The efficacy of the BOPPPS teaching model in clinical and health education: a systematic review and meta-analysis

Abstract

Background

BOPPPS (Bridge-in, Objective, Preassessment, Participatory learning, Post-assessment, Summary) has emerged as a compelling alternative in clinical and health education, particularly in medical and nursing education. This study aimed to assess the efficacy of BOPPPS in clinical and health education, with a primary focus on medical education, while also considering its applications in related disciplines such as nursing and health services management.

Methods

A systematic review and meta-analysis were conducted using databases of PubMed, EMBASE, Cochrane Library, Scopus, and Web of Science, covering studies up to May 15th, 2023. Inclusion criteria were studies involving undergraduate students in clinical and health disciplines (e.g., medicine, nursing, health services management) using BOPPPS, comparing it to traditional teaching methods, and reporting on relevant outcomes. Exclusion criteria were studies not focused on clinical and health education or without a comparison group. Quality assessment was performed using the Newcastle-Ottawa Scale (NOS) for non-randomized studies and the Jadad scale for randomized controlled trials (RCTs). Heterogeneity among the studies was evaluated using the I² statistic and Cochran’s Q test. Publication bias was assessed using funnel plots and Egger’s test.

Results

A total of 146 publications were initially retrieved, with 16 studies (1198 in the BOPPPS group and 1122 in the control group) included. The pooled result revealed that BOPPPS significantly improved final examination scores (Standardized mean difference: 1.14, 95% CI 0.84–1.43; P < 0.001) compared to traditional teaching. Egger’s test indicated no significant publication bias (p-value = 0.12). Additional benefits included improved student satisfaction (SMD 0.94, 95% CI 0.63–1.26; P < 0.001), classroom interaction (SMD 0.83, 95% CI 0.46–1.21; P < 0.001), and learning initiative (SMD 0.73, 95% CI 0.48–0.98; P < 0.001).

Conclusion

BOPPPS demonstrates significant potential for enhancing various dimensions of clinical and health education, including academic performance, student engagement, and satisfaction. Policymakers and educational leaders should consider integrating BOPPPS into teacher training and curriculum design to promote active learning and improve learning outcomes. However, further research is necessary to explore its effectiveness in diverse cultural and educational contexts, as well as its potential impact on developing higher-order cognitive skills like critical thinking and problem-solving skills. While these findings are generalizable to similar educational settings, caution is recommended when applying them to different cultural contexts.

Introduction

Medical education is the crucible where students in clinical and health disciplines forge their competencies and assimilate into the healthcare profession [1, 2].However, traditional pedagogical strategies, such as Lecture-Based Learning (LBL), often rely heavily on didactic lectures, which foster passive learning, prioritize rote memorization, and struggle to bridge theoretical knowledge with practical application. These methods can limit interaction and fail to effectively prepare students with essential clinical skills, often relegating them to passive recipients of information and leading to declining engagement in the learning process [3,4,5,6]. The limitations of this traditional approach raise the pressing need for transformative strategies in clinical and health education.

Active learning strategies, in contrast, have proven to enhance student engagement, critical thinking, and performance. Meta-analyses have shown that active learning methods, such as flipped classrooms and problem-based learning, significantly improve student outcomes by encouraging deeper understanding and fostering skills such as problem-solving [7,8,9,10]. For example, Lin et al. explored innovative methods in dental education, emphasizing interactive approaches that replace traditional lectures, and found positive student responses and improved learning outcomes [11].

In this pursuit of innovation, BOPPPS (Bridge-in, Objective, Preassessment, Participatory learning, Post-assessment, Summary) emerges as a compelling proposition. BOPPPS is an instructional model designed to enhance teaching and learning experiences [12]. Based on constructionist theory and the communicative approach, BOPPPS challenges the status quo by putting students at the center of their educational journey [13]. Constructivist theory suggests that learners build knowledge through interaction with their environment, integrating new concepts with prior knowledge for deeper understanding and retention. This emphasizes active learning and contextualizing information. The communicative approach, central to BOPPPS, fosters dialogue and collaboration between students and instructors, promoting critical thinking and practical application. Together, these principles shift the teacher’s role from a knowledge provider to a facilitator, empowering students to own their learning process. Figure 1 outlines the primary tasks associated with each step of this framework. Table 1 highlights the key differences between BOPPPS and traditional teaching strategies.

