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2012
GHP19110.1177/1757975911428818W. Madsen and T. BellGlobal Health Promotion
Original Article Using health promotion competencies for curriculum development in higher education Wendy Madsen1 and Tanya Bell1
Abstract: Health promotion core competencies are used for a variety of reasons. Recently there have been moves to gain international consensus regarding core competencies within health promotion. One of the main reasons put forward for having core competencies is to guide curriculum development within higher education institutions. This article outlines the endeavours of one institution to develop undergraduate and postgraduate curricula around the Australian core competencies for health promotion practitioners. It argues that until core competencies have been agreed upon internationally, basing curricula on these carries a risk associated with change. However, delaying curricula until such risks are ameliorated decreases opportunities to deliver dynamic and current health promotion education within higher institutions. (Global Health Promotion, 2012; 19(1): 43–49) Keywords: education, health promotion
Introduction Although various aspects of what we now understand as health promotion have been evident in different guises for a number of centuries, health promotion has been emerging as a distinct discipline since 1986 as heralded by the Ottawa Charter. As such, there is still debate as to what constitutes health promotion in a way that is not seen in older, more established discipline areas such as medicine or law. One of the consequences of this ongoing debate is a lack of certainty for those teaching the new generation of health promotion practitioners. Traditionally, academia has provided the nurturing grounds for new professionals, steeping novices in the culture of the professional discipline area, feeding their minds with the concepts and knowledge needed to emerge as graduates and take up their positions in society and the profession. Tradition and research formed the basis of such nurturing grounds. However, for emerging fields of study and disciplines such as health promotion, there is more of a ‘chicken-and-egg’ situation within academia
as the discipline grows and matures within a praxis context rather than one that is strictly theoretical or academic. This raises questions for those teaching into health promotion programs at undergraduate or postgraduate levels regarding how to prepare the curricula for these programs: what is to be included? How is it to be taught? How can theory inform practice? How is practice driving theoretical developments? This article explores how one higher educational institution has approached these challenges using national core competencies for health promotion practitioners as the basis of curricula. A brief outline of the development of core competencies will be offered as the context within which the curricula were constructed, followed by a presentation of the curricula models and a discussion of the limitations of taking this approach. Throughout this article, it will be argued that while there are risks associated with using core competencies as the foundation of curricula in a climate of ongoing change, the benefits of keeping the curricula dynamic and relevant to health promotion outweigh the concerns.
1. CQ University, Bundaberg, Australia. Correspondence to: Wendy Madsen, CQ University, Locked Bag 3333, Bundaberg, Qld. 4670, Australia. Email: [email protected] (This manuscript was submitted on September 5, 2010. Following blind peer review, it was accepted for publication on May 26, 2011) Global Health Promotion 1757-9759; Vol 19(1): 43 –49; 428818 Copyright © The Author(s) 2012, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975911428818 http://ghp.sagepub.com Downloaded from ped.sagepub.com at Bobst Library, New York University on June 25, 2015
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W. Madsen and T. Bell
Background The concept of constructing core competencies for health promotion professionals has been around some time (1,2), but has gained ascendancy since the Galway Consensus Conference in 2008 that instigated the process of compiling a set of internationally agreed upon competencies. This conference needs to be seen in the context of health promotion as an emerging discipline. Indeed, in their outline of the conference outcomes, Barry et al. (3) highlight the various meanings associated with terminology used to depict health promotion and health education. Other papers published from this conference provide a clear picture of how health promotion has evolved; the cultural variations within health promotion’s history; and the diverse workforce within health promotion (4,5). Bennett et al.’s (6) analysis of public health education in Australia also illustrates health promotion has emerged from the broader discipline area of public health with a Masters of Public Health being taken by disparate professionals as the traditional pathway into this field. Thus, the health promotion workforce is perceived as ‘ill-defined’, with professional development often ‘ad hoc’ (7). The collection of papers that came out of the Galway Consensus Conference offers a useful history of the development of core competencies within health promotion. A number of authors outline the credentialing moves within the USA and the UK over the past three decades (8–10) and the status quo within Europe (5). Battel-Kirk et al. (11) provide a literature review of competencies, including the arguments for and against going down this path, suggesting that one of the main problems with core competencies is that they are often backward looking rather than forward looking. Amidst this literature and that offered by others, such as Wright (12), issues related to core competencies as setting the entry level into health promotion as a discipline are raised. In particular, as Bennett et al. (6) indicate, there are a number of entry points into health promotion now: via undergraduate programs; specific health promotion postgraduate programs; as well as the more traditional Masters in Public Health. Is it appropriate, therefore, for all of these entry points into the practice of health promotion to have the same entry level expectations? In Australia, core competencies for health promotion practitioners have been available for a number of years. These were
initially devised with course development in mind across a range of academic levels, from undergraduate to postgraduate degree programs (13) and have recently been updated (14). Like others, these core competencies outline entry level criteria for beginning health promotion practitioners. As such, one of their primary purposes is to provide a framework for health promotion curricula. A number of the reasons put forward at the Galway Consensus Conference for developing competencies relate to curricula development and building the capacity of the health promotion workforce (3–5,11). The International Union for Health Promotion and Education (IUHPE) in its 2007 Shaping the future of health promotion statement considers that core competencies ‘define the field and provide common direction for curriculum development’ (15). Indeed, Barry’s commentary (16) regarding the work of the IUHPE Global Vice-President for Capacity Building, Education and Training highlights the challenges for curricula development including: multiple levels of qualifications to suit at least two levels of practitioners; and the responsiveness of curricula to the needs of practitioners working in diverse social and political contexts. However, there is an emerging consensus within the literature that, despite such challenges, the development of core competencies for health promotion practitioners is useful for curriculum developers and provides frameworks and direction that has been previously missing. Where programs may have once been based on a compilation of multidisciplinary courses, particularly those relevant to public health, with the occasional health promotion specific course (6), programs are now becoming more prevalent that have been intentionally constructed for the specific needs of health promotion practitioners. Core competencies help provide coherence to such curricula. Alongside discussion of competencies within curricula, and not just those related to health promotion, is the question of how to show a curriculum is addressing the competencies. This is often done by ‘mapping’ across the curriculum. This has become increasingly popular as generic skills have been introduced into higher education institutions and there are now a number of computer programs that allow mapping of various competencies (17,18). However, such mapping is often retrospective in that its aim is to identify components within an established curriculum. Howat et al. (19) outline a much more prospective process whereby identified health promotion competencies were used to
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construct the curricula at undergraduate and postgraduate levels. It is this latter approach that has been used to construct the curricula models outlined in this article.
