Structured internship in health promotion: an approach used in a middle-income developing country — Jamaica

Introduction

With financial challenges and high demand for scarce resources, low- and middle-income countries are often faced with inadequate numbers of trained health professionals to properly address the needs of their populations (1). With changes in the epidemiologic transition, there are issues such as the emergence of new diseases and the re-emergence of others. There are challenges due to the aging of populations and issues surrounding climate change and environmental management. At this time, it is imperative that the health workforce be diverse to address a wider cross-section of health issues while engendering collaboration and partnerships. An important area of focus, therefore, must be health promotion which seeks to promote increased attention to social determinants of health as we pursue the Sustainable Development Goals (2).

To address the need of what is referred to as the ‘looming public health workforce crisis’, it was proposed by the Association of Schools of Public Health that public health education programmes be increased at the undergraduate level (3). Not only is there an increased need for health promotion at the undergraduate level, but there is a growing need for training at the postgraduate level. Health promotion by nature is a cross-cutting tool for all public health programmes and requires special skills and competencies for successful implementation. In Brazil in 1999, the cohort of health promotion specialists at the University of Franca was primarily nurses, physical therapists and teachers. This has changed and since 2011 a wider cross-section of professionals has been enrolling in the health promotion training programme, to include doctors, dentists, psychologists, nutritionists, business managers and lawyers (4). Inter-professional education (IPE) at both the graduate and postgraduate levels has been identified as one recommendation for transforming and improving health professionals’ education and training (5).

The training of a workforce competent in health promotion has afforded the opportunity to address actual health determinants in the field, and can ultimately lead to improvements in health care. There is increased demand for competency-based education which equips the learner with the attitude and knowledge to act appropriately in a given scenario (4). According to the International Labour Organization (ILO) (6), the ‘world of learning and the world of work’ are often viewed as having different objectives and not necessarily influencing each other. The ILO posits that in order to produce the best workforce, training must be relevant to bridge this gap. The inclusion of internships can be one of the strategies in bridging this gap.

Internship has been defined as any period of time during which a beginner acquires experience in an occupation, profession or pursuit, or any official or formal programme. This is aimed at providing practical experiences for beginners in an occupation or profession (7). An internship period provides students with the real-life experiences needed to build their competencies before graduation. In India both the employment and education sector have agreed on the importance of internship with the All Indian Council for Technical Education, making it mandatory for students to be deemed qualified (8).

Coco cited by O’Neill (9) described internship as a period that serves to benefit all stakeholders, including the interns, employers and the university. For interns, this period has been described as making a positive impact on career and future academic pursuits. Other benefits to be derived from an internship programme include the fact that it is one of the best ways to gain experience, make decisions about career paths and improve one’s resume and readiness for employment. The period of internship allows potential employers the chance to assess the suitability of candidates for employment, while interns often seize the opportunity to impress the employers. As interns gain new experiences, both hard and soft skills are developed, including time management skills and other professional habits. According to Schnoes et al. (10), internship builds confidence and is a critical element for entering unfamiliar territories.

While many benefits from internship have been described, some negatives have been documented, including the lack of direction and meaning. It has been posited that internships are more worthwhile when they are well organized and students are given the opportunity to apply theory to practice and receive feedback (9). Some persons further recommend flexibility around the structure of internship and believe that unpaid internships would discourage students from gaining the internship experience (11,12).

Justification

While internships facilitate professional prepa-ration, how they are organized is important to satisfy the needs of interns and participating organizations and workplaces. Preparation starts with the training content that prepares students for application in the field. It is further enhanced if organizations have a basic understanding of what to expect of interns and if there is scope for health promotion practice.

Background

The internship experiences described in this paper originate at the University of the West Indies, Mona. A Master of Public Health (MPH) degree programme at this university is based in the faculty of medical sciences and includes a health education and promotion track (15). Health promotion competencies developed in this graduate programme are informed by recommended standards for the practice of health education and promotion (16,17). They include assessing needs, planning, implementing and evaluating health promotion programmes and communicating and advocating for improvements in health. As a means of ensuring that the students are knowledgeable and gain experience in the application of theory to practice, a 12-month classroom component is executed. This is then followed by a 12-week structured internship that is mandatory to completion of the training. This is an unpaid internship, although some organizations opt to give their interns a stipend.

Guidelines for the programme (15) outline that internship is pursued after students have completed all the theoretical aspects of the course and successfully completed written and oral examinations. The theoretical component consists of health promotion and public health core courses. The internship must be completed before being recommended for graduation and has five general objectives. These objectives can be grouped into two categories, learning and administrative. The learning objectives are threefold: to provide experiences that will allow for theory to be put into practice, to enable the development of health education and promotion competencies in a new work setting, and to provide opportunities for teamwork and creativity. The administrative objectives are to expose participating interns to the various disciplines and organizations involved in the promotion of health and wellbeing and to experience the range of opportunities for influencing health determinants.

