Curricular Innovation and the Science of Public Health Education: A Call to Action

Why is the study of public health education and instruction so important at this time? The 2003 Institute of Medicine (IOM) Report, Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century, made it clear that schools of public health should embrace as “a primary mission the preparation of individuals for positions of senior responsibility in public health practice, research, and teaching.” The report further made it clear that “schools of public health should emphasize the importance and centrality of the ecological approach.”¹ This report implies that schools of public health are not just about educating individuals for content alone; they are about educating leaders who are expected to take responsible roles in the professional practice of public health.

These statements make explicit that schools need to assure their curricula are structured to meet the contemporary needs of the practice community. Thus, as the needs of the practice community change, the curriculum of the school needs to adjust accordingly. The twin challenges of making these adjustments to the curriculum and devising instructional strategies for their incorporation into the curriculum form the ideal interface for educational scholarship.

This special issue of Public Health Reports is so important because it serves as a mechanism for disseminating instructional scholarship and theoretical principles, and as a call to action for excellence in public health education. Curricular innovation is essential if we are going to meet the needs of educating the next generation of public health leaders both in quality and quantity. This special issue contains manuscripts that outline the call for curricular action, the insights from public health instructional scholarship, lessons from our history, and the importance of ethics. As guest editors, we see this special issue as an important contribution to the advancement of public health education.

Curricular innovation in public health has perhaps never been as critical as now. Numerous indicators have led to this conclusion: the need for additional trained professionals in the public health workforce; insufficient diversity in the public health workforce, including both academic and practice-based professionals; an inefficient pipeline drawing new professionals into public health; increasing expectations of public health practitioners as people in the post-9/11 era have come to realize that public health exists; and increasing numbers of schools of public health.

The need for increased numbers of public health professionals is clear. While reliance on public health has increased in recent decades as we coped with such broadly ranging challenges as acquired immunodeficiency syndrome (AIDS), obesity-related conditions, and anthrax, the actual number of public health professionals has decreased. In 2000, public health agencies in the United States employed 50,000 fewer people than they did in 1980.^2,3 The Association of Schools of Public Health's (ASPH's) recent “Statement on the Public Health Workforce” convincingly makes the case for the addition of 250,000 professionals to the public health workforce by the year 2020.⁴

Public health also is challenged by the need to replace the large number of seasoned professionals who will opt for retirement within the next few years. More than 100,000 public health workers are likely to retire by 2012. This represents almost a quarter of the public health workforce.³ Replacing this lost expertise is critical.

In addition to increasing the actual number of people in the public health workforce, it will be important to diversify the workforce. The Sullivan Commission on Diversity in the Healthcare Workforce points to the disconnect between the diversity of the health-care workforce and the diversity of the population it serves, and cites this disconnect as contributing to “disparities in health access and outcomes.”⁵ The ASPH/Kellogg Taskforce on Engaging Schools of Public Health in the Elimination of Racial and Ethnic Health Disparities cites the lack of diversity in public health faculty as a barrier to bringing minority students and faculty into the field.⁶

Drawing new professionals into public health is a challenge. Most people have a much clearer idea of what a clinical health-care provider does than what a population-focused health professional does. While the events of 9/11 and the immediate post-disaster period did raise the profile of certain public health entities (for instance, public health laboratories dealing with anthrax scares), academic public health has not always captured this peaked interest. Informing the public's perception of what public health is and how it contributes to bettering the lives of our citizens is a continuing challenge.

The need for a larger and more diverse public health workforce and the need to increase the visibility of public health practice to the public it serves both accentuate the importance of creating a more identifiable “pipeline” through which students enter public health as a field of study and, ultimately, as a profession. In creating such a pipeline, it is important to infuse public health concepts early in students' school experiences, even beginning in grade school. Making public health available at the undergraduate level also contributes to shaping students' career choices, as well as making basic public health training available to those who will pursue other majors in the health professions and health-policy arenas. Perhaps the most exciting and challenging curricular dilemma facing public health is the increasing number of schools and programs offering accredited graduate degrees. The excitement comes from the recognition that there is an increased demand for graduate professional education in the field. The challenge arises from maintaining the quality and quantity of the faculty who provide surety of the curricula throughout the core areas of public health, which raises the bar on the importance of teaching within doctoral education.

