“Teaching population health to medical students through the community health assessment”

Introduction

Clinical medicine and population health typically operate independently in the United States but they should be more integrated. Recent calls to integrate include an Institute of Medicine report[1] and the Academic Partnership to Improve Health,[2] an agreement between the Centers for Disease Control and Prevention and academic associations that represent health professions’ training programmes. The goal of these appeals is to ensure that the nation’s health care workforce is equipped to work with public health professionals to meet the nation’s population health goals. To respond to these calls effectively, population health perspectives need to be integrated into the education and training of primary care physicians.[3–5] Innovative approaches are needed to integrate these education and training needs in the already crowded and demanding United States medical school curricula.

An innovative solution

We describe a course entitled ‘Population Health and Community Health Assessment’ as an innovative approach to integrating population health into medical education. The City University of New York School of Medicine/Sophie Davis Program in Biomedical Education is a 7-year BS/MD programme founded in 1973 to train primary care physicians to work in underserved communities. Our course, required in the second year of the programme, is the second in a series of courses that aim to develop primary care physicians who can apply population health perspectives to the development of community-based health improvement programmes. We provide a detailed description of the course, challenges encountered, and a critical analysis of the course in 2015 and 2016 from the perspective of the students and instructors.

Course background

A community health assessment uses quantitative and qualitative methods to systematically collect and analyse data to understand the health status and health-related goals of a specific community. A methodologically sound community health assessment provides the foundation for the development of collaborative strategies to address the community’s health promotion and disease prevention needs. A community health assessment is guided by basic public health principles for improving community health, such as multisector collaborations, community engagement, and evidence-based interventions. It incorporates the priorities of community members as well as information about quality of life, social determinants of health, risk factors, mortality, morbidity, and community and public health assets.[6] An understanding of population health perspectives is necessary for understanding the methods used to conduct a sound community health assessment. Because non-profit hospitals are now required by the Patient Protection and Affordable Care Act to conduct participatory community health needs assessments every three years in order to maintain non-profit status, there is a growing awareness in the medical community and among community health organisations of the importance of conducting methodologically sound community health assessments.

Although this topic and its prominence in the BS/MD programme curriculum are innovative and timely in medical education at present, this course has been a requirement in the BS/MD curriculum for about 40 years. The course has been the responsibility of the Department of Community Health and Social Medicine, which is historically composed of faculty from diverse professional backgrounds, and was designed by a particularly dynamic faculty member, Pyser Edelsack, to enable the students to meet the mission and goals of the programme.

Course goals and objectives

The goal of this course is to contribute significantly to the goals of the BS/MD programme by facilitating the training of physicians who have the skills and knowledge to support community-based population health programmes in their practice. This course seeks to introduce students to foundational population science concepts; develop students’ foundational skills needed to understand, participate in, and lead a community health assessment; introduce students to the use of theories and models in behavioural science; and enhance students’ understanding of multidisciplinary collaboration in community health promotion. The teaching objectives for this course are primarily knowledge acquisition and skills building and secondarily the development of critical, creative, and dialogical thinking.

Course design and structure

The course was designed to provide students with a methodologically sound framework for conducting community health assessments in any community context. The course uses a well-established, widely used model for health programme planning called the PRECEDE-PROCEED Model (PPM) as its structural framework.[6,7] PRECEDE is an acronym for Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation. PROCEED is an acronym for Policy, Regulatory, and Organisational Constructs in Educational and Environmental Development. The course focuses on the PRECEDE portion of the PPM as students complete social, epidemiological, ecological, educational, administrative, and policy assessment assignments. Nonetheless, the PROCEED components are actively linked to the PRECEDE components throughout the course to encourage critical thinking about how the assessment components affect health programme planning, implementation, and evaluation.

The application of the PPM requires a working knowledge of population health concepts such as the ecological model, social and environmental determinants of health, and incidence and prevalence of disease. These concepts, which are novel to clinically-focused medical students, are introduced at the beginning of the course and cultivated and contrasted with clinical treatment perspectives throughout the course. For example, early on, students are given examples of patients who return to clinic repeatedly with the same illnesses. They are encouraged to examine aspects of individuals’ social and built environments to understand causes and effective community-based solutions.

The course contains 13 content modules, most of which closely follow the PPM framework. See Appendix 1 (in online version only). Each module builds on the content of previous modules and consists of readings, lectures, workshops, and written community assessment activities. Students select a specific, well-defined community at the beginning of the course and complete structured, guided written assignments for the PRECEDE portion of the PPM for this community. Students integrate their written assignments into a coherent community health assessment with theory-based health programme planning recommendations in their final assignment.

