Analysis of academic performance of medical students in studying pharmacology during quarantine and martial law in Ukraine

The objective is to analyze the quantitative indicators of academic performance of medical students studied Pharmacology remotely or in a hybrid form of education under the conditions of pandemic and Russian invasion of Ukraine. Regulatory documents related to quarantine due to COVID-19 and martial law in Ukraine, as well as forms of education for 2018–2023, were studied. The quantitative indicators of students' academic performance during the study of Pharmacology Modules 1–2 in Poltava State Medical University were analyzed. The 2018/2019 academic year with face-to-face study (period I) served as a control. The 2019/2020 academic year was characterized by the beginning of quarantine and the transition to distance learning (period II). The next three academic years were spent under conditions of quarantine or its combination with martial law and a hybrid form of education (periods III–V). It is shown that the average current grade of students mastering Pharmacology Module 1 during periods IV and V was higher than in the period I. It exceeded that at the final module control. The final control grade in period IV was higher than in the face-to-face form of education. Mean scores from Module 2 in periods IV and V also were better against control.

1 Introduction

Modern medical education must adapt to different healthcare contexts, including digital systems and a digital generation of students. Integrative themes and sub-themes of 21^st century medical education are a humanistic approach to patient safety, early exposure to patient-centered integration and integrated health care; moving beyond hospitals into society, responding to changing community needs and showing respect for diversity; student-driven learning using advanced technologies with individualization, social interaction, and resource availability (Han et al., 2019). As medicine and healthcare enters the era of artificial intelligence, there is a growing need for competent human-machine interaction to facilitate clinical decisions and gain professional knowledge and skills (Grunhut et al., 2021).

Technological innovations have not only influenced social changes in recent years, but have also become the main driver of the transformation of higher education. The newest graduates of higher education, the so-called “digital natives”, have come to expect that education will be delivered in a way that offers increased usability (Sinclair et al., 2015). Certain circumstances, such as epidemics, natural disasters or military actions, can disrupt the normal process of acquiring medical education and its convenience. In this case, the implementation of the educational process can be saved with the help of electronic (e)-learning. The term “e-learning” is broadly defined as any type of educational media that is provided in electronic form and uses a variety of multimedia tools to construct and assess knowledge in asynchronous or synchronous formats. The global experience of undergraduate medical education during the COVID-19 pandemic has demonstrated two main trends in the crisis situation based on e-learning: the replacement of face-to-face lectures with online classes in the preclinical years and the use of various distance education methods to compensate for discontinued or reduced clinical experience in senior years (Lee et al., 2021). Martial law, which, for example, currently operates in Ukraine, also causes challenges and problems in the field of education, no less than COVID-19. Under these conditions, educational institutions are once again forced to switch to distance learning (Biliuk et al., 2023; Armitage and Pavlenko, 2022) or hybrid forms or learning and teaching.

The Ukrainian system of medical education is considered one of the highest quality and relatively affordable in the world, and therefore every year attracts thousands of domestic and foreign students who study medicine for 6 years in one of the medical universities of Ukraine to obtain a specialist diploma (equivalent to MD/MBBS) (Armitage and Pavlenko, 2022). Pharmacology is one of the cornerstones of health science curricula and science-oriented biomedical programs in higher education. New educational ideas and scientific developments in teaching and learning, as well as modern discoveries in pharmacological research, prompt Pharmacology teachers to regularly revise and adjust their teaching (Engels, 2018). The study of this discipline, like other disciplines in higher medical education, is under the pressure of social and political conditions, which can include an epidemic situation or military actions on the territory of the country (Mayer et al., 2023).

The impact of war and quarantine on education, particularly the study of pharmacology by higher medical education students, requires serious discussion. The future of the country depends on young people's education, and graduates' competence is an indicator of their readiness for professional activity and an active role in public life.

Although teaching methods are widely discussed in the scientific community, the forms of the educational process, particularly in higher medical education institutions, are not covered sufficiently and require further study, especially with regard to pharmacology teaching (Vallée et al., 2020; Basuodan, 2024).