At the graduate level, we must identify opportunities to attract new as well as mid-career professionals to public health. Innovations in curricular content and delivery modes will enable academic public health to enlarge the pool of students it serves. As we explore ideas, such as “schools without walls,” we must address the challenges posed by providing cohesive degrees to students with whom we rarely interact other than via computer, text messaging, and cell phone. Can blogs, vlogs, and wikis substitute for lectures and classroom discussions? Can schools that have no residential faculty provide public health degrees? These and other questions challenge faculty and administrators as we undertake to provide education to more students and bolster the public health workforce. How we construct and deliver the public health curriculum in general and individual courses in particular will affect our ability to appeal to the larger and more diverse population needed to sustain the future public health workforce.

If we need curricular innovation, can innovation arise from and be confirmed by studying teaching as a science? The answer to this question appears to be “yes” for most of the professional disciplines, including engineering, law, business, and education. The evidence to support this argument includes graduate degrees and journals dedicated to the scholarship of curriculum design, instructional design, cognitive theory, and measurement. Within the health sciences, the fields of medicine, nursing, dentistry, pharmacy, medical technology, and physical therapy have journals dedicated to the educational preparation of their students and the maintenance of quality standards of professional practice. In each of these fields, graduate-level courses are offered that prepare individuals to become specialized instructors in their respective professions. Within the individual public health disciplines, journals in health administration education, public health education, and environmental health (focusing mostly on the K–12 grade levels) encourage manuscripts on the scholarship of professional preparation in these respective fields. However, there is no journal dedicated to education within the larger public health profession.

In most scientific enterprises, the credence for innovation is supported by evidence and grounded in theory. So, what kind of science forms the basis of the inquiry that leads to educational innovation, and how does this add to the quality of professional practice? One category of inquiry is the study of teaching methodology. This type of research studies the teaching-learning interface, which looks at things such as the instructional environment: the beliefs, values, and behaviors of the faculty and learner(s); the relevance of content; enhancement from technology; and the utility of competencies. In the past, this area of inquiry looked at instruction in a more traditional sense, but in recent times, this area has been broadened to include distance-based learning, exercises/drills, gaming programs, and just-in-time formats.

The results from these types of studies provide the profession with transformative information.⁷ The concept of transformative education means that the insights gained from instructional inquiry, when exchanged through publication and peer review, will raise the standards of acceptable instructional practice. In some cases, the results from these studies may push the bar from what is considered contemporary to what is considered passé. Through the publication of the scholarship, faculty can disseminate the lessons learned from their own inquiry and, over time, there will be an accumulation of knowledge about how public health professionals are or should be educated. These studies bring to the forefront the notion of best practices or suggested instructional strategies to resolve particular challenges, such as articulation agreements between undergraduate and graduate coursework, and the incorporation of nondegree certificates into the formal graduate catalog.

Underpinning teaching methodology is a second pillar of scientific enterprise that has not yet taken hold in public health: that is, determining the theoretical or philosophical basis for our educational mission. The study of public health curricular theory raises questions such as the following: (1) If public health accepts social justice as a major tenet in its professional practice, how does this translate into its instructional practice? (2) How well do the constructs of adult learning theory overlap with those of pedagogy of the master of public health (MPH) curricula? (3) If the MPH is the entry-level practice degree for public health professionals, what should be the balance between content and skill in the curriculum? These questions are the types of probes that other professions have struggled with and are continuing to struggle with as they define their theoretical underpinnings. Thoughtful inquiry within public health on these issues would benefit our profession, as it has other professions in the health sciences. These theoretical insights would also provide the common bases upon which to build cross-disciplinary professional degree programs, including professional certificates.

