Jang, Ji-Hyun MPH; Alston, Jill MD; Tyler, Ingrid MD, MHSc, MEd; Hau, Monica MD, MSc; Donovan, Denise MB, MPH; Johnson, Ian MD; Shore, Barbie; Shahin, Melissa
Public health has been an unpopular area of study amongst medical students in Canada and elsewhere.1–3 In 2006, focus groups at five Canadian medical schools found that medical students were largely disillusioned by and not engaged in the public health curriculum.4 Students often reported both a poor understanding of the role of public health and preventive medicine specialists and a perception of public health as irrelevant to clinical work.4 Despite their perceptions, medical students need to graduate with basic public health knowledge and skills in order to successfully practice in a society in which epidemics of both infectious and chronic diseases demand their attention, and in which health promotion and disease prevention are increasingly necessary.5,6
Previous reports have described various methods of boosting interest in public health among medical students. For example, Buffington and colleagues7 describe an elective program in epidemiology and public health offered by the Centers for Disease Control and Prevention to senior medical students. Review of program participants’ education and careers showed that almost one-fifth of the participants attained subsequent training, and of those, almost 80% went on to careers in public health.7 Other investigators have demonstrated similar trends; that is, medical students who have received formal public health education during medical school have pursued careers in public health.8 One effective method of incorporating public health into medical school curricula is case-based learning, through which clinical and public health concepts are taught in an integrated fashion.9
The Public Health Task Group and Public Health Interest Groups
The Association of Faculties of Medicine of Canada (AFMC), which represents Canada’s 17 medical schools and provides support for health education and research,10 established a Public Health Task Group (PHTG) in 2001 as part of its Social Accountability Initiative.11 The overall goal of the PHTG was to enhance public health education through the development of educational resources for faculty and students. Since its establishment, the PHTG has worked toward creating both a set of common public health educational objectives across Canadian medical schools and a supportive network for effective public health education.12
One initiative of the PHTG was the creation of public health interest groups (PHIGs). The PHTG created these groups, piloted in 2007, to raise the profile of and interest in public health issues amongst medical students.13
The AFMC states that the purpose of PHIGs, as expressed through four objectives13 is
1. To provide students with information about the importance of incorporating population and public health concepts into all areas of practice;
2. To expose students both to community activities that demonstrate public health concepts and to professionals in the field of public health;
3. To provide an opportunity for students to learn, to network, and to develop leadership skills; and
4. To provide an opportunity for students to explore public health and preventive medicine as a career option.
In addition, PHIGs aim to encourage interprofessional networking amongst medical students and other allied health trainees.
The PHIGs were modeled after other interest groups (e.g., those for family medicine and internal medicine) that have been able to create greater awareness of their specialties by increasing medical students’ exposure to role models in academic and community settings.14 Reports from these medical specialties14–19 have described the positive influence of medical student interest groups on dispelling negative myths about the specialty by providing, along with other initiatives, hands-on experiences and mentorship opportunities.
Similarly, PHIGs were formed to promote better awareness of public health; however, they may be operated and funded differently from other specialty interest groups. PHIGs are student-led initiatives that are overseen by the AFMC, which approves and distributes Public Health Agency of Canada (PHAC)-provided funding. The AFMC also supports interaction between the Public Health Educators Network and individual PHIG executive committees (comprising volunteer students) at each school. This model of national coordination provided by AFMC fosters collaboration among PHIGs through semiannual teleconferences and an online discussion forum for PHIG members through which groups are able to exchange ideas for events and receive support for their work.20 Further, whereas one of the major objectives of family medicine interest groups is to promote a career in that specialty,17,18 PHIGs seek not only to promote public health careers but also, importantly, to emphasize the importance of incorporating public health concepts into all areas of practice, regardless of career interest.
The objectives of the present report are to provide a description of the membership, activities, and funding arrangements of PHIGs, and to examine how successfully PHIGs have been able to meet AFMC’s objectives (outlined above).
Document analysis of PHIG files
We conducted a document analysis of funding applications, interim reports, and annual reports submitted by each PHIG executive committee to the AFMC for four academic years (2007–2008 to 2010–2011).
Four of us (I.T., M.H., J.H.J., and J.A.) created a data extraction sheet in Microsoft Excel (Redmond, Washington). To test this tool and to ensure consistency, two of us (J.H.J. and J.A.) extracted and compared data from the funding applications, interim reports, and annual reports submitted by two randomly chosen schools in one academic year. We (J.H.J., J.A. and I.T.) resolved any disagreements in this initial comparison by discussion. For the full analysis, two of us (J.H.J. and J.A.) divided all of the available reports for all schools between us and extracted data individually. The data we extracted included information on the school, on prior PHIGs if applicable, and on PHIG activities and structure, including budgeting and sustainability.
Because of the large variability in the descriptions provided by the various PHIGs across four years, we created standard categories for activities conducted, budget items, recruitment strategies, and sustainability strategies, and we extracted simple counts of PHIGs, funding applications, and activities within categories. We then used these data to assess how successfully PHIGs have been able to meet the objectives set out for them by the AFMC.
