Global recognition of the importance of nutrition in promoting the health of populations has led to the development of new professional education programmes in public health nutrition(1–Reference Laraia, Dodds and Benjamin5). In Canada, current and projected shortages of nutrition professionals, particularly in northern and rural communities(Reference Fox, Chenhall and Traynor6–Reference Brewer9), challenge the public health system’s capacity to effectively address issues such as obesity and chronic disease prevention, maternal and child health, and food security(Reference Fox, Chenhall and Traynor6). The purpose of the present paper is to describe the planning of a more accessible graduate programme for experienced nutrition professionals.
Background
In 2004, the Public Health Agency of Canada was established to coordinate and enhance public health services on a national level(10). One of the major initiatives of the Agency has been skills enhancement of the public health workforce. New core competencies for public health practice have been developed for all public health disciplines(11) and there is significant momentum to promote the development of discipline-specific competency sets(10). Meanwhile local health units, challenged by decades of resource constraints, an ageing workforce and in many cases vast geographical areas to service, are experiencing gaps in personnel(Reference Brewer9). Northern and rural health units, in particular, have struggled to recruit qualified dietitians to deliver federally, provincially and locally mandated programming(8, Reference Brewer9).
In 2002, nutritionists from northern Ontario approached the University of Toronto to explore opportunities for enhancing access to graduate training for dietitians working in northern and rural health units. With few exceptions, public health nutrition professionals in Canada are registered dietitians who then acquire public health expertise through on-the-job training and/or additional graduate education(Reference Fox, Chenhall and Traynor6). Unlike the European Credit Transfer and Accumulation System(12) and the Strategies for Success: Curriculum Guide (13) in the USA, no standardized tools existed in Canada to guide curriculum development and recognition across jurisdictions. Specific educational requirements for public health nutrition professionals vary among the country’s ten provinces and three territories; however, a 4-year undergraduate degree in food and nutrition accompanied by an internship or practicum is a minimum requirement all round. Health units often employ dietitians directly from their internship training, where exposure to public and population health curriculum is often limited. Few graduate programmes specific to public health nutrition existed, and those that did required students to leave their workplaces for up to 2 years to complete their graduate training. This suggested the need for advanced education in public health nutrition that did not require dietitians to leave their communities for extended time periods.
In 2005 we became aware of an opportunity to apply for internal university funding to develop a new programme and spent 3 months exploring the feasibility of such an application. In 2006 the proposal for development funding was submitted and approved by the university and we immediately applied to the Ontario Council of Graduate Studies to have the new programme approved as a graduate degree offering in Ontario. This submission was approved in June of 2007. This timing gave us the option of admitting students in the autumn of 2007, only three months away, and one year earlier than planned. Initiating the programme early would alter the year of detailed curriculum planning that we had envisioned, but would enable us to get going at a time when there was significant stakeholder support. We decided that our existing graduate programme in Community Nutrition provided a strong base upon which to move forward and we opted to admit a small group of students that autumn. While some of the needs assessment data had been gathered previously, most of the formal planning described in the present paper took place within this 3-month period and into the first year of programme operations. This represents an unusually brief planning timeframe and we hope that sharing our efforts to optimize the opportunity we faced will be helpful to readers needing to construct new academic programmes in similarly short order.
The planning model
The programme planning model developed by The Health Communication Unit (THCU) at the Centre for Health Promotion, University of Toronto(14) was used to guide the planning process. This model is used widely by health units in Canada for planning health promotion initiatives and provides a framework that is applicable to diverse planning contexts. The model is founded on the Ottawa Charter of Health Promotion(15) and incorporates a ‘social determinants of health’(Reference Raphael16, 17) perspective. This model was selected because of its focus on existing strengths and assets, not just on gaps and needs(14), and because of its familiarity among stakeholders who would be involved in our planning. Figure 1 illustrates the steps involved in this planning approach.
The Health Communication Unit (THCU) planning model (reprinted with permission of THCU, Centre for Health Promotion, University of Toronto)
Step 1 addresses how the planning process will take place. During this phase, stakeholders are identified and discuss how they will work together, how data will be collected and how decisions will be made. Step 2 involves assessing the current situation including needs, gaps and opportunities as well as strengths and existing resources. This phase attempts to confirm whether or not planning should proceed. Steps 3 to 5 carve out the goals and objectives, strategies and activities, and desired outcomes. This includes identification of indicators that will be used to track progress. Step 6 links goals, objectives and strategies to indicators in order to support programme evaluation. Feedback is built into each step of the process. While each step is represented separately in the model, some planning situations require more than one step to happen simultaneously or in different sequences(14).
