2. Have completed at least one full year as a public health major

3. Commit to completing a second semester of peer advising after the fall seminar

## **RESPONSIBILITIES AND ASSESSMENT**

Peer advisors receive three internship credits in the fall and two in the spring. The Head PAs receive an additional credit each semester. The PAs are assessed on the completion of their responsibilities, including:

The goal is to have the peer advising drop-in center open 30– 40 h per week. Each PA is expected to staff the center 3 h per week. The PAs are trained to provide PHS majors academic advising and guidance to meet department and University requirements. Before each advising session, advisees have to sign a form giving permission to the PAs to review their academic requirement report and discuss courses. Advisees are allowed to decline permission for the PA to view their academic information if they only want to ask questions. After each advising session, the PA must complete an advising log stating whom they spoke to (name of student, student ID number, year, major, and track), the reason for the visit, advice that was provided, actions taken, and referrals. The logs are

reviewed on a weekly basis to ensure the correct information was provided. PAs are required to write a weekly online post about their experience in the Peer Advising Center. The posts provide a place for students to discuss and resolve issues, create cohesiveness with shared experiences, and increase feeling of support.

## **ROLE OF A PA IN ONE-TO-ONE ADVISING SESSIONS**

In meeting with advisees, PAs provide guidance in the following areas:

Each PA must contribute to the Department, PHS student body, community, and/or SPHHS through a departmental service project. PAs have the option to collaborate with other PAs or create their own project/event. A proposal must be submitted and approved before the start of the project. Due to the success, many of the projects are repeated the following year (**Table 2**). Another component of the PA program is to engage in the community

## **Table 2 | Peer advisor departmental service projects**.

through the PHS club. The PAs are required to attend at least three PHS Club events and/or meetings each semester.

## **METHODS**

Several methods were used to understand the perceived benefits and challenges of the program and experiences of students who utilized the Peer Advising Center. The data for this evaluation were drawn from three sources:

## **ARCHIVAL RECORDS**

The PAs completed a record of each visit. The total number of student visits during the 2013–2014 academic year and the reason for the visit was summarized.

#### **PEER ADVISORS' REFLECTION PAPER**

Reflection papers from nine of the PAs (female = seven and male = two) were analyzed. Each of the PAs were required to submit a 5–10-page paper at the end of both fall and spring semesters reflecting on their experience as a PA. They were asked to reflect upon their experiences broadly, including skills learned and suggestions for departmental, advising, and training improvements (**Table 3**). A codebook was developed and modified as analyses progressed to reflect emerging themes or to merge thematically equivalent codes. On completion of coding, patterns in the data were identified. Recurrent themes were summarized into several broad categories. The reflection papers were also reviewed for key quotes that highlighted their experiences in the internship.

## **UTILIZATION OF THE PEER ADVISING CENTER**

In April 2014, an electronic survey was sent to 507 undergraduate public health students for input into their experiences as a Public Health major. The survey included demographics of the participants' class year and major track. Two questions from this survey focused on their experience of using the Peer Advising Center. The first question was "How often do you seek Public Health advising with peer advisors?"Participants could select"never, once a semester, two-to-three times per semester, over four times per semester." The second question was "Based on your last advising session with a PA, how would you rate your experience on a scale 1–5 with 1 = not good and 5 = excellent?"

## **RESULTS**

#### **ARCHIVAL RECORDS**

In the 2013–2014 academic year, the PAs had a total of 573 one-to-one meetings with students in the Peer Advising Center. Of the 573 visits, sophomores visited the office most frequently (*n* = 195), followed by juniors (*n* = 130), seniors (*n* = 86), first years (*n* = 86), and unclassified (*n* = 76). The three most common reasons that students visited the Peer Advising Center were questions about course selection, applying to the major, and collateral field.

### **Table 3 | Questions PAs were requested to address in their reflection papers during fall and spring semesters 2013–2014**.

	- b. Comment on what did and did not work, barriers, and successes
	- a. What additional classroom knowledge might have been useful?
	- b. Do you have any specific topics that you would like to include or exclude? Please explain why

## **PEER ADVISORS' REFLECTION PAPER**

#### **Perceived benefits of the Peer Advising Program**

Peer advisors identified several benefits that the Peer Advising Program had on their personal development.

*Skill building.* Peer advisors identified a wide variety of skills obtained from their peer advising experiences with interpersonal communication skills (*n* = 9), organizational and time management skills (*n* = 6), and presentation skills (*n* = 6) most frequently identified. With more experiences, PAs (*n* = 7) gained more confidence in their ability to make presentations and conduct one-toone advising sessions. The following quotes from PAs' reflection papers illustrate the variety of skills they obtained from their peer advising experiences.

I have seen myself transform over the course of the year as I learned to take control over my own projects and ideas, feel confident in a role of support for fellow students and be a valuable member of a productive team.

I enjoy asking students about their interests within Public Health, and bouncing ideas off each other about possible career options, course offerings, or extracurricular opportunities. The most rewarding aspect of advising students is when they feel a sense of relief; students leave the office feeling somewhat less stressed and profoundly grateful for my help. When students express their gratitude after brainstorming a solution together, it feels like I made a difference.

Instead of giving a student the answer to his/her question, I try to provide the tools, resources, and information necessary for the student to find the answer. This instills a sense of responsibility and self-efficacy in the student.

I have been told by professors after [a] presentation that I come off to the class [in] a very professional way, I can attribute this to the skill developed as a peer advisor.

*Feeling valued and supported.* Many PAs reported that they felt valued (*n* = 6) and made a difference (*n* = 9) in improving the major and in one-to-one sessions with advisees.

I think the best part about being a peer advisor is that we have the ability to make changes within the major based on students' interests. We are somewhat like ambassadors for the other public health students. Friends and peers alike come to us with their issues. We analyze them, speak up when necessary, and advocate for change.

Peer advisors feel that they add a valuable insight to being a successful student that a staff or faculty member may not be able to offer.

As undergraduate students, we have a current experience of the public health major that faculty members don't necessarily have, making us able to better understand the questions and attitudes of students. Some students also find us more approachable as peers their own age and level while they might find an adult to be someone they have to impress or be over-prepared to talk to.

Peer advisors expressed a sense of pride (*n* = 8) when referring to their creation and implementation of departmental projects, representing the department, and identifying strategies to improve major and students' experience in the major.

Now that I have worked to make the school more functional for the student body, I want to see it succeed even further. I feel an obligation to work to make the major the best it can be.

Two PAs reported students approaching them outside of the Peer Advising Center for academic advice and resources. PAs found their work to be rewarding (*n* = 7). They felt that they made positive changes in the major and ability to provide academic resources and strategies to get involved in public health outside of the classroom (*n* = 8).

*Engaged in the community.* A major goal of the PA program was to emphasis teamwork and build community. Consequently, PAs were required to regularly work together in event planning and conducting workshops. The PAs commented on their increased ability to work well with others (*n* = 7), and their strong sense of community within the major (*n* = 7).

The public health peer advising internship has been one of the most defining and influential experiences of my time here at UMass. The role has made an incredible impact on the UMass community I have worked with and been a part of, and I'm so fortunate to have been given the opportunity to make such a difference and have a strong voice within it.

Without this internship, I would have never found this amazing support system.

*Gained knowledge of the public health field, major, and University.* Peer advisors reported that their PA experiences provided them increased knowledge about academic and professional resources (*n* = 8) that were beneficial to their advisees and themselves. PAs reported an increased understanding of the public health field and careers (*n* = 6), major (*n* = 5), and University.

Now that peer advising has ended and I move on from college to a new chapter in my life, I am going to take everything I have gained through this internship and at UMass with me on my journey. I am going to take my excellent interpersonal, time management, organizational, and networking skills along with so many other acquired skills to my new career in public health. I am leaving this internship with so much more knowledge around public health and how the different domains all come together. I have a much clearer view on what I want out of my career and my life and I am confident I have gained the skills and knowledge necessary to be successful.

Becoming a peer advisor this semester was an amazing experience that enhanced my understanding of the public health major and connected me more with the public health community at UMass Amherst.

*Cultural competency.* Four PAs highlighted their increased knowledge of cultural competency and diversity from the internship. It encouraged them to be non-judgmental and more understanding of other students' experience. One PA commented on a guest speaker who talked about diversity on campus:

[The guest speaker's] talk really opened my eyes to all the factors that make students diverse. Race and culture tend to be better-known areas of diversity since they are more apparent, but things regarding sexual orientation and learning disabilities, among others that tend to be forgotten, are equally important when it comes to recognizing diversity among students. . . This kind of information and perspective was great for becoming a better-rounded peer advisor since we come in contact with so many students and its important to recognize that not everyone is a cookie-cutter student.

## **Perceived challenges of the program**

Peer advisors also highlighted several challenges with the program, including: (1) low attendance rates for large advising sessions, (2) difficult advising scenarios, (3) not knowing all of the answers, and (4) variable workload throughout the semester.

*Low attendance rates for large advising sessions.* Since the implementation of the program, PAs have conducted large advising sessions that are tailored to the advising needs of specific class years within the PHS major. For example, at the sophomore advising sessions, PAs share information on study abroad programs, and at the junior advising event, the PAs would talk about volunteer, research, and internship opportunities. Several PAs (*n* = 3) expressed their frustration with the low attendance rates at these advising sessions and possible reasons for low turnout.

Getting a very low attendance at [large advising sessions] demonstrated that this might not be the best approach to getting information to students and also that students prefer to meet with advisors one on one. It was noticed that students are using the advising office more and more.

*Increase role-play for difficult advising scenarios.* Peer advisors (*n* = 5) suggested that they would have benefited from more role-plays especially as it related to dealing with difficult student situations. For example, PAs identified the need for more training related to working with: (1) students who discovered they will not be graduating on time, (2) students who were angry about departmental issues such as a lack of class availability, (3) students who were not motivated, and (4) students who expressed concern over having a lower GPA than required for graduate school.

*Not knowing all of the answers.* Five PAs reported it was difficult when they did not know all of the answers. Several PAs were especially nervous at the beginning of the internship when they were still learning. Further, several of the PAs had not yet taken all of the core public health courses, making it difficult to fully describe each of the courses to advisees. PAs suggested several strategies for this situation, including: (1) referring the student to the Undergraduate Program Advisor or Director, (2) accessing the manual or online material, and (3) telling the student that they would find the answer and email them later in the day.

*Variable workloads.* Four PAs commented on their variable workloads in meeting the departmental and student demands throughout the semester. Departmental events tend to be concentrated during the semester and advising needs are especially high at the beginning of each semester and enrollment periods when there is a large influx of students in the Peer Advising Center. Additionally, many of the PAs are our top students who are often involved in a multitude of extracurricular activities. One PA commented, "*I did learn a great lesson from this semester; do not overcommit yourself.*"

#### **SURVEY**

Ninety-nine of the 507 majors completed the survey (response rate = 20%). Respondents represented various class years with seven freshman (8%), 29 sophomores (14%), 30 juniors (39%), and 33 seniors (39%). A slightly higher amount of PHS majors on the social science track (59%) responded to the survey compared to those on the science track (41%). Of the respondents, 17% never visited the Peer Advising Center, 49% visited the center once a semester, 29% visited two-to-three times per semester, and 5% visited more than four times per semester. The average rating for

their last advising session was 3.8 (*n* = 82) distributed across the following scores 1 (not good) = 1%, 2 = 9%, 3 = 29%, 4 = 34%, and 5 (excellent) = 27%.

