A Delphi study to curriculum modifying through the application of the course objective and competencies.

BACKGROUND: In order to incorporate new knowledge, skills and emerging concepts from dynamic fields of public health into ongoing courses reform of curriculums sounds necessary. Accordingly, this study was performed to modify health education curriculum of public health undergraduate level.
MATERIALS AND METHODS: Using Delphi technique, 18 health education lecturers from Tehran, Tabriz, Yazd, Shiraz, Gonabad, Ghazvin, Avhvaz and Kurdistan Universities Medical of Sciences based on their expertize in health education with PhD degree as scientific members, also 5 heads of departments according to working at health deputy for at least more than 5 years were asked during three rounds through panel experts to suggest and rate topics they deemed most important to graduate public health experts and curricula related to the areas of knowledge and skills in health education course.
RESULTS: The experts suggested that health enhancing behaviors and reduce health risks, advocate health, behavior change theories and developing a framework are key objects in the curriculum. Much more new topical outlines were related to previous course. Skills rated as important included need assessment and health communication. The most evaluators suggested that adding a practicum unit to two theory units will be helpful.
CONCLUSION: The results from our survey suggested that changes in the course definition including new course objectives, topical outlines, and required skills were deemed important by the lecturers and were appropriately integrated into the health education course curriculum. The new curriculum should be evaluated constantly to seek and provide experiences that will best prepare students to meet challenges as a health educator.

INTRODUCTION

Transition from control of preventable diseases toward chronic and emerging diseases promotes protective behaviors and defines a new approach toward the role of health education in health care system. Based on this new approach, reduced illness, death, and advanced health care could best be achieved through a focus on health promotion and disease prevention.[1] Recommended strategies to improve teaching of public health at undergraduate level[2] along with requirements and challenges facing health education experts show the importance of the health educator responsibility. The role of a health educator is placed on the heart of the new approach.[3] A health educator is who “serves in a variety of roles and is specifically trained to use appropriate educational strategies and methods to facilitate the development of policies, procedures, interventions, and systems conducive to the health of individuals, groups, and communities.[3] National commission health education[4] outlined health educators’ seven areas of responsibilities as follows: Planning assessment processes; planning health education; health education implementation; conducting evaluation and research related to health education; administration and managing health education; severing as a health education resource person; communication and advocate health education. However, the goal of health education is the transference of understanding into healthy behaviors.

Employers state frequently that new graduates as health education experts often have difficulty adapting to the range of tasks required in their workplace. Medical sciences universities in general and the health schools in particular must define how or what curricula content would be presented within an academic training program to meet the diverse needs of the society. Curricula usually define the learning that is expected to take place during a course or study program in terms of knowledge, skills and attitudes.[5] Health higher education curricula should include mastery of basic skills based on the latest scientific finding, conducting research, planning learning experiences based on sound theories to provide the opportunity of acquirement of information and the skills needed to make quality health decisions.[3] Despite expanded theoretical and experimental behavioral sciences in the context of health promotion programs, in recent years, there have not been renewed efforts to modify health education curriculum in bachelor degree of public health to include applying behavioral sciences or practical communication health skills. Furthermore, no survey was conducted to evaluate inconsistencies in what was being taught in health education course for public health students across the demands of the new approach of health education in workplace. The research team members of the current study who were three health education specialists encouraged conversations among 9 health education specialists known as lecturers and department health education heads from 5 universities to modify, expand, and standardize health education curricula to meet the challenges graduates encounter in future workplace. Health education lecturers also provided feedback from their students who were dissatisfied with the course and had difficulty adjusting with the majority of the health education topics, which were either so impractical in the real world or were duplicated in educational technology course or other courses. Results of the conversations supported the importance of improving curriculum by adding core competencies to health education course. According to the defined areas of responsibilities of health educators and tasks expected from graduates, the current curriculum of health education in undergraduate public health level needs to be modified. The modified curricula should strive to include mastery and procedures provided through courses and research activities in order to help the students to meet the workplace requirements. The goals of revising the curriculum should be consistent with the national education associations’ principles[6] such as faculty control, equal access to the qualified education for all students, and multicultural understanding. It also is expected that institutes of public health are set of core competencies that all health educators should possess and has recommended that these be used as an overarching vision for all health care professional education in the 21st century[7] that including: Education; work in interdisciplinary teams; employ evidence-based practice; apply qualify improvement; utilize informatics. Therefore, this study was performed to modify the public health undergraduate health education curriculum.

