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A novel integration of online and flipped classroom instructional models in public health higher education Galway, Lindsay P; Corbett, Kitty K; Takaro, Timothy K; Tairyan, Kate; Frank, Erica Aug 29, 2014

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RESEARCH ARTICLE Open AccessA novel integration of online and flippedclassroom instructional models in publicKeywords: Flipped classroom, Blended learning, E-learning, Public health education, Master of Public Health,Galway et al. BMC Medical Education 2014, 14:181http://www.biomedcentral.com/1472-6920/14/181CanadaFull list of author information is available at the end of the articleEnvironmental and occupational health* Correspondence: lpg@sfu.ca1Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6,Lindsay P Galway1*, Kitty K Corbett1,2, Timothy K Takaro1, Kate Tairyan1 and Erica Frank3AbstractBackground: In 2013, a cohort of public health students participated in a ‘flipped’ Environmental and OccupationalHealth course. Content for the course was delivered through NextGenU.org and active learning activities werecarried out during in-class time. This paper reports on the design, implementation, and evaluation of this novelapproach.Methods: Using mixed-methods, we examined learning experiences and perceptions of the flipped classroom modeland assessed changes in students' self-perceived knowledge after participation in the course. We used pre- andpost-course surveys to measure changes in self-perceived knowledge. The post-course survey also included itemsregarding learning experiences and perceptions of the flipped classroom model. We also compared standardcourse review and examination scores for the 2013 NextGenU/Flipped Classroom students to previous years whenthe course was taught with a lecture-based model. We conducted a focus group session to gain more in-depthunderstanding of student learning experiences and perceptions.Results: Students reported an increase in knowledge and survey and focus group data revealed positive learningexperiences and perceptions of the flipped classroom model. Mean examination scores for the 2013 NextGenU/Flipped classroom students were 88.8% compared to 86.4% for traditional students (2011). On a scale of 1–5 (1 = lowestrank, 5 = highest rank), the mean overall rating for the 2013 NextGenU/Flipped classroom students was 4.7/5 comparedto prior years’ overall ratings of 3.7 (2012), 4.3 (2011), 4.1 (2010), and 3.9 (2009). Two key themes emerged from the focusgroup data: 1) factors influencing positive learning experience (e.g., interactions with students and instructor); and 2)changes in attitudes towards environmental and occupation health (e.g., deepened interest in the field).Conclusion: Our results show that integration of the flipped classroom model with online NextGenU courses can be aneffective innovation in public health higher education: students achieved similar examination scores, but NextGenU/Flipped classroom students rated their course experience more highly and reported positive learning experiences andan increase in self-perceived knowledge. These results are promising and suggest that this approach warrants furtherconsideration and research.health higher education© 2014 Galway et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.Galway et al. BMC Medical Education 2014, 14:181 Page 2 of 9http://www.biomedcentral.com/1472-6920/14/181BackgroundThe rapid increase in Internet access and advances inonline technology over the last decade present an oppor-tunity to rethink the way we teach and learn in thecontext of public health higher education. The flippedclassroom instructional model (also known as theinverted classroom) has emerged as a promising alterna-tive to conventional lecture-based teaching as it offersa framework for integrating emerging online learningtechnologies with active and collaborative learning. Theflipped classroom model is a type of blended learningwhere in-class learning is integrated with online learningexperiences [1,2]. A meta-analysis from the United StatesDepartment of Education in 2010 showed that blendedlearning, such as the flipped classroom, is more effectivethan either face-to-face (i.e. lecture-based instruction) oronline learning alone [3]. This meta-analysis was focusedon K-12 education. There has been limited research ex-ploring the flipped classroom model in the context ofhigher education (and none in the realm of public healthhigher education) highlighting an important knowledgegap. In an era of rising education costs and declining publicfunding for higher education, innovative approaches thatfoster positive learning experiences while taking advantageof emerging technologies and use both student and in-structor time more efficiently are called for [4].The defining characteristic of the flipped classroominstructional model is that content and material are de-livered primarily outside of the classroom while in-classtime is used “to work through problems, advance con-cepts, and engage in collaborative learning” [5]. Usingonline educational technologies to deliver content andmaterial outside of the classroom frees up in-class timefor active and collaborative application of content withthe support of classmates and the instructor [2]. Thismodel is designed to allow students to independently