Integrating Competencies and Learning Outcomes in Core Courses for the MPH

The Council on Education for Public Health requires that all schools of public health (SPHs) offer instruction in the five core disciplines of public health—biostatistics, environmental health, epidemiology, health policy and management, and social and behavioral sciences.¹ Many SPHs offer concentrations in specific disciplines of public health. However, the proportion of master of public health (MPH) students who choose some disciplines (e.g., biostatistics) is consistently low.² Thus, the core course may be the only exposure that some students have to formal training in that discipline. It is critically important that all students develop key skills and knowledge in all core disciplines, and that instructors gather evidence to ensure that learning goals are met.

COMPETENCIES

Competencies are defined by the needs of the professional workforce that students join post-graduation. They are bundles of the essential knowledge, skills, and attitudes (KSAs) required to achieve an acceptable level of performance in the world of practice. Competencies are achieved through formal training in the classroom, individual or group assignments, and hands-on fieldwork. By redesigning curricula based on competencies, SPHs can better monitor educational programs and ensure that upon completion of an MPH degree, students will be able to apply their learned KSAs to their work in public health. Competency-based curricula act as a contractual agreement among the school, the faculty, and the student.

Core competencies for the MPH are the minimum KSAs required to achieve an acceptable level of performance and are ideally achieved through the core course requirement. Students may gain increasing levels of mastery through additional coursework or co-curricular activities.

In 2006, the Association of Schools of Public Health (ASPH) Education Committee published its Master's Degree in Public Health Core Competency Model, which provides competencies for each of the five core disciplines as well as for seven cross-cutting areas.³ The competencies are intended as a resource, but not a prescriptive mandate, for schools, programs, employers, and other stakeholders. Schools and programs can adopt the ASPH core competencies, derive their own, or use a combination of the two.

COURSE DESIGN

In designing courses and curricula, educators define content, strategies for effective teaching and learning, and systems for assessment and evaluation. Instructors define the content and learning objectives for the course and for each class session. They also determine measurable indicators of what the student is expected to demonstrate upon course completion and for each class session. Competency-based (or outcomes-based) education requires the instructor to work backwards, from desired outcomes to method, by first defining the outcomes and then creating the content and learning objectives for the course and each class session that will yield those desired outcomes, as well as determining the assessment mechanisms that will supply data on whether those outcomes were actually met.⁴

Once the competencies are defined, learning objectives, which are generally more discrete, are mapped to each competency. Each competency is supported by multiple learning objectives, and the process of moving from competencies to learning objectives is one of deconstruction. A competency, as previously noted, is a bundle of KSAs, and we create course and weekly learning objectives by unbundling those -competencies into their requisite parts. We can unbundle the competencies by asking, “What would a student need to know to perform this competency at a given level?” We can iterate upon this process until we feel we have reached an indivisible individual unit of learning. To ensure that these objectives are measurable or observable, we ask, “How will I know the students learned this? What behaviors or products would serve as evidence that students had met this learning goal?” The answer determines the appropriate assessment methods (-Figure). Critical in designing those assessments, then, is the assessments' authenticity. Authentic exercises and activities are scenarios that reflect or simulate what students would actually do in practice; they are not merely hypothetical or regurgitative exercises.

Figure.

Deconstructing competencies for a core course in the master of public health program into measurable learning

It is important to note that the learning objectives for the core competencies generally fall in the lower to middle cognitive domains of Bloom's Taxonomy, including knowledge, comprehension, application, and analysis.⁵ Concentration-specific and cross-cutting (i.e., interdisciplinary) competencies are based on more complex domains, including synthesis and evaluation.

PUBLIC HEALTH STUDENT AND FACULTY CHALLENGES

Discussion of optimal learning approaches must consider the learners' characteristics. Public health students have increased in number and diversity during the past 10 years.² Applicants to SPHs come from a variety of socioeconomic and educational backgrounds. Public health itself is a heterogeneous, mosaic discipline, one that draws from a variety of trainings and backgrounds; thus, our students' prior academic backgrounds are similarly diverse.

There are benefits and challenges in a heterogeneous classroom; one of the greatest challenges for the instructor is to design a course that can address multiple learning styles. Personal, intellectual, and emotional development affects the ways in which people learn,⁶ and the trajectories of this development vary by generation and cohort.⁷ Ideally, instruction should be differentiated sufficiently to address the developmental spectra present in the classroom, such that each student can access content with his or her “zone of proximal development” (i.e., the space between what a learner can do independently and what he or she can do with guidance from an expert or peer).⁸ Yet, short of creating individualized instruction for each student—an impossibly laborious task—what is today's core course instructor to do?

