# **Experiential Teaching for Public Health Practice**

**Edited By:**

**Bud Nicola &**

**Amy Hagopian**

*University of Washington Seattle, WA USA*

#### **Experiential Teaching for Public Health Practice: Using Cases in**

#### **Problem-Based Learning**

Editors: Bud Nicola and Amy Hagopian

eISBN (Online): 978-1-68108-387-2

ISBN (Print): 978-1-68108-388-9

Published by Bentham Science Publishers – Sharjah, UAE.

First published in 2017.

© 201 by the Editor / Authors. Chapters in this eBook are Open Access and distributed under the Creative Commons Attribution (CC BY 4.0) license, which allows users to download, copy and build upon published chapters, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications.

The book taken as a whole is © 201 Bentham Science Publishers under the terms and conditions of the Creative Commons license CC BY-NC-ND.







# **FOREWORD**

How can we best prepare the public health workforce for today's world?

Diseases and disabilities in the human population today are extraordinarily complex: from chronic diseases such as heart disease, diabetes, and cancer; to infectious diseases such as HIV/AIDS, H1N1 influenza, and Ebola; to illnesses related to occupational and environmental conditions such as asbestosis and lead poisoning. Further, the causes and determinants of these diseases and conditions are frequently multi-factorial and include broad social, economic, and environmental factors such as income, education, and influences associated with where we live, work, learn, and play. Indeed, further progress in promoting the health of all Americans may well depend on an enhanced approach to what constitutes public health practice—one that seeks explicitly to positively affect "upstream" social, economic, and environmental determinants of health.

We know that working on problems whose causes and solutions are unclear requires collaborating with and leading many different groups. This means that the people working in public health from a variety of different professional backgrounds require training that prepares them to deal with this complexity and with the different groups of stakeholders required to collectively address complex public health challenges.

As the Regional Health Administrator for the U.S. Department of Health and Human Services for Region X in the Northwest part of the United States, I have experience in observing and leading teams of public health professionals to work on major public health issues and have had an opportunity to work with a program that is effective in training students to become impressive and confident practitioners. The MPH in Community-Oriented Public Health Practice program at the University of Washington in Seattle has created a rigorous academic environment that allows students to engage closely with health problems in the community and that teaches students to learn by doing.

Students help our region's practitioners solve real problems and develop practice skills that will be used every day to move public health teams to take effective data-driven preventive action.

I urge other schools of public health to consider how they can best incorporate the lessons

prepare members of our future workforce for the complex challenges that await them. from this effective and inspiring program into their own teaching methods. Such efforts will

> **Patrick O'Carroll** Regional Health Administrator, Region X U.S. Public Health Service Seattle, WA USA

*ii*

# **PREFACE**

In 2000, I returned to Seattle from the U.S. Centers for Disease Control and Prevention in Atlanta to work at the University of Washington School of Public Health and Community Medicine. At that time, my UW colleagues made me aware of a remarkable new enterprise: the development of a Master of Public Health program focused on the *practice* of public health. The MPH in Community-Oriented Public Health Practice (COPHP) would be an unorthodox undertaking for two primary reasons. Firstly, the school had a reputation for training future researchers on the fundamentals of research. Secondly, the group of faculty involved in developing the program had decided to base it on the best principles of adult learning theory, and as a result, they were determined to use the problem-based learning (PBL) method as the program's anchor. As a life-long practitioner of public health, I was intrigued and hooked. I was pleased to join with several colleagues in a multi-year exploration of how best to design a program for adult learners so that they could enter the employ of a non-profit or government agency or health care institution and "hit the ground running." Testimonials from employers hiring the graduates of this program as well as from the students themselves have confirmed that, with COPHP, we took the right approach.

This book tells the story of that exploration, our initial program design, and the lessons we learned as faculty and students together re-shaped the program each year to improve the effectiveness of the learning experience. It is directed at all teaching programs that wish to move from conventional methods of teaching and learning, where faculty lectures predominate, to an environment where the faculty craft PBL cases that students use to teach each other; from faculty-governed learning to a shared learning space; and from a knowledge base dominated by theory to one where students discover theory by looking at problems in a practice field. In this book, we provide examples of the PBL cases that faculty have written and used in COPHP courses. A companion project will make the entire set of COPHP PBL cases available for an annual subscription fee (see Appendix L).

The editors and authors of this book understand that it will be the rare program that converts completely from traditional learning methods to PBL. We offer advice and insight into the many aspects of PBL and how, over the years, we have tried to be flexible and pragmatic about its use and interpretation. One of our foremost tenets has been to monitor how both students and faculty have contributed to programmatic quality improvement.

The COPHP program has been fortunate, particularly at its inception, to have the support and vision of leaders in the School of Public Health. COPHP was launched under the direction of Dr. Frederick A. Connell, Associate Dean of the school at the time, who oversaw the first set of PBL cases created from the practice environment and worked through the complexity of training faculty in a new method of teaching. Dr. Connell had the challenging task of turning a start-up into an accepted institutionalized program. His experience as an epidemic intelligence officer and a pediatrician anchored him in the practice world; his academic credentials as a researcher and ties throughout the school's academic departments helped to assure the program's successful launch. Dr. Connell now has emeritus status.

After the program was stabilized, I took the leadership reins for three years and was followed by Peter House, a senior lecturer in the Department of Health Services and a clinical associate professor in the Department of Family Medicine. Peter successfully met the challenge of moving the program from partial funding by the State of Washington to complete funding from student tuition. The current COPHP Director, Dr. Amy Hagopian, with research interests in global health around health worker migration from low-income to wealthy countries, has helped expand the program's annual cohort to three groups of eight students.

COPHP has been fortunate to have strong faculty leadership for each of the required curricular areas. Several of these faculty members—Aaron Katz, Jack Thompson, Fred Connell, and Stephen Gloyd, with support from then Health Services Chair, Bill Dowling—participated in early conversations about developing a program over post-class libations at a nearby cantina. The conversations over time developed into a formal proposal to the School of Public Health that generated the COPHP program.

Case-writing leads for programmatic content in the PBL cases at the beginning of the program include: Management (Bill Dowling); Population Health (Stephen Bezruchka); Community Development (Jack Thompson and Peter House); Epidemiology and Biostatistics (Fred Connell and Jim Gale); Health Promotion/Health Behavior (Karen Hartfield); Policy and Evaluation (Aaron Katz and Amy Hagopian); and Environmental Health (Bill Daniels). Many current faculty members are chapter authors for this book (Sharon Bogan [former student], Brett Niessen [former student], A. Gita Krishnaswamy [former student], Aaron Katz, Amy Hagopian, Peter House, Karen Hartfield, Jsani Henry [former student], Stephen Bezruchka, Ann Vander Stoep, Michelle Garrison, Tania Busch-Isaksen, Wayne Turnberg, Jude Van Buren, Sarah Ross-Viles [former student], Hendrika Meischke, Chris Hurley, Katie Bell, Ian Painter, Jack Thompson).

To credit all who have contributed to the success of COPHP, I should really name the program's alumni since many of them are substantial contributors to the development and improvement of all aspects of the program. The book chapter on CORE (Anne Althauser, Tara Bostock, Ariel Hart, Jennifer Hagedorn, and Afomeia Tesfai) describes the major contribution that students made to incorporate anti-racism principles into the curriculum.

Thanks to all of the students and faculty who have been a part of COPHP over the years for

*iv*

their energy, enthusiasm, and devotion to learning. This learning community has shared the insights, the joy, and the continuing relationships resulting from many months of hard work.

> **Bud Nicola** University of Washington School of Public Health Seattle, WA USA

*v*

# **ACKNOWLEDGMENTS**

The co-editors would like to thank Alice Porter, manuscript editor, and Sarah Cohen, copy editor, for all their hard work and impressive professional help on this book. Their effort improved the final product immensely.

The enthusiasm and thoughtfulness of COPHP faculty, students, staff, and community partners over the years inspired us to create this resource for other academic public health colleagues.

# **List of Contributors**


*viii*


# **Dedication**

This e-book is dedicated to faculty and teachers from around the world who are searching for effective and exciting ways to improve student learning.

# **Introduction and Background**

**Aaron Katz\* , Jack Thompson** and **Frederick A. Connell**

*University of Washington, Seattle, USA*

**Abstract:** Faculty at the University of Washington School of Public Health developed an MPH program that departs significantly from traditional graduate training. They initially sought a pedagogy rooted in adult learning theory and social justice that would prepare courageous problem solvers and excellent critical thinkers. The first step toward this goal was selection of the problem-based learning method to replace the lecture mode. Faculty secured funds to support training in writing PBL cases and facilitating PBL groups, designing a curriculum, and developing administrative processes. They created a two-year curriculum that covers all the core competencies of public health through PBL cases, which are in part shaped by community partners. Fifteen years later, the program that resulted from this effort—the MPH in Community-Oriented Public Health Practice—continues to prepare public health professionals who demonstrate exceptional skills in self-discovery, leadership, teamwork, and collective analysis.

**Keywords:** Adult learning theory, Community, Curriculum, Critical thinking, Education, MPH, Pedagogy, Practice, Problem-based learning, Public health.

"The key challenge facing public health education today is reconciliation of the academic environment in which most public health education takes place with the practice environment for which students are destined".


How can we train excellent public health practitioners?

\* **Corresponding author Aaron Katz:** University of Washington School of Public Health Seattle, WA, USA; Tel: (206) 616-5227; Fax: (206) 616-9415; E-mail: garlyk@uw.edu

> **Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

#### **4** *Experiential Teaching for Public Health Practice Katz et al.*

That was the question that vexed the four founders of COPHP when, 15 years ago, we sat down over bottles of beer. Our public health school at the University of Washington had a strong reputation in public health training and research—it consistently ranked among the top six public health schools in the country. Many of our colleagues were nationally renowned scholars in environmental health, epidemiology, biostatistics, and other fields, and each year the competition to get into our MPH, MS, and PhD programs was intense.

Still, we shared an uneasiness about whether our students, particularly our MPH students, left us well-prepared to work in public health. And our sense of uncertainty was supported by what we heard from the potential employers of our students. These employers—local health departments, health care providers, community organizations, and advocacy groups—sought not just specific research skills or methods expertise but also strong problem-solvers and critical thinkers. They tended to hire students from other disciplines, such as business or health administration, that apparently offered more flexible and applicable skill sets.

So we wondered, what would a curriculum look like that produced creative, courageous problem-solvers who could, according to the WHO definition of public health, help create the "conditions in which people can be healthy?" We were fairly confident that traditional graduate-level courses were unlikely to fit the bill. How does a student learn critical thinking skills by sitting passively in a lecture, watching a continuous stream of bulleted PowerPoint slides? How does a midterm exam or theory-based paper help a student learn the sensitivity and humility needed to work with and in support of communities?

# **PROBLEM-BASED LEARNING**

What we needed was a pedagogy rooted in experiential learning and selfdiscovery, concepts consistent with adult learning theory [2]. Some of us had used case studies in our courses, placing students in realistic situations and posing questions that pushed them to research contexts, options, and impacts. But each of us has also worked in public health practice, and we knew that real challenges did not come in such neat packages—rarely is anyone around to set the stage or pose

#### *Introduction and Background Experiential Teaching for Public Health Practice* **5**

the right questions. Once at work, many of our graduates had to gain the knowledge and confidence to start from zero and still find good solutions and effective strategies.

Another goal we had was for students to gain strong skills in teamwork and collective analysis. Certainly public health professionals must conduct independent research and take individual initiative. But public health is at its core a group effort: professionals working in teams, across disciplines, with community groups and stakeholder organizations. We wanted to create an educa-tional environment in which our students learned and excelled at leadership skills, meeting facilitation techniques, respectful criticism, and other competencies needed to contribute to and lead high-performing teams.

Many of us in higher education learned how to teach on the job, with little or no formal training, and with only our own teachers as models; this means that lecture is what we're comfortable doing. We have confidence that if we design and deliver a lecture effectively, students will hear and "get" what we consider to be the main lessons, skills, and knowledge. This "I talk, you listen" pedagogy is ageold, but the research on adult education suggests that it rarely results in sustained learning [3]. We began to look for an alternative to the lecture model in which the instructor has total control over the content and flow of a session; we sought instead a method of teaching and learning in which the initiative and control would switch to students.

Through some personal contacts and a bit of literature review, we learned about problem-based learning (PBL), a non-didactic learning method that has been used, notably, in various medical schools. As we learned more about this pedagogy, an opportunity to obtain funding from the university administration arose. Backed by our dean's office, we crafted a successful proposal, which provided support for a year of learning, planning, training, and case-writing.

#### **CHALLENGES**

Finding the right pedagogy was the first step, but only the first, and perhaps the easiest. We faced three main challenges to creating the kind of innovative signature program we envisioned:

#### **6** *Experiential Teaching for Public Health Practice Katz et al.*


As we discussed our ideas with other faculty, we discovered that one of our new faculty members had direct experience with problem-based learning in his former academic setting. He provided us with good advice from his experience and directed us to national experts in this area. With the planning funds, we were able to hire a staff person who visited the Hahnemann (now Drexel) School of Public Health, which had established an all-PBL MPH program. What she learned on that visit gave us great insight into the process of PBL and the nature of cases that

would generate deep learning. We were also able to bring a PBL expert who had worked on the Hahnemann program to our school to train faculty on case writing and PBL facilitation.

Of course, planning and training resources would mean nothing without sufficient faculty to run the various modules for a two-year program. As we discussed our budding idea with colleagues, we found the idea of a cutting-edge MPH program to be very attractive to many; indeed, the program's focus on public health practice and its basis in adult learning made recruiting faculty with strong practice credentials fairly easy.

# **COMMUNITY AND SOCIAL JUSTICE**

In addition to working with a pedagogy that encourages self-discovery, leadership, and teamwork, we sought to design a program that would adhere to two key principles: application of learning to community settings and a priority focus on social justice and equity. This approach requires a very close involvement with communities served by public health. We were confident that PBL would support identification and discussion of public health competencies in class settings, but we wanted to ensure that our students could demonstrate mastery of specific competencies in work situations.

In this regard, we knew we did not want to follow a traditional approach of public health programs—inviting community leaders to participate in individual class sessions organized by academic faculty. Rather, COPHP faculty would bring experience from and connections with state and local health departments, community organizations, education, housing, and community planning. This wealth of community connections and experience with actual community problem-solving would inform case development and offer opportunities for hands-on class projects.

Our faculty achieve this standard by engaging in dialogue with community leaders prior to case-writing and block development. Today community partners help shape the direction of many of the blocks and even co-write cases with faculty. This is particularly true for those blocks that have direct community interaction as part of the work. Community leaders are also engaged with the program in

#### **8** *Experiential Teaching for Public Health Practice Katz et al.*

seminar leadership and in service as practicum and capstone advisers. (See Chapter 10.2 on our community development curriculum).

The practicum requirement had to be reconsidered in light of this new curriculum. Our school has a major partner in our local public health department, Public Health—Seattle & King County. Several faculty members either are current health department employees with clinical appointments or are former health department employees now at the university. In 2003, the school and the health department successfully applied to the U.S. Centers for Disease Control and Prevention for pilot funding as an *academic* health department. One of the lasting benefits of this collaboration was the agreement to hire a health department employee to coordinate a group practicum that would be housed at the health department. We now have an ongoing contractual relationship with this local health department to provide practicum settings and instructional faculty.

The program also emphasizes capstones, rather than traditional theses, as defining projects for the MPH degree. A capstone, like a thesis, is a rigorous, scholarly effort. Unlike a thesis, a capstone requires negotiation with a community partner to develop a project that is of value to the partner. The COPHP program was the first degree program in our school to use the capstone approach. This is consistent with our community focus and has extended our emphasis on application of learning to the program's culminating project.

The COPHP program has, we believe, fulfilled the vision of its founding faculty. It now has graduated 13 cohorts of highly competent, committed public health professionals who have transmitted the program's social justice "DNA" into practice at local, state, federal, and international levels; some have even returned to become the next generation of the program's faculty. Problem-based learning has, indeed, proven to be a pedagogy well-matched to the public health challenges of tomorrow.

#### **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

#### **REFERENCES**


# **CHAPTER 2**

# **Competencies**

#### **Amy Hagopian\***

*University of Washington, Seattle, USA*

**Abstract:** All MPH programs in the United States seek accreditation by the Council on Education for Public Health (CEPH). CEPH promotes competency-based education, an institutional process that moves education from an emphasis on what academics believe graduates should know (teacher-focused) to an emphasis on what students should be able to do (student and workplace-focused). These competencies are associated with skills that will be demanded of graduates in their public health workplaces. To assess attainment of competencies, faculty must ask students to produce work products that demonstrate skill mastery. In contrast to typical classrooms, the MPH in Community-Oriented Public Health Practice (COPHP) uses problem-based learning (PBL) cases as the method for achieving competencies and creates real partnerships with government public health agencies and community-based organizations to engage students in producing work these organizations really need. The University of Washington adopted a set of MPH competencies in line with CEPH accreditation requirements, and we have mapped COPHP case learning objectives to these competencies. In this chapter, we discuss the evolution of the competency-based approach in our program, offer examples of problem-based cases from our public policy curriculum, and list the competencies that students will attain by the end of their participation in COPHP.

**Keywords:** Accreditation, Benjamin Bloom, Case learning, Competencies, Council on Education for Public Health, Paulo Freire, Problem-based learning, Skill mastery, Student-centered learning, Systems thinking.

#### **INTRODUCTION**

The Community-Oriented Public Health Program (COPHP) is built on the

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author Amy Hagopian:** University of Washington School of Public Health Seattle, WA, USA; Tel: (206) 616-4989; Fax: (206) 543-3964; E-mail: hagopian@uw.edu

#### *Competencies Experiential Teaching for Public Health Practice* **11**

principle that cases and problems naturally produce competencies in adult learners. Our program's founders had in mind a revolutionary approach to public health education—one that placed teachers in the role of "problem-posers" rather than collectors and depositors of information in students' heads. This orientation is based on the work of educational theorists such as Paulo Freire, who advanced and popularized the concept of "problem-posing education" [1], as well as Benjamin Bloom, who categorized and ranked various ways of knowing, valuing, and doing things in an educational context [2]. Bloom and Freire understood that remembering facts and concepts is a fairly low-level cognitive act, one that is easily fulfilled by simply telling students what they need to know. By contrast, to demonstrate competency in a complex field like public health, students must analyze, apply, evaluate, and synthesize information and ideas. In addition, they must apply important public health values, including collective action, to advance social justice and face down power structures that threaten the public's health.

The Council on Education for Public Health (CEPH), the organization that accredits schools of public health in the United States, has promoted competencybased public health education for more than a decade. At the time of COPHP's inception in 2002, CEPH had already begun calling on schools to document the competencies they were attempting to develop in MPH students [3]. Clinical training programs had for some time embraced problem-based learning (PBL); it seemed logical that presenting students with a set of presenting signs and symptoms—a "problem"— stimulated students to synthesize their knowledge in ways they would soon be required to demonstrate in a clinical role [4]. This method also seemed to be a natural fit for the practice-oriented and competencybased approach of COPHP.

#### **WHAT THE WORKPLACE DEMANDS**

CEPH describes competencies as "what students need to know and be able to do in varying and complex situations (student and/or workplace focused)" [5]. Competencies encourage institutions to focus on developing the observable skills and knowledge that will be demanded of graduates in their public health workplaces, as defined by employers and professional leaders. After a series of working group discussions and negotiations involving more than 400 individuals,

#### **12** *Experiential Teaching for Public Health Practice Amy Hagopian*

CEPH in 2006 identified the following competency domains: biostatistics, epidemiology, environmental health, policy and management, and social and behavioral sciences. Crosscutting competencies included communication, diversity, leadership, professionalism, program planning, biology, and systems thinking. As this book was being written, CEPH was completing its overhaul of the public health competency inventory for the next round of accreditation assessments [6, 7].

In addition to defining competency domains and calling on schools to identify and break down large skill sets into discrete competencies, CEPH further challenges schools to design learning experiences and contexts that support students to master competencies as bundled sets. Each competency may have various levels of mastery, from basic understanding to advanced capacity to the ability to lead a project requiring the named skills and knowledge. The guidelines also present a set of verbs to define observable mastery. For example, "understand" is not an allowed verb because a teacher cannot directly observe understanding; "describe" is preferred because it is something a student can *do*. More advanced levels of mastery require verbs such as "synthesize", "design", or "create".

The University of Washington and COPHP were early leaders in competencybased education. The university first established public health competencies in 1999 as part of a self-study in preparation for CEPH accreditation. At around the same time, competencies also drove the creation of COPHP curriculum. Frederick A. Connell, a founding faculty member who was associate dean at the time noted recently, "When we began the COPHP program, we started by articulating 'competencies' for each block —before any cases were written. At the time we may have been the first competency-driven curriculum in the school". <sup>1</sup> Subsequent re-accreditation self-studies occasioned competency revisions across the school. In 2013, using the CEPH competency domains, the School of Public Health and Community Medicine called on its departments (Biostatistics, Epidemiology, Environmental Health, and Health Services) to engage in a process of establishing competencies that could be observed and measured among MPH graduates.

As a UW program, COPHP ensures that our problem-based cases meet the CEPH-identified competencies required of MPH graduates. This is relatively

#### *Competencies Experiential Teaching for Public Health Practice* **13**

simple to demonstrate, because each COPHP case has a set of learning objectives that can be mapped to the competencies. In fact, when faculty write cases, they *start* with the learning objectives, for the case overall and for each day of the case. They then write a story that offers students a scenario from which the learning objectives can be derived. Each COPHP course, therefore, includes dozens of learning objectives that can be mapped to competencies. (See Appendix C).

But CEPH competency domains are derived periodically and as the result of a political process involving the leadership of member schools, not from empirical work. There are likely important learning areas that don't emerge in this process. Researchers in the field have attempted to measure the views of both public health workers and employers about the skills, fields of knowledge, and other aspects of competency they feel are most important. Kaufman and colleagues conducted key informant interviews with public health workers from 31 agencies to learn what knowledge, skills, and attitudes the public health workforce needed the most to meet emerging challenges, yet currently lacked [8]. The top areas included systems thinking, persuasive communication, and managing change with flexibility and adaptability. The top 10 also included political sensitivity, recruitment, problem-solving, and managing a diverse workforce. Similarly, Sellers and colleagues surveyed central office employees at state health agencies in 37 states, with responses from more than 10,000 workers (46% response rate) [9]. Among their top training needs were "influencing policy development" and training related to understanding the "broad array of factors that influence specific public health problems [social determinants of health]".

When our COPHP began in 2002, we did not have the benefit of Kaufman and Sellers' research or even the first set of CEPH competencies that emerged shortly thereafter. By happy coincidence (or perhaps prescience), our curriculum has aligned with these priorities. In particular, we have an extraordinary focus on the competency areas that emerged from Kaufman and Sellers as most important: systems thinking, persuasive communications, problem-solving, and cultural diversity. Because our students work in teams on community-based projects from the first day, additional competencies we develop include: engaging staff within public health organizations, engaging partners outside the organization, applying evidence-based approaches to solve public health problems, and assessing the

#### **14** *Experiential Teaching for Public Health Practice Amy Hagopian*

broad array of factors that influence public health problems—all of these named in the Sellers survey as vitally important. Because COPHP faculty tend to be politically engaged in pursuit of social justice, all our cases and courses are also infused with discussion of political sensitivity and strategy.

# **COPHP COMPETENCIES**

Upon satisfactory completion of the MPH in Community-Oriented Public Health Practice concentration, graduates will be able to:


#### **MASTERING REAL WORK**

To assess successful attainment of competencies, faculty ask students to produce work products that demonstrate skill mastery. In typical classrooms, these assignments include artificial products, such as a paper on a topic assigned by the professor or a hypothetical project employers or communities might want. At best, there might be role plays. In COPHP, by contrast, we use problem-based learning (PBL) as the method for achieving competencies and create real partnerships with government public health agencies and community-based organizations to engage our students in producing work these organizations really need. In these settings, we can watch students conduct fieldwork and interact with clients. Faculty assign products these organizations have requested: a design for an evaluation of a school-based health clinic; an assessment of the content of sex education in a rural school district; or an analysis of attributable risk to inform a policy decision. Students take on tasks such as conducting interviews with homeless youth to help shelter organizers understand their needs with regard to job searches and financial management.

