Peer Review

For the Profession and for All: Toward Liberal Education in Public Health

In September 2009, a group of public health educators and advocates met in Chicago to plan the future of undergraduate education in public health. It was a timely meeting. The nation was debating the healthcare plan advanced by President Barack Obama. The Institute of Medicine of the National Academy of Sciences (IOM) had some years earlier issued a call, making the case that all undergraduates should have access to education in public health. Growing support in the field of public health registered the urgency of that call and the daunting scale of the commitment necessary to achieve it. And there was professional urgency. In the first decade of the twenty-first century, undergraduate public health major and minor programs, in a wide variety of designs, had been springing to life across all types of colleges and universities. It was therefore both timely and significant that the Association of Schools of Public Health (ASPH)—dedicated first to graduate and professional education—stepped forward to lead the September 2009 meeting.

The Educated Citizen and Public Health

By its close, ASPH leaders and partners from the Association of American Colleges and Universities (AAC&U), the Association for Prevention Teaching and Research (APTR), and the Centers for Disease Control and Prevention (CDC) had made a decision that held the potential to make a significant impact on the profession. Here are the extraordinary points: the leading organization for graduate and professional education in the field of public health reached a collaborative interprofessional decision to use the Essential Learning Outcomes (ELOs) of Liberal Education and America’s Promise (LEAP) as a framework for the design of learning outcomes in public health for all undergraduates. The choice had been theirs to make. The group might have elected to develop learning frameworks for the burgeoning new major programs in integrative public health. They did not have to put all undergraduates first. But that is exactly what the group decided to do.

For AAC&U, the hope and intention to bring access to education in public health to all undergraduates was a continuation of work begun in 2006. AAC&U had become involved that year in an initiative called the Educated Citizen and Public Health (ECPH; http://www.aacu.org/public_health/). ECPH began as a collaborative effort responding to the IOM call, which was originally published in 2003 in a monograph titled Who Will Keep the Public Healthy?: Educating Health Professionals for the 21st Century. While the IOM call pointed to health professionals, it made the case that all undergraduates—all—should have access to education in public health. The ECPH initiative took that call seriously and formed a partnership with the Council of Colleges of Arts and Sciences (CCAS), AAC&U, APTR, ASPH, and others to reach the goal. The Analysis article in the summer 2009 Peer Review issue on Liberal Education and Undergraduate Public Health Studies describes much of the early work of ECPH.

As the association representing the accredited graduate schools of the profession, ASPH took a more concerted role when they stepped forward to lead the September 2009 meeting and in that way to articulate a plan for future essential work. It was a historic moment for the profession in that it had been convened by ASPH as an interdisciplinary and inter-professional venture: in the first century of its existence, since 1915, academic public health had been primarily focused on graduate and professional education in public health and across the full array of health professions. But by 2009 it was clear that the future of public health education needed to consider both undergraduate majors and general education. Exactly how to do that was the big question—the reason for the meeting.

To newcomers, the convergence of LEAP and public health might seem at first glance unusual and unexpected. While many of the attendees had been involved in the initiative for years, never before had any of us seen LEAP used in this way—to define and align Essential Learning Outcomes for all undergraduates within an interdisciplinary and inter-professional framework. And the work was successful. After a collaborative process that took two years following the September 2009 meeting, ASPH announced and published the 1.0 version of the working model: Undergraduate Public Health Learning Outcomes (http://www.asph.org/document.cfm?page=1085). This achievement is the first such application of the LEAP ELOs. We believe that the process and the model can point the way for other interdisciplinary and interprofessional leaders dedicated to liberal education and to the LEAP framework of ELOs for all undergraduates.

