Addressing Public Mental Health Challenges: A Mixed-Methods Evaluation of Problem-Based Learning

Abstract

Problem-based learning (PBL) is a pedagogical framework that centers on a problem of interest and structures classroom tasks around teams formulating practical, evidence-based solutions. This approach is particularly well-suited for public health curricula, as it prepares students for a dynamic, interdisciplinary, professional environment. This study explores the piloting of a PBL approach with three student cohorts in a graduate-level public mental health course. Biweekly, interdisciplinary student teams were presented with a public mental health case provided by an expert in the field and asked to develop and present evidence-based solutions through a process grounded in knowledge acquisition, critical thinking, and faculty guidance. A mixed-methods evaluation was completed to examine student perceptions of PBL components and the benefits of PBL and to gather recommendations to enhance this approach. Among 37 students who completed self-administered surveys, more than 70% found case analysis, reviewing additional literature to support case solutions, and discussions with an expert to be the components “Most Helpful” to their learning. Four focus groups with 21 students were conducted to further examine perceived course benefits and suggested changes. Participants appreciated real-world simulations of public health issues and interdisciplinary teams and offered recommendations for future improvements, such as adding a culminating project. Findings support the benefits of a PBL approach in equipping graduate students with the knowledge and skills to successfully pursue professional public health work. Recommendations inform future efforts to implement this approach in other public health curricula as well as for other courses and settings.

Keywords

problem-based learning public health graduate education pedagogy

Master of Public Health (MPH) programs are tasked with preparing students for a dynamic, collaborative, professional environment. To ready graduate students, faculty are exploring innovative pedagogical approaches that offer applied, immersive experiences tailored to public health careers (Berić-Stojšić et al., 2019; Lang et al., 2018). In keeping with core competencies outlined by the Council on Education for Public Health (2016), these active learning approaches seek to emphasize the multifaceted nature of public health work while developing skills such as self-directed learning, critical thinking, and effective communication.

Active learning formats improve student learning and course performance compared to traditional lecture-based formats (Freeman et al., 2014). Research supports the success of inquiry-driven pedagogical approaches that consider the evidence base and context of persistent health issues for public health curricula (Reinschmidt et al., 2019; Sandhu et al., 2015). Problem-based learning (PBL) as an active instructional method was originally developed in medical education and subsequently adopted by schools of business, education, architecture, law, and to a more limited extent public health (Ali et al., 2011; Barrows, 1992; Boud & Feletti, 1991; Bridges & Hallinger, 1992; Leon et al., 2015; Milter & Stinson, 1995; Streichert et al., 2005). PBL centers on an “ill-structured” problem (i.e., designed to have multiple potential solutions). Student teams are tasked with researching literature to determine the scope of the problem and constructing evidence-based solutions—thus, PBL promotes knowledge acquisition while strengthening critical thinking, collaboration, and communication skills. PBL also includes reflective elements, where students examine their learning processes. A review of studies evaluating PBL in the public health context concluded that this approach enhances student learning and problem-solving skills, particularly for long-term application to solving global health challenges (Leon et al., 2015). While nontraditional pedagogical approaches are valuable for graduate public health programs that emphasize applied, practical, and interdisciplinary learning, to our knowledge, no studies have evaluated the use of PBL for interdisciplinary public mental health (PMH) coursework centered on complex, multifaceted content.

Case Studies in Public Mental Health Course

The two–credit hour Case Studies in Public Mental Health course is required of graduate students at Emory University pursuing a mental health certificate along with their MPH degree and addresses the following learning objectives:

Critically assessing risk and protective factors that contribute to mental disorders and mental health at various levels of influence

Evaluating evidence-based programs/policies aimed at prevention of mental disorders or promoting mental health

Synthesizing findings on mental health prevention or promotion programs to identify best practices

Conceptualizing novel solutions to address modifiable risk factors for specific PMH cases

Communicating solutions to stakeholders

In 2016, faculty designed this PBL course aiming to (a) enhance skills in critical analysis and evaluation of relevant empirical publications related to PMH, (b) advance foundational knowledge of current PMH problems and potential solutions using an interdisciplinary approach, (c) improve presentation and group facilitation skills, and (d) provide a forum for students, faculty, and professionals with interest and expertise in PMH to interact, exchange ideas, and foster professional collaborations. The course incorporated core PBL elements such as the presentation of a PMH case study to interdisciplinary teams of students who were tasked with generating evidence-based, feasible solutions to each case. The interdisciplinary teams were purposefully composed of students from different departments, allowing them to draw on and incorporate perspectives of their disciplines into a coherent response to the cases (Aboelela et al., 2007).

