# Educating the Global Workforce for Public Health

edited by: Sanjay P. Zodpey, Roger A. Harrison, Michal Grivna, John R. Finnegan and Connie J. Evashwick published in: Frontiers in Public Health and Frontiers in Education

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ISSN 1664-8714 ISBN 978-2-88945-447-1 DOI 10.3389/978-2-88945-447-1

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## **Educating the Global Workforce for Public Health**

Topic Editors:

**Sanjay P. Zodpey,** Public Health Foundation of India, India **Roger A. Harrison,** University of Manchester, United Kingdom **Michal Grivna,** United Arab Emirates University, United Arab Emirates **John R. Finnegan,** University of Minnesota, United States **Connie J. Evashwick,** George Washington University, United States

Good quality management of the health system demands a critical mass of health professionals with sound technical knowledge. The education that produces a workforce of appropriate size and skills is often a challenge in the delivery of quality health services. Incidentally, health professionals' education has not kept pace with the new emerging challenges. Recent globalization of health has further led to international migration of health professionals, thereby leading to cross-border recognition of health workers with an appropriate skill-mix, knowledge, and competence.

The Lancet Commission Report of 2010 highlighted the need to develop a common strategy at a global level for postgraduate medical, nursing, and public health education that reaches beyond the confines of national borders and the silos of individual professions. This

vision would require a series of instructional and institutional reforms, which should be guided by two proposed outcomes: transformative learning and interdependence in education. The purpose of this Research Topic is to increase the shared understanding of the current status of the education of the health workforce around the globe, particularly those working in the public health sector. With this foundation, further research and evaluation studies can then be done with a perspective that addresses global workforce issues impacting access, prevention, and care.

**Citation:** Zodpey, S. P., Harrison, R. A., Grivna, M., Finnegan, J. R., Evashwick, C. J., eds. (2018). Educating the Global Workforce for Public Health. Lausanne: Frontiers Media. doi: 10.3389/978-2-88945-447-1

# Table of Contents

#### **1. Editorial**

## *05 Editorial: Educating the Global Workforce for Public Health* Sanjay P. Zodpey, Connie J. Evashwick, Michal Grivna, Roger A. Harrison and John R. Finnegan **2. Cross-cutting Competencies** *08 A Review of Global Health Competencies for Postgraduate Public Health Education* Shailendra Sawleshwarkar and Joel Negin *20 One Health Core Competency Domains* Rebekah Frankson, William Hueston, Kira Christian, Debra Olson, Mary Lee, Linda Valeri, Raymond Hyatt, Joseph Annelli and Carol Rubin *26 Educating the Public Health Workforce: A Scoping Review* Donghua Tao, Connie J. Evashwick, Michal Grivna and Roger Harrison **3. Region-Specific Focus**  *34 Preparation of European Public Health Professionals in the Twenty-first Century* Vesna Bjegovic-Mikanovic and Robert Otok

#### *40 Global Health Teaching in India: A Curricular Landscape*

Sanghamitra Pati, Rajeshwari Sinha, Meely Panda, Sandipana Pati, Anjali Sharma and Sanjay Zodpey

#### *48 How Do Masters of Public Health Programs Teach Monitoring and Evaluation?*

Himanshu Negandhi, Preeti Negandhi, Sanjay P. Zodpey, Hemali Kulatilaka, Radhika Dayal, Lauren J. Hart and Marybeth Grewe

#### **4. Individual Institutions**

### *55 The Educated Citizen and Global Public-Health Issues: One Model for Integration into the Undergraduate Curriculum*

Rosemary M. Caron

### *61 Global Health Master's Students: Demographics and Career Goals* Ashti A. Doobay-Persaud, Shannon R. Galvin, Natalie E. Sheneman and Robert L. Murphy

*66 An Effective Model for Improving Global Health Nursing Competence* Sun-Joo Kang

*71 Integrating Public Health and Health Promotion Practice in the Medical Curriculum: A Self-Directed Team-Based Project Approach*

Geraldine Kershaw, Michal Grivna, Iffat Elbarazi, Souheila AliHassan, Faisal Aziz and Aysha Ibrahim Al Dhaheri

*80 Analysis of the Preventive Medicine Undergraduate Curriculum in China: The West China School of Public Heath Experience: A Case Study*

Li Zhao, Ruiou Wang, Junguo Xin, Quan Chen, Chunyan Li, James W. Holsinger Jr. and Xiao Ma

# Editorial: Educating the Global Workforce for Public Health

*Sanjay P. Zodpey1 \*, Connie J. Evashwick 2 , Michal Grivna3 , Roger A. Harrison4 and John R. Finnegan5*

*1Vice President – Academics, Public Health Foundation of India, New Delhi, India, 2Associate Professor, Milken Institute School of Public Health, Washington, DC, United States, 3Professor and Director, Institute of Public Health, College of Medicine & Health Sciences, UAE University, AlAin, United Arab Emirates, 4Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health Sciences, School of Health Sciences, University of Manchester, Manchester, United Kingdom, 5Professor and Dean, School of Public Health, University of Minnesota, Minneapolis, MN, United States*

Keywords: public health education, health workforce, competencies, global health, global health workforce

#### **Editorial on the Research Topic**

#### **Educating the Global Workforce for Public Health**

A strong health workforce is one of the six building blocks of the World Health Organization's framework for health (1). A critical mass of health professionals with sound technical knowledge is necessary to manage a health system. The education that produces a workforce of appropriate size and skills is often a crucial limiting factor in the delivery of quality health services. The health workforce is characterized by its diversity and complexity, encompassing professionals from a wide range of occupational backgrounds and types of training. The purpose of this Research Topic is to increase the shared understanding of the current status of the education of the health workforce around the globe, particularly those working in the public health sector. With this foundation, further research and evaluation studies can then be done with a perspective that addresses global workforce issues impacting access, prevention, and care.

Education has traditionally been recognized as an important tool for creating trained health professionals. However, health professionals' education has not kept pace with the new emerging challenges, such as rapid demographic and epidemiological transitions, fresh emerging and re-emerging health challenges, new environmental and behavioral risks, and increasing appreciation of the social determinants of health. Recent globalization of health has led to international migration of health professionals, thereby leading to cross-border recognition of health workers with an appropriate skill-mix, knowledge, and competence. While some encouraging progress has been made in health workforce development globally, challenges such as investments, planning, and interventions for advancing the agenda of health workforce development continue to persist (2).

Restructured curricula and training programs are needed that emphasize primary care and prevention; basic, clinical and population sciences; evolving health-care competencies and skills; and new teaching-learning methodologies. The Lancet Commission Report (3) has also highlighted the need to develop a common strategy at a global level for postgraduate medical, nursing, and public health education that reaches beyond the confines of national borders and the silos of individual professions. This vision would require a series of instructional and institutional reforms, which should be guided by two proposed outcomes: transformative learning and interdependence in education (3).

With an aim toward advancing this agenda, this Research Topic invited manuscripts for a wide range of topics and article types. After thorough demand generation for papers, the RT received 10 submissions matching the criteria. Each article provides valuable insight into critical issues related to public health professionals' education for global engagement.

#### *Edited and Reviewed by:*

*Marcia G. Ory, Texas A&M School of Public Health, United States*

> *\*Correspondence: Sanjay P. Zodpey<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health*

*Received: 01 November 2017 Accepted: 22 December 2017 Published: 22 January 2018*

#### *Citation:*

*Zodpey SP, Evashwick CJ, Grivna M, Harrison RA and Finnegan JR (2018) Editorial: Educating the Global Workforce for Public Health. Front. Public Health 5:364. doi: 10.3389/fpubh.2017.00364*

Sawleshwarkar and Negin's article provides an introduction to the topic with a review of the competencies for global health (Sawleshwarkar and Negin). A comprehensive literature search using relevant keywords identified 13 relevant articles for review. Three aspects of global health competency domains emerged: burden of disease and health determinants, core public health skills, and soft skills.

Frankson et al. highlighted yet another dimension of competencies for global health—the "One Health" approach. The core competency domains considered critically important for guiding curriculum development and continuing professional education using the One Health approach were identified as "management," "communication and informatics," "values and ethics," "leadership," "teams and collaboration," "roles and responsibilities," and "systems thinking."

Bjegovic-Mikanovic and Otok describe the public health problems confronting public health professionals in European public health schools, the exit competencies at the end of their public health training, and the expectations of the prospective employees. Their article stresses the need for an interface between public health functions, competencies, and performance, the importance of competence-driven education, and furthermore, the need for educational institutions to look beyond national boundaries since public health challenges are increasingly global.

The article written by Pati et al. maps global health teaching in the Indian public health education context. Pati and colleagues conducted a thorough literature search of the public health programs including global health in India. They found that while this was being covered as part of larger public health programs, a distinct program for global health teaching is missing. They emphasized that more efforts need to be directed toward integrating global health into the broader public health curricula.

Negandhi et al. undertook a desk review of monitoring and evaluation (M&E) curricula and teaching in Masters programs globally, followed by a detailed review of M&E teaching across ten institutions representing four South Asian countries. The findings of the review were utilized to identify ten core competencies for M&E teaching in a consultative meeting of academicians from the four countries. The desk review showed similarities in M&E course content but variations in course structure and delivery. The identified core competencies included basic M&E concepts.

In addition to articles with a broad perspective, several articles from a single institution present case studies with lessons learned for wider application. Caron's article focuses on support for the recommendation that all undergraduates should have access to public health education (Caron). Her paper describes the experience of the University of New Hampshire in generating an educated citizenry that is aware of comprehensive public health conflicts, thereby contributing to both a local and global perspective on learning.

Doobay-Persaud et al. conducted a survey of students seeking admission to the MSc Global Health course at the Northwestern University, as well as a separate survey of those students already active. The aim was to describe the market characteristics for this degree, provide student backgrounds that will guide curricular and programmatic improvements, and determine if these students intend to pursue degrees in global health. Results showed a wide variety of disciplines represented in students' previous work histories, underscoring and supporting the inter-professional nature of the field and the workforce.

Kang's article focusing on improving global health competence among nursing undergraduates echoes the significance of global public health in today's clinical education (Kang). This article discusses the implementation and evaluation of four field training programs for undergraduates nursing students conducted in collaboration with nursing programs in developing countries.

Kershaw et al. emphasized the importance of developing health promotion skills through a self-directed project-based learning task during which the students of the medical degree program at United Arab Emirates University were introduced to public health and health promotion practice, and their soft skills such as literature searching, writing, presentation skills, and team work.

Zhao et al. presented the reforms needed in Chinese undergraduate preventive medicine programs in areas such as the traditional preventive medicine course content, revision of its curriculum structure, the need to increase practical experience, developing variety in teaching and assessment techniques, and systematic planning for curricular reforms.

