Abstract
The College of Public Health at East Tennessee State University started a program in 2011 to teach the skills needed to protect and promote health and well-being in resource-limited settings. The need to provide public health services in resource-limited settings exists in both wilderness and isolated settings and when a disaster disrupts basic societal infrastructure. In these settings, lives may depend on the ability to provide water, sanitation, hygiene, shelter, first aid, and other basic services. Over the last decade, the college expanded the program considerably into what is now known as Project EARTH (Employing Available Resources to Transform Health) that now includes several different academic courses as well as programs designed to develop innovative solutions to address the needs of people in resource-limited settings. Working in a resource-limited setting requires effectively utilizing locally available resources to improve and protect people’s health and well-being. Project EARTH focuses on teaching students to design and create specific products for these situations while progressively honing those cross-cutting skills necessary to work effectively in these settings—notably teamwork, creativity, and resilience. To this end, Project EARTH implements a sequential learning process that includes significant hands-on training and simulated experiences with debriefing opportunities at the end of each activity. Project EARTH may serve as a useful model for others considering a similar training program.
Introduction
Saving lives and protecting health and well-being in resource-limited settings often requires attention to a range of basic public health interventions. Access to safe drinking water, basic sanitation, hygiene, and shelter, for example, can be essential in geographically isolated areas and post-disaster scenarios. 1
In 2011, the College of Public Health at East Tennessee State University started a program to teach the skills needed to help people practice effectively in any resource-limited setting. The college was motivated to create this program for several reasons. As the first school of public health located in central Appalachia, graduates of the college work in rural and medically underserved communities that have inadequate housing and lack basic sanitation and hygiene. Several students, following field experiences in rural parts of Africa, reported they did not have the practical skills to reliably provide clean drinking water. Additionally, the college was motivated by reports of increased mortality occurring after natural disasters because working professionals in affected areas could not provide basic public health services. 1
There are many aspects to the training program as it has evolved over its first decade. Project EARTH currently includes 3 interconnected components: academic coursework, a simulation facility composed of replicas of actual homes from resource-limited areas, and a creative component focusing on encouraging innovation.
The main academic course is a 15-wk, 3-credit-hour course required for all students in the bachelor of public health and bachelor of health administration degree programs, as well as those in the global health and development minor and the disaster preparedness minor. It teaches students to use basic tools and to make basic products while focusing on developing teamwork, creativity, and resilience.
There is also a required course for all doctor of public health students that stresses teamwork and innovation within the framework of resource-limited settings. The class challenges students to make a variety of products from recycled or repurposed materials while working together to address the public health needs of a simulated resource-limited community.
As part of their undergraduate and graduate degrees, students in the college complete an internship in their final semester. Some students opt to complete this internship in another country. For several years, students returned with concerns about the health of citizens in their host communities. The residents came to the students with needs or the students identified health challenges in the areas and did not have sufficient knowledge or skill to address them. For instance, a children’s home in Rwanda and the surrounding town lacked access to clean water. A college student worked with several faculty members, including an environmental health water treatment expert, to study different types of water filters. She reached out to an artisan in Rwanda who built biosand water filters for the community.
The course faculty wanted to simulate the conditions faced by people living in resource-limited settings to prepare students to work in such areas. Working with her hosts in Rwanda, the student was able to provide the schematic of an actual house in the area, and course faculty and student workers recreated it. They built replicas of actual homes from other places where faculty and students had worked. Now including dwellings from El Salvador, Mongolia, Nicaragua, Rwanda, and South Africa, as well as a replica of a UNICEF tent from a refugee camp, the simulated community also has several types of gardens and a large tent that can be used as a resource-limited hospital. The replicas serve as a basis for a variety of simulated activities. Students use the simulated community to practice technical skills utilizing roleplaying, simulation, and problem-solving.
To encourage innovation, students participate in identifying and addressing the needs of people in resource-limited settings. With input from a colleague who works with Médecins Sans Frontières (Doctors Without Borders), course faculty began a project that guides students making toys from commonly available products. Course participants also make products from recycled bicycles and shoes from a variety of materials. Working with physical and occupational therapists and volunteer engineers, course faculty and students explore ways to retrofit electronic toys for children with significant physical limitations.
