Development and evaluation of an undergraduate curriculum on non-communicable disease research in Guam: The Pacific Islands Cohort of College Students (PICCS)

Background The non-communicable disease (NCD) epidemic among Pacific Islanders prompted the declaration of a regional state of NCD emergency throughout the United States-Affiliated Pacific Islands (USAPIs) in 2010. Subsequently, the University of Guam Health Science Program launched a pilot study on NCD research in its undergraduate curriculum modeled after the Pacific Data for Decision Making (DDM) framework – a field epidemiology training program employed in the USAPIs. The primary objective of the research is to conduct annual assessments of student health indicators with plans for longitudinal follow-up. Here, development and evaluation of the undergraduate research curriculum are described. Methods The Pacific DDM framework covering knowledge and skills in resourcing, types of data and indicators, data sources, data management, information products, and data dissemination and use were incorporated in undergraduate core courses of the Health Science Program. During the data collection pilot years, 2013 and 2014, a survey containing questions predominantly on NCD risk factors was launched at the university. The survey was administered by upperclassmen in the Health Science Program and evolved into the Pacific Islands Cohort of College Students (PICCS) research study. The initial years were spent developing the infrastructure. Program outputs were tracked annually to measure program success. Results Students in the Health Science Program obtained research knowledge and skills through various courses while enrolled in the program. The PICCS data collection continued annually as a cross-sectional survey from 2015 to current. Numerous successes have resulted including student abstracts and publications, acceptances to summer programs and fellowships, a sustained annual health fair for college students, a grant award, and other program-related impacts. Conclusion The PICCS framework provided the organizational structure and documented tools, protocols, roles, and responsibilities to enhance consistency and reproducibility. Undergraduate students applied their knowledge and skills to an ongoing study focused on NCD risk factor surveillance of college students. Additionally, multiple research successes have been achieved through the PICCS curriculum. Plans are underway to begin the longitudinal design of the PICCS research study and sustain it through the curriculum, with room for adaptation as courses are updated over time.


Conclusion:
The PICCS framework provided the organizational structure and documented tools, protocols, roles, and responsibilities to enhance consistency and reproducibility. Undergraduate students applied their knowledge and skills to an ongoing study focused on NCD risk factor surveillance of college students. Additionally, multiple research successes have been achieved through the PICCS curriculum. Plans are underway to begin the longitudinal design of the PICCS research study and sustain it through the curriculum, with room for adaptation as courses are updated over time.
Keywords: Curriculum development, Data for decision making, Epidemiology, Health disparities, Minority health, Native Hawaiian or other Pacific Islander, Non-communicable diseases, Public health, Undergraduate research, US-Affiliated Pacific Islands Background Non-communicable diseases (NCDs), including cardiovascular diseases, cancer, respiratory diseases, and diabetes, remain among the leading causes of death globally. Combined NCDs account for 71% (41 of 57 million) of all deaths [1], with a projected increase to 52 million by 2030. In the Pacific region, 40% of the 9.7 million residents endure NCDs while 75% of deaths are NCD-related [2]. To mitigate NCDs in the Pacific, stakeholders developed and circulated the NCD Roadmap suggesting a multisectoral approach to implement four key strategies: control tobacco use through increased taxes, reduce consumption of foods and drinks linked to NCDs through policies, improve efficiency and impact, and improve evidence base for decision making [3]. Monitoring and surveillance of NCD-related health indicators have been prioritized through the Pacific Monitoring Alliance for NCD Action framework in at least 22 Pacific Island countries and territories, including those affiliated with the United States (US) [4].

Response to NCDs in the USAPIs
Ministers and directors of health from the USAPIs form the Pacific Islands Health Officers' Association (PIHOA). In 2010, PIHOA declared a Regional State of Health Emergency due to the NCD epidemic in the USAPI through Board Resolution #48-01 [22]. Prior to the resolution, the Pacific Chronic Disease Council (PCDC) developed a Pacific NCD Collaborative Initiative assessing the USAPIs' NCD-related services and expanding the population outreach [23]. Subsequently, Board Resolution #48-01 reinforced the development of an NCD strategic plan among the USAPIs. PIHOA guided the islands on development and implementation of their strategic plan through participation in an epidemiology training program for Pacific health workforce [24] adopted from the Pacific Data for Decision Making (DDM) Program [25]. The primary objective of the Pacific Islands Cohort of College Students (PICCS) research is to conduct annual assessments of NCD health risk factors of students enrolled at the University of Guam (UOG), with plans for a long-term longitudinal follow-up. In this paper, the development and evaluation of the undergraduate research curriculum are described.