Weekly, interactive lectures introduce new content and actively link the content to students’ experiences. Real-life examples of community health assessments and health programme planning activities are presented. Lectures are organised as follows: review of module learning objectives; introduction of new content and vocabulary; link new content to students’ experience; provide examples of real-life applications; discussion; link to workshop activities; summarize reactions; review success at achieving learning objectives. Real-life applications have been provided through 5- to 15-min videos, such as the Vermont Public Health Association’s ‘Healthy Community Design in Action’[8] and excerpts from the Centers for Disease Control and Prevention’s The Weight of the Nation.[9] Student interaction is elicited using an active learning approach to support critical, creative, and dialogical thinking.

Weekly workshops support the acquisition of new concepts, but focus on practical community health assessment skills by guiding students through specific, structured written assignments. The workshops are organised as follows: review of lecture and assigned readings; clarification of concepts; and introduction of strategies for conducting community assessment component, and completing assignments. The first half of workshops includes interactive discussion of new content, the assigned readings, and the role of the learning module in the context of the PPM and a community health assessment. The second half of the workshops is spent providing guidance on the written assignments, including assessment planning, raising questions within the group, and sharing resources and strategies. An integrative understanding of how the components of the PPM form a cohesive assessment of the health needs of a community is encouraged.

Skills are developed and assessed through the series of brief, structured written assignments that correspond with assessment components of the PPM. See Appendix 1. These assignments are designed to engage students by actively applying and integrating assessment components and structuring their approach so that the processes are evident, replicable, and easily integrated. Structured processes help students organise and interpret data for each assessment component. These processes support a ‘big picture’ perspective and meaningful critical, creative, and dialogical thinking in the context of a multifaceted approach to conducting community health assessments.

Outcomes

Evaluation

The evaluation of this course includes quantitative and qualitative data from student course evaluations and a discussion of the challenges from the perspective of the instructors. Course evaluations were solicited from students immediately after they completed the course. We provide a summary of student evaluations from the spring 2015 class in Table 1. The closed-response options included ‘Excellent’ (5); ‘Good’ (4); ‘Fair’ (3); ‘Poor’ (2); and ‘Unacceptable’ (1). All course evaluations were anonymous. The course evaluation response rate for this class was 93% (n = 65). Overall, students rated the course favourably with the average rating for the seven questions being ≥3.75.

Table 1.

Spring 2015 student evaluations; options included ‘Excellent’ (5); ‘Good’ (4); ‘fair’ (3); ‘Poor’ (2); and ‘unacceptable’ (1).

Prompt	Average rating
Overall organization of course	3.8
Clarity of the course	3.88
Clarity of the learning objectives	3.86
Achievement of the learning objectives	3.75
Exam(s) success in assessing the understanding of important course concepts	3.82
Overall course quality rate	3.77
Overall faculty teaching	3.83

Students also provided responses to open-ended questions about course strengths, weaknesses, and suggestions for improvement. As a strength, they cited the integration of the written assignments in the final assignment. As one student put it, ‘The small assignments that lead up to the larger assignment is the best way to do the course.’ Some students reported that the real-life examples were less useful because the content was not specifically linked to a grade: ‘I had difficulty staying focused in lecture (not due to the professor, rather there was no incentive to since our entire grade was based on the workshop portion of the class).’ Suggestions for improvement included more closely linking the lectures and workshops. Other suggestions included making all assignments available at the beginning of the semester ‘to help better understand the big picture.’

Challenges

One of the most significant challenges was facilitating a shift in students’ perspectives from a clinical, individual approach to treatment to a population health approach. As one student stated, ‘What are we going to do – diagnose people at the bus stop?’ The course addresses this challenge with multiple strategies. We recognise that the acquisition of population health perspective takes time and competes with a clinical perspective and that a community health assessment can be overwhelming when viewed as a whole. Thus, the course provides structured learning and well-defined learning components to facilitate knowledge acquisition and skills-based training. Population health concepts are presented via multiple modalities using direct, indirect, and active learning strategies. Finally, skills-based training is guided in small-group workshops with, ideally, about 20 students per group.

Impact on students

Community health assessment skills enhance students’ understanding of population health and active integration of population health perspectives into clinical medicine. Alumni consistently identify this course as changing their perspective on health care. Students become aware of the limits of a clinical approach and are more prepared to work with public health professionals to meet community health needs. Students are also more likely to look toward more creative approaches to community health improvement that prioritise community engagement and participation. Additionally, students approach individualised care with an understanding of how patients’ health is influenced by social, structural, and environmental factors, and how these factors influence both the appropriateness and success of different forms of treatment and care.

