Student reflections on an interdisciplinary pandemics course utilising systems thinking

1.1 Public health and health promotion education nexus

There are increasing calls for the use of integrated and collaborative approaches to address the growing complexity of contemporary health issues. The World Federation of Public Health Associations (WFPHA) in partnership with the World Health Organization (WHO) established the “Global Charter for Public Health” in 2016 to address the fragmented nature of public health services and functions. The Global Charter includes objectives for building resilient public health systems that incorporate inter-sectoral and interdisciplinary collaboration (WFPHA¹). This acknowledges the nexus between prevention, promotion and protection of health, underpinned by foundational functions of governance, advocacy, capacity and information (WFPHA¹). The WHO² has called for a change in the way the public health workforce is trained and prepared to manage increasingly complex health issues in uncertain times that moves away from siloed³ specialisations to a greater focus on interdisciplinary collaboration. Additionally, WHO proposes professional training to be transformative and focus on lifelong learning to better equip public health professionals with skills to “prevent disease, prolong life and protect and promote the health of …communities” (p. 7). The COVID-19 pandemic has both disrupted and provided an opportunity for expansion of public health education and training as more people become aware of the roles the public health workforce performs.⁴ However, educators must be able to leverage and extrapolate this personal experience to a broader focus on population-level health initiatives.

Public health educators utilise several health promotion and public health competency frameworks to support the design of courses that include a shift to more interdisciplinary curricula.¹ These include the International Union for Health Promotion and Education (IUHPE) Core Competencies and Professional Standards for Health Promotion,⁵ the WHO-ASPHER (Association of Schools of Public Health in the European Region) Competency Framework for the Public Health Workforce² and in Australia, the Council of Public Health Institutions of Australia (CAPHIA) Foundation Competencies.⁶ Designing new interdisciplinary curricula is challenging because of the lack of evidence on best practice for course or curriculum design using interdisciplinary approaches in the context of health sciences,⁷ particularly when also incorporating systems thinking.

Interdisciplinary teaching has been shown to increase student learning, and can lead to improved cognitive abilities.¹² Importantly, education researchers note the benefits of interdisciplinary approaches to teaching and learning including the ability to recognize bias, think critically, tolerate ambiguity and acknowledge and appreciate ethical issues^{13, 14} Interdisciplinary teaching supports students in putting aside their pre-existing notions and develop insights into the role of different disciplines.¹² Taken together, a system thinking approach that integrates the different perspectives of the disciplines integral to public health and health promotion, could support learning. This article presents a concrete example of how an interdisciplinary course, Public Health in Pandemics, was designed and delivered utilising systems thinking, guided by the WHO-ASPHER and IUHPE⁵ competency frameworks.

1.2 Design of Public Health in Pandemics course

The teaching team were presented with the opportunity to design a short intensive course* PUBH7116 Public Health in Pandemics at the end of 2020, which was delivered for a second time in 2021. The course was an elective in the Master of Public Health (MPH) program but was open to students from other programs. The course was designed and delivered collaboratively with experts from a range of diverse disciplines including health promotion, public health, One Health,† health policy, history, epidemiology, virology, economics and law, and was supported by a dedicated learning designer. The decision to use systems thinking to frame the course curriculum was made to ensure students developed an understanding of how the approach can be used to understand and manage complex problems. It addressed the WHO-ASPHER Competency 5.9, Relations and Interactions to, “…[u]nderstand the principles of systems thinking and… apply them within systematic enquiry to analyse, model and improve public health organizations and services at different strategic levels” (WHO²). The curriculum included instruction in the principles and techniques used to develop systems models and to use them to identify points for intervention. The knowledge and skills learnt in the course were assessed using an open access COVID-19 simulator that uses a systems dynamics simulation model accessed via a web interface (Isee Systems Inc.¹⁶). The simulator allows users to modify the parameters of control variables such as contact tracing efficiency, testing rates and quarantine and simulate their impact on COVID-19 case numbers over time compared with a “base-case” that reflects the status quo.

