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This article compares activities of the University of Michigan School of Public Health Public Health Action Support Team (PHAST) to the Centers for Disease Control and Prevention/Council of State and Territorial Epidemiologists Applied Epidemiology Competencies (AECs) to determine the utility of using the competencies to assess extracurricular student training. We mapped the activities from eight PHAST trips occurring from 2006 to 2009 to the 34 AECs for Tier 1 epidemiologists by examining project activities to determine how closely they aligned with the AECs. PHAST trips provided students with opportunities to address 65% of the AECs; 29% of the AECs were addressed by all eight trips. The domains of AECs most often addressed by PHAST trips were leadership and systems thinking, cultural competency, and community dimensions of practice. Mapping PHAST trips to the AECs was useful for all public health students, not just epidemiologists in training.
In accordance with congressional requirements,1 the Centers for Disease Control and Prevention (CDC) funds a network of Centers for Public Health Preparedness (CPHPs), which provides training to ensure the public health workforce is ready and able to respond to public health emergencies. In addition to training the current workforce, many of the CPHPs also provide training to public health students in the form of graduate student epidemiology response programs (GSERPs).2 Given the public health workforce shortages that are predicted for the near future,3–6 it is crucial that graduate students are interested in and prepared for entering that workforce.
Because epidemiology is the science of public health, it is essential that it guide public health emergency response, policies, and disease prevention activities. However, a multidisciplinary approach to training and response is necessary so that students employ a wider-angle lens to appropriately prioritize response-based activities. Thus, most GSERPs reach beyond epidemiology students and focus on interdisciplinary training activities.
In 2002, the Institute of Medicine (IOM) called for the provision of service-learning experiences, along with integrated, interdisciplinary learning opportunities and competency-based education for public health students.7 The IOM provides the following criteria for the types of service learning: (1) the service provided should be relevant and meaningful to all stakeholders, (2) the service should help the community and enhance student academic learning, and (3) the service should prepare students for active civic participation.2 In 2008, CDC and the Council of State and Territorial Epidemiologists (CSTE) established core competencies for ensuring a well-trained workforce by publishing a set of Applied Epidemiology Competencies (AECs).8 We selected the AECs for this study because they have been reviewed extensively by academics and public health practitioners and reach beyond basic epidemiology to include many core public health skills. Therefore, they are relevant to students who plan to become epidemiologists, as well as students specializing in other areas of public health.
Moser et al. explain the effectiveness of using competencies, declaring that competency-based education “has the potential to transform both the content and the form of MPH [master of public health] education.”9 However, they caution that sets of competencies should not be seen as static or canonical; rather, they should be seen as “a starting point for discussion.” Gelletlie asserts that, while competencies potentially serve as useful frameworks for assessing skill levels and describing expectations of the public health workforce, the public health workforce must be able to see the interconnections among the competencies.10 Gelletlie believes that, to be successful, public health practitioners need to learn to synthesize and “make situation-specific judgments in a complex and dynamic environment.”10
At the University of Michigan School of Public Health (UMSPH), graduate students have the opportunity to synthesize the entry-level competencies that are developed through extensive coursework by participating in the Public Health Action Support Team (PHAST)—a GSERP coordinated by the Office of Public Health Practice, which houses the Michigan Center for Public Health Preparedness (MI-CPHP). Since 2005, PHAST has provided training and field experience opportunities for students to actively assist local and state health departments and community health agencies to meet the demands of emergencies such as disasters, outbreak investigations, and other public health events. In addition to one-day deployments to health departments within Michigan, PHAST students may participate in week-long deployments (hereafter, PHAST trips) that include direct supervision by UMSPH faculty and professional-level staff. As demand for PHAST trips grew among students, the UMSPH Office of Public Health Practice began funding and leading international trips as well.
PHAST is unique because it places students in interdisciplinary teams to assist with solving real-world preparedness-related problems. PHAST trips open a window into the complexity of public health that enables students to experience firsthand how the various disciplines within and external to public health intersect to examine and solve real-world public health problems. PHAST students receive hands-on training so they may better synthesize their academic and practice learning. This training prepares students to work in the field by providing an opportunity to apply the methods they learn in the classroom.
In this article, we map the trips that are part of the PHAST program to the CDC/CSTE AECs8 using pre-established methods11 to evaluate how effectively the PHAST trip activities help students address individual AECs and synthesize multiple competencies.
