Developing distance learning in postgraduate public health education

P U B L I C H E A L T H E D U C A T I O N Developing distance learning in postgraduate public health education Promoting quality in design and delivery of postgraduate public health training through open learning DEBBI L. STANISTREET, NIGEL G. BRUCE, IAN TAYLOR Background: Adapting a postgraduate public health course which relies on a lot of classroom contact into one with a high proportion of distance learning Is complex and there is little published literature available which focuses on this type of course development in public health. This paper examines the experience of converting the Master of Public Health (MPH) degree at the University of Liverpool into one that combines both distance learning and contact time in the classroom. Methods: The methods section is divided Into 3 parts. Part 1 (structure) examines the importance of systematic planning prior to course development. Part 2 (process) describes staff training and development, writing, piloting and production of materials, methods of delivery and student support and Part 3 (outcomes) describes the model of evaluation used. Results: This section presents the preliminary results of the evaluation of the new course and implications for future development. The main issues arising from the evaluation include excessive demands in terms of student study time, some inconsistency in materials and teaching, varying levels of experience among students and the importance of ensuring integration of learning objectives where a modular approach is used. Conclusions: The evidence from the educational literature on the value of distance learning is supported by the experience of the Liverpool course. Distance learning based courses offer an important way forward for academic institutions throughout Europe which are becoming increasingly market driven and resource conscious. They also offer an important medium for the current development of Europe-wide postgraduate education. -European academic institutions providing postgraduate degrees in public health are currently under substantial pressure to revise their mode of course delivery for a number of reasons. Modularisation offers two important advantages: greater flexibility in student learning and 'off the shelf materials which facilitate sharing of educational processes between departments and institutions. Ever-increasing budgetary restrictions mean that it is becoming more difficult to identify resources in order to release health professionals from their work commitments to attend degree courses. Master of Public Health (MPH) courses are under pressure to integrate student learning more effectively with work-place responsibilities. Increasing flexibility is being demanded by students who wish to undertake study at more than one academic institution. * D.L Starustreet 1, N.G. Bruce', I. Taylor" 1 Department of Publk Health, University of Liverpool, Liverpool, UK 2 Department of Education, University of Liverpool, Liverpool, UK Correspondence Debbi L Stanistreet, Lecturer in Public Health. Department of Public Hearth, University of Liverpool, Liverpool L69 3GB, UK, tel. +44 151 794 5583, fax +44 151 794 5588, e-mail: debblwiv.acuk Keywords: course development, distance learning, MPH It is becoming recognised diat postgraduate public health training should encourage students to develop greater ability to manage their learning. Over the last 10 years, the World Health Organisation, Association of Schools of Public Health in the European Region and the European Commission have been working towards uniformity in European-level accreditation for postgraduate public health courses and shared sites for European MPH degrees. This has resulted in die need to develop shared modules and distance learning packages among European institutions. Literature on adult learning ^ stresses the importance of developing a learning environment which involves the following. Decreasing dependence on others by having individuals take responsibility for dieir own development. Providing opportunities to promote active enquiry which enables individuals to build understanding in terms of dieir own professional experience. Reinforcing individuals by providing a supportive climate, ongoing feedback on development and opportunities for active participation. This type of learning environment is of particular relevance in the professional development of practi-

Distance learning in public health education tioners such as those engaged in public health. Duke 4 wrote of the implications for universities if the above needs are to be met and Laurillard 5 and Bates 6 identified both the potential of distance learning in meeting these needs and the practical implications of adopting such an approach. It has a number of practical advantages over more traditional methods of delivering teaching in that the student has more control over the time, pace, place and process of their learning and it is student rather than subject centred. 7 BACKGROUND TO CHANGES IN THE LIVERPOOL COURSE In addition to these broader pressures for change, diere have also been local factors which provide some relevant additional background to this report. The existing postgraduate course at die University of Liverpool offered a full-time (4 days per week over 1 year) and part-time (2 days per week over 2 years) masters degree in public health. During die early 1990s, pressure from students, die health service and odier funders was growing for a more flexible course, widi a larger component of self-directed learning to be incorporated. Employers of public health professionals were willing to provide funding for postgraduate public healdi courses which could be delivered in a more flexible way and which took work responsibilities into account and provided better syndiesis between student learning and employee work-place responsibilities. In order to respond in a systematic and effective way to diese various requirements, funding was sought from die North West Regional Office of die National Health Service (NHS) for die Department of Public Health at die University of Liverpool to make significant modifications to die design and delivery of its MPH course. This report describes die experience gained at Liverpool in replacing a classroom-based MPH course with a course based on a substantial proportion of open learning (twothirds), widi only one-diird of learning being based on contact time. The report analyses die development of die course using Donabedian's quality framework of structure, process and outcome. Under structure we examine die importance of systematic planning prior to course development. Process considers staff training and development, writing, piloting and production of materials and mediods of delivery and student support. Outcome briefly presents die approach taken in and preliminary results of die evaluation of die new course and implications for future development. METHODS Part 1 - Structure Development plan In order to design and implement a course which effectively addressed the rationale for change, a number of factors needed to be considered and structures put into place to ensure die process of change was smoodi and effective. As a first step, the goals and aspirations for change were discussed with an educational advisor (Ian Taylor) from widiin die University of Liverpool. This laid die basis for careful planning of die background research, personnel, training and time required in order to deliver what was proposed. Part of the regional funding was used to employ a course development officer, die main responsibilities of this post being twofold: to carry out a detailed review of die existing course and to prepare a comprehensive development plan which met the changing university regulations for postgraduate courses. The key elements of die review and development plan are as follows. Potential market The potential market for die course as a whole and for certain topics (e.g. research mediods) which were expected to have a broad appeal was assessed. Stakeholders in die course were identified, (including local healdi authorities, health services, the regional office of die NHS Executive and odier agencies who expressed an interest in die MPH course) and interviewed in order to estimate the potential need for MPH-qualified professionals within die region. Costs of the course to students and stakeholders Past and potential students and relevant stakeholders were questioned to assess how much time and financial resources they were willing to contribute. Entry level and prerequisites of the course Consideration was given to die skills and knowledge base students would need in order to be able to undertake die course. It was recognised that die distance learning element would imply a need for students to have a strong independent motivation to learn. Course content Stakeholders were also asked to identify die skills and knowledge requirements of public healdi trained employees. In addition, a survey was carried out of students who had already undertaken die MPH course to ascertain die strengdis and weaknesses of the existing course and to assess which elements had been most relevant and useful to their subsequent careers. Student support This is an integral part of assuring quality in any distance learning course 9 and a variety of approaches to strengthening student support were considered in recognition of diverse student needs. One important component was die integration of self-assessment questions throughout the learning materials. These questions do not contribute to formal module assessment, but provide students with a good indication of whedier diey require additional help. The options for providing additional help from tutors included designated times each week when tutors would be available in their rooms to answer die telephone and also the use of e-mails and faxes. Course design While modularisation may provide a number of advantages, as discussed in die Introduction, a high degree of 'flexibility' resulting in pick-and-mix courses can threaten integration. Options to preserve integration in the new MPH were discussed and a decision was taken to

EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 10 2000 NO. 4 develop a project-based half module designed specifically to promote integration of subject areas. The design chosen was that of a 12 module masters course. Eight taught modules of equal weighting were to be offered, seven of these being core modules and one being an area of specialist study from which the students could choose from a number of different options. The equivalent of a four-module weighting was given to the dissertation, a piece of original research, totalling 12 modules overall to achieve an MPH qualification. In addition, exit points were built in, on completion of four taught modules for a postgraduate certificate and eight taught modules for a postgraduate diploma (table 1). One other new aspect of the course design requiring careful consideration was the optimum division of student time between contact sessions, structured open learning based on the newly developed learning materials, background reading and preparing assignments. Some of the issues that needed to be considered, bearing in mind the diverse situations and resources of the students, are highlighted in the table 2. Planning for material production and distribution Race 7 suggested that one of the major problems with converting full-contact courses to distance learning is that die amount of time required to write learning materials is grossly underestimated. Indeed, it has been suggested that for every hour of open learning-based study, at least 8 h of writing are required. With this in mind, the following decisions were taken. Table 1 Available modules on the University of Liverpool MPH degree Core modules Research methods I Research methods II Qualitative research methods Management Health services Health economics (half module) and integrated public health (half module) Applied public health (including health promotion and European public health) Optional modules Environment and health Communicable disease control Veterinary public health Public health nutrition European health promotion Law and public health - A full year was allowed for development of the new course. - An additional academic member of staff was given responsibility for coordination of die MPH course development. - Each module would be developed by a team and new learning materials piloted. - Careful evaluation would be carried out during the first year, in collaboration widi the educational experts. - Student numbers would be reduced by not admitting part-time students for 1 year, primarily to avoid the problem of part-time students in consecutive