One practical approach to differentiation is to survey students prior to the start of the course to collect information on prior experience, preferred learning modalities, levels of familiarity with the content, and techniques of the core course. Thanks to technologies such as SurveyMonkey^®, for example, instructors can poll students on their self-assessed abilities, query information on undergraduate or professional backgrounds and training, and even provide ungraded quizzes to assess knowledge. The results of these surveys may be useful in a variety of instructional interventions. If one discovered, for example, a gap in one specific area, then the instructor may spend more time during the course to fill that gap. The data could also be used to form groups; for example, if an instructor discovered that seven students in the course were medical doctors with similar backgrounds, they may want to identify these students to form one group for specific activities or to mix them into other groups with students of heterogeneous backgrounds. The data can provide useful background information so that instructors can, within appropriate parameters, differentiate instruction to best meet their students' needs.

STRATEGIES FOR TEACHING THE CORE COURSES

In this article, we outline several strategies to maximize learning in the core courses for the MPH. Carnegie Mellon University's Eberly Center for Teaching Excellence has devised seven principles of learning that translate years of research on teaching and learning into actionable best practices for instructors.⁹ We use these principles as signposts to organize how we translate learning objectives into meaningful student activities and assessments and strategic uses of class time. Each of the following principles comes directly from Ambrose et al.¹⁰

Principle 1: students' prior knowledge can help or hinder learning

Students enter our classrooms with a wealth of knowledge from a variety of life, work, and educational experiences. Learning is most robust when students can connect new content to their existing knowledge, thereby refining misconceptions and correcting inaccuracies. However, this process of refinement rarely happens without ongoing dialogue and feedback; often, unless the instructor explicitly engages this prior knowledge, it remains inert. The use of pre-assignments is one way to get students thinking about a particular topic or application before the discipline-specific details are discussed in class. While activating the students' prior knowledge on a subject, this technique also encourages students to work, perhaps struggle, through the application and to think about/reflect on it prior to class. Recently published articles or studies that are highlighted on popular websites (e.g., www.cnn.com/health or www.sciencedaily.com/news/health_-medicine) pique students' interest.

Principle 2: how students organize knowledge influences how they learn and apply what they know

Ambrose et al. note that students often enter classrooms with knowledge organizations that are “sparse and superficial,” but “effective instruction can help them develop more connected and meaningful” understanding.¹⁰ In each core course, we present students with many tools and techniques and help the students organize them such that they are confident when applying those tools and techniques and recognize their limitations. Graphical approaches, such as Venn diagrams and flow charts, and nonlinear presentation software such as Prezi^® can help students organize knowledge spatially, helping them to make connections among discrete concepts, skills, and techniques.

Principle 3: students' motivation generates, directs, and sustains what they do to learn

Learning motivation exists at the intersection of students' belief in the subjective value of a goal and their expectations for achieving that goal.¹¹ In short, students need to believe that course content is valuable and that they are capable of mastering it. Faculty must clearly articulate that solutions to complex public health problems require interdisciplinary approaches. Sharing our own experiences working on a variety of medical and public health problems is one way to connect students to specific applications of the core discipline. Faculty must be explicit in highlighting how the various disciplines of public health work together to find solutions to public health problems. Encouraging students to bring a project or research paper from another course or program into a core course is a good way to make connections and to build on students' prior knowledge (i.e., Principle 1).

Principle 4: to develop mastery, students must acquire component skills, practice integrating them, and know when to apply what they have learned

Mastery “refers to the attainment of a high degree of competence within a particular area.”¹² To gain mastery, students must acquire skills, practice them, and learn when—and when not—to apply what they've learned. It is much more difficult, however, to know which activities will enable them to develop mastery. Several options exist to assess knowledge acquisition and application. Breaking complex analyses into more manageable pieces allows students to master each step before progressing to the next step. Students must have the opportunity, through authentic examples and scenarios, to apply and practice techniques in each core discipline.

Principle 5: goal-directed practice and targeted feedback are critical to learning

“Practice” is any activity that requires students to engage their KSAs and can range from homework problems and in-class presentations to service projects and team-based activities. “Feedback” is information about a student's performance that guides his or her learning; effective feedback means that this information can shape or direct the student's next steps.

There are several ways in which to provide targeted feedback to students in the core courses. One example is peer-to-peer exchange, in which students practice a technique through a targeted short in-class activity (see Principle 4) and share their results with their neighbor. The instructor then provides feedback after a brief peer-to-peer discussion. Another option for feedback is through multiple-choice questions posed to the class to assess students' understanding of specific concepts. There are many foundational concepts in the core disciplines that are subject to common misunderstanding; providing multiple-choice questions with these common misunderstandings as response options can help identify not only that students have misunderstood the concept, but also the exact nature of their misunderstanding. Students can respond by a show of hands or by using an audience response system (e.g., clickers) where responses are keyed in and the distribution of responses for the class is produced immediately. Responses can be attributable to individual students or anonymous. We favor using the anonymous approach, as students are often less anxious about the activity and can participate more freely without the concern of poor performance. In all cases, the questions posed should support the learning objectives and ideally create opportunities for critical and creative thinking. The best questions are those with several possible answers, the optimal answer requiring careful consideration among the various response options. Misunderstandings and incorrect answers offer the opportunity to revisit concepts before progressing.

