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1.  Assessment of Epidemiology Capacity in State Health Departments, 2004–2009 
Public Health Reports  2011;126(1):84-93.
To assess the number of epidemiologists and epidemiology capacity nationally, the Council of State and Territorial Epidemiologists surveyed state health departments in 2004, 2006, and 2009. This article summarizes findings of the 2009 assessment and analyzes five-year (2004–2009) trends in the epidemiology workforce.
Online surveys collected information from all 50 states and the District of Columbia about the number of epidemiologists employed, their training and education, program and technologic capacity, organizational structure, and funding sources. State epidemiologists were the key informants; 1,544 epidemiologists provided individual-level information.
The number of epidemiologists in state health departments decreased approximately 12% from 2004 to 2009. Two-thirds or more states reported less than substantial (<50% of optimum) surveillance and epidemiology capacity in five of nine program areas. Capacity has diminished since 2006 for three of four epidemiology-related Essential Services of Public Health (ESPHs). Fewer than half of all states reported using surveillance technologies such as Web-based provider reporting systems. State health departments need 68% more epidemiologists to reach optimal capacity in all program areas; smaller states (<5 million population) have higher epidemiologist-to-population ratios than more populous states.
Epidemiology capacity in state health departments is suboptimal and has decreased, as assessed by states' ability to carry out the ESPHs, by their ability to use newer surveillance technologies, and by the number of epidemiologists employed. Federal emergency preparedness funding, which supported more than 20% of state-based epidemiologists in 2006, has decreased. The 2009 Epidemiology Capacity Assessment demonstrates the negative impact of this decrease on states' epidemiology capacity.
PMCID: PMC3001826  PMID: 21337933
2.  Assessment of Applied Epidemiology Competencies Among the Virginia Department of Health Workforce 
Public Health Reports  2008;123(Suppl 1):119-127.
Epidemiologists play critical roles in public health. However, until recently, no formal standards existed for epidemiology practice. In 2005, the Centers for Disease Control and Prevention and Council of State and Territorial Epidemiologists drafted Competencies for Applied Epidemiologists in Governmental Public Health Agencies (AECs) that provide a foundation for expectations and training programs for three tiers of practice. We characterized the Virginia Department of Health (VDH) epidemiology workforce and assessed its baseline applied epidemiology competency by using these competencies.
Epidemiologists representing multiple divisions developed an Internet survey based on the AECs. Staff who met the definition of an epidemiologist were requested to complete the survey. Within eight skill domains, specific competencies were listed. For each competency, frequency and confidence in performing and need for training were measured by using Likert scales. Differences among tier levels were assessed using analysis of variance.
Eighty-eight people from 10 program areas responded and were included in the analysis. Median epidemiology experience was four years, with 52% having completed formal training. Respondents self-identified as Tier 1/entry-level (38%), Tier 2/mid-level (47%), or Tier 3/senior-level (15%) epidemiologists. Compared with lower tiers, Tier 3 epidemiologists more frequently performed financial or operational planning and management (p=0.023) and communication activities (p=0.018) and had higher confidence in assessment and analysis (p<0.001). Overall, training needs were highest for assessment/analysis and basic public health sciences skills.
VDH has a robust epidemiology workforce with varying levels of experience. Frequency and confidence in performing competencies varied by tier of practice. VDH plans to use these results and the AECs to target staff training activities.
PMCID: PMC2233729  PMID: 18497022
3.  FIRST Things First: A Practice-Academic Collaboration to Develop and Deliver a Competency-Based Series of Applied Epidemiology Trainings 
Public Health Reports  2008;123(Suppl 1):53-58.
The Florida Center for Public Health Preparedness in the University of South Florida College of Public Health and the Florida Department of Health (FDOH) collaborated to design, develop, and deliver two competency-based epidemiology training programs aimed at increasing the epidemiologic preparedness and response capability of the FDOH workforce. They were also designed to meet the requirements of the National Incident Management System and recommendations or needs identified in national studies. The basis for the trainings is an epidemiology competency set developed by the Northwest Center for Public Health Practice at the University of Washington School of Public Health and Community Medicine. The target audiences for the two trainings are non-epidemiologists or practicing epidemiologists who have relatively little formal education in epidemiology. Both courses have online as well as onsite modules. Alternate tabletop exercises have been completed and delivered for anthrax and plague. Both trainings require participant demonstration of skills. The trainings have been well received, appear to be effective, and are used to credential members of Florida's epidemiology strike teams.
