The Health Resources and Services Administration's (HRSA) Public Health Training Center (PHTC) program works to strengthen the public health workforce through ongoing training and skill development. In response to evolving public health needs, the PHTC program transitioned to a regional model in 2014 and prioritized the use of remote or distance-based training modalities.1 Based within schools and programs of public health, Regional PHTCs provide the public health workforce with skills and competency-based trainings using a variety of synchronous (eg, webinars, live learning) and asynchronous (eg, video, online tool kits, online modules) remote learning modalities that offer several advantages over in-person trainings.2,3 Specifically, remote learning opportunities offer a more flexible training environment, allowing learners to access content from anywhere using variety of different devices (eg, computer, smartphone). They are also less of a resource burden (money and staff time) than in-person trainings that require learners to travel to a central location, making them more accessible and increasing access to training for professionals working in rural or underserved areas.
While remote learning opportunities offer important advantages over in-person trainings, most are not designed to promote the type of active engagement and learning achieved through in-person learning opportunities. This is important because adult learning principles tell us that adults learn best in an interactive social environment when they can use their own knowledge base and life experiences to solve problems that are immediately relevant to their own lives.4 This is especially true when tackling adaptive challenges that are complex, nuanced, lack quick and easy solutions, and require a transformation of values and beliefs.5 Notably, several public health workforce development reports have highlighted the need for expanded skill development for professionals to deal with today's more complex public health challenges.6–8
The Rocky Mountain Public Health Training Center (RM-PHTC) is one of 10 Regional PHTCs. Based at the Colorado School of Public Health, the RM-PHTC supports training for the public health workforce in Colorado, Montana, North and South Dakota, Utah, and Wyoming. This article describes the approach used by the RM-PHTC to design and deliver remote learning opportunities that address adaptive public health challenges.
The RM-PHTC's overarching training framework is depicted in the Figure. It includes multiple learning modalities and considers the complexity of the challenge being addressed. The complexity of the challenge can be viewed on a spectrum from technical to adaptive (complex), where technical challenges include those in which the issue is well known and there are proven best practices, and adaptive challenges are those that deal with emerging practices that require adaptive and collaborative leadership and systems thinking. For example, administering a COVID-19 vaccine or establishing a Safe Outdoor Space program in response to homelessness is a technical challenge. Overcoming hesitancy to the COVID-19 vaccine due to cultural beliefs, historical mistrust of the medical system, or political ideation or addressing underlying causes leading to homelessness such as behavioral health, income and housing affordability, racism, and systemic inequities is an adaptive challenge.
Under this framework, the modality selected for the learning opportunity should match the complexity of the challenge being addressed. Technical challenges can be effectively addressed using remote learning modalities such as webinars, recordings, online modules, or tool kits. However, adaptive challenges are best addressed using virtual workshops, online courses, ECHO (Extension for Community Healthcare Outcomes) series, or communities of practice because they include a combination of the following elements (Table)9–12:
- Multiple sessions: Multiple sessions allow for ongoing dialogue and sharing of expertise. Because adaptive challenges require the people with the problem to do the work of solving it, trainings that tackle adaptive challenges often require more frequent sessions with opportunities for ongoing learning and interaction.
- Cohort-based learning: Cohort-based learning provides learners with the opportunity to become both professionally and personally familiar with colleagues and regional topic experts. This familiarity can become valuable for off-line communications and consultation, allowing learners to form wider collaborative groups for ongoing interaction and problem solving even after the learning opportunity has ended.
- Peer learning: Peer learning acknowledges the value of peer-to-peer sharing of experiences and expertise and acknowledges peers as topic experts. This is important because adaptive challenges require the people who have the problem to find the solutions; therefore, while subject matter experts may contribute content to the learning opportunity, learning from the experience and expertise of peers and creating solution together are supported and promoted.
- Practice-based application: Learning opportunities are more impactful when they are relevant and apply to the learners' professional practice and can incorporate the learners' experience. The use of authentic stories and practice-based or case-based examples allows the learner opportunity for applying the knowledge gained to solving real and current problems.
