A Case Report of Formative and Summative Evaluations of a Graduate Course on Foundations of Health Promotion for Masters of Public Health Students

CASE REPORT Development of foundational skills among Masters of Public Health (MPH) students is challenging with regard to the mastery of delivering health education and health promotion methods. In this case report we documented the conceptualization details and results from the formative and summative evaluations of one foundational course on health promotion implemented at a Southern US University. The course was based on the constructs of a fourth generation framework of Multi-Theory-Model (MTM) of health behavior change that aimed at helping the students to acquire the behaviors needed for imparting the health education and health promotion methods in the real world settings. In formative evaluation, a qualitative assessment is used, whereas, in the summative evaluation both qualitative and quantitative approaches are applied. We used a Strengths, Weaknesses, Opportunities and Threats (SWOT) framework to conduct this study. Some of the documented strengths of the course included practical applications, interactive learning, and good use of the Canvas platform, group work, and skill building activities. The weaknesses of the course were the difficult nature of the subject and the fact that some presented methods were not clear. Some suggested opportunities for future offerings included having better environmental props, more online participation, and guest speakers. Some threats identified by the students were decrease of enrolment and possible reduction of face-to-face interactions due to online offerings. Overall, the instructor was successful in imparting skills pertaining to the methods for conducting health promotion within public health. The skill building activities and assignments elaborated in this course can be freely replicated for enhancing the learning acumen of MPH students around the world. This case report forms the basis for critical reflection among educators entrusted with designing such courses.


Introduction
Training of public health professionals requires them to master the foundations of health behavior, health education, and health promotion. 1 Masters of Public Health (MPH) is a graduate degree that prepares professionals coming from different backgrounds and disciplines in the art and science of public health. 2 We need to prepare the MPH students to develop their competence to conduct work in health promotion. In this case study, we descriptively documented the results of a graduate level introductory course on teaching health behavior, health education, and health promotion to MPH students at a US University. Case study is an acceptable method in medical, behavioral, and social science research. Case study is also a preferred strategy for answering the "how" or "why" questions in research and helps in investigating a contemporary phenomenon within its real-life context. 3 Case study method has been used to document teaching experiences. [4][5][6] In this study, the case was located in Southern United States and the data were taught at a Historically Black College/University (HBCU) in the United States to the predominantly African American students. The case describes the theoretical underpinnings, layout, assignments, and activities, course competencies and learning objectives, as well as grading in the course and results of formative and summative evaluations. Ethical approval for reporting this case was obtained from the Institutional Review Board of Jackson State University with the approval number of 0146-18 dated June 18, 2018. This case report is supposed to help other researchers to stimulate discussions and replicate some parts of the conducted course in teaching health promotion around the world.

Case Report
Theoretical underpinnings of the course The course was based on the fourth-generation behavioral theory, i.e. multi theory model (MTM) of health behavior change. [7][8] The framework showed the behavior changes in the application of health education and health promotion methods.
The aim of this course was to help the students to initiate their mastery over delivery of health education and health promotion methods. After the course, the participants were supposed to use this practical knowledge learned during internship in their professional lives. The first construct in behavior change is participatory dialogue, in which the advantages of behavior change are underscored over its disadvantages. In this course, this process was conducted by discussing over all topics either in face-to-face meetings or through discussions in online classes in Canvas Learning Management System platform. 9 The second construct is that of behavioral confidence, which is carried out by providing the chance for the students to practice the skills using group discussions, nominal group, case study, psychodrama, role play, and simulation. In addition, the structured assignments and skill-building activities were carried out by the students throughout the course, which were elaborated further in the case report. The third construct pertains to changes in physical environment that was fostered by creating a supportive non-threatening class environment in which students presented their methods. For sustaining the behavior change, the construct of emotional transformation was built through delivery of affective methods (such as simulation on importance of cooperation as opposed to competition facilitated by the instructor and other methods conducted by the students) and students' goal setting to complete their assignments. The construct of practice for change is developed through peer and instructor evaluation of methods presented by the learners in composing a selfreflective report. The construct of changes in social environment is inculcated through peer support in delivery of the health education methods.

