Christopher A. Davidson

The Flipped Classroom: A Course Redesign to Foster Learning and Engagement in a Health Professions School

Recent calls for educational reform highlight ongoing concerns about the ability of current curricula to equip aspiring health care professionals with the skills for success. Whereas a wide range of proposed solutions attempt to address apparent deficiencies in current educational models, a growing body of literature consistently points to the need to rethink the traditional in-class, lecture-based course model. One such proposal is the flipped classroom, in which content is offloaded for students to learn on their own, and class time is dedicated to engaging students in student-centered learning activities, like problem-based learning and inquiry-oriented strategies. In 2012, the authors flipped a required first-year pharmaceutics course at the University of North Carolina Eshelman School of Pharmacy. They offloaded all lectures to self-paced online videos and used class time to engage students in active learning exercises. In this article, the authors describe the philosophy and methodology used to redesign the Basic Pharmaceutics II course and outline the research they conducted to investigate the resulting outcomes. This article is intended to serve as a guide to instructors and educational programs seeking to develop, implement, and evaluate innovative and practical strategies to transform students’ learning experience. As class attendance, students’ learning, and the perceived value of this model all increased following participation in the flipped classroom, the authors conclude that this approach warrants careful consideration as educators aim to enhance learning, improve outcomes, and fully equip students to address 21st-century health care needs.

Pharmacy student engagement, performance, and perception in a flipped satellite classroom.

Objective. To determine whether “flipping” a traditional basic pharmaceutics course delivered synchronously to 2 satellite campuses would improve student academic performance, engagement, and perception. Design. In 2012, the basic pharmaceutics course was flipped and delivered to 22 satellite students on 2 different campuses. Twenty-five condensed, recorded course lectures were placed on the course Web site for students to watch prior to class. Scheduled class periods were dedicated to participating in active-learning exercises. Students also completed 2 course projects, 3 midterm examinations, 8 graded quizzes, and a cumulative and comprehensive final examination. Assessment. Results of a survey administered at the beginning and end of the flipped course in 2012 revealed an increase in students’ support for learning content prior to class and using class time for more applied learning (p=0.01) and in the belief that learning key foundational content prior to coming to class greatly enhanced in-class learning (p=0.001). Significantly more students preferred the flipped classroom format after completing the course (89.5%) than before completing the course (34.6%). Course evaluation responses and final examination performance did not differ significantly for 2011 when the course was taught using a traditional format and the 2012 flipped-course format. Qualitative findings suggested that the flipped classroom promoted student empowerment, development, and engagement. Conclusion. The flipped pharmacy classroom can enhance the quality of satellite students’ experiences in a basic pharmaceutics course through thoughtful course design, enriched dialogue, and promotion of learner autonomy.

Indoor air pollutants and health in the United Arab Emirates

Background: Comprehensive global data on the health effects of indoor air pollutants are lacking. There are few large population-based multi–air pollutant health assessments. Further, little is known about indoor air health risks in the Middle East, especially in countries undergoing rapid economic development. Objectives: To provide multifactorial indoor air exposure and health data, we conducted a population-based study of indoor air pollution and health in the United Arab Emirates (UAE). Methods: We conducted a cross-sectional study in a population-based sample of 628 households in the UAE. Indoor air pollutants [sulfur dioxide (SO2), nitrogen dioxide (NO2), hydrogen sulfide (H2S), formaldehyde (HCHO), carbon monoxide (CO), and particulate matter] were measured using passive samplers over a 7-day period. Health information was collected from 1,590 household members via in-person interviews. Results: Participants in households with quantified SO2, NO2, and H2S (i.e., with measured concentrations above the limit of quantification) were twice as likely to report doctor-diagnosed asthma. Participants in homes with quantified SO2 were more likely to report wheezing symptoms {ever wheezing, prevalence odds ratio [POR] 1.79 [95% confidence interval (CI) 1.05, 3.05]; speech-limiting wheeze, POR 3.53 (95% CI: 1.06, 11.74)}. NO2 and H2S were similarly associated with wheezing symptoms. Quantified HCHO was associated with neurologic symptoms (difficulty concentrating POR 1.47; 95% CI: 1.02, 2.13). Burning incense daily was associated with increased headaches (POR 1.87; 95% CI: 1.09, 3.21), difficulty concentrating (POR 3.08; 95% CI: 1.70, 5.58), and forgetfulness (POR 2.68: 95% CI: 1.47, 4.89). Conclusions: This study provides new information regarding potential health risks from pollutants commonly found in indoor environments in the UAE and other countries. Multipollutant exposure and health assessments in cohort studies are needed to better characterize health effects of indoor air pollutants.

