The effects of single and multiple BOPPPS-integrated model sessions on public health students' competences: a two-stage study combining quasi-experimental and cross-sectional analyses

Abstract

Background

Effective instructional approaches for fostering students' competences in public health education remain to be explored. This study aimed to integrate the bridge-in, objective, pre-assessment, participatory learning, post-assessment, and summary (BOPPPS) framework with problem-based learning (PBL), team-based learning (TBL), and case-based learning (CBL) to develop a novel instructional model, termed the BOPPPS-integrated model (BIM), and to assess the influences of single and multiple BIM interventions on the competences of undergraduate public health students.

Methods

A two-stage study was conducted by a quasi-experimental pilot study and a cross-sectional survey. First, the quasi-experiment compared a traditional lecture-based learning (LBL) group (n = 50) with a BIM group (n = 48) to evaluate the effect of a single BIM intervention. Second, a cross-sectional study was conducted to analyze the impacts of multiple BIM sessions across three groups: control (n = 96), basic intervention (1–2 times BIM, n = 66), and intensive intervention (≥ 3 times BIM, n = 62). All participants completed a self-administered questionnaire designed to evaluate seven competence dimensions: information literacy, summarization, expressive communication, critical thinking, self-directed learning, teamwork, and objective evaluation, which are essential for public health students to address complex public health challenges.

Results

Students who received single and multiple BIM instructional sessions scored significantly higher in information literacy, expressive communication, and teamwork than those who received LBL method (P < 0.05). Multiple BIM interventions further improved scores in summarization, self-directed learning, and objective evaluation (P < 0.05). The scores of six dimensions like information literacy, summarization, expressive communication, self-directed learning, teamwork, and objective evaluation showed an upward trend as the number of interventions increased (P for trend < 0.05).

Conclusions

A single BIM intervention effectively improved students’ competences in information literacy, teamwork, and expressive communication. Additionally, multiple BIM interventions not only consolidated these competences but also fostered summarization, self-directed learning, and objective evaluation, thereby highlighting the importance of BIM in developing students’ competences in public health education.

Introduction

The growing complexity of global public health challenges, such as COVID-19, chronic diseases, and health inequities, requires professionals who possess multidisciplinary knowledge and integrated competences [1,2,3]. Therefore, public health education must evolve to prepare graduates to rapidly conduct epidemiological investigations, collect and analyze data for chronic disease surveillance, and engage in evidence-based health policy development and advocacy after graduation [4, 5]. Accordingly, this requires students to acquire some essential competences, including information literacy to rapidly acquire and disseminate accurate information, self-directed learning to continuously update their knowledge and skills in response to dynamic public health issues, and the ability to analyze and synthesize data for effective decision-making [6,7,8]. However, traditional lecture-based learning (LBL) in public health courses often emphasizes theoretical knowledge at the expense of practical application and skill development [9,10,11]. To bridge this gap, it is imperative to develop an innovative instructional model that integrates theoretical knowledge with building practical skills.

In recent years, student-centered instructional methods such as team-based learning (TBL), problem-based learning (PBL), and case-based learning (CBL) have been increasing implemented in higher education [12,13,14,15]. TBL is characterized by a collaborative framework that fosters the development of a comprehensive knowledge system through self-directed pre-study and teamwork, with an emphasis on enhancing students' teamwork, knowledge integration and application, and communication skills [16, 17]. PBL, on the other hand, is a problem-driven approach that facilitates knowledge acquisition through independent learning and teamwork, prioritizing the cultivation of self-directed learning, problem-solving, critical thinking, and innovation skills [18]. Conversely, CBL engages students through the real-world case, enabling them to construct structured knowledge frameworks while simultaneously developing analytical, problem-solving, and communication skills [19, 20]. Despite the individual merits of these approaches, their isolated application in public health education presents certain limitations. TBL may diminish individual accountability, PBL might lack comprehensive knowledge integration, and CBL may hinder knowledge transfer due to its context-specific nature [17, 21, 22]. While each approach has distinct strengths and limitations, the integration of these methods into a unified framework that capitalizes on their unique advantages remains a significant challenge in public health education. Such integration is essential to enhance students' knowledge systems and the necessary competences to address complex public health challenges.

