|ORIGINAL RESEARCH PAPER
|Year : 2012 | Volume
| Issue : 2 | Page : 98-104
Towards a Public Health Curriculum in Undergraduate Medicine
S Basu1, C Roberts2
1 Academic Unit of Medical Education, University of Sheffield, Sheffield, United Kingdom
2 Sydney Medical School-Northern University of Sydney, Australia
|Date of Submission||15-Mar-2011|
|Date of Decision||12-Jun-2012|
|Date of Acceptance||04-Jul-2012|
|Date of Web Publication||14-Nov-2012|
Academic Unit of Medical Education, University of Sheffield, S10 2GJ
Source of Support: None, Conflict of Interest: None
Background: The need to adequately train medical professionals in public health has been recognised internationally. Despite this, public health curricula, particularly in undergraduate medicine, are poorly defined. This study explored the public health disciplines that newly qualified doctors in the United Kingdom (UK) should know. Methods: We developed a 31-item questionnaire covering public health subject areas and expected competencies that medical graduates should know. The questionnaire was then administered to a stratified sample of medically trained individuals across a number of postgraduate schools of public health in the UK. Following administration, a ranking list was developed by subject area and by competency. Results: There was an 85% response rate (69/81). Subject areas ranked highest included epidemiology, health promotion and health protection. Sociology and the history of public health ranked lowest. Competencies perceived as important by the respondents included understanding health inequalities, empowering people about health issues and assessing the effectiveness of healthcare programmes. Discussion: Our study identifies the expected public health subject areas and competencies that newly graduating medical students should know. They provide a context through which to begin addressing concerns over the disparity between these expectations and what is actually taught in medical school, highlighting the continuing need to reframe undergraduate public health education in the UK.
Keywords: Curriculum, medical education, public health, undergraduate
|How to cite this article:|
Basu S, Roberts C. Towards a Public Health Curriculum in Undergraduate Medicine. Educ Health 2012;25:98-104
| Background|| |
Doctors today are faced with a plethora of public health challenges including ageing and growing populations, resource strains, rising healthcare costs and global market economies in healthcare.  Modern medicine demands they are involved in addressing health inequalities and understanding social forces that determine health.  In the United Kingdom (UK), this includes not only dealing with the rising burden of non-communicable diseases such as obesity, alcohol abuse and tobacco consumption but also wider issues such as child protection, protecting vulnerable adults and domestic violence as part of multi-agency approaches.  Despite these challenges, there are concerns that undergraduate medical doctors in the UK are not adequately prepared for these wide-ranging public health responsibilities. Accordingly, adequately training healthcare workforces in public health, including medical doctors, has become an international priority as highlighted by the World Health Organisation. 
Recent work in this area has focused on the generic public health training that healthcare workers and medical doctors should receive. Much of this, however, has been at the postgraduate level. The Association of Schools of Public Health in the United States outlined five "core elements" in health services: Administration; biostatistics; epidemiology; behavioural sciences; and environmental health science.  Other work outlined 10 essential skills that all healthcare professionals should be competent in, including investigating community health hazards, monitoring community health status and developing policies to support community health.  Empirical research in the United States, based upon consensus panels of administrators, health educators, nurses and physicians, also identified advocacy, business management, communication and community development as critical competencies. 
Although public health curricula at the postgraduate level are now better defined, this is not the case in undergraduate medicine within the UK.  Elsewhere in North America, for example, "Public Health 101" and "Epidemiology 101" have served as models for curriculum orientation in population health.  Representatives of the Public Health Agency of Canada, Canadian Faculties of Medicine and Canadian medical students have also outlined objectives for undergraduate public health training including measurement of population health, outbreak management and administration of health programs.  Other work has included the development of an eight-part toolkit towards introducing population health into the undergraduate medical curriculum  as well as community-based and rural programmes broadening students' exposure to public health issues. ,,
Despite these innovations, there remain some concerns that undergraduate public health teaching lacks clear structure, leaving many students disillusioned and unable to see the relevance of public health to their training. , The first stage in developing any successful curriculum must be to define its learning 'outcome objectives'.  These are the end goals that should be achieved by the time of graduation. Such clarity is, as yet, substantively lacking in the context of devising a public health curriculum for undergraduate medical students. This study explores this issue in the context of undergraduate public health training within the UK.
