MPH Internship Proposal

Gillian Adler

HEA 648- Program Planning

The University of North Carolina at Greensboro

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“What we change inwardly will change outer reality”Plutarch, Lives

Mental health is an area of public health that has not garnered the same amount of

interventions for it is a long term, individualistic health problem (Le Gales-Camus, 2004). In the

WHO 1946 preamble, they defined health as “a state of complete physical, mental, and social

well-being rather than merely the absence of disease or infirmity” (WHO, 1948). However, the

mental health aspect has been a side note. Even more so, not having a mental health component

along with any program ignores how behavior is mainly psychological. For instance, depression

has been found to be a detrimental to diabetic patients. Depressed diabetes patients saw worse

health outcomes as opposed to other patients (Zhang, Norris, & Gregg, 2005). Worse health

outcomes could be as a result of not having the emotional energy to take insulin or eat properly.

This is not limited to public health interventions, mental health in general is not a generally

acceptable to be addressed openly in society like physical problems, so we are facing a mental

health crises (Le Gales-Camus, 2004).

Mental health is a state of wellness wherein which every individual realizes their own

potential, can cope with the normal stresses of life, work productively and fruitfully, and

contribute to their community (WHO, 2014). Mental health can affect anyone, at any time, but is

stressed by environmental, biological, and socioeconomic factors (Esterling, L'Abate, Murray, &

Pennebaker 1999). Mental health is also associated with rapid social change, stressful work

conditions, gender discrimination, social exclusion, etc. (WHO, 2014). Keeping this in mind,

incidence is a hard measure to find for mental health. Mental health usually is associated with

mental health disorders, which are ongoing, serious conditions.

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Finding figures for mental health disorders are important, but that does not include people

who experience periods of stress that do not have mental health disorders. The prevalence of

mental health and its detrimental effects were found using PubMed, TedX, and others using

prevalence keywords such as ‘mental,’ ‘emotional,’ and ‘depression.’ Statistics and figures found

help illuminate how widespread mental illness is globally and in the NYC community

specifically.

Globally, 450 million people suffer from mental health disorders. Although this seems

like a larger number, this goes up exponentially when accounting for all the people going

through episodes of mental illness. One in four adults (61.5 million people) in America will

experience a mental illness within this next year along with 1 in 17 (13.6 million) Americans

facing a severe mental illness, such as schizophrenia, major depression or bipolar disorder (NIH).

About 3.6% of New Yorkers face mental illness, which is below the US rate of 4%, but only

38.5% of mentally ill adults in NY state access services (SAMHSA, 2013). Breaking it down to

New York City dwellers alone, a much more urban environment than the rest of New York state,

furthers the viewpoint that the burden of mental health is continuous.

New York City has declared in their mission statement for the Community Health Survey

that “Understanding how community conditions affect our physical and mental health is the first

step toward building a healthier New York City” (King, Hinterland, Dragan, 2015). New York

City believes in the importance of mental health, for it contributes to a better state of being. The

population of interest for this internship will be college students at City University of New York

(CUNY). College is an already a stressful experience; additionally one-half of all chronic mental

illness begins by the age of 14, increasing to three-quarters by age 24 (NAMI). The New York

City Youth Risk Behavior Survey found that suicide was the third leading cause of death for

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youth in the city along with 24 to 40% reporting persistent emotional disturbance (2008). The

internship is focused on the college aged population of NYC and their mental well-being, for

they are the focus of much of the CUNY departments public health efforts.

What the CUNY Public Health Department site strives for is to, “Promote health and

social justice in New York City and across the globe through innovation and leadership”

(CUNY). This program developed specifically for this internship will take place in New York

City, but the mission of the program is to tackle a global problem. Depression is estimated by

2040 to be up there with diabetes and heart disease as one of the leading causes of disability

(WHO, 2014). Since half of all college students who drop out for mental health reasons did not

seek out mental health services (NAMI), innovative programming needs to be established to

tackle this burden.

