Excellence in the Design and Delivery of an Online Global Health Survey Course: A Roadmap for Educators

Abstract

The release of the United Nations Sustainable Development Goals in 2016, the growing use of online delivery formats for public health education, and the urgent need to train an expanding global health workforce all reflect the need to adopt best practices in the design and delivery of online global health courses. The purpose of this coaching article is to share peer-to-peer strategies and best practices for developing a global health survey course for online delivery. Important elements for consideration include the use of a backward design approach, global health competency review and selection, the scope and sequencing of key content areas, meaningful assessments of competency mastery, the development of authentic learning strategies, the potential use of open educational resources, and strategies for ongoing course evaluation and refinement. A backward course design, with well-selected content domains and competencies, opens the way for the development of the best possible learning experiences that are consistent with national benchmarks for online course development. The use of this strategy has resulted in a much keener sense of course “ownership” on our part, along with enhanced learning experiences and satisfaction for students.

Keywords

global health curriculum design online course development distance learning

Background and Introduction

With the release of the Sustainable Development Goals (SDGs) in January of 2016 the United Nations laid out a blueprint for achieving a more “sustainable future for all” by the year 2030 (United Nations, n.d.). The introduction of the SDGs has strengthened interest in global health promotion and education worldwide (Boulton, 2016; Drain et al., 2017). This coincides with the rapidly growing utilization of fully online formats for delivering higher education in the United States (Allen & Seaman, 2016), including public health education in general (Hawks & Gast, 2018), and global health programs and courses in particular (e.g., Coursera, n.d.; Poirier, Devraj, Blankson, & Xin, 2016; Utley-Smith, 2017).

The alignment of energized interest in global health with the growing demand for online offerings, and the essential need for a highly trained global health workforce, creates an opportune moment for carefully examining strategies for designing and delivering innovative, online global health curricula of the highest possible quality (Addo-Atuah, Dutta, & Kovera, 2014; Jacquet et al., 2018). The purpose of this article is to present peer-to-peer strategies for designing and delivering a fully online global health survey course based on best practices for online education, attainment of key global health promotion competencies, authentic learning activities, and robust learning outcomes.

Backward Design

A useful conceptual strategy for designing a global health survey course begins with a “backward design” approach (Crossman, 2017; Ozdemir & Duffy, 2017). The goal of using a backward design is to encourage learning-centered teaching, moving away from more passive approaches aimed at a simple knowledge transfer from teacher to student (Davidovitch, 2013). With this emphasis in mind, your focus will initially turn to learning outcomes (the skills students need to be successful in their future careers), rather than course content (simply relaying information from textbooks or other sources; Davidovitch, 2013).

Specifically, the application of this approach follows a three-step process as outlined by Wiggins and McTighe (2005). First, identify the desired results and outcomes. In this initial step, you should determine not only the knowledge you expect students to obtain but also the attitudes, skills, and competencies you expect them to demonstrate by the end of the course (Davidovitch, 2013). Second, you need to consider and determine appropriate measures for assessing learning outcomes. Acceptable assessment methods and criteria must be established for students to demonstrate their understanding and capabilities and for instructors to determine whether the desired results and outcomes have been met (Davidovitch, 2013). The final step is to choose the instructional methods and learning strategies you will use to achieve these goals. This is where you begin to consider published textbooks (or open educational resources [OERs]), assignments, activities, and other methods that will be used to promote active student learning and accountability related to desired outcomes.

Global Health Competency Selection

The discipline of public health has been steadily moving toward competency-based models of education (Bennett & Walston, 2015), culminating in the adoption of competency-attainment criteria for accrediting public health programs in the United States at all levels (Council on Education for Public Health, 2018). Based on an extensive literature review and multiphase deliberations, the Consortium of Universities for Global Health (CUGH) has similarly proposed interprofessional competencies for global health across multiple domains that range from entry to advanced levels (Jogerst et al., 2015). From a backward design perspective, the selection of relevant competencies represents the key first step.

As you begin the process of identifying overarching competencies for a global health survey course at your university, the CUGH model is a good place to start (Drain et al., 2017). In making final selections of domains and competencies, you should carefully consider the fit with your university’s vision and mission, level of instruction (undergraduate or graduate), program concentration, student career goals, and available faculty expertise. Open discussions within faculty or steering committee meetings is helpful in refining thinking and gaining consensus.