- Live, interactive sessions: Learning in a social context. The interactive sessions included as part of these learning opportunities connect learners with each other and with subject matter experts, allowing for deep discussion and interaction between participants. Interactive sessions use real-time, bidirectional video technology in which participants connect via their computer, smartphone, or tablet to a virtual meeting room. Their image is seen by the group, and they see everyone else. This type of virtual meeting space technology is now capable of supporting large groups and is bringing the desired face-to-face learning experience to remote learning.
Types of Remote Learning Opportunities for Training on Adaptive Challenges
|Type of Learning Opportunity
||Amount of Content
||Audience of Learners
||Single event held via bidirectional video that encourages peer learning on practice-based topics of shared interest using a blend of instruction and practice work in small groups
||Similar or varied background
||Delivery of content through online platform combined with multiple, facilitated, face-to-face “live learning sessions” held via bidirectional video, with a cohort of learners over several weeks
||Blended (synchronous and asynchronous)
||Moderate to large
||Similar or varied backgrounds
||Short delivery of content by an expert, combined with multiple, facilitated, face-to-face case-based learning sessions with a cohort of peers, held via bidirectional video over a period of several weeks
||Similar background and experience required
Community of Practice
||Bidirectional exchange of information as peers come together to share resources and discuss challenges and innovative approaches through online sharing platforms and face-to-face meetings via bidirectional video
||Synchronous or blended (synchronous and synchronous)
||Similar or varied backgrounds
a●, primary/core element; ◌, secondary element.
Determining which modality—virtual workshop, online course, ECHO series, or community of practice—is best suited to training on a particular adaptive challenge will depend on the audience of learners and the amount of content to be delivered (Table). The audience of learners considers how similar learners are in terms of their experience, role/position, and knowledge of the topic. While ECHO series benefit from learners with a similar baseline knowledge or similar role in relation to the challenge to be addressed, virtual workshops, online courses, and communities of practice can support the needs of learners with different roles, levels of experience, and knowledge. The amount of content delivery required to support learning varies depending on the goal of the learning opportunity and the challenge being addressed. For problems that require more content to be shared, virtual workshops and online courses are most appropriate. ECHO series are designed to share a modest amount of content, whereas communities of practice focus on peer interaction, with the choice of content shared being driven by the participants.
Training design and delivery are improved using learner feedback. All learning opportunities are evaluated on the basis of the Kirkpatrick evaluation model. Survey data collected during the postcourse evaluation focus on participant reaction and learning and ask learners to rate their confidence level using knowledge and skills both before and immediately after the learning opportunity using a retrospective post-then-predesign. The RM-PHTC's evaluations also solicit free responses regarding the most valuable components of the training, areas for improvement, and specific examples of what participants plan to apply from the training. Through follow-up evaluation of courses at 6 months, the RM-PHTC assesses sustained changes by asking learners how they are implementing learning and what implementation barriers they have encountered.
Learning opportunities for adaptive challenges
The RM-PHTC's approach to the design and delivery of virtual workshops, online courses, ECHO series, and communities of practice is described (and summarized in the Table), along with examples of specific learning opportunities.
Virtual workshops are single events that encourage peer learning on practice-based topics of shared interest. Virtual workshops are held using bidirectional video over 3 to 4 hours and feature a blend of instruction and practice work in small groups. Interspersed with brief presentations and demonstrations, learners have an opportunity to break into smaller groups to practice using the tools and discuss the application of strategies in their work context with presenters and peers. Virtual workshops are highly interactive and require a higher level of engagement than other single-event learning opportunities (eg, webinars). Learners are encouraged to bring their questions and experience to share with other workshop participants and to consider how the content can be applied to their work.