The non-health problem the internship will address is finding innovative ways to tackle

mental health, specifically the utility of art to reduce stress. This a critical point for public health,

as result of the spread of new forms of communication, for now new innovations will spread

even more rapidly than in the past, so understanding innovations is now more important than

ever (Greenberg, 2006). College is a time of great stress and this can be exacerbated by multiple

factors, so while mental health services can intervene, their lack of unlimited funds makes them

vulnerable to not providing for each student (Stein, Sontag-Padilla, Osilla 2012, and Holterman,

2015). There has been a substantial increase in people accessing mental health services, but not

all of their needs can be met (Stein, Sontag-Padilla, Osilla 2012). Innovation allows for newer,

more democratic, and more cost effective means to go into schools to resolve shortfalls in mental

health care.

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Innovation needs to be tested, for it could lead to longstanding benefits. We need to

know much more about the implications of innovations for the public as a whole, for specific

segments of the public, for government, and for business. Innovations are successful in some

places and times and failures in others, but this information will tell us how innovators deal with

the diversity of norms that can influence the adoption and long-term prognosis of a public

health–related innovation. In some settings, public health practitioners trying to develop and

market innovative programs and tools face a much more difficult path that requires them to go

through hoops to identify the right ways to shape their innovations to their organizations specific

requirements (Greenberg, 2006). CUNY is allowing the internship to break this mold and to

utilize innovation to improve the field. Although the health and non health problem have been

approved by CUNY, there still needs to be compensation for any ethical problems that arise with

sensitive subject matter.

As with working with any population in mental health, there will be ethical dilemmas that

come up. The first ethical dilemma is how to properly address mental health while being

sensitive to each individuals’ emotional welfare. Mental health is a deeply private issue, so steps

and training need to be taken to better manage how to deal with someone who may be showing

erratic emotional health while in the focus groups. A primary ethical dilemma is not bringing in

personal bias on youth and maturity. It is easy dismiss the complexity of emotional growth,

partly because mental health is seen as a character flaw, but it is important to recognize that

people have a greater knowledge of their own health care than I could ever assume. Keeping in

mind that innovation could have unforeseen pitfalls, a SWOT Analysis Worksheet will be used

to outline some key issues that could occur from a variety of physical to cultural sources.

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The major components of a SWOT Analysis Worksheet are the strength and weaknesses

of the internal environment, and the opportunities and threats of the external environment. By

mapping out strengths and weaknesses, the interventionist will know what to expect internally

and try to compensate for these elements. For the external environment, although it can not as

likely be controlled, it is important to take into consideration what could be the assets and

challenges of the world outside the intervention. Being aware of all these elements could lead to

compensating for these elements, while being prepared for things to go well when they do and

not go well when they do not.

INTERNAL Environment

Strengths Weaknesses

Use of university funds and space for research and program implementation

Matches with the mission statement of the department

Academic environment has a wide breadth of specialties and structural knowledge

Only me and preceptor now, need to hire student workers

Cannot do some parts of the intervention without University approval such as focus groups

EXTERNAL

Environment

Opportunities Threats

Large, diverse city

Convenient population

Partnerships with local organizations

Public transit will make it less expensive for clients to come to testing

Scheduling focus groups

Continuation of project beyond May

Summer will disrupt population size

Test subjects not being able to return as a result of transfer,

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graduation

Mental health innovation is needed to further not only the mission of CUNY, but also to

further the fields of mental and public health. The purpose of innovation is to formulate new

ways of tackling complex problems that could benefit the entire public health field. Public health

touches on every challenge to our health, so finding strategies outside the norm should be

encouraged. These new strategies could go beyond what is currently offered. “Mental health

services historically have been marginalised and neglected, implying the need for the

introduction of radical innovation” (Brooks, Pilgrim, Rogers, 2011). Mental health has so many

intricacies that not one approach will help all, so a multitude of innovative approaches is needed

(Patel and Saxena, 2014).