From 2006 to 2009, eight PHAST trips took place. The trips included travel to the Gulf of Mexico for response and recovery activities related to Hurricanes Katrina and Rita, to China to work with the Tianjin Centers for Disease Control and Prevention (TJCDC), and to the Dominican Republic to work with vulnerable populations.
PHAST membership is open to all UMSPH graduate students. Trip eligibility requires PHAST membership, good academic standing, and submission of a complete application for trip participation. Funding comes from MI-CPHP for domestic trips and from the UMSPH Office of Public Heath Practice for international trips. Student selection was based on available space (determined by the capacity of each host agency, and by faculty and staff availability for supervision), high trip-application ranking, and departmental distribution (to ensure multidisciplinary diversity on each trip).
Students were required to attend a one-day training session to become PHAST members. Prior to each trip, PHAST staff conducted two or three training sessions to inform students of trip logistics, facilitate linkages between their academic coursework and the practice contexts they would encounter, and set the stage for the ethical application of public health practice. Expectations were set for the students regarding professionalism, leadership, and partnership work. Students were also given background information on the communities and exercises to help prepare them for entering and exiting the communities in a professional and culturally responsible manner. Students were required to keep journals and complete exercises to record their observations of community needs and strengths and the roles that gender, race/ethnicity, and socioeconomic status play in community health. During the trips, faculty and staff provided daily sessions to help students synthesize the public health aspects of the experience. Details regarding the annual training are available at http://practice.sph.umich.edu/practice/phast.php.
The pre-trip trainings were designed to address the following subset of the AECs,8 which we identified as essential to the development of practical skills:
Each trip included specific projects that were designed to have a cross-cutting emphasis on the competencies. A complete list of the AECs for Tier-1 epidemiologists is presented in the Figure.
As part of the epidemiology workforce initiative, CSTE worked with the CDC Office of Workforce and Career Development to convene an expert panel comprising local, state, and federal health representatives; schools of public health; and private sector professionals to develop the AECs.8 The intent of the applied competencies was to define the skills a competent epidemiologist working in public health practice would need to effectively carry out his or her job duties. The eight skill domains in the Core Competencies for Public Health Professionals12 developed by the Council on Linkages Between Academia and Public Health Practice were used as a starting point by the panel in developing the AECs. The panel identified four different levels of practicing epidemiologists whose desired competencies were felt to differ in significant ways and developed four corresponding tiers: basic or entry level (Tier 1), mid-level (Tier 2), senior-level supervisor or manager (Tier 3a), and senior-level scientist (Tier 3b). Eight skill domains cut across these tiers, and a total of 38 competencies and multiple sub-competencies further describe the components of the skill domains. The Tier 1 epidemiologist category includes 34 competencies within the eight domains (Figure). While other competency sets exist or are in development, to date, the AECs have been the most widely vetted by the practice community.
For each PHAST trip, we compared the activities students conducted to each of the Tier 1 AECs8 to assess how well the PHAST program was meeting the competencies. We selected Tier 1 because, while some graduates are likely to work in Tier 2 positions, we determined that Tier 1 demonstrated a minimum level of achievement for graduation from the UMSPH master's program.
The process of mapping the PHAST trips to the AECs was completed by a review of the trip activities to determine how closely each one aligned with each competency. Methods used were described previously.11 This process allowed us to identify which competencies are addressed by PHAST and which are not.
We mapped the eight PHAST trips that took place from 2006 to 2009 to the 34 Tier 1 AECs.8 The Figure illustrates the specific competencies addressed during each PHAST trip. Overall, 22 of 34 competencies (65%) were addressed by at least one PHAST trip, including competencies from seven of the eight domains. Ten competencies (29%) were addressed by all of the PHAST trips. Following are examples of how competencies were addressed by specific trip activities.
During the China 2009 trip, one faculty member led a discussion with students about public health issues the students had witnessed in China. Students mentioned many public health problems that faced the community. Interestingly, the list of issues they initially provided consisted exclusively of problems such as smoking, hand-washing practices, and air pollution. As the discussion proceeded, students began to identify positive public health activities in the community as well, such as physical activity (e.g., many people rode bikes to work), highway signs with public health messages, and government-funded vaccines for all children.
During the Biloxi, Mississippi, May 2009 trip, students completed door-to-door interviews with area residents, collecting information about health conditions such as hypertension, diabetes, depression, and stroke. This allowed students to gain firsthand knowledge about specific health conditions impacting the community. Furthermore, they asked how often the health conditions kept respondents from doing regular activities; this provided insight as to the effects of poor health on a community.