Pacific Islands Cohort of College Students (PICCS) curriculum
The Pacific DDM framework, which aligns with the Health Metrics Framework, incorporates six major components of health data utilization to inform decisionmaking. The components include resourcing, types of data and indicators, data sources, data management (data collection, data entry and storage, data cleaning, data analysis and interpretation, organizing and presenting data), information products, and data dissemination and use [24]. During 2013 and 2014, the UOG Health Science Program adopted components of the Pacific DDM framework as it began exploring a sustainable approach to undergraduate research. A pilot survey of health questions predominantly on NCD risk factors was launched. Individuals eligible to participate in the survey were students currently attending the university and at least 18 years of age. The survey was administered by upperclassmen and evolved into the student-led PICCS research study.
The Pacific DDM concepts and the PICCS activities were phased into selected Health Science Program core courses described in Table 1. The insertion of population health research-related themes such as health assessment, study design, data collection and analysis, dissemination, translation, and application were scaffolded from sophomore level courses to senior level courses. Specifically, students were introduced to anthropometry (HS200), NCD risk factor assessment (HS216), study design and survey development (HS405), PICCS data collection (HS416), analysis (MA387), dissemination (HS451), translation (HS491), and application (HS498). These curricular concepts corresponded to components of the Pacific DDM framework.

Research study
The PICCS research study has been incorporated in the Health Science Program. Data collection was piloted in 2013 to 2014 in the HS416 course and conducted annually thereafter as a cross-sectional survey on the health status of college students. Initial ethics approval was obtained in 2013 (CHRS#13-96) from the Committee on Human Research Subjects at the University of Guam and remains current (CHRS#20-121). Recruitment for participation in the PICCS research study was held every Fall semester in HS416 from September to December. Individuals eligible to participate in the survey were students at least 18 years of age and currently attending the university. Over the years, participants were recruited through announcements via word-of-mouth, flyers posted throughout campus, social media, and the university's student email list. Except for Fall 2020 due to the coronavirus pandemic, face-to-face interviews were conducted on campus in a designated research room. All the study materials and equipment were kept secured in locked cabinets or by locking the room accessible only to two research teams.
Years 2015 to 2017 were spent developing the processes and establishing the infrastructure according to Fig. 1. Instructors remained principal investigators (PI) throughout the project. During junior and senior year, student researchers were upgraded to co-investigators and assumed one of the following roles: 1) Coordinator -Project Coordinator (assisted PI with trainings, scheduling, operations, logistics) or Data/Quality Assurance Coordinator (assisted PI with standardization, equipment calibration, survey completion); or 2) Collector -Recruiter (sought participants), Interviewer (administered questionnaires), or Measurer (collected body measurements). All student co-investigators practiced roleplaying the informed consent process and administering the questionnaires several times before recruitment commenced each year. Measurers were trained and standardized to collect height and weight measurements using similar protocols from the Children's Healthy Living (CHL) Program [26]. Measurers who did not pass the standardization were encouraged to select from other co-investigator roles.

Data collection
Initial health indicators were selected by research students in 2013 and 2014 based on the Healthy People 2020 topics taught in the HS200 course, perception of relevance, and availability of tools. Subsequently, indicators were added or modified as seen in Table 2 by request or to reflect changes to other local surveys such as the Guam Behavioral Risk Factor Surveillance System (BRFSS), the CHL Program, and the University of Guam/University of Hawai'i Cancer Center cuff, sphygmomanometer, and stethoscope) and digitally (with automated blood pressure machine), and acanthosis nigricans [27]. The measurer performed the anthropometry and reported the numbers for the interviewer to record. Measurements continued until two consecutive measurements were within ±0.2 units, except for blood pressure which was measured at least twice regardless of reading. Self-reported data included background information [28] (demographics and culture), food security and spicy food intake [28], areca nut use [29], sexually transmitted infections (STIs) awareness [30], physical activity [20,31], personal medical history, sleep [32], stress [33], anxiety and depression [34], occupational and environmental exposure [35], and questions adopted from the BRFSS including alcohol, dental  visits, e-cigarettes, fast food consumption, fruit and vegetable consumption, health care access, medical marijuana, and tobacco use [36].

Evaluation
Outputs of the Health Science Program were tracked annually to measure the success of the PICCS curriculum. Tracked outputs included the number of PICCS-related abstracts and publications, acceptances to summer programs and fellowships, annual health fair activities, contributions to external research funding, and overall program impact (number of Health Science student internships and graduates with PICCS research experience). Additionally, the student researchers submitted comments on their experiences during HS451, the final research course in the program.