Worldwide, immense focus is being placed on the public health response required to spread beyond national boundaries, and the need for the public health workforce to be appropriately armed with the knowledge, skills, and behaviors to handle these global health challenges of the 21st century. The Recife Declaration (2) has acknowledged international commitment toward building a stronger and competent health workforce for greater progress in the HRH field. The 10 articles from this Research Topic have artfully landscaped issues that directly or indirectly point toward how knowledge and skills can be imparted to public health students using innovative teaching techniques and updated curricula. Overall, this RT has stayed focused on its objective: to highlight the importance of "educating the global workforce in public health."

### AUTHOR CONTRIBUTIONS

All five authors contributed significantly to the Editorial. SZ took the lead in articulating the editorial and preparing the first draft. CE edited the first draft and also added other significant details in the manuscript. MG, RH, and JF also gave their respective inputs to the manuscript from time to time.

#### REFERENCES

3. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. *Lancet* (2010) 76(9756):1923–58. doi:10.1016/ S0140-6736(10)61854-5

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2018 Zodpey, Evashwick, Grivna, Harrison and Finnegan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# A Review of Global Health Competencies for Postgraduate Public Health Education

*Shailendra Sawleshwarkar1,2\* and Joel Negin2*

*1Western Sydney Sexual Health Centre, Sydney Medical School Westmead, Marie Bashir Institute for Infectious Diseases, University of Sydney, Sydney, NSW, Australia, 2School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia*

During the last decade, the literature about global health has grown exponentially. Academic institutions are also exploring the scope of their public health educational programs to meet the demand for a global health professional. This has become more relevant in the context of the sustainable development goals. There have been attempts to describe global health competencies for specific professional groups. The focus of these competencies has been variable with a variety of different themes being described ranging from globalization and health care, analysis and program management, as well as equity and capacity strengthening. This review aims to describe global health competencies and attempts to distill common competency domains to assist in curriculum development and integration in postgraduate public health education programs. A literature search was conducted using relevant keywords with a focus on public health education. This resulted in identification of 13 articles that described global health competencies. All these articles were published between 2005 and 2015 with six from the USA, two each from Canada and Australia, and one each from UK, Europe, and Americas. A range of methods used to describe competency domains included literature review, interviews with experts and employers, surveys of staff and students, and description or review of an academic program. Eleven competency domains were distilled from the selected articles. These competency domains primarily referred to three main aspects, one that focuses on burden of disease and the determinants of health. A second set focuses on core public health skills including policy development, analysis, and program management. Another set of competency domains could be classified as "soft skills" and includes collaboration, partnering, communication, professionalism, capacity building, and political awareness. This review presents the landscape of defined global health competencies for postgraduate public health education. The discussion about use of "global health," "international health," and "global public health" will continue, and academic institutions need to explore ways to integrate these competencies in postgraduate public health programs. This is critical in the post-MDG era that we prepare global public health workforce for the challenges of improving health of the "global" population in the context of sustainable development goals.

#### *Edited by:*

*Sanjay P. Zodpey, Public Health Foundation of India, India*

#### *Reviewed by:*

*Jason Scott Turner, Saint Louis University, USA Darcell P. Scharff, Saint Louis University College for Public Health and Social Justice, USA*

#### *\*Correspondence:*

*Shailendra Sawleshwarkar shailendra.sawleshwarkar@sydney. edu.au*

#### *Specialty section:*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health*

> *Received: 24 October 2016 Accepted: 24 February 2017 Published: 20 March 2017*

#### *Citation:*

*Sawleshwarkar S and Negin J (2017) A Review of Global Health Competencies for Postgraduate Public Health Education. Front. Public Health 5:46. doi: 10.3389/fpubh.2017.00046*

Keywords: global health, competencies, international health, postgraduate education, public health

## INTRODUCTION

In the post-MDG era, there is increasing recognition that health and sustainable development are inseparable in an increasingly globalized and interconnected world (1, 2). The complex interplay between humans, animals, and environment; dual burden of communicable and non-communicable diseases; emerging economies; and mobility of people are having profound political, social, and economic consequences (3). The concept of "global health" as the health of an interdependent global population is not only shaping our understanding of which and whose problems we tackle but also the way in which we educate students and design the global institutions that govern our collective efforts to protect and promote public health worldwide (3).

During the last decade, there has emerged a growing body of literature about global health. Based on MEDLINE searches, from 1996 to 2000, there were fewer than 50 publications with "global health" in either the title or abstract, which increased to more than 6,000 from 2011 to 2015. Global health has been defined in the context of various professional groupings such as medicine, nursing, oral health, pharmacy, allied health, and also medical subspecialties (4–10). Global health overlaps with international health and tropical medicine, and there are calls to explore similarities and differences between global health, international health, and public health (11, 12). The global aspect of this term has been debated, and several meanings have been discussed. Global may imply worldwide or transcending national boundaries, or it could signal the interdisciplinary nature of public health in a globalized world (2).

The generation of knowledge and its optimal use and application, especially in the field of global health and development, has garnered significant attention in recent years. There has been a dramatic growth in the number of educational programs that offer global health programs at undergraduate and postgraduate levels. A consensus definition for global health remains elusive. Commonly used is that of Koplan and colleagues who defined global health as "an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care" (12).

Educational competencies are informed by the needs of professional workforce and include a combination of knowledge, skills, and attitudes required for acceptable level of practice. Educational competencies are critical to curriculum development and evaluation, coordination across education programs, faculty development, and scholarship. The Institute of Medicine's report "Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century" published in 2003 identified eight emerging areas significant to the future of public health education, which included global health, communication, cultural competence, and ethics (13). The report also recommended that competencies in these emerging content areas need to be identified and incorporated in graduate public health education (13). Calhoun and colleagues described the development of the Association of School of Public Health's Core competency model for Master of Public Health (MPH) degree and discussed that the aim of these competencies was to provide knowledge, skills, and expected attributes of emerging public health professional (14). Recently, several reports including the Lancet Report on Health Professional education and the WHO report on "Transforming and Scaling up Health Professionals Education and Training" guidelines have highlighted the centrality of competency-driven education for bringing in educational reforms (15, 16). Calhoun and colleagues reviewed competency-based education program development in the context of global health workforce and discussed the status of competency model adoption across public health schools in the USA (17). This review analyzed the competency domains and outcomes using Blooms Taxonomy of educational outcomes showing that most competencies are in cognitive domain at a higher application level (17).

The recent literature in global health education has elicited several reviews that have sought to identify "core competencies" for various professional groups including medical, nursing, and public health education (5, 17–21). Academic institutions are also exploring the scope of their public health educational programs in the context of global health education to meet the demand for a global health professional in the context of the sustainable development goals. The American Association of Schools and Programs of Public Health Global Health Committee proposed a Global Health Competency Model, and the Consortium of Universities for Global Health (CUGH) global health subcommittee published four levels of interprofessional global health competencies (20, 21). There have been other attempts to describe global health competencies in the context of specific education programs and perspectives from stakeholders (22–25). The focus of these competencies has been variable with a range of different themes being described ranging from globalization and health care, analysis and program management, as well as equity and capacity strengthening. This review of the literature will provide a landscape of global health competencies and attempt to distill common competency domains to assist in curriculum development and integration in postgraduate public health education programs.

### METHODS

### Search Strategy

A literature review was conducted in April 2016 using six electronic databases using the keywords: TITLE-ABS (Global Adj3 health OR international Adj3 health) AND (education\* or training\* or universit\* or curriculum\* or college\*) AND (competenc\* or skill\* or outcome\* or objective\*). The search was limited to English language only, and all document types were searched with a focus on primary research studies, evaluation reports, conference abstracts, and all types of review articles.

Title/abstract was searched in the following databases: Ovid Medline (1946–present), Embase (1974–present), Global Health (1910–present), ERIC—Education (1966–present), EBM Reviews—Cochrane Database of Systematic Reviews (2005– present), and PsycINFO (1967–present). Additional search was undertaken using Scopus using keywords "global health" and "competenc\*"to explore additional references.

Two reviewers (Shailendra Sawleshwarkar and Joel Negin) initially reviewed the titles and selected articles that discussed global health from an educational aspect for the abstract review. All shortlisted titles were directly imported into Endnote© version 7 (Thomson Reuters, Philadelphia, PA, USA). Duplicate results were then removed. During abstract review stage, studies related to specific medical, nursing, and medical subspecialties professions that were related to global health but not dealing with public health were excluded. After limiting abstracts to those related to global health from educational point of view, a full text review was conducted to identify those dealing with global public health education. At this stage, a detailed analysis was done of all those articles, and specific articles addressing global health competencies in the context of graduate public health education were identified. After going through the bibliographies of these articles a cross search was undertaken to identify any additional relevant articles.

Articles were discussed by two authors (Shailendra Sawleshwarkar and Joel Negin), and full review of the selected articles was undertaken. Information was extracted on global health competencies, year of publication, type of program global health/international public health/public health/other, location of the review, method used for developing or describing competencies (if relevant), competency domains/themes, and list of competencies in each domain/theme.

Core competency articles were read in detail, and a list was generated with all competencies mentioned in these articles. A note was made if the article identified the competency domain directly in their article, and this was noted as "Yes," and if this was not identified, then "No" was recorded. If the article described the competency domains in the context of learning outcomes but competency domain was not explicitly stated then this was recorded as "Implied."

### RESULTS

**Figure 1** presents a flow chart of the search strategy. The titles of 6,242 references were screened by 1 independent reviewer, and 510 unique references were selected for abstract review. After limiting abstracts to those that dealt with global health education from public health aspect and after excluding duplicates, this reduced the number of abstracts to 126. Additional search with and cross references yielded 10 additional abstracts that were added and resulted in a total of 136 for a review. Fifteen articles described competencies either as a focus of the article or in the context of a program. Two of these were not included in the final set as one of them described the same program and as another article focused on global health research competencies. Thirteen articles described competencies in the context of public health education and are summarized in the **Table 1**.

### Article Characteristics

All the 13 shortlisted articles that described global public health competencies were published between 2005 and 2015 with 6 from the USA, 2 each from Canada and Australia, and 1 each from UK, Europe, and Americas (18–30). A range of methods were utilized to describe competencies and included literature review, interviews with experts and employers, surveys of staff and students, and description or review of an academic program.

Jogerst and colleagues described the work of Global Health Competency Subcommittee of CUGH to identify interprofessional global health competencies and proposed 2 competency levels with 13 competencies across 8 domains for the Global Citizen Level and 39 competencies across 11 domains for the Basic Operational Program-Oriented Level (21). Ablah and colleagues described a Global Health Competency Model developed through a multistage modified-Delphi process and described 7 domains and 36 competencies that complement the foundational public health competencies (20). Pfeiffer and colleagues conducted 26 semi-structured interviews with global health practitioners and leaders about the competencies and curriculum for global health professionals of the future and identified key knowledge (health systems and determinants of health) and skills (analytical, leadership and management, and policy development) areas (30).