On all PHAST trips, good ethical and legal practices are emphasized. Issues such as confidentiality of interview information (Biloxi 2008, Biloxi 2009) and medical/dental records (Gulf Coast 2006) provide specific learning situations in which students must practice good ethical principles.
During the Biloxi 2008 trip, students conducted interviews and entered the information into a database each day. This exercise in basic data management improved their data-collection skills as they saw the need for organized and complete responses.
During the Gulf Coast 2006 trip, students worked with an environmental justice organization to research the information needs of a community regarding the health risks of a large oil spill in the area. Students developed a health education flyer that provided basic information about the toxins known to be in the air and soil and the direct health risks associated with the pollutants.
During the Biloxi 2008 trip, students conducted door-to-door interviews with community members to help a local community-based organization evaluate its program activities.
During the Gulf Coast 2006 trip, students worked with an environmental justice organization to teach citizens living near an oil refinery that had experienced a massive spill during Hurricane Katrina how to collect air samples to determine what toxins were present and at what levels. Students worked with community members to facilitate laboratory testing of the samples, the results of which could be used for neighborhood planning in the rebuilding process.
During the Gulf Coast 2007 trip, students worked with a local organization to map locations where food was available for purchase. Because of the depth of physical destruction of buildings in New Orleans, the need for viable food stores was a priority for the city's residents. As food stores became operational throughout the city, disseminating this information was important. Students visited each known and rumored food store and provided an assessment of the type of store, its location, payment options, and whether it provided local produce.
During the Gulf Coast 2007 trip, students mapped food locations in the Greater New Orleans area. At the conclusion of the project, the students provided a local organization with a detailed written report of food establishments in the community.
During the Gulf Coast 2006 trip, students worked with a forensic dentist to identify the deceased. The work required talking with family members of those missing to ascertain additional information that could provide important clues for establishing the identity of the deceased. The students successfully maintained a professional demeanor throughout the project, although they were challenged with stressful and emotional situations, including notifying family members of a death.
During the Biloxi May 2009 trip, students learned the importance of high-quality data. Before conducting interviews, they had the opportunity to critique the data-collection tools and think through how they could obtain the best data possible. One student commented, “I didn't realize how much planning and time goes into designing and implementing a study.”
During the Gulf Coast 2006 trip, students worked alongside a forensic dentist to identify the deceased. The students worked with several government agencies—the Louisiana State Police, the Louisiana Department of Health and Human Services, and the city of New Orleans—and Louisiana State University to locate and examine dental records to match bodies being held by the Disaster Mortuary Operational Response Team. They learned why and how the interagency cooperation developed and the important role it played in the successful reunification of families.
During the Gulf Coast 2006 trip, students worked with a forensic dentist to identify the deceased. One student noted that among the deceased were a disproportionate number of older (>70 years of age) and impoverished people. This suggested that age and socioeconomic status were risk factors for death during this disaster.
During the Dominican Republic 2009 trip, students worked in impoverished “batey” communities, which were originally housing areas for sugar plantation workers. As plantations have closed, many of the community residents have become unemployed. Students spent the week working side by side with community members to beautify the neighborhood and deliver basic hygiene-related health education messages. Students quickly learned that first building a trust-based relationship was key to the success of their health education efforts.
During the China 2008 trip, students were introduced to the real-time infectious diseases surveillance system used by the Chinese government. This system helped them to identify a large measles outbreak in young children.
After visiting two immunization clinics during the China 2009 trip, students developed a brief questionnaire about childhood immunization practices. The questionnaire was translated by staff at the TJCDC and taken to a village where adults with young children were interviewed. The interviews were conducted in Chinese, with students recording responses and interacting with participants and translators.
All PHAST projects include participation in ongoing activities that are initiated by the local community. Students work with community members and leaders to learn about and work with the affected community.
The trips to Biloxi have all been based on collaboration with two other universities and a community organization. Students have the opportunity to work side by side with students from these other universities and meet with the executive director of the community organization. Students see firsthand how crucial these relationships are, as they often have difficulty recruiting interview participants without discussing the connection with the local organization. They are amazed when doors open with the simple mention of a locally respected organization.
During the Biloxi October 2009 trip, at the request of a community organization, students researched the service needs of two communities into which the organization was trying to expand. The vision was to provide services to a larger catchment area. Students helped to develop an evidence base for this expansion.