MATERIALS AND METHODS

The Delphi technique using objective sampling method was used to explore experts’ opinion through panel experts about health education curriculum modification in undergraduate-level of public health. Twenty scientific members from 8 universities and 5 heads of departments from 5 provinces were selected based on their expertize in health education with PhD degree as scientific members or working at health deputy for at least more than 5 years. Thereafter, the experts were invited to participate in this study through an email stating the aim of the study in addition to the current health education curriculum. In total, 18 scientific members from 8 universities and 5 department heads from 5 provinces agreed to participate.

Data collection and analysis

In the first round of this study, each expert was asked to respond to the following questions in short answer form with up to 10 non-similar responses and to express her/his opinion and rational justify if necessary:

What is the health education course description?

What course objectives are essential to support health education course description?

How is the arrangement offering course objectives?

What topical outlines are essential for achieving the course objectives?

What skills and competencies should the students have to meet the requirements of their future workplace?

Panel experts were also asked about the number of units needed to achieve the course objectives, and they were asked if these units should be taught theoretical or as a practicum?

Twenty-three experts answered the questions. To extract and distill group, round 1 suggestion into logical categories and phrase for course description the constant comparative technique[8] was applied. The constant comparative is a method for analyzing data in order to identify a phenomenon, object, event or setting of interest. The validity of the data in this study was supported through reviewing all raw results and categories by at least 3 research team members.

In the second round, participants were provided with the distilled suggestions and were asked to rate the “importance” and “to be suitable” of each on a five-point Likert scale ranging from 1 = unimportant, 2 = somewhat important, 3 = unimportant or not applicable, 4 = important, and 5 = very important and 1 = unsuitable to 5 = very suitable. According to the results of the second round, in order to elicit consensus on items rated as important, the research team decided to remove the statements with a mean of less than 3.5. In addition, the statements with a standard deviation of greater than 1 were removed, except those with above 55% of distribution of scores or more than 4 or 5 rated values.

In the third round, participants were presented their prior individual rating from round 2 and group mean rating. They were asked if they accepted the first ratings, and if not, to revise their ratings. Descriptive statistics including mean score and standard deviation (SD) were computed to describe the final round. The Statistical Package for the Social Sciences (SPSS) version 16 was used for all statistical analyses.

RESULTS

Course description

After the experts provided their definition of course description the main themes were extracted. Six main concepts based on mean rating for each definition were as follows: Identification of the factors that influence health, concepts of learning and behavior change, development of teaching skills, introductory theories and models of behavior change, identification of the competencies and skills of health educators, current and future issues in health education. The research team arranged these into the following phrase: This course focuses on many factors that influence health and emphasis will be placed on the concepts of learning and behavior change, development of teaching skills for health educator, using appropriate educational strategies and methods in the interventions conducive to the health of individuals, groups, and communities, and current and future issues in health education. The majorities of the experts (89%) assessed the above description very suitable.

Course objectives

In the first round, 83 experts’ personal suggestions as the priorities of the course objectives were collected. Then, at the final round of the study, the 37 remained non-identical suggestions with average rating of 3.5 and higher were classified into 16 categories. Some new objects have been included in the suggested curriculum and some were kept the same. Health enhancing behaviors and avoid or reduce health risks, advocate for personal, family and community health, learning and behavior change theories and models, developing a framework or model of change were new objects included in the suggested curriculum. In addition, the object of learning principles was modified by focusing on human learning and behavior modification [Table 1].

