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There are significant shortages in the public health workforce and it's expected to worsen. Efforts to reduce this shortage are varied and include building the workforce by increasing exposure of students and young professionals in applied public health experiences. Providing these experiences increases productivity, and may help alleviate some of the workforce shortages in public health. This article seeks to highlight the work done at the Family Health Services Division (FHSD) in the Hawai‘i Department of Health over the past 6 and half years in working with students in epidemiology practicum and fellowship experiences.
The work in public health is multi-disciplinary in types of positions (eg, epidemiologists, public health clinicians, biostatisticians, planners, health economists, program administrators, health informaticists, toxicologists, lab techs, microbiologists, etc.) and type of agencies (federal, state, local, academic, community based, etc.). A 2008 publication by the Association of Schools for Public Health estimated there were about 50,000 fewer people in the public health workforce in 2000 compared to 1980; with the ratio of the public health workforce to the US population reported as just 158 per 100,000 in 2000 compared to the 220 per 100,000 in 1980.1 The situation has become worse. The Association of State and Territorial Health Officials reported a loss of more than 50,600 state and local public health jobs since 2008. This figure of 50,600 represents nearly 22% of the total state and local health department public health workforce.2 The combination of severe budget cuts and retirements is expected to result in a public health workforce shortage of 250,000 by the year 2020 in order to just get back to the ratio found in 1980 (which likely still underestimates the true need).1
Since 1995, the Council of State and Territorial Epidemiologists (CSTE) has surveyed its members on epidemiological capacity to identify needs of states and territories.3 The latest assessment from 2010 identified 2,476 epidemiologists working at the state level, which represented a decrease of 0.9% from 2004. The diversity of subject matter for these state epidemiologists has also shifted since 2004 with a large increase in infectious disease; a small increase in maternal and child health; and declines in bioterrorism/emergency response, chronic disease, environmental health, injury, occupational health, and oral health. There are many factors that likely contribute to these patterns. Further surveillance, including an assessment in 2013, will provide additional information on epidemiological workforce issues.
Solutions to improving the overall public health workforce will need to be multi-disciplinary and utilize diverse approaches that account for public health funding as well as ensuring a highly skilled workforce. Some of the ways to improve the workforce are promoted through the workforce development initiative at CSTE and include expansion of training fellowship programs in public health; introducing college and high school students to the field of epidemiology; linking practical mentorship experiences with formal training; increasing faculty with practical pubic health experience; addressing barriers to recruitment and retention; increasing funding for public health; and developing leadership opportunities for public health professionals.4 This article highlights work done within the State of Hawai‘i to improve epidemiological capacity through mentoring experiences in the FHSD at the Department of Health.
The epidemiological capacity workforce in Hawai‘i is of particular concern due to the closure of the University of Hawai‘i School of Public Health in 1999. The Program in Public Health was accredited in 2002, with tremendous ongoing efforts by faculty and staff to re-establish the Office of Public Health Studies as a school by 2015. In 2006, there were approximately 50 students in the graduate public health program, a significant decline from the 200 students at the height of the school; this decline has significant implications for the state's ability to meet the demands of the workforce.5 The program has gone through substantial changes as it re-emerges as a School of Public Health, but still only includes about 100 graduate level students in 2014; including 37 enrolled in degrees with an epidemiology focus (21 at Masters level and 16 at Doctorate level).6 The recent addition of an undergraduate curriculum in public health should help in meeting the challenges of growing the pubic health workforce in Hawai‘i. Mentoring students and providing practical experiences at the Department of Health can help to both grow the states epidemiological capacity and support public health students gaining applied experience as part of their work towards an advanced degree.
I started my current position in FHSD at the Hawaii Department of Health in 2007 as an epidemiologist assigned through the Division of Reproductive Health at the Centers for Disease Control and Prevention (CDC) (http://www.cdc.gov/reproductivehealth/MCHEpi/). In 2012, this assignee program celebrated 25 years of placing epidemiologists and fellows in nearly 40 states, districts, territories, agencies, and border regions. One of the fundamental goals of the program is to promote and build epidemiological capacity. Over the last 6.5 years, I have felt privileged and honored to be in my current position where I have worked with over 25 individuals in practicum and fellowship experiences including undergraduate, graduate, doctorate, post-doctorate students, and applied epidemiology fellows. In all of these experiences, the focus has been on building and developing epidemiological skills, including analysis and interpretation of data for diverse audiences.