Lessons Learned
Over the course of 10 y, the college learned several lessons about developing programs to teach public health skills relevant to resource-limited areas (Table 1).
Ten lessons learned
Initially, some students who anticipated careers in urban centers in the United States did not see how Project EARTH would apply to their careers. Understanding the ways in which a disaster disrupts healthcare delivery helps students to see the importance of being able to work in a resource-limited setting. When students in health administration, for example, learned of the challenges Hurricane Katrina posed for both hospital administrators and leaders of long-term care facilities, they understood the importance of flexibility and creativity.
It is essential, therefore, that students start by understanding that the skills necessary to work in a resource-limited setting will be relevant to their careers. Once students comprehended this connection, their engagement in and support for the training increased. A 2007 study of Appalachian cultural values and their impact on career development indicated a preference for concrete experiences rather than theoretical concepts and found exposing students to possible work environments will benefit them more than reading or hearing about careers. 2
Because familiarity with tools is necessary for many projects in resource-limited settings, and because learning to use tools is essential to developing a personal sense of capacity, almost all Project EARTH activities start with a basic introduction to the use of tools, with a significant focus on tool safety. The introduction to each tool starts with education in safe use or with a demonstration of proper and efficient use. Local community artisans have visited the campus and provided expertise on using certain tools and techniques.
While Project EARTH started as an effort to teach students to make the products they might need in a resource-limited setting, it quickly became clear that there are more products, or variations of them, than faculty could teach in a single course. Different types of latrines, for example, work better in different types of environmental conditions. No single course in the project could reasonably teach students how to make every different type of latrine, nor teach them the various soil, water table, surface conditions, and other factors that dictate the most appropriate latrine for any given situation. By giving students the tools and the knowledge to make one type of latrine, however, it is hoped they can transfer effective practices to build an environmentally appropriate latrine when the need arises. While students are still taught to make specific products, one of the lessons learned from Project EARTH has become it is the process, not the product.
Focusing on applied learning, especially when taught through the modality of peer engagement activities, appears to resonate with both students and faculty. To stress the hands-on approach to learning, instructors avoid detailed instructions. Students are initially provided a basic description of a newly introduced product and some general guidance on the fabrication of the product. 3 Small groups of students are then provided the basic materials and tools they need and are encouraged to work together to create the best version of the product that they can. Through trial and error, the small groups are usually able to produce a reasonable facsimile of the desired product. Faculty guide students to self-assess, monitor, and evaluate their progress in order to promote self-regulated learning. 4
Just as most clinical health professions use simulation as a vehicle for student learning, it is valuable for students learning to work in resource-limited settings to be exposed to realistic simulations of those settings. To this end, Project EARTH uses the replicas of homes from 8 locations around the world that simulate the student’s placement into a resource-limited setting. Using the homes and other resources, the project attempts to recreate situations that someone might face working in a resource-limited setting. The simulated refugee activity, for example, is a 5- to 7-h activity where the participants are required to prepare for, and respond to, the needs of 25 refugees who will be on-site for 24 h. Participants purchase supplies from the simulated store with a limited budget and then create shelter, sanitation, food distribution, medical care, and other essential services for these simulated refugees. As participants are setting up their refugee camp, a small number of actors arrive, portraying refugees facing a range of medical and social challenges to which the students must respond. Table 2 outlines the various simulation activities that are part of the project.
Examples of hands-on learning experiences at Project EARTH: brief description, duration, and teamwork/creativity/resilience score
See Table 3.
Students engaging in Project EARTH learn more than the ability to use tools to make products. They also develop a set of cross-cutting skills essential to working in resource-limited settings. While these skills can be described in various ways, the team felt they generally fell into 3 areas: teamwork, creativity, and resilience.3,5,6 Teamwork encompasses oral communication skills, listening skills, interpersonal and cultural sensitivity, collaboration, and other skills. Creativity includes thoughtful imagination and problem-oriented innovation. Resilience requires adaptability, flexibility, and, more colloquially, the grit necessary to work in less-than-ideal situations. Over time, the students come to understand that these skills are relevant to almost all work settings.
