Using problem-based learning in public health service based training

Problem-based learning (PBL) is valued in undergraduate health science curricula as a means of developing critical thinking, problem-solving skills, teamwork skills and the ability to deal with complexity ¹ – all attributes considered important for public health practice. The distinguishing features of PBL include active self-directed learning where small tutor-facilitated groups encounter a problem and then seek solutions, with no advanced readings or lectures. ² The method involves learners exploring their pre-existing knowledge and seeking additional information to advance their understanding. ² Active participation leads to more satisfying learning ³ and greater knowledge and clinical reasoning skills. ⁴ PBL has focused mainly on clinical situations; however, population problems can effectively be used when they use ‘progressive disclosure’, reflect ‘real-life situations’, and have a broad title that directs thinking to population issues. ⁵ While the inclusion of PBL in undergraduate public health education appears sound, ⁶ its suitability has largely been ignored in professional training. ⁷

During November 2005, nine trainees, seven in their final year of the NSW Public Health Officer Training Program (the Program), who had completed a 6-month rural rotation, and two from linked programs, participated in a week-long rural training retreat that incorporated PBL. The retreat was held in Broken Hill, a small city in arid Australia located 1200 km west of Sydney (where the Program is based). The retreat included active learning about the communities located along the rail corridor that trainees travelled through during a 12-hour train trip from Sydney to Broken Hill; a 4-day PBL on water quality (a major public health issue in Broken Hill); site visits; and meetings with public health professionals. The PBL involved three facilitated sessions over 4 days. The first session focused on the scenario, problem identification, information gathering and problem reformulation; the second session considered options for solving the problem; and the third session addressed emerging issues and discussion points.

The development of a public health PBL scenario for the Program was the initiative of the NSW Department of Health and arose from an interest in exploring new ways in which to deliver service-based training. The Broken Hill University Department of Rural Health was contracted to develop the PBL scenario, and this was accomplished in consultation with key stakeholders, including staff from the Program.

The study explored the benefits that exist for trainee public health officers who undertake rural training within a retreat that incorporates a public health PBL exercise and how well this fits with the delivery of a competency-based postgraduate training program. The impact and desirability of new ways of delivering public health training through active on-site learning about rural public health issues and communities involving PBL and site visits (including the train journey) were examined.

Data collection for the evaluation of the training package was by qualitative means. Semistructured in-depth interviews averaging 30 minutes in duration were undertaken with 19 respondents (all nine trainees and 10 key informants). Key informants were staff involved in the retreat planning or PBL delivery from the Program, Greater Western Area Health Service Population Health Unit and two university departments of rural health. They were invited to participate in the evaluation by two of the authors (GH or JF). Two potential key informants were not available at the time of interview. Interviewing commenced the week after the training finished and took about 3 weeks. All respondents gave informed consent. Interviews were tape-recorded, with notes typed into a word-processor file. Data were separately coded (by GH and JF) with cross-coder verification. There was high agreement between coders. A few minor differences in interpretation were discussed and agreement was reached about a thematic framework. The evaluation explored the: (a) value of a PBL approach within a training retreat; (b) learning impact; and (c) factors to explain the effectiveness of this means of delivery. The results section presents the findings for the first two points while the value of retreat-style training that incorporates PBL is explored in the discussion section.

Trainees (three male and six female) liked the practical focus of the retreat and the PBL, and also the hospitality they received in Broken Hill. The key informants involved in the development of the PBL and its delivery wanted to know if it would work, and were pleased with the trainees’ engagement with the exercise. The local public health unit staff were satisfied with their involvement, as the exercise allowed them to reflect on their work and to see the problem examined in a broader context (Box 1, quotes 1–2).

While experiential learning was the most valuable aspect of the retreat, there were a few minor problems such as the 3-hour delay in the departure of the train from Sydney. While the delay added frustration to a long trip, the journey was designed as a learning opportunity, introducing trainees to rural issues including the realities of travelling to remote locations (Box 2, quote 3).

There was unanimous support for the use of a PBL exercise and learning in situ. The benefit of studying remote public health issues through a PBL exercise in a rural location was recognised as having an ‘impact bigger than being in [the city]’. Trainees were happy with the pace of learning and length of the training and valued having access to experts, local professionals, site visits and written resources. More than half of the trainees commented on the resources and how the PBL was supported by ‘easy access to information’ and ‘experts’, which allowed ‘clarity and guidance’. A few thought that it would have been better if they had to undertake more of a ‘mental hunt down’ for appropriate resources; however, others noted that easy access to resources was beneficial given that only 4 days were available for the PBL.

Trainees enjoyed the engaging nature of the PBL. The retreat–PBL combination created a ‘variety of learning experiences’ and trainees appreciated how the PBL topic had ‘complexity that unfolded gradually’. According to the trainees, this made the training realistic, relevant, practical and ‘learner centred’ (Table 2, quotes 4–6). There was some criticism, however, when a site visit was not linked well to the PBL and did not capitalise on an expected learning opportunity. This experience illustrated the effort required to maximise the learning potential from site visits.

The focus on one public health issue in one location did limit trainees’ exposure to a broad range of rural and remote public health issues and about half of the trainees expressed the desire to have explored additional environmental health and Aboriginal health issues. Other trainees, however, reported that dealing with one problem enabled them to gain a deeper understanding of the principles of public health practice. Moreover, additional content would have limited their immersion in the historical, cultural and social context in which the problem arose. As public health strategies are implemented within and influenced by local context, experiencing this is a relevant and important aspect of learning.

