Educational Crossword Puzzles as A Tool for Engaging Active Learning among Undergraduate Health Professional Students

In contemporary health professional education, students are exposed to an array of intricate scientific concepts and terminologies within a brief academic period. This demanding requirement often results in cognitive overload and superficial understanding of the concepts which are essential for internalization of key ideas [1,2].

Traditional instructional strategies may prove effective for imparting fundamental knowledge but might not enhance thinking skills, student engagement or prolonged retention of information [3,4]. Consequently, in the discipline of health sciences, emphasis is placed on the active learning strategies which encourage cognitive depth and strengthen internal motivation and collaborative learning. Numerous teaching methods are included in active learning where students participate in meaningful educational tasks and evaluate their performance [5]. Game Based Learning (GBL) has emerged as an innovative learning tool that uplifts motivation, interaction and retention of learned material by integrating the aspects of fun and competition [6,7].

Crossword puzzles, a kind of instructional game has demonstrated positive results in improving the vocabulary, memory and encouraging integration of interrelated concepts in the biomedical disciplines [8,9]. Students can actively recall knowledge, identify relationship between phrases and reinforce learning through practice and discussion because of their structured yet engaging nature [10]. Regardless of the recognized benefits of active and game based learning in health professional education, the implementation of crossword puzzles as an organized teaching-learning tool in undergraduate health sciences curricula is underexplored. Studies have indicated that crossword activities can be a valuable tool in boosting self-evaluation, improving comprehension of medical terms and promoting teamwork [11,12].

The present study was undertaken to assess how well undergraduate health professional students use crossword puzzles as a novel T-L technique to reinforce key scientific terms and concepts. It provides insight into how students perceive their enjoyment, competitive and collaborative engagement, learning utility and ability to identify and remember important disciplinary vocabulary. By evaluating these perspectives, this study adds to the expanding body of data supporting interactive and student-centered learning techniques in health professional education. Unlike previous reports that have generally examined crossword puzzles within a single subject area or small class setting, the present study evaluates a structured, multi-domain perception framework across a large cohort (n = 375) spanning more than one basic-science topic area (Figure 1 and 4), thereby providing a more comprehensive assessment of students’ perceived learning utility, collaborative engagement and vocabulary reinforcement associated with this instructional tool.

A total of 375 health professional students participated in this study. Data were gathered in 2024 by using a pre-validated, self-structured questionnaire designed to assess students’ perceptions of crossword puzzles as a teaching and learning tool. The survey questions were chosen from the topics taught in the health science curriculum. This was a descriptive, cross-sectional study of student perceptions following a single crossword-puzzle learning activity; no comparison group or objective pre-/post-test of knowledge was included and the results should therefore be interpreted as perception data rather than as evidence of an experimentally demonstrated learning effect. The study received ethical approval from the Local Committee of Bioethics at Northern Border University, Arar, Saudi Arabia (Decision No. 30/43/H, dated 02/03/2022). Participant data were collected in 2024. The study followed the principles of the Declaration of Helsinki and its amendments. Participation was voluntary and informed consent was obtained from all participating students after the purpose and objectives of the study were explained.

Participants were recruited via convenience (total-population) sampling: all students enrolled in the relevant 2024 course sessions who were present during the scheduled crossword-puzzle activity were invited to participate and completed the questionnaire in class immediately afterward (response rate ≈100% of students present; a separate count of enrolled students who were absent that day was not tracked). Approximately 60% of respondents were female. Detailed baseline characteristics-age, specific program/discipline, academic year and prior exposure to crossword/game-based learning-were not captured in the original questionnaire and are therefore not reported (Supplementary Table S1); this is acknowledged as a limitation (see Limitations).

The aim of the study was to evaluate students' impression of crosswords across four domains: student satisfaction, collaborative and competitive attributes, learning benefit and usefulness in comprehending important concepts and language.

The 15-item questionnaire was developed by the study investigators, with items mapped a priori to the four conceptual domains listed above; the mapping of individual items to each domain is provided in Supplementary Table S2. Content validity was established through review by three subject-matter experts in health professions education. A separate formal pilot test was not conducted. Internal-consistency reliability (Cronbach’s alpha) was not calculated for this descriptive analysis; this is acknowledged as a limitation of the study (Limitations).