This determined the objective of this article: to compare and analyze the effectiveness of different learning methods (traditional, distance and hybrid) for studying pharmacology during the pandemic and Russia's invasion of Ukraine.

2 Materials and methods

2.1 Determination of research periods

Regulatory documents (decrees of the President of Ukraine, resolutions of the Cabinet of Ministers of Ukraine) related to quarantine due to COVID-19 and martial law due to the Russian invasion of Ukraine were selected and studied. The orders of the Rector of Poltava State Medical University regarding the form of education for each academic year starting from 2018/2019 to 2022/2023 academic year were analyzed. On this basis, the educational process periodization was developed with a division into five periods, which was used to describe the students' academic performance in different academic years (Figure 1).

Figure 1

Figure 1. Medical higher education in Ukraine. Pharmacology teaching and learning.

2.2 Periods and forms of education

The pre-crisis 2018/2019 academic year when education was full-time was taken as control and marked as period I. The following 2019/2020 academic year was characterized by the beginning of the quarantine due to the COVID-19 pandemic (Pro zapobihannya poshyrennyu na terytoriyi Ukrayiny koronavirusnoyi khvoroby COVID-19 [On preventing the spread of the COVID-19 coronavirus on the territory of Ukraine], 2020) and the transition to distance learning at Poltava State Medical University during the spring semester (Order of the Rector, No. 120, 2020). We labeled it “period II” (transition to quarantine). The 2020/2021 academic year took place under the conditions of quarantine restrictions and a hybrid form of education Pro orhanizatsiyu osvitn′oho protsesu v osinn′omu semestri 2020/2021 navchal′noho roku za zmishanoyu (auditorno-dystantsiynoyu) formoyu navchannya v umovakh adaptyvnoho karantynu [On the organization of the educational process in the autumn semester of the 2020/2021 academic year using a blended (auditory-distance learning-distance) form of education in the conditions of adaptive quarantine], 2020 – period III (quarantine). The academic year 2021/2022, in addition to quarantine restrictions, was characterized by the beginning of Russian aggression against Ukraine and the introduction of martial law throughout the country (Pro vvedennya voyennoho stanu v Ukrayini [On the introduction of martial law in Ukraine]., 2022). In this period of time, education took place in a hybrid form (Pro orhanizatsiyu osvitn′oho protsesu v osinn′omu semestri 2021/2022 navchal′noho roku za zmishanoyu (audytorno-dystantsiynoyu) formoyu navchannya v umovakh adaptyvnoyi karantyn [On the organization of the educational process in the fall semester of the 2021/2022 academic year using a blended (auditory-distance) form of education in the conditions of adaptive quarantine]., 2021). This period is designated as period IV (quarantine and transition to martial law). Finally, the 2022/2023 academic year, when the quarantine (was lifted only in the summer of 2023 (Pro skasuvannya karantynu , vstanovlenoho na vsiy terytoriyi Ukrayiny z metoyu zapobihannya poshyrennyu na terytoriyi oblasti hostroyi respiratornoyi khvoroby COVID-19, sprychynenoyi koronavirusom SARS-CoV-2 [On the cancellation of the quarantine imposed on the entire territory of Ukraine to prevent the spread of the acute respiratory disease COVID-19 caused by the SARS-CoV-2 coronavirus on the territory of Ukraine], 2023) and military operations continued, and education was carried out in a hybrid mode (Pro orhanizatsiyu osvitn′oho protsesu na tret′omu (osvitn′o-naukovomu) rivni vyshchoyi osvity v osinn′omu semestri 2022/2023 navchal′noho roku za zmishanoyu formoyu. osvity v umovakh voyennoho stanu [On the organization of the educational process at the third (educational scientific) level of higher education in the autumn semester of the 2022/2023 academic year under the blended form of education under martial law], 2022), was labeled as period V (quarantine and martial law). The hybrid form of education involved online lectures, face-to-face practical classes and individual communication between the teacher and a student online or offline (Il′yenko et al., 2023). The lecture material was delivered in the form of presentations and short summaries on the Internet pages of departments.