PMCID: PMC2233726  PMID: 18497019
4.  Analysis of the Literature Pertaining to the Education of Public Health Professionals 
A well-educated workforce is essential to the infrastructure of a public health system (1). At a time when global focus on public health is increasing, a severe shortage of public health professionals is projected (2). A strong educational framework is thus imperative to ensure the capacity and capability of the worldwide public health workforce for the future. The education of those who work in public health is spread across disciplines, subject-specific training programs and types of academic institutions. In the 2011 report on the Health Professionals for a New Century, Frenk and Chen comment that, compared to medicine and nursing, public health has done the least to examine what and how it teaches (3). This does not bode well for meeting the demands of the public health workforce for the future. The purpose of the study reported here is to analyze the state of pedagogy pertaining to the education of the public health workforce as evidenced by published literature. The focus is on “professionals,” defined as those who have formal education, are self-governing, and can work independently.
PMCID: PMC3859983  PMID: 24350216
education of the public health workforce; public health workforce pedagogy; literature on public health pedagogy; literature on education of public health professionals; public health professionals’ education
5.  Florida Epidemic Intelligence Service Program: The First Five Years, 2001–2006 
Public Health Reports  2008;123(Suppl 1):21-27.
The Florida Epidemic Intelligence Service Program was created in 2001 to increase epidemiologic capacity within the state. Patterned after applied epidemiology training programs such as the Centers for Disease Control and Prevention Epidemic Intelligence Service and the California Epidemiologic Investigation Service, the two-year postgraduate program is designed to train public leaders of the future. The long-term goal is to increase the capacity of the Florida Department of Health to respond to new challenges in disease control and prevention. Placement is with experienced epidemiologists in county health departments/consortia. Fellows participate in didactic and experiential components, and complete core activities for learning as evidence of competency. As evidenced by graduate employment, the program is successfully meeting its goal. As of 2006, three classes (n=18) have graduated. Among graduates, 83% are employed as epidemiologists, 67% in Florida. Training in local health departments and an emphasis on graduate retention may assist states in strengthening their epidemiologic capacity.
PMCID: PMC2233739  PMID: 18497015
6.  From Competencies to Capacity: Assessing the National Epidemiology Workforce 
Public Health Reports  2008;123(Suppl 1):128-135.
We determined the competency of the public health epidemiology workforce within state health agencies based on the Centers for Disease Control and Prevention/Council of State and Territorial Epidemiologists Competencies for Applied Epidemiologists in Governmental Public Health Agencies (AECs).
The competence level of current state health agency staff and the need for additional training was assessed against 30 mid-level AECs. Respondents used a five-point Likert scale—ranging from “strongly agree” to “strongly disagree”—to designate whether staff was competent in certain areas or whether additional training was needed for each of the competencies.
Most states indicated their epidemiology workforce was competent in most of the AECs subject areas. Subject areas with the greatest number of states reporting competency (82%) are creating and managing databases and applying privacy laws. However, at least one-third of the states reported a need for additional training in all competencies assessed. The greatest reported needs were for additional training in surveillance system evaluation and use of knowledge of environmental and behavioral science in epidemiology practice.
The results indicate that most epidemiologists mastered the traditional discipline-specific competencies. However, it is unclear how this level of competency was achieved and what strategies are in place to sustain and strengthen it. The results indicate that epidemiologists have lower levels of competence in the nontraditional epidemiologic fields of knowledge. Future steps to ensure a well-qualified epidemiology workforce include assessing the full AECs in a subgroup of Tier 2 epidemiologists and implementing competencies in academic curricula to sustain reported competency achievements.
PMCID: PMC2233730  PMID: 18497023
7.  The future of public health: the importance of workforce 
Health workforce has become a major concern and a significant health policy issue around the world in recent years. With recent international and national initiatives and models being developed and implemented in Australia and other countries, it is timely to understand the need and the rationale for a better trained and educated public health workforce for the future. Much more attention should also be given to evaluation and research in this field.
Through this thematic series on Workforce and Public Health, we have drawn on the diverse nature of public health, workforce implications, education and training and national and international case examples of ongoing improvements and issues in this sector.
PMCID: PMC2673230  PMID: 19358709
8.  Establishing a clinical trials network in nephrology: experience of the Australasian Kidney Trials Network 
Kidney International  2013;85(1):23-30.
Chronic kidney disease is a major public health problem globally. Despite this, there are fewer high-quality, high-impact clinical trials in nephrology than other internal medicine specialties, which has led to large gaps in evidence. To address this deficiency, the Australasian Kidney Trials Network, a Collaborative Research Group, was formed in 2005. Since then, the Network has provided infrastructure and expertise to conduct patient-focused high-quality, investigator-initiated clinical trials in nephrology. The Network has not only been successful in engaging the nephrology community in Australia and New Zealand but also in forming collaborations with leading researchers from other countries. This article describes the establishment, development, and functions of the Network. The article also discusses the current and future funding strategies to ensure uninterrupted conduct of much needed clinical trials in nephrology to improve the outcomes of patients affected by kidney diseases with cost-effective interventions.
