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ORIGINAL ARTICLE Table of Contents  
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Application of flipped classroom combined with problem-based learning - An effective learning approach to upgrade learning in medical students: A randomized controlled trial

1 Department of Community Medicine, GSL Medical College, Rajahmundry, Andhra Pradesh, India
2 Department of Biochemistry, GSL Medical College, Rajahmundry, Andhra Pradesh, India
3 Department of Pharmacology, GSL Medical College, Rajahmundry, Andhra Pradesh, India

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Date of Submission30-Aug-2022
Date of Decision29-Sep-2022
Date of Acceptance30-Oct-2022
Date of Web Publication20-Mar-2023


Background: As per the recent advancement in medicine, novel learning methodological innovations such as flipped classroom (FC) and problem-based learning (PBL) have earned ample recognition in medical education. The present study was directed with an aim to assess the effectiveness of combined learning method (CLM: FC combined with PBL) over traditional lecture-based classroom (TLC).
Objectives: The objectives of this study were as follows: to determine whether CLM improves learning outcome among medical students and to determine whether there is any significant difference in students' perceptions regarding learning method implemented.
Materials and Methods: A randomized controlled trial (educational interventional study) was conducted with 100 medical students; they were randomly allocated into two equal groups: experimental group (EG) was taught by CLM, whereas control group (CG) was taught by TLC method. Closed- and open-ended questionnaire was used for the collection of data. Statistical analysis was done by applying independent samples t-test and Chi-square test.
Results: A significant difference in the learning outcome was observed between the mean posttest scores of the two groups (CG = 31.5, EG = 46.2). There was a significant difference in the mean scores of perception between the groups (P ≤ 0.05). Chi-square test showed that students' satisfaction is associated with the CLM (P = 0.00001).
Conclusion: FC combined with PBL can be considered a better alternative to the lecture-based classroom for educating medical students on maternal and child health care.

Keywords: Combined learning method, flipped classroom, maternal and child health care, problem-based learning, traditional lecture-based classroom

How to cite this URL:
Palla J, Moparthi S, Kaki SB, Komaram RB. Application of flipped classroom combined with problem-based learning - An effective learning approach to upgrade learning in medical students: A randomized controlled trial. MRIMS J Health Sci [Epub ahead of print] [cited 2023 May 29]. Available from: http://www.mrimsjournal.com/preprintarticle.asp?id=372136

  Introduction Top

Learning is an uninterrupted process that involves the conversion of facts and experience into knowledge and abilities. It is no more a product conveyed from lecturer to student,[1] but rather a procedure that involves detailed practices and methods to trigger self-regulation, reasoning, and problem-solving skills.[2],[3] These skills are considered crucial for long-lasting achievement as learners enter the workforce.[4] In a traditional classroom model, lecture will be delivered by teacher and students take notes; homework is then done outside the classroom. In a modernized classroom, students are highly focused on building content and creating innovative ideas. One of the most exciting advancements in modern classroom is flipped classroom (FC) learning. Two high school chemistry teachers from the USA, Jonathan Bergmann and Aaron Sams, coined the term “FC” in 2012. They started flipping the teaching and learning scenarios in 2007.[5] Therefore, the FC model, also called as inverted classroom, has expanded to multiple disciplines of learning and education around the world. It is an application to education that “flips” the traditional method of knowledge presentation and implementation activities. In medical education, straightforward lectures can be replaced by FCs supported by individual assignments or teamwork.[6] It is defined as “a learning methodology that consists of two parts: direct computer-based individual instructions outside the classroom and interactive group learning activities inside the classroom.”[7] The four pillars of FC learning are flexible environment, learning culture, intentional content, and professional educators.[8] In a FC, the students learn subject matter outside the class, and in the class, practice and application of content will be facilitated. Here, the role of a teacher is more of a facilitator than a lecturer. Problem-based learning (PBL) is another learning strategy which motivates students to think critically and to generate ideas and to gain knowledge, skills, and behavior required to become competent doctors.[9],[10] It is a pedagogical approach by which students are given opportunities to problem-solving in a collaborative setting, to create mental models for learning, and to develop self-directed learning habits through practice and reflection.[11],[12],[13] FC when combined with PBL, it may allow the learning methods to complement each other. The 2030 Agenda for Sustainable Development Goal 4 aims to provide equitable quality education for all by 2030.[14] To recognize the quality of education, we need to assess the teaching–learning process. Hence, assessment plays an immense role; it provides a valuable feedback on the design, implementation, and quality of educational program. It is very essential to assess the effectiveness of these learning approaches before implementation in the medical curriculum; medical students form the core part in assessment of these teaching strategies and learning methods. For further improvement in medical education, there is also a need to determine the importance of combined learning method (CLM) (FC with PBL); very few studies have been conducted among medical undergraduate students to assess the effectiveness of FC combined with PBL, but its application to teach maternal and child health (MCH) care has not been explored; Therefore, the present study was conducted with an aim to assess the effectiveness of combined learning approach which includes FC combined with PBL. We hypothesized that participants receiving CLM would demonstrate better performance and skills in the academics compared to traditional lecture-based classroom (TLC). To achieve the aim, the following objectives have been set: to determine whether FC combined with PBL improves learning outcome among medical students and to determine whether there is any significant difference in students' perceptions regarding CLM and TLC method in terms of its utilization and usefulness for learning.

