Flipping the Classroom and the Pedagogy: Using Active Learning Principles to Bring Leadership Training in Affirmative Sexuality to Public Health Education

With increasing frequency, public health and health-care services scholars are putting forward proposals and strategic plans of action to improve the nation's ability to promote sexual health,^1–3 including reports from the U.S. Surgeon General⁴ and Centers for Disease Control and Prevention.⁵ What these proposals and plans have in common is not just their call for improved leadership and training on sexual health in general, but also the positive and affirming aspects of sexuality and sexual relationships, often referred to as an “affirmative sexuality approach.”^6–8

Despite the increasing interest in developing national leadership in sexual health, focused training in schools of public health that would support these goals is absent. In a simple comparison, an informal review of inclusion of nutrition and sexual health in the curricula at 51 accredited schools of public health in the United States was conducted in 2014. Not surprisingly, courses in nutrition were standard fare in the curricula, with 20% of the schools housing an academic department of nutrition. By contrast, courses covering sexual health from an affirmative sexuality perspective were rare, and none of the schools had departments of sexual health (Unpublished data. S. Bryn Austin, 2014). In another comparison, an informal PubMed search for literature on sexual health in the curricula of medical schools identified dozens of articles on the topic, including several review articles. By contrast, a similar search of the literature focused on sexual health in the curricula of schools of public health turned up no articles (Unpublished data. S. Bryn Austin, 2015).

The purpose of this article is to describe a course, Women, Gender and Health (WGH) 220: Sexuality and Public Health, offered as part of the WGH Interdepartmental Concentration at the Harvard T.H. Chan School of Public Health (hereinafter, Harvard Chan School) in Boston, Massachusetts, which was developed in 2007 to address the gap in affirmative sexuality curricula in schools of public health. What follows is an explanation of the pedagogical rationale and design of the course. It is hoped that this course may serve as a way for faculty and curricular planners at other institutions to introduce affirmative sexuality into their curricula while emphasizing professional competencies necessary for public health leadership in sexual health.

METHODS AND RATIONALE

Why an emphasis on affirmative sexuality?

Feminist and sexual minority scholars, among others, have argued that a singular focus on risk, referred to as a “protectionist approach,” in public health and medical discourse on sexual health is harmful. They argue that this myopic attention to risk has served to reinforce stigma and shame by associating sexual health topics almost exclusively with their potential negative consequences.^1,3,6,8 In a commentary, Swartzendruber and Zenilman² point to stigma, shame, and lack of open discussion as prime barriers to improving the nation's sexual health. They and others argue that these barriers interfere with communication at all levels: among sexual partners, patients, and providers; between parents and children; and among professionals themselves in public health program planning, health-care services, and policy-making.^1,3 As a counterbalance to a protectionist approach, scholars are advocating for an affirmative approach, shifting the emphasis to include sexual well-being, sexual diversity, self-expression, and the role of pleasure and satisfaction in healthy relationships.^1,3,4,6–9 These scholars envision a new brand of leadership and professional training that does not assume that public health must cede the realms of pleasure, satisfaction, and well-being until after all risks have been eliminated. They argue that the stigma and shame that constrain and undermine the public health community's progress in sexual health promotion must be disarmed and dissipated with the curative power of open discussion of sexual well-being, including in health professional training programs.

Addressing the need for leadership

The WGH 220 course is designed to build professional capacity to advance public health leadership in sexual health by increasing expertise and competencies using evidence-based teaching techniques for topics in sexual health generally and in affirmative sexuality specifically. Ivankovich and colleagues recently put forward a strategic plan for advancing national public health leadership for sexual health that includes an affirmative rather than a protectionist orientation to sexuality.³ Their plan outlines six critical strategies for leadership in sexual health: (1) work at all levels of governance, from national to state to local levels; (2) enhance multisectoral, strategic partnerships with diverse interest groups with a stake in promoting sexual health and wellness; (3) strengthen the science base through surveillance, research, and program evaluation; (4) promote evidence-based policies; (5) strengthen infrastructure and training to provide appropriate sexual health services; and (6) develop effective communications with multisectoral partners, policy makers, and the public. Importantly, although strategy #5 highlights the need to strengthen professional training to improve sexual health services, all six strategies necessitate a public health workforce with the appropriate expertise and professional competencies. The pedagogical approach of WGH 220 is grounded in this six-point strategy.