Crossword puzzles were developed for selected topics within the health science curriculum. Each student received a printed crossword puzzle, consisting of terms and concepts arranged in horizontal and vertical rows and columns. After completing the puzzles, students filled out the questionnaire to provide feedback on their learning experience.

Two crossword puzzles covering different topic areas were used in the study: one focused on basic biochemical and metabolic concepts (Figure 1, 2) and the other focused on hematology-oncology concepts (Figure 3, 4). The same two crossword puzzles were provided to all groups. Students were randomly assigned to groups of 6-7 participants. All groups received the same standardized instructions from the facilitator and completed the activity within 30 minutes. The crossword puzzles were developed by academically trained professionals, ensuring content accuracy and alignment with course objectives. Each puzzle comprised 10 questions accompanied by a list of potential answers, from which students selected the correct responses and entered them in the appropriate crossword grid spaces. To maintain the difficulty level at an acceptable level, both short and long words were used. From simple to complex, the clues were methodically designed around key phrases that represented major ideas and concepts and their associations. Content validity was ensured by linking all clues and answers directly to the intended learning objectives. The level of difficulty was established by taking into account the participants' understanding of fundamental concepts: Simple recall and rote learning questions were regarded as easy, while questions that required problem-solving and critical thinking skills and application based questions were regarded as challenging.

Figure 1: Crossword Grid on Basic Concepts Questions Without Filled Up Answers

Clues

Across

• 1: Which condition results from insulin resistance and an insulin deficiency in obese patient?
• 3: Which form of severe protein malnutrition is characterized by edema and an enlarged liver with fatty infiltrates?
• 4: Name the form of severe malnutrition characterized by energy and calorie deficiency.
• 5: Name an autosomal recessive metabolic disorder that affects amino acid transport, leading the body's inability to digest and use protein building blocks.
• 8: Name the disorder that occurs from failure to inherit the gene for producing the enzyme homogentisic acid oxidase.

Down

• 2: Name the main inhibitory neurotransmitter in the human brain (other than glutamate, which is primarily excitatory).
• 6: Name the condition caused by high plasma LDL-cholesterol concentrations in the blood.
• 7: Name an enzymatic disorder caused by a mutation of a single amino acid leading to the disruption of the normal conversion of phenylalanine to tyrosine.
• 9: Name severe thiamine-deficiency syndrome found in areas where polished rice is the major component of the diet.
• 10: Name the disease caused by deficiency of Niacin involving the skin, gastrointestinal tract and central nervous system

Answers

• 1: Type 2 Diabetes Mellitus
• 2: Gamma Amino Butyric Acid
• 3: Kwashiorkor
• 4: Marasmus
• 5: Lysinuric protein intolerance
• 6: Atherosclerosis
• 7: Phenylketonuria
• 8: Alkaptonuria
• 9: Beriberi
• 10: Pellagra

Each crossword puzzle included typical clues derived from the course content, designed to assess students’ understanding of key terms and concepts. The activity was conducted during a 30 minute classroom session, providing adequate time for puzzle completion and subsequent reflection. During the session, students were organized into small groups of six to seven members to encourage collaboration and peer learning. Following completion of the crossword puzzles, the facilitator led a group discussion during which the correct answers were discussed and constructive feedback was provided to the students. Figure 1-4 provide an example of questions given to the students along with answers to be filled in the crossword puzzles made by the subject experts.

Figure 2: Crossword Grid on Basic Concepts Questions with Filled Up Answers

Data analysis

For Data analysis, the Statistical Package for Social Sciences (SPSS) was used. Descriptive statistics was performedusing frequencies and percentages for categorical variables. A p-value of <0.05 was considered statistically significant.