The sections that follow describe the experiences and challenges encountered during each step of implementing the THCU programme planning framework.
Step 1: Pre-planning and project management
Preparing the funding proposal enabled us to assemble key stakeholders to help formulate the vision for the new programme and to guide programme development. While public health renewal was occurring nation-wide,Footnote * most health service delivery in Canada is the responsibility of provincial jurisdictions. As we imagined that our initial efforts would target an audience largely from our local province, Ontario, members of our advisory committee were selected to represent both national and Ontario-specific perspectives. Table 1 lists the advisory committee members who agreed to support the project and their roles. The committee established terms of reference that outlined members’ roles as advisors, with the university being ultimately responsible for decision making and resource provision.
Advisory committee membership
Step 2: Situational assessment
The advisory committee identified several educational needs and a situational assessment involving qualitative and quantitative information gathering was undertaken to explore gaps, issues and assets upon which to build.
Gaps/needs assessment
Ongoing discussion with public health leaders and nutrition professionals confirmed our view that dietitians, particularly those working in northern and rural communities, had limited access to graduate education programmes specific to public health nutrition. We did not know, however, what kind of programmes would best address the need and what the demand would be. Dietitians of Canada (DC), the national professional association responsible for promoting dietetics practice and accrediting education programmes, and a contributing member of our advisory committee, conducted a survey of its membership to help address these issues. An electronic survey was sent to all 5000 members of DC. Some 633 members (13 %) responded and 203 (32 %) of those respondents indicated they would apply to a programme such as the one we were planning. Although we presented other options for continuing education, such as certificate programmes, most respondents viewed a masters programme as more advantageous in advancing their careers. Survey results also suggested the need to limit students’ time away from family and community, provide curricula that builds on work and life experiences, and minimize the cost of the programme. Students indicated interest in distance education options and we noted that there were no distance graduate education programmes specific to public health nutrition in Canada.
PEEST analysis
The THCU model suggests considering the political, economic, environmental, social and technological (PEEST) factors that impact the planning situation. Accordingly, we noted that there was a tide of public health development activity across the country and we were not the only university developing education programmes for this sector. We anticipated that we could be faced with significant ‘competition’ for graduate students in public health; however, our programme was the only one under development that we were aware of that would focus specifically on nutrition. Within the university, plans were underway to re-establish a School of Public Health and programmes that fit within that domain would further strengthen the strategic direction. From an economic perspective the Academic Initiatives Fund (AIF)Footnote * within our own university would provide development and start-up funds; however, ongoing financial support would need to be generated from the government’s tuition funding formula, which would require considerable rationalization of resources.
Space and the availability of faculty with appropriate expertise were also limited. We presented our ideas to colleagues at faculty and department meetings. While faculty supported the programme in principle, most expressed concern about resources and distance education in particular. Those who had taught online courses found this approach to be more time-demanding than traditional classroom teaching. Student feedback indicated the desire to interact with leaders in practice, as well those in academia, and we discovered that technical support for online instruction through our Faculty of Medicine could enable practice leaders in different parts of the province to teach our students.
Strengths and opportunities
In addition to the distance delivery support, we identified expertise in adult education within the university. Our most significant opportunity, however, lay in the fact that we had an existing graduate programme in community nutrition upon which to build additional curricula(19). In fact several of the courses offered in this programme were specific to public health and could be accessed by students in the new programme. This minimized the need to develop an entirely new curriculum. The development of new Masters of Public Health (MPH) programmes across Canada, some of which incorporated distance learning, also presented collaborative opportunities to share course development so that curricula were not duplicated. The final opportunity identified involved existing collaborative relationships with the Pan-Canadian Task Force on Public Health Nutrition Practice. This group was in the process of developing competencies and recommendations for the enhancement of public health nutrition practice in Canada(Reference Fox, Chenhall and Traynor6), and the University of Toronto was a participant in this process. The work of this group was helpful in informing programme development.