  Materials and Methods Top

A randomized controlled trial (an educational interventional study) was conducted in the Department of Community Medicine, at GSL Medical college, Rajahmundry, Andhra Pradesh, among sixth-semester medical students, for a period of 3 months from July 2019 to September 2019. All undergraduate medical students of the sixth semester were invited for the study; students who are willing to participate in the study were included. Students not available twice even after prior intimation and those nonconsenting to the study were excluded.

The sample size was calculated by using a standard formula, n = 16 × 1/effect size2.[15] Keeping (α) at 0.05, the power (β) of the test at 0.8, effect size of 0.6, and considering dropout rate of 14%, the final sample size was 100. A total of 100 medical students were enrolled in the study by purposive sampling.

Closed- and open-ended questionnaire was used for the collection of data; it includes three sections: the first section of questionnaire included closed-type questions, 50 multiple choice questions (MCQs), based on MCH theory and clinico-social case studies; it included four domains: knowledge, attitude, practice, and communication skills. The second section included predesigned, prevalidated, self-administered, structured, closed-ended survey questionnaire (5-point Likert scale) to assess students' perceptions regarding the learning method implemented during learning activities. The third section included a closed-ended question to know the status of satisfaction among the participants, and an open-ended question was administered to experimental group (EG) to know their proposals for implementation of CLM in future.

A total of 100 sixth-semester medical students were enrolled in the study. The purpose of the study was explained to all participants, verbal consent was taken, and they were informed that taking the tests or survey was optional; a code was allotted to each participant and was instructed to mention the code in the tests and survey rather than real names; they were assured that it would have no pros and cons on students' performance in the class.

An independent researcher who has no involvement in the process of trial made random allocation cards using computer-generated random numbers. Another researcher allocated the participants into two equal groups of 50 each, control group (CG) and EG, by simple randomization. Allocation concealment technique was applied to prevent selection bias. The sequence of allocation of the study participants to the groups was concealed in opaque, sequentially numbered, sealed, and stapled envelopes. Whether a participant will be receiving TLC or CLM was decided by random sampling numbers drawn up by another researcher; the details were unknown to any of the researchers or coordinators. After allocation to the groups, the participants, teaching faculty, and facilitators were aware of the learning method, whereas the researchers, outcome assessors, and data analysts were completely blinded to the allocation. After allocation, both the groups were given prior intimation of the schedule for learning activities, pretests, posttests, and surveys. The EG was taught by CLM, whereas the CG was taught by TLC method. They were inspected by a faculty team comprising one teacher, three facilitators, and three assistants.

Control group

Students randomized to CG were informed about the date and time when they would have face-to-face class. Chapter on MCH care was selected to teach the group. Prior to TLC, the purpose of the study was explained, and on assigned day, pretest was conducted with 50 MCQs (50 marks) on MCH care. During the lecture, the theoretical content of the topic was explained by the teacher to the entire group. At the end of the class, the teacher entrusted an assignment, and on a fixed date, posttest was conducted with 50 MCQs (50 marks) on MCH care. Next, survey questions were given to assess their perceptions regarding traditional classroom learning. At the end, a closed-ended question was given to assess their satisfaction status.