A total of six case studies covered the following content areas: comorbidity of disease outcomes, substance use, suicide, mental health stigma, and global mental health. Two separate case studies were used for the global mental health category reflecting relevant issues in a developed and a developing country. Experts from the Centers for Disease Control and Prevention, the Carter Center, Emory School of Medicine, Emory Counseling and Psychological Services, and other mental health service provider organizations were invited to develop a unique case based on their work in PMH. They provided a one- to three-paragraph description of a problem they encountered in their work that aligned with one of the content areas described above. Experts were asked to outline issues that would allow students to consider solutions at three levels of influence: individual, health care system, and policy levels. Students presented solutions to the expert, who then discussed the pros and cons of each solution with the class. Students prepared an individual reflection paper for each case that synthesized the solutions proposed by all teams and examined the students’ learning process. Minor adaptations to the course were made based on feedback from the 2017 and 2018 cohorts, most notably assigning teams to develop solutions for one level to reduce redundancy in team presentations. The purpose of this study was to evaluate the implementation of the PBL components in the Case Studies in Public Mental Health course.

Method

Evaluation Design

A mixed-methods evaluation assessed the PBL approach across three cohorts of MPH students in Spring 2016 to 2018. At the end of each iteration of the course, students were invited to participate in a survey and a semistructured focus group. Participation was voluntary and did not affect students’ course grades. All study procedures were approved by the Emory University Institutional Review Board, and participants provided written informed consent for the survey and interviews.

Student Survey

At the end of the final class, students completed a 27-item survey assessing demographic characteristics, perceived mastery of course learning objectives, perceived effectiveness, and benefits of PBL course components. The PBL components were required readings, case analysis, additional literature review, solution presentation, discussion with expert, and individual reflection. The learning objectives included assessing risk and protective factors, evaluating evidence-based programs/policies, synthesizing findings on mental health prevention/promotion programs to identify best practices, conceptualizing novel solutions, and communicating solutions to stakeholders. Most survey items were assessed on Likert-type scales (e.g., not confident to very confident, not at all helpful to very helpful).

Focus Groups

Four focus groups were conducted with each student cohort at the end of their semester (one in 2016, one in 2017, and two in 2018). Focus groups were facilitated by a researcher who had not served as an instructor for the course. The facilitator’s guide included questions and prompts to gather information on students’ overall reactions to the PBL approach, their opinions of course components, and their team experiences. Focus groups were recorded and later transcribed verbatim for analysis. Two members of the research team coded focus group transcripts in Microsoft Word using inductive thematic analysis (Braun & Clarke, 2006). The research team developed codes through review of one transcript. The final codebook contained 19 codes categorized under five main categories and was applied to the remaining three transcripts. After independently coding the transcripts, the two team members discussed their coding, addressed any discrepancies, and finalized the coding for further analysis. The research team focused on themes related to students’ perspectives and experiences with the PBL course. Findings were triangulated to identify where the qualitative themes could provide explanation and a deeper understanding of the survey data.

Results

A total of 44 students enrolled in this course across the three cohorts. Of these, 37 (84%) students participated in the PBL course survey, of which 21 (57%) participated in a focus group. Across the three cohorts, the average age was 25 years (SD = 1.94 years) and most participants (83.78%) were female. Nearly half (48.65%) identified as White/Caucasian, 24.32% as Black/African American, 21.62% as Asian/Pacific Islander, and 5.41% as Other. The sample was demographically similar to all those enrolled in the course across cohorts.

Perceived Mastery of Course Learning Objectives

Students in later cohorts (2017 and 2018) were asked about their mastery of the course learning objectives. Most students indicated that they were somewhat confident or very confident that they could complete these objectives (Table 1).