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By fostering active participation and collaboration, BOPPPS creates a sense of ownership and excitement in the learning process. This innovative approach has been effectively applied across various medical disciplines, including ophthalmology [14], health services management [15], thoracic surgery education [16, 17], physiology education [18], and Dental Materials Education [19], and others. Its adaptability underscores its potential as a transformative model in clinical and health education.

Despite these applications, there has been no comprehensive evaluation of BOPPPS across diverse clinical and health education contexts. This study aims to fill that gap by conducting a systematic review and meta-analysis to assess the efficacy of BOPPPS in improving educational outcomes, thereby providing valuable insights to enhance clinical and health education globally.

Methods

Study protocol

A PRISMA-compliant study (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was conducted in this study [20]. A predefined protocol ensured transparency and reproducibility, specifying research questions, inclusion/exclusion criteria, search strategy, data extraction methods, and statistical analysis plan. The protocol was registered [INPLASY2023100043], and any deviations were documented in the final report. The full protocol can be accessed on INPLASY’s website.

Search strategy

We conducted a literature search across PubMed, EMBASE, Cochrane Library, Scopus, and Web of Science until May 15, 2023. The search employed keywords and subject headings related to clinical and health education, medical learning, medical education, and BOPPPS (Supplementary Table 1).

Study selection criteria (PICOS framework)

Population (P): Undergraduate students in clinical and health disciplines (e.g., medicine, nursing, health services management).

Intervention (I): BOPPPS as a teaching strategy in clinical and health education.

Comparison (C): Traditional teaching strategies (e.g., lecture-based learning).

Outcome (O): Primary: Final exam scores; Secondary: Student satisfaction, classroom interaction, learning initiative, analytical ability, clinical thinking ability, self-study ability, problem-solving, learning retention, and critical thinking skills.

Study Design (S): Randomized/Non-randomized controlled trials (RCTs).

Study Selection.

Two independent reviewers screened titles and abstracts based on inclusion and exclusion criteria. Discrepancies were discussed regularly, following a structured process:

Initial Screening: Independent title/abstract screening.

Full-Text Review: Assessment of potentially relevant articles.

Discussion: Resolution of discrepancies.

Consensus: Agreement on inclusion/exclusion decisions.

Third Reviewer: In case of unresolved discrepancies, a third reviewer was consulted.

Geographic regions

The studies included in this systematic review and meta-analysis originated from a variety of geographic regions, though a significant proportion were conducted in China. This distribution is discussed in greater detail in the results section.

Inclusion and exclusion criteria

Inclusion: Studies with undergraduate students in clinical/health disciplines, using BOPPPS as an intervention, and comparing BOPPPS to traditional teaching strategies, reporting objective or subjective outcome measures, including RCTs and non-RCTs.

Exclusion: Studies not focusing on clinical/health education, lacking a comparison group, or missing relevant outcome measures.

Data extraction

Two investigators independently extracted data using an electronic form (Microsoft Excel), including study characteristics, participant details, BOPPPS intervention specifics, comparison group information, and outcome measures. Any discrepancies were resolved through discussion or third-party consultation.

Quality assessment

Study quality was assessed using the Newcastle-Ottawa Scale (NOS) for non-randomized studies, focusing on study population selection, group comparability, and exposure/outcome assessment. For RCTs, the Jadad scale was used. Disagreements were resolved by the corresponding author.

Study outcomes

Primary outcome: Final examination scores. Secondary outcomes: Student satisfaction, classroom interaction, learning initiative, analytical ability, clinical thinking ability, self-study ability, problem-solving skills, learning retention, and critical thinking skills. Data extraction details are provided in Supplementary Table 2.