Process

As we have mentioned, the selection of the LEAP framework was an option, not a fait accompli. After reviewing LEAP, specifically considering how the Essential Learning Outcomes could align with and engage big questions of public health on a local and global scale, the group was inspired. Attendees remarked how beautifully the LEAP ELOs mirror the cross-disciplinary and applied approach of public health. In fact, the group wondered if the prolific growth of public health courses and programs on college campuses was itself a sign, a response indicating how well a public health approach facilitates the adoption of the LEAP ELOs. Setting hubris aside, the group had no trouble seeing that the big questions of public health in the twenty-first century—of human and environmental well-being and thriving, of health and human rights and the responsibilities of an educated citizenry—actually could advance the work of LEAP.

Armed with the IOM call, the Educated Citizen and Public Health effort, and the LEAP framework, the group proceeded to outline the process for developing a set of undergraduate learning outcomes in public health.

Determining that the effort would focus broadly on educating all undergraduates, and that the audience would then necessarily include faculty, students, and administrative leaders in two- and four-year institutions of all types, the group chose to use the LEAP ELOs rather than a more traditional public health professional framework to organize its work. Public health education at the graduate level calls for demonstrated achievement of competencies; frameworks of professional competencies do indeed exist and might in fact have been tailored to undergraduate learning. But that approach appeared too narrowly professional. LEAP provided not only a framework of outcomes but also an inclusive language and diction for learning and pedagogy that could be used to foster inter-professional and interdisciplinary communication. The group chose to develop a set of public health learning outcomes aligned with the first three ELOs—knowledge of human cultures and the physical and natural world, intellectual and practical skills, and personal and social responsibility. Instead of calling these three “essential learning outcomes,” the group called them “domains.”

We agreed to develop sets of learning outcomes within the first three domains of the framework and to come back to the fourth domain—integrative and applied learning—after the first three domains had been populated with public health content, concepts, tools, and values. The first domain was modified for public health: knowledge of human cultures and the physical and natural world as it relates to individual and population health. The second and third domains remained as in the original LEAP framework: intellectual and practical skills and personal and social responsibility The full set of public health education domains and outcomes can be found at http://www.asph.org/userfiles/learningoutcomes.pdf.

The learning outcomes within each of these three domains were subsequently developed by three ten-member workgroups. The September 2009 leadership group agreed that it was important to populate each of these workgroups with an equal number of representatives from the liberal arts and sciences and from inter-professional public health and to have co-chairs representing each of these two worlds. Following the September meeting, the leaders sent out a call for nominations and were overwhelmed by the expressions of interest. To accommodate the many people who wished to participate, the leaders created additional resource groups to support each appointed workgroup; all told, over 130 people contributed to the process of developing undergraduate public health learning outcomes.

Developing learning outcomes within the three domains was a challenging and invigorating process. When the leadership group eventually progressed to considering the fourth domain, integrative and applied learning, the level of challenge and excitement grew even greater. It is in application and integration that the work of the first three domains produces informed learning, skill development, and responsible action. Through application and integration, highly effective and high-impact learning will be most likely to occur in undergraduate students and by extension, in faculty who embrace and incorporate engaged learning. The fourth domain is also the area in which public health excels because so much of what is accomplished in public health is carried out through integrative and applied approaches. The leadership group developed an initial list of examples within domain four, using learning outcomes from the first three domains and suggesting innovative and dynamic ways to integrate and apply them in both classroom and out-of-classroom settings. Those of us in public health like to say that everything in human experience “is public health.” The potential for integration and application of public health issues and topics across every discipline and field has driven, we are sure, the growth of this twenty-first-century integrative field.

Model

The concepts and skills articulated in the thirty-four learning outcomes are intended for faculty to select and integrate into curricular and cocurricular learning opportunities in ways that make sense for the learning, in context. They are not meant to be prescriptive, and the list is not exhaustive; rather it provides illustrative examples of how public health contributes to quality of life locally and globally and how the science and the art of public health can enhance the achievement of the learning outcomes that are essential to undergraduate education. The beauty of this approach lies in its simplicity and flexibility: the learning outcomes call for neither a particular course nor a specified curriculum, but rather provide opportunities for learning across educational experiences.