Experimental group

Fifty students were randomized to EG. They were further subdivided into three subgroups A, B, and C (A – 18, B – 16, and C – 16 students). Each subgroup was allocated a facilitator and an assistant. Chapter on MCH care was selected to implement the CLM. The EG was exposed to CLM; FC was combined with PBL; it proceeded as follows: first, before any learning activity, on assigned date and time, pretest was conducted with 50 MCQs (50 marks) related to MCH care; next, 3 days prior to classroom activity, the facilitator distributed relevant lecture videos and supplementary materials regarding MCH care and gave assignments to the participants. Each student was instructed to view them on his or her own time, outside the classroom. On the day assigned for the classroom session, brief introduction of the topic and the schedule was given by the facilitator. Then, trigger material was applied, i.e., a PowerPoint presentation on clinico-social case scenario was presented by the facilitator. Next, the facilitator presented queries about the clinico-social case in a stepwise approach as per PBL method. The questions included were as follows: (1) identify the key information, (2) generate and rank the hypothesis, (3) generate an inquiry strategy, (4) revise the hypothesis, (5) define learning objectives, (6) report back, and (7) integrate new knowledge. After the question session, the participants initiated small-group discussion, with the facilitator guiding the discussion. Next, a student representative from each small group delivered a presentation to review the main points from the topic and has put forward their answers to the questions, asked the unsolved questions from their small group, and extended the discussion by integrating new knowledge with regard to MCH care. At the end, the facilitator summarized for the class and solved the difficult questions raised during discussion. On the assigned days, students were invited to complete a posttest with the same set of questions as in the pretest; as well as to complete a posttest survey with questions on their perceptions regarding CLM. Finally, their satisfaction status was assessed with a closed-ended question, followed by an open-ended question to identify their proposals for implementation of CLM in future. To assess their learning ability, during the test, the same set of questions were given to both the groups. The tests and survey forms were accepted and filled without any discussion or assistance from peers or faculty. Informed consent was obtained from all the participants, and the research was approved by the Institutional Ethics Committee of the medical college. After implementing the teaching methods to CG and EG, learning outcome was assessed by posttest scores; mean score was calculated and compared between the groups. Perceptions were assessed by survey scores; each item of the survey questionnaire was given scores as per 5-point Likert scale; it includes 5 grades, from 1 point (poor) to 5 points (excellent); for each question, total score and mean value were calculated. The mean values were compared between the CG and EG by an independent samples t-test. Chi-square test was applied to examine the relationship between students' satisfaction and learning method.

  Results Top

A total of 100 medical students were eligible and enrolled for participation in the study. All students completed the pretests, posttests, and survey forms. There was no loss or exclusion of participants after randomization. [Table 1] shows that students of CG received TLC, and students of EG received CLM. [Table 2] represents that the mean age of EG was more than the CG.
Table 1: The learning activities of control group and experimental group

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Table 2: Demographic characteristics of the study participants

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[Table 3] represents the mean values of test scores before and after implementation of learning methods; there was no significant difference between the mean pretest scores of the two groups, indicating that the baseline mean values between the two groups were comparable. After the intervention, a significant difference was observed between the posttest scores of the two groups. In the EG, the mean posttest score increased to 46.2 which is well notable. [Table 4] depicts that there is a difference between the mean scores of EG and CG, which is statistically significant (P < 0.05). [Table 5] represents that the difference between the means of the two groups is statistically significant (P < 0.05). EG had higher mean scores than CG; high scores were obtained for brainstorming sessions, teamwork skills, and development of interpersonal relationships. [Table 6] explains that students' satisfaction was found associated with the EG, which received CLM. The result is significant at P < 0.05. [Table 7] represents that majority of the students proposed to increase the number of learning sessions through CLM and to implement the method to other subjects as well.
Table 3: Assessment of learning outcome among study participants by mean test scores

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Table 4: Comparison of student's perceptions regarding role of learning method in knowledge acquisition

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Table 5: Comparison of student's perceptions regarding role of learning method in abilities, time management, and communication skills

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Table 6: Comparison of student's satisfaction regarding learning method

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Table 7: Proposals given by experimental group regarding implementation of combined learning method in future

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  Discussion Top

In the present study, it was observed that FC, when combined with PBL, revealed assuring results in the education and performance of students in examination by upgrading students' independent learning ability. The descriptive data showed that the mean test scores improved significantly after the learning activity. Compared with the CG, the mean posttest score of the EG was higher (46.2). Overall, majority (96%) of the students in the EG were satisfied with the new CLM. The findings of this study were comparable with the results of a study conducted by Hu et al.;[16] their study reported that students of combination group had better performance in their academics and were more satisfied with the CLM.

