A RENEWED VISION FOR PUBLIC HEALTH EDUCATION

A Renewed Vision for Higher Education in Public Health We are transforming the educational strategy at the Harvard T. H. Chan School of Public Health guided by 5 principles: (1) development of T-shaped competencies (breadthacrossfields, depth in primary fields), (2) flexible and modular design accommodating different needs through the lifecycle, (3) greater experiential learning, (4) 3 levels of education (informative, formative, and transformative learning), and (5) integrated instructional design (online, in person, and in the field). We aim to create an arc of education resulting in continuous learning. We seek to bridge the research versus education dichotomy and create research–teaching congruence, adapting the values of peer review and quality assessment that we routinely accept for grant and article review to education. (Am J Public Health. 2015;105:S109–S113. doi: 10.2105/AJPH.2014.302468)

Julio Frenk, MD, PhD, MPH, David J. Hunter, ScD, MBBS, MPH, and Ian Lapp, PhD

THE PAST CENTURY HAS witnessed a momentous transformation in human health, as epitomized by the near doubling of life expectancy. Not surprisingly, there has been a concomitant explosion of interest in public health education, especially in recent years. In North America alone, over the past decade the number of Council on Education for Public Health--accredited graduate schools of public health has jumped to 52 from 32, and accredited schools and programs now number 160 and include a growing number of Council on Education for Public Health---accredited programs outside North America. There is also increasing interest in other regions of the world. As more students are attracted to the field, our mandate as educators is crucial: to pay close attention to what we teach and how we teach it. Today, however, the way we educate public health professionals falls short of the needs of a changing world. Although a large part of the progress in public health during the past century can be attributed to advances in knowledge nurtured in universities, that momentum may wane if we fail to adapt our curricula and pedagogical styles both to the new array of public health challenges that confront us (e.g., the health consequences of globalization) and to advances in cognitive science and technology—a convergence that holds substantial promise for enlivening educational experience inside and outside the classroom. To mark its centennial in 2013, the Harvard School of Public Health (HSPH; recently renamed the Harvard T. H. Chan School of

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Public Health) has launched a newly designed educational strategy that combines the most current insights into learning with the most far-reaching technological platforms. This includes the comprehensive redesign of the Master of Public Health (MPH), Master of Science (MS), Doctor of Public Health (DrPH), and Doctor of Philosophy (PhD) programs. Our approach reflects recommendations contained in the 2010 Lancet report titled “Health professionals for a new century: transforming education to strengthen health systems in an interdependent world”1—the product of the Commission on Education of Health Professionals for the 21st Century, cochaired by one of us (J. F.) and Lincoln Chen. At HSPH, our goal is to deepen the educational experience by combining the values of excellence and relevance—not only for graduate students and postdoctoral fellows but also for current practitioners and leaders in a field in which learning never truly ends. Since the publication of the Lancet report, numerous educational institutions around the world have explored ways to implement its recommendations.

A CENTURY OF REFORMS This article is the most recent in a long line of reports over the past century that has offered forward-looking conceptions of health professional education. Yet as the 2010 Lancet report describes, a very small proportion of these reports have specifically examined public health education. A literature review of the previous

century revealed that of 8746 articles devoted to the health professional curriculum in developed countries, 73% focused on medical education, 25% on nursing education, and only 2% on public health education.1 The eclipsing of public health in the scholarly debate on health professional education reform adds to the urgency of addressing the issue today. The list of educational reform recommendations begins with the iconic 1910 Flexner Report titled “Medical education in the United States and Canada,” which argued that the medical curriculum should be founded on modern science.2 Perhaps the first influential document to focus on modern public health education was a 1915 article in the Journal of the American Medical Association authored by Milton J. Rosenau, one of the visionary founders of HSPH (which was then known as the Harvard---MIT School for Health Officers). Titled “Courses and degrees in public health work,”3 it emphasized the broad mix of competencies needed to fulfill the public health mission. Presciently anticipating our school’s current reform strategy, Rosenau stated, “The student should know something of everything and everything of something”3(p794)—a model for which we have adopted the notion of “T-shaped education.” Rosenau’s article was followed a few months later by the influential Welch---Rose report,4 which recommended that schools of public health be part of a university, be science based, and be independent of medical schools. Other pivotal documents include