Conducting Environmental Health Research in the Arabian Middle East: Lessons Learned and Opportunities

Background: The Arabian Gulf nations are undergoing rapid economic development, leading to major shifts in both the traditional lifestyle and the environment. Although the pace of change is brisk, there is a dearth of environmental health research in this region. Objective: We describe challenges and successes of conducting an environmental epidemiologic study in the United Arab Emirates (UAE), a Gulf nation in the Middle East, with an inter-disciplinary team that includes in-country academic and government collaborators as well as U.S. academic collaborators. Discussion: We present several issues, including study and data collection design, exposure assessment, scheduling and time coordination, quality assurance and quality control, and institutional review board protocols. These topics are considered in a cultural context. Benefits of this research included building linkages among multinational, interdisciplinary team members, generating data for local environmental decision making, and developing local epidemiologic research capacity. The Middle Eastern culture of hospitality greatly benefited the project team. Conclusion: Cultural differences impact multiple aspects of epidemiologic research and should be respectfully addressed. Conducting international population-based environmental research poses many challenges; these challenges can be met successfully with careful planning, cultural knowledge, and flexibility. Lessons learned are applicable to interdisciplinary research all over the world. The research conducted will benefit the environmental and public health agencies of the UAE and provide the nation’s leadership with country-specific environmental health data that can be used to protect the public’s health in a rapidly changing environment.

Burden of Disease from Indoor Air Pollution

Indoor air pollution has evolved into a high-priority risk across the globe, with various organizations ranking indoor air pollution in the top category of environmental risks. Indoor air pollutant concentrations are a function of indoor source emissions, the infiltration of ambient pollution via building leakage, and the air exchange rate (ventilation) in the building. Health effects range from acute conditions such as sensory irritation to chronic, potentially life-threatening conditions such as cancer and cardiovascular disease. The three primary factors that affect indoor air quality are the nature of indoor pollutant sources, ventilation of the building, and occupant behaviors. This initial modeling effort focuses on the residential environment because people spend the majority of their time indoors in residential dwellings. Deficient air quality can exist in all types of enclosed buildings and structures. In the future, the methods and models developed here could be applied to other indoor environments. The burden of disease due to a particular pollutant was calculated by multiplying the attributable fraction by the observed number of cases of the relevant health outcome in the population. The leading source of indoor air pollution contributing to excess cases of illness is environmental tobacco smoke. Altogether, it appears to cause more than 80% of the health-care facility visits attributed to indoor air pollution. The leading health outcomes attributed to indoor air pollution are cardiovascular disease and lower respiratory tract infections. An estimated 280 deaths result from those diseases, with approximately 88% of those deaths attributed to cardiovascular disease caused by environmental tobacco smoke. Our analyses suggest that indoor air pollution is a considerable risk to public health in the United Arab Emirates (UAE), accounting for at least 77,000 excess visits to health-care facilities in 2008 in addition to the 280 excess deaths. In terms of mortality, indoor air quality ranks second only to outdoor air pollution as a cause of environmentally related diseases in the UAE.

Foodborne exposure to pesticides and methylmercury in the United Arab Emirates.