After considerable discussion within our MPH steering committee, we selected CUGH global health domains and competencies associated with “Level III: Basic Operational Level.” This includes competencies “required of students aiming to spend a moderate amount of time, but not necessarily an entire career, working in the field of global health” (Jogerst et al., 2015, p. 242). As a steering committee, we further refined domains and competencies to reflect our university’s values, available faculty expertise, student career goals, and concentration competencies that support the health education and promotion emphasis within our MPH program (see Table 1).

Table 1.

CUGH Level III Global Health Domains and Competencies.

Domain	Sample competencies
Global burden of disease	• Describe major causes of global morbidity and mortality • Validate the health status of populations using available data
Globalization of health and health care	• Describe different national models or systems for provision of health care • Describe how global trends contribute to the quality and availability of health and health
Social and environmental determinants of health	• List major social determinants of health and their effects on access to and quality of health services • Describe the relationship between access to and quality of water, sanitation, food, and air on individual and population health
Capacity strengthening	• Co-create strategies with the community to strengthen community capabilities • Integrate community assets and resources to improve the health of individuals and populations
Collaboration, partnering, and communication	• Include representatives of diverse constituencies in community partnerships • Demonstrate diplomacy and build trust with community partners
Ethics	• Demonstrate awareness of local and national codes of ethics • Apply fundamental principles for the protection of human subjects in diverse cultural settings
Professional practice	• Articulate barriers to health and health care in low-resource settings locally and internationally • Demonstrate the ability to adapt clinical or discipline-specific skills and practice in a resource-constrained setting
Health equity and social justice	• Apply social justice and human rights principles in addressing global health problems • Demonstrate a basic understanding of the relationships between health, human rights, and global inequities
Program management	• Plan, implement, and evaluate an evidence-based program • Apply project management techniques
Sociocultural and political awareness	• Describe the roles and relationships of the major entities influencing global health and development
Strategic analysis	• Conduct a community health needs assessment • Design context-specific health interventions based on situation analysis

Note. CUGH = Consortium of Universities for Global Health.

Content Scope and Sequencing

There can be a great deal of content variability in a survey course based on disciplinary framework and the level of emphasis placed on key themes emerging in global health arenas. Global health courses often cover common topics such as social and environmental determinants of health; causes of disease, disability, and death; and ethics, financing, and implementation of global health programs. As you begin to refine content selection and sequencing for your course, a review of the domains in Table 1 is a helpful reference. Your ultimate selection of content and sequencing will be driven by university priorities, program emphases, faculty interests, and student needs. For our graduate level, online course we focused our content around the 11 CUGH global health domains highlighted in Table 1 with a specific emphasis on skills related to global health education and promotion. We organized content into five sequential modules with each module containing three-related units—one unit to be covered each week in a traditional, 15-week semester-based format (see Table 2).

Table 2.

Content Scope and Sequencing for a Global Health Survey Course.

Module	Unit
Module 1: Characteristics and Themes for Global Health Promotion	• Unit 1: Background, definitions and context for global health • Unit 2: Social justice, equity, and human rights • Unit 3: Globalization and the determinants of health
Module 2: Global Health Priorities and Measures of Progress	• Unit 4: From MDGs to SDGs, implications for health promotion • Unit 5: The global burden of disease • Unit 6: Measurement, monitoring, and global health security
Module 3: Culture, Behavior, and Health in Global Contexts	• Unit 7: Medical anthropology and global health • Unit 8: Cultural views of health, illness, and healers • Unit 9: Health beliefs and practices
Module 4: Global Health Infrastructure	• Unit 10: Key players, partnerships, and collaboration • Unit 11: Strengthening global health systems capacity • Unit 12: Global health financing
Module 5: Evidence-Based Approaches to Global Health Promotion	• Unit 13: Global health promotion theories and models • Unit 14: Strategic analysis in global health • Unit 15: Program management and evaluation in global health

Note. MDG = Millennium Development Goal; SDG = Sustainable Development Goal.

Content sequence was designed to first introduce students to the definitions, background, and context of global health and then explore the concepts of social justice, equity, and human rights as they relate to globalization and the social and environmental determinants of health in diverse settings. This sets the stage for Module 2 that focuses on understanding the SDGs, the global burden of disease, issues related to global health security, and the measurement and monitoring of global health indicators. Module 3 explores cultural and sociopolitical influences on global health, and Module 4 analyzes global health infrastructure including key players, partnerships, collaboration, health systems strengthening, and global health financing. The final module takes an in-depth look at health promotion theory, models, systems analysis, and program management in a global health context.