Table 1

Priorities of course objectives with mean rating of more than 3.5 in health education course for undergraduate degree in public health

Arrangement offering course objectives

After investigating the opinions related the arrangement offering course objects during a term, suggestions rated 3.8 - to 4.9 deemed suitable order. Results are shown in [Table 2].

Table 2

Arrangement offering course objectives with mean rating of more than 3.5 in health education course for undergraduate degree in public health

Topical outlines

More than 182 topical outlines were provided by the experts. These were each categorized in terms of course objectives. Seventy eight non-similar suggestions remained at the completion of the survey. Besides, the 49 new suggestions were rated from 3.6 to 4.9 as topical outlines to support course objectives. Much more new topical outlines were related to previous course objectives including principles of learning renewed by emphasis on human learning and behavior modification, application of teaching and learning principles in the development of a teaching project, relationships among behavioral and environmental and factors that affect the health, evaluation of health education programs and communications. Remained topical outlines rated very important or important were associated with the new objects including learning and behavior change theories and models, developing a framework, health-enhancing behaviors, avoid or reduce health risks and advocate personal, and family and community health. Results are summarized in Table 3.

Table 3

Topical outlines related to course objectives with mean rating of more than 3.5 in health education course for undergraduate degree in public health

Skills and competencies

As it is shown in Table 4, the experts agreed on a variety of experiences essential for public health students to be better prepared. Need assessment process, implementation of a plan of action, as well as plan communication in health education programs were rated as very important skills. Other important ideas included conduct evaluation and research related to the health education, serving as a health education consultant and being engaged in health education advocacy.

Table 4

Experiences desired in health education course. Skill categories were derived with mean rating based on likert scale of 1=unimportant to 5=very important for these suggestions in round 3

Number of units

As application of behavioral theories needs practical implementation, most evaluators (84%) suggested adding a practicum unit to two theory units. Their justification was simplifying the course in the areas of behavioral theories and research in health education.

DISCUSSION

Revision of health education curricula in health schools has not taken place at regular intervals and the changing health needs of the communities and graduates have not been considered.

The current health education course definition has failed to include the defined role definition from ministry of health and medical education, health care, research and educational role. Inconsistency between expert public health role definition and health education course definition stimulated revising the course curriculum. Previous definition aimed to get familiar with the concepts, principles of health education and to acquire planning ability, and to implement and evaluate health education programs. However, revised definition emphasizes on social, economic and environmental conditions influencing the health, individual risk factors and risk behaviors, using educational strategies and methods to facilitate interventions in the health of individuals, groups, and communities.

As a course definition contributes to development and definition of course objectives, it was necessary to revise the course objectives.

The panel experts did not completely eliminate the previous objects. Considering importance of introductory on health education, role of health education in health promotion, principles of learning, planning of health education, health communications, assessing community needs and resources, evaluation of health education programs, research in health education and future trends in health education were kept the same. Health education in diverse settings, health-enhancing behaviors and avoided or reduced health risks, advocate personal, family and community health, learning and behavior change theories and models, developing a framework or model of change and application of teaching and learning principles to the development of a teaching project, in addition to the relationships among behavioral and environmental factors affecting health were new objectives.