This internship’s innovative approach to analyzing mental health is through art

programming. This will be done specifically through developing an arts based curriculum to help

the mental welfare of college students. Stress indicators will be pinpointed to focus the

curriculum. “Given the ubiquity of creative expression, as well as the relative ease of

engagement, the extent to which psychological and physiological effects are sustainably health

enhancing is an important area for public health investigation” (Stuckey & Nobel, 2010). The act

of creating art comes from an emotional reflection of everyday triumphs and challenges,

therefore art is best utilized when managing emotional health. Health psychologists have looked

at how the arts might be used to heal emotional injuries, increase understanding of oneself and

others, and alter behaviors and thinking patterns (Camic, 2008). The following changeability

matrix will relay broader contributing factors, while the conceptual model will show how certain

contributing factors lead to stress. The socioecological model for health promotion was used to

consider contributing factors of stress among college students across multiple ecological levels.

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Factors identified using this framework will then be used to develop a conceptual model of the

health problem

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Before this creation of the conceptual map, a changeability matrix was used to reduce the

variety of factors that could be used as contributors to stress. The factors included in the

conceptual map are high to moderate priority according to the changeability matrix. The

conceptual model above shows all of the factors that could contribute to stress and how stress

affects the life of a student.

Cultural factors that could be indicators of stress level could be negative or positive.

Negative cultural factors include being away from home, seeing mental illness as a character

flaw, while a positive cultural factor is the positive shift in attitudes towards mental health .

Many students’ first experience with adulthood could be going away to college, so being away

for a protracted period of time could feelings of isolation (Leibow, 2010). Many who experience

mental disorders are worried about how their new independence may affect their drug fidelity

and relation to others, which could exacerbate pre-existing conditions (Kitzrow, 2003). On the

other side, a wider cultural acceptance of mental health could lead to more people recognizing

mental health management as an important part of personal development (Berger, 2002).

Social factors are related to cultural factors, for they are the result of how the culture is

disseminated in our lives in social media, dealing with peer pressure, getting into bad social

situations, and academic pressure. Students who typically drop out of college in poor academic

standing reported difficulties with anxiety, adjustment difficulties, loneliness, and self-doubt

issues that have been identified as negative influences on retention (Tinto, 1985). Many students

felt pressure to engage in ‘normal’ college activities such as sex, drugs, and hanging out with

new people, but this could lead to relationships that could hurt one’s academic standing (Leibow,

2010). A variety of social cultural factors such as early experimentation with drugs, alcohol, sex,

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and poor interpersonal attachments may account for some of the increase of people using mental

health services (Gallagher, Gill, & Sysko, 2000).

The built environment and access to health services are separate entities, but could be in

conjunction since CUNY is an urban school. The need to provide counseling for such a broad

range of students and issues including getting to appointments on time, living with new people

(strangers), life transitions, stress, and serious psychological problems is one of the major

challenges facing college counseling centers, a challenge that can be "daunting" at times (Archer

& Cooper 1998). At the very least, the needs of troubled students can be demanding and require

extra attention and time from administrators, faculty, and staff (Kitztrow, 2003).

All of these contributing factors are important to address in the global context, but it

would be impossible to address all of these factors. Socio-economic factors and the built

environment cannot be controlled in this setting, but these system-wide problems need to be

there for context of where some stress/anxiety can come from. We wish to address the cultural

and social factors presented in the causal model, but keeping in mind that the contributions of the

built environment and access to health services are important since they provide lens upon the

daily lives of the students. Innovation is key to this strategy for it allows a new way to look at the

issue, but we must learn from the past to understand how innovation could work.

Innovation is viewed as a pressing need within the field of mental health. It is, however,

poorly understood, because it is a new field with ever-present barriers (Brooks, Pilgrim, Rogers,

2011). Sometimes innovation is seen as a failure, even if it is successful in reaching its goals.