Principle 6: students' current level of development interacts with the social, emotional, and intellectual climate of the course to impact learning

This principle foregrounds the importance of understanding students' generational temperament, personal development, and psychosocial needs. Although many models of student development exist, their shared key concept is that, between the ages of 17 and 25 years, students are undergoing a process of tremendous change. Emerging research on cognitive development suggests that important areas of brain development, especially the maturation of the prefrontal cortex (responsible for problem solving, strategizing and planning, and synthesizing complex information), are complete much later than previously thought, often not until an individual is 25 years of age. As such, students' dynamic development combined with the environment of the course will have a major impact on learning.

Ambrose et al. define course climate as a constellation of factors, including the quality and tone of faculty-student interactions, instructor's overall mien and effect, quality and frequency of student-student interactions, course size and makeup, and diversity of perspectives represented in the course materials.¹⁰ This constellation can combine to create marginalizing or centralizing experiences for students. Not all students will experience the course content the same way, but all students' learning will be impacted by the perceived climate. It is important to note that a positive climate does not equate to one in which expectations are low; we maintain that instructors can and should strive to create an environment that is both rigorous and supportive.

We have found a number of ways to nurture a supportive environment without reducing the rigor of the course. Outlining expectations at the start of the course (e.g., regarding assignments, exam-taking, and class participation) clearly in the syllabus helps to avoid misalignment of expectations. Seeking input and feedback from students throughout the course, through e-mail or a blog, keeps lines of communication open and reassures students that their opinions matter. Anonymous mid-course surveys, which typically garner high response rates, are also an excellent way to gather student feedback.

Principle 7: to become self-directed learners, students must learn to assess the demands of a task, evaluate their own knowledge and skills, plan their approach, monitor their progress, and adjust their strategies as needed

To become lifelong learners and mature thinkers, students must develop a capacity for self-directedness. Self-directed learning requires students to engage in a cycle of assessing the task at hand, evaluating their own abilities for the task, planning an approach, applying a variety of strategies to implement the plan, and reflecting on the success of the current approach and whether it needs adjustment.¹⁰ Varying backgrounds, abilities, and interests directly affect the amount of time required for students to master core concepts. Offering students ample opportunity to practice techniques allows those who need more repetition the opportunity to improve with practice. Monitoring student progress is facilitated by multiple carefully timed assessments. Feedback helps students to identify problem areas and make modifications as needed to stay on schedule and achieve course goals.

DISCUSSION

Competency-based education holds the promise of providing students with a more accurate, comprehensive, and realistic sense of what they will be able to do upon course or program completion. It also has the potential to provide faculty with more structured thinking concerning what they are trying to teach, and perhaps a better sense of how students will best learn. Competency-based approaches lead us more directly to ideas for assessment, because instructional content is explicitly tied to learning outcomes. To realize the full potential of competency-based education, however, it is essential for faculty to be knowledgeable and facile with the tenets of competencies, learning objectives, and relationships among them. Some serious threats to this goal include failure on the part of some schools or faculty members to operationalize competency-based educational strategies, failure to distinguish between competencies and learning objectives, and a perception among many faculty that competencies are merely a distraction and another administrative hurdle in the way of real teaching.

To convert competencies from another bureaucratic hurdle into meaningful guideposts and teaching aids, the first step is to ensure that faculty clearly understand the rationale for competency-based education and have tips for actualizing it. Many public health students will not pursue additional coursework beyond the core course in a specific area; hence, the core course provides their only exposure to concepts and methods in that area. Given that this exposure typically will not last more than one semester, we have to be realistic about how ambitious the competencies and corresponding curriculum can become. Adopting the Dreyfus model for adult skill acquisition^13,14 to address this challenge, we can think about adult learning in terms of five levels of mastery: novice, advanced beginner, competent, proficient, and expert. What level of mastery can reasonably be expected after a one-semester course? We posit that the best-case scenario would encompass the first three levels of Bloom's taxonomy (KSAa)⁵ with some capability in the fourth domain (analysis—allowing for students to have some ability to differentiate/distinguish among methods, check inconsistencies, and interpret their findings). This range of competency would likely extend to the stage 3 mastery level of the Dreyfus model (i.e., competent). It might be feasible, in a one-semester course, to attain the competent mastery level of a carefully selected set of techniques, but we must take care to limit the list to those that are essential. By expanding the list to include extensive coverage of a broader range of techniques, the depth of coverage of each topic would have to be reduced, leaving the students with lesser knowledge of a greater number of topics. It becomes a trade-off, then, between depth and breadth.

CONCLUSION

Clearly, the approaches laid out in this article do not obviate these challenges, but we think it wise to be mindful of them in designing core curricula. No matter how comprehensive a core course is planned, thoughtful selection of teaching/educational goals may be facilitated by careful application of competency-based approaches combined with best practices for adult learning. While offering no easy solutions, we hope the approach set forth in this article will be useful to other educators facing similar challenges with respect to course design and assessment methods.