Assessing the effectiveness of flipped classroom teaching–learning method among undergraduate medical students at gondar university, college of medicine and health sciences: an interventional study

Abstract

Introduction

The flipped classroom teaching–learning method has been increasingly adopted in higher education to enhance student-centered learning. Despite its growing popularity, limited evidence exists regarding its effectiveness in medical education in Ethiopia. This study aimed to assess the impact of the flipped classroom method on academic performance, student engagement, and satisfaction among undergraduate medical students at Gondar University, College of Medicine and Health Science.

Methods

A quasi-experimental study was conducted involving 100 s-year undergraduate medical students, divided into two groups: the flipped classroom group (n = 50) and the traditional lecture-based group (n = 50). The flipped classroom group received online instructional materials before class, while classroom sessions focused on interactive activities. The traditional lecture-based group attended conventional lectures followed by homework assignments. Data were collected using pre- and post-intervention tests to measure academic performance, the Student Engagement Scale to gauge engagement, and a validated questionnaire to assess student satisfaction. Data were analyzed using Statistical Package for the Social Sciences version 25, with descriptive statistics, paired t-tests, independent t-tests, and Chi-square tests employed to interpret the findings.

Results

The flipped classroom group demonstrated a significant improvement in academic performance, with mean pre-test and post-test scores of 65.2 ± 8.1 and 78.6 ± 6.9, respectively. In contrast, the traditional lecture-based group had pre-test and post-test mean scores of 62.8 ± 7.5 and 74.2 ± 8.3, respectively. Additionally, the flipped classroom group showed higher levels of student engagement mean scores of 4.5 ± 0.8 and satisfaction mean scores of 4.2 ± 0.7 compared to the traditional lecture-based group, which had engagement mean scores of 3.8 ± 0.6 and satisfaction mean scores of 3.9 ± 0.5. Chi-square tests showed a statistically significant association between the teaching method and both pass/fail rates and participation in activities, but not a significant association with gender distribution.

Conclusion

The flipped classroom approach proves to be a superior teaching method, promoting better academic outcomes and greater student engagement and satisfaction. This study adds to the growing body of evidence advocating for the implementation of flipped classrooms in medical education.

Trial registration

Not applicable.

Introduction

In the rapidly evolving higher education sector, colleges and universities worldwide are increasingly emphasizing the adoption of innovative teaching strategies such as flipped learning. This approach promotes inventive thinking and better prepares students to meet the demands of 21st -century society. Despite its potential, there is not much written literature on the use of flipped learning at the university level [1, 2]. Much of the traditional lecture time is, in the researcher’s view, spent delivering basic content, which leaves little room for the development of higher-order thinking skills [3–5]. Over the past three decades, student-centered learning approaches, grounded in the principles of active and discovery-based learning, have revolutionized teaching methods in many higher education institutions globally, leading to significant improvements in learning outcomes [6, 7]. However, in many developing countries, including Ethiopia, the teacher-centered model of education remains prevalent. In this model, the instructor plays the primary role in disseminating knowledge, and students passively receive information, often relying on memorization rather than active engagement [8, 9].

The flipped classroom model emerged to address the challenges posed when students miss classes due to unforeseen circumstances, such as illness or family emergencies. Initially developed by Jonathan Bergmann and Aaron Sams in their high school chemistry classes, this approach allowed students to continue their learning outside the classroom by providing instructional videos on new concepts and clarifying ambiguous topics. This innovative strategy shifted the traditional lecture model, where direct instruction is delivered outside class, while classroom time is used for active learning and application of higher-order thinking skills [10–12]. This innovative strategy equips students with preliminary knowledge before class, enabling both teachers and students to focus on higher-order thinking skills during classroom sessions. To ensure its success, teachers must balance three critical components: content delivery, pedagogical expertise, and the integration of technology for instructional purposes [13]. In the flipped classroom model, the instructor typically provides students with pre-class resources, such as videos, reading materials, or interactive assignments, to equip them with foundational knowledge. This pre-class preparation enables students to engage more actively during class time, where the teacher assumes the role of a facilitator, guiding discussions and encouraging deeper understanding through active participation [14, 15]. The flipped classroom approach emphasizes the importance of assessments, multimedia tools, and web-based resources to support student preparation before class [16].

Despite the numerous benefits of flipped learning, such as increased student participation and engagement, its effectiveness largely depends on how students perceive the teaching approach. Previous studies have shown that flipped classrooms can enhance student satisfaction, attendance, and academic performance [17–22]. Specifically, research in various educational settings, including medical schools, has demonstrated that the flipped classroom method positively impacts student performance and engagement [23, 24]. However, there is limited research on the implementation of this method in medical education in Ethiopia, particularly at Gondar University.