Measuring Mastery in Competency-Based Education

The second step of the backward design approach is to identify strategies for measuring competency mastery. To outline the structure of modules and units listed in Table 2, a competency-based education (CBE) model can be used effectively. Encompassed within CBE models are frameworks which outline specific learning objectives that describe the skills, abilities, and knowledge needed to demonstrate mastery of the objectives (McClarty & Gertner, 2015).

Table 3 utilizes a CBE framework to outline Module 1 of our global health survey course. Using Bloom’s Taxonomy of Educational Objectives (Bloom, Englehart, Furst, Hill, & Krathwohl, 1956), specifically the top tiers of “analyze,” “evaluate,” and “create,” potential learning objectives for Module 1, Units 1 to 3, are proposed in the middle column of Table 3. Note, some objectives are drawn from Jogerst et al. (2015) where additional domains and competencies can be found and explored.

Table 3.

Competency-Based Learning Objectives and Assessment Methods for Units in Module 1.

Unit	Learning objectives	Assessment methods
Unit 1: Background, definitions and context for global health	• Examine general trends and influences of the increased interest and movement in global health their impacts on health. • Critique the impact of the SDGs on global health outcomes.	• “Pretest” survey on current global health status and trends. • 2-minute video discussion post highlighting an impact of the SDGs on global health.
Unit 2: Social justice, equity, and human rights	• Analyze and weigh the most important economic and social class determinants on health. • Evaluate ways in which gender inequity impacts a nation’s health outcomes and economic development. • Design strategies to engage marginalized and vulnerable populations in making decisions that affect their health and well-being.	• Conduct a search for an organization or recent article that addresses gender inequality in that country and how or what strategies are being utilized to reach vulnerable populations and share via discussion post.
Unit 3: Globalization and the determinants of health	• Evaluate the relationship between globalization and its impacts on global health. • Examine the major social and economic determinants of health and their impacts on the access to and quality of health services and on differences in morbidity and mortality between and within countries. • Critique political systems and policies within the context of globalization and their impact on health.	• End of module case study: provide a relevant case study encompassing topics within each unit and have students complete a written assignment addressing the case study prompts and possible solutions.

The third column in Table 3 suggests various learning assessment methods related to the learning objectives in column 2. It is wise to use a variety of assessment strategies to avoid an exam culture that promotes “learning to pass” rather than “learning to learn” (Medland, 2016). Encouraging students’ active participation, by employing innovation in a variety of assessment methods, promotes a deep learning culture (Medland, 2016). There are many direct and indirect assessment methods for you to consider, including open-ended exam questions, quizzes, presentations, case studies, discussions, reflective essays, team-building exercises, data-based analyses, and more (McClarty & Gaertner, 2015).

Authentic Learning Strategies

Once course competencies have been finalized and learning assessment strategies are in place, the final step in the backward design process is to develop authentic learning activities that will contribute to attainment of course competencies. Implementing authentic learning activities helps bridge the gap between formal education within the classroom, and real-life experiences outside the classroom (Stein, Isaacs, & Andrews, 2004). Online course formats are associated with independent learning, which may inhibit levels of student engagement with the course content and with peers. Authentic learning strategies can help overcome this challenge by creating higher levels of student interest and broad engagement (Herrington, Oliver, & Reeves, 2003).

Examples of authentic learning activities include case studies to promote critical thinking and problem solving; participation in community organizations, meetings, or projects; interprofessional team building tasks; or student-defined projects related to real-world problems. Consistent with the assessment strategies outlined for Module 1 (see Table 3), the following authentic learning examples might be tailored for adoption in units covered in Module 1:

Read through the case study provided and determine the overall problem, the social determinants involved, implications for global health outcomes, and potential solutions.

Participate in a local community organization (such as a refugee center, global nonprofit, or local UN meeting). Present an analysis of the organization’s approach to a specific social determinant of global health.

Propose a global health project related to a real-world problem to be worked on throughout the duration of the course. (Based on a topic of interest to you, or related to your future career goals.)

Open Educational Resources

Educational resources that are supportive of authentic learning strategies within a competency-based, backward design approach will be unique to each course. It should be noted that a number of very good textbooks, many with strong instructor resources, are available that address many of the domains and competencies outlined above (Birn, Pillay, & Holtz, 2017; Brown & Closser, 2018; Jacobsen, 2018; Merson, Black, & Mills, 2018; Skolnik, 2017; Zimmerman, DiClemente, Andrus, & Hosein, 2016). Some textbooks can be rented or purchased less expensively as ebooks, or can be purchased electronically on a chapter by chapter basis to reduce textbook costs and more closely match the sequencing of course content.