Community Engagement & Coalition Building is a 3-hour virtual workshop that was initially offered as an in-person workshop and then translated into an online format in 2020. The virtual workshop covers principles of community engagement including partner analysis, strategies to encourage involvement, meeting planning and design, decision making, and power-sharing strategies. Appropriate for a diverse set of learners who are new or experienced coalition leaders, this virtual workshop encourages the sharing of strategies among peers as well as content experts. This virtual workshop has run 4 times since 2020 (70 learners total). Most (91%) learners agreed or strongly agreed that their understanding of the subject matter improved after this workshop, and 95% agreed or strongly agreed that they had identified actions they would take following the training. Learners reported that elements such as the breakout sessions “gave us a chance to talk with each other like we would in an in-person workshop.” And despite the relatively short amount of time, the virtual workshop format was effective at creating a space for adult professionals to learn from each other:
The use of small and large group discussions and individual reflection time made it easy to engage in the discussions and felt like it was meeting the different needs/comfort levels that all of us had with engaging in discussions and sharing ideas.
Several of us asked to be connected with the people we worked with [in breakout rooms]. I think building lasting connections and networks through this workshop would be great!
Online courses are designed to deliver content asynchronously, in addition to multiple, synchronous, face-to-face “live learning sessions” held via bidirectional video, with a cohort of learners over several weeks. Online courses typically include 15 to 20 learners and are structured like a “flipped classroom” where the introduction to the topic and homework are completed prior to the session, allowing learners to utilize the live, synchronous session for deeper learning through application, interaction, and collaboration.13,14 Asynchronous, didactic content is delivered through an online platform using a variety of modalities including short informative videos, graphics, articles, reflections, and case studies. These homework activities invite learners to consider the content in the context of their personal and practice-based experience. Synchronous sessions last 1 to 2 hours depending on the course. During these facilitated sessions, learners spend time in large and small breakout groups, engaged in role-play, discussing scenarios, or participating in activities. Doing the activities and assignments ahead of time makes better use of the time spent in live sessions and allows learners the opportunity to connect concepts with their everyday work. A facilitator guides discussions and activities related to the online content with the cohort of learners. A topic expert is also available to answer questions and engage in the discussion.
Evidence-Based Public Health (EBPH) online course was adapted from a 3.5-day in-person training developed by the Prevention and Research Center at Washington University in St Louis.15 The course shares a large amount of new content with learners covering core concepts in program planning and evaluation, such as defining public health issues, conducting community assessments, prioritizing options, and evaluating program and policy impacts. In 2015, the RM-PHTC worked with the original course developers to translate the EBPH in-person course into a 9-week online course. The “flipped classroom” approach used as part of an online course allows learners to interact with the asynchronous content materials more deeply in advance of the synchronous live sessions. Providing the prework assignments also enables the course to meet the needs of a diverse set of learners who come from a variety of different backgrounds. During the live sessions, learners can then discuss the content in large and small groups and apply concepts or tools to their own work. Learning is enhanced through the questions and experiences shared by the learners, as well as the expertise provided by subject matter experts. The EBPH online course had been delivered to 8 cohorts of learners since 2018 (108 learners total). After the EBPH online course, 92% of learners agreed or strongly agreed that their understanding of the subject matter had improved, and 92% agreed or strongly agreed that they had identified actions that they would apply to their work. One learner commented that the course was “definitely a great learning experience with practical tools for immediate implementation.” Another highlighted the value of peer learning in small groups: “The small group discussions made such a big impact on me and my understanding of the course materials. It was like being in a live class.”
Addressing the Social Determinants of Health online course aims to equip public health professionals with the information and skills they need to apply via a systems thinking approach to addressing social determinants of health. A significant amount of content is shared and while learners are expected to come to the course with a baseline knowledge of social determinants of health and shared risk and protective factors, their backgrounds can be varied. A unique aspect of this advanced level course is the requirement that learners register for the learning opportunity with a partner from their organization or community. Together, these teams can take the “practical application” idea to the next level. Learners are challenged to directly apply the lessons learned from the course through project-based work in their organization or community, with their partner. Working with a partner increases accountability for learners in the course and reflects the collaborative nature of this work in the “real world.” As stated by a course subject matter expert, “You don't do this work alone.” The course takes 17 weeks to complete, with 6 synchronous, facilitated live sessions every other week, giving learners more time to review and complete asynchronous content. New in 2021, this online course has been delivered twice (86 learners total). After attending the course, 93% of participants agreed or strongly agreed that their understanding of the subject matter had improved, and 80% agreed or strongly agreed that they had identified actions they would apply to their work. One learner shared that “the shared experiences of my partners were incredibly valuable both to hear about different strategies that they've tried as well as to hear how far the work has come.”