This study aimed to evaluate the effectiveness of the flipped classroom approach on the academic performance of undergraduate medical students at Gondar University, Ethiopia. It also assessed student engagement and satisfaction with the method, comparing it to traditional lecture-based teaching. By focusing on this context, the study provides valuable insights into the impact of both teaching methods within Ethiopian medical education, while contributing to the broader body of literature on flipped learning. Although the flipped classroom model was initially developed elsewhere, this study explores its relevance and applicability in an Ethiopian setting.

Methods

Study design

This study was an interventional, quasi-experimental study conducted at Gondar University, College of Medicine and Health Sciences in the Pharmacology Department. The study was conducted over a period of 7 months, from November 1, 2023, to May 30, 2024.

Study population

The study involved second-year undergraduate medical students who were enrolled in the 2023/2024 academic year. This group is transitioning from foundational courses to more complex, discipline-specific subjects, making it an ideal time to implement and evaluate innovative teaching methods like the flipped classroom. Second-year students typically have more flexible schedules and are familiar with university learning environments, facilitating the experimentation of different teaching approaches. They are generally better prepared for active learning, having completed introductory courses, which enhances their engagement with pre-class materials and class discussions. This group also allows for assessing how the flipped classroom influences the integration of theoretical knowledge with clinical applications, increasing the study’s educational impact.

Sample size

A total of 100 students were selected using a stratified random sampling method, with 50 students assigned to the flipped classroom group and 50 to the traditional lecture-based group (Fig. 1).

Fig. 1.

Process of sample size selection using stratified random sampling

Intervention

Data were collected through multiple methods to ensure a comprehensive evaluation. Academic performance was assessed by administering pre- and post-intervention tests to measure knowledge acquisition. The data tested and collected through the use of pre- and post-intervention tests is quantitative data. Specifically, it involves continuous data in the form of test scores or percentages, measuring students’ knowledge acquisition. The tests likely assessed the students’ knowledge or skills on a particular subject before and after the intervention, with the raw scores or percentages representing the students’ performance. These scores were then used to calculate descriptive statistics such as means and standard deviations for both the Flipped Classroom and Traditional Lecture-based groups. This type of data allows for the analysis of changes in academic performance due to the interventions, such as the increase in mean scores after the flipped classroom or traditional lecture approach [25].

We assessed student engagement using the Student Engagement Scale, which measures how actively and attentively students participate in the flipped classroom. In addition to evaluating engagement, we also assessed student satisfaction, which reflects their overall contentment with the teaching method and learning experience.

To ensure the validity and reliability of the questionnaire used to assess student satisfaction with the teaching methods, several steps were followed. Content validity was established by having the questionnaire reviewed by experts to ensure it comprehensively covers relevant aspects of student satisfaction [26]. Construct validity was confirmed through statistical analyses to align the items with the theoretical framework of student satisfaction [27]. Reliability was tested using Cronbach’s alpha to measure internal consistency and test-retest methods to evaluate stability over time [28]. Additionally, a pilot test was conducted with a small sample of students to identify and address any issues before the main study.

The questionnaire was adapted from a previously published journal [29], with modifications made to better fit the flipped classroom context, including changes in wording and scaling. Feedback from students and faculty was collected via a modified and validated 5-point Likert scale [29]. The validation of the student and faculty feedback forms followed a structured process, involving several critical steps to ensure accuracy and relevance.

Initially, the feedback forms were reviewed by experts in education and curriculum development to establish content validity. This review was essential to determine whether the questions adequately covered key aspects of the flipped classroom experience, such as student engagement, satisfaction, and instructional effectiveness. The experts ensured that the questions aligned with the theoretical framework of flipped learning, which emphasizes active learning and pre-class preparation [30, 31].

After the expert review, the forms were pilot tested on a small group of students and faculty members to assess their clarity and practicality. This phase helped identify any ambiguous questions, unclear wording, or response scale issues. Feedback from the pilot group was then used to make necessary modifications, which enhanced the clarity and contextual appropriateness of the forms.

Following the pilot test, the feedback forms underwent statistical validation to evaluate their reliability and internal consistency. Methods like Cronbach’s alpha were likely applied to ensure that the items on the Likert scale measured the intended constructs consistently. This step was crucial for establishing the forms’ ability to provide reliable and consistent results in the larger study [32].

