Abstract
Critical thinking is an important skill for students and public health practitioners alike, but ensuring and measuring its development beyond a theoretical framework is challenging. In this article, we describe the development and implementation of our undergraduate public health program’s signature assignment–the Scenario Analysis (SA). SAs are team-based problem-oriented simulations structured using Elements of Thought from the Paul-Elder critical thinking model. Through deliberate design and evaluation, this assignment allows student efforts to reflect critical thinking standards in a practical and measurable format. The SA assignment is highly adaptable to specific course content and topics and has utility beyond public health curricula. The purpose of this article is to highlight the value of ensuring critical thinking development within public health education and to offer an innovative assignment and pedagogical approach designed to meet this objective.
Introduction
Critical thinking is essential for public health practice to be effective in reaching its goals—promoting health, preventing disease, and prolonging life in a population (World Health Organization, 1998). The field of public health necessitates the use of critical thinking for the following reasons: (a) each population and its health patterns are unique and often are in constant flux, requiring tailored, evidence-based approaches; (b) public health practitioners must be able to critically analyze competing evidence in an increasingly complex information age; (c) practitioners must consider multiple points of view, political agendas, public perceptions, and conflicts of interest to bring about effective population-level changes; (d) the scope of public health encompasses a wide range of issues that are often complex and multifaceted (e.g., access to health care, socioeconomic disparities, infectious diseases, environmental hazards, bioterrorism, etc.); and (e) public health practice without critical thinking can result in serious consequences and dangerous health outcomes for communities and populations. Despite this, there is very limited research about the facilitation and application of critical thinking in either public health practice or public health education (Alexander, 2014).
The definition of critical thinking, its elements, and the activities to achieve it have been discussed throughout the past 50 years in the field of education and recently in several other disciplines. Critical thinking has been described as having the ability to question, to acknowledge and test previously held assumptions, and to examine, interpret, evaluate, reason, and reflect in order to make informed judgments and decisions (Ennis, 1962; Holyoak & Morrison, 2005; Paul & Elder, 2001). Developing critical thinkers is generally accepted as one of the primary goals of a liberal arts higher education (National Education Goals Panel, 1991), but the challenge facing academic programs is how to design instruction that is effective in achieving this goal (Halpern, 1999; King, Wood, & Mines, 1990; Nosich, 2005; Pascarella & Terenzini, 1991; Reinstein & Lander, 2008; Snyder & Snyder, 2008; Van Gelder, 2005).
Since the goal of incorporating critical thinking into curricula is for students to think critically in varied situations outside the classroom, simply gaining knowledge of critical thinking principles is not enough for developing critical thinking (Van Gelder, 2005). Instead, it is important to incorporate critical thinking across a program’s curriculum (Paul, 1984; Thayer-Bacon, 2000). Several instructional approaches have been explored to foster critical thinking development in higher education such as problem-centered learning (Hmelo-Silver, 2004; Savery, 2006), collaborative learning (Quarstein & Peterson, 2001), and metacognition with reflection (Beyer, 1985; Paul & Elder, 2009).The Paul-Elder framework of critical thinking is currently one of the most widely published and cited frameworks in the literature, and since 2005, our institution has incorporated it as the university-wide framework for critical thinking initiatives. According to this framework, critical thinking involves the following: (a) analyzing thinking by focusing on the individual parts of thinking (i.e., Elements of Thought), (b) evaluating the quality of thinking (i.e., Intellectual Standards), and (c) improving thinking by reflecting on Intellectual Traits (Paul & Elder, 2001). In general, Intellectual Standards should be applied to the Elements of Thought in order to develop Intellectual Traits.
Although critical thinking principles are meant to be universal, different fields may have specific approaches to developing critical thinking skills; therefore, applying the principles to a specific discipline requires a process of “reflective contextualization” (Alexander, 2014; Paul & Elder, 2001). For our new public health undergraduate program at the University of Louisville, the process of purposefully incorporating critical thinking into our curriculum led to the development of the Scenario Analysis (SA) assignment.
Scenario Analysis: Framework
Scenario Analyses are a signature assignment within the University of Louisville’s undergraduate public health courses and have been in use for more than 3 years. SAs are team-based problem-oriented simulations on topics involving current events and important public health issues that are relevant to both society and the students themselves. SAs are different from other problem-oriented assignments because they are structured using the Paul-Elder Elements of Thought, guiding students to apply critical thinking constructs while analyzing real-life situations.
The Elements of Thought in the Paul-Elder model provide a useful generic structure for examining one’s reasoning in smaller components. However, the utilization of each element often needs to be contextualized in application for specific disciplines and activities. Figure 1 illustrates how each Element of Thought is related to a respective SA component, with certain adaptations.