The bridge-in, objective, pre-assessment, participatory learning, post-assessment, and summary (BOPPPS) model represents a modular, student-centered instructional design framework that emphasizes systematic and interactive teaching and learning processes [23,24,25]. Its well-defined structure provides a flexible platform for integrating PBL, CBL and TBL into a cohesive framework, particularly within participatory learning and assessment sessions. To optimize the strengths of these methods, we have developed a BOPPPS-integrated model (BIM). This instructional model systematically integrates PBL and CBL into bridge-in and summary sessions to contextualize learning and reinforce core concepts; PBL into pre-assessment and post-assessment sessions to facilitate self-directed learning and evaluate outcomes; and PBL, TBL, and CBL into participatory learning sessions to promote collaboration, knowledge integration, and practical skill development. By leveraging the unique advantages of these approaches, the BIM aims to enhance students' essential competences for addressing public health challenges within professional courses. This study also assessed the impacts of single and multiple BIM instructional sessions on students' competences using a self-designed questionnaire, with the goal of informing reforms in public health education.

Methods

Design of the BIM instruction

The BIM instruction was systematically developed based on the analysis, design, development, implementation, and evaluation (ADDIE) instructional design model and implemented through the BOPPPS structure, with the integration of PBL, TBL, and CBL in each phase (Fig. 1).

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In the analysis phase, we conducted a comprehensive review of the course objectives and content, students' interests and needs, public health practice requirements, and available resources to identify relative teaching themes and learning objectives.

In the design phase, we integrated PBL, CBL, and TBL methods into specific phases of the BOPPPS model. Specifically, PBL and CBL were initially integrated into the "Bridge-In" session of BOPPPS by selecting appropriate theme-driven cases, social events and questions to stimulate students' engagement with the course knowledge. In the "Objective" session, we clearly identified the learning objectives to guide students throughout the lesson. In the "Pre-Assessment" session, PBL was employed by posting questions on the online teaching platform and followed by an interactive question-and-answer (Q&A) session between students and the instructor to assess students' prior knowledge. In the "Participatory Learning" session, PBL, TBL, and CBL were integrated after theoretical instruction. Students were encouraged to engage in group discussions on questions and cases, collaborate on data and information retrieval after class and ultimately present their synthesized findings in class. Peer evaluation was conducted to assess individual contributions and learning outcomes after the presentation using pre-established criteria. In the "Post-Assessment" session, PBL was incorporated through the online platform to allow students to immediately review and self-assess their mastery of core knowledge. Finally, PBL and CBL were integrated into the "Summary" session by guiding students to summarize knowledge and consider its application to real-world scenarios.

In the development phase, we developed theme-driven cases and built the databases of test questions based on current social events, and expert opinion in the field of public health. This phase presented several challenges. Specifically, in creating theme-driven cases, we occasionally faced difficulties in identifying suitable social events that met the criteria of timeliness, typicality and teachability to support learning objectives. To address this issue, we often used a combination of literature reviews, officially published events and data, news analysis, and expert consultation to ensure that the cases were closely aligned with the course content. Additionally, we encountered challenges in constructing question databases, particularly in designing questions with appropriate levels of difficulty and differentiation. The test questions which included single-choice, multiple-choice, short-answer, and case study formats, were designed using a progressive pattern of difficulty that included memorization, application, and analysis. This approach ensured that the questions accurately assessed students' competences at multiple cognitive levels, and we refined the questions through iterative feedback processes.

In the implementation phase, we adhered to the process of BIM instruction to conduct teaching and learning activities, emphasizing student group discussions, post-class collaboration, and class presentations during participatory learning.

In the evaluation phase, we analyzed pre- and post-assessment data using online platforms and classroom assessment tools to assess the learning outcomes. Based on the test data and classroom observation records, we evaluated the learning effect, optimized cases, reflected on design and group collaboration issues, and subsequently conducted iterative improvements to the BIM instructional implementation.