## **DISCUSSION**

The archival records provided data on the undergraduates' utilization of the Peer Advising Center. The high rate of sophomore (*n* = 195) and juniors (*n* = 130) visiting the center may be related to students wanting information about switching into the PHS major. It is unclear why so few seniors (*n* = 86) accessed the Peer Advising Center. Perhaps, seniors were utilizing other resources on campus that were more relevant to their advising and career needs, such as meeting with Career Services, the Program Advisor and Director, or the Graduate Admissions Staff. Although 83% of the respondents used the advising center one or more times, we do not know how representative that is of all the PHS majors. It is estimated that over 70% of the majors used the Peer Advising Center, but records do not provide the means to determine the exact number. In the future, staff will utilize a different method to better track students who visit the center.

While the program was implemented to assist with the advising load, the evaluation results indicate that there are benefits for both PA and advisees. The PAs gained valuable leadership skills, such as communication, public speaking, organization, and working with others. Although not a main focus for all PAs, learning about cultural competency and applying the skills in practice is important for student success. Thus, we plan to expand our PA training to emphasize meeting the advising needs of students from diverse backgrounds, such as students of color and first generation, international, and LGBTQ students.

All the PAs described having a stronger connection to their major and feeling supported in their role. PAs identified that their ability to participate in leadership roles in the department (i.e., serving on the Undergraduate Faculty Advisory Board, executive committee of PHS Club, and Undergraduate Student Advisory Board) provided them with a voice to make change. Having a stronger connection to the department motivates them to encourage other students to become involved. As they identify department needs, they propose and implement projects to meet these needs.

Helping students select courses and providing students with information about the public health major were two of the top reasons students sought advising services. Consequently, PA training includes much information about the public health field and careers. This training not only benefits the students being advised, but also helps the PAs increase their own career readiness and understanding of career options.

In addition to the required PA reflection paper at the end of each semester, we plan to develop a survey tool that evaluates the specific skills gained and achievement of program objectives to evaluate the impacts of the Peer Advising Program on the PAs. The PAs would complete the survey in the beginning, middle, and end of the internship to identify what skills had been acquired and improved, and to identify additional skills PAs needed to work on. PAs will also receive more one-to-one feedback from both the Head PAs and Program Advisor following each survey.

In general, survey responses across campus continue to be low as students receive surveys from multiple offices and programs on campus. Our response rate of 20% was low, but not atypical for student surveys on campus. In the future, we aim to increase the response rate by offering incentives for survey completion and sending an anonymous electronic survey to students within 30 days after their appointment.

Survey participation across the class years was similar for sophomore, juniors, and seniors with approximately 30% for each class year. In contrast, only 7% of survey participants were freshman. The response rate from freshman was low because most students typically enter the PHS major as sophomores and juniors, so there are relatively few freshmen in the PH major.

Due to students being surveyed at the end of an academic year, recall about their experience may be difficult. To better assess the students' experiences, we plan to initiate a monthly electronic survey of students who used the center. We believe this will increase respondent rates, and respondents will be better able to assess their experiences because of the shortened duration of time between the advising session and survey. The questions would provide information about what was helpful in the advising session and what needed to be improved. Further, the timely feedback will allow PAs to better identify what they need to work on to improve future advising sessions.

Student satisfaction with advising in general has been an area in need of attention since the number of students began to increase rapidly. The Peer Advising Program was implemented as a way to improve overall satisfaction. The PAs' unique perspective has been a resource in identifying strategies to improve students' experience in the PHS major. Student satisfaction with peer advising averaged a 3.8 out of a 5.0 scale. While we hope to see this average improve over the coming years, it is notable that approximately 90% of students who used the Peer Advising Center rated their experience as a 3 (average) or above, and approximately 60% rated it as 4 (very good) or 5 (excellent). More investigation is needed to understand the benefits of peer advising for advisees and factors that make for a positive peer advising interaction for students.

## **CONCLUSION**

The Peer Advising Program is a useful program to implement to meet the growing demands of undergraduate public health programs. Results of our work with PAs indicate that PAs gain valuable skills that they can carry into their professional world. The program is also a way to engage students in building community within the major. While this program has many benefits, it also requires intensive training and mentoring by a staff person to prepare students for this role. While these results are preliminary, future program evaluation will more thoroughly assess the

perception of student satisfaction with the Peer Advising Program for undergraduate students enrolled in the major. We will also be exploring the role of peer advising in student retention within the major.

## **REFERENCES**

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

#### *Received: 18 September 2014; accepted: 11 December 2014; published online: 05 January 2015.*

*Citation: Griffin M, DiFulvio GT and Gerber DS (2015) Developing leaders: implementation of a peer advising program for a public health sciences undergraduate program. Front. Public Health 2:288. doi: 10.3389/fpubh.2014.00288*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health.*

*Copyright © 2015 Griffin, DiFulvio and Gerber. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

## Active learning by design: an undergraduate introductory public health course

## **Karin B.Yeatts\***

Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

#### **Edited by:**

Cheryl Lynn Addy, University of South Carolina, USA

#### **Reviewed by:**

Debbie Humphries, Yale School of Public Health, USA Jim P. Stimpson, University of Nebraska Medical Center, USA

#### **\*Correspondence:**

Karin B. Yeatts, Campus Box #7435, McGavran Greenberg Hall, Chapel Hill, North Carolina, USA e-mail<EMAIL_ADDRESS>
Principles of active learning were used to design and implement an introductory public health course. Students were introduced to the breadth and practice of public health through team and individual-based activities.Team assignments covered topics in epidemiology, biostatistics, health behavior, nutrition, maternal and child health, environment, and health policy. Students developed an appreciation of the population perspective through an "experience" trip and related intervention project in a public health area of their choice. Students experienced several key critical component elements of a public health undergraduate major; they explored key public health domains, experience public health practice, and integrated concepts with their assignments. In this paper, course assignments, lessons learned, and student successes are described. Given the increased growth in the undergraduate public health major, these active learning assignments may be of interest to undergraduate public health programs at both liberal arts colleges and research universities.

**Keywords: undergraduate, public health, introductory, active, learning**

## **INTRODUCTION**

**GROWING INTEREST IN THE UNDERGRADUATE PUBLIC HEALTH MAJOR**

A recent report by Leider et al. (1) shows a dramatic increase (750%) in undergraduate degree public health conferrals from 759 in 1992 to 6,464 in 2012. With the growth in the undergraduate public health major, there will be an increase in demand for introductory public health courses. In this paper, an introductory public health course designed using active learning principles and Liberal Education and America's Promise (LEAP) outcomes (2, 3) is described. The assignments may be of interest to a range of institutions offering or planning to offer an undergraduate public health major.

## **UNDERGRADUATE PUBLIC HEALTH CRITICAL CORE COMPONENTS**

In 2003, the IOM called for incorporating public health into undergraduate education. Since that time, AAPH and Association of Liberal Arts Colleges developed critical component elements (CCEs) of a public health education and the Association of American Colleges and Universities LEAP outcomes (2, 4–6). LEAP learning outcomes (2, 5, 6) include intellectual and practical skills such as inquiry and analysis, critical and creative thinking, written and oral communication, quantitative literacy, information literacy, teamwork, and problem solving. The CCEs include a broad education with liberal arts, a breadth of understanding of public health domains, and experiential knowledge of the field (4). LEAP principles and the CCEs both encompass personal and social responsibility as well as integrative learning (4, 6).

More than 20 years ago, Barr and Tagg (7) elegantly described the shift from an "Instruction Paradigm" to a "Learning Paradigm" with respect to learning theory. Active learning, is defined as "any instructional method that engages students in the learning process" and is in contrast to students receiving information passively from the instructor (8). Reviews of the literature on active learning by Michael (9) and Prince (8) make several key points. First, active learning works across disciplines of physics, biology, and chemistry and engineering (8, 9). Most recently in 2014, Freeman (10) showed that students learned better in an active learning environment compared with a passive lecture format in engineering, mathematics, and natural sciences (10).

Onefacet of active learning is collaborative team-based learning "individuals are more likely to learn more when they learn with others than when they learn alone" (9). Collaborative efforts fit well with Fink's detailed descriptions of creating significant learning experiences (11). Team learning in pharmacy (12) and nursing (13) has shown increased levels of engagement and enhanced critical thinking. While literature in the public health field is more limited, Kjellgren (14) and Goldman (15) provide evidence that active learning techniques such as reflective journals and blogging led to students increased questioning of their own understanding and reporting of enriched learning on course topics.

## **INTEGRATING ACTIVE LEARNING WITH COURSE OBJECTIVES**

In this course, students are provided with multiple opportunities to apply and integrate concepts. The course objectives listed in **Table 1** were created in consideration of current undergraduate public health domains and LEAP learning outcomes (2, 4, 5, 16). These domains and learning outcomes include inquiry and analysis, critical and creative thinking,written and oral communication, quantitative literacy, information literacy, teamwork, and problem solving (2–6, 16).

## **TARGET AUDIENCE**

Our target audience for this course is composed of undergraduate honors students ranging from freshmen to seniors. Students from all majors are welcome to take the course. In the first 3 years, the diverse group of majors ranged from biology and chemistry to

#### **Table 1 | List of course objectives**.

A. Recognize local to global aspects of public health and appreciate the field's breadth and core values

B. Describe key events in the history of public health and their influence on the development of today's public health approaches

D. Identify and describe major health-related needs of populations using evidence-based data

C. Identify the determinants of health (socioeconomic, behavioral, biological, environmental, etc.) that affect health of individuals and populations across the life course

F. Critically evaluate public health interventions for evidence for relevance, application, and evaluation

G. Describe how the characteristics and organizational structures (including health policies, regulations, ethics, and economics) of health systems contribute to public health issues in the US and other countries

H. Value the ethical considerations in human subject research

I. Effectively communicate public health concepts

anthropology, business, and English. In terms of course recruitment, information on the course offering is circulated each summer by the Honor's Program Associate Director of Curriculum. In the future, we would like to open the course to all undergraduate students.

## **COURSE STRUCTURE AND CONTENT Overview**

The course is structured with two major components. The first component comprises a series of team-based activities; the second component comprises an experience trip and intervention project. In **Table 2**, we illustrate how team and individual assignments align with various course objectives. The first course component incorporates team activities that explore various public health disciplines in greater depth. In the second course component, students select and visit a local public health organization, and then use their experience to inform their final project examining a public health intervention. The activities for each of the two components are described in more detail below.

#### **Component 1-team activities**

Throughout the semester, students engage in a series of team assignments that allow them to actively learn about the various public health disciplines. Students are introduced to a wide range of different disciplines and topics within the field of public health-including environmental science, nutrition, health behavior, maternal and child health, biostatistics, epidemiology, and health policy. As the course progresses, students discuss protecting the public's health from different aspects including behavioral education, environment, and policy.