Structure of the internship

The University of the West Indies, Mona maintains a growing list of agencies that are willing to collaborate in providing internship experiences. As outlined in the resource manual for interns (15), participating agencies must be willing to accommodate an intern, have the capacity to provide a professional experience in the field and provide suitable supervision for the intern. The agency supervisor is provided with guidelines which include orientation of the intern, assigning responsibilities, and providing assistance in identifying a project or specific area of service based on the organization’s mandates. The agency is expected to complete mid and end of internship evaluation reports indicating interns’ progress and performance. A prescribed evaluation tool is provided for this purpose.

Each intern is provided with a list of guidelines for internship and each must submit to a faculty supervisor, before the internship period begins, a list of personal internship learning goals. Additionally, interns are expected to have periodic meetings with their agency supervisors with one of the agenda items being ‘personal learning goals and organization’s goals’. All interns must attend at least two of three monthly seminars organized for them to present oral reports of each block of activities. These seminars are organized by faculty at the university and are for all interns in a given cohort. A final report of the overall internship experience is submitted and kept by the faculty supervisor and one copy submitted to respective agencies. For this paper, available written internship reports of health promotion specialists completing the programme during the period 2007 to 2017 were targeted for analysis. Details of the programme along with the structured internship component are outlined in Figure 1.

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Figure 1.

Summary of the structured internship process.

Methods

A mix of quantitative and qualitative approaches was integrated in the analysis to provide both objective and subjective accounts of the internship arrangements and experiences. Twenty-four reports were available for review and all were included. Quantitatively, a data extraction sheet was developed and used to summarize the information describing the internship process and experiences in each report. The variables included were: demographics including professional background, country of residence of the interns, internship agencies and their locations; the activities in which interns participated; and the relevant areas of health promotion competency engaged. This information was then entered on an Excel spreadsheet and analysed using descriptive statistics with some data displayed in figures and tables.

Qualitatively, content analysis of participants’ personal reflections about their experiences was used to connect with the quantitative component. The analysis was done manually and was started by reading and re-reading the reflections section of each report, then identifying and colour-coding key words and statements as recommended by Vaismoradi et al. (18) about qualitative content analysis. The selected words and phrases were analysed for meanings and led to the development of themes. The focus of the analysis was more on participants’ perspectives as described by them since the aim is to describe their experiences. The essence of the experiences based on these themes is described using predominantly their language and supported by relevant excerpts from the reflections. Both quantitative and qualitative findings are then discussed together.

Findings

Learning goals and actual experiences gained

Personal learning goals

In three reports, personal goals were missing. Of those reports with goals included, 19 (90%) interns had a goal that was aimed at either planning, implementing or evaluating a health promotion programme. Eight (38%) of the interns wanted to conduct needs assessments and nine (42.8%) had goals to apply theory to practice. Sixty-seven per cent (14) of interns had a goal that addressed communication competency and 14.3% (3) to improve skills in research. Acting as a resource person was a skill that 19% (4) of interns had as a goal.

Experiences gained

Activities undertaken by interns were varied and addressed areas of professional competencies. Activities in the areas of planning, implementing and evaluating were conducted by 71% (17) of all interns, with the majority of these (10) engaging in the planning of projects they initiated or as part of pre-existing activities. There were 15 (63%) interns who conducted needs assessments, including paper-based surveys (47%), focus group discussions (13%) and SWOT analysis (3%).

Sixty per cent (15) of interns reported gaining experience in communication-related activities, including the development, pre-testing and production of educational and training materials, oral presentations and facilitating collaboration and team meetings. There were eight (33.3%) who identified serving as health education resource persons by developing and revising health-related policies and in advancing programme evaluation initiatives. Advocacy and collaboration with other agencies to achieve goals were reported by 21% (5) of interns and one intern represented the assigned organization at an international conference. Table 1 shows comparisons.

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Table 1.

Projected goals and reported achievements of interns.

Areas	Projected		Achieved
	N = 21%		N = 24%
Planning, implementing and evaluating programmes/activities	19	90.0	17	71.0
Communication	14	67.0	15	43.0
Apply theory to practice	9	42.8	–	–
Needs assessment	8	38.0	15	63.0
Research	3	14.0	–	–
Act as resource person	4	19.0	8	33.3
Advocacy and collaboration	0	0	5	21.0

The basic principle of ensuring sustainability of initiatives was assessed in the reports. There were two reports (8.3%) that did not record plans for sustainability. For others, several approaches were taken, with some interns and their teams using multiple approaches. In 55% of cases, stakeholders were included from the planning stage to ensure buy-in. In 23% of cases, planning committees were established and in another 14% of cases persons were trained along the way to take charge of activities. Written documents were produced to provide guidelines in 59% of cases and as much as 48% of interns reported employment of more than one measure.

