{'fraction_non_alphanumeric': 0.019479257747984067, 'fraction_numerical': 0.006460701447585738, 'mean_word_length': 5.471864193649796, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 2, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Beginning Early: Reflective Practice Development in a Pre-health Course on Health Literacy and Health Disparities

Background : Learning reflective practices and understanding the complexity of health literacy and health disparities need to start early in health professions training. The primary objective of this inquiry was to evaluate the feasibility and effectiveness of using reflection categorization for assessing learner progression on reflective practice development. The secondary objective was to evaluate student reflection as a strategy for introducing and advancing pre-professional learners' understanding of health literacy and health disparities. Case Description : Within an online undergraduate health literacy course, two written reflection assignments were coded using Kember’s four categories: habitual action, understanding, reflection, and critical reflection. Students received feedback based on this reflection categorization to promote development of reflective practices. However, reflections were not graded using the reflection categorization. Case Themes : Most (78%) students were at the level of understanding for the first reflection. For the second reflection, 29% of students were at the reflection level, demonstrating health literacy application and describing the important contributing role of personal context to health outcomes. Sixteen (33%) students progressed in their level of reflection. Within the reflections, students discussed knowledge gained and plans for future application. Conclusion : Using a structured reflection activity allowed pre-health students to begin developing reflection practices. Through reflection, students were able to describe and apply health literacy and health disparities knowledge.

Challenges, such as packed curricula and lack of established approaches and assessment strategies, are stated as reasons for the lack of progress on this common goal across the health professions education programs. 4 Addressing topics as systemic and complex as health literacy and health disparities will require the use and evaluation of multifaceted and longitudinal approaches, including pre-professional education. Teaching topics such as health literacy and health disparities should focus on application 5 and start early, in undergraduate studies rather than solely in health professional curricula. 6 As a result, a health literacy course for undergraduates was designed for the purpose of preparing future health professionals to be reflective practitioners, who are knowledgeable and empowered to address health disparities.
In 2018, a 15-week asynchronous online undergraduate course was designed to focus on health literacy and its implications for patients, healthcare providers, and the healthcare system at large. The course involves 10 weeks of instructor-facilitated small group discussions with course topics including defining and measuring health literacy, disparities in healthcare, cultural competency, communication strategies, strategies to improve health literacy for individuals and at the system level, and navigating health insurance. Students are divided into small groups of six to nine students and an instructor, and begin the semester with video introductions. For each discussion week, instructors introduce the week's topic with a short, recorded presentation and/or applicable newspaper or journal article. Students are provided an initial discussion prompt for the week, available to them the Thursday before the week begins.
Students are expected to respond (with 200 words minimum and include a source) to the initial prompt by Monday at midnight. On Tuesday, the instructor posts a detailed response to each group, making sure to highlight contributions by each student and amplify student insights, specifically mentioning each student by name. Instructor responses end with the next questions or activities for the group to engage with for the week. By Wednesday at midnight, students are expected to respond to the Tuesday prompt with another post of at least 200 words with a source. To encourage dialogue among group members, students are also asked to post questions to at least two different group members. By Friday, students are expected to answer any question(s) asked of them by their group members. See Appendix A for an example of a week's discussion prompts. To encourage the creation of safe and productive spaces, students remain in the same groups all semester. In tandem with the outward-focused writing in the discussions, students also engage in reflective writing at specific points during the semester. Students begin the course by writing personal learning objectives, to aid in applying course content in a personally meaningful way. Creating personal learning objectives is a critical component of the course and has been shown to foster learner engagement and enrich the student learning experience. 7 In addition, there are two reflection assignments that provide students with space to revisit their objectives and consider their own reactions to the content. Reflection also provides the space for students to consider their own role in addressing health disparities and the ways their current life experiences offer opportunities to intervene. The two course instructors are experienced in online education and practice in underserved populations.
Guided reflection is a key activity for confronting and processing potentially uncomfortable and dissonant ideas regarding sources of health disparities. 8 Developing intentional habits of reflection are essential for becoming a reflective practitioner 9 and an understanding of health literacy and health disparities needs to begin before entry into a health professional program. The course was designed to draw on established theoretical frameworks of reflective practice and critical consciousness. 9,10,11 The primary objective of this inquiry was to evaluate the feasibility and effectiveness of using reflection categorization for assessing learner progression on reflective practice development. The secondary objective was to evaluate student reflection as a strategy for introducing and advancing preprofessional learners' understanding of health literacy and health disparities.

Case Description
Fall 2020 was the fifth offering of the course, with each offering having successful outcomes of students demonstrating understanding of health literacy and health disparities topics. To further emphasize reflective practice, we explored the use of reflective categorization to help students construct their own understanding of health literacy and the impact of health disparities. For the Fall 2020 semester, the reflection activity (Reflection 1 and Reflection 2) was revised to incorporate the use of four reflection categories described by Kember et al.: habitual action, understanding, reflection, and critical reflection. 12 (Table 1) The reflection categorization was used to provide a clear definition of the reflection categories and a progression roadmap for learners. This, combined with the personal learning objectives each student created at the beginning of the course, fostered a sense of personal responsibility and agency.