*Population perspective.* Students use Hans Rosling's Gapminder, http://www.gapminder.org/, to investigate at a global level how population health varies by place, time, and macro-level factors

such as a country's Gross Domestic Product (GDP) or health care accessibility. This tool helps to clarify the ecologic study design and its contribution to generating hypotheses.With thefree online data visualization tool, we explain the population perspective and contrast this with the biomedical perspective of health. Students are able to link health outcomes such as infant mortality with historic events such as droughts, famine, or war. For example, we discuss the Great Famine (1958–1961) in China and the large increase in infant and total mortality during this time period.

*Supertasters.* Students are introduced to concepts and tools of human health data collection. The super taster activity is designed to engage students in epidemiological concepts of measurement and screening test sensitivity and specificity. Students compare the sensitivity and specificity of two different tests with a "gold standard" for identifying "Supertasters," individuals who "experience the five basic tastes with greater intensity" (http://www.bbc.co. uk/science/0/22941835). The first test, a strip of propylthiouracil (PROP),is our"gold standard"because of its ease of use and apparent objectivity. The second test is a short questionnaire; the third test is a count of the number of papillae on the tongue in 1 cm area. In teams, students collect data from their own team members, and then build a dataset for the entire class. Students are introduced to human subject research concepts of confidentiality, and deductive disclosure in a discussion of the privacy of their own test results. Students use the data set to calculate sensitivity and specificity of two tests compared to the gold standard.

*Social media campaign.* Each team selects a health behavior (such as hand washing) or an organization that promotes healthy behavior. Teams then define a target population and formulate a specific message for their population. Next, teams create a social media video with the message to encourage/support a behavioral change. Using digital media, each team produces a video and publishes the campaign online. For example, a student team chose proper hand washing technique1 , targeting the student population at UNC Chapel Hill. Another student team promoted the use of a campus organization "Safe Walk," which provides safety to students walking home late at night.

*Clean or contaminated water?* Students learn about environmental health through environmental water sampling. Each team selects and defines a different water sampling location (bathroom in dorm, kitchen in apartment, office, airport bathrooms, local creek, University Lake, etc.). Each team receives a low cost water testing kit; some teams test microbial contamination, other teams test chemical contamination. Students also identify their local watershed and drinking water source. Results are presented in class and students discuss variations in sampling sites and results.

*Health care race.* Students gain personal experience with the user end of the health care system. Teams are assigned a specific rural county and a description of a person with a health issue as well as financial/access restrictions. Teams identify local medical providers in the county, and record how long it would take

1https://www.youtube.com/watch?v=oRshGys7AUs

#### **Table 2 | Class assignment alignment with course objectives**.

(Continued)

#### **Table 2 | Continued**

appointment with a health care provider. They also search for transportation options if the person did not have their own transportation. Students answer the question "In a rural area, how long would it take for an elderly person with a pressing health issue to see doctor? " Each team reports on both successes and challenges.

*Ecosystem of health care.* Students are asked to draw a diagram with interactions among various entities in the health care system, including patients, insurers, and industry. They reflect upon how the Affordable Care Act is starting to change the medical care system at the state and federal levels.

*Introduction to local public health related organizations/programs.* While the large majority of the classes are with one professor, occasionally speakers come from local organizations involved with public health issues. Organizations range from those that help young mothers (Durham Connects, Horizons) to those that increase healthy food availability to low income families and change organic local food market networks (Farmer Foodshare), to those that help individuals lift themselves out of poverty (Community Empowerment Fund).

## **Component 2 – experience trip and final project**

We follow Wykoff et al.'s (4) recommendation that "students should be exposed to local-level public health professionals and/or agencies that engage in population health practice." This assignment integrates course concepts with public health practice in a two-part assignment. First, students conduct an "experience trip." Then, for their final project students examine or propose an intervention connected with their experience trip topic.

The experience trip is designed for students to come into contact with public health practice. Students are asked to select a local organization (or with a local branch) or program that either directly or indirectly deals with public health. Students are asked to observe, ask questions, and find out about this organization and its activities. The experience takes about 1–3 h. Students write a reflection on their experience trip and answer questions on the goals of the organization, why they chose this topic, their observations, how it fits with public health concepts learned in class, and what they learned from the experience.

We would like students to have a "direct encounter with the phenomena being studied rather than merely thinking about the encounter, or only considering the possibility of doing something about it" (17, 18). By visiting an organization that deals with a public health issue, students have the opportunity to meet individuals that are engaged in giving or receiving some type of intervention and see the environment in which the intervention is conducted. Thus, students can be introduced to a "complex problem in a complex setting, rather than simplified problems in isolation" (17). Their reflection encourages students to synthesize their practical experience with theoretical knowledge.

For the final project paper, students examine an intervention related to their experience trip topic. For example, some students visited local organizations, which deal with increasing nutritional food availability to impoverished primary schoolchildren. Then, for their final project, the students examined existing interventions dealing with food insecurity. Students review the literature related to the intervention, and outline the factors that define the problem the intervention is designed to address. Next, they describe how the intervention was implemented, and explain relevant policies, regulations, ethics, and economics that influence the selected problem and intervention being explored. Lastly, they communicate their analysis in the form of a written report and an in class presentation to their classmates.

## **RESULTS AND DISCUSSION**

## **INCREASING INTEREST IN PUBLIC HEALTH**

The UNC Gillings School of Global Public Health has four strong undergraduate BSPH programs – with approximately 215 students enrolled in biostatistics, environmental health, health policy and management, and nutrition. However, with a total of approximately 18,350 UNC undergraduates, there are many UNC undergraduates who have no exposure to the public health field or the School. This course aimed to begin addressing that lack of exposure. In the first 2 years of the course offering, on average 27% of the students who took the introductory public health course applied to the UNC BSPH programs. Of the students who applied, 90% were accepted.

Student feedback on the course demonstrated increasing student excitement and interest in public health. For example, students expressed their appreciation of the experience trip/final project assignment:

"[the professor] gave us the freedom to choose any local organization that addresses a public health issue, and she provided plenty of ideas and resources for us to get started. This final project allowed me to learn about TABLE and the issue of local childhood hunger, which I am now passionate about." "As my cumulative project, I got to research food deserts and food insecurity, and learned that this is something I am very passionate about."

#### **LESSONS LEARNED**

#### **Understanding the population perspective**

One lesson learned from teaching the course in the first 2 years was the need to foster and encourage students to approach their experience trip and public health topics from the a population perspective. For example, attending an Alcoholics Anonymous meeting, several students struggled with stepping out of a biomedical perspective; they only saw the individual's addiction being the result of their own actions, and were initially not able to recognize additional social–ecological influences on patterns of behavior. For these students, the biomedical perspective was entrenched. With faculty encouragement, the students worked hard to understand the population perspective.

Sometimes students approach community agencies, organizations, and self-help groups without an adequate understanding of the population that the organization serves. For instance, AA and NA are designed for recovering alcoholics and addicts; these are social recovery programs, and provide social support in obtaining and maintaining sobriety. These programs do not aspire to be medical model approaches. Students often miss this subtlety. Likewise, a community garden intended to serve an immigrant population would want to plant crops that appeal to their consumer population, rather than follow dietary principles taught in nutrition class. Students need to learn to articulate a client view, rather than a provider view, of the organization and service.

#### **Student creativity**

One strength of the course, has been the student's creativity with the focal "experience trip" and final project assignment. Students demonstrated creativity with regards to the selection of an organization or program for their experience trip. For example, one student delved into the problems of youth violence and programs that address issues of school suspensions and restorative justice. Her interest led her to a local organization Boomerang2 which focuses on teaching resiliency skills to suspended middle and high school students. She began volunteering with the organization, and subsequently took a position working with the organization the next semester.

Another student used a fall break service-learning trip to a migrant farm camp to investigate migrant worker health issues. The problem she said, after she returned, was which problem to select from all the issues facing the migrant worker community. She chose to focus on pesticide exposures among farm workers and their families; she described a lay health advisor education program targeted to both the parents and children to help reduce pesticide exposures. Allowing the students to pick an organization or program that fits their interest gives them the opportunity to explore new topics and integrate public health issues in ways that substantially extend course learning. As noted by Cashman (17), public health practice lends itself to experiential learning.

#### **Reflections on achieving LEAP learning outcomes**

Graded team and individual projects throughout the semester provide evidence of students achieving LEAP outcomes. As described above, the completed assignments illustrated systematic inquiry and analysis on a variety of public health topics. Critical and creative thinking was evident on the team assignments, as well as on the student experience trip reflections and final projects. Students practiced written and oral communication throughout the semester in their team assignments and class presentations. Students also worked on problem solving and developing information literacy in their assignments. Next steps will include a more formal evaluation of changes in LEAP outcomes of intellectual and practical skills.

#### **Scalability/community capacity**

This class was designed as honors seminar with a class size of 24 students. With the current course structure, there are some limitations of scalability. Some institutions have large programs with hundreds of students interested in an introduction to public health. The course presented here, with some reorganization and redesign, could be scaled up. Community capacity needs to be considered. In order for each student to successfully complete their project, there must be enough community resources for all to have an experience trip without overburdening community resources. This may be more challenging for schools that are in geographically isolated areas. However,in 2012 the majority (73%) of students receiving an undergraduate public health degree lived in cities (1).

It is possible to increase the number of visitation sites in several ways: for example, there are often multiple AA and NA meetings throughout the week. There may be local agencies with multiple programs, and there may be sites, such as a community garden, that can accommodate any number of students. Despite this challenge, in the future, we would like to incorporate a larger service-learning component.

Given the increasing rise of the undergraduate public health major, these active learning assignments may be of interest to undergraduate public health programs at institutions ranging from liberal arts colleges to research universities. The advantage of a broad introductory course like this one is providing the next generation of students with basic public health literacy. Additional benefits include capturing student interest early on in their professional development, and introducing them to potential previously unrecognized career options. Yet, while only a small proportion of students may become public health professionals, the course promotes the values of protecting the public's health to all students. The ultimate benefit is increased awareness and support of public health in our global society.

#### **REFERENCES**

1. Leider JP, Blakely BC, Plepys CM, Blakely C, Burke E, Sprague JB. Characterizing the growth of the undergraduate public health major: US, 1992-2012. *Public Health Rep* (2015) **130**:104–13.

2http://www.boomerangymca.org/our-program/mission-vision/

**Conflict of Interest Statement:** The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Received: 12 September 2014; accepted: 05 December 2014; published online: 23 December 2014.*

*Citation: Yeatts KB (2014) Active learning by design: an undergraduate introductory public health course. Front. Public Health 2:284. doi: 10.3389/fpubh.2014.00284*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health.*

*Copyright © 2014 Yeatts. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

## Developing an undergraduate applied learning experience

## **Denise C. Nelson-Hurwitz\* and Michelle Tagorda**

Office of Public Health Studies, University of Hawai'i at M¯anoa, Honolulu, HI, USA

#### **Edited by:**

Connie J. Evashwick, George Mason University, USA

#### **Reviewed by:**

Karin Joann Opacich, University of Illinois at Chicago, USA Laura Rudkin, University of Texas Medical Branch, USA

#### **\*Correspondence:**

Denise C. Nelson-Hurwitz, Office of Public Health Studies, University of Hawai'i at M¯anoa, 1960 East-West Road, BioMedical Building D-204, Honolulu, HI 96822, USA e-mail<EMAIL_ADDRESS>
To foster student development, critical thinking, and application skills among public health students at the University of Hawai'i at Manoa,¯ a three-course capstone series was developed as a key component of the public health Bachelor of Arts degree program. Over the course of 1.5 academic years students are actively involved in developing an interdisciplinary project proposal, then executing and presenting an independent, supervised, applied learning project. In the first course, students are introduced to a diverse range of public health projects and methods while working to develop their own project proposal – the foundation for the applied learning experience.The project execution course is designed to allow students to execute their proposed applied learning projects.This experience focuses on the application and integration of public health knowledge, skills, and practice acquired during the bachelor's degree course of study. Finally, students will be involved in reflecting on, finalizing, and sharing their completed projects in an undergraduate capstone seminar. Through implementation of this series, the program hopes to provide students with the opportunity to actively apply academic skills to real-world application.