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the Milbank Memorial Fund Commission’s 1976 report “Higher education for public health,”5 which evaluated the relations between professional education and practice, and the Institute of Medicine’s 1988 report, “The future of public health,”6 which argued for a stronger government role in advancing public health. In 1994, Harvey Fineberg (dean of HSPH) et al. published a thorough review of professional education in public health.7 The authors posed a searching question: “What is preventing . . . schools from completely fulfilling their mission to train public health leaders and professionals?” Fineberg et al. concluded with a call to action: “The time is ripe to realize a new vision of public health education.”7(p257)

outdated and static curricula producing ill-equipped graduates from underfinanced institutions in almost all countries.”1(p1926) Against this sobering backdrop, there are positive breakthroughs in cognitive science, along with powerful new technological platforms for learning. Universities are evolving from their traditional role as places where people go to obtain information (through libraries or faculty expertise) to centers that incorporate novel forms of learning beyond the confines of the classroom. These groundbreaking developments will help create a new generation of learners with the capacity to untangle vast amounts of information and extract and synthesize the knowledge necessary for populationbased decision making.

NEW PROBLEMS, NEW MODES OF LEARNING

FORGING A STRATEGY FOR EDUCATIONAL REFORM

We believe the time is ripe for a renewed call to action. The new educational strategy of HSPH arrives at a moment of critical change in the field. First, the global public health picture is shifting. As the 2010 Lancet commission noted, glaring gaps and inequities in health persist both within and between nations. Meanwhile, the world is in the midst of a complex epidemiological transition characterized by the coexistence of the unfinished agenda of common infections and reproductive health problems with the emerging challenge of noncommunicable diseases. Health systems worldwide are struggling to keep up, as they become more complex and costly, placing additional demands on an inadequate supply of health workers. As the Lancet report notes, public health education has failed to keep up with these shifts and is stymied by “fragmentary,

HSPH began planning its educational overhaul in 2010, when the faculty embarked on a process of reexamining how and what we teach our students—an effort we called the “roadmap to 2013.” This reexamination occurred in the context of a broader reflection about the future of higher education that was catalyzed by the launch of the Harvard Initiative for Learning and Teaching in 2011 and the 2012 launch of edX8—an online learning consortium in which HSPH has been an important contributor. From the start, HSPH faculty had no interest in carrying out an inward-looking exercise; rather, we saw ourselves as an institution with a distinguished legacy that compelled us to look outward. Over a 3-year period, we conducted a comprehensive review of our educational strategy. In

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November 2013, the school’s centennial celebration offered the occasion to formally launch the new plan. Guided by the framework in the 2010 Lancet report, our strategy is built on 2 pillars, 1 instructional and the other institutional.

INSTRUCTIONAL INNOVATIONS The instructional dimension of the new strategy is founded on a critical shift in the way we think about the purpose of our work. Traditionally, higher education has been construed as a kind of tube, with an entrance on 1 end— admissions—and an exit on the other—graduation. As educators, we assume that students benefit in the journey between these 2 portals. Yet public health education requires a more open architecture, where students enter and exit educational institutions throughout their lives and where full-time students shuttle between the university and the communities where their growing research skills can be usefully applied. With that open architecture in mind, we have developed 5 principles for educational redesign:

T-Shaped Competencies The first principle calls for competency-based learning. These competencies result in what is called in the human resources literature a “T-shaped” individual. Until now, most professional and graduate schools, particularly at the doctoral level, have largely been graduating “I-shaped” individuals—those with depth in 1 specialized area. But to fulfill the modern public health mission, we also need to develop the horizontal segment of the “T,” with a breadth of core competencies requisite in any field.

These competencies, traditionally taught in survey courses of the basic areas of knowledge defined by the Council on Education in Public Health, may be better developed as part of interdisciplinary curricula that also include skills in leadership, communication, innovation, and the capacity to translate scientific knowledge into policies and action.

Flexible and Modular Education As public health professionals and as experts in diverse fields, students need to master the foundational knowledge of public health. Achieving the proper balance of widely applicable skills and deep expertise is a key goal of competency-based learning. To strike that balance, we have espoused a principle of flexible and modular education in which individuals can supplement their education as needed throughout their careers and lifecycles, focusing on specific skills or areas of scholarship that they need to enhance their work. Both medical and nursing education, driven by credentialing agencies, have mandated continuing medical and nursing education requirements for decades. Public health workers should be no less up-to-date. Because of the constraints imposed by residential programs, much of this will be achieved using new digital approaches to distance learning.

