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Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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3
The Future of Public Health Education

Public health in the United States in the early 1900s focused on improving sanitation, controlling infectious diseases, assuring the safety of the food and water supply, and providing immunizations to children with a workforce composed mostly of physicians, nurses, and biological scientists (Brandt and Gardner, 2000; Garrett, 2000; Mullan, 2000). Today’s public health challenges are much broader. Healthy People 2010 lays out a broad agenda for public health efforts aimed at increasing health-related quality of life and eliminating health disparities (U.S. DHHS, 2000). Koplan and Fleming (2000) outline 10 challenges for public health that include cleaning up the environment, eliminating health disparities, wisely using new scientific knowledge and technology, attending to children’s physical and emotional development, and aging healthily. Numerous authors have highlighted the importance of public health in addressing the effects of globalization (Lee, 2000; McMichael and Beaglehole, 2000; Barks-Ruggles, 2001; Kickbusch and Buse, 2001) and the impacts of an aging and increasingly diverse society (Brownson and Kreuter, 1997; Butler, 1997; Koplan and Fleming, 2000; Turnock, 2001).

These complex problems require multi-faceted public health actions based on an ecological approach to problem solving. Such an approach requires a well-educated interdisciplinary cadre of public health professionals who focus on population health and understand the multiple determinants that affect health. A cadre of professionals who also understand that successful interventions require understanding not only of the effects of biology and behavior, but also the social, environmental, and economic contexts within which populations exist. A cadre of profession-

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

als who understand that public health research must focus not only on secondary prevention and risk factor analysis, but also on evaluation of public health systems, on practice approaches and interventions, and on effective collaborations and partnerships with diverse communities.

Public health professionals of the future will need to understand and be able to use the new information systems that provide the data upon which public health research and practice is based. They will need to be able to communicate with diverse populations, to understand the issues, concerns, and needs of these groups in order to work collaboratively to improve population health. Public health professionals must have the skills and competencies necessary to engage in public health practice at many levels: leadership, management, and supervisory.

The committee reaffirms the importance of the traditional core public health areas of epidemiology, biostatistics, environmental health, health services administration, and social and behavioral sciences. However, the committee believes that public health professionals will be better prepared to address the major health problems and challenges facing society if they achieve competency in the following eight content areas: informatics, genomics, communication, cultural competence, community-based participatory research, global health, policy and law, and public health ethics. These eight areas are now and will continue to be significant to public health and public health education in programs and schools of public health for some time to come. These areas are natural outgrowths of the traditional core public health sciences as they have evolved in response to ongoing social, economic, technological, and demographic changes. For example, community-based participatory research (CBPR) is a contemporary approach to research that has its roots in the public health sciences of epidemiology and biostatistics, enriched by emerging community knowledge from the social and behavioral sciences.

The following sections of this chapter provide an in-depth examination of these eight areas of critical importance to public health education in the 21st century. Competency in each of these areas will enable public health professionals to better function within the ecological model (discussed in Chapter 1), thereby contributing effectively to programs, policies, and research designed to improve the health of the public. For each of these areas we provide a brief definition and description, explore why each is important to public health, examine the minimum level of knowledge or understanding public health professionals should have about each area, and highlight potential ethical issues.

INFORMATICS

Capacity to perform the public health functions specified in The Future of Public Health (IOM, 1988), namely, assessment, policy development

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

and assurance, is principally dependent upon information. For example, assessment involves the collection, analysis, interpretation, and communication of information. Currently, this information comes from a wide variety of sources with attendant problems of fragmentation, lack of standardization, and redundancy. Policy development also is dependent upon current and reliable information and the ability to manipulate and display this information so that it is meaningful to those who make decisions about public health. Assurance requires information about access to health care services based upon community needs, which is monitored with community-level data. With increasing accessibility to more and more data, public health practitioners and researchers will find that a basic understanding of informatics, the use of informatics tools, and interaction with informaticians are essential to carrying out these functions.

Public health informatics is defined as the systematic application of information, computer science, and technology to public health practice and learning (Yasnoff et al., 2000). Its scope includes the conceptualization, design, development, deployment, refinement, maintenance, and evaluation of communication, surveillance, and information systems relevant to public health. Public health informatics involves more than automating existing activities; it enables the redesign of systems using approaches that were previously impractical or not even contemplated.

Public health informatics has immense potential not only to improve current public health practice, but to transform present-day capacity. The September 11, 2001, terrorist attack on the World Trade Center in New York City and the following anthrax distribution and deaths dramatically exemplifies the need for transformation and improvement. Of crucial importance is the collection of real time data on the occurrence of suspicious respiratory syndromes (e.g., possible early anthrax, plague, smallpox, or tularemia) to generate a more rapid and effective public health response (Rotz et al., 2000). For early response to bioterrorism, new data sources, such as emergency room, over-the-counter pharmacy data, absentee or 911 call data may supply potentially essential information. This type of surveillance will require an integrated approach, standardization, closer integration of public health and the health care system, and the timely capture of data.

Improved surveillance systems are likely to tax the public health system’s capacity to process the growing quantity of health data required for public health improvement. Progressively, state and local governments are collecting and disseminating health status data at greater levels of detail, the number of reportable diseases is enlarging, and new developments in electronic laboratory reporting systems and electronic medical record systems will also increase the volume of data available to the public health system. Informatics methods and applications, such as decision support and expert systems, modeling and simulation techniques, can

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

help public health face this challenge by providing increased capacity to handle, analyze, and act on data that is likely to increase during the coming years.

Health promotion and disease prevention is another aspect of public health that can be dramatically transformed by informatics. Methods and applications ranging from interactive guideline dissemination, preventive care reminders linked to the electronic medical record, computerized health risk assessments, and tailored messages can help health promotion and disease prevention interventions become more effective than ever before. Web-based systems are offering new strategies in health education. Applications can provide decision support for consumers, focusing on personalized goal setting, feedback regarding progress toward goals, and social support. Consumers of health care and patients managing chronic health conditions can make use of electronic portals to share coping strategies, provide emotional support, and exchange information on relevant health Websites.

Consumer health informatics has been defined as the field of biomedical informatics that is concerned with this area. Informatics methods and applications are stimulating research and development in the use of information and communication technologies. In the broadest sense, consumer health informatics involves (1) analyzing, formalizing, and modeling consumer preferences and information needs; (2) developing methods to integrate these into information management in health promotion, clinical, educational, and research activities; (3) investigating the effectiveness and efficacy of computerized information, telecommunication, and network systems for consumers in relation to their participation in health and health care related activities; and (4) studying the effects of these systems on public health, the patient-professional relationship, and society.

It is both inevitable and desirable that health promotion and disease prevention interventions become more available electronically, empowering consumers with enhanced control over their health. Public health professionals working to ensure the public’s health can help consumers by developing and increasing the availability of health-promoting technology based applications, and by safeguarding the confidentiality and security of the health data to which consumers are likely to be electronically exposed.

A critical challenge for public health informatics is to educate the public health workforce in computing and communication technology applicable to public health activities. Some level of informatics training for both new and existing public health workers is essential. Just as every public health professional needs basic knowledge of epidemiology, a basic understanding of public health informatics is critical for effective practice in the information age (Yasnoff et al., 2000). The extent to which

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

information transforms the practice of public health will be determined, in large part, by the willingness of public health leaders to recognize the need for informatics training. Several initiatives have been undertaken recently to promote this recognition.

The American Medical Informatics Association (AMIA) 2001 Spring Congress brought together the public health and informatics communities to develop a national agenda for public health informatics (PHI). The consensus of the session devoted to the topic of informatics training for the public health workforce was that the public health workforce urgently needed informatics knowledge and skills that could best be provided by a spectrum of educational programs (Yasnoff et al., 2001). Other, more detailed recommendations were to establish new and strengthen existing academic programs in PHI, develop a national competency-based continuing education program in PHI, adapt the American Association of Medical Colleges (AAMC) medical school informatics objectives to PHI, and support the Centers for Disease Control and Prevention (CDC) and other efforts to develop core competencies in PHI.

CDC has established the Public Health Informatics Competencies Working Group to develop core competencies in public health informatics within the broader context of the Global and National Implementation Plan for Public Health Workforce Development with an initial focus on developing informatics competencies for the existing U.S. public health workforce. As of this writing, a document has been drafted identifying competencies for the three workforce segments defined by the Council on Linkages. Competencies are divided into two general classes. The first class includes competencies related to the use of information and computer sciences and technology to increase one’s individual effectiveness as a public health professional. Examples of these competencies include:

  • electronic communication (use of IT tools for the full range of electronic communication appropriate to one’s programmatic area);

  • on-line information access (use of IT tools to identify, locate, access, assess, and appropriately interpret and use on-line public health-related information and data);

  • data and system protection (application of relevant procedures to ensure that confidential information is appropriately protected);

  • distance learning (use of distance-learning technologies to support life-long learning); and

  • strategic use of IT to promote health (use of IT as a strategic tool to promote public health).

The second class of competencies is related to the development, deployment, and maintenance of information systems to improve the effectiveness of the public health enterprise.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

CDC also has made initial efforts to develop needed education programs through the public health informatics fellowship, a public health informatics course, and a cooperative effort with the National Library of Medicine to help train public health workers in the effective use of the information resources available on the Internet.

Most current public health workers, lacking the knowledge and skills necessary to apply information and science technology, are unable to take advantage of its potential to enhance and facilitate public health activities (Lasker et al., 1995). For general public health practitioners, it may be adequate to have a basic understanding of well-established processes used in information systems development as well as an understanding of the roles public health practitioners should play in those processes. For public health professionals wishing to specialize, a higher-level proficiency in informatics is needed as it relates to project management; organizational behavior and management, information and knowledge development (data standards, security, privacy, and confidentiality); systems development, planning, and procurement; fundamental aspects of IT research, decision-making, and outcomes research. Facilitating advanced public health applications of information technology will require a cadre of public health professionals with advanced informatics training in addition to significant improvements in the basic technology literacy of the general workforce in public health, and ongoing training to continuously update information skills (Lasker et al., 1995).

Ideally, public health informatics education would include developing degree and certificate granting programs, and instructional courses for public health agencies and collaborators. Informatics training is becoming increasingly widespread, although training varies by institution, some offering graduate degrees or certificates in informatics, others a course for graduate credit or continuing education. Several graduate programs in public health already offer an informatics course, and a few are offering degrees specializing in informatics. Efforts to provide informatics training through distance education also are increasing. The Association of Schools of Public Health (ASPH) has sponsored conferences on public health informatics and distance learning that focused on how people and technology can work together to positively impact public health practice. The User Liaison Program (ULP) of the Agency for Healthcare Research and Quality (AHRQ) has broadcast a Web-assisted audio teleconference series via the World Wide Web and telephone designed to help state and local policy makers make policy decisions and allocate resources related to health care informatics. Expansion of these and other efforts are important to provide the public health informatics education for the current and future public health workforce.

Research efforts are also required to investigate the applicability of information science and technology to public health. Public health infor-

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

matics research is essential to help set priorities for resources and ensure that new ideas are adequately tested prior to implementation. Academic researchers in public health have important roles to perform at the cross-roads between informatics and public health. The focus of public health on prevention, communities, surveillance, and longitudinal analysis introduces unique opportunities for informatics research (Yasnoff et al., 2001). Academic researchers in public health possess the expertise to help guide a research agenda and priorities for allocation of resources that concentrate on unique public health concerns that could have a substantial impact on public health practice. Contributions of this expertise to multidisciplinary research collaborations can increase the chances that this complex research will be successful and relevant to public health.