Each day of the intensive course was organised around a specific theme that tracked the evolution of the public health response to the pandemic predominantly in the Australian context. This commenced with the start of the pandemic, tracking initial responses including failures, progressing to subsequent waves, examining the post pandemic phase with an emphasis on communicating and finally putting all the pieces of the pandemic puzzle together (Figure 1). Individual sessions across each day were facilitated by discipline experts that spoke to the “parts of the system” involved in understanding and responding to pandemics. For example, on day one, the second session concerned historical perspectives of pandemics and was facilitated by a history expert (Content and Context Competency); the impact of pandemic responses from an equity lens delivered by a public health sociologist (Science and Practice Competency); and on day three there was a session with an overview of public health law, human rights and legal implications of the response delivered by a health policy specialist with an extensive background in international law, global health policy and human rights. A total of 16 co-presenters from diverse fields were supported by the course coordinator to deliver 25 sessions over the duration of the week-long intensive course – weaving together the complex and complicated story of pandemics, pandemic response management and the broad social, political, economic and medical implications.

A key strategy that was applied in the design of the course was to provide formal opportunities for students to reflect on course content. The use of reflection and reflective practice in higher education is not new,¹⁷ and can improve learning outcomes and engagement.¹⁸ Reflection has different levels and can help to bridge the theory/practice divide. Critical reflection bridges the “what” and “how” with the “why”—raising issues of ethics, politics and inequities and injustices.¹⁹ Given the complexity and diversity of the disciplinary-specific content that was being covered each day, building in dedicated and purposeful reflection aimed to support students and provide space for processing and thinking through how each of the discipline contributed to a system.

At the conclusion of each session, that is, three to four times per day, students were given the opportunity to reflect on what they had seen and heard and take notes. As part of the first assessment task for the course, students were required to upload a 2-min video blog (Vlog) reflection based on the day's proceedings for the first 4 days of the teaching week (worth 2% each). Students were able to reflect on any aspect of the content presented in the day and were directed to structure their Vlog using Kolb's²⁰ Experiential Learning Framework to assist in structuring their response. Within this framework, students were instructed to both refer to any relevant literature and to consider ways in which this learning experience might impact on them both personally and professionally. At the conclusion of the teaching week, students were to use this information to construct a written meta-reflection on the course, which formed part of their assessment (worth 12% of the final grade).

2.1 Data collection

3.1 Focus group interviews

A total of eight students agreed to be interviewed in the FGI (three males and five females). Subsequently, two FGI were conducted on the Wednesday and Thursday of the intensive teaching week. We were keen to capture students while they were attending the course, as students were enrolled in the course nationally and internationally and the multiple time zones were tricky to navigate outside scheduled course hours. Additionally, our prior experience with students enrolled in short courses suggested they are time poor and unlikely to make time for course evaluations after the course was completed – as evidenced by the fact that no students completed the student evaluations on this course the previous year. The first FGI was conducted online via Zoom on Wednesday (day three) during the lunch break and consisted of five participants. Two students were enrolled online—one in Singapore and one locally; other three students were enrolled face to face but chose to attend the Zoom interview. This interview lasted 41:21 min. Of these students, two were full time students, one was working in public health; one in higher education sector and the other a scientist. The second FGI interview was conducted face-to-face at the conclusion of teaching on Thursday (day 4) with three participants. The three participants had biomedical backgrounds. This interview was 48:05 min in duration.

3.2 Online exit survey

Thirteen students commenced the online exit survey and eleven completed all survey questions, indicating a response rate of 23%. Of these students—36% (n = 4) were under 25 years old, 36% (n = 4) were between 25 and 44 years of age, 27% (n = 3) were aged between 45 and 54 years of age. Most respondents were female (n = 7, 64%). Most students indicated that they enjoyed the course (n = 9, 82%), with this same nine students indicating they would recommend the course to fellow students or colleagues, with one indicating they were unsure. One student said they had only somewhat enjoyed the course and would not recommend it yet noted that they found the course challenging to keep up with online, particularly as an international student. Overall, 90% of respondents indicated that complexity of the pandemic was sufficiently presented in the course, and they found the systems thinking approach was useful in helping them engage effectively and understand this complexity. Importantly, 90% of students also indicated that the multiple presenters reflecting different disciplinary experts helped them to understand how disciplines work together in practice for pandemic response and management.