On all PHAST trips, good ethical practices are emphasized. Issues such as confidentiality of interview information (Biloxi 2008, Biloxi 2009) and medical/dental records (Gulf Coast 2006) provide specific learning situations in which students must practice good ethical principles.
All PHAST trips provide students with the opportunity to interact with public health professionals. This interaction requires students to develop professionally as they reach outside of their comfort zones to participate in public health activities.
During the Gulf Coast 2007 trip, students worked with five community organizations to develop their own strategic plans to better address the needs of their specific communities. The plans focused on how to adapt to the post-hurricane environment and how to better prepare for upcoming hurricane seasons.
PHAST supplements the provision of intensive academic training by offering supervised field experiences for public health graduate students. Through the trips and interaction with their peers, students learned how to work in multidisciplinary teams and the importance of these teams. Students brought the perspectives of their public health disciplines (students have represented all five departments within UMSPH) to a project. Students had the opportunity to synthesize their knowledge from the various disciplines in determining how best to address a health issue. All of this was done under the supervision of faculty and staff who have experience working in public health practice settings and who help the students make the connections.
On each trip, students had the opportunity to address multiple competencies simultaneously. This is important to their learning process, as didactic courses tend to teach concepts in silos, whereas PHAST requires that these concepts be interconnected. For example, students must work with community partners and community members to build trust to recruit participants for an interview. Once data are collected and managed, they can consider interventions. While the process seems obvious to public health professionals, it is often a student's first opportunity to try out the concepts they have learned in various classes and see how they work in practice.
PHAST students were exposed to public health preparedness in such a way that many have considered focusing on preparedness as a career option. Through continued relationship and partnership building—for instance, in the Mississippi Gulf Coast—PHAST has helped inform local organizations about services and programs to meet the needs of their residents. This longstanding relationship highlights for students the importance of community connections and gives them opportunities to learn more about the population they are working with by spending time with organization members who are very open to student questions about cultural differences and similarities. Again, this provides a context for synthesizing several of the AECs. At the same time, the trips have dramatically increased student awareness and consideration of careers in practice, particularly in the growing field of emergency preparedness. Work in a post-disaster community has proven to be an invaluable experience that has transformed and continues to transform the thinking of our students about the importance of public health.
The focus of PHAST has been providing students with experiences; however, the trips have also produced benefits to the host agencies and UMSPH. Sites have been able to accomplish tasks that they either did not have the resources or time to address previously. PHAST has provided organizations with needed assistance to maintain capacity, complete projects, and develop new materials. In particular, the Biloxi and China trips have created strong, long-term academic-practice relationships. PHAST students benefit from learning how these bonds are created and sustained.
After conducting PHAST trips for the past four years, we have learned some valuable lessons that have strengthened the trips and the experiences of the students. In the early stages of PHAST, trips included a large number of students and had multiple projects to accommodate this large number. Subsequently, we have learned that smaller trips (six to eight students) are of higher quality, and having just one project allows faculty and staff to focus on competency development in individual students. The projects are best when our faculty and staff, along with the local organization, play an active role in the project's development. Additionally, we have found that ongoing collaboration with local organizations make the process smoother, multidisciplinary teams (within and external to public health professions) provide for more opportunities for synthesis of activities, and trips that return annually to the same communities build relationships and create additional opportunities. Furthermore, we need to develop a better system for tracking post-graduation employment and evaluating the impact PHAST has on practice-based careers.
Mapping PHAST trips to the AECs helped us to identify program strengths as well as areas we could improve to expand opportunities for students. While many courses are likely to focus on one or two of the domains, PHAST trips afford cross-domain application of competencies, which aids in synthesizing public health concepts and skills. Additionally, as a result of this project, we plan to incorporate an introduction to the AECs into PHAST training activities and student evaluations so students can record for themselves when they have addressed and synthesized competencies during their coursework and PHAST projects.
Through PHAST trips, many of the AECs are met in real-world situations and are a complement to and application of students' academic coursework. These competencies are useful for evaluating PHAST trips for all public health students, not just epidemiology students. Furthermore, PHAST trainings and trips emphasize that public health strategies that are successful in one community context might not be successful in another. Thus, students who take full advantage of PHAST trips can better equip themselves to make vital “situation-specific judgments”10 that will maximize their effectiveness as public health practitioners throughout their careers.