Learning objectives course competencies and assessments
The specific learning objectives of the course, the developed public health competency, and the method of assessment are depicted in Table 1. The links among these three components are also evident in Table 1.

Skill building activities
The course was divided into 13 modules. Each module had a set of Power Point slides on the topic and a skill building activity at the end. The skill building activities had to be completed in the Discussion Forum in Canvas platform of the course at the end of each class. The skill building activities for each module are summarized in Table 2.

Graded course assignments
Four graded assignments existed in the course, which are explained in details as follows: Assignment #1: Professional philosophy of health education: In this 500-600 word APA style-referenced paper the students described their philosophy in designing and implementing the health education interventions. The students should conduct a brief literature search and cite 2-3 journal articles supporting their viewpoints. Following criteria are used in grading the paper: Style Issues (50 points) Assignment #2: Delineation of a health problem: In this 1,000-1,200 word APA stylereferenced paper the students delineated any contemporary local, regional, national, or international health problem modifiable using a health education or health promotion intervention with specification of a target population. The student conducted a brief literature search to highlight significance and epidemiological aspects (such as mortality statistics, morbidity patterns, and determinants of the health problem). They also provided a brief strategy based on a behavioral/social science theory/model to address this problem. The following criteria were used in grading the paper: Style issues (30 points) 1. APA Style title page and references (with close attention to comma, space, period etc.) 2. Correct grammar and spelling 3. Adherence to specified word limit Content issues (70 points) 1. Significance (10 points) 2. Epidemiological aspects (10 points) 3. Determinants (20 points) 4. Strategy on a theory/model including diagram (30 points) Assignment #3: Class presentation of three assigned educational methods: each student prepared and presented three cognitive/affective educational methods used in health education and health promotion such as (1) focus group discussion, (2) nominal group process, (3) case study, (4) role play, (5) simulation, or (6) psychodrama for 10-15 minutes. The rest of the students were considered as the appropriate target population/participants for the presentation. The lecturer used some or all class members in implementing the method. It was recommended to students to rehearse and practice the method before the actual presentation outside the class. However, some class time was devoted to this purpose. The presentation was followed by constructive feedback by all classmates and instructor underscoring the strengths, weaknesses, and suggestions for improvement. The speaker submitted a brief paper in which the presented plan was documented. The reflective summary of the feedback attached to the planning paper was submitted on the subsequent class for grading. Following criteria were also used in grading the assignment: Presentation issues (50 points x 3 = 150 points) 1. Planning paper (10 points) 2. Setting the stage: Case description or scenario (including roles) etc. (10 points) 3. Execution: Implementing (10 points) 4. Debriefing at the end of the presentation (10 points) 5. Class feedback summary (10 points) Assignment #4: Presentation on an agency/association/organization: Regarding this assignment, the instructor assigned a local, regional, national, or international agency/ association/ organization in the area of health education and health promotion. The students tried to gather all the information about the studied agency using textbooks, websites, and personal visits (if possible), telephone/e-mail contacts etc. The student was also required to summarize the organizational structure of the paper, salient functions performed by the agency, Strengths, Weaknesses, Opportunities, and Threats (SWOT) Confronting of the Agency. The speaker should present the mentioned descriptions to the class using Power Point Slides in 10-15 minutes. Following criteria were used in grading the paper: Content issues (150 points

Grading in the course
Half of the grade was devoted to completion of skill-building assignments and half of the grade was covered by the scores of mid-term and final exams. The exams included questions on application of the knowledge achieved from the material covered in the class and the assigned textbook chapters.

Formative evaluation
For formative evaluation of the course, the instructor elicited written qualitative feedback during the course regarding the aspects that the students liked, aspects that the students thought could be improved at mid-point and additional topics that could be covered in the course (Table  3).