#### Table 1 | Summary of 13 included articles in global health competency review.

(*Continued*)

#### table 1 | Continued

(*Continued*)

#### table 1 | Continued

(*Continued*)

#### table 1 | Continued

A few articles described global health competencies in the context of either a master's program in international health or tropical medicine or global health component of a program and included those at the course review at the Emory University (24), alumni survey at the University of Toronto (28), program review of international health program at the Pan American Health Organization (26), alumni survey of program run by the tropEd network (25), and curriculum development through review and survey at the University of Washington (22).

#### Global Health Competency Domains

The 13 articles listed various competency domains and described them—these are summarized in **Table 1**. These competency domains primarily refer to three main aspects, one that focuses on knowledge aspects of health and disease with inclusion of burden of disease and the determinants of health. A second set focuses on core public health skills including policy development, analysis, and program management. Another set of competency domains could be classified as "soft skills" with a combination of knowledge, skill, and attitude and include collaboration, partnering, communication, professionalism, capacity building, and political awareness. These 3 aspects of the 11 competency domain grouped as predominantly knowledge based, skill based, or a combination of knowledge, skill, and attitude are depicted in **Figure 2**. The list of competencies was reviewed, and similarly defined competencies were included under the same domain. There were some differences between articles regarding how these competencies were described and how they were grouped. This was more pronounced in the competency domains that discussed soft skills. Competency domains that were described by at least 6 of the 13 articles selected for review were included in the final list of 11 core

competency domains along with a summary of the key elements of the identified competency domains distilled from selected articles (**Table 2**). **Table 2** also lists the category (knowledge, skill, or attitude) of each competency domain as per the Bloom's Taxonomy for educational objectives (31).

Analysis of the frequency of competency domains identified by the selected articles is shown in **Figure 3** with domains 2, 8, and 10 being the most commonly identified domains. The competency domains that were mainly categorized as knowledge according to Bloom's Taxonomy included Global burden of Disease, Globalization of Health and Health care, and Social, Economic, and Environmental Determinants of Health. Those that could be categorized as both skill and attitude included mainly "soft skills" such as communication, collaboration and partnering, ethics and professionalism, capacity strengthening, and sociocultural and political awareness.

Although this list captures the most of the competencies described in the selected articles, there were few competencies that were not included as separate domains in the 11 core competencies. These included those with specific focus on disease conditions or groups such as maternal and child health or travel medicine or some components of health systems or broader themes such as primary health care, health promotion, or global governance.

### DISCUSSION

Health is central to the discussions about achieving sustainable development, and there are calls to review the role of public health in this era of globalization through the recently proposed Global Charter for the Public's Health by the World Federation of Public Health Associations (32). Jenkins and colleagues argued for new conceptualization, review, and evaluation of "global public health" and also argued for curriculum change in public health education for the global public health workforce (33). Global health education has attracted increasing interest from academic institutions in the last decade. Current discussion about global health also presents an opportunity to explore integration of globalization, equity, political awareness, and interconnectedness in the public health curriculum in both high-income and low-income settings.

In this review, we identified 11 core competencies that may be relevant to postgraduate public health education. These competencies comprised those mainly dealing with knowledge such as global aspects of burden of disease and health care and mainly skill-based domains such as core public health skills of strategic analysis, and program management. The competencies also included those dealing with attitude and skill with key underlying themes of equity, ethics, professionalism, and human rights along with a set of "soft skills" such as communication, collaboration, partnering, and capacity strengthening and leadership were also identified. The competencies belonged to lower cognitive domains of 'understand' and 'apply' and also included a number of competencies with higher order cognitive domains of 'analysis' and 'evaluation.' The articles described mainly the knowledge aspects of health and disease and core public health skills of management and analysis

#### Table 2 | Core competency domains or themes for global health education and summary of the key elements of the identified competency domains distilled from selected articles.

[Harmer et al., Hagopian et al., and Karkee et al. generally did not include soft skills (19, 22, 29)]. Those articles that put more emphasis on "soft skills" typically did not include global burden of disease, but this may be due to assumption that it is a part of core public health knowledge (24, 26). The interprofessional competencies described by Jogerst et al. described two levels of competencies—global citizen level and basic programoriented competencies (21). Global citizen level competencies

include those that focus on health and disease along with communication skills and sociopolitical and cultural awareness at the global citizen level. At the program level these include program management, capacity strengthening, and strategic analysis, which include core public health competencies but also add a set of skills that also described by Ablah et al. in the global health competency model (20, 21). The Global Health Competency Model described by Ablah et al. specifically mentioned that the global health competency domains should be constructed upon the foundational MPH core competencies (20).

Global health competencies have been described for many professional groups—medical (4, 7, 34), nursing (5), and allied health (6). There seem to be some differences in the core competency domains for clinical health professionals and public health professionals: those for medical professionals focus more on the global burden of disease and health-care services. In a large-scale consultation on global health competencies for UK postgraduate doctors in the United Kingdom, involving over 250 diverse stakeholders identified 5 key competencies, which focused on global epidemiology, determinants of health and health systems along with global governance and ethics/human rights (4). There is significant overlap in the competency domains with the MPH core competencies (version 2.3) by the United States Association of Schools of Public Health in 2006 (14), but additional "soft skills" can be seen as building on the core public health competencies (20). The new soft skills such as political awareness, communication, and collaboration are an important tool in today's globalized and politicized field of health.

The development of competencies allows for deeper thought on the definition and practice of global health. The similarities and differences in competencies are a good opportunity for academic public health institutions to engage in reviewing curriculum regarding knowledge, skill, and attitude required to prepare the global health professional. In their effort to define the field, Wernli and colleagues used a term "academic global health (AGH)" and suggested that it integrates the three traditional areas of health care, international health, and public health (35). They defined AGH as "within the normative framework of human rights, global health is a system–based, ecological and transdisciplinary approach to research, education, and practice which seeks to provide innovative, integrated, and sustainable solutions to address complex health problems across national boundaries and improve health for all" (35). The key dimensions described in this paper broadly deal with set of competency domains we have described in our paper including core knowledge areas in health care, core skills in public health, and set of "soft skills". These "new public health professional skills" have been highlighted in a recent paper describing the collaborative consultation by the World Federation of Public Health Association about how to adapt public health to a future role in global health (36). Global health education in public health programs needs to explore ways to incorporate the soft skills in the curriculum in addition to the technical focus on knowledge and skills to prepare the public health professional to face challenges of global health in the context of sustainable development.

Our review has a few limitations. There are a relatively few articles published about global health competencies, and hence we have also included articles that described competencies in the context of postgraduate programs in international health. We also recognize that global health competencies in individual programs in school of public health may not be published but are important, and we are planning to review this information in future. This review only focused on literature published in English and so may have overlooked information that was published in other languages. In this review we mainly focused on domains of global health competencies and not detailed sub competencies and learning outcomes for each domain and learning outcomes and more detailed analysis of the identified competency domains. We plan to conduct the detailed analysis in the context of postgraduate public health educational program in the Asian region.

Most of our articles discussed competencies based on programs or discussions in developed countries with some limited representation from the Asia. While the concept of global health originated in the developed world, due to the nature of global health, the long-term relevance and success of education in global public health education depends on the adaptation of the curriculum in both high-income countries and low- and middleincome countries (LMIC) (35, 37). In a recent review, Rabbani and colleagues have argued that schools of public health in LMIC can contribute to overcoming several public health challenges faced by LMIC by building the capacity of cadres of competent

### REFERENCES

and well-motivated public health workforce including educators, practitioners, and researchers (38).

### CONCLUSION

This review presents the landscape of defined global health competency domains for postgraduate public health education. The discussion about use of "global health," "international health," and "global public health" will continue, and academic institutions need to explore ways to integrate these competencies in postgraduate public health programs. This is critical in the post-MDG era that we prepare global public health workforce for the challenges of improving health of the "global" population in the context of sustainable development goals.

### AUTHOR CONTRIBUTIONS

SS and JN were involved in conception and design of the review; involved in the interpretation of the data; approved the final submitted version. SS worked on the first draft with review by JN.

Rosenstock L, Hernandez LM, editors. *Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century*. Washington, DC: National Academies Press (US) (2003). p. 61–107.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2017 Sawleshwarkar and Negin. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# One Health Core Competency Domains

*Rebekah Frankson1,2\*, William Hueston3,4, Kira Christian1 , Debra Olson3 , Mary Lee5 , Linda Valeri3 , Raymond Hyatt5 , Joseph Annelli6 and Carol Rubin1*

*1Centers for Disease Control and Prevention, Atlanta, GA, USA, 2Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA, 3University of Minnesota, Minneapolis, MN, USA, 4Chiang Mai University, Chiang Mai, Thailand, 5 Tufts University, Boston, MA, USA, 6United States Department of Agriculture, Washington, DC, USA*

The emergence of complex global challenges at the convergence of human, animal, and environmental health has catalyzed a movement supporting "One Health" approaches. Despite recognition of the importance of One Health approaches to address these complex challenges, little effort has been directed at identifying the seminal knowledge, skills, and attitudes necessary for individuals to successfully contribute to One Health efforts. Between 2008 and 2011, three groups independently embarked on separate initiatives to identify core competencies for professionals involved with One Health approaches. Core competencies were considered critically important for guiding curriculum development and continuing professional education, as they describe the knowledge, skills, and attitudes required to be effective. A workshop was convened in 2012 to synthesize the various strands of work on One Health competencies. Despite having different mandates, participants, and approaches, all of these initiatives identified similar core competency domains: management; communication and informatics; values and ethics; leadership; teams and collaboration; roles and responsibilities; and systems thinking. These core competency domains have been used to develop new continuing professional education programs for One Health professionals and help university curricula prepare new graduates to be able to contribute more effectively to One Health approaches.

Keywords: One Health, competency-based education, interdisciplinary studies, professional competence, medical education, veterinary education

### BACKGROUND AND RATIONALE

The last decade of the twentieth century and the first decade of the twenty-first century saw the emergence of a plethora of public health challenges at the convergence of human, animal, and environmental health, including bovine spongiform encephalopathy (BSE) and variant Creutzfeldt–Jakob Disease, H5N1 influenza, Nipah virus, West Nile Virus, 9/11 and the threat of bioterrorism, SARS, and the impact of climate change on global food systems. While the concept of zoonotic disease (i.e., diseases that are transmitted from animals to humans), and social and environmental determinants of health are well recognized in the public health community, education of medical professionals, by and large, remains segregated between human health (human medicine, nursing, public health), animal health (veterinary medicine, agricultural workers), and environmental health (ecologists).