Specifically, the aims of this study were to identify the main public health subject areas that should be covered within an undergraduate medical curriculum and to define the key public health competencies that medical students should possess by the time of graduation.
| Methods|| |
The first step of the study involved the development of a questionnaire to identify the major public health subject areas and competencies that newly graduated doctors should know about. Second was a cross-sectional study in which the questionnaire was administered to a sample of medically trained individuals training and working in public health. These types of questionnaires have been used successfully in curriculum design within a number of medical specialities. ,
Within the UK, all medical programs are accredited by the General Medical Council. At the time of the study, the Sheffield undergraduate curriculum was systems-based, in which individual modules were covered in periods of around 10 weeks during the first two and one-half years of the course. Longer clinical attachments began in earnest in the second half of the course. These were specialty-based ranging from 7 to 14 weeks in duration. Throughout all five years of the course, student learning through lecture-based and bedside teaching was complemented with special study components, integrated learning activities (a type of facilitated problem-based learning tool) and personal and professional development tutorials. These included, but were not limited to, areas such as ethics, professionalism, humanities and law, encouraging an in-depth and holistic approach to learning. The bulk of formal population health teaching at the time of the study occurred within the two family medicine (general practice) modules with sporadic teaching elsewhere throughout the course. Consequently, concerns had been raised by course directors that the format and delivery of teaching lacked clear structure. At the time of the study, this was reinforced by concerns raised by the General Medical Council that many medical schools in the UK taught population health on an opportunistic and haphazard basis.
Questionnaire development was initiated by the first author holding a focus group in which 16 academics, working at the University of Sheffield and the School of Health and Related Research (ScHARR) involved in undergraduate public health teaching, met to determine the public health topics that should be possessed by the newly qualified doctor as part of curriculum development at the institution. The group included individuals from mixed backgrounds including epidemiology, health promotion, sociology, statistics and health economics. All of the participants were involved in teaching public health lectures, seminars and tutorials to undergraduate medical students. Importantly, these individuals also had an awareness of the structure and content of all five years of the Sheffield undergraduate medical curriculum, including the extent to which population health was covered within each course module. Furthermore, we felt this wider awareness would be invaluable in the context of adopting a coherent strategy towards further developing the population health curriculum at the Sheffield Medical School.
At the beginning of the focus group meeting, participants were informed that the discussions would be used to inform a questionnaire for wider evaluation amongst the public health community. In addition to debate, the group of experts also considered evidence from the published literature in prioritising curriculum content. ,,, The discussions produced over 60 items, which could potentially be included in an undergraduate medical public health curriculum, including 23 subject areas and 41 competencies. These were recorded by the researcher in the form of an itemised list, which was refined through a voting process amongst the participants. In the absence of formal guidance and after further discussion amongst the group, it was agreed that those items that received less than one-quarter of votes would also be discarded. In the interest of keeping the questionnaire short, it was the consensus that these items would be regarded of lower importance by those involved in undergraduate public health education elsewhere.