PMCID: PMC3898483  PMID: 24088955
chronic kidney disease; clinical trials; collaborative research; health policy; investigator initiated; randomized controlled trial
9.  Central African Field Epidemiology and Laboratory Training Program: building and strengthening regional workforce capacity in public health 
The Pan African Medical Journal  2011;10(Suppl 1):4.
The Central African Field Epidemiology and Laboratory Training Program (CAFELTP) is a 2-year public health leadership capacity building training program. It was established in October 2010 to enhance capacity for applied epidemiology and public health laboratory services in three countries: Cameroon, Central African Republic, and the Democratic Republic of Congo. The aim of the program is to develop a trained public health workforce to assure that acute public health events are detected, investigated, and responded to quickly and effectively. The program consists of 25% didactic and 75% practical training (field based activities). Although the program is still in its infancy, the residents have already responded to six outbreak investigations in the region, evaluated 18 public health surveillance systems and public health programs, and completed 18 management projects. Through these various activities, information is shared to understand similarities and differences in the region leading to new and innovative approaches in public health. The program provides opportunities for regional and international networking in field epidemiology and laboratory activities, and is particularly beneficial for countries that may not have the immediate resources to host an individual country program. Several of the trainees from the first cohort already hold leadership positions within the ministries of health and national laboratories, and will return to their assignments better equipped to face the public health challenges in the region. They bring with them knowledge, practical training, and experiences gained through the program to shape the future of the public health landscape in their countries.
PMCID: PMC3266671  PMID: 22359692
epidemiology; education; training; public health; Central Africa
10.  The Health Information Technology Workforce 
Applied Clinical Informatics  2010;1(2):197-212.
There is increasing recognition that a competent and well-trained workforce is required for successful implementation of health information technology.
New and previous research was gathered through literature and Web searching as well as domain experts. Overall themes were extracted and specific data collated within each.
There is still a paucity of research concerning the health information technology workforce. What research has been done can be classified into five categories: quantities and staffing ratios, job roles, gaps and growth, leadership qualifications, and education and competencies. From several countries it can be seen that substantial numbers of individuals are needed with diverse backgrounds and competencies.
Additional research is necessary to determine the optimal organization and education of the health information technology workforce.
PMCID: PMC3632279  PMID: 23616836
Health information technology; biomedical and health informatics; clinical informatics; workforce
11.  A national public health service. 
The development of the British public health services is briefly reviewed and it is suggested that two types of epidemiologist (Community Physician) are necessary in each locality: one concerned with medical administration and health care planning-the medical administrator, and the other with the prevention of disease-the clinical epidemiologist. A new nation public health service is proposed to revive disease prevention with four main features: (1) A district Clinical Epidemiologist who is a member of the district department of community medicine with responsibility for prevention but with no district administrative duties. (2) A District Epidemiology Unit comprising other appropriate staff. (3) National specialist epidemiology units within the NHS with service roles to support and coordinate the District Clinical Epidemiologists. (4) A national authority within the NHS with responsibility for prevention and for administering the national specialist units.
PMCID: PMC1438324  PMID: 7007637
12.  Paving Pathways: shaping the Public Health workforce through tertiary education 
Public health educational pathways in Australia have traditionally been the province of Universities, with the Master of Public Health (MPH) recognised as the flagship professional entry program. Public health education also occurs within the fellowship training of the Faculty of Public Health Medicine, but within Australia this remains confined to medical graduates. In recent years, however, we have seen a proliferation of undergraduate degrees as well as an increasing public health presence in the Vocational Education and Training (VET) sector.
Following the 2007 Australian Federal election, the new Labour government brought with it a refreshing commitment to a more inclusive and strategic style of government. An important example of this was the 2020 visioning process that identified key issues of public health concern, including an acknowledgment that it was unacceptable to allocate less than 2% of the health budget towards disease prevention. This led to the recommendation for the establishment of a national preventive health agency (Australia: the healthiest country by 2020 National Preventative Health Strategy, Prepared by the Preventative Health Taskforce 2009).
The focus on disease prevention places a spotlight on the workforce that will be required to deliver the new investment in health prevention, and also on the role of public health education in developing and upskilling the workforce. It is therefore timely to reflect on trends, challenges and opportunities from a tertiary sector perspective. Is it more desirable to focus education efforts on selected lead issues such as the "obesity epidemic", climate change, Indigenous health and so on, or on the underlying theory and skills that build a flexible workforce capable of responding to a range of health challenges? Or should we aspire to both?