Our assignments comprise a mixture of products that are low stakes (seen only by faculty and fellow students) and high stakes (delivered to clients). Traditional educational settings would be arranged so that students deliver their papers or projects only to their faculty member; their classmates would not see these materials. We believe the transparency of deliverables mimics the workplace more closely and therefore helps build the communications competency that is so important.

Our competencies also prepare students for real-world work by focusing on "systems thinking". Typically, educators break complex problems into discrete, manageable pieces rather than expecting students to bring together many branches of knowledge in a complex systems approach [10]. In contrast our faculty pose scenarios that integrate, rather than separate, the components of the problem. We help students understand that problems rarely come pre-packaged in bite-sized pieces and that one of the greatest skills they can bring to a team is the ability to "turn a mess into a problem", as we like to say. In the realm of data analysis, we aim to guide students away from a focus on the smaller concerns of type I or type

#### **16** *Experiential Teaching for Public Health Practice Amy Hagopian*

II errors (false positives and false negatives) and toward the big-picture, critical thinking skills to identify whether the right question is being asked [11]. These critical thinking skills are increasingly vital in public health. The traditional approach to ensuring good nutrition, for example, has been to encourage individuals to make better food choices, when instead we need to analyze the problem on a systems level and look at industry, which offers so many poor food choices packaged attractively and flavored alluringly. To this end, our cases pose the multiple facets of a problem all at once, and students work together to produce a product that integrates multiple realities. We appreciate the overlapping interests and conflicting views required to create viable solutions and teach that understanding the whole system is more important than being able to dissect each distinct component.

Other programs, of course, use similar models and approaches, with different emphases and values. For example, East Stroudsburg University in northeastern Pennsylvania reported on its use of community collaboration to guide public health training [12]. Leon *et al.* reported on efforts by the Rollins School of Public Health at Emory University to provide some case-based instruction, offering the examples of a norovirus outbreak in Jamaica and food fortification in Bangladesh [13]. These are retrospective cases, however, rather than live community-engaged projects, and they began with one lecture and concluded with another "to ensure all learning objectives were met". Each student also produced an individual deliverable (*e.g.*, a food fortification intervention plan). By contrast, COPHP has abandoned lectures altogether as a means of ensuring learning objectives are met, to demonstrate our full faith in the case-based approach and to mimic a real workplace environment through a mix of individual and group products. We also often require group-produced reports and presentations, as these more realistically mimic a practice-based environment.

#### **CASE EXAMPLES**

We describe here three cases from COPHP policy block, which we have designed to build student capacity to integrate knowledge and skills in complex systems. The cases illustrate how real-world problems can focus students on developing specific competencies.

#### **You Never Die of Just One Thing**

Our first case in the policy block is set in Ghana. The protagonist is a Ministry of Health analyst with a personal situation requiring him to travel north (his sister has just died, leaving him in care of his nieces and nephews). Meanwhile, he is advising the ministry on its engagement with an international food fortification scheme, the Global Alliance for Improved Nutrition (GAIN). In the story line, we drop hints the first day to lead students to investigate the role of the Ghanaian Ministry of Health, the problematic nature of vertical diagnosis and treatment, the goals of food fortification, and issues facing orphans and vulnerable children. Students also discover the importance of public health biology, including the causes and consequences of TB, malaria, HIV, anemia, and how HIV care for pregnant women is organized.

On the second day of the case, students examine large multinational private-sector philanthropic entities (such as GAIN) and how they are governed. Students explore the predilection of philanthro-capitalist entities for imposing selfinterested solutions on low-income countries while also assessing the dilemmas of ministries of health weighing the costs and benefits of being on the receiving end of those activities. Key critical voices in these debates are introduced, including Amartya Sen, Anne-Emanuelle Birn, Rick Rowden, and others. The concepts of food insecurity and the social and political context of hunger are introduced, and students explore the history of anemia and the Ghanaian diet and whether Ghanaians were malnourished before colonials arrived. Finally, students are introduced to the concept of attributable risk as a tool in policy making.

On the final day of the case, students are presented with several 2 X 2 tables illustrating the results of a study involving 1,173 subjects in relation to their exposure to various factors (iron status, malaria, and bednets) in relation to anemia status. For the final assignment of this three-day case, students produce a memo in the voice of the case protagonist to the Minister of Health presenting advice with regard to an anemia control program, using attributable risk calculations. The idea is to present a politically savvy solution (in a two-page memo), taking into account the value of the contributions by GAIN, while recognizing that a far greater contributor to the anemia problem in Ghana is

**18** *Experiential Teaching for Public Health Practice Amy Hagopian*

malaria rather than iron-poor food intake.

This case incorporates a wide range of issues influencing the anemia status of Ghana's population, from colonialism to biology, and it asks students to produce a persuasive, politically sensitive policy communication that requires problemsolving and systems thinking, important MPH competencies. This case starts on a Monday and is completed when students turn in their memos on Wednesday evening of the following week.

On Thursday, after reviewing the findings from the memos turned in the night before, we start the next case.

## **Mystery at Saddle Mountain**

In the second case, protagonists are three graduate students, camping in eastern Washington State, who stumble upon a farmworker encampment. (In the design of PBL cases, the use of important storytelling elements such as protagonists drives student interest in the learning process). They soon learn about the taxonomy of the migrant farmer workforce, the health issues farmworkers face, the housing options available to them, the relationship between housing and health, the politics of public housing, the economic realities of farming (for both large and small landowners), and the implications of those realities for paying reasonable wages and/or offering housing. Students discuss the views of various stakeholders on these issues as well as the role of government agencies in farmworker labor and housing issues.

On the next day of the case, the lens widens. Students explore international trade agreements and their roles in affecting the health of migrant laborers. They explore the various views of Americans in relation to immigrants, the U.S. Farm Bill (most recently, the Agriculture Act of 2014) and its many components, and international food aid (circling back to aspects of the Ghana case). For their final assignment, students take on roles of various constituents and are asked to present farmworker housing solutions to a (hypothetical) governor's aide. Solutions that require a budget must identify a funding source.

#### **When Groundhog Day Meets Kafka**

The protagonist in this case is a newly hired aide to the Washington State Attorney General who has come to staff the state's new lawsuit against the U.S. Department of Energy. The federal agency operates the Hanford site in eastern Washington, location of one of the largest nuclear cleanup efforts in the world, where hundreds of billions of gallons of liquid waste were generated by production of plutonium, including that used in the bomb dropped on Nagasaki in 1945. Students learn about the stakeholders involved, the governance of the cleanup operation, the science of nuclear physics, the health effects of radiation, exposure and clean up standards, how government agencies work together (and don't) on such a project, the legal wrangling among parties, the Cold War, and the role of whistleblowers in protecting health and safety. They also learn about risk assessment, the "healthy worker effect", and the differential benefits of personal protective equipment as compared to engineered industrial hygiene. The role of the media and the power of workplace safety culture are explored. Finally, we strongly feature the issue of the rights of native tribes to the land and discuss how treaties were abrogated in the rush to produce an atomic bomb.

For their final assignments in the Hanford case, students design a lesson plan for teaching high school students about Hanford, its history, and the cleanup operation underway. We make arrangements at Seattle's Garfield High School for students to deliver several classroom lessons, each 55 minutes long, at the conclusion of the case. The competencies demonstrated by students to fulfill this assignment are high on the Bloom Taxonomy Scale, requiring synthesis of a great deal of information, design of a lesson plan, and communication to an audience.

#### **Research Project**

In addition to the cases, each year, we ask students to spend two to three weeks investigating an important public health topic, with the final assignment being to write a policy resolution for consideration by the American Public Health Association's governing council. To date, APHA has adopted eight policy resolutions drafted by our students, including transportation of spent nuclear fuel, improving farmworker housing, higher education access for undocumented

#### **20** *Experiential Teaching for Public Health Practice Amy Hagopian*

immigrant youth, strengthening Social Security, watershed pollution, removing barriers to mental health services for veterans, and improving the minimum wage.

#### **LOOKING TOWARD THE FUTURE**

In response to new accreditation requirements, COPHP will be more explicit with students at the outset of the program about the competencies we hope to develop. We will provide a checklist for students to monitor on their own behalf that prompts them to recognize progress at the end of each case, month, or each quarter, and require them to produce portfolios demonstrating achievement of the competencies.

#### **NOTES**

1 Personal communication, 2016 Jan 6.

#### **CONFLICT OF INTEREST**

The author confirms that author has no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

#### **REFERENCES**


[http://dx.doi.org/10.1016/S0959-4752(02)00025-7]


#### *Competencies Experiential Teaching for Public Health Practice* **21**

Available from: http://ceph.org/criteria-revision/


[http://dx.doi.org/10.2105/AJPH.2014.302416]

# **CHAPTER 3**

# **Pedagogy**

#### **A. Gita Krishnaswamy\*** and **Bud Nicola**

*University of Washington, Seattle, USA*

**Abstract:** The founding faculty of the MPH in Community-Oriented Public Health Practice (COPHP) considered several learning models appropriate for students preparing for careers in public health practice (rather than research). They selected problem-based learning (PBL), which has been successfully applied by other practicebased disciplines and incorporates elements such as strong faculty-student collaboration, group learning, a reiterative research cycle, and case learning based on realworld problems. At its core, PBL is a method in which learning results from the intellectual process involved in understanding and resolving problems. These problems are presented in cases, written by COPHP faculty, that are often based on real public health situations at the state, national, or global level. Most courses also present at least one case that requires students to complete a real-time project at the request of a partner agency such as the local health department. Students explore and discuss the cases in small groups that simulate the structure of actual work environments such as health and human service agencies; and they learn to lead groups and to cope with functional and dysfunctional group dynamics. PBL cases are built on community issues, reinforcing the program's grounding in service learning in the community. The COPHP program also trains students and in use of a course management system through which students post their coursework. Both students and faculty provide continuous feedback on progress in facilitating student learning.

**Keywords:** Adult learning principles, Case learning, Competencies, Evaluation, Facilitated learning, Group dynamics, Learner-centered education, Learning cycle, Pedagogy, Problem-based learning, Reiterative learning, Research methods, Service learning, Small-group learning, Technology.

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author A. Gita Krishnaswamy** University of Washington School of Public Health Seattle, WA, USA; Tel: (415) 309-5202; Fax: (206) 543-3964; E-mail: krishna2@uw.edu

#### **INTRODUCTION**

During the development of the Community-Oriented Public Health Practice (COPHP) program, the founding faculty discussed and reviewed available pedagogical methods to match program learning needs. They wanted to target COPHP curriculum to a population of students interested in working in public health practice, rather than in research careers. As they reviewed the many teaching methods available, faculty were most interested in methods based on adult learning principles that would require them to assess and respond to the needs, wants, concerns, and current abilities of the target learners. Any educational program should account for the motivation of the learner; reinforce the skills and knowledge being developed; and help students retain key learning and transfer it to new situations [1]. Learning—both in adults and youth— should encourage a sense of self-worth and personal power in learners [2].

Several learning models promote adult learning principles, but serendipity played a role in COPHP's embrace of a model perfectly suited to the approach the founding faculty were seeking: problem-based learning (PBL). One of our new faculty members at the time, Dr. Will Welton, had just arrived from Hahnemann University in Philadelphia and had helped develop a public health master's program there based on PBL.

Furthermore, national organizations such as the Association of Schools and Programs of Public Health had argued for a new commitment to service as part of the educational process. They also supported the use of Boyer's concept of the "scholarship of engagement", in which the practice-based scholar is engaged with practitioners, policy makers, communities, and organizations [3]. As noted in Chapter 1, this idea was wholeheartedly adopted by the founding faculty and reflected in the first year practicum and the second year master's project or capstone. PBL cases are built on community issues. Thus, from its inception, COPHP has been grounded in PBL and service learning in the community.

#### **PBL METHODS AND PRINCIPLES**

As implemented in COPHP, PBL involves a small group of students deciding for themselves what they need to study, after discussing some trigger material such as

#### **24** *Experiential Teaching for Public Health Practice Krishnaswamy and Nicola*

a written problem or situation taken from the real world [4]. After a period of individual study, the students meet to share, compare, and relate their findings to the original material and to determine whether they have acquired enough knowledge to address the situation or case.

The following definition captures some of the above elements:

PBL asks students to confront "ill-structured", real-world problems that have no immediate or clear solution. Well-constructed PBL experiences provide a genuine stimulus for learning; are culturally accessible and relevant; allow students to balance cooperative and independent work; require students to self-direct the learning process using a multidisciplinary perspective; and promote metacognitive habits that allow students to selfassess the development and quality of their learning [5].

The PBL method—in which learning results from the intellectual process involved in understanding and resolving problems— has been used successfully for many years in medicine, law and business programs [6, 7]. Its key features are that it is problem based, reiterative, learner centered, small group-oriented, and facilitated.

"Problem-based" refers to the use of simulations of realistic problems or real problems presented by external partners, carefully selected and designed to challenge learners to discover and accomplish the curriculum's major learning objectives. The primary motivation to learn comes from the natural desire to understand and resolve the problem; the problem serves as a vehicle to stimulate and motivate learning. In COPHP, students are also motivated to engage with problems that build their capacity to understand and address the health needs of communities. Learners respond to the problematic situation by defining the problem, identifying areas for further research, synthesizing findings, applying existing knowledge to interpret data, and generating multiple hypotheses. Learners work in a reiterative sequence in which the problem stimulates them to investigate to acquire new information and then return to the problem and incorporate the new knowledge into thinking and decision-making [8].

"Learner-centered" refers to a focus on the students' responsibility to collectively design the steps needed to navigate through the problem. Students have a responsibility to each other to research and present different pieces of the information puzzle and to achieve a basic understanding of key concepts. Small group facilitation skills process are essential for modern public health workers, indeed for workers, in general, in a knowledge-based society. Every group has a faculty facilitator who maintains the focus on learning, demands rigorous critical thinking, assists in the teaching of effective group process, and promotes individual and group self-evaluation.

COPHP faculty members have developed PBL cases for successful continuingeducation training of public health practitioners, using the same principles as those used in COPHP case development [9]. But faculty are not purists about using the PBL method, because learners can respond positively to several different teaching methods. They rely on other strategies in their teaching repertoire including small, focused didactic or interactive presentations both in class and between classes [10].

# **TRANSLATING PBL ELEMENTS**

# **Case Development**

Many COPHP cases are taken from real public health situations at the state, national, or global level. In addition, most courses have at least one case that requires students to complete a real-time project at the request of a partner agency such as the local health department. The program first trained faculty in facilitating and writing PBL cases when it started in 2002 [10]. Faculty members have since begin to develop in-house trainings on PBL topics most relevant for new and experienced instructors. A University of Washington staff editor reviewed all of the cases for the initial years of COPHP and also coordinated many aspects of the program. More recently, faculty have written and edited cases for each block of content without staff support.

Examples of student work generated through case analyses include developing a social media campaign to educate the public on the health status of the United States; on the health status of the U.S. population, developing a strategic plan for

#### **26** *Experiential Teaching for Public Health Practice Krishnaswamy and Nicola*

a health department, investigating youth homelessness in the University District, and other work products referenced in the other chapters of this book.

## **Small Group Composition**

COPHP is designed for students who are interested in working in public health practice situations. The small group structure simulates the working environment of current health and human service agencies in providing services and tackling problems. Students learn to lead small groups and to cope with functional and dysfunctional group dynamics. Early in the program, faculty facilitate the small groups to provide a model for group facilitation. After group dynamics and facilitation skills are covered in a first quarter seminar, students assume the role of group facilitator, and faculty give regular coaching and feedback.

COPHP group size has varied from six to nine students. A group of six or smaller means that students must do more individual work to cover all faculty designed learning objectives for the cases; groups of ten or more can become more difficult for facilitators to manage.

### **Group Work and Individual Work**

At the first meeting for a new case, students typically assign learning objectives for each member of the group to guide basic research around the case problem. Some cases require students to make a group presentation or report, and, as in so many facets of COPHP, they rely on each other for background knowledge.

#### **Research Methods**

At student orientation and again early in the first year, COPHP introduces students to modern research methods and technology. Students also learn to evaluate information sources for credibility. Research on PBL problems frequently requires sources of information outside of peer-reviewed literature, such as newspapers, interviews, windshield surveys, focus groups, or other primary data sources. Faculty facilitators help students think about the most effective means of gathering and analyzing pertinent information.

#### **Reiterative Learning Cycle**

PBL class groups meet twice a week for three-hour sessions (either Monday/Thursday or Tuesday/Friday). In *The Journal of Public Health Management and Practice*, former COPHP director Peter House *et al.* describe the learning cycle students experience:

They read cases, talk about what they already know about the public health issues at hand, and what they think is going on. Then, they develop a list of learning objectives (LOs). Each student takes an LO, researches the LO, and then submits a 5-page referenced paper to a Web-based instructional technology site using the Canvas program, (a knowledge-sharing and learning platform discussed later in the chapter. Examples of LOs include the following: "Population Health: Critique Public Health's Role in Producing a Healthy Nation", and "Policy: What Is a Superfund Site? What Are the Clean-up Issues at Hanford and How Do They Fit Under the Superfund Law?") The faculty facilitator for the groups reads each of the papers before the next class and offers written feedback to the students. The students in the groups read and critique each other's papers, creating strong and healthy peer pressure to do good work. On the second day of the case, the students start by rereading the case and then discussing the key learning from their independent work. At this point, students typically receive a next section of the case or a group assignment that builds on their collective research. Faculty members participate in class sessions by asking questions in a moderator role, rather than by lecturing [10].

#### **Technology**

The University of Washington uses an online course management system (CMS) for official for-credit courses. Support staff posts the faculty-developed PBL case to a discussion board. Students then post five-page papers on the board so that other students and the group's faculty member can read them. COPHP is currently running three concurrent groups of eight students using the same set of PBL cases, but students can read postings only from their own group. This reinforces group integrity and reliance on fellow group members for research results. Faculty may use the online CMS or email for feedback comments. Canvas has the capacity to deliver faculty audio or video files to all group members. This is another way

#### **28** *Experiential Teaching for Public Health Practice Krishnaswamy and Nicola*

faculty can provide feedback on the group performance as a whole.

#### **Academic Content**

The COPHP program confers an MPH degree. Over two academic years (six quarters), students address required competencies in blocks of cases in the following areas:


# **Evaluation of the Pedagogy**

Students provide feedback to COPHP *via* online questionnaires developed in collaboration with the University of Washington's Center for Teaching and Learning (CTL). Each faculty member receives a summary of this feedback after the academic quarter has concluded. Feedback to faculty from students through COPHP/CTL evaluation includes student ratings of: effectiveness in facilitating student learning, openness to student views, interest in whether students learned, what the instructor did that may have hindered learning or could be improved, and as of 2014, how well the faculty member shaped the classroom to support an antiracist learning culture. The COPHP Program Director uses this feedback at the annual faculty retreat to help improve COPHP teaching methods and practices. These data have also been useful in reviewing student feedback longitudinally.

For several years now, COPHP faculty have been using a peer consultation system to provide feedback to each other. The reviewing faculty member reads the syllabus and PBL cases, attends one or more classes, and observes faculty interaction with the group and with individual students. Feedback is performed on

an informal basis by sharing observations and recommendations. These observations and recommendations are also shared with the COPHP Program Director.

#### **Future Evolution of the Pedagogy**

COPHP faculty and students have been enthusiastic about the PBL methodology. They are invested in the program and eager to help make it even more effective in promoting learning. Each year during the day-long annual faculty retreat (attended by many student guests), faculty review and discuss specific practices with the aim of improving the effectiveness of learning methods and the knowledge content in COPHP.

#### **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

#### **REFERENCES**


#### **30** *Experiential Teaching for Public Health Practice Krishnaswamy and Nicola*


# **Administrative Considerations**

#### **Peter House\***

*University of Washington, Seattle, USA*

**Abstract:** The University of Washington's MPH in Community-Oriented Public Health Practice (COPHP) program is fully committed to a problem-based learning pedagogy that is unique among degree programs in our School of Public Health and rare across the country. This intense method of teaching and learning places uncommon demands on teachers and students alike. To teach all aspects of public health practice and to craft a broad curriculum, we draw faculty from other departments in our school and from the practice field as well as from the academy. We select students who bring work experience in public health practice, who share our dedication to social justice, and who are fully prepared to undertake problem-based learning. In this chapter, we discuss the customized set of administrative skills and practices that we have developed to support COPHP and govern admissions, marketing, student support, faculty support and recruiting, instructional technology, educational evaluation, institutional relationships, anti-racism and social justice strategies, and alumni relations. Together, these processes ensure the success of COPHP in producing effective public health practitioners while keeping our fee-based program affordable to students.

**Keywords:** Admissions, Administration, Advising, Alumni relations, Antiracism, Case editing, Faculty meetings, Faculty recruiting, Faculty retreats, Faculty support, Institutional relationships, Instructional technology, Internet presence, Marketing, Peer mentors, Peer review, Self-reflection, Seminars, Social justice, Student feedback, Student support.

#### **INTRODUCTION**

Our program, the MPH in Community-Oriented Public Health Practice (COPHP),

\* **Corresponding author Peter House** University of Washington School of Public Health Seattle, WA, USA; Tel: (206) 616-4985; Fax: (206) 543-3964; E-mail: phinney6@uw.edu

> **Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

#### **32** *Experiential Teaching for Public Health Practice Peter House*

is committed to using a problem-based learning (PBL) pedagogy that is unique among degree programs in the University of Washington School of Public Health and Community Medicine and rare among comparable schools across the nation. We teach all aspects of public health practice, so we have an unusually diverse faculty, drawing from other departments in our school and from the practice field as well as the academy. Another factor that sets us apart is that our program is fee-based, which means that we are forced to operate as a business by balancing costs with tuition receipts—all the while working to keep our program affordable to our students. For all these reasons, we have developed and continue to apply a customized set of administrative skills and functions, which we describe in this chapter. These practices govern admissions, marketing, student support, faculty support and recruiting, instructional technology, educational evaluation, budgeting and staffing, strategic planning, institutional relationships, anti-racism and social justice strategies, and alumni relations.

#### **ADMISSIONS**

We know that COPHP is not for all students pursuing MPH degrees. Since our program's inception in 2002, we have been careful to recruit applicants who we think will thrive in our program's pedagogy. For each case we explore in our classes, our faculty direct two three-hour sessions of in-class discussion, and we require our students to do a lot of writing and meet inviolable deadlines. We simply cannot accommodate students who are not comfortable with these demands. At the same time, we undertake the admissions process with respect and humility. We know how important our decisions are to the applicants' lives and how imprecise we humans are in judging each other. Every year we admit students from the lower end of our waiting list who later turn out to be star students and strong public health practitioners.

Our admissions process entails several steps:

● **Interviews**. A second-year student is hired to manage our recruitment efforts. She conducts a telephone interview with every applicant. The interview emphasizes questions about how good a fit the applicant would be with our program. We allow time for the applicant to ask us questions. Most applicants

are then referred to a faculty member for a second interview. Both the student assistant and the faculty member complete a short survey after the interview, and we include these notes in the applicant's files.


We know that the reviewers vary in how much emphasis they give to each element of the written application. Some reviewers read the personal statement very carefully while others home in on the letters of recommendation. Several elements, however, are common across most reviewers. Our pedagogy works best when we have students who bring knowledge and experience to the table in their groups, so we look closely at resumes to make sure that we admit applicants with at least two or three years of work experience in public health practice. On the GRE scores, we pay special attention to very high or very low scores. Very high scores (greater than the 85th percentile) correlate with the ability to keep up academically while in school. Very low scores (lower than the 15th percentile) signal applicants who will likely need extra help on academics. For the "great middle" of applicants with neither very high nor very low scores, we pay little attention to performance on the GRE.

