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The Principles and Practice of Cancer Prevention and Control course (Principles course) is offered annually by the National Cancer Institute Cancer Prevention Fellowship Program. This four-week post-graduate course covers the spectrum of cancer prevention and control research (e.g. epidemiology, laboratory, clinical, social, and behavioral sciences) and is open to attendees from medical, academic, government, and related institutions across the world. In this report, we describe a new addition to the Principles course syllabus, which was exclusively a lecture-based format for over 20 years. In 2011, Cancer Prevention Fellows and staff designed and implemented small group discussion sessions as part of the curriculum. The goals of these sessions were to foster an interactive environment, discuss concepts presented during the Principles course, exchange ideas, and enhance networking amongst the course participants, and provide a teaching and leadership opportunity to current Cancer Prevention Fellows. Overall, both the participants and facilitators who returned the evaluation forms (n=61/87, and 8/10, respectively), reported high satisfaction with the experience for providing both an opportunity to explore course concepts in greater detail and to network with colleagues. Participants (93%) and facilitators (100%) stated they would like to see this component remain a part of the Principles course curriculum, and both groups provided recommendations for the 2012 program. The design, implementation, and evaluation of this initial discussion group component of the Principles course are described herein. The findings in this report will not only inform future discussion group sessions in the Principles course but may also be useful to others planning to incorporate group learning into large primarily lecture-based courses.
Individuals with formal training in cancer prevention and control efforts have an especially important role in this time of rising global cancer incidence [1, 2]. In the United States, formal cancer prevention education has largely been limited to medical school settings ; however, the responsibility in reducing the burden of cancer cannot be limited to physicians only. This is especially true in low- and middle-income countries where the population per physician ratio is high , over half of the world’s cancers occur , and cancer incidence is increasing due not only to the aging of populations, but also to increasing prevalence of modifiable risk factors such as cigarette smoking and obesity .
The spectrum of cancer prevention activities ranges from primary prevention methods such as vaccinations and the reduction of tobacco use to secondary prevention tools such as screening tests. Improvements in screening and cancer treatment also have extended the challenge of prevention to including growing population of cancer survivors , who are at risk of impaired quality of life , cancer recurrence, and second primary cancers . The range and complexity of cancer prevention and control activities requires professionals from various disciplines to collaborate in order to generate innovative and transdisciplinary solutions.
The National Cancer Institute (NCI)’s Cancer Prevention Fellowship Program sponsors a four-week, post-graduate summer course in cancer prevention each year with the goal of bringing broad formal training in cancer prevention to a diverse, international audience of 85–90 scientists and practitioners . The Principles and Practice of Cancer Prevention and Control (referred to as Principles course) was initially developed for NCI Cancer Prevention Fellows who are postdoctoral researchers coming from various health-related backgrounds . The course attendance has expanded to include participants from across the United States and the world. Approximately half of the participants have been from low- and middle-income countries in recent years. To our knowledge, the Principles course is the only course of its kind providing a comprehensive overview of cancer prevention research across all disciplines where individuals from low- and middle-income countries can receive this training and network with peers from across the globe.
The course sponsors seek to make improvements to the curriculum each year. Evaluations of individual lectures from the Principles course have been very positive. However, responses from recent evaluations and discussions with NCI Cancer Prevention Fellows who took the course indicated an interest in creating more interaction opportunities among course participants. The course is traditionally taught in large didactic lecture format. Prior research shows that group learning can complement lecture content and enhance student engagement, particularly in adult education settings, and provide an opportunity to not only explore knowledge but also to build relationships . In 2011, we decided to add a group learning component to the curriculum to capitalize on the great diversity among the attendees of the course in professional and life experiences with cancer prevention and control activities.
In addition to enriching the Principles course experience for the participants, this new component provided Cancer Prevention Fellows who previously took the course an opportunity to facilitate group discussions with current participants. The role of facilitator was a unique leadership and teaching opportunity for the fellows given the diversity of the course participants and topics. The facilitators were intimately involved in planning these sessions for the summer course participants, from the first planning meeting through to the evaluation process and preparation of this report.
In this article we explain the development, implementation, and evaluation of this pilot group discussion. Our purpose for communicating this endeavor is to not only inform the cancer education community about this interactive component new to the course but to also provide an example of a process others could consider for incorporating small group discussions into predominantly lecture-based training. The main goals of the discussion group sessions were to foster an interactive environment, provide an opportunity to discuss concepts presented throughout the course, and allow participants to share their real-world experiences as they related to lecture material. In addition, these sessions were designed to facilitate networking and future collaborations among the diverse group of participants and provide a teaching and leadership opportunity to current Cancer Prevention Fellows.