Several modifications were made to adapt the Likert scale to the flipped classroom context. For instance, questions were tailored to reflect specific elements of flipped learning, such as pre-class preparation, in-class participation, and the use of multimedia tools for learning. Additionally, the language of the questions was adjusted to be culturally and contextually relevant for the students and faculty at Gondar University, ensuring that the feedback gathered was both meaningful and reflective of their experiences [4, 33]. The response scale was also modified to capture more nuanced feedback, allowing participants to express varying degrees of agreement or disagreement on a 5-point scale, ranging from “strongly disagree” to “strongly agree” [34].

Through this comprehensive validation process, the feedback forms were designed to accurately capture the perceptions of both students and faculty regarding the flipped classroom approach, ensuring the results were reliable and representative.

The study focused on the topic “Drugs Acting on the Cardiovascular System” from the pharmacology curriculum, comparing two groups: a traditional lecture-based group and a flipped classroom group. The traditional lecture-based group participated in conventional tutorials, where students engaged in instructor-led discussions and problem-solving sessions aimed at reinforcing the content presented during lectures [35, 36]. “Pre- and post-tests were conducted during each session, culminating in a summative test 15 days after the completion of all topics. Administering a summative test 15 days after the completion of all topics offers several advantages. Firstly, it allows for the assessment of retention, providing insights into how well students have retained the material over a short period and their long-term retention of knowledge. Conducting the test sometime after the instructional sessions helps evaluate the effectiveness of the teaching methods, determining whether students have truly understood and remembered the content. This approach minimizes the influence of short-term memory effects, as immediate post-tests may only reflect transient recall. Additionally, the results from the delayed summative test offer valuable feedback for refining future instructional strategies and assessing the lasting impact of the teaching methods. Overall, the delay facilitates a comprehensive evaluation of students’ understanding of the entire course content, rather than just their immediate recall abilities.

In contrast, the flipped classroom group utilized a two-part module. The first part involved self-study through an online ‘Google group’ where study aids, topic introductions, and prerecorded videos were posted a week before the class. The second part consisted of in-class activities, where students applied the knowledge gained from their self-study through discussions and problem-solving exercises. Each session began with a multiple-choice questions pretest, followed by group discussions in smaller subgroups of 5–6 students. Case scenarios were projected for class discussion, and answers were discussed collectively. Supplemental information was provided by the facilitator, and a post-test concluded each session. Performance was further assessed by an end-of-module test consisting of short essay-type questions, conducted 15 days post-session completion.

Data analysis

Data were coded and entered into the Microsoft Excel spreadsheet. Data were analyzed using Statistical Packages and Social Science version 25 (SPSS). Descriptive statistics were used to summarize the data collected. Paired t-tests were conducted to compare pre- and post-intervention test scores within each group, while independent t-tests were used to compare scores between the flipped classroom and traditional lecture-based groups. Additionally, Chi-square tests were employed to analyze categorical data gathered during the study. P ≤ 0.05 was considered statistically significant for all statistical tests.

Results

Descriptive statistics for pre-test and post-test scores of students in both the flipped classroom and traditional lecture-based groups

For the Flipped Classroom Group, the mean pre-test score was 65.2 with a standard deviation (SD) of 8.1. After the intervention, the mean post-test score increased to 78.6 with a standard deviation of 6.9. This indicates a significant improvement in the students’ performance following the flipped classroom intervention. In comparison, the Traditional Lecture-based Group had a mean pre-test score of 62.8 with a standard deviation of 7.5. Their mean post-test score was 74.2 with a standard deviation of 8.3. This also shows an improvement in scores after the traditional lecture-based intervention, though the increase appears to be smaller compared to the flipped classroom group (See table 1).

Table 1.

Comparison of pre-test and post-test scores between flipped classroom and traditional lecture-based groups

Group	Sample Size (n)	Mean Pre-test Score (± SD)	Mean Post-test Score (± SD)
Flipped Classroom Group	50	65.2 ± 8.1	78.6 ± 6.9
Traditional Lecture-based Group	50	62.8 ± 7.5	74.2 ± 8.3

Paired t-tests comparing pre-test and post-test scores within the flipped classroom and traditional lecture-based groups

For the Flipped Classroom Group, the mean difference between the pre-test and post-test scores was 13.4 points, with a standard error of 2.2. The t-value for this difference was 6.09 with 49 degrees of freedom, and the p-value was 0.001. This indicates a statistically significant improvement in test scores following the flipped classroom intervention. Similarly, the Traditional Lecture-based Group showed a mean difference of 11.4 points between pre-test and post-test scores, with a standard error of 1.8. The t-value for this difference was 6.34 with 49 degrees of freedom, and the p-value was 0.001. This also represents a statistically significant improvement in test scores after the traditional lecture-based intervention (See table 2).