Experiential Learning Because public health plays out primarily in the field—scenarios that demand effective and efficient solutions—students must be steeped in the unpredictable dynamics of real-world challenges. At the Harvard Humanitarian Academy, for example, our school uses a section of forest on the

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outskirts of Boston to simulate the conditions of a refugee camp. Through an experiential, highly scripted pedagogical set of materials, we create an immersive and engaged learning experience by which we educate future leaders in the exigencies of humanitarian action.

Three Levels of Learning HSPH’s new educational strategy aspires to inculcate 3 successive levels of learning, which we frame as informative, formative, and transformative (Figure 1). Informative learning entails acquiring knowledge and skills and involves transmitting foundational knowledge—such as biostatistics, epidemiology, social science theory, environmental health, health policy, and management. This level of learning lends itself to the digital realm, both interactive flipped classroom experiences and high-quality online resources. Although informative learning helps cultivate individuals as experts, it is not enough to produce a true public health professional.9 At the formative learning level, experts become professionals, as they are socialized with a set of values and codes of ethics; at this level, face-to-face interaction and onsite experiences are essential for assimilating the philosophical underpinnings of public health and for becoming ethically grounded professionals. Finally, at the transformative learning level—the highest of the 3 successive stages, and one in which face-to-face interactions among students and faculty are paramount—students develop leadership attributes to become enlightened agents of change. Here, memorizing facts is supplanted by searching analysis and synthesizing information to make decisions,10 the individual quest

for professional credentials is replaced by the refinement of skills necessary for effective teamwork,11 and the uncritical adoption of models acquired during coursework gives way to the ability to creatively adapt global resources to solve local problems and to recognize local solutions that can be scaled up to the regional or global level.

Integrated Instructional Design Because each of the earlier principles of education depends on a somewhat different mix of educational settings, HSPH’s strategy aims for a blended learning experience. The goal is a harmonious balance of online, onsite, and in-the-field learning (Figure 2). This concept moves beyond the divisive and outdated debates about which learning approach is superior. In the 21st century, a solid public health education must move through all modes and levels of learning.

EDUCATING FOR AN ARC OF LEADERSHIP The new instructional strategy at HSPH is founded on the notion of continuous leadership development. We recognize an arc of leadership that develops over a lifetime, which means we must address the needs of future public health leaders: our young residential students. But our strategy is also geared toward emerging public health leaders; these are professionals who, in the midst of challenging careers, perceive further educational goals. In addition, the strategy includes current and mature leaders who, through decades-long experience, have crucial lessons to impart (Figure 3). In hewing to this arc of education, we have reshaped many

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Online

Onsite

Transformative Learning Formative Learning Informative Learning

FIGURE 1—Succesive levels of learning inculcated by the new education strategy at Harvard T. H. Chan School of Public Health: Boston, MA.

aspects of our degree-granting programs. Our PhD program is a research-oriented doctoral program undergoing renovation. To complement this degree, we have recently launched a new doctor of public health program—a professional doctorate program focused on leadership development. Unifying our dual approach to doctoral degrees is a concept that we call “from the genes to the globe.” How do we address a complex problem, such as malaria or obesity and solve it by cutting across levels of analysis and academic disciplines? HSPH is also recasting its master of public health curriculum. The new master of public health program is designed to serve the needs of emerging leaders through

both early and midcareer programs. The school has a long history of offering such programs, particularly in the area of clinical effectiveness. We plan to multiply these efforts in a more modular approach that satisfies the targeted needs of midcareer professionals fully using the new technological platforms for blended learning. We are also expanding our presence in executive education. One example is the Ministerial Leadership in Health Program. Since 2012, 56 ministers of health and of finance from 40 countries in Africa, Southeast Asia, and Latin America have participated in the program. They come to our campus for a 4-day intensive immersion experience in leadership development

Online

Onsite

In field

FIGURE 2—Blended learning experience harmonizing 3 essential educational settings at Harvard T. H. Chan School of Public Health: Boston, MA.