Content validity of the questionnaire was established by eight different members of the academic public health staff at ScHARR that had been unable to attend the focus group meeting but had involvement with undergraduate population health teaching, as well as an awareness of the wider medical curriculum. This group included two epidemiologists, three statisticians, a medical sociologist, a medical ethicist and a health economist. Their involvement with teaching medical students ranged from 2 to 15 years of experience. Each individual was asked to determine the relevance of each question within the questionnaire to the training needs of the newly qualified doctor within the UK. The relevance of questions was established through consideration of relevant published literature provided to them by the researcher, guidance from the General Medical Council review of the Sheffield undergraduate medical curriculum (which included recommendations on population health teaching) and their own teaching experience. The staff members were also asked to comment upon the format of the questionnaire, ease of completion, spelling, grammar and clarity of questions. Their comments were fed back to the researcher and used to refine the questionnaire prior to administration. Example questions are shown in [Figure 1].
|Figure 1: Sample questions from survey completed by Academic Public Health staff of University of Sheffield, United Kingdom|
Click here to view
The final questionnaire consisted of a total of 31 items. These covered the core public health subject areas that could be included within an undergraduate medical curriculum (13 items) and specific public health competencies relevant to undergraduate medical training (18 items). Additional space for free text comments was placed beside each questionnaire item to capture any insights into participants' given ratings.
We wished to identify a cohort of respondents with a strong understanding of the role of public health within medicine. Two groups we considered were those of undergraduate medical students and junior doctors. Nevertheless, we felt that practising medical doctors who had more substantial experience of both public health as well as the medical working environment would have better insight into the knowledge, skills and professional behaviours needed in day-to-day practice. We also perceived that this cohort would have more deeply reflected on learning outcomes required for public health education programs as part of their academic studies.
To this end, we contacted the course directors of all of the institutions that, to our knowledge, held a postgraduate Masters course in Public Health within the UK by telephone and e-mail (12 institutions at the time of the study). We asked each institution to affirm whether they would participate in the study, and provide the number of practising medical doctors attending the course that year. Although some of the course directors were uncertain of the number of individuals enrolled in their course that were practising medical doctors, the sum of the estimates received totalled 157 individuals. Of those institutions contacted, six universities agreed to participate, (four in England, one in Wales and one in Scotland). According to the figures we were provided, the sum total of medically trained individuals studying at these sites was 101.
At all sites, an e-mail was sent to each of the course directors. The directors disseminated the invitation to take part in the study to their student e-mail list. The eligibility criteria of the study (to be medically trained), its purpose, format, timetable, contact e-mail and telephone for the researcher, and confirmation of ethical approval were communicated within this e-mail. Those individuals at each institution that were eligible to take part were asked to communicate their e-mail address to the researcher if they wished to participate. The researcher maintained a contact e-mail list through which to deliver the questionnaire. Lecture announcements to invite participants fulfilling the eligibility criteria of the study were also made by the researcher at the two local sites.
The questionnaire was sent out by e-mail to all participants that responded to the invitation to take part in the study (n = 81), with a three-week deadline for completion. Respondents rated their endorsement of checklist items using a standard 5-point Likert scale, ranging from strongly disagree to strongly agree. Completed questionnaires were e-mailed back to the researcher for analysis.
The study was conducted in line with established principles of conducting educational research.  Due to the possibility of participants having the dual role of students of public health and also National Health Service staff members, approval for the study was sought from the Local National Health Service Research Ethics Committee in South Yorkshire (Ethics and Governance). For university students, approval was sought from the Sheffield University Research Ethics Committee. As the primary purpose of the study was to inform teaching and education, however, both the Local NHS and University Research committees stated that the study did not require formal ethics approval and were aware of the nature of the research to be conducted.
The data from the questionnaires were analysed using SPSS version 11.0 (SPSS Inc., 233 South Wacker Drive, 11th. Floor, Chicago, IL 60606-6412. Patent No. 7,023,453). Reliability coefficients (Cronbach's Alpha) were calculated for both the first section (subject areas) and second section (competencies) of the questionnaire. Likert ratings for each individual item were averaged to provide a mean score for the whole group for each round of questionnaire administration. Given the relatively equal number of males and female participants responding to the invitation to participate in the study, a post-hoc analysis of results by gender was also conducted to provide insight into any observed differences between male and female participants. For ease of interpretation, and to provide more practical meaning in terms of application, ratings of strongly disagree and disagree were combined as disagree and ratings of strongly agree and agree were combined as agree.  Given the relatively limited number of free-text comments, these were individually assessed by the researcher to identify the presence of common words or phrases within them. These were grouped together to provide an interpretative framework for given ratings.  For example, content relating to health promotion included "individual-orientated" and "population-orientated". Those relating to medical sociology included the "social model" and "relevance to practice".