Specific research agenda items suggested at the American Medication Informatics 2001 Spring Congress include assessing informatics tools as they relate to real-time data acquisition; data mining for population data; assessing informatics tools for managing temporal, spatial, or multilevel data; developing methods of measuring the cost of informatics and the benefit that accrues from its use; determining the informatics aspects of a preventive health record for the community; studying the ethical issues needed to guide confidentiality policy; and determining the value and impact of the use of uniform coding and common clinical vocabulary on public health activities (Yasnoff et al., 2001). Uniform coding, the use of existing national standards, and identifying priorities for the development of new data standards are of great importance to public health informatics research. Representation in collaborations such as the Public Health Data Standards Consortium (PHDSC) is yet another significant role for public health academic researchers.

Cross-fertilization between government and academia and local and state agencies can stimulate interest and capacity to support new innovations in the use of technology in public health practice. An example initiated by CDC is the national network of Centers for Public Health Preparedness (CPHP) to strengthen bioterrorism and emergency preparedness at the front lines by linking academic expertise and assets to state and local health agency needs. A number of centers are currently providing public health professionals with connections to online resources and the opportunities to learn technology-based skills that can be applied in their work setting.

The critical challenge of educating the public health workforce in computing and communication technology applicable to public health activities will require collaborative action involving those working in the field; professional associations; local, state, and federal government agencies; library and information service providers; and programs and schools of public health.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

We live in an information age that is transforming the ways in which we engage in actions to improve health. Public health professionals of the 21st century must learn about public health informatics and understand how this science contributes to the core functions of assessment, policy development, and assurance activities. Public health professionals must be prepared to understand and use these new information technologies to most effectively work to improve the health of the public. Another major area of scientific and technological development is the field of genomics. The following section discusses this important area.

GENOMICS

We have entered an era in which the genetic factors in common and complex diseases are becoming well understood and in which important new preventive and therapeutic approaches will derive from improved understanding of genetics and genomics. Research in genetics— the study of single genes and their functions and effects—has provided increasingly detailed information about both the basic biology and the phenotypic manifestations of several disorders that are caused by abnormality in the number of chromosomes present (such as Down syndrome, Trisomy 18 and Turner syndrome). Such also has been the case in a somewhat larger number of disorders caused by deletions or additions of fairly large segments of chromosomes (such as “cri-du-chat” syndrome and 22q11 deletion syndrome), and for several thousand conditions caused by mutations in single genes (such as cystic fibrosis, sickle cell disease, Tay-Sachs disease, hereditary hemochromatosis, Marfan syndrome, Prader-Willi syndrome, and hereditary hemorrhagic telangiectasia). Having one of these thousands of disorders often has significant impact on the health, and even life, of an affected individual and, frequently, on other family members.

Certain of these “chromosomal” or “single-gene” conditions (such as Down syndrome and hemochromatosis) are relatively common in the general population in the United States, but even they occur in only one of several hundred individuals. Others (such as sickle cell disease among African Americans and Tay-Sachs disease among Ashkenazi Jews), while rare in the general population, are more common in specific population groups. Nonetheless, the overall frequency of chromosomal and single-gene conditions as a group is low in the general population in the United States. Moreover, there have been relatively few effective therapeutic interventions for chromosomal and single-gene conditions. Because of the relative rarity of chromosomal and single-gene conditions and the limited effective therapeutic strategies for them, genetics has not played a significant role in most individuals’ health care, and therefore, genetics has been a relatively minor part of medicine.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

Genetics has traditionally played an even smaller role in public health. Not only has it been relevant to the health of relatively few people, but there have been almost no effective preventive strategies for chromosomal and single-gene conditions. The major exception to this has been newborn screening (prenatal genetic screening has also been widely practiced; however, it differs importantly from newborn screening in that it is used early in pregnancy to detect major chromosomal abnormalities and birth defects). In the almost 40 years since its inception, newborn screening has become an important public health activity in all states of the United States and in many other developed countries.

However, genetics has now evolved into genomics, the study of the entire human genome—the approximately 35,000 genes that humans possess. Because genomics encompasses not only the actions of single genes but also the interactions of multiple genes with each other and with the environment, genomics has far wider applicability to health and disease than does genetics alone. With the arrival of the era in which we will have the ability to understand gene-environment interactions comes not only the era of genomic medicine, but of genomics-based public health. Understanding genomics, therefore, is essential for an effective public health workforce.

Consider for instance, Table 3-1, which is based upon preliminary figures from the CDC, and shows the 10 leading causes of mortality in the United States in 2000. Genetic factors play a significant causative role in at least 9 of these 10 leading causes of morbidity in the United States—injury is the only possible exception. (However, this may hold true for injuries; since genetic factors often play a significant role in the individual host’s response to trauma, they play a significant role in determining whether a specific injury proves fatal to a specific person.)

Although it has been widely known that genetic factors played a role in conditions like those in Table 3-1, until recently the precise identity of those factors was not known. However, we have entered an era in which we are rapidly identifying these factors. Moreover, we also are beginning to be able to design new effective therapeutic and preventive strategies based upon this knowledge.

One might assume that it is only in the United States and other developed countries that genomics is on the brink of making major contributions to health. That is not the case. A recent report on genomics and world health (WHO, 2002) points out that genetic research has the potential to lead to major advances in combating such important global diseases as tuberculosis, malaria, and HIV/AIDS in the developing world within the next three to five years.

If understanding genomics is essential to today’s and tomorrow’s public health workforce, what is the appropriate level of understanding of genomics that programs and schools of public health should endeavor

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

TABLE 3-1 Causes of Death in the United States, 2000

 

Cause of Death

Percentage of All U.S. Deaths

1

Heart disease

29.5%

2

Cancer

22.9%

3

Cerebrovascular diseases

6.9%

4

Chronic lower respiratory diseases

5.1%

5

Injury

3.9%

6

Diabetes

2.9%

7

Pneumonia/influenza

2.8%

8

Alzheimer disease

2.0%

9

Renal disease

1.6%

10

Septicemia

1.3%

Based on preliminary data. Derived from information obtained on http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_12.pdf.

to provide to their students? All public health students should learn to “think genomically,” to be able to apply an understanding of genomics to a variety of public health issues. Two groups have provided valuable considerations of “core competencies” in genomics and genetics that help pinpoint what this might mean in terms of public health education.

The National Coalition for Health Professional Education in Genetics, a coalition of more than 120 health professional organizations, has promulgated a set of competencies in genetics and genomics (Jenkins et al., 2001). The CDC also convened an interdisciplinary group that produced a set of competencies in genetics and genomics specific to the public health workforce (CDC, 2001d). These competencies supply a particularly worthwhile set of guideposts for public health education. The competencies are recommended for all public health professionals, and thus one might consider these the competencies that programs and schools of public health should provide all of their students. These are the abilities to:

  • apply the basic public health sciences, (including behavioral and social sciences, biostatistics, epidemiology, informatics, and environmental health) to genomic issues and studies and genetic testing, using the genomic vocabulary to attain the goal of disease prevention;

  • identify ethical and medical limitations to genetic testing, including uses that don’t benefit the individual;

  • maintain up-to-date knowledge on the development of genetic advances and technologies relevant to an individual in his/her specialty or field of expertise and learn the uses of genomics as a tool for achieving public health goals related to that person’s field or area of practice;

  • identify the role of cultural, social, behavioral, environmental, and genetic factors in the development of disease, in disease prevention, and

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

in health promoting behaviors; and the impact of these factors on medical service organization and delivery of services to maximize wellness and prevent disease;

  • participate in strategic policy planning and development related to genetic testing or genomic programs;

  • collaborate with existing and emerging health agencies and organizations, and academic, research, private, and commercial enterprises, including genomic-related businesses, agencies and organizations and community partnerships to identify and solve genomic-related problems;

  • participate in the evaluation of program effectiveness, accessibility, cost-benefit, cost effectiveness, and quality of personal and population-based genomic services in public health; and

  • develop protocols to ensure informed consent and human subject protection in research.

There are also competency sets developed for particular types of public health professionals including public health leaders and administrators, and public health professionals in clinical services evaluating individuals and families, in epidemiology and data management, in population-based health education, in laboratory sciences, and professionals in environmental health.

Few, if any, public health education programs have developed comprehensive curricula in genomics. Genomics is not only new, but also changing as rapidly as any area of bioscience. This combination presents a particularly daunting challenge to designing curricula. Schools and programs need to integrate a largely new content area while, at the same time, recognizing that what is currently known, even at the cutting-edge frontiers of that content area will be woefully out of date and/or incorrect early in their students’ professional lives. Thus, public health curricula in genomics may need to focus on creating a framework of appreciation for the importance of genomics and a basic understanding of the topic.

It has long been widely agreed in the field of genomics that its ethical, legal, and social implications (ELSI) are important for society at large and, particularly so, for health professionals. In educating students about genetics and genomics, programs and schools of public health have a responsibility to consider these issues. Some of these ELSI issues are included in each of the two organizations’ sets of competencies cited above. Undoubtedly new issues that we cannot yet foresee will arise in this area during the professional lives of today’s students. Thus, it is important that schools of public health constantly update their curricula in all areas of genomics, including the ELSI issues.

Ethical, legal, and social issues are important to many areas in the education of students of public health, including genomics. Therefore, it is important that consideration of these issues not be an afterthought or

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

an ancillary part of education in genomics. The curriculum needs to include ELSI issues as a basic, essential component of its genomics instruction; indeed, no school of public health can be thought to teach genomics effectively or appropriately if its curriculum fails to do so. Similarly, faculty responsible for this area of the curriculum must have real expertise in the subject area.

Advances in genomics hold great promise for future improvements in health. However it is not only the future of genomics that warrants the attention of public health education. Because few in the current public health workforce have the level of understanding of genomics that is required today, major continuing education efforts must be undertaken to ready practicing public heath professionals to use genomics effectively. Public health education programs and schools must provide their students with a framework for understanding the importance of genomics to public health and with the ability to apply genomics to basic public health sciences.

COMMUNICATION

The role of public health in the daily lives of U.S. citizens has become increasingly prominent at the same time that evidence of gaps in the training of public health professionals has emerged. A critical gap is the need for understanding and skills-based performance and practice in communication. The body of knowledge associated with communication has evolved to the extent that evidence-based research affords a solid core to guide public health professionals’ training in this domain. Reflecting this fact, for the first time since its adoption in 1979, the Healthy People framework for providing a national prevention agenda included a chapter on Health Communication in the 2010 objectives. In this chapter health communication is defined as

the art and technique of informing, influencing, and motivating individual, institutional, and public audiences about important health issues. The scope of health communication includes disease prevention, health promotion, health care policy, and the business of health care as well as enhancement of the quality of life and health of individuals within the community (U.S. DHHS, 2000).

As emphasized within an ecological model, public health professionals interact with groups representing all the foci addressed in the 2010 definition of health communication. An examination of past successes and failures in public health emphasizes this reality. Whether working with communities, interacting with members of the lay public from different cultural backgrounds, or making the case for public health to Con-

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

gress, communication forms the foundation on which these efforts are built. Public health professionals depend upon being perceived as credible, with the creation and maintenance of images of trustworthiness and expertise occurring more often by intention than accident and dependent upon effective communication.