Table 2.

Paired t-Tests of pre-test and post-test scores in flipped and traditional groups

Group	Mean Difference (± SE)	t-value	df	p-value
Flipped Classroom Group	13.4 ± 2.2	6.09	49	0.001
Traditional Lecture-based Group	11.4 ± 1.8	6.34	49	0.001

Paired t-test, P < 0.05 was significant

Independent t-tests comparing the flipped classroom and traditional lecture-based groups across four measures: pre-test scores, post-test scores, student engagement, and student satisfaction

The mean pre-test score for the Flipped Classroom Group was 65.2 (± 8.1 SD) compared to 62.8 (± 7.5 SD) for the Traditional Lecture-based Group. The t-value was 1.85 with 98 degrees of freedom, resulting in a p-value of 0.068. This indicates that there was no statistically significant difference in pre-test scores between the two groups, suggesting that the groups were comparable at baseline. However, the mean post-test score for the Flipped Classroom Group was 78.6 (± 6.9 SD) versus 74.2 (± 8.3 SD) for the Traditional Lecture-based Group. The t-value was 3.21 with 98 degrees of freedom, and the p-value was 0.002. This demonstrates a statistically significant difference in post-test scores, indicating that the Flipped Classroom Group performed better on the post-test compared to the Traditional Lecture-based Group.

The Flipped Classroom Group had a mean engagement score of 4.5 (± 0.8 SD), while the Traditional Lecture-based Group had a mean score of 3.8 (± 0.6 SD). The t-value was 4.78 with 98 degrees of freedom, and the p-value was less than 0.001. This indicates a statistically significant higher level of engagement in the Flipped Classroom Group. Moreover, the mean satisfaction score for the Flipped Classroom Group was 4.2 (± 0.7 SD) compared to 3.9 (± 0.5 SD) for the Traditional Lecture-based Group. The t-value was 2.34 with 98 degrees of freedom, and the p-value was 0.021. This shows a statistically significant higher level of satisfaction among students in the Flipped Classroom Group (See table 3).

Table 3.

Independent t-tests comparing flipped classroom and traditional lecture-based groups

Measure	Flipped vs. Traditional	t-value	df	p-value
Pre-test Scores (mean ± SD)	65.2 ± 8.1 vs. 62.8 ± 7.5	1.85	98	0.068
Post-test Scores (mean ± SD)	78.6 ± 6.9 vs. 74.2 ± 8.3	3.21	98	0.002
Student Engagement (mean ± SD)	4.5 ± 0.8 vs. 3.8 ± 0.6	4.78	98	< 0.001
Student Satisfaction (mean ± SD)	0.2 ± 0.7 vs. 3.9 ± 0.5	2.34	98	0.021

Independent t‑test, P < 0.05 was significant

Chi-square tests for three categorical measures: pass/fail rates, gender distribution, and participation in activities

The Chi-square value for pass/fail rates was 4.85 with 1 degree of freedom, and the p-value was 0.028, indicating a statistically significant association between the teaching method and pass/fail rates. Specifically, the difference in pass/fail rates between the Flipped Classroom Group and the Traditional Lecture-based Group is unlikely to be due to chance. For gender Distribution, the Chi-square value was 0.98 with 1 degree of freedom, and the p-value was 0.322, showing no statistically significant association between the teaching method and gender distribution. Therefore, gender distribution was similar across both the Flipped Classroom Group and the Traditional Lecture-based Group, suggesting that any observed differences in outcomes are not influenced by gender composition. However, for participation in activities, the Chi-square value was 6.34 with 1 degree of freedom, and the p-value was 0.012, demonstrating a statistically significant association between the teaching method and participation in activities. The higher participation rates in activities among students in the Flipped Classroom Group compared to those in the Traditional Lecture-based Group suggest that the flipped classroom method may encourage more active involvement in learning activities (See table 4).

Table 4.

Chi-square tests for categorical measures

Measure	Chi-square value	df	p-value
Pass/Fail Rates	4.85	1	0.028
Gender Distribution	0.98	1	0.322
Participation in Activities	6.34	1	0.012

Chi-square Test, P < 0.05 was significant

Student perceptions of flipped classroom teaching-learning approach

The perceptions of the students regarding the flipped classroom teaching-learning activity were generally positive. 76% of students reported improved understanding due to the flipped classroom approach, while 84% found the materials provided before class to be helpful. 80% of students reported being more engaged during the flipped classroom sessions. Additionally, 84% acknowledged that the flipped classroom method encouraged active learning, indicating a strong endorsement of this teaching method among those who were directly exposed to it. 76% of students found the in-class activities effective in enhancing learning, while 66% expressed a preference for the flipped classroom method over traditional lectures. Overall satisfaction with the flipped classroom approach was 76%. The mean ratings for each category ranged between 3.8 and 4.2, proving the fact that the students appreciated the flipped classroom approach (See table 5).