As part of a comprehensive environmental health strategic planning project initiated by the government of Abu Dhabi, we assessed potential dietary exposure in the United Arab Emirates (UAE) to methylmercury (in seafood) and pesticides (in fruits and vegetables) above international guideline levels. We present results for the UAE population by age, gender, and body mass index. Our results show very low daily risks of exposure to pesticides in fruits and vegetables at levels exceeding WHO guidelines even under the conservative assumption that no pesticides are removed during washing and food preparation. Thus, exposure to pesticides on fruits and vegetables does not appear to be a major public health concern in the UAE. The chances of exposure to methylmercury in seafood are much higher; our model estimates a mean 1 in 5 daily risk of exceeding the FAO/WHO provisional tolerable weekly intake. However, great caution should be used in interpreting these results, as we analyzed only the risks and not the substantial benefits of fish consumption. In fact, previous studies have demonstrated that exposure to the n-3 polyunsaturated fatty acids in fish can increase IQ in developing children, and it can substantially decrease the risk in adults of coronary heart disease and stroke. Further research is warranted to compare the risk of Me-Hg exposure from fish to the nutritional benefits of fish consumption in the UAE and to determine appropriate methods to communicate risk and benefit information to the UAE population.

Prioritizing Environmental Risks to Health

This chapter discusses in detail the process we used to engage stakeholders in further refining the scope of issues to consider in this environmental burden of disease assessment. First, we provide background on innate human cognitive biases that affect our perceptions of risk and how these biases pose challenges to rational priority setting. Then, we describe previous international experiences in prioritizing environmental risks to health for policymaking. Next, we describe the systematic approach used here to prioritize environmental risk factors—an approach that compensates for cognitive biases, incorporates scientific information, systematically involves multiple stakeholders, and builds on international experiences. Finally, we describe how we implemented this ranking process and how the results led to the eight environmental risk factor categories that are the subjects of the remaining chapters of this book: outdoor air pollution, indoor air pollution, occupational exposures, climate change, drinking water contamination, coastal water pollution, soil and groundwater contamination, and produce and seafood contamination.

Burden of Disease from Produce and Seafood Contamination

Eating fruits and vegetables is beneficial to human health but exposes people to risk if the produce contains hazardous contaminants. Two potential contaminants are human pathogens (e.g., Salmonella, E. coli) and agricultural pesticides (e.g., organophosphates, carbamates), both of which can be reduced with proper food handling and preparation. Foodborne pathogens can cause and/or contribute to an array of human illnesses, including acute gastroenteritis as well as more complex chronic conditions such as organ failure, arthritis, and heart disease. Agricultural pesticide exposure can result in dizziness, nausea, abdominal cramps, diarrhea, tremors, anxiety, confusion, neurological disorders, developmental/reproductive disorders, and death. Because large percentages of fruit, vegetables, grains, and legumes consumed in the United Arab Emirates are produced abroad, pesticide use and other farm management practices in countries exporting to the UAE will affect contamination levels of food consumed in the UAE. Domestically harvested seafood has historically been a primary staple of the Emirati diet. More than 90% of citizens eat fish during at least one meal every week. Consumption of fish provides numerous documented health benefits, including a reduction in risk of chronic heart disease; however, fish can also serve as a vector for pathogenic microorganisms (e.g., Vibrio spp.), heavy metals (e.g., mercury) and other toxins (e.g., dioxin). Estimates of illness resulting from seafood consumption focus on exposure to mercury. Although numerous metals can result in adverse health effects if consumed in seafood, mercury is generally regarded as of greatest concern. Chronic mercury poisoning results in a host of neurological and psychological symptoms, including tremors, motor/cognitive dysfunction, and memory loss. Exposure in utero can result in serious lifetime illness, including mental retardation, sensory loss, developmental delay, cerebral palsy, and seizures. In lieu of estimating foodborne mortality and morbidity cases, our modeling approach directly calculates the probability of exceeding international guidelines for exposure to specific hazardous chemicals in fruit, vegetables, and seafood in the UAE. For fruits and vegetables, the model estimates the number of daily incidents in which UAE residents are exposed to a particular type of pesticide residue above a prespecified benchmark dose, due to eating a particular type of fruit or vegetable. For seafood, the model estimates the number of daily incidents in which UAE residents are exposed to mercury levels above the reference dose maintained by the U.S. Environmental Protection Agency due to eating fish. Results of daily cases in which a UAE resident may be at risk of overexposure to methylmercury from eating seafood and exceeding the reference dose suggest 2,927 women and 11,882 men—with the gender imbalance an artifact of the male-dominated expatriate workforce—could be at risk for health effects. Of all pesticides and crops, chlorpyrifos on tomato has the highest mean ratio (0.26) of average estimated pesticide exposure (0.000078 mg/kg) to its chronic population adjusted dose (cPAD) value (0.0003 mg/kg), making tomatoes the most suitable candidate for a worst-case hypothetical scenario. Considering an atypical but theoretical UAE resident eating 100% tomatoes, and assuming no reduction in pesticide due to washing, peeling, and/or cooking, the model estimates this person has 20.6% (chlorpyrifos) and 1.0% (vinclozolin) chances of exceeding cPAD values each day. Overall, this model estimates 631,074 worst-case daily incidents (cPAD exceedance) contributing to potential chronic illness. Although these probabilities may seem high, daily cPAD incidents are assumed contributory toward potential cases of annual chronic illness; the model assumes (worst-case) no reduction in pesticide due to washing, peeling, and/or cooking for all incidents; and, only very limited human epidemiologic studies exist to objectively link chronic pesticide exposure with adverse health effects—a major reason for the safety factors already built into the cPAD and other benchmarks.