Using core competencies as the basis of curricula In their argument about the need to bring curricula into higher education debates on teaching and learning, Barnett and Coate (20) suggest the silence surrounding curriculum issues has resulted in a stealthy sliding of curriculum towards a ‘skills, standards and outcomes model’ rather than a ‘reflexive, collective, developmental and process-oriented model’. That is, that attention has drifted towards skills rather than knowledge and understanding. Such concerns need to be considered carefully when using core competencies as the foundation of health promotion curricula as there is a danger that these will be viewed as a set of ‘skills’ rather than broader competencies based on knowledge and understanding. The Australian Health Promotion Association’s (AHPA) core competencies for health promotion practitioners (14) indicate the competencies relate to knowledge, skills, attitudes and values that ‘constitute a common baseline for all health promotion roles’. Thus, while skills certainly feature within these competencies, they are placed within a broader context based on health promotion program planning, implementation and evaluation; partnership building; communication and report writing; technology; and knowledge competencies. It is these core competencies that have been used in the curricula outlined here, with the understanding that these competencies need to be considered within their broader contexts. In addition to the core competencies for health promotion practitioners, many universities across the globe also want to see evidence of ‘generic’ attributes embedded into curricula. This is in response to a shifting role of universities within society and a need to better prepare graduates for the workplace (20,21). Interestingly, many of these graduate attributes correspond with the core competencies for health promotion practitioners as outlined by the AHPA and others internationally. However, there is some divergence around the areas of developing the student (and graduate) as a ‘person’. While graduate attributes across institutions vary, some do articulate a number of personal qualities as being a valued part of completing a degree from that particular institution. For example,
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the University of Tasmania includes global perspective and social responsibility among the more common attributes of ‘knowledge’, ‘communication skills’ and ‘problem-solving skills’ (21). The graduate attributes needed to be considered within the curricula outlined in this article include: communication, problem solving, critical thinking, information literacy, team work, information technology competence, cross cultural competence, and ethical practice. The inclusion of so many ‘personal’ attributes confirms the three domains of curricula put forward by Barnett and Coate (20) of: knowing, acting, and being. That is, any curriculum can be considered as containing elements that relate to the knowledge and the manipulation of knowledge; to acting out and conducting certain skills; and to personal development of learning to engage with knowledge and practice in an authentic and meaningful way and developing an open mind towards other viewpoints. The AHPA core competencies for health promotion practitioners relate very well to the knowing and acting domains as outlined by Barnett and Coate (20). However, there is little in the way of being. Indeed, a criticism of these core competencies would be the lack of attention paid to articulating the need to be a reflective practitioner as the basis of professional (and personal) development. While this attribute is often implied within the core competencies and in the spirit in which they were developed whereby they do attach importance to attitudes and values, including cultural competencies, there is no explicit competency related to reflective practice. Yet, it could be argued that reflective practice is fundamental to many of the AHPA competencies and of the domains outlined by Barry et al. (3) that are being considered as the basis of international competencies for health promotion practitioners. This can be seen in earlier attempts to develop a European core curriculum for health promotion (22) and in the application of competencies to the development of a portfolio within the Masters of health promotion program at the National University of Galway, in Ireland, both of which place a great deal of emphasis on developing reflective practice (23). Indeed, Chiu (24) argues that critical reflection and conscientization processes are very useful in health promotion practice that is focused on social transformation. It is acknowledged that the concept of reflective practice within health promotion is contested as outlined by Issitt (25) and Cronin and Connolly (26) whereas there seems to be a greater acceptance of critical reflection and reflective practice IUHPE – Global Health Promotion Vol. 19, No. 1 2012
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Figure 1. Curriculum model for Bachelor of Health Promotion
in other health disciplines such as nursing and social work. Despite this, from the basis of incorporating being elements into the health promotion curricula outlined here, the curriculum design team included reflective practice strategies in both the undergraduate and postgraduate programs. The previous undergraduate curriculum was loosely based on the AHPA 2005 core competencies as outlined by Shilton et al. (13). It was certainly possible to map most of these competencies across the program. However, in 2009 as part of a major program review, it was decided there needed to be a greater level of focus on the Ottawa Charter and the core competencies within the program, and rather than fit these concepts into certain courses, it was necessary to allow these fundamental concepts to ‘drive’ the curriculum. A curriculum model was created based on these fundamental concepts to provide a visual representation of the importance they played in dictating what was included in the intended and taught curriculum. This curriculum model is illustrated in Figure 1. Barnett and Coate (20) warn that such diagrammatic representations of curricula need to be understood from a teacher’s perspective (what is intended and actually taught) rather than a representation of the student’s experience of the curriculum (often termed ‘received’ curriculum). Thus, the curriculum models presented in this article are intended to outline what