Summative evaluation
For summative evaluation qualitative feedback in the form of SWOT analysis was conducted (Table 4). 10,11 In addition, a 21-item quantitative survey of student responses was carried out that was validated by the University ( Competency Assessments/Outcomes (1) Define basic terms used in health education, health promotion, and public health and identify factors that foster or hinder well-being.
--Explains basic theories, concepts and models from a range of social and behavioral disciplines that contributes to public health research and practice --Skill building activity at the end of the module (2) Access existing health related data for assessing needs for health education.
--Assess population needs, assets and capacities that affect communities' health --Explains basic theories, concepts and models from a range of social and behavioral disciplines that contributes to public health research and practice --Skill building activity at the end of the module (3) Delineate the philosophical underpinnings in the field of health education and promotion.
--Explains basic theories, concepts and models from a range of social and behavioral disciplines that contributes to public health research and practice --Skill building activity at the end of the module --Assignment #1: Professional philosophy of health education (4) Trace the historical genesis of public health and health education and identify contemporary challenges confronting the profession.
--Explain public health history, philosophy and values --Skill building activity at the end of the module (5) Explain commonly used behavioral and social science theories/models in planning health education and health promotion programs.
--Explains basic theories, concepts and models from a range of social and behavioral disciplines that contributes to public health research and practice --Skill building activity at the end of the module (6) Describe quantitative and qualitative methods used in health education and promotion.
--Select quantitative and qualitative data collection methods appropriate for a given public health context.
--Skill building activity at the end of the module --Assignment #2: Delineation of a health problem (7) Discuss the advantages and disadvantages of commonly used cognitive educational, affective educational and environmental change methods.
--Explains basic theories, concepts and models from a range of social and behavioral disciplines that contributes to public health research and practice --Skill building activity at the end of the module --Assignment #3: Class presentation of three assigned educational methods (8) Formulate a variety of educational methods in implementing health education interventions.
--Explains basic theories, concepts and models from a range of social and behavioral disciplines that contributes to public health research and practice --Skill building activity at the end of the module --Assignment #3: Class presentation of three assigned educational methods (9) Plan training and instructional programs for diverse populations.
--Explains basic theories, concepts and models from a range of social and behavioral disciplines that contributes to public health research and practice --Skill building activity at the end of the module --Assignment #3: Class presentation of three assigned educational methods (10) Demonstrate a variety of skills in delivering health promotion and education strategies, interventions, and programs.
--Explains basic theories, concepts and models from a range of social and behavioral disciplines that contributes to public health research and practice --Skill building activity at the end of the module --Assignment #3: Class presentation of three assigned educational methods --Identify the core functions of public health and the 10 Essential Services --Skill building activity at the end of the module --Assignments # 1-4 (13) Discuss the structure and functions of salient agencies, associations, organizations at local, regional, national, and international levels in health education and promotion.
--Specifies multiple targets and levels of intervention for social and behavioral science programs and/or policies --Skill building activity at the end of the module --Assignment #4: Presentation on an agency/ association/organization (14) Retrieve and critically analyze current scientific literature in health education and promotion.
--Explains basic theories, concepts and models from a range of social and behavioral disciplines that contributes to public health research and practice --Skill building activity at the end of the module --Assignments # 1-4 (15) Identify principles of effective teaching and learning in health education.
--Explains basic theories, concepts and models from a range of social and behavioral disciplines that contributes to public health research and practice --Applies ethical principles to public health program planning, implementation and evaluation --Skill building activity at the end of the module --Assignments # 1-4 Brain storm on all possible behaviors that can be modified for improving health Classify these behaviors into two categories: positive and negative Choose any one behavior Choose any one target population where this behavior will be most suitable Identify all possible health-directed and health-related reasons why people will or will not engage in initiating and continuing this behavior Present your final work in a matrix in the discussion forum. 2.

Philosophy of Health Education & Health Promotion
Discuss all philosophical perspectives of health education Choose the one which you like Come up with all advantages and disadvantages of this philosophical perspective Submit it in the discussion forum. 3.

