Public Health Practice Teaching research and epidemiology to undergraduate students in the health sciences Erica L. James Abstract School of Public Health, La Trobe University, Victoria Objective: To identify and address particular challenges in the teaching of Melissa L. Graham epidemiological concepts to undergraduate School of Health and Social Development, Deakin University, Victoria students in non-clinical health disciplines. Methods and Results: Relevant Pamela C. Snow pedagogical literature was reviewed School of Psychology, Psychiatry and Psychological Medicine, Monash University, Victoria to identify a range of evidence-based teaching approaches. The authors also drew on their experience in curriculum development and teaching in this ield Bernadette M. Ward School of Public Health, La Trobe University, Victoria to provide guidelines for teaching epidemiology in a way that is engaging to students and likely to promote deep, rather than surface, learning. Discussion of E pidemiological concepts are recognised as essential components in an increasing number of undergraduate health courses (such as public health, nursing, the allied health professions, health promotion and environmental health), and similarly in some non-medical postgraduate qualifications (such as public health). Professional competencies for public health, 1 health promotion 2 and environmental health 3 recognise the importance of epidemiological skills and knowledge as core requirements. Research and critical appraisal skills have also been identified as having an important role to play in public health practice.4-6 There are several challenges associated with the effective pedagogy (the art or science of teaching)7 of epidemiological concepts to undergraduate students in general, and in particular to those who do not hold a clinical qualification (medical, allied health or nursing). For example, the absence of a core clinical knowledge base can seriously limit the pedagogical usefulness of the clinical examples presented in many epidemiology text books. Increasingly, there is a stronger emphasis on the importance of quality education and improved learning outcomes in higher education.8 While there are guidelines for the content of postgraduate epidemiological courses9 and for undergraduate epidemiology training for medical students (see, for example, references 10 and 11), there is a paucity of evidence available on how to teach public health epidemiology to undergraduate health science students. A further challenge stems from the fact that it is common for students in undergraduate health programs to hold a strong vocational orientation whereby professional practice is somehow seen as ‘divorced’ from research or the use of research data in professional decision making.12 It is not uncommon, therefore, for undergraduate students in the health sciences to view epidemiological concepts as part of the ‘mysterious world of research’, rather than as tools that will be both relevant and accessible to them as practitioners. From a teaching perspective, the shift in recent years to more cost-effective undergraduate course delivery has meant larger class sizes and fewer opportunities for teaching staff to engage with students in small-group tutorials. These factors almost certainly conspire to lessen the confidence of students to engage as active, deep learners.13 That is, Correspondence to: Dr Erica James, Department of Health and Environment, School of Public Health, la Trobe University, Po Box 199, Bendigo, victoria 3552. Fax: (03) 5444 7977; email: Erica.James@latrobe.edu.au 2006 vol. 30 no. 6 a range of practical strategies is included along with applied examples of teaching epidemiological content. Conclusions and Implications: Increasingly, there is a greater emphasis on improved learning outcomes in higher education. Graduates from non-clinical health courses are required to have a core understanding of epidemiology and teachers of epidemiology need to be able to access resources that are relevant and useful for these students. A theoretically grounded framework for effective teaching of epidemiological principles to non-clinical undergraduates is provided, together with a range of useful teaching resources (both paper and web-based). Implementation of the strategies discussed will help ensure graduates are able to appropriately apply epidemiological skills in their professional practice. (Aust N Z J Public Health 2006; 30: 575-8) Submitted: June 2006 Revision requested: August 2006 Accepted: September 2006 AUSTRAlIAn AnD nEW ZEAlAnD JoURnAl oF PUBlIC HEAlTH 575 Jones et al. Brief Report learners who are intent on understanding as opposed to superficial learners who are intent on only completing the task requirements13 and have the mindset of ‘I just want to pass this unit’. The aim of this paper is to provide practical recommendations to effectively teach epidemiology to non-clinical undergraduate health students based on a review of the current evidence on best practice in teaching research (in particular epidemiology and critical appraisal) and on our experience teaching epidemiology to undergraduate non-clinical students. We use examples from the Bachelor of Public Health (BPH) program offered at the Bendigo campus of La Trobe University, Victoria. The BPH program provides education and training for the health promotion and environmental health workforces. It is informed by a primary health care philosophy and has themes in social, behavioural and life sciences, research and epidemiology, health systems and health policy. The BPH program also includes a number of applied health promotion areas covering the continuum of health promotion approaches from policy action, community development and health education through to social marketing. Selecting teaching and learning strategies A common challenge facing lecturers is how to best teach epidemiological concepts and skills to non-clinical undergraduate students. In order to actively engage students, adult learning principles should be used.12,13 Recognising learner diversity and using a range