Population Thinking Instruction in High Schools: a Public Health Intervention with Triple Benefits

Abstract

America faces a series of intersecting problems that relate to health inequities, failing schools, and an inadequate science, technology, engineering, and math (STEM) workforce, particularly in cities and among low-income Black and Latino youth. Here, we propose a solution, namely reforming secondary school education to include mandatory exposure to population thinking instruction to address these overlapping issues. Public health education has expanded in recent decades in undergraduate education, though it has yet to become an integral component of high school curricula. In this paper, we make the case that all youth should gain exposure to the skills of population thinking through public health education initiated in high school. We further provide a rationale for this approach drawn from multiple youth development frameworks and the community schools movement for honing youth critical thinking skills and problem solving relating to individual and community health, policy, and activism.

Introduction

The USA faces a series of intersecting problems that relate to health inequities, failing schools, and an inadequate science, technology, engineering, and math (STEM) workforce, particularly in urban settings and among Black, Latino, and other youth of color. Here, we propose a partial solution, namely reforming secondary school education to include mandatory exposure to population thinking instruction to address these overlapping issues related to health, equity, empowerment, and population wellness. This article summarizes the background, rationale, method, and beneficiaries for this proposal.

Background

In 2013, following the bicentenary of John Snow’s birth, Fine et al. called for obligatory epidemiology instruction in secondary schools to promote wide-scale science literacy to assist public interpretation of scientific evidence and making health-promoting decisions [1]. The author proposed a liberal or broad-based and applied instructional approach whereby epidemiology methods could be connected to a wide range of societal and human ills “far beyond its original home territory …from learning disabilities and poverty to crime and ecological or social disruption.” [1, pp. 1250–1]. Shortly after the publication of Fine et al.’s work, several papers were published in the epidemiology literature which directly responded to the call for more undergraduate [2–5] and high school [2, 6–8] epidemiological education. While the authors acknowledged the importance of expanding epidemiology instruction in these settings, they identified several challenges, including developing curricula well-suited to high school youth [5], staying current with an ever-changing field [3], and limitations of currently available curricula [8].

These barriers required teachers to acquire the skills and time to develop lessons appropriate for engaging youth and teaching concepts difficult even for higher education students [4]. Specifically, Keyes et al. held that many higher education students learning Epidemiology 101 have trouble understanding fundamental core concepts of the discipline, noting, “population-level thinking is not easy” [4, p. 663] and proposed in lieu of traditional approaches a principle-based framework. Six years after Snow’s bicentenary, scant evidence suggests that wide-scale high school public health education has expanded beyond the realm of extracurricular science competitions. Moreover, schools, particularly in low-income and urban areas, are failing to adequately prepare their students for success in STEM and related fields [9, 10]. This failure in turn risks perpetuation of inequities in the health care and STEM workforces that contribute to inequities in health [10].

In this paper, we explore the call for promoting widespread exposure to population thinking in youth as a mechanism for addressing multiple intersecting problems related in particular to low-income, Black and Latino, immigrant, and urban youth. We reframe epidemiology instruction in secondary schools as “population thinking instruction” and discuss a framework by which youth may gain exposure to engaging in population thinking. In describing key elements of this framework, we draw from multiple youth programs that similarly target critical thinking, science literacy, youth empowerment, and community-based participatory action research. We focus particularly on the role of public health education in promoting urban youth academic success, whereby high schools, already located in every community, can create triple benefits: as educational institutions, as “health hubs” that connect young people to services, and as catalysts for health-related activism and civic engagement. Consistent with a growing body of literature [11–13], this approach recognizes that a liberal education that embraces activism, critical thinking, and a community schools approach can foster opportunities for successful high school-university public health-oriented partnerships, prepare young people for the public health pipeline, and ultimately reduce health inequities in our highest-need communities.