Because health is affected by a variety of positive and negative factors within the society, the relationship among behavioral and environmental factors was included as a new objective. This object with 76.47% favorability focuses on identifying and understanding the diverse internal and external factors that influence health practices and behaviors including personal values, beliefs, and perceived norms. The justification of 78.3% of expert panel for considering health-enhancing behaviors and avoided or reduced health risk object was the fact that many diseases and injuries can be prevented by reducing harmful and risk-taking behaviors. Therefore, it appears that achieving maintenance healthy behaviors would be facilitated by acceptance of personal responsibility. Personal, family and community health object advocate had a favorability of 82.7%. The main justification in this regard was that advocacy skills help the students to develop important skills to target their health-enhancing messages and to encourage others to adopt healthy behaviors. According to receive the stakeholders’ feedback and in respond to dissatisfaction of them related to weakness of public health experts in conducting health system research and according to the practical implementation of the research in health education, the learning and behavior change theories and models were evaluated favorable by 78.3% of the experts. The survey showed that 4 experts disagreed with including this object, because they believed that this topic was not necessary at the graduate level. Nonetheless, other experts believed that including this topic might develop the students’ ability to meet the research expectations and educational role, as well as effectively planning of health interventions. In turn, learning and behavior change theories and models support developing a framework or model of change besides applying teaching and learning principles into a teaching project.

Identifying topical outlines helps the lecturer in designing the framework and avoiding personal topical outlines when covering a course objective. Therefore, the topical outlines were revised to support the course objects. The expert panel reflected their view, as well as students’ disinterest and dissatisfaction with some of topical outlines related to course objectives like learning theories, communications models in health education, teaching and learning principles application in the development of a teaching project and research in health education. The most reasons for dissatisfactions were impracticability of communication models in health education, current learning principles and usefulness of health education in research. Health communication cycle, analysis situation communication in health program, objectives and strategies in health communication program, impact of interpersonal communications on behavior were the topical outlines evaluated to be very important or important related communications in health education object. The communication models in health education were removed from the curriculum. Based on the suggestions of the experts, the learning and behavior change theories and models and application of the teaching and learning principles in the development of a teaching project should be incorporated into the curriculum. It has also been explained that behavioral and social sciences contribute to understanding of the social determinants of health and acquired skills necessary for effective communication and implementation of intervention programs. The majority of experts (78.5%) expressed that this topic would promote students’ ability for applying learning principles, research in health education and also will improve positive feeling of useful reflected students’ disinterest.

The skill development should be directed to the desired competencies.[2] Many experiences suggested by expert panel focused on need assessment, planned and implemented health education programs besides communication skills. These suggestions rated between 3.5 and 4.6. Need assessment had a largest number of suggestions deemed important including collecting information, relationships among behavioral and environmental factors, inferred needs for health education based on assessment findings, analyzing a health problem from a behavioral point of view and prioritizing health education needs. The total number of skill suggestions deemed important was much higher than course objectives, which may be due to the fact that multiple skills can be gained through a single objective.

There is needed to comply with rational sequences when teaching. Regardless of the curriculum which is developed, the sequence of objectives should be aligned to the outlines what students should know and be able to do throughout their experience. The experts agreed on the following points: Assessment of community needs, the relationships between behavioral and environmental factors affecting the health, learning and behavior change theories, developing a framework, and planning and evaluating health education programs will offer the best sequence. To explain the reason, they stated that familiarity with the relationships among behavioral and environmental factors contributes to better learning and understanding of behavior change theories, and subsequently, it simplifies developing a framework, and planning and evaluating health education programs.

Most evaluators (72.5%) suggested that the units should increase from 2 to 3. The experts explained that learning requires time and effort. Hence, adequate time for skill development is needed. Because student performance should be measured, given the required competencies, considering one practicum unit, in addition to two theory units was suggested. There were 4 experts who believed that students have the opportunity to repeat the learned topics during the training and it is not necessary to increase the number of units.

CONCLUSION

This study provides the first evidence for health education curriculum modification for public health undergraduates based on the expert panel. Assessing the suggestion of study displayed health promote behaviors, advocate health, behavior change theory and models, as well as developing a framework are key objects in the curriculum. Much more new topical outlines were related to previous course. Skills have utility more included need assessment and health communication. The majority of evaluators agreed that adding a practicum unit to two theory units will be useful. Accordingly, changes should be evaluated constantly to cover the challenges graduated encounter at workplace.