Dr. Sistrom is Associate Professor, School of Nursing, Ms. Zeigen is Librarian, Ms. Durham is Research Assistant, and Dr. Boudrot is Program Manager, Instructional Technology, Oregon Health and Science University, Portland, and Ms. Jones is Instructor, Linfield College of Nursing, McMinnville, Oregon.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Maria Gilson Sistrom, PhD, MSN, RN, Associate Professor, Oregon Health and Science University School of Nursing, SN-4S, 3455 SW US Veterans Hospital Road, Portland, OR 97202; e-mail: firstname.lastname@example.org.
The Institute of Medicine’s (IOM) (2003c) report, Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century, addresses the question of reforms to public health education in the United States and preparation of the public health workforce for the next century. The report “emphasize[s] the importance and centrality of the ecological approach” (p. 5). The report also recommends that “undergraduate schools [of nursing] be encouraged to assure that curricula are designed to develop an understanding of the ecological model of health and core competencies in population-focused practice” (p. 19). Finally, the report advocates for distance learning as a means to improve access to public health education.
This article presents the development, implementation, and evaluation of two courses constituting the population health nursing curriculum of a baccalaureate nursing program at one university. Ecological principles and relationships served as the focus of both courses (Population-Based Care and Epidemiology), and integrated methods (online and classroom) were used by an interdisciplinary faculty group to teach the approach to a large group of students in both theory and clinical settings.
Both courses were designed to address the IOM’s (2003c) goals for distance learning and application of the ecological approach. In addition, we intended to meet most of the Quad Council goals for public health nurses (Association of State and Territorial Directors of Nursing [ASTDN], 2003) at an awareness or proficiency level. Our specific objective was to answer the question: Can distance learning be designed to support learning goals and outcomes specific to an ecological approach and population health concepts in general?
The idea that the health outcomes of groups are not influenced solely by individual action is widespread in the public health literature (Krieger, 2003; Lynch, 2003; Phelan, Link, Diez-Roux, Kawachi, & Levin, 2004). This concept has its roots in Bronfenbrenner’s Ecological Systems Theory (1979) but has been adopted in differing iterations by many fields.
Bronfenbrenner’s theory (1979), which postulates that four systems (micro, meso, exo, and macro) contain roles, behavior norms, and rules that shape human development, has a natural fit with the development of health and population health in particular. The environment in which humans develop, including family, political, and economic structures, the so-called human ecology, forms the life course of individuals and is an iterative function of Bronfenbrenner’s four systems. The application of ecological and systems approaches is ideal for public and population health because the field is specifically not solely concerned with the individual.
Buffardi, Thomas, Holmes, and Manhart (2008), in an application of an ecological approach, noted that:
Numerous scholars have described the role of overlapping, macro level social, political, economic, legal and environmental forces that intertwine with individual biomedical and behavioral risk factors to maintain adverse health conditions within a population.
In their study, the authors described a specific application of social context (i.e., housing and safety) to the incidence of sexually transmitted infections in young adults.
There have also been several iterations of socioecological models applied to both nursing and public health education. In particular, the ecosocial model (Krieger, 2003) or ecological approach (Dahlgren & Whitehead, 1991, as cited in IOM, 2003c) has the purpose of informing public health practice beyond the individualistic biomedical approach (McKinlay & Marceau, 1999) and also represents a return to the profession’s historical population-based focus (McLaren & Hawe, 2005). In addition, the ecological approach is compatible with another desirable historical focus of nursing and public heath, that of social justice (Hofrichter, 2003).
There are difficulties, however, in adopting a socioecological approach to teaching public health. Jakeway, Cantrell, Cason, and Talley (2006) discovered limited understanding of population-health concepts in Georgia public health nurses after years of primary care practice focus. In Canada, a place in which population-based care has long been practiced, public health practitioners have limited understanding of population health as a concept (Cohen, 2006). In the United Kingdom, a country with an established policy platform surrounding the social determinants of health, many concepts associated with macro-level influences are not well understood or accepted (Smith, 2007).