A 2007 Salzburg Global Seminar, "New Century, New Challenges, New Dilemma: The Global Nexus of Animal and Public Health," recognized that progress on emerging issues like pandemic influenza response and global food security was slowed by the lack of communication and

#### *Edited by:*

*Michal Grivna, United Arab Emirates University, United Arab Emirates*

#### *Reviewed by:*

*Darcell P. Scharff, Saint Louis University College for Public Health and Social Justice, USA Armin D. Weinberg, Baylor College of Medicine, USA*

#### *\*Correspondence:*

*Rebekah Frankson<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health*

*Received: 23 June 2016 Accepted: 24 August 2016 Published: 13 September 2016*

#### *Citation:*

*Frankson R, Hueston W, Christian K, Olson D, Lee M, Valeri L, Hyatt R, Annelli J and Rubin C (2016) One Health Core Competency Domains. Front. Public Health 4:192. doi: 10.3389/fpubh.2016.00192*

collaboration among different health professions and the public and private sectors. The seminar focused attention on the need for training health professionals to think globally and facilitate transdisciplinary approaches to health improvement that bring together human, animal, and environmental health practitioners (1). Participants from public, private, academic, and philanthropic organizations reached consensus that this new group of professionals, referred to as "One Health" practitioners, needed to possess unique professional competencies, including "soft skills" to complement the depth of knowledge in their individual areas of expertise, although no specific set of core competencies was developed at that time.

The One Health approach recognizes that the health of humans, animals, and the environment are interdependent and that promoting optimal health in any of these sectors requires cross-sectoral collaboration, communication, and respect (2). The American Veterinary Medical Association defines One Health as "the collaborative effort of multiple disciplines – working locally, nationally, and globally – to attain optimal health for people, animals, and our environment" (3). Implementation of a One Health approach requires a team effort that brings together professionals who come from a variety of disciplines, including human medicine, veterinary medicine, ecosystem health, and agriculture. The Word Health Organization, World Organisation for Animal Health, and the Food and Agriculture Organization of the United Nations have recognized their shared responsibility to use One Health approaches for addressing a number of complex global challenges, such as rabies and antimicrobial resistance (4).

Although the One Health approach has resurfaced in recent years as a strategy to address complex problems at the interface of human, animal, and environmental health, little effort has been directed at identifying the seminal knowledge, skills, and attitudes necessary for individuals to successfully contribute to One Health efforts. The multidisciplinary nature of the One Health approach requires that One Health professionals are proficient in knowledge, skills, behaviors, and attitudes that go beyond the discipline-specific knowledge gained through traditional training programs. Identifying a set of One Health core competencies is critical to prepare professionals to tackle the health threats of the twenty-first century by working collaboratively with peers in other areas of expertise using a One Health approach. Education and training programs, which incorporate these core competencies, will create a workforce better able to address One Health challenges (5, 6).

### THE PEDAGOGICAL PRINCIPLES UNDERLYING COMPETENCY-BASED EDUCATION AND TRAINING

Traditionally, professional training curricula and academic course design have been guided by topic-specific and knowledge-based standards. A competency-based approach also considers the skills, behaviors, and attitudes that graduates need to become proficient in their future profession (7). Although initially developed as a way to improve corporate strategy (8), core competencies have been found to provide an excellent foundation for developing professionally relevant training programs that better equip individuals to work collaboratively (9). Professionals working in interdisciplinary environments using One Health approaches to address complex public health challenges must possess knowledge, skills, behaviors, and attitudes that go beyond their discipline-specific knowledge. Identifying these core competencies is necessary to develop relevant training programs for One Health professionals (7–10).

The public health profession has recognized the value of core competencies for more than a decade. In 2006, the Association of Schools of Public Health adopted a competency-based educational model for the Master of Public Health degree. The model currently recognizes 12 domains and a total of 119 core competencies (11). In 2010, the Council on Linkages Between Academia and Public Health adopted a set of eight core competency domains to strengthen the public health workforce (12). Within each of these domains, core competencies were delineated for three tiers of public health positions: entry level, program management/ supervisory level, and senior management/executive level. The domains in each of these models represent logical content categories that encompass multiple competencies. Domains are critical for curriculum development as they indicate the main areas in which a professional should be competent. Domains are intended to be stable over time, although the individual core competencies within a domain may be adapted for specific course goals (13). Because of their transferability, core competency domains are particularly useful when developing training programs for interdisciplinary fields.

Between 2008 and 2011, three groups independently embarked on separate initiatives to identify core competencies for One Health professionals – the Bellagio Working Group supported by the Rockefeller Foundation and University of Minnesota; the Stone Mountain Meeting (SMM) Training Workgroup; and the RESPOND Initiative funded by the United States Agency for International Development's Emerging Pandemic Threats Program (USAID/RESPOND). An additional activity, a 2012 workshop in Rome, was designed to integrate the findings of these three groups and synthesize a single set of One Health competencies. Here, we provide a brief overview of each of the original initiatives, a description of the core competency domains they have identified, and some examples of how these core competency domains have been used to develop training programs for One Health professionals.

#### Bellagio Working Group

The 2007 Salzburg Seminar set the stage for a follow-up activity sponsored by the Rockefeller Foundation. In September 2008, the University of Minnesota convened a multinational, multidisciplinary workgroup at the Rockefeller Foundation's Bellagio Center in Bellagio, Italy, to identify core competencies for global food systems leadership (14). Workgroup participants came from five continents and represented a variety of backgrounds, including governments, academia, non-governmental organizations, the private sector, and intergovernmental organizations, including several who had participated in the Salzburg Seminar. During the week-long process, the relevance of these same leadership competencies for all One Health professionals was recognized since global food security and other food systems issues require a One Health approach. Five major domains and a set of personal characteristics were identified for successful One Health leadership. Following the meeting, indicators of competence in each domain were outlined for three workforce levels: foundational, intermediate, and advanced.

### Stone Mountain Meeting Training Workgroup

The SMM Training Workgroup was established following the May 2010 international meeting *Operationalizing "One Health": A Policy Perspective – Taking Stock and Shaping an Implementation Roadmap* that took place in Stone Mountain, GA, USA (15). The goal of the SMM was to identify clear and concrete actions to move the concept of One Health from vision to implementation. During the meeting, participants deigned a 3- to 5-year vision of One Health encompassing four main areas: culture change, increased visibility, political will and financial support, and optimal coordinated efforts. Seven activities, including training, were identified as critical to attain this vision, and separate workgroups were formed to address these activities. The Training Workgroup comprised of over 50 subject matter experts from U.S. and international government and non-governmental agencies, academic institutions, and other public, animal, and environmental health organizations.

The Training Workgroup was tasked with several activities to build skills and expertise in One Health, including developing a list of essential core competencies for different levels of One Health practitioner. To draft the One Health core competencies, a wide range of existing core competency frameworks were reviewed, including the Association of Schools of Public Health Global Health Competency Model, the Guide to Senior Executive Service Qualifications of the U.S. Office of Personnel Management, the Leadership Core Competencies of the Farm Service Agency of U.S. Department of Agriculture, and the Core Learning Activities for the Nigerian Field Epidemiology and Laboratory Training Program. Through discussions with Workgroup members, the core competencies were refined to be more specific to One Health. The Workgroup identified essential core competency domains for three levels of One Health practitioners – field and entry level workers, program and project managers, and national policy leaders. Each domain was further defined with specific core competencies (16).

### USAID/RESPOND

A multiagency Global One Health Core Competency Workgroup was assembled in 2011 under Tufts University leadership to develop a One Health core competency framework which could be used as a template to assess existing curricula and as an aid in the development or strengthening of university curriculum and workforce training programs (13). The workgroup was funded through USAID/RESPOND with the goal to build capacity for medicine, veterinary medicine, nursing, and public health faculty and trainees from countries in Southeast Asia (Thailand, Indonesia, Vietnam, and Malaysia) and Central and Eastern Africa (Republic of the Congo, Ethiopia, Uganda, Kenya, Tanzania, and Rwanda). Since these regions are "zoonotic hotspots," or areas where the risk of disease emergence is high, building capacity was critical to enable countries to manage pandemic threats in collaboration with each other and governmental agencies both within a country and across an entire region. Members of the workgroup included representatives of the United States Department of Agriculture, the Centers for Disease Control and Prevention, and academia.

The workgroup met several times in 2011 and 2012 and identified core competencies through a literature review of existing core competency frameworks in the public health, veterinary medicine, and infectious disease fields; telephone interviews with subject matter experts; and iterative feedback from interactive workshops with RESPOND African and Southeast Asian institutional partners in veterinary medicine, public health, nursing, and human medicine. The Workgroup distilled these core competencies into a set of One Health core competency domains and subdomains.

### Rome Synthesis

Through funding provided by the Rockefeller Foundation, the Centers for Disease Control and Prevention, and the Food and Agriculture Organization of the United Nations, the University of Minnesota sponsored a workshop in Rome, Italy, in March 2012 to synthesize One Health Global Core Competencies (17). Attendees came from a broad range of One Health disciplines across the globe, and all worked actively on One Health approaches. Many of the attendees had participated in one or more of the previously mentioned efforts for developing One Health core competency frameworks. The workshop consisted of presentations from each of the different efforts, large group discussions, and small group activities. The immediate goal of the workshop was to validate the existing work related to One Health core competencies. The long range goal was to develop a consensus framework for One Health core competency domains that could be utilized by the global One Health community.

Workshop attendees reviewed nine existing competency frameworks to identify commonalities, including three specific to One Health (the previously mentioned frameworks developed by the Bellagio Working Group, the SMM Training Workgroup, and USAID/RESPOND). Attendees of the Rome meeting found that although the three One Health oriented groups developed their core competencies independently and drew from the expertise of a variety of professional disciplines, each initiative identified similar core competency domains (**Table 1**). These commonalities among the independent efforts were used to describe seven core competency domains, which were further defined with specific One Health core competencies. The major core competency domains identified were management, communication and informatics, values and ethics, leadership, team and collaboration, roles and responsibilities, and systems thinking.

### RESULTS TO DATE

These One Health core competency frameworks outline the skills and behaviors necessary for successful performance within the One Health workforce. Educators at all levels of One Health training can use these frameworks as a resource for curriculum development. The competency framework is flexible enough to

Table 1 | Major One Health core competency domains identified during the Rome synthesis meeting using the Bellagio Working Group, the Stone Mountain Meeting Training Workgroup, and the RESPOND initiative core competency frameworks.

*a Used to describe a portfolio of value-driven personal attributes: confidence, courage, credibility, emotional intelligence, empathy, ethics, passion, self-awareness, spirituality, and wisdom.*

allow educators the opportunity to tailor their learning objectives to local needs.

The Bellagio model has been used to develop in-service One Health leadership training programs in Africa, Asia, and the Americas aimed at university teaching staff and government officials. In 2010, Chiang Mai University, Thailand, piloted a One Health Leadership continuing professional education course based on the Bellagio model. The course is now the cornerstone of a Global Health Institute held annually at Chiang Mai University. These continuing professional education courses provide intensive experiential learning for working professionals over the course of 2–5 days. Self-assessment, individual skill building, group exercises, and reflections are used to create a positive climate for behavior change among adult learners.