was in the minds of those designing the curriculum of the program as a whole. The models were used as the basis for their decision making of how to piece together various courses and what may be contained within these courses. Thus the core competencies were woven into the curriculum from the beginning and while these competencies are mapped across the curriculum — that is, constructed in a matrix that identifies which competencies are introduced and developed in which courses — the process was prospective. The Masters program in health promotion will be offered for the first time in 2011. The process of designing the curriculum for this program followed a similar pathway to that outlined above and the model produced had similar purposes. The difficulty presented here was that the AHPA core competencies are written for entry level practitioners. In a traditional discipline, these would be conceptualized as appropriate for graduates of an undergraduate program. However, because of the multiple entry levels within the health promotion workforce, this creates some difficulty for developing curriculum at a postgraduate level. To overcome this difficulty, the core competencies were integrated into a curriculum model that was also based on Transformative Learning principles. In particular, elements of alternative perspectives, centrality of experience, critical reflection, collaboration, learnercentred approach, peer review, reflective dialogue and self-assessment (27) were incorporated. As students of this program need to be working in the field of health promotion as a prerequisite (but do not have to have any extensive health promotion experience), taking this approach to the curriculum allows core competencies to be extended beyond the entry level to better meet the learning needs of these students. Evidently, this approach relies heavily on self-reflective strategies as the basis of extending the core competencies as students need to critique their own practices, uncovering unquestioned assumptions and using each others’ experiences to construct a new collective understanding. However, the extensive literature surrounding transformative learning principles provides a reasonable level of confidence in this approach (28,29). Such an approach may not solve all problems of using entry level competencies for postgraduate studies as outlined in the literature (6,16), but in the absence of any alternatives, this may provide one approach to address the dilemma. The curriculum model for the Masters program is illustrated in Figure 2.
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Figure 2. Curriculum model for Masters of Health Promotion
Integrating core competencies into a curriculum model is probably the easy part of curriculum design. The visual representations can be seen as pretty pictures, but unless the ideas contained in these models are distilled down to course structure, content, delivery and assessment levels, they remain simply as ideas. Furthermore, competencies need to be developed and woven across the entire program, although some courses are likely to have a stronger focus on one or two competencies. For example, the undergraduate course community needs assessment relates quite specifically to the AHPA Core Competency 1.1 needs (or situational) assessment competencies. The process used by the teaching team for the programs outlined here starts by providing students with the historical, political, social and
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cultural background to health, before moving to more knowledge based courses that picked up specific health promotion theories and procedural competencies. This means competencies are developed across a number of courses, from a fundamental level in first year courses, to a more complex understanding and application in higher level courses. For instance, first year students are introduced to working in teams as part of the learning activities and assessment for health promotion concepts, but are required to work in partnership with someone from industry in third year as part of health promotion in practice A & B assessment. Some aspects of the AHPA core competencies are more readily divided across various courses. For example, the competency related to communication outlines a number of genres of writing and these were simply allocated a particular assessment item or activity within a particular course. There was no precise science involved in this, but rather a movement around of the various components to come up with a course-of-best-fit that stayed true to the overall curriculum model and that collectively accounted for all the components. A broad outline of how the core competencies have been mapped across a number of central courses within the Bachelor of health promotion is contained in Table 1. Health promotion is not an accredited program in Australia, nor is there any regulation of programs by a regulatory or credentialing body. There are no checks
Table 1. Map of Australian core competencies across Bachelor of Health Promotion central courses Program planning, implementation and evaluation competencies
Partnership building competencies
Foundations of health promotion
Communication and report writing competencies
Technology competencies
Knowledge competencies
√
√
√
Health promotion concepts
√
√
√
√
Health communications
√
√
√
√
Community needs assessment
√
√
√
√
√
Health promotion strategies
√
√
√
√
√
Health promotion in practice A & B
√
√
√
√
√
Population health epidemiology
√
√
√
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and balances in place to ensure prospective students or the public at large that programs being offered through higher education institutions are appropriate for the health promotion workforce. Many universities have industry advisory committees to help guide their decision making in regards to curricula matters, and this was the process used to guide the curriculum development for the programs outlined in this article. However, much is expected from these industry representatives, including having an understanding of curriculum issues as well as being cognisant of the broader industry. Integrating the AHPA core competencies into the curriculum models for the undergraduate and Masters level programs has kept the knowledge, skills, attitudes and values of health promotion practitioners in the foreground throughout the decision making process of constructing program outcomes and subsequent course outcomes, teaching strategies and assessments. Models have not replaced the need for industry consultation, but have perhaps eased the pressure on these representatives to be allknowing, and reduced the ‘guess work’ involved. The models also assisted in constructing more coherent curricula, although it is not until the programs have actually been taught in their entirety and evaluated through the university systems that these impressions will be confirmed or challenged.