Data synthesis

Data were synthesized using Microsoft Excel, with pooled effect sizes computed for key outcomes. Standardized mean differences (SMD) were calculated for continuous outcomes, and odds ratios (OR) for dichotomous outcomes. Random-effect models were employed in all meta-analyses, with statistical significance set at P < 0.05. RevMan 5.4 was used for statistical analysis.

Publication bias assessment

To assess the potential for publication bias, funnel plots were visually inspected, and Egger’s test was performed to statistically evaluate asymmetry. These methods were employed to determine whether publication bias might have influenced the results of the meta-analysis.

Results

Literature search and study selection

This search yielded a total of 146 studies. Subsequently, 78 duplicate studies were removed. After a thorough screening, an additional 43 studies were excluded due to incompatibility with the study design, including issues related to populations, subjects, or research types. Following a detailed examination of the full texts, 3 more articles were excluded. Ultimately, a total of 16 studies [14,15,16, 19, 21,22,23,24,25,26,27,28,29,30,31,32] were included in this systematic review. An analysis of Cohen’s kappa statistic for screening inclusion/exclusion judgments is 0.7. Figure 2 illustrates the study selection process.

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Study characteristics

Among the 16 studies incorporated into this systematic review, the sample sizes ranged from 51 to 454, with a total of 2624 participants. All these studies were predominantly conducted in China, spanning the period from 2018 to 2022. Seven studies involved undergraduate nursing students, while the remaining studies focused on undergraduate students majoring in medicine (Undergraduate students: students at a college or university who have not yet received a bachelor’s degree). The versatile application of the BOPPPS teaching strategy was observed across various clinical and health education, encompassing thoracic surgery education, ophthalmology education, evidence-based medicine teaching, medical nursing, dental materials education, physiology education, and gastrointestinal surgery nursing.

Table 2 provides a comparative overview of the BOPPPS model and other widely used teaching frameworks, such as Understanding by Design, the 5E Model, and traditional instructional frameworks. This table highlights the unique theoretical foundation and design features of BOPPPS, emphasizing its structured and student-centered approach. By presenting these comparisons, the table contextualizes the pedagogical strengths of BOPPPS and its potential advantages over other models, thus offering a theoretical basis for its application in clinical and health education.

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Table 3 presents our interpretation and exploration of the BOPPPS model. This table outlines how the BOPPPS framework is adapted for clinical and health education, emphasizing its structured yet flexible approach to fostering active learning, student engagement, and participatory teaching.

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Table 4 summarizes the baseline characteristics of the included studies, including population details, course content, and comparison groups. This table demonstrates the diversity of populations, disciplines, and study designs represented in the systematic review and meta-analysis. By showcasing these characteristics, Table 4 highlights the varied applications of the BOPPPS model across clinical and health education and underlines the methodological heterogeneity of the included studies, which is further discussed in the limitations section. The quality of the included studies according to the NOS and Jadad scale is described in Supplementary Table 3.

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Power analysis

To ensure the meta-analysis was adequately powered, we conducted a power analysis for meta-analyses. Based on the observed effect size (SMD = 1.14), the number of included studies (n = 16), and the average sample size per study, we determined that the meta-analysis had sufficient power (> 80%) to detect a significant effect.

Publication bias

Publication bias was assessed using funnel plots and Egger’s test. The funnel plot (Supplementary Fig. 1) shows some degree of asymmetry, with an uneven distribution of studies around the pooled effect size, particularly for studies with smaller sample sizes. This asymmetry suggests the potential presence of publication bias, where smaller studies with non-significant or negative results may have been underreported or excluded. However, Egger’s test did not detect a statistically significant bias (p-value = 0.12). While the test suggests minimal statistical evidence of bias, the asymmetry in the funnel plot warrants caution in interpreting the pooled effect size. This limitation should be considered when generalizing the findings.

Heterogeneity assessment

Study heterogeneity was evaluated using the I² statistic and Cochran’s Q test. An I² value of 0–40% might not be important; 30–60% may represent moderate heterogeneity; 50–90% may represent substantial heterogeneity; and 75–100% considerable heterogeneity. Our analysis showed substantial heterogeneity among the included studies (I² = 91%, P < 0.001). This level of heterogeneity suggests variability in the study results, which could be due to differences in study design, population, and implementation of the BOPPPS teaching strategy.