ECHO learning opportunities
ECHO is a training model developed in 2003 at the University of New Mexico that has been widely used for training in many clinical health care settings.16,17 Project ECHO was originally designed to connect health care providers in the community, especially those in rural and underserved areas, with university-based specialists using telehealth technology, thereby building the capacities of primary care providers to support the delivery of evidence-based care for patients with long-term health conditions. Early on, the RM-PHTC partnered with ECHO Colorado to develop an ECHO model for addressing population health and public health topics.10 This public health ECHO model is based on the same adult learning principles as the clinical ECHO—peer-to-peer learning, interactive sessions using bidirectional video, and case-based learning. ECHO series typically include 15 to 20 learners who connect synchronously using bidirectional video over multiple sessions conducted over 4 to 8 weeks. Sessions typically last 60 to 90 minutes. A topic expert delivers a short, 10- to 15-minute presentation, with the remainder of the session dedicated to facilitated case-based discussions that engage all learners and the topic expert. An adaptation from the clinical model was the presentation of specific program challenges or scenarios from public health practice as a basis for case-based learning, rather than individual patients.
Leading Effective Coalitions ECHO Series aims to support experienced coalition leaders by addressing the complex issues that occur during the process of managing coalitions. Learners have similar backgrounds, with at least 1 year of experience as the leader of a coalition. Over 5 sessions, coalition leaders discuss relevant strategies, tools, and best practices both with topics experts and with their peers. There are a wealth of tool kits and “principles” for coalition management—and yet application of these is situational and nuanced. Working together, ECHO learners explore topics such as developing a culture that supports diversity and group power dynamics, facilitating constructive dialogue, and cocreating solutions for identified challenges. This ECHO series was fully evaluated twice since 2019 (35 learners total). After taking the Leading Effective Coalitions ECHO Series, 100% agreed or strongly agreed that their understanding of the subject matter had improved, and 93% agreed or strongly agreed that they had identified actions that they would apply to their work. One learner shared that “[a]ddressing diversity, shifting our power dynamics, and re-articulating our shared vision are all priorities to bring back to the coalition.” Another commented that “[t]his was a really nice experience. I enjoyed learning more from my peers from around Colorado and the region.”
Communities of practice
Cohort-based learning opportunities provide learners with the opportunity to become professionally and personally familiar with both peers and regional experts. This familiarity can lead to continued professional interaction after the learning opportunity is completed. One of the ways that the RM-PHTC has been working to promote this is through communities of practice. A community of practice is a group of professionals who come together to discuss a topic or issue they all have in common. Bidirectional exchange of information takes place as peers come together to share resources and discuss challenges and innovative approaches through face-to-face meetings via bidirectional video for 1 hour. A facilitator may be available early on to set prompts and encourage discussions. Later topics and discussion items are set by the group themselves.
