Preventive medicine undergraduates at a medical university in Shandong Province, China, show only a moderate overall level of higher-order thinking skills, according to a convergent mixed-methods study published in BMC Medical Education. The research, made available as an open-access article on 29 August 2026, combined a quantitative survey with qualitative interviews to assess how these skills develop across the degree programme and which factors help or hinder them.
Quantitatively, the team conducted a cross-sectional survey of 118 preventive medicine undergraduates using the Higher-Order Thinking Skills Scale for College Students together with a demographic questionnaire. The total score averaged 147.47 with a standard deviation of 26.03, against a theoretical maximum of 200. That places the cohort at a moderate level overall, and even the most senior students’ absolute scores left clear room for improvement relative to the scale’s ceiling.
Among the demographic variables examined, academic year stood out as the only significant predictor of higher-order thinking skills, with a beta coefficient of 9.838 and a p-value below 0.01. In other words, students in later years of the programme tended to score higher, and academic year explained a substantial portion of the variance in scores. The authors interpret this as evidence of inter-cohort progression: skills appear to accumulate as students move through the curriculum.
Yet the study’s central tension lies in what that progression does not achieve. Although scores rise with academic year, the absolute levels remain moderate, and the researchers conclude that the current educational paradigm appears insufficient for optimal cultivation of these skills. They describe a disconnect between yearly progression and the achievement of competency targets, suggesting that time in the programme alone does not close the gap.
The qualitative strand of the study aimed to explain why. The researchers conducted semi-structured interviews with 10 purposively selected students to explore their lived experiences of learning, and the analysis surfaced two overarching themes: enablers and inhibitors of higher-order thinking development.
On the enabling side, students pointed to practical application of knowledge, integration of technology into teaching, critical thinking pedagogy, and teamwork as experiences that supported their higher-order thinking.
The inhibitors were equally concrete. Students reported a lack of personalized guidance, monotonous teaching activities, and a fixed mindset about their own abilities as factors that held back their development.
Integrating both strands through a joint display analysis, the authors generated meta-inferences linking the moderate quantitative scores to the prevalent pedagogical inhibitors identified in the interviews. Their conclusion is deliberately cautious: reforms targeting the identified inhibitors—such as expanding active learning opportunities, providing personalized feedback, and fostering a growth mindset—may help address the competency gap, but the study notes that the effectiveness of such interventions awaits empirical evaluation. The findings are also bounded by the study’s design: the survey was cross-sectional and drawn from a single medical university, so it captures associations at one point in time rather than individual change over the course of a degree, and the interview sample comprised 10 students from the same institution. Within those limits, the study offers a detailed portrait of where higher-order thinking stands among Chinese public health undergraduates and a concrete map of the classroom conditions that students themselves say shape it.
Subject of Research: Development and influencing factors of higher-order thinking skills among public health undergraduates in China
Article Title: Unveiling the development and influencing factors of higher-order thinking skills among public health undergraduates: a convergent mixed-methods study
Article References: Zhu, S., Liu, L., Zhang, Q., Wang, H., Bao, Y., Bi, X., Lu, Y., & Zhang, X. (2026). Unveiling the development and influencing factors of higher-order thinking skills among public health undergraduates: a convergent mixed-methods study. BMC Medical Education. https://doi.org/10.1186/s12909-026-10259-x
Image Credits: AI Generated
DOI: 10.1186/s12909-026-10259-x
Keywords: higher-order thinking skills, public health education, preventive medicine, mixed methods, cross-sectional survey, medical education, China, critical thinking, pedagogy, undergraduate students, Unveiling, development
News Source: Phoebe Ingram. (October 29, 2026). Public health undergraduates show only moderate higher-order thinking skills in Chinese mixed-methods study. Scienmag.
