From Clues to Competence: A Comparative Study of Three Educational Puzzle Formats as Perceived Teaching and Formative Assessment Tools Among Undergraduate Health Professional Students

Background: Active learning strategies are essential in health professional education. Three novel educational puzzle formats: (1) Diagnostic Riddles, (2) Clinical Case Puzzles and (3) Medical Crosswords-were designed, implemented across four subject areas and comparatively evaluated among undergraduate health professional students as teaching and formative assessment tools. Methods: A within-subject (repeated-measures), comparative observational study (January-December 2025) enrolled 164 second-and third-year undergraduate students from the health sciences colleges of the University of Hail, Saudi Arabia. A pre-validated 30-item Likert questionnaire assessed perceptions across seven domains. Statistical analysis included descriptive statistics, repeated-measures ANOVA (or linear mixed-effects model), paired post-hoc comparisons with correction for multiple comparisons and chi-square/Cochran's Q tests as appropriate (IBM SPSS v.20). Results: Response rate was 100% (n = 164). Clinical Case Puzzles (Type 2) achieved the highest overall mean satisfaction score (4.84±0.36),  followed  by  Diagnostic  Riddles (Type 1; 4.77±0.41)  and  Medical  Crosswords (Type 3; 4.63±0.48). One-way ANOVA revealed significant inter-format differences (F (2,489) = 8.42, p = 0.0002, η² = 0.033). Post-hoc Tukey HSD confirmed Type 2 was significantly preferred over Type 3 (p<0.001). Chi-square analysis confirmed that curriculum inclusion preference was significantly associated with puzzle format (χ² = 12.34, df = 2, p = 0.002). [EDITOR/AUTHOR NOTE: The F-, p- and χ²-values above were computed treating repeated observations from the same students as independent (one-way ANOVA/ordinary chi-square). Per Reviewer Comments 32-39 and 41-42, these must be recalculated using a repeated-measures ANOVA or linear mixed-effects model (and, if applicable, a repeated-measures categorical method) before resubmission; the values here are retained from the original submission pending that reanalysis]. Conclusions: All three puzzle formats were highly rated and positively perceived active learning tools. Clinical Case Puzzles are most strongly endorsed for formative assessment; Diagnostic Riddles are optimal for vocabulary and lower-order recall; Medical Crosswords were designed to target higher-order clinical reasoning, although this was not independently measured in the present study. A tiered, format-differentiated implementation strategy is recommended for health sciences curricula.