**Keywords: bachelors of public health, curriculum, undergraduate capstone, undergraduate public health education, undergraduate research**

## **BACKGROUND**

It has been recommended by several entities that undergraduate programs, particularly those focused on public health, include opportunities for integrative and experiential learning (1–4). Experts have also recommended bachelor degree programs specifically include a capstone experience, promote inquiry-based learning, and better involve students in research activities, specifically at research universities1 (5–7). Furthermore, the Institute of Medicine (8) recommended public health as an essential part of training for citizens – a proposal supported by the Association of American Colleges and Universities (6) as well as several other academic organizations (3).

During the development of the Bachelor of Arts degree in Public Health at the University of Hawai'i at M¯anoa (a research university and land-, sea-, and space-grant institution), a threecourse integrative learning experience capstone was created so as to provide students with an opportunity to apply course knowledge and skills to a real-world issue, develop a passion for a topic of personal interest, and gain experience working with collaborators (possibly in the community). This capstone series has been named the applied learning experience.

## **DEVELOPMENT OF CAPSTONE SERIES**

The three-course applied learning experience was initially developed and proposed by a departmental committee comprises faculty, staff, and a student representative, formed to develop the B.A. Public Health program for the University of Hawai'i at M¯anoa (UHM). The need for a capstone experience was supported during preliminary meetings with both local community members, many of who would be potential employers of our graduates, and key on-campus stakeholders. The UHM Honors Program initially inspired the three-course progression, where students are guided through development of a project proposal in one semester then execute the project in subsequent semesters. The process was further refined to reflect the needs of students, faculty, and community members as identified from past experiences with the Master of Public Health (MPH) practicum and subsequent MPH capstone course.

## **APPLIED LEARNING EXPERIENCE PROGRAM STRUCTURE**

The intent of the culminating experience in the B.A. program is to provide students the opportunity to actively apply classroom knowledge and associated skills to real-world application in the public health field. This is facilitated by a three-course series required for graduation with the B.A. Public Health degree: PH480 Application of Public Health Principles in Research and Practice, PH485 Applied Learning Experience, and PH489 Public Health Undergraduate Capstone Seminar.

Student project selections may have either a research or practice-based focus, depending on the preference of the individual student, as well as their post-graduation plans. For example, a student interested in employment with a non-profit organization following graduation may prefer a service-learning oriented experience with a local non-profit, whereas a student applying for a graduate program may be more interested in working with, or designing their own, research project. Examples of selected student topics are included in **Table 1**.

Throughout the applied learning experience each course instructor evaluates students on performance and competence through class assignments and class activities. The student's selected, and approved mentor or advisor additionally assesses

1Council on Undergraduate Research. Faculty-Undergraduate Collaborative Research and Publishing (2003).

#### **Table 1 | Examples of selected applied learning experience projects**.

the execution of the applied learning experience during PH485. Additional Public Health departmental faculty members, other University of Hawai'i at M¯anoa faculty, or approved community experts are encouraged to serve as advisors and mentors to specific applied learning experience projects, as appropriate to the student-selected topics.

## **UNDERGRADUATE PUBLIC HEALTH SUMMIT**

The Undergraduate Public Health Summit is a semi-annual, open, public forum, and a vital opportunity for students to interact with faculty (in public health and other disciplines), program alumni, and other community resources. Students participate in the Undergraduate Public Health Summit twice during their capstone series. First, they are involved in presenting their applied learning experience project proposals as poster presentations within the last 2 weeks of PH480. Students are also required to present their final applied learning experience projects (experiences and any results or analyses) as both poster and oral presentations during the last weeks of the PH489 capstone seminar. This experience provides students with practice presenting their projects and outcomes in a professional format and both interacting and receiving feedback from a range of forum participants.

## **PH480: APPLICATION OF PUBLIC HEALTH PRINCIPLES IN RESEARCH AND PRACTICE**

This course is typically taken during the first semester of a student's third (junior) year of the Bachelor of Arts degree program, and is the students' first introduction to the applied learning experience. The purpose of PH 480 is to prepare students for an independent, supervised, integrated learning project to be performed as part of the public health undergraduate capstone experience. The course begins with career counseling and post-graduation preparation in a group setting. By focusing on both short- and long-term personal objectives students are better able to create an experience that will support their future goals. This course also exposes students to common research tools and practices, including writing a literature review, creating a written and oral project proposal, designing a poster for public presentation, seeking external funding, ethics education, and working with an Institutional Review Board.

PH480 additionally introduces students to a diverse range of public health projects and associated methods. Throughout the semester, students are exposed to short, 10-min research and practice profiles called "Public Health in Action Profiles." Profiles are presented by program faculty as well as community partners and provide a brief overview of current public health projects, what responsibilities the presenter's specific role entails. Profiles are intended to provide undergraduate students with ideas of what public health research looks like in practice and also provide inspiration as students work toward developing their own applied learning experience proposals. For some students, meeting faculty and community partners during presentations also serves as a valuable networking opportunity. Student feedback to Public Health in Action Profiles has been overwhelmingly positive.

At the conclusion of PH480, students will have a written proposal for an applied learning experience project, as well as experience presenting their project proposals at an open, public forum – the Undergraduate Public Health Summit.

## **EXPERIENCE PROPOSAL GUIDELINES**

Essential components of experience proposals include (1) project objective, (2) project abstract, (3) significance of study or experience, (4) background and literature review, (5) proposed research or experience methodology, (6) expected deliverables, outcomes, or results, (7) proposed collaborators, partners, and next steps, and (8) references. Optional components include an itemized budget, estimate of costs, description of host organization or host research project, and Institutional Review Board application, as appropriate to the specific project.

These components are written in draft form and submitted throughout the semester (roughly four months) of PH480. Feedback is provided for each section, and the final versions of individual components are compiled as a complete project proposal submitted as the final product of the PH480 course. Generally, completed proposals range from 8 to 12 pages (excluding references). Additional research tools developed (e.g., a proposed survey or qualitative research tools) are included as appendices as appropriate.

## **PH485: PUBLIC HEALTH APPLIED LEARNING EXPERIENCE**

Based on each student's individual applied learning project proposal, developed during PH480, students are involved in independent research projects under the supervision of both a course instructor and an appropriate, approved project mentor or advisor. Mentors and advisors may be university faculty or approved community experts in a student's identified research or practice area.

The applied learning experiences take place over the course of a full semester, and involve roughly 100–125 hours of project execution. Students who are executing research-based projects primarily spend their time conducting a more thorough literature review and, in most cases, working to collect data and/or conduct supervised data analyses. Students with practice-focused projects spend the majority of their specified time actively working within an organization under a service-learning format.

Finally, students will be involved in reflecting on, finalizing, and presenting their completed applied learning experience projects throughout an Undergraduate Capstone Seminar (PH489).

#### **PH489: PUBLIC HEALTH UNDERGRADUATE CAPSTONE SEMINAR**

The Public Health Undergraduate Capstone Seminar is taken near the completion of the B.A. degree program. It focuses on integration of public health knowledge, skills, and practice acquired during the course of study. Students will be involved in assessing their level of achievement of educational degree objectives, develop professional goals, and reflect on, finalize, and present their applied learning experience projects. This course also summarizes key content and skills applied throughout the B.A. public health degree program, prepares students for a higher level of learning (either in graduate school or as a working professional), and addresses pragmatic post-graduation skills (e.g., resume/C.V. writing and career planning). Key deliverables following completion of this course include an applied learning reflection paper, a final applied learning experience report, and a final oral and poster presentation delivered at the Undergraduate Public Health Summit.

#### **CULMINATING EXPERIENCE EVIDENCE**

The instructor of the PH489 course and the Undergraduate Program Chair make the final assessment of the undergraduate capstone experience jointly. The undergraduate culminating expectations include the following:

Concrete evidence of successful completion of culminating experience include the following:

Students must also complete and obtain passing grades (above "C−") in all required and elective coursework associated with the B.A. in Public Health degree as evaluated by faculty instructors indicating mastery of the content and competency.

## **DISCUSSION**

The applied learning experience serves as a capstone to the B.A. Public Health degree program at the University of Hawai'i at M¯anoa. Through a three-course series, students engage in inquirybased learning centered on a topic of interest of their choosing. As previously discussed, there are two potential tracks for Applied Learning Experience projects – research or practice based, so as to allow students to select which type of experience would be most suitable to their academic needs and future plans. Both tracks provide an opportunity for integrative and experiential learning through slightly variable approaches. The research-based track exposes students to the inner workings of academic investigation, whereas the practice-based track provides real-world work experience. Both tracks include continuous application of critical thinking skills and student reflection, particularly throughout the execution of the applied learning experience in keeping with a service-learning framework.

Preliminary feedback from B.A. students who are currently participating in the applied learning experience has been very positive overall. The primary adjustment made based on student feedback has been to place more emphasis on advising of students preparing for the undergraduate culminating experience during mandatory advising session. The intent of this emphasis would be to help students begin thinking about possible projects and to increase awareness of the three-course series in the context of their full undergraduate degree program.

Through the applied learning experience, this program hopes to better prepare undergraduate public health students for both public health practices in the workforce, improve transition into graduate programs, and more broadly, fully embrace application of the educated citizen framework (8).

## **ACKNOWLEDGMENTS**

The authors acknowledge that without the commitment of the current, inaugural class of B.A. Public Health students at the University of Hawai'i at M¯anoa, as well as the support of our current public health program director, Dr. Kathryn L. Braun, our past director, Dr. Jay Maddock, our past undergraduate chair, Dr. Robert Cooney, and our excellent student service support staff, Ms. Kimberly Inouye and Ms. Kirsten Sensano, this experience and program would not be possible. Contributions of these individuals are greatly, and gratefully, acknowledged. Contributions by Denise C. Nelson-Hurwitz partially funded by post-doctoral Research Supplement to Promote Diversity in Health-Related Research Award (U54CA153459).