Another area that could lead to public health curriculum study would be cutting-edge topics that are often associated with the role of faculty. These topics would be based in theory and evidence, but would be linked to the specific disciplinary interests of the faculty. Depending upon university expectations for tenure and promotion, faculty members are required to balance their time among teaching, service, and research/extramural funding. While not always designed as research, each of these obligations can provide opportunities for the study of instruction. For illustrative purposes in the areas of teaching and service, studies could be developed to look at (1) the role of the faculty as mentors, (2) characteristics of high-quality intensive courses, (3) accountability models for faculty performance, (4) cross- or transdisciplinary instructional methods, (5) the role of the practitioner-researcher in academia, and (6) the development of indices to measure competencies from the curriculum into practice.

The areas of research and extramural funding are related to the many grants awarded to faculty that include instructional activities. As an example, the Centers for Disease Control and Prevention (CDC)-funded Prevention Research Centers have a required training core; the CDC-funded Centers for Public Health Preparedness, Health Resources and Services Administration (HRSA)-funded Public Health Training Centers, and AIDS Education and Training Centers all train health professionals. The HRSA-funded Area Centers for Health Education serve as focal points for academic community partnerships and the training of health-care providers.

A more specific elaboration of this illustration is in the recently released 2008 IOM Report, Research Priorities in Emergency Preparedness and Response for Public Health Systems, which states as its first research recommendation, “enhance the usefulness of training.” This recommendation explicitly tasks the Centers for Public Health Preparedness located within schools of public health to engage in the research that would “create best practices… and facilitate the translation of their results into the improvements in public health preparedness.”⁸ This type of research is expected to result in valid and measurable performance indicators by type of public health employee, decision-analysis paradigms, standardized assessment tools, and the best training methods for special populations.

The 2008 IOM report's other three research recommendations—improve communications in preparedness and response, create and maintain sustainable preparedness and response systems, and generate criteria and metrics to measure effectiveness and efficiency—can generate the type of study designs that could produce findings to improve public health systems and encourage support for public health professionals.⁸ The important lesson from the 2008 IOM report calling for research priorities is the overarching demand for increased rigor in instructional scholarship. The background for this report was preparedness, but its utility has repercussions throughout the entire public health curriculum. At its core, the report is calling for accountability in education. While these last examples are content driven, there can be overlap in methodology, theoretical bases, and communities, all of which can have relevance to both academic and practicing public health professionals.

As guest editors, we wanted to provide an introduction to this supplement that would stimulate your thinking about the importance of the educational mission of public health. The public health profession is facing several serious challenges in the coming years. A major challenge is the loss of a lot of talent through retirement and attrition. Another challenge is the expectation of new skills and expectations of the workforce in a post-9/11 world. To meet these challenges, public health faculty will need to develop more innovative instructional strategies. They will need to become more diligent in conducting research in instructional methodologies and educational outcomes. And, they will need to be more persistent in publishing educational scholarship.

We are pleased to be a part of this supplement. We see this effort as offering a forum for the greater exchange of public health educational scholarship. It is an example of the type of publication that should become a customary part of the public health literature.

In conclusion, we want to thank the authors for their manuscripts and their revisions. We also want to thank the many authors who submitted manuscripts and whose articles were not selected for this supplement. We encourage them to continue to find venues for the publication of their public health educational scholarship. We want to thank the many reviewers for their complicated, often tricky, task of assessing another person's work. We would be remiss if we did not acknowledge the excellent editorial staff of the journal. Their professionalism is both commendable and unflappable. We want to thank ASPH, the ASPH staff, and the Education Committee for their support for this supplement. Most importantly, we want to thank ASPH for the financial resources for the publication. It means a lot to have ASPH as a strong supporter of the importance of the scholarship in public health education. The number of manuscript submissions for this supplement gives credence to the anonymous adage, “most of us hate to write but would like to have written.” What appears to be needed in the field of public health education is the place to “have written.”