The perceived relevance of PBL to public health training was in the development of problem solving and teamwork competencies in a simulated real world context (Box 3, quotes 7–9). While trainees reported increased knowledge about water quality, the more profound and surprising impact for them was to see the mutually supportive form of public health practice that has developed in Broken Hill. While this has been born of necessity due to distance from other public health specialists, it has been actively cultivated by local practitioners (Box 3, Quotes 10–11). The awareness that distance did not mean absolute professional isolation appeared to open a few trainees to the possibility of future remote public health work (Box 3, quotes 12–13).

While the impact of PBL in a 1-week retreat may be limited, one trainee made the point that the impact was amplified by the magnitude of the difference between urban Sydney and Broken Hill. The impact of training held in less-isolated rural settings is worth exploring. Another trainee noted the importance of undertaking site visits to develop a sound understanding of a location and the related issues. They reported how the retreat–PBL had confirmed for them the value of undertaking site visits and how they would build these into future work practice (Box 3, quote 14).

The retreat–PBL approach appears to be constructive and is aligned with the aims of the Program, which is to produce graduates who are competent to work strategically with other public health practitioners to resolve public health issues in NSW. This learning approach also requires the simultaneous application of many of the competency areas from the competency framework on which the Program is based. ⁸ Further, it augments the learning that trainees gain during the 6-month rural work experience that they are required to undertake.

The learning principles underpinning the PBL are aligned with contemporary learning theory (e.g. constructive, self-directed, collaborative and contextual learning). ⁹ Although electronic and class room learning may eliminate the need for rural visits, the results suggest that the efficacy of the PBL was directly linked to the experiential and contextual aspects derived from the rural visit, which led to increased knowledge and greater understanding and insight (e.g. into practical solutions to isolated practice). These same positive outcomes may not be present if trainees study a rural public health topic from an urban location. In addition, site visits can avoid some of the weaknesses related to distance learning such as content inflexibility ¹⁰ and are an important part of a problem assessment.

The location, structure and suitability of the problems used to develop a rural PBL need consideration. In this case, the PBL within a retreat worked. The effectiveness of this experience may be related in part to the remote location of its delivery, which was very different from the trainees’ usual experience and so captured their interest. A less isolated rural retreat may not have the same impact.

Other crucial ingredients for effectiveness appear to be collaboration between the NSW Public Health Officer Training Program, public health academics and public health practitioners at the planning and delivery stages. In this case, the lead academic involved with the development and delivery had a public health background, was familiar with the Program and had good relationships in Broken Hill. The PBL designers knew what a public health PBL should contain and how it should unfold. The PBL kept the interest of the trainees as it covered the technical, human and political aspects of the problem. Collaboration made the PBL real, with a variety of expertise contributing to the learning, the problem and the context. Despite the constructive planning process based on transparency and trust and the associated positive learning environment, additional stakeholder involvement by site managers at the planning stage would have assisted with managing expectations and role clarity during site visits.

While positive learning experiences have been associated with PBL, ^{11 – 13} the satisfaction with the PBL and the rural retreat may be linked to the variety of learning modalities involved, including experiential learning – described elsewhere as ‘significant’ learning – as opposed to cognitive ‘meaningless’ learning. ¹⁴ Such a mix would cater to the heterogeneity that exists in all groups, recognising that participants would not share the same learning style preference. ¹⁵

Satisfaction with the PBL appears to be derived in part from the study of a problem that requires active participation as opposed to problem simulation. ⁴ The effectiveness of the PBL could also be due to the trainees being adult learners within a pre-existing well-formed group, which enabled them to quickly and productively focus on the topic. Because of the resources invested and the commitment by the trainees to be away from home, trainees may need to be ‘made ready’ for both the PBL and the retreat in order to maximise the learning opportunity. Not all groups may be as highly motivated or functional, so implementation issues, such as the level of problem structure and tutor directiveness, ¹¹ would need to be considered. Alternatively, the PBL might only be used where self-direction is assured. The model described, however, may work for other appropriately prepared public or primary health care staff involved in professional development.

Incorporating a public health PBL topic in a 1-week rural training retreat provides a positive learning experience for trainees undertaking postgraduate public health competency-based training. The value of a PBL within a rural retreat is linked to experiential learning where knowledge, insight and understanding are built with the potential to change individual practice and openness to work rurally. Rural educational retreats could play an important workforce role and should be considered for use with the range of health disciplines involved in such training.

A 1-week retreat with a single public health problem combined with good hospitality appears to be the right mix. Targeting motivated trainees at a level where they will be able to optimise the experience should be considered.

Preparatory work requires the design of a complex public health problem with appropriate site visits considered. Stakeholder involvement in planning will ensure roles are clear and expectations are managed. This style of learning should include orientation to the location and to the local public health unit staff so that trainees understand the organisational structures and resources available to practitioners. When evaluating the effectiveness of future public health training retreats, elements beyond learning domains should be considered, including the contextual elements of place and people. The question remains open as to whether this approach has a role in the broader implementation of the Program in both rural and non-rural settings.

To fully appreciate why this PBL was effective, comparative data from other rural training retreats involving PBL delivered for the Program is required. Such comparisons would identify the optimal range of sites and the suitability of public health problems.