History of Public Health, Health Education & Health Promotion
Choose an area within public health education such as school health education or poliomyelitis or coronary heart disease or breast cancer etc. Conduct an Internet-based search on the history of that topic Also search PubMed (MEDLINE) for any article delineating historical aspects of that topic Draw a timeline or trace the salient developments within that area that have occurred. Post your findings in the discussion forum.

Planning Models in Health Education & Health Promotion
Choose any one behavior Choose any one target population where this behavior will be most suitable Draw a diagram explicating the links between various components of the PRECEDE-PROCEED Model and the chosen health behavior Present your final work in a word-processed diagram in the discussion forum 5.

Theories in Health Education & Health Promotion
Choose a health behavior change of your choice Choose a target population of your choice Develop a health behavior change intervention for initiation and sustenance of health behavior change using the constructs of MTM and specifying the behavioral and learning objectives, educational processes, activities, and duration. Downloaded from sbrh.ssu.ac.ir at 14:52 IRDT on Sunday April 26th 2020 SBRH. Volume 2, Issue 2, Nov 2018; 275-286 281 6.

Qualitative Methods for Health Education & Health Promotion
Choose any one target population with which you want to work Choose any one qualitative method for identifying needs and capacities Develop a detailed protocol for implementing the selected method (as detailed as a cookbook) Present in class or post your protocol on the discussion forum 7.

Quantitative Methods for Health Education & Promotion
Choose any one disease or health problem Choose any one target population with which you want to work Conduct a data based search to discern descriptive epidemiological data for this population: Mortality, morbidity, other health indicators by population, area, and time. Conduct a data based search to discern analytical epidemiological evidence related to changing behaviors and environments for influencing this problem Integrate the evidence and post to the discussion board 8.

Ethics in Health Education & Health Promotion
A written system of norms or professional moral consensus is known as code of ethics Brainstorm and develop a code of ethics for health educators based on the four ethical principles Compare your code with that discussed in the class. Discuss the similarities and differences and post them on the discussion forum.

Cognitive Educational Methods
Form yourselves in small groups Discuss the advantages & disadvantages of each AV device listed in the preceding slide Based on your experience identify ten ways in which Audiovisual aids can be made more effective Summarize your responses through a chosen audiovisual device or post your reflection on the discussion forum 10.

Affective & Experiential Educational Methods
Form yourselves in a small group (4 -5 students) One group will observe other groups: participation, task completion, strengths and weaknesses of the discussion, & ways for improving group discussion Other groups will discuss the advantages & disadvantages of experiential methods They will also, based on their experience, identify five ways in which experiential methods can be made more effective The observing group will debrief the exercise.

Advanced Level Competencies for Health Education Specialists
Choose any one advanced level sub competency. Using your textbook or any other health education textbook develop 2 -3 multiple choice questions that would measure that sub competency. In a small group evaluate each MCQ as to whether it is measuring Bloom's level one knowledge, level two comprehension, level three application, level four analysis, level five synthesis, or level six evaluation. Post all MCQs with their sub competency, knowledge level, and reference with page number to the discussion forum.

Principles of Effective Teaching Learning
Discuss the pros and cons of effective learning-teaching principles presented in this presentation Rate all these principles from most important to least important Post your five top choices in the discussion forum 13.