Reflection category Definitions
Habitual action • The answer shows no evidence of the student attempting to reach an understanding of the concept or theory which underpins the topic. • Material has been placed into an essay without the student thinking seriously about it, trying to interpret the material, or forming a view. • Largely reproduction, with or without adaptation, of the work of others.

Understanding
• Evidence of understanding of a concept or topic.
• Material is confined to theory.
• Reliance upon what was in the textbook or the lecture notes.
• Theory is not related to personal experiences, real-life applications or practical situations.

Reflection
• Theory is applied to practical situations.
• Situations encountered in practice will be considered and successfully discussed in relationship to what has been taught. There will be personal insights which go beyond book theory.

Critical reflection
• Evidence of a change in perspective over a fundamental belief of the understanding of a key concept or phenomenon.
• Critical reflection is unlikely to occur frequently.
Reflection is a commonly used educational strategy, but a clear purpose for the assignment and timely and personalized instructor feedback is not always employed, leaving students to potentially misunderstand the intended outcome and minimize the importance of the activity. To address this issue, the reflection categorization was explained to students at the beginning of the course to emphasize the importance of the activity and to make explicit the learning roadmap beyond this particular course. Students were provided the definitions of the four categories in the assignment directions. The reflection categorization also served as an intentional way to support learners as they were confronted with potentially distressing topics, providing students with a structure for processing and also receiving feedback. Students were asked to not only gain understanding of health literacy principles and be exposed to health disparities data, but also attempt to examine health disparities through their own lived experience and identities. 10,11 To emphasize the goal of examining health disparities through their own lived experience, both Reflection 1 and Reflection 2 directed students to consider their progress on the personal learning objectives they created at the beginning of the course.
Reflections were required to be one to two pages in length, double spaced. Reflection 1 was due in week nine of the course and Reflection was due in week 15. The reflection assignments were designed as a measure of both expanded understanding of health literacy and health disparities and personal sense of empowerment to make a difference (See Appendix B for reflection directions and prompts). The reflection categorization (Table 1) was used to provide feedback to students to promote the growth and development of reflective practices. A rubric was used for grading, and assessed structure, mechanics, if questions posed were thoughtfully answered, and if specific examples were provided. When grading the assignments, instructors provided written comments, including the level of reflection. However, students' reflection grades were not based on their level of reflection as described in the assignment directions (Appendix B).
For the inquiry, four investigators independently reviewed both reflections and coded each submitted reflection into one of the four reflection categories. The whole reflection was reviewed to determine the reflection category. The category of reflection and any comments justifying the selected category were recorded into a spreadsheet. Then the investigators met to discuss any discrepancies and came to a consensus on how each reflection should be coded. Any reflections with discrepancies in coding were reviewed and discussed as a group until the group reached consensus. The number of reflections within each category for each reflection assignment and the number of students who moved categories between the two reflections were analyzed using descriptive statistics. Comments from student reflections on their development were categorized by two instructors. At the same time, a summary of the types of reported insights gained on health disparities and health literacy was developed. The project was determined to be not human research by the Institutional Review Board at the University of Minnesota.

Case Analysis
For the Fall 2020 offering, 54 students enrolled in the course and 52 completed it. Fifty-one (98%) students passed the course and one student received an incomplete. The majority of students were seniors (63%) in sciences/health-related majors (63%). In course introductions, 33 (63%) students stated that they intended to pursue a health-related career. Examples of those intended careers included genetic counselor, pharmacist, physician, physician assistant, nurse, nurse practitioner, health services manager, and health coach.
The reflection categories coded for each reflection are shown in Table 2. Most (78%) students were at the level of understanding for Reflection 1. For Reflection 2, 29% of students were in the reflection level compared to 10% for Reflection 1. The majority (60%) of students remained at the same level of reflection for both assignments (Table 3). Sixteen (33%) students progressed in their level of reflection, including one student who moved from habitual action to reflection over the course. In the reflections, students discussed the following topics: difficult topics in a safe learning space, knowledge gained, plans for future application, and the reflective categories (Table 4).

Reflection level Reflection 1 n (%)
Reflection 2 n (%) Habitual action 6 (12) 3 (6) Understanding 38 (78) 33 (65) Reflection 5 (10) 15 (29) a Three students did not submit an assignment for Reflection 1 and one student did not submit an assignment for Reflection 2. Understanding to habitual action Reflection to understanding 3 (6) 1 2 a Four students did not have submissions for one of the assignments. b One student moved two levels. "I have made a bigger attempt to learn more about their culture and incorporate that in their day to day lives (celebrating their cultural holidays in addition to American holidays)."