Public Health Communication Defined

As a form of health communication, public health communication involves a translation process that begins with the basic science of what is known about a health topic. From the science, public health professionals derive messages about attitudes and behaviors the public should adopt, together with policies that organizations and government should enact to support population health. Public health professionals often communicate within a learning model approach in which practices are based on the formation of attitudes that are derived from knowledge and contribute to the ability to make informed choices about their health (Valente et al., 1998). Public health professionals sell products, services, and/or points of view, making strategic communication in the form of social marketing common (Cirksena and Flora, 1995). The attainment of communication goals associated with social marketing depends upon audience analysis to segment “publics” and guides the design of relevant messages. Social marketers focus on the product as an idea, behavior, or item that they want to be accepted, evaluating the price in terms of costs associated with adoption, including economic but also social and psychological barriers. Promotion of the product occurs with these costs in mind, together with attention to placing the promotion where a particular audience will gain access to it at an appropriate time (Parrott et al., 1998a). Public health professionals who want the public to be aware of food safety inspections, for example, may strive to “place” these ratings at the entrance of restaurants.

A common term used in the process of translating science to public health communication is “risk.” Risk communication addresses a negative event or hazard that threatens the public’s safety, with communication about that hazard focusing on the probability of its occurrence multiplied by its magnitude, weighed together with consideration of less quantifiable factors such as social values (Covello, 1992). Public health professionals may intend to communicate particular meanings when using the term “risk” in their messages, but policy making and public audiences who receive the messages interpret them based on their own experiences, including cultural, social, and personal frameworks (Carrese and Rhodes, 1995; Glasgow et al., 1999). Beliefs that a risk is voluntary, under one’s own control, has clear benefits, is fairly distributed, and/or occurs naturally contribute to acceptance of risk as compared to beliefs that a risk is im-

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

posed, is controlled by others, has little benefit, is unfairly distributed, or is manmade (Fischhoff, 1999).

Public health professionals who apply this knowledge to communication with different audiences would consider that a critical component of assessing the “price” associated with adopting a “product” is analysis of costs versus benefits (Fishbein and Ajzen, 1975) and recognize that humans usually resist communication that arouses feelings that freedoms are being violated (Brehm, 1966; Engs and Hanson, 1989). These and other frameworks may be applied to increase the effectiveness of public health communication.

Strategies to Facilitate Public Health Communication

Public health professionals should plan risk communication to include strategies for coping with risk rather than just information about risk. Communicating these guidelines together with information about a risk will enable the public to have a sense of confidence and control, contributing to perceived self-efficacy in abilities and skills to adapt to a situation (Bandura, 1986). When communicating about health, prescriptions frequently become injunctions to avoid behaviors that relate to individual occupations, recreational pursuits, and cultural backgrounds. Communication science may be summarized to predict that individuals will behave in ways that promote their health and well being more often when they are asked to adapt to rather than avoid health risks. Behavior adaptation is more likely when individuals:

  • have access to the information, products, and services associated with adapting to health risk;

  • hold accurate procedural knowledge about strategies to adapt to risk;

  • perceive themselves to have such knowledge;

  • perceive those in their personal networks as expecting them to adapt to the risk; and

  • make a public commitment to adapt to risk (Parrott et al., 1998b).

Public health communication sometimes includes statistics, at other times depends upon personal narratives, and often combines the two, communicating through the use of multiple channels, including varied forms of media such as television and radio, but also in combination with interpersonal channels such as health educators and/or public health nurses. Use of multiple channels has been found to be more effective in changing behavior than reliance on a single modality (Schooler et al., 1998), as long as the message remains consistent.

Communication about health exists in environments cluttered with

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

inconsistent messages and unable to support many prescribed practices. Individuals must cope with public health recommendations to exercise in ecological environments where air quality does not support the practice, drink water when water quality has been reported to be poor, and follow a host of other messages that often can be attributed to public health professionals (Parrott et al., 2002). Conflicting health information causes perceptions that, regardless of what we do, we will be unable to control our future health (Wortman and Brehm, 1975). Public health professionals want to avoid such perceptions. Thus, in using multiple channels, public health professionals should be trained to recognize conflicting messages that may occur as a result of different values associated with reporting the news versus informing the public about health.

News depends on controversy and magnitude to make a story more personally relevant (Bell, 1991). These values sometimes conflict with efforts to avoid distorting public health information and contribute to the general public’s perceptions that private information will be made public as a result of interaction with the public health system.

Barriers to Overcome in Public Health Communication

The public’s cooperation with public health goals includes disclosing personal information in medical and public health settings, contributing to the collection of data for disease registries, allocating resources to health and health care needs, and recognizing gaps in policy and health law. A population perspective to communicating about health may be a barrier at the level of the individual who must disclose personal information to promote the public’s health. Public health professionals communicate with many different audiences, which may cause concern about the confidentiality associated with personal information and violations of privacy.

If members of the public are uncertain about how disclosing personal information may affect health insurance coverage, personal relationships, and/or their own self concept, they may avoid participating in public health activities perceived to threaten these areas, with computerization of health information increasing such avoidance (Brown and Levinson, 1978; Parrott et al., 2001). People living with AIDS and cancer survivors, as well as African Americans living with the legacy of Tuskeegee illustrate direct experience with such concerns. Moreover, members of the lay public who live in rural areas where public health agencies often seek to fill the gap in access to information, products, and services exhibit extended social interconnectedness. These relationships have an impact on confidentiality and require extra vigilance in efforts to safeguard information and to communicate how confidentiality will be maintained (Ullom-Muinich and Kallail, 1993).

Public health professionals may increase individual confidence in

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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these efforts by limiting the number of questions asked, evaluating the content of information requests, restricting access to individual information, and securing adequate space to accommodate individuals so that they will not be overheard (Parrott, 1995), which are intentional efforts associated with maintaining public health professionals’ credibility.

To balance the goals of population health with the rights and concerns of individual citizens, public health communication should be conducted within a framework associated with communication that does not raise expectations that cannot be met (Guttman, 1997). In these efforts, public health professionals must balance knowledge of strategies to involve audiences with efforts to avoid manipulating information so that lay audiences do what public health professionals want them to do. Public health communication should contribute to the adoption of policies and regulations that safeguard public health, while respecting individual rights to privacy. Moreover, public health professionals must acknowledge that different groups vary in the access they have to the personal and societal resources needed for them to be informed about public health or act on public health promotion recommendations. Thus, without careful efforts to conceptualize and assess the environment, public health communication may widen gaps between knowledge and behavior.

Public Health Communication Competence

Public health professionals require different communication skills to interact with various publics, including co-workers, elected officials and policymakers, health care providers, media, and lay citizens, all comprising the public health professionals’ sphere of influence. At a macro level, public health professionals should be able to state the case for public health programs and activities, which often requires knowledge of the history of public health promotion and research efforts associated with a topic, an audience, and one’s own agency and area. Cross-cutting skills associated with public health communication include the ability to conduct audience analysis to assess perceptions associated with “risk” (voluntary, control, distribution equity, natural) and audience perspectives of costs versus benefits of health-promoting behaviors and policies. This requires training in traditional and innovative formative evaluation strategies to uncover individual, community, and societal models associated with health and health care issues, and implicit costs versus benefits of healthy and unhealthy habits. Public health professionals also need skills to assess what and how information is being collected from the public, keeping these to a minimum to enhance disclosure.

Public health professionals work with and respond to communities to monitor the public’s health. Communities exist in a social environment that includes the health knowledge, attitudes, and practices of families,

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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friends, co-workers, and others in the social network as they relate to a designated campaign topic. Training is needed to assess supportive as compared to unsupportive characteristics of the existing environments associated with public health goals. Access to information, products, and services associated with public health action and promotion is necessary but not sufficient to support population health. Social processes contribute to definitions of health within a group and should be assessed in terms of whether personal and/or social responsibility is compatible with group values. The message environment may include inconsistent guidelines for treatment and prevention that need to be addressed. National, social, and political agendas and biases direct what is and is not communicated to the public about health. Public health professionals’ training should support their skills in identifying these situations.

Public health professionals will work with and respond to the news in efforts to make policy and evolve public health strategies. Media advocacy acknowledges this relationship and strives to strategically plan for and use news to educate and involve community members with important issues (Wallack and Dorfman, 2001). Public health communication requires skills to use mass media strategically in combination with community organizing to advance public health policies through media advocacy, targeting policymakers, organizations, and/or legislative bodies. Public health professionals should be able to frame public health problems as social inequities to derive policy solutions, as well as apply news values and advertising principles to design stories about these public health issues for media outlets. Public health professionals should also be able to identify people, groups, and/or organizations that have the authority, power, and influence to create and change policy, and work with them to increase exposure and reach of messages. This often requires skills in working effectively with media gatekeepers to build media partnerships and access strategies, and in designing and conducting media evaluation research.

Finally, public health professionals’ communication illustrates a long-standing ethical dilemma between utility and justice, and training should be examined with such issues in the forefront, emphasizing the application of ethical principles to communication about health and health information. Public health professionals should be able to evaluate strategic communication for evidence that information is being distorted to achieve public health aims. They should also look for unintended outcomes that may occur as a result of communication. Such unintended outcomes include labeling some members of the public, depriving individuals of affordable pleasures or important resources (e.g., time), and/or a focus on personal responsibility when societal conditions cause the public health threat.

Public health professionals’ job expectations will be more readily met

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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through training and education in communication. Such training should emphasize the role of individual level theories in explaining information seeking and processing as well as individual judgments and decision-making, individual and societal level theories focusing on the interrelationships between individuals and groups or media and gatekeeping processes, and societal level theories relating to social, political, and economic theories of health. Derived from these theories are guidelines for suggesting how public health professionals may attain skills for practice relating to collecting and interpreting formative data at the individual level; working with diverse audiences and groups, including policymakers and opinion leaders at the individual and societal levels; reframing issues as societal rather than individual; and analyzing and formulating public policy (Maibach et al., 1994).

CULTURAL COMPETENCE

Globalization, changing demographics, and disparities in health care have brought renewed attention to cultural competence skills and information in public health education and training. The term cultural competence has been so heavily overworked that it is often perceived and responded to as an empty cliché or ideology (Vega and Lopez, 2001). How is it possible to address the cultural variety inherent in the social world and to incorporate the most essential information within public health education? Where are the incentives to do so? These are difficult questions, and time will be required to develop or create adequate responses to them. Scientists do not resist investigation of the human genome because it represents too much variety; the same scientific logic works equally well for sorting and classifying information about culture, ethnicity, and race. Culture has many meanings and expressions; however the role of public health practitioners is to determine which sociocultural aspects are most relevant to their mission.

Cultural competence in public health is a systematic process. Its purpose is to change public health practice by effective education and training of public health students and practitioners. Cultural sensitivity, on the other hand, is rooted in developing attitudes of respect and appreciation for individual and cultural difference, and forms a foundation and rationale for cultural competence. Cultural competence is based on an empirically derived body of knowledge that is translated and integrated into the curricula and an established stock of knowledge imparted in programs and schools of public health. This process is accomplished by translating knowledge into skill sets that are continuously reviewed, refined, and disseminated. Cultural competency should be defined through operational criteria. These cultural competence criteria can be infused into public health organizations at all levels, staff development, reward structures,

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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community assessments, developing community outreach or stakeholder involvement, planning community programs, distribution of human resources, and system change. Similar practice skills and criteria pertain to community research and evaluation because they affect selection of topics, design of research, development and selection of measures, data analyses, and interpretation of findings.