This paper presents some of the key discussion points from 2008 - 2009 of the Public Health Educational Pathways workshops and working group of the Australian Network of Public Health Institutions. We highlight some of the competing tensions in public health tertiary education, their impact on public health training programs, and the educational pathways that are needed to grow, shape and prepare the public health workforce for future challenges.
PMCID: PMC2818649  PMID: 20044939
13.  An informatics agenda for public health: summarized recommendations from the 2011 AMIA PHI Conference 
The AMIA Public Health Informatics 2011 Conference brought together members of the public health and health informatics communities to revisit the national agenda developed at the AMIA Spring Congress in 2001, assess the progress that has been made in the past decade, and develop recommendations to further guide the field. Participants met in five discussion tracks: technical framework; research and evaluation; ethics; education, professional training, and workforce development; and sustainability. Participants identified 62 recommendations, which clustered into three key themes related to the need to (1) enhance communication and information sharing within the public health informatics community, (2) improve the consistency of public health informatics through common public health terminologies, rigorous evaluation methodologies, and competency-based training, and (3) promote effective coordination and leadership that will champion and drive the field forward. The agenda and recommendations from the meeting will be disseminated and discussed throughout the public health and informatics communities. Both communities stand to gain much by working together to use these recommendations to further advance the application of information technology to improve health.
PMCID: PMC3422819  PMID: 22395299
Conferences; consensus development as topic; informatics; public health informatics; public health practice; public health; ethics; privacy; confidentiality; bioethics; policy; monitoring the health of populations; knowledge representations; statistical analysis of large datasets; developing/using clinical decision support (other than diagnostic) and guideline systems; discovery; and text and data mining methods; other methods of information extraction; automated learning; systems to support and improve diagnostic accuracy; distributed systems, agents; software engineering: architecture; health services research; health reform; health data standards; qualitative/ethnographic field study; improving the education and skills training of health professionals; knowledge acquisition and knowledge management; system implementation and management issues; quality measures
14.  The role of the applied epidemiologist in armed conflict 
Applied epidemiologists are increasingly working in areas of insecurity and active conflict to define the health risks, suggest feasible means to reduce these risks and, monitor the capacity and reconstruction of the public health system. In 2001, The Carter Center and the United States Institute for Peace sponsored a conference within which "Violence and Health" was discussed and a working group on applied epidemiology formed. The group was tasked to describe the skills that are essential to effective functioning in these settings and thereby provide guidance to the applied epidemiology training programs.
We conducted a literature review and consultation of a convenience sample of practitioners of applied epidemiology with experience in conflict areas.
Results and conclusions
The health programs designed to prevent and mitigate conflict are in their early stages of implementation and the evaluation measures for success are still being defined. The practice of epidemiology in conflict must occur within a larger humanitarian and political context to be effective. The skills required extend beyond the normal epidemiological training that focuses on the valid collection and interpretation of data and fall into two general categories: (1) Conducting a thorough assessment of the conflict setting in order to design more effective public health action in conflict settings, and (2) Communicating effectively to guide health program implementation, to advocate for needed policy changes and to facilitate interagency coordination. These are described and illustrated using examples from different countries.
PMCID: PMC544942  PMID: 15679905
15.  State epidemiology programs and state epidemiologists: results of a national survey. 
Public Health Reports  1989;104(2):170-177.
In 1983, the State Epidemiologists in 46 States completed a survey questionnaire describing the professional qualifications, training, and experience of State health department epidemiologists and the scope of participation by the State Epidemiologists and their staffs in public health programs. The survey identified 224 State health department epidemiologists (estimated U.S. ratio 1.1 per million population). A State health department epidemiologist was most often male (80 percent), frequently (57 percent) was a physician, had an average age of 41 years, and had worked as an epidemiologist for 9 years. Participation in public health programs (either by supervising or providing consultation) by the State Epidemiologists and their staffs focused mainly on general epidemiology and communicable disease programs; fewer than half had participated in programs relating to the health of women and children, chronic diseases, injuries, or in other programs directed towards preventing premature mortality. Recently, the State Epidemiologists have been trying to broaden their activities into these areas; however, the demands created by the acquired immunodeficiency syndrome (AIDS) will mostly likely slow this process. Based on the overall findings and collective experience, it was concluded that State health departments have too few epidemiologists to address the wide variety of important public health problems facing our communities. It was proposed that each State health department have at least four epidemiologists (including one or more physician epidemiologists) and at least one master's level biostatistician and that the epidemiologists-per-population ratio not be less than 1 per million.