Prediction intervals

Prediction intervals were calculated to provide a range in which the effect size of a new study is expected to fall. The prediction interval for the primary outcome (final examination scores) was calculated and interpreted, indicating the expected range of effect sizes in similar future studies. The prediction interval for the final examination scores was [0.35, 1.93], which suggests that future studies are expected to show a positive effect of BOPPPS on final examination scores.

Interpretation of effect size

The size of the pooled effect was interpreted using Cohen’s guidelines, where an SMD of 0.2 is considered a small effect, 0.5 a medium effect, and 0.8 a large effect. The pooled effect size in our analysis (SMD = 1.14) indicates a large effect, suggesting that the BOPPPS teaching strategy has a substantial impact on final examination scores compared to traditional teaching methods.

Primary outcomes

Final examination scores

15 studies including 1198 in the BOPPPS group and 1122 in the control group were pooled to evaluate the final examination scores. Significant improvement in final examination scores was noted within the BOPPPS group when compared to the control group (SMD 1.14, 95% CI 0.84–1.43; P < 0.001; Fig. 3) with heterogeneity of 91% (P < 0.001).

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Secondary outcomes

Student satisfaction

Two studies employed continuous variables, indicating a substantial improvement within the BOPPPS group concerning student satisfaction when compared to the control group (SMD 0.94, 95% CI 0.63–1.26; P < 0.001; Table 5). Three studies with dichotomous variables also showed statistically significant differences between the two groups (OR 2.31, 95% CI 1.18–4.49; P = 0.01; Table 5).

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Classroom interaction

Classroom interaction encompassed both peer-to-peer and student-teacher interactions. Two studies employed continuous variables, indicating a substantial improvement within the BOPPPS group concerning classroom interaction when compared to the control group (SMD 0.83, 95% CI 0.46–1.21; P < 0.001; Table 5). In three studies utilizing dichotomous variables, no statistically significant difference was observed between the two groups, although relevant trends were evident (OR 4.11, 95% CI 0.79–21.35; P = 0.09; Table 5).

Learning initiative

Four studies employed continuous variables. These studies demonstrated a significant improvement in learning initiative within the BOPPPS group compared to the control group (SMD 0.73, 95% CI 0.48–0.98; P < 0.001; Table 5). In three studies utilizing dichotomous variables, a significant difference was also observed between the two groups (OR 3.65, 95% CI 1.17–11.41; P = 0.03; Table 5).

Analytical ability

For analytical ability, three studies employed continuous variables. These studies indicated a significant improvement within the BOPPPS group concerning analytical ability compared to the control group (SMD 1.06, 95% CI 0.46–1.65; P < 0.001; Table 5).

Clinical thinking ability

Two studies reported scores related to clinical thinking ability. The BOPPPS group exhibited significantly enhanced clinical thinking ability compared to the control group, demonstrating statistical significance (SMD 0.58, 95% CI 0.29–0.86; P < 0.001; Table 5).

Self-study ability

Regarding self-study ability, three studies employed continuous variables, but they did not indicate a significant improvement within the BOPPPS group when compared to the control group (SMD 0.17, 95% CI -0.82-1.16; P = 0.74; Table 5). In three studies employing dichotomous variables, a significant difference was observed between the BOPPPS group and the control group (OR 5.70, 95% CI 1.18–27.58; P = 0.03; Table 5).

Problem-solving skill

Two studies reported scores related to problem-solving skills, with no significant difference observed between the BOPPPS group and the control group (SMD 0.27, 95% CI -0.43-0.97; P = 0.45; Table 5).

Learning retention skill

In the context of learning retention skills, two studies employed continuous variables, revealing a significant improvement within the BOPPPS group compared to the control group (SMD 0.64, 95% CI 0.35–0.93; P < 0.001; Table 5).