en-gage with materials on their own time and at their ownpace, shifts focus from the instructor to the learner, andpromotes active learning and problem-solving.The flipped classroom model involves more than shift-ing content delivery outside of class time [6]. It repre-sents a broader shift in how we think about the learningprocess. It is grounded in several interconnected theoriesof learning and pedagogy. The explicit attention to inter-active and collaborative learning draws on Piaget’s theoryof active learning which highlights that learning occurswhen we act on and apply new ideas and concepts [7].In terms of Bloom’s influential (revised) taxonomy ofthinking and learning, the flipped classroom enables bothhigher and lower levels of cognitive work [8,9]. More spe-cifically, students do lower level cognitive work, i.e., theacquisition of knowledge, independently and outside ofclass while higher-order cognitive work including know-ledge application, analysis, and synthesis occurs duringclass time with the support of peers and instructors. Inour application of the flipped classroom design within thecontext of graduate level public health education, we alsodraw on Mesirow’s theory of transformative adult learning[10] and Habermas’ related theory of knowledge and hu-man interests [11]. We therefore integrate reflection, a keyaspect of learning according Mesirow and an essentialtype of knowledge according to Habermas, into the courseto complement the online content delivery and the in-class application of knowledge.There is no single or standard way to design and im-plement the flipped classroom instructional model inpractice [6,12]. The means of delivering content and theways in which face-to-face class time is used will varywith the characteristics of the students, background ofthe instructor, available resources and the subject matter.To date, electronic video-recordings (vodcasts) and pod-casts have been the primary means of content delivery,however online courses can also be used for this pur-pose. In our application of the flipped classroom model,we have used an environmental and occupational healthcourse offered by NextGenU.org, a portal to free andaccredited higher education [13]. Partnering with univer-sities, professional societies, and government organiza-tions, NextGenU creates online courses referred to asDOOHICHEs (Democratically-Open Outstanding Hybridsof Internet-aided, Computer-aided, and Human-aidedEducation, pronounced as “doohickey”). These DOO-HICHEs are competency-based and include high-qualitylearning resources, online peer activities and discussionforums, and quizzes. As of February 22nd 2014, NextGenUhas over 2,000 students registered in 105 countries, andhas 130 trainings in development, primarily focusing onhealth sciences and public health education. The waysin which NextGenU builds on and differs from trad-itional education and Massive Open Online Courses canbe reviewed at www.NextGenU.org.The goal of this study was to examine the impact ofthis NextGenU/Flipped classroom instructional modelon self-perceived environmental and occupational health(EOH) knowledge and student learning experiences andperceptions of the instructional model. Our specific ob-jectives were: 1) to design and implement a master’s levelenvironmental and occupational health course (EOHC) in-tegrating a NextGenU DOOHICHE and the flipped class-room model, 2) to assess changes in students' self-reportedEOH knowledge after participating in the course, and 3) tounderstand student learning experiences and perceptionsof this NextGenU/Flipped classroom model.MethodsCourse design and implementationThe first author designed the EOH DOOHICHE forNextGenU in 2012. The content and structure of theDOOHICHE was based on core Master of Public Healthcompetencies developed by the Association of Schoolsof Public Health (APSH) [14,15] and the Associationof Schools of Public Health in the European Region(ASPHER) [16,17]. These core competencies “delineatefundamental knowledge, attitudes, and skills that everyMPH student, regardless of their major field, shouldpossess upon graduation” [18]. The final version wasreviewed by an advisory committee of environmentalhealth professionals, and endorsed by the InternationalSociety of Doctors for the Environment, Physicians forSocial Responsibility, and Simon Fraser University’sFaculty of Health Sciences.NextGenU’s EOH DOOHICHE can be accessed forfree in its entirety at www.NextGenU.org. Each of thecourse’s nine modules (see Table 1), offered students theopportunity to learn content and material by engagingwith a diversity of learning material (e.g., reports, journalarticles, videos, websites) from reputable sources includ-ing universities, governments, professional societies, andpeer-reviewed publications. The online course platformalso included discussion forums, peer-to-peer activities,quizzes, and additional learning resources for those stu-dents wanting to explore certain subject areas moredeeply. In-class sessions were held every other week,which gave students two weeks to complete the assignedmodules. Students were assigned either one or two mod-ules for each two-week period. Within the two-weekperiod, students could move through the materials attheir own pace. After engaging with the learning mate-rials and completing peer activities in a given module,and before