Table 5.

Perceptions of the students to flipped classroom as a teaching-learning activities

Item	Strongly Disagree (1	Disagree (2)	Neutral (3)	Agree (4)	Strongly Agree (5)	Mean rating
The flipped classroom approach improved my understanding	2 (4%)	3 (6%)	7 (14%)	20 (40%)	18 (36%)	4.0
The materials provided before class were helpful	1 (2%)	2 (4%	5 (10%)	22 (44%	20 (40%)	4.2
I was more engaged during the flipped classroom sessions	1 (2%)	3 (6%)	6 (12%)	18 (36%)	22 (44%	4.2
The flipped classroom method encouraged active learning	0 (0%)	2 (4%)	6 (12%)	20 (40%)	22 (44%)	4.2
The in-class activities were effective in enhancing learning	1 (2%)	3 (6%)	8 (16%)	17 (34%)	21 (42%)	4.1
I prefer the flipped classroom method over traditional lectures.	3 (6%)	4 (8%	10 (20%)	18 (36%	15 (30%)	3.8
Overall satisfaction with the flipped classroom approach	2 (4%)	3 (6%)	7 (14%)	21 (42%)	17 (34%)	4.0

The feedback collected from students through open-ended questions about the flipped classroom approach offers valuable insights into their perceptions and experiences. Many students noted that the flipped classroom method significantly improved their understanding of the material. The use of pre-class videos and resources allowed them to arrive in class better prepared, facilitating more meaningful engagement in discussions. Students expressed feeling more engaged during flipped classroom sessions compared to traditional lectures. The interactive nature of activities such as case discussions and problem-solving exercises captured their interest and encouraged active participation in the learning process.

Moreover, the structure of in-class activities fostered critical thinking and the application of concepts. Students reported that these exercises prompted them to think critically about the material, enhancing their ability to apply theoretical knowledge in practical situations. Feedback also indicated that utilizing class time for interactive discussions and activities was perceived as more productive than traditional lectures, helping students clarify doubts and reinforcing their understanding of the topics covered.

Working in small groups and discussing case scenarios proved to be particularly advantageous. Students appreciated the opportunity to learn from different perspectives and collaborate, contributing to a deeper comprehension of the material. A notable sentiment among students was their preference for the flipped classroom approach over traditional lectures, which they found more enjoyable and less monotonous. Many expressed a desire for this method to be adopted in more courses.

The flipped classroom method also instilled a sense of responsibility regarding their learning. Knowing they had to prepare for class motivated students to engage with the material more consistently, fostering better study habits. Additionally, several students reported improved retention of information, attributing this to the active engagement and ongoing reinforcement of concepts, which solidified their understanding and memory.

Overall, the consensus among students was that the flipped classroom provided a positive learning experience. They felt it not only enhanced their academic performance but also made the learning process more enjoyable and interactive, marking a significant shift in their educational experience.

Discussion

An analysis of pre-test and post-test scores for students in both the flipped classroom and traditional lecture-based groups reveals significant differences, highlighting the potential benefits of the flipped classroom approach.

For the Flipped Classroom Group, the mean pre-test score increased significantly after the intervention. This substantial rise indicates a marked improvement in student performance resulting from the flipped classroom approach. This finding is consistent with several recent studies that have highlighted the effectiveness of flipped classrooms in enhancing student learning outcomes. For instance, previous studies demonstrated that students in flipped classrooms achieved higher academic performance and reported greater satisfaction with their learning experience compared to those in traditional lecture-based settings [37]. Another study found that flipped classrooms improved students’ critical thinking skills and engagement [38] .

In comparison, the mean pre-test score for the traditional lecture-based group also increased following the intervention. Although scores improved, the increase was slightly smaller in the traditional lecture-based group compared to the flipped classroom group. This result aligns with findings from other studies that have examined the effectiveness of traditional lecture-based teaching methods. For example, a meta-analysis found that traditional lectures are less effective than active learning strategies, such as flipped classrooms, in promoting student learning and engagement [39].