However, the return to an ecological perspective in public health practice serves to address a crisis of relevance in the profession, as we continue to discover the multilevel influences of the structures of society on population health. Calls by the IOM (2003a, 2003b, 2003c) to adjust public health curriculum should, therefore, not go unheeded. Population health in the United States is unlikely to improve unless we do.
Early calls have been made for distance learning as one methodology by which public health education can become more accessible (Ibrahim, House, & Levine, 1995), as well as the establishment of core curricula and competencies that are at least amenable to if not specifically addressing an ecological approach (e.g., see Quad Council PHN Competencies [ASTDN, 2003]). In addition, theory-driven evaluations of online or distance learning in public health have been developed (Umble, Cervero, Yang, & Atkinson, 2000), although in most cases the theory applied has to do with approaches to learning itself and not approaches to practice. However, the call remains to update public health curriculum (MacDonald, 2004), and there is little in the literature specifically regarding how to do so using an ecological approach.
For this study evaluation, instructional methods were developed of necessity using both online and classroom strategies due to the unexpected volume of students (n = 92 in one class and n = 63 in the second class). Originally, the two undergraduate courses (Population-Based Care and Epidemiology) were intended to be offered as online courses, but faculty could not accommodate both theory and clinical components of the curriculum completely online. Therefore, an integrated method using curriculum based on the ecological approach was adopted to meet student competencies for these large classes.
Faculty and support staff for the course included: 1 faculty coordinator for the theory component, 1 faculty coordinator for the clinical component, 11 faculty to integrate theory and clinical (online) components for each clinical group, 2 teaching assistants from a master’s of public health program, 1 librarian Web designer, and 1 instructional designer with a doctorate in education. Students were divided into groups of 8 with a clinical instructor for the clinical portion of the Population-Based Care class. All of the students attended live lecture classes together for both courses.
Transitioning from the traditional classroom course to a hybrid online/classroom course required extensive reengineering of assignments. Learning that had heretofore been delivered in lecture format only had to be revised extensively to meet the same learning goals but without the lecture format since no recorded lectures were used in the online portion of the classes (voiceover PowerPoint® lectures have subsequently been incorporated into the courses).
For example, teaching students to use public data had formerly been taught in a lecture with a discussion and activity session following the lecture; in the online version, supporting materials were provided and students had to use the materials to complete an activity. In this way, papers, discussion forums, quizzes, and short assignments were all managed using the online platform (Sakai) designed in collaboration with the theory and clinical course coordinators and the instructional technology designer.
Teaching assistants managed the Epidemiology course discussion forums with the theory course coordinator; there was no clinical component to this course. Clinical instructors managed the online components of the Population-Based Care class with their group of eight students, serving to integrate the theory with the clinical components of the course. The instructional designer was vital to both the design process and the daily functioning of the course. He attended all live classes and made technological and design adjustments to the course as student and faculty needs arose.
Both courses were newly developed and were intended to meet core competencies designed by the Quad Council (ASTDN, 2003) for entry-level public health nurses to practice at an awareness level in most cases and at a proficiency level in some. The following competencies were included:
- Analytic assessment skills (Domain #1).
- Policy development/program planning skills (Domain #2).
- Communication skills (Domain #3, except use of the media).
- Cultural competency skills (Domain #4).
- Community dimensions of practice skills (Domain #5).
- Basic public health sciences (Domain #6).
- Leadership and systems thinking skills (Domain #8).
Financial planning and management skills (Domain #7) were excluded because they were beyond the scope of this undergraduate course.
Overall course objectives for both courses included the ability to:
- Use social, economic, environmental, cultural, and political assessments in program planning and policy development.
- Recognize, intervene, and collaborate with the community as client.
- Use the evidence base to inform practice.