3.3 Key themes from focus groups and open-ended questions

The following sections describe the key themes that emerged from the FGI according to the deductive thematic analysis that was conducted combined with the data from the exit survey.

4.1 Relations and interactions—Collaboration, partnerships and systems thinking

In designing the postgraduate course, Public Health in Pandemics, it became clear early in planning the course, that no one single lecturer would be able to deliver the breadth of course content. The course would need to involve multiple different experts from different fields to authentically deliver the course curriculum and to model collaboration and partnerships. Simply using multiple “guest lecturers” could create a fragmented learning experience for students. The use of guest speakers and or guest lecturers as a pedagogical device in higher education has been common practice across many discipline areas.^{25, 26} Typically, guest speakers are used to complement content and add real-world application of content. There have, however, been issues identified with the use of guest speakers/lecturers beyond budgetary and timetabling issues.²⁷ It has been suggested that guest lecturers need to be well versed in the course content, teaching and learning styles used in the course²⁸ to enhance the course. The course was intentionally designed to use a truly interdisciplinary, approach as described by Spelt et al.,¹³ and to reflect authentic public health practice in complex systems, where relations and interactions are critical to successful outcomes. Feedback from students confirms we were successful in achieving this goal. Students indicated that they enjoyed the multiple disciplinary expert presenters, and this helped them understand how disciplines work together in practice for pandemic response. To ensure this process was seamless, the course coordinator met with every presenter prior to course implementation and discussed the focus of the individual presentation and outlined where it fit in overall narrative of the course. The course coordinator then reviewed each presentation prior to delivery to ensure the presentation fit the course curriculum plan. This approach was more time intensive in pre-course planning compared with more traditional course delivery yet was critical for its success.

Students reported that the use of the multiple presenters was coherent and assisted their understanding of needing to involve multiple stakeholders for pandemic responses at an individual and community level. Students who were in biomedically/clinically focused health professions, reported the course made them more aware of the need to communicate more broadly with various stakeholders, and to involve them in decision-making. For these biomedically focused students, there was a realisation that medicine alone was not going to effectively address the pandemic. This is particularly interesting as it has been long acknowledged that medical professionals tend to remain in their own disciplines²⁹ in best efforts to deliver quality patient-centred care, with a trend toward narrower specialisations,³⁰ not broader collaboration. There is growing concern within the medical profession of the complexities of modern health conditions and the impact of broader social, cultural and environmental determinants on individual-level health outcomes. The medical and clinical professions seem increasingly aware of the need to look not only sideward to allied health professionals to deliver optimal patient care, but also to cast their gaze upward to acknowledge the role and impact of social and systemic factors that enable and constrain their capability to care for their patients. Ultimately this shift in focus could result in more medical professionals advocating for system-level change to improve patient health outcomes.³¹ There is encouraging evidence in our research to support this aspiration.

Regarding the use of systems-modelling software to explore pandemic response, students appeared to see the value and utility in its use. The focus group that was conducted in the middle of the intensive week found that students were still learning how to use the software and grappling with technical aspects. In some students' meta-reflections the utility of the approach once they had mastered the use of the software, was appreciated. This reinforces the calls in the academy to incorporate systems-thinking into health promotion courses in higher education^{8, 10, 32} and provides some evidence on the effectiveness of this approach in assisting students to understand the complexity of health issues. Future course deliveries will need to consider if more time is needed for students to become more familiar with new software before being asked to apply it in class.

4.2 Performance and achievement—Reflective practice

While reflective practice is a core competency for public health practitioners in the WHO-ASPHER² Framework and IUHPE competencies, it is omitted in the Australian CAPHIA Foundation Competencies for Public Health Graduates in Australia.^{6, 33-35} Despite this omission, scholars advocate for the inclusion of reflection and critical reflection in public health and health promotion degrees as critical reflection “presents a challenge to traditional health promotion approaches that are underpinned by biomedical and behavioural health discourses”³³ (p. 217) and can have a significant impact in challenging assumptions and analysing power relations³⁶ to address social justice and equity issues that continue to proliferate health issues.