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FIGURE 3—Instructional strategy based on continuous leadership development: Harvard T. H. Chan School of Public Health: Boston, MA. conducted jointly with the Harvard Kennedy School of Government. Finally, we have introduced a program called the senior leadership fellows for individuals who have just finished a term of duty as leaders. These are seasoned professionals who spend 3 months on campus imparting lessons from their vast public health experience to the future leaders among the residential students—thus closing the arc of leadership. The goal is to create a community in which those who occupy a place on the continuum of public health leadership can enrich each other’s skills and knowledge.

major challenge. It is especially so in this case, because our educational reforms spring from a new comprehension of the art of teaching and the science of learning. HSPH, in particular, is a research-intensive school. In this context, motivating faculty to think in a different light about education is a major undertaking. Yet we have found that the new educational opportunities have led most of the faculty to embrace the reform process. It has also furthered our commitment to incorporate pedagogical training for doctoral students.

Capacity

INSTITUTIONAL REFORM To carry out such instructional reforms, we must adapt our institutions to today’s new realities. In the case of HSPH—an institution that is 100 years old—the shift will be profound. We believe the key to institutional adaptation is conveyed in what we term the 3 “C’s”: colleagues, capacity, and culture.

Colleagues “Colleagues” refers to faculty members. In any academic context, faculty development is a

The second “C,” capacity, supports educational reform with infrastructure and modern technological platforms. Capacity starts with new learning spaces—flexible arrangements that facilitate interaction and connectivity to improve learning. It also includes new pedagogical materials, such as high-quality cases and simulations of some of the most pressing public health problems. One example is the Harvard Humanitarian Academy’s simulation of a refugee camp. Taking this a step further, it is necessary to mobilize computer

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simulation technologies to generate immersive learning scenarios. Capacity also rests on new technological platforms with powerful global reach. Our school is an active participant in edX, an educational partnership involving many of the best universities in the world. (Other such partnerships include Coursera12 and Udacity.13) These platforms have 3 main strengths. One is to improve access to knowledge. At HSPH, the first 6 massive open online courses registered 220 000 learners and issued more than 11 000 no-fee certificates of completion. The second use of these new technological platforms is to enrich the educational experience of onsite students. The informative level of learning is conducted online—an effective approach, especially if the material is of high quality, as in edX. This provides the basis for the flipped classroom, in which the traditional lecture is conducted online, whereas the traditional task of homework is conducted in the classroom through group problem solving. Clearly, the conventional classroom experience of the past century will be radically transformed over the next 100 years. HSPH is leveraging its experience from massive open online courses and classroom flipping to launch a new, blended MPH degree. A third use of new technological platforms is to expand global engagement through the development of consortia among educational institutions from around the world. Through such consortia, HSPH and its partners expect to learn alongside each other how to employ online material in flipped classrooms at their respective sites. Clearly, such partnerships offer enormous potential for building global institutions to address the

acute shortage of competent professionals. A final element of capacity is financial resources. We need to find new ways of sustaining these forward-looking—and costly— technologies. Although online education may reduce costs for users, they typically increase expenses for the producers of online content. Thus, we have the need for new sources of revenue, including philanthropy—the enlightened force that has generated many signal achievements over public health history.

Culture The third “C” is “culture.” The stark truth is that we need to alter the organizational culture in universities. This evolution includes replacing the language we use— not talking about teaching loads, for instance, but teaching privileges. More broadly, it is imperative to modify the relative valuation of research versus education in the corresponding reward schemes (including the criteria for promotion). Cultural adaptation also includes how members of the organization construe their own identity. At research-intensive schools such as ours, a faculty member may self-identify as a top-ranked researcher who does some teaching. Instead, we need to forge the identity of researcher---teacher, an individual who merges both of those elements of the public health mission into a single role.

THE TEACHING– RESEARCH CONGRUENCE At HSPH, the essence of institutional reform could be described as the teaching---research congruence. We aspire to adapt the values that imbue the research enterprise— values such as collaboration and

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team-based efforts—and apply them to the teaching enterprise, which is still largely a solo activity. Similarly, although researchers think nothing of submitting grant proposals and articles to the scrutiny of peer review, by and large such an approach is eschewed in education. By contrast, we believe that the pursuit of excellence is a core goal of education and that peer review of teaching is an important complement to student evaluations in assessment. Most importantly, we intend to build a body of knowledge—an evidence base—on what works and what does not in educational innovation so that we can rigorously assess next steps. To that end, we aim to develop a comprehensive program of educational research in public health.