coming to the in-class sessions, studentscompleted a quiz that helped students and the instructoridentify poorly-understood areas.Table 1 Overview of the courseTarget participants MPH studentsDescription of the course Students will gain familiarity with fundamental principles and general areas of knowledge that are important to thebroad field of environmental health. Students will learn about approaches and tools used to recognize, assess, andmanage environmental and occupational health hazards. This course also aims to expose students to numerousenvironmental and occupational health issues and to encourage critical thinking and reflection on these issues; wewill consider what can be done about environmental and occupational health issues to ultimately protect andpromote health and well-being. Finally, this course aims to inspire interest in the role of the environment inpromoting and maintaining the health of populations in both local and global settings.Online learning modules from NextGenU DOOHICHE 1:Module 1: Introduction to environmental and occupational healthModule 2: Environmental and occupational hazards and their effects on human health and ecosystemsModule 3: Principles of exposure assessmentModule 4: Toxicology and epidemiology in environmental healthModule 5: Risk assessment: Concepts and applicationModule 6: Risk management, communication, and regulationtycal hthssmpreenoitenGalway et al. BMC Medical Education 2014, 14:181 Page 3 of 9http://www.biomedcentral.com/1472-6920/14/181Module 7: Susceptibility, vulnerability, and inequaliModule 8: Environmental and occupational healthModule 9: Emerging perspectives in environmentaLearning activities used during class time:Module 1: Linking thinking for environmental healModule 2: Exposure assessment in actionModule 3: Shipbreaking in Alang, IndiaModule 4 and 5: Toxicology, epidemiology, and risk asseModule 6: Class debate- Should Canada apply theModule 7: A closer look at Air Quality GuidelinesModule 8 and 9: Presentation and discussion of environmEvaluation:Final grades were based on: 1) A final exam consisting of multiple ch2) Four graded reflective responses writ3) In-class and online participation4) A final group project exploring a selecte1The online Learning modules in the NextGenU DOOHICHE can be accessed in fullin environmental healthse studiesealthent problem setcautionary principle in environmental health policy and decision-makingtal health case studiesce and short answer application questionsthroughout the semesterd environmental or occupational health issueat http://www.nextgenu.org/course/view.php?id=52#0.The general routine of in-class time included a mini-lesson addressing concepts or aspects that were identi-fied as challenging by students, along with a brief ques-tion and answer period to give students the opportunityto clarify any remaining aspects from the assigned mod-ules. The remaining in-class time (90 minutes) was usedto carry out active learning activities. The learning activ-ities varied for each in-class session. Examples include: atoxicology problem set that students worked on in pairs;an occupational health case-study examined in smallgroups; and a whole-class debate on the topic of envir-onmental health decision-making (see Table 2 for a de-scription of three in-class activities). Over the course ofthe 13-week semester there were eight in-class sessionsthat ran for two hours.An additional requirement was writing four reflectiveresponses. Students were instructed to reflect on themeaning and importance of the course material fromtheir own perspective, to make links between the variousaspects of EOH within the course, and to make links tothe student’s other public-health-related interests. Thereflective responses acted as an ongoing conversationbetween the instructor and the students, and were alsoused by the instructor to identify areas of particularinterest among the group and to influence and informthe direction of in-class activities.Finally, students completed a final exam at the end ofthe semester that included multiple choice and shortanswer questions.Study participantsStudy participants were MPH students (n = 11) enrolledin the 2013 spring session of an EOHC at a Canadianuniversity. All participants were graduate students intheir first or second year of study in the MPH program.An EOHC is offered in the second year of study and is arequired core course of the MPH degree. Primary areasof interest among the students within the broad field ofpublic health ranged from gender and health to socialinequities and health. None of the students were focusedTable 2 Description of a selection of in-class learning activitiesExample 1Activity name: Linking thinking for environmental healthSummary of activity: Each student selects a health issue of interest. Working on their own, students create an influence diagram ona large blank piece of paper that explicitly illustrates the links between their selected health issue and theenvironment or environmental factors. In pairs, the students describe their influence diagram to one another.Finally, the instructor facilitates a discussion around the following questions “Was it difficult to integrate theenvironment and/or environmental factors into the influence diagram for your selected health issue? Why orwhy not?”Adapted from [19]ruce ce Hovingersof wenDssoe (Biooteistrhapr, oGalway et al. BMC Medical Education 2014, 14:181 Page 4 of 9http://www.biomedcentral.com/1472-6920/14/181Example 2Activity name: Shipbreaking in Alang, IndiaSummary of activity: Before coming to class, students are instbackground knowledge to complete thof 3 or 4.You and your co-workers from Workplacshipbreaking port in Alang, India (the mAlthough it was a short trip, while in Alaas well as to speak with many shipbreakreturn, your boss has asked for a reviewyou and your colleagues to create a pres1. Who works in the shipbreaking yards?2. What are the major health hazards a3. Use the following classification schemthe hazards you have identified as: a)(noise, radiation); e) Psychosocial.4. For the chemical hazards identified, nfor Toxic Substances and Disease Reg5. Drawing on your experience in Alang, wour organization could implement to imfor your proposed research, interventionExample 3Activity name: Toxicology, epidemiology, and risk assessSummary of activity: Students work in pairs to solve problemsted to watch the documentary ‘Shipbreakers’. This documentary acted asase-study described below. Students work on the case-study in groupsealth Without Borders have recently returned from a visit to thee that you watched before coming to class this week served as your visit).you had the opportunity to observe the work setting and living conditions, port owners, the doctor, and other members of the community. Upon yourhat you saw and learned while visiting Alang. Specifically, she would liketation that addresses the following questions:escribe relevant characteristics of workers in the shipbreaking yards.ciated with shipbreaking identified during your visit?from the Canadian Centre for Occupational Hazards and Safety) to classifylogical; b) Chemical; c) Ergonomic (i.e. repetitive strain injury); d) Physicalthe potential health implications using information provided by the Agencyy at the following website: http://www.atsdr.cdc.gov/toxfaqs/index.asp.t are possible research activities, interventions, or policy changes thatove the current situation in Alang? Be sure to provide ample justificationr policy ideas.ment problem setapplying toxicology, epidemiology, and risk assessment concepts.the same individual. A Mann–Whitney U test (5% sig-Galway et al. BMC Medical Education 2014, 14:181 Page 5 of 9http://www.biomedcentral.com/1472-6920/14/181specifically on environmental or occupational health norenrolled in the EOH concentration of the MPH pro-gram. All of the students in the class agreed to partici-pate in the study.Evaluation and analysisWe used a mixed-method approach including a pre- andpost-survey, comparisons of overall course ratings andexamination scores across years, and a post-course focusgroup session. A mixed-methods approach was used se-lected surveys are an effective tool for assessing pre andpost student knowledge while focus groups are usefulfor gaining a more in-depth understanding of studentperceptions and are also convenient and appropriate fornon-sensitive topics.Pre- and post-course survey instruments were developedby the course instructor and reviewed by three colleagues.Participants electronically completed the pre-course surveyone week prior to the beginning of the course and thepost-course survey one week following course completion.To measure self-perceived knowledge, students wereasked to rate their knowledge regarding EOH competen-cies. Students rated their knowledge relating to eachcompetency (12 in total, see Figure 1) on a 5-pointLikert scale (1 = strongly disagree; 5 = strongly agree).The self-perceived knowledge questions were identicalin the pre- and post-course survey instruments. Thepost-course survey instrument also contained 10 itemspertaining to student learning experiences and percep-tions of the flipped classroom, and one open-endedquestion where students were asked for general com-ments and/or feedback.To determine whether there was a statistically signifi-cant change in self-perceived EOH knowledge followingparticipation in the class we used the Wilcoxon signed-rank test for paired data (5% significance level). Thisnon-parametric test was selected because the data wasnon-normally distributed and ranked, and due to thesmall sample size. Descriptive statistics were used toreport items pertaining to learning experiences andstudent perceptions of the flipped classroom model asmeasured in the post-course survey. For reporting ofthese items, agreement (strongly agree and agree) anddisagreement (strongly disagree and disagree) werecombined.We also compared overall course ratings and examin-ation scores for the NextGenU/Flipped classroom stu-dents against course ratings and examination scores forstudent who took a lecture-based EOHC in previousyears. Specifically, we compared overall course ratingscollected by the university from the 2013 students (n = 9who participated in the course and completed the stand-ard course review) with overall course ratings for stu-dents from 2012, 2011, 2010, and 2009 (n = 130). Tonificance level) was used to assess whether there was astatistically significant difference in the examinationscores for the 2013 vs. the 2011 students.Finally, to gain a more in-depth understanding of stu-dent perceptions of the NextGenU/Flipped classroommodel, we (LPG) collected, audiotaped, and transcribedqualitative data