The goal in cultural competence education is to increase public health professionals’ cultural awareness, knowledge of self and others, communication skills, attitudes, and behaviors. Part of this process is confronting stereotypes, because many students entering public health have minimal experience with ethnic minorities. This is accomplished by a systematic exposure to a knowledge base that, combined with practice methods, provides an additional dimension to public health education. The knowledge base includes specificity about inter-ethnic and intra-ethnic health indices, sociocultural aspects of health and help seeking, assessment techniques adapted to community cultural diversity, improving communication of health prevention and promotion, and medical care information, cultural translation and mobilization strategies for communities and their institutions, and methodologies to improve the delivery of public health interventions and to evaluate their effectiveness (Lee, 1988; Gold, 1992; Mo, 1992; Alcalay et al., 1993; Vega and VanOss-Marin, 1997; House and Williams, 2000; Kaplan et al., 2000; Schulz et al., 2001).

The need for cross-cultural sensitivity becomes apparent when placed in a global context. Other societies, such as Chinese, South Indian, and African societies have rich traditions in the medical arts that are centuries old and based on an epistemology that is distinct from western thought and action. Cross-cultural sensitivity is no less important for public health within the United States. There are now in excess of 80 million people in the United States in the four groups customarily categorized as “minorities”: African Americans, Hispanics, American Indians, and Asians and Pacific Islanders (U.S. Census, 2001). There are many other people, perhaps less visible, whose cultural background or sexual orientation places them outside the cultural mainstream.

Definitive reviews have appeared from authoritative sources highlighting disparities in health status, barriers to services, and lower quality of medical care received by minorities. The Office of Minority Health (U.S. DHHS, 2002b) issued a report, Teaching Cultural Competence in Health Care, where current concepts, policies and practices were reviewed. This report identifies several recommended cultural competence guidelines and standards issued by professional groups such as the American Psychological Association (APA), the American Medical Association (AMA), the National Association of Social Workers (NASW), the American Public Health Association (APHA), and minority medical associations. The Institute of Medicine (IOM) (2002) released a report that carefully describes

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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and documents how disparities are pervasive and manifested in the organization and delivery of medical care, resulting in consistently inferior health status and treatment outcomes for minorities. Among the most important factors cited in both reports are low health care access, poverty, poor patient communication (including cultural conflicts and language problems), racism, and discrimination. Although the public health mission is not focused primarily on medical care, there is ample experiential and empirical evidence that these same key factors should be addressed in programs and schools of public health through research, comprehensive curricular integration, and practice.

The need to contour public health according to the cultural ways of different groups is an important theme in the public health literature. For instance, substance abuse prevention practitioners working in cross-cultural settings are advised to be inclusive of those who have a stake in the program if resistance is to be minimized (Orlandi, 1992; Scott, 1990); to use multiple methods that may emphasize oral traditions versus written and experimental protocols (Airhihenbuwa, 1995); to take into account factors that are not only behavioral, but also contextual (Braithwaite and Taylor, 1992); and to learn how to gain access and trust in forging cross-cultural relationships by being aware of and sensitive to cultural nuances in interacting with others (Airhihenbuwa, 1995). These elements are shared by writers concerned with communities that are African American (Grace, 1992), Hispanic (Casas, 1992), American Indian (Beauvais and Trimble, 1992), and Asian/Pacific Islander (Yen, 1992). Lack of cultural competence in domestic practice is one of the factors that guides the objectives in Healthy People 2010 (U.S. DHHS, 2000). Educators, researchers, and practitioners must intensify their efforts to ensure that public health students are properly prepared to address the needs of these populations.

The Council on Linkages Between Academia and Public Health Practice has developed eight competency domains for public health professionals, one of which is cultural competency. The committee believes that this core competency as explicated by the council is important and forms a focus for education of culturally competent public health professionals. Ultimately, all areas of public health instruction are encompassed by cultural competence to a greater or lesser degree. The exploration of cultural competence improves core skills including attention to cultural-linguistic nuance in health screening, improving the ability of public health professionals to pose and answer research questions, redesigning interventions to fit ethnic community environments, and evaluating health policy issues. Improving screening for cancer, diabetes, and heart disease, increasing exercise regularity, reducing toxic exposures, stopping tobacco use, reducing HIV risk, and helping individuals make informed decisions about health care providers are examples of typical public health projects improved by cultural competence. Cultural competence includes supply-

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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ing students with better interpersonal communication tools for entering multi-ethnic communities to conduct research and interventions. There are now many research articles, books, and Web sites available that offer information and additional resources to provide a concrete foundation for commencing cultural competence instruction in programs and schools of public health. The next step is to integrate this information where it is needed across the curricula and to continue refining the knowledge base and pedagogy of cultural competence.

Cultural and ethnic awareness must also be increased in public health research. There has been relatively slow progress in including ethnic minorities in public health research and intervention trials. In recent years federal requirements at the National Institutes of Health (NIH) have made the inclusion of ethnic minorities nearly compulsory in research. However, these requirements pertain primarily to participation of human subjects in research. There are no guidelines about researcher responsibility or ethical practices when research is conducted in minority communities. In addition criteria have not been established for adequacy of research designs that increase the likelihood of high quality research results with external validity for minority populations. Minority communities often are suspicious of, or even hostile to, public health researchers because they have seen little benefit or improved conditions within their own communities from previous research.

Padilla and Medina (1996) assert that cultural sensitivity should span the entire research study process, including the adaptation, translation, and administration of measures, along with the analysis, scoring, and interpretation of results. Without such cultural adaptations, biases may occur that can lead to misinterpretation of a program’s results (Keitel et al., 1996). To reduce culturally induced bias, Suzuki et al. (1996) offer the following suggestions: develop alternative measures and procedures for diverse populations, understand the norms of ethnic groups to which evaluations are applied, increase collaboration with bilingual and bicultural professionals in developing evaluations, increase racial and ethnic community involvement in the assessment process, and consult the literature and research available regarding multicultural assessment procedures.

Orlandi conceptualized what he terms an “expert linkage approach,” in which public health experts are brought together with members of a cultural group and each is accorded equal significance in the collaboration. The approach is similar to that identified in the section on community-based participatory practices; therefore, the skills required are also similar. In particular, cross-cultural competence requires the public health professional to combine the perspective of a group that is the focus of study or practice with the science that informs public health research and practice. To do so means that professional training should

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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include courses in cross-cultural understanding that are influenced by anthropology and other similar disciplines. Additionally, training in methodology should be multioperational, thus exposing the learner to a broad array of methods that take into account cultures in which oral (and other non-Western) traditions predominate. Training should focus on ways in which methods can be adapted in partnership with cross-cultural groups and still retain scientific validity.

Cultural competence skills and knowledge are applicable to dual priorities in public health education, global health, and U.S. ethnic minority health. There is substantial overlap in the cross-cultural and linguistic challenges each area presents for improving public health education. Thus, it is logical and parsimonious for programs and schools of public health to disseminate cultural competence skills that are applicable in a transnational context, bearing in mind the inescapable truth that local public health practice requires local knowledge—including awareness of the cultural world, its heterogeneity, resources, and conflicts.

Several schools of public health have strong international health programs that already emphasize the importance of cross-cultural understanding and the adaptation of practices for working outside of the United States. They may serve as models that may be more widely adopted and applied to both international and domestic public health.

A fundamental challenge in achieving cultural competency in public health education and research is the need to increase the number of students and faculty from under-represented minority groups. In some instances these groups represent a cultural continuum extending from nations of origin in Latin America, Asia, Africa, the Caribbean, and Europe, to new communities of resettlement in the United States. The volume of students from many of these ethnic groups in public health education is inadequate, especially blacks and Latinos, who comprise nearly 90 percent of the total U.S. minority population.

Although data are scarce, a recent unpublished inquiry conducted by faculty of Columbia University found that about 40 percent (n = 12) of the 29 respondent schools of public health offered no specific courses on minority health in 2001 (Personal Communication, M. Aguirre-Molina, Columbia University, June 15, 2002). A total of 34 courses were offered among the remaining 17 schools, and of these, 29 were general survey (overview) courses. Only 10 schools offered 2 or more courses on health issues of minorities. This brief profile suggests that with few exceptions, U.S. schools of public health are poorly positioned to adequately motivate or prepare students for addressing disparities in health among minority populations.

The absence of undergraduate degree programs in public health at many schools delays the potential exposure of minority candidates, thus decreasing the number of recruits available for graduate training directly

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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from undergraduate schools. Mentoring programs in the sciences have been developed at the NIH for high school students from minority backgrounds to better equip them to compete academically at the university level, thus increasing their survival rates for advanced career preparation in the sciences. However, most of these programs are limited to the biological sciences. The minority pipelines at the secondary school and community college levels are poorly developed for public health. Even high school magnet programs in the health sciences tend to focus on classic career tracks, such as nursing and medicine. Public health has not established sufficient visibility in this arena and has received little federal support or leadership to do so. This must change.

Programs and schools of public health must demonstrate leadership and creativity in developing outreach programs in their local areas. They could sponsor courses in public health and help high schools implement their own courses by providing technical assistance. One such program has been developed by the University of California at Los Angeles School of Public Health. This program offers an introductory public health course at a local community college for both high school and community college students. The objective is to expose students to the opportunities available for positively improving their communities through a career in public health. Special programs on minority health accompanied by outreach to minority communities, secondary schools, and community colleges could also be created.

A related issue is the wholly inadequate supply of minority faculty. This is compounded by a dearth of tenured faculty that have direct experience with public health practice in minority communities. Some faculty may even be attitudinally resistant or substantively unprepared to address the renovation of curricula to achieve greater cultural competence among their students. Programs and schools must be willing to engage in reform and leadership development and to examine mechanisms for attracting, training, and retaining faculty from minority backgrounds.

The “pipeline” issue requires attention and action. A comprehensive approach is needed to identify, encourage, and support a greater diversity of students in schools and programs of public health, and to help those students complete their graduate degrees at the masters and doctoral levels. Greater attention should be given to undergraduate courses in public health that specifically address minority health issues and to developing outreach efforts to minority organizations to garner their assistance in reaching minority students. Programs could be established to partially or wholly support education to earn a master of public health (M.P.H.) degree for qualified minority scholars with doctorates in needed fields such as the social and behavioral sciences of psychology, sociology, demography, anthropology, etc.

The practice of public health requires culturally competent public

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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health professionals who know how to effectively communicate public health messages to an increasingly diverse population. These messages must be based on high quality information, obtained in a timely fashion, and shared in a manner that respects the values, opinions, beliefs, and practices of the communities with which public health interacts. In an era of expanded awareness of health disparities and an emphasis on prevention, do we have the requisite knowledge to reach ethnic minority communities and create awareness of specific health threats and reduce population risk? Will the enriched public health infrastructure adequately incorporate the needs of ethnic and cultural minorities? These are long-range challenges. Some progress has been made, but an active use of technological capability is needed to identify and rapidly disseminate cultural competency information and to integrate it into the core competency curricula. The importance of supervised practical experience to the mastering of cultural competency cannot be overstated. This may require some public health faculty to augment their own personal experience in minority communities in order to provide improved student field supervision and classroom instruction.

