SYNOPSIS
Objective
We developed competencies for applied epidemiologic practice by using a process that is based on existing competency frameworks, that engages professionals in academic and applied epidemiology at all governmental levels (local, state, and federal), and that provides ample opportunity for input from practicing epidemiologists throughout the U.S.
Methods
The model set of core public health competencies, consisting of eight core domains of public health practice, developed in 2001 by the Council on Linkages Between Academia and Public Health Practice, were adopted as the foundation of the Competencies for Applied Epidemiologists in Governmental Public Health Agencies (AECs). A panel of experts was convened and met over a period of 20 months to develop a draft set of AECs. Drafts were presented at the annual meetings of the Council of State and Territorial Epidemiologists (CSTE) and the American Public Health Association. Input and comments were also solicited from practicing epidemiologists and 14 national organizations representing epidemiology and public health.
Results
In all, we developed 149 competency statements across the eight domains of public health practice and four tiers of applied epidemiologic practice. In addition, sub- and sub-subcompetency statements were developed to increase the document's specificity. During the process, >800 comments from all governmental and academic levels and tiers of epidemiology practice were considered for the final statements.
Conclusion
The AECs are available for use in improving the training for and skill levels of practicing applied epidemiologists and should also be useful for educators, employers, and supervisors. Both CDC and CSTE plan to evaluate their implementation and usefulness in providing information for future competency development.
Recent studies have demonstrated a substantial shortage of epidemiologists, particularly at local or state public health agencies.1–3 In addition, up to one-third of epidemiologists practicing in state, local, or federal governmental public health agencies—referred to in this article as applied epidemiologists—may not have sufficient training to fully meet their responsibilities or to conduct more advanced work. For example, a 2004 survey by the Council of State and Territorial Epidemiologists (CSTE) reported that 29% of applied epidemiologists working in state health departments had no formal training or academic coursework in epidemiology.1 The assessment indicated a need for additional training in certain key areas, particularly design of epidemiologic studies, design of data-collection tools, data management, evaluation of public health interventions, and leadership and management, depending on the respondents' current job description.
Development of educational and workforce competencies has a long history in the field of public health. In the early 1900s, the Flexner and Welch-Rose reports recognized public health as a discrete area of professional practice, with unique requirements.4,5 From that time to the present, efforts have been made to define more specifically the precise content and skills within public health.6 After the 1988 Institute of Medicine report, The Future of Public Health, which concluded that public health preparation and public health practice were disconnected, the subsequent The Public Health Faculty/Agency Forum recommended development of universal competencies for all public health professionals and specific competencies for those practicing as content area specialists (e.g., epidemiologists).7,8 The resultant Council on Linkages Between Academia and Public Health Practice (COL) in 2001 adopted a model set of core public health competencies for all public health professionals that were organized across eight domains of practice.9
Rigorous definition of competencies for such a professional identity as epidemiology should result from an iterative process that involves representation of a broad spectrum of practitioners and academicians. The definition process includes identification of knowledge and skills associated with types of practice (e.g., entry level and advanced). The knowledge and skills are then formatted into competency statements that include both the content and proficiency level for each type of practice.10,11
In January 2004, the Centers for Disease Control and Prevention (CDC) and CSTE hosted a summit for leaders in epidemiology to address key workforce concerns affecting applied public health epidemiologists. Participants strongly supported the need to establish core competencies for these epidemiologists.12 In October 2004, CDC and CSTE convened an expert panel to define Competencies for Applied Epidemiologists in Governmental Public Health Agencies (AECs) for local, state, and federal public health epidemiologists.
This article summarizes the approach to competency development for applied epidemiology—the first national effort to focus on competencies in the applied epidemiology field. Other efforts to date have focused broadly on public health or only on academic epidemiology.9,13 Other key aspects of this effort included: (1) broad-based representation from state and local health agencies, schools of public health, private industry, and CDC; (2) integration of epidemiologic and workforce development expertise in the process; and (3) validation of the competencies by survey of practicing epidemiologists.