from one 40-minute focus group sessionwith all students in the course after the final in-class ses-sion. All focus group participants reviewed and signed aconsent form. Open-ended queries addressed learningexperiences and perceptions of the flipped classroommodel in general. The data were analyzed using qualita-tive thematic analysis, selected because of the explora-tory and descriptive nature of this study. First, thetranscribed text was read in its entirety to get a generaloverview and sense of the data. During a second readingof the transcript, the data were coded to identify and ex-plore themes. Major themes were therefore derived in-ductively from the data. Data were then summarizedand representative excerpts from the focus group wereidentified to illustrate the major themes.All data collection was completed by the end of the2013 spring session of the university. Statistical analyseswere conducted using R statistical software version2.13.0. Given the manageable length of the single focusgroup session, we used Microsoft Word to analyze thequalitative data [20].Ethics approval was obtained from The University ofBritish Columbia Ethics Committee. Recruitment wasconducted by the lead author (LPG) during the first classsession. All participants gave written informed consentand were assured of confidentiality and anonymity. Also,the voluntary nature of the study was underscored, andit was made clear to students that they could end theirparticipation in the study at any point and that theirmarks in the class would not be affected by their deci-sion to participate in the study.ResultsSelf-perceived knowledge assessmentThe response rate for the pre-and post-course surveywas 100%. A comparison of self-perceived knowledge ofEOH competencies before and after the course is pre-sented in Figure 1. A statistically significant increase wascompare examination scores, we looked at scores fromthe course exam for the 2013 NextGenU/Flipped class-room students (n = 11) compared to scores for the 2011lecture-based EOHC students (n = 22). Examination re-sult data were only available for 2011. The exam con-tained 11 short answer questions, and was marked byfound in students’ self-perceived knowledge for everycompetency (p-value < 0.05).Galway et al. BMC Medical Education 2014, 14:181 Page 6 of 9http://www.biomedcentral.com/1472-6920/14/181Students’ perceptions of the NextGenU/flippedclassroom modelOur results show that student perceptions of the courseand the NextGenU/Flipped classroom instructional modelwere highly favorable overall. In response to the item “Inthe future, would you rather take a ‘flipped’ course than atraditional lecture-based course”, 82% of students agreedor strongly agreed. All students agreed or strongly agreedwith the statement, “The flipped classroom model was adifferent learning experience than other MPH courses.”Also, the use of a NextGenU DOOHICHE for the onlinedelivery of content and materials was favorably received. Inresponse to the item, “I was comfortable with self-directedonline learning through NextGenU”, all students eitheragreed or strongly agreed (see Table 3 for a summary ofresults from the post-course survey).In response to the only open-ended question in the post-course survey “Do you have any additional feedback/comments about the flipped classroom model?” stu-dents provided additional generally-positive feedback.One participant wrote: “I really enjoyed the structureand content of this course. I would say it was one of thebest courses I’ve taken during the MPH! Also, it changedFigure 1 Comparison of pre- and post-course self-perceived knowledmy perspective on online learning. I never thought on-line learning would be beneficial for me, but I will def-initely consider it if I decide to do continued studieslater on.” A second student wrote, “It was a greatclass and ignited an interest in enviro health that was notpreviously there!”Comparison of overall course ratings and examination scoresThe 2013 NextGenU/Flipped Classroom students ratedtheir overall course experience more highly than thosestudents who took the EOHC in previous years whena lecture-based model was used. On a scale of 1–5(1 = lowest rank; 5 = highest rank), the mean overallrating for the course in 2013 was 4.7/5 vs. prior years’overall ratings of 3.7 (2012), 4.3 (2011), 4.1 (2010), and3.9 (2009). We compared examination scores for the2013 NextGenU/Flipped classroom students to those forthe 2011 lecture-based EOHC students. The mean testscore was 88.8% for the 2013 students and 86.4% for the2011 students. A Mann–Whitney U test revealed no sta-tistically significant difference (p = 0.72) between examin-ation scores across the two groups .ge of EOH competencies.curniterarser ang pd)“StragrGalway et al. BMC Medical Education 2014, 14:181 Page 7 of 9http://www.biomedcentral.com/1472-6920/14/181Key themes from focus group dataQualitative thematic analysis of the focus group dataturned up two major themes: factors influencing positivelearning experiences and changes in attitudes towardsenvironmental and occupational health. These themes arediscussed below along with excerpts from participants’responses.Students discussed multiple factors that contributed totheir positive learning experiences. High amounts ofinteraction with other students and the instructor, smallclass size, the use of active in-class