Critical thinking skill

Two studies reported scores related to critical thinking skills with no significant improvement observed within the BOPPPS group compared to the control group (SMD 0.88, 95% CI -0.12-1.88; P = 0.08; Table 5).

Discussion

Medical education institutions continually explore innovative pedagogical approaches to enhance learning outcomes. Among these, numerous teaching strategies have garnered attention, offering distinct methodologies to engage students and improve learning efficacy. Effective lesson planning must cater to the diverse needs of students and support various teaching-learning modalities [33, 34]. Recognizing the interconnectedness of healthcare education disciplines, this systematic review, while centered on medical education, also included studies from nursing and health services management. These fields share common pedagogical frameworks and rely on active learning strategies to cultivate critical thinking and practical skills. The inclusion of nursing and health services management studies expands the scope of this review, offering valuable insights into the broader applicability of BOPPPS across healthcare education settings.

Traditional instructional frameworks, though widely used, often fail to foster active engagement. Table 2 presents a comparative analysis of these strategies, showcasing their theoretical foundations and practical benefits. For example, Understanding by Design (UbD) emphasizes goal-setting and planning, the Madeline Hunter Lesson Cycle focuses on teaching sequences, and the 5E Model promotes exploratory learning. While these frameworks have unique strengths grounded in cognitive, behaviorist, or constructivist theories, their practical applications may not fully integrate comprehensive, student-centered engagement. BOPPPS distinguishes itself with its holistic and structured framework that emphasizes participatory learning and continuous assessment, and this can be particularly valuable in environments where student engagement is traditionally low. Its integration of pre-assessment, participatory activities, and post-assessment ensures a cohesive learning experience. Beyond its primary application in medical education, BOPPPS has demonstrated effectiveness in nursing and health services management, making it a versatile model for clinical and healthcare education. This versatility suggests that BOPPPS can be adapted to various educational contexts, provided that careful attention is paid to institutional and cultural factors. Table 3 outlines our adaptation of BOPPPS, highlighting its structured approach and potential impact on diverse healthcare disciplines. However, prior studies, such as one focusing on Chinese medical students [35], have raised concerns about limited scope and variable methodological quality. Addressing these gaps, our study aims to evaluate the global applicability of BOPPPS, considering diverse cultural and educational contexts with rigorous inclusion standards.

In this systematic review, we examined 16 studies that implemented BOPPPS across various healthcare disciplines, including medicine, nursing, and health services management. Our findings indicated a significant improvement in the final examination scores of medical students, including nursing students when BOPPPS was employed. This improvement suggests that BOPPPS aids students in comprehending and applying knowledge more effectively during classroom learning, ultimately resulting in enhanced academic performance. Such improvement is pivotal for nurturing the clinical knowledge and skills of medical students, which are essential for their future roles as healthcare professionals. Another noteworthy outcome was the increase in student satisfaction. Most of the reviewed studies indicated that students favored BOPPPS teaching and reported higher satisfaction levels when compared to traditional teaching. This suggests that BOPPPS not only improves academic performance but also boosts students’ overall engagement and enthusiasm for the subject, making it a viable option for both motivation and learning outcomes in a variety of healthcare education settings.

This is particularly significant in maintaining student motivation and interest, especially in challenging medical courses. Our review also revealed improvements in classroom interaction. This heightened interaction could be beneficial in fostering collaboration skills that are vital for clinical practice, as well as improving communication between peers and between students and teachers. Through the adoption of BOPPPS teaching, there was an increased level of interaction among students and between students and teachers. This heightened interaction is critical for promoting collaboration, communication, and engagement among students, contributing to the establishment of a more positive and cooperative learning environment. Such interaction, once nurtured, could further contribute to the integration of teamwork and communication into students’ professional practice.

Furthermore, we observed enhancements in learning initiatives. Students exhibited higher levels of initiative in BOPPPS-modeled classrooms and were more willing to actively participate in the learning process. This reflects the success of BOPPPS in encouraging students to take an active role in mastering knowledge, rather than passively receiving information. In this context, we recommend that healthcare educators in diverse settings incorporate pre-assessment and post-assessment methods to monitor and support students’ learning initiatives effectively. Such learning initiative is vital for the long-term learning and professional development of medical students.