In developing our global health survey course, however, we chose to rely on OERs for several reasons. Philosophically, the ability to access OERs is an essential tool for enhancing global access to information that is critical to reaching SDGs (Lane, 2017). This alone makes the use of OERs in a global health survey course uniquely instructive. Importantly, we also felt that using OERs would result pedagogically in very strong learning outcomes at a substantially lower cost to students, and in a manner that is regarded positively by both students and instructors (Hilton, 2016; Lawton, 2018). For example, the use of OERs has significant potential to engage students directly with the source material of relevant professional associations, national and multilateral global health agencies, nongovernmental organizations, the professional literature, relevant podcasts, multimedia applications, and the growing wealth of streaming videos from a wide variety of sources (from TED Talks to professional webinars to YouTube and beyond; Lawton, 2018).

Our experience has been that using OERs exclusively to develop a fully online course creates significantly more workload for the instructor initially. Once competencies and learning objectives have been established, for example, you must throw yourself into the maelstrom of available OERs and determine which readings, streaming videos, podcasts, multimedia applications, and other learning experiences will best support learning goals and outcomes for each content domain. This workload was made much more manageable at our university given the presence of an OER office that employs student interns to help identify relevant OER materials and help build them into online courses. Once learning content has been identified and incorporated into the course, you must further design quizzes, discussion boards, exams, written assignments, and other authentic learning and assessment tools that align well with selected course competencies.

Course Evaluation and Refinement

Once the course is fully designed, developed, and ready for implementation, the next major concern is course evaluation and subsequent strategies for continuous course improvement (Addo-Atuah et al., 2014). A typical strategy for obtaining student feedback and evaluation is the use of online, quantitative surveys. Numerous instruments, such as the Quality Matters Higher Education Rubrics, Open SUNY Course Quality Review Rubric, and the IDEA Student Ratings of Instruction, focus on continuous improvement, peer review, and alignment of learning objectives, assessments, learner interactions, and course technology that promotes student-centered learning (Baldwin, Ching, & Hsu, 2018). The advantages of online student course evaluations include rapid feedback, less vulnerability to professional influence, and ample time for student completion. However, low student response rates have been a characteristic disadvantage of online evaluations since their implementation. One strategy that has been effective in increasing response rates, along with instrument validity and reliability, is the use of incentives such as extra credit (Jaquett, VanMaaren, & Williams, 2017).

Other course evaluation methods to consider include informal mid-semester student evaluations or the use of a peer reviewer. The use of mid-semester evaluations allows students to provide feedback and voice concerns before the course has been completed, allowing for minor adjustments or better alignment of learning objectives and teaching strategies. Timely student feedback not only leads directly to course improvements but can guide decisions about how the course fits into the larger curriculum and how it is used toward other ends—such as becoming a prerequisite for global health applied practice experiences (Addo-Atuah et al., 2014).

The use of a peer reviewer, usually another faculty member (either internal or external to the discipline), to formally review your online course using a high-quality rubric can also provide helpful feedback for improvement. As you consider what methods are best for you, select those strategies that focus on delivering and improving high-quality, student-centered learning.

Conclusion

Going forward, online education for developing the global health workforce will continue to be a dynamic arena (George et al., 2014; Hawks & Gast, 2018). Current research provides mounting evidence that fully online global health courses can have a positive impact on student knowledge, attitudes, and skills related to global health competencies among students from a variety of disciplines (Addo-Atuah et al., 2014; George et al., 2014; Poirier et al., 2016; Utley-Smith, 2017). A massive open online course has showed promise as a tool for preparing students for short-term experiences in global health (Jacquet et al., 2018), and online global health courses are being used to promote interprofessional collaboration and teamwork (Ambrose, Murray, Handoyo, Tunggal, & Cooling, 2017; Martini & Caceres, 2012), and prepare students for applied practice experiences in global settings (Addo-Atuah et al., 2014).

A backward course design, with well-selected content domains and competencies, opens the way for the development of the best possible learning resources and authentic learning activities that are consistent with national benchmarks for online course development (Kanekar, 2018). In spite of course development workload and challenges, the use of this strategy, along with the exclusive use of OERs, has resulted in a much keener sense of course “ownership” on our part and a more nuanced understanding of the wealth of very good teaching and learning strategies and materials that are freely available “out there.” Students have also expressed appreciation for greater engagement with a wide variety of content sources and activities than textbook-based instruction might typically offer.

Footnotes

Acknowledgements

The authors wish to express appreciation to the Center for Innovative Design and Instruction and the University Libraries Open Educational Resources program, both at Utah State University, for technical consultation and shared expertise.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Steven R. Hawks

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