Series In Population-Oriented Prevention Research Articles

An Enhancement Strategy for Integration of Population Health into Medical School Education: Employing the Framework Developed by the Healthy People Curriculum Task Force

The authors describe an enhancement strategy for integration of population health content into the medical school curriculum at The Brody School of Medicine at East Carolina University conducted in 2005-2006. The Clinical Prevention and Population Health Curriculum Framework developed by the Healthy People Curriculum Task Force served as the planning template for curriculum analysis. Key to success was the incorporation of population health as a "curriculum enhancement," as opposed to curricular expansion or substitution. Strategies included introduction of a Case-Based Series in Population-Oriented Prevention (C-POP) in the preclinical years; community assessments, home visits, and public health assignments in the family medicine and pediatrics clinical clerkships; and prevention history-taking. The Brody integrated curriculum included a wide range of topics and clinical experiences specific to prevention and population health; however, the coverage was uneven. Hybrid teaching cases were developed from four C-POP cases which were adapted to existing instructional materials. Students learned to define the determinants of health, disease burden in their community settings, and community strengths and obstacles specific to dealing with chronic conditions. Factors contributing to the successful integration of population health included a receptive primary care medical school, use of the Framework, analysis of gaps between the Framework and the existing curriculum, providing enhancements to the existing curriculum, employment of patient cases, and integrating population health into a variety of classroom and community medical learning experiences. This approach, as opposed to a separate and distinct course, seeks to reinforce the interconnectedness of communities, families, and individuals.

Integration of the case-based series in population-oriented prevention into a problem-based medical curriculum

This article describes the pilot testing of the Case-Based Series in Population-Oriented Prevention (C-POP) and accompanying evaluation instruments in a problem-based medical curriculum at the University of Rochester Medical Center. Several of the cases were successfully taught in the curriculum, but the evaluation instruments revealed no change in population-oriented skills or orientation. Issues of implementation and evaluation of the C-POP curriculum are discussed.

Outbreak of tuberculosis in a homeless men’s shelter

This case—tuberculosis in a homeless men’s shelter—is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. Tuberculosis presents a significant public health challenge. In this teaching case, medical students are given information about four cases of active tuberculosis that occurred over a short period of time in residents of a homeless men’s shelter. The students then walk through the steps that a local health department takes to identify and screen those individuals at risk for transmission of tuberculosis during an outbreak. During this process, they learn skills in epidemiology (such as defining “epidemic” and distinguishing uses for incidence and prevalence) as well as in population-based prevention of tuberculosis. Finally students discuss health policy as it relates to the control and prevention of tuberculosis.

Racial and ethnic disparity in low birth weight in Syracuse, New York

This case—racial and ethnic disparity in low birth weight—is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. Low birth weight is a leading cause of infant mortality. Unfortunately, despite declining rates of infant mortality, racial and ethnic disparities in both low birth weight and infant mortality rates persist. In this teaching case, a clinical vignette is used to draw attention to this public health priority in Syracuse, New York. Students learn essential epidemiology skills such as identifying limitations of sources of data and calculating relative risks, using the example of low birth weight. In performing these skills, students also identify etiologies for such disparity. Finally, students discuss interventions that, when implemented, may decrease infant mortality rates.

Future applications of case-based teaching in population-based prevention

The Case-Based Series in Population-Oriented Prevention (C-POP) introduced in this supplement to the American Journal of Preventive Medicine provides a set of tools to integrate clinical- and community-based prevention into interactive teaching cases. These cases, which address recommended core competencies in prevention education, have been taught to both medical students and preventive medicine residents. Initial experience with the cases indicates that this method is a promising tool to enhance prevention education in medical schools and primary care residencies. Because prevention education is essential in other fields, such as public health and nursing, extension of this approach to other professional schools is possible. Such extension is feasible because the cases are designed to be adaptable for different levels of education, flexible to be tailored to local situations, and expandable to accommodate changes in the field. In addition, the cases can be made accessible to all educators through a national library and in interactive web-based format. This article describes how the C-POP series can be used to strengthen prevention education for a wide audience of physician and nonphysician learners.