However, BOPPPS did not show consistent or significant improvements in problem-solving skills and critical thinking skills across the included studies. There could be several potential reasons behind this observation. Firstly, the nature of BOPPPS, which focuses on a structured and holistic approach to teaching, may prioritize the delivery of content and student engagement over explicitly targeting problem-solving and critical thinking skills. The emphasis on clear learning objectives and predefined activities might not inherently stimulate the development of these higher-order cognitive skills. Secondly, the evaluation criteria used in the studies might not have adequately captured the nuances of problem-solving and critical thinking. If the assessment tools primarily measured factual recall or lower-order cognitive skills, it might not have effectively reflected the impact of BOPPPS on more complex cognitive processes. Furthermore, the timeframe of most included studies may have been insufficient to capture the gradual development of these higher-order skills, which often require prolonged exposure to specific teaching methodologies. To address this, we suggest future research explore more specific interventions targeting critical thinking and problem-solving within the BOPPPS framework, as well as extending study durations to better evaluate these outcomes.

It is important to note that the outcomes of classroom interaction and self-study ability varied depending on the use of continuous or categorical variables, which may be attributed to the limited sample size in some studies. This suggests that future research should aim to standardize assessment tools and ensure larger, more diverse sample sizes to improve the reliability of results. In studies where sample sizes were constrained, the impact on statistical power becomes a pertinent consideration. Smaller samples may lead to increased variability, making it challenging to draw definitive conclusions. This emphasizes the need for future research endeavors to strive for larger and more diverse samples, ensuring the robustness and generalizability of findings. We will revise the discussion to provide more detailed insights into these factors, particularly the influence of different assessment methods (continuous vs. dichotomous variables) and sample size on the consistency of the results.

Overall, the study comparing the BOPPPS teaching strategy with traditional teaching yielded a positive conclusion. There are several reasons why BOPPPS is considered superior to traditional teaching strategies. First and foremost, traditional medical theory instruction often relies on cramming teaching, lacking clearly defined teaching objectives. Consequently, students may struggle to comprehend the learning objectives, leaving them without specific learning targets or a clear direction. In contrast, BOPPPS places students at the center of the classroom teaching process. This approach enables teachers to better understand students’ learning needs, leading to well-defined teaching objectives. Importantly, students can identify their own learning goals within BOPPPS, which provides direction and motivation, empowering them to become active participants in their learning journey. Teachers optimize the teaching mode by setting reasonable and effective teaching goals. Activities like pre- and post-tests allow for careful selection and tailoring of the teaching and learning content. Consequently, BOPPPS offers students clear teaching objectives and encourages active engagement, resulting in significant improvements in teaching effectiveness. Secondly, traditional teaching strategies often involve teachers delivering lectures while students passively receive information, characterized by rote learning and knowledge transfer. In contrast, BOPPPS places students at the forefront of the classroom, facilitating communication and discussion among peers and providing students with an active role in the learning process. Medical teaching teachers assume a guiding role, offering support and guidance throughout students’ learning journey. This approach fosters increased peer-to-peer interaction, encourages active identification, and stimulates critical thinking among students. Consequently, students’ independent learning abilities and their understanding of clinical knowledge are greatly enhanced. The application of BOPPPS cultivates students’ autonomy and self-study skills, thereby fostering their learning thinking, enthusiasm, and initiative, all of which are valuable in their future professional contexts. Thirdly, the BOPPPS places strong emphasis on student-teacher interaction, requiring teachers to possess advanced teaching abilities, rooted in a solid foundation of medical teaching skills and relevant theoretical knowledge. Teachers are expected to promptly address student learning issues and actively engage with students. Consequently, teachers’ teaching abilities are greatly improved, allowing them to achieve the desired medical practice teaching objectives more effectively.