This could be the result of a disagreement between programmatic capacities and expectations of

the organization. Health educators were not able to help their clients in ways seen as directly

relevant to policy makers (Jewell, Davidson, Rowe, 2006). A key barrier to innovation is

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programmatic complexity. Even if evidence based, a lack of similar studies could make the

program not appealing enough to replicate. (Brooks, Pilgrim, Rogers, 2011). Even in evaluation,

assessing individual project successes by the end of the evaluation was provisional, because it

was not clear what might happen to participants or the program itself in the long term (Brooks,

Pilgrim, Rogers, 2011). There has not been much innovation in mental health, but that should not

deter from trying more, for it is an asset to the field.

The outcome objectives for this internship is that it finds an innovative approach to

mental health that is not dependent upon counseling only as an intervention for emotional health.

Counseling centers are necessary for students needing those services, but they have limited space

to meet those needs. By having alternative approaches to address mental health, more students

can access services and even more students who may not be comfortable in a counseling setting

could deal with mental health issues in an expressive way. The participants will be creating art

and discussing their artistic impetus in order to address plus alleviate stress. All people can create

art and creating art is a cathartic practice, especially if it is created with a sound plan and

curriculum. Innovation is the goal of the CUNY department, but this project is not just for the

internship. It is also furthering the field into the next generation, wherein innovation can lead to

better health outcomes.

During this internship, an innovative arts program will be built based upon the knowledge

gathered during the internship. Below will be a graphic representation of the intended impact of

the program from short to long term. This will serve as the first draft of the program model.

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The art program will help better the daily lives of students, while giving CUNY a new

method of addressing student stress. Furthermore, following the socio-ecological the data and

findings collected during this internship could provide evidence that supports future mental

health related legislation. Since the program models framework is based on the socio-ecological

model, all levels of the model have been compensated for so the outcomes abide by a multi-level

intervention.

All programs have desired outcomes, but they need an idea of how to measure the

activities needed to reach the outcomes. This program’s goal is to see the feasibility of how the

arts could fit into a more traditional intervention. While expanding knowledge of the field

through this program, careful consideration needs to be put in about what steps need to be taken

for the desired result. This program will be built on creating an arts based curriculum, which

could fall into just being a collection of data and not a flow of useful information (Kimpston and

Rogers, 1986). A logic model will be used to outline how the inputs, activities, and outputs lead

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to a desired outcome. This model will be especially useful to guide the efforts of the program,

the process of how it will happen, and the instruments for evaluation.

Inputs: Resources dedicated to or consumed by the program or internship

Activities: What the program internship does with the inputs to fulfill its mission

Outputs: The direct products of program or internship activities

Outcomes:Results anticipated as a consequence of the Outputs

Use of CUNY Facilities

Campus and Dept wide emails can be used

Incentives supplied through university funds

Survey of stress indicators sent through email

Focus Group on Stress Indicators

Analyze Data on focus group

Research how art can address top stress indicators

Build curriculum around stress indicators

Focus Group on art towards chosen stress indicators

Edit Curriculum based on focus groups

Survey will have a 60% response rate so certain trends can come aboutInsight into which stressors are the most pressingDetermine which stressors to focus on for curriculumFinding 3 arts based interventions to build into curriculumBuild curriculum based on interventions that is accessible to participantsMap out level of engagement with the curriculumEdit curriculum based on feedback from the focus groups

More insight into what stressors college students see as affecting work/life balanceGreater knowledge of which stressors to focus on with college studentsWider knowledge of students perspective on stressFind what others are doing to use art in public healthHave a basis for future curriculumsHow feasible it to take existing programs and adapt them into a curriculumAdapt the program with community insight

The first step of the internship will be to send a survey to students targeting the four

different stress areas from the conceptual model: cultural factors, social factors, built

environment, and access to health services. They will be pointing out which levels of stress