The data suggests that while both teaching methods can improve student performance, the flipped classroom approach may offer greater benefits in terms of enhancing learning outcomes. This likely stems from the active learning components of the flipped classroom model, where students engage with the material before class and apply their knowledge during in-class activities. Such an approach encourages deeper understanding and retention of the material, as supported by the cognitive theory of multimedia learning [40].

The paired t-tests conducted to compare pre-test and post-test scores within both the flipped classroom and traditional lecture-based groups reveal significant improvements in students’ performance following each intervention.

For the flipped classroom group, the mean difference between the pre-test and post-test scores was 13.4 points, with a standard error of 2.2. The calculated t-value was 6.09 with 49 degrees of freedom, and the p-value was 0.001. This statistically significant result indicates a substantial improvement in test scores due to the flipped classroom intervention. Recent literature highlights the effectiveness of the flipped classroom model in enhancing learning outcomes, supporting these findings. For example, a previous study found that students in a flipped classroom had better performance in assessments and higher levels of engagement compared to those in traditional settings [41]. Furthermore, another study reported that the flipped classroom approach leads to higher student achievement and satisfaction [14].

Similarly, the traditional lecture-based group showed a mean difference of 11.4 points between pre-test and post-test scores, with a standard error of 1.8. The t-value for this difference was 6.34 with 49 degrees of freedom, and the p-value was 0.001. This indicates a statistically significant improvement in test scores following the traditional lecture-based intervention. Although traditional lecture methods are less interactive, they effectively convey information and improve knowledge retention in certain contexts. For instance, a previous study noted that lectures are particularly effective for transmitting factual knowledge and providing clear, structured content [42]. Additionally, another study highlighted that traditional lectures can be beneficial when complemented with other teaching methods, such as discussions and practical applications [43].

Comparing the improvements between the two groups, the larger mean difference and t-value in the flipped classroom group suggest a more pronounced effect of the flipped classroom intervention on student performance. This is in line with findings from another study, which conducted a comprehensive review of flipped classrooms and concluded that this model often results in higher student achievement and engagement [44]. Moreover, a previous study demonstrated that the flipped classroom approach not only enhances academic performance but also fosters critical thinking and problem-solving skills [45].

The mean pre-test score for the flipped classroom group showed a slight increase compared to the traditional lecture-based group. The t-value of 1.85 with 98 degrees of freedom and a p-value of 0.068 indicate that there was no statistically significant difference in pre-test scores between the two groups. This lack of a significant difference suggests that both groups were comparable at baseline, ensuring that any observed differences in post-test scores and other measures reflect the impact of the instructional methods rather than pre-existing differences in student ability.

Post-test scores

The t-value of 3.21 with 98 degrees of freedom and a p-value of 0.002 indicate a statistically significant difference in post-test scores, demonstrating that the flipped classroom group performed better than the traditional lecture-based group. This finding is in line with the growing body of literature suggesting that the flipped classroom model enhances student learning outcomes.

The flipped classroom model enhances student learning experiences for several key reasons.

First, it promotes active learning by encouraging students to engage with content before class through videos or readings. This preparation enables more active participation in discussions and problem-solving during class [3]. Second, by shifting passive learning to outside the classroom, students can engage more deeply with the material. Class time is then focused on interactive activities that capture students’ attention more effectively than traditional lectures [46].

The model also supports personalized learning, allowing students to progress at their own pace and review challenging concepts as needed. This tailored approach accommodates individual learning styles, enhancing the overall educational experience [37]. Furthermore, the flipped classroom fosters collaboration, as students work together on projects or problem sets, improving their communication and teamwork skills [47].

Another significant advantage is the opportunity for immediate feedback. Instructors can provide real-time responses during class activities, enabling students to address misconceptions and clarify their understanding promptly [48].

Additionally, the model facilitates deeper comprehension of the material. With more time dedicated to applying concepts in class, students can better connect theory to practice [49]. Finally, the flipped classroom encourages improved time management, as students take responsibility for their learning by organizing their study schedules and prioritizing time for content review and classroom activities [50].

For example, a meta-analysis study found that flipped classrooms are associated with higher academic performance compared to traditional lectures [51]. Similarly, another study reported that flipped classrooms improve students’ understanding and retention of course material [19].

Student engagement

The flipped classroom group had a significantly higher mean engagement score than the traditional lecture-based group. The t-value was 4.78 with 98 degrees of freedom, and the p-value was less than 0.001, indicating a statistically significant higher level of engagement in the flipped classroom group. Increased student engagement is a key advantage of the flipped classroom model, as highlighted by another study that found that active learning strategies, including flipped classrooms, promote higher levels of student engagement and participation [52]. Furthermore, another study also observed that students in flipped classrooms were more motivated and engaged during class activities compared to those in traditional settings [33].