Basic principles and calculations of epidemiology were also course objectives, as was a basic understanding of concepts of social epidemiology.
Given the IOM’s recommendations for public health education (2003c), the current controversy regarding individual versus population health practice (McKinlay & Marceau, 2000), the growing body of research on structural determinants of health (Sistrom, 2006), and the effects of racism, in particular, on population health (Williams, 2000), it was vital to develop courses that would prepare students for practice in this environment. Therefore, the courses were developed and modeled around the ecological approach to promote understanding of and interventions aimed at health disparities and the structural determinants of health, in addition to traditional aspects of public health nursing practice.
Concepts of structural determinants, population health, and links between individual, group, and community effects are complicated, novel, and difficult to convey at the undergraduate level. Therefore, the materials used to introduce the ecological approach and population concepts included popular media, literary fiction, anthropological studies, and population health research using mixed media.
The television documentary, Unnatural Causes (Adelman, 2008) was used as the core focus of both courses and introduced the students to the ecological approach and population health concepts in a compelling and accessible way. Literary fiction (Year of Wonders by Geraldine Brooks ) was used to teach the role of the public health nurse, principles of epidemiology, and community organizing as an intervention. Martha Balshem’s (1993) Cancer in the Community: Class and Medical Authority, an anthropological study of perceived cancer risk and community health education, was used to teach students principles of environmental health and also the influence of class, social status, and access to resources on health.
In addition, several recent studies were assigned to students, and group discussions were held to help students read and interpret the studies in the context of their new understanding of the ecological context and health. Table 1 outlines some of the materials used and compares them to the ecological approach (Dahlgren & Whitehead, 1991, as cited in IOM, 2003c).
Table 1: Selected Media and Methods with Corresponding Ecological Approach Elements
The focus of the two courses and the purposes of using integrated teaching methods as well as the ecological approach was to ensure that students could incorporate the new concepts they learned into practice. Umble et al. (2000) used a measure of students’ self-efficacy to estimate the effect of online learning on public health practice. However, given that our students had not yet graduated from nursing school, we used a measure of perceived utility for their future practice and a general understanding of population health to evaluate course outcomes.
Students were asked to rate 16 specific course materials or activities using a 5-point Likert-type scale (1 = not useful and 5 = very useful) to their future practice as (potential) public health nurses or their general understanding of population health and ecological principles. In addition, students were asked to evaluate the use of the online platform (Sakai), including design, effectiveness, and technological support. The evaluation was completed anonymously by students using Survey Monkey via a link within the online platform in the last week of the course.
Sixty-three students responded to the evaluation survey; this represented a 100% response rate for the students who took both the Population-Based Care and Epidemiology courses. Students rated 16 course exercises or lectures using a 5-point Likert-type scale (1 = not useful and 5 = very useful). Table 2 shows students’ ratings for some of these exercises. Ninety-eight percent of students rated these items as somewhat to very useful to their practice as public health nurses and their understanding of population health concepts. Three items were rated by 4.8% to 6.3% of students as not useful to their practice or understanding. Only one item, the book by Balshem (1993) was rated by 11.3% of students as not useful. The television documentary, Unnatural Causes, was rated by 81% of students as very useful to their practice as public health nurses and to the understanding of the field of population health in general.
Table 2: Students’ Rating for Selected Evaluation Items
In their evaluation of the design, effectiveness, and technological support of the online component of the courses, 67% to 93% of students rated the course as better compared to other online courses and as very effective in these two courses in particular. Qualitative assessment revealed the great importance of having the online and classroom components of the course well integrated; in particular, the presence of the instructional designer in class and the designer’s availability to students and faculty on a regular basis was key to successful integration. In informal discussions after the course concluded, faculty reported satisfaction with the course and relative ease of online/classroom teaching, given the course design and set-up were developed for them (by the course coordinator and the instructional designer).