PMCID: PMC1580032  PMID: 2495551
16.  Research capacity and culture in podiatry: early observations within Queensland Health 
Research is a major driver of health care improvement and evidence-based practice is becoming the foundation of health care delivery. For health professions to develop within emerging models of health care delivery, it would seem imperative to develop and monitor the research capacity and evidence-based literacy of the health care workforce. This observational paper aims to report the research capacity levels of statewide populations of public-sector podiatrists at two different time points twelve-months apart.
The Research Capacity & Culture (RCC) survey was electronically distributed to all Queensland Health (Australia) employed podiatrists in January 2011 (n = 58) and January 2012 (n = 60). The RCC is a validated tool designed to measure indicators of research skill in health professionals. Participants rate skill levels against each individual, team and organisation statement on a 10-point scale (one = lowest, ten = highest). Chi-squared and Mann Whitney U tests were used to determine any differences between the results of the two survey samples. A minimum significance of p < 0.05 was used throughout.
Thirty-seven (64%) podiatrists responded to the 2011 survey and 33 (55%) the 2012 survey. The 2011 survey respondents reported low skill levels (Median < 4) on most aspects of individual research aspects, except for their ability to locate and critically review research literature (Median > 6). Whereas, most reported their organisation’s skills to perform and support research at much higher levels (Median > 6). The 2012 survey respondents reported significantly higher skill ratings compared to the 2011 survey in individuals’ ability to secure research funding, submit ethics applications, and provide research advice, plus, in their organisation’s skills to support, fund, monitor, mentor and engage universities to partner their research (p < 0.05).
This study appears to report the research capacity levels of the largest populations of podiatrists published. The 2011 survey findings indicate podiatrists have similarly low research capacity skill levels to those reported in the allied health literature. The 2012 survey, compared to the 2011 survey, suggests podiatrists perceived higher skills and support to initiate research in 2012. This improvement coincided with the implementation of research capacity building strategies.
PMCID: PMC3549934  PMID: 23302627
Podiatry; Research; Culture; Capacity; Australia
17.  Is there a crisis in nursing retention in New South Wales? 
There is a severe shortage of nurses in Australia. Policy makers and researchers are especially concerned that retention levels of nurses in the health workforce have worsened over the last decade. There are also concerns that rapidly growing private sector hospitals are attracting qualified nurses away from the public sector. To date no systematic analysis of trends in nursing retention rates over time has been conducted due to the lack of consistent panel data.
A 1.4 percentage point improvement in retention has led to a 10% increase in the overall supply of nurses in NSW. There has also been a substantial aging of the workforce, due to greater retention and an increase in mature age entrants. The improvement in retention is found in all types of premises and is largest in nursing homes. There is a substantial amount of year to year movement in and out of the workforce and across premises. The shortage of nurses in public hospitals is due to a slowdown in entry rather than competition from the rapidly growing private sector hospitals.
Policy Implications
The finding of an improvement (rather than a worsening) in retention suggests that additional improvements may be difficult to achieve as further retention must involve individuals more and more dissatisfied with nursing relative to other opportunities. Hence policies targeting entry such as increased places in nursing programs and additional subsidies for training costs may be more effective in dealing with the workforce shortage. This is also the case for shortages in public sector hospitals as retention in nursing is found to be relatively high in this sector. However, the large amount of year to year movements across nursing jobs, especially among the younger nurses, also suggests that policies aimed at reducing job switches and increasing the number who return to nursing should also be pursued. More research is needed in understanding the relative importance of detailed working conditions and the problems associated with combining family responsibilities and nursing jobs.
PMCID: PMC2546412  PMID: 18681970
18.  Staff patterns of epidemiologists in the health departments of 12 southern states. 
Public Health Reports  1991;106(5):583-586.
In November 1989, representatives from 12 States attending the Annual Convocation of Southern State Epidemiologists completed a survey to enumerate epidemiologists working in central offices of State health departments. Epidemiologists were classified according to education and program area. A total of 117 epidemiologists were identified, yielding a range among the States of 0.6 to 8.3 (median 1.9) epidemiologists per million population. The most common degree was a medical degree, followed by master's training in epidemiology or biostatistics; only 9 percent had doctoral training in epidemiology or biostatistics. More than one-third of the epidemiologists worked in infectious diseases, including acquired immunodeficiency syndrome (AIDS) and sexually transmitted diseases, and about one-fifth worked in environmental epidemiology. The areas of injuries, cancer, chronic diseases, maternal and child health, and occupational health collectively accounted for about one-fifth of epidemiologists. The results of the survey suggest room for further epidemiologic training among health department epidemiologists. The results also identify areas where additional epidemiologic input would be beneficial.