| Results|| |
A total of 69 out of a maximum possible 81 respondents (85%) completed the questionnaire. The internal consistency of the questionnaire sections were P = 0.69 (subject areas) and P = 0.75 (competencies), respectively. Thirty-six participants were male and 33 female.
[Table 1] presents the ratings given by the participants for the major public health subject areas covered in the questionnaire, as well as a breakdown by gender. Nearly all of the participants felt that epidemiology, health protection and health promotion should be essential aspects of the undergraduate public health curriculum. Levels of agreement were more divided upon the relevance of medical sociology and ethics and law, with variation seen by gender (P = 0.0001 and P = 0.002, respectively).
|Table 1: Public health subject areas as assessed by practising medical doctors (n = 69)|
Click here to view
[Table 2] displays the participants' perceptions of the importance of public health competencies contained within the questionnaire to the undergraduate medical curriculum, with a breakdown of results by gender. Competencies ranked highest were related to understanding inequalities and empowering and educating people around health issues. Competencies scored lowest were developing public health workforces and enforcing laws. There was little variation in results by gender in this section of the questionnaire.
|Table 2: Public health competencies as assessed by practising medical doctors (n = 69)|
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In all, 78 written comments were provided by participants relating to items on the questionnaire. The majority of these (62) focused on the subject areas and competencies ranked most important and least important by the group, namely epidemiology, health promotion, ethics and law, medical sociology and history of public health. Only three comments were provided relating to specific competencies listed in [Table 2].
Respondents felt that epidemiology and health protection should form core building blocks of the undergraduate medical curriculum throughout all specialities. Participants' responses suggested that understanding the distribution and burden of chronic disease in particular was an important challenge facing the newly qualified doctor. Comments captured relating to health promotion, however, showed greater variation with some participants questioning its value and ease of application. Others suggested that a continuing focus upon an individual responsibility for health could have long-term damaging consequences to public health.
"If it is well taught, doctors can really make use of it. So much difference can be made by simple lifestyle measures particularly in dealing with the rising burden of chronic disease"
"The more we continue to push individual responsibility, the wider inequalities between the richest and poorest in this country will become"
"Most health promotion measures seem to be individual focused and most advertising and public campaigns miss the point totally"
Comments relating to medical sociology, ethics and law and the history of public health provided interesting insight into given ratings. Although some felt the history of public health was of academic intrigue, most comments suggested respondents felt it could be an optional part of the curriculum, undertaken by those interested in the subject. A number of participants suggested ethics was an important area but did not think there was a requirement for formal teaching as it could be 'picked up' through practice. Medical sociology was perhaps a more divisive subject area, with some participants suggesting a social model to health would be a more appropriate approach towards dealing with the challenges of managing chronic conditions in particular.
"Sociology is interesting but it just doesn't have a day-to-day impact"
"It is important to question the medical model. Sociology helps us to do that and consider alternative possibilities"
"The social model has to become a greater part of undergraduate medical teaching. There is still too big a focus upon trying to cure people and many doctors don't get that"
| Discussion|| |
Our data suggest that academic public health physicians rate epidemiology, health promotion and health protection highest; whilst sociology and the history of public health were rated lower. Competencies perceived as important by the respondents included understanding health inequalities, empowering people about health issues and assessing the effectiveness of healthcare programmes.
This study informs the important debate within medical schools about the public health disciplines and competencies that undergraduate medical students should know by the time of graduation, and may act as the first step towards developing an outcomes-based undergraduate medical public health curriculum. Indeed, these findings have influenced the approach taken by the population health committee at Sheffield Medical School in developing such a curriculum and may be relevant elsewhere, where similar concerns regarding the structure and content of public health teaching exist.
