Unveiling the development and influencing factors of higher-order thinking skills among public health undergraduates: a convergent mixed-methods study

Cultivating higher-order thinking skills (HOTS) is essential for preparing public health undergraduates to tackle complex health challenges. However, the developmental trajectory and influencing factors of HOTS in this specific population remain underexplored, particularly in the Chinese context. This study aimed to assess the status of HOTS among preventive medicine undergraduates, identify influencing factors, and explore the educational mechanisms that enable or hinder its development. A convergent mixed-methods design was employed. Quantitatively, a cross-sectional survey was conducted among 118 preventive medicine undergraduates from a medical university in Shandong Province, China, using the Higher-Order Thinking Skills Scale for College Students and a demographic questionnaire. Qualitatively, semi-structured interviews were conducted with 10 purposively selected students to explore their lived experiences. Data integration occurred through a joint display analysis, comparing and contrasting quantitative and qualitative findings to generate meta-inferences. The quantitative results revealed a moderate overall HOTS level (Total score: 147.47 ± 26.03, max = 200). Academic year was the only significant demographic predictor of HOTS (β = 9.838, p < 0.01), explaining a substantial portion of the variance. However, even seniors’ absolute scores indicated room for improvement against the scale’s theoretical maximum. The qualitative analysis unearthed two overarching themes: enablers (e.g., practical application, technology integration, critical thinking pedagogy, teamwork) and inhibitors (e.g., lack of personalized guidance, monotonous teaching activities, fixed mindset) of HOTS development. The integrated findings suggest that the observed level, despite inter-cohort progression, is associated with prevalent pedagogical inhibitors within the current educational environment. While HOTS scores improve with academic year, the current educational paradigm appears insufficient for optimal cultivation. The study highlights a disconnect between yearly progression and achieving competency targets. Reforms targeting the identified inhibitors—such as expanding active learning opportunities, providing personalized feedback, and fostering a growth mindset—may help address this competency gap, though their effectiveness awaits empirical evaluation.