Bicycle helmet effectiveness in preventing injury and death

This case—bicycle helmet effectiveness—is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine.This case examines the cost-effectiveness of three interventions to increase utilization of bicycle helmets to avert head injuries in individuals aged 18 years and under in Onondaga Count NY. Students are initially presented with data on head injuries, hospitalization, and death related to bicycle use. They then appraise a published study on the effectiveness of bicycle helmets in averting head injury. Finally, students work in groups to determine the cost-effectiveness of each intervention by calculating implementation costs and the specific number of head injuries averted associated with intervention. The three interventions are legislative, school, and community-based campaigns to increase helmet use. Students are provided with budget estimates and assumptions needed to complete the exercise. Cost-effectiveness analysis, cost-benefit analysis, and related concepts are discussed, including provider versus societal perspectives and importance of sensitivity analysis.

Preventive medicine teaching cases for preventive medicine residents

Preventive medicine education is unique in that its successes are measured in groups of people. Conveying this population perspective can be difficult, even to preventive medicine residents, some of whom have been in clinical practice for many years. The Case-Based Series in Population-Oriented Prevention (C-POP) was adapted for use in the New York State Preventive Medicine Residency curriculum. Parts of two of the cases were felt to be too clinical for use in this setting, but the other cases were well received and imparted the desired population perspective. Although the C-POP series was produced for undergraduate medical education, it is generally adaptable to the needs of a preventive medicine curriculum.

A user’s guide to teaching the C-POP series

The following section of this supplement to the American Journal of Preventive Medicine contains the eight Case-Based Series in Population-Oriented Prevention (C-POP) modules, seven of which were developed at the State University of New York (SUNY)–Upstate Medical University to enhance the teaching of preventive medicine. Most of the cases begin with a clinical vignette and then progress to a population perspective. The cases are based on actual data provided by the Onondaga County Health Department in Syracuse, New York. In this guide we present practical recommendations on how to teach these cases and information on how the cases can be adapted to suit the needs of existing curricula, learners, and preceptors. The cases were developed for a class size of 20 to 30 students, although they have been taught in classes with fewer than 10 students and, on rare occasion, in classes with 50 or more students. Splitting the class into subgroups is frequently recommended to facilitate more detailed discussions about specific points or to divide time-consuming tasks, such as the calculations in Racial and Ethnic Disparity in Low Birth Weight in Syracuse, New York. After adequate preparation time, the subgroups reconvene to share and discuss their information with the larger group. Just as the cases can be taught to a variety of class sizes, they can be taught to a variety of students at different stages in their medical education. Four of the cases—Racial and Ethnic Disparity in Low Birth Weight in Syracuse, New York, Community Health Assessment, Outbreak of Tuberculosis in a Homeless Men’s Shelter, and A Critical Look at Prevention: Colorectal Cancer Screening—were developed for firstand second-year medical students. Three of the remaining cases—Sexually Transmitted Disease in Adolescents, Bicycle Helmet Effectiveness in Preventing Injury and Death, and Adolescent Suicide Prevention—were developed for third-year medical students. The last case, Maternal Mortality, was developed for residents in preventive medicine. All of the cases can be adapted for learners at any point in the medical school curriculum or resident education. The cases are typically taught in one 2-hour session (except for Racial and Ethnic Disparity in Low Birth Weight in Syracuse, New York, for which two 2-hour sessions are recommended). Section A is given to students in advance. Students are expected to complete this part of the case before class such that they come prepared to engage in group discussion. Extended discussion points are integrated into each of the cases. The facilitator may choose which points to focus on, depending on the time available, the facilitators’ comfort with the subject matter, and the learners’ clinical orientation and experience. For example, a clinician teaching thirdor fourth-year medical students the tuberculosis (TB)/homeless shelter case may devote more time to discussing the complexities of the interactions of human immunodeficiency virus and tuberculosis. A preceptor teaching second-year preventive medicine residents the same case may choose instead to spend more time discussing the nuances of screening procedures in a contact investigation involving a hardto-reach population. Similarly, in the adolescent sexually transmitted disease (STD) case, a preceptor teaching public health students or medical students who are in their preclinical years, may opt to spend less time on the clinical aspects of the case and more time discussing issues of domestic violence or statutory rape. As is evident from these examples, there is considerable content presented in each case. Although all of the objectives of each case can be covered in a 2-hour time frame, it is not feasible to expect to be able to have in-depth discussion of every point. Facilitators must, therefore, choose to conduct focused discussions on selected sections as mentioned earlier, to extend the session time per case, or to teach a case over more than one session. The flexibility of the cases is apparent in the content as well. As noted earlier, most of the cases presented in this supplement are based on actual data from a local health department. Faculty members at other institutions are encouraged to substitute local data if possible. Although this is not necessary, it will likely increase the relevance of the learning situation for the target audience. Because the cases present numerous opportunities for extended discussions and because they have a significant local health department presence, preceptors may initially feel they need to be experts in the field before teaching a particular case. However, as is good practice with small group–discussion cases, the From SUNY–Upstate Medical University, Syracuse, New York Address correspondence and reprint requests to: Lloyd F. Novick, MD, MPH, Preventive Medicine Program, Department of Medicine, State University of New York, Upstate Medical University, 714 Irving Avenue, Syracuse NY 13210. E-mail: PMP@upstate.edu.