of teaching strategies to meet students’ learning styles/needs is essential to good teaching and learning.14 To promote greater depth of understanding and retention, encourage the active involvement of students, emphasise higher-order skills (such as critical analysis), and increase student motivation and enthusiasm we use a range of different strategies. Although conventional lectures lend themselves to surface, passive learning, different teaching approaches within a lecture can lead to deeper learning.13 So, it is not the lectures themselves that lead to surface approaches to learning but rather the way in which they are designed and delivered. ‘Speed dating’ or ‘buzz groups’ can be used in lectures to initiate ‘get to know you’ scenarios for group work, for students to share reflections, to make students form an opinion and to build knowledge and discussion.15 By way of illustration, in a lecture on health indicators and the issues of prevalence and incidence, once the definitions have been provided and some examples discussed, students are asked to turn to the person next to them and think of one health condition where prevalence and incidence data would be most useful. This is a valuable strategy for engaging large classes. In many cases, epidemiology units incorporate conventional lectures as well as tutorial or workshop opportunities. In such cases, discussion is superior to passive lectures with respect to students’ retention and understanding of unit material.16 Small group activities can achieve learning through the interaction with other students. Such activities can also increase student confidence and motivation, and can be a powerful source of both positive and negative feedback for students.17 Activities should be 576 selected that are appealing to students and also have the capacity to enable misunderstandings or misconceptions to be addressed in a constructive way. Peer-supported learning groups are especially useful when the group has a variety of skills and confidence levels, for example, numeracy and mathematical literacy. In such a case the strong students can be allocated as ‘leaders’ to support struggling students in activities such as calculating odds ratios (OR), risk ratios (RR), number needed to treat (NNT), sensitivity and specificity. We find that small group, problem-based learning is also very useful when teaching students the skills of critical appraisal. In this instance we provide tools to guide the appraisal of both quantitative and qualitative methodologies, and then as a whole class activity conduct a critique of carefully selected example papers. We then provide time for the students to critique a different paper in a small group, using the tools provided earlier. When we select the papers to be critiqued in such exercises we ensure the paper is on a topic of interest to the group and also that there are obvious methodological limitations or omissions in the published manuscript. This helps build students’ confidence. See Table 1 for examples of tools to guide the teaching of critical appraisal. ‘Teachback opportunities’ involve recently skilled workers training others in new techniques and sharing their understanding.18 Teachback opportunities are extremely useful when teaching epidemiological study designs. In this instance, we divide the class into small groups and allocate one design to each group along with relevant resource material. Each group then has 10 minutes to prepare a short presentation to the whole class on their particular study design. This activity encourages the students to take responsibility for their own learning and highlights common misunderstandings, such as the direction of inquiry in retrospective longitudinal studies and case control studies. A structured personal learning log can be used to identify and meet new learning needs as they arise. These activities can be supplemented with non-assessable ‘milestone quizzes’ where students assess their own understanding of concepts. Learning logs can be used in tutorials by giving students time to reflect on the objectives of the tutorial. See Table 1 for suggested sources of questions for quizzes. The use of modular courses with a high degree of variety and choice is also useful. When planning a tutorial program, we ensure that there is a mix of activities from week to week, e.g., brainstorming activities, true-false quizzes, case studies and discussion, short answer questions, problembased activities, ‘teach-each-other’ tutorials, and hands-on classes held in the computer laboratory. Using a variety of different text books (and their corresponding study guides) can be useful for the lecturer in locating ideas for activities. See Table 1 for suggested references that provide examples and activities. In a hands-on session held in the computer laboratory, we use ‘Epi Bingo’ to engage students in the process of learning about sources of epidemiological data. In this activity, we demonstrate a relevant website or online data cube and then ask a series of questions that require the students to use the data source and answer the question. The first student with a correct answer calls ‘bingo!’ and AUSTRAlIAn AnD nEW ZEAlAnD JoURnAl oF PUBlIC HEAlTH 2006 vol. 30 no. 6 Public Health Practice Teaching research and epidemiology to undergraduate students receives a reward (a sweet). This activity transformed a formerly challenging and poorly received tutorial activity in to one that receives excellent feedback from students. Real-life examples can also be incorporated into the content of epidemiology and research units so students can easily see how they could use the knowledge and skills they are learning.12,19 For example, when teaching students about various population and health indicators we get them to use Australian Bureau of Statistics (ABS) data and compile demographic data from their home towns. When teaching about epidemic investigation we have found that using real scenarios of outbreaks and recent media clippings increases student interest in the tutorial activities (see Table 1 for suggested sources of