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impacted their school/work/life balance the most then measure which areas are the most stressful

for students. Once all the survey data is compiled, students who identified the most changeable

stressors as their most stressful areas will be invited to focus groups. The most changeable

stressor will be determined between the intern and preceptor based on the feasibility of it being

addressed during the internship. They will be encouraged to come to the focus groups with the

promise of an incentive. It is has not been decided yet what the incentive will be, but it will most

likely be food related. At the focus group, we will get qualitative data from the group and do a

post survey to reflect on their experience in the focus group. The post survey will be qualitative

based on the reflection, but also will ask them their personal relaxation techniques to gauge

where the groups is at and how to move forward (Hopkins, 2007).

Focus group data and surveys will be analyzed to pinpoint stress areas and events that are

the most prevalent. Research will be done to see how art can influence these stress areas and

events. The literature will be reviewed to see how art therapists, psychologists, public health

practitioners, etc. have used art to pinpoint certain stress areas. Once a comprehensive literature

review has been done, then will come curriculum building (Behar, 1994). There will be some

more research if needed to see how others have built curriculum, and to mold it into a time frame

that will be discussed during development. The length of the curriculum will be based on

research during the internship. Once the curriculum has been built, the focus groups will be

invited back to do an initial activity with the curriculum. This time will also be used to reflect on

if they feel art is an appropriate coping mechanism in the college setting. Their insight will be

taken and recorded in order to analyze further how the curriculum could be adjusted for future

uses. Unfortunately, the time allowed for the internship will not be enough to implement the full

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curriculum, but the building and research for the curriculum will set a foundation for future uses

of the program.

For more insight into the sequencing of the program, below is a Gantt Chart. This chart

will lay out in two sequences when certain activities will be performed. While this is subject to

change, the basic sequence is here to direct the actions of the internship. It is important to

understand how much time should be devoted to certain parts of the internship, especially if it

turns out some parts of the internship will take longer or shorter than other parts. This chart is

also dependent upon use of CUNY facilities, which will have to be organized in advance of the

focus groups.

January February March April

Initial Survey

Analyze Survey

Stressor Focus Group

Analyze Focus Group Data

Research and Curriculum Building

Art Curriculum Focus Group

Analyze Data/Final Report

Another aspect of the internship that cannot be in concrete yet is incentives and IRB. For

the incentives they are dependent upon the amounts. The IRB cannot be attached at this time,

since the process for the IRB at CUNY has not been initiated yet. This will hopefully be initiated

soon so that by the beginning of the internship in January, recruiting for the internship could be

started.

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After all of this work into the theoretical and practical backgrounds of this internship, it is

also important to see why a personal experience like art is important to population based health.

This is the question that needs to be answered by this internship, because there are some arts

based mental health strategies already out there. While art in mental health is something that

already exists, art therapy as it stands now has the momentous barriers of having to deal with

health care system, high pay, already existing anxiety, and the barriers of getting into a clinic

(Anderson and Landgarten, 1973). These barriers are especially difficult in the urban

environment (Caracci, 2006), so finding something that could make widespread change without

too many existing barriers could prove even more beneficial. Public health has the breadth to

make widespread change, so this internship is not intended to end after May. This internship will

be the first building block in a long term process of building something that could change the

face of public health.

What I hope to contribute to the current state of knowledge about mental health is to

expand the innovative practices of the field, especially when dealing with these complex issues.

There is no question there is a prevalent need for mental health care. Public health has the

capacity to cover a variety of areas in a variety of ways. That is why the loose definition of

health allows for so many diverse programs to proliferate. Innovation will take this program even

further so that it can be disseminated to great effects in other areas and settings.

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Works Cited

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Behar, L. S.. (1994). An Empirical Analysis of Curriculum Domains: Implications for Program Development and Evaluation. Peabody Journal of Education, 69(4), 100–112.

Berger, L. (2002, January 13). The therapy generation. New York Times.

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