Growth of public health education

Public health education has expanded at the undergraduate level [14, 15], with significant, sustained growth in the number of bachelor’s degrees awarded in public health each year in the USA, from 759 in 1992 to 1469 in 2004 and 13,605 in 2017 [16, 17]. Although epidemiology was formerly considered a graduate-level course for students preparing for health sciences careers [6, 13], undergraduate public health education, and epidemiology instruction in particular, have been proposed to prepare students with foundational skills that will fuel expansion of the public health workforce [4, 11, 13], and promote critical thinking and health literacy skills in the general population [18, 2, 7, 19]. St. George et al. also portray epidemiology instruction in secondary and undergraduate schools as a mechanism to promote positive health-related behaviors from youth into adulthood [6]. Kiviniemi and Mackenzie similarly describe public health education as a method for teaching students higher order thinking skills applied to a myriad of real-world contexts that serve to empower students with problem solving tools. For example, they discuss how to “obtain, evaluate, analyze and apply information to understand and address problems,” [11, p. 3] and to also cultivate a sense of social responsibility, or, “value system” [11, p. 5] to address a community’s health needs.

Cities, in particular, can benefit from education reform that promotes student understanding and achievement in public health–related disciplines. For example, in half of the nation’s 100 largest cities, half or more of students attend schools where only half or fewer students reach senior status on time [9]. Moreover, in 2010, more than 80% of Americans live in urban areas, and population density is of course higher in urban regions [19], increasing the opportunity for population-wide impact in areas where health inequities are concentrated.

By helping urban youth to adopt a community-based or population lens to investigate health and wellness, educational institutions serving youth can foster an appreciation for group and environmental factors that predict health and empower young people to become engaged in acting to mitigate health problems. Areas with poor high school graduation rates are not coincidentally burdened by poor health, as well as high rates of crime, unemployment, and chronic despair [9]. In this way, the expansion of public health education, particularly in urban settings, becomes a population health intervention, as others have suggested [6, 20].

Public health education and STEM in underrepresented youth

Poor retention and academic success in STEM programs, evidence shows, lead to underrepresentation of minority students and females in STEM careers [10, 20–24]. Racial/ethnic and gender disparities in STEM educational attainment and career success are attributed in part to inequitable schooling experiences as well as poor preparation, self-confidence, and self-efficacy related to STEM coursework and the feasibility of STEM careers [10, 21, 24]. Public health instruction in high schools can provide students with opportunities to practice real-world science and demonstrate their learning while simultaneously relating understanding specifically to their lives. For example, understanding how differing food retail systems lead to different patterns of health and disease can provide insights into ecological analyses and systems science [24]. In grounding the pedagogy in the lives, interests, and challenges that students face on an individual and community level, educators can increase student engagement, success, and retention, therein reducing the current high rates of urban school failure [9]. By capitalizing on public health’s capacity to promote personal engagement with STEM-related topics, underrepresented youth can gain critical skills that will promote their success in STEM. Also, because epidemiology can be considered a “low-technology” science applicable to a broad range of phenomenon and everyday problem solving [13], it may be more accessible to students who are not traditionally drawn to the STEM fields.

Characteristics of high school public health instruction

We propose a broad-based, student-centered, and thinking-oriented curriculum. We derive this instructional approach from Fraser, who eloquently presented epidemiology instruction as teaching a method of thinking [13]. This framework has also been informed by our backgrounds as both an epidemiologist and former high school instructor of epidemiology, and also a professor of public health and director of an urban food policy institute. Based on our experiences both practicing and teaching in the public health field, and consistent with the literature [1, 2, 6, 8], we suggest that the best ways to engage youth in public health coursework and also help them to grasp complicated foundational concepts in the field are by starting instruction with an emphasis on solving individual youth and community health–related problems (see Table 1).

Table 1.