#### **MARKETING**

Our marketing has two main elements:

#### **34** *Experiential Teaching for Public Health Practice Peter House*


#### **STUDENT SUPPORT**

We support our students at each stage of their journey through the complexities of graduate education and our program itself. These supports include:


expert in issues concerning class registration, tuition payments, graduation requirements, support for field work, scheduling meeting space, *etc*.

#### **FACULTY SUPPORT AND RECRUITING**

We recognize that our most important asset is our faculty. Just as PBL can be arduous for students, it is similarly challenging for faculty. All faculty members have competing demands on their time and creative energy, and many are employed in public health "day jobs". It is therefore essential to our success to keep faculty well supported. Some elements of that support are:


#### **36** *Experiential Teaching for Public Health Practice Peter House*

public health practice. This stands in contrast to faculty meetings in other settings that can get bogged down in administrative issues. This emphasis on education makes the meetings lively, energizing, and fun. We have very strong turnout for our faculty meetings and we use the time to keep our teaching fresh and our inter-faculty relationships strong.


#### **INSTRUCTIONAL TECHNOLOGY**

To function efficiently, our program needs an Internet-based instructional technology platform to manage case documents and student written work. We currently use Canvas as our platform. Our students write five-page papers on their learning—sometimes twice per week—and post them to Canvas, the University's Learning Management System platform. The platform provides a single place to go to find student papers and allows review to occur on a very timely basis. Our students read each other's papers, as does the faculty facilitator. The faculty facilitator comments on the student papers and returns them to the students either *via* the Canvas site or email. Presenting all the papers in one place also allows students to quickly and easily refer back to any of the papers from the group at any time. Often our students review papers their peers have written for previous blocks.

#### **EDUCATIONAL EVALUATION**

We care intensely about the quality of teaching in COPHP. We consulted with the Center for Teaching and Learning (CTL) on the UW campus to help us think about how to evaluate our teaching. The center helped us to understand that there are at least six ways to evaluate graduate student instruction. We chose to focus on the following three methods:


#### **38** *Experiential Teaching for Public Health Practice Peter House*

after the completion of each block *via* an on-line platform. The survey focuses on both the quality of the block itself as well as the quality of the instruction of the faculty facilitator. It asks for numerical ratings on several elements of the blocks and allows space for students to write comments. In recent years, we added some questions about classroom climate in relation to race and culture. In our experience, students make extensive and thoughtful comments that help us to keep improving our program. We also have the resources for faculty to request a very simple mid-block survey of the students. This allows faculty facilitators to identify any elements of the block that could change before the block is over. While we value student feedback, we avoid using the term *course evaluation* when referring to the student feedback survey. Student feedback is only one element of educational evaluation.

#### **INSTITUTIONAL RELATIONSHIPS**

As a program aimed at training practitioners, we seek partnerships with local public health agencies to keep our teaching grounded in the realities of the public health practice world. We want to expose our students to real world problems, and we seek experiences for our students where they work on real issues for community-based organizations. Working in the community puts pressure on both students and faculty to perform to high standards as our reputation depends on the quality of our work. We need a solid reputation in the community to teach the way we do. The following are three ways that we connect with our community partners.


Chapter 10.2 for more information.

## **ANTI-RACISM AND SOCIAL JUSTICE STRATEGIES**

Our website clearly states that:

COPHP faculty and students are dedicated to making sure everyone has the opportunity to live healthy, productive lives. The program recognizes that health inequities are created by institutions and policies that deliver health resources based on socioeconomic status, race, ethnicity, gender, and sexual orientation. Our mission is to work collaboratively with communities to address these barriers to improve health and well-being for all.

We know from experience that our commitment to social justice is a main attraction of the program. As such, it is a central part of our approach to teaching. We do several things to hold true to these ideals:


#### **ALUMNI RELATIONS**

We maintain a database of our alumni. Many programs do this as a way to raise money, but our purpose is to create opportunities for our alumni and current students to network and to build their careers. When our students approach graduation, we put them in touch with alumni located where the soon-to-be graduates intend to launch their careers. We also offer the same service to alumni

#### **40** *Experiential Teaching for Public Health Practice Peter House*

seeking to make career changes. We invite alumni to participate in our admissions process. And we let alumni know when we have openings for teaching in the program. We currently have five alumni teaching in the program. The fact that we maintain such close relationships with former students is one of many indicators that they value COPHP's customized approach to prepare them for careers in public health practice.

#### **CONFLICT OF INTEREST**

The author confirms that author has no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

# **Building a Culture**

#### **A. Gita Krishnaswamy\*** and **Amy Hagopian**

*University of Washington, Seattle, USA*

**Abstract:** Faculty of the Community-Oriented Public Health Practice program (COPHP) continually refine our curriculum to support an anti-racist, inclusive program culture. COPHP faculty draws the most from successful contributions to their own learning, including trial and error, expert and personalized coaching, clear social and cultural expectations, and constructive feedback. COPHP "community of learners" begins to take shape at the first contact prospective students make with the program, as faculty and a graduate student coordinator assess applicants' potential to succeed in COPHP and in using the problem-based learning (PBL) method. Program culture continues to evolve through a busy orientation week designed to prepare new students for the unique demands of PBL and introduce library research methods and the roles of public health workers. Perhaps the most important orientation week activity is "Case 0", a practice PBL case through which students learn about the radical history of public health, adult learning theory, and institutional racism. In analyzing the case, students are exposed to a classroom culture that support formative, reiterative learning as well as self-reflection and equitable team roles and processes. The combination of COPHP's dynamic learning culture, social justice orientation, and student leadership strives to support student activism and community service. In the recent years, COPHP students have helped form two important student-led organizations that address racism, oppression, and reproductive rights. Graduates tend to maintain strong relationships with the program, faculty, and local organizations, further extending COPHP's vital community.

**Keywords:** Admissions, Anti-racism, Collaboration, Culture, Graduation, Group skills, Multi-cultural, Norms, Orientation, Personal growth, Service, Studentdriven.

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author A. Gita Krishnaswamy:** University of Washington School of Public Health Seattle, WA, USA; Tel: (415) 309-5202; Fax: (206) 543-3964; E-mail: krishna2@uw.edu

#### **INTRODUCTION**

COPHP's problem-based learning (PBL) environment supports intellectual growth by providing opportunities for both individual and team-based learning in an intense environment. The group dynamics and cohesiveness of PBL influence both students' learning experience and the outputs of their learning processes. We work to create a strong internal community with shared values and practices—a dynamic, critical learning culture that models and prepares students to participate effectively in public health practice.

The PBL method is particularly significant for cases that involve students in community-based projects with requested deliverables. Our explicit commitment to developing an anti-racist program culture shapes our individual facilitation practices and other program structures. We are striving to evaluate where we sit on a continuum from a mono-cultural, exclusive culture to a multicultural and fully inclusive one. We believe this effort is essential to our roles in educating the future public health workforce. The commitment to social justice drives our emphasis on health inequity and the social determinants of health. We continually refine our curriculum to give students tools of humility, critical analysis, and compassion to ensure that public health is, in fact, the science of social justice Richard Horton in The Lancet, from 2011.

#### **CONTENT IN CONTEXT**

During the 2015–16 academic year, several new faculty members joined the COPHP program due to an expansion in class size and some retirements. This unprecedented expansion necessitated the first, formalized orientation to welcome new faculty to the program's core values, collaborative community, and unique learning culture. Orientation participants consisted of faculty new to COPHP, experienced COPHP faculty, and current students.

At the start of the orientation, participants were asked to think about something they had learned to do well and then to write down what helped them learn it well. Some recalled when they learned to bake or swim for the first time; others described the process of learning how to mediate conflict or communicate complex mathematical concepts to a general audience.

#### *Building a Culture Experiential Teaching for Public Health Practice* **43**

When asked to share the factors that helped them learn, participants eagerly created a long list as a group. The list below shows some factors shared by multiple participants:


When prompted to think about what *didn't* make the list—in other words, what factors are less conducive or prohibitive to learning—participants were quick to note that textbooks, worksheets, lectures, force, high-stakes assessments, and lack of relevance or purpose did not facilitate their most significant or memorable learning experiences. In addition, the student participants emphasized the ways that racial micro-aggressions, lack of student-endorsed group norms, imbalanced student-student and student-teacher relationships, and a normative academic culture catering to dominant groups disrupt learning for individually affected students and reduce group collegiality.

This opening activity reveals what we instinctively and empirically know about relevance and "learning by doing" and also affirms that *content* cannot be separated from the *environment* in which it is learned. At its most successful, PBL not only exposes students to public health competencies through real world, relevant learning experiences but also necessitates a classroom environment that reflects many of the factors our orientation participants listed.

Apart from the classroom environment, COPHP's overall program culture includes defining characteristics and expectations of its community, including:

● Opportunities for personal growth and accountability to our commitment to

#### **44** *Experiential Teaching for Public Health Practice Krishnaswamy and Hagopian*

developing an anti-racist culture, both internally and in our relationships with community partners.


#### **CREATING A COMMUNITY OF LEARNERS**

While each cohort of students develops its own unique culture, we expect all members of COPHP community—faculty, students, and staff—to uphold certain core expectations and practices. We start developing these characteristics in students before they ever arrive on campus.

#### **The Admissions Process**

We begin the work of assembling the right group of students each year during our pre-admissions process. We request that applicants speak to our program coordinator and at least one faculty member before submitting their applications. These are not formal interviews; instead, we use them as a two-way vetting process to determine mutual fit. During these conversations, we assess applicants' potential to succeed in the PBL environment, their alignment with the program's anti-racist commitment, and their existing knowledge of the program's pedagogy and culture. We also encourage applicants to visit the university to observe a PBL class in action. Through these activities, we maximize the chance that applicants "know what they are getting into", and that we have explicitly communicated our values to those wishing to join our community.

The program coordinator—usually a graduate student assistant position for a second year COPHP student—is invaluable to this process. This individual works very closely with all applicants who make contact with us and helps them navigate our admissions process. We greatly value the program coordinator's assessment of each applicant, which provides a qualified perspective as a studentstaff member who has worked closely with most applicants. In recent years,

faculty have invited student representatives from CORE (see below and Chapter 10.9) to assist during the admissions process.

We apply no initial filters to students' applications, but we tend not to favor "blind" applications from students who have never attempted to contact a representative of our program. Multiple faculty, student, and alumni representatives review a subset of applications, giving particular weight to criteria that assess applicants' leadership potential, social justice orientation, understanding of PBL, and likelihood to remain in public health practice and/or work with underserved populations (rather than pursuing an MPH as a "stepping stone" to another degree or career). As the admissions committee makes accep-tance decisions on individual applicants, we also review the composition of the cohort we are assembling for racial and socioeconomic diversity, a wide breadth of academic and work experience, and life experiences that will contribute to the public health field and the shared learning process in PBL.

Once accepted, students receive personal phone calls from faculty, foreshadowing the accessibility and involvement of COPHP faculty throughout the life of the program. In the spring accepted students are invited to attend a Visiting Students' day where they interact with COPHP faculty and students, visit a PBL session, receive an orientation to the School of Public Health and the Department of Health Services, and have an opportunity to ask questions. During the summer the program coordinator fields questions from interested and accepted students.

#### **Arriving at the UW**

While our new graduate students typically spend the summer wrapping up work or enjoying some travel before embarking on a new adventure, we spend the summer preparing for a weeklong orientation that immerses new arrivals in the life of a COPHP student. Over the course of orientation week, students begin forming relationships with each other and with second year students and faculty during information sessions, social events, and a preview PBL session. We make every effort to provide a personal welcome to new students when they arrive in Seattle and encourage advisors to meet one on one with advisees before the school year starts. Faculty, as well as second-year students, host a "Tips and Tricks"

#### **46** *Experiential Teaching for Public Health Practice Krishnaswamy and Hagopian*

session; the student-led sessions show trust in our second-years as mentors. Second year students and/or alumni facilitate a library and research orientation session on conducting academic research and using citation software; again, entrusting experienced students to facilitate this session signals our trust and respect for students' mentorship abilities. Finally, we arrange a program potluck and happy hour get-togethers (See Appendix E for an example of an orientation week schedule).

#### **Case 0: Heading Upstream, Together**

Perhaps the most important activity that students experience during orientation week is what we have dubbed Case 0, a practice PBL experience that immediately immerses students in the process of analyzing problems and developing learning objectives as a team. Working with a practice case—students are not evaluated on the work they produce nor held to specific expectations—reinforces a classroom culture that supports formative, reiterative learning. Students' initial work on Case 0 may be below the level we eventually expect from them, but we favor growth over a one-time display of mastery. When analyzing Case 0, students also experience self-directed learning by making decisions (within reason) about their desired length for their first research paper, due dates and times, and expectations around depth and scope. New COPHP students tend to display some hesitance or try to seek approval from the faculty facilitator during this process. By challenging students from day one to take control of some aspects their learning, we signal that we value and rely on student input in each day of class.

Over time, Case 0 has transitioned to focus on three main topics: the radical history of public health and its current role in protecting the public's health; adult learning theory and group dynamics; and institutional racism and other subtle forms of racism. Case 0 asks students to consider their role as future public health practitioners and demands that students consider the role of institutional racism and other forms of oppression in influencing health outcomes. In analyzing the case, students must acknowledge that to be successful in community-based work as individuals and teams, they must engage in consistent self-reflection and establish equitable team roles and processes. Subsequent cases during the first quarter revisit the themes established in Case 0, and in "exit interviews" during

the quarter, students have often commented on the importance of Case 0 in setting the tone for the quarter and the entire program.

#### **Classroom Culture**

Most students come to COPHP comfortable in traditional classroom hierarchies with faculty at the top. In PBL, students fill specific roles during each class and have to negotiate and select roles during longer group projects. Indeed, the student-directed PBL process necessitates a learning environment with specific norms and practices; ideally, faculty facilitate opportunities to build those practices intentionally, and the locus of control over the classroom culture shifts largely from faculty to students. While COPHP faculty still carry responsibility for guiding students toward course learning objectives and public health competencies, students themselves develop much of their culture in the classroom. Within the first month of the program, faculty shift the responsibility for class facilitation to students, immediately instigating their leadership development. For each class, a different student facilitator creates an agenda, develops a facilitation plan that helps students synthesize their learning, and fosters group participation.

During PBL cases and longer projects, students must put themselves in stakeholder roles (sometimes multiple stakeholders), which also supports a culture of student-driven, active learning. Students develop learning objectives for each case as a group, divide project tasks, decide on deadlines and project milestones, establish group norms, and hold each other accountable to specific group norms as well as the universal expectation that students work toward an anti-racist, inclusive culture. To do this with efficient, sustainable methods requires students to identify the best ways for their team to work together. Throughout each course, faculty facilitators pose metacognitive questions to help students self-assess their growth and areas for development as individuals and as a team.

Because students are not passive receivers of information in PBL, we evaluate them on their understanding of course concepts as well as the ways they contribute to the learning culture in the room. Many faculty ask students to submit academic and personal goals at the beginning of each class, and we provide feedback on their assignments such as whether we observe them moving the PBL

#### **48** *Experiential Teaching for Public Health Practice Krishnaswamy and Hagopian*

process forward, whether they support classmates intellectually and emotionally, and whether they adhere to the norms established by the group.

And—staying faithful to a culture that values student feedback—we provide regular informal and formal opportunities for students to provide feedback about facilitation, curriculum, and other pertinent issues as they arise. During a course, students may provide feedback in group discussions, mid-course feedback surveys, one-on-one meetings, and anonymous end-of-course evaluations that contain targeted questions on faculty facilitation of an anti-racist learning environment.

#### **Student Leadership and Service**

The combination of COPHP's social justice orientation and multiple avenues for student leadership has led to student activism and community service through the university and city of Seattle. Former UW Department of Health Services Chair Larry Kessler described COPHP students as "the ones you can always count on to 'show up'". COPHP students are often the first to volunteer for departmental or school-wide committees, and they show a high level of attendance at voluntary lectures and school events. Service learning through the formal curriculum as well as a strong spirit of volunteerism are integral components of our program culture.

Engaging in the PBL process gives students a unique level of ownership and commitment to their work. Many community-based projects that students complete, particularly in our community development courses, have required students to maintain some involvement with community partners well after the course has ended. For example, at the request of the partner agency, students have presented their work to local boards of health, presented evidence-based testimony to the Seattle City Council, prepared press kits, and facilitated meetings between local community-based organizations and their city councils. These activities have often required students to travel to rural counties and take on additional work while already engaged in new courses.

This level of additional commitment is most apparent during and after the health policy block in the second year. Each year, students write an American Public Health Association (APHA) policy resolution as a group assignment on a topic

#### *Building a Culture Experiential Teaching for Public Health Practice* **49**

ranging from migrant farmworker housing to removing mental health barriers for returning veterans. Students who wish to carry the resolution forward to the annual APHA meeting must continue to revise and polish the resolution for several months after the health policy course has ended. And they must attend and defend the resolution at the annual meeting itself. The APHA governing council has passed all of the student-written policy resolutions.

COPHP has also institutionalized some volunteer activities such as Seattle's One Night Count of homeless residents. The Seattle/King County Coalition on Homelessness organizes the one night count each January to establish a point-intime count of the number of people who sleep outside. Each year, several COPHP students and faculty members participate together in this initiative, and at least one student volunteer will typically go on to serve as a team captain the following year. The count takes place during very early morning hours, which does little to dissuade student interest.

In recent years, two important student-led organizations formed under the leadership of COPHP students: the Committee on Racism and Oppression in Education (CORE) and the University of Washington Students of Public Health Engaged in Reproductive Rights (UW SPHERE). As discussed in Chapter 10.9 CORE has been instrumental in initiating our program's commitment to developing an antiracist culture and has facilitated trainings on undoing institutional racism for students, staff, and faculty in the School for Public Health. UW SPHERE members play a leadership role in the university's "Sextravaganza", a weeklong series of educational and social events on healthy sexual practices, gender identity, and other topics to promote a sex-positive campus culture.

#### **BEYOND THE PROGRAM**

Perhaps one of the most significant student-led experiences comes at the very end of students' experience in the program: graduation. Students organize and plan their own COPHP graduation ceremony, which reflects that cohort's particular culture and is in fact that final PBL experience for students. Graduation planning is done by a core committee of students as well as various subcommittees involving nearly every student in the cohort. Faculty participate through monetary

#### **50** *Experiential Teaching for Public Health Practice Krishnaswamy and Hagopian*

sponsorship and informal speeches (and an annual musical comedy performance); the bulk of the event celebrates students' accomplishments and gives family and friends in the audience insight into the great scope of what students achieve through the PBL process and in a program that strongly values student voices and leadership.

Once our students graduate, many maintain strong relationships with the program. Our low student-to-faculty ratio and emphasis on community foster advising relationships that last well beyond the program. Alumni are eager to re-connect with other alums in the program and have organized periodic social gatherings in the Seattle area and at American Public Health Association annual meetings.

We also recruit alumni to participate on our admissions committee and contribute to the formation of each new cohort that joins COPHP community. Typically, we have to turn people away due to large numbers of alumni willing to serve on the admissions committee. COPHP graduates also serve as mentors to current students in a number of ways, including as practicum and capstone supervisors and informal advisers on many of these projects. Finally, several alumni have returned to the program as clinical and regular faculty. We view alumni interest and participation as an extension of the strong community students experience while in the program.

#### **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

# **The Handbooks**

**Brett Niessen\*** and **Kelly Gilmore**

*University of Washington School of Public Health Seattle, WA, USA*

**Abstract:** COPHP uses a series of handbooks to orient students and faculty to the program and to share the program policies and practices. The student handbook for the Community-Oriented Public Health Practice (COPHP) program describes a shared vision of expectations for students, faculty, and alumni. COPHP faculty members drafted the initial version of the handbook, which described the problem-based learning (PBL) process, expectations for student work, and information on capstone and practicum projects. Student coordinators have since developed three handbooks: a general guide for students, a resource about capstones, and an introduction for new faculty. This chapter summarizes the history, development, and purpose of the student handbook and a brief description of the faculty handbook and the capstone handbook. It also describes specific components that are included to facilitate PBL and communitybuilding within the program; because students depend on each other for their learning in PBL, it is important to outline expectations for participation within COPHP community. The student handbook is available online to give prospective students the opportunity to learn what it means to be a part of COPHP community and decide whether the program is right for them. We encourage anyone creating a program similar to COPHP to engage students, faculty, and alumni in the process of creating such a document, which functions as a statement of shared values.

**Keywords:** Alumni, Community, Components, Coordinators, COPHP, CORE, Culture, Expectations, Faculty, Handbook, Online, Participation, PBL, PCE, Program, Prospective students, Recruitment, Successful, Values, Website.

#### **BACKGROUND**

Since the first COPHP cohort enrolled in 2002, it was clear that the program

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author Brett Niessen:** University of Washington School of Public Health Seattle, WA, USA; Email: brettniessen@cardiaservices.org

#### **52** *Experiential Teaching for Public Health Practice Niessen and Gilmore*

needed a document to codify expectations for student work and participation. COPHP is built on the idea of community engagement within and outside of the program. The PBL process requires a high level of interpersonal skills, and—in common with real-life work environments—it can produce conflict and difficulty. The student handbook serves first and foremost as a guide to help students navigate the unique aspects of this program including:


The initial handbook was long and distributed mainly in paper or over email; it covered everything from the PBL process to where students could register for classes and pick up their student ID cards. Over the years, the handbook has evolved into three separate handbooks, each with specific guidance on particular components of the COPHP program. These documents are:


expectations for student mentorship and academic advising relationships.

● **Capstone handbook:**. COPHP capstone project is a major, year-long (and in some cases longer) undertaking by second-year students. In contrast to a thesis project, required by most schools of public health, COPHP capstone project requires students to work with a community, governmental, or academic agency to respond to a community need with a useful product. The capstone project requires careful planning as well as constant stakeholder engagement. For this reason, we removed capstone information from the general student handbook and created a separate capstone manual for COPHP students.

## **CREATING AND UPDATING THE HANDBOOK**

It would be ideal for a new program to draft initial student and faculty handbooks using the PBL process with the first cohort and founding faculty. Use this opportunity to create a shared vision of student culture, participation, and expectations. Incorporating students and alumni into drafting and revising future versions of the handbook creates a living document that is responsive to the needs of students in the program.

In COPHP, yearly revisions to the handbook are supervised by the student program coordinator, a second-year student in a dedicated part-time graduate student appointee (GSA) position. This position, created during the 2005–06 academic year, provides the dual benefit of administrative support and a scholarship opportunity for the student.

As the main point of contact for current students, the student program coordinator is in a good position to lead the process of updating the student and capstone handbooks each year based on student and faculty feedback. In the spirit of community engagement, we recommend involving students, staff, faculty, and alumni in the updating process. Particular sections, such as guidance on faculty mentorship roles and expectations, should be revisited each year by faculty and students to determine if roles and expectations should be re-defined.

#### **STUDENT HANDBOOK COMPONENTS**

Each version of the student handbook includes the following sections:


#### **LOGISTICAL AND PRACTICAL INFORMATION**

Since the first version of the student handbook, we have removed most of the logistical information about the University of Washington, the Graduate School, and the School of Public Health. We still include the following information that is important and relevant for incoming students:


# **COPHP STRUCTURE**

The student handbook explains the roles of staff and faculty in the program. This information helps explain how COPHP is different from other graduate MPH programs.