The situational assessment was a vital planning component that confirmed the need – as well as the demand – for a programme that could enhance access to graduate education in public health nutrition. The political climate was favourable and resources within the university and among external partners were identified. The next step was to establish goals and objectives for the programme.
Step 3: Goals and objectives
The THCU model(14) and Bloom’s taxonomy of educational objectives(Reference Gronlund20) informed the development of goals and objectives. The TCHU model suggests that goals provide visionary direction without necessarily being measurable, while objectives provide specific and measurable outcomes. Bloom’s taxonomy encourages the construction of objectives that extend beyond the acquisition of knowledge to the promotion of skills development and application, critical reflection and transformation of practice(Reference Gronlund20). The three major goals for the programme were identified as follows.
The new graduate Public Health Nutrition programme will:
1. Enhance knowledge, skills and leadership potential of public health nutrition professionals in communities across Canada.
2. Contribute to public health renewal in Canada by strengthening the public health nutrition workforce.
3. Enhance capacity of the public health system to promote the nutritional health of Canadians.
Specific objectives are listed in Table 2, along with the indicators developed in the steps that follow.
Programme goals, objectives and evaluation indicators
RD, registered dietitian.
Steps 4–6: Developing strategies, approaches and indicators
Based on the data gathered in the situational assessment, and the goals and objectives of the programme, a curriculum was developed that incorporated both face-to-face and distance learning strategies, provided students with substantive opportunities to share practice experiences with each other, and enabled them to apply new learning in the workplace. The format consisted of one semester on campus, two or three online courses, a one-week intensive summer institute accompanied by readings and assignments, and completion of a major workplace project. Table 3 provides an overview of the programme structure and content. The programme may be completed within a 1-year period or more gradually up to 5 years depending on student needs and preferences(19).
Programme overview
On-campus courses
Currently students wishing to complete the programme within 12 months are required to spend the autumn semester (September to December) on campus completing four or five half-credit courses. This provides students with opportunities to establish relationships with peers and instructors. This coursework is shared with the pre-existing masters programme in Community Nutrition, which provides foundational courses in public health nutrition theory and practice(19).
Online courses
In the winter semester, students return to their communities and resume their jobs while completing online coursework. Two new online courses have been developed and implemented to meet the specific learning needs of students in this programme. The course ‘Nutrition Metabolism for Public Health Nutrition Professionals’ was developed to update students on nutritional science and enhance their ability to assess the primary literature in this field. The online version of the second course, ‘Nutrition Programs and Strategies’, was adapted from an existing classroom course, with a particular focus on experiential learning(Reference Kaufman and Mann21–Reference Vince23) and reflective practice(Reference Kaufman and Mann21, Reference Schön24). Development of additional online courses is underway and students may take up to two approved courses at other universities.
Summer institute
At the end of June, students gather for a one-week intensive programme on leadership. During this time, they attend workshops and meet with experts in programme planning and evaluation, leadership development and communications to plan projects that are completed over the summer months.
Workplace practicum project
Students spend approximately 160 h completing a workplace project that allows them to apply new knowledge and to showcase their acquired skills. Examples of projects that have been undertaken include: the development of a position paper on trans fat; the development and implementation of an online workplace health programme; the development of a workplace healthy food policy; and an environmental scan of ‘buy local’ food initiatives.
Challenges, opportunities and lessons learned
The main challenges and dilemmas encountered in planning this programme were resource constraints and the development of online v. classroom-based learning. Several opportunities arose, however, that enabled us to address these.
Resource constraints
Implementing the programme sooner than expected provided momentum to move forward, but meant that we had to make decisions quickly and sometimes without the data we would have liked to inform those decisions. We received funding for planning the programme, developing two new online courses and hiring a part-time coordinator; however, other administrative, teaching and capital costs had to be absorbed within the existing infrastructure. Recruiting a coordinator proved to be challenging due the very shortage of expertise in the workplace that we were trying to address with the new programme.