Individual Likert-scale items were treated as ordinal data and are presented descriptively as frequencies, percentages, means and standard deviations. A one-sample t-test was additionally used to compare the mean response for each item with the neutral midpoint of the scale (3.0); given the recognized debate around parametric analysis of Likert-type data, these comparisons are presented as an exploratory index of the direction and magnitude of agreement rather than as confirmatory evidence of statistically demonstrated learning effectiveness and are interpreted alongside the corresponding means and standard deviations rather than in isolation. Item 11 and Item 14 were negatively worded; consistent with this, lower mean agreement on these two items reflects a favourable perception and they were interpreted in the reverse direction to the remaining items. No composite or domain-level score was calculated in this descriptive analysis (Limitations), so no additional reverse-scoring beyond this interpretive note was required.

Figure 3: Crossword Grid on Hematology and Neoplasia Questions Without Filled Up Answers

Clues

Across

• A 23 year old previously healthy man develops moderate to severe hemolytic anemia. Urinalysis shows free hemoglobin and Coombs test is negative. Supravital staining of the blood smear demonstrates Heinz bodies within erythrocytes. Diagnosis?
• A 30 year old woman complains of recent fatigability, bruising and recurrent throat infections. Abnormal laboratory findings include reduced hemoglobin, white blood cell count and platelets. The bone marrow is hypocellular and displays increased fat. Diagnosis?
• In a laboratory exercise, a 23 year-old female was found to have a prolonged bleeding time and a prolonged APPT. Her platelet count was normal. These findings are strongly suggestive of:
• A bone marrow aspiration from a 65 year-old man with long-standing profound anemia shows megaloblastic erythroid hyperplasia and presence of hypersegmented neutrophils in peripheral blood smear. Diagnosis?
• A 5 year-old African boy develops a rapidly enlarging mass that involves the right side of his face. Biopsies reveal a prominent 'starry sky' pattern produced by proliferating small, noncleaved malignant lymphocytes. Which virus is most closely associated with this malignancy?
• Which malignancy is strongly associated with Chinese liver fluke infestation?

Down

• Mycosis fungoides represents a malignancy of: ________
• The mammogram of a 44 year-old female shows several 0.5-1.5 cm foci of irregular density in both breasts. Fine needle aspirates of lesions in both breasts show malignant cells. Diagnosis?
• Which carcinoma is locally invasive but rarely forms metastases in lymph nodes and distant sites?
• Most non-neoplastic polyps of the stomach are microscopically classified as: _________

Answers

• 1: G6PD deficiency
• 2: Aplastic anemia
• 3: T lymphocyte
• 4: Infiltrating duct carcinoma
• 5: Basal cell carcinoma
• 6: Von willebrand disease
• 7: Pernicious anemia
• 8: Hyperplastic polyps
• 9: Epstein-barr virus
• 10: Cholangiocarcinoma

Figure 4: Crossword Grid on Hematology and Neoplasia Questions with Filled Up Answers

The judicious use of crosswords was useful for near transfer content and provided an opportunity to discuss and recall essential concepts, think critically, and collaborate in small groups.

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A crossword puzzle activity was created for students enrolled in health science courses and their perceptions of the activity were assessed through a structured questionnaire (Table 1). The majority of participants (95%) reported that the crossword puzzles were extremely helpful in improving their comprehension of the core concepts and were willing to engage in similar activities in the future. Furthermore, 95% of respondents reported that the crossword puzzles helped them recognize and remember important words and ideas. Approximately 91% of those surveyed stated that they would recommend this approach to their juniors and ask instructors to use it as a method of instruction. While a small proportion of participants indicated that additional time was needed to answer these kinds of puzzles, 85% of them agreed that tackling crossword puzzles gave them the chance to explore important ideas and exercise critical thinking.

About 96% of students reported that crossword puzzle exercises were beneficial when compared with other small-group learning techniques, especially for improving spelling accuracy and broadening their vocabulary of scientific terms. Most participants also indicated that collaborative problem-solving during the exercise strengthened conceptual understanding from a variety of angles and encouraged knowledge integration and that the activity created an interesting and dynamic learning environment. Additionally, 94% of participants strongly agreed that the crossword sessions promoted quick team building by providing a challenging but relaxed task that boosted group members' confidence and collaboration. Remarkably, 98% of participants said that the crossword exercise helped them focus on important details of the topic (Table 1).

