Scaffolding our way to better HPSR teaching and a stronger field
Health policy and systems research (HPSR) students often have to learn and do things that are outside their comfort zones. There is the new knowledge, but also the teaching style, types of thinking they are encouraged to do, and nature of student tasks and assessments. This is all good and well – after all, what is higher education for? However, if these leaps outside their comfort zones are taken too far and too soon, it will mostly leave students baffled, demotivated and not learning much of anything. This blog explores the educational concept of scaffolding. Scaffolding can help us to navigate many of the dilemmas that we face in teaching HPSR, so maximising in-course learning and interest in our work as we build this emerging field.
Scaffolding begins with what students know and can do already. Going beyond this, the required learning is then divided into manageable pieces, with more knowledgeable others – teachers, experts, or peers – supporting this learning by making available knowledge, skills, tools, structures and strategies. As students increase their knowledge and skill, the support is removed to enable more independent learning and practice.
What content should students learn?
The academic course content is, of course, a natural candidate for scaffolding. What do students know or think they know about HPSR? What do I want them to know? And how do I link and organise the knowledge in-between? Some call this conceptual scaffolding.
The content to cover is a well-recognised dilemma in HPSR teaching, not least because of the diverse and inter-disciplinary nature of the field. Classes often contain students from medical and social science disciplines; different countries; the public, private and NGO sectors; and varied levels of work experience. A shared departure point, a common baseline of knowledge and perspectives, cannot simply be assumed.
One way of scaffolding content is to tap into students’ prior knowledge by getting them to share their experiences and ideas. In CHEPSAA’s courses, examples include "What is policy?" and the "Martian exercise". The former asks students to list all the ideas that come to mind when they think about policy, while the latter entails drawing rich pictures to explain to a Martian what a health system is. Both exercises start with what students know already, but then prompt the lecturer to use the course material to refer back to these initial ideas, while taking students beyond them.
Another idea, which is perhaps most useful in diverse settings or with inexperienced students, is to discuss important or unusual concepts before students read about them.
I once used, as part of an exercise, a paper that reported the results of a discrete choice experiment. The students engaged enthusiastically with the paper’s findings, but it quickly became apparent that they had no idea what a discrete choice experiment entailed in practice. This was corrected when I explained the structure of the questionnaire and the choices offered to the research participants, but clearly some “front-loading” of vocabulary would have improved comprehension.
How do students learn?
Students in post-graduate HPSR courses have often been exposed to years of quite traditional lectures. These prepare them for being talked at, not talked with; usually involve trying to transfer as much content to students as possible in a short time; and often go hand-in-hand with valuing memorisation and then replaying information in assessments.
Yet, many HPSR educators aspire to teach in a student-centred way that actively involves students in the process. This suggests that one might need to do some work to get all students comfortable with the learning environment and its expectations, a task with which scaffolding can help.
One could, for example, start with easy and low-risk activities such as shout-outs in plenary or brainstorming in groups before moving to more intense and consequential activities such as completing a group task or working on a group assignment. Guidelines on topics such as giving constructive criticism and approaches to effective group work can also be essential scaffolds to support interactive learning.
Educators such as Nixon also challenge us to think of in-class learning activities not as an essentially haphazard set of exercises through which students can learn something, but as things that can be sequenced and scaffolded – from easy to complex, the expected to the unexpected, the guided to the independent – so that students become more engaged in the course material over time.
One example is an exercise in which students analyse information in pairs. They then connect with other pairs to explain their analysis and hear the ideas of others. Next, they return to the original pairs to find evidence of the views expressed by others, after which the pairs meet again to produce a synthesised analysis. This task incorporates run-of-the-mill elements such as analysing information and reporting on it, but also the unexpected task of finding supporting evidence for the views of others. It engages analysis, speaking, listening and synthesis skills through which students continue to deepen their interpretation of the material until they reach the final synthesis.
What should students be able to do?
HPSR courses require students to read, comprehend and synthesise large amounts of text. Students must be able to compare across contexts and systems. We value it if they are able to think critically and adopt different perspectives to analyse and solve health system problems. And we routinely require them to write long, well-reasoned and persuasive essays as part of their assessments.
But if students come from different disciplines, know different things and have been taught in certain ways, then it follows that some will be better equipped for these higher order cognitive tasks than others. Some will be adept at memorising large amounts of information, but will be uncomfortable engaging critically with text. Others will know how to write in bullet-point format, but will have little experience of stringing together a discursive essay. Yet others will be able to deal with descriptive, empirical information, but will struggle to apply more general concepts to this experience. Again, scaffolding can help to address some of these problems.
Rosenshine and Meister provide a useful framework for scaffolding higher order cognitive strategies such as comprehending text, summarising information, generating questions, and writing essays. It begins with providing students with prompts that will support them in the task. The educator then demonstrates the skill, for example by talking the students through using the prompts, thinking aloud in class to make transparent the relevant thought processes, or providing students with a model essay that can guide their writing. The box below summarises the framework and, for illustration, contains selected prompts that can be used to scaffold writing.
How are students assessed?
Finally, scaffolding can help to ensure that students are prepared for assessments and that they have a good chance of doing well in them. The successful scaffolding of course content, interactive learning activities and higher-order cognitive skills will, of course, go a long way to preparing students for assessments. However, high-stakes assessments deserve their own scaffolding.
As Caruana argues, students have often “…not had any preparation to meet these high expectations and no opportunity to revise and resubmit their work…they will benefit from the energy you put in providing scaffolding opportunities for each major or key assignment in a course. A good rule of thumb is the higher the stakes, the more scaffolding you need to include. In other words, the heavier the weight, the stronger the support". She suggests issues to consider in scaffolding for assignments.
One strategy could be to have small-group work, which builds up to a group presentation and eventually a full essay as the major assessment. This allows students various rounds of thinking, practising and revision before being confronted with the high-stakes assessment. When it comes to essays, useful scaffolding can also include giving students clear task instructions, being transparent about the assessment criteria, and guiding them on what a good and poor answer will look like. Here is one such attempt at scaffolding from CHEPSAA’s health policy analysis course.
Reading about scaffolding has reminded me that we teach students a lot more than HPSR content. We also teach them ways of learning, ways of interacting, generic skills such as synthesis and writing, and specific skills related to our field that draw on these generic skills, for example the use of systems thinking tools, research methods, or stakeholder analysis.
As educators, we have a responsibility to be aware of this multi-dimensionality and to do what we can to enable the necessary learning on all these fronts. Thankfully, scholars in other disciplines have already done a lot of the thinking for us.
While scaffolding is indispensable to student learning, it also has a role in building our own teaching competencies and skills. Emerging HPSR educators are sometimes daunted by the teaching responsibilities they have to take on, especially when they don’t feel particularly sure-footed in this emerging terrain. Scaffolding strategies - whether through formal teaching development programmes or informally watching and learning from good teachers - can surely be of use as we seek to lay solid foundations for the discipline and build it out further.
Ermin Erasmus, CHEPSAA coordinator