## **REFERENCES**

8. Gebbie K, Rosenstock L, Hernandez LM. *Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century*. Washington, DC: National Academy Press (2003). 144 p.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Received: 08 November 2014; paper pending published: 28 November 2014; accepted: 02 January 2015; published online: 13 February 2015.*

*Citation: Nelson-Hurwitz DC and Tagorda M (2015) Developing an undergraduate applied learning experience. Front. Public Health 3:2. doi: 10.3389/fpubh.2015.00002 This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health.*

*Copyright © 2015 Nelson-Hurwitz and Tagorda. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited andthatthe original publication inthis journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

## **Richard Kenneth Riegelman1\* and CynthiaWilson2**

1 Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA

2 Vice President Learning and Research, League for Innovation in the Community College, Chandler, AZ, USA

\*Correspondence<EMAIL_ADDRESS>
#### **Edited by:**

Connie J. Evashwick, George Mason University, USA

**Reviewed by:** Robert L. Seidman, San Diego State University, USA Caroline A. Macera, San Diego State University, USA

**Keywords: undergraduate public health education, community colleges, continuum of public health education, health education, health administration, environmental health sciences, health navigator, community health workers**

## **INTRODUCTION AND BACKGROUND**

Undergraduate education for public health has grown rapidly in the last decade since the Institute of Medicine recommended that ". . .all undergraduates should have access to education in public health." Despite the growth of undergraduate education for public health in 4-year institutions, public health education in community colleges is at an early stage of development. In a comprehensive 2011–12 webbased catalog search of community colleges, only seven associate degree programs in public health or related fields could be identified (1, 2).

Public health organizations are encouraging growth of education for public health in community colleges as well as 4-year colleges. The American Public Health Association has endorsed undergraduate public health education at both community colleges and 4-year colleges (3). Healthy People 2020 includes objectives to substantially increase the number of community colleges as well as 4-year institutions offering undergraduate public health education (4).

As part of the Framing the Future Task Force, convened by the Association of Schools and Programs of Public Health, the Community Colleges and Public Health (CC&PH) project, has been developed and co-sponsored by the League for Innovation in the Community College (the League), which represents over 800 of the 1100

community colleges. The CC&PH is cochaired by the two authors of this article. The mission of the CC&PH project is to fully include community colleges in the continuum of public health education. The Community Colleges and Public Health Report (5) is expected to be a component of the final report of the Framing the Future Task Force (6).

The CC&PH project has included two phases, a first phase consisting of an Expert Panel, which developed a series of Foundation and Consensus Statements that reflected what public health and community college educational organizations could do together (5). The second phase, recommended by the Expert Panel, focused on development of "prototype curricular models" designed for associate degrees and academic certificate programs in community colleges. Two basic models, (1) Public Health: Generalist and Specialization and (2) Health Navigator,1 were chosen after consultations with community colleges, project and Task Force leadership, and public health practice organizations (ASTHO and NACCHO), as well as academic associations in disciplines, which offer related bachelor's degree programs (SOPHE, AUPHA, and AEHAP2 ).

The CC&PH report recommends that Public Health associate degrees should be built on fundamental skills including writing, oral communications, and quantitative skills consistent with the Association of American Colleges and Universities (AAC&U) LEAP initiative (7) and VALUE Rubrics (8). Associate degrees and academic certificate programs are also encouraged to incorporate ASPPH Undergraduate Public Health Learning Outcomes. (9).

The Community Colleges and Public Health Project report recommends academic programs in Public Health: Generalist and Specializations designed for transfer to bachelor's degree programs in general public health, health education, health administration, or environmental health. It also recommends Health Navigator academic certificate and associate degree programs. The CC&PH report also recommends specific courses and provides recommended content outlines: http://www. league.org/league/projects/ccph/.

The remainder of this article summarizes the two prototype curricular models and discusses next steps in implementation.

## **PUBLIC HEALTH: GENERALIST AND SPECIALIZATION – RECOMMENDA-TIONS**

These associate degree programs are designed as transfer degrees to enable students to enroll in the rapidly growing bachelor's degree programs in public health (generalist), as well as the specializations

1The term Health Navigator is intended to be a generic term to describe the academic certificate or degree program. It is not designed as a job title and it is not intended to imply a connection with the Affordable Care Act.

2Association of State and Territorial Health Officials (ASTHO), National Association of County and City Health Officials (NACCHO), Society for Public Health Education (SOPHE), Association of University Programs in Health Administration (AUPHA), and the Association of Environmental Health Academic Programs (AEHAP).

of health education, health administration, and environmental health. Specializations have been designed in collaboration with SOPHE, AUPHA, and AEHAP. The involvement of these organizations should facilitate but not ensure transferability of the recommended course work to bachelor's degree programs.

Associate degrees designed for transfer to a bachelor's degree are encouraged to include 30 semester credit hours of public health related course work, including experiential practice-based learning, out of a 60 semester credit hour degree program. To optimize student transfer and student mobility to 4-year programs, the associate degree programs are encouraged to teach associate degree courses that meet baccalaureate degree expectations.

Public Health: Generalist and Specialization – the 30 semester hours of public health and related coursework in a 60 semester credit hour associate degree program should include the following.

## **FOUNDATIONAL**

Human Health/Personal Health and Wellness – 3 semester credit hours.

Students need an introduction to the underlying science of human health and disease including opportunities for promoting and protecting health across the lifespan and including principles of population health and determinants of health.

## **PUBLIC HEALTH CORE**

Overview of Public Health – 3 semester credit hours.

Health Communications – 3 semester credit hours.

Coursework should be consistent with the ASPPH Undergraduate Baccalaureate Critical Component Elements (CCEs) Report.

## **REQUIRED COURSES**

Health Education – 3 semester credit hours.

Health Administration – 3 semester credit hours.

Environmental Health – 3 semester credit hours.

Alternatively, nine semester credit hours in one of these three disciplines may be substituted utilizing content outlines for three coordinated courses developed in collaboration with the corresponding academic association and designed for transfer to a bachelor's degree. Detailed content outlines developed in collaboration with SOPHE, AUPHA, and AEHAP are available at http://www.league.org/league/ projects/ccph/.

## **EXPERIENTIAL LEARNING**

Experiential learning – 3 semester credit hours.

Supervised curriculum with learning outcomes and opportunities for reflection.

## **ELECTIVES**

Six to nine credit hours including a course in Public Health Preparedness as well as such courses as Prevention and Community Health, Health and Diversity, Global Health, etc.

Together the foundation and core public health courses should provide an introduction to at least the following CCEs: introduction to the biological and life sciences and the concepts of health and disease; overview of public health; health communications; identifying and addressing population health challenges; determinants of health; and overview of the health system (10): http://www.aspph.org/educate/models/

undergraduate-baccalaureate-cce-report/. Specific bachelor's degree programs may require additional course work. Students are advised to consult the specific requirements of the bachelor's degree program to which they wish to transfer. The development of the recommended content outlines in collaboration with SOPHE, AUPHA, and AEHAP is expected to facilitate transfer of these courses to bachelor's degree programs. Community colleges may want to develop articulation agreements with bachelor's degree programs to ensure transferability.

## **HEALTH NAVIGATOR PROGRAMS – RECOMMENDATIONS**

Health Navigator associate degree programs are designed primarily as applied degrees intended to respond to the rapidly growing job market for assisting individuals to navigate the increasingly complex public health, health care, and health insurance systems. The rapid increase in employment opportunities as Community Health Workers, patient care navigators, and health insurance navigators increasingly requires professionalization of the field.

In addition to employment opportunities immediately upon graduation, the Society for Public Health Education (SOPHE) has endorsed the development of Health Navigator associate degrees designed for transfer to a bachelor's degree in Health Education. SOPHE has encouraged the development of transfer programs and articulation of degrees with the large number of bachelor's degree programs in Health Education as part of the continuum of public health education.

Academic certificate programs may also be offered for those with the work experience or previous academic degrees. In addition, those enrolled in other associate degree programs in the health professions and human services fields may find a Health Navigator academic certificate program is a valuable addition to their degree. All academic certificate programs should include the four required Health Navigator courses described below using the content outlines included in the CC&PH report: http://www.league. org/league/projects/ccph/.

The recommendations for Health Navigator degree and academic certificate programs are intentionally designed to provide community colleges with flexibility to meet local needs and state certificate requirements where applicable. In addition, the electives offered by each institution may be tailored to the needs of the local workforce.

New funding mechanisms as part of Medicaid and the Medicare 30-day hospital re-admission policy, as well as the Affordable Care Act have dramatically increased the interest in developing the types of paid positions requiring academic Health Navigator education. The Labor Department estimates that the positions for Community Health Workers, the only Health Navigators job classification tracked by the Labor Department, will increase over 20% by 2022 (11).

Thirty public health and related semester credit hours are recommended as part of a 60 semester credit hour Health Navigator associate degree program. These should incorporate many of the Association of Schools and Programs of Public Health's Undergraduate Baccalaureate CCEs. Additional general education courses including those that focus on written and oral communication skills and basic quantitative skills are key to student success.

## **FOUNDATIONAL**

Human Health/Personal Health and Wellness – 3 semester credit hours.

## **PUBLIC HEALTH CORE**

Overview of Public Health – 3 semester credit hours.

Health Communications – 3 semester credit hours.

## **REQUIRED COURSES**

Accessing and Analyzing Health Information – including searching for health information and evaluating its validity – 3 semester credit hours.

Prevention and Community Health – 3 semester credit hours.

Health Care Delivery – 3 semester credit hours.

Health Insurance – 3 semester credit hours.

## **EXPERIENTIAL LEARNING**

Experiential Learning in Community Health, Health Care Delivery and/or Health Insurance – 3 semester credit hours.

The experience needs to address outreach methods and strategies; client and community assessment; support, advocacy and coordination of care for clients; and community capacity building, including supervised curriculum with learning outcomes and opportunities for reflection.

## **ELECTIVES**

Six semester credit hours addressing state and local regulations and job markets. These may include specific diseases such as diabetes, cancer, cardiovascular disease, HIV, defined populations such as the elderly, maternal, and child, and/or population issues such as health and diversity, as well as global health. A public health preparedness course should also be offered.

Additional courses, Introduction to Health Education and the Public Health Advocacy and Leadership in Action courses, designed by SOPHE for transfer to bachelor's degree programs in Health Education should be taken by students who intend to transfer to a Health Education bachelor's degree program. Content outlines for these courses can be found at http://www.league.org/ league/projects/ccph/.

Health navigator education is in the early phase of development and is likely to undergo rapid growth and change. Growth is likely to be very rapid in the remaining years of this decade as the need for team-based delivery of health services gains momentum and the new funding mechanisms for paid positions become established.

Note that the Foundation course and the two core public health courses are the same for all associate degree programs recommended in the CC&PH report. This should allow students enrolled in community colleges with multiple public health related programs to initially pursue foundational and core public health courses before selecting between available associate degree offerings.

The recommended programs are not the only possible public health programs that may be offered in community colleges. For instance, the CC&PH report recognizes the potential for health information management programs with a public health focus. Community colleges may identify additional public health programs that meet their mission and the needs of the local workforce. In addition, community colleges may play an important role in the continuing education of the public health workforce, especially entry-level employees and those without prior education for public health.

## **NEXT STEPS AS RECOMMENDED IN THE COMMUNITY COLLEGES AND PUBLIC HEATH REPORT**

The commitment of public health education and practice organizations provides opportunities to fully develop the continuum of public health education from community colleges through graduate education. Based on the extraordinarily diverse student body represented in many community colleges, this collaboration also provides unique opportunities to develop a diverse public health workforce, which reflects the current and future populations of the United States.