#### **Program Director and Staff Roles**

Under the guidance of the Health Services Department chair and administrator, the program director has always been a faculty member as well. The director teaches PBL classes in addition to overseeing the budget, directing the admissions process, orienting and recruiting faculty, engaging with alumni, mentoring students, ensuring program consistency, scheduling and overseeing social events such as potluck dinners, new student orientation, and graduation. University staff

#### **56** *Experiential Teaching for Public Health Practice Niessen and Gilmore*

help manage the program and assist with student services, technology issues, and marketing. The student program coordinator, a graduate student assistant, markets to and recruits new students with a focus on seeking out underrepresented populations.

## **Student-to-Faculty Ratio**

COPHP consists of six quarters across two years with one to two blocks per quarter. A faculty member facilitates each block class, which seven to nine students attend. All faculty, both tenured professors and adjunct faculty, are easily reached *via* contact information listed in the student handbook and on the program website.

COPHP's small student-to-faculty ratio is critical so that every student can receive the personalized attention needed to take an active role in class participation and projects. Faculty members work together to plan and conduct PBL cases for each block. For example, in the community development block, three faculty work together to partner with community-based organizations for our homeless youth case and public health departments for our rural public health cases. They write the cases, meet with the external partners, and determine what student projects would be most helpful for the organizations. Once the class gets started, faculty allow students to facilitate and initiate contact with the community organizations and health departments, then complete field work in preparation for a final group report and presentation. Throughout this process, faculty check in on facilitation plans with students and meet one-on-one or *via* email or phone to provide extensive feedback on writing and class participation. In evaluations, students frequently cite these close interactions with faculty, together with taking charge of their own learning, as key reasons they quickly improve as learners and public health professionals.

# **COPHP's Fee-based Structure**

The low student to faculty ratio is expensive to maintain, and for this reason, COPHP became a fee-based program following the UW's loss of state-supported graduate education funds. The student handbook explains how the recession and subsequent state budget cuts prompted this change and makes clear that the

#### *The Handbooks Experiential Teaching for Public Health Practice* **57**

program is funded solely by student tuition. It also explains several nuanced outcomes of the fee-based arrangement in terms of graduate teaching and research assistantships, availability of electives from non-fee-based departments, financial aid, and increased costs. The handbook also explains options offered by the School of Public Health, such as graduate certificates in Public Health, Global Health, and Maternal & Child Health, including tuition information. As the handbook states, we encourage students to investigate how high costs limit access to education and health:

COPHP students and staff have been leaders in the fight against higher education cuts and in bringing the inequities faced by fee-based students to the school administration. We urge you as incoming students to continue to keep this issue visible in our academic community. One of our core values at COPHP is eliminating health and economic inequities—and access to higher education is a critical social determinant of both.

#### **BUILDING COMMUNITY THROUGH SHARED VALUES AND NORMS**

The student handbook lays out the mission, goals, and objectives of COPHP:

The mission of the Health Services COPHP is to prepare students to be problem solvers, advocates, and leaders in community health. Combining an active style of learning, rigorous academic preparation, and a commitment to social justice and community engagement, this two-year, full-time program equips graduates with the knowledge and skills to effectively address public health challenges.

A major benefit of creating the student handbook was getting all founding faculty members together in a room to brainstorm and create a shared set of values and norms for the program. The process addressed such questions as:


#### **58** *Experiential Teaching for Public Health Practice Niessen and Gilmore*

from faculty to students, help answer questions and pass on wisdom?

● How can admissions and hiring serve to create an inclusive and diverse student and faculty body?

As the program director, student program assistant, faculty, and other program staff meet to update the student handbook each year, they reflect on lessons learned and other updates. They lay out expectations for faculty mentors and advisers and suggest what information students should offer and seek out from their advisers. The same is true for faculty capstone advisers, who may not be the same as the first-year faculty adviser. The handbook also reinforces academic norms of the program. It presents expectations for students when they read, interpret, and divide up responsibilities from a case. For most PBL classes, students are evaluated on:


Faculty are expected to provide extensive written and/or verbal feedback on individual writing assignments, group presentations and reports, and group participation and general guidance on what students are doing well and how they can improve. This form of qualitative feedback is a key element of COPHP, as opposed to wholly quantitative exams—epidemiology and biostatistics blocks notwithstanding.

# **HANDBOOK CHALLENGES AND SUGGESTIONS FOR IMPROVE-MENT**

One problem with the student handbook is that many students say they don't read it—undoubtedly because it has been very long. By making most information linkbased and available on COPHP website, we have reduced the length of the handbook from more than 100 pages to 34 currently. Students can now read the highlights and click on hyperlinks when they require more in-depth information about a topic. There are also plans to make the student handbook more accessible

#### *The Handbooks Experiential Teaching for Public Health Practice* **59**

and reinforce its importance several times during a student's experience: as applicants, accepted students, new students at orientation, during initial block classes and seminars, and as contributors to annual revisions. With each year, the student handbook will continue to evolve as a reference document so that students can better understand how to succeed and thrive in COPHP. We recommend it as a key element of COPHP's success.

The principal challenge with the **faculty handbook** is keeping it up-to-date. With an evolving set of PBL cases, new policies and practices discussed at monthly faculty meetings and in an annual faculty retreat, feedback from the faculty peer review process and the student feedback process, there is a wealth of material for faculty to cover and to reference. Periodic updates of the faculty handbook (at least every 2–3 years) are necessary for an informed faculty.

#### **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

### **ACKNOWLEDGMENTS**

Declared none.

# **The Capstone**

#### **Amy Hagopian\***

*University of Washington School of Public Health Seattle, WA, USA*

**Abstract:** All MPH programs accredited by the Council on Education for Public Health are required to provide a culminating experience in which students demonstrate their skills and integrate knowledge. In the MPH in Community-Oriented Public Health Practice (COPHP), this experience is the capstone. The idea is to apply theoretical knowledge learned in the classroom to a situation that mimics the demands of professional practice. Faculty coach students through this project, and they assess at its conclusion how well students have mastered the identified body of knowledge and whether they have acquired the competencies required to be public health professionals. For their capstone projects, students establish relationships with clients—typically government public health agencies or community-based organizations—who have real work to do and can support such a learning experience for COPHP students. We have developed an approach to the capstone that allows students a wide range of choices of types of projects while providing a highly structured and motivating environment in which to complete the work. To help our students produce strong culminating projects, we have developed strong expectations and norms. We also apply our own tracking and organizing tools and adhere to our clearly defined philosophy and culture.

**Keywords:** Accreditation, Capstone, Client, Culminating project, Literature review, Research, Thesis.

#### **INTRODUCTION**

The Council on Education for Public Health (CEPH) requires MPH programs to provide a culminating experience that requires each student "to synthesize and

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author Amy Hagopian:** University of Washington School of Public Health Seattle, WA, USA; Email: hagopian@uw.edu

#### *The Capstone Experiential Teaching for Public Health Practice* **61**

integrate knowledge acquired in coursework and other learning experiences and to apply theory and principles in a situation that approximates some aspect of professional practice. It must be used as a means by which faculty judges whether the student has mastered the body of knowledge and can demonstrate proficiency in the required competencies".

In COPHP, our culminating experience is called a capstone, and it requires each student to establish a relationship with a client organization that wants work done and is prepared to provide a synthesizing learning experience for the student. These organizations are typically government public health agencies or community-based organizations. We have developed an approach to the capstone that allows students a wide range of choices of types of projects while also providing a highly structured and motivating environment in which to complete the work.

COPHP faculty coach students both individually and collectively through the process of evaluating and selecting their projects. We rather deliberately herd students through the capstone experience by employing several cohort-wide milestone deadlines and tracking tools, and we encourage students to notice each other's progress and struggles along the way. The reward for all this collective attention to the capstone is that almost all students complete a satisfactory project on time.

As our cohorts have grown over the years, we have developed the role of "capstone director". This person establishes mechanisms to track students as they move through the milestones, identifies any individual difficulties, and manages presentations at both mid-point (January) and graduation (June).

# **CAPSTONE** *VERSUS* **THESIS**

COPHP founding faculty felt strongly that a culminating project for a practiceoriented degree should be, well, practice-oriented. In a practice-oriented program such as ours, it would be inappropriate for students to think up independent research projects to be performed in the privacy of the library or a laboratory. This is why each COPHP student pursues a capstone and not a traditional thesis. A capstone, the way we define it, is conducted with an organization that is eager to

#### **62** *Experiential Teaching for Public Health Practice Amy Hagopian*

employ the results to improve its operations. Students are expected to define the bounds of the project in negotiations with client organizations, and in each of these arrangements, the student and the client both sign an agreement that spells out deliverables. COPHP faculty are encouraged to coach students in how to interact effectively with the client organization, improve time management and writing skills, and think through large projects with many moving parts.

Another differentiation between a thesis and COPHP capstone is that the supervisory committee for the capstone consists of a single faculty member and the site-based mentor (representative of the client organization). In a traditional MPH thesis, the committee consists of two faculty members.

Despite COPHP approach of collectivizing the experience so that students are shepherded through the capstone in a supportive way, we still have many anxieties to manage. Much can go wrong, with significant implications for the student: the client organization might have fiscal trouble and stop the project; the executive director or another principal could feel threatened by the project (such as when an evaluation reveals cracks in the organization); the mentor assigned to the student could leave the organization or lose interest in the project; human subject approval may be held up long enough to significantly delay data collection; recruiting difficulties for subjects could crop up; and so on. We try to help students understand that these are routine problems in organization-based projects and that they are part of the learning process. This is accomplished by following the timeline outlined below.

### **THE TIMELINE**

On or about December 1 of their first year of COPHP, we introduce the capstone to students in a formal way. In their seminar class, we assemble a panel of alumni who have completed a variety of capstone projects to talk about their experiences. In our most recent session, we showcased an international project, a project in a public health department, a public school-based project, a project with a nonprofit organization, and even a project that proved to be somewhat challenging to the student because the client organization was disappointingly disengaged. (Clearly, the best projects are those whose sponsoring organization assigns an

#### *The Capstone Experiential Teaching for Public Health Practice* **63**

accomplished professional as a strong mentor; regrettably, this doesn't occur in every case).

To help students think about project selection, we provide a tool with an empty grid with skills along the vertical dimension and topics across the horizontal dimension. Students are encouraged to think about the skills they'd like to develop (such as data analysis, evaluations, working in a large organization) and the topics that attract them (racial equity, sex education, labor union organizing, *etc.*). The process of finding a client organization during the first year is not a linear one—it requires some fumbling around, some bravery (to seek informational interviews), and some luck.

We pull together first-year students during their winter quarter in a session or two to hear what they're thinking about their capstone preferences (skills, topics, geography, organizations they'd like to explore, *etc.*), and fellow students and faculty offer suggestions.

For each cohort, the capstone director posts a Google spreadsheet where students can fill in information about their capstones—the faculty adviser (not necessarily the same as the first year adviser), client organization, site supervisor, working title, and deliverables—as things develop. Faculty can check the spreadsheet, and students notice each other's progress (another motivator). We also use a Dropbox website to deposit deliverables along the way.

Capstone proposals are due on Labor Day for students who have completed their first year of classes. Our quarter system starts in late September, so many students and faculty members spend their summer "vacations" completing and reviewing these proposals. Other students propose projects that require significant work in the summer months (travel to Bangladesh, say). These students must submit their capstone proposals much earlier—certainly no one would be allowed to travel abroad on a capstone project without a completed agreement. Some students also require approval from the University of Washington human subjects research office. No projects involving human subjects research can start without this approval. Once the proposal is completed, students have a month to fine-tune their negotiations with the capstone client and submit a signed agreement by October 1.

#### **64** *Experiential Teaching for Public Health Practice Amy Hagopian*

The next collective milestone is the completion of a formal literature review. Before we instituted this requirement of all students, we found many were skipping the completion of a formal, rigorous, and academically sound literature review. We wanted to signal that while this is a practice-based degree and project, it must still be grounded in academic research. The literature is rich with both pertinent theory and descriptions of practice-based case studies. We found students sometimes didn't notice this resource until they were nearing the end of their projects and realized, "Oh yeah, I'm supposed to include a literature review in my report, I'd better do one of those now". The completion of an analysis of the literature should *inform* the design and conduct of the project, not just pose another hoop to leap through.

In January, we schedule a series of lunchtime "Works in Progress" (WIP) hours during which students present their capstone progress to their fellow students and faculty. Students use the WIPs to pose questions, seek advice, and practice talking out loud about their projects. These presentations pose an opportunity to focus attention and provide motivation for those who might have lost momentum on their capstone efforts.

First drafts of project reports are due on April 1, with final papers due in mid-May. We schedule a full day of capstone presentations in June, the day before graduation. We had experimented with other schedules but settled on presentations the day prior to graduation because we found we could include families who would travel to Seattle for the ceremony. Having parents and aunts and brothers and boyfriends and wives and sisters and cousins in the audience lends a certain gravitas to the occasion.

We also strongly encourage the capstone clients to come to hear these presentations; they always enjoy the presentations of students in addition to the ones who have been working directly with them. This event serves the additional purpose of building support for the program among our client organizations. (Students are expected to present their projects to the client organization in their own home setting, as well).

These presentation days are organized along the lines of a professional association

conference. We cluster the projects in groups of about five around a similar theme ("work in schools," or "health promotion campaigns") and give students about 11 minutes to present, with 3 minutes for questions.

We also encourage them to submit abstracts of their work to the American Public Health Association and its Washington State affiliate, along with other professional organizations, for conference presentations. Some faculty are enthusiastic about encouraging publication of final projects in academic journals, and several of our students have published their work— despite it being of a "practice" nature.<sup>1</sup>

# **THE CAPSTONE HANDBOOK**

We have a fairly detailed capstone handbook with all expectations clearly spelled out, along with deadlines, forms, and nuggets of advice. The handbook has been with us since nearly the beginning of the program, and we revise it fairly frequently. For example, the expansion of Internet-based tools has changed how we do things.

The appendix to the capstone handbook includes several evaluation forms:


We maintain an open list of all our students' capstone titles, by year and author, on our website. (We've also organized the list by organization, so that future students can see where students have worked before them, which can ignite their imaginations and prompt networking).

# **ASPECTS OF SUCCESSFUL CAPSTONES**

COPHP faculty used a brainstorming process to generate a list of aspects of a successful capstone project. Following is what we learned about the elements of a

#### **66** *Experiential Teaching for Public Health Practice Amy Hagopian*

successful culminating experience in COPHP:


project.


COPHP approach to the capstone allows students a wide range of choices of types of projects while providing a highly structured and motivating environment in which to complete the work. The strong expectations, norms, and tracking and organizing tools add to the program's clearly defined philosophy and culture.

# **NOTES**

1 Academic publications include Hagedorn J, Campe J, Gilmore K, Stahl N, Sousa C. News items associated with capstone projects have also been published.

# **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

**68** *Experiential Teaching for Public Health Practice Amy Hagopian*

#### **ACKNOWLEDGMENTS**

Declared none.

# **The Practicum**

#### **Karen Hartfield\***

*University of Washington School of Public Health Seattle, WA, USA*

**Abstract:** The MPH in Community-Oriented Public Health Practice (COPHP) supports a robust practicum program through a formal partnership with its local health department, Public Health—Seattle & King County, that provides students an opportunity to integrate academic training and practice within a metropolitan health department setting. This arrangement began in 2003, when the University of Washington School of Public Health and Community Medicine and the Public Health agency received a one-year Associated Schools of Public Health "academic health department" grant. Since then, the health department has served as a teaching institution for COPHP students and a venue to train students on-site in real-world public health practice. COPHP student and faculty linkages provide a vehicle to enhance the public health workforce through resource sharing and technical assistance, and have expanded public health department staff opportunities to conduct community-based public health research and projects with UW faculty. Nearly all first year COPHP students are placed in practicum assignments at Public Health that complement their coursework. COPHP pays for a part-time practicum coordinator who is a Public Health employee and a COPHP graduate. The coordinator solicits practicum opportunities from Public Health staff, reviews projects for feasibility and appropriateness of skills, oversees students' self-assessments, and works with site supervisors to initiate the practicums. Students work closely with faculty advisers throughout the process. Practicum projects include community assessment, health education, program planning and evaluation, policy development, and community mobilization. The service learning experience has been beneficial to Public Health, COPHP students, and the greater King County community.

**Keywords:** Academic health department, Employment, Experience, Faculty adviser, Learning contract, Networking, Partnership, Practicum, Project, Selfassessment, Site supervisor.

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author Karen Hartfield:** University of Washington School of Public Health Seattle, WA, USA; Email: Karen.hartfield@kingcounty.gov

#### **INTRODUCTION**

A practicum is an essential element of any MPH curriculum and especially of COPHP. Council on Education for Public Health guidelines stipulate that accredited institutions include a practice experience requirement for all students prior to graduation. While classroom education is essential to developing robust skills in core public health areas such as epidemiology and policy development, the practicum experience provides an opportunity to apply classroom learning in real-world settings. When students ask, "Why do I need to study biostatistics if I'm planning to be a health educator?" they usually need not look further than their first-year practicum experience.

In COPHP, problem-based learning is a powerful teaching method designed to prepare students for the work environments they will encounter in governmental and community-based agencies. Given that focus, we wanted to provide a robust practicum program that guaranteed students a comprehensive and well-mentored public health practice experience.

#### **PRACTICUM PARTNERSHIP**

Our practicum program is driven by a formal partnership between COPHP and Public Health— Seattle & King County (Public Health), a large metropolitan health department providing the full range of local public health services. Public Health provides prevention-oriented programming and primary care services. The agency partners with community-based organizations to directly provide, as well as advise on, public health initiatives and services. These community connections provide additional networking opportunities for practicum students. Public Health has a strong investment in public health research and a long history of academicpractice collaborations, including a formal "academic health department" program. In 2003, motivated by the Institute of Medicine *Future of Public Health* report urging more academic-practice linkages, Public Health and the University of Washington jointly applied for and received a one-year Academic Health Department grant from the Association of Schools of Public Health (ASPH – now known as the Association of Schools and Programs of Public Health, ASPPH).

#### *The Practicum Experiential Teaching for Public Health Practice* **71**

Public Health envisioned its health department serving as a teaching institution for public health students, in the same way that the county hospital serves as a teaching hospital for the university's medical school. The partnership would also allow the health department to train students on-site in real world public health practice, enhance the public health workforce through resource sharing and technical assistance, and conduct community-based public health research with UW faculty. The UW shared many of the same partnership goals, and beginning with the ASPH grant, COPHP made a major investment in student training.

Through a unique arrangement with Public Health, nearly all first year COPHP students are placed in practicum assignments at Public Health that complement their coursework; less than 5% of practicum placements are in other communitybased organizations. COPHP pays for a part-time practicum coordinator who is a Public Health prevention specialist and a COPHP graduate. Practicum projects include community assessment, health education, program planning and evaluation, policy development, and community mobilization. All students are mentored by master's level staff. The result is a service learning experience that is mutually beneficial to Public Health, COPHP, and the King County community. COPHP students have built a strong reputation with public health staff over the years. They are seen as having a strong work ethic, commitment to social justice, comfort with assignments that entail some ambiguity, and aptitude for working in teams. With these qualities in high demand, there are always more practicum projects available than students.

The practicum program benefits both partners. On the university side, our students are taught to apply what they've learned in the classroom. On Public Health's side, students import new ideas and skills to Public Health. And the program also provides Public Health staff with opportunities to enhance their skills in coaching, mentoring, and supervision. In many instances, the practicum has turned into a capstone, part-time employment, or fulltime employment post-graduation, as Public Health frequently hires COPHP graduates to continue infusing their programs with new ideas and the latest skills in community-based public health.

# **HOW IT WORKS**

Organizing the practicum experience begins before our students arrive on campus and continues through the fall quarter. The following steps are involved:


coordinator may assign students to projects they did not select, but this is always done in consultation with the student.


#### **74** *Experiential Teaching for Public Health Practice Karen Hartfield*

course corrections are warranted. Site supervisors meet with students weekly to assess progress on meeting deliverables and adjust the service learning agreement as needed.


#### **PROGRAM SUCCESS**

Since 2005, Public Health has mentored more than 200 COPHP students. The students have worked in nearly all Public Health programs, including the Office of the Director, Communicable Disease Epidemiology, Immunizations, HIV/ AIDS, Environmental Health, Emergency Medical Services, Communications, and Chronic Disease and Injury Prevention. Projects have included community needs assessments, qualitative and quantitative surveys, educational materials development, curriculum development, policy analysis, and social media projects.

Over the years, we have amassed a great deal of practical experience and outcome data, and the ingredients for success are clear. The following are critical program elements:

● **Ensure project deliverables are substantive and precise**. Our experience tells us that service learning contracts with clear and measurable deliverables are essential. For example, a deliverable such as "help health educator update a curriculum" is replaced with "revise two sex education lessons for the sixth

#### *The Practicum Experiential Teaching for Public Health Practice* **75**

grade curriculum". We have learned that projects should provide students with exposure to new skills and experiences, and they must be challenging. At the same time, we are explicit with students that not all of their work will be substantive. On occasion, students have complained that they've had to photocopy or do mailings, but they end up understanding that often, public health professionals are tasked with carrying out activities that run the gamut from strategic thinking to making their own copies, all of which are essential to supporting the workplace.


This kind of practicum program is possible only if partners commit to a long-term partnership. It takes time to establish relationships and systems, but after 10 years,

#### **76** *Experiential Teaching for Public Health Practice Karen Hartfield*

our practicum process runs efficiently. One of the strengths of the program is that COPHP pays the Public Health practicum coordinator *via* a contract with the county agency. This allows COPHP to have an on-site coordinator with inside knowledge and connections to the local practice community. While the contract is renewed annually, neither Public Health nor COPHP has wavered in its commitment. Furthermore, COPHP and the University of Washington demonstrate commitment by supporting affiliate faculty appointments for Public Health site supervisors. This support is a tangible marker of the respect the University of Washington has for the health department supervisors, and it provides an important participation incentive for staff. The faculty appointment allows the supervisor unlimited access to University of Washington e-journals as well as to all libraries. It is also a resume builder and is widely viewed as a major benefit.

#### **PROGRAM CHALLENGES**

While our evaluation data and experience clearly demonstrate program effectiveness, we have experienced challenges. As our cohort size expanded, we decided to seek practicum assignments outside of Public Health to assure enough project choice for students. We asked local community-based agencies such as YWCA and Planned Parenthood to develop projects and supervise students. While some of these projects have gone smoothly, the practicum assignments outside of Public Health are more difficult for the practicum coordinator to oversee. In addition, students working outside of Public Health have experienced some isolation from the rest of the students who are working in the same building and could more easily collaborate and commiserate. We continue to accept practicum assignments from outside agencies, but we are judicious about them and careful to be clear about expectations. We want to assure students have similar mentorship experiences regardless of what program they work for.

On occasion, the fit between the student and the project and/or site supervisor has been problematic. To help prevent this, the practicum supervisor now meets individually with all students prior to matching them to their projects. This helps identify potential mismatches and gives the practicum coordinator the opportunity to gain important information about student preferences and needs. Occasionally, unwieldy projects or projects that change over time create challenges; students

#### *The Practicum Experiential Teaching for Public Health Practice* **77**

express disappointment and distress when their practicum doesn't go according to plan. Any number of things can affect a practicum: grants that come through, grants that *don't* come through, parental leaves, illnesses, and staff turnover. Sometimes project scopes of work must be adjusted. These are the same kinds of issues students will encounter when they enter the workforce, but they can present particular problems for students who are working only six hours a week. We have found that requiring students to meet with site supervisors regularly, and urging them to proactively address problems, resolves most concerns. We also ask students to keep a weekly log of their practicum activities as a way to track their own progress and notice issues.

Budget constraints also pose challenges. Real costs are associated with taking on a public health student who will need an office cubicle, a computer, a phone, and related technical support. And there is the cost in time— mentoring students takes time away from supervisors' ability to accomplish their own work. In the current budget environment, the true cost of mentoring students is a factor programs must consider. Occasionally, supervisors who have enjoyed mutually beneficial relationships with COPHP students are no longer able to host students because of costs. Both partners must be honest about the true costs of this kind of program and commit to creative ways to address them. In our program, each partner contributes in-kind support. University of Washington faculty provide consultation to Public Health when possible, and the health department takes on increasing numbers of students each year with little additional funding.