PMCID: PMC1580310  PMID: 1910195
19.  Considerations for increasing the competences and capacities of the public health workforce: assessing the training needs of public health workers in Texas 
Over the last two decades, concern has been expressed about the readiness of the public health workforce to adequately address the scientific, technological, social, political and economic challenges facing the field. A 1988 report from the Institute of Medicine (IOM) served as a catalyst for the re-examination of the public health workforce. The IOM's call to increase the relevance of public health education and training prompted a renewed effort to identify competences needed by public health personnel and the organizations that employ them.
A recent evaluation sought to address the role of the 10 essential public health services in job services among the Texas public health workforce. Additionally, the evaluation examined the Texas public health workforce's need for training in the 10 essential public health services.
Results and conclusion
Overall, the level of perceived training needs varied dramatically by job category and health department type. When comparing aggregate training needs, public health workers with greater day-to-day contact (nurses, health educators) indicated a greater need for training than their peers who did not, such as those working in administrative positions. When prioritizing and designing future training modules regarding the 10 essential public health services, trainers should consider the effects of job function, location and contact with the public.
PMCID: PMC1555609  PMID: 16872494
20.  Mapping Student Response Team Activities to Public Health Competencies: Are We Adequately Preparing the Next Generation of Public Health Practitioners? 
Public Health Reports  2010;125(Suppl 5):78-86.
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.
PMCID: PMC2966648  PMID: 21133064
21.  Developing Competencies for Applied Epidemiology: From Process to Product 
Public Health Reports  2008;123(Suppl 1):67-118.
We developed competencies for applied epidemiologic practice by using a process that is based on existing competency frameworks, that engages professionals in academic and applied epidemiology at all governmental levels (local, state, and federal), and that provides ample opportunity for input from practicing epidemiologists throughout the U.S.
The model set of core public health competencies, consisting of eight core domains of public health practice, developed in 2001 by the Council on Linkages Between Academia and Public Health Practice, were adopted as the foundation of the Competencies for Applied Epidemiologists in Governmental Public Health Agencies (AECs). A panel of experts was convened and met over a period of 20 months to develop a draft set of AECs. Drafts were presented at the annual meetings of the Council of State and Territorial Epidemiologists (CSTE) and the American Public Health Association. Input and comments were also solicited from practicing epidemiologists and 14 national organizations representing epidemiology and public health.
In all, we developed 149 competency statements across the eight domains of public health practice and four tiers of applied epidemiologic practice. In addition, sub- and sub-subcompetency statements were developed to increase the document's specificity. During the process, >800 comments from all governmental and academic levels and tiers of epidemiology practice were considered for the final statements.
The AECs are available for use in improving the training for and skill levels of practicing applied epidemiologists and should also be useful for educators, employers, and supervisors. Both CDC and CSTE plan to evaluate their implementation and usefulness in providing information for future competency development.
PMCID: PMC2233728  PMID: 18497021
22.  Epidemiology Competency Development and Application to Training for Local and Regional Public Health Practitioners 
Public Health Reports  2008;123(Suppl 1):44-57.
In 2002, the Northwest Center for Public Health Practice (NWCPHP) at the University of Washington initiated the Epidemiology Competencies Project, with the goal of developing competency-based epidemiology training for non-epidemiologist public health practitioners in the northwestern United States. An advisory committee consisting of epidemiology faculty and experienced public health practitioners developed the epidemiology competencies. NWCPHP used the competencies to guide the development of in-person trainings, a series of online epidemiology modules, and a Web-based repository of epidemiology teaching materials. The epidemiology competencies provided a framework for collaborative work between NWCPHP and local and regional public health partners to develop trainings that best met the needs of a particular public health organization. Evaluation surveys indicated a high level of satisfaction with the online epidemiology modules developed from the epidemiology competencies. However, measuring the effectiveness of -competency-based epidemiology training for expanding epidemiology knowledge and skills of the public health workforce remains a challenge.
PMCID: PMC2233725  PMID: 18497018
23.  Science and social responsibility in public health. 
Environmental Health Perspectives  2003;111(14):1804-1808.
Epidemiologists and environmental health researchers have a joint responsibility to acquire scientific knowledge that matters to public health and to apply the knowledge gained in public health practice. We examine the nature and source of these social responsibilities, discuss a debate in the epidemiological literature on roles and responsibilities, and cite approaches to environmental justice as reflective of them. At one level, responsibility refers to accountability, as in being responsible for actions taken. A deeper meaning of responsibility corresponds to commitment to the pursuit and achievement of a valued end. Epidemiologists are committed to the scientific study of health and disease in human populations and to the application of scientific knowledge to improve the public's health. Responsibility is also closely linked to reliability. Responsible professionals reliably perform the tasks they set for themselves as well as the tasks society expects them to undertake. The defining axiom for our approach is that the health of the public is a social good we commit ourselves to pursue, thus assuming an obligation to contribute to its achievement. Epidemiologists cannot claim to be committed to public health as a social good and not accept the responsibility of ensuring that the knowledge gained in their roles as scientists is used to achieve that good. The social responsibilities of environmental health researchers are conspicuous in the environmental justice movement, for example, in community-based participatory research. Responsibility is an ethical concept particularly well suited to frame many key aspects of the ethics of our profession.