Cultural competency must emerge from the category of “necessary nuisance” that it too often occupies, which both isolates and trivializes its role. Cultural competency should be supported as an essential element in teaching, research, and practice.

COMMUNITY-BASED PARTICIPATORY RESEARCH

Public health research has contributed greatly to improvements in population- and individual-level health. Basic research, conducted for the purpose of advancing our knowledge, has helped us learn about such things as the basic biology of infectious agents (e.g., viruses and bacteria) and the biochemical and molecular mechanisms by which specific environmental factors cause or contribute to chronic diseases. Applied or translational research, designed to use the results of other research to solve real world problems, helps us understand, for example, how antibiotic resistance develops in certain types of organisms, so that the most effective treatments can be used. Evaluative research can be used to help us analyze the impact of welfare reform on the health of immigrant children or the effectiveness of high blood pressure prevention programs. Descriptive research that attempts to discover facts or describe reality provides us with hypothesis-generating studies, epidemiological studies, observational studies, and surveys. A prime example of this type of study is the original Framingham study that led to identification of risk factors for cardiovascular disease in middle-aged adults. All of these types of research are crucial to the field of public health and continue to be necessary components of the public health research portfolio.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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Additionally, given the demographic transformations in the United States, there is increasing need to incorporate lessons learned about community engagement, and the complex nature of interventions into community-based research. Community-based research is an overarching concept of collaborative research that encompasses many different types of studies, for example, applied, descriptive, and evaluative. Green and Mercer (2001) define participatory research as “an approach that entails involving all potential users of the research and other stakeholders in the formulation as well as the application of the research.” According to Green and Mercer, maximum participation occurs when the stakeholders remain active throughout the study—posing the research question, engaging in the selection and application of methods, and applying the findings. Minimum participation requires involvement in question formulation, interpretation, and application of findings. To Green and Mercer, the focus on participation separates community research from basic and applied research, with basic research involving only the researcher, and applied involving the research and practitioners.

Israel and colleagues (2001) define community-based participatory research (CBPR) as “a partnership approach to research that equitably involves community members, organizational representatives, and researchers in all aspects of the research process.” Whereas Green and Mercer focus on the participatory quality of the research, Israel and colleagues anchor the approach in geographically defined communities. Thus, CBPR and the training that it requires is most linked to practice in geographically-determined community settings. The NIH National Institute of Environmental Health Sciences defines community-based participatory research as a methodology that promotes active community involvement in the processes that shape research and intervention strategies, as well as in the conduct of research studies (NIH, 2002).

A Rationale for CBPR and Practice

Green and Mercer (2001) observe that communities often find that they participate in research that has limited applicability and is insensitive to the community in the process. Lack of access to and cooperation from community groups are common ramifications of poor relationships with communities. The breach in relationships also is discussed in the IOM reports on the future of public health (1988) and linkages between research and practice (1997). It is further recognized by investigators who have wrestled with the complexities of community research and who have helped reshape public health programming in community settings over the past 25 years. For instance, in considering the mixed record in protecting the integrity of research subjects, Strauss et al. (2001) propose

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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that community advisory boards be established to minimize the possibility of ethical violations of research participants’ rights. The authors define the functions required of investigators in the research process, including the following:

  • maximize the participants’ ability to make informed decisions;

  • assure that participation is voluntary;

  • reveal openly all ramifications of the research; and

  • accommodate community concerns about design or conduct of the research.

In addition to the ethical considerations that incorporate active oversight by community groups, the complex nature of the interventions underscores the importance of CBPR approaches. Of particular note are the 10 year community trials in the late 1970s and early 1980s, funded by the National Heart, Lung and Blood Institute (NHLBI), and directed at cardiovascular risk reduction (Farquhar et al., 1985; Elder et al., 1986; Jacobs et al., 1986; Mittelmark et al., 1993). Each implemented numerous community activities that included risk factor screening, general and specific media messages, work site physical activity, menu labeling at restaurants, grocery labeling, school programs, work with health practitioners, community-wide contests, community task forces, and speakers bureaus, as well as others (Jacobs et al., 1986).

The lessons learned about community engagement from these complex community trials were reinforced during the last decade by the emergence of social ecology principles for informing public health interventions (Shinn, 1996; Green and Kreuter, 1999). Social ecology is the application of multiple and linked intervention strategies across multiple social levels—the individual, family, social network, service organizations, community groups, and policy bodies (Goodman, 2000a; McLeroy et al., 1988). Stokols and colleagues (1996) suggest that research and practice based on comprehensive ecological formulations are needed in community health because limited intervention programs produce high relapse and attrition rates.

Empirical evidence is accumulating that suggests that CBPR approaches are consequential in producing important outcomes. As discussed earlier, in CBPR the community is a full partner in identifying the research questions to be addressed. These research questions are not developed or structured in the same manner as those posed by the quantitative researcher nor are they necessarily hypothesis driven, and they are not determined a priori and out of context from the communities in which the solutions arise. The National Institute of Environmental Health Sciences (NIEHS) funded a community-based participatory research project in Oregon aimed at reducing pesticide exposures

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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in families. Participants included migrant farm workers, community representatives, analytical chemists, epidemiologists, exposure assessment scientists, investigators skilled in qualitative research methods, and neurobehavioral scientists. According to NIEHS, “the blend of each of these areas of expertise allows for the generation of information to the community (e.g., workshops, training videos) and scientific information on the pesticide exposures of farm workers and their families and the effects of exposures on human health. The community benefits from the increased knowledge of the nature and extent of pesticide exposures in their work and home environments while the basic and applied scientist gains an increased sensitivity of community priorities and the need for culturally appropriate research methods and communication (www.niehs.nih.gov/translat/cbr-final.pdf). Further examples of successful CBPR projects can be found in the NIEHS report entitled Successful Models of Community-Based Participatory Research at (www.niehs.nih.gov/translat/cbr-final.pdf).

The CBPR approach has developed in response to the lack of success of other approaches that excluded the community from the research process (Green and Mercer, 2001). As with other evolving approaches (e.g., genomics, an important area for research that we support in the present report), much of the evidence base is emergent. Currently, CBPR approaches are receiving a great deal of attention from the public health community. CDC recently funded 25 community-based research projects founded on CBPR principles (Personal Communication, L. Green, Centers for Disease Control and Prevention, September 13, 2002), and the June 2002 issue of Health Education & Behavior, the most widely cited journal in the Health Education field, devoted an entire special issue to the topic (Schulz et al., 2002).

In short, the underlying rationale for CBPR and practice entails increased sensitivity to a community’s rightful place as a partner in research and practice. Furthermore, practical considerations dictate that community cooperation is predicated on processes that are participatory. Lastly, complex, interventions require communities to work in partnership with researchers and providers. Without comprehensive community approaches, pockets of prevalence may not be addressed effectively.

CBPR and Other Approaches

Community Research and Practice

Israel et al. (2001) draw a distinction between CBPR as “community-based” and other approaches as “community-placed.” The 1997 IOM report on linkages between research and practice draws a similar distinction for research projects, noting three levels:

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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  1. current proactive practice of academically driven research initiatives,

  2. a more reactive practice for designing research in response to the needs and input of community agencies,

  3. the development of interactive practices that involve both academic researchers and the community as equal partners in all phases of a research project.

The first level of research typically involves the researcher as the sole inquirer (Green and Mercer’s definition of basic research). The second level involves community concerns with academicians defining the methods of inquiry and the range of answers (Green and Mercer’s definition of applied research). The third type enjoins community representatives and academicians in collective exploration (Green’s and Mercer’s definition of participatory research). Three levels of practice that are analogous to the research levels include:

  1. community programs that often have minimum input from community organizations and/or community members (public health clinics may be one such example),

  2. collaborative models in which community organizations and members join programs with predetermined practices (WIC [the Women, Infants, and Children program] may be one such example),

  3. efforts that involve joint definitions of processes and outcomes (REACH [Racial and Ethnic Approach to Community Health] may be one such example).

Proponents of CBPR and practice view them as distinct paradigmatically from levels 1 and 2, whereas the 1997 IOM report views the three types as a continuum along which research may evolve.

Social Determinants of Health

Research into social determinants of health (SDOH) is another area that has implications for community engagement and that can be distinguished from CBPR. SDOH has its foundations in social epidemiology, particularly that aspect which focuses on social inequalities in contributing to disease and disability (Berkman and Kawachi, 2000). A concentration on social inequalities incorporates the study of social determinants of health (SDOH), or factors that contribute to “how society shapes the health of people” (Berkman and Kawachi, 2000). The SDOH perspective shares many characteristics with social ecology principles in that both take a population perspective, highlight social context in understanding individual behavior, and operate on multiple social levels.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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SDOH may be distinguished from social protective factors (SPF), or conditions that can mitigate social ills. For instance, Krieger (2000) enumerates research studies on the effects of discrimination on a range of health outcomes, including blood pressure, hypertension, cigarette smoking, depression, and other forms of psychological distress. Thus, discrimination as a social determinant is linked empirically to health outcomes. The question remains, what can public health offer in the face of pernicious social determinants like discrimination, poverty, and job dislocation? One practical response is to study other SPF that may have salutary effects on a community’s health.

Community capacity is one example of a cluster of SPF that do not necessarily reduce the presence of negative determinants like discrimination, but may bolster proactive community responses in the face of such determinants. Currently, CDC funds several special interest projects to understand how community capacity may improve community health outcomes. Measures for capacity, social capital, and SPF are in development. Preliminary findings indicate that communities that are most successful in producing desired community health and social outcomes tend to have important capacities in leadership, a strong set of values and principles, organizing abilities, and strategic community actions. Although these findings remain preliminary, they reinforce the prominent role that community-based participatory research and practice should be accorded in public health. SDOH and SPF are mutually supportive approaches, with the former focusing on the social context that produces social disparities, disease, and disability (sometimes referred to as “downstream” approaches), and SPF focusing on community-based interventions that may augur resistance to harmful social conditions (sometimes referred to as “upstream” approaches).

Skills Training in CBPR and Practice

Israel and colleagues (2001) characterize CBPR as incorporating several operating principles including the following:

  • the central place that communities are accorded as units of identity and as co-equals in research;

  • a process that is not perceived by community constituents as university-dominated or elitist;

  • the emphasis on long-term commitment by all partners;

  • the emphasis on co-learning so that the process flows back and forth;

  • the use of exercises that stimulate collective visioning among all partners;

  • the incorporation of social ecology approaches as departures for

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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research and practice;

  • the use of innovative problem-solving approaches;

  • the use of multiple methods of data collection to produce a rich and textured picture of partnership functioning and the outcomes that will result.

Israel and colleagues also suggest that challenges in implementing CBPR include the following:

  • the time and effort required to build trust and true partnering;

  • the difficulties in developing a common purpose;

  • the challenges of working with partners from diverse backgrounds and experiences;

  • the practical constraints that compromise CBPR principles in practice;

  • the difficulties in reaching balance and equity in the distribution of resources and other benefits.