The service learning experience has been beneficial to Public Health, COPHP students, and the greater King County community.

#### **CONFLICT OF INTEREST**

The authors confirm that author has no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

# **Skills Seminars**

#### **Bud Nicola\***

*University of Washington School of Public Health Seattle, WA, USA*

**Abstract:** As we developed the curriculum for the MPH in Community-Oriented Public Health Practice (COPHP), it became clear that there were skills and competencies that might best be taught using traditional lecture or interactive faculty presentation and discussion methods rather than problem-based learning (PBL). We see some of these skills as prerequisites to PBL. We try to align these traditional learning sessions, or seminars, with PBL cases and the faculty who facilitate them. Since students, through their periodic input, helped to design the overall COPHP, we have integrated into our program design opportunities for students to take charge of organizing seminars during the second year.

**Keywords:** Active learning, Competencies, Curriculum, Lecture, Seminar, Skills, Student involvement, Teaching methods.

#### **HISTORY AND BACKGROUND**

We designed COPHP around the principle that active learning increases student performance [1]. Nonetheless we recognized that students would benefit early in the program from short presentations or learning labs to impart certain essential skills. We also realized that seminars were an opportunity to showcase local public health role models who were engaged in exemplary work. One such skill is the facility to conduct rapid research using online library resources, understand how to use library databases, and recognize credible sources of information. Over time, this learning took the format of weekly skills seminars in 90-minute sessions.

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author Bud Nicola:** University of Washington School of Public Health Seattle, WA, USA; Email: bnicola@uw.edu

#### *Skills Seminars Experiential Teaching for Public Health Practice* **79**

During the first six years of COPHP, the program director planned all sessions for the first year of the program and involved faculty in planning seminar content for second-year students. More recently students have taken charge of the secondyear seminars and have worked with faculty from each block to coordinate with block material, to organize sessions, and to invite speakers on various topics. During a recent year, second year students even took it on themselves to sponsor seminar topics in an impromptu additional forum, with first year students as their primary audience.

The COPHP program directors learned what skills were essential early in the program. These skills include library research, group facilitation, and basic knowledge of the University of Washington's Institutional Review Board and the steps required to obtain approval for a master's thesis or project that involves human subjects. We have found that student ownership of the planning and scheduling of second-year topics has increased interest and participation in these sessions. The student involvement also resulted in active participation by block faculty in attending seminars and coordinating them with PBL cases.

### **FIRST-YEAR TOPICS**

Students have helped identify topics that are better learned *via* structured skills seminar or bringing in community experts to discuss their experiences than through the free-form research cycle that is PBL. In particular, seminars address aspects of these topics where a seminar will provide an overall framework, teach a specific skill, or share perspectives from experts and community members. For the first year, topics are selected to address the following overall learning objectives:

	- ❍ Global burden of disease
	- ❍ Institutional racism
	- ❍ Challenges faced by immigrants
	- ❍ Conducting community-based participatory research
	- ❍ Reading journal articles and conducting literature reviews
	- ❍ Conducting stakeholder analysis
	- ❍ Facilitating small groups
	- ❍ Writing well
	- ❍ Conceptualizing and planning for the capstone project

# **Examples of Seminar Sessions in the First Year**

# *Methods #1: Small Group Facilitation*

This session addresses issues such as the indicators and factors contributing to successful meetings, ways to become a better facilitator, how students can best prepare for roles as facilitator or group participant, and ways to provide feedback to group facilitators to improve their skills.

# *Capstone Master's Projects*

In this session, a panel of recent graduates discusses how to choose a capstone project.

# *Working in Communities*

This session supports conversations about the effect of working in communities and the role of students and faculty in cultivating and sustaining community relationships.

# **SECOND-YEAR TOPICS**

The following are the overall learning objectives for second year seminars:

	- ❍ Running for office
	- ❍ Running a policy institute
	- ❍ Professional association involvement
	- ❍ Farmworker housing advocacy: NW Justice Project

#### *Skills Seminars Experiential Teaching for Public Health Practice* **81**

	- ❍ AIDS, malaria, TB, anemia
	- ❍ Cancer
	- ❍ Toxic waste in the environment
	- ❍ Conflict resolution
	- ❍ State agency rule-making
	- ❍ Health impact assessments

# **Examples of Seminar Sessions in the Second Year**

# *Conflict Resolution Skills*

This class explores the basic theory around causes and resolutions of conflict, how interpersonal conflicts differ from policy or political conflicts, examples of policy conflicts students have experienced, and lessons and resources for public health professionals working on contentious issues.

# *Hanford Case Background*

This session explores the history of the Hanford site (a former plutonium production facility in central Washington state), what it means that it was designated a Superfund site, strategies around clean up and how citizens influenced that process, what we should be worrying about in relation to Hanford, and where to go for information.

# *Farmworker Housing*

This session considers the history of the workforce that does farm labor in Washington state and how their working and living conditions affect their health. It examines the success of various policy initiatives to address these conditions, the differing views of the stakeholders regarding these policies, and whether the current policy landscape offers opportunities for progress.

**82** *Experiential Teaching for Public Health Practice Bud Nicola*

#### **CONFLICT OF INTEREST**

The authors confirm that author has no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

#### **REFERENCES**

[1] Freeman S, Eddy S, McDonough M, *et al.* Active learning increases student performance in science, engineering, and mathematics. Proc Natl Acad Sci 2014,. 111(23): 8410-5. [http://dx.doi.org/10.1073/pnas.1319030111]

**CHAPTER 10**

# **COPHP Curricular Content Areas**

The following subchapters represent the main teaching blocks of the COPHP program. Each subchapter will include:


**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

# **CHAPTER 10-1**

# **Population Health**

**Stephen A. Bezruchka\***

*University of Washington, Seattle, WA, United States*

**Abstract:** A population's health status and factors determining it are vital to producing health of the citizens therein. The evidence is overwhelming that people in the United States have worse health outcomes than those in other rich nations. Yet this fact is little appreciated in the United States. U.S. public health practice remains rooted in the 20th century with efforts to change personal behaviors, access health care, and ensure satisfactory sanitation outcomes. Professional public health education remains similarly stuck in the last century's paradigms. The population health block of the MPH in Community-Oriented Public Health Practice attempts to orient students to 21st century public health with a focus on creating appropriate structures in societies to make a population healthy. Such an approach is inherently political, which is a challenge in the United States because we tend to view health through an apolitical lens. This chapter explains the population health approach, which requires students to look at other countries to learn about health production. The goal: for people in the United States to not be dead first but to live longer healthier lives.

**Keywords:** Barker hypothesis, Early life, First thousand days, Health, Inequality, Inequities, Life expectancy, Medical harm, Morbidity, Mortality, Population health, Socioeconomic gradient, U.S. mortality.

#### **LEARNING OBJECTIVES FOR THE POPULATION HEALTH BLOCK**

As in the other blocks of the COPHP program, we build our coursework on learning objectives. By the end of the population health block, students should be able to do the following:

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author Stephen A. Bezruchka:** University of Washington, Seattle, WA, United States USA; E-mail: sabez@uw.edu


#### **CASE EXAMPLES**

When we launched the COPHP program in 2002, we decided to begin with population health. Our first challenge was to situate health status in the United States in the context of other nations. This context is relevant in the current selection of cases we use for the population block, summaries of which are as follows:

#### **Americans: Dead First**

The initial case in the population health block exposes students to the fact that U.S. mortality outcomes are shockingly poor. We die younger than people in the other rich nations. The mechanism we use to make this point is that of a speechwriter for the president who wants to tell the people this bad news. The case brings students to the Institute of Medicine's report on "U.S. Health in International Perspective: Shorter Lives, Poorer Health", a reputable source that is backed up by many others. Students outline the speech and it is then recorded as they present it. The case requires students to come up with conceptualizations of health for a society. People in the United States seem to prioritize living a longer life rather than a shorter one. U.S. health care spending—an estimated \$3 trillion in 2014, or fully a sixth of the U.S. economy—amounts to close to half of the world's total health care expenditures. In this case, we expose students to our high

#### **86** *Experiential Teaching for Public Health Practice Stephen A. Bezruchka*

level of spending as well as the paradox that it does not buy us health (life expectancy). The rest of the block continues to explore these points.

#### **The 49th Parallel: A Health Divide**

The University of Washington is located close to the U.S.-Canada border, so it is natural to compare the health of people in Canada with those in the United States. This comparison reveals vast health inequities—namely, poorer health outcomes for those in United States. A similar contrast is revealed when we compare the status of residents of Washington State with those of our provincial neighbor to the immediate north, British Columbia. The case situates an MPH graduate working in the Washington State Department of Health who is asked to make health comparisons with Canada. Students are tasked with playing a board game on the social determinants of health developed by a Canadian medical student and a public health student. They are also required to organize a community event and hold a screening of one of two documentaries: *These are Unnatural Causes: Is Inequality Making Us Sick,* or *The Raising of America: Early Childhood and the Future of our Nation.* New documentaries are forthcoming.

#### **More Health Care = More Health**

In the United States, medical care is considered to be the key factor in producing health, and the terms "health" and "health care" are widely considered to be synonymous. This case continues the story of the Department of Health student employee, who must come up with a media campaign to inform the public about the limitations of health care in producing health. In the process, the student is exposed to the concept that medical care, that is, the provision of medical services to sick people, is always a leading cause of death (medical harm). As with all cases in the population health block, we hope to challenge students' core beliefs. The students have to consider the profit motive in delivering medical care in the United States, an exercise that also explores the possibility that not-for-profit institutions may achieve lower associated mortality than do for-profit institutions in the health care system. The students grapple with ways to inform the public about these matters. During this block, students come to appreciate the limitations of medical care in producing health, a concept that is rarely addressed in MPH

programs because access issues continue to be a main focus of public health policy in the United States.

# **Early Life Lasts a Life Time**

A substantial portion of our health as adults is programmed in early life, especially the first thousand days after conception. Continuing the Department of Health employee role, students are challenged to synthesize a research brief on this concept and to explore the developmental origins of heath and disease paradigms. They are expected to review cohort studies, examine the Barker Hypothesis, and explore the Dutch Hunger Winter natural experiment, along with others that demonstrate the importance of the period in *utero*. Students consider maternity leave policies, investments other countries take to establish health in early life, and surrogate markers such as rates of hypertension as proxies for desirable outcomes including longer life. They are then asked to write an opinion piece for a local paper presenting these ideas.

# **Untangling the Gordian Knot**

The final case challenges students to improve U.S. health status compared to other nations while working in a position not directly in public health—namely, working for the City of Seattle Department of Neighborhoods. In this position, students recognize the intersections of race, class, and inequality that are reflected in the city's housing crisis. They are asked to contribute to the Public Health Insider blog of the local health department, Public Health—Seattle & King County. This case reflects a new effort within this block to explore ways to inform those working in public health about the great extent to which our health outcomes can improve.

# **WORKING WITH COMMUNITIES**

This block addresses community collaboration in myriad ways. We ask students to organize and carry out a community event, to present concepts they have learned from a documentary, and to write speeches so that concepts of public health may be understood by the public at large. They conceptualize a media campaign and also write op-eds and blog material that can be submitted for

**88** *Experiential Teaching for Public Health Practice Stephen A. Bezruchka*

publication.

# **CHALLENGES**

The major difficulty in facilitating this block is getting students to accept the "killer facts" we present. Most believe that the population health strategies we present don't apply to them because they do all the recommended things to be healthy. Recognizing that this isn't enough flies in the face of U.S. exceptionalism and individualism. Our curriculum is designed to encourage students to accept paradigmatic shifts by understanding the difference between health and health care and to present this difference to others.

# **CONFLICT OF INTEREST**

The author confirms that author has no conflict of interest to declare for this publication.

# **ACKNOWLEDGMENTS**

Declared none.

# **CHAPTER 10-2**

# **Community Development**

#### **Peter House\***

*University of Washington, Seattle, WA, United States*

**Abstract:** Community development is a key concern of public health and a central focus of the MPH in Community-Oriented Public Health Practice (COPHP) curriculum. Our community development blocks, which occur in both the first and second year of COPHP, introduce students to the challenges of working with communities on issues related to health. These blocks are intense for faculty and students alike because they must cover in a short period a broad range of material that spans sociology, organizational theory, epidemiology, and psychology. They also require students to make quick connections between a growing body of research literature and real word community challenges; entail organizing and conducting fieldwork with community partners; and expose students to provocative ideas and norms. The COPHP program has achieved considerable success with its community development blocks in meeting learning objectives that address issues such as defining and applying a true concept of community in a variety of settings; recognizing communities' assets and problems; describing approaches to getting things done at the community level and assembling a team to do them; and completing strong written assignments on tight deadlines. Through the community development blocks and student projects, the COPHP program has built enduring connections with community partners and has helped address local challenges ranging from securing housing and health services for homeless youth to accommodating the needs of recent immigrants in disaster preparedness.

**Keywords:** Cognitive distortions, Communications skills, Community, Community assets, Community based participatory research, Community development, Community organizing, Community partners, Practical applications of theory, Project planning, Public health practice, Student presentations.

\* **Corresponding author Peter House:** University of Washington, Seattle, WA, United States; E-mail: phinney6@uw.edu

> **Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

### **INTRODUCTION**

As public health professionals come to recognize the underlying and fundamental determinants of health, we become more interested in the power of social capital and community factors in promoting health. Until fairly recently, the profession's focus has been on the proximate causes of morbidity and mortality (heart disease, cancer, stroke, *etc.*) rather than the fundamental issues that lead to those manifestations of poor health. These underlying factors include racism, poverty, isolation, alienation, powerlessness, and other problems that are better addressed by social activism than by medical intervention. Public health activists have long recognized the power that lies within communities to advance public health and well-being, and there is a growing body of literature and experience from which to draw for this course.

A major challenge associated with offering a course addressing community development is the range of material that must be covered. Community development is an interest of sociologists, organization theorists, political scientists, epidemiologists, and psychologists, to name a few disciplines contributing to our knowledge of working with communities. Another challenge is resolving what, exactly, to call this concept. "Community" must be one of the most worn-out words in the social services field. Many government agencies and voluntary organizations use the word in their names or mission statements. But if you ask folks what the term means, they will have a hard time agreeing on a definition. Similarly, some believe the phrase "community development" is paternalistic, thus leading us to some of the political issues in the field. An overriding goal of this block is for our students to understand the concept of community.

We know from our work developing the COPHP program that there are few courses on community development for health, *per se*, on the University of Washington campus or elsewhere in the country. We also know that the concepts concerning communities commonly arise as we teach other subjects essential to public health practice.

# **OUR APPROACH: LEARNING THROUGH APPLICATION**

The key to our teaching approach in this block is practical application. We

emphasize skill development over the attainment of knowledge. Just as we expect students to explore community development theory, we also search for opportunities for practical applications of the theories. We believe that community development skills are achieved through application, and we believe that the applications must be real; students must undertake actual useful work to give context to the theory. Without context, community development theory can appear to be turgid and pedantic, especially for those students who have never worked in communities. The COPHP program offers two courses in community development, and the timing is key.

#### **First-Year Course**

First-year students start our program with a block on population health and the social determinants of health. There is a lot to learn in this block, and much can be learned in the library. We encourage our students to read academic studies as well as the popular press, government documents, and white papers. The population health view is from "10,000 feet" and is strong on theory. For the community development block, however, we intentionally bring the students back down to earth to work on problems at the community level. We want them on the ground in communities talking to people from all parts of the community and not just sitting in front of their computer screens to complete learning assignments.

We find community partners that have real work they would like to have done, and students get assignment memos from agencies with specific work requests. This step assures that agencies' expectations are clear and it puts gentle, but real, pressure on students to get something done in a short time frame. That pressure, we know from the literature on adult learning [1], instills in students a compelling need to develop and *retain* knowledge and skills.

Day One of cases in this block supports a theoretical exploration of a communitybased problem to prepare students for their assignments. In Day Two, a community-based agency makes specific work requests, including a letter with the assignment. From this point, students fill in remaining knowledge gaps and make a plan to get the work done. Typically the students have about 10 calendar days to 1) do their fieldwork, 2) write a report, and 3) make a presentation.

#### **92** *Experiential Teaching for Public Health Practice Peter House*

The students make their presentations to all COPHP groups in their cohort. (As of this writing, we have three groups per year). We invite community partners to the presentations and promise to make another presentation directly to the community partner at a time and place of its choosing. This can require students to come back to communities or organizations many weeks after the end of the course, mimicking the way health professionals must manage a portfolio of projects that overlap in sometimes inconvenient ways. Nonetheless, students are always eager for this "real world" opportunity to develop presentation skills.

## **Second-Year Course**

Students return to community development in the middle of their second year, at which point they are well-grounded in all the elements of public health practice. We start the block with a short theoretical case (that is, not a real assignment) where the students think about how to apply some of their previous learning to help an elected official work in the community to gain support for social justice programs. The remainder of the block, however, is spent working on a real assignment for a community-based organization. We expect students to fit this work into the schedules of the partner agency. At this point on COPHP calendar, our students are deeply engaged in their capstone projects, so the case they work on is a welcome break from the "read-and-post" grind of problem-based learning. We endeavor to find opportunities for our students in a Seattle-based organization that is willing to work with us over several years. Again, the students write a report and make presentations in a variety of settings.

# **LEARNING OBJECTIVES FOR COMMUNITY DEVELOPMENT**

In all COPHP courses, we build cases on defined learning objectives. The following are the learning objectives for the community development blocks.

1. **Define the concept of community and apply that concept to a variety of settings**. Struggling with the concept of community engenders important learning. Students come to understand the importance of *place* when thinking about communities. They learn to contrast populations (groups of people with similar characteristics such as sexual orientation, color, and language) with actual working communities.

	- ❍ Community structures, power, and the concept of governance
	- ❍ The dynamics of a community development approach to health problems
	- ❍ Social capital
	- ❍ Community competence

#### **FINDING AND WORKING WITH COMMUNITY PARTNERS**

All of COPHP faculty in this block have experience working with community partners, and we tap our colleagues in the community to find projects. We start this work months before the community development blocks begin. We draw on relationships with agencies we have worked with or with which we are engaged as volunteers or allies. Sometimes we must "sell" an agency on working with our students. While we recognize that the agencies will need to spend some time with our students, we work very hard to have the students do as much of the work as possible. We set up some preliminary meetings, but from then on, the students are on their own. We believe that learning how to organize a team to do a lot of work in a short time is a fundamental skill of public health practice.

Over the years, our students have done great work on these projects, and this success helps enormously when we search for new community partners or ask to

#### **94** *Experiential Teaching for Public Health Practice Peter House*

continue existing relationships. Some of our community partners have invited us work with them more than five years in a row, and some organizations hear about what we are up to and seek us out as partners. Following are examples of community-based projects that COPHP students have conducted in recent years:


immigrant groups. They performed many work tasks that the health department did not have time to do.


## **CHALLENGES**

COPHP faculty have learned to anticipate challenges facilitating the community development block, including:


#### **96** *Experiential Teaching for Public Health Practice Peter House*

and we faculty can see them growing and learning as they struggle with challenges.


#### **CONFLICT OF INTEREST**

The author confirms that author has no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

#### **REFERENCES**

[1] Council of Public Health Practice Coordinators, Association of Schools of Public Health. Demonstrating excellence in the scholarship of practice-based service for public health. Spring 2009.

# **Quantitative Research Methods**

**Ann Vander Stoep\* , Jim Gale, Michelle Garrison** and **Susan Buskin**

*University of Washington, Seattle, WA, United States*

**Abstract:** When public health graduate students enroll in their first epidemiology and biostatistics courses, they vary widely in their knowledge of and comfort with quantitative research methods. This chapter highlights the challenges and rewards of presenting quantitative concepts to students using a problem-based learning (PBL) approach. We suggest adaptations to usual PBL practice to optimize learning for a diverse group of learners. We introduce instructors to a variety of teaching tools for conveying quantitative methods course learning objectives. We provide synopses of six PBL cases and suggest ways to develop cases that incorporate "shoe leather epidemiology" and meet community data analytic needs. Finally, we contrast learning through lecture with learning through experience, arguing that with PBL, students gain knowledge about quantitative research methods that is more than skin deep, and as such, has longer and deeper staying power when graduates embark on their careers as public health practitioners.

**Keywords:** Biostatistics, Case writing, Community-based teaching, Didactic *versus* experiential instruction, Epidemiology, Learning environment, Learning objectives, Math anxiety, Preparing public health practitioners, Problem-based learning, Public health learners, Public health pedagogy, Public health practice, Quantitative methods, Teaching.

#### **INTRODUCTION**

Epidemiology and biostatistics form the backbone for public health research and practice. Epidemiologists and biostatisticians develop, hone, and apply quantitative research methods to count, describe, and ascribe risk to potential

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author Ann Vander Stoep:** University of Washington, Seattle, WA, United States; E-mail: annv@uw.edu

#### **98** *Experiential Teaching for Public Health Practice Vander Stoep et al.*

causes of health conditions and evaluate health interventions, programs, and policies [1, 2]. Communities rely on epidemiologists and biostatisticians to characterize the prominent health problems affecting their populations, to provide and interpret the evidence for making decisions about which health programs to implement, to track temporal trends in diseases and exposures, and to serve as public health detectives when diseases of mysterious origin appear. This chapter is about how we use problem-based learning (PBL) pedagogy to prepare public health practitioners to appreciate and use quantitative research methods to improve health in populations.

#### **TEACHING QUANTITATIVE RESEARCH METHODS** *VIA* **PBL**

Previous chapters introduced PBL as a method of teaching in public health courses. Teaching quantitative research methods *via* PBL is both highly challenging and rewarding and differs from teaching population health, community development, or other COPHP courses in two important ways:

● **In epidemiology and biostatistics, there are right and wrong answers**. While perspectives on the political forces that shape population health are to some extent based on opinion, questions about the strength of association between a risk factor and a health outcome, the sensitivity of a screening test, or the crude *versus* age-adjusted mortality rate are answered *via* computations and formulas. Thus in addressing quantitative methods, PBL discussions focus less on debating global issues and more on struggling to grasp quantitative concepts: underlying variable coding and regression equations, the meaning of statistically significant effect modification, or the implications of a low positive predictive value.

In addition, course concepts are taught in sequence. Students must grasp the initial building blocks—differences between proportions, rates, and ratios—before they can move forward to understanding prevalence, incidence, odds ratios, and relative risks. Instructors must follow a logical, linear progression to introduce these quantitative research concepts. Once the learning momentum accelerates, if students fall behind, it is difficult for them to catch up.

● **There is wide variation among students in experience, skills, aptitude, and confidence about quantitative methods.** Many able students emerge from their primary, secondary, and post-secondary education with an unhealthy anxiety about performing poorly in math. Student anxiety is a major impediment to successful attainment of learning objectives in a PBL context. To optimize learning, the instructor must listen to and appreciate the variation among students in comfort, learning styles, and skills. Rather than expecting one size to fit all, the instructor charts and supports multiple pathways to mastery.

#### **PBL TEACHING STRATEGIES FOR QUANTITATIVE METHODS**

To address the unique features and specific challenges of teaching "public health math", we offer students a variety of learning modalities. Over the 10-week Quantitative Methods (or Quant) course, groups of eight students meet together to read, digest, and discuss six PBL cases during two 3-hour sessions per week. During these sessions, the students work together, with minimal instructor intervention, to make sense of the case and identify the questions the case is raising. By the end of the class session, they have compiled a list of "need to know" items that they divide into eight pieces, one for each student. Each student conducts research, composes a three-page "posting" to teach classmates the concepts, and submits the posting prior to the next class. All members of the group are expected to read classmates' postings and prepare for discussion in the next classroom session. The instructor reads student posts and comments on epidemiology/biostatistics points that were well-made as well as those that were poorly articulated or incorrect. The following day, in a pre-class coaching session, the instructor reviews these points with a student facilitator who will lead the class discussion.