Future trends in Health Education & Health Promotion
Form yourselves in groups of 4 -5 students Discuss and come up with a list of 10 things you would do now in order to prepare yourself for becoming a successful health education specialist 5 years from now. Share your list in the large group or post in the discussion forum Downloaded from sbrh.ssu.ac.ir at 14:52 IRDT on Sunday April 26th 2020 SBRH. Volume 2, Issue 2, Nov 2018; 275-286 282 Table3. Qualitative mid-term feedback from students on the course Question Feedback Please list any two aspects of this course that you like.
• I like the class application of different qualitative and educational methods through which I am able to learn them more intensively and learn the practical aspects • I like the skill building activities which we need to complete in online forum; they are interactive and great learning experience • Importance to health education • Determinants of health • I appreciate the fact that my professor is always prepared when presenting in front of the class.
• I also like that all information that is needed is explained thoroughly on Canvas • I like the fact that we have online discussions for class but unlike other online class discussions, instructor keeps us engaged. • Teaching style • Activities • Option to learn from skill builder • I like the way the instructor retouches on past courses • I like the fact that the instructor is willing to give us a chance • I enjoy that the instructor is knowledgeable in the course • I like the hands on approach that is provided • I enjoy the group implementation activities because it allows us to get a real feel for the subject area of focus Please list any aspect(s) that you see can be improved in this course at this midpoint.
• More skill building activities can be made compulsory so that we can learn the applications even thoroughly • There is no improvement needed regarding the course itself. it is all dependent on me, the student • Announcement on upcoming assignments • May be public speaking on health promotion • The class is going great and I can't think of anything at the moment. • I think the instructor is doing a great job in the course, no improvement needed at this time.
• I am okay with mostly everything • Not many improvements needed • Be more patronizing Please list any topic(s) that you want covered in this course which you have not noticed in the syllabus that seems to be essential for this course for you.
• Nothing • Everything is fine • I would like to have more discussion on the application of theories as well as community empowerment • Not applicable • Good course • The essential materials are being covered throughout the course • We are on target with the syllabus • Ways to perfect my APA style writing • I think we have covered great topics thus far Downloaded from sbrh.ssu.ac.ir at 14:52 IRDT on Sunday April 26th 2020 • I found that the instructor had an upbeat attitude during class that made me enjoy the class more. I look forward to class every Thursday • Instructor's teaching style was very hands on incorporating discussions with in class activities. Was very useful. • Practical application of different theories • Interactive learning • That we were allowed to interact with each other in different projects setting and this was positive because we had a chance to work with different attitudes and that brought about a "positive" contribution from each student • I felt the class was very educational, so the strength would be that I learned about different methods in practical way.
• Good course • The essential materials are being covered throughout the course. • I love the group projects because it gave us a chance to relate with others • I love that you gave us an opportunity to understand and evaluate the assignments • Instructor was very knowledgeable on course material • The content and sessions were very helpful in teaching how health promotion is supposed to be implemented in the community • Good content • Teacher was always prepared • Learning activities (skill builders) • Hands-on • Group interactions • Implementing methods to understand learning Please list any two Weaknesses (areas for improvement) of the course that you found.
• In my opinion the course had little weakness • The subject line is a little tough, so sometimes it takes more time to understand and implicate learnings • There wasn't any in this class, I found the class to be very informative and educational • Not many improvements needed • Clarity on methods assignments • Allow students to turn in assignments via e-mail • More discussions of case study, assignments • Requiring more class participation from students Please list any two Opportunities (areas for growth) of this course in future offerings.
• If the instructor allowed this class to be held in multiple settings like the conference room for focus groups to set the stage • Professional training like set-up • This class has growth from the course in different settings and the opportunities were it allowed us to view the Power Points and do the skill building activities. This was a great opportunity because it gave us a chance to do more than just read the Power pointswe had to apply them. • Learning health education, promotion, option to learn from skill building activities, case study and presentations • Understanding the skill builders a little more • More on-line participation • Provide students the opportunity to present presentations in another setting such as conferences etc. • Guest speaker from a local, regional, or national health agency • Health education is a valuable profession • I have learned the practical application of different theories in a very interactive way so it will retain in my memory for a long time.
• This course was very rewarding, and I took home that this class was good and the instructor delivered the intents of the class in a way that was very interesting and in a way that was easy to obtain learning and not confusing. Great class! • If you apply everything is possible • Thank you for everythingyou are a great teacher! • If you apply yourself anything is possible. • I really enjoyed this course. I liked how we met in class and online. The course work was designed to educate, inform, and provide knowledge to the students. I really enjoyed the interaction during the sessions and the constructive criticism the instructor provided. • It is important to read and study material in order to be able to apply it in the future. Learning new skills are imperative in public health. • Health education drives public health.
• Be clear about your message. • Understanding qualitative and quantitative methods are very important in health education.