Motivation is a complex part of human psychology and attitude that influences an individual how to spend their time and energy;[17] it enhances the performance of student in learning. Students in EG felt more motivated to learn when compared to those in the CG; EG believed that CLM is productive in providing better content of topic, understanding key concepts, and clarification of doubts; it also promotes more engagement in learning activity, critical thinking and reasoning; in addition it encourages self-directed learning and student-teacher interaction; they also observed improvement in their multiple abilities, such as communication, teamwork, participation, presentation, and expression. Similar findings were reported by students pursuing medical specialty in a study conducted by Yang et al.;[18] in their study, the intervention applied was FC combined with human anatomy web-based learning system. On the contrary, another study by Veeramani et al.[5] evaluated the FC model alone, among 1st-year medical students; their study reported that 98% of participants opined that FC model was more engaging and thought-provoking in comparison with TLC. A similar study conducted by Halasa et al.[19] among nursing students reported that students of EG achieved higher grades (mean test value: 77.77) after implementing blended learning with FC. In contrast, Riddell et al.[20] reported that they found mixed statistical results; as the differences were small, their study concluded that the FC and traditional lecture were essentially equivalent.

In a typical PBL setting, learning is triggered by a problem which needs solution. In the current study, students of EG reported that PBL activity promoted their critical thinking, reasoning, and independent learning abilities; encouraged them in teamwork and communication skills; and uplifted them in exercising time management. Zhao et al.[21] in West China reported similar findings where the survey scores are significantly higher in the combined learning group. A similar study by Dhawo[22] revealed that the intervention group had higher critical thinking and independent learning skills than nonintervention group.

Quality of education is considered the heart of any educational system; it refers to its input, teaching–learning process, and the outcome.[23] In the present study, survey scores of EG indicated that participants are satisfied with the quality of CLM imparted to them; they opined that it has promoted active participation and encouraged and improved their communications skills; as a whole, it helped them to identify their strengths and weaknesses. A study by Tazijan et al.[24] also concluded that flipped learning is supportive in upgrading students' verbal communication skills. EG also revealed that group discussions conducted during brainstorming sessions were helpful to them in their learning process; in contrast to this finding, Hillyard et al.[25] reported that students have negative perceptions regarding group work and discussions. Notably, we further analyzed the association between the categorical variables; the Chi-square test showed that there is a significant relationship between students' satisfaction and CLM. This finding is comparable with the results of a study conducted by Hu et al.;[16] finally, in EG, majority (90%) of the students recommended that in future, more learning sessions should be conducted through CLM.

The findings of the present study indicate that the mean posttest score value of EG was higher than the CG; independent samples t-test revealed that the mean survey values of EG were significantly higher than the CG, and P value for all items was <0.05. Role of teacher as facilitator and engagement of students in meaningful activities might be the additional reasons for better performance of EG in the evaluation test.

Likely biases were identified as: selection bias, minimized by randomization; recall bias, reduced by conducting tests and surveys within a short period after intervention; and repeat testing bias, minimized by avoiding fatigue in repeat testing. The sample size, sampling technique, and the statistical procedures applied in this study indicate that the findings may be limited to sixth-semester medical students and generalizability may be limited.


First, the sample size was small. Second, blinding of participants was not possible as it is an educational intervention study. Third, only short-term results of the CLM were assessed. Hence, further research with large sample size and analysis of long-term results of this CLM is recommended in future.

  Conclusion Top

The study findings suggest that application of FC combined with PBL upgrades students' learning outcome and enhances their skills. It is an effective learning approach to implement and also to educate medical students on MCH care.