years having to study both old and new versions of the course. - To deal with the increased demands of organising the production and distribution of materials, provision was made for additional secretarial support. The process of implementing diese decisions is described more fully in the next section. Part 2 - Process Although in practice it is always difficult to adhere to a development plan strictly, the fair degree of success achieved at the end of the development year did result from implementing the structure outlined in part 1. Module teams and training One of the first tasks of the coordinator was to identify writing teams. These were to consist of between two and five individuals, including academic members of staff and those representing the work-place. With the assistance of the educational experts, a training and support programme was prepared incorporating workshops, the production of writers guidelines and assistance with the development of aims, objectives and learning outcomes for each individual module, as well as ongoing supervision and support during material development. Writing distance learning materials differs from the conventional style used in academic writing and the workshops provided writers with the practical skills required for the tasks. In all cases, writing teams were encouraged to begin by reviewing whether currently available distance learning materials in their subject area could be used or adapted. In many cases, however, none existed and it was necessary to produce new learning materials. In view of Table 2 Activities requiring presence in University and activities that can be carried out away from the university Activities requiring presence in the university Face-to-face teaching (reinforcement and clarification of key ideas) Group work (planning, preparation of projects, etc. and class exercises) IT skills teaching (requiring tutors and IT teaching facilities Use of library Face-to-face tutorial support Use of computer (if unable to use work facilities for course work or unavailable at home, etc) Activities diat can be carried out away from the university Studying learning materials Reading (papers, books, etc.) Preparing assignments Preparing work on computer (if facilities available: this includes not just the computer, but also software required for word processing, data analysis, presentations, etc) Telephone contact with tutor Use of e-mail (if available) Use of e-mail (if not available at work or home)

Distance learning in pubic health education the uncertainty about the resources students would have for using computers in self-study time, it was decided to rely primarily on paper-based materials and to develop computer-aided learning resources at a later stage (this is currently under way). Writing teams were also encouraged to consider at an early stage how learning materials would relate to the subsequent use of contact time. For example, contact sessions could be used to consolidate concepts introduced in the course materials and to introduce new topics to the students for group work or for feedback on exercises undertaken by the student in die distance learning materials. The multidisciplinary nature of die students and die opportunities for group and individual learning were tiiought to be particularly valuable. These educational considerations had to take into account the practical constraints listed in table 2. In practice, the writing teams opted to use contact time in all four of these ways and experience has shown that learning opportunities are optimised if die learning materials comprehensively cover all core modular content. Piloting This was a very important aspect of the material development process and one that was carefully planned and executed in collaboration widi die educational advisors. A decision was made to pilot parts of each module, so what was being tested was something close to the final version. The advantage of this approach was that it would allow die results to guide die completion of die remaining parts of the module. Limitations were that a completed section had to be prepared early on, the rest of the module was not available to refer to and, for practical reasons, it was not possible to provide die contact sessions as part of the piloting. Pilotees were selected from among former students and paid for dieir time. Each was given a form on which to record time spent studying and carrying out the self-assessment exercises and to comment on clarity, style and ease of comprehension. The educational advisor designed and carried out the piloting and fed the results back to the writing teams. Part 3 - Outcomes There are a number of different approaches to evaluation. 10 ' 11 Evaluation in this instance was to meet two basic needs. To ascertain the impact of the course in terms of promoting learning. To identify those aspects of course provision (both the materials developed and die elements taught) which had operated to promote and to limit learning. Evidence for the former was obtained from a structured questionnaire, generating both quantitative and qualitative evidence and developed in collaboration with teaching staff. This questionnaire was completed by all students during contact time. In-depdi interviews with a representative sample of participants and regular attendance of student representatives at course meetings provided more detailed evidence about die factors promoting and limiting learning. RESULTS Interestingly, both die questionnaire-based module reviews and die student feedback at course meetings provided very similar information. This internal consistency provided some validation for the two mediods of evaluation. Overall, the formal evaluation of the first year of the new course was positive. A number of issues emerged and table 3 summarises the main strengths and limitations relating specifically to the move to distance learning. Excessive demand In judging whedier a given module places too great a demand on students it was important to take into account whedier students had adapted dieir expectations and learning methods to die new approach. However, in respect of the two research method modules it was agreed that too much material had been included. In retrospect, the time estimates reported from piloting should have been interpreted with a 10-20% additional margin. These modules have subsequently been trimmed. Inconsistency