Resources for population thinking instruction in secondary schools

Professional development	Teacher resources
Why teach population thinking in high school?	• Source: 13 • Source: 1 • Source: 7 • Source: 4
Participatory action research frameworks and student-centered/community-centered learning	• Source: 40 • Source: 27 • Source: 8
Sample population thinking assessments in high school coursework	• Interview community members on “What health problems face our community?” and write a synthesis of findings.
	• Discuss a problem you would like to solve that is important to you and explain why it matters. Cite and summarize the science literature using a systematic review to build your case on why this issue is important.
	• Group activity: select a community-based health problem you will study. Define two groups to compare in your local community to study the risk factors for your chosen topic.
	• Pilot-test surveys or interview scripts with peers for eventual data collection in your community. Once complete, describe and provide a rationale for any changes you will make to your surveys/interview scripts.
	• Collect your data, work together with your teacher to analyze/interpret the findings, and report your study’s findings to the class; include background, methods, results, discussion, and conclusion sections in your presentation.
	• Devlop and peer-evaluate logic models drafted for a proposed community intervention based on your study findings.
	• Synthesize and reflect on your findings in a class presentation after speaking to at least one elected official, school administrator, or influential community member about your intervention proposal.
Alignment of population thinking instruction to national science education standards	• National Research Council’s Next Generation Science Standards [38, 39]
	• American Association for the Advancement of Science Benchmarks: Scientific Inquiry; The Scientific Worldview; The Scientific Enterprise.
	• The College Board Standards Outline: Scientific Practices (Scientific Questions and Predictions; Generation of Evidence; Data Analysis; Evidence-Based Explanations and Models; Quantitative Applications).

Furthermore, this approach aligns with Paulo Freire’s philosophy of empowerment education, which states that education takes place within the context of people’s lives, and therefore should build critical consciousness to empower people to change the contextual forces that keep them powerless [25]. In general terms, an empowerment model of youth education fosters a sense of control over one’s life and the ability to contribute to the life of one’s community [26]. By adapting and applying these definitions of empowerment education to high school population thinking instruction, we can target students’ acquired understanding of concepts pertaining to population wellness to actions that directly or indirectly promote individual and/or community health (see Fig. 1). We similarly argue that if we capitalize on the wide application and versatility of public health instruction to connect with students’ lived experiences, we can best engage youth in population thinking.

Fig. 1.

Population thinking education for secondary students begins with student-derived problem solving within the community. Teacher mentorship and engagement with classroom and community members to gather data, critically analyze findings, and engage in policy-making dialogue hone science literacy and problem solving skills, and social justice and civic engagement practices. These practices foster youth development to inform individual and community health–related decisions, promote STEM access, and reduce health disparities

Population thinking instruction delivery through youth development frameworks

We posit that specific methods for engaging youth in population thinking in and outside of the classroom are through the application of youth development instructional frameworks (see Table 2) that fall within a larger umbrella of participatory action research. These educational strategies are aligned to high school population thinking instructional objectives by targeting community health improvement and health disparities reduction. Moreover, these strategies educate youth and foster engagement in social action through incorporating data collection, critical analysis, and evidence-informed change [20, 27].

Table 2.

Youth development instructional frameworks to facilitate engagement in population thinking in and outside of the classroom

Instructional strategy	Defining characteristics	Examples	Resources to learn more
Photovoice	Use of photos and other visual data or evidence to document community conditions, conduct needs assessments, map, evaluate, and engage stakeholders in promoting community health.	Visual data sources used to support arguments that inform recommendations for public policy (e.g., living/school/workplace conditions, challenges to accessing health services)	Sources: 12, 27–30
Positive youth development	Leveraging youth interests and talents to hone skills that promote positive development, healthy decision-making and relationships, and positive identity.	Identifying with youth their goals related to sexual health, relationships, and risk taking.	Source: 31
Food and environmental activism	Empowering youth to take action to combat neighborhood inaccessibility of affordable and healthy foods, and the social, economic, and political factors leading to structural inequities.	Engaging in dialogue with community residents, data collection and analysis pertaining to climate change and its relationship to food insecurity.	Sources: 12, 30, 32–34
Citizen science	Helping to define the problem, collect data, analyze and interpret data, disseminate findings, and prompt public health action related to science and environmental decision-making.	Volunteered geographic information; crowd-sourced data collection; health ambassadors	Sources: 35–37