We did not seek formal ethical approval for this program evaluation activity because this documentary analysis falls under article 2.5 of the Tri-Council Policy Statement and therefore does not require approval.21 No identifying information is included in this article.
PHIGs in Canada
Over a four-year period, 52 funding applications, 50 interim reports, and 48 annual final reports were available for analysis. The reports were written and submitted by student members of the PHIGs who volunteered to sit on each PHIG’s executive committee.
All 17 medical schools in Canada had at least one established PHIG between 2007–2008 and 2010–2011. The total number of schools that received AFMC funding (Figure 1) ranged from 12 of the 17 Canadian medical schools (70.6%) during the 2007–2008 academic year to 14 of 17 Canadian medical schools (82.4%) in both 2009–2010 and 2010–2011. Figure 2 illustrates the percentage of schools that applied for PHIG funding by the number of years that they applied. The majority of schools (n = 9; 52.9%) applied for PHIG funding during all four years that funding has been available.
Our data suggest that at least 14 schools did not have an existing PHIG prior to the availability of AFMC coordination and PHAC funding. Most schools continued to operate their PHIGs, once they were created, using AFMC funding. Two schools continued to participate in AFMC-supported PHIG activities throughout the year without requiring AFMC funding. A total of 16 out of 17 Canadian medical schools had established PHIGs in the last school year studied.
Description of PHIGs’ structures and activities
The total number of PHIG members ranged from 3 to 100 (median = 33) per school. On the basis of the reports we analyzed, we determined that, for the majority of PHIGs, both the membership and leadership consist of undergraduate medical students. The leadership structure of PHIGs generally consists of a small group of individuals who share the tasks and responsibilities necessary to organize events.
PHIG activities and budgeting.
We defined an activity loosely, and we included a range of “activities” from a single event conducted at a point in time (e.g., a lecture) to an ongoing project, including many steps or events, that was completed over a period of time (e.g., creation and maintenance of a mentor list). Table 1 conveys the types of activities conducted by all PHIGs combined across all four years. Academic activities such as lectures, seminars, and workshops were by far the most common (total count = 100), followed by career exploration and networking events featuring public health physicians (total count = 38). Other frequently conducted activities included public awareness campaigns related to infectious diseases and global health issues (total count = 34). Some PHIGs also conducted academic support activities, such as providing grant funding to enroll in a public health and preventive medicine elective, organizing a conference on infectious diseases, or providing financial support to be able to attend a graduate student public health conference held by other organizations (total count = 12). Approximately half (51.9%, n = 109/210) of the total number of activities organized by PHIGs across all schools over all four years, according to the documents submitted, entailed interprofessional participation.
The most common challenge noted in PHIG reports was low attendance at sponsored events. The major reasons for low attendance related to logistical issues, such as scheduling meetings and events that work well for PHIG members, speakers, and the student body (total count = 43).
Some of the strengths that PHIG reports frequently mentioned included having engaging speakers at events (total count = 6) and developing strong networks with other student groups, faculty, and public health organizations (total count = 20).
The most commonly allocated budget items were office supplies, such as photocopying and printing materials (total count = 79), followed by food and refreshments for events (total count = 48).
PHIG strategies for recruitment and sustainability.
Recruitment strategies are important to start and maintain PHIGs in medical schools. The two most commonly cited recruitment methods were (1) networking and/or collaborating with other medical student and public health groups (total count = 38) and (2) networking with faculty members and residents (total count = 30). Other common advertising techniques included e-mailing announcements to the student body (total count = 10) and displaying posters on campus to promote events (total count = 7).
A common strategy for PHIG sustainability was a focus on recruitment of PHIG members. The most commonly described strategies included creating and maintaining a plan of executive transition (total count = 34) and securing funds (total count = 29). Executive transition often consisted of, first, the membership electing an executive team for the following academic year and, then, the outgoing executive team training the incoming executive team. Specific examples of securing funds include applying for additional funding from a school’s medical student society and, simply, conducting fundraising activities (e.g., bake sales).
Although PHIGs are targeted toward medical faculties and, as mentioned, the membership of the majority of PHIGs comprised medical students, some schools appeared to have established highly interdisciplinary PHIGs. For example, graduate students in public health led one PHIG, and other executive teams included PHIG members from health disciplines outside of medicine.
PHIGs and the AFMC objectives
Through our analysis, we were able to assign the reported PHIG activities to the four objectives that constitute the AFMC’s stated overall purpose for PHIGs, and in so doing, we determined that the groups were actually accomplishing the goals the AFMC intended for them
1. To provide students with information about the importance of incorporating population and public health concepts into all areas of practice. The majority of activities (84.7%, n = 178) held by PHIGs incorporated public health themes. For example, information nights were common; these often included presentations by public health physicians and/or lectures on population health concepts. Some PHIGs organized practice-based sessions such as skills nights, during which physicians led workshops on counseling patients on healthy lifestyles. We determined that, through the breadth of their activities, PHIGs met the AFMC objective of conveying to students the importance of integrating public health concepts into medical practice; however, it is important to note that, given the extracurricular nature of these events, this increased exposure to public health may be limited to those students with a preexisting interest in population and public health who are more likely to attend PHIG events.