Tufts University, along with USAID/RESPOND partners at the University of Minnesota Colleges of Veterinary Medicine, Public Health, Nursing, and Medicine, is using their framework with institutional partners across Southeast Asia and Africa. Having faculty from multiple disciplines, institutions, and countries agree on the major competency domains meant that the competency framework could be used to develop specific training modules to address the individual domains. The competency framework has been used to evaluate coverage in existing curricula, enhance current courses, and create new ones. Graduate programs emphasizing One Health approaches use the framework to guide curriculum design. Finally, the framework also facilitates identification of faculty development needs.

Faculty have used these frameworks to improve One Health programs and training for graduate students and early career professionals at the University of Minnesota. For example, faculty from the College of Veterinary Medicine, School of Public Health, and Humphrey School of Public Affairs created a new course, "Leadership to Address Global Grand Challenges," that is built around the One Health competency domains described here. Originally listed as a public health course entitled "Global One Health Leadership," the early course enrollment was primarily Master of Public Health Students. Changing the name to "Leadership to Address Global Grand Challenges" and listing the course in public affairs rather than in public health increased the diversity of students registering to include graduate students from veterinary medicine, public health, agriculture, liberal arts, education, and public affairs. The learning objectives of this course demonstrate the integration of the One Health competencies (**Table 2**). The course differs from most other graduate courses in that skill building and group activities predominate instead of lectures. The course also involves student-facilitated discussions with internal and external stakeholders on current complex challenges. Feedback from the course is overwhelmingly positive, with participants commonly citing the immediate usefulness of these skills in

#### Table 2 | Course objectives for PA5152, "Leadership to Address Global Grand Challenges: Focus on Food Systems," held May 23–27, 2016, at the University of Minnesota.

#### Course objectives

At the conclusion of the course, participants will have a deeper understanding of – and an opportunity to apply – leadership skills that foster collective action across industry, government, academia, and civil society sectors. Specifically, participants will:

	- a. Leading one's self
	- b. Leading in teams (where you have authority and responsibility)
	- c. Leading up in organizations (where you may have responsibility but no authority)
	- d. Leading across (where you have neither responsibility or authority)
	- a. Listening to understand and be understood
	- b. Building trust and credibility
	- c. Facilitating dialog, debate, and deliberation
	- d. Aligning policy implementation tools with desired outcomes
	- e. Anticipating and leveraging windows of opportunity
	- f. Designing inclusive structures and facilitating decision-making processes
	- g. Providing constructive feedback and fostering continuous self-improvement

their jobs, communities, and families. One hundred percent (100%) of the 28 participants in the last three One Health leadership courses taught in Thailand and the United States have mentioned communication competencies in their reflections on the question "What new One Health skills have I learned that I can use immediately?" The specific communications skills most commonly cited were listening (61%), collaboration skills (46%), and appreciating differences (29%).

In addition to providing guidance for curriculum and training design, core competency frameworks can be used to evaluate existing training programs. The SMM Training Workgroup plans to use their list of core competencies to identify gaps in existing One Health training programs. For example, involvement in the development of the One Health core competencies helped the One Health Coordination Center in the Animal and Plant Health Inspection Service of the United States Department of Agriculture identify the need for new in-service training of field staff so that staff members were better able to foster collaboration with local public health agencies. The One Health Systems Mapping and Analysis Resource Toolkit (OH-SMART) was designed to strengthen systems thinking competencies.

#### DISCUSSION

Although the three groups described here developed their core competencies independently and employed expertise from different disciplines, each initiative identified similar core competency domains. This consistency further substantiates the validity of these domains for One Health professionals. None of these domains are specific to any single discipline and, thus, can be easily adapted by different professions and institutions across the globe. Although this paper focused on the core competency domains, the individual core competencies within these domains can provide additional guidance for developing curricula relevant to local and national One Health needs.

These One Health core competency frameworks provide a common foundation for continuing professional education and training programs that move beyond the focus on disciplinespecific knowledge. The overarching goal of One Health training is to impart trainees with the non-technical skills and attitudes that all One Health practitioners need, regardless of discipline or work level. Although many of the domains identified in this review are not traditionally incorporated into discipline-specific training programs, faculty who work in the field of One Health feel that such training is long overdue. The impetus driving the development of these One Health competency domains reinforces the need to equip public health professionals with a breadth of skills to complement their own specific areas of expertise.

The core competency frameworks designed by USAID/ RESPOND and the Bellagio Working Group, and the core competency synthesis from the Rome Synthesis meeting were designed to assist in the development of One Health continuing professional education. These frameworks can be used by universities, governments, and regional networks as a starting point for identifying specific core competencies relevant to local needs, which can in turn be used to guide development of new training programs. Educators also can use the domains to identify strengths within existing curricula, as well as opportunities in the curricula to incorporate additional One Health learning needs.

Curriculum change is difficult, in part because acknowledging a need to change suggests to some that the current curriculum and/or the instructors delivering it are inadequate. Agreement on a set of competency domains may be less threatening as it acknowledges that the specific competencies in each domain vary by setting and require constant tweaking to meet the needs of the changing world around us. Some competencies can be achieved by modifying existing courses rather than creating brand new ones. For example, USAID/RESPOND is aware that many programs are overcrowded with material and encourages integrating training modules into existing courses, rather than trying to create new zoonotic disease and pandemic management courses. USAID/RESPOND worked with faculty to think about where existing cases could be replaced with cases designed to highlight One Health competencies.

The Global Health Security Agenda (GHSA) has recognized the importance of multidisciplinary coordination to prevent, detect, and respond to the disease threats facing health systems around the globe (18). In addition to an overall recommendation of utilizing multidisciplinary coordination to meet GHSA targets when possible, the GHSA Workforce Development Action Package specifically recommends the development of a multisectoral workforce to better detect global health threats (19). The One Health competency domains can serve as a resource for countries implementing the GHSA Workforce Development Action Package to ensure that graduates of their training programs are equipped to handle the complex health threats in their countries and regions.

As transdisciplinary One Health approaches continue to gain more attention worldwide, these common core competency domains can provide a foundation for developing and revising One Health training programs. Educators and organizations wishing to adopt One Health approaches can use these domains as a framework to help them evaluate current curricula, identify gaps and opportunities for enhancement of design curricula, and develop evaluation instruments.

### AUTHOR CONTRIBUTIONS

CR and RF coordinated all workgroup activities associated with the Stone Mountain Meeting. KC and JA led the Stone Mountain Meeting Training Workgroup and the development of the workgroup's core competency domains. ML and RH led development of the USAID One Health Core Competency Framework. WH and LV led the Bellagio Working Group. WH and DO led the Rome Synthesis. WH and LV developed new university courses and continuing education programs based on these OH

### REFERENCES

competencies. RF drafted the initial manuscript draft. All authors contributed to the idea and manuscript framework, revisions, and final manuscript approval.

### ACKNOWLEDGMENTS

The authors appreciate the contributions of Heather Davis and Sarah File.

### FUNDING

This project was supported in part by an appointment in the Research Participation Program at the One Health Office, Centers for Disease Control and Prevention, administered by the Oak Ridge Institute for Science and Education. Funding for the initiatives was provided by the Rockefeller Foundation, the United States Agency for International Development, the Centers for Disease Control and Prevention, and the Food and Agriculture Organization of the United Nations.

Foundation (2014). Available from: http://www.phf.org/resourcestools/ Documents/Core\_Competencies\_for\_Public\_Health\_Professionals\_2014June.pdf

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2016 Frankson, Hueston, Christian, Olson, Lee, Valeri, Hyatt, Annelli and Rubin. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Educating the Public Health Workforce: A Scoping Review

#### *Donghua Tao1 , Connie J. Evashwick 2 \*, Michal Grivna3 and Roger Harrison4*

*1Saint Louis University Medical Center Library, St. Louis, MO, United States, 2Milken Institute of Public Health, George Washington University, Washington, DC, United States, 3College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates, 4School of Health Sciences, University of Manchester, Manchester, United Kingdom*

The aim of this scoping review was to identify and characterize the recent literature pertaining to the education of the public health workforce worldwide. The importance of preparing a public health workforce with sufficient capacity and appropriate capabilities has been recognized by major organizations around the world (1). Champions for public health note that a suitably educated workforce is essential to the delivery of public health services, including emergency response to biological, manmade, and natural disasters, within countries and across the globe. No single repository offers a comprehensive compilation of who is teaching public health, to whom, and for what end. Moreover, no international consensus prevails on what higher education should entail or what pedagogy is optimal for providing the necessary education. Although health agencies, public or private, might project workforce needs, the higher level of education remains the sole responsibility of higher education institutions. The long-term goal of this study is to describe approaches to the education of the public health workforce around the world by identifying the peer-reviewed literature, published primarily by academicians involved in educating those who will perform public health functions. This paper reports on the first phase of the study: identifying and categorizing papers published in peer-reviewed literature between 2000 and 2015.

#### *Edited by:*

*Rosemary M. Caron, University of New Hampshire, United States*

#### *Reviewed by:*

*Emmanuel D. Jadhav, Ferris State University, United States Donna Jeanne Petersen, University of South Florida, United States*

#### *\*Correspondence:*

*Connie J. Evashwick<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health*

*Received: 30 October 2017 Accepted: 26 January 2018 Published: 19 February 2018*

#### *Citation:*

*Tao D, Evashwick CJ, Grivna M and Harrison R (2018) Educating the Public Health Workforce: A Scoping Review. Front. Public Health 6:27. doi: 10.3389/fpubh.2018.00027*

Keywords: public health workforce, public health workforce training, public health workforce pedagogy, literature search, public health workforce education, health workforce worldwide, global health workforce

## INTRODUCTION

The World Health Organization (WHO) has a defined list of activities necessary to effectively keep the public healthy, continue to improve population health, and reduce global inequalities (2). As the enactors of these functions, the public health workforce is widely recognized as critical to promoting the health of communities within and across nations. The WHO (1), Institute of Medicine (3), the Centers for Disease Control and Prevention of the USA (4), and the Harvard School of Public Health and China Medical Board (5) have all highlighted the importance of educating the public health workforce to continue to improve health around the world. Recent recognition of the importance of the social determinants of health (6) has called even more attention to the need for comprehensive training of all those with primary or secondary public health roles.

Preparing those who will promote the health of the public is challenged by the unresolved, if academic, controversy about whether public health is a distinct discipline or not (7). "Health professionals who perform public health functions" and "public health professionals" are considered distinct by some and singular by others. A recent report by two universities in the United States (US) (8) explains how different sources define the public health workforce differently and the resulting challenge this poses in getting an accurate count of practitioners and the related issue of calculating and ultimately creating optimum capacity.