Table 1: Questionnaire Items Assessing Students’ Perceptions of Crossword Puzzles in Health Science Courses

N: Frequency (Number of participants), %: Percentage of participants, n = 375, Mean and SD calculated based on 5-point Likert scale (1: Strongly Disagree, 5: Strongly Agree), p-values calculated using one-sample t-test against neutral value of 3.0, Items 11 and 14 are negatively worded, lower mean scores for these two items indicate more favourable perceptions rather than disagreement with the overall utility of crossword puzzles, Domain-level summary scores and reliability coefficients (Cronbach’s α) were not calculated for this descriptive analysis (Limitations), The “S. No.” column has been retained pending the journal’s formatting preference

In the framework of small-group teaching, crossword puzzles are an example of a more student-centered approach that necessitates participation and interaction from learners [13]. Activities in small groups encourage more profound understanding, problem-solving, personal accountability for learning and the development of intercultural and interpersonal teamwork [14]. Small-group learners tend to show stronger academic achievement and a more optimistic outlook towards learning [15]. In the present study, 94% of those surveyed strongly agreed that the crosswords provided opportunities for speedy team building and that the exercise gave them an overwhelming feeling of challenge, pushing them to perform and count on team members without any pressure, which boosted their confidence. About 98% of respondents in the study highly reported that the crossword tool assisted them in determining the key points of the subject.

Crossword puzzles gave students immediate feedback by promptly evaluating their current grasp of understanding in an informal manner [16]. This is consistent with the results of earlier gamification-related studies on active learning [17-21]. The questions' replies are concept-based hints that aid in vocabulary reinforcement and help pupils retain the material for longer time. Crosswords have been used for educational settings [17,22]. It is remarkable that more studies and applications of this kind of approach have not been uncovered. A plausible reason for this could be because some educators believe that the usage of games is not adequately looked over and that developing topic-specific, appropriate crosswords takes an excessively long time. Because crosswords don't seem like traditional teaching and could be viewed as an improper use of class time, some people may despise them and view them as non-educational [23]. A few studies have suggested that students' liking of this seldom utilized tool may be due to the fact that puzzles make the classroom more enjoyable by offering comedy, intellectual stimulation, a sense of accomplishment when the task is finished and a connection between the exercise and general learning [24]. In the current study, 95% of students agreed that the crosswords were extremely helpful in identifying important terminology and concepts and had made a big difference in their understanding. The use of crossword puzzles in educational settings is seen to have several advantages [25]. Another self-correcting feature of crossword puzzles is that if a word fits, it fits; if not, it is incorrect. Our aim has been to maintain these puzzles challenging enough for the students to "stretch"—that is, to find them just a bit too difficult for them to solve. As an answer to the question in puzzle is partially accomplished, specific letters in specific positions are found to provide hints [26].

Findings from an earlier study provided insight that students feel a sense of accomplishment when they solve and finish a crossword puzzle because the exercises are difficult and it tests their ability to learn about, visualize, forecast and solve the puzzle's clues, which increases their self-confidence [27]. In another study, there was no discernible difference between learners who utilized crossword puzzles and those who did not use them in the courses taken by them and no change was found in the scores obtained by students in the final assessments, thereby, questioning the usefulness of crosswords in students learning as reflected by final grades obtained by them [28]. This emphasizes the need to study further as how educational games could support and engage a particular class of learners and improve their performance because there is a greater variation in learning styles among students nowadays [24,29,30]. In the present study, 91% of those surveyed stated that additional time was needed to answer these kinds of puzzles, 85% of them agreed that tackling crosswords gave them the chance to explore important ideas and exercise critical thinking.

When compared to other small group activities, 96% of students agreed that crosswords were helpful, particularly because they helped them understand how to spell correctly and broadened their vocabulary. Solving puzzles together also made the educational environment more enjoyable and entertaining while allowing the students to integrate information and demonstrate their understanding of various points of view [31-33]. In the present educational environment, it is essential that educators provide programs that guide students how to put their scientific knowledge into practice [34]. Since the introduction of active learning interventions, students' performance in many courses has improved, as seen by increased average scores and a closing gap between the highest and lowest grades [35].