METHODS
Expert panel composition
An expert panel was assembled to develop the AECs. Every effort was made to make the group representative of government (federal, state, and local) and academia, and across subject areas of epidemiology (e.g., infectious disease, chronic disease, and maternal child health), educational backgrounds (e.g., physicians, veterinarians, doctoral epidemiologists, and nurses), and geographic location. Panel members were solicited from national organizations with an interest in public health education or applied public health, as well as national professional organizations in public health (e.g., the American Public Health Association [APHA], National Association of County and City Health Officials [NACCHO], Association of State and Territorial Health Officials [ASTHO], and the Association of Schools of Public Health [ASPH]).
Academicians as well as practitioners were included. The cochairs represented both applied epidemiology (one is a state health department-based epidemiologist) and academia/workforce development (one has a background in competency development). The final group had approximately 20 members, balancing the need for inclusiveness with having a group of practical size. Selected panel members were assigned additional responsibilities as reviewers and were remunerated for those additional efforts. An editor-writer with an extensive public health background was employed as a project consultant. The AECs expert panel first met in October 2004.
Definition of terms
Epidemiologist
A person who investigates the occurrence of disease, injury, or other health-related conditions or events among populations to describe the distribution of disease or risk factors for disease occurrence for population-based prevention and control.12
Applied epidemiologist
An epidemiologist who works in a governmental public health agency (i.e., an agency with a legal mandate to conduct public health activities).
Competency
The knowledge, skills, and abilities demonstrated by organization or system members needed to perform specific functions within organizations or professional practice.14
Competency domains
Eight competency areas contained in the Core Competencies for Public Health Professionals, developed by the COL (Figure 1), that apply to all public health professionals, including epidemiologists.9
Figure 1.
Competency domains of public health practice
Source: Public Health Foundation. Council on Linkages Between Academia and Public Health Practice. Washington: Public Health Foundation; 2006. Also available from: URL: http://www.phf.org/Link.htm [cited 2006 May 31].
Expert panel working group process
The panel conducted three in-person two-day meetings of the entire group in October 2004, March 2005, and May 2006. Multiple conference calls of the whole group and with selected subgroups were held between meetings, and report drafts were circulated for comment.
Before the panel's first meeting, the editor-writer consultant conducted a thorough review of the published literature, including a Web search, to identify any previously developed public health and epidemiology competencies. Existing sets of competencies in the public health field in English were summarized and arrayed in a matrix for ease of comparison. At the first meeting, the panel reviewed the background material and agreed to build the AECs within the framework of the COL competencies to facilitate consistency with the larger field of public health practice. Many of the AECs originated from the existing COL general competency set, but the panel modified them to reflect the particular needs of epidemiologic practice.
Also, at the initial meeting, the panel agreed on the definition of terms and acknowledged the need to define competencies for four tiers of applied epidemiology practice at local, state, and federal public health agencies: entry-, mid-, and senior-level epidemiologists—either supervisory or senior scientist (Figure 2). The group then focused on developing Tier 2 (mid-level practitioner) competency statements, which were revised after the panel solicited and received input. The Tier 2 competencies were then used as the basis for developing the Tier 1 (entry-level) and Tiers 3a and 3b (supervisory- and senior scientist-level) competencies.
Figure 2.
Four tiers of applied epidemiology practice
RN = registered nurse
MD = medical degree
DO = Doctor of Osteopathy
DDS = Doctor of Dental Surgery
DMD = Doctor of Dental Medicine
DVM = Doctor of Veterinary Medicine
PhD = Doctor of Philosophy
RS = registered sanitarian
CDC = Centers for Disease Control and Prevention
MPH = Master of Public Health
Soliciting input on draft competencies
After creating the first draft of Tier 2 competencies, the panel developed a survey to collect feedback from the practice and academic communities on the appropriateness and validity of the proposed competency statements. The survey presented all of the high-level competency statements within each skill domain, and for each competency it asked: (1) Do you perform this task, and, if so, how often? and (2) Is this competency appropriate for a Tier 2 epidemiologist?