Maternal mortality

This case—maternal mortality—is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. Maternal mortality remains an important public health concern, even though it is a rare event. This teaching module introduces five case reports of maternal death to provide a clinical lead into discussions about data sources such as death certificates and their limitations. The students will also calculate maternal mortality rates and explore racial disparities in this health indicator. Finally, the students will develop intervention strategies to identify and prevent maternal mortality.

Measuring orientation to population-based prevention

Background Assessing orientation to population-based preventive alternatives is useful in the evaluation of preventive medicine curricula. Methods An instrument was developed using hypothetical situations describing a health issue that could be encountered by a primary care physician. Options to be selected were in three categories: (1) treatment, (2) clinical prevention, or (3) population-based prevention. Respondents allocated 900 points among alternatives for nine situations (100 points per situation). Pilot testing of the instrument was implemented, comparing the responses of public health physicians with two groups (Syracuse and Baltimore) of family medicine physicians. Results For the overall instrument, the scores on the population scale and population–treatment differential showed statistically significant differences between the public health physicians and both groups of family medicine physicians ( p<0.01). For medical students taught the Case-Based Series in Population-Oriented Prevention (C-POP), there was an overall increase in the population scale ( p<0.0001) and the population–treatment differential ( p<0.0004). Conclusions The development of a scenario-based tool to assess changes in population-based prevention orientation shows preliminary promise for future evaluation efforts involving preventive medicine curricula.

Preventive medicine teaching cases in the preclinical undergraduate medical curriculum

The implementation of the Case-Based Series in Population-Oriented Prevention (C-POP) at the University of California at Davis Medical School is described. The implementation and planning for the integration of a case-based curriculum into a previously didactic-focused preventive medicine course are discussed. Issues include flexibility of the curriculum, student acceptance of case-based learning, and effect of preceptor availability and training on the successful implementation of the C-POP curriculum.

Adolescent suicide prevention

This case—prevention of adolescent suicide—is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the A merican Journal of Preventive Medicine. This teaching case examines the issue of prevention of adolescent and young adult suicide both at an individual and at a population or community level, using data from the Onondaga County Health Department. In the first section of the case, students are asked to determine whether five deaths related to falling or jumping at a local shopping mall should be considered to be suicidal deaths. Students then develop skills in the reporting as well as in the epidemiology of adolescent suicidal deaths in Onondaga County. As the case progresses, students analyze the results of a local surveillance study of suicidal attempts and ideation. The case concludes with students evaluating a hypothetical screening study intended to reduce the risk of suicidal death and discussing a research design to examine the effectiveness of this prevention strategy.

A critical look at prevention: Colorectal cancer screening

This case—colorectal cancer screening—is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. This preventive medicine teaching case discusses the concepts of diagnostic test evaluation, prevention, and screening using the example of colorectal cancer screening. Features of the case include a health policy exercise concerning community screening programs and an exercise in clinical prevention decision making.

Community health assessment

This case—community health assessment—is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. Community health assessment is key to understanding the health problems and priorities of a population. This case outlines a process by which the participants can complete a health assessment of a community using indicator-based methods. Students construct a set of health indicators from a variety of domains, evaluate problems, and report on the health priorities for a community. The students relate identified health issues to underlying behavioral risk factors.

Sexually transmitted disease in adolescents

This case—sexually transmitted diseases in adolescents—is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. Sexually transmitted diseases (STDs) are common among adolescents. This case focuses on the population-based prevention of STDs. The case begins with clinical, diagnostic, and laboratory management of an adolescent female diagnosed with gonorrhea. Students then examine how the diagnosis of an STD can be used as an opportunity to provide preventive care and counseling on safer sexual behaviors. Questions addressing HIV testing and counseling are included in this section. Students proceed to explore how the diagnosis and reporting of an STD calls for interaction, such as partner notification, between clinical providers and public health departments. Finally, students are provided with actual information from local focus groups on attitudes and behaviors of high-risk adolescents. At the conclusion of the case, they are asked to interpret the data and formulate strategies to decrease gonorrhea rates in the community.