This approach made it possible to compare the effectiveness of traditional face-to-face education in the medical higher education with distance and hybrid forms, which was done by us on the example of studying Pharmacology by medical students.

2.3 Organization of the educational process

During Period I, the educational process proceeded as usual. Lecture material was provided in person in university classrooms and practical classes were held in groups at the department. During quarantine Period II, online learning took place using the Zoom platform for lectures and practical classes via Zoom, Viber and Telegram. Teachers were at home if this was technically possible, as were students. During Periods III–V of the observation, teachers were at their workplaces at the university. Students attended lectures online and practical classes were held in classrooms.

2.4 Methods of academic performance analysis

A retrospective observational study was conducted, during which the quantitative indicators of academic performance of the 3^rd-year medical students of Poltava State Medical University over the past 5 academic years were analyzed. All students were residents of Ukraine and studied under the Educational and Professional Program “Medicine” (master's level). They mastered Pharmacology during two modules.

Structure of the discipline Pharmacology:

The number of credits/hours 7,0/210 of which:

Lectures (hours) 24

Seminar classes (hours.) 70

Self-directed work (hours) 116

Type of control – Exam (Semester final certification)

Training was carried out in accordance to the requirements of the Law of Ukraine “On Higher Education” (Pro vyshchu osvitu [On Higher Education]., 2014) under the European Credit Transfer System (ECTS). ECTS categories are a system for assessing student performance. They include letter grades (A, B, C, D, and E), which correspond to a certain percentage of the best students. There are also Fx and F grades for those who have failed the exam. The ECTS is part of the European Credit Transfer and Accumulation System (ECTS), which enables academic workloads and learning outcomes to be measured and compared (European Commission, 2015). Its results were evaluated on a traditional four-point scale and the average grade of each student was converted into a score on a 200-point scale separately for current academic performance (maximum 120 points) and final module control within each module (maximum 80 points) (Polozhennya pro orhanizatsiyu ta metodyku otsinyuvannya osvitn′oyi diyal′nosti zdobuvachiv vyshchoyi osvity Poltavs′koho derzhavnoho medychnoho universytetu [Regulations on the organization methodology of evaluating the educational activities of higher education applicants at the Poltava State Medical University]., 2021). The results of the assessment on a 200-point scale were used for statistical analysis and were characterized by A-E ECTS categories (Table 1).

Table 1

Table 1. Correspondence of points and ECTS categories to traditional assessment the students' knowledge in Poltava State Medical University.

2.5 Restrictions

The research was conducted at Poltava State Medical University in Poltava, Ukraine. Students' academic achievements were limited to one subject (Pharmacology), and those who had to retake exams were excluded.

2.6 Statistical analysis

The obtained digital material was statistically processed using one-way analysis of variance ANOVA with a posteriori Tukey test. Results were expressed as mean and its standard error (M ± SEM). The difference between groups was considered probable at p < 0.05.

3 Results

Quantitative results of assessment of students' knowledge in different periods of the educational process.

The number of the 3^rd-year students of the medical faculty who studied Pharmacology changed in different academic years and ranged from 309 to 66 persons, which averaged 168 ± 36 students. The largest number of studied sample was recorded in the 2019/2020 academic year, and the minimum number was in the 2022/2023 academic year, when the number of the 3^rd year medical students was 2.5 times less than the average for the entire observation period.

Module 1 coincided with the autumn semester and was called “Medical Prescription. General Pharmacology. Medicines affecting nervous and cardiovascular systems”. It consisted of 4 semantic modules. The average grade of the current academic performance of students mastering Module 1 varied in different academic years on average from 85.83 to 93.41 points (Figure 2).

Figure 2

Figure 2. The academic performance of medical students of the Poltava State Medical University studying Pharmacology Module 1 in different periods: I – control, II – transition to quarantine, III – quarantine, IV – quarantine and transition to martial law, V – quarantine and martial law. The value axis shows the average score on a 200-point scale. *p < 0.05 as compared to the average current grade in this period; ^#p < 0.05 as compared to the average current grade in period I; ^∧p < 0.05 as compared to the average grade for the final module control in period I.