Design of the BIM instruction in a specific curriculum

Selection of course and specific chapter

This study selected the "Environmental Hygiene" course, a core requirement for public health majors, with a focus on the "Water Hygiene" chapter. This chapter covers key issues such as water pollution, water purification, and drinking water hygiene, all of which are closely related to public health.

Themes and current social events selection criteria

The theme "Water and Health" is derived from the knowledge structure and content of the "Water Hygiene" chapter, ensuring alignment with criteria such as coherence with curriculum objectives, relevance to students' life and professional contexts, exploratory problem-solving potential, applicability of transferable skills, timeliness reflecting the latest disciplinary advancements, and ethical considerations.

The guidelines for selecting current social events related to "Water and Health" focus on six key areas: direct connection to course material; recent water health incidents with significant global or regional impact; discussions on water allocation, pollution, and health; policy initiatives or campaigns concerning drinking water health; and water-related events with clear social and health implications. Illustrative examples include water pollution incidents, India's Jal Jeevan Mission, the influence of climate change on water availability, global water inequality, and water eutrophication.

BIM instructional implementation in the curriculum

The BIM instruction has been implemented in the "Water Hygiene" chapter of the Environmental Hygiene course, following the BOPPPS model. Each phase of the BIM instruction was described in detail below:

In the "Bridge-In" session, we introduced the theme by engaging students in a discussion on recent water-related events, such as the Jal Jeevan Mission, to highlight the relevance of the topic to their prospective careers in public health.

In the "Objective" session, clear learning objectives were set, including understanding the impact of water quality on health, identifying indicators of water pollution, and developing strategies for water quality improvement.

In the "Pre-Assessment" session, an online evaluation was conducted to assess students' prior knowledge of water pollution and its health effects. The assessment included questions such as "What are the common sources of water pollution?" and"How does water pollution affect public health?".

The "Participatory Learning" session formed the core of the BIM, where students participated in group discussions and analyzed case studies. They examined scenarios such as a eutrophication event causing water quality issues in a local area and deliberated on questions like "What are the health risks associated with eutrophication?" and "What preventive measures can be adopted?" Following the theoretical instruction, students were divided into groups to analyze the case study, engage in discussions and receive guidance to facilitate collaborative dialogue. Group members worked together outside of class to gather data and information, presented their synthesized findings during class sessions. Upon the completion of each group's presentation, peer evaluations were conducted based on pre-established scoring criteria.

An online post-assessment was administered to gauge students' comprehension of the course. Students were tasked with developing strategies for the management and prevention of water pollution, addressing primary, secondary, and tertiary prevention measures.

The "Summary" session provided synthesis of key concepts and their practical applications, illustrated through a case study on the use of wastewater irrigation in agriculture. This case study enabled students to reorganize all learned knowledge and reinforce the course's learning objectives.

Design of the student competence assessment questionnaire (SCAQ)

SCAQ content design

The SCAQ used in this study was a self-developed scale which underwent evaluation by educators experienced in medical education. It was refined through a four-stage process involving initial review, presurvey, revision and re-presurvey. The finalized version of the SCAQ is presented in Supplementary Table 1, with a detailed methodology provided in the Supplementary Methods section.

Re-presurvey analysis

A total of 70 questionnaires were collected during the re-presurvey, of which 68 were deemed valid, yielding a response rate of 97.14%. The presurvey analysis included item analysis, reliability analysis, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA) to assess the item discrimination, internal reliability, and structural validity of the SCAQ.

The competence scale exhibited robust measurement properties, as confirmed by comprehensive validation. Item analysis demonstrated strong discriminative capacity across all items (t > 4.0, P < 0.05), coupled with high internal consistency (Cronbach's α > 0.8), as detailed in Supplementary Tables 2–3. EFA established structural validity, indicating adequate data suitability (KMO = 0.71) and a significant Bartlett's test of sphericity (P < 0.01). The derived factor structure aligned with the original scale design, comprising seven factors that accounted for 80.83% of the total variance. The near-zero inter-factor correlations further underscored their statistical independence (Supplementary Tables 4–7). CFA provided additional validation of the scale structure, achieving an acceptable model fit (χ2/df = 1.35; RMSEA = 0.07; CFI = 0.78) with strong standardized loadings (0.79–0.95) on the designated dimensions (Supplementary Tables 8–9). Detailed analytical procedures and outputs are available in the Supplementary Methods.