Discussion and conclusions

The education and training of primary care physicians requires integration of population health content.[1–5] A course in community health assessment can be used to train primary care physicians in population health. The authors have identified no comparable required courses at other medical schools that teach population health through the applied lens of a community health assessment. The content can be taught online without the applied components of a community health assessment or through a standalone population health internship; however, we found that coupling population health concepts with practical application supports students’ engagement and understanding.

A more comprehensive integration might include incorporating population health perspectives as a thematic content thread throughout the curriculum. For example, coursework in embryology and immunology might include content that demonstrates how structural and environmental factors like housing, vaccination, cultural practices, and socioeconomic status impact these fields. Integration might also be strengthened by linking classroom experiences to practicums with non-profit hospitals conducting community health assessments, which are much more involved than those that can be accomplished by students in this course.

Appendix 1.

Community health assessment module content, learning objectives, and assignments

Learning objectives	Assignment
Module 1: Introduction to the function and utilization of community health assessments and the PRECEDE-PROCEED model  • Describe the purposes of a community health assessment  • Describe the elements of the PRECEDE-PROCEED model  • Describe the advantages of using a framework for guiding  • Describe the development of a community health assessment	None
Module 2: Introduction to population description and population health concepts  • List sources of information for performing a community health assessment  • Describe the use of each of these sources of information  • Describe a population of interest with relevant needs assessment-based parameters	Select and describe a community population
Module 3: Quantitative and qualitative data and data sources  • Describe differences between the assumptions made by qualitative and quantitative data  • Contrast the conclusions that can be drawn from qualitative and quantitative data  • Identify appropriate data sources for each component of your community health assessment	Online discussion board posts about quantitative vs. qualitative data
Module 4: Social determinants of health  • List five social determinants of health  • Describe the effects of five social determinants of health  • Document and describe the effects of three primary social determinants of health in a specified population  • Discuss how these social determinants might be effectively addressed  • Describe the effects of socioeconomic status on health  • Discuss the socioeconomic gradient in health  • Discuss how the socioeconomic gradient relates to the health of a selected population	Online discussion board posts about social determinants of health
Module 5: Social assessment*  • Describe the purposes of social assessment  • Discuss how social assessment is appropriately conducted  • List the elements of a social assessment  • Explain how a social assessment is appropriately used in a specified population  • Describe the parameters of a social assessment in a specified population  • Discuss the information one would expect to gain from a social assessment	Conduct a social assessment in your identified community population
Module 6: Epidemiological assessment: health*  • Define epidemiological assessment  • Define health assessment  • Discuss the purposes of a health assessment  • Relate one example of how health assessment has been used  • Explain how a health assessment is appropriately used in a specified population  • Describe the parameters of a health assessment in a specified population  • Discuss the information one would expect to gain from a health assessment	Conduct an epidemiological health assessment of your identified community population
Module 7: Epidemiological assessment: behaviour*  • Explain how a behavioural assessment is appropriately used in a specified population  • Describe the parameters of a behavioural assessment in a specified population  • Discuss the information one would expect to gain from a behavioural assessment  • Define behavioural assessment  • Discuss the purposes of a behavioural assessment  • Relate one example of how a behavioural assessment has been used	Conduct a behavioural assessment of your identified community population
Module 8: Epidemiological assessment: environment*  • Define environmental assessment  • Discuss the purposes of an environmental assessment  • Relate one example of how an environmental assessment has been used in the past	Conduct an environmental assessment of your identified community population
Module 9: Ecological and educational diagnosis*  • Describe the purpose of an ecological and educational diagnosis  • Discuss how predisposing factors are related to ecological and educational diagnoses  • Discuss how enabling and reinforcing factors are related to ecological and educational diagnoses  • Describe the types of questions one would ask to identify predisposing, enabling, and reinforcing factors	Conduct an assessment of predisposing, enabling, and reinforcing factors for one health issue selected from your environmental or behavioural health assessment of your identified community population
Module 10: Administrative assessment*  • Describe the purposes of an administrative assessment  • Discuss how an administrative assessment is appropriately conducted  • List the elements of an administrative assessment	Conduct an administrative assessment of your identified community population
Module 11: Policy assessment*  • Describe the purposes of a policy assessment  • Discuss how a policy assessment is appropriately conducted	Conduct a policy assessment of your identified community population
Module 12: Introduction to theory and its application  • Describe the purpose of theory in interpreting needs assessment findings  • Discuss how theories are appropriately identified  • Describe at least two theories relevant to your community health assessment  • Discuss how identified theories could guide programme development	None
Module 13: Integration and synthesis  • Integrate and synthesise knowledge, enabling students to analyse open-ended problems or complex issues with a community health assessment	Integrative summary with theoretical considerations

^*Indicates components of the PRECEDE-PROCEED Model.