learning activitiesand reflective responses, and engagement with con-Table 3 Descriptive statistics of post-course survey items foSurvey itemI was comfortable with self-directed learning through NextGenU.The online learning materials contributed to my learning.I completed the activities and learning materials before in-class sessions.The quizzes encouraged completion of the online learning materials.In-class learning activities complemented online self-directed learning.The reflective responses contributed to my learning.Interaction with my instructor and other classmates contributed to my leaThe flipped classroom model (online learning plus in-person classroom inproblem-solving) was a different learning experience than other MPH couThe flipped classroom model enabled more interaction with my instructothan did other MPH courses.In the future, I would rather take a ‘flipped’ course (blended online learninclassroom interaction and problem-solving) than a traditional (lecture-baseNB: Students were asked to react to statements on a 5-point Likert scale where 1 =agreement (strongly agree and agree) and disagreement (strongly disagree and distent online before attending in-class sessions were allpositively-cited aspects of the course and its design.Students commented that the class size and the flippedmodel contributed to a more interactive learning environ-ment and greater interaction with the instructor and theirpeers. This was recognized as deficient in previouscourses: “…the discussions that we were able to have inclass, by having a small class, that what we were able toget out of an in-class session was a lot more than a 3 hourlecture once per week of fifty people.” Several students alsonoted that they were unsure whether the flipped class-room model would be as effective with a larger class. Forexample, one student stated, “So if they are just going totry and flip i,t then just throw 50 people in there, I don’tknow if it would work.”The focus group also highlighted the contribution ofreflective responses to positive learning experiences.They allowed students to make connections betweenvarious aspects of the course with other areas of publichealth and student lives in general. One student stated:“And I found I would be like noticing environmentalhealth news articles or stuff coming up, and you wouldthink ‘Oh! I could really try and incorporate this into myreflection’. A second student followed up on this com-ment stating: “Ya – that is what I found. I found the re-flections really encouraged me to be thinking about thecourse beyond the content, like beyond the actual read-ings because you don’t really reflect about readings a lotof the time. But I was drawing on other things, and itkind of encouraged me to make those connections, thosebigger connections.”Students also had positive comments about applyingcontent through in-class learning activities. Students re-ported that the variety of learning activities used in thesing on learning experience and perceptionsAgree/stronglyagree (%)Disagree/stronglydisagree (%)Neutral (%)100 0 0100 0 0100 0 082 0 18100 0 091 0 9ng. 100 0 0ction ands.100 0 0d classmates 82 0 18lus in-personscourse.82 9 9ongly disagree” and 5 = “Strongly agree.” For reporting of these survey items,ee) were combined.in-class sessions contributed to positive learning experi-ences. One student commented, “So I feel like I took in alot of it, so that when I came to class I was cementing theknowledge that I just read.” Another student said, “everyweek there was something that was fresh and new and…interactive and I appreciated that.”Finally, several students noted that they were muchmore likely to complete readings and engage with con-tent before coming to class in the flipped classroommodel than the traditional lecture-based model. Onestudent stated, “it is really easy to justify that you don’thave time to do readings, but for this set-up I think thatis was just like, something I needed to get done.”When students began this course, there was very littleinterest in the field of environmental health and occupa-tional health in the group. For example, none of the stu-dents were part of the EOH concentration optionavailable for the MPH students at the test-site university.The majority of students noted that they would not havetaken the course had it not been a required core coursefor their degree. However, a major theme that emergedfrom the focus group was that this course contributed toGalway et al. BMC Medical Education 2014, 14:181 Page 8 of 9http://www.biomedcentral.com/1472-6920/14/181greater interest in environmental health and environ-mental health issues in general. One student noted aboutthe course: “It gave me a huge appreciation for environ-mental health, it really did truly.” A second studentagreed and stated: “I feel like I got a tremendous appreci-ation for environmental health and I got a really goodgrounding in environmental and occupation health andso that is why, you know, I really really liked the course.”DiscussionThis paper reported on the design, implementation,and evaluation of a master’s level EOHC that inte-grated two emerging instructional models: NextGenU’sDOOHICHE and the flipped classroom. Our resultssuggest that this innovative approach fostered learningand provided positive learning experiences for thissmall group of graduate students. To quote