This corresponded to the ECTS category C, which means that the student is able to compare, summarize, systematize information under the guidance of the teacher, is generally able to independently apply it in practice, control his/her own activities; correct mistakes (including significant ones), choose arguments to confirm opinions, possesses at least 75% knowledge of the topic during the survey and all types of control. At the same time, it turned out that in periods IV and V when education was carried out in a hybrid form the current academic performance during the study of Pharmacology Module 1 was higher (p < 0.0001) than in period I when the study of Pharmacology took place entirely in the traditional face-to-face form.

In all studied periods, the average score for the final module control in Module 1 was probably lower than current grade. It ranged from 55.33 to 59.86 points, which according to the ECTS scale closely approached or corresponded to the C level and could be characterized similarly to the results of the students' current academic performance in studying Pharmacology Module 1. The lowest level of this indicator was observed in the control period I. In period IV, it was probably higher than the control (p < 0.005), and in period III it had a tendency to increase compared to control (p < 0.1).

Module 2 coincided with the spring semester and was entitled “Drugs affecting the functions of effector organs and systems. Chemotherapeutic drugs. Antidotes”. Like Module 1, it consisted of four semantic modules. The average current score when mastering Module 1I varied from 90.56 to 99.7 points in different academic years (Figure 3).

Figure 3

Figure 3. The academic performance of medical students of the Poltava State Medical University studying Pharmacology Module 2 in different periods: I – control, II – transition to quarantine, III – quarantine, IV – quarantine and transitio n to martial law, V – quarantine and martial law. The value axis shows the average score on a 200-point scale. *p < 0.05 as compared to the average current grade in this period; ^#p < 0.05 as compared to the average current grade in period I; ^∧p < 0.05 as compared to the average grade for the final module control in period I.

In all analyzed periods, except period III, it was significantly higher than when studying Pharmacology Module 1 (p < 0.0001) and corresponded to levels C (end fragment) and B according to the ECTS descriptive scale. At level B, the student is fluent in the studied material, applies it in practice, freely solves exercises and problems in standardized situations, corrects own errors the number of which is insignificant, demonstrates at least 85% knowledge of the topic during the survey and all other types of control. It is shown that in periods IV and V, when students studied in a hybrid form, receiving face-to-face practical classes and online lectures, the indicators of current academic performance in Module 2 were better (p < 0.02 and p < 0.0001, respectively) compared to period I with face-to-face by learning.

In all studied periods, the average score for the final control in Module 2 was probably lower than the current grade in this module. It ranged from 58.68 to 66.24 points, which according to the ECTS scale corresponded to the transition from level C to level B, i.e., the students had satisfactory knowledge with significant limitations. The lowest level of this indicator was observed in the control period I and in the period II. In periods IV and V, it was significantly higher as compared to control (p < 0.02 and p < 0.001, respectively).

Similar trends were noted in relation to the students' total grade for Modules 1 and 2 in different academic years (Figure 4).

Figure 4

Figure 4. The academic performance of medical students of the Poltava State Medical University studying Pharmacology Modules 1 and 2 in different periods: I – control, II – transition to quarantine, III – quarantine, IV – quarantine and transition to martial law, V – quarantine and martial law. The value axis shows the average score on a 200-point scale. *p < 0.05 as compared to the average total grade in period I; ^#p < 0.05 as compared to the average total grade in period II; ^∧p < 0.05 as compared to the average total grade in period III.

The students' total score from Module 1 in Pharmacology was the lowest in period 1 with face-to-face training, which was significantly different from other periods (p < 0.001). It increased with the transition from distance learning to the hybrid form (period III) (p < 0.05) in comparison with period II. This indicator became even higher at the end of the observations and in period V significantly exceeded that not only in the control (p < 0.001), but also in periods II (p < 0.001) and III (p < 0.05). The revealed regularity was completely preserved for the total grade from Module 2. In all years, the total score in Modules 1 and 2 was within the C level. The only exception was Module 2 for the V period, when this indicator increased to 165.9 points, which corresponded to the level B.