A foundation in student-centered, active learning principles

The “flipped classroom” is a term popularized in the mainstream media for a family of pedagogical techniques also referred to in the educational literature as student-centered, active learning, scientific teaching, and problem-based learning.^10–16 Active learning techniques emphasize higher-order cognition (e.g., creating, evaluating, analyzing, and applying) over lower-order cognition (e.g., remembering factual information).^17,18 A basic principle of a student-centered, active learning course design is to use classroom time for critical thinking and creative experimentation. Foundational learning happens outside the classroom, such as learning factual information and preparing for class activities. In-class time is focused on activities to motivate students, frame concepts and theoretical models, identify challenges in the field, organize and synthesize factual information, and engage students in inquiry-based learning, often through team-based problem-solving and other techniques that lead students to apply and generate new knowledge.^11,16

Student-centered, active learning techniques are more effective than traditional teaching methods, such as Socratic discussion and lectures.^10,11,16 The advantage of student-centered, active learning is seen in longer-term knowledge retention and greater gains in skills,^12,19–21 in addition to a stronger sense of mastery, as reported by former students, when utilizing skills in the field.^10,19,20,22 Basing course design on active learning principles is an evidence-based approach to education that maximizes the potential to increase students' mastery of the desired knowledge and skills. WGH 220 incorporates student-centered, active learning principles throughout all aspects of the lesson plans.

COURSE DESIGN

WGH 220: Sexuality and Public Health is a graduate-level, introductory, elective course designed in eight weekly, three-hour sessions with a 10-minute break. Lesson plans for each class interweave active learning techniques that vary from session to session and are designed for a preferred class size of 20 students, although the activities could be easily adapted for seminar classes of different sizes. All elements of the course, from professional competencies to substantive topics to teaching techniques, were selected with the goal of addressing gaps in public health curriculum for leadership development in affirmative sexual health using evidence-based teaching approaches. Public health professional competencies addressed in the course include introductions to program planning and evaluation, research proposal writing, critical evaluation of research literature, legislative advocacy, strategic negotiation, and social marketing communications. Sexual health topics include theories of sexuality and sexual behavior; methods and ethical issues in sexuality research; sexual orientation, gender identity, and sexual health equity; and affirmative sexuality approaches to sexual education, risk reduction, and promotion of sexual well-being for individuals, relationship partners, and communities.

Classroom activities, all based on principles of student-centered, active learning, include individual 3-minute writing assignments to elicit first reactions to a provocative question or thorny dilemma in the field, followed by paired or full-group discussions; ungraded quizzes followed by group-level comparisons to reveal unexamined and heterogeneous assumptions about the definition of sex or biases in existing research literature; group problem-solving and role-play activities on current dilemmas in the field; and case-method teaching with cases researched and developed for the course (Table).

Table.

Strategic actions, professional competencies, and exemplar classroom activities related to the graduate public health course WGH 220: Sexuality and Public Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, 2016

^aIvankovich MB, Fenton KA, Douglas JM. Considerations for national public health leadership in advancing sexual health. Public Health Rep 2013;128:102-10.

WGH = Women, Gender, and Health

OUTCOMES

WGH 220 has been offered at the Harvard Chan School every year since the 2007–2008 academic year. It has garnered two teaching awards from the school and each year receives high evaluation scores from students, with an average overall course rating of 4.7 of 5 across the eight years it has been taught. Students invariably report enthusiasm and appreciation for the student-centered, active learning teaching techniques. For example, on formal course evaluations, exemplar comments from students included:

• “I loved that there were elements of negotiation, advocacy, and communication. Not only were we able to learn a lot about sexual health, but we also left with real concrete tools that we can use in any aspect of our future work.”