Limitations of using core competencies in curricula At this point in time there are no internationally agreed upon core competencies for health promotion practitioners. The literature outlines moves towards this goal and the experiences of a handful of countries that have competencies that have been formally adopted as part of accreditation processes. Placing core competencies at the very foundation of curricula when these have not been confirmed at an international level can be seen as somewhat risky. Even the AHPA core competencies changed quite dramatically between 2005 and 2009 raising questions of whether further changes would undermine curricula that have been based on these competencies; and given the glacial speed most university processes operate, would faculty be able to move quickly enough to adapt to changes that do occur to ensure the curricula remains appropriate to the needs of students? Placing the competencies at the core of the curriculum does mean that changes do have a potentially greater effect than
simply mapping competencies in retrospect. However, as indicated by Allegrante et al. (8), there do seem to be sufficient commonalities regarding what health promotion is to take the risk of basing curricula on these ideas. Furthermore, constructing a curriculum that is based on the current and prospective competencies breathes life into the teaching and learning plans for delivering health promotion programs, knowing the content and strategies are up to date and relevant to health promotion practitioners now and when students graduate. Yes, changes that occur at national and international levels may mean significant changes also need to happen in the curriculum but rather than seeing this as a problem, such changes can be welcomed as opportunities to keep the curriculum dynamic and fresh. Indeed, Barnett and Coate (20) argue a curriculum should be dynamic as it responds to consistent internal and external influences.
Conclusion Constructing curricula within the higher education sector is fraught with challenges and competing tensions. There are internal and external factors that need to be taken into consideration: industry concerns; national and international expectations; graduate attributes; student cohort characteristics; delivery opportunities and constraints; staffing profiles and workload issues. In the absence of an external accrediting body to oversee curricula and determine content and processes, as with health promotion, using core competencies for health promotion practitioners as the fundamental basis of curriculum models is one way of trying to keep curricula coherent and relevant while juggling these internal and external factors. This article has outlined how the AHPA core competencies have been used to guide curriculum development in one institution. Taking this approach is not without risks as the international health promotion community progress towards developing agreed upon core competencies that may not be the same as those used to build the curriculum models outlined here, necessitating significant revision. However, rather than seeing this as a threat to the curricula, curriculum developers should be prepared to view all changes as opportunities to keep the teaching and learning within programs dynamic and responsive to the ‘real world’ of health promotion. Core competencies are not a panacea, but they do provide a framework, along with research, of further engaging the tertiary sector with
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the health promotion industry to help ensure higher education institutions provide an appropriate nurturing ground for health promotion graduates. References 1. O’Neill M, Hills M. Education and training in health promotion and health education: trends, challenges and critical issues. Promot Educ. 2000; 7 (1): 7–9. 2. McCracken H, Rance H. Developing competencies for health promotion training in Aotearoa-New Zealand. Promot Educ. 2000; 7 (1): 40–43. 3. Barry MM, Allegrante JP, Lamarre M-C, Auld ME, Taub A. The Galway Consensus Conference: international collaboration on the development of core competencies for health promotion and health education. Glob Health Promot. 2009; 16 (2): 5–11. 4. Taub A, Allegrante JP, Barry MM, Sakagami K. Perspectives on terminology and conceptual and professional issues in health education and health promotion credentialing. Health Educ Behav. 2009; 36 (3): 439–450. 5. Santa-Maria Morales ASM, Battel-Kirk B, Barry MM, Bosker L, Kasmel A, Griffiths J. Perspectives on health promotion competencies and accreditation in Europe. Glob Health Promot. 2009; 16 (2): 21–31. 6. Bennett CM, Lilley K, Yeatman H, Parker E, Geelhoed E, Hanna EG, Robinson P. Paving pathways: shaping the public health workforce through tertiary education. Aust New Zealand Health Policy. January 2010; 7 (2). http://www.anzhealthpolicy.com/content/7/1/2 7. O’Connor-Fleming ML, Parker E, Oldenberg B. Health promotion workforce development in Australia. Health Promot J of Austral. 2000; 10 (2): 140–147. 8. Allegrante JP, Barry MM, Auld ME, Lamarre M-C, Taub A. Toward international collaboration on credentialing in health promotion and health education: the Galway Consensus Conference. Health Educ Behav. 2009; 36 (3): 427–438. 9. Cottrell RR, Lysoby L, Rasar King L, Airhihenbuwa CO, Roe KM, Allegrante JP. Current developments in accreditation and certification for health promotion and health education: a perspective on systems of quality assurance in the United States. Health Educ Behav. 2009; 36 (6): 451–463. 10. Speller V, Smith BJ, Lysoby L. Development and utilization of professional standards in health education and promotion: US and UK experiences. Glob Health Promot. 2009; 16 (2): 32–41. 11. Battel-Kirk B, Barry MM, Taub A, Lysoby L. A review of the international literature on health promotion competencies: identifying frameworks and core competencies. Glob Health Promot. 2009; 16 (2): 12–20. 12. Wright K, Hann N, McLeroy KR et al. Health education leadership development: a conceptual