The principles outlined in the report should help local and state health departments and other employers address the educational needs and aspirations of the public health workforce of the future. These programs should be accessible to entry-level employees.

As a key component of the next steps, the League for Innovation in the Community College seeks to work closely with the national practice and academic organizations collaborating in this report to identify funding to support demonstration projects. These demonstration projects should provide opportunities for community colleges to fully develop curricula complete with learning outcomes/ competencies, assessments tools, etc. The League also intends to develop community college recognition awards for excellence in planning education for public health.

The ongoing collaboration of public health academic and professional organizations with the League for Innovation in the Community College bodes well for the future of community college education for public health.

## **ACKNOWLEDGMENTS**

This article was supported under a cooperative agreement from the Centers for Disease Control and Prevention (CDC) through the Association of Schools and Programs of Public Health (ASPPH) grant number 5U36OE000002. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of CDC or ASPPH.

## **REFERENCES**

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Received: 12 August 2014; paper pending published: 29 September 2014; accepted: 22 October 2014; published online: 05 November 2014.*

*Citation: Riegelman RK and Wilson C (2014) Community colleges and public health: an integral part of the continuum of education for public health. Front. Public Health 2:226. doi: 10.3389/fpubh.2014.00226*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health.*

*Copyright © 2014 Riegelman and Wilson. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

## **Leonard H. Friedman1\* and Joel M. Lee2**

1 Milken Institute School of Public Health, The George Washington University, Washington, DC, USA

2 John A. Drew Professor of Healthcare Administration, The University of Georgia College of Public Health, Athens, GA, USA

\*Correspondence<EMAIL_ADDRESS>
#### **Edited by:**

Cheryl Lynn Addy, University of South Carolina, USA

**Reviewed by:** Kara Montgomery, University of South Carolina, USA

Pamela Booth Teaster, Virginia Tech, USA

**Keywords: undergraduate students, undergraduate public health education, public health, curriculum, education, medical, competencies, BSPH**

This commentary speaks to the need to design a curriculum that best meets the needs of students who are enrolled in Bachelor of Science in Public Health (BSPH) degree programs. The past 10 years has witnessed a dramatic growth in the number and size of these programs. While several of these degrees are housed within schools and colleges of public health, many are located in colleges of arts and science, allied health, medicine, and many other academic homes. It is difficult to determine the actual number of BSPH programs (or similar type degrees but with different names) due to a lack of national accrediting standard. The number of students in these programs varies widely with as few as 25 to as many as 600. In addition to stand-alone BSPH degrees, there are a number of what is known in the field as three plus two programs where a student spends 3 years completing their undergraduate courses and then an additional 2 years of study that completes both their BS degree in addition to their Master of Public Health (MPH).

The point here is that there is a significant demand for the BSPH degree on the part of students and universities are more than happy to meet that demand. A legitimate question that we have is what career or education paths do students pursue once they complete their BSPH degrees. Evidence suggests that the largest fraction of BSPH students use the degree as pre-professional preparation for entry into advanced clinical training including medicine, nursing, physical therapy, physician assistant, pharmacy, and other specialty areas. Given the implementation of the Affordable Care Act and the movement toward population health, it is critical that future clinicians know and can potentially apply core public health principles into their practices.

A second path for BSPH graduates is into MPH degree programs. Once the spark is ignited during their undergraduate education, students see that they can make a profound difference in public health practice but know that the MPH is the degree of choice for a large number of employers. In our companion commentary ("Undergraduate Public Health, Lessons Learned from Undergraduate Health Administration Education"), we ask whether courses taken in the BSPH degree might have the capacity to either transfer into the MPH or perhaps students should be waived out of one or more of the core courses and instead be allowed to take additional electives. If this practice were to become commonplace, prospective MPH students might see an opportunity to better tailor their graduate education.

In addition to preparation for clinical education or entry into an MPH program, current BSPH students sometimes move directly into Public Health related jobs at the entry level where they obtain important work experience before advancing to an MPH degree. There are also students who upon graduation go into a whole variety of other education or work related opportunities including Peace Corps or Teach for America. Given the four paths that BSPH graduates can potentially take, it is

important to clearly understand where students go once they depart our programs and how our curricula can add value to the career options for graduates. Toward that end, does it make sense to craft a single unified BSPH curriculum that provides a rigorous preparation in public health and at the same time is flexible enough to accommodate the multiple career paths of graduates? Although various frameworks have been proposed (AAC&U, ASPPH, and CEPH), no model has been developed in sufficient detail to consider the challenges of implementing a truly well-articulated program. Do we as a field wish to develop a BSPH curriculum that mirrors the current CEPH requirement for accredited MPH degrees with a required core and multiple program tracks? If this is the option selected, what differentiates the BSPH from the MPH? As noted in our companion commentary, graduates from AUPHA certified undergraduate health administration programs compete successfully for entry level management jobs with graduates from CAHME accredited MHA programs. Regardless of how we design our BSPH curriculum, programs need to keep in mind what is in the best interest of their students.

As programs think about either designing a BSPH curriculum *de novo* or modifying an existing curriculum, there are four important elements to keep in mind:

• Begin with a market analysis of alumni and prospective employers. It is vital for BSPH programs to have a good handle on where graduates are going and then determining how well they are preparing students to enter the market. One commonly used strategy is to regularly survey alumni to determine where their first jobs take them.

Once the program has gone through the hard work of looking at the market for graduates and the forces exerted by competitors, it is time to think about the nuts and bolts of the curriculum. In general, the authors recommend the following five criteria – all of which are influenced by your global university undergraduate requirements and the outcome of your market analysis, competency decisions, programmatic strengths/weaknesses, and value determination.

would be a semester/quarter long. The field experience (or some other name) should be supervised by an experienced public health practitioner and would be a required, credit bearing experience.

In addition to the outline that has been detailed here, there are a number of other important attributes to a highly effective BSPH curriculum. Students need the opportunity to develop their skills as professionals. What are the professional norms in the field and how are these transmitted to students? While some of these professional norms will be organization dependent, others are cross-cutting across public health including respect for others, dignity, enhancing diversity, and building cultural competence. For those of us in faculty roles, let us never forget that we too serve as role models for our students and if we want our students to behave in a professional manner, we need to do the same thing.

Leadership is another critical skill for BSPH students to develop. Leadership is not confined to persons holding executive management positions and should be part of the educational preparation of all public health students. It is not enough to attend a lecture about leadership or to read the latest leadership book. Students must get out and practice being a leader – and along with this learn what it is like to fail. Student led clubs and organizations are an ideal way for students to begin to hone their skill and talent in leadership. Faculty mentoring will be a critical part of any student led activity.

Public health is a team sport and BSPH students need to be given the opportunity to work in teams throughout the curriculum. Most students dread this experience but it is vital that they learn how to work effectively with diverse team members who possess differential skills and varying levels of motivation and commitment. Through group work, perhaps most importantly, students learn how to deal with group conflict.

Finally, identify alumni and other local public health leaders who are willing to come in and talk with students about the breadth of opportunities in the field and provide an insider's perspective on their work. Sometimes called Executives in Residence (EIR's), these people can help with mock interviews, resume reviews, and can serve as mentors to current students.

In conclusion, the authors are "bullish" on the future of the BSPH degree. We believe that the demand for this degree will only get stronger in the years to come. Given this level of confidence, it is important to recognize that your students are pursuing multiple pathways after graduation. In order to be most closely aligned with the needs of the market, you will need to develop, implement, and continuously evaluate a set of competencies for program graduates. Along with the competencies, answer the value proposition question – why should students study with you and why should employers hire your graduates? In order to do this, you can craft a

curriculum that simultaneously provides flexibility, rigor, and practical value to your students.

## **AUTHOR NOTE**

The authors who presently serve in administrative leadership positions in graduate education have both previously served as directors of undergraduate programs in health administration as well as on committees and the Board of the Association of University Programs in Health Administration and as site visitors for Council on Accreditation in Health Management Education.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Received: 10 November 2014; accepted: 14 January 2015; published online: 02 February 2015.*

*Citation: Friedman LH and Lee JM (2015) Undergraduate public health education: is there an ideal curriculum? Front. Public Health 3:16. doi: 10.3389/fpubh.2015.00016*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health.*

*Copyright © 2015 Friedman and Lee. This is an openaccess article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

#### **RandyWykoff 1\*, Amal Khoury 1 , J. Michael Stoots 2 and Robert Pack 2**

1 Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City, TN, USA

2 Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, TN, USA

\*Correspondence<EMAIL_ADDRESS>
#### **Edited by:**

Connie J. Evashwick, George Mason University, USA

**Reviewed by:** Christopher G. Atchison, The University of Iowa, USA

**Keywords: undergraduate public health, BSPH, workforce preparation, public health job market, college of public health, benchmarking**

There has been a rapid growth in the number of programs awarding undergraduate degrees in public health and the number of students receiving such degrees (1). There has not, however, been a significant discussion of the purpose of such degree programs. What, if anything, are the recipients of these degrees being trained to do? What careers, if any, are they being prepared to enter? Is the degree designed primarily to prepare students to enter graduate training in public health or some other graduate or health professional programs? Alternatively, does the degree exist because "an understanding of public health is a critical component of good citizenship and a prerequisite for taking responsibility for building healthy societies"? (2).

While a reasonable case could be made for all of these purposes, we strongly believe that the undergraduate degree in public health should be seen primarily as a professional degree that is designed to prepare students to enter a well-defined and vital career track.

Our perspective is informed by a 60-year history of providing undergraduate training in public health and by a long-standing relationship with alumni, preceptors, and employers who regularly provide quantitative survey data to us. While our specific experience reflects our long history and our geographic location in a relatively rural area of central Appalachia, we believe that our "lessons learned" are relevant to any program currently or potentially providing undergraduate education in public health.

Specifically, it is helpful for any program to seek to understand its market and its students; tailor its competencies and curriculum to match the needs of its employers; and continuously evaluate its performance by seeking input from students, alumni, employers, and other stakeholders. As seen below, those processes and self-assessment tools have been key to the success and longevity of our program.

East Tennessee State University (ETSU) has been offering undergraduate training in public health for well over 60 years. In 1933, the State Teacher's College, Johnson City (the predecessor of ETSU) began offering a concentration in Health within the degree that was then known as Physical Education and Health. A minor in Health was first offered in 1950, and the School of Health was created in 1955. It included the newly formed Department of Health Education1 and offered, for the first time, a BS in Health Education. The Department of Environmental Health was created and first offered the Bachelor of Science in Environmental Health (BSEH) in 1965. The Bachelor of Science in Health Science (BSHS) was also first offered in 1965. In 1969, the BSEH became the first undergraduate program in the United States accredited by the National Accreditation Council for Undergraduate Curricula in Environmental Health. In 1973, a concentration in Health Administration was offered by the Department of Health Education and, in 1978, the School of Public and Allied Health2 was established.