The survey also asked whether any competencies were missing in each of the eight skill domains and whether the respondent would suggest any changes. Respondents were asked to self-identify as a Tier 1, 2, 3a, or 3b epidemiologist and to identify their governmental level of practice (local, state, federal, or other).
The draft Tier 2 competencies were first presented and the survey administered at the June 2005 CSTE annual meeting. All 855 registered attendees were asked to complete the survey, and 259 people (30.3%) responded. We invited further input from the CSTE membership, CDC scientific staff, and 14 professional public health organizations, including ASTHO, NACCHO, American College of Epidemiology, Society for Epidemiologic Research, Association of American Medical Colleges, Association of Teachers of Preventive Medicine, ASPH, Association of Maternal and Child Health Programs, National Environmental Health Association, National Association of Local Boards of Health, Association of State and Territorial Directors of Nursing, State and Territorial Injury Prevention Directors Association, APHA, and National Association of Chronic Disease Directors. A Notice to Readers was also placed in CDC's Morbidity and Mortality Weekly Report (MMWR).15 To facilitate responses from this broader audience, the survey was placed on the CSTE website, resulting in 121 additional responses. The draft Tier 2 competencies were also presented at the December 2005 APHA annual conference.
The panel analyzed input on the draft Tier 2 competencies and revised them. The Tier 2 competencies were then used to develop the Tier 1 and Tier 3 competencies. In certain cases, this involved changing the verb in the competency statement to reflect a more limited or more advanced level of competency (e.g., Tier 1: “identify a health problem” vs. Tier 3: “oversee implementation of a program to address a health problem”). In other cases, new competencies were added at the higher tier levels.
Following this activity, we sought input and validation of the process. In April 2006, the complete draft of all competency statements was posted on CSTE's website, along with a revised online survey that included separate sections for each tier. The survey instructions asked respondents to focus on the tier with which they self-identified and, if appropriate, to comment on other tiers for which they felt qualified, including tiers for epidemiologists that they supervised. The survey also collected respondents' basic demographic information and self-identified tier.
As during the first round, professional organizations were asked to encourage their members to respond to the survey, with the National Association of Health Data Organizations and the American College of Preventive Medicine added to the list. Information on the survey was published in MMWR16 and featured prominently on the CSTE website. There were 420 responses to this second survey, covering all four tiers.
Given the importance of informatics competencies for the practicing epidemiologist in the computer age, the CDC convener specifically sought feedback regarding key informatics competencies from public health informaticians and epidemiologists, especially from groups with representation from local, state, and federal practitioners actively engaged in developing the Public Health Information Network.17
Final competency development
For the final revision process, the consulting editor-writer, the CDC convener, and the cochairs reviewed comments from all survey respondents during the first round (Tier 2 only) and the second round (all tiers). The comments were categorized according to whether they proposed a new competency, recommended a reformulation or found a statement confusing, stated the competency was inappropriate, or provided a general comment.
For the first two categories of comments, the panel reviewed the proposed changes and determined whether to accept the change, accept the change with modifications, or reject the change. For the second two categories of comments, the panel identified major trends or concerns and addressed them either by changing the competency statements or by adding clarifications in the preface document, which accompanies and explains the competencies. The majority of the recommended changes focused on the tier definitions, and the panel reviewed and revised these as well.
In addition to analyzing the qualitative data (written comments), the panel reviewed the quantitative data from the surveys in terms of the proportion responding favorably or unfavorably to each competency stratified by the commenters' tier level and governmental level of practice. The panel discussed any competency statement for which overall agreement with the question, “Is this an appropriate competency?” declined below 75% and decided whether to retain or change the competency. Overall, the acceptance level for the draft competency statements was high, and only 7.4% (11/149) of the competency statements in the April 2006 survey declined below the 75% acceptance level. After final discussion, review, and editing, all panel members agreed that the AECs were final.