Cancer Prevention Fellows in the 2nd to 4th year of their fellowship training (n=24) were invited to participate in planning and facilitating small group discussion sessions for the participants of the 2011 Principles course. These fellows had the experience of being a prior participant in the course and also had at least one full year of training with the Cancer Prevention Fellowship Program. This provided them with exposure to a wide array of presentations and scientists representing the cancer prevention research continuum. Therefore, they were familiar with the course content, diversity of the audience, and had developed a broad background from which to lead discussions of current issues in the field of cancer prevention research. Ten fellows (42%), including eight of the co-authors, expressed interest and were available to participate on the dates when the sessions were scheduled.
To begin the planning process, fellows were provided with examples of topics and a process that had been used to facilitate discussion groups focused on presentations at a professional scientific meeting. Three in-person meetings of the participating facilitators and Cancer Prevention Fellowship Program staff were held to discuss implementation procedures, including: selecting overarching themes relating to cancer prevention; determining group structure (size of groups and assignment of participants); and discussing facilitator guides and an evaluation process.
The facilitators generated nine cross-cutting themes for the discussion groups. Facilitators then ranked their top five choices. Facilitators who ranked the same theme as their first or second choice were paired together to develop a facilitator guide with potential discussion points for that particular theme. The themes were broad enough to be relevant to the entire course but the discussion guides also included content related to specific topics in the syllabus (Table 1). Themes were also designed so that individuals from a wide array of backgrounds could contribute to the conversation.
Each theme was discussed by two independent groups (approximately nine participants each) in order to maximize the opportunity for sharing experiences and to have diversity in interpretation about how the theme was relevant to the course. Group designation was by random assignment of participants prior to arrival. This method was chosen to ensure that each group was balanced across geographic representation of the participants and in number of participants per group.
Participants were asked to attend two formal meetings of their discussion group. The initial meeting was during the first week of the Principles course and provided an opportunity to introduce the purpose of the discussion group, the group theme, and the participants. During this meeting the facilitator encouraged the group to meet beyond the two formal sessions to discuss the theme and how it related to the lectures presented. Although these additional meetings were encouraged, they were not required for either the participants or the facilitators. The second formal meeting was held near the end of the Principles course and served a dual purpose. The first was for participants to discuss the assigned theme after attending most of the lectures presented during the four-week course, supplementing the material in the lectures with their own experiences, and to create a summary slide to be presented to the other course participants. The role of the facilitator for this activity was to ensure that conversations were relevant to the theme assigned to the group and that each participant had an opportunity to contribute to the discussion. The group discussion culminated in each group preparing a five-minute presentation accompanied by a PowerPoint® slide summarizing the ideas discussed within the group. All the Principles course participants reconvened to attend the presentations given by representatives of each of the 10 groups.
At the conclusion of the group presentations, all participants were given a short evaluation to complete regarding the discussion group component of the summer course. Approximately 70% (61 of 87 of the participants) who attended the Principles course returned the questionnaire. Similarly, each group facilitator was provided with an evaluation designed to capture the facilitator’s experience of this interactive component, and 80% (8 out of 10 of the facilitators) responded. Results from course participants and facilitators were compiled separately. The questions that formed the evaluations can be found in Table 2 and largely relate to satisfaction with the experience and suggestions for improvement. One week after the completion of this activity, facilitators had an in-person meeting with the Associate Director of the Cancer Prevention Fellowship Program to evaluate the experience in more depth.
Participants were asked to rate on a range of 1–5 (with 5 being the highest score) whether the small group discussion sessions provided an opportunity to explore the course concepts in greater depth. The 61 participants who responded to this question gave this a high rating (average=4.21, standard deviation=0.87). When asked to rate whether the small group discussion sessions provided an opportunity to network with colleagues and learn from each other’s experiences, the average score was 4.53 (standard deviation=0.89).
While facilitator evaluation was not the primary goal of our questionnaire, the participants were also asked to briefly evaluate the role and effectiveness of the facilitator. A high percentage (89%) of the participants reported that their facilitator introduced the purpose of the discussion group and focused the discussion on the group’s assigned theme. Similarly, 82% of the participants reported that their facilitator effectively led the group discussion by encouraging comments from all group members and guiding them to develop the final presentation.
Most participants (93%) endorsed the idea that the discussion groups should remain a part of the Principles course curriculum. Overall, 39% felt the discussion groups should meet at a greater frequency (Table 3), but a substantial number of participants did not provide a preferred frequency of the meetings. Additionally, several groups had meetings outside of the two required, with variation in the number and type (i.e., facilitated or not facilitated). Interest in meeting at greater frequency was similar between the groups that only met the minimum number of times and the groups having additional meetings (Table 3).
Approximately 67% of the participants who completed evaluations provided responses to the open-ended questions regarding suggestions for future discussion topics and general comments about the discussion group experience. The majority of participants expressed high levels of satisfaction with the experience. Many noted that the discussion groups provided a valuable context for networking and sharing ideas. As one participant remarked:
“It was a great experience. It provided a good opportunity to mix with other members of the course and discuss topics covered throughout.”