Burden of Disease from Occupational Exposures

Workers may be exposed to physical, chemical, and biological hazards at work that may lead to occupational illness. Hazardous substance exposure routes include dermal and inhalation exposure and ingestion. Families of workers also can face risks from toxic substances brought home on contaminated work clothes or vehicles. This chapter estimates occupational exposures to harmful chemicals and noise in the United Arab Emirates (UAE) and calculates the burden of disease related to selected occupational hazards. Occupational health studies conducted in the UAE have revealed unsafe work practices and unhealthy working conditions in many industry sectors, but the majority of UAE workers who are potentially exposed to hazardous substances and noise are employed in construction, agriculture, or manufacturing. The exposures covered in this study were selected following the approach by the World Health Organization, covering common occupational carcinogens, occupational airborne particulates, and noise, excluding occupational injuries and ergonomic stressors. The estimated total number of annual deaths due to health outcomes included in this study is 47, and the total number of health-care facility visits is 17,160. In addition, the model estimates that 4,770 cases of noise-induced hearing loss occur due to occupational exposures each year. Of the health outcomes covered in the study, lung cancer and leukemia were responsible for the highest number of deaths (25 and 12, respectively). For health-care facility visits, asthma and chronic obstructive pulmonary disease contributed most to the disease burden with 11,854 and 5,012 visits, respectively. It is likely that the UAE could reduce the amount it spends on medical care by reducing exposure to respiratory irritants, carcinogens, and noise in workplaces. These numbers should not be considered to represent the total disease burden arising from all occupational exposures. Many prevalent occupational hazards, such as injuries and ergonomic stressors, were excluded because this study focuses on health risks due to releases of hazardous physical, chemical, and biological agents into the environment as a result of human activities.

Applying Environmental Burden of Disease Models to Strengthen Public Policy

The methods described in this book can provide a foundation for the next generation of environment and health strategic plans. Our approach provides an empirically validated means for the kinds of cooperative planning by the various levels of government, nongovernmental organizations and local communities needed in order to reduce human impacts on the environment and environmental impacts on human health. The project documented in this book followed three major steps: (1) developing preliminary environmental burden of disease estimates for 14 risk categories, (2) engaging stakeholders in a systematic process to prioritize these 14 risk categories based on the burden of disease information and other factors, and (3) analyzing in detail the burden of disease for eight key risk categories emerging from the priority-setting exercise. This chapter integrates the environmental burden of disease estimates from Chaps. 4, 5, 6, 7, 8, 9, 10, and 11. It provides a big-picture view of the United Arab Emirates’ environmental disease burden across risk categories. It then outlines how the environmental burden of disease model described in these chapters can serve as a foundation for systematically analyzing interventions to improve environmental quality and lessen the associated disease burden. Next, it explains how a process like that in Chap. 2 could provide the foundation for the next generation of environment and health strategic plans, in which stakeholders come together to prioritize environmental interventions from a menu of options. The chapter also explains how ecological impacts of interventions could be incorporated in this priority-setting process. The budget struggles that many nations face as they contend with the continuing global economic crisis underline the need for renewed environment and health strategic planning. The approach outlined in this book paves the way for doing more with less—for increasing the public health gains of environmental interventions without necessarily increasing the economic burden on governments and their citizens.