PMCID: PMC1241728  PMID: 14602514
24.  Public health workforce: challenges and policy issues 
This paper reviews the challenges facing the public health workforce in developing countries and the main policy issues that must be addressed in order to strengthen the public health workforce. The public health workforce is diverse and includes all those whose prime responsibility is the provision of core public health activities, irrespective of their organizational base. Although the public health workforce is central to the performance of health systems, very little is known about its composition, training or performance. The key policy question is: Should governments invest more in building and supporting the public health workforce and infrastructure to ensure the more effective functioning of health systems? Other questions concern: the nature of the public health workforce, including its size, composition, skills, training needs, current functions and performance; the appropriate roles of the workforce; and how the workforce can be strengthened to support new approaches to priority health problems.
The available evidence to shed light on these policy issues is limited. The World Health Organization is supporting the development of evidence to inform discussion on the best approaches to strengthening public health capacity in developing countries. WHO's priorities are to build an evidence base on the size and structure of the public health workforce, beginning with ongoing data collection activities, and to map the current public health training programmes in developing countries and in Central and Eastern Europe. Other steps will include developing a consensus on the desired functions and activities of the public health workforce and developing a framework and methods for assisting countries to assess and enhance the performance of public health training institutions and of the public health workforce.
PMCID: PMC179882  PMID: 12904251
25.  Physician Emigration from Sub-Saharan Africa to the United States: Analysis of the 2011 AMA Physician Masterfile 
PLoS Medicine  2013;10(9):e1001513.
Siankam Tankwanchi and colleagues used the AMA Physician Masterfile and the WHO Global Health Workforce Statistics on physicians in sub-Saharan Africa to determine trends in physician emigration to the United States.
Please see later in the article for the Editors' Summary
The large-scale emigration of physicians from sub-Saharan Africa (SSA) to high-income nations is a serious development concern. Our objective was to determine current emigration trends of SSA physicians found in the physician workforce of the United States.
Methods and Findings
We analyzed physician data from the World Health Organization (WHO) Global Health Workforce Statistics along with graduation and residency data from the 2011 American Medical Association Physician Masterfile (AMA-PM) on physicians trained or born in SSA countries who currently practice in the US. We estimated emigration proportions, year of US entry, years of practice before emigration, and length of time in the US. According to the 2011 AMA-PM, 10,819 physicians were born or trained in 28 SSA countries. Sixty-eight percent (n = 7,370) were SSA-trained, 20% (n = 2,126) were US-trained, and 12% (n = 1,323) were trained outside both SSA and the US. We estimated active physicians (age ≤70 years) to represent 96% (n = 10,377) of the total. Migration trends among SSA-trained physicians increased from 2002 to 2011 for all but one principal source country; the exception was South Africa whose physician migration to the US decreased by 8% (−156). The increase in last-decade migration was >50% in Nigeria (+1,113) and Ghana (+243), >100% in Ethiopia (+274), and >200% (+244) in Sudan. Liberia was the most affected by migration to the US with 77% (n = 175) of its estimated physicians in the 2011 AMA-PM. On average, SSA-trained physicians have been in the US for 18 years. They practiced for 6.5 years before US entry, and nearly half emigrated during the implementation years (1984–1999) of the structural adjustment programs.
Physician emigration from SSA to the US is increasing for most SSA source countries. Unless far-reaching policies are implemented by the US and SSA countries, the current emigration trends will persist, and the US will remain a leading destination for SSA physicians emigrating from the continent of greatest need.
Please see later in the article for the Editors' Summary
Editors' Summary
Population growth and aging and increasingly complex health care interventions, as well as existing policies and market forces, mean that many countries are facing a shortage of health care professionals. High-income countries are addressing this problem in part by encouraging the immigration of foreign health care professionals from low- and middle-income countries. In the US, for example, international medical graduates (IMGs) can secure visas and permanent residency by passing examinations provided by the Educational Commission of Foreign Medical Graduates and by agreeing to provide care in areas that are underserved by US physicians. Inevitably, the emigration of physicians from low- and middle-income countries undermines health service delivery in the emigrating physicians' country of origin because physician supply is already inadequate in those countries. Physician emigration from sub-Saharan Africa, which has only 2% of the global physician workforce but a quarter of the global burden of disease, is particularly worrying. Since 1970, as a result of large-scale emigration and limited medical education, there has been negligible or negative growth in the density of physicians in many countries in sub-Saharan Africa. In Liberia, for example, in 1973, there were 7.76 physicians per 100,000 people but by 2008 there were only 1.37 physicians per 100,000 people; in the US, there are 250 physicians per 100,000 people.