Managing Effective Coalitions Community of Practice is open to anyone working with a coalition tackling issues related to public health, behavioral health, or environmental health located in the RM-PHTC's 6-state region. Learners are invited to come chat once a month with peers who are managing, leading, or supporting coalitions in their community. Together, they explore successes, challenges, ideas, and solutions for building effective coalitions that create and sustain lasting change. By joining the community of practice, learners commit to having something to share from their own work with coalitions and to having things that they want to learn in order to advance their practice in this area. The Managing Effective Coalitions Community of Practice is facilitated with initial topic areas identified as a jumping-off point for the conversation each month. There is no formal presentation, and the conversation is driven by the learners themselves. The learning community is ongoing, but learners do not need to attend every month. A total of 243 learners participated in 3 annual runs of this community of practice since 2018. Although low response rates prevent the RM-PHTC from reporting similar participant reaction metrics as workshops, courses, and ECHO series, some participant feedback is revealed through written comments. One learner wrote that “[t]ools and resources shared have also been really valuable.” Others commented that “I appreciated being able to hear how others have addressed common challenges (or even being assured that we have similar challenges!)” and “I will continue to use networking with other coalition coordinators as a resource.”
Remote learning opportunities increase access for professionals in rural areas and encourage knowledge exchange region-wide. While traditional online learning opportunities such as webinars or self-paced online modules are limited in the level of learner interaction, formats such as online virtual workshops, courses, ECHO series, and communities of practice engage professionals and offer them the opportunity to address adaptive or complex challenges. To be effective, remote learning opportunities that address adaptive challenges should incorporate peer learning, practice-based application, and live, interactive sessions that encourage the sharing of ideas and cocreation of solutions. There are countless demands on professionals' time. The RM-PHTC uses innovative strategies (eg, bidirectional video) and offers trainings that hold learners' attention; values the knowledge and experience they have; and provides challenging new content they can apply to their work. The COVID-19 pandemic and the transition to remote work for a large majority of professionals have underscored the value of providing learning opportunities that can address complex challenges through remote learning approaches.
We discuss some lessons learned from developing and delivering online virtual workshops, courses, ECHO series, and communities of practice.
Cohort-based learning opportunities benefit from having a highly invested champion agency during the development of the learning opportunity. Having a champion that is connected to the priority audience can help with the recruitment and retention of suitable participants. This is especially true for ECHO series where the goal is to bring together a group of learners who have a similar level of experience and can contribute equally to practice-based discussions.
Clear communication with learners around expectations for the learning opportunities is important. If the learning opportunity includes interactive sessions that use bidirectional video, learners should be told in advance that the expectation is that they are on camera and ready to actively participate in discussions. If the learning opportunity includes asynchronous content and homework activities, this also needs to be communicated to learners. At the RM-PHTC, we send out a registration confirmation immediately after registering for the course and reminder e-mails, reiterating participation expectations in the days leading up to live sessions. For online courses, the RM-PHTC sends a course welcome 2 weeks before the first live session with detailed instructions on how to access the related online content so that participants can engage with the required prework. The facilitators and content experts leading the live sessions reiterate participation expectations, underscoring the rationale for the importance of on-camera participation (as well as engagement using the chat or reactions features).
Bidirectional video is a valuable asset for training on adaptive challenges where rich engagement and interaction are central to learning. Bidirectional video is more effective when all learners are utilizing the video feature (as opposed to only joining by telephone or joining with cameras turned off). The RM-PHTC uses the Zoom platform due to its excellent quality, ease of use, functionality, and minimal bandwidth requirements, along with its capability of virtual breakout rooms for small group activities/discussions. Moreover, Zoom is free for learners to download and easy to use. At the RM-PHTC, we reach out to learners to ensure that they can use the technology and offer drop-in Zoom Office Hours and other opportunities to connect, if needed.
For online courses and ECHO series, most learning opportunities comprise 4 to 6 live sessions. This duration provides sufficient time for participants to connect with each other and the topic, without experiencing participation fatigue. Courses and ECHO series that met weekly or biweekly (every other week) are more successful at creating connected peer groups. Early on, the RM-PHTC held ECHO sessions 1 month apart but found these were not frequent enough to keep learners engaged.