SCAQ content

The SCAQ was structured into three distinct sections: an introductory narrative elucidating the survey's purpose and content to facilitate respondent comfort; a section collecting fundamental personal information, such as the respondent's name, academic major, and frequency of participation in BIM; and a competence assessment scale comprising seven dimensions of competences, which are informed by prior research [6,7,8, 10, 18, 26]. These dimensions included information literacy, summarization, expressive communication, critical thinking, self-directed learning, teamwork, and objective evaluation. Each dimension was assessed through 5 questions, culminating in a total of 35 questions. The SCAQ employed a five-point Likert scale to capture the variability in relationships among the variables, with scale points labeled as "strongly disagree", "disagree", "neutral", "agree", and "strongly agree", corresponding to scores from 1 to 5 points. Each question carried a maximum score of 5 points, and each competence dimension had a potential score of 25 points, derived from its five questions. The scores were indicative of the participants' positive perceptions regarding each question.

Evaluation of the effects of BIM interventions on students' competences

A quasi-experiment to evaluate the effect of a single BIM intervention

A quasi-experimental pilot design was conducted to evaluate the impact of a single implementation of BIM on student competences. Two classes of public health students in the same grade level who had not previously been exposed to the BIM intervention and whose college entrance exam scores differed by no more than 10 points, were selected for the study. A random selection process designated one class as the intervention group (n = 50) and the other as the control group (n = 48) (Fig. 2A). Both groups received instruction on the content of "Water Hygiene" chapter, with the primary distinction being the instructional method employed. The intervention group was taught using BIM, while the control group received traditional lecture-based learning (LBL) method. Immediately after water hygiene content instruction, students from both classes completed the SCAQ.

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A cross-sectional survey to evaluate the effects of multiple BIM interventions

In this cross-sectional survey, our objective was to assess the level of students' competences in the School of Public Health after receiving the BIM instructional intervention. The SCAQ was distributed to all students enrolled in the School of Public Health during class sessions between April 1, 2024, and May 31, 2024, encompassing a total of 350 students. To maintain a high level of confidentiality and to encourage honest self-assessment, all responses were anonymized. Ultimately, 230 students actively participated and completed the SCAQ, with a response rate of 65.71%. Of these, 224 responses were deemed valid, yielding a validity rate of 97.39%. Based on the frequency of BIM instructional interventions received, students were categorized into three groups: a control group without BIM intervention (n = 96), a basic intervention group with 1–2 times BIM interventions (n = 66), and an intensive intervention group with 3 or more times BIM interventions (n = 62) (Fig. 2B).

Statistical analysis

The competence scores for each dimension are expressed as the means ± standard deviations. To assess the effectiveness of a single session of BIM intervention, we used an independent samples t-test to compare score differences across the seven dimensions of students' competence between the BIM intervention group and the LBL control group. For comparisons involving three groups, a one-way analysis of variance (ANOVA) was conducted, followed by the least significant difference (LSD) test. All statistical analyses, except for the CFA in the presurvey, were carried out via SPSS version 26.0. The CFA was performed via R version 4.4.0. Statistical significance was set at P < 0.05.

Results

Effects of a single BIM intervention on students' competences

Overall, students in the BIM group exhibited higher scores than those in the LBL group across all seven competence dimensions (Fig. 3). Specifically, students in the BIM group performed significantly better than the LBL group in information literacy, expressive communication, and teamwork (P < 0.05, Table 1).

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Effects of multiple BIM interventions on students' competences

Compared with the control group, the intervention group exhibited superior scores across all seven competence dimensions as the number of interventions increased (Fig. 4). Statistically significant differences in scores were observed among the three groups (P < 0.05) for six competence dimensions: information literacy, summarization, expressive communication, self-directed learning, teamwork, and objective evaluation. An upward trend in scores was noted with an increasing number of interventions (P for trend < 0.05). Specifically, the basic intervention group outperformed the control group in the dimensions of information literacy, expressive communication, and teamwork (P < 0.05), which is consistent with the results of the single BIM intervention on students' competences. The intensive intervention group surpassed the control group in these dimensions as well as in summarization, self-directed learning, and objective evaluation (P < 0.05). Furthermore, the intensive intervention group performed better than did the basic intervention group in information literacy, expressive communication, and teamwork (P < 0.05) (Table 2).