Student satisfaction

The flipped classroom group had a relatively higher mean satisfaction score compared to the traditional lecture-based group. The t-value of 2.34 with 98 degrees of freedom and a p-value of 0.021 indicate a statistically significant higher level of satisfaction among students in the flipped classroom group. This finding aligns with other research, which showed that students in flipped classrooms report higher levels of satisfaction due to the interactive and student-centered nature of the learning environment [53]. Additionally, another study found that the flexibility and active learning opportunities provided by the flipped classroom model contribute to increased student satisfaction [54].

Chi-square tests for categorical measures: pass/fail rates, gender distribution, and participation in activities

The chi-square tests conducted for three categorical measures—pass/fail rates, gender distribution, and participation in activities provide valuable insights into the differences between the flipped classroom and traditional lecture-based teaching methods.

Pass/fail rates

The chi-square value for pass/fail rates was 4.85 with 1 degree of freedom and a p-value of 0.028, indicating a statistically significant association between the teaching method and pass/fail rates. This indicates that the difference in pass/fail rates between the flipped classroom group and the traditional lecture-based group is likely significant and not just a result of chance. The flipped classroom method appears to contribute to higher pass rates, which aligns with findings from recent studies. For instance, a previous study demonstrated that students in flipped classrooms had higher pass rates and overall course grades compared to those in traditional lecture-based courses [55]. Similarly, another study also found that the flipped classroom approach significantly improved student pass rates and reduced the number of failing grades [56] .

Gender distribution

The chi-square value for gender distribution was 0.98 with 1 degree of freedom and a p-value of 0.322, indicating no statistically significant association between the teaching method and gender distribution. This result suggests that the gender composition of students was similar across both the flipped classroom group and the traditional lecture-based group. Therefore, teaching methods, rather than gender composition, account for differences in educational outcomes. This finding is important because it controls for gender as a potential confounding variable, providing a clearer interpretation of the impact of instructional methods. A previous study emphasized the importance of ensuring balanced gender distribution in educational research to avoid biases in the results [39].

Participation in activities

The chi-square value for participation in activities was 6.34 with 1 degree of freedom and a p-value of 0.012, demonstrating a statistically significant association between the teaching method and participation in activities. The higher participation rates in activities among students in the flipped classroom group implies that this teaching method may encourage more active involvement in learning activities. Recent literature highlights the role of active learning strategies in promoting student engagement and participation. For example, a previous study reported that students in flipped classrooms participated more actively in class discussions and group activities compared to those in traditional lecture-based settings [57]. Additionally, another study found that the flipped classroom model fosters a more interactive and participatory learning environment, leading to higher levels of student involvement in educational activities [58].

Student perceptions of the flipped classroom teaching-learning approach

The flipped classroom teaching-learning approach has garnered generally positive perceptions from students, as indicated by various measures of their feedback. The following analysis draws on recent studies to contextualize and support these findings.

Improved understanding

76% of students reported improved understanding due to the flipped classroom approach. This aligns with findings from recent literature. For example, a previous study reported that students felt more prepared and had a better understanding of the material due to the pre-class activities in a flipped classroom setting [54]. Similarly, another study found that the flipped classroom approach enhanced students’ comprehension and retention of course content [37].

Usefulness of pre-class materials

84% of students found the materials provided before class to be helpful. This is consistent with another study’s findings, which noted that pre-class materials in flipped classrooms help students prepare better and understand the subject matter more effectively [59]. By allowing students to engage with the content at their own pace, these materials contribute to a more effective learning experience.

Engagement during sessions

80% of students reported being more engaged during flipped classroom sessions. Research shows that the interactive nature of flipped classrooms promotes higher levels of student engagement. For instance, a previous study found that students in flipped classrooms were more engaged and participated more actively in discussions and activities compared to those in traditional lecture-based settings [60]. Additionally, another study highlighted that active learning strategies, such as those employed in flipped classrooms, significantly increase student engagement and participation [39].

Encouragement of active learning

84% of students acknowledged that the flipped classroom method encouraged active learning. This is in line with the study, which emphasized that flipped classrooms inherently promote active learning by shifting the focus from passive reception of information to active engagement with the content [44]. Moreover, another study found that flipped classrooms effectively foster critical thinking and problem-solving skills through active learning strategies [38].