Our study is novel in that it was able to define the perceived importance of different public health subject areas and competencies within undergraduate medical training on a comparative scale. The findings also help to draw together and clarify some of the findings documented elsewhere within the literature. Our data relating to the relevance of epidemiology within the curriculum and the related competency of understanding health inequalities are reassuring as medical doctors are asked to play an increasingly large role in this area as agents of change within the community. Although medical students may initially find this topic difficult to understand, they do appear to appreciate its relevance as they pass further through their medical education. 
Interestingly, fewer participants agreed that ethics and law, medical sociology and the history of public health were important. This may be of concern since it is somewhat at odds with the current emphasis on patient-centred care. Previous work has also suggested medical students do not maintain the awareness of these issues as a priority throughout their training, even though they may consider it an important attribute of practice.  Similar concerns may be held by medical educators with respect to the participants' perceptions of medical sociology as the current emphasis in undergraduate training moves to a broader, less-medicalised model of healthcare. Previous work, though now nearly 30 years old, has suggested that this may take significant attitudinal change amongst both students and teachers.  The divide seen between genders upon the importance of medical sociology and ethics within the population health curriculum is of interest, with results suggesting that women may perceive these population health subject areas to be of greater relevance to undergraduate training. Whilst this study has not explored this issue in depth, whether this is related to features of advanced emotional intelligence suggested previously, or for other reasons, merits further study. 
Our study has some important limitations. Although the individuals that attended the initial consensus group were from a range of public health backgrounds, and had insight into the undergraduate medical curriculum, the relatively small numbers at the meeting may reduce the generalisability of findings. Second, a relatively small number of people completed the questionnaires, and although these individuals had both the experience of practising medicine and public health, other groups such as medical students, family doctors and faculty members could not be included. Their responses are also valuable in determining the public health priorities for undergraduate medicine, and future work should explore this on a larger scale. A third significant limitation is that the study was only conducted at a number of UK locations and thus the generalisability of our findings to the wider national and particularly international audience may be diminished.
Delivering, implementing and evaluating a curriculum in public health for medical students is a substantial challenge, given an already crowded undergraduate medical curriculum and growing financial pressures during the current global economic recession. Further work in this area should capture the opinions of a wider range of stakeholders in varied settings. The potential for cross-disciplinary and inter-professional learning in public health is another area which remains to be fully explored. Future work may also further examine the implications of gender differences upon the perception of the importance of including individual public health topics within the undergraduate medical curriculum.
| Acknowledgments|| |
The authors would like to thank Dr. Ravi Maheswaran for his supervision of SB during his thesis. The authors would also like to thank all the participants who agreed to take part in this study.