Qualitative findings: reflections on internship in the reports

One hundred and twenty-five significant statements were identified from the reflections section of the 24 students’ reports. From these significant statements, meanings were summarized then organized into six overarching themes about satisfaction or lack thereof, with respect to internship. These themes were: ‘Supervisors are busy people’, ‘Making things work’, ‘Embrace emerging opportunities’, ‘Seminars provide supportive environment’, ’Internship facilitates real learning’ and ‘Experiencing satisfaction’.

Supervisors are busy people

The issue of supervision was a recurrent theme as ‘supervisors are busy people’. Except in a few cases, supervisors were often unavailable for various reasons, to give feedback on actions taken or to serve as a sounding board for ideas. Some were either traveling, participating in meetings or caught up with other regular duties. This for some interns was disruptive but often encouraged problem-solving and relationship-building skills. These included situations in which answers were not readily available and where resources were inadequate to facilitate the implementation of some activities. At other times there was reportedly a lack of interest among some team members to support or participate in some activities and in other cases competing priorities became barriers.

Making things work

The issue of supervisors being busy engendered the use of initiatives among interns. Some reported how at times, when supervisors were unavailable, they found ways to ‘make things work’ so that their internship goals could be met. Sometimes it was through building relationships with other agency personnel and volunteering to assist in other agency activities that doors were opened for ‘making things work’.

Embracing emerging opportunities

When faced with barriers to the achievement of personal goals, some interns found new ways to either change their perspectives or to pursue other goals by ‘embracing emerging opportunities’. Those reporting this kind of change also reflected on how such moves helped them to gain experience and strengthen areas of competence that were not part of projections at the start of internship. There were, however, those who just reflected on the fact that they were unable to achieve all their goals due to lack of opportunity to do so.

Seminars provide supportive environment

The reflections revealed a common perception that ‘internship seminars provide a supportive environment’. Comments across 20 reports included sentiments that feedback received from peers and faculty when internship activities were shared facilitated necessary foci and changes in perspectives. One reflection read: ‘I looked forward to internship seminars. Sometimes I felt nervous about sharing, doubting if I was on the right track but I would then leave seeing things clearer and even learnt from the work of other interns’. Another said: ‘I left the first seminar determined to improve my internship activities and my classmates gave me needed support.’ Others mentioned benefits such as being nudged to consider missed opportunities and viable alternatives around issues previously perceived as barriers. One value repeatedly reflected relates to being questioned in seminars about the principles that should be applicable in given situations and how helpful this was in getting them to put things in context.

Internship facilitates real learning

Interns reflected on real opportunities for applying classroom concepts to real issues. Opportunities described included use of the PRECEDE-PROCEED planning model and behaviour change theories, engaging in research and developing guidelines including terms of references for working with partners. Commenting on planning, one intern reflected as follows: ‘The first two phases of PRECEDE PROCEED were critical in providing guidance to focus on the issues.’ Another excerpt exemplifying this was: ‘While behaviour change theories are taught during the programme, there was not enough opportunity for me to test them and as a practical learner I seized the opportunity on internship to do so.’

Internship was also a time for some to change their human relations skills: an important comment in this regard was made by someone in a workplace wellness assignment. It said: ‘I learnt to appreciate communication cascades and to slow down my usual “let’s get the work done” attitude.’

Experiencing satisfaction

Satisfaction with the acquisition of new skills and concepts is the ultimate goal for an adult learner and there were different ways in which interns expressed feeling satisfied. Phrases used that seem to sum up the various ways in which satisfaction was experienced included: ‘It was worth it,’ ‘I am pleased,’ ‘[They] were very appreciative of my input,’ ‘I am satisfied, my goals were achieved,’ and ‘There is no price I can put to this experience.’ Table 2 shows a joint display of projected goals and selected quotes indicating interns’ feelings of satisfaction. There were some other reflections showing evidence that some interns wanted things to be more compatible with their desires, although they experienced varying levels of satisfaction.

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Table 2.

Joint display of interns’ projections (quantitative) and areas of satisfaction (qualitative).