Masters degrees were added in Environmental Health (MSEH in 1971) and Public Health (MPH in 1986). In 2000, ETSU was accredited by the Council on Education for Public Health (CEPH) as a graduate program in public health and, in 2009, was accredited as the first school of public health in Tennessee and the first to be located in central Appalachia. By definition, with full accreditation as a school of public health, all academic programs in the college, including the undergraduate degrees, were part of the CEPH-accredited unit. This chronology makes ETSU one of the few accredited schools of public health in the country that started with undergraduate training and added graduate programs at a later date.

Today, the ETSU College of Public Health, in addition to a full complement of graduate degrees and certificates, offers five undergraduate degrees – BS Public Health (BSPH) with concentrations in Community Health and Health Care Administration; BSHS with concentrations in Microbiology and Human Health; and the BSEH. In the 25 years between 1989 and 2014, ETSU awarded over 1,500 undergraduate degrees from what became the College of Public Health – 722 BSPH degrees, 530 BSEH degrees and 294 BSHS degrees.

This article addresses recent data generated by the alumni, preceptors, and employers of the BSPH graduates. According to the ASPPH interactive website, in the first 5 years reported (1992–1996), ETSU was the fifth most productive

1The name of this department was changed to Public Health in 1995.

2By 2007, Departments in the College of Public and Allied Health that were split off in the forming of the College of Public Health included Dental Hygiene, Radiography, Cardiopulmonary, Speech and Language Pathology, and Physical Therapy.

**Table 1 | Reported placement data: BSPH alumni survey (2009/2010, 2010/2011, 2011/2012 alumni) (65 responders: response rate 69.5%)**.

aExcludes those unemployed: not looking for work.

program in the country. In the most recent 5 years (2009–2013), despite having awarded 18% more degrees than in the first 5 years, ETSU's relative position has dropped to 29th nationally, reflecting the rapid growth in number and size of other programs (3).

In 2009/2010, 2010/2011, and 2011/2012, 65 BSPH graduates have responded to our alumni survey,conducted each year about 18 months after graduation (**Table 1**).

It is clear, from these data that our BSPH graduates are most likely to enter the workforce, especially into positions with hospitals and healthcare delivery organizations. They are relatively less likely to enter into the "traditional" public health careers in local, state, and federal government organizations. Only about a fifth directly enter graduate school. This latter finding is consistent with the findings of Leider et al. that report that fewer than 10% of graduates from undergraduate programs in public health apply to medical school or graduate programs in public health.

Results from our alumni survey also indicate that these graduates felt adequately prepared for their careers. Of those 65 BSPH graduates who responded to the 2011, 2012, and 2013 alumni surveys, 97% reported being "very satisfied" or "somewhat satisfied" with their overall academic experience and 95% said that they would recommend the college to others.

Their perspectives are supported by the College's employer surveys and field preceptor surveys. Every other year, the college surveys employers who report hiring

one or more graduates from the College. Of the 107 employers who responded to the 2011 and 2013 surveys (in some cases, the same employers responded to both surveys), 96 employers identified the academic degrees of their recent employees, and of those, 53 (55%) reported hiring one or more BSPH graduates. Because the same employer often hires graduates of multiple degree programs, we are not able to report results specifically for employers of BSPH graduates. However, 102 of 107 (95%) employers ranked the College's graduates as "high" or "highest" in "overall competence of graduates in their field of practice"; 98% for "ability to understand and use technical information"; 89% in"knowledge of public health"; and 93% reported "likelihood of hiring future College graduates."

The other source of information suggesting that BSPH graduates are ready to enter the job market comes from the students' preceptors. Prior to graduation, all BSPH students must complete an internship (culminating experience) that includes at least 400 servicelearning hours at a relevant organization, and under the supervision of a qualified preceptor. At the conclusion of each internship, the College formally surveys the students' preceptors.

In 2011/2012, 2012/2013, and 2013/2014, 155 BSPH students received preceptor evaluations. Using a 5.0 scale, preceptors are asked to evaluate students for a range of concentration-specific competencies (which vary by concentration) and for six cross-cutting competencies (work ethic; reliability; self confidence

and interpersonal skills; systems thinking and innovation; inquisitiveness and desire to learn; and ability to manage multiple assignments simultaneously). Over the 3 years, the average score for the crosscutting competencies was 4.80 and the average score for the concentration-specific competencies was 4.71.

While the curriculum for the BSPH has been recently revised (see accompanying article by Stoots et al.), it retains the key elements that have defined the degree for its more than half century of history – notably its commitment to preparing students to enter the workforce.

## **CONCLUSION**

The current shortage of trained professionals in public health has heightened potential interest in undergraduate training for public health.

Data from our program, and recently reported national data, document that graduates from undergraduate programs in public health are overwhelmingly entering the workforce upon graduation. In our experience, most students enter a healthrelated job in hospitals, medical practices, nursing homes, or other healthcare industries, though the job destinations may vary in other job markets. The students' own reports, the evaluations from their internship preceptors, and the evaluations from their employers all suggest that these students are well-prepared and successful in meeting the needs of the workforce.

While recognizing that a minority of students do enter graduate school upon graduation (and presumably more do, sometime later) and while recognizing that training in public health is valuable preparation for many career tracks, the fact that the vast majority of undergraduate public health graduates enter the workforce leads, we believe, to three major conclusions:

(1) Undergraduate degree programs in public health should be designed, delivered, modified, and evaluated primarily with the understanding that they are preparing students for the workforce. Specific attention should be given to assuring that students are "exposed to local level public health professionals and/or to agencies that engage in population health practice" (4), and that they acquire the practical

and applied skills necessary for success in the workforce. To achieve these ends, we strongly believe that students should complete a substantial internship in the public health workforce prior to graduation.

nor the best interest of the graduates. New programs should grow slowly, assuring that the supply of graduates does not exceed the "carrying capacity" of the local job market. A close relationship between the schools and local employers is essential in this process.

We believe that to treat the degree as one that provides only a basic level of understanding of the field is to deny students the quality of training that is essential to protect the public's health in the future. Undergraduate-trained engineers build bridges and buildings. Why would not undergraduate – trained public health professionals have a comparable level of expertise and skill?

For years academia has recognized the Master of Public Health degree as a "professional" degree designed and executed to prepare students to enter the workforce. The undergraduate degree should be seen in no different light.

## **REFERENCES**

1. Leider JP, Castrucci BC, Plepys CM, Blakely C, Burke E, Sprague JB. Characterizing the growth of the undergraduate public health major: U.S., 1992–2012. *Public Health Rep* (2014) **130**:104–13. Available from: http://www.publichealthreports. org/userfiles/15\_508\_PHR130-1\_ASPPH.pdf

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Received: 27 October 2014; paper pending published: 10 November 2014; accepted: 07 December 2014; published online: 05 January 2015.*

*Citation: Wykoff R, Khoury A, Stoots JM and Pack R (2015) Undergraduate training in public health should prepare graduates for the workforce. Front. Public Health 2:285. doi: 10.3389/fpubh.2014.00285*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health.*

*Copyright © 2015Wykoff, Khoury, Stoots and Pack. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

## Undergraduate public health education: does it meet public health workforce needs?

## **JamesW. Holsinger Jr.1\*, Andrea L. Lewis 2 and Quan Chen2**

1 Department of Preventive Medicine, University of Kentucky, Lexington, KY, USA

2 Department of Health Management and Policy, University of Kentucky, Lexington, KY, USA

\*Correspondence<EMAIL_ADDRESS>
#### **Edited by:**

Connie J. Evashwick, George Mason University, USA

**Reviewed by:**

Debbie Humphries, Yale School of Public Health, USA Loretta Cannistraci, Massachusetts Educational Technology Administrators Association, USA

**Keywords: undergraduate, bachelor's degree, professional degrees, academic degrees, public health practitioner**

## **INTRODUCTION**

The professional bachelor's degree [Bachelor of Public Health (BPH) or Bachelor of Science (BS) in Public Health] provides a cadre of trained individuals to fill entrylevel positions in American public health agencies. The traditional Bachelors of Arts or Science degrees with majors in public health produce an informed citizenry, but may not provide sufficient public health course content to enable graduates of such programs to effectively enter the public health workforce.

## **BACKGROUND**

The 2003 report of the Institute of Medicine (IOM) Committee on Educating Public Health Professionals for the twentyfirst century anticipated that developing broad undergraduate public health education would result in a cadre of trained individuals to enter the public health workforce as well as provide a "public health perspective" to their worksite (1). The report also called training in public health an essential part of the education of an informed citizenry. These concepts have been the underlying themes on which undergraduate public health education has developed over the last decade. As a result, Riegelman and Albertine have stated: "undergraduate public health at 4-year institutions: it is here to stay" (2).

The need for additional members of the public health workforce at all levels is expected to reach 250,000 by 2020 (3, 4). These estimates, made in 2008, have been confounded by the recession of 2008– 2010 and by a projected retirement eligibility rate of 29% among public health practitioners (5). To meet the required

workforce projections, the graduation rate from Association of Schools and Programs of Public Health (ASPPH) schools needs to triple (3, 4). Arnold and Schneider have postulated that public health undergraduates completing their degrees and entering the workforce have the potential of relieving the pressure on graduate programs by providing entry-level practitioners (6).

Although bachelor's degree prepared individuals may help to reduce the projected shortage of public health practitioners, the variety of bachelor's degree programs and their variability may impede these efforts. A pilot review of programs at colleges and universities with established schools of public health was conducted to determine whether there were significant differences between bachelor's degree programs at these institutions. It should be noted that a number of the new undergraduate programs are being developed in universities without schools of public health, including liberal arts and community colleges, and such institutions may not possess the breadth and depth of faculty expertise to produce entry-level public health practitioners, although they may certainly produce graduates that meet the recommendation for producing citizens well informed concerning public health issues. As a consequence, some institutions will produce the "educated citizen" (academic), while others will educate practitioners for the public health "workforce" (professional).

Undergraduate degree programs with public health majors are based on the various public health core disciplines (administration, epidemiology, biostatistics, environmental health, and health behavior) as well as general public health. These academic majors may occur as either BA or BS degrees. The BPH degree is a professional degree functioning at the undergraduate equivalent of the Masters of Public Health (MPH). The Bachelor of Science in Public Health (BSPH), although technically an academic degree, functions as the undergraduate equivalent of the Master of Science in Public Health (MSPH).

## **REVIEW OF BACHELOR DEGREES IN TOP RANKED PUBLIC HEALTH PROGRAMS**

In an effort to gain a better understanding of the undergraduate public health degrees currently being offered at colleges and universities with established public health programs, a general, preliminary review of the course content of university-based undergraduate public health degree programs was conducted. Owing to its ready availability, a convenience sample from the U.S. News top 25 schools of public health was utilized as the study set (7). A total of 28 institutions' websites (3 institutions tied for the 25th place) were searched for undergraduate degree curricula containing public health content.

Of the 28 schools reviewed, 17 (60.7%) offered undergraduate public health programs, with 2 institutions offering public health majors in both BA and BS degree programs. Two institutions were not considered due to offering combined undergraduate and graduate programs. A total of 19 programs from 17 schools were considered, and 3 groups of degree programs emerged: public health majors in BA degree programs, public health majors in BS degree programs, and a combination of the 5 BSPH programs and the single BPH program, the latter 2 functioning as professional degree programs. The curriculum requirements listed on the websites for each of the 19 programs were reviewed by at least two authors to determine public health content. Public health content courses included general public health courses, courses in any of the five public health core disciplines, public health practicum requirements, student research projects, and any other courses considered by the program to contain public health content.