This set of courses was designed to answer the question: Can distance learning be designed to support learning goals and outcomes specific to the ecological approach and population health concepts? In addition, the courses sought also to address larger goals set by the Quad Council for nursing practice (ASTDN, 2003), as well as the IOM (2003c) for practice application of the ecological approach and availability of distance learning to public health practitioners. The answer to this question is “yes, very well”; however, it requires an extremely well-integrated effort, a good number of collaborative faculty, and extensive technological support and expertise to do so.
Students evaluated the courses positively in terms of application to practice and their understanding of population health concepts, including structural determinants of health and the ecological approach. Interestingly, several students are now exploring careers in public health in consequence of the course, which in our experience is an uncommon outcome for undergraduate nursing students.
Faculty were challenged to perform in and coordinate several different settings but were enthusiastic about student outcomes. Based on outcomes from this class experience, faculty said they would incorporate the following elements in future iterations of these classes:
- Use of the online platform to integrate clinical and theory components.
- Use of the documentary, Unnatural Causes, to introduce the ecological approach.
- Use of audience response systems in class to test immediate understanding of concepts.
Faculty asked for revision of the environmental health aspect of the courses, however, because they felt it was lengthy and did not directly inform the ecological approach at an undergraduate level. Interestingly, faculty not involved in these two courses have recently adopted a number of the integrated technology elements into their classes. In addition, community concepts have been introduced into a lower level nursing course to establish an early understanding of population health determinants in the curriculum on which to build.
There are several limitations to this evaluation, not least of which is the inability to evaluate practice applications of course concepts. A follow-up evaluation of this cohort of students’ understanding of population health concepts and the ecological approach when they become practicing nurses would be useful to examine. The Epidemiology course was offered in Spring 2010 in a statewide online and classroom format at five campuses with approximately 240 students, and is currently being evaluated as a follow up to this article. It is hoped that the finding of this larger pilot study will confirm the utility of both the hybrid course as well as the ecological approach to be used as an encompassing theory to teach public health nursing.
- Adelman, L. (Executive producer). (2008). Unnatural causes [Television documentary]. San Francisco, CA: California Newsreel.
- Association of State and Territorial Directors of Nursing. (2003). Quad Council PHN competencies. Retrieved from http://www.astdn.org/publication_quad_council_phn_competencies.htm
- Balshem, M. (1993). Cancer in the community: Class and medical authority. Washington, DC: Smithsonian Institution Press.
- Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.
- Brooks, G. (2002). Year of wonders. London, UK: Penguin.
- Buffardi, A.L., Thomas, K.K., Holmes, K.K. & Manhart, L.E. (2008). Moving upstream: Ecosocial and psychosocial correlates of sexually transmitted infections among young adults in the United States. American Journal of Public Health, 98, 1128–1136. doi:10.2105/AJPH.2007.120451 [CrossRef]
- Cohen, B.E. (2006). Population health as a framework for public health practice: A Canadian perspective. American Journal of Public Health, 96, 1574–1576. doi:10.2105/AJPH.2005.075192 [CrossRef]
- Hofrichter, R. (Ed.). (2003). Health and social justice: Politics, ideology, and inequity in the distribution of disease. San Francisco, CA: Jossey-Bass.
- Ibrahim, M.A., House, R.M. & Levine, R.H. (1995). Educating the public health work force for the 21st century. Family & Community Health, 18(3), 17–25.
- Institute of Medicine. (2003a). The future of the public’s health in the 21st century. Washington, DC: National Academies Press.
- Institute of Medicine. (2003b). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.
- Institute of Medicine. (2003c). Who will keep the public healthy? Educating public health professionals for the 21st century. Washington, DC: National Academies Press.