Photovoice

Photovoice, a community-based participatory action research strategy, can help youth to acquire skills related to data collection and application of evidence to uncover their community’s lived experiences. This learning approach also fosters student critical thinking about strategies for community change targeting enhanced health and wellness [28, 29]. Parallels can be drawn between population thinking instructional strategies and photovoice across topics that have been studied by young individuals engaged in photovoice projects for community action, including violence, sexually transmitted infections and sexual health, poverty, tobacco and alcohol use, and healthy relationships. While photos can be considered visual data or evidence to document community conditions, youth can also collect data on community health conditions through interviews with family, friends, and mentors, conducting a needs assessment, mapping and evaluating data, and engaging stakeholders [28, 29]. This learning process can empower youth to report on data as both evidence of community conditions faced by the students themselves, their families, or other local community members, and also as a mechanism for taking an active role in effecting change to promote community well-being [12, 27–30]. As Wang states, “Youth involvement in photovoice harnesses the desire of young people to exercise autonomy and express creativity while documenting their lives. Photovoice enables young people─including those who may be underrepresented… to advocate their concerns using their languages and experiences.” [28, p. 159] Analysis and evaluation of findings from these data sources can then be used to inform arguments made by students to shape recommendations for public policy.

Positive youth development

Positive youth development is another learning strategy that draws many parallels to high school population thinking instruction and has been applied to program design targeting youth health promotion, including adolescent sexual health [31]. This framework aims to help youth develop skills such as healthy decision-making, effective responses to developmental challenges, healthy relationships, and positive identity to promote behavior change pertaining to future goals and risk taking. Positive youth development programs provide active and authentic learning opportunities that similarly empower youth. Gavin et al. hold that, “High-quality youth development programs are characterized by the presence of goals that promote positive development, the creation of opportunities and experiences that enable young people to nurture their interests and talents, practice new skills, and gain a sense of confidence…” [31, p. 53]. Population thinking instruction in high schools in this sense leverages youth interests and lived experiences to increase engagement and self-concept.

Food and environmental activism

Food and environmental activism similarly aligns with population thinking instruction by tasking students with engaging community members to document the social, economic, and political factors impacting health outcomes in their neighborhood food environments, and acting on these factors to promote health equity [12]. Youth food activism programs foster opportunities for engaging in dialogue with community residents on health problems, data collection and analysis pertaining to immediate health issues, and empowerment learning. Through these experiences, youth are encouraged to take action to combat neighborhood inaccessibility of affordable, healthy foods. This learning approach also can be considered within the realm of place-based education in that the urban youth residing in underrepresented communities can learn the downstream effects of environmental challenges, such as toxic pollution or climate change, and associated health risks including food insecurity [30, 32]. Moreover, this instructional approach helps youth to appreciate the ways that environmental and other place-based interventions can serve to reduce, or in some cases unintentionally widen, health disparities [33, 34].

Citizen science movement

Another body of experience that can guide the practice of high school population thinking instruction is the citizen science movement, also termed street science and science agency. According to this framework, citizens should participate in meaningful information generating and data collection, assessments, and health-related environmental decision-making to improve community health [35, 36]. Citizen involvement runs on a continuum, whereby more hands-on, or, engaged citizen scientists help to define the problem, collect data, analyze and interpret data, disseminate findings, and prompt public health action [35]. The advancement of volunteered geographic information and crowdsourcing data collection methods has fueled this movement by providing citizen scientists with tools to measure and communicate environmental exposures that may be hazardous.

Research has shown that when youth engage in citizen science educational activities, such as environmental science data collection, investigating complex ecosystems, and disseminating findings to authentic audiences (e.g., scientists, agencies, managers, etc.), they build their capacity for participating in current and future conservation actions [37]. Citizen science learning exposes youth to the diversity of roles/entry points into science careers, potentially inciting interest in the STEM fields. This framework also provides youth with a sense of ownership and responsibility in partnering with “real” scientists and in presenting information that is meaningful to local members of the public, scientists, and policymakers. In this way, the citizen science framework fosters student learning of science skills, and self-efficacy in asking/answering questions of consequence for students’ lives.

In summary, these frameworks support population thinking instruction in high schools by connecting the lived experience of learners to the concepts and thinking skills needed for epidemiological investigations. At best, these pedagogies enable (rather than a substitute for) teaching rigorous analysis, critical thinking, and mastery of the scientific method. Given that current high school curriculums in many settings are overextended, these learning strategies can support teachers and administrators in meeting current shifts in US high school science education standards. These guidelines, as established by the National Research Council [38, 39], prioritize student scientific inquiry and problem solving within authentic settings. Moreover, it is unlikely that many high school teachers have the background to effectively teach epidemiology, specifically. However, the instructional strategies outlined above can be incorporated into a wide array of curricula as learning exercises to facilitate youths’ exposure to population thinking. For example, rather than teach lessons from a traditional Epidemiology 101 curriculum, these youth development frameworks provide instructors with the flexibility to hone student skills and design assignments within the context of their instructional objectives and curriculum content matter. These strategies are also universal to best practices and robust instruction by empowering youth to ask and answer real-world questions and positioning teachers as mentors and facilitators [40–43].