The obtained results showed that the educational process in the Ukrainian medical higher school underwent a serious transformation during the last 5 years, which was connected with the external factors and was realized through the implementation of distance and hybrid forms of education. The analysis of quantitative indicators of academic performance of medical students who studied Pharmacology during these years proved that it not only did not deteriorate, but even improved at the end of observations compared to the traditional face-to-face form of education.

4 Discussion

The presented data showed that over the past 5 years, Ukraine has faced serious challenges in the form of the coronavirus pandemic and the beginning of Russian invasion. This caused a quick reaction of the central authorities, which was transformed into specific orders of the management of higher medical education institutions and, in particular, of Poltava State Medical University. These documents became the regulatory basis for changes in the form of future doctors' education from face-to-face to online and hybrid ones. This required organizational and methodical measures, approbation of synchronous and asynchronous learning modes, selection of the best options for online learning, certain training of both teachers and students of higher medical education in terms of computer literacy and psychology (Pro orhanizatsiyu osvitn′oho protsesu na tret′omu (osvitn′o-naukovomu) rivni vyshchoyi osvity v osinn′omu semestri 2022/2023 navchal′noho roku za zmishanoyu formoyu. osvity v umovakh voyennoho stanu [On the organization of the educational process at the third (educational and scientific) level of higher education in the autumn semester of the 2022/2023 academic year under the blended form of education under martial law], 2022). The results of these transformations turned out to be encouraging, which we proved by the example of teaching Pharmacology and its learning by the 3^rd-year medical students.

The number of the 3^rd-year medical students of Poltava State Medical University in the analyzed periods fluctuated widely. Its increase in period II can be explained by an increase in the standard of living in the pre-crisis period, since these were students who entered the university in 2017 and had the financial resources to receive the desired education. The lowest number of the 3^rd-year medical students we observed in period V. Apparently, it was due to this generation starting their medical training during the quarantine restrictions of 2020. This situation was also aggravated by the fact that some students suspended their studies in relation with the beginning of military operations in Ukraine, changed the place of study, and went to safer regions of the country or abroad.

Since the academic performance associated with the achievement of the highest average score is an important characteristic not only for students, but also for educational institutions and countries of the world (Duzhych et al., 2023), we analyzed the academic performance of students. As an example of a preclinical discipline, we took Pharmacology, which is one of the classic disciplines of higher medical education, which is based on the knowledge of Latin Medical Terminology, Chemistry, Biochemistry, Biophysics, Biology, Genetics, Microbiology, Normal and Pathological Physiology, Histology, and Anatomy and at the same time serves as a foundation for almost all clinical disciplines. In all periods, students' current performance in both modules was quite high (level C-B according to the ECTS scale), which indicated good training in other basic disciplines, wide access to educational resources (in particular, electronic ones), and high motivation to study. It should be assumed that the last factor was the most important and led to a probable increase in the current academic performance of students who studied Pharmacology under difficult circumstances (periods IV and V) compared to the control (period I). This assumption is consistent with the opinion of other authors, who indicate that among the most important factors of academic performance of higher education applicants, there are regular study, conscientious attendance of classes and completion of tasks, motivation and perseverance in achieving the set goals (Alhadabi and Karpinski, 2020). The improvement in students' academic performance observed in periods IV and V is consistent with the data of the survey of students of Poltava State Medical University, according to which the majority of respondents considered it necessary to continue their studies under difficult conditions, cheered for grades and became more conscious of self-education (Skrypnyk et al., 2022).

It is also noteworthy that the current academic performance for Module 2 in all periods, except for period III, was higher than for Pharmacology Module 1. Obviously, this can be explained by the students' accumulation of experience in learning this discipline, including the skills of working with educational and reference literature or test databases in training mode.

A lower level of grades on the final module tests in Pharmacology was observed to the same extent in all academic years (periods I–V). It was sufficient and met the minimum criteria. This can be explained by the fact that the form of conducting final module controls has evolved less over the past 5 years than conducting practical classes and lectures in a distance and hybrid format. Obviously, the factor of emotional stress is also important, when students are asked to solve tasks on prescription, pharmacotherapy, tests and cases under time limits, although intermediate controls prepare medical students for the specified test.