Table 1.

Student-Perceived Mastery of Course Learning Objectives for the Public Mental Health Course Using Problem-Based Learning (n = 37).

Course learning objective	Not confident, % (n)	Somewhat confident, % (n)	Very confident, % (n)
Critically assessing risk and protective factors that contribute to mental disorders and mental health at various levels of influence	4.6 (1)	31.8 (7)	63.6 (14)
Evaluating evidence-based programs/policies aimed at preventing mental disorders or promoting mental health	0 (0)	54.6 (12)	45.5 (10)
Synthesizing findings on mental health prevention or promotion programs to identify best practices	0 (0)	40.9 (9)	59.1 (13)
Conceptualizing novel solutions to address modifiable risk factors for specific public mental health cases	0 (0)	59.1 (13)	40.9 (9)
Communicating solutions to stakeholders	0 (0)	50.0 (11)	50.0 (11)

Perceived Effectiveness of PBL Course Components

Respondents indicated that analyzing cases in teams (78%), reviewing additional literature (72%), and class discussions with case experts (78%) were most helpful to their learning (Table 2).

Table 2.

Student-Perceived Effectiveness of Problem-Based Learning Course Components (n = 37).

Problem-based learning course component	Not helpful at all, % (n)	Somewhat helpful, % (n)	Very helpful, % (n)
Required reading	32.4 (12)	56.8 (21)	10.8 (4)
Case analysis	2.8 (1)	19.4 (7)	77.8 (28)
Additional literature	0 (0)	27.8 (10)	72.2. (26)
Solution presentation	2.8 (1)	55.6 (20)	41.7 (15)
Discussion with expert	8.3 (3)	13.9 (5)	77.8 (28)
Individual reflection paper	38.9 (14)	52.8 (19)	8.3 (3)

Focus group participants responded positively to the case analysis. Participants perceived that this activity mirrored the steps professionals take to address complex PMH issues. Participants appreciated discussing with the experts how cases are approached in real-world contexts, and they valued experts’ feedback on their case presentation. Students suggested utilizing a presentation rubric to help the expert focus their feedback and discussion in a way that better aligned with class expectations. Example focus group quotes are provided in Table 3.

Table 3.

Themes and Sample Quotes on Perceptions of Problem-Based Learning From Student Focus Group Participants (n = 21).