The principles and challenges suggest the skills necessary to conduct CBPR and practice. For many researchers and practitioners, the development of new skills or the modification of existing skills will be required, including the ability to collaborate and share control in decision making and action regarding program design, implementation, and evaluation; the non-trivial use of community resources, skills, and relationships; and the cultivation of new capacities and partnerships among organizations and individuals (Paxman et al., 2000). Several programs at schools of public health teach skills in CBPR (e.g., University of Michigan). The curricula from these programs may provide guidance for establishing additional training requirements.

Skills that foster collaborative control in decision making and action

Researchers engaged in CBPR are program stakeholders, collaborators, and builders of capacity for the community interventions. They provide continuous feedback during each stage of a community program’s development. To reach the stage at which the researchers (or practitioners) can work collaboratively with community groups, they must learn skills to gain entrée into the community and to foster cooperation and trust among various community groups. They must have competencies in team building, group process, negotiation, developing consensus, teaching, interpersonal communication, and the acquisition of political acumen. Programs and schools of public health have at least three important roles that they can take in training researchers and practitioners to use community-based participatory approaches. First, course work on community engagement concepts should be integrated into the M.P.H.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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curriculum. Topics to include involve community theory, development strategies, promising interventions, group development techniques, community diagnosis, and capacity assessments. Secondly, the practicum or capstone experience should incorporate community-based experience. In many instances, students receive no academic credit for this requirement, and little faculty time is devoted to group discussions or debriefing sessions with students regarding community practice. The practicum or capstone experience may be used more fully to train in community-based approaches. Third, faculty should be encouraged to include students on funded community-based research enterprises. Research clusters of faculty and students that work on ongoing community projects can form academic “incubators” for growing mature community researchers and practitioners.

Technical competencies—research and evaluation

Many facets of community-based research and evaluation are unique. For instance, in CBPR the researcher provides continuous feedback to the community. In classical research approaches, such incursions by the researcher are considered to be threats to internal validity because the researcher influences the intervention. In research that is participatory, the investigator learns to develop methods for assuring internal validity that may deviate from classical approaches (Goodman, 2000b). Moreover, the movement towards multiple, complex, and community-based interventions has implications for redefining the types of skills required to research and practice community public health approaches. Flay (1986) focused on the impediments in implementing complex community programs, including reaching the planned targets at the correct time with adequate intensity and desired effects. Altman (1986) sought methods for disaggregating program components to understand the multiple causal mechanisms within complex community interventions.

Research, development, and assessment of community programs are difficult because they are necessarily different in different communities, need to be flexible and responsive to changing local needs and conditions, have broad and multiple goals, take many years to produce major outcomes, and require multiple data collection and analysis methods extended over long periods of time (Goodman, 2000b). Programs and schools of public health should have a central role in training researchers and practitioners to research, implement, and evaluate complex community interventions. The implications for programs and schools of public health concerning training for CBPR and practice are that multiple methods are important given the complexities of community health factors. The researcher, evaluator, and practitioner should be trained to tailor strategies to the specific questions and concerns of a community project.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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In developing the widest array of possible strategies, the public health profession requires training in both quantitative and qualitative approaches. Quantitative approaches typically use statistical techniques to judge whether program recipients benefit from the program in contrast to controls or comparisons. Qualitative approaches seldom use randomization and often do not have comparison groups; rather they focus on the program itself and use detailed observations of activities and events, interviews with program stakeholders, and reviews of program documents to judge program results. Moreover, new approaches should be incorporated as they develop. For instance, recent advances in geographic information systems (GIS) technology allows for increased availability and interpretation of geographic or location-based information (Richards et al., 1999).

Beyond the learning techniques, part of student training requires adeptness at community consultation as the basis for making adaptations in research, evaluation, and practice designs so that they hold “constituent validity.” Thus, the implications for training are two-fold. First, an array of research methods courses, both qualitative and quantitative should be part of training, particularly at the doctoral level. Second, the courses should focus not only on the acquisition of technical skills in design, data collection, and analysis but also on developing creative problem solving skills in contouring designs to fit with community input and social ecology principles (that is, multiple interventions at multiple social levels).

Possible Institutional Consequences for University-Based Researchers

CBPR takes time. Researchers and practitioners must be responsive both to the slow and deliberate pace that often accompanies community engagement and to the pressures and timelines programs and schools of public health maintain for promotion and tenure. If expectations regarding scholarly productivity are not met, those early in their careers may soon be out of a job. The irony is that those who become well-mentored in CBPR may not have the opportunity to build upon years of productive partnering because they do not pass muster at the university. If CBPR and practice are to be established as core methods in public health, then reward and incentive systems for faculty promotion and tenure may require adjustments to accommodate the complex nature of the work.

Community-based research involves active partnerships between the community and researchers. These partnerships are important to developing prevention research and health promotion programs because no single agency or institution has the resources, access, and trust relationships to address the wide range of community determinants of public health problems (Green and Mercer, 2001). Public health professionals in

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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the 21st century must understand the major concepts and principles underlying community-based research to engage more effectively in research and practice activities.

GLOBAL HEALTH

America has a vital and direct stake in the health of people around the globe, and . . . this interest derives from both America’s long and enduring tradition of humanitarian concern and compelling reasons of enlightened self-interest (IOM, 1997).

It is clear that health concerns and interventions cannot be limited by national borders. Increased travel, migration, and refugees from conflict have had an impact on the demographics of the United States. It is not unusual for a local U.S. community to be composed of immigrants from many areas of the globe with different cultural traditions and beliefs. The extent to which these immigrants adjust well to life in the United States and experience healthy development depends on several things, including (1) the assets and resources they bring from their country of origin, (2) how they are officially categorized and treated by federal, state, and local governments, (3) the social and economic circumstances and cultural environment in which they reside in the U.S., and (4) the treatment they receive from other individuals and from health and social institutions in the receiving community (IOM, 1998). These rapidly growing immigrant communities are creating a need for new services or for providing old services in a way that takes into account the traditions and beliefs of the different cultures.

There is a growing need to address issues that impact global health, such as the increasing income differentials between and among countries that foster poverty-associated conditions for poor health; the variance in environmental and occupational health and safety standards that contributes to hazardous production facilities and dangerous working conditions; global environmental changes leading to such things as depletion of freshwater supplies and the loss of arable lands; and the re-emergence of infectious diseases (IOM, 1997; McMichael and Beaglehole, 2000).

Poverty and ill health have long been associated, and the number of poor and marginalized people is increasing (Macfarlane et al., 2000). For every 100,000 births in developing regions, 500 women die as a result of pregnancy and childbirth while the rich countries have a rate of 7 maternal deaths per 100,000 births (IOM, 1997). Poverty contributes to population growth, which, in turn, leads to overcrowded and unsanitary living conditions in poor communities which, in turn, leads to the spread of infectious diseases. HIV/AIDS and tuberculosis continue to cause substantial numbers of deaths in many developing countries. Other diseases

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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such as malaria, dengue, and cholera are re-emerging. Table 3-2, outlines factors contributing to disease reemergence.

Overpopulation also affects the environment. “Humankind is now disrupting at a global level some of the biosphere’s life-support systems,” for example, changing the composition of the atmosphere and depleting ocean fisheries (McMichael and Beaglehole, 2000). With increasing population comes a need for increased food production. However erosion, compaction, salination, waterlogging, and chemicalization that destroys organic content have damaged an estimated one-third of the world’s previously productive land (McMichael and Beaglehole, 2000).

Some multinational companies, taking advantage of cross-national variations in environmental and worker safety standards, place hazardous production facilities in developing countries that either do not have strict regulations governing such facilities or that have lax enforcement. Lee (1999) quotes Deacon as saying “[E]conomic competition between countries may be leading them to shed the economic costs of social protection in order to be more competitive (social dumping) unless there are supranational or global regulations in place that discourage this.” The result of this social dumping has, according to Lee, been a long-term deterioration of public health systems, including the ability to manage infectious diseases. Additionally, pollution has caused the creation of “hot zones” that are believed to have led to a new strain of Vibrio Cholerae that may be starting the world’s eighth cholera pandemic (Epstein, 1992).

Issues related to food safety and diet are also of global concern. According to Kickbusch and Buse (2001), “A 300 percent increase in the real

TABLE 3-2 Factors Contributing to Disease Reemergence and Examples of Associated Infections

Contributing Factors

Associated Infectious Diseases

Human demographics and behavior

Dengue/dengue hemorrhagic fever, sexually transmitted diseases, giardiasis

Technology and industry

Toxic shock syndrome, nosocomial (hospital acquired) infections, hemorrhagic colitis/ hemolytic uremic syndrome

Economic development and land use

Lyme disease, malaria, plague, rabies, yellow fever, Rift Valley fever, schistosomiasis

International travel and commerce

Malaria, cholera, pneumococcal pneumonia

Microbial adaptation and change

Influenza, HIV/AIDS, malaria, Staphlococcus aureus infections

Breakdown of public health measures

Rabies, tuberculosis, trench fever, diphtheria, whooping cough (pertussis), cholera

 

SOURCE: IOM, 1997.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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value of the global trade in food between 1974 and 1994 (Kaferstein et al., 1997), coupled with increased travel and changes in lifestyles and nutrition patterns, demographics and vulnerability, and microbial populations, all intertwine to create a new pattern of susceptibility.” The recent European concern over “mad cow disease” in English beef is an illustration in point.

The transfer of unhealthy diets (e.g., high fat) and unsafe products (e.g., tobacco and firearms) are also relevant to global health. For example, the decline in smoking in western countries has been accompanied by massive marketing and increased smoking rates in low- and middle-income countries. It is estimated that one-third of Chinese males under age 30 will be killed by tobacco and about 22 percent of all deaths in Eastern Europe will be related to smoking by the year 2020 (Kickbusch and Buse, 2001).

Another area of concern is preparedness against bioterrorism. Since the anthrax attacks of September 2001, there has been heightened awareness of the possiblity of bioterrorism. International surveillance and safeguards against man-made infectious outbreaks are in the process of being strengthened. Public health professionals of the 21st century must be better prepared to respond in the face of such attacks, including understanding the actions available to them to respond and the authorities under which those actions can be taken.

Global health challenges are increasingly important. Many of these challenges are beyond the scope of this report. However, the committee believes that public health professionals must understand global health issues and their determinants; they must understand how local actions can have health impacts across the globe. Public health must be prepared to work with individuals from other countries to solve the problems facing our global community. To effectively engage with others on an international basis will require not only knowledge and skills described under the other seven content areas discussed in this chapter, but also an ecological perspective of the determinants of health.

We are all on this planet together. It behooves us to care for the natural and human resources so vital to the existence of us all.

POLICY AND LAW

Although the importance of policy in public health has long been recognized (IOM, 1988), education in policy and law at many programs and schools of public health is currently minimal. Education in policy analysis and, in particular, in policy methods, needs to be strengthened and systematically provided to all students, consistent with the inclusion of policy development as a core competency for public health professionals (Council on Linkages, 2001).

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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Turnock (2001) writes that “policy development involves serving the public interest in the development of comprehensive public health outcomes by promoting the use of the scientific knowledge base in decision making and by leading in developing public health policy.” The pace of policy development is poorly matched with the pace of scientific research, however. Policy-makers are accustomed to making decisions based on incomplete information; public health professionals can be a more effective part of that process if they are familiar and equipped with reliable data produced on a shorter time frame. It is also important to recognize the underlying difficulty that choices based upon incomplete information are inevitable and that our programs and schools of public health are not doing a particularly good job of educating students to manage the associated uncertainties. Educating students in traditional epidemiologic and biostatistical methods is important, but in addition to those methods, students also need training in quantitative methods (e.g., decision analysis, policy modeling, Bayesian statistics) aimed at promoting better policy decisions under conditions of uncertainty.