Some inconsistency in materials and teaching was to an extent inevitable. However, there is also the question of whether some topics are better suited to a predominantly open learning approach, while others should continue to rely more on contact sessions. In practice, however, progress in learning material development has been determined more by logistic aspects of teaching arrangements rather than by an educational analysis of diis issue. Thus, Table 3 Main strengths and weaknesses of the new course identified through evaluation Strengths The majority of students enjoyed the course Some of the learning materials were reported to be very effective. For these, strengths were: - produced to a high standard, - effectively sequenced, - appropriate level of detail, - reinforced learning effectively through self-assessment questions, - interest of students in subject increased over course of module Arrangements for student support were effective and there was a good response to concerns expressed by students Limitations For some modules, demands on students were too great, mainly due to the amount of material Open learning materials were not prepared in a consistent way for all modules Within die student group, there was a wide range of experience. This was not allowed for sufficiently, particularly in respect of IT

EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 10 2000 NO. 4 modules requiring substantial theoretical or practical input from topics that are not well represented among university-based teaching staff (e.g. management and communicable disease) will take longer to convert. This is because the key people involved were not able to commit the time required or were not yet ready in die context of dieir overall teaching commitments to adopt die same open learning approach. It is perhaps too early to offer definite suggestions on which subjects within the public health education curriculum are best suited to open learning delivery. However, it should be emphasised that die mix of contact time and self-study being used in diis course is quite flexible and there seems to be no obvious reason why open learning cannot be substantially applied to all topics. Varying levels of experience In order to address the issue of managing such a diverse range of experience, die course has now put into place a more detailed system of assessment of students' skills and experiences when they embark on the course. For example, within information technology (IT), students are asked at die beginning of the course about their expenence widi individual IT packages and about access to computing facilities outside the university. This should allow subsequent IT learning to be tailored to individual students' needs. Integration One of the odier primary concerns about moving to die modular approach was the potential lack of integration. In the new course, a group project-based module was introduced to encourage students to develop an integrated public healdi response to topical issues such as suicide in young men and teenage pregnancy. This module does appear to be meeting its primary objectives and initial evaluation by students has been positive. CONCLUSION The decision to develop a distance learning approach was originally motivated by die requirement to meet the needs of busy professionals who were required to become active learners. The evidence from die educational literature 1 " 6 supporting this approach to learning has been well demonstrated by the success of die Liverpool course. In practice, die translation of a full-time course into distance learning mode proved to be a lengthy and complex exercise. Nevertheless, the structure put into place at an early stage ensured diat die process was a positive experience for all involved. The course has benefited from die process in a number of ways: student intake and demand has increased substantially, communication between die academic department and stakeholders in healdi and related service provision has improved, a more systematic and integrated approach to teaching has been achieved and, in die long term, if it were not for the increase in student intake, there would have been a reduction in workload for academic staff teaching on the course. Currently the course is running as a part distance learning course, 33% of learning based on contact time, widi full- or part-time options. It is envisaged that the option of a full distance learning course will be offered from September 2001 subject to funding being obtained for further development. In conclusion, distance learning-based courses offer an important way forward for academic institutions throughout Europe which are becoming increasingly market driven and resource conscious. They also offer an important medium for the current development of Europe-wide postgraduate education in Europe. As far as die authors are aware, diis is die first course of its kind but it is likely diat similar courses will increasingly be developed, offering a rich opportunity for promoting greater integration of public health teaching in Europe. 1 Association of Schools of Public Health in the European Region. A European Union programme for promoting the development of European Union perspectives in the training programmes in public hearth. Second phase 97-99. Final report. Saint-Maurice, France: ASPHER, 1999. 2 Knowles MS. The making of an adult education. San Francisco: Jossey Bass, 1989 3 Brookfield SD Understanding and facilitating adult learning. Milton Keynes; Open University Press, 1986. 4 Duke C. The learning experience. Buckingham: Open University Press in association with Society for Research in Higher Education, 1992. 5 Laurilliard DM. Rethinking university teaching. London: Routledge, 1993. 6 Bates AW. Technology, open learning and distance education. London: Routledge, 1995. 7 Race P. The open learning handbook. London: Kogan Page, 1995. 8 Donabedian A. Basic approaches to assessment structure, process and outcome. Ann Arbor, Ml: Hearth Administration Press, 1989. 9 Lodcwood F. Materials production in open and distance learning. London: Paul Chapman, 1994. 10 Lawton D. Curriculum studies and educational planning. London: Hodderand Stoughton, 1983. 11 Stake R. Evaluating education programmes. In: Hopkins D, editor. Inservice training and educational development. London: Croon Helm, 1986:65-73. Received 24 November 1998, accepted 16 December 1999