2. To expose students both to community activities that demonstrate population and public health concepts and to professionals in the field of public health. PHIGs at all schools held at least one lecture by an individual or individuals who had made public health their career, and most PHIGs held networking events featuring public health physicians. As well, the PHIG of at least one school started a formal mentorship program whereby students were paired with a public health physician mentor. Again, we determined that through the breadth of their activities, PHIGs met the AFMC objective of exposing students to public health through both practitioners and community activities; however, as with objective 1, this exposure is limited to those who take advantage of the offerings.
3. To provide an opportunity for students to learn, to network, and to develop leadership skills. As mentioned, the most common PHIG activities (n = 100) were academic and provided learning opportunities for students. These included interprofessional events, which increased the opportunity for student networking. The development of leadership skills was limited to executive committee members who were involved in planning activities and setting the annual budget. We determined that by fostering the development of PHIGs, AFMC has supported learning, networking, and skills development among students.
4. To provide an opportunity for students to explore public health and preventive medicine as a career option. Career exploration initiatives, such as observerships and the development of mentor lists, were the second most common type of activity (n = 38) coordinated by the PHIGs. Furthermore, through their participation in various activities, particularly lectures by public health physicians, students were exposed to public health and preventive medicine as a career option; thus, we have concluded that this objective was met.
Findings and implications
We are encouraged by our finding that all 17 Canadian medical schools had at least one established PHIG between 2007–2008 and 2010–2011, which suggests that Canadian medical students are interested in public health. Furthermore, as illustrated by Figures 1 and 2, the increasing trend in the number of PHIGs per year and the finding that a majority of schools have applied for funding for all four years together suggest that an increasing number of schools are establishing PHIGs and that, once established, the PHIGs remain active. AFMC coordination increased medical student involvement in at least 14 schools. Our findings indicate that the oversight provided by AFMC, along with the funding offered by PHAC to PHIGs, is associated with increased medical student involvement in public health initiatives and awareness-raising activities. Further, the inclusion of members of other disciplines in PHIG initiatives is consistent with the vision AFMC set out for the groups and may lead to improved interdisciplinary understanding and relationships between medical students and other health professionals.
However, not all schools have been able to sustain PHIGs in every academic year, which may be due to lack of new leadership or competing priorities.20 This lack of continuity may also reflect differences in public health interest levels among medical student cohorts. The PHIGs at schools with several campuses faced challenges in recruiting enough representatives to cover all campuses. As more medical schools establish remote campuses in the future, this may continue to be a challenge.
This study, describing the purpose, structure, and activities of PHIGs in Canadian medical schools, may be informative to leaders of other institutions who may be interested in initiating similar groups.
Limitations and future research
However, many questions are left unanswered. Because of the limitations of our data source (i.e., PHIG documents submitted by PHIG executives), the extent of faculty involvement in each PHIG and how faculty may have influenced the nature or success of the activities is unknown. Faculty engagement may be an important factor in creating interest in a PHIG, especially given previous research indicating that the lack of effective public health role models in medical schools is a barrier to promoting interest in public health.12
Discrepancies in the way the schools reported results also added to the difficulties interpreting the data. The funding applications, interim reports, and annual reports that we analyzed did not include standard categories (i.e., specific reporting requirements) for counting members, describing activities, or accounting for budgetary elements, which resulted in significant variations in reporting. For example, we had difficulty assessing the number of PHIG members because some PHIGs counted only executive members whereas other PHIGs counted all individuals attending their events.
Last, although we were able both to assign the groups’ reported activities to one or more of the AFMC’s stated PHIG objectives and to conclude that the groups were meeting their objectives, we recognize that this was not an evaluative study. Carefully designed evaluations examining the impact of PHIGs on medical students’ knowledge, skills, attitudes, and behaviors relating to public health—as well as their impact of on career choice—would add to the literature on PHIGs.
We report the first descriptive study on undergraduate medical PHIGs in Canada. We found that PHIGs are important student-led initiatives that increase medical student awareness about public health and promote interprofessional collaboration. We also determined that, on the basis of the reported activities of PHIGs, this initiative has met its objectives by fostering students’ extracurricular involvement related to public health and preventive medicine, including the opportunity to explore this area as a career option, in all medical schools across Canada. PHIGs may also be an effective method of increasing public health interest amongst undergraduate medical students in other countries.
Other disclosures: J.J. and J.A. have both been past members of the Association of Faculties of Medicine of Canada (AFMC)-funded public health interest group at the University of Toronto. B.S. and M.S. are employees of the AFMC. I.J. and D.D. are, respectively, previous and current members of the Public Health Educators Network.
Ethical approval: Formal ethical approval was not sought for this program evaluation activity because this documentary analysis falls under article 2.5 of the Tri-Council Policy Statement and therefore does not require approval.21 No identifying information is included in this article.
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