regard. Therefore, that better methodologies and longer time duration are
there was a need for an original article regarding the area required for the researches on educational intervention
under investigation. The rigor of studies on evaluation in future studies to determine its educational effects on
of educational outcomes has been relatively weak, the students’ performance.
mostly regarding the limited tools utilized to measure
the learning results. The major part of the reports on None of the articles under study mentioned any changes
in organizational practice or improvement in patients’
health results as a direct effect of the educational
Table 2: Distribution of reviewed studies based on
Kirkpatrick outcome levels intervention  (Kirkpatrick’s 4 levels) and a change in
Levels Kirkpatrick outcome level Studies (n)
behavior  (Kirkpatrick’s 3 levels). However, this is
1 Reaction‑learners’ reactions 5 an ordinary practice in medical education reviews.
2A Learning ‑change in view or attitude 1 Knowing this, such a level of evaluation needs a
2B Learning‑modification of knowledge or skill 10 long‑term follow‑up. Moreover, it is not feasible to take
3 Behavior‑change in behavior (transfer of 1 into account the complexity of the factors affecting the
learning to the workplace) practice of patient care. Although this study was about
4A Results‑change in the system/ 0 preclinical performance, the author can examine the
organizational practice effect of such intervention through following up the
4B Results‑in patent care outcome 0 participants.

Table 3: Summary of the reviewed studies

ID Authors Countries Aims of the study Participants Design Main findings
1 Leggett UK Improve their academic performance by 51 2nd‑year Randomized Improved their BMS exam score
(2010) self‑monitoring exercises students trial compared with the control group
2 Surapaneni USA Effect of concept‑ mapping on learning 150 1st‑year Experimental Concept‑mapping program resulted in
(2013) (Chicago) biochemistry students higher academic performance
3 Taradi Croatia Effect of blending PBLwith web 121 2nd‑year Experimental Blending PBL with web technology
(2005) technology on learning physiology students positively impacted on student learning
4 Mysorekar India Effectiveness of counseling and advice 73 1st‑year Quasi‑ Improvement in the postprogram
(2012) regarding study skills in improving students experimental performance
performance
5 Peets Canada Effects of teaching on learning outcomes 135 1st‑year Randomized Involvement in teaching small group
(2009) of peer educators students cross‑over sessions improved medical students’
knowledge acquisition and retention
6 Peine Germany Self‑directed learning on learning effect 244 3rd‑year Randomized Self‑directed learning improved
(2016) and student satisfaction. students trial learning and satisfaction
7 Sahin Turkey Effects of sleep hygiene education on 131 1st‑year Quasi‑ Education on sleep hygiene improved
(2016) academic performance students experimental academic performance
8 Sukhlecha India Effect of SLOT on academic performance 171 2nd‑ year Quasi‑ SLOT improved academic
(2016) students experimental performance
9 Vashe India Self‑directed learning on academic 230 1st‑year Quasi‑ Self‑directed learning improved
(2013) performance students experimental academic performance
10 Gulpinar Turkey Effect on PBL program enriched with 295 1st‑year Quasi‑ PBL program enriched with BML
(2015) BML principles on academic performance students experimental principles improved academic success
PBL=Problem‑based learning, BML=Brain/mind learning, SLOT=Student‑led objective tutorial, BMS=Burning mouth syndrome

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Ahmady, et al.: Educational intervention to improve preclinical academic performance

The results of the present review indicated that educational suggested in the literature and provide medical teachers
intervention with three different types such as attention with the best and most recent evidence to select the
to teaching method (e.g., embedded e‑learning, different best intervention(s) in medical curriculums. Using the
type of PBL, and self‑directed learning), attention to findings, the students will also better enjoy the advantages
physiological needs (sleep hygiene), and self‑monitoring of interventions in their academic, clinical, and
skills (e.g., self‑regulation exercise and teaching study skill) professional endeavors. Besides, they will be prepared
can be used to improve the academic performance in light for future licensing requirements. The main points that
of both domains of Bloom’s taxonomy such as cognitive medical education policymakers and practitioners need
and affective for the students in medical programs. In fact, to take into account in the design of a proper program
Bloom’s taxonomy is an easy way employed to describe are attention to new teaching strategies, attention to
the required degree of understanding and using concepts self‑monitoring skills, and sleep hygiene. Moreover,
and to influence their values, attitudes, and interests.[24] the obtained results can be used as a basis for further
Studies which is consistent with the finding of the present studies and development of knowledge in this field.
study about active teaching method is a study by Moust Future studies on different student groups of medical
et  al., that compared students who had participated in sciences and countries require focusing on standardized
PBL with study teams with students who had used the and validated evaluation tools in randomized controlled
traditional self‑study showed that working with teams trial settings. With regard to the limitations of the study,
fostered deeper learning as well as increased students’ lack of a meta‑analysis was notable. However, it was not
workloads;[25] although, there is challenges that researchers possible to do a meta‑analysis because of the wide range
and instructors faced recently is working with active of different study designs, measurement tools, results,
teaching method such as small groups, including problems and the nature of the results reported. Nonetheless, the
experienced during group tutorial processes such as current review had a strong point in terms of not having
insufficient use of scenarios; improper management of any language limitation.
tutorial processes; difficulties in some of the steps of the
seven‑step approach. Managing group dynamics, and Acknowledgment
deepening discussions. Hence to handle this challenge, This study is the result of a PhD thesis in the Shahid
we need workshop for faculty development. Another one, Beheshti University of Medical Sciences by the second
it seems using self‑monitoring skill have no challenge. author.
Hence, self‑monitoring, can be developed by appropriate
interventions and also that academic performance can Financial support and sponsorship
be improved. Moreover the next one, sleep quality is Nil.
important for academic performance among medical
students, it has been suggested that by awareness of the Conflicts of interest
possible impact of excessive daytime sleepiness on the There are no conflicts of interest.
medical students will help to the teaching staffs to manage
sleep education and sleep hygiene, especially to those who References
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