During several of the PBL sessions, students gather in a computer lab to learn to use statistical software and accumulate skills in statistical analysis. We offer weekly 1.5-hour seminars in a semi-didactic format during which a skilled math communicator uses PowerPoint slides to convey quantitative concepts and demonstrate their application through examples. We augment didactics with problem sets that students complete in small groups. Assigned readings—usually deemed impediments to discovery learning in other PBL courses—help to even the playing field among students with different learning styles and abilities and to establish a common vocabulary and library of examples. A reference shelf in the

#### **100** *Experiential Teaching for Public Health Practice Vander Stoep et al.*

university library contains a collection of basic epidemiology and biostatistics textbooks that students can read to augment or clarify their understanding and gather additional examples of concepts applied to different health problems. Instructors offer students pre-PBL class time for remediation and to review practice problems, as well as one on one meetings as needed.

The instructor strives to create a learning environment in which "no graduate student is left behind", using instructional time to promote the development of competence and confidence for each student. While student collaboration and discussion are the mainstays of PBL, Quant students can confuse one another by assuredly explaining concepts incorrectly or by explaining concepts correctly but hesitantly. Classmates can become anxious if they lose their tenuous grasp on a new concept. At this point a gentle intervention by the instructor with a question such as, "Is this the way all of you understand this concept?" suggests that the answer may not be correct, without directly calling out a student for giving a wrong answer. Knowing when to stand back and when to step in is an art.

Because instructors come from different backgrounds and have learned epidemiology and biostatistics at different universities using different textbooks, they must make a special effort to teach course concepts using the same terminology, definitions, and formulas. In the COPHP program, all students take a common Quant methods midterm and final. These examinations are graded using the same key across instructors. The stakes are high when teaching concepts differently might yield systematic differences in student grades across PBL subgroups. Weekly or biweekly meetings among Quant faculty help to keep instructors aligned.

#### **Learning Objectives**

In designing COPHP Quant course, instructors kept in mind the jobs that COPHP students would be performing as program managers and administrators in local health departments and community-based organizations. The Association of Schools of Public Health monograph on competency-based epidemiologic training in public health practice includes a helpful grid illustrating the quantitative research competencies that public health practitioners should be prepared to

#### *Quantitative Research Methods Experiential Teaching for Public Health Practice* **101**

demonstrate at different levels of responsibility within local health departments [3]. At the top levels of responsibility are senior-level epidemiologists and senior scientists, who use critical thinking processes to design, conduct, and disseminate research and synthesize original and published findings to guide decisions the health department director makes about public health problems and public health policy questions. In our Quant course, we aim for an understanding of methodology adequate to assisting or even, with additional experience and education, serving as a mid- or senior-level epidemiologist. While we do not expect students who complete the course to be able to set up an active surveillance system on their own, we do expect them to have a strong grasp of how an outbreak of a communicable disease is investigated. To this end, they learn to apply the steps of outbreak investigation within a PBL case. Course learning objectives aim to prepare students for this level of practice.

The Quant course incorporates epidemiology and biostatistics objectives that are required for MPH accreditation by CEPH, the Council on Education for Public Health, and recommended by the Association of Schools and Programs of Public Health [4]. This enables our students to emerge from COPHP with a globally recognized MPH degree and allows interested students to pursue additional upper level quantitative methods courses at the University of Washington. To fulfill these objectives, the "Quant block" goals are to acquaint students with methods of epidemiology and biostatistics as they are used in conceptualizing, collecting, analyzing, and interpreting quantitative data on health outcomes and risk factors. We also work to expand and refine student skills in communicating with different audiences about quantitative aspects of public health, through writing reports and constructing and presenting tables and graphs. Even if program graduates do not fully remember or frequently employ every technical concept taught within the Quant course, the broader goal is to imbue future public health practitioners with the beliefs that:


#### **102** *Experiential Teaching for Public Health Practice Vander Stoep et al.*


Following are the Quantitative Methods course learning objectives as stated in the course syllabus.

#### *Epidemiology*



#### *Biostatistics*


# **INCORPORATING QUANTITATIVE METHODS LEARNING OBJEC-TIVES INTO PBL CASES**

PBL cases are composed, selected, or adapted to teach students each facet of the course learning objectives. There is an art to writing cases in such a way that information unfolds in a logical sequence that leads students to realize what they need to know to "solve" the research problem. We use humorous names for our cases and characters and colorful language within the text to keep students engaged. For instructors who are PBL and case-writing novices, Quant methods cases are available online. Many are posted on the Association for Prevention and Teaching Research (APTR) and Centers for Disease Control and Prevention (CDC) websites.

Below are synopses of three COPHP Quant course cases.

#### **Fair Outbreak**

This case is adapted from one of several excellent cases that the U.S. Centers for Disease Control and Prevention designed to immerse epidemiology students in the process of investigating an e. coli outbreak that occurred at a county fair. The case presents an introduction to infectious disease epidemiology, outbreak investigation and surveillance, sampling, prevalence and incidence, and writing up methods and results.

#### **To Screen or Not to Screen, That is the Question**

Written by a COPHP instructor, this case introduces public health screening in the context of a public school considering whether to implement an early intervention program. The program uses universal screening to detect emotional distress in students transitioning from elementary to middle school. The case introduces students to public mental health; screening as a public health strategy; universal, targeted, and indicated screening; 2 X 2 tables and screening statistics; design of studies to validate screening tools; and conditions communities weigh and controversies they face in deciding whether it is appropriate to implement a screening program.

#### **Starting Right**

Written by another COPHP instructor, this case is set in a maternal and child health division of a state health department that is evaluating the effectiveness of a community-based outreach program designed to increase women's access to timely, comprehensive prenatal care and to decrease the number of low birth weight babies born in the state. The case provides an introduction to variable types, basic descriptive statistics, common statistical distributions, tables, graphs, and manipulation of data in the Stata statistical software package [5]. The case explores hypothesis testing, criteria for inferring causality, cohort and case-control study designs, and bivariate measures of association.

## **COLLABORATING WITH COMMUNITY PARTNERS**

In all COPHP courses, instructors are encouraged to collaborate with community partners. Arguably, study design and implementation are best learned through experience in conducting research—that is, by gathering information from real people in real community settings such as schools, parks, neighborhoods, nursing homes, bars, and sidewalks. "Shoe leather epidemiology" is challenging, but not impossible, for a group of students to implement in a 10-week course. Challenges include time constraints that make it difficult to learn methods quickly and adequately to design and conduct a study within several weeks' time.

Additionally, gathering information from real people for research purposes (*versus* educational exercises) usually requires permission from an institutional review board (IRB), and the turn-around time for review of new human subjects IRB applications is generally longer than the 10-week course. Furthermore, studies conceived of and executed rapidly by novices are apt to produce uninterpretable results, which can be frustrating as well as enlightening to students.

We work in real community settings when possible. Our hypothetical Quant cases are set within communities and provide students with opportunities to role play delivering communications of quantitative research questions, methods, and results to the public. Quant cases that involve data analysis use real publicly available datasets. Instructors can also forge community collaborations by asking local health departments for data sets that COPHP students can analyze to provide

#### **106** *Experiential Teaching for Public Health Practice Vander Stoep et al.*

assistance in addressing local public health questions. To expose students to practical community-based research experiences, we have written cases that send students to the field to address public health questions with studies that can be conducted quickly and don't involve human subjects.

Below are examples of cases with original data collection that we have used to address Quant learning objectives.

## **Walk it Out**

In this case, students plan and execute assessments requiring street-corner observations of neighborhood walkability in the vicinity of elementary schools. Information from this case was used in feasibility determinations for a Walking School Bus program that was in the planning stages.

## **Crackin' the Case, Not the Head**

This case takes students to neighborhoods to systematically observe, document, and then compare helmet-wearing habits of bicyclists.

#### **Pedestrian Potluck**

In this case, university-based epidemiologists gave us data they had gathered from the Seattle city traffic office about the incidence of vehicle-pedestrian accidents at 28 local intersections. Half were low and half were high collision intersections. Blind to the collision records of the intersections, students developed a methodology, determining what information to gather and how to gather information about environmental and human features at these intersections. After carrying out the fieldwork, they analyzed their data in an attempt to identify systematic differences in features of high and low collision intersections.

# **PREPARING STUDENTS FOR PUBLIC HEALTH PRACTICE**

Students who learn epidemiology and biostatistics through PBL are both learners and teachers. Their mastery is enhanced through the efforts they make to clearly convey quantitative concepts to their classmates. These are major benefits for practicing with real live people in real live communities! Some of our colleagues

who teach public health research methods to graduate students with a didactic approach raise concerns that a case-based curriculum is not rigorous enough. Several years ago we compiled data on the grades earned by COPHP students who opted to enroll in upper level epidemiology courses. We were pleasantly surprised at the exceptionally strong performance of our students in these advanced courses, as measured by grades that were on par with those of students from other backgrounds.

Probably the most valuable outcome of students who learn concepts through PBL is that they are resourceful and able to figure out what they don't know, seek information they need to know, and bring knowledge to bear in practical ways. These skills serve students well in the workplace. On the basis of "exit surveys" with former students in public health jobs and with employers of our former students, we have evidence that our PBL approach yields students with a high capacity for appreciating and employing quantitative research methods to address public health problems in community settings.

#### **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

#### **REFERENCES**


#### **108** *Experiential Teaching for Public Health Practice Vander Stoep et al.*

[5] StataCorp. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP 2015.

# **Environmental Health**

**Tania M. Busch Isaksen\* , Wayne Turnberg** and **Jude Van Buren**

*University of Washington, Seattle, WA, United States*

**Abstract:** The Environmental Health block of the MPH in Community-Oriented Public Health Practice is designed to help students understand the environmental public health system and how it investigates and reduces community risks from agents that cause disease, injury, and death. The case studies primarily address the recognition of various hazards in the environmental and occupational setting; the theoretical construct for understanding the properties of these hazards; the exploration of the factors that can generate or diminish exposure and reduce disease incidence and severity, especially in vulnerable populations; and the importance of risk communication in addressing environmental issues. The cases ensure that students learn about local, state, and national laws and regulations promulgated to reduce exposure and disease from environmental factors and also how to mine these standards for gaps and incongruent policies. They focus on determining causal factors and mitigation approaches as they explore the politics and pressures of the environmental health challenge. We press students to search for inequities in exposure and disease risk such as evidence of institutional racism in high risk communities. This core prepares public health practitioners to work on community environmental health risks to reach fair resolutions and reduce adverse health outcomes.

**Keywords:** Built environments, Causality, Climate change, Environmental contamination, Environmental epidemiology, Environmental health, Environmental racism, Executive briefing, Exposure pathway, Exposure potential, Hazard analysis, Health disparities, Institutional racism, Protection standards, Regulations, Risk benefit analysis, Risk mitigation, Town hall meeting, Toxicology, Vulnerable populations.

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author Tania M. Busch Isaksen:** University of Washington, Seattle, WA, United States; E-mail: tania@uw.edu

### **LEARNING OBJECTIVES**

We expect students to understand the core concepts of environmental health (EH) in the current paradigm of public health practice, and the learning objectives for this block reflect this expectation. They are:


proposing sustainable solutions to environmental health problems.


# **CASE EXAMPLES**

We select cases for the environmental health core with the goal of providing a learning platform of relevant current events that illustrates the complexity of a particular environmental health issue. For example:

#### **Water Contamination**

A case examining a real world incident of drinking water pollution relates a field investigation of the level of contamination in a community's drinking water supply. It also explores the long and short term health risks posed to the population that is drinking the water, the economic risks to the community that no longer has potable water, the occupational hazards of exposure or employment loss due to the economic downturn resulting from a long term drinking water problem, and the intensified effects to the vulnerable populations living in that community and to the food distribution and ecologic life system in that community.

#### **But I Love Raw Oysters On the Half-Shell!**

Another case explores an outbreak of shellfish-borne *Vibrio parahaemolyticus,* its effects on human health, and the steps taken by the public health community to minimize the risk to the public from commercial, recreational, and subsistence shellfish harvesting. Students research the etiologic agent, where the agent is found in the environment, how it is transmitted to humans, and the symptoms it causes. Environmental laws and regulations, as well as the roles of the public health agencies responsible for monitoring and enforcing shellfish food protection standards, are examined. A tour of the State Environmental Laboratory provides insight into specimen collection and testing processes. Steps taken to conduct an epidemiologic case investigation are analyzed as well as the human communicable disease reporting surveillance systems used to monitor disease trends in populations. We discuss mechanisms used by public health agencies to alert executive leaders, elected officials, and the public about disease outbreak risks and prevention messaging.

#### **Is It Getting HOT in Here?**

A third case explores the effects of climate change on public health outcomes. Unlike the previous two cases, which have a pre-defined geographical context, this case allows students to consider a major environmental public health risk

from a local, national or global perspective. Basic scientific principles are identified and examined, highlighting the importance of credible sources of information. Connections with deleterious changes to environmental systems are drawn to both observed and predicted public health outcomes. Inequitable distribution of harms is emphasized along with particularly susceptible and vulnerable population characteristics. The roles and responsibilities for public health agencies around mitigation, adaptation, and the leveraging of health benefits are explored along with current local, state, and national policy decisions.

#### **COMMUNICATING RISK AND ACTION**

A key part of the environmental health block is risk communication—how to communicate a risk and a potential action to deter or control its effects on a concerned population. These communication styles include:


#### **114** *Experiential Teaching for Public Health Practice Isaksen et al.*

major role in a community or incident. By researching the perceived viewpoints of community members, they learn to represent their perspectives on the incident and their choice of solutions. This approach helps students fully realize the challenges and frustrations of community members and recognize factors that lead to environmental racism, economic inequalities, and health disparities in a community.

● **Working with communities**. The EH core is currently a four week block, which is not enough time for students to engage the community in substantive projects or interactions. COPHP faculty address this need for real world exposure by inviting speakers to class to discuss environmental equity issues and experience exercises that demonstrate the challenges to equity with environmental exposures. We encourage students to interview citizens and government officials who are or would be involved in an environmental health incident. Students also participate in a field trip to Washington State's public health laboratory to view how shellfish samples are presented to the state lab for analysis of various viruses and shellfish toxins from state beaches. Students see how lab scientists and epidemiologists work together in a public health setting with various local, state, and federal partners to piece together the causative steps in a nationwide food outbreak and how to stop it.

#### **CHALLENGES**

COPHP students bring a diverse range of educational backgrounds with varying levels of the type of science-based expertise needed to critically analyze complex issues such as the fate and transport of chemicals in the environment. In response, we design cases to address learning objectives that define the basic tenets of hazard analysis (exposures, agent, host, environmental pathway). Often, students must learn basic biological concepts to avoid misdirection in the research.

Many students also require a refresher on how local, state, and federal laws and rules are created and work, or don't work, together. The environmental health field is largely based on laws and rules, so student understanding of our basic legislative and regulatory structure is essential.

*Environmental Health Experiential Teaching for Public Health Practice* **115**

### **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

# **Health Behavior and Health Promotion**

#### **Sarah Ross-Viles\*** and **Hendrika Meischke**

*University of Washington, Seattle, WA, United States*

**Abstract:** Students in the MPH in Community-Oriented Public Health Practice (COPHP) frequently progress to careers that require strong skills in health behavior and health promotion. Learning objectives for COPHP's Health Behavior and Health Promotion block cover skills in program planning and assessment, theories of behavior change, and application of an equity lens in health promotion. Cases in this block explore content through specific health topics. As in other COPHP blocks, students teach themselves and each other as they review cases, write and discuss learning objectives, post research findings, and conduct practical assignments. Faculty who facilitate this block rewrite cases annually to ensure they include at least one timely topic that the students will be eager to explore, and real world practitioners lead seminars that complement the cases. Challenges of the Health Behavior and Health Promotion block include teaching complex theory and extensive skills in a short time, keeping the health topics compelling to students, and making sure students maintain an appropriate balance between exploring interesting health topics and understanding the fundamentals of health promotion.

**Keywords:** Assessment, Communication, Cultural competency, Ethics, Health behavior, Health promotion, Literacy, Objectives, Planning models, Prevention, Primary prevention, Program design, Program planning, Protective factors, Risk, Secondary prevention, Tertiary prevention.

#### **INTRODUCTION**

COPHP students take the Health Behavior and Health Promotion block at the end of their first year in the program. At this point, they have been immersed in

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author Sarah Ross-Viles:** University of Washington, Seattle, WA, United States; E-mail: sarahrv@uw.edu

*Health Behavior and Health Promotion Experiential Teaching for Public Health Practice* **117**

population health, community development, quantitative methods, and environmental health, and they are ready to synthesize skills from those topics and design health promotion programs. Students are typically very excited for this block; many declare in their admission materials that they picture their futures working with communities to implement successful health programs. Many COPHP graduates do indeed find health program management jobs in community organizations or governmental agencies.

The coursework in the Health Behavior and Health Promotion block covers program planning models, assessment techniques, theories of behavior change, equity in program planning, health communication, and an introduction to program evaluation. Students approach these fundamentals through the COPHP program's social justice lens, which encourages them to analyze the faults as well as the merits of health interventions and exposes them to the ambiguities and challenges of developing health programs as community outsiders.

#### **APPROACH**

As with other COPHP blocks, we teach Health Behavior and Health Promotion with a set of cases built around a health topic (obesity, communicable disease, tobacco) that also include teaching notes with prompts and questions to ensure students cover important learning objectives. We use classroom time to collectively generate learning objectives, and then students have two or three days to research an objective using primary and secondary sources and write up a post for their peers. We then analyze the posts in class. Faculty participate very little in the discussions but provide extensive feedback on postings, especially focusing on how well students synthesize information from their research and are able to communicate their ideas to their peers. Most of the cases culminate in a practical project that the students do alone, in small groups, or as a class. Examples of projects are designing and presenting a health communications campaign, developing a sample health intervention that focuses on an assigned level of the social-ecological model, and creating a mock town meeting to discuss a disease outbreak.

#### **WORKING WITH COMMUNITIES**

This block uses weekly seminars to introduce students to local examples of health promotion efforts similar to those in the cases. The seminars provide an opportunity for students to conduct a dialogue with experienced professionals about health topics and the skills involved in health promotion. Seminar speakers have included health outreach workers who engage with men who have sex with men, a health communications account manager from a national firm, and a panel of professionals developing obesity programs for families, employees, and large geographic populations. We encourage students to develop questions in advance for the speakers, and a faculty moderator assures that the questions are equally distributed across the small group cohorts—this assures that all groups receive information relevant to their specific interests or concerns.

#### **LEARNING OBJECTIVES AND CASE EXAMPLES**

The Health Behavior and Health Promotion block covers a broad area to equip students for public health careers. As the list below reveals, most of the objectives include understanding a key concept and being able to apply it. The application occurs in the practical assignments and posts. The learning objectives are:


health promotion/disease prevention practice and research.


#### **120** *Experiential Teaching for Public Health Practice Ross-Viles and Meischke*

#### **CASE EXAMPLES**

As we describe above, the health topics of each case are vehicles to lead students to the Health Behavior and Health Promotion learning objectives. The cases are a mix of classic and prominent health promotion topics and trending hot topics students find very appealing.

#### *No One Cares Any More, Do They?*

The first case of the block introduces students to the Precede/Proceed planning model and assessment techniques for identifying factors affecting a health issue. The protagonist is a student intern surprised by the high rates of sexuallytransmitted infections remaining in gay populations served by the local health department. As he learns fundamental planning skills, the intern is also forced to reexamine his preconceptions about a community—which is not the way the community actually are sees itself. He learns that the populations he wants to help may have trauma from previous "help" by the health department that he needs to consider in formulating his actions.

#### *Mrs. Rose's Dilemma*

The matriarch of a Fairbanks, Alaska, family worries that her three children are perhaps more than just chubby. She is inundated by shaming and information overload as she considers how to create a more active and nutritionally healthy lifestyle for her family. She works long hours, and a McDonald's is conveniently located on her way home. A co-worker puts her in a touch with a nutritionist at the state health department. In meeting Mrs. Rose, the health professional comes to understand how complex it is to achieve healthy weight for individuals and families and how it demands integrated solutions at multiple levels. The nutritionist digs into her knowledge of health behavior theory and recruits a coalition of community members to design a comprehensive intervention (using an ecological framework) addressing overweight and obesity in Fairbanks.

#### *Meningitis at The Prom*

A teenager in a small community dies from meningitis shortly after her *quinceañera*. The tragedy inflames students, parents, and community members with worry and fear, even after the health department has followed proven steps to stop an outbreak. A health information officer from the county health department employs his skills in risk communication to cut through the mental noise in the community. He eventually decides to set up a town hall meeting so trusted people in the community can speak directly to citizens and address concerns and misinformation.

#### *Still Smoking After All These Years*

A high school science teacher in a lower-income school had no idea what a vaping device looked like until he saw one on TV. Now he is worried that his students may be using them on campus. This is especially worrisome considering how tobacco companies target their messages to specific high-risk populations, including his students. He involves his classes in designing a communications campaign for fellow students while he undertakes a public will campaign to shift local policy on youth access to tobacco products.

#### **CHALLENGES**

The foremost challenge of this block is introducing a high volume of new content to students— include health behavior theory—and asking them to apply their new knowledge with a very quick turnaround. This challenge is fairly universal in COPHP. In the Health Behavior and Health Promotion block, we create opportunities to explore theories, planning models, and other content didactically. Students take on learning objectives that require them to deliver a class presentation, present content in a seminar, or offer special sessions with faculty to help iron out and connect the many ideas in the cases.

A second challenge is keeping the health topics fresh. The health topics themselves are not the key content of Health Behavior and Health Promotion, and we can switch them up, applying the same key theories and planning models that are the principal block content. At the end of the first year of COPHP, students are fairly exhausted from the often bi-weekly cycle of researching, analyzing, writing, reading, and discussing. We try to keep their attention by refreshing our cases to add a new topic with a current hook. During the 2015–16 academic year, for example, we transformed the health communication objectives from the vaping

case into a marijuana case. This change acknowledged that Washington State legalized recreational use by popular vote two years ago, and stores are now popping up in many neighborhoods.

The last significant challenge is a result of using timely topics for the cases. Students are often eager to research and discuss the community experience of a health topic in a case and not balance their interest with a focus on the competencies related to theory or methods of program planning. We work with the student facilitator to make sure that the class covers the learning objectives on core health promotion skills, and at times, intervene to keep the class focused on these concepts.

#### **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

# **CHAPTER 10-6**

# **Evaluation**

#### **Ian Painter\* , Tao Sheng Kwan-Gett** and **Amy Hagopian**

*University of Washington, Seattle, WA, United States*

**Abstract:** COPHP Evaluation block occurs over a four week period during the second year of the program. It builds on a case that focuses on designing an evaluation for an outside client. The evaluation requirements are detailed early on in the case, and the class subsequently meets with the client to clarify questions about the evaluation and understand constraints on the process. Students then design the evaluation, write a report on the evaluation plan, and present the plan to the client at the end of the course. The case covers evaluation theory in the first two days, and the course focuses on applying to the design process both evaluation theory and quantitative design skills covered previously in the quantitative methods block (epidemiology and biostatistics). The block emphasizes the important skills of interacting with clients and eliciting and clarifying evaluation requirements.

**Keywords:** Barriers, Data, Evaluation, Evaluation design, Evaluation theory, Evaluator, Logical framework, Policy, Program theory, Variables.

#### **INTRODUCTION**

The evaluation block takes place at the start of the winter quarter in the second year of the program. As the block lasts for just four weeks, the class designs, rather than conducts, an evaluation. The focus on the design process has the advantage of emphasizing the process of developing an evaluation question through interactions with an outside client. Students lead this process, producing a detailed evaluation plan for the client and presenting the results to the client on the last day of the block. We cover evaluation theory through a combination of the

\* **Corresponding author Ian Painter:** University of Washington, Seattle, WA, United States; E-mail: ipainter@uw.edu

> **Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

learning objectives for the second day of the case and class seminars.