one of thestudents, “This was a successful experiment!” Studentsalso expressed a preference for the flipped classroominstructional model over the traditional lecture-basedmodel, with most (82%) agreeing that, “In the future, Iwould rather take a ‘flipped’ course (blended online learn-ing plus in-persons classroom interaction and problem-solving) than a traditional (lecture-based) course. Inaddition, the instructor (LPG) had positive experiencesregarding the design, implementation, and overall out-comes of the course.This instructional model should be considered formore widespread experimentation in the context of pub-lic health higher education and beyond. It is worth not-ing that the flipped classroom, blended learning, andNextGenUs DOOHICHEs are three of many emergingapproaches that are student-centered, promote applica-tion and collaboration, and optimize face-to-face timeand complementary educational technologies [6]. Weurge instructors interested in moving away from conven-tional lecture-based teaching to consider the wide rangeof instructional models available and to select the modelwhich bests suits the course content, student needs, andavailable resources to optimally facilitate learning.For those instructors considering applying the flippedclassroom instructional model, we caution that ‘flipping’the classroom is not simply about shifting lectures out-side of the classroom. Content delivery is “just one smallpiece of the overall learning experience…” [21]. ‘Flipping’the classroom involves seeing students as active learners,shifting control of both learning and the classroom fromthe instructor to the students; it should promote a focuson higher-order cognitive work. Additionally, researchshows that, “for blended learning environments to besuccessful, it is important to structure the face-to-faceand the online portions of the learning experience sothat they coherently support one another” [22]. Educatorsshould think purposefully about course design, developeffective learning activities that engage students, encouragereflections, and complement online content, and take max-imal advantage of invaluable face-to-face class time.Further, we encourage instructors to think creativelyabout how to use emerging educational technologiesin their teaching. For this work, we have employed aNextGenU DOOHICHE to deliver content online, butother opportunities for innovation in blended learningalso exist. The use of open online courses within theflipped classroom, and blended learning more broadlycan reduce the burden of course re-design on instructorsand institutions by most-fully utilizing already-existingand free courses.Although we agree with others who suggest that thatthe flipped classroom model has the potential to influ-ence the landscape of higher education [23-25], we alsonote that more research is needed to evaluate the im-pacts of this model on teaching and learning experiencesand to better understand the specific characteristics of‘flipped’ courses that lead to positive impacts. It is alsoimportant for instructors to share their experiences andcourse design to ensure that we are collectively capitaliz-ing on lessons learned in implementation. Finally, moreresearch is needed to understand the role of reflection inthe flipped classroom instructional model. Reflectionwhich plays a key role in adult learning, has not been ex-plicitly considered within the flipped classroom model[10]. Students in the flipped classroom environments“need to have more space to reflect on their learning ac-tivities so that they can make necessary connections tocourse content” [1]. Qualitative evidence from this smallcohort, as well as the opinions of the course instructor,suggest that reflection is an important yet overlookedelement of applying the flipped classroom model.There are limitations that should be noted. We cannotexclude the possibility that students answered questionsin a socially desirable way nor that the positive percep-tions of this instructional model were attributable to itbeing a different experience than other courses offeredto the students. A major limitation of this study is thesmall sample size. As this was a pilot study, the samplesize was simply the number of students that participatedin the class. Finally, comparisons of overall course rat-ings and examination scores should be interpreted withcaution. Although the courses were designed around thesame MPH core competencies, there were important dif-ferences across years that we have not controlled for inthe design or analysis. Specifically, different instructorstaught the course, class sizes were higher in previousyears (as high as 50) compared to 11 in the 2013, and re-flection was only included as part of the curriculum inthe flipped classroom EOHC. These factors could cer-tainly influence both overall course ratings and examin-ation scores.students: one health department practitioner’s perspective. Am J PublicHealth 2008, 98:1559–1561.19. McCullagh S, Hunter B, Houle K, Massey C, Waltner-Toews D, Lemire M:Ecosystem Approaches to Health Teaching Manual. Ottawa: CanadianCommunity of Practice in Ecosystem Approaches to Health; 2012.20. Ryan GW: Using a word processor to tag and retrieve blocks of text.Field Methods 2004, 16:109–130.21. Davies E: Will MOOCs transform medicine? BMJ 2013, 346:f2877.22. Ginns P, Ellis R: Quality in