Quantitative findings	% of interns (n = 21)	Selected qualitative quotes about interns’ satisfaction
Areas of competence projected
Planning, implementing and evaluating programmes/projects	90	‘Planning and implementing with the team was key to success of the activities.’
		‘My personal learning goals were met in terms of assessing needs, planning and evaluating.’
Communicating	67	‘The need for proper documentation was reinforced for me.’
		‘I learnt how to prepare terms of reference.’
		‘I learnt to mobilize a team and was helped by using the broken squares activity I learnt in class.’
Applying theories to practice	42.8	‘. . .behaviour change theories are taught during the programme. . . there was not enough chance for me to test them and as a practical learner I seized the opportunity on internship to do so.’
Needs assessment	38	‘The first two phases of PRECEDE PROCEED were critical in providing guidance to focus on the issues.’
Research	14	‘In doing the needs assessment I had to apply research principles.’
		‘To complete the evaluation of the diabetes programme, I had to apply research principles and this was very useful.’
Acting as resource person	19	‘I gained experience in training community leaders.’

Discussion

In this paper we set out to describe the extent to which a structured internship approach contributed to experience and competency-building, provided focus and met learners’ satisfaction among a cohort of unpaid health promotion interns. Generally, internships can benefit relevant organizations, educational institutions involved and interns themselves. O’Neill (19) posits that interns should not be left on their own to plan and complete internships that are expected to strengthen professional development. She further asserts that internships that offer opportunities for mentoring by supervisors and faculty members can make a great impact on interns’ professional development. It has been highlighted in the findings that getting real work experiences and feedback from peers and faculty were achieved in this structured internship approach. However, the qualitative findings also show how competing priorities sometimes led to a lack of feedback from supervisors due to various issues. On the other hand, however, resilience and creativity driven by this very issue, with supervisors’ absence, created a balance. Both of these qualities are necessary in the real world of work.

The primary objective of the structured internship programme was to enable the health promotion specialists to strengthen various areas of competence as described in the literature (16,17). Based on the reflections of the interns, the opportunities for developing these competencies were available in the various organizations. The skills garnered from the experience were varied and included both softer skills such as building relationships to the more complex skills of experiential learning in areas of required competence described in the literature (16,17). Planning, evaluating and implementing programmes were areas of competency that most interns (90%) reported (including those without projected goals). For needs assessment alone, 63% of interns reported gaining experience. The proportion for needs assessment is notably much higher than the proportion of interns who included it in projections. This may have been due to reporting of research with needs assessment skills.

While in the quantitative findings participants did not set goals for applying theory to practice, the qualitative findings highlighted this achievement. These are evidence of experience gained and interns’ satisfaction. Two comments that exemplify this are references to the application of behaviour change theory and the PRECEDE PROCEED model. These values about bridging classroom learning with field experiences cannot be overlooked.

The role of internship seminars in gaining support and building confidence seemed to have been a high point for interns. Opportunities for advocacy and intersectoral collaboration were other key areas of experience highlighted by 21% of interns. This is of particular importance as a health promotion specialist since advocacy can lead to collaboration and, according to Corbin et al. (20), intersectoral collaboration is imperative in health promotion. Additionally, credence is given to collaboration through the WHO’s expanded mandate that social determinants of health must be addressed to bridge gaps in health and is best achieved through intersectoral collaboration (21). In the real world of work, health promotion practice must also uphold the value that health is a fundamental human right (22) and attention to the social determinants of health advocated in Sustainable Development Goal 4 (23) is best pursued through collaborative efforts.

Planning for sustainability of health promotion initiatives is important since this is in keeping with the Ottawa Charter’s tenet of empowering communities to achieve health and wellbeing (24). The findings show that several attempts were made by interns to engender leadership to foster sustainability of activities. Planning with their teams (55%), training individuals to lead (14%) and developing guidelines (59%) were listed among the multiple approaches utilized, and this is a positive.

The literature shows that interns’ fear of being penalized may have influenced under-reporting of negative experiences and personal deficiencies and a greater emphasis on reporting positive experiences (25). This and the fact that feedback from the organizations involved are excluded from this analysis contribute to limitations of this paper. One strength of the paper, however, is the use of mixed methods to make subjective and objective analyses of the value of the structured internship approach in helping to achieve goals and lead to satisfaction among interns.

Conclusions/recommendations

It can be concluded from these reports that the structured internship approach for health promotion specialists provided experiences to strengthen competence. Opportunities included: acting as health promotion resource persons, planning, implementing and evaluating health promotion programmes, communicating at different levels and in various forms, collaboration, advocacy and policy-related contributions. While agency supervision was often limited, internship seminars facilitated support through feedback from faculty and peers. Interns reported growth and satisfaction with the exposures they received. Future analysis of this approach should include agency evaluation of interns and the benefit of the internship from the perspectives of the agencies. We recommend that extensive research be done to investigate the benefits of including structured internships in the training of health education and promotion specialists.