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Discussion

Analysis of the effects of a single BIM intervention on students' competence development

Compared with the LBL group, a single BIM intervention significantly improved students' overall competences, especially in terms of information literacy, expressive communication, and teamwork.

Previous studies have indicated that a low frequency of information literacy training lectures in universities may hinder students' ability to enhance their information searching skills [27,28,29]. The BIM intervention required students to collaborate in groups to search for information and solve specific problems using guided search methods and strategies. This structured practice afforded students the opportunity to retrieve and share information, thereby improving their information literacy. Supporting our findings, a study reported that over 81% of students who participated in at least one information retrieval training course were able to articulate methods for searching online resources [30], highlighting the effectiveness of targeted training.

The improvement in teamwork skills among students in the BIM group can be attributed to the inherently collaborative nature of the BIM intervention. The process of mutual cooperation within these groups afforded students practical experience in teamwork. This observation is consistent with the findings of Shen's study, which demonstrated that BOPPPS-based instructional methods effectively foster the development of students' teamwork skills [31].

In addition, there was a notable enhancement in students' competence in expressive communication, likely resulting from the structured opportunities to explain complex concepts during presentation sessions. Previous research has indicated that group discussions and presentations significantly enhance students' expressive communication skills [32, 33], which is in line with our findings.

Analysis of the effects of multiple BIM interventions on students' competence development

Multiple BIM interventions further augmented students' competence in information literacy, expressive communication, and teamwork as the frequency of interventions increased. The diverse knowledge and themes presented across various courses provided students with opportunities to cultivate competence in information retrieval, teamwork, and communication from multiple perspectives. This is further supported by the evidence suggesting that the long-term implementation of "student-centered" instruction could improve students' conceptual learning [34].

Although a single BIM intervention did not yield significant improvements in summarization, self-directed learning, or objective evaluation, these competences demonstrated notable enhancement with an increased number of BIM interventions. A recent study revealed that knowledge application and cognitive levels significantly improved only after two years of continuous "problem-solving and practice-oriented" instruction [35], underscoring the necessity for multiple interventions to effectively enhance students' competences.

Regarding summarization skills, multiple BIM interventions require students to identify and extract key information from numerous articles. Students can effectively improve their summarization competence by practicing summarizing article abstracts and drawing connections between articles [8]. This finding aligns with our results, suggesting that persistent practice fosters improved summarization habits.

Moreover, multiple BIM interventions have been shown to positively impact students' self-directed learning capabilities. This observation is consistent with previous studies indicating that the BOPPPS instructional model can significantly enhance students' abilities in self-directed learning [26, 36,37,38]. This enhancement is likely attributable to the iterative guidance and optimization of the learning environment, which fosters the development of habitual learning practices.

Additionally, multiple BIM interventions have been found to positively affect students' objective evaluation competence, corroborating the findings of Haydée De Loof's [35]. The improvement in competence is likely due to the diverse evaluation activities incorporated into the long-term course, which afford students opportunities to compare various course topics and engage in group debriefings. These findings underscore the critical role of multiple BIM instructional interventions in fostering students' competences.

However, both single- and multiple-session BIM interventions demonstrated limited efficacy in enhancing critical thinking skills, suggesting a need for instructional improvements in this domain. Critical thinking, a higher-order cognitive skill involving synthesis, analysis, and reflection, and is essential for effective knowledge acquisition and social adaptation [39, 40]. Several studies have shown that incorporating simulated laboratory practice with PBL or CBL in medical education significantly enhances students' critical thinking competence [41, 42]. Nevertheless, our results diverged from the results, likely due to an inadequate incorporation of multi-perspective analysis in the design of problem and case studies. To address this, future instructional designs should integrate more debatable topics within TBL and CBL sessions and encourage intergroup discussions through "brainstorming" activities to promote multi-perspective thinking.