Themes	Quotes
Perceived effectiveness of problem-based learning course components
Looking for additional literature	“. . . this would be something I’d have to do as a professional. Like, I would have to do my own research. Like, they’re not always going to give it to me; so I felt like that was a good skill for me to get used to is, you know, knowing how to utilize a database, knowing how to do my own google searches just to get, like background context.” (2016)
Case analysis and presentation	“. . . you have to be quick, you’re up there presenting . . . everything you say has to be based on something, you can’t just ramble on. You have an expert in the field that’s sitting with you listening to your solution to their case. So, it just holds you accountable . . . that’s a really cool opportunity.” (2016)
Discussion with guest expert	“. . . I really enjoyed having people from like a variety of different fields come in because you can kind of see like the type of work that you’d be doing after graduate school, and kind of just looking at public mental health in like—in like an applied way.” (2018)
Individual reflection paper	“ . . . the part where we had to do reflective papers after, I think that’s just kind of for them to see l like what did we actually do, but I would feel like the presentations that we do, the discussions that we had, that should be enough of a point to show what did we really learn. So the papers, like honestly, I could do without it.” (2016)
Perceived benefits of problem-based learning course
Experience with interdisciplinary team	“I was in a group of four, and we had one GH [global health], one BSHE [behavioral sciences and health education], one Epi [epidemiology], and one HPM [health policy and management], so like it was really, really good to have all those different disciplines, because I mean, you could definitely tell with like the way each of us thought we all brought something like completely different to the table, and it was really useful.” (2018) “I think if we had like at some point switched up groups, not like all the time, but like at some point, just to like, because we were so dependent on like other people’s personal experiences and like informing the direction of our case. Like, it just did for our group get very repetitive in the kind of proposals we were putting out.” (2016)
Simulation of real-life work environment	“I think case-based learning is very important because we will be doing that if we go on into further public health careers, especially when you consult . . . That’s just the nature of consulting that you set down and you do a lot of research, you present a lot, you make lots of weekly presentations.” (2016) “We already had all those courses, and we kind of had like the introduction to like the academic evidence and stuff, so now it’s more like putting all of that together . . . and it really forces us to apply what we learned in those previous semesters to a real-world problem, which is very much like what we’ll be doing after we graduate.” (2018)
Exposure to public mental health	“It was very immersive, and just honestly, I think at sometimes overwhelming, because there was so much complexity to all of these cases, more than we could have ever imagined, . . . and I think one of the most important things that we learned or at least I learned, was that you have to define the problem, even when the prompt gives you something to talk about, there are so many issues involved (laughs) that you actually have to narrow it down to one or two, um, and I think that was probably the most difficult part of the class, so you kind of wanted to tackle everything.” (2017)
Critical thinking skills	“It’s been a cool experience to like, to be able to see that I can actually address these cases and I can come up with solutions. It’s kind of like a—I don’t know, a confidence booster for me. And I’m like oh wow, you know, I could actually—like if I was on a job and I was presented with a case with this information and you know, in the beginning I feel kind of overwhelmed and I don’t know what I’m going to do, but then at the end, you know, after, you know, thinking about it, like some people said you might need to take a day or two to just kind of like reflect and so forth. You can actually come up with a solution which I think is pretty cool.” (2018) “I mean, so five of them [cases] were based in the US, and I think like three or four of them were like based on college campuses. And so, within the like a system that we are familiar with on, in you know, in a community that we were familiar with . . . like, we understand that community and that culture well enough that I think we could kind of come up with some of those solutions, but the last two [international] cases at least I personally found to be a lot more challenging because I wasn’t as familiar with those cultures and those communities.” (2016) “And I think there was like sometimes a little bit of contradiction, because it would say like oh yeah, think of new, creative, innovative ideas, but then it was like how can you do that if everything needs to be evidence based? Because it obviously is something with a new innovative idea, then there isn’t any evidence for it.” (2017)
Communication skills	“So I would, personally, I’m in [a nonbehavioral sciences] program, and we don’t get to present anything. We sit behind a computer, do some data analysis and then we turn it in, like that’s it. So, it was really cool to like for the first time to like, ok so this is what I found and I’m going to apply it and then I’m going to get up and talk about it ‘cause I think it’s so important to like effectively communicate your findings, which we don’t get to do that in [my] program.” (2016)
Recommendations
Increase faculty instruction and peer learning	“I think what would really cement that learning is also having a little bit of lecture, just a bit sprinkled in, and perhaps it could be like what a faculty member . . . might have thought of our particular solutions, because sure, it helps to have it from an expert, but half the time they’re stretched for time. They’re not able to get in everything they want to get in, and it kind of helps to like really cement the learning by having feedback from people who have worked in this field . . . ” (2018) “Like, I like, I love the idea of being presented with um, with a problem to like and everyone, you work together as a team to try and come up with a solution, but again, it also needs to be integrated with background, um, with a little more structure, with information from the person who’s presenting the case. Um, because I mean like if you’re consulting, you’re gonna have a discussion, I would assume, with the person who’s giving you the case.” (2016) “I would love resources of sharing. So like a discussion on BlackBoard, like a group where when people come across articles that, you know, maybe don’t pertain necessarily to their specific group, but might help another group, would be awesome. Like that’s great collaboration. I feel like that’s what we would do in the real world.” (2017)
Adjust course assignments	“Maybe perhaps instead of doing a case, like seven cases, like maybe we could whittle it down to three and spend more time on each case.” (2016)

Note. Focus group notation: The cohort year (2016, 2017, or 2018) is included in parentheses at the end of quote.

Preclass required readings (89%) and individual reflection papers (92%) were perceived by students as either somewhat helpful or not helpful at all. While some participants acknowledged the benefits of assigned readings, many reported not reading the articles, citing a perceived lack of connection between the case and the readings. Students regarded individual reflections as a reiteration of ideas from the case presentations. Some participants found the reflection format restrictive, with too many requirements to address within the page limitation.