Regardless of the methods used to define and enumerate its size, the "public health workforce" is huge and diverse (9). As such, educators have attempted to address effective methods to support workforce needs in terms of education and skills development. A wide array of competency frameworks exists which aim to link education to effective practice, both discipline-specific (10, 11) and interdisciplinary public health (12). Diversity also prevails across and within countries (13), with different organizations responsible for public health education and training. Some education and competency frameworks are linked to professional standards (14); others to accrediting agencies (15). Some organizations have recently come together to promote coordination of competencies across disciplines (16) and in support of a global perspective for international education and collective action on the ground (17). Arguably, this level of diversity in terms of workforce right through to local and global quality assurance sharply contrasts with other key health-related occupations, such as medicine, nursing, and dentistry. Thus, a fragmented and inconsistent approach to public health manpower planning and education seems endemic throughout the global public health community.

Moreover, for several decades, there has been a strengthening in using evidence-based principles to ensure effective design and delivery of education for medical, dental, and nursing students despite the methodological challenges it presents (18–21). Yet until recently, no specific journal was dedicated to the pedagogy for educating the public health students and future workforce. The complexity of public health as a discipline, along with a wide variation in training provision, makes it difficult to determine the strengths and weaknesses of different teaching practices for public heath students in higher education.

The fragmentation about how and in what to train the public health workforce becomes particularly detrimental in confronting an increasingly global world. Infectious diseases once contained in local regions now spread rapidly across continents. Advocacy campaigns that previously might have been local, regional, or at most, national, now quickly "go viral" through the use of social media. From the business perspective, multi-national trade deals are common; yet multi-national collaboration to prepare the public health workforce falls short. Accreditation, licensing, visas, foreign clinical privileges, and other barriers prevent health professionals, including those serving public health functions, in one country from working in another country, at least not without meeting extensive legal and training requirements.

This diminishes opportunities to create a global public health workforce with the capacity to address cross-national emergencies and the competencies required for global tasks. French et al. recommend "a systems approach" to education and manpower planning (5). It is unclear how other countries, governments, universities, and public health professional bodies are ensuring that workforce capacity building fits current needs and future projections.

*The purpose of this study was to begin to build a basis for discussion about cross-national public health workforce education by identifying who is teaching what, where, and with what competency or learning objective framework.* Phase 1 of the study is the scoping review reported here. From this base, subsequent analyses will examine the content of the literature and the implications for current and future worldwide education of the public health workforce.

#### MATERIALS AND METHODS

Scoping review has become an increasingly common tool to provide a descriptive overview of the reviewed materials as the body of literature worldwide has grown and become more accessible (22). A scoping review can be of particular use when the topic has not yet been extensively reviewed or is of a complex or heterogeneous nature (22), which is appropriate for public health workforce issues. This scoping review found and characterized the peer-reviewed literature from around the globe between 2000 and 2015 pertaining to the education of those providing public health functions at a professional level.

#### Search Process

**Figure 1** shows the search process. Eligible studies were first identified from a search of the major databases of health and education-related publications: Scopus, PubMed, and ERIC. The search terms were developed from essential functions of public health and broadened with the use of additional medical subject headings, combined with Boolean operators. United Kingdom (UK) and US variations in spelling were accommodated. Main free-text search terms included Public Health, Environmental Health, Occupational Health, Biostatistics, Health Behavior, Health Education, Health Services Administration, Health Policy, Population Health, Health Regulations, Pedagogy, Competency, Learning outcomes, Accreditation, Certificate and licensure, Competencies, Interprofessional, and Service Learning. Only English language publications were included from January 1, 2000, to December 31, 2015.

The time frame 2000–2015 was selected as relevant because it is during this recent era that the use of competencies has come into being as a way to shape and evaluate education (23) and that worldwide communication methods, particularly the Internet, has fostered globalization, including the delivery of education (24). When the study was initiated in 2016, the last year for which complete data were available was 2015.

#### Inclusion Criteria

Given the diverse nature of public health roles, the review included journal articles that matched the WHO definition of essential activities for the public's health (2) and/or for which a published framework of educational competency or additional defined essential content existed either as a main or subspecialty. Primary disciplines, such as medical, nursing, and dental undergraduate degrees, were included along with public health, as were sub-specialties of public health, such as epidemiology, health administration, and health education. Definitions and competency frameworks were current through the end of 2015.

Given that the focus was on "professional" public health providers, level of education was considered as that which provides a terminal degree leading to employment in public health in the relevant country. For example, in the US, a master's of public health (MPH) is the most common degree, as post-high school baccalaureate education in public health tends to take an "educated citizen" generalist outcome approach. In countries where post-high school education is 6 years and includes focused health professions education, such as China, articles deemed acceptable for the scoping review would include those covering baccalaureate curricula.

#### Selection Process

The first 100 citations were used as a pilot to go over the process iteratively until the acceptable level of interrater reliability with Cohen kappa >0.8 was reached (25). The first stage of the process was based on the title/abstract review. Four reviewers formed two pairs. Two reviewers of each pair reviewed the same 100 citations independently, then met to discuss and resolve discrepancies in whether a study met the inclusion criteria or not. For the studies without reaching agreement, full text articles were reviewed to finalize the consensus on the inclusion or exclusion. Once the interrater reliability level was acceptable, the rest of the unique citations after removing 100 sample citations were divided evenly for each of four reviewers to code "Yes" with 1, "No" with 2, and "Maybe" with 3. For the citations with the "Maybe" code, two pairs of review teams were formed with different members in the pilot process to ensure the coding reliability. Each pair reviewed half of the citations with the "Maybe" code until the consensus on inclusion/exclusion was reached. A final list of inclusive citations was identified after this entire iterative process.

### Categorization Process

Data extracted from each article included authors, year of publication, country/region, discipline/program of study, and article "type." The type of articles referred to methodology and was based on the description for eligible articles used by an international, peer-reviewed, open-access journal of public health education (26). The category of curriculum/instruction/pedagogy encompassed description of a course, description of curriculum, case study (i.e., unique situation), description of field experience, or competency framework. The category of evaluation was used for articles reporting data on formal evaluation studies assessing the outcomes of courses, curricula, or specific teaching methods.

A challenge to the study was in assigning articles to just one specific category. For example, a case study might include a formal evaluation of student learning outcomes. The authors agreed to allow two classifications of article type for each article. This explains why the number of article types is greater than the number of individual articles in the reported results. A more detailed analysis using free-text mining considered the methodologies employed, independent of article type.

### RESULTS

As shown in **Figure 1**, from 1,860 citations originally identified from the searches, a total of 350 articles met the final inclusion criteria for the review. The list is available in Data Sheet S1 in Supplemental Material.

#### Year of Publication

**Figure 2** shows the number of articles published in each year. The distribution indicates that articles pertaining to the education of the public health workforce have steadily increased over the 15 years between 2000 and 2015.

### Geographic Distribution

**Table 1** shows the geographic location of the articles. A total of 46 countries and/or regions were included in the review, and all continents were represented. The predominant countries were those in North America and Europe. Of the 350 articles, 177

focused on education pertinent to the US. Twenty-four articles focused on the UK; 17 on Canada; and 14 on Australia. Several articles described multi-national efforts, including across

regions, or a global emphasis without being geographically specific.

#### Discipline

As shown in **Table 2**, the majority of articles focused on public health as a main discipline in general (166 in total) or subspecialties of public health (60 in total), such as epidemiology, health management, or health education. Nonetheless, articles also emanated from the disciplines of medicine, nursing, dentistry, veterinary medicine, pharmacy, social work, and others.

#### Article Type

**Table 3** gives the article types of the publications. The largest proportion of article types from the original list of 350 was for curriculum, instruction, pedagogy (36%, 102), followed by evaluation

Table 3 | Number of article types as the primary or secondary focus.

*N.B. percentages add up to more than as some articles were included in more than one "article type."*

(24%, 84) and perspective/opinion (15%, 53). One-in-ten or less were identified as studies primarily focused on original research (10%, 36), case study (10%, 34), "other" (6%, 23), review (4%, 16), competency (4%, 13). Less than five articles met the format of a hypothesis/theory focused article, accreditation/certification, or commentary. When regrouped into a single category of original research, evaluation, teaching method, curriculum/instruction/ pedagogy, and competency, 290 articles had focused on this as a part of the primary or secondary investigation.

As shown in **Table 4**, 97 (28%, 97) articles mentioned a research design keyword in the title or abstract. The most frequent study design mentioned was cross-sectional/survey design, stated in 76% of articles (74/97), 14% (14/97) conducted interviews, and 8% (8/97) employed focus groups.  Some studies were double counted with more than one keyword identified (such as mixed-methods studies).

Of the entire 350 articles, only 3 had a primary focus of accreditation/licensure/certification, and for 2 of these, this was the secondary topic of emphasis. The single randomized controlled trial, conducted in Canada and published in 2015, examined the benefits of learning compared with use of printed articles/resources.

#### Authors

The distribution of authors was examined as an indication of the breadth of interest in the education of the public health workforce. The 350 articles were written by a total of 2,432 authors. The number of authors for an article averaged nearly 7, with a range from 1 to 17. Single author papers numbered only 16. The papers with a larger number of authors typically represented the work of multi-institutional task forces to develop competency models, such as global competencies or MPH competencies. As noted in the number of countries represented by the 350 articles, authors came from all over the world. Very few authors (less than 12) appeared on more than one paper. The most articles authored or coauthored by a single author numbered five.

### DISCUSSION

The comprehensive review of literature investigating undergraduate and postgraduate education for the public health workforce identified 350 articles over 16 years from 2000 to 2015. The number of relevant publications increased steadily overtime,

Table 4 | Core methodologies based on text mining for key methodological terms.

*N.B. total is less than 350 as articles with non-rigorous designs were excluded, such as articles describing courses or curricula.*

suggesting increasing recognition in what historically has been an overlooked field. Many countries and all continents had conducted studies in this area. Few can deny that public health has become a global discipline. As such, educators around the world need to ensure effective pedagogy that meets the teaching needs of their own students and incorporates application and knowledge transfer to other populations.

The current review also identified a diverse public health workforce in terms of other professions and included medicine, nursing, dentistry, veterinary medicine, social work, pharmacy, physical therapy, occupational therapy, among others. The collection of articles revealed attention being given to components of education across the spectrum of public health workers, be it as sub-activity within their wider professional grouping or as a primary public health worker.

The distribution of authorship supports the assertion that interest in educating the public health workforce is starting to become widespread. Most articles were written by multiple authors, perhaps indicating the complexity of the subject matter and the value of multiple perspectives. Many were written by coauthors representing several institutions. In contrast to biomedical research or health systems research, where centers, institutes, and program projects have a research team that produces many articles, perhaps with variation in order to first author, neither single author nor institution dominated, with fewer than a dozen authors appearing more than once. This might indicate involvement by many people, but few, if any, centers dedicated to examining the pedagogy pertinent to the public health workforce.