- Jakeway, C.C., Cantrell, E.E., Cason, J.B. & Talley, B.S. (2006). Developing population health competencies among public health nurses in Georgia. Public Health Nursing, 23, 161–167. doi:10.1111/j.1525-1446.2006.230207.x [CrossRef]
- Krieger, N. (2003). Theories for social epidemiology in the 21st century: An ecosocial perspective. In Hofrichter, R. (Ed.), Health and social justice: Politics, ideology, and inequity in the distribution of disease: A public health reader (pp. 428–452). San Francisco, CA: Jossey-Bass.
- Lynch, J. (2003). Income inequality and health: Expanding the debate. In Hofrichter, R. (Ed.), Health and social justice: Politics, ideology, and inequity in the distribution of disease: A public health reader (pp. 356–364). San Francisco, CA: Jossey-Bass.
- MacDonald, M. (2004). From miasma to fractals: The epidemiology revolution and public health nursing. Public Health Nursing, 21, 380–391. doi:10.1111/j.0737-1209.2004.21412.x [CrossRef]
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- Murray, C.J., Kulkarni, S.C., Michaud, C., Tomijima, N., Bulzacchelli, M.T. & Iandiorio, T.J. et al. (2006). Eight Americas: Investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Medicine, 3(9), e260. doi:10.1371/journal.pmed.0030260 [CrossRef]
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- Sistrom, M. (2006). Integrative review of population health, income, social capital and structural equality. The Journal of Multicultural Nursing & Health, 12(2), 21–27.
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Selected Media and Methods with Corresponding Ecological Approach Elements
|Resource/Media||Methods||IOM’s Ecological Approach Element|
|Unnatural Causes (Adelman, 2008)||Biology of disease; social, family, and community networks; living and working conditions; social, economic, cultural, and political conditions|
|Year of Wonders (Brooks, 2002)||Construction of epidemic curves; small group (live) discussion; online discussion forum||Biology of disease; individual behavior; social, family, and community networks|
|Cancer in the Community: Class and Medical Authority (Balshem, 1993)||Integrated (live) seminar, small group discussion; online discussion||Individual behavior; social, family, and community networks; living and working conditions; social, economic, cultural, and political conditions|
|“Eight Americas” (Murray et al., 2006); “Geographic Data on Health Inequities: Understanding Policy Implications” (Pappas, 2006); “Two Oregon Counties Score High in Longevity” (O’Neill, 2006)||Integrated (live) seminar, small group discussion; online discussion; classroom lecture||Social, economic, cultural, and political conditions|
|Lecture and article|
|Strategies of Prevention; “Sick Populations, Sick Individuals” (Rose, 1985)||Classroom lecture; large group discussion|
|Individual behavior; living and working conditions; social, economic, cultural, and political conditions|
Students’ Rating for Selected Evaluation Items
|Course Material/Activity||Not Usefuln(%)||Somewhat Usefuln(%)||Usefuln(%)||Pretty Usefuln(%)||Very Usefuln(%)||Rating Average|
|Television documentary: Unnatural Causes (Adelman, 2008)a||1 (1.6)||0 (0)||9 (14.3)||19 (30.2)||51 (81)||4.62|
|Book, epidemic curves, discussion groups: Year of Wonders (Brooks, 2002)||4 (6.3)||13 (20.6)||10 (15.9)||17 (27)||19 (30.2)||3.5|
|Book, discussion groups: Cancer in the Community: Class and Medical Authority (Balshem, 1993)||7 (11.3)||14 (22.6)||21 (33.9)||12 (19.4)||8 (12.9)||3.03|
|Set of articles and discussion activities: “Eight Americas” (Murray et al., 2006); “Geographic Data on Health Inequities: Understanding Policy Implications” (Pappas, 2006); “Two Oregon Counties Score High in Longevity” (O’Neill, 2006)||1 (1.6)||10 (15.9)||12 (19)||19 (30.2)||21 (33.3)||3.82|
|Lecture and article: Strategies of Prevention; “Sick Populations, Sick Individuals” (Rose, 1985)||0 (0)||5 (7.9)||17 (27)||27 (42.9)||14 (22.2)||3.79|