The goal of Project EARTH is to expose students to progressively greater demands in the products they make and the skills they demonstrate. The process of teaching students to make a physical product has an obvious sequence. 7 The team has created a sequence by which students are exposed to the cross-cutting skills. The first step in creating this sequence is to identify the ultimate expression of each of the 3 cross-cutting skills. For example, the ultimate expression of teamwork would be the ability of an individual to effectively lead a large, interprofessional team.8,9 Then, the starting point of each cross-cutting skills was identified. For teamwork, this would logically be working alone. Finally, 3 progressive steps between the starting point and the ultimate expression were identified, creating a 5-step progression. Table 3 shows the 5-step progression for teamwork, creativity, and resilience. Each activity is given a score of 1 to 5 for each of the 3 areas (Table 2). Projects are sequenced so that participants face increasing demands in each area. Studies suggest the skills employers want and expect are not those thought to be taught in institutions of higher learning; however, Project EARTH attempts to hone these valuable workforce skills.6,10
Grading the cross-cutting skills of Project EARTH
Faculty discovered one of the most useful skills for working in a limited-resource setting is the ability to innovate. The ability to use a range of basic tools, when combined with an understanding of the physical needs and cultural parameters of resource-limited settings, provides students with the attributes necessary to innovate. Project EARTH focuses on 2 types of innovation: need-based and product-based. In need-based innovation, students learn to identify a challenge facing people living in resource-limited settings and then develop 1 or more approaches to address that challenge. Students have developed several dozen toys made from basic recycled or repurposed materials so children in refugee camps could have toys for play. In product-based innovation, students are asked to identify alternative uses and applications for an abundant material. For example, students developed a range of products from recycled bicycles, ranging from pedal-powered water pumps to spinning wheels to washing machines. At the highest end of need-based innovation, students have repurposed children’s toys so they are usable by children with physical and developmental disabilities.
Virtually every activity ends with a formal debriefing session. In addition to a 3-part questionnaire, most experiences end with an open-ended discussion that often focuses on the how and why of decision-making.4,7 The formal class activities always end with an end-of-semester student assessment of instruction. In addition to the student debrief, the team frequently ends each activity with a debriefing session just for the instructors and student workers. This session provides an immediate after-action review and allows the instructors to propose and consider modifications that can improve the activity in the future.
Limitations
While each course ends with a systematic evaluation and each pilot project documents the students’ ability to successfully create the specified products, there has not been a systematic mechanism to evaluate the extent to which the students have acquired the desired cross-cutting skills: teamwork, creativity, and resilience. To this end, the college of public health has partnered with other faculty at East Tennessee State University who have experience in pedagogical research to design and implement a study of the impact of the course in developing these skills.
Conclusions
The ability to provide basic public health services is an essential part of keeping people alive in wilderness, geographically isolated and resource-limited environments, and, especially, in any post-disaster setting. While students are often taught the importance of these services, they are not always taught the practical skills necessary to provide them.
Over the past 11 y, Project EARTH has taught students to make a range of products relevant to resource-limited settings, and, at the same time, focused on helping students develop the cross-cutting skills of teamwork, creativity, and resilience necessary to work effectively in those settings. Understanding the lessons learned from the Project EARTH experience may be relevant for other academic programs and related training centers who will develop and implement hands-on training programs relevant to their own mission.
Footnotes
Acknowledgements
Acknowledgments: Thanks to all of the faculty, staff, and students who participated in, and contributed to, the development of Project EARTH.
Author contributions: Study concept and design (JMS, RFW, DCY); drafting of the manuscript (JMS, RFW, DCY); critical revision of the manuscript (JMS, RFW, DCY); approval of final manuscript (JMS, RFW, DCY).
Financial/Material Support: Funding for the VILLAGE was provided by a local philanthropist, Scott Niswonger, with significant in-kind donation from Summers-Taylor, Inc. The urban garden was funded by a GoFundMe campaign. Expertise related to solar power, welding, small scale agriculture, and other topics donated by local businesses and individuals.
Disclosures: None.