Results
The Health Science Program successes related to the PICCS from the years 2015 to 2020 are listed in Table 3. In addition to the successes tracked, the student researchers provided positive comments and suggested areas for improvement. The positive comments included an appreciation for enhanced research skills and the opportunity to engage stakeholders: "My research skills have actually improved … searching for and citing peer reviewed articles." "I used software to create visual data in a way that would be legible to Non-Health Science majors to ensure they would be able to interpret …".
"Another good experience was that we had a feedback loop with our instructor in which we submitted our research and feedback would be given to us promptly … This process happened multiple times … in the research and writing process." "The HART Fair gave us a chance to be part of an activity that benefits a population. These are skills many of us will use when performing outreach in the community post-graduation." The suggested areas for improvement were directed towards enhancing dissemination.
"Increase the number of classes involved in hosting the HART Fair … nursing class, psychology class …".
"Invite other student organizations and challenge them to focus on health, mental health, wealth, civics, and social justice (all of which pertain to health)." "Provide clear criteria and evaluation of group contributions." "Transitioning from face-to-face to online event during the pandemic was stressful at first … should incorporate more committee meetings...consider expanding presence on social media platforms." The first category of program successes listed in Table  3 is student internships with various government and non-government organizations. The internships corresponded with the number of graduates as internships were performed during the semester of graduation. Over 200 undergraduates were enrolled in the program each year, with a range of 9 to 12% graduating each year. Other successes included a total of 17 student and faculty abstract presentations at conferences, one research grant award from the National Institute on Minority Health and Health Disparities (NIMHD) under the National Institutes of Health (NIH) (Grant Number 5U24MD011201), development of a 1-credit computer laboratory course added to the MA387 statistics course to enhance students' statistical skills in research, creation of the village health profiles for 19 villages and shared with the mayors of the villages, and one student-led manuscript publication [37]. Three students were selected to participate in the Centers for Disease Control and Prevention Undergraduate Public Health Scholars (CUPS) Program [38], but unlike the CUPS, the PICCS curriculum engages students over multiple undergraduate years. Three other students were selected to participate in the Child Health Assessment in the Pacific Undergraduate Summer Fellowship Program [39]. Over the years, the program has maintained a leadership role on the Data and Surveillance Team of the Guam Non-Communicable Disease Consortium and continued to host the annual Health Awareness to Reach Tritons (HART) Fair, which is an event initiated by students from the 2016 class to share the research results with their fellow Tritons (UOG's mascot). Although not an intended outcome, the HART Fair evolved into a space for linking students to disease prevention activities (e.g., nutrition education booths, physical activity competition, meditation demonstrations) and free services (e.g., access to tobacco prevention and cessation coordinators, access to tests for sexually transmitted infections). The impact of this linkage on NCD prevention among the college students may be further explored.

PICCS as a sustainable undergraduate training for research
Students majoring in the Health Science Program at the University of Guam beginning 2013 received training on the knowledge and skills pertinent to research ethics, planning, implementation, analysis, dissemination, and translation of the PICCS study through core courses described in Table 1 and reinforced in other courses required of the program. The incorporation of PICCS activities into the program courses encourages sustained undergraduate research experiences, with room for adaptation as courses are updated over time. Students' suggestions for improvement would be considered with course updates. For example, the PICCS learning outcomes could be aligned with those of courses from other interested disciplines across campus. Criteria and evaluation of collaborative group efforts will be articulated.
The engagement of undergraduates in research has been a practice for many years. The US National Science Foundation first launched an undergraduate research program in 1958, and two decades later the Council on Undergraduate Research was formed [40]. There are many programs promoting undergraduate research experiences, especially in the fields of science, technology, engineering, and mathematics [40], and some are now promoting course-based undergraduate research experiences to reach undergraduates in masses [41]. The PICCS curriculum may be considered an expansion of this course-based undergraduate research experiences, with the research experience sustained through the PICCS research study targeting college students. The university presents a unique space for young adults to lead research targeting their peers and translate findings into meaningful outcomes. In 2013, the average age of undergraduates at the University of Guam was 23 years old [42] which is in the age range of when the propensity for health risk taking, such as drinking alcohol and smoking cigarettes, is heightened [43]. Fortunately, young adults are in a period of their life when "mistakes and failures can be reversed" and they are "responsive to education and training and to incentives to create and contribute." [44] Thus, the PICCS curriculum offers a critical window of opportunity for health risk interventions including education, training, and innovation among young adults in college.

Future plans
Plans are underway to begin the longitudinal cohort design of the PICCS. Research participants that consented to be recontacted will be invited to participate in the follow-up. The PICCS team will develop additional tools, methods, and processes, including the follow-up schedule, in preparation of the NCD cohort of college students.

Conclusion
NCD morbidity and mortality are problematic even in the remote areas of the Pacific where challenges are further exacerbated by distance and limited resources. Through the PICCS curriculum, students learn research and apply their knowledge and skills to an ongoing study focused on NCD risk factor surveillance of college students. Incorporation of the PICCS in an undergraduate curriculum provides a unique opportunity for young adults to lead research targeting their peers. The PICCS framework provides the organizational structure and documented tools, protocols, roles, and responsibilities to ensure consistency and reproducibility. Plans are underway to begin the prospective follow-up design of the PICCS research study, which can be sustained through the curriculum with room for adaptation as courses are updated over time.