Elements of thought adapted to scenario analysis components.
First, we adapted Question at Issue into Burden at Issue to encourage students to consider the health, social, political, environmental, and economic costs to the individual and society. Understanding the Burden at Issue is critical in public health to be able to appropriately prioritize health issues, allocate resources, increase awareness, and develop policies. Second, Information is renamed Evidence to steer students toward critically examining their research and to emphasize the importance of evidence-based public health practice. Requiring students to present their research gathered necessitates the addition of a References component. Third, Points of View is modified to Roles with Points of View, which encourages students to identify key stakeholders, perspectives, and why it is necessary to consider them in the analysis.
Finally, the most significant change from the Paul-Elder model is the addition of two components to the SA framework—Recommendations and Rationale. While the Elements of Thought identify components of reasoning, they do not suggest actions based on this reasoning. While this is helpful in terms of critical thinking development, it misses applicability in public health practice. Recommendations based on this reasoning is the missing piece the SA provides, supported by Rationale drawn from the analysis itself.
The SA components are summarized individually in Table 1; however, it is important to note that the components do not have a linear relationship. Rather, they are related interdependently, with the contents of each element affecting the contents of all other elements, as illustrated in Figure 2. This is often the most challenging aspect for students who attempt to divide the SA components among their group members, rather than approach the SA together, as a team. When applied properly, the SA framework ultimately guides students to develop Recommendations that are critically thought out, evidence-based, and logically supported by each SA component.
Description of Scenario Analysis Components.
Concept map of scenario analysis components.
Scenario Analysis: Prompts
Instructors develop problem-centered public health scenario prompts that require students to develop a response using the SA framework. While often based in current, historical, or fictional events, prompts are meant to exemplify real-world situations with relevance and impact to the students’ lives or profession. Over the past 3 years, a diverse set of prompts has been developed within specific undergraduate public health courses, requiring students to critically adapt their approaches to different contexts. Table 2 shows categorized examples of SA prompt topics.
Examples of Scenario Analysis Content Areas.
A key feature of SA prompts is that they are somewhat complex without a simple, straightforward solution, requiring students to critically explore the issue using the SA components and systematically build up support for their final recommendations. Therefore, evaluation of SA assignments is also not a simple correct or incorrect. Instead, the students are evaluated on the extent to which each SA component supports and provides justification for their recommendations. To ensure objective assessment and a continued focus on critical thinking, the evaluation rubric is designed using relevant Paul-Elder Intellectual Standards, such as clarity, accuracy, relevance, completeness, significance, and logic. (Paul & Elder, 2009).
Scenario Analysis: Adaptable Implementation Across Courses
Scenario Analyses are used primarily in three courses in our undergraduate public health curriculum. In general, the following evidence-based teaching practices are used for implementing SAs within a course: collaborative teamwork (Oakley, Felder, Brent, & Elhajj, 2004), scaffolding assignments (Rosenshine & Meister, 1992), providing timely and detailed feedback (Hattie & Timperley, 2007), and involving learners in decision making (MacBeath, Demetriou, Rudduck, & Myers, 2003). Moreover, the SA framework can be easily adapted to specific course content, as demonstrated in the examples below. Through regular practice with the SA assignment, both individuals and teams show greater competency and confidence, resulting in improved cohesiveness and quality of work later in each semester.
Course: Introduction to Public Health
Students are first introduced to the SA assignment in Introduction to Public Health, which is a General Education course in which both majors and non-majors enroll each semester. The course is structured so that it builds up to the final module, which discusses the assignment and allows students to work in teams in order to complete it. In this course, the assignment is intended to be introductory and is completed in smaller segments to guide students to think about the scenario critically. Working in teams with a mix of majors and non-major students demonstrates the interdisciplinary nature of public health practice and how to address complex issues as a team of professionals, as opposed to individuals. Last, topics for this SA are purposefully chosen to be as relevant to the students as possible (e.g., distracted driving, binge drinking, opioid epidemic).
Course: Contemporary Issues in Public Health
This course is taken by public health majors in multiple semesters, designed as their seminar-style course to address the breadth of issues relevant to public health. As such, course topics are framed by Healthy People 2020 topic areas. Each week, students explore a different topic and related objectives, and student teams respond to an SA that is related to that topic. To ensure that individual students demonstrate competency with the assignment and its completion, midterm and final SAs are completed by individuals. These are timed and require students to respond to a scenario with which they are unfamiliar, in a process that mimics public health career interview processes at the federal level.