Engagement in policy also requires a set of practical political skills (IOM, 1988; Gebbie and Hwang, 2000). Successful community public health work at the policy level typically requires political collaboration with stakeholders (Freudenberg and Golub, 1987). Public health professionals in the community can be more effective if they can understand the dynamics of community politics, identify and work with stakeholders, identify legal and policy structures currently influencing community health and efficacy, and motivate and educate stakeholders and officials.

These skills can be taught to some extent, but also require “interdisciplinary dialogue, faculty modeling of political competence; opportunities for students to realize personal, professional, and political connections; and a concern of socialization in the context of global citizenship” (Rains and Barton-Kriese, 2001). People in practice report the need for more skills in policy development and law (Liang et al., 1993).

Law is an essential component of training in policy. Most public health policies are embodied in or effectuated through law, and law provides the institutional framework and procedures through which policies are debated, codified, implemented, and interpreted (Burris, 1994; Gostin, 2000). Law is more than just the rules written down in statutes and court decisions; it encompasses the institutional arrangements and day-to-day practices through which law influences behavior and attitudes (Ewick and Silbey, 1998; Sarat, 1990; Burris, 2002). The effectiveness of public health leaders at the local, state or national level will be significantly enhanced by knowledge about law including its structure, its typical modes of operation, the powers (and the limitations on power) provided for public health actions, and its role in population health and behavior. These do-

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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mains have been embodied in a set of core legal competencies, prepared by the Center for Law and the Public’s Health with support from CDC.

A critical area in public health policy research is engagement with law. Within the ecological model of health, laws and legal practices may be important constituents of the “fundamental social causes of disease” that broadly determine population vulnerability and immunity from illness (Link and Phelan, 1995; Sweat, 1995; Burris et al., 2002; Sumartojo, 2000). Public health research seeking to understand the relationship of multiple determinants of health will be enhanced by integrating law and legal practices into research on individuals, partners, communities, and whole populations. Because laws are used as structural interventions to regulate individual behavior and to change social and material conditions that endanger health (Blankenship, 2000; Hemenway, 2001; Schmid et al., 1995), law is also an important tool for intervention in public health, and here research has a vital role to play.

Research in public health can help to document how health policy is made (and the process influenced) (Backstrom and Robins, 1995; Mittelmark, 1999), as well as the difference between law on the books and law in practice (Boden, 1996; Cotton-Oldenburg, 2001). The challenge is not only to recognize law as a part of the universe of factors to be studied, but also to develop and support methods that are appropriate to the study of law’s operation in a population over time. The operation of law cannot often be studied in experimental designs. More attention to and respect for observational studies, rapid assessments, qualitative methods, and modeling is essential to expanding the public health research base in law.

Major barriers to increasing law-related research in public health are lack of funding and faculty incentives for efforts to make research more useful in the policy process (Nutbeam, 1996). Historically, funding for law-related research in public health has been minimal. In recent years, the CDC has made an important commitment to funding public health law research, but awareness of and support for this field of work remains rare in the National Institutes of Health.

Ethics, too, play an important role in politics and policy development as elsewhere in practice. Ethics are a tool through which public health professionals can interrogate their own values, formulate policy goals, and articulate a rationale for change in policy. Gostin suggests that

[p]ublic health ethics . . . can illuminate the field of public health in several ways. Ethics can offer guidance on (i) the meaning of public health professionalism and the ethical practice of the profession; (ii) the moral weight and value of the community’s health and wellbeing; (iii) the recurring themes of the field and the dilemmas faced in everyday public health practice; and (iv) the role of advocacy to achieve the goal of safer and healthier populations (Gostin, 2002).

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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While the content of public health ethics will continue to develop, the committee believes that ethics are an important and heretofore neglected element of a thorough education in policy.

Finally, policy training in programs and schools of public health also can be enhanced by considering human rights and their relation to health. As used in public health circles, human rights cut across law, ethics, and advocacy. When evoked in terms of the various international human rights conventions and national constitutions, they are a species of law (Burris, 2002). As deployed in efforts to secure just and effective public health policies, they are a tool of advocacy (Gostin and Lazzarini, 1997). Jonathan Mann argued that human rights could also take the place of an ethics for public health (Mann, 1997). While much work remains to be done to develop the public health potential of human rights analysis (Gostin, 2002), a human rights perspective has already become an important part of international health practice.

ETHICS1

Public health raises a number of moral problems that extend beyond the earlier boundaries of bioethics and require their own form of ethical analysis (Callahan and Jennings, 2002).

Ethics, in general terms, are “values or standards designed to shed light on the relative rightness or wrongness of actions based on moral principles, professionally endorsed and practiced” (Modeste, 1996). Public health is confronted with a wide array of ethical issues and questions, including issues involving: advances in technology and how they will be applied to improve the health of populations (e.g., information technology and genomics), the decisions we make about what and how to communicate, the ways in which we interact with diverse populations, the extent to which we develop partnerships and collaboration for public health programs and research, and resource allocation for provision of care.

The ethical basis for the practice of the health professions has been well studied by both health professionals and ethicists for some time. A statement of public health practice ethics has only recently been produced, and very little attention is paid to public health ethics in educational programs. Few schools of public health have trained ethicists on faculty, despite the fact that 22 of the 25 responding schools of public health report teaching ethics. To foster appropriate thinking and action

1  

Much of the material in this section is abstracted from the commissioned paper prepared for the committee by James C. Thomas, M.P.H., Ph.D.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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in public health, with its immense potential to influence populations, research and teaching in ethics as they apply to public health must be strengthened.

Callahan and Jennings (2002) have described the scope of issues in public health ethics as encompassing four general categories: health promotion and disease prevention, risk reduction, epidemiological and other public health research, and structural and socioeconomic disparities. They further identify different types of ethical analysis: professional ethics, applied ethics, advocacy ethics, and critical ethics, and they encourage all schools of public health to promote the teaching of ethics.

The American Public Health Association (APHA) has recently adopted a public health code of ethics (see Box 3-1). This code is based upon certain identified values and beliefs of public health including:

  • a belief in the interdependence of people and between people and their environment,

  • the importance of addressing root causes of health and illness,

  • the utility of the scientific method for gaining information, and

  • the importance of acting on reliable information that is in hand when the resources are available to do so (Thomas et al., 2002).

Public health ethics differs from medical ethics, which is typically concerned with an individual who is ill or disabled. Part of the ethical equation in medicine is whether withholding a treatment is tantamount to failing to rescue a person when rescue is possible. Moreover, the risks of introducing an intervention may be more palatable in view of the suffering that is likely in the absence of the intervention. In the case of public health prevention,2 however, the person or population is not necessarily ill or disabled, and the potential benefits of an intervention are less salient to those who might experience them. Even after an intervention to prevent an illness or injury is in place, benefits are often invisible or at least not in the forefront of people’s minds. Seldom do people think, for example, of the illnesses they did not get because they were vaccinated, or the cavities they did not have because the water supply was fluoridated. The hidden nature of some prevention benefits places an extra burden on public health professionals to clarify to the public the benefits of an intervention and how those benefits outweigh the risks of not intervening.

2  

Prevention can be categorized into three types: primary, secondary, and tertiary. Primary prevention, to which this statement refers, is the prevention of an illness or a disability. Secondary prevention is the treatment of a curable illness, and is designed to limit the progression of an illness or a disability. In the case of irreversible conditions, tertiary prevention is prevention of the progression to a more serious illness or disability, or the postponement of death.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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BOX 3-1 Principles of the Ethical Practice of Public Health

  1. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.

  2. Public health should achieve community health in a way that respects the rights of individuals in the community.

  3. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.

  4. Public health should advocate for, or work for the empowerment of, disenfranchised community members, ensuring that the basic resources and conditions necessary for health are accessible to all people in the community.

  5. Public health should seek the information needed to implement effective policies and programs that protect and promote health.

  6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.

  7. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public.

  8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.

  9. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment.

  10. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others.

  11. Public health institutions should ensure the professional competence of their employees.

  12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.

SOURCE: Thomas et al., 2002. Reprinted with permission of Am J Public Health, 2002; 7:1057–9.

The public health focus on populations also differs from the medical focus on interactions between a patient and a care provider. With a population perspective, public health institutions think in terms of healthy populations and communities as well as healthy individuals. The health of a community includes the quality of interactions among community members (consider, for example, the prevention of violence) and among institutions serving the community (e.g., the need for collaboration to achieve complex goals). A community perspective thus highlights the interdependence of individuals and organizations. This stands in contrast to the importance given to autonomy in medical ethics, in which the concern is principally to prevent a patient from being abused by a care provider who wields much power. Although personal autonomy remains

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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an important consideration in public health ethics, it is counterbalanced by concern for the well-being of a whole population and a realization that not everyone affected by a particular public health action will agree with it. Thus, in public health the personal choices and preferences of some will be overridden by a greater concern for the well-being of a whole population.

Policies and practices affecting a population are typically designed and implemented by government and other organizations, raising the question of how an agency develops and maintains an ethical compass. Is it through policy-making, or, in the case of governmental agencies, through legislation? Does it include understandings within a community that transcend legislation (e.g., a concern for equal access that is not legally mandated)? How are ethical conundrums resolved or decisions made in an organization that includes employees with different perspectives and sensibilities? An important part of public health ethics is sorting through ethical issues in a group setting.

The combination of a population perspective and institutional action presents a particular ethical danger to public health. “Population” and “institution” are abstract concepts, neither of which bears a human face. The ability to sympathize with another is a fundamental aspect of being able to think and act ethically towards that person. Personal interactions can lead to sympathy. However, interactions between an institution and a population occur in such a way that sympathy is not a common element of the interaction. To an epidemiologist, the population may be represented as a data set. Even to a public health ethicist, thinking about a population may be an exercise in wrestling with other abstract concepts such as the distribution of scarce resources. All too frequently such an exercise does not stem from direct interaction with those who will be most affected by a decision regarding those resources.

From the perspective of the individual in the community, the public health institution also lacks a human face. In this situation, however, the primary concern resulting from the impersonal nature of the institution is not the ethical treatment of the institution by individuals but the ability of individuals to trust the institution. A widespread absence of trust can severely limit the effectiveness of the institution. Ethical treatment of an individual and community by the institution, however, builds trust. In this way, the ethical functioning of a public health institution also affects its effectiveness in accomplishing its mission.

Public health needs both scholars who can articulate the unique aspects of public health ethics and public health practitioners who understand and operate within the ethics structures of the field. Nancy Kass (2001) discusses a six-step ethics framework for public health that can serve as an analytic tool used to help consider ethical implications of

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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proposed interventions, policies, research, and programs. The six steps are as follows:

  1. What are the public health goals of the proposed program?

  2. How effective is the program in achieving its stated goals?

  3. What are the known or potential burdens of the program?

  4. Can burdens be minimized? Are there alternative approaches?

  5. Is the program implemented fairly?

  6. How can the benefits and burdens of a program be fairly balanced?

Thomas, in the paper prepared for this committee, identified seven areas for education in public health ethics. First, are the values and beliefs inherent to a public health perspective. A list of these was developed in conjunction with the Public Health Code of Ethics (Thomas et al., 2002). They are presented on the Web at www.apha.org/codeofethics and include: a belief in the interdependence of people and between people and their environment; the importance of addressing root causes of health and illness; the use of the scientific method for gaining information; and the importance of acting upon reliable information when the resources are available to do so.

