Student-Authored Cases: A Novel Pedagogical Approach to Public Health Education

Background

Public health is constantly changing; it lives in a complex and integrated context, where new challenges are continually arising. Consequently, knowledge, skills, and content taught in the Master of Public Health (MPH) classrooms are constantly evolving; it is imperative that MPH pedagogy also evolve to meet the complex demands of the public health ecosystem (Frenk et al., 2015; Leon et al., 2015). As public health challenges become more global and complex, educators must teach critical thinking, imperfect reasoning, and core competencies; it is not practical to teach MPH students using solely a lecture-based approach (Speechley et al., 2015). The rising interest of employers in hiring students who demonstrate a well-rounded understanding of the health system and practical skills has also contributed to the need to transition MPH curriculum from being content-based to more competency-based (Sullivan et al., 2018).

Established public health core competencies outline the industry standards needed to practice in the public health sector, and accordingly, ensure that there is quality and consistency in knowledge and skills among public health professionals (Council on Education for Public Health, 2024; Public Health Agency of Canada, 2007). Core competencies have been defined as the baseline set of knowledge, skills, and attitudes required for an individual to practice in the public health sector (Council on Education for Public Health, 2024; Public Health Agency of Canada, 2007). These competencies ensure quality among institutions providing education in public health (Council on Education for Public Health, 2024). While knowledge and skill-based competencies can be explicitly applied, the attitudes and values needed by public health professionals serve more of an implicit function as they form the foundation that underpin all core competencies (Public Health Agency of Canada, 2007). The skills and knowledge defined by MPH core competencies are not directly related to a specific area of study (i.e., epidemiology), instead they emphasize general skills that all MPH graduates require to be successful (i.e., communication, leadership, and management; Moser, 2008).

The Schulich Interfaculty Program in Public Health within the Schulich School of Medicine and Dentistry at Western University, London, Ontario set out with an audacious goal—to change the way public health education was being delivered in Ontario, Canada, and beyond. When the program was formed in 2013, there were only 15 MPH programs across the country; prior to 2005, there were none. Recent counts of programs show there are upwards of 40 program offerings related to public health across 30 universities (as of 2017, according to the Government of Canada, 2017). Clearly, there were gaps in public health training that needed to be addressed.

To differentiate the Schulich MPH program from others, we decided to use a business-like, case-based pedagogical approach (Speechley et al., 2015). Our approach provides an adaptation of the case-based models used in the Richard Ivey School of Business at Western University and the Harvard T.H. Chan School of Public Health (Ivey Business School, 2023). The primary foci of the Schulich MPH program were addressing public health issues within Southwestern Ontario as well as within First Nations communities across Canada and globally (Speechley et al., 2015). Due to an insufficient number of cases reflecting these foci, faculty were left with few choices: use existing (often business-focused) cases in creative ways, allowing the case-based process to unearth public health concepts; find real-world examples to use as cases and get students to think critically about public health implications; and lastly, perhaps most ambitiously, create our own repertoire of cases to use. In the end, we chose a blend of all three and determined that the cases we developed would be used not only in our classroom, but that we would also make them available for classrooms around the world to serve the program’s goals and objectives (Speechley et al., 2015).

What is Case-Based Learning?

Traditional lecturing follows a teacher-student dynamic in which students are expected to absorb information and facts delivered by teachers, taught in lectures. Case-based learning (CBL) however, changes the student role to “learners” who play an active role in their education through engaging in case-based discussions (Master of Public Health Program, 2023a). CBL is a method of active learning that allows students to align their knowledge with a specific practical case scenario in order to reach an action plan with the given data (Thistlethwaite et al., 2012). The CBL approach (from individual to large group) enables students to be actively involved in tackling public health challenges; each student is given the opportunity to participate, collaborate, and construct their knowledge across the layers of learning (Tanner, 2013).The use of CBL has been correlated to higher rates of knowledge retention among university students than passive learning strategies (Malau-Aduli et al., 2013). This is due to students perceiving a clinical relevance of lecture-learned knowledge through its application into clinical scenarios, reinforcing their understanding and retention of these concepts (Malau-Aduli et al., 2013). CBL actively engages students in their learning, giving them more responsibility in their learning experience. Students are introduced to complex scenarios where decisions need to be made based off incomplete information. This enhances learning as real-life scenarios are mimicked within the classroom (Master of Public Health Program, 2023a; S. L. Sibbald & Haggerty, 2019).