Another participant noted:
“Since the course was essentially lecture based, I was really pleased to be involved in an interactive group session. It gave us a better opportunity to get to know our course mates from other parts of the world, hear about working conditions and resources. The group activity was small enough for every member of the group to put forth their ideas whilst filled with variety at the same time. It was also good to hear from the other NCI fellows.”
Other participants’ comments also reflected an appreciation for gaining exposure to the diverse perspectives and experiences with cancer prevention and control represented by the attendants. Participants described benefits stemming from their interactions with individuals from various countries. For example, one participant stated that the discussion group was a:
“Very good opportunity to share the experiences and ideas among a group of people with similar interests from different countries. Helped to clear some doubts and gain knowledge of new ideas/concepts/facts.”
Another participant noted:
“It was a very enjoyable experience and great to hear how the situation is in other delegates’ countries. It was a very worthwhile exercise.”
Several areas for change were suggested and varied by discussion group participants. For example, some expressed a preference for discussing multiple topics throughout the course, rather than being assigned to discuss a single broad theme. Other participants expressed a desire for the discussion groups to focus more in depth on a narrower topic, such as cancer prevention solutions, strategies, and interventions specifically tailored for developing countries.
As one participant stated:
“Our topic was very broad which led to some conversations being unfocused, and making it difficult to get to real learning outcomes. I would suggest making [the] topics more focused and [unique to each] group.”
Some participants also perceived a lack of clear expectations related to the discussion groups:
“The purpose of the actual deliverable was ambiguous; however, the discussions it elicited were very interesting, thought-provoking, and a great use of time.”
Eight of the 10 facilitators who participated in the discussion group experience provided an evaluation of the sessions. Six responded that the discussion group provided an opportunity to explore course concepts in more depth (score=4 or 5) while two were neutral (score=3). Most facilitators (7/8) also felt the discussion groups provided an opportunity to network with colleagues (score=4 or 5). All of the facilitators who responded to the questionnaire would recommend the experience to other fellows and felt the discussion groups should continue as part of the Principles course curriculum (Table 3).
Seven facilitators attended the in-person meeting after the completion of the Principles course and provided additional feedback. The facilitators felt they benefited from the discussion group experience in several ways. First, the facilitators enjoyed interacting with diverse course participants and learning about their experiences “working on the front lines” in cancer prevention and control. The facilitators described interacting with the participants in this way as “enriching,” “powerful,” and “generative.” One facilitator noted that engagement with the participants provided personal connections that reinforce his efforts conducting research. Additionally, the facilitators felt leading the discussion groups broadened their understanding of cancer prevention and control. One facilitator noted:
“Serving as a discussion group facilitator gave me the chance to think about the Principles course material in a deeper and more comprehensive way than I had when I took the course as a participant last year. It challenged me to think about how my group’s theme applied across the cancer control continuum, across multiple levels of intervention, and across different geographic and research settings.”
Another facilitator noted the experience allowed her to make connections among the course material, her own research program, and her experiences at NCI, including participating in workshops on emerging ideas in cancer prevention, helping to develop funding opportunity announcements, and participating in meetings to draft policy recommendations. Finally, the facilitators also felt they enhanced their leadership and facilitation skills through leading a discussion group and obtaining feedback from group members about ways to improve. One facilitator noted “It was also a good opportunity to practice moderating a discussion involving diverse perspectives, experiences, and personalities.”
The facilitators identified several suggestions for improving the discussion group process. First, the facilitators felt the groups should have a required number of facilitated meetings. Although the facilitators had intended to encourage flexibility and voluntary participation, this led to variability in the frequency of facilitated meetings across groups and concern among some participants about the productivity of their groups. Further, additional meetings of the groups without the facilitators present appeared to be difficult to initiate and maintain discussion germane to the topic. Overall, the facilitators felt their personal benefit, as well as the productivity of the discussions, increased with more frequent facilitated group meetings.
The facilitators also felt that the participants would benefit from clearer guidance regarding making connections among course lectures, their discussion group theme, and the participants’ home country, as well as how to look at the material from multiple perspectives (e.g., across the cancer continuum, related to developed versus developing countries, from a socioecological perspective, etc). Facilitators also suggested that participants needed more focused instructions on the group assignment (e.g., five minute presentation with one slide) in the first group meeting, including expectations about when and how the product will be created, in order to reduce participant anxiety about the assignment. Further, the facilitators felt there should be an explicit emphasis on the process of the discussion rather than the product.
Two issues related to the themes for discussion groups were reviewed in detail: participant choice in the theme and whether or not each group should cover one or multiple themes. The facilitators came to consensus that participants should have more of a voice in their assigned theme. They also concluded that rotating themes would not allow for enough depth in group discussions.