Effectiveness of in-class activities

76% of students found the in-class activities effective in enhancing learning. This finding aligns with a study that reported students in flipped classrooms benefit from hands-on activities and collaborative exercises, which reinforce their understanding of the material [58]. Another study also supports the effectiveness of these in-class activities, showing that interactive exercises in flipped classrooms enhance learning outcomes and increase student satisfaction [19].

Preference for flipped classroom method

66% of students expressed a preference for the flipped classroom method over traditional lectures. The previous study found that a majority of students favored the flipped classroom approach due to its flexibility and the active learning opportunities it provided [61]. Additionally, another study reported that students preferred the flipped classroom model because it allowed for more personalized and interactive learning experiences [45].

Overall satisfaction

Overall satisfaction with the flipped classroom approach was 76%, with mean ratings for each category ranging between 3.8 and 4.2. This high level of satisfaction is consistent with findings from other studies. For example, a previous study found that students in flipped classrooms reported higher satisfaction levels due to the engaging and student-centered nature of the learning environment [53]. Moreover, another study highlighted that the flipped classroom model’s focus on active learning and student participation contributes to higher overall satisfaction [33].

Conclusion

The flipped classroom group showed an increase in post-test scores (mean = 78.6 ± 6.9) compared to the traditional lecture-based group (mean = 74.2 ± 8.3), highlighting the effectiveness of the flipped method in enhancing academic performance (p = 0.002). Additionally, the flipped classroom group reported significantly higher levels of engagement (mean = 4.5 ± 0.8 vs. 3.8 ± 0.6, p < 0.001) and satisfaction (mean = 4.2 ± 0.7 vs. 3.9 ± 0.5, p = 0.021). Chi-square analysis also revealed significant associations between the flipped classroom and both pass/fail rates (p = 0.028) and participation in activities (p = 0.012), indicating greater student involvement in this group. Student feedback supported these results, with 84% acknowledging that the flipped classroom encouraged active learning and 76% reporting improved understanding.

Overall, these findings suggest that the flipped classroom is a highly effective pedagogical approach that enhances both student learning outcomes and experiences in medical education.

Limitations and recommendations

Despite the promising results, this study has several limitations. The sample size was relatively small, comprising only 100 students from a single institution, which limits the generalizability of the findings to other medical schools or larger populations. Additionally, the study duration was short, spanning only 7 months, which may not fully capture the long-term effects of the flipped classroom approach on student performance and satisfaction. Potential selection bias could also be present despite the use of a stratified random sampling method. The study focused exclusively on the topic “Drugs Acting on the Cardiovascular System,” so the results may not be applicable to other subjects or disciplines within medical education. Data collection relied on self-reported measures for student engagement and satisfaction, which might introduce response bias. Moreover, differences in the quality and style of facilitators leading the flipped classroom sessions versus traditional lectures could have influenced the outcomes. Lastly, the use of online tools assumes all students have equal access to technology and the internet, which might not be the case, potentially affecting participation and learning.

To address these limitations, future studies should include a larger and more diverse sample of students from multiple institutions to enhance the generalizability of the findings. Long-term studies are recommended to assess the sustained impact of the flipped classroom approach on student performance, engagement, and satisfaction over multiple semesters or years. Expanding the application of the flipped classroom method to a broader range of subjects within the medical curriculum would help determine if the benefits observed are consistent across different content areas. Implementing standardized training for facilitators would ensure consistent delivery of both flipped classroom and traditional lecture-based sessions, minimizing variability in teaching quality. Enhanced data collection techniques, such as direct observations, interviews, and focus groups, would provide deeper insights into student experiences and perceptions. Ensuring all students have access to necessary technological resources and support would address potential barriers to engagement. Employing a mixed-methods approach in future research would allow for triangulation of data from various sources, providing a more comprehensive understanding of the flipped classroom’s impact. Finally, replication studies in different educational contexts and with varied student populations are encouraged to validate the findings and establish broader applicability.

Author contributions

A.K. and A.T. wrote the main manuscript text and H.S. and M.F. prepared Tables 1, 2, 3, 4 and 5 as well as Fig. 1. All authors reviewed the manuscript.

Funding

We did not receive any financial support for this research. We conducted the study independently, without external funding.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethical clearance and participation consent

The University of Gondar’s College of Medicine and Health Science, School of Pharmacy, received ethical clearance (SOP/146/2023) on the date of November 1, 2023 from its ethical review board. The objectives and importance of the study were explained to the participants. Their names and other personally identifying information were withheld in order to preserve the anonymity of the data, after their informed written consent was obtained.

Consent for publication

Not relevant.

Competing interests

The authors declare no competing interests.