By far, this is the largest and most current scoping review on the topic of public health workforce education. In the seminal work by Frenk et al. (5), only 221 of 11,054 articles (2%) reviewed for education related to the "health" workforce were focused on public health; the majority were for physicians 8,069 (73%) and 2,764 (25%) nurses. This leads to the conclusion that the education of those providing public health functions receives less attention, either from its own discipline or other health professions disciplines.

As noted by Evashwick et al. (7), articles about the education of the public health workforce are difficult to find for several reasons. These include that, unlike most health professions, until recently, public health had no journal of its own devoted to pedagogy. Yet they exist for medical education (for example, the *Indian Journal of Medical Education*), nursing education (for example, the *Journal of Nursing Education*), and dental education (for example, the *European Journal of Dental Education*), to name just a few. Furthermore, alongside the more context- and community-orientated focus of public health, there is a vast array of "gray literature," including that from government agencies, local health administrators, universities, and the third sector/ non-government organizations. Consequently, the true size and scope of activity associated with educating the public health workforce is likely to be considerably bigger than that reported here and in other studies.

The results show a lack of rigorously controlled studies, either as randomized or non-randomized intervention studies. The results identified just one study of this article type. Yet this type of methodology is as well suited to examining the effectiveness of education interventions for different groups of students, as it is for a specific procedure, therapy, or policy. Moreover, it is used to inform education of other health-related disciplines (27). Despite the trend to base pedagogy on competencies, the education community as a whole seems to continue to use student grades and satisfaction questionnaires as the main markers of "effectiveness." Other methods/theoretical evaluation designs, for example, as a comparator against benchmarks or employer demands, are not the norm. The results from the current review support cross-sectional studies being the typical evaluation method of educational interventions for public health workers through higher education. Yet the many uncontrollable biases of cross-sectional studies in clinical epidemiology remain when transferred to other forms of enquiry. To promote the evolution of educational evaluation and adoption of evolving pedagogical frameworks, funders of educational provision and accrediting authorities need to consider more tightly controlled studies to demonstrate effectiveness of teaching interventions.

The link between educational programs and workforce needs was absent from the majority of articles. Although a few articles mentioned the need for "more" public health professionals, more experts in certain sub-disciplines, or specific content (such as training in gerontology), most articles did not relate to external projections of workforce need or demand. This calls to question the basis universities use to develop training programs. If there is no relationship to the job market, how do educational programs determine the content, or indeed, which degrees to offer? Leading experts have called for a systems approach to education and manpower planning (5) and countries, such as New Zealand, are trail-blazing efforts to project new demands and revise training accordingly (28).

The absence of any literature, except for three articles, specifically mentioning accreditation, licensure, or certification raises concern. The link between education and workplace outcomes comes into question and challenges university programs educating students to join the public health workforce to relate to current and future employment needs. A couple of studies reported on feedback from students, and one study surveyed alumni for their assessment of how well prepared they were for their subsequent job demands. Although accrediting authorities typically require feedback from alumni and/or employers of their graduates on the competencies learned through a training program, these apparently are not conducted in a way rigorous enough to warrant publication, or alternatively, those conducting the studies are not motivated to turn their information into publications for external audiences. At the same time, not all countries or accrediting bodies have such requirements, but that very few articles were identified in this global review is disconcerting.

A limitation of the methods of this scoping review was that it included different programs of study rather than examining those for final degrees in public health (e.g., Bachelors and Masters in Public Health). This was an intentional decision. Focusing on a degree alone would have excluded possibly informative research on the medical, nursing, dental students, among others, included in the review, many of whom are being taught key components included in any public health degree. Moreover, degree titles, levels, and content vary across countries. An alternative approach would have been to have started the search by focusing on a particular profession/occupation group (e.g., nursing) and then searched for publications on education and public health as lower-level key words. The total number of studies included in the review might have been different using this approach. However, this path ran the risk of excluding other occupations not often regarded as participating in public health work-related activity. Yet another facet of the search criteria was using competencies. Traditional content areas, such as Maternal and Child Health, do not appear. Rather, the content would be spread across competencies, such as epidemiology or health promotion. The approach selected was chosen as the best to maximize finding relevant articles.

The scoping review did not attempt to critically assess any of the research studies, other than classifying by main study designs. By definition, a scoping review identifies and describes the breadth of literature but does not analyze the content (22). The content of the articles will be examined in detail for each category of article type as a next phase of the study. The category of curriculum, instruction, and pedagogy is of particular interest, as these are the articles that contain discussions of competencies, pedagogical techniques, evaluation outcomes, and cross-national comparisons.

As in most reviews of the literature, the search terms, their operation, and the different literature databases used all have strengths and weaknesses. Similarly, the review did not search the gray literature, including internal reports and program evaluations. No doubt, some work will have been missed, but it is unlikely this would have substantially changed the overall conclusions. Only literature published in English was used. Future review teams should include literature published in other languages, especially Spanish and those from emerging economies such as China, particularly in countries having extensive undergraduate and postgraduate education programs and emerging programs for Bachelor and Masters in Public Health degrees.

### REFERENCES

## CONCLUSION

Like other aspects of health-related activity, educating students so that they can effectively execute public health roles requires pedagogical research and scholarship. The current scoping review identified a widely eclectic mix of articles, predominantly from North America and Europe that examined this activity in some way. The scoping review included many descriptive reports, cross-sectional studies, few formal evaluations, and just one randomized study on teaching methods for higher education in public health. The pool of studies on this subject is relatively small over the 16-year timeframe. Nonetheless, publishing on public health workforce education has increased over the years. Moreover, the articles represent the diverse landscape of public health and its international community. Using published literature to share basic knowledge of who is being trained, by whom, with what curricula, pedagogical elements, and evaluation methods lays the groundwork for the systems approach in educating the public health workforce. A workforce trained using contemporary approaches to education and current, global-oriented content is an essential component of creating a healthy population worldwide.

## AUTHOR CONTRIBUTIONS

CE, DT, and RH conceived this study. DT conducted the literature search and revisions. MG, RH, DT, and CE participated equally in reviewing and categorizing the articles of the literature search. MG and DT produced the graphics. RH and CE produced the tables. CE, RH, DT, and MG contributed to the writing and editing of the text.

### SUPPLEMENTARY MATERIAL

The Supplementary Material for this article can be found online at http://www.frontiersin.org/articles/10.3389/fpubh.2018.00027/ full#supplementary-material.

Data Sheet S1 | Database of articles pertaining to health workforce education.

enhancing the consistency. *Res Synth Methods* (2014) 5(4):371–85. doi:10.1002/ jrsm.1123

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2018 Tao, Evashwick, Grivna and Harrison. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Preparation of European Public Health Professionals in the Twenty-first Century

#### *Vesna Bjegovic-Mikanovic1 \* and Robert Otok2*

*1 Faculty of Medicine, Belgrade University, Belgrade, Serbia, 2Association of Schools of Public Health in the European Region (ASPHER), Brussels, Belgium*

The public health profession in Europe has a leadership role for ensuring European's health in the twenty-first century and therefore must assume responsibility for advancing education for research and practice. Three fundamental questions are explored: (1) What are the main public health problems facing public health professionals; (2) What are their existing competencies after training; and (3) What competencies do European employers expect? The European Schools of Public Health assessed their best success to be in the field of health promotion, followed by disease prevention including identification of priority health problems, and elimination of health hazards in the community. Conversely, they see the least success in dealing with preparedness and planning for public health emergencies. From an employer's perspective, significant gaps between current and desired levels of performance at the job exist for all Essential Public Health Operations of World Health Organization. Based on prior research and recent European surveys of Schools and Departments of Public Health, the following recommendations are made, which emphasize the leadership role of the European public health community: (1) the preparation of public health professionals requires an interface between public health functions, competencies, and performance; (2) competence-based education is important and allows debates on the scope of the required education; (3) governments have to realize that the present lack of infrastructure and capacity is detrimental to the people's health; (4) as public health challenges are increasingly global, educational institutions have to look beyond the national boundaries and participate in European and global networks for education, research, and practice.

#### Keywords: public health, education, professionals, partnerships, Europe

### INTRODUCTION

Today public health professionals face many new and demanding challenges such as how to increase healthy life expectancy and to minimize health inequalities in times of repeated financial crises. Equity in health across the European region and beyond is viewed as one of the central goals of sustainable development and dedicated work of public health professionals to achieve improvements in planetary health (1, 2). To cope effectively with these challenges, it is essential to address the multiple socioeconomic, environmental, and individual determinants of health. This requires that the public health profession assumes leadership in the twenty-first century and understands that "working differently means leading and learning differently" (3).

#### *Edited by:*

*Connie J. Evashwick, George Mason University, USA*

#### *Reviewed by:*

*Kimberley Shoaf, University of California Los Angeles, USA Marcia G. Ory, Texas A&M University, USA*

> *\*Correspondence: Vesna Bjegovic-Mikanovic<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health*

*Received: 13 November 2016 Accepted: 30 January 2017 Published: 15 February 2017*

#### *Citation:*

*Bjegovic-Mikanovic V and Otok R (2017) Preparation of European Public Health Professionals in the Twenty-first Century. Front. Public Health 5:18. doi: 10.3389/fpubh.2017.00018*

This perspective article starts out with a description of the European landscape of professional education including reference to US American developments. Against this background, we try to find answers to three fundamental questions based on the published literature and the European survey of Schools and Departments of Public Health (SDPHs) (4):

### THE EUROPEAN LANDSCAPE OF PROFESSIONAL EDUCATION

Globally and also within the European Region with its 53 countries, public health professionals are confronted with an extremely heterogeneous landscape. Nevertheless, the European public health education and training has the same cornerstones and develops along the Bologna Process, which is designed to harmonize the fragmented educational scene in Europe and to facilitate the international exchange of students and lecturers. Meanwhile, almost all European countries have fully joined in promoting the attractiveness of European Higher Education Area (5). The degree structure is now based either on two or three of the major strata—bachelor, master, and doctoral level (6). Application of the European Credit Transfer System (ECTS)1 in academic programs is the primary instrument for the mutual recognition of diplomas and professional mobility. Recent challenges lead to the development of student-centered learning, modularization, focus on learning outcomes, and on applications for lifelong learning (7).

Despite many different educational backgrounds of the current public health workforce, consensus is emerging to focus on three main layers (8): (1) public health professionals; (2) health professionals; and (3) other professionals with job functions bearing on the population's health. Also, understanding of the different job settings is of great importance for accountable performance (9). A European set of competencies has been developed led by the Association of Schools of Public Health in the European Region (ASPHER) (10) and adopted by the World Health Organization (WHO) (11). The European competencies comprise six domains (abbreviated) (12): (1) methods in public health; (2) population health—its social and economic determinants; (3) population health—its material environmental determinants; (4) policy, economics, organization, management, and leadership; (5) health promotion, health education, health protection, and disease prevention; and (6) ethics. US American competence frameworks have also been discussed for many years (13). In 2014, the Council on Linkages Between Academia and Public Health Practice published a very differentiated set of competencies (14) organized according to eight domains. In spite of the different systems and wording, the contents are quite similar, especially in respect to an outcome-based education and the apparent need for interprofessional education and lifelong learning.