Secondly, education in public health ethics should address ethical principles that follow from the values and beliefs outlined above. The Public Health Code of Ethics consists of 12 ethical principles (see Box 3-1) that address the relationship between public health institutions and the populations they serve. Other codes of ethics for epidemiology and health education provide additional information more specific to these practices (located on the Web, respectively, at www.acepidemiology.org/policystmts/EthicsGuide.htm and www.sophe.org/).

Public health mandates and powers is another important component of education. Students should understand the legal mandates given to public health institutions and the powers available to them to meet the mandates and the potential abuses of these powers. It is also important to know that the powers of non-public-health organizations, such as some private companies, affect the health of the public and to consider how public health ethics might extend to them.

Further, ethical tensions within public health should be included in an understanding of public health ethics. Some ethical questions arise frequently because of an underlying, irresolvable tension between ethical principles. One that is common in public health is the tension between the need to protect the health of an entire community and the need to honor the rights of individuals in the community. This tension is brought to the fore when an individual claims that a public health regulation violates his or her rights. Examples of how some of these situations have been handled can be helpful in navigating future conflicts.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

It is important to review historical ethical failures and triumphs. One ethical failure in public health was the study of syphilis that was conducted by the Public Health Service and the Tuskegee Institute. Students should be aware of this study and what went wrong. It is also important to provide examples of ethical triumphs and more modest failures. An exclusive focus on “monstrous” failures can lead some to believe that ethics are not a concern for “normal” people such as themselves.

Two other areas to include are the history and purposes of research ethics institutions and the application of ethics to specific topics such as informatics and genomics. Institutional Review Boards (IRBs) currently review research proposals to ensure that they are consistent with rules and regulations concerning human experimentation. It is imperative that public health researchers and practitioners know how to interact with such boards and appreciate the value of this review system. In terms of specific topics, much of contemporary practical ethics is driven by new technological developments. The use of information about individuals that can be managed through sophisticated electronic systems, and in some instances acquired through genetic tools are two that bear directly on public health and affect nearly every public health practitioner. Students need to be informed of the prevalent ethical standards for using these tools.

“Ethical analysis can further understanding in every area of public health practice” (Levin, 2002), and it is essential that programs and schools of public health incorporate the teaching of ethics. However, the barriers to teaching ethics are substantial and, if not required, it is likely that ethics will not be taught in any meaningful way. Requiring ethics instruction in the curriculum does not necessarily mean requiring a free-standing course. A free-standing course entitled “ethics” might unintentionally convey the notion that ethics stands apart from other topics in public health, as opposed to the notion that it permeates every topic. Conversely, sometimes ethics teaching is best received when it is not billed as ethics. For example, a course may include instruction in how to interact with community members and thus communicate the importance of community input without appealing to it explicitly as an ethical principle.

There are dangers in not creating a free-standing course in ethics, however. In the absence of a required course, individual courses are likely to include an ethics lecture or two. Unless there is some coordination among courses, they are likely to cover similar material. A student may thus sit through three lectures on the Tuskegee study of syphilis or the functions of an IRB, but never learn to reason through tensions between individual interests and the good of the community or how to avoid unethical conflicts of interest. An uncoordinated ethics curriculum can easily be neither broad nor deep; it can be an inch wide and an inch deep.

However a program or school chooses to integrate ethics, a necessary first step is to identify competencies in public health ethics. Once the core

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

competencies are identified, a curriculum committee can ensure that they are covered within the required courses, regardless of whether a topic is labeled as ethics when it is taught.

The committee recognizes that teaching ethics in programs and schools of public health requires faculty educated to do so. This means that faculty will, themselves, require education in ethics, and schools and programs will need to provide professional incentives and rewards that encourage and value ethics as a subject of teaching and research.

Ethics is most stale and irrelevant when it is solely academic. Ethics is something less than ethics when it is not put into practice. Putting ethics into practice means that ethics should not be limited to a list of rules and regulations. Although these often represent the encoding of the ethical values of an institution, they are seldom adequate to address all situations, and they will never obviate the need for individuals and groups to have skills in reasoning through ethical conundrums.

It is also important that classroom teaching on ethics be linked to practical, real-life situations. Ideally, this might involve site visits to various neighborhoods or discussions with study participants. To counter the dehumanizing potential of a population perspective, mentioned above, public health students need to interact with individuals who are most affected by a particular ethical decision.

Regardless of whether ethics is taught explicitly, ethical values are communicated though teaching, mentoring, public health research and interventions, interactions between the school and other institutions, and more. If not taught explicitly, the accidental teaching of ethics is likely to be inconsistent and nonsystematic, and may perpetuate unethical actions. To promote ethical practices and to prepare students for the multitude of ethical decisions they will confront, students must be taught ethics in an intentional way. The means by which this is done, whether in a free-standing course or integrated into the curriculum, is less important than the identification of competencies along with a system of ensuring that these competencies are fully covered in the curriculum. To facilitate the teaching of ethics, schools and programs must institutionalize incentives for faculty to develop interest in ethics and the ability to teach the topic. For the teaching of ethics to be credible and vital to students, ethical education must include a practical component, most likely in the field, and schools and programs of public health education must personify a high ethical standard.

Law is another emerging area for public health scholarship, and while ethics and law are often discussed as related fields, each deserves attention in its own right. However, law overlaps with ethics, in that public health laws themselves should be ethical, as should the implementation of those laws. Since law can influence the social and physical environ-

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

ment in ways that are important to health, it is much more than a set of rules; law also encompasses the institutions and practices that bring these rules to daily life. Understanding this ethical perspective of law and using law in this way requires much more than mastery of regulations about specific businesses (restaurants, water systems) and the administrative procedures through which they are administered, though these are important. It brings to the forefront the use of law to influence choices made by individuals through the rewards or penalties that accrue.

SUMMARY

Each of the eight content areas discussed in this chapter is important for the future of public health and public health education. Understanding and being able to apply information and computer science technology to public health practice and learning (i.e., public health informatics) are crucial competencies for public health professionals in this information age in which we are vitally dependent upon data and information. Genomics is helping us understand the causative role of genetic factors in leading causes of morbidity in the United States, information that is important to the ecological model public health professionals must use to better understand how to improve health. Public health professionals must be proficient in communication in order to interact effectively with multiple audiences. They also must be able to understand and incorporate the needs and perspectives of culturally diverse communities in public health interventions and research. New approaches to research that involve practitioners, researchers, and the community in joint efforts to improve health are becoming more necessary as we recognize the importance of the impact of multiple determinants on health, for example, social relationships, living conditions, neighborhoods, and communities. Understanding global health issues is increasingly important as public health professionals are called upon to address problems that transcend national boundaries. Public health professionals must also understand how best to inform policy makers as they develop policies, laws, and regulations that have an impact on the public’s health. Finally, public health professionals must be able to identify and address the numerous ethical issues that arise in public health practice and research.

Therefore, for each of these eight emerging content areas, the committee recommends that:

  • competencies be identified;

  • each area be included in graduate level public health education;

  • continuing development and creation of new knowledge be pursued; and

  • opportunity for specialization be offered.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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The committee has highlighted the importance of these eight areas because it believes that they are and will continue to be central to public health for some time to come. It is beyond the charge of this committee to prepare curricula for educating public health professionals in these areas, yet it is crucial that such curricula be developed. As our understanding evolves, and as conditions change, other new knowledge and skills will be identified that will need to be incorporated into public health professional education. The committee emphasizes that it is important that public health education not “freeze” with the focus as identified in this report. Rather, the committee believes that the progress made in understanding and incorporating these eight important areas into public health practice, education, and research will enable us, in the future, to identify other new and emerging areas that must be addressed.

The committee also believes that it is important to enhance the development of the profession of public health, with some advocating the use of credentialing and certification as approaches to workforce development. Credentialing is a formal process used to ensure that persons practicing in a profession meet minimum standards (Modeste, 1996). Certification is “a process by which a quasi-governmental agency or association grants recognition or licensure to a person who has met certain qualifications specified by that agency. For example, the National Commission for Health Education Credentialing (NCHEC) certifies health educators. CDC and other public health agencies and organizations such as the National Association of County and City Health Officers (NACCHO), ASPH, and APHA are examining the feasibility of creating a credentialing system for public health. Their efforts are focused on credentialing based on competencies linked to the essential public health services framework.

Many issues that need to be pursued in this area are beyond the scope of this report. Certification, however, relates to the education of public health professionals. Within the various professions in the world of health and illness, the process of certification is common. In some cases, such as medicine and nursing, specialty certification is available only to those who have first qualified for a license to practice that is granted by a state authority. The specialty certification attests to skills beyond the legal minimum that apply to a limited set of patients (e.g., pediatrics), conditions (e.g., infectious diseases), or interventions (e.g., anesthesia). There are also areas of practice for which there is no required state licensure but for which members of the practice field have created certification as a way of attesting to minimum or common capacities. In public health, perhaps the best known is the Certified Health Education Specialist (CHES). In environmental health, there is also the mixed model of the registered sanitarian, who may be certified by the National Environmental Health Association but is required to achieve a state license in some states.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
×

The range of individuals entering M.P.H. programs, many with no previous health-specific education and with no access to the public health-related certifications currently in existence, makes this group likely candidates for a certification program. Defining specific criteria for such certification as well as designating a responsible organization to carry out out the process is beyond the scope of this report. However, the committee believes that voluntary certification for the M.P.H. graduate would enhance the profession. Therefore, the committee recommends the development of a voluntary certification of competence in the ecological approach to public health as a mechanism for encouraging the development of new M.P.H. graduates.

This chapter has described the future of public health professional education, no matter the site at which that education is obtained. Chapter 4 discusses the role of schools of public health in educating public health professionals, while Chapter 5 discusses the roles of other schools and programs. Chapter 6 focuses on the state, local, and federal public health agencies.

Suggested Citation:"3. The Future of Public Health Education." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542.
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Bioterrorism, drug--resistant disease, transmission of disease by global travel . . . there’s no shortage of challenges facing America’s public health officials. Men and women preparing to enter the field require state-of-the-art training to meet these increasing threats to the public health. But are the programs they rely on provide the high caliber professional training they require?

Who Will Keep the Public Healthy? provides an overview of the past, present, and future of public health education, assessing its readiness to provide the training and education needed to prepare men and women to face 21st century challenges. Advocating an ecological approach to public health, the Institute of Medicine examines the role of public health schools and degree--granting programs, medical schools, nursing schools, and government agencies, as well as other institutions that foster public health education and leadership. Specific recommendations address the content of public health education, qualifications for faculty, availability of supervised practice, opportunities for cross--disciplinary research and education, cooperation with government agencies, and government funding for education.

Eight areas of critical importance to public health education in the 21st century are examined in depth: informatics, genomics, communication, cultural competence, community-based participatory research, global health, policy and law, and public health ethics. The book also includes a discussion of the policy implications of its ecological framework.

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