There is a tendency to improve the average score of both module controls in periods III–V. We believe this is due to a number of key factors: the first, by improving the hybrid form of education, which has gained stability, informational adequacy, and reliable evaluation systems based on the best global models (Zoom Workplace was used for online communication, Google Classroom for tests and other tasks, and other platforms were used as well); the second, the psychological adaptation of teaching staff and students to the new form of education; and, finally, as mentioned above, by increasing the motivation of students to study in a difficult time for their homeland (Il′yenko et al., 2023). The hybrid learning model reduced attendance issues (Raes et al., 2020), as students no longer needed to attend lectures in person (sometimes arriving late) or skip classes altogether due to illness or a lack of engagement with certain lecturers who struggled to present the material effectively. With the hybrid model, students could connect to the lecture from home and listen to and review the lectures several times if necessary.

Distance education is a purposeful process of interaction between a teacher and a student, based on modern information and telecommunication technologies enabling distance learning, which saves the educational process in case of force majeure (Bezkorovayna et al., 2021). As can be seen from the obtained data, the remote form of education, which was implemented during the spring semester (Module 2) of the 2019/2020 academic year (period II) did not cause significant changes in either an average current grade or the grade for the final module control in comparison with the face-to-face training (period I). This means that it did not disrupt students' acquisition of knowledge and practical skills in Pharmacology. At the same time during this period, online education did not show any advantages, possibly due to organizational problems associated with the initial stage of its implementation. The identified regularity, along with other known disadvantages of purely distance learning, such as the time-consuming process of preparing didactic material, too long stay in front of the computer, disruption of the usual communication between the teacher and students and between the students themselves, require us to agree with the conclusion that the specified form of education in medical institutions of higher education should be applied only for the limited time (Fedonyuk et al., 2023).

In contrast to the absence of changes in academic performance under purely distance learning, the hybrid form of learning and teaching Pharmacology demonstrated its effectiveness even with the complication of the situation in Ukraine in periods IV and V, which can be seen from the analysis of current grade, final control score, and total scores for Modules 1 and 2 in Pharmacology. The results obtained by us are close to the data of Goudarzi et al., who, using the example of the study of English Medical Terminology by 2^nd-year medical students of Hokkaido University (Japan), proved that online/combined courses showed better quantitative academic results compared to face-to-face courses (Goudarzi et al., 2024). This makes it possible to use the accumulated experience in teaching and learning Pharmacology by medical students in the future, and not only under crisis conditions. It can be assumed that a similar situation is typical for other preclinical disciplines.

5 Conclusions

Therefore, the academic performance of the 3^rd-year students of the medical faculty of Poltava State Medical University for five academic years was analyzed. The basis of the analysis was the distribution of observations for periods depending on the situation in the country (quarantine restrictions, martial law) and the prevalence of a certain form of education (face-to-face, distance and hybrid). It is shown that the remote form did not worsen the average grades of students in such an important discipline as Pharmacology, but the hybrid form that combines online educational materials and interactions online with classroom methods to the extent of its improvement contributed to the improvement of the medical students' knowledge. It carries no less informational load than the traditional face-to-face form of studying a preclinical discipline in a medical institution of higher education and requires more advanced computer skills, but allows for more rational use of time, makes learning more comfortable for students, increases the efficiency, accessibility and flexibility of medical education, which corresponds to modern trends in the educational process. Although more large-scale studies of the influence of the form of education on the students' academic performance are needed, it can already be argued that it is reasonable for medical universities to consider the issue of including hybrid courses of preclinical disciplines in their programs even in a normal, non-crisis situation.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Author contributions

RL: Methodology, Writing – review & editing. OL: Data curation, Formal analysis, Writing – original draft. EV: Methodology, Writing – review & editing. AS: Writing – original draft. MR: Resources, Writing – original draft. LP: Conceptualization, Formal analysis, Methodology, Writing – review & editing.

Funding

The author(s) declared that financial support was not received for this work and/or its publication.

Acknowledgments

The authors express gratitude to the leadership of Poltava State University for assistance in conducting the presented research.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

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