# **CASE DEVELOPMENT**

COPHP finds clients for its evaluation block either directly through faculty contacts or through requests sent by email to program faculty and graduates. Cases are not recycled; each year, every class features its own case, although occasionally classes that occur simultaneously will uses cases that share the same client. After a client has agreed to participate, faculty draft the case based on interactions with the client, typically in person or by phone. Following are some recent clients and cases:

# **Real Change Organization**

Evaluation of services offered to the vendors of *Real Change*, a weekly street newspaper sold by homeless and other very low income individuals in Seattle.

# **The Seattle Office of City Auditor and The Seattle Office of Civil Rights**

One project involving evaluation of the effects of the new Seattle paid sick and safe leave ordinance on employment of low-wage vulnerable populations. A second project involving evaluation of the effects of the Seattle paid sick and safe leave ordinance on minority and immigrant employers who own small businesses (*e.g.* nail salons, restaurants, *etc.*).

Assessment, Policy Development, and Evaluation Unit (**APDE**), Public Health —Seattle & King County

Evaluation of the SeaTac and Tukwila Food Innovation Network

# **Neighbor Care and King County School Health, Public Health—Seattle & King County**

Evaluation of knowledge and uptake of long-acting contraceptives in Seattle high school-based clinics.

## **Health Equity Circle and IAF Northwest**

Evaluation of clinic based organizing.

### **CLASS PROCESS**

The cases are relatively short; day 1 is written to elicit learning objectives that target knowledge the students will need about the client and about the subject matter domain. During the first week a seminar is also typically given by a guest presenter with experience designing and conducing public health evaluations (for example, as an evaluation consultant). This seminar covers the process of developing evaluation questions, developing a theory of change, and using logic models.

Day 2 targets evaluation theory and is generally similar year to year. We hint that students may generate suitable learning objectives for this day by summarizing individual chapters of an evaluation textbook (for example, Grembowski's *The Practice of Health Program Evaluation*). Some topics (such as reliability and validity) are already familiar to the class from the quantitative block. Day 2 learning objectives also focus on evaluation theory for vulnerable or difficult-toreach populations.

Day 3 ideally occurs immediately after a "meet the client" seminar, and it starts the process of designing the evaluation. We usually provide the evaluation question, but students often refine it further in consultation with the client. As part of the assignment, we provide a table outlining different aspects of an evaluation plan that should be included in the report; this serves as a grading rubric for the final project. Students typically assign roles during Day 3, and a specific student (often the student who takes on the role of project manager) has responsibility for coordinating all client interactions, as additional questions for the client are usually generated throughout the design process.

Students often begin by developing a theory of change and/or logic model, followed by selection of specific methods to answer different aspects of the evaluation question. We encourage students to create skeleton tables so they become familiar with clearly defining their data needs and thinking in terms of

#### **126** *Experiential Teaching for Public Health Practice Painter et al.*

variables required to answer the evaluation question. During the last week, students write the evaluation plan and make their presentation. See Appendix I for an example of daily learning objectives from the Evaluation block.

Following are learning objectives for the whole of the Evaluation block:


# **CHALLENGES**

As the Evaluation block is based on an actual assignment with a real client, domain and client knowledge must be built into the case. This limits the amount of time that can be devoted to evaluation theory, and it may be necessary to prompt the class to revisit aspects of evaluation theory during the design process. Students are often surprised when the client doesn't already have some documentation of a program theory, but this mimics real-life evaluation consulting work. Some confusion may also result when clients' evaluation requirements don't fit neatly into evaluation theory divisions (for example, formative *versus* summative; process *versus* outcome). In this situation students can become focused on trying to fit needs into the theory rather than focusing on

the design process, and it may be necessary to refocus the class to the specific needs of the client.

#### **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

# **CHAPTER 10-7**

# **Policy**

#### **Lena Nachand<sup>1</sup> , Aaron Katz2,\*** and **Amy Hagopian<sup>2</sup>**

*1 Washington State Health Care Authority, WA, United States*

*2 University of Washington, Seattle, WA, United States*

> **Abstract:** The policy block is a cornerstone of COPHP experience. For 10 weeks at the beginning of the second year of the program, students engage in public discussions across all spectrums of the social determinants of health and such non-traditional public health topics as free trade and nuclear waste disposal. During this block, students work through real-life scenarios and participate in actual policy development. They benefit from the close relationships the program maintains with non-profit organizations, and the work they have conducted under their auspices during the policy block has been well-received and influential. In the course of community-based projects, students work in concert with local stakeholders and public policy makers. By the end of the block, students have learned the basic concepts, analytical tools, and skills for policy analysis, development, and advocacy, and some have also developed the inclination to pursue public health policy careers.

**Keywords:** Advocacy, Analytic tools, Conflict, Context, Cultural framework, Delivery, Financing, Health policy, Policy, Policy analysis, Political framework, Public policy, Stakeholder, Values.

#### **INTRODUCTION**

At the beginning of students' second year, an entire academic quarter (10 weeks) is dedicated to the study of health policy. Health policy refers to public decisions that guide organizational and individual behaviors affecting health and financing, delivery, and use of health services. Students learn the basic concepts, analytical

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author Aaron Katz:** University of Washington School of Public Health Seattle, WA, USA; Tel/Fax: 206.616.5227/206.616.9415; E-mail: garlyk@uw.edu

tools, and skills for policy analysis, development, and advocacy. By understanding the complex array of factors that affect public policy, and therefore how organizational and individual behaviors are influenced in regards to health, students are able to work within the cultural and political frameworks that influence and change the nation's health system.

Without adequate exposure and study of this topic, students would leave the program with a significant gap in their ability to be effective public health practitioners. Public policy in particular touches aspects of every life in the United States and is a major determinant of health outcomes. Even if students chose not to pursue a career in policy, this block prepares them to know how to get a health promotion campaign funded, assess critically whether initiatives or levies will benefit their community, or how to design a study that will both get the necessary answers and be useful in addressing conflicts among key stakeholders.

# **LEARNING OBJECTIVES**

The learning objectives identified in the policy syllabus are:


# **MAKING POLICY**

The COPHP program is rooted in experiential and problem-based learning and this continues in the policy block. No case of the policy block occurs in isolation, as each block is rooted in real-life scenarios and requires students to reach out to public health professionals around the world. The block also takes the students on

#### **130** *Experiential Teaching for Public Health Practice Nachand et al.*

an all-day field trip to visit the Hanford nuclear site in southeastern Washington State, followed by activities to develop and execute a lesson plan for local high school students that addresses the site's long history producing plutonium for the nation's defense program and the cleanup of the nuclear waste it generated.

Additionally, the policy block draws on the real-world needs of partner organizations to develop policy stances. Faculty have relationships with a number of policy-related organizations and agencies, and they have engaged students in working on cases with these partners. For example, as a service to the Seattlebased Economic Opportunity Institute, COPHP students conducted some of the early research on stakeholder views of city-mandated sick leave policies, contributing to the 2012 ordinance adopted by the Seattle City Council. One of our alumni works for the Washington State Board of Health developing health impact assessments (HIAs) for legislators seeking estimates of the health effects of proposed legislation; we now have a case where students help develop procedures for those HIAs and actually conduct them. For the county health department, students have researched best practices in policy to reduce the consumption of sugar-loaded beverages, how the federal Patient Protection and Affordable Care Act (ACA) could be leveraged to improve the health of jailinvolved individuals, and how the ACA would affect insurance coverage in King County, especially as related to small businesses.

Since 2010, the American Public Health Association has adopted eight policies authored by COPHP students. They are:


A key lesson of the policy block is that no policy is developed in a vacuum. It is essential that students master practical skills that they then have the opportunity to put into practice in real world situations. This is a continuation and further example of the values and mission of COPHP.

#### **PBL CASES**

The cases for the policy block cover local, national, and global topics. Some of the cases we use in this block are not specifically policy issues but are designed to cover ground not addressed in any other block. For example, our case set in Ghana, "You Never Die of Just One Thing", introduces students to the Big Diseases globally: malaria, TB, HIV, and anemia. Remarkably, many domestic MPH students never learn about these diseases because they are not among the biggest health problems in the United States. After students explore issues related to the imposition of colonial-style international aid on low-income country ministries of health, we present them with a final problem set in which they are asked to calculate the attributable risk factors for anemia. If they do the calculations correctly, they will conclude malaria is a much larger contributor to the incidence of anemia—although the international aid agency in the case is redirecting resources toward food fortification. We ask students to write a memo to the Minister of Health from their assigned position as an analyst in the Ministry of Health. This case challenges students to conduct statistical analysis, explore the political and economic interests of aid agencies, and review historical and biological issues of health in low-income countries. It culminates in a critical thinking assignment to produce a policy recommendation. For more detail about specific cases used in the policy block, see Chapter 2. See Appendix J for sample case facilitator notes from the policy block.

# **WORKING WITH COMMUNITIES**

A successful and relevant policy analyst, policy writer, and policy advocate must maintain relationships with a broad range of organizations, agencies, movements,

#### **132** *Experiential Teaching for Public Health Practice Nachand et al.*

and communities. The first learning objective of the block is to understand the various contexts in which public policy is formed. A key context is how advocates can turn a problem into a policy issue. Further, we help students understand that policy makers and advocates must meaningfully and forthrightly engage with the affected community or communities to ensure sufficient stakeholder engagement to make progress.

Immersing public health students in real health policy issues within a 10-week block requires faculty to have and nurture relationships with local and state public agencies, public policy makers, and advocacy organizations. As a result, various people and organizations have given vast amounts of time to students and their learning. Maintaining these relationships, both through faculty and quality student work, is critical for the policy block and COPHP.

## **CHALLENGES**

Public policy involves both science and art. The "science"—how policy agendas get set, stakeholder analysis, policy analysis, *etc.*—can be appreciated through PBL cases in a 10-week block. But the "art"—how to work with stakeholders of many different points of view, how to forge compromise, how to gauge the right "timing" for moving a policy initiative—takes much more time and experience. The policy block can give students a sense of the art and a framework they can then use when they start or continue their careers.

A second challenge concerns the experience and preparation of students who come to COPHP. Many are attracted to the program and the pedagogy because they want to do community-level work or "get their hands dirty" in helping communities be healthy places. They often don't come with extensive —or any—experience or background in policy or political work, not even something as simple as dinner table conversations growing up about how to eliminate racism or poverty or whether to invade a country. Some enter the program thinking that the only mechanism for improving public health is (or should be) communication targeting individuals, such as posters admonishing the public to quit smoking, wear a condom, and eat right. As a result, this block has the challenge of expanding students' understanding of what affects health from the individual to the collective, and that can be a struggle for some.

# **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

# **ACKNOWLEDGMENTS**

Declared none.

# **CHAPTER 10-8**

# **Management and Leadership**

**Chris Hurley\* , Katie Bell** and **Bud Nicola\***

*University of Washington, Seattle, WA, United States*

**Abstract:** The Management and Leadership block in the COPHP program focuses on providing students with the skills and knowledge needed to direct and coordinate the efforts of individuals and organizations. Managers and leaders accomplish their work through and with others and must understand, motivate, and manage individuals, groups, and teams. Managers also establish directions, plan and organize the work to be done, identify and resolve problems, budget and manage the organization's resources, evaluate and improve performance, drive change, and establish and manage external relationships. In this block, we use cases set in a variety of different community health settings to explore the full range of management and leadership skills. Mini-cases illustrate management principles. Students visit several community organizations to observe management at work.

**Keywords:** Communication, Conflict management, Financial management, Interpersonal competence, Leadership, Leading change, Management, Organizational equity, Personal awareness, Strategic planning, Team dynamics.

# **MANAGEMENT AND LEADERSHIP ROLES IN PUBLIC HEALTH PRACTICE**

COPHP graduates will practice their population health skills in organizations with other people. Without regard to a student's precise career trajectory, the COPHP program encourages all students to acknowledge and embrace their responsibilities as both formal and informal leaders in improving population health. Skills taught in the Management and Leadership block will help students work effec-

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding authors Chris Hurley and Bud Nicola:** University of Washington, Seattle, WA, United States; Emails: xtine.hurley@gmail.com and bnicola@uw.edu

tively in groups and teams, in large and small organizations, with for-profit and non-profit and governmental organizations, and across organizations in collaborative teams.

## **LEARNING OBJECTIVES**

The Management and Leadership block aims to help students explore the evidence and experience base underlying and informing management best practices. Students gain insight in assessing their own proclivities, strengths, and weaknesses relevant to management and leadership. They strengthen their competencies and skills to carry out core management and leadership functions and responsibilities, including the following fundamental learning objectives:

	- ❍ Describe the basic roles and responsibilities of managers and leaders. Understand the major theories of management and leadership. Describe approaches for energizing commitment and involvement by an organization's people in addressing challenges, achieving goals, and improving performance.
	- ❍ Describe approaches for recruiting, retaining, and developing human resources.
	- ❍ Assess personal strengths, weakness, and preferences and explore the implications of personal style and behaviors on abilities to work effectively with others.
	- ❍ Describe the elements and methods for formulating organizational strategies, plans, and programs. Explore the limits of long term planning and the importance of contingent approaches in response to change.
	- ❍ Develop and communicate an organization's mission, vision, and values to motivate the organization's people and guide unit-level planning.
	- ❍ Explain the importance of aligning organizational goals, culture, structure, reporting relationships, budgets, and reward systems.
	- ❍ Manage effective group decision-making, collaborative problem-solving, conflict resolution, team-building, and teamwork.

**136** *Experiential Teaching for Public Health Practice Hurley et al.*

	- ❍ Explain methods for budgeting financial and human resources in support of goals, programs, and projects, and explain techniques for managing within a budget.
	- ❍ Describe sources of external funding and processes for seeking grants and other external resources.
	- ❍ Explain approaches for bringing about change in organizations, including empowerment, training, removing obstacles, dealing with resistance, and rewarding successes.
	- ❍ Describe the elements and process of formulating a plan for introducing significant change in an organization.
	- ❍ Describe approaches for developing effective working relationships between an organization, its community, and other external stakeholders important to its mission.
	- ❍ Describe approaches for advocacy, collaboration, and social marketing to gain support for an organization's mission and programs.
	- ❍ Describe performance measures and monitoring methods and the use of data and best practices to improve performance.
	- ❍ Define the core tools for analyzing and improving workflows and processes.
	- ❍ Explore the roles and responsibilities of managers and front line staff in improving safety, service, and financial performance.
	- ❍ Describe tools to assess and enhance an organization's competence and effectiveness to engage and serve the diverse constituencies that make up its workforce and community.
	- ❍ Explain best practices for creating an equitable inclusive workplace.

# **APPLICATION OF EXPERIENTIAL LEARNING AND PROBLEM-BASED LEARNING**

Cases within the block attempt to capture the breadth, depth, and complexity of the roles of managers and leaders and reflect management and leadership responsibilities both within an organization and in relating the organization to the environment in which it operates. Cases are set within a variety of community and public health contexts, including community health centers, human service providers, public health departments, and large public hospitals. Effective management and leadership require thoughtful, sensitive, skilled interaction with others. Public health practitioners must understand their own beliefs, values, and preferred styles of interacting with others in the work setting to enhance their capacities to lead and manage successfully. To support the growth of personal insight, the block provides students with the opportunity to explore their own "emotional intelligence" and managerial "style" and "skills" by completing a number of self-assessment instruments. Results of these assessments are shared only with student consent.

#### **CASE EXAMPLES**

#### **Leading for Equity**

This case shifts the focus from the inequities of the larger health care delivery system and affected communities to the internal inequities of a small community health center. The center's new director comes to his job expecting to be able to really leverage his experience to affect disparities experienced by the clinic's patient population. Instead he finds his clinic's culture and structures might actually be part of the upstream sources of those disparities. The new leader inherits a diverse front line team but a leadership team dominated by welleducated white males like himself. Staff feel that the odds of advancement are stacked against them, that rules are unclear and differentially applied, and that they do not have a voice in how the clinic operates. And patient satisfaction is less than stellar, with community members asking about all the promises the center made to them in its last planning cycle. Students explore the questions that a leader encounters when looking deeply at how to improve an organization's

#### **138** *Experiential Teaching for Public Health Practice Hurley et al.*

internal equity. Topics include audits for diversity and equity, strategies for improving and measuring performance, methods to enhance accountability to the community, and the emotional skills needed by managers to change culture and practices.

#### **Improve or Else**

This case gives students the opportunity to learn about some fundamental process improvement techniques that every public health practitioner should be familiar with regardless of her or his career destination. All public programs and services face pressure to do more with less, while improving the safety and satisfaction of consumers and staff. The case begins with a leader of an HIV/AIDS service organization confronting a federal funding requirement: the organization must reduce its longstanding wait times without new funding, or face future funding reductions. With the help of a newly hired manager with process improvement experience, the leadership team begins its introduction to basic tools and builds a plan for bringing its wait times down—and identifying other opportunities for improvement. Topics include the role of leadership; the composition of improvement teams; the process of identifying sources of waste, especially overprocessing and re-work; the use of tools such as value streams, spaghetti charts, 5S, Kanbans, and lead time measurement; and a description of a typical rapid process improvement workshop.

#### **CHALLENGES**

This block is scheduled for the final quarter of the two-year COPHP. Students are facing the distracting pressures of completing their second year capstone projects and beginning their job search for life after graduate school. In light of this student context, the format of the block returns to a more traditional exploration of learning objectives and postings with less emphasis on external community engagement. Instead, students are urged to approach their written products as real work communications with an emphasis on conciseness, clarity, and a compelling story. Because management and leadership take place only in the context of other human beings, the course encourages direct contact with community leaders and managers as sources, allows students to explore a series of personal assessments,

*Management and Leadership Experiential Teaching for Public Health Practice* **139** and includes role-play practice of interpersonal skills.

Faculty for the block comprises of all deeply experienced senior managers and leaders from various public and community-based organizations. Their participation in the block creates a unique temptation to step outside of the PBL traditional faculty role and participate more actively in class discussion. Students are eager to understand the "real world" of leaders and managers as they stand on the cusp of entering the public health workforce. Faculty must constantly weigh the value of sharing their own perspective, seeking the proper balance of contributing observations and holding back and asking questions on a limited basis.

# **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

#### **ACKNOWLEDGMENTS**

Declared none.

# **The Committee on Oppression, Racism, & Education (CORE)**

**Ariel Hart\* , Jennifer Hagedorn, Anne Althauser, Tara Bostock, Afomeia Tesfai, CORE Founders** and **Amy Hagopian\***

*Washington State Health Care Authority, University of Washington, Seattle, WA, USA*

**Abstract:** The Committee on Oppression, Racism, and Education (CORE) is a group of Community-Oriented Public Health Practice (COPHP) students working to integrate anti-racist principles into the program. CORE provides a common language and framework to discuss racism in COPHP. It has a twofold overall purpose: to tackle manifestations of racism playing out in the classroom environment and in the COPHP program structures, and to ensure all students graduating from the COPHP program are prepared to address issues of racial equity as public health practitioners. By confronting the underlying drivers of health disparities that plague people of color, CORE has become a force for institutional change not just in COPHP but also in the School of Public Health, elsewhere in the University of Washington, and in the community.

**Keywords:** Anti-racism, Anti-racist education, Anti-racist principles, Anti-racist public health program, Classroom culture, Community engagement, Community organizing, Health equity, Institutional change, Institutional organizing, Institutional racism, Internalized racial inferiority, Internalized racial oppression, Internalized racial superiority, Micro-aggressions, Racism, Student-driven change, Systems of oppression, Undoing institutional racism, White privilege.

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding authors Ariel Hart and Amy Hagopian:** University of Washington, Seattle, WA, USA; E-mails: amhart521@gmail.com and hagopian@uw.edu

# **BACKGROUND**

Problem-based learning, the teaching and learning method used in COPHP, gives students an opportunity to create the learning environment they want. But even within COPHP classrooms, students of color were experiencing the same, and sometimes more severe, micro-aggressions and marginalization than they had in past work and educational settings.

Before CORE, students lacked a common language or framework to discuss racism in COPHP, and it became clear that the program needed additional resources and dedicated time for anti-racist education. Several cases offered opportunities for students to discuss racism and its effects on health, but the conversations lacked depth and highlighted students' hesitancy to focus on racism. The program offered one two-hour seminar during fall quarter to explore the ways racism affects public health. But as future public health professionals, students felt it would be negligence to graduate with an MPH and not have a more comprehensive understanding and vocabulary about racism than could be offered in a couple of seminars.

## **CREATING CORE**

In fall 2013, a few students came together to discuss the manifestations of racism in the classroom and within the structures of the COPHP program. They decided the program needed external support to become anti-racist. Students initially formed CORE to bring anti-racism organizers to COPHP, but the group quickly expanded its goals to become a force for institutional change within COPHP, the School of Public Health, other schools within the University of Washington, and the community.

CORE's goals are:


#### **142** *Experiential Teaching for Public Health Practice Hart et al.*

mutual caring.

3. To build and maintain relationships with community organizations to establish accountability to racially oppressed communities in the Seattle-King County region.

#### **FOCUS ON RACISM**

In the United States, the racial categorization of human beings has enabled certain groups of people to have disproportionate access to educational, economic, social, and health opportunities. This specious categorization has played a pivotal role in creating the economic inequality and the poor health outcomes that we see in our country today. Our current societal institutions and systems frequently screen out people of color in a systematic manner from obtaining wealth, prosperity, and general success. Therefore, CORE members felt it was vital to critically analyze their own institution, the COPHP program within the University of Washington School of Public Health, to move toward a fully inclusive environment.

Other oppressions (sexism, heterosexism, classism, *etc.*) are also linked to health outcomes. But without an intentional focus on eliminating racist policies and protocols (both formal and informal), efforts to confront these other "-isms" will undoubtedly perpetuate racial disparities. Confronting the underlying drivers of health disparities that plague people of color requires that students build the skills necessary to identify barriers to health equity and challenge the systems and institutions that privilege white people to the detriment of people of color.

#### **Guiding Principles**

CORE adopted the anti-racist organizing principles of the People's Institute for Survival and Beyond as a framework to guide efforts internally and externally. Before fully embracing and using the principles, CORE brought anti-racist organizers to campus for a deep dive into racism in the United States and an examination of how internalized racial oppression and superiority were playing out in the classroom. CORE called for an anti-racist analysis to be integrated into the curriculum and competencies for all future cohorts as well. Partnering with the People's Institute provided students with a common analysis of racism as well as a deep understanding of oppression and organizing strategies to bring social liberation in public health and in the many other spaces students occupy.

CORE's work within the COPHP program, with support from the People's Institute community organizers, provides students with the language to name and challenge racism in the classroom and beyond. CORE believes students' capacity to change racist institutions begins with COPHP giving students the understanding and skills to stand against oppressions and injustices.

# **CORE ACTIVITIES**

Since its inception, CORE has acted as a change team, paving the way for antiracist work. Throughout this anti-racism process, CORE members have intentionally engaged students, faculty, and community partners in multiple conversations about anti-racism goals and activities. Following are some of CORE's approaches.

	- ❍ Integrating questions about anti-racism into end-of-quarter student feedback questionnaires
	- ❍ Developing anti-racist approaches to faculty hiring, including revising job descriptions to include the program's vision of undoing structural racism
	- ❍ Crafting and including a statement of COPHP's anti-racist commitment into program syllabi
	- ❍ Collaborating with faculty to revise PBL cases and integrate content on racism and public health into learning objectives and class discussions
	- ❍ Serving on the admissions committee to bring transparency to this process

and increase the diversity of voices making these decisions


CORE's work within the COPHP program has gained the attention of the School of Public Health more broadly, as well as other schools within the University of Washington. Members of CORE were asked to teach a one-credit elective course on racism in public health practice each quarter of the academic year to expose students in the larger School of Public Health to discussions about structural racism. CORE members may in the future be involved in the creation of a class in the School of Public Health to fulfill a new core competency regarding racism. CORE members presented about the journey of working towards becoming an anti-racist program at the 2015 American Public Health Association. Students in other programs at the University of Washington have reached out to CORE members for consultation and partnership, and CORE has supported their organizing.