Faculty expressed concerns about the capacity within existing courses to take additional students from the new programme, for instructors to teach new courses and to provide students with adequate mentorship. These concerns were addressed by limiting the number of potential enrolees in existing courses and seeking instructors from the field, rather than from within the academy, to develop and teach some of the new courses. A PhD scientist with expertise in nutrition metabolism and online course development was hired to develop and teach ‘Nutrition Metabolism for Public Health Nutrition Professionals’. The programme advisory committee was instrumental in reviewing drafts and providing suggestions for topics and resources. The second distance course, ‘Nutrition Programs and Strategies’, was taught by a masters-prepared senior public health nutritionist from northern Ontario with years of provincial leadership experience. Her involvement enriched the professional and experiential content of the course.
We anticipated that some students might need extra support as they adjusted to online learning and therefore introduced them to resources during the on-campus period, to enhance these skills. We also made efforts to pair students from this programme with those from our Community Nutrition programme throughout the campus courses shared by the two programmes, so that the students straight from their undergraduate training could assist the mature learners with some of the recent scientific advances, and the experienced students could help the others appreciate the relevance of the material for practice.
Distance v. on-campus
One of our biggest dilemmas was determining what part(s) of, and through what means, the programme should be distance-oriented. If we implemented some of the existing classroom-based courses, the programme could be underway immediately, giving us a semester lead time to start to develop online and other learning strategies. Attempting to provide the entire programme electronically would require many more months of development and was beyond the resources available to us. Instructors with the specific expertise needed to develop and teach online public health nutrition courses were also in short supply and our funding enabled the development of two online courses only. We considered other distance-oriented approaches such as mail-out packages and modular formats; however, respondents to our initial survey identified the latter option as being too costly. The distance education literature identifies a number of challenges and opportunities associated with web-based learning(Reference Bernard, Abrami and Lou25–Reference Sternberger29) and we wanted to take advantage of new venues for students to share insights and experiences. The literature on distance graduate pubic health nutrition education is limited, but studies on undergraduate and business programmes(Reference Sitzmann, Kraiger and Stewart30–Reference Lapsley, Kulik and Moody32) suggest using clusters of learning modes (e.g. text, audio, video, synchronous and asynchronous communication) to suit students’ individual learning styles(Reference Sitzmann, Kraiger and Stewart30, Reference Lapsley, Kulik and Moody32). These were incorporated into course delivery.
In the end, we felt that proceeding with one semester on campus, followed by online courses conducive to completion while students were back in their workplaces, along with the summer institute and worksite practicum project made best use of resources while addressing student needs. We noted the financial and practical limitations of the one semester on campus requirement for students, and committed to monitor student responses and employer receptivity to this component of the programme.
Lessons learned
We initially admitted a cohort of four students, followed by a second cohort of six, and aim to admit ten to fifteen students to the programme annually over the next two to three years. Through this process, we have garnered valuable insights about developing a new graduate programme that we hope will be useful to others embarking on similar initiatives.
Situational assessment is critical
Conducting a situational assessment is a key focus of the THCU planning model(14) and our experience confirms this. The survey proved to be particularly informative in guiding programme development. For example, we initially considered offering the programme in a modular format that would require students to come to campus four times per year for a few weeks at a time. However the survey feedback was clear that this format was not well received by potential applicants, so other options were pursued.
Engage stakeholders
Identifying the concerns of faculty, students, administrators, professional groups and the public health community during the planning process helped us anticipate challenges and align our programme with other initiatives that were underway. Establishing an advisory committee was an effective means of gathering expertise, support and insight as to how to make the programme relevant. Members of the public health community provided direction in curriculum content that would prepare students for leadership roles in the field. Professional groups helped us tap into our target audience to assess the best ways of offering education programmes. Faculty provided input into course offerings and existing curricula across the university.
Build on existing strengths and assets
The THCU model also encourages planners to identify existing strengths and assets and optimize the use of these in programme development(14). This led us to list tools and resources available to us. Tapping into ‘in-house’ expertise in online course development helped orient us to new ways of approaching teaching and learning. Incorporating existing courses into the programme enabled us to provide ‘tried and true’ content while experimenting with new ideas, such as the incorporation of electronic portfolios for students to document their work. It also allowed us to use limited funds to develop the more unique aspects of the programme such as the worksite practicum project and summer institute. Table 4 outlines the course components of both the pre-existing and the new programmes.