blended learning: exploring the relationshipsbetween on-line and face-to-face teaching and learning. Internet HigherGalway et al. BMC Medical Education 2014, 14:181 Page 9 of 9http://www.biomedcentral.com/1472-6920/14/181ConclusionThe lecture-based teaching model continues to domin-ate higher education despite massive advances in onlineaccess and technology and developments in pedagogicaltheory [26,27]. Our results show that the flipped class-room model can have positive impacts on learning andlearning experiences in public health higher education.Our data suggest that the use of a DOOHICHE fromNextGenU was an effective and efficient means of con-tent delivery and could facilitate more widespread appli-cation of the flipped classroom in public health highereducation.AbbreviationsASPH: Association of Schools of Public Health; ASPHER: Association of Schoolsof Public Health in the European Region; DOOHICHE: Democratically-OpenOutstanding Hybrid of Internet-aided Computer-aided, and Human-aidedEducation; MPH: Master of Public Health.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsLPG, TT, KC, KT and EF designed the online course and the flipped course.LPG implemented the course and conducted the evaluation. All authorsparticipated in drafting the manuscript. All authors read and approved thefinal manuscript.AcknowledgementLPG is supported by the Canadian Institute for Health Research. KT issupported by Grand Challenges Canada. EF is supported by GrandChallenges Canada and the Canada Research Chair program. No fundingbody had any influence over the design, data collection, analysis,interpretation, or writing of the manuscript.Author details1Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6,Canada. 2School of Public Health and Health Systems, University of Waterloo,Waterloo, Ontario N2L 3G1, Canada. 3School of Population and Public Health,University of British Columbia, Vancouver, BC V6T 1Z3, Canada.Received: 5 March 2014 Accepted: 18 August 2014Published: 29 August 2014References1. Strayer J: How learning in an inverted classroom influences cooperation,innovation and task orientation. Learn Environ Res 2012, 15:171–193.2. Baker J: The “Classroom Flip”: Using web course management tools tobecome the guide by the side. In Selected Papers from the 11thInternational Conference on College Teaching and Learning. Jacksonville, Fl:Bepress; 2000:9–17.3. Means B, Toyama Y, Murphy R, Bakia M, Jones K: Evaluation of Evidence-Based Practices in Online Learning: A Meta-Analysis and Review of OnlineLearning Studies. Washington, D.C.: U.S. Department of Education, Office ofPlanning, Evaluation, and Policy Development; 2010.4. Vogel L: Educators propose “flipping” medical training. CMAJ 2012,184:E625–E626.5. Tucker B: The flipped classroom. Educ Next 2012, 12(1):82–83.6. Herreid CF, Schiller NA: Case studies and the flipped classroom. J Coll SciTeach 2013, 42:62–66.7. Piaget J: Genetic Epistemology. New York: W.W. Norton & Co.; 1971.8. Bloom B, Engelhart M, Furst E, Hill W, Krathwohl D: Taxonomy of EducationalObjectives: The Classification of Educational Goals. Handbook 1: CognitiveDomain. New York: David McKa; 1956.9. Anderson LW, Krathwohl DR, Bloom BS: A Taxonomy for Learning, Teaching,and Assessing. New York: Longman; 2005.10. Mezirow J: Transformative Dimensions of Adult Learning. 1st edition.San Francisco: Jossey-Bass; 1991.Educ 2007, 10:53–64.23. Houston M, Lin L: Humanizing the Classroom by Flipping the Homeworkversus Lecture Equation. In Proceedings of Society for InformationTechnology & Teacher Education International Conference 2012. Chesapeake,VA: AACE; 2012:1177–1182.24. Szafir D, Mutlu B: ARTFul: adaptive review technology for flippedlearning. In Proceedings of the SIGCHI Conference on Human Factors inComputing Systems. Albany NY: ACM; 2013:1001–1010.25. Bergmann J, Sams A: Flip your Classroom: Reach Every Student in Every ClassEvery Day. Eugene, Or.; Alexandria, Va: International Society for Technologyin Education; ASCD; 2012.26. Pierce R, Fox J: Vodcasts and active-learning exercises in a “flippedclassroom” model of a renal pharmacotherapy module. Am J PharmEduc 2012, 76(10):196–201.27. Eapen ZJ, Vavalle JP, Harrington RA: Lecture halls without lectures. N Engl JMed 2012, 367(16):678–679.doi:10.1186/1472-6920-14-181Cite this article as: Galway et al.: A novel integration of online andflipped classroom instructional models in public health highereducation. BMC Medical Education 2014 14:181.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistribution11. Habermas J: Knowledge and Human Interests. USA: Beacon Press; 1972.12. Topp G: Flipped’ classrooms take advantage of technology. USA Today 2011.13. NextGenU.org. [http://www.nextgenu.org/]14. MPH Core Competency Model. [http://www.aspph.org/]15. Calhoun JG, Ramiah K, Weist EM, Shortell SM: Development of a corecompetency model for the master of public health degree. J Info 2008,98(9):1598–1607.16. Birt C, Foldspang A: European Core Competences for MPH Education(ECCMPHE). Brussels: ASPHER’s European Public Health Core CompetencesProgramme; 2011.17. ASPHER’s European Programme on Public Health Core Competences.[http://aspher.org/pg/profile/aspher_phcc]18. Moser M: Core academic competencies for master of public healthSubmit your manuscript at www.biomedcentral.com/submit

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