Course: Global Health
The Global Health instructor adapted the SA assignment to promote student understanding of varied global health perspectives. During the semester, the course incorporates five SAs in an interactive role-playing format, requiring students to work in assigned Alliances in order to critically analyze the scenario prompt and develop appropriate recommendations. Each student is assigned a specific global health actor to take on as his or her role for that specific scenario. The categories of global health actors include the following: government ministries, United Nations agencies, funding agencies or development banks, grassroots agencies or local community leaders, and relevant nongovernmental organizations or experts.
To promote critical thinking development for both individuals and teams, the instructor divided the SA framework into two separate assignments: an individual position paper and an alliance intervention paper. The individual position paper requires each student to independently complete the Burden at Issue, Evidence, and Concepts components from the perspective of their assigned role. Then each Alliance, with five unique roles, gathers to reconcile the various perspectives and develop a final cohesive SA where Rationale and Recommendations are developed through the critical thinking process.
Completing the Paul-Elder Cycle: The Development of Intellectual Traits
Within the Paul-Elder framework, consistently applying the Intellectual Standards while using the Elements of Thought should lead to critical thinkers who exude Intellectual Traits, a main objective of the model (Paul & Elder, 2001). Furthermore, to become an effective critical thinker, one must regularly reflect on one’s thinking and learning, also known as metacognition (Paul & Elder, 2001). Several researchers have found that having students metacognitively reflect and analyze their thinking can explicitly improve critical thinking skills (Beyer, 1985; Mezirow, 1981; Wolcott, 1997). While SAs are an appropriate framework for the application of critical thinking, they lack the aspect of metacognition, necessary to both improve and assess one’s Intellectual Traits. Recognizing this necessity, program instructors incorporated Critical Reflection assignments into their courses, a concept rooted in John Dewey’s model of reflective thinking (Dewey, 1910/2007).
The Critical Reflection assignment provides a framework for students to describe, examine, and articulate their learning in the course, at various time points in the semester. It is very common for students to choose SAs as the learning experience to reflect on, and specifically, the effects of working in teams and applying critical thinking skills. For example, a student in Introduction to Public Health wrote, [Before] I only looked for the quick fix instead of taking my time and thinking about all the effects of the problem. Now that I know how to use those skills I have done well on the last scenario analysis and will continue to use critical thinking on my individual analysis. Critical thinking doesn’t apply to just public health, you can use it in all sorts of disciplines and even problems that you would face in day to day life.
While examining the student reflections for demonstration of Intellectual Trait development related to the SA experience, instructors in these courses have determined that the five most common appear to be Intellectual Empathy, Intellectual Autonomy, Confidence in Reason, Fairmindedness, and Intellectual Humility. For example, a student discussed how the SA on Louisville’s opioid crisis “radically changed” his perspective on approaching drug addiction interventions. He reflected, I have had many family members that have struggled with addiction and have therefore experienced many betrayals. . . . I narrowly viewed drug addiction as a criminal act. In considering drug addiction from public health perspective however, my opinion as to how to best address the burden altered significantly, because my perception as to the nature of the burden itself changed.
This compassionate shift in perspective was due to the “methodological approach” of the SA, which he said helped him realize that his prior reasoning was “corrupted by subjective, emotional experience, and not an evidenced-based public health perspective.”
A Global Health student, after completing the SA on maternal mortality in Sierra Leone, noted that she had gained an “important personal characteristic” of “considering and understanding different perspectives.” She reflected, being able to look at an issue . . . is the best way to create a solution that benefits the most people . . . [for example] for maternal mortality in Sierra Leone, I need to remember not only the women, but their children and husbands, the community workers, the medical personnel, and the government.
Some reflections highlight the development of two or more traits. For example, one student wrote,
[this] turned out to be an exploration of my own self and my opinions of events around the world and it allowed me to examine my personal bias and perspectives of scenarios which I had previously neglected to even consider,
which demonstrates aspects of both Intellectual Humility and Intellectual Autonomy.
In general, these reflections are indicative of Intellectual Trait development; however, determining the specific trait they exemplify requires clear definitions and boundaries of each trait. Therefore, an in-depth qualitative analysis of student reflections is needed to establish a framework for the evaluation and categorization of responses as evidence for specific Intellectual Trait development.
Conclusion
Despite limited research on the application and importance of teaching critical thinking in the context of public health, critical thinking is necessary for effective evidence-based public health practice. Through well-designed assignments with deliberately integrated critical thinking components, critical thinking can be taught and developed in students. The SA assignment requires students to explore complex public health issues through a critical thinking framework and shows evidence of successfully developing the preliminary intellectual traits of critical thinkers.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.