translated, it leads to action, which in turn spurs new questions and new knowledge. Our field is fueled by this virtuous circle of knowledge, which will sustain the second century of public health education. j

A SECOND CENTURY OF PUBLIC HEALTH EDUCATION

Contributors

We have offered a brief summary of 1 school’s new education agenda. As the entire public health profession moves forward in tandem with the transformation of health worldwide, we must make sure that our higher education continues to foster the creative leaders that will steer the next century of progress. We are on the threshold of a revolution in education, akin to the health revolution of the 20th century. One of the timeless goals of public health education is to pursue and disseminate knowledge— knowledge that will be translated into beneficial technologies, such as better drugs and vaccines; improved diagnostic methods and algorithms; and evidence that informs decision making at all levels, from the household to the health ministry. When that knowledge is successfully

About the Authors Julio Frenk is with the Office of the Dean, Harvard T. H. Chan School of Public Health, Boston, and the Harvard Kennedy School of Government, Cambridge, MA. David J. Hunter is with the Office of the Dean, Harvard T. H. Chan School of Public Health. Ian Lapp is with the Department of Global Health and Population, Harvard T. H. Chan School of Public Health. Correspondence should be sent to Julio Frenk, MD, PhD, MPH, Dean, 677 Huntington Ave, Harvard T. H. School of Public Health, Boston, MA 02115 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted November 11, 2014.

J. Frenk developed the conceptual framework and designed the overall structure for the article. All authors contributed to the refinement of concepts and arguments and the writing of the article.

Acknowledgments We thank all the faculty members at the Harvard T. H. Chan School of Public Health who have played a crucial role in the development of the new research strategy, especially Nancy Turnbull, associate dean for professional education, and Nancy Kane, associate dean for casebased teaching and learning. We have also benefitted from helpful discussions with Robert Lue, faculty director of HarvardX, and Erin Driver-Linn, director of the Harvard Initiative for Learning and Teaching. Madeline Drexler provided editorial assistance.

2. Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the Advancement of Teaching. 1910. Available at: http:// www.carnegiefoundation.org/sites/default/ files/elibrary/Carnegie_Flexner_Report. pdf. Accessed June 20, 2014. 3. Rosenau MJ. Courses and degrees in public health work. JAMA. 1915;64(10): 794---796. 4. Welch WH, Rose W. Institute of Hygiene: A Report to the General Education Board of Rockefeller Foundation. New York, NY: Rockefeller Foundation; 1915. 5. Sheps CG; Milbank Memorial Fund Commission. Higher Education for Public Health: A Report of the Milbank Memorial Fund Commission. New York, NY: PRODIST; 1976. 6. US Institute of Medicine; Committee for the Study of the Future of Public Health. The Future of Public Health. Washington, DC: National Academy Press; 1988. 7. Fineberg HV, Green GM, Ware JH, Anderson BL. Changing public health needs: professional education and the paradigm of public health. Annu Rev Public Health. 1994;15:237---257. 8. edX Inc. edX. 2014. Available at: http://www.edx.org. Accessed June 20, 2014. 9. Ambrose SA, Bridges MW, DiPietro M, Lovett MC, Norman MK, Mayer RE. How Learning Works: Seven ResearchBased Principles for Smart Teaching. San Francisco, CA: Jossey-Bass; 2010. 10. Caffarella RS. Planning Programs for Adult Learners: A Practical Guide for Educators, Trainers, and Staff Developers. 2nd ed. San Francisco, CA: Jossey-Bass; 2002. 11. Wlodkowski RJ. Enhancing Adult Motivation to Learn: A Comprehensive Guide for Teaching All Adults. 3rd ed. San Francisco, CA: Wiley; 2008. 12. Coursera Inc. Coursera. 2014. Available at: http://www.coursera.org. Accessed June 20, 2014. 13. Udacity Inc. Udacity. 2014. Available at: http://www.udacity.com. Accessed June 20, 2014.

Human Participant Protection There were no human participants involved in this work so institutional review board approval was not needed.

References 1. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756): 1923---1958.

Supplement 1, 2015, Vol 105, No. S1 | American Journal of Public Health

Frenk et al. | Peer Reviewed | A Renewed Vision for Public Health Education | S113

A renewed vision for higher education in public health.

We are transforming the educational strategy at the Harvard T. H. Chan School of Public Health guided by 5 principles: (1) development of T-shaped com...
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