Overview of existing (MHSc Community Nutrition) and new masters (MScCH Public Health Nutrition) programmes
Identify desired outcomes
Identifying learning outcomes is considered to be a major component of developing learning-centred curricula(Reference Hubball and Burt33). Our long-term objectives attempted to provide vision and direction, while our shorter-term objectives were supported by directly measurable outcome indicators so that we could monitor the programme in progress and make changes early if need be. For example, by monitoring the number of applicants each year from northern and rural communities, we will be able to determine whether or not we are reaching our target audience and adjust our programme and promotional strategies accordingly.
Acknowledge that changes will need to be made and plan to monitor
Approaching programme development as a work in progress supports flexibility and the ability to refocus attention where and when it is needed. For example, early programme approval necessitated that we ‘fast-track’ some of the extensive curriculum design review that we had intended, in order to meet a moved-up start date. By viewing the curriculum as dynamic, we continually sought student feedback through questionnaires, focus groups and informal discussions as the programme unfolded. This approach enabled students to not only evaluate the programme and their learning experiences at frequent intervals, but also to proactively contribute to the design of what would come next for them and for others. The first group of students was especially influential in shaping the content and delivery of the programme that was offered to the subsequent cohort, and valued the opportunity to help evolve the programme.
Fraser and Greenhalgh encourage educators to educate not only for competence (‘what individuals know or are able to do in terms of knowledge, skill and attitude’, p. 799) but also for capability (the ‘extent to which individuals can adapt to change, generate new knowledge and continue to improve their performance’, p. 799)(Reference Fraser and Greenhalgh34). They suggest that the latter is brought about by processes that support learner engagement in goal setting, reflection, continuous feedback and improvement, and educational methods that avoid prescriptive content(Reference Fraser and Greenhalgh34). While the flexibility and high degree of involvement of students in creating the curriculum were originally intended as interim measures to see us through the initiation phase of the programme, they will remain in place for incoming groups of students to foster learning approaches that bring about both ‘competent’ and ‘capable’ graduates.
Impact on students
Initial data suggest the programme is addressing workforce development objectives. The ten initial students (all female) will have completed the programme at various paces ranging from 12 months to one who will take 5 years to complete. This reflects a wide range of learning needs and competing demands. Of the eight students who have completed the programme, all have experienced enriching work opportunities. Five graduates have benefited from advancement and/or new project opportunities within their existing workplaces, while three have pursued opportunities in new places of employment. One graduate was an international student from Brazil who pursued the programme specifically to acquire expertise for her role in her home country. All ten students are currently working in roles related to public health nutrition. Six students work in local public health units or regional health authorities (three in northern or rural communities), one works at the provincial government level, one at the federal government level and one in the private food service sector. Like their American counterparts(Reference Laraia, Dodds and Benjamin31), students in these cohorts have identified employer support as a key determinant of their success and we have commenced a study to explore employer perspectives. Understanding student support is a key next step and monitoring of student outcomes will form a major component of our long-term evaluation strategy.
Conclusions
Planning a new graduate programme in Public Health Nutrition within a short timeframe presented challenges and opportunities. While extensive data gathering to inform decision making was not always possible, involvement of enrolled students in programme design proved advantageous in meeting their needs. Establishing an advisory committee and involving instructors from the field optimized use of existing resources and grounded the curriculum in the professional development needs of the workforce and of students. The THCU programme planning model provided a useful framework that was well understood by stakeholders and provided a common perspective that facilitated planning. Preliminary data suggest that graduates are benefiting from their educational experiences. Ongoing programme evaluation will provide further insights into the effectiveness of our efforts.
Acknowledgements
Source of funding: The development of the programme described was funded by the Academic Initiatives Fund at the University of Toronto. Conflicts of interest: The authors declare no conflicts of interest. Author contributions: A.F. was the project lead and wrote the first and subsequent drafts of the paper. J.B. was a major contributor to programme planning and development and reviewed and revised several drafts of the manuscript. Acknowledgements: The authors wish to thank Lee Rysdale, Renee Gaudet and Sandra Laclet for their early commitment and invaluable input; and Harvey Skinner, Michael Archer, Bart Harvey, Andrea Sass-Kortsak and Karin Domnick for their support at multiple stages of planning and implementation. We extend special appreciation to the first group of programme students for their patience, enthusiasm and involvement in the planning process.