A practicum experience can take many forms, including having a student work with an organization to learn first-hand and to apply skills learned in the classroom in a field setting. A practicum can be an opportunity for an employee to work with students in a teaching and mentoring relationship that is mutually beneficial. The mentor often learns from the student while guiding the student through the practicum. A successful practicum experience requires good communication between the mentor and the student, so regular meetings are established and feedback is provided throughout the experience. Developing a topic of mutual interest often requires discussion early on for the mentor to understand the goals of the student and for the student to learn about the objectives of the host agency. This communication occurs with every interaction in areas such as developing a topic of interest to both parties involved, basic orientation to the host agency, identifying objectives of the practicum experience, regular meetings during the practicum, and ongoing dialog to ensure that everyone is benefiting from the experience. A technique that can be useful is the joint development of a work plan at the very beginning of the practicum that includes a description of the topic, schedule, goals and objectives with specific deadlines. The work plans are referred to throughout the experience to ensure that all objective and skills are met and the student and the host agency benefit from the practicum experience. These are dynamic documents that are updated as needed and provide the student with a record of the practicum, which can be helpful when summarizing the results of the experience. These work plans are also often in alignment with, or can be adjusted to meet, school requirements so that the student can receive academic credit for the practicum.
In FHSD, the practicum experiences are of two major types: Short term (3 months); and long-term (2-year commitment through a post-graduate fellowship). There are also situations where a student may do a short-term practicum as part of the requirement for a doctorate degree, but the mentor may also participate over the duration of the student's study as part of the dissertation committee. With these diverse time commitments, there are definitely distinct expectations that come into play that should be addressed as part of the whole practicum experience. For example, it may be unreasonable to expect a student doing a short practicum to be able to generate a complex report, complete an abstract, and submit a paper for peer-reviewed publication all within the confines of the practicum. It is likely more appropriate for the student to learn about a specific data set, complete an analysis, and generate an abstract that could be submitted to a conference. Oftentimes, a student will want to turn that analysis into a published peer-reviewed manuscript that will depend on a lot of factors including the ability for the student and other co-authors to work on it after the practicum. Working over the longer term with an applied epidemiology fellow allows a much more extensive experience, including contributions to many different reports and projects. Additionally, fellows have exposure to diverse data sources and complex analyses that can lead to multiple presentations and peer-reviewed manuscripts. Past fellows have also been able to gain experience with other activities such as questionnaire design, working with stakeholders, program evaluation, collaboration on outbreak and preparedness activities, and taking leadership roles on various projects.
Efforts have been made in practicum and fellowship experiences to promote epidemiological analyses on a wide diversity of topics using existing data sets (eg, Behavioral Risk Factor Surveillance System; Hospital Discharge Data; National Survey of Children's Health; Pregnancy Risk Assessment Monitoring System; Supplemental Nutrition Program for Women Infants and Children; Vital Statistics; and Youth Risk Behavior Survey; Table 1). In addition to the analyses of existing data sets, primary data collection is a method often used for those involved in doctoral or fellowship level work (eg, provider surveys, participant surveys, and key informant interviews).
Through these mentoring experiences, we have been able to develop many products (eg, fact sheet, reports, abstracts, conference presentations, manuscripts) that have been used by the Department of Health and stakeholders in the community. Without the work of students, the volume of products would be significantly lower due to lack of staff time to devote to all of these analyses. Stakeholders and other staff in the Department of Health have used these products to increase awareness on many issues, help in grant applications and grant reporting, support efforts to promote programs and activities, and to promote legislation and policy.
In addition to primary analyses, opportunities are provided to experience working in public health at the department through attendance at lectures and meetings, involvement in committees and other activities, to highlight the work done by epidemiologists. This includes working with community stakeholders and program staff to conduct analyses useful to their efforts. In addition, attempts are made to include individual presentations at the conclusion of the practicum to various stakeholders to foster collaboration as well as to highlight and reinforce the great work done by the students. These efforts with stakeholders have increased awareness and have led to new analyses for other practicum students and staff. They are also a great opportunity for students to share their experiences and improve their presentation skills, particularly as many will go on to present the material at a national conference.
