# Approaches to learning in pre-medicine: a multi-university mixed-methods study

## TL;DR

This study explores how pre-medicine students from different universities approach learning, finding that they often use strategic or deep methods, with context and background factors influencing their choices.

## Contribution

The study provides new insights into learning approaches among pre-medicine students across multiple international sites, combining quantitative and qualitative methods.

## Key findings

- Strategic and Deep approaches were most common among pre-medicine students across three international sites.
- Qualitative interviews showed students adapt their learning approaches based on subject, task, and assessment demands.
- Strategic learning correlated with academic performance, but this link weakened after accounting for background factors.

## Abstract

In the approaches to learning model, it is proposed that learners’ methodologies are acquired and adjusted according to the environment and context. Learners can be classified as adopting deep, surface or strategic approaches to learning. Understanding learners’ preferences and the factors associated with these approaches can benefit their learning journey.

We conducted an exploratory multi-university mixed-methods cross-sectional study of pre-medicine foundation/pathway students at three medical schools (Europe/Middle East). Students completed the short-form ASSIST (Deep, Strategic, Surface); n = 159. We assessed internal consistency, compared ASSIST scale scores across groups using non-parametric tests, examined correlations between ASSIST scales and academic performance, and ran a hierarchical linear regression as a confirmatory test. We purposively sampled students (n = 25) based on learning approach and background, and completed semi-structured interviews. Data were analysed using thematic analysis.

Students most commonly reported Strategic (21%), Deep (21%), or Deep–Strategic (29%) preferences. Between-site differences were detected for Deep (Dublin < Bahrain; small) and Surface (Malta < Dublin and Bahrain; small–to–moderate), with no site effect for Strategic. No differences were observed by gender or academic achievement on entry. English proficiency (B2 > C2) and prior education (CHSD < prior foundation programme) showed differences on the Deep scale. The Strategic scale correlated positively with academic performance (r ≈ 0.23), but this attenuated and lost conventional significance in regression once entry achievement and background were included. Qualitative interviews revealed that students switch approaches based on subject, task, and assessment demands. Organisation, time-management, utilisation of resources, and assessment awareness were strong features in strategic approach learners, while surface learners reflected a passive, memorisation-focused approach under pressure.

Across three international cohorts, Deep and Strategic approaches predominated, with modest between-site differences, and approach–achievement links were limited after accounting for background factors. Qualitative data highlighted context-responsive switching and the role of practical strategic behaviours in managing assessment demands. Rather than aiming to shift students to a single “ideal” approach through curriculum change, programmes may achieve more by teaching self-regulated study skills, refining assessment/feedback to discourage unhelpful surface tactics, and targeting transition supports for students with differing educational and language backgrounds.

The online version contains supplementary material available at 10.1186/s12909-025-08228-x.