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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.
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

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

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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.
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

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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.
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

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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,
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

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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.
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 about
Insight into which
stressors are the
most pressing
Determine which
stressors to focus
on for curriculum
Finding 3 arts
based interventions
to build into
curriculum
Build curriculum
based on
interventions that is
accessible to
participants
Map out level of
engagement with
the curriculum
Edit curriculum
based on feedback
from the focus
groups
More insight into
what stressors
college students see
as affecting
work/life balance
Greater knowledge
of which stressors
to focus on with
college students
Wider knowledge
of students
perspective on
stress
Find what others
are doing to use art
in public health
Have a basis for
future curriculums
How feasible it to
take existing
programs and adapt
them into a
curriculum
Adapt 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

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