This review demonstrated that the six BA degree programs contained an average total of 120 hours of coursework with public health content consisting of an average of 34.50 semester hours or 28.8% of the total degree hours. For the majors in the seven BS degree programs, the average total degree program hours was 120.86 with public health content representing an average of 35.86 semester hours or 29.7% of the total hours. The BPH/BSPH degree programs averaged a total of 120 semester hours with 51.83 semester hours of public health content representing 43.2% of the total. Thus, the BPH/BSPH programs contained a statistically significant 47% more public health content than BA and BS degree programs with public health majors (*p* < 0.0001) (see **Table 1**).

This review of bachelor degree programs in public health provides a preliminary picture of the variability between these programs. However, this is not meant to be a comprehensive analysis of these programs or their course content, but rather it should be considered a starting point for future study. A limitation of this analysis includes the number of public health

**Table 1 | Public health content hours by degree type**.

specific credit hours being deduced from reviewing online bachelor program curricula. In undergraduate education, some freedom is given to students to choose additional courses as electives. Some students obtaining BA, BS, BPH, or BSPH degrees could choose to focus their additional electives on public health courses. Thus, the calculation of credit hours here only reflects what is minimally required of students to complete the degree, but the actual exposure of students to public health courses may be higher. Similarly, undergraduate students may have other opportunities to gain experience in the field of public health during their education such as working with a faculty member in the school of public health on research or a special project or participating in voluntary internships or shadowing opportunities.

In order to fully evaluate the current state of undergraduate education in public health, bachelor degree programs from accredited schools of public health, accredited programs of public health, and colleges and universities without accredited schools or programs of public health should be evaluated. Further, a more detailed analysis of course content, the public health competencies addressed, and learning outcomes of the curricula need to be considered.

## **DISCUSSION**

In order to effectively fill the projected vacancies in the public health workforce, adequately prepared practitioners will be required. Undergraduate public health degree programs may be a solution to this problem. However, if graduates of such programs are to be capable of filling entry-level public health practitioner positions previously filled by individuals with an MPH degree, a level of academic content such as is found in graduate degree programs will be required. Currently, the Council on Education in Public Health (CEPH) requires that accredited MPH programs consist of at least 42 credit hours. As shown in this preliminary review, the average number of public health content credit hours in BA and BS programs fall below the MPH requirement, while the BPH and BSPH programs on average meet it. Unlike BA and BS programs, the BPH and BSPH programs mirror the content found in graduate MPH and MSPH degree programs, but at an undergraduate level.

Using the current credit hour requirements of an MPH degree as a benchmark, a BA or BS degree with a public health major may provide a level of understanding appropriate to an informed citizenry as called for in the 2003 IOM report (1, 8). These degree programs will certainly provide students with an understanding of public health issues that can then be utilized in the workforce or graduate level studies. However, if undergraduate degree prepared individuals are to effectively replace individuals completing an MPH degree and fill entry-level public health practitioner positions, the two professional degree programs offered by American universities, the BPH and BSPH degrees,which provide nearly 47% more content than that found in BA and BS degree programs with public health majors, preliminarily appear to offer a more suitable level of training. As the university-based schools of public health possess the faculty expertise, the time has come for their undergraduate public health programs to produce

well-trained practitioners for the public health "workforce" to meet the nation's needs in 2020 and beyond.

Future studies should be conducted to look in depth at the course content of all public health bachelor's degree programs in order to determine their specific course content as well as reviewing the actual experiences of recent graduates. Obtaining a better understanding of the students' preparation for becoming part of the public health workforce will also provide important information for developing effective education programs for public health practitioners.

### **REFERENCES**

*Am J Prev Med* (2011) **40**:226–31. doi:10.1016/j. amepre.2010.10.013

Williamsburg, VA: Council of Colleges of Arts and Sciences (2007).

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Received: 13 October 2014; accepted: 02 January 2015; published online: 26 January 2015.*

*Citation: Holsinger JW Jr, Lewis AL and Chen Q (2015) Undergraduate public health education: does it meet public health workforce needs? Front. Public Health 3:1. doi: 10.3389/fpubh.2015.00001*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health.*

*Copyright © 2015 Holsinger, Lewis and Chen. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

## Undergraduate public health, lessons learned from undergraduate health administration education

#### **Joel M. Lee1\* † and Leonard H. Friedman2†**

1 John A. Drew Professor of Healthcare Administration, College of Public Health, University of Georgia, Athens, GA, USA

†The authors who presently serve in administrative leadership positions in graduate education have both previously served as directors of undergraduate programs in health administration as well as on committees and the Board of the Association of University Programs in Health Administration and as site visitors for Council on Accreditation in Health Management Education. While there are published reports addressing components of the establishment and incorporation of undergraduate programs into health administration education, there is not a complete formal history and a great deal of the experience that follows is anecdotal and unpublished.

#### **Edited by:**

David Thomas Dyjack, National Association of County and City Health Officials, USA

#### **Reviewed by:**

Jason Scott Turner, Saint Louis University, USA Diana W. Hilberman, UCLA Fielding School of Public Health, USA

**Keywords: undergraduate students, public health, education, medical, undergraduate public health education, lessons learned, MPH, MHA**

## **INTRODUCTION**

The rapid growth in the number of undergraduate programs in public health reflects a similar earlier experience in health administration education in North America and offers a set of experiences that we may both learn from and contribute to. In a similar fashion to the public health discipline first awarding the MPH degree, the entry level health administration credential began as a masters degree in 1933, and subsequent degrees followed awarding the Master of Health Administration (MHA) and similar degrees. In the 1970s, undergraduate programs in health administration began to proliferate, and the graduate programs were "initially very cautious about establishing formal relationships" (1) requiring consideration of a set of questions about the relationship between baccalaureate and masters degree education in the discipline. This experience may be beneficial in addressing the more recent undergraduate/graduate degree relationship in public health. While there are numerous issues to consider, this commentary will address several of the most important issues. In 1975, Andrew Patullo, then Senior Vice-President of the W. K. Kellogg Foundation noted that "in light" of health administration being associated with graduate education, the development of undergraduate education presented a perplexing development, and nonetheless, the establishment of baccalaureate programs was seen as a "logical sequential development" (2) **Table 1** presents a series of key events in the evolution of baccalaureate education

in health administration, and a surprisingly similar set of parallel events in the more recent evolution of public health education. While it is not a certainty that parallel events will continue, the authors believe that anticipating subsequent issues from health administration will facilitate the maturation of undergraduate public health education.

## **PATHWAYS FOR GRADUATES**

As noted in our companion papers (11, 12), undergraduate programs in public health have been described as a pathway for several alternatives, liberal education for an informed citizenry, undergraduate education for professional programs including law or medicine, preparation for masters degrees in the discipline, and preparation for entry level positions in the profession. In health administration education, programs typically followed the same pattern and many students selected the opportunities for entry level and frequently midlevel career positions such as hospital department heads and associate administrators. These opportunities were enhanced by the fact that many recent masters level graduates had no more work experience than their baccalaureate graduate counterparts, had higher target incomes, and were less interested in positions in rural and underserved areas. Similar opportunities may well exist for the baccalaureate public health graduate. However, as MHA programs proliferated, their graduates have displaced many baccalaureate graduates for these opportunities and the MHA has

frequently become the entry level credential repositioning baccalaureate graduates away positions that they previously pursued. This degree escalation has resulted in many health administration baccalaureate graduates returning to graduate education for credentials that they may not have planned to pursue in order to obtain positions they desire. In a similar fashion, concurrent to the growth in undergraduate public health education, there has also been rapid growth in graduate public health education. A similar phenomenon may affect public health.

## **INTRODUCTORY COURSEWORK AT BOTH DEGREE LEVELS**

There is a common and somewhat unique characteristic to education in each of the two disciplines as baccalaureate education was preceded by entry level graduate education and curriculum was then "reverse engineered" from the established graduate education that preceded it. This contrast, with many other professions where completing an undergraduate curriculum, is a prerequisite to graduate education in the discipline. For example, a Bachelor of Science in Nursing (BSN) degree is almost a universal expectation of applicants to a Master of Science in Nursing (MSN) program. While an undergraduate business degree is not a universal requirement for Master of Business Administration (MBA) programs, many programs have some undergraduate introductory course prerequisite requirements in areas such as accounting and economics.

#### **Table 1 | Comparable events in the development of undergraduate health administration and public health education**.

As there are rarely prerequisite areas or specific degree requirements in both graduate health administration and public health, introductory courses in disciplinary content are a norm in both MHA and MPH degree curricula.

This is noteworthy as introductory disciplinary coursework is a most unusual component in graduate curricula. As undergraduate programs in public health proliferate, graduate admissions are likely to include a mix of students with undergraduate introductory public health course content and degrees, and those with other undergraduate majors without the relevant undergraduate introductory coursework. In the absence of MPH programs requiring undergraduate coursework or degrees, it will be impossible to remove these introductory courses from graduate education. The mix of backgrounds of matriculating MPH students creates a complication for the graduates of baccalaureate programs, and curriculum design for the graduate programs. Waiving or substituting these courses for baccalaureate graduates presents an interesting question for the graduate programs in assessing the difference between an undergraduate "introduction to . . .." course and a graduate "introduction to . . .." course. In some cases noting this, undergraduate health administration students choose a different graduate degree such as business or public administration. These degrees frequently led the baccalaureate health administration graduates to careers in other disciplines such as banking or government and excellent people were lost to health administration careers.

In other cases as undergraduate health administration faculty, the authors have experienced calls from undergraduate students in health administration expressing concern for their choice in pursuing an MHA degree as they were using the same textbooks in courses with similar titles, and earning high test grades without studying. While this typically resolved itself as students move beyond the introductory courses, the overlap does present issues related to best use of time and money for the health administration baccalaureate graduate as well as the public health undergraduate.

## **DUPLICATION OF CURRICULUM CONTENT**

Frequently, faculty teaching at both the undergraduate and graduate levels in health administration speaks to the importance of considering variations in depth, breadth, and competencies to differentiate courses at the two levels, and the need to carefully consider alternatives if a graduate course were to be waived. Faculty in public health needs to be aware of this issue and carefully consider it in course and curriculum design as subsequent coursework will rely on introductory course competency. Experience in health administration education also demonstrates that undergraduate advisors must play a careful role in addressing this issue for their students considering graduate education and selecting appropriate programs in the same discipline. Undergraduate advisors in public heath need to be aware of these issues in counseling their students.

### **PROGRAM LOCATION AND FACULTY**

Achieving excellence is also an issue that is shared by the two disciplines. While some undergraduate programs are colocated in the same unit as a graduate program with faculty teaching at both levels, some undergraduate programs are located in other disciplinary units. In the case of health administration, this included allied health, political science, nursing, business, or the humanities. Health administration faculty in some of these settings previously focused on teaching other

subjects. In some instances, the faculties were educated in other disciplines retraining themselves to teach health administration courses. Public health programs share similar units and similar issues based on rising interest in public health and in some cases declining interest in other majors.