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model and competency framework. Health Promot Pract. 2003; 4 (3): 293–302. 13. Shilton T, Howat P, James R, Burke,L, Hutchins C, Woodman R. Health promotion competencies for Australia 2001-5: trends and their implications. Promot Educ. 2008; 15 (2): 21–25. 14. Australian Health Promotion Association. Core competencies for health promotion practitioners. Maroochydoore; 2009. 15. International Union for Health Promotion and Education (IUHPE). Shaping the future for health promotion: priorities for action. Promot Educ. 2007; 14 (4): 199–202. 16. Barry MM. Capacity building for the future of health promotion. Promot Educ. 2008; 15 (4): 56–58. 17. Willett TG. Current status of curriculum mapping in Canada and the UK. Med Educ. 2008; 42: 786–793. 18. Cuevas NM, Matveev AG, Miller KO. Mapping general education outcomes in the major: intentionality and transparency. Peer Review. 2010; Winter: 10–15. 19. Howat P, Maycock B, Jackson L et al. Development of competency-based university health promotion courses. Promot Educ. 2000; 7 (1): 33–38. 20. Barnett R, Coate K. Engaging the curriculum in higher education. Berkshire: Society for Research into Higher Education and Open University Press; 2005. 21. Jones SM, Dermoundy J, Hannan G, James S, Osborn,J, Yates B. Designing and mapping generic attributes curriculum for science undergraduate students: a facultywide collaborative project. Sydney: UniServe Science Teaching and Learning Research Conference; 2007. 22. Davies JK, Colomer C, Lindstrom B et al. The EUMAHP project – the development of a European Masters program in health promotion. Promot Educat. 2000; 7 (1): 15–18. 23. McKenna V, Connolly C, Hodgins M. Usefulness of a competency-based reflective portfolio for student learning on a Masters Health Promotion programme. Health Educ J. 2010; 20 (10): 1–6. 24. Chiu LF. Critical reflection: more than nuts and bolts. Action Research. 2006; 4 (2): 183–203. 25. Issitt M. Reflecting on reflective practice for professional education and development in health promotion. Health Educ J. 2003; 62 (2): 173–188. 26. Cronin M, Connolly C. Exploring the use of experiential learning workshops and reflective practice within professional practice development for postgraduate health promotion students. Health Educ J. 2007; 66 (3): 286–303. 27. Taylor D. Fostering Mezirow’s transformative learning theory in the adult education classroom: a critical review. Can J for the Study of Adult Educ. 2000; 14 (2): 1–28. 28. Mezirow J, Taylor EW (eds). Transformative learning in practice: insights from community, workplace and higher education. San Francisco: Jossey-Bass Publishers; 2009. 29. Cranton P (ed). Transformative learning in action: insights from practice. San Francisco: Jossey-Bass Publishers; 2007.
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GHP19110.1177/1757975911428818W. Madsen and T. BellGlobal Health Promotion
Original Article Using health promotion competencies for curriculum development in higher education Wendy Madsen1 and Tanya Bell1
Abstract: Health promotion core competencies are used for a variety of reasons. Recently there have been moves to gain international consensus regarding core competencies within health promotion. One of the main reasons put forward for having core competencies is to guide curriculum development within higher education institutions. This article outlines the endeavours of one institution to develop undergraduate and postgraduate curricula around the Australian core competencies for health promotion practitioners. It argues that until core competencies have been agreed upon internationally, basing curricula on these carries a risk associated with change. However, delaying curricula until such risks are ameliorated decreases opportunities to deliver dynamic and current health promotion education within higher institutions. (Global Health Promotion, 2012; 19(1): 43–49) Keywords: education, health promotion
Introduction Although various aspects of what we now understand as health promotion have been evident in different guises for a number of centuries, health promotion has been emerging as a distinct discipline since 1986 as heralded by the Ottawa Charter. As such, there is still debate as to what constitutes health promotion in a way that is not seen in older, more established discipline areas such as medicine or law. One of the consequences of this ongoing debate is a lack of certainty for those teaching the new generation of health promotion practitioners. Traditionally, academia has provided the nurturing grounds for new professionals, steeping novices in the culture of the professional discipline area, feeding their minds with the concepts and knowledge needed to emerge as graduates and take up their positions in society and the profession. Tradition and research formed the basis of such nurturing grounds. However, for emerging fields of study and disciplines such as health promotion, there is more of a ‘chicken-and-egg’ situation within academia
as the discipline grows and matures within a praxis context rather than one that is strictly theoretical or academic. This raises questions for those teaching into health promotion programs at undergraduate or postgraduate levels regarding how to prepare the curricula for these programs: what is to be included? How is it to be taught? How can theory inform practice? How is practice driving theoretical developments? This article explores how one higher educational institution has approached these challenges using national core competencies for health promotion practitioners as the basis of curricula. A brief outline of the development of core competencies will be offered as the context within which the curricula were constructed, followed by a presentation of the curricula models and a discussion of the limitations of taking this approach. Throughout this article, it will be argued that while there are risks associated with using core competencies as the foundation of curricula in a climate of ongoing change, the benefits of keeping the curricula dynamic and relevant to health promotion outweigh the concerns.