Perceived Benefits of PBL Course Components

Focus group participants elaborated on the perceived benefits of PBL course components.

Experience With Interdisciplinary Team

Student perceptions of interdisciplinary teams were mixed. Some participants described productive group work and task division, while others expressed challenges with team members that, at times, impeded the progress of developing case solutions and presentations.

Students appreciated that faculty created interdisciplinary groups based on content knowledge (i.e., epidemiology, behavioral sciences and health education, health policy and management, and global health backgrounds). Participants found that these varied public health perspectives encouraged them to consider cases from alternative angles that ultimately prompted multifaceted solutions.

Several students felt that after a few presentations, groups became stagnant and continued to problem-solve and divide the work in similar ways without much growth in their approach. In some cases, participants would have appreciated the opportunity to work with other colleagues in the class, especially if their current group was relatively homogenous in the composition of public health disciplines (e.g., majority epidemiology students).

Simulation of Real-Life Work Environment

For students, a benefit of the course was the applicability of PBL components to future public health careers. Participants cited researching contextual information, incorporating interdisciplinary perspectives, collaborating on a team, and presenting comprehensive solutions as beneficial skills from the course that could directly translate into professional work.

When compared to previous lecture-based courses, students noted that the PBL format better prepared them for collaborative work encountered in the public health workforce. Participants appreciated the opportunity to define the scope of a problem, create evidence-based solutions, and propose and defend solutions to others in the field.

Exposure to Public Mental Health

Students reflected on how the course captured the complexities of PMH work, simulating realistic challenges associated with developing tailored, feasible solutions in the field. Students gained practical experience identifying contextual factors (e.g., environment, social norms, risk behaviors) that influence PMH and potential facilitators and barriers of proposed solutions.

Critical Thinking Skills

Participants noted how the PBL format encouraged them to develop evidence-based, feasible solutions that responded to the specific context of cases. From case analysis to discussing a proposed solution with experts, students felt compelled to provide thorough, thoughtful responses that aligned with published literature and existing programs.

Previous experiences in PMH directly influenced students’ ability to respond to complex cases. Participants who had taken other PMH courses or who were more familiar with the field reported greater ease with case analysis than others less familiar with PMH. Students also mentioned greater ease proposing solutions for domestic college campuses, a more familiar environment, than for international contexts.

Communication Skills

Students honed important public health communication skills not offered in more traditional course formats. Participants noted how an emphasis on communication skills, especially in presentations, allowed them to better articulate and debate solutions.

Student Recommendations for Course Improvement

Increase Faculty Instruction

Students from all cohorts suggested that the course would benefit from some traditional pedagogical structures. These students requested more class time for lectures on case-related PMH topics and skills (e.g., program evaluation).

Additionally, while students appreciated tailored guidance and advice from professors on the cases, participants described how this guidance often was provided at the beginning for initial solution ideas, rather than for later, more developed proposals. Students also requested more opportunities for sharing knowledge, not just from the professors to the students but between students.

Adjust Course Assignments

Most participants agreed that they would have preferred fewer cases over the semester in order to develop more detailed solutions. Students suggested adding a longer culminating assignment to demonstrate their learning over the entire semester in place of individual reflection papers. Sample quotes associated with each theme are provided in Table 3.

Discussion

The findings illustrate the general utility of a PBL approach for public health graduate work, similar to previous implementations in medical and allied health curricula (Applin et al., 2011; Koh et al., 2008; Vernon & Blake, 1993). Overall, students self-reported mastery of course learning objectives likely due to key PBL course components that they perceived as beneficial to learning.