The authors are deeply indebted to all students who participated in this study and to the faculty team for their wholehearted support in completion of this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Steen-Utheim A, Foldnes N. A qualitative investigation of student engagement in a flipped classroom. Teach High Educ 2017;23:307-24.  Back to cited text no. 1
Hattie JA, Donoghue GM. Learning strategies: A synthesis and conceptual model. NPJ Sci Learn 2016;1:16013.  Back to cited text no. 2
Lee KY, Lai YC. Facilitating higher-order thinking with the flipped classroom model: A student teacher's experience in a Hong Kong secondary school. Res Pract Technol Enhanc Learn 2017;12:8.  Back to cited text no. 3
Rateau R, Kaufman E, Cletzer D. Innovative classroom strategies that prepare college graduates for workplace success. J Agric Educ 2015;56:52-68.  Back to cited text no. 4
Veeramani R, Madhugiri VS, Chand P. Perception of MBBS students to “flipped class room” approach in neuroanatomy module. Anat Cell Biol 2015;48:138-43.  Back to cited text no. 5
Mehta NB, Hull AL, Young JB, Stoller JK. Just imagine: New paradigms for medical education. Acad Med 2013;88:1418-23.  Back to cited text no. 6
Bishop J, Verleger M. The Flipped Classroom: A Survey of the Research. Available from: https://peer.asee.org/the-flipped-classroom-a-survey-of-the-research. [Last accessed on 2022 Jun 23].  Back to cited text no. 7
Chen Y, Wang Y, Kinshuk K, Chen N. Is FLIP enough? Or should we use the FLIPPED model instead? Comput Educ 2014;79:16-27.  Back to cited text no. 8
Choi E, Lindquist R, Song Y. Effects of problem-based learning versus traditional lecture on Korean nursing students' critical thinking, problem-solving, and self-directed learning. Nurse Educ Today 2014;34:52-6.  Back to cited text no. 9
Zahid MA, Varghese R, Mohammed AM, Ayed AK. Comparison of the problem based learning-driven with the traditional didactic-lecture-based curricula. Int J Med Educ 2016;7:181-7.  Back to cited text no. 10
Schmidt H. Factors Affecting Small-Group Tutorial Learning: A Review of Research; 2000. Available from: https://www.academia.edu/en/1301662/Factors_affecting_small_group_tutorial_learning_A_review_of_research. [Last accessed on 2022 Jun 23].  Back to cited text no. 11
Dochy F, Segers M, Van den Bossche P, Gijbels D. Effects of problem-based learning: A meta-analysis. Learn Instr 2003;13:533-68.  Back to cited text no. 12
Norman GR, Schmidt HG. The psychological basis of problem-based learning: A review of the evidence. Acad Med 1992;67:557-65.  Back to cited text no. 13
SDG Goal 4: Quality Education-UNICEF DATA. Available from: https://data.unicef.org/sdgs/goal-4-quality-education/. [Last accessed on 2022 Jun 23].  Back to cited text no. 14
McConnell MM, Monteiro S, Bryson GL. Sample size calculations for educational interventions: Principles and methods. Can J Anaesth 2019;66:864-73.  Back to cited text no. 15
Hu X, Zhang H, Song Y, Wu C, Yang Q, Shi Z, et al. Implementation of flipped classroom combined with problem-based learning: An approach to promote learning about hyperthyroidism in the endocrinology internship. BMC Med Educ 2019;19:290.  Back to cited text no. 16
Bakar R. The effect of learning motivation on student's productive competencies in vocational high school, West Sumatra. Int J Asian Soc Sci 2014;4:722-32.  Back to cited text no. 17
Yang C, Yang X, Yang H, Fan Y. Flipped classroom combined with human anatomy web-based learning system shows promising effects in anatomy education. Medicine (Baltimore) 2020;99:e23096.  Back to cited text no. 18
Halasa S, Abusalim N, Rayyan M, Constantino RE, Nassar O, Amre H, et al. Comparing student achievement in traditional learning with a combination of blended and flipped learning. Nurs Open 2020;7:1129-38.  Back to cited text no. 19
Riddell J, Jhun P, Fung CC, Comes J, Sawtelle S, Tabatabai R, et al. Does the flipped classroom improve learning in graduate medical education? J Grad Med Educ 2017;9:491-6.  Back to cited text no. 20
Zhao W, He L, Deng W, Zhu J, Su A, Zhang Y. The effectiveness of the combined Problem-Based Learning (PBL) and Case-Based Learning (CBL) teaching method in the clinical practical teaching of thyroid disease. BMC Med Educ 2020;20:381.  Back to cited text no. 21
Dhawo MS. Effectiveness of combined problem-based learning and flipped classroom strategies in teaching a medical-surgical nursing course: A randomized controlled trial study. KnE Life Sci 2019;4:837-46.  Back to cited text no. 22
Madani R. Analysis of educational quality, a goal of education for all policy. High Educ Stud 2019;9:100.  Back to cited text no. 23
Tazijan FN, Abdullah CH, Zainol N, Noor SM, Johari NR. Building communication skills through flipped classroom. Int Acad Res J Soc Sci 2017;3:142-7.  Back to cited text no. 24
Hillyard C, Gillespie D, Littig P. University students' attitudes about learning in small groups after frequent participation. Act Learn High Educ 2010;11:9-20.  Back to cited text no. 25

Correspondence Address:
Jayasree Palla,
Department of Community Medicine, GSL Medical College, Rajahmundry, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjhs.mjhs_92_22


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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