Public health cases illustrate scenarios that are faced in real life situations in which available data is often incomplete and complex with no single decision being unarguably optimal (S. L. Sibbald & Haggerty, 2019). Students are guided to take into consideration the social, economic, environmental, and other relevant factors when navigating through the decision-making process while simultaneously consistently evaluating the possible repercussions of any potential decision (Speechley et al., 2015). The use of cases in the Schulich MPH program gears the focus toward developing critical thinking skills necessary to solve novel problems that may unexpectedly arise in a workplace setting. Having students integrate prior knowledge, synthesize potential solutions, and analyze the resulting consequences of an action allows them to learn at a much deeper level (Speechley et al., 2015).

CBL in public health specifically allows the students to realize and understand the complexity of problem-solving within or outside the scope of healthcare; there are multiple competing variables that must be considered (S. L. Sibbald & Haggerty, 2019). In addition, there are, and often competing, stakeholders with different needs, agendas, values and priorities. Unlike traditional lecture-based learning, with CBL, students practice and develop proficient decision-making skills, exploring different avenues for decision-making, role-playing different stakeholders, and consider different contexts and scenarios—all essential to the field of public health (Butler-Jones et al., 2018). The ability to make decisions with imperfect information, competing interests, and a multitude of stakeholders is an inevitable part of public health, and thus invaluable in the workplace. In public health, the absence of a decision may in fact risk the very populations that professionals are trying to support (Butler-Jones et al., 2018). To adequately teach our students these skills, our cases needed to be able to steer discussions in various directions, allowing for the exploration of diverse potential outcomes. There is often no one “best” answer or solution to a public health challenge, which requires students to consider all potential unintended consequences of their decisions. This involves evaluating the potential impact on stakeholders and effective priority setting to ultimately reach a decision aimed at maximizing positive outcomes while minimizing negative ones. Thus, this shift toward CBL makes way for competency-centered learning which better prepares students for the workplace (Sullivan et al., 2018). In the Schulich MPH program, cases serve as the primary teaching method and are seamlessly integrated throughout the entire curriculum. A course has roughly 25 classes (sessions); cases are typically assigned per class, and are discussed over 1 to 2 sessions, with each discussion sequentially building upon the previous one. Typically, the complexity of the cases builds throughout the semester—more straightforward (content or task-heavy) cases are done earlier in the semester, while more complex (theoretical, transdisciplinary) cases are taught in the latter half of the term. This approach allows for in-depth discussion and sequential learning for each case, while also exposing students to a greater number of cases throughout the course. While cases are typically used in one course, throughout the year, faculty share cases to enhance the integration of concepts across courses and encourage critical, cross-disciplinary thinking. Students individually review a case in advance of class, they then collaborate in groups (learning teams) to work on assigned preparatory questions. The discussion is then augmented in the classroom, where students share diverse perspectives on case problems and explore further concepts.

Based in the literature on pedagogical best practices, classroom cases provide context and background information, along with learning objectives and discussion questions that encourage students to apply critical thinking. For example, one case discussed a health clinic in a small town in the province of Ontario, focused on Hepatitis C Virus (HCV) testing for specific populations. It highlighted that current Ministry guidelines do not explicitly include sex workers, though some are indirectly covered. Students also explored proposed legislation, which criminalized sex-related purchases and may limit sex workers’ access to health services, prompting discussion on its impact on HCV prevention and potential measures to improve health outcomes (Bhullar et al., 2017).

When searching for cases to be used to teach public health, most healthcare-related cases were found to be written from a business perspective, lacking details that would be relevant to a public health professional. As a result, they were not suitable for use in a public health classroom. We needed to develop our own cases to support our pedagogical goals. We were determined to take this one step further by engaging our students in creating the cases. We believed having students support the development of cases would not only help build a repertoire of cases for our use, but it would also allow us to have an international presence in case-based teaching, and most importantly, it would support student learning through integrating their learning both practically and theoretically (Speechley et al., 2015).

The Schulich MPH Program: Addressing the Need for Change

The Schulich Interfaculty Program in Public Health has several key features: it uses team-based learning in a cohort model, it follows competency-based learning and uses case-based pedagogy as the primary method of teaching. The details of these elements of our program have been described elsewhere (Master of Public Health Program, 2023a, 2023b, 2023c). The Schulich MPH program sets itself apart from other MPH programs in Ontario and across the country by its unique approach to addressing the current need for competency centered learning; currently, the Schulich MPH program is one of the few programs in Canada to receive accreditation from the Council on Education for Public Health (CEPH), and is the only CEPH-accredited program in Ontario.