| References|| |
|1.||McMichael AJ, Beaglehole R. The changing global context of public health. Lancet 2000;356:495-9. |
|2.||Sanson-Fisher RW, Williams N, Outram S. Health inequities: The need for action by schools of medicine. Med Teach 2008;30:389-94. |
|3.||Augustyn M, Groves BM. Training clinicians to identify the hidden victims: Children and adolescents who witness violence. Am J Prev Med 2005;29:272-8. |
|4.||World Health Organization. The World Health Report 2000. Health systems: Improving performance. Geneva: World Health Organization; 2000. |
|5.||ASPH. What Is Public Health? Core Areas of Public Health 2002. Available from: http://www.asph.org/aa-section.cfm/3/53. [Last Accessed on 2008 Mar 28]. |
|6.||Public Health Functions Steering Committee. Public Health in America, 28 November 2000. Available from: http://www.web.health.gov/phfunctions. [Last Accessed on 2008 Mar 11]. |
|7.||Allegrante JP, Moon RW, Auld ME, Gebbie KM. Continuing-education needs of the currently employed public health education workforce. Am J Public Health 2001;91:1230-4. |
|8.||Petersen DJ, Hovinga ME, Pass MA, Kohler C, Oestenstad RK, Katholi C. Assuring public health professionals are prepared for the future: The UAB public health integrated core curriculum. Public Health Rep 2005;120:496-503. |
|9.||Riegelmann R. Public Health 101: Healthy People-Healthy Populations. London: Jones and Bartlett; 1999. |
|10.||Johnson I, Donovan D, Parboosingh J. Steps to improve the teaching of public health to undergraduate medical students in Canada. Acad Med 2008;83:414-8. |
|11.||Trevena LJ, Sainsbury P, Henderson-Smart C, Clarke R, Rubin G, Cumming R. Population health integration within a medical curriculum: An eight-part toolkit. Am J Prev Med 2005;29:234-9. |
|12.||Poole P, Bagg W, O'Connor B, Dare A, McKimm J, Meredith K, et al. The Northland Regional-Rural program (Pûkawakawa): Broadening medical undergraduate learning in New Zealand. Rural Remote Health 2010;10:1254. |
|13.||Gregg J, Solotaroff R, Amann T, Michael Y, Bowen J. Health and disease in context: A community-based social medicine curriculum. Acad Med 2008;83:14-9. |
|14.||Jones KV, Hsu-Hage BH. Health promotion projects: Skill and attitude learning for medical students. Med Educ 1999;33:585-91. |
|15.||Tyler IV, Hau M, Buxton JA, Elliott LJ, Harvey BJ, Hockin JC, et al. Canadian medical students' perceptions of public health education in the undergraduate medical curriculum. Acad Med 2009;84:1307-12. |
|16.||Epling JW, Morrow CB, Sutphen SM, Novick LF. Case-based teaching in preventive medicine: Rationale, development, and implementation. Am J Prev Med 2003;24:85-9. |
|17.||Newble D, Stark P, Bax N, Lawson M. Developing an outcome-focused core curriculum. Med Educ 2005;39:680-7. |
|18.||Rampes H, Sharples F, Maragh S, Fisher P. Introducing complementary medicine into the medical curriculum. J R Soc Med 1997;90:19-22. |
|19.||Hege I, Nowak D, Kolb S, Fischer MR, Radon K. Developing and analysing a curriculum map in Occupational and Environmental Medicine. BMC Med Educ 2010;10:60. |
|20.||Edwards R, White M, Chappel D, Gray J. Teaching public health to medical students in the United Kingdom - Are the General Medical Council's recommendations being implemented? J Public Health Med 1999;21:150-7. |
|21.||Gillam S, Bagade A. Undergraduate public health education in UK medical schools - struggling to deliver. Med Educ 2006;40:430-6. |
|22.||Roberts LW, Geppert C, Connor R, Nguyen K, Warner TD. An invitation for medical educators to focus on ethical and policy issues in research and scholarly practice. Acad Med 2001;76:876-85. |
|23.||Al-Jishi E, Khalek NA, Hamdy HM. Students' perceptions of the effectiveness of a professional skills program in preparation for clerkship training. Educ Health (Abingdon) 2009;22:57. |
|24.||Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15:1277-88. |
|25.||Moffat M, Sinclair HK, Cleland JA, Smith WC, Taylor RJ. Epidemiology teaching: Student and tutor perceptions. Med Teach 2004;26:691-5. |
|26.||Madigosky WS, Headrick LA, Nelson K, Cox KR, Anderson T. Changing and sustaining medical students' knowledge, skills, and attitudes about patient safety and medical fallibility. Acad Med 2006;81:94-101. |
|27.||Gale J, Wakeford R. Medical students' perceptions of teachers' attitudes towards psychology and sociology. Med Teach 1984;6:97-100. |
|28.||Carrothers RM, Gregory SW Jr, Gallagher TJ. Measuring emotional intelligence of medical school applicants. Acad Med 2000;75:456-63. |
[Table 1], [Table 2]