Community schools as urban health hubs that foster population thinking and youth activism

Community schools aim to have a positive population effect by emphasizing student learning, but also safe, supportive, stable schools and communities for residents with and without children [44]. Ultimately, community schools contribute to more equitable educational and health outcomes by connecting schools and residents to local health, financial, educational, and other resources. For example, community schools can connect residents to school-based health centers, family mental health counseling, job training, and education on violence prevention, sexuality, and financial literacy.

By drawing from the education frameworks described above, high school population thinking instruction can contribute to enacting positive community health effects, and also further enhance the community schools model. For example, photovoice lessons can incorporate students documenting with their phone cameras evidence of neighborhood pollution, drawing data from state and national databases to identify significant sources of pollution in their community, and reviewing whether existing regulations or policies could mitigate the hazards. Positive youth development instructional approaches can involve collaboration with a local health department or community health center in which students study human papillomavirus immunization rates among adolescents in their community and propose strategies for increasing rates and safe sex practices in young adults. Similarly, student citizen scientists can investigate the prevalence or geographic distribution of common problems such as bronchial asthma presenting in the school-based clinic or nurse’s office and, using mapping methods, search for community-based environmental triggers. In another example, a food and environmental activism lens could inform student learning exercises documenting the sources of food served in the school cafeteria and developing a plan for increasing sourcing from local and regional farms.

Forging high school-undergraduate institution partnerships

Community schools by definition link students and families with local populations and services, including proximal institutions of higher education. Local universities with public health faculty can serve as anchor institutions to promote opportunities for youth from nearby secondary schools to engage in population thinking. For example, undergraduate students can engage in coursework directly relevant to solving local health programs, collaborating with community members, and teaching high school youth and their families about health promotion [45].

An additional step might be to prepare local university students/graduate-level mentees to serve as teaching assistants to support high school educators in developing curriculum content and to mentor youth. Public health students at the university level also can collaborate with local high schools on independent student research projects. These activities can provide mentorship to high school students and also opportunities to apply population thinking to community betterment. These interactions furthermore can help to recruit more diverse students into the public health pipeline by familiarizing at-risk youth with public health career paths, [45].

Reflections and future recommendations

The science education literature maintains that young people need to develop scientific ways of thinking in order to prosper as life-long learners in an ever-evolving global and technological society [46–48]. On a deeper level, expanding the teaching of population thinking in high schools can make other contributions to science, democracy, and population health. In the last decade, truth itself has come into question [49]. Partisans and special interests reject climate science, nutritional science, vaccine science, even evolutionary science. Facts that challenge ideological positions are dismissed as “fake news.” At risk are the beliefs that evidence can guide daily lives and that science can contribute to human improvement. By helping young people to understand how science is created and tested, it may be possible to create future leaders and citizens who “own” science and can make independent judgements about the ubiquitous scientific claims and counter-claims that bombard Americans.

Here, we have argued for mandatory exposure to population thinking instruction for secondary school youth. Population thinking skills can fuel student and community empowerment, high school-undergraduate partnerships, urban/at-risk youth mentorship, and the expansion of a public health workforce, particularly among underrepresented youth who can play a central role in reducing health inequities. Some teachers across disciplines may draw from learning exercises that promote population thinking, regardless of the topic at hand. Others may pursue entire units or even curricula devoted to population thinking research within and outside of the school. Some students may have repeated exposures to this instructional approach to foster STEM success and the pursuit of public health–related post-secondary coursework and even careers. Initiating population thinking in high schools can play a vital role in responding to a desperate need for an educated citizenry, a scientifically literate public, and a health-empowered population.

Abbreviations

STEM

Science, technology, engineering, and math