INNOVATIONS in pharmacy
Reflective categories "My last reflection was put into the 'Understanding' category, and I agreed with that assessment. I tried to use more specific examples in this reflection, and apply things I have learned to more realistic situations that may occur in the future for me." "When looking back at my previous reflection… I believe I was struggling trying to find real life applications… So, I was certainly surprised that I was able to apply my knowledge about strong communication with your doctor to a real experience. Even though it wasn't my direct experience, I am very happy that I was able to help my families [sic] understanding of healthcare visits and encourage them to be willing to communicate."

Instructor Summary of Student Insights from Reflection Assignments
In both reflections, many students discussed how they now recognize their own privilege in healthcare settings and will bring this awareness with them into their future careers. Students also discussed feeling more informed about systemic racism and disparities in the healthcare system. Some students discussed learning about their own implicit bias and plans they have for continued learning and growth. Multiple students described the importance of action from both individual healthcare providers and the healthcare system to address gaps in health literacy and to reduce health disparities. Students proposed strategies they will use to improve patient and community-wide health literacy in their future health careers. Interestingly, many students also discussed how this will change their personal behavior as a patient, such as asking more questions, clarifying information when they feel confused, and using reliable sources of health information.
Students also reported the value of hearing multiple viewpoints from their group members during discussions, which fostered diverse voices when considering complex course topics such as implicit bias and health disparities. Students discussed feedback from their peers and instructors and expressed appreciation for being asked difficult questions by group members.

Exploration of Case Impact
In this undergraduate, asynchronous online course of primarily pre-health profession learners, the combination of reflection practices and new health literacy and health disparities knowledge increased awareness of the health professional's role in addressing health disparities and the possibility to influence change through culturally-informed practice (Table  4). By the end of the course, 29% of students demonstrated skills at the level of reflection in Kember's reflection categories (Table 2), meaning they were able to apply what they learned, as well as share personal context to health literacy and health disparities.
Giving structure and explicit definition to the reflection assignments may have provided learners with an enhanced sense of purpose to the activity. Reflection as an educational activity is commonly used, but not consistently implemented or guided. There is suggestion that assessing reflection corrupts the key purpose of reflection and that students may not engage with the activity in a way that enhances personal learning. 13,14 The use of reflection in this design was to address these documented challenges; specifically, not assigning a grade based on level of reflection and providing individualized feedback based on the learner's own personal learning goals.
These are learners early in their career journeys, so finding that many students began and remained at the understanding level of reflection is not surprising given that the reflection level requires personal application. Many of these learners simply may not have had an opportunity to apply. Additionally, some students faced challenges with application of their learning as the opportunities for experiences during the COVID-19 pandemic were limited for some. Despite this, 33% of students were able to progress along the reflection continuum (Table 3), and most students were able to articulate the importance of practicing reflection even without reaching the level of reflection.
In the reflection assignments, students were able to articulate an expanded understanding of health disparities and also state ways they can make a difference now and in the future. Systemic and complex societal issues, such as health disparities, can seem overwhelming to an individual and lead to deferring to government, healthcare systems, and other mechanisms to address the problem. The structure of the course was intentionally countering this common response by having students examine these issues through their own personal goals and the ways their current life experiences offer opportunities to intervene. Health literacy topics are complex, posing challenges for creating meaningful and engaging educational activities. 15 The hope of this design was to create a sense of empowerment among a group of early health professional students by nurturing the habit of reflective practices, following recommendations to focus on application and starting in undergraduate studies. 5,6 While this course experience showed some movement towards Kember's highest level of reflection (reflection), ways to increase the percentage of students who are able to move into this category over a semester needs to be explored. Further, incorporating this strategy into other educational experiences to expand the number of students practicing this important skill as they move towards becoming practicing healthcare professionals should be explored.
One limitation of this inquiry is that it was an evaluation of a single offering of this course. In addition, a potential unintended consequence of the reflection categorization could be learners trying to contrive experiences to meet a higher reflection category. Even though the reflection category feedback was separate from the grade received and the directions explicitly acknowledged that it may not be possible to meet the higher reflection criteria due to lack of application opportunities, some students may have still viewed the reflection categorization as a type of assessment. However, the instructors did not find this to be the case. A few students may have tried to relate experiences that were somewhat tangential, but the experiences they were describing seemed authentic.

Conclusion
Health literacy and health disparities are important considerations for clinical practice, and health professionals must understand and acknowledge the influence of health disparities, culture, and environment on interpretation of information and decision making. Learning reflection practices and beginning to understand these complex topics needs to start early in training. Through reflection, students were able to describe and apply health literacy and health disparities knowledge. Using a structured reflection categorization for feedback allowed pre-health students to begin developing reflection practices.
Funding/Support: none Conflicts of Interest: none