1. CQ University, Bundaberg, Australia. Correspondence to: Wendy Madsen, CQ University, Locked Bag 3333, Bundaberg, Qld. 4670, Australia. Email: [email protected] (This manuscript was submitted on September 5, 2010. Following blind peer review, it was accepted for publication on May 26, 2011) Global Health Promotion 1757-9759; Vol 19(1): 43 –49; 428818 Copyright © The Author(s) 2012, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975911428818 http://ghp.sagepub.com Downloaded from ped.sagepub.com at Bobst Library, New York University on June 25, 2015
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Background The concept of constructing core competencies for health promotion professionals has been around some time (1,2), but has gained ascendancy since the Galway Consensus Conference in 2008 that instigated the process of compiling a set of internationally agreed upon competencies. This conference needs to be seen in the context of health promotion as an emerging discipline. Indeed, in their outline of the conference outcomes, Barry et al. (3) highlight the various meanings associated with terminology used to depict health promotion and health education. Other papers published from this conference provide a clear picture of how health promotion has evolved; the cultural variations within health promotion’s history; and the diverse workforce within health promotion (4,5). Bennett et al.’s (6) analysis of public health education in Australia also illustrates health promotion has emerged from the broader discipline area of public health with a Masters of Public Health being taken by disparate professionals as the traditional pathway into this field. Thus, the health promotion workforce is perceived as ‘ill-defined’, with professional development often ‘ad hoc’ (7). The collection of papers that came out of the Galway Consensus Conference offers a useful history of the development of core competencies within health promotion. A number of authors outline the credentialing moves within the USA and the UK over the past three decades (8–10) and the status quo within Europe (5). Battel-Kirk et al. (11) provide a literature review of competencies, including the arguments for and against going down this path, suggesting that one of the main problems with core competencies is that they are often backward looking rather than forward looking. Amidst this literature and that offered by others, such as Wright (12), issues related to core competencies as setting the entry level into health promotion as a discipline are raised. In particular, as Bennett et al. (6) indicate, there are a number of entry points into health promotion now: via undergraduate programs; specific health promotion postgraduate programs; as well as the more traditional Masters in Public Health. Is it appropriate, therefore, for all of these entry points into the practice of health promotion to have the same entry level expectations? In Australia, core competencies for health promotion practitioners have been available for a number of years. These were
initially devised with course development in mind across a range of academic levels, from undergraduate to postgraduate degree programs (13) and have recently been updated (14). Like others, these core competencies outline entry level criteria for beginning health promotion practitioners. As such, one of their primary purposes is to provide a framework for health promotion curricula. A number of the reasons put forward at the Galway Consensus Conference for developing competencies relate to curricula development and building the capacity of the health promotion workforce (3–5,11). The International Union for Health Promotion and Education (IUHPE) in its 2007 Shaping the future of health promotion statement considers that core competencies ‘define the field and provide common direction for curriculum development’ (15). Indeed, Barry’s commentary (16) regarding the work of the IUHPE Global Vice-President for Capacity Building, Education and Training highlights the challenges for curricula development including: multiple levels of qualifications to suit at least two levels of practitioners; and the responsiveness of curricula to the needs of practitioners working in diverse social and political contexts. However, there is an emerging consensus within the literature that, despite such challenges, the development of core competencies for health promotion practitioners is useful for curriculum developers and provides frameworks and direction that has been previously missing. Where programs may have once been based on a compilation of multidisciplinary courses, particularly those relevant to public health, with the occasional health promotion specific course (6), programs are now becoming more prevalent that have been intentionally constructed for the specific needs of health promotion practitioners. Core competencies help provide coherence to such curricula. Alongside discussion of competencies within curricula, and not just those related to health promotion, is the question of how to show a curriculum is addressing the competencies. This is often done by ‘mapping’ across the curriculum. This has become increasingly popular as generic skills have been introduced into higher education institutions and there are now a number of computer programs that allow mapping of various competencies (17,18). However, such mapping is often retrospective in that its aim is to identify components within an established curriculum. Howat et al. (19) outline a much more prospective process whereby identified health promotion competencies were used to
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construct the curricula at undergraduate and postgraduate levels. It is this latter approach that has been used to construct the curricula models outlined in this article.