Collective feedback from both participants and facilitators identified several key recommendations for satisfaction with and productivity of the discussion groups (Table 4). Specifically, participants valued having facilitators who were familiar with the content of the summer curriculum and who currently worked at NCI. The facilitators appreciated the opportunity to work with participants from such diverse backgrounds and countries to generate transdisciplinary ideas. Similar benefits have been shown in other group learning programs . The evaluations and debriefing discussions also yielded three areas for improvement the program is using to refine the course for future participants: (1) consistent format across the discussion groups; (2) participant choice in theme selection; and (3) clear identification of a final product and potential for application.
Although guidelines were distributed to both participants and facilitators, feedback from participants as well as literature on group learning  suggests that providing more structured learning objectives would facilitate better management of expectations for the discussion group experience. These learning objectives should communicate actionable goals for the participants with an emphasis on active engagement in discussion and presentation of themes. In addition, delineating participant and facilitator roles may also prevent confusion among participants or inconsistencies from group to group with regard to level of participation.
Because the discussion group setting relies on exchange of experiences and knowledge about the topic, it is not surprising participants would feel a connection to some topics more than to others and, therefore, they would prefer some choice in group topics . Concern regarding participants’ preferences about themes could be ameliorated by soliciting theme ideas in the evaluation for use in subsequent years. For example, “best practices for cancer control in developing countries” was a suggested theme that could be included in future years. In addition, before the start of the summer curriculum, incoming participants could be briefed on the discussion group component of the session and given the option to rank order their preferences of theme, which could be considered in making group assignments. In future years, the desire of participants to self-select a discussion group would need to be balanced with a desire for diversity of experiences across the group to maximize the richness of the exchange . Facilitators also indicated that although their preference would be groups assigned to one primary theme to discuss, more time per meeting or a greater number of facilitated meetings would permit groups to have far-reaching discussions not limited to only their assigned theme.
Reflected in participant evaluations and debriefing discussions with the facilitators, the importance of clearly defining the goals of the discussion group component in terms of process and product was emphasized. Process goals include having dedicated time to discuss the course material and interact with other course participants, both of which were regarded as benefits in the participant evaluations. Product goals entail having a clearly defined outcome of the discussion group experience. Having concrete guidelines and examples of a product may aid both facilitators and participants in understanding the task. One suggestion for an adaptation of the discussion group product was the identification of a challenging research question(s), mirroring a process similar to the development of NCI’s Provocative Questions . Regardless of the exact specifications, a more defined product with potential for application would likely improve the group discussion process by helping to focus efforts on a clear goal.
The discussion group experience successfully achieved the goals envisioned at the beginning of the planning process for this pilot session as evidenced by the evaluations from both participants and facilitators. These goals were to foster an interactive environment, discuss concepts presented during the Principles course, exchange experiences, and provide opportunities to create networks and possible collaborations. There are many unique features to the Principles course curriculum and its attendees. Our format of participants working in interdisciplinary teams and providing networking opportunities are benefits recognized by other cancer prevention training programs [15, 16].
The development and implementation of the discussion groups described here could be adapted for almost any training setting; therefore, we hope the description and evaluation of our process will be of use to others who may consider incorporating group learning into traditional lecture-based courses. There was great diversity in career stage, areas of research interest and/or patient care, and geographic distribution across the participants in the Principles course. We have emphasized the geographic distribution as an asset to this course and the discussion; however, other settings will undoubtedly have participants who collectively have a wide-array of experiences relevant to the training topic. The feedback we received regarding interest in self-selecting discussion groups and a more uniform format across groups also reflected general preferences others have reported for group learning (regardless of topic) in adult education . This format also did not rely on having senior faculty available to lead the discussion groups, but rather provided postdoctoral fellows with the opportunity to be involved in curriculum discussions, design this new interactive component, and be a facilitator. Moving into the role of facilitator of a discussion group gave the fellows the opportunity to have more in-depth experience working with and leading a diverse group.
The Principles course discussion groups provided a new opportunity to expand upon the overarching course goal of bringing cutting-edge research in cancer prevention to a diverse audience of cancer researchers and global public health practitioners . The facilitators and participants overwhelmingly agreed that the discussion groups should remain part of the Principles course syllabus, based upon the evaluations. We look forward to refining the experience with the recommendations made by both the facilitators and participants and implementing the discussion groups again for future Principles courses.
Support: All authors are currently or at the initiation of this project were supported by the Cancer Prevention Fellowship Program, Center for Cancer Training, NCI.
We thank Drs. Annette Kaufman and Todd Gibson for serving as facilitators and participating in the planning process for the discussion groups and Ms. Aisha Kudura and Ms. Studly Auguste for administrative assistance with implementing the discussion groups. We also thank Drs. David Nelson and Jonathan Wiest for critical reading and comments on the manuscript.