● **Community organizing.** CORE places a high value on engaging with community issues because it creates accountable relationships between anti-racist community organizing groups and COPHP. They partner with community organizations affiliated with the People's Institute to support community organizing. Among these partnerships are:

#### ❍ **Ending the Prison Industrial Complex (EPIC)**

This multi-racial, multicultural, inter-generational collective of anti-racist community organizers works to create alternatives to detention; it advocates that the county stop the construction of a new youth jail. CORE provided support by engaging faculty and students from other departments to testify at city and county council meetings about the public health benefit of reducing racial disproportionality within juvenile justice and creating healing spaces to respond to the underlying issues with a punitive criminal justice system.

#### ❍ **European Dissent**

This is an anti-racist collective of white people who organize to undo racism in accountable relationships with groups led by people of color. Members of CORE have collaborated with European Dissent to give community presentations and do organizing within predominantly white institutions and communities.

# ❍ **The Village of Hope**

This Black-centered collective supports communities of color, especially in relation to the criminal justice system. CORE members hosted meetings of elected officials about issues chosen by the Village of Hope and the Black Prisoners' Caucus.

Informally, CORE students and COPHP faculty run into each other at Black Lives Matter events, picket lines, marches, City Council meetings, and other events and activities in the community. These solidarity moments create opportunities for team-building and a sense that our program is part of something larger than just an academic enterprise.

# **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

# **ACKNOWLEDGMENTS**

Declared none.

# **Final Thoughts about the Future of COPHP and Conclusions**

**Amy Hagopian\* , Bud Nicola** and **Peter House**

*University of Washington, Seattle, WA, USA*

**Abstract:** Public higher education in the United States is in great flux. A number of factors adversely affecting the effectiveness of higher education in the U.S., such as the erosion of public financial support, have undermined the COPHP program. Recruiting and retaining an ideal mix of motivated students and faculty are ongoing program tasks. In spite of these challenges, COPHP is an effective program for producing successful, motivated, and highly sought-after graduates in public health.

**Keywords:** Culture, Higher education, Faculty, Funding, MPH, Program size, Students.

#### **REFLECTIONS**

Now that our the COPHP program is a little more than a dozen years old, we have enough experience to reflect on how we might have designed some things differently. We also have some musings about our future.

We have highlighted all the ways in which our program succeeds and thrives in the previous chapters of this book. In this chapter we will reveal some of our continuing concerns and some of the downsides of this pedagogical model.

First, we exist in the context of public higher education in America, which is seriously in disarray. "Contingent" faculty are now the norm in U.S. higher education, with tenured or tenure track faculty at most institutions in the minority,

**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

<sup>\*</sup> **Corresponding author Amy Hagopian:** University of Washington,Seattle, WA, USA; E-mail: hagopian@uw.edu

#### *Final Thoughts about the Future of COPHP Experiential Teaching for Public Health Practice* **147**

and at our university this reality is even more exaggerated. The University of Washington (UW) as a whole moved from a position of 70% regular tenure track faculty before the 2008 economic collapse to 30% now. Public health master's programs at our university, and across the U.S., commonly supplement regular faculty ranks with part-time faculty whose regular employment is elsewhere; this can bring in niche areas of expertise. COPHP does this to an extreme. Further, those who do have more regular faculty appointments at the university are obligated to bring in the bulk of their salaries through grant funding, as state appropriations are far too small to support a full-sized school of public health. This context creates a situation where our highly student-focused program relies on faculty willingness to volunteer time to assess twice-weekly postings (usually in the evenings, when class is the next morning), as well as to contribute to the life of the program through monthly faculty meetings, admissions committee, student orientation, first-year student advising (which includes practicum supervision), annual faculty retreat, capstone presentation day, graduation celebrations, and our many social events throughout the year. It is not clear that this arrangement is sustainable, especially as grant opportunities dwindle for our regular faculty and appropriations for our faculty with public health day jobs decline in tandem.

Our program is one of many programs in the UW School of Public Health, which admits nearly 200 MPH students each year (along with other master's degrees, such as health administration). Other MPHs include programs in social and behavioral sciences, maternal and child health, environmental health, epidemiology, global health, international health metrics and evaluation, genetics, nutrition, an executive MPH using distance learning, and even an occasional biostatistics MPH. We swim in that rich stew and benefit from much crossfertilization and the elective courses generated by a school of this size. Some of our faculty teach in other programs as well. Our program is well known in the school, and other faculty have occasionally approached us about how to introduce some problem-based learning into their courses. Nonetheless, because our PBL classes are entirely self-contained, each of our students is surrounded by only 23 other students (in groups of 8) for all their core course time—about seven hours per week. This kind of insularity and intensity has contributed to a mixed reputation in the school. Our students are known for being intensely driven, hard-

#### **148** *Experiential Teaching for Public Health Practice Hagopian et al.*

working, and vigilantly focused on social justice concerns. They are popular with faculty offering electives in that our students are attentive and prepared, they contribute to class discussions, and they skillfully take on leadership roles in small group projects and discussions. They can also be overly focused on the process aspects of their classroom dynamics and when a problem arises can spend quite a bit of time and energy on what to an outsider can look like self-absorbed activity. It has also happened that a group of students will decide a faculty member is not sufficiently attentive to classroom dynamics and deferential to student-driven norms and expectations, which can be painful and discouraging for that faculty member. The student intensity has definite advantages for a strong, well-regarded faculty member, but can lead to burnout and loss of some faculty members where there is a teaching style and cultural mismatch with the program.

One of the goals we set for ourselves was to make available our model to international universities. One of the clear advantages of U.S. higher education is that it nourishes creativity, curiosity, questioning and well, just sassiness. In many places, especially in low and lower-middle income countries, higher education is still stuck in more traditional models of lecturing and memorization for exams. Ideally, our program could attract international students who could then return to their home countries to teach in their universities using this approach. The fiscal reality, however, is that because COPHP is so expensive, and has so little public funding support, we cannot make it available to international students at a price they can afford.

This price issue has other negative consequences. Our high tuition and lack of publicly funded scholarship opportunities limits our ability to attract first generation and other low-income students. We have considered ways to "scale" the program to make it more affordable; all scenarios include increasing the class size or leaving students to manage PBL class sessions without faculty presence. This year, we are experimenting with a 30-student public health skills class for MPH students in other programs where students will select projects from among several offerings proposed by community-based partner organizations.

We believe we have reached a maximum program size at 24 students per year. This puts some practical limits on any academic or social event involving all

*Final Thoughts about the Future of COPHP Experiential Teaching for Public Health Practice* **149**

students along with faculty and others. Our capstone presentations are now structured to have parallel sessions, because a single session would require more than five continuous hours, at 13 minutes per presentation for 24 students.

As program directors, the most important task we faced was to attract, orient, and retain faculty who were well-suited for our pedagogy. The traditional MPH core courses required to meet accreditation-required competencies at the UW include epidemiology, biostatistics, health systems, social determinants of health and environmental health. Each of these five courses enrolls more than 100 students. Long-standing senior faculty typically teach them, and department chairs rarely have difficulty filling these teaching spots. By contrast, recruiting 26 suitable faculty to staff nine core courses (times three sections each) is a substantial challenge.

In a similar vein, attracting 24 well-matched students to the program each year is also challenging. Students must be PBL-ready and know exactly what they're getting into. We have to carefully monitor the admissions process to be sure we don't admit too many or too few, and we don't want any drop-outs because the class size is optimal at 8. We've been fortunate to have very few drop-outs over the years because we pay a lot of attention in the admissions process to ensuring enrollees are fully aware of what they are getting into and will fit into COPHP culture. In addition, one of our recruitment goals is to identify a cohort of students whose diversity contributes to the group knowledge base. This means our admissions process considers factors far outside the usual GRE and GPA numbers, resulting in the acceptance of students who sometimes require more academic support than traditional programs would be prepared to sustain. We believe our graduates are better public health professionals, although perhaps not all are academic powerhouses.

We have a strategic plan to guide our future. Our plan includes two important goals: "Build on our success to maintain an exciting, thriving, academic program to train practitioners who will improve the public's health", and "Improve our fiscal and administrative situation". The action steps for these goals are offered in Appendix K.

## **CONCLUSION**

We know we can manage and overcome several challenges discussed above in this chapter. COPHP is succeeding in training the next generation of public health practitioners. Problem-based learning can be arduous for students and faculty alike, but, in the end, it can be done and it really works. Our graduates think critically; they are skilled in all forms of communication; they know how to find, manage, and evaluate information; and they are skilled facilitators and team players. Our cases change yearly, which means that our graduates are knowledgeable about the current issues and contents of public health practice. And, importantly, our graduates are finding meaningful and rewarding employment, and they are active in their communities.

The intent of this book is to educate and build enthusiasm about the power of case-based and problem-based learning in public health, and the importance of creating a tightly-knit program that emphasizes social justice and anti-racist principles. If you are reading this as an academic leader with an interest in learning from our approach, we would like to encourage you to visit us, borrow from our cases, and experiment in your own school of public health. The world needs new public health professionals who are ready to take on ambiguous and daunting situations, fearless about tackling emerging challenges, highly skilled (especially with regard to systems thinking, written and oral communication and working in teams), and who are driven by progressive public health values.

#### **CONFLICT OF INTEREST**

The authors confirm that they have no conflict of interest to declare for this publication.

# **ACKNOWLEDGMENTS**

Declared none.

# **Appendix A-List of Online Resources**

#### 1. **COPHP website**

http://www.mphpublichealthpractice.uw.edu/

2. **Capstone titles, sorted by general topic areas, or in a matrix by international, quantitative, schools-based, environment, vulnerable populations, population health, health departments**

http://www.mphpublichealthpractice.uw.edu/overview/capstone/


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# **Appendix B-COPHP Peer Review Process**

Community Oriented Public Health Practice Program Faculty Peer Review for 2014 - 2016 (Revised May 2014)

Background and purpose:


Process:

	- ❍ What day of the block will allow the most variety of activities?
	- ❍ What day (and time within the day) of the block will afford observations opportunities of most use to the observed faculty?

# **Appendix C-COPHP Learning Objectives Compared to University of Washington MPH Competencies**


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#### *COPHP Case Subscription Information Experiential Teaching for Public Health Practice* **155**


*Nicola & Hagopian*

# **Appendix D-Student Feedback Form**




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# **Appendix E-Orientation Week Schedule**


# **Appendix F-Sample Practicum Project Description**

MPH in Community Oriented Public Health Practice Practicum Placement Request Form Public Health—Seattle & King County

1. Project Name Jail Health Services Diabetes Project


2. Practicum Site Location/Address Jail Health Services, King County Correctional Facility, 500 Fifth Avenue, Seattle.

3. Briefly describe the section or program that will house the practicum project (*e.g.* Family Planning/CHS). What are the overall goals of the section or program? Provide link to additional information about your section.

Jail Health Services is responsible for the provision of medical, dental and mental health services provided to the inmate-patients in the King County Jails. This includes the two facilities: King County Correctional Facility in downtown Seattle and the Maleng Regional Justice Center in Kent.

The Jail Health Services Mission Statement is as follows:

To assess and stabilize serious health problems for the detained population of the King County Correctional Facility and the Maleng Regional Justice Center with a focus on transition from jail.

The mission of Jail Health Services is carried out through the following commitments:

Foundation


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#### Understanding


#### Clinical Services


#### Outcomes


What is the purpose of the project?


The purpose of this project would be to assist Jail Health Services in better understanding the characteristics of the incarcerated diabetic population and to examine possible strategies for developing stronger linkages with the Public Health clinics for this patient population. The project would ultimately aim to improve provider follow-up at the clinic visits and track key indicators for the care of diabetic patients. This project would align with several of the commitments in the JHS strategic framework, including responsiveness to the characteristics of our population, identification of patients with serious health problems and stabilization and continuity of care for our patients.

The student activities would include helping to determine key diabetes indicators. Data sources would include existing data from the electronic health record and from patient interviews using a student-developed data collection tool. This data would be used to create a descriptive report on the diabetic patient population in the two King County correctional facilities. The student would be involved in the dissemination of this data to the JHS clinical

#### *Nicola & Hagopian*

#### *COPHP Case Subscription Information Experiential Teaching for Public Health Practice* **163**

staff and developing associated recommendations. Strategies for improving linkages with King County Public Health clinics for continuity of care will be explored.

The specific deliverables would include a data-collection tool and a descriptive report with recommendations. The student would learn how to use existing data and determine how to obtain additional data to thoroughly describe a specific at-risk population. The student would develop skill in compiling the data, analyzing it for recommendations, and sharing it with the health professionals that provide the direct patient care to the population studied. The student will learn about the challenges and opportunities for public health interventions in a correctional setting. The scope of this project would be appropriate for one student.

5. Please estimate the percentage of time students will engage in the following activities:

Internet or Library Research (~10%) Website development (N/A) Observing public health staff (~5%) Analyzing Data (~50%) Field activities (*e.g.* trainings, focus groups) (~15%) Preparing written materials (~20%)

6. List any essential skills students must have (*e.g.* SPSS, epidemiology skills, materials development, foreign language) as well as:


7. List any desirable skills you would like your student to have.

8. Practicum students work 6 hours per week. How much of the practicum work should be done on-site or in the field? How much can be done off-site (*e.g.* UW library)?

On-site ~approximately 50% of the time, with on-site time more concentrated at the beginning and the end of the project

Off-site ~ approximately 50% of the time, particularly when analyzing the data

9. Work Hours/Schedule Requirements (please note if you have special requirements):

The expected student practicum hours would be during regular business hours, Monday through Friday.

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10. Other Comments:

Must pass background check.

© 2017 The Author(s). Published by Bentham Science Publisher. This is an open access chapter published under CC BY 4.0 https://creativecommons.org/licenses/by/4.0/legalcode h

*Nicola & Hagopian*

# **Appendix G-Practicum Self-Assessment Survey**

What kind of job do you see yourself in after you graduate? What setting (e.g. local public health, state, federal, community-based agency, hospital)?

Think about yourself as a public health student and intern. What do you see as your greatest strengths? What do you think you have to offer a public health department?

Think about yourself as a public health student and intern. What do you see as your weaknesses? What do you need to learn?

Do you speak any languages other than English? Which ones? How fluent?

The following are typical public health practicum skill areas. Please circle the ones you've had experience with:


Circle the computer programs you can use:


What areas of public health are you most interested in? Circle up to 3.

Adolescent Health/School Health Asthma

#### *Nicola & Hagopian*

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Cancer Prevention Chronic Disease Prevention Emergency Preparedness Environmental Health Epidemiology Health Education Health Disparities HIV/STD Prevention Immunizations Injury Prevention International Health Nutrition/Physical Activity Rural Health

Anything else I should know:

# **Appendix H-Service Learning Contract**



#### *Experiential Teaching for Public Health Practice Nicola & Hagopian*


#### *COPHP Case Subscription Information Experiential Teaching for Public Health Practice* **169**



#### *Experiential Teaching for Public Health Practice Nicola & Hagopian*



# **Appendix I-Sample Daily Learning Objectives**

Following are daily learning objectives from the NeighborCare–LARC case in the Evaluation block:

#### **Day 1**


#### **Day 2**


the two related? What might some questions be for this case?


# **Appendix J-Sample Case Facilitator Notes**

Since we have three faculty for each "block," or course topic area, the writing of cases is typically distributed among the faculty. The case writer is encouraged to write "facilitator notes" for fellow faculty, to guide them in how they work through the case with students. The following facilitator notes from one case within the Policy block provide some insights into the ways facilitators prompt students to grasp issues in particular ways.

The first set of notes concern the case "You Never Die of Just One Thing," which takes place in Ghana.

#### **Day 1**


#### **Day 2**

1. Notes: This is a wide-ranging day, and you should encourage students to think broadly about global health aid and whose interests are served. We plant seeds to lead them to two critics in the field. The key thing I want them to get from Amartya Sen is that it's not enough to make more food (or food fortification) available. There's rarely a

shortage of food that's the problem. The problem is people can't afford to buy it because they're poor. This gets them to the economics of importing and exporting food.


#### **Day 3: Assignment**


The second set of notes concerns a case addressing minimum wage policy in Seattle.

#### **Day 1 and 2**

The purpose of the LOs on Days 1 and 2 is to get them immersed in the issues surrounding the minimum wage as a public health issue. We want to be sure they have a sufficient grasp of the issues to write smart products.

This is one of the few cases where we address **economic issues**, and students have requested more of this. Some concepts: effects on unemployment of higher wages; surplus value; whether higher wages contribute to or detract from the strength of the economy.

Students should be encouraged to **connect dots**: For example, the proportion of FTE employment is related to health benefits.

We don't discuss **campaigns** anywhere else in this course, so if we want to spend some time discussing how the Fight for Fifteen occurred, that wouldn't be a bad thing. Marilyn Watkins will be coming to seminar to talk about the initial statewide initiative campaign.

At the same time they are chasing down content knowledge on minimum wage, they should be conscious of developing specific skills related to policy analysis.


# **Appendix K-Strategic Plan Excerpts**

# **1. BUILD ON OUR SUCCESS TO MAINTAIN AN EXCITING, THRIVING, ACADEMIC PROGRAM TO TRAIN PRACTITIONERS WHO WILL IMPROVE THE PUBLIC'S HEALTH**


#### **2. IMPROVE OUR FISCAL AND ADMINISTRATIVE SITUATION**

1. With grave concerns about the adequacy of funding for graduate education, we will continually re-evaluate our program's "privatized education" relationship to the UW. We propose a formal faculty/administration joint review of both activity-based

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*Nicola & Hagopian*

budgeting (ABB) and Professional and Continuing Education (PCE) models.

We seek principled alternatives to the current arrangement, in which COPHP students pay the fully-loaded costs of their MPH education. All UW graduate students should expect State of Washington investment their education.


# **Appendix L-COPHP Case Subscription Information**

In the near future, annual subscriptions to all of COPHP PBL cases will be available (approximately 30 over a two year curriculum). Cases will cover the entire syllabus of COPHP MPH curriculum with each block represented. PBL cases in the COPHP program are revised and replaced on an annual basis. **Please contact cophp@uw.edu if you are interested for more information.**

#### **SUBJECT INDEX**

#### **A**


## **B**

Barriers 20, 39, 49, 94, 123, 131, 142, 173 Biostatistics iv, 4, 6, 12, 28, 58, 70, 103, 106, 123, 147, 149 Built environments 109, 110

#### **C**


#### Collaboration 8, 16, 28, 41, 43, 87, 100, 136


#### **D**

Data i, 15, 24, 26, 28, 62, 63, 66, 74, 76, 97, 119, 123, 125, 126, 136, 154, 155, 162, 163, 165, 172-174 Delivery 128, 137

## **E**


**Bud Nicola & Amy Hagopian (Eds.) © 2017 The Author(s). Published by Bentham Science Publishers**

Environmental epidemiology 109 Environmental health i, iv, 4, 12, 28, 74, 117, 147, 149, 155, 166 Environmental racism 114 Ethics 116 Executive briefing 109, 113 Expectations 34, 41, 43, 44, 46, 58, 60, 76, 91, 148 Experience i, iii, iv, 6, 7, 27, 31, 33, 38, 39, 42, 43, 45, 46, 49, 50, 52, 66, 90, 93, 95, 97, 98, 101, 105, 114, 122, 125, 128, 132, 135, 137, 138, 146, 165 Experiential instruction 97

## **F**

Facilitated learning 22 Facilitator i, 36, 38, 46, 47, 80, 99, 122, 131, 152, 174, 175, 177 Faculty ix, 3, 10, 22, 23, 41, 42, 69, 71, 73, 74, 89, 93, 95, 96, 100, 114, 121, 124, 130, 132, 139, 174, 176-178 Financial management 15, 134 Financing 128, 155

#### **G**

Graduation 35, 39, 41, 44, 49, 55, 61, 64, 70, 71, 147, 177 Group dynamics 22, 26, 42, 46 Group skills 41

# **H**

Handbooks i, 51-53 Hazard analysis 109, 111, 114 Health behavior i, iv, 6, 28, 153, 154 Health disparities 109, 114, 140, 142, 154, 166 Health equity 125, 140, 142 Health policy 6, 28, 48, 49, 80, 87, 101, 128, 130, 132 Health promotion i, iv, 6, 65, 129, 154, 155

# **I**

Inequality 84, 86, 87, 142 Inequities 39, 57, 109, 137, 154, 155 Institutional change 140, 141 Institutional racism 39, 41, 46, 49, 79, 109, 140 Instructional technology 27, 31, 32, 36 Internalized racial inferiority 140 Internalized racial superiority 140

#### **L**

Leadership i, iv, 5, 8, 13, 14, 20, 28, 41, 44, 55, 134, 135, 137, 138, 148, 155, 175 Leading change 134 Learner-centered education 22 Learning contract i, 69, 73, 167 Learning cycle 22, 27 Learning environment 47, 48, 97, 100, 141 Learning objectives i, 13, 14, 16, 20, 24, 26, 27, 46, 47, 72, 73, 79, 80, 83, 84, 89, 92, 97, 104, 106, 110, 111, 114, 129, 135, 138, 143, 172, 174 Lecture 16, 78, 97 Literacy 94, 116, 119 Literature review 5, 60, 64, 66 **M**

Marketing 56, 119, 136 Medical harm 84, 86 Micro-aggressions 43, 140, 141, 177 Morbidity 84, 85, 90, 110 Mortality 90, 98, 110, 153 MPH i, iii, 3, 4, 14, 18, 22, 28, 31, 32, 45, 55, 60, 62, 69, 70, 72, 78, 83, 84, 86, 89, 101, 109, 116, 131, 141, 161, 178, 179

Multi-cultural 41

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## **N**

Networking 65, 69, 70

Norms 41, 43, 47, 48, 57, 58, 60, 67, 89, 148

## **O**


## **P**


54, 56, 67, 69, 80, 89, 114, 117, 128, 136, 148 Prospective students 41, 51, 52 Protection standards 109, 112 Protective factors 116, 118 Public health pedagogy 97 Public health practice i, iii, vii, viii, 3, 4, 7, 10, 14, 26, 38, 45, 51, 60, 78, 81, 83,

84, 89, 90, 92, 93, 96, 97, 100, 106, 107, 109, 110, 116, 134, 140, 144, 150, 152, 155, 161, 177 Public policy vii, 10, 81, 128, 129, 132

# **Q**

Quantitative methods 101, 102, 104, 117, 123, 175

# **R**


# **S**


Strategic plan i, 25, 149, 177 Strategic planning 32, 134 Student-driven 41, 47, 140, 148 Student feedback i, 28, 31, 37, 38, 48, 59, 143, 156 Student presentations 89 Student support 6, 31, 32, 34 Systems of oppression 140

#### **T**

Teaching i, iii, iv, 5, 6, 19, 23, 25, 28, 31, 43, 57, 78, 83, 90, 104, 116, 117, 141, 148, 149, 152 Team dynamics 134 Tertiary prevention 116

#### *Subject Index Experiential Teaching for Public Health Practice* **183**

Thesis 6, 8, 53, 66, 79 Town hall meeting 109, 113, 121 Toxicology 109, 111

#### **U**

Undoing institutional racism 49, 140

#### **V**

Values 11, 16, 42, 44, 48, 50, 51, 54, 57, 103, 128, 129, 131, 135, 137, 150, 178 Variables 66, 118, 123, 126, 154, 172, 173

#### **W**

Website 39, 51, 52, 58, 63, 65, 151, 163, 165 White privilege 39, 140