We intend that the first three domains and their specific outcomes will be brought to life through the activities of domain four. As published now online, the model offers examples for incorporating or integrating the learning outcomes of each domain into general education or discipline-specific courses, and into cocurricular and experiential learning opportunities. The model suggests varied possibilities for incorporating the learning outcomes. For example, domain 2 [Intellectual and practical skills], learning outcome 6: “communicate health information to a wide range of audiences using all types of media.” But this outcome could be accomplished under domain 4 [Integrative and Applied Learning] by engaging a group of journalism students to develop a multimedia public information campaign promoting influenza vaccines among older adults.

To do this, students would need to understand the influenza virus, why a new vaccine is developed every year, why older adults are particularly susceptible to influenza, how that susceptibility translates into premature mortality and costly hospitalizations, and how these results affect society at large—worldwide. They would also learn how health messaging and social marketing differ from other communication strategies and perhaps have the opportunity to engage local health care and public health professionals as well as those from the local media to complete the project. Similarly, a political science or public policy class could stage a mock town hall meeting in which a variety of stakeholders, including the local hospital, the police department, the school board and the leading employers in the community review the latest health status report prepared by the local health department and consider approaches to improving health outcomes in the community. This activity would address domain 3 [Personal and Social Responsibility], learning outcome 1: “identify stakeholders who influence health programs and interventions.” In addition, the learning outcomes can expand beyond the classroom into cocurricular activities and also beyond the students’ local university setting. A learning community of students from a variety of fields, such as the biological, social, behavioral, physical, and natural sciences; business; architecture; urban planning; and engineering, could explore the epidemic of obesity locally and globally, researching the rates of obesity in different countries, its causes and effects, and how different countries approach the epidemic. By studying obesity, students would come to “appreciate the multiple determinants of health, ” in domain 2 [Intellectual and Practical Skills], learning outcome 9.

Conclusion

The fundamental guiding inspiration for the September 2009 group was the potential to advance the public’s knowledge of public health and its importance in sustaining vibrant and viable communities locally and globally as the world population passes seven billion and continues its explosive growth. Public health is public both because it addresses the needs of entire populations and because we all own public health: it is what we do collectively to advance our self-interests in our own health. If the public neither acknowledges a public health threat nor accepts the proffered solution, there will be no support. The stories of public health failures are legion and often stem from this absence of community ownership, which in turn is a function of a lack of knowledge of public health. Public health suffers from being part of “government,” having the word “public” in its name, and being largely unfamiliar to the general populace. One need only read the letters to the editor in any local newspaper or monitor the decisions of local city or county commissions to see evidence of this disconnect. The fact that we continue to debate the benefits of immunizations, motorcycle helmets, or fluoridation speaks to this fundamental lack of understanding and trust. Thoughtfully and deliberatively working to build a basic knowledge and an appreciation for public health efforts can only reap benefits for the public health system and ultimately society at large.

The development of the undergraduate public health learning outcomes was an important step for public health education and an historic opportunity for LEAP. By providing a solid foundation on which to build the public health learning outcomes, the LEAP framework helped the field of public health respond to the IOM’s call for every undergraduate to be exposed to education in public health. With the model in hand, faculty and students have the opportunity to work together with each other, with other disciplines and fields, and with public health professionals to integrate and apply the learning outcomes directly into the widest possible array of educational settings. These creative partnerships and ideas need to be gathered into a continuously expanding knowledge base of ways by which the learning outcomes are utilized. We hope you will join us in this work. Suggestions and examples on using the public health learning outcomes are welcome at learningoutcomes@asph.org.

Acknowledgment

This article was supported under a cooperative agreement from the Centers for Disease Control and Prevention (CDC) through the Association of Schools of Public Health (ASPH) Grant Number CD300430. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of CDC.


Susan Albertine is the vice president of Engagement, Inclusion, and Student Success at the Association of American Colleges and Universities; Donna J. Petersen is the dean of the College of Public Health at the University of South Florida; Christine Plepys is the assistant director of grants and contracts at the Association of Schools of Public Health.

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