Advantages and limitations

This study presents several notable advantages. Firstly, it introduces an innovative, student-centered BIM instruction for public health education. By modularly integrating the closed-loop structure of the BOPPPS model with PBL, CBL, and TBL, this approach addresses the limitations of single-method teaching, thereby promoting both theoretical knowledge and essential practical skills. Secondly, the BIM instruction emphasizes the development of key competences necessary for handling complex public health events, such as information literacy, self-directed learning, summarization, and teamwork. These competences are expected to facilitate a smoother transition to professional practice after graduation. Thirdly, this study utilizes a two-stage research design, combining quasi-experimental pilot and cross-sectional study to evaluate the effects of both single and multiple BIM instructional sessions. This design allows for a more thorough comprehension of BIM's sustained impact on students' competence development. Lastly, the BIM effectively integrates theoretical knowledge with practical skills, thereby enhancing students' preparedness to tackle future public health challenges.

There are some limitations in this study. First, the quasi-experimental and cross-sectional design lacks a rigorous control group and randomized assignment, which constrains the ability to draw causal inferences and evaluate multiple-sessions effects. Second, quasi-experimental did not assess students' baseline competence levels prior to the intervention, rendering precise individual analyses of learning gains infeasible. Third, the cross-sectional survey could not ensure homogeneity in knowledge and competence levels or thematic consistency among student groups, potentially compromising the accuracy of the results. Fourth, the study's generalizability is constrained by its restricted sample size and its focus on a single institution. Fifth, the reliability and validity of the SCAQ remain inconclusive due to the limited sample size in the re-presurvey, indicating the necessity for future expansion of the presurvey sample. Finally, the study encompasses multiple t-tests and ANOVA without adjusting for P values, which might potentially heighten the likelihood of Type I errors.

Challenges and possible solutions in BIM implementation

The implementation of BIM instruction presents several challenges. Firstly, BIM implementation requires faculty to possess advanced instructional design skills and expertise in student-centered instructional methods to be effectively utilized [17]. These challenges may be addressed through specialized training, the use of online resources, and increased peer collaboration. Secondly, the emphasis of BIM instruction on independent learning and teamwork may increase students' workload, particularly affecting those with weaker learning abilities or lower autonomy, potentially leading to disengagement, reduced efficiency, and uneven group participation. To address these challenges, the implementation of small-group hierarchical teaching and individual contribution tracking is recommended. For example, collaborative platforms can be utilized to monitor students' literature review activities and the frequency of their participation in discussion, thereby ensuring active engagement and equitable contributions. Thirdly, BIM implementation requires additional resources such as case libraries and technological support. The long-term sustainability of multiple BIM interventions can be facilitated through the use of open-source resources, free online platforms, inter-institutional resource sharing, industry partnerships, or educational grants. Lastly, the integration of multiple instructional methods within the BOPPPS framework presents a complex challenge, which could be solved by developing course design templates, collaborating with educational design experts, and adopting a modular approach.

Conclusion

In conclusion, BIM instruction represents an innovative approach to public health education by integrating PBL, TBL, and CBL within the BOPPPS framework, thereby offering a distinctive method for fostering students' competences. Unlike LBL, BIM emphasizes student engagement and active learning, promoting both theoretical understanding and competence development. A single session of BIM intervention can rapidly improve students' competence in information literacy, expressive communication, and teamwork, with potential for further improvement through additional interventions. However, more complex competences such as summarization, self-directed learning, and objective evaluation require ongoing instructional support and a structured learning environment to achieve significant and enduring advancements.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

ADDIE:

Analysis, design, development, implementation, and evaluation

BOPPPS:

Bridge-in, objective, pre-assessment, participatory learning, post-assessment, and summary

LBL:

Lecture-based learning

PBL:

Problem-based learning

TBL:

Team-based learning

CBL:

Case-based learning

EFA:

Exploratory factor analysis

CFA:

Confirmatory factor analysis

BIM:

BOPPPS-integrated model

SCAQ:

Student competence assessment questionnaire

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