RESULTS
A summary of the primary AEC statements for Tier 2 epidemiologists is included in Figure 3. The full AECs are included in the Appendix.
Figure 3.
Summary of the primary applied epidemiology competency statements for Tier 2 epidemiologists
Structure of competency statements
Within each competency domain defined by the COL is a primary competency statement, followed by subcompetency and, in certain cases, sub-subcompetency statements that detail the specific knowledge, skills, and abilities necessary to meet the required competency. The number of competency statements by each competency domain is displayed in the Table. Additional competencies have been added throughout all the skill domains to capture specific knowledge, skills, and abilities necessary for epidemiologists in public health agencies. The Analytic/Assessment and Basic Public Health Sciences skill domains are the most closely linked to applied epidemiologic practice and, therefore, received the greatest number of epidemiology-specific competencies.
Table.
Table. Number of competency and subcompetency statements by tier and competency domain
An example of a competency and subcompetency statement illustrating the different mastery required by tier level, as well as the hierarchical nature of primary and subcompetencies, is listed in Figure 4. Each competency statement has been adapted to reflect the knowledge and skills necessary for each level of responsibility and experience—entry level (Tier 1), mid-level (Tier 2), or senior level (Tiers 3a and 3b). For certain competency statements in which the expert panel believed that all epidemiologists, regardless of level, needed a certain set of knowledge and skills, the language is identical across all tiers. Other competency statements are only present for the higher levels, when those skills or responsibilities might not be expected of entry-level epidemiologists.
Figure 4.
Example of primary and subcompetency statements in the Analytic/Assessment skill domain, by tier level
DISCUSSION
Scope of competencies
The AECs define the discipline of applied epidemiology as practiced in governmental public health agencies. Given the scope and content of epidemiology, the competencies emphasize analytical and assessment knowledge and skills. However, by following the COL's framework for competencies for all public health workers, the competency set also covers all aspects of practice that are necessary to be an effective epidemiologist: communication, management and leadership, and cultural competency skills. In these non-epidemiologic competency areas, the focus is on what an epidemiologist should know. For example, regarding communication, epidemiologists should be able to communicate clearly the results of epidemiologic studies, including limitations of such studies.
Intended uses
The intended uses of the AECs vary by category of user. For practicing epidemiologists, the competencies can serve to define the scope and limits of their profession and, in so doing, define a career path and aid in assessing knowledge gaps that can lead to the development of a specific training plan to meet education gaps. For employers, the AECs can provide a guide for creating career ladders for epidemiologists, drafting position descriptions and job qualification statements, developing continuing education training plans, and assessing the organization's epidemiologic capacity. For educators, the AECs can assist in designing educational programs and curricula focused on applied epidemiology, both for primary epidemiologic education and for continuing education. Finally, the competencies can form the basis for future certification of epidemiologists.
Limitations
The process of competency development was limited in several ways. First, the AECs are the work of an expert committee and may suffer from the inconsistencies and compromises that such a process might entail. The expert panel had to make editorial decisions between sometimes conflicting comments, although such decisions were usually made after the panelists came to a general consensus. Also, the panel cast a very wide net in an attempt to include many points of view in epidemiology practice and education.
Second, people who provided input and comments on the document were self-selected and therefore may not be representative of all practicing applied epidemiologists. However, as described previously, the expert panel solicited participation in the review process via many relevant organizations and through MMWR in an attempt to include many points of view in epidemiology practice and education.
Applying the competency statements
The expert panel intentionally created broad competencies that cover the discipline of applied epidemiology, which itself is broad and diverse. CDC and CSTE intend that all people practicing applied epidemiology—including those who might not have the title of epidemiologist but