• “This is a great class! The professor fosters a unique learning environment by employing multiple innovative educational techniques: small groups, free writes, enactments of legislative procedures, and media. There was also ample opportunity to learn from peers who had very interesting and diverse perspectives and backgrounds. This is the first class that I have taken here which really required individual engagement and critical thinking, and I found it very refreshing!”

• “This class is really a delight—you probably won't find anything else quite like it at [Harvard Chan School]. Not only is it highly participatory and activity-driven (without being oppressively stressful), but the material is so important and so often undervalued within public health. I also think the course is accessible to people approaching the topic from a variety of perspectives, and with a range of levels of exposure to this material. I already had some experience in the field of sexuality and health, but I still found the class fresh, engaging, and provocative.”

The three teaching cases developed for the course and their lesson plans have been published and are available for other teachers to use in their courses. One case guides students in applying social marketing campaign design principles to promote the use of the internal (or “female”) condom in diverse populations.²³ Another teaching case, “Sex Ed at the Crossroads in East Point, Columbia,” trains students in basic methods of strategic negotiation in the context of a school district in the fictitious U.S. state of Columbia that must decide whether to adopt comprehensive sex education or abstinence-only education. This teaching case is available through the Harvard Chan School online teaching case library.²⁴ A third teaching case, “To Vaccinate or Not to Vaccinate: The Story of Hamilton, Columbia,” also available through the Harvard Chan School case library,²⁵ focuses on policy advocacy in the context of a fictional proposed state mandate of the human papillomavirus vaccine for schoolchildren and provides students with the opportunity to develop skills in writing and delivering testimony for a legislative hearing on a bill.

LESSONS LEARNED

A number of lessons have been learned during the years the course has been taught. Students have been able to engage with affirmative sexuality topics, even when unfamiliar with them or challenging to more conventional perspectives on sexual health. Because the course is elective and students self-select to enroll, it is possible that students less comfortable with affirmative sexuality perspectives choose not to enroll. The choice to keep the class enrollment to 20 students each year has worked well as a way to help the teacher and teaching assistant monitor each student's learning and comfort level with topics and to ensure respectful interactions among students. In addition, the class size allows fellow students to get to know their classmates by working closely together in class each week, which eliminates the type of anonymity that can occur in large classes and provides opportunities to build trust, respect, and accountability among students.

Roughly one-quarter of the students in the course have been international students from most continents. The international diversity adds to the already diverse domestic student population, bringing a richness and complexity of views and experiences. The presence of a sizable minority of international students also serves as a reminder to the teacher and students to explain references and perspectives that might be specific to the U.S. context or to another culture or subculture, so that all students can follow the thread of a discussion or argument; ultimately, the class as a whole benefits. One recurring critique of the course from students is that it is too short, lasting only eight weeks, which is typical of courses offered at the Harvard Chan School. Extending the course to a full semester would allow more topics to be covered and, more importantly, allow more time for focused activities where students can further practice and refine new skills and professional competencies.

The student-centered, active learning basis for the course, which emphasizes open and creative intellectual inquiry into critical dilemmas in sexual health, sets the stage for respectful sharing of divergent views, with a goal of generating a broad range of solutions and innovations. All public health work, whether in sexual health or any other priority concern, benefits from open inquiry and respect for the diversity of community perspectives, values, and solutions. In this way, the course provides students with an introduction to expertise and competencies they will need to lead our nation from a protectionist to an affirmative sexual health promotion strategy.

CONCLUSION

The pedagogical method used for WGH 220 offers an ideal approach to integrate sexual health with affirmative sexuality perspectives into the public health education curricula. Courses such as this one, using evidence-based teaching techniques and emphasizing professional competencies necessary to develop public health leadership in sexual health, are vitally needed in schools and programs of public health across the country and should be considered essential to the core curricula of public health professional education.