Why Was This Study Done?
Before policy proposals can be formulated to address global inequities in physician distribution, a clear picture of the patterns of physician emigration from resource-limited countries is needed. In this study, the researchers use data from the 2011 American Medical Association Physician Masterfile (AMA-PM) to investigate the “brain drain” of physicians from sub-Saharan Africa to the US. The AMA-PM collects annual demographic, academic, and professional data on all residents (physicians undergoing training in a medical specialty) and licensed physicians who practice in the US.
What Did the Researchers Do and Find?
The researchers used data from the World Health Organization (WHO) Global Health Workforce Statistics and graduation and residency data from the 2011 AMA-PM to estimate physician emigration rates from sub-Saharan African countries, year of US entry, years of service provided before emigration to the US, and length of time in the US. There were 10,819 physicians who were born or trained in 28 sub-Saharan African countries in the 2011 AMA-PM. By using a published analysis of the 2002 AMA-PM, the researchers estimated that US immigration among sub-Saharan African-trained physicians had increased over the past decade for all the countries examined except South Africa, where physician emigration had decreased by 8%. Overall, the number of sub-Saharan African IMGs in the US had increased by 38% since 2002. More than half of this increase was accounted for by Nigerian IMGs. Liberia was the country most affected by migration of its physicians to the US—77% of its estimated 226 physicians were in the 2011 AMA-PM. On average, sub-Saharan African IMGs had been in the US for 18 years and had practiced for 6.5 years before emigration. Finally, nearly half of the sub-Saharan African IMGs had migrated to US between 1984 and 1995, years during which structural adjustment programs, which resulted in deep cuts to public health care services, were implemented in developing countries by international financial institutions as conditions for refinancing.
What Do These Findings Mean?
Although the sub-Saharan African IMGs in the 2011 AMA-PM only represent about 1% of all the physicians and less than 5% of the IMGs in the AMA-PM, these findings reveal a major loss of physicians from sub-Saharan Africa. They also suggest that emigration of physicians from sub-Saharan Africa is a growing problem and is likely to continue unless job satisfaction for physicians is improved in their country of origin. Moreover, because the AMA-PM only lists physicians who qualify for a US residency position, more physicians may have moved from sub-Saharan Africa to the US than reported here and may be working in other jobs incommensurate with their medical degrees (“brain waste”). The researchers suggest that physician emigration from sub-Saharan Africa to the US reflects the complexities in the labor markets for health care professionals in both Africa and the US and can be seen as low- and middle-income nations subsidizing the education of physicians in high-income countries. Policy proposals to address global inequities in physician distribution will therefore need both to encourage the recruitment, training, and retention of health care professionals in resource-limited countries and to persuade high-income countries to train more home-grown physicians to meet the needs of their own populations.
Additional Information
Please access these websites via the online version of this summary at
The Foundation for Advancement of International Medical Education and Research is a non-profit foundation committed to improving world health through education that was established in 2000 by the Educational Commission for Foreign Medical Graduates
The Global Health Workforce Alliance is a partnership of national governments, civil society, international agencies, finance institutions, researchers, educators, and professional associations dedicated to identifying, implementing and advocating for solutions to the chronic global shortage of health care professionals (available in several languages)
Information on the American Medical Association Physician Masterfile and the providers of physician data lists is available via the American Medical Associations website
The World Health Organization (WHO) annual World Health Statistics reports present the most recent health statistics for the WHO Member States
The Medical Education Partnership Initiative is a US-sponsored initiative that supports medical education and research in sub-Saharan African institutions, aiming to increase the quantity, quality, and retention of graduates with specific skills addressing the health needs of their national populations
CapacityPlus is the USAID-funded global project uniquely focused on the health workforce needed to achieve the Millennium Development Goals
Seed Global Health cultivates the next generation of health professionals by allying medical and nursing volunteers with their peers in resource-limited settings
"America is Stealing the Worlds Doctors", a 2012 New York Times article by Matt McAllester, describes the personal experience of a young doctor who emigrated from Zambia to the US
Path to United States Practice Is Long Slog to Foreign Doctors, a 2013 New York Times article by Catherine Rampell, describes the hurdles that immigrant physicians face in practicing in the US
PMCID: PMC3775724  PMID: 24068894

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