Using core competencies as the basis of curricula In their argument about the need to bring curricula into higher education debates on teaching and learning, Barnett and Coate (20) suggest the silence surrounding curriculum issues has resulted in a stealthy sliding of curriculum towards a ‘skills, standards and outcomes model’ rather than a ‘reflexive, collective, developmental and process-oriented model’. That is, that attention has drifted towards skills rather than knowledge and understanding. Such concerns need to be considered carefully when using core competencies as the foundation of health promotion curricula as there is a danger that these will be viewed as a set of ‘skills’ rather than broader competencies based on knowledge and understanding. The Australian Health Promotion Association’s (AHPA) core competencies for health promotion practitioners (14) indicate the competencies relate to knowledge, skills, attitudes and values that ‘constitute a common baseline for all health promotion roles’. Thus, while skills certainly feature within these competencies, they are placed within a broader context based on health promotion program planning, implementation and evaluation; partnership building; communication and report writing; technology; and knowledge competencies. It is these core competencies that have been used in the curricula outlined here, with the understanding that these competencies need to be considered within their broader contexts. In addition to the core competencies for health promotion practitioners, many universities across the globe also want to see evidence of ‘generic’ attributes embedded into curricula. This is in response to a shifting role of universities within society and a need to better prepare graduates for the workplace (20,21). Interestingly, many of these graduate attributes correspond with the core competencies for health promotion practitioners as outlined by the AHPA and others internationally. However, there is some divergence around the areas of developing the student (and graduate) as a ‘person’. While graduate attributes across institutions vary, some do articulate a number of personal qualities as being a valued part of completing a degree from that particular institution. For example,
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the University of Tasmania includes global perspective and social responsibility among the more common attributes of ‘knowledge’, ‘communication skills’ and ‘problem-solving skills’ (21). The graduate attributes needed to be considered within the curricula outlined in this article include: communication, problem solving, critical thinking, information literacy, team work, information technology competence, cross cultural competence, and ethical practice. The inclusion of so many ‘personal’ attributes confirms the three domains of curricula put forward by Barnett and Coate (20) of: knowing, acting, and being. That is, any curriculum can be considered as containing elements that relate to the knowledge and the manipulation of knowledge; to acting out and conducting certain skills; and to personal development of learning to engage with knowledge and practice in an authentic and meaningful way and developing an open mind towards other viewpoints. The AHPA core competencies for health promotion practitioners relate very well to the knowing and acting domains as outlined by Barnett and Coate (20). However, there is little in the way of being. Indeed, a criticism of these core competencies would be the lack of attention paid to articulating the need to be a reflective practitioner as the basis of professional (and personal) development. While this attribute is often implied within the core competencies and in the spirit in which they were developed whereby they do attach importance to attitudes and values, including cultural competencies, there is no explicit competency related to reflective practice. Yet, it could be argued that reflective practice is fundamental to many of the AHPA competencies and of the domains outlined by Barry et al. (3) that are being considered as the basis of international competencies for health promotion practitioners. This can be seen in earlier attempts to develop a European core curriculum for health promotion (22) and in the application of competencies to the development of a portfolio within the Masters of health promotion program at the National University of Galway, in Ireland, both of which place a great deal of emphasis on developing reflective practice (23). Indeed, Chiu (24) argues that critical reflection and conscientization processes are very useful in health promotion practice that is focused on social transformation. It is acknowledged that the concept of reflective practice within health promotion is contested as outlined by Issitt (25) and Cronin and Connolly (26) whereas there seems to be a greater acceptance of critical reflection and reflective practice IUHPE – Global Health Promotion Vol. 19, No. 1 2012
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Figure 1. Curriculum model for Bachelor of Health Promotion
in other health disciplines such as nursing and social work. Despite this, from the basis of incorporating being elements into the health promotion curricula outlined here, the curriculum design team included reflective practice strategies in both the undergraduate and postgraduate programs. The previous undergraduate curriculum was loosely based on the AHPA 2005 core competencies as outlined by Shilton et al. (13). It was certainly possible to map most of these competencies across the program. However, in 2009 as part of a major program review, it was decided there needed to be a greater level of focus on the Ottawa Charter and the core competencies within the program, and rather than fit these concepts into certain courses, it was necessary to allow these fundamental concepts to ‘drive’ the curriculum. A curriculum model was created based on these fundamental concepts to provide a visual representation of the importance they played in dictating what was included in the intended and taught curriculum. This curriculum model is illustrated in Figure 1. Barnett and Coate (20) warn that such diagrammatic representations of curricula need to be understood from a teacher’s perspective (what is intended and actually taught) rather than a representation of the student’s experience of the curriculum (often termed ‘received’ curriculum). Thus, the curriculum models presented in this article are intended to outline what
was in the minds of those designing the curriculum of the program as a whole. The models were used as the basis for their decision making of how to piece together various courses and what may be contained within these courses. Thus the core competencies were woven into the curriculum from the beginning and while these competencies are mapped across the curriculum — that is, constructed in a matrix that identifies which competencies are introduced and developed in which courses — the process was prospective. The Masters program in health promotion will be offered for the first time in 2011. The process of designing the curriculum for this program followed a similar pathway to that outlined above and the model produced had similar purposes. The difficulty presented here was that the AHPA core competencies are written for entry level practitioners. In a traditional discipline, these would be conceptualized as appropriate for graduates of an undergraduate program. However, because of the multiple entry levels within the health promotion workforce, this creates some difficulty for developing curriculum at a postgraduate level. To overcome this difficulty, the core competencies were integrated into a curriculum model that was also based on Transformative Learning principles. In particular, elements of alternative perspectives, centrality of experience, critical reflection, collaboration, learnercentred approach, peer review, reflective dialogue and self-assessment (27) were incorporated. As students of this program need to be working in the field of health promotion as a prerequisite (but do not have to have any extensive health promotion experience), taking this approach to the curriculum allows core competencies to be extended beyond the entry level to better meet the learning needs of these students. Evidently, this approach relies heavily on self-reflective strategies as the basis of extending the core competencies as students need to critique their own practices, uncovering unquestioned assumptions and using each others’ experiences to construct a new collective understanding. However, the extensive literature surrounding transformative learning principles provides a reasonable level of confidence in this approach (28,29). Such an approach may not solve all problems of using entry level competencies for postgraduate studies as outlined in the literature (6,16), but in the absence of any alternatives, this may provide one approach to address the dilemma. The curriculum model for the Masters program is illustrated in Figure 2.