The intentional use of multiple opportunities for reflection during the intensive teaching week was well received by students. When designing the course, reflection was explicitly built into the week-long program, as it was considered necessary to give students time to process the volume of complex information being presented over a short period of time and connect to prior learning.³⁷ Informal opportunities reflect were linked to daily Vlog reflection assessments, which contributed to a final written meta reflection. This ensured that students took the reflection seriously, as Brown³⁸ reminds us, students may avoid learning experiences that we provide in higher education, but they cannot avoid assessment. However, it has been noted that “reflection in assessment tasks with little or no pedagogical scaffolding generally results in superficial reflections that have virtually no impact on learning or future practice”¹⁹ (p. 144). To avoid this, Kolb's²⁰ framework was utilised, to scaffold students through their reflections—by intentionally directing students to think about how their learning would link to current or future practice. Reflection is also included in the IUHPE Competency Framework⁵ in supporting the development of ethical and professional health promotion practitioners yet can be difficult to embed authentically into course design and associated assessment,³⁹ due to the tendency for students to tell us what they think we want to hear in “superficial descriptions of events”⁴⁰ (p. 159) rather than deep, authentic and critical reflection. Reflecting on own behaviour and practice while identifying attitudes, values, beliefs and where improvements should be made encourages the development of thoughtful, evidence-informed health promotion practitioners.^{5, 41, 42}

4.3 Content and context—Science, health promotion; law, politics, ethics and one health

This course provided the perfect opportunity to incorporate all the elements of the WHO-ASPHER Competencies Framework² Content and Context domain. Traditionally, Higher Education courses in public health might address these individual elements in separate courses. Piecing them together and not marginalising one or another was a challenge, along with achieving this in an integrated, seamless way. In the development of this course, it was considered important to embed health promotion as one of the key disciplines involved in pandemic response, and to highlight that health promotion practitioners, alongside others, need to work closely together. There is evidence from discussion with students that it is possible to effectively 'defrost” old, siloed teaching paradigms (Yassi⁴³; p. 46). The Public Health in Pandemics course is one example of how to design a course that is guided by competency frameworks which can support student learning of complex public health issues, and importantly understand that no one discipline is responsible for effective outcomes. It is perhaps ironic that the global COVID-19 pandemic may have been the impetus for positive pedagogical change in health promotion and public health education that has long been desired. Ultimately, the teaching team is cautiously confident, that the interdisciplinary approach reflected and modelled best practice approaches in contemporary public health and health promotion that included more holistic/ecological approaches.⁴¹

4.4 Recommendations

The findings from this small research project support the use Competency Frameworks to inform course design. Competency frameworks are comprehensive, developed by experts, to ensure that if competencies are covered in curriculum, it ensures graduates can meet industry needs. In Australia, it is a voluntary process for education institutions to become accredited using health promotion and public health competency frameworks, whereas for many other health professional training it is mandatory. To ensure graduates are contemporary, effective and recognised health promotion and public health practitioners it is recommended accreditation is strongly considered for these health professional disciplines. The perceived success of the interdisciplinary approach taken has been the impetus for discussions about the formation of teaching teams to deliver courses moving forward. Involving the number of “experts” as was done with this course may well be difficult to sustain given the extent of pre-planning and careful oversight by the course coordinator and implications for already time poor academics. However, the recognition of the complexity of contemporary health issues and the need for interdisciplinary approaches to address them has inspired conversations and a desire to move to collaborative teaching in smaller “expert” teams to co-course coordinate and deliver curriculum, moving beyond old approaches of incorporating guest lecturers.

4.5 Strengths and limitations

The low response rate is a clear limitation of this study and the associated broader applicability of the findings. Asking students for their opinions of the pedagogical approaches taken in this course may have limitations as students may only be able to perceive the course being delivered this way, even though students were asked their experience compared with other courses undertaken. Additionally, while students could see the utility of interdisciplinary approaches for pandemic responses, it is not clear whether students see the value of interdisciplinary approaches in public health practice more broadly. There may also be an element of participant bias in both the focus group interviews and, in the survey, with only engaged students who were happy with the course agreeing to participate. Additional limitation of this study is the timing of the focus group interviews while the course was being undertaken. The absence of feedback of students on the course in the previous year drove a desire to capture students while we had their attention during the delivery of the course itself. Therefore, future research evaluating students' perceptions of courses, should consider the timing of evaluation and student burden.³⁹