Good facilitation is critical. Facilitators should be energetic, engaging, and comfortable operating in the remote, virtual setting. In addition, skilled facilitators are inclusive, develop welcoming and trusting spaces, and draw out dynamic discussion among participants. The best expert on a given topic is not necessarily the best group facilitator. Plans for future trainings include asking facilitators and topic experts to observe learning opportunities to become familiar with the learning process and effective teaching and facilitation practices within this unique learning setting. The RM-PHTC has found it essential to support its facilitators by providing a “course TA” or team member serving as “session support” who manages the technical aspect of live sessions including troubleshooting with participants, setting up breakout rooms, posting instructions in the chat, launching polls, etc. This frees the facilitator to focus on time, group dynamics, and flow of the session.
Strategies for successful learner engagement
Successful learner engagement begins from the time of registration. Having a “presence” and being responsive to learners' questions at every stage of the learning opportunity are important. If the learning opportunity includes asynchronous content, learners will be more engaged if the content is delivered in multiple modalities (eg, videos, readings, online data sources, infographics). During synchronous live sessions, the facilitator and topic experts should be responsive and adapt their facilitation and instruction to meet the needs of each cohort. Effective live sessions engage learners in applying the concepts through a variety of strategies including individual reflection, polling, use of the chat box, large and small group discussion, and practice activities. As mentioned earlier, creating a welcoming space of belonging, which could include acknowledging and normalizing distractions in a home environment, making space for introductions and connection making, encouraging the use of pronouns, and/or cocreating group agreements are important ways that facilitators lay the foundation for high learner engagement.
Over the years, the RM-PHTC has integrated continuous quality improvement processes into our offering of learning opportunities. For multisession courses and ECHO series, the RM-PHTC encourages learners to complete an optional session-level evaluation survey to provide real-time feedback to the facilitator and content experts. This can provide a valuable opportunity for course correction or response mid-learning opportunity. For newly developed courses and ECHO series, the session-level survey is slightly more extensive to account for the new content. The evaluation results collected at the end of a learning opportunity are shared across the RM-PHTC team as well as with any external facilitators or subject matter experts. Session-level and postevaluation results provide valuable guidance as to content that needs to be refined or added and any changes that need to be made to the design of the learning opportunity.
The RM-PHTC's training suite includes a spectrum of learning opportunities to meet the needs of a diverse public health audience and to provide a continuum of learning that can build toward a comprehensive training plan with greater impact. We focus resources on developing robust trainings that fall on the right end of the training spectrum (eg, online virtual workshops, online courses, ECHO series, communities of practice) as they are best suited for equipping public health practitioners to address the increasingly complex public health challenges in their communities. However, we continue to conduct scans to identify, curate, and promote existing trainings from the “technical” domain and develop new technical trainings when a gap is identified. The RM-PHTC's technical training includes webinars, self-paced training modules, and micro-learning videos.
In 2019, the RM-PHTC was pleased to join a national workgroup of 5 PHTCs and community-based training partners working on the creation of a “Public Health Learning Agenda,” focused on building an adaptive public health workforce prepared to use learning to address systems change. The RM-PHTC was able to contribute the training approach framework we had been using to best match learning modalities with the type of challenge and learning outcomes desired.18 Moving forward, the Learning Agenda proposes that we think beyond individual learning opportunities and begin to intentionally layer learning to achieve deeper levels of impact and thus be more successful at addressing large, systemic issues such as racism, homelessness, or climate change. The RM-PHTC is energized to work with public health and learning partners to now think about strategically linking and layering learning opportunities in order to further advance professionals' ability to respond to the complex, systems-level challenges affecting public health.
Implications for Policy & Practice
- The modality selected for a learning opportunity should match the complexity of the challenge being addressed. The complexity of the challenge can be viewed on a spectrum from technical to adaptive (complex).
- Modalities selected for remote learning on adaptive challenges should include a combination of multiple sessions, cohort-based learning, peer learning, practice-based application, and live, interactive sessions. These elements encourage active engagement and learning and facilitate the sharing of ideas and the cocreation of solutions.
- Formats such as the RM-PHTC's virtual workshops, online courses, ECHO series, and communities of practice offer the opportunity to address adaptive or complex challenges expanding the reach of these learning opportunities and increasing access to practitioners in rural and underserved areas.
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