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Figure 2. Curriculum model for Masters of Health Promotion
Integrating core competencies into a curriculum model is probably the easy part of curriculum design. The visual representations can be seen as pretty pictures, but unless the ideas contained in these models are distilled down to course structure, content, delivery and assessment levels, they remain simply as ideas. Furthermore, competencies need to be developed and woven across the entire program, although some courses are likely to have a stronger focus on one or two competencies. For example, the undergraduate course community needs assessment relates quite specifically to the AHPA Core Competency 1.1 needs (or situational) assessment competencies. The process used by the teaching team for the programs outlined here starts by providing students with the historical, political, social and
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cultural background to health, before moving to more knowledge based courses that picked up specific health promotion theories and procedural competencies. This means competencies are developed across a number of courses, from a fundamental level in first year courses, to a more complex understanding and application in higher level courses. For instance, first year students are introduced to working in teams as part of the learning activities and assessment for health promotion concepts, but are required to work in partnership with someone from industry in third year as part of health promotion in practice A & B assessment. Some aspects of the AHPA core competencies are more readily divided across various courses. For example, the competency related to communication outlines a number of genres of writing and these were simply allocated a particular assessment item or activity within a particular course. There was no precise science involved in this, but rather a movement around of the various components to come up with a course-of-best-fit that stayed true to the overall curriculum model and that collectively accounted for all the components. A broad outline of how the core competencies have been mapped across a number of central courses within the Bachelor of health promotion is contained in Table 1. Health promotion is not an accredited program in Australia, nor is there any regulation of programs by a regulatory or credentialing body. There are no checks
Table 1. Map of Australian core competencies across Bachelor of Health Promotion central courses Program planning, implementation and evaluation competencies
Partnership building competencies
Foundations of health promotion
Communication and report writing competencies
Technology competencies
Knowledge competencies
√
√
√
Health promotion concepts
√
√
√
√
Health communications
√
√
√
√
Community needs assessment
√
√
√
√
√
Health promotion strategies
√
√
√
√
√
Health promotion in practice A & B
√
√
√
√
√
Population health epidemiology
√
√
√
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and balances in place to ensure prospective students or the public at large that programs being offered through higher education institutions are appropriate for the health promotion workforce. Many universities have industry advisory committees to help guide their decision making in regards to curricula matters, and this was the process used to guide the curriculum development for the programs outlined in this article. However, much is expected from these industry representatives, including having an understanding of curriculum issues as well as being cognisant of the broader industry. Integrating the AHPA core competencies into the curriculum models for the undergraduate and Masters level programs has kept the knowledge, skills, attitudes and values of health promotion practitioners in the foreground throughout the decision making process of constructing program outcomes and subsequent course outcomes, teaching strategies and assessments. Models have not replaced the need for industry consultation, but have perhaps eased the pressure on these representatives to be allknowing, and reduced the ‘guess work’ involved. The models also assisted in constructing more coherent curricula, although it is not until the programs have actually been taught in their entirety and evaluated through the university systems that these impressions will be confirmed or challenged.
Limitations of using core competencies in curricula At this point in time there are no internationally agreed upon core competencies for health promotion practitioners. The literature outlines moves towards this goal and the experiences of a handful of countries that have competencies that have been formally adopted as part of accreditation processes. Placing core competencies at the very foundation of curricula when these have not been confirmed at an international level can be seen as somewhat risky. Even the AHPA core competencies changed quite dramatically between 2005 and 2009 raising questions of whether further changes would undermine curricula that have been based on these competencies; and given the glacial speed most university processes operate, would faculty be able to move quickly enough to adapt to changes that do occur to ensure the curricula remains appropriate to the needs of students? Placing the competencies at the core of the curriculum does mean that changes do have a potentially greater effect than
simply mapping competencies in retrospect. However, as indicated by Allegrante et al. (8), there do seem to be sufficient commonalities regarding what health promotion is to take the risk of basing curricula on these ideas. Furthermore, constructing a curriculum that is based on the current and prospective competencies breathes life into the teaching and learning plans for delivering health promotion programs, knowing the content and strategies are up to date and relevant to health promotion practitioners now and when students graduate. Yes, changes that occur at national and international levels may mean significant changes also need to happen in the curriculum but rather than seeing this as a problem, such changes can be welcomed as opportunities to keep the curriculum dynamic and fresh. Indeed, Barnett and Coate (20) argue a curriculum should be dynamic as it responds to consistent internal and external influences.
Conclusion Constructing curricula within the higher education sector is fraught with challenges and competing tensions. There are internal and external factors that need to be taken into consideration: industry concerns; national and international expectations; graduate attributes; student cohort characteristics; delivery opportunities and constraints; staffing profiles and workload issues. In the absence of an external accrediting body to oversee curricula and determine content and processes, as with health promotion, using core competencies for health promotion practitioners as the fundamental basis of curriculum models is one way of trying to keep curricula coherent and relevant while juggling these internal and external factors. This article has outlined how the AHPA core competencies have been used to guide curriculum development in one institution. Taking this approach is not without risks as the international health promotion community progress towards developing agreed upon core competencies that may not be the same as those used to build the curriculum models outlined here, necessitating significant revision. However, rather than seeing this as a threat to the curricula, curriculum developers should be prepared to view all changes as opportunities to keep the teaching and learning within programs dynamic and responsive to the ‘real world’ of health promotion. Core competencies are not a panacea, but they do provide a framework, along with research, of further engaging the tertiary sector with
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