case study data and activities). Feeding back responses that provide the learner with information on the real or projected outcome of their actions is also useful. For example, when teaching the phases of epidemic investigation, students decide on a course of action and follow through the potential outcomes, that is, containment or outbreak. Traditionally, the focus in higher education has been on research and not education. More recently, there has been a greater emphasis on the importance of high-quality teaching and improved learning outcomes.8 In public health, core epidemiological skills have been recognised as important in producing “safe public health practitioners”.20 These factors mean that teachers of epidemiology need to focus on their teaching to develop innovative and interesting ways to engage undergraduate students to develop epidemiology skills. Conclusion The value of teaching epidemiological concepts to non-clinical students is well recognised by both academics and professionals in the field and, as such, epidemiology is increasingly being included in undergraduate health degree programs. The challenge for educators is to ensure that the content of epidemiology curricula is tailored to meet the needs of non-clinical students and that it also meets professional practice accreditation and competency requirements. Graduates with epidemiology skills need to be able to apply and update their knowledge so it is critical that innovative teaching strategies that promote applied learning are developed. This paper provides clear recommendations to promote more effective teaching and learning in epidemiology that will, when used, encourage students to learn and apply epidemiological skills in their professional practice. Table 1: Useful resources for teaching epidemiology to undergraduate students. Useful texts that include activities Most epidemiology text books provide activities at the end of each chapter. We especially recommend: • Beaglehole R, Bonita R, Kjellstrom T. Basic Epidemiology. Geneva: World Health organization; 1994. • Friis R, Sellers T. Epidemiology for Public Health Practice. Boston: Jones and Bartlett Publishers; 2004. • Jeckel J, Elmore J, Katz D. Epidemiology, Biostatistics and Preventive Medicine. Philadelpia: WB Saunders; 1996. Text books with study guides/instructor’s manuals available • Burns n, Grove S. The Practice of Nursing Research. Conduct, Critique and Utilisation. Philadelpia: WB Saunders; 1997. This text has a corresponding study guide that provides activities and puzzles that match text book chapters. • Burns R. Introduction to Research Methods. longman Chesire. This text has a corresponding test bank of multiple choice questions for lecturers. • Kleinbaum D, Sullivan K, Barker n. ActivEpi. Companion Textbook. A Supplement for use with the ActivEpi CD-Rom. new York: Springer; 2003. This is a workbook and CD with interactive activities. • leedy P, Ellis ormrod J. Practical Research Planning & Design. new Jersey: Pearson; 2005. This text has a corresponding instructor’s manual and test bank including multiple choice and essay questions. • Sarantakas S. Social Research. Melbourne: MacMillan Education Australia; 1998. This text has a study guide called ‘Working with Social Research’ that includes true/false quizzes, multiple choice questions, and short answer quizzes. Resources for case study data and scenarios for epidemic investigation The Epidemic Intelligence Service of the Centers for Disease Control provides useful scenarios, data and activities on a range of conditions including use of contraceptive pill and ovarian cancer, an outbreak of Thyrotoxicosis, smoking and lung cancer, and legionnaires’ Disease, among others. Go to www.cdc.gov/eis/casestudies/casestudies.htm Useful tools for teaching critical appraisal • Critical Appraisal Skills Program (CASP) www.phru.nhs.uk/casp/critical_appraisal_tools.htm • Center for Evidence Based Medicine www.cebm.utoronto.ca/teach/materials/caworksheets.htm • Evidence based medicine tool kit www.med.ualberta.ca/ebm/ebm.htm • Greenhalgh T. How to read a paper: Assessing the methodological quality of published papers. Br Med J. 1997;(Aug)315:305-8. This is one of a journal’s series of useful papers guiding critical appraisal. • The Cochrane Qualitative Research Methods Group & Campbell Process Implementation Methods Group provide a comprehensive list of critical appraisal tools for qualitative research, see: mysite.wanadoo-members.co.uk/Cochrane_Qual_Method/biblio.htm Useful websites for hands-on sessions accessing epidemiological data • World Health organization (WHo), go to www.who.int/en/, then select ‘health topics’. • Centers for Disease Control and Prevention (USA), go to www.cdc.gov/, then select ‘data and statistics’. • Australian Bureau of Statistics (ABS), go to www.abs.gov.au/ • Australian Institute for Health & Welfare (AIHW), go to www.aihw.gov.au/, then click on ‘data online’ for links to interactive data cubes. • Australian Population Health network, go to www.geosp.uq.edu.au/qcpr/aprn/, then select ‘data’. It has links to other sources of data. 2006 vol. 30 no. 6 AUSTRAlIAn AnD nEW ZEAlAnD JoURnAl oF PUBlIC HEAlTH 577 Jones et al. Brief Report Acknowledgements A previous version of this paper was presented as a poster at the 14th Annual Scientific Meeting of the Australasian Epidemiological Association, Newcastle, NSW, 6-7 October 2005. We are grateful to Dr Virginia Dickson-Swift, Ms Sandra Kippen and three anonymous peer reviewers for their thoughtful feedback. References 1. Public Health Association of Australia. The Public Health Workforce Education and Training Study. Canberra (AUST): PHAA; 1995. 2. Shilton T, Howat P, James R, Lower T. Health promotion development and health promotion workforce competency in Australia. Health Promot J Aust. 2001;12(2):117-23. 3. Australian Institute of Environmental Health. Course Accreditation Policy 2005. Brisbane (AUST): AIEH; 2004. 4. Lumley J, Daly J. In praise of critical appraisal. Aust N Z J Public Health. 2006;30(4):303-4. 5. 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