Background <p>In the approaches to learning model, it is proposed that learners’ methodologies are acquired and adjusted according to the environment and context. Learners can be classified as adopting deep, surface or strategic approaches to learning. Understanding learners’ preferences and the factors associated with these approaches can benefit their learning journey.</p> Methods <p>We conducted an exploratory multi-university mixed-methods cross-sectional study of pre-medicine foundation/pathway students at three medical schools (Europe/Middle East). Students completed the short-form ASSIST (Deep, Strategic, Surface); <i>n</i> = 159. We assessed internal consistency, compared ASSIST scale scores across groups using non-parametric tests, examined correlations between ASSIST scales and academic performance, and ran a hierarchical linear regression as a confirmatory test. We purposively sampled students (<i>n</i> = 25) based on learning approach and background, and completed semi-structured interviews. Data were analysed using thematic analysis.</p> Results <p>Students most commonly reported Strategic (21%), Deep (21%), or Deep–Strategic (29%) preferences. Between-site differences were detected for Deep (Dublin &lt; Bahrain; small) and Surface (Malta &lt; Dublin and Bahrain; small–to–moderate), with no site effect for Strategic. No differences were observed by gender or academic achievement on entry. English proficiency (B2 &gt; C2) and prior education (CHSD &lt; prior foundation programme) showed differences on the Deep scale. The Strategic scale correlated positively with academic performance (<i>r</i> ≈ 0.23), but this attenuated and lost conventional significance in regression once entry achievement and background were included. Qualitative interviews revealed that students switch approaches based on subject, task, and assessment demands. Organisation, time-management, utilisation of resources, and assessment awareness were strong features in strategic approach learners, while surface learners reflected a passive, memorisation-focused approach under pressure.</p> Conclusions <p>Across three international cohorts, Deep and Strategic approaches predominated, with modest between-site differences, and approach–achievement links were limited after accounting for background factors. Qualitative data highlighted context-responsive switching and the role of practical strategic behaviours in managing assessment demands. Rather than aiming to shift students to a single “ideal” approach through curriculum change, programmes may achieve more by teaching self-regulated study skills, refining assessment/feedback to discourage unhelpful surface tactics, and targeting transition supports for students with differing educational and language backgrounds.</p>