Limitations

Several key limitations emerged in this review, primarily related to geographic concentration, publication bias, and substantial heterogeneity. Firstly, while our systematic review aimed to examine international studies on BOPPPS, all 16 studies included in the final analysis were conducted in China. This geographic concentration raises questions about the broader adoption of BOPPPS in clinical and health education globally.

Several factors may explain this observation. First, BOPPPS aligns closely with pedagogical priorities and challenges in Chinese educational settings, particularly in addressing active learning gaps in large-scale, test-driven environments. Second, while our search strategy included both English- and Chinese-language databases, many BOPPPS studies are published in Chinese, contributing to language and publication biases that are common in healthcare education research. Third, our inclusion criteria required studies to meet specific methodological standards, which may have excluded potentially relevant but lower-quality international studies.

The geographic concentration of studies in China has important implications for the generalizability of our findings. While the positive results observed in the Chinese context suggest that BOPPPS holds promise, these findings may not fully reflect the effectiveness of the teaching model in different educational and cultural settings. For example, differences in teaching styles, student characteristics, and institutional resources could affect how BOPPPS is implemented and its resulting impact in other countries. Future research should focus on including studies from a wider range of cultural and geographic contexts, which will help address the limitations posed by geographic concentration and enhance the global applicability of BOPPPS.

Another important limitation of this study is the potential for publication bias. While Egger’s test did not reveal statistically significant evidence of bias, the asymmetry observed in the funnel plot indicates a possible overrepresentation of studies with positive findings. This could arise from selective reporting of smaller studies with favorable outcomes, as studies with null or negative results are less likely to be published. Additionally, heterogeneity in study design and context may contribute to the observed asymmetry.

The substantial heterogeneity among the included studies further complicates the interpretation of the pooled effect size. Variations in study designs, sample sizes, and teaching contexts could contribute to differences in the observed effects, making it challenging to draw definitive conclusions regarding the overall impact of BOPPPS. This heterogeneity may reduce the robustness of the pooled effect size, limiting the generalizability of the findings to diverse healthcare education settings. The observed heterogeneity suggests that the impact of BOPPPS may vary depending on the specific characteristics of the educational environment and population studied. Future research should aim to address this heterogeneity by including studies with more homogeneous designs, larger sample sizes, and standardized outcome measures. Sensitivity analyses could also be performed to assess the influence of different study characteristics on the overall effect size.

Despite these limitations, the findings of our review hold broader implications for global healthcare education. The principles underlying BOPPPS—active learning, student engagement, and participatory learning—are universal. To ensure its broader applicability, future studies should explore BOPPPS implementation in diverse cultural and educational contexts, with particular attention to the unique challenges faced in different geographical regions. The successful implementation of BOPPPS across diverse settings requires careful consideration of potential barriers, such as resistance from educators or logistical challenges in curriculum redesign. Future studies should explore strategies to overcome these challenges, such as professional development programs for educators or collaborative approaches to curriculum adaptation.

Challenges and future directions

Implementing BOPPPS in healthcare education is not without challenges. Firstly, significant investments in teacher training are necessary to familiarize educators with the framework and ensure its effective integration. Secondly, resistance to change from educators and institutions accustomed to traditional methods can impede widespread adoption. Lastly, adapting existing curricula to align with BOPPPS involves substantial logistical and resource considerations.

To address these challenges, future research should also focus on identifying specific strategies for overcoming resistance and resource limitations. This could include developing professional development programs for educators and exploring collaborative approaches to curriculum redesign. Future research should address several critical gaps. For instance, there is a lack of large-scale randomized controlled trials (RCTs) examining the long-term impact of BOPPPS on academic performance and skill development. Additionally, studies exploring BOPPPS in diverse cultural contexts are necessary to determine its generalizability. Robust mixed-methods approaches combining quantitative and qualitative data would provide a holistic understanding of its impact. Longitudinal studies tracking students’ progress across various healthcare disciplines would also be valuable.

By addressing these implementation challenges and broadening its research base, BOPPPS has the potential to serve as a cornerstone teaching strategy in global healthcare education.

Data availability

All data generated or analysed during this study are included in this published article and its supplementary information files.

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