PBL Course Components Perceived to Support Mastery of Learning Objectives

Our mixed-methods findings highlight three key PBL components that students perceived as beneficial to their learning: case analysis in interdisciplinary teams, engaging subject matter experts, and focusing on real-world scenarios. Teams are a critical element of active learning, shown to improve academic performance and student perceptions toward working collaboratively with peers (Huitt et al., 2015). Our findings provide additional evidence to support the importance of team-based problem-solving. Specifically, due to the complex, interdisciplinary nature of the cases utilized in this course, students recognized that their contributions to comprehensive solutions were limited when cases were viewed solely through their particular disciplinary lens. Rather, learning alongside their peers and considering other public health perspectives were at the core of students’ success in mastering important PMH learning outcomes. To enhance team experiences and to address student concerns about unbalanced participation, the addition of peer reviews, where students rate the effort of each team member, can be useful (Sibbald et al., 2019).

While faculty offer strong expertise in the coursework, students appreciated the inclusion of external experts who provided real-life cases and subsequently critiqued student-proposed solutions. This finding aligns with past research on the importance of tutors with strong content knowledge for student learning (Schmidt et al., 2011) and supports engaging faculty and professionals with strong content knowledge and experience as course contributors to enhance PBL.

Unlike previous PBL implementations in medical education that center on “diagnosis-solution” problems (Walker & Leary, 2009), faculty purposefully solicited multifaceted case studies from experts to simulate complex PMH challenges, to which students responded positively. This finding is similar to previous PBL research that noted benefits from student exposure to circumstances they will likely encounter in future professional environments (Nathoo et al., 2005). The realistic, applied elements of this PBL approach effectively position students to meet core public health competencies, which include skills in critical thinking and communication (Council on Education for Public Health, 2016).

Student Recommendations of PBL Course Implementation

Key lessons learned focus on student course preparation, faculty instruction and input, and course assignments. Some students felt ill-prepared when completing course tasks such as case analysis because of a perceived lack of PMH knowledge. In response, faculty instituted prerequisites for enrollment in the PBL course, such as the Introduction to Public Mental Health course, to ensure that students have the baseline knowledge to complete coursework. Preclass readings were intended to provide foundational content in PMH topics, though students did not always complete them. While a reduction in lecture-based classes is part of the PBL approach, students still desired some structured instruction from faculty. For later cohorts, faculty structured the first session to provide a detailed and interactive example of a case analysis. However, a sustained emphasis on self-directed learning is critical when implementing PBL (Hung, 2011). Thus, it is important to consider how to motivate engagement with existing components, like preclass readings, to enhance learning.

Self-reflection is integral to self-directed learning as it facilitates students’ personal reactions to their learning process and considerations for improvement (English & Kitsantas, 2013). Students’ critique of the individual reflection paper was largely due an inadequate explanation of its purpose. In response, faculty revised the guiding questions and clarified expectations. An alternative approach may be an online discussion board where students can create and respond in real time to reflection posts. Goldman et al. (2008) implemented a similar approach where students posted coursework in online blog posts for group members to review and provide feedback. Following implementation, the majority of students found this method useful to their learning and beneficial for current or future work (Goldman et al., 2008).

Strengths and Limitations

Strengths include the use of mixed-methods design, which allowed for a comprehensive exploration of perceptions of the PBL approach across three cohorts of graduate students.

Limitations include limited generalizability since the PBL approach was implemented for a single course in one public health school. However, lessons learned may be useful to other instructors as they tailor PBL to their unique context. This study also did not have a comparison group, as the course was newly designed. All data reflect student perceptions of their learning, rather than measures such as course grades. Though faculty implemented minor adaptations to the course in 2017 and 2018, these adaptations were not specifically evaluated in the administered surveys. In the future, additional data collection may help better understand the utility of yearly adaptations.

Conclusions and Implications

The PBL approach in the Case Studies in Public Mental Health course successfully provided graduate students with an applied curriculum focused on honing critical thinking, communication, collaboration, and reflective skills essential for the dynamic, interdisciplinary work of public health professionals. In general, the course format was perceived positively and led to increased mastery of learning objectives. This study offers an effective framework to inform the implementation of PBL in other academic contexts.

Footnotes

Acknowledgements

We thank all our students for contributing to thoughtful and energetic learning environments as well as for their participation in this study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support from the Office of Evidence Based Learning at the Rollins School of Public Health, Emory University.

ORCID iDs

Elizabeth Reisinger Walker

Delia L. Lang

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