According to Kirkpatrick's approach, the effectiveness of instructional programs and learning interventions can be evaluated at several levels, including behavior, learning, reactions and results [36]. A positive correlation between assessments and concepts covered in puzzles and games has been reported by previous studies [37]. Despite the fact that we have not explicitly linked crossword components to exam topics, students' clinical and analytical reasoning skills have been evaluated using an extended matching crossword problem. Future research in this area could investigate the impact of crossword puzzles on students’ retention of terminology and conceptual understanding in undergraduate health professions education. Further studies should also examine their influence on teamwork and critical thinking skills and conduct unbiased evaluations to substantiate the effectiveness of this instructional tool in health professions education.

It is important to distinguish clearly between the two levels of evidence reported here. The quantitative results (Table 1) describe students' self-reported perceptions and reactions to the crossword-puzzle activity-that is, Kirkpatrick Level 1 (reaction) evidence-rather than objectively measured learning gains, retention or examination performance (Kirkpatrick Levels 2-4), which were not assessed in this study. High levels of self-reported enjoyment and perceived usefulness do not, by themselves, establish that crossword puzzles improve measurable learning outcomes; prior studies cited above have reported mixed findings when objective outcomes were examined [27,28]. In addition, because participants were recruited from a single institution using convenience sampling rather than a randomized or multi-institutional sample, the findings may not generalize to other student populations, curricula or health professional disciplines. Controlled, multi-site studies that pair self-reported perceptions with objective, examination-linked outcome measures are needed before firm conclusions can be drawn about the educational effectiveness of crossword puzzles in this setting.

Crossword puzzles were positively perceived by students in this large, single-institution cohort as an engaging addition to conventional teaching methods, particularly when implemented within a welcoming, competitive and collaborative environment. Students reported that the activity helped them recall and discuss important scientific terminology, while also fostering self-perceived critical thinking, teamwork and healthy competition. As this study assessed self-reported perceptions rather than objectively measured learning outcomes, these findings should be interpreted as evidence that students found crossword puzzles engaging and useful, rather than as confirmed evidence of improved learning; controlled, multi-institutional studies with objective outcome measures are needed to substantiate the educational effectiveness of this instructional tool.

Limitations

This study has several limitations that should be considered when interpreting the findings. First, no control or comparison group was included and no objective pre-/post-test of knowledge or examination-linked outcome was used; consequently, the study demonstrates students' perceptions of, rather than objectively demonstrated improvement in, learning. Second, all outcomes were based on self-report, which may be subject to response bias and social-desirability bias. Third, the study was conducted at a single institution, which may limit the generalizability of the findings to other curricula and teaching contexts. Fourth, participants were recruited via convenience (total-population) sampling from students present during the scheduled activity rather than a randomly selected sample and detailed baseline characteristics-age, specific program, academic year and prior exposure to game-based learning-were not captured (Supplementary Table S1); this limits assessment of how representative the sample was of the broader eligible student population. Fifth, perceptions were assessed immediately after a single crossword-puzzle session, so the durability of any perceived benefit over time is unknown. Finally, internal-consistency reliability (Cronbach's alpha) of the questionnaire was not formally assessed in this study, which limits conclusions about the psychometric robustness of the instrument and is an important target for future work.

Ethical Approval and Informed Consent

The study received ethical approval from the Local Committee of Bioethics at Northern Border University, Arar, Saudi Arabia (Decision No. 30/43/H, dated 02/03/2022). Participant data were collected in 2024. The study followed the principles of the Declaration of Helsinki and its amendments. Participation was voluntary and informed consent was obtained from all participating students after the purpose and objectives of the study were explained.

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38. Table S1: Baseline Demographic and Academic Characteristics of Participants (N = 375)

59. N: Number; %: Percentage of respondents, Sex distribution is reported as approximate percentages, Age, program, academic year and prior game-based-learning exposure were not captured by the study questionnaire, their absence is noted as a limitation in the manuscript (see Limitations section)