### EXPLORATION OF KEY QUESTIONS

### What Are the Main Public Health Problems That We Have to Address in Europe and Beyond?

The competence acquired during the public health education has to support qualified performance to solve dominating (global) public health problems as there are threats to humanity (15) and planetary health (1) coming with climate change (e.g., floods, desertification), social inequity (e.g., poverty, hunger), insecurity (e.g., armed conflicts, terrorism), and instability (e.g., financial crises).

To some degree, public health functions and services are regionally specific (11, 16, 17), nevertheless in its document "Health Workforce 2030" WHO underlines the unmet global demand for qualified health professionals including the public health workforce (18). By now, public health interventions in all countries target predominantly socioeconomic factors (19). One of the most significant public health challenges—well-being—has attracted the particular interest of public health professionals. It represents one of the most complete and profound reflections of health. In the new European health policy "Health 2020," signed and adopted by 53 member states of the Region in September 2012, WHO stated that the aim is to improve the health and wellbeing of populations significantly (20). Moreover, in September 2015, 193 countries that are members of the United Nations signed the "2030 Agenda for Sustainable Development"; Goal 3 is specific: "to ensure healthy lives and promote well-being for all at all ages" (21).

### What Are the Exiting Competences of Public Health Professionals after Training in Europe?

For this and the third question, we refer mainly to the unique regionwide surveys organized and published on behalf of ASPHER, "*the key independent European organisation dedicated to strengthening the role of public health by improving education and training of public health professionals for both practice and research*" (22). WHO Europe invited ASPHER to take the lead on the Essential Public Health Operation (EPHO) No. 7 on "Assuring a sufficient and competent public health workforce" (23).

Looking at the performance of public health professionals, while there are different published models of health system performance (24–26), very few of them exist in the field of public health and very often relate exclusively to the concept of management (27). ASPHER's approach assumes that performance varies and strives for success in achieving long-term objectives. Therefore, all four dimensions of the WHO performance model

1One credit point of ECTS corresponds to 25–30 h of student's workload, thereof up to 30% in direct contact with a lecturer (through an interactive presentation, exercise, seminar, field work, or research).

should be included in a comprehensive assessment of public health performance in the future (25):

The Global Independent Commission on Education of Health Professionals for the twenty-first century stated that vocational education had not kept pace with the new global challenges, largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates (28). ASPHER (29) reacted by executing in 2011–2012 the first systematic survey of, at that time, 81 members, SDPHs. With a participation rate of 81.5%, the survey included the evaluation of exiting competencies of their Master of Public Health (MPH) graduates making use of the European list of public health competencies (10) and the EPHOs, endorsed by WHO (11).

Together more than 80 different master programs in the broader field of public health are offered in Europe. Although epidemiology maintains the first rank in a list of curricular contents, critical new areas like informatics, genomics, community-based participatory research, policy and law, global health, and ethics are also present. One major focus of the survey was the dimension of competencies for good public health performance (29). SDPHs assessed their best success to be in the field of health promotion, followed by disease prevention including identification of priority health problems, and health hazards in the community while they see the least success in dealing with preparedness and planning for public health emergencies.

However, European training capacities are entirely insufficient, even taking into consideration that not all MPH training programs in Europe are based on schools of public health and are not covered by the ASPHER survey. Their role in the development of the public health workforce warrants separate consideration. The ASPHER survey found an overall average of 46 graduates per institution per year (all programs of the Bologna levels and equivalents). This total annual number of 3,035 graduates by the institutions participating in the survey can by no means satisfy the need for public health professionals which for the European Union alone can be estimated to be 22,000 based on levels proposed for the United States (30, 31).

Given an accelerated globalization and the impact of developments outside of Europe, training for global public health has rapidly gained relevance. Global health is present in the curricula of 82% of ASPHER members with a median of 40 h, only a bit higher than recommended for medical students as a minimum (30 h) (32).

### What Are the Expectations of European Employers of Public Health Professionals?

The ASPHER survey 2012–2013 identifies in addition to exit competencies of graduates also the current as well as the desired performance of public health professionals as determined by 63 out of 109 (57.8%) contacted European employers (33). Employers were asked: "*How often public health professionals in your job environment perform the task, which requires selected competence*?" Furthermore, they had to specify the current level of performance the desired level. It turned out that the regular performance of a particular competence is defined by what is "necessary" and driven by assigned tasks. Employed professionals rarely have occasion to perform a particular public health competence on an everyday basis or weekly. Significant gaps exist between current and desired levels of performance on the job for all EPHOs (4).

Schools and Departments of Public Health estimates of their success in terms of the public health exiting competencies of their graduates often are not in congruence with employers' estimates of current levels of performance of their staff (see the representative example of EPHO 7 with its related competencies in **Figure 1**). This observation can be due to a favorable overestimation by SDPHs or a generational representation in the sense that the current employees do not perform accordingly because they were educated in earlier times. In most areas however, SPHDs' opinion about their present success corresponds quite closely to desired levels of performance as stated by employers. The main exceptions as published (33) are EPHOs related to preparedness and planning for public health emergencies, health protection operations, and core communication for public health. SPHDs estimate their success considerably lower in those EPHOs than public health employers expect as desired level of performance. A way to improve this deficit could be to involve public and private employers already in the curriculum development.

### NETWORKING AND PARTNERSHIPS IN PREPARING PUBLIC HEALTH PROFESSIONALS

The answers we found to the three questions discussed can be summarized as follows:

Given the small infrastructural base, the logical way forward is the advancement of partnerships joining capacities at the European and global level (32). Today learning from public health experience in other countries by including international students in the program and fostering mobility becomes increasingly important. Various forms of regional collaboration are improving outcomes in public health education and practice.

An example is the intergovernmental South-Eastern Europe Health Network (SEEHN) (34) of WHO Europe and in the recent past the Forum for Public Health Education, Training and Research in Southeastern Europe (35), supported by the European Stability Pact. Examples of such cooperation are common sets of flexible teaching materials which in the meantime comprise six thematic volumes with close to 250 modules on some 4,000 pages and the open-access South Eastern European Journal of Public Health (36), which also offers the second edition of the mentioned teaching books (37, 38).

This experience represents not only a valuable support for students and faculties but also has served to establish close collaboration across borders and among people who have been on different sides during the wars of the 90s. As an example, to the volume on Management in Health Care Practice, published 2008, 49 authors from 10 countries have contributed. There were many occasions to test teaching modules as applied (39) and learn through conferences/meetings, summer/winter schools, and students' conferences during a decade of cooperation.

Also, a joint project of the Open Society Foundations and ASPHER facilitated the establishment of schools of public health in selected countries of Southeastern Europe, with the primary focus on the development of teaching curricula at Masters' level in the field of public health sciences (40).

Schools of Public Health, Institutes of Public Health, and National Public Health Association have established a permanent collaboration to improve the performance of public health professionals. For example, ASPHER (7) and the European Public Health Association (41) are both regional members of the World Federation of Public Health Associations (WFPHA) (42), whereas the International Association of National Public Health Institutes is a member of the Advisory Board of WFPHA.

### RECOMMENDATIONS

The authors recommend the following to prepare a competent public health leadership in Europe:

preparing public health professionals to perform at highest levels.

#### REFERENCES

boundaries and participate in European and global networks for education, research, and practice.

### AUTHOR CONTRIBUTIONS

VB-M: conceptualization, introduction, sections 2 and 3, section on networking. RO: section on European landscape, section 1. VB-M and RO: recommendations.

www.phf.org/resourcestools/Documents/Core\_Competencies\_for\_Public\_ Health\_Professionals\_2014June.pdf

of handbooks prepared within the frame of the "forum for public health in South-Eastern Europe" network. *Slov J Public Health* (2012) 51:237–50. doi:10.2478/v10152-012-0027-7

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2017 Bjegovic-Mikanovic and Otok. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Global Health Teaching in India: A Curricular Landscape

*Sanghamitra Pati1 \*, Rajeshwari Sinha2 , Meely Panda3 , Sandipana Pati4 , Anjali Sharma5 and Sanjay Zodpey5*

*1Department of Health Research, Regional Medical Research Centre (ICMR), Bhubaneswar, India, 2 Independent Researcher, New Delhi, India, 3 Jamia Hamdard University, New Delhi, India, 4Department of Health and Family Welfare, Government of Odisha, Bhubaneswar, India, 5Public Health Foundation of India, Gurugram, India*

Today, health has transcended national boundaries and become more multifaceted. Global health has evolved as a new paradigm and is recently being identified as a thrust area now in India. Despite an existing need for a standardized global health curriculum, there is little information available on its education and curriculum in medical and health education space. In the Indian context, we are yet to have a fuller picture of the current status, including, content, structure, selection, teaching methods of global health, and how students are evaluated in India. The objective of this study was to map courses relating to studies on global health in India and analyze its mode of delivery. A detailed Internet search was carried out to identify global health courses and analyzed for: (i) whether global health is a part of the teaching curriculum, (ii) mode of teaching, (iii) broad contents, (iv) instructional formats, (v) assessment, and (vi) selection process. It was found that delivery of global health education in India was fragmented with limited focus at the undergraduate and postgraduate levels. Global health teaching was largely based on certificate courses or online courses, with hardly any institutions imparting a distinct global health education program. There is also no definite specification as to which institutes can impart teaching on global health education and what the specific eligibility requirements are. Our analysis suggests that efforts should be directed toward integrating global health education into broader public health curriculum. At the same time, the need for generation of global health leaders, creation of a common forum for addressing merits and demerits of global health issues, as well as creation of more opportunities for placements are recognized.

Keywords: global health, international health, public health education, curriculum, India

### INTRODUCTION

In recent years, the world has made rapid progress toward economic globalization, populations have become more multicultural and borders are being traversed easily. Health issues have therefore moved beyond communities and countries. Increased migration, international travel, commodity and food supply globalization, climate change, reemerging disease patterns and rising burden of chronic diseases, have caused health to transcend national boundaries and become more multifaceted. The concept of health is therefore no longer restricted to disease based and clinical interventions, but has evolved further to assume global dimensions (1).

#### *Edited by:*

*William Edson Aaronson, Temple University, United States*

#### *Reviewed by:*

*Jeff Bolles, University of Mount Olive, United States Al F. Alassaf, American Institute for Healthcare Quality, United States*

*\*Correspondence: Sanghamitra Pati<EMAIL_ADDRESS>