Some of the outcomes that can be documented within FHSD are the 39 abstracts completed by practicum students (29) and fellows (10) and presented at state and national conferences in either a verbal or a poster format since 2008. An additional 12 abstracts were submitted to two conferences for consideration of presentation just this year. Another way to highlight the work is through the 25 state reports and fact sheets to which these practicum students or fellows have provided substantial contributions. These reports and fact sheets are used by various stakeholders and other department staff to raise awareness about particular issues and are helpful in highlighting disparate populations which can help in public health planning efforts. Another measure of impact would be the 15 published peer-reviewed manuscripts in which a practicum student or fellow substantially contributed to the article on a diversity of topics in multiple journals. All of these experiences are important in increasing knowledge and awareness through sharing the information and findings from the particular work done by the students during the practicum, but also highlight some of the continued work that some are able to do after returning to their schools. The work completed during practicum experiences can enhance the curriculum vitae of participants while increasing analytic skills. Additionally, the practicum experience increases connections between the public health workforce and programs in academia.
Other less tangible benefits, like the good feelings associated with sharing knowledge, seeing increased confidence and skills in a student over the duration of the practicum, and seeing them grow in their public health careers are just some of the personally fulfilling benefits of mentoring and building the public health epidemiology workforce.
Funding is always a challenge as there has not been an easy mechanism or dedicated funds to support practicum experiences. However, FHSD has been fortunate to have had several students receive a small stipend through the Graduate Student Epidemiology Program http://www.mchb.hrsa.gov/researchdata/mchirc/gsip/index.html) sponsored by the Maternal and Child Health Bureau at the Health Resources and Services Administration. Another mechanism has been the support of the CSTE Applied Epidemiology Training Program (http://www.cste.org/?page=Fellowship) from which we have had 2 fellows within FHSD since 2008. Additionally, we have some students participate that receive course credit while others just participate for the experience and receive no monetary or school benefit. All the practicum students and fellows are able to improve their skills in epidemiology particularly in data analysis and translation of the data to diverse audiences, but also learn about work done in a larger context at the Department of Health.
The challenges of improving workforce capacity is not unique to public health and has been well documented in this journal over the years for a number of other health professions including clinical providers, biomedical researchers, social workers, dental hygienists, and public health laboratory professionals.5,7–10 All of these professions, including epidemiology, highlight the importance of partnerships with young professionals and suggest various ways to improve the workforce across many disciplines. The need to improve epidemiology capacity will continue to grow along with the ability to understand the large volume of data available in society today. The experiences in FHSD over the last six years demonstrate a substantial contribution to the work in public health by practicum students and fellowship experiences.
Although the focus of this article was on epidemiology practicum and fellowship experiences within FHSD, the division has also hosted other practicum students in various capacities. There are also many other programs and divisions within the Department of Health that support students and fellows through practicum experiences and each has its own structure, policies, and experiences.
I feel fortunate to have had excellent experiences as both a mentor and as a mentee and continue to communicate with many of them on a regular basis as colleagues. I often get the question why do I work with so many students and I mention the enjoyment I get with teaching and mentoring, but also talk about my experiences during medical school and in public health training where I was able to make a difference through my contributions as a student trainee. I enjoy giving practicum students and fellows the opportunity to contribute to epidemiology and make a difference while improving their skills and getting the chance to learn more about a career in public health.
In summary, hosting practicum students and fellows is an opportunity to develop professionally and improve productivity while contributing to the development of the public health workforce. Public health professionals should consider partnering with academia and other organizations to host students through practicum and fellowship experiences.host students through practicum and fellowship experiences.
The author acknowledges all the individuals involved in making these efforts possible and effective, and appreciates the contributions and review of this editorial from Danette Wong Tomiyasu, Tonya Lowery St. John, and Ranjani Starr from the Hawai‘i Department of Health.
Jay Maddock, Office of Public Health Studies at John A Burns School of Medicine.
Donald Hayes, Hawai‘i Department of Health.
The opinions, findings, and conclusions in this article are those of the author and do not represent the official position of the Hawai‘i Department of Health.