What is entirely unique to our program is our use of student-developed cases within our curriculum. An overview of the case-making process is highlighted in Supplemental Figure 1. Teaching cases include a case note (a one-page summary of the case), the case (a well-polished narrative), and the teaching note (an explanation of how the case should be used in teaching). These cases are developed by students in their final term (term 3/3) of their placement. Students experience CBL in terms 1 and 2; they receive several workshops throughout the year detailing how to learn with cases (term 1) and how to write cases (term 2). The case is (most often) based on a real issue encountered during the student practicum; this serves to reinforce the constructivist theory of learning, connecting concepts learned in coursework to personal experiences (Kudryashova et al., 2015). Students participate in a day-long workshop on case writing and are provided with templates for both the case and teaching note. A grading rubric is also provided to students to outline learning objectives and solidify the expectations of case writing.

The practicum is a core experience of the MPH program. Students are placed in practica in various public health-related settings and are able to apply their knowledge to complete real projects in the industry (Speechley et al., 2015). In addition to giving students an opportunity to garner workplace experience, the MPH practicum offers students the chance to experience the array of unexpected issues that may arise when working on a real project, allowing them to see how professionals deal with and resolve these issues (S. Sibbald et al., 2022; Speechley et al., 2015). It is during this time that students work on developing a case for potential use in the MPH classroom. During the practicum experience, students work to complete a public health-related project with the guidance of practicum supervisors. To preserve the realism of the case study, students are encouraged to base their design on a real issue that they had faced during the course of the practicum, with modifications when needed to ensure confidentiality and provide anonymity (Speechley et al., 2015).

Students must demonstrate both accumulation and synthesis of knowledge over the year to meet (and exceed) core and concentration competencies (Thind, 2022). Placing students in the role of an educator supports the “protégé effect”; a phenomenon where students are found to engage more in their learning when required to teach the content to someone else (Chase et al., 2009). The best cases enable a multi-layer learning experience: from individual learning through the initial reading of a case to large group (classroom) discussion where the case learning experience is culminated (Master of Public Health Program, 2023b). Case development continues by providing students with an opportunity to work through a peer-review process toward potential publication. Each year, two faculty members from the Schulich MPH program serve as editors for the casebook. Editors select approximately 15 cases from the class. The review process ensures that published cases meet the highest standards and helps students hash out the key details required for future learners. Through the editorial process, the casebook ensures the inclusion of “real-world” problems and core competency-focused materials in the Schulich MPH classroom. The topics of cases presented in casebooks vary, covering a range of topics from the implementation of emerging artificial intelligence technology into primary care systems, to the barriers that prevent sex workers from adequate access to sexual health and harm reduction services (Bahniwal et al., 2021; Bhullar et al., 2017). A link to an example student-authored case is provided in the supplemental case material.

Our program has changed over the years as we implemented incremental changes based on the student learning experience. To better support students in the writing process, we invite students/alumni who had authored the case to co-teach the class. Emphasizing more transparency about utilizing student cases and teaching notes from an instructional perspective has helped shape the workshop over the years. A major limitation of our work is that we do not have access to evaluation data. We acknowledge that assessment data would strengthen our argument. That said, our experience provides rich experiential evidence to support the pedagogical approach. We also acknowledge that we have not presented strong student perceptions in this paper - we can say with confidence that the students who are engaged in this process find it rewarding and value their contribution to the knowledge.

Casebooks have been made publicly available since 2015 through the Schulich MPH website with the intent to make public health cases freely accessible for educational purposes (Thind, 2017). We track downloads around the world in an effort to understand the reach and impact of our cases on a global scale. As of 2023, our casebooks have had over 26,000 downloads worldwide, with the highest number of downloads coming from Southern Ontario.

Conclusion

In response to the need for changes in training for public health professionals, many universities have dropped traditional didactic lecturing methods in favor of more active teaching pedagogies. CBL focuses on developing key decision-making and problem-solving skills (Begg et al., 2014; Sullivan et al., 2018) and enables students to exercise both critical thinking, through analyzing problems, and creative thinking, through brainstorming and refining possible solutions to case-based problems (Begg et al., 2014). The Schulich MPH program has taken a novel approach to CBL, bringing the students into the role of case-writer. This successful method, grounded in the literature on pedagogical best practices, enhances overall learning through engagement in pedagogy. Students develop high-quality teaching cases; the best of which are selected for publishing into the yearly casebook which become pedagogical tools for MPH classes in future years. The CBL approach in combination with case writing is an effective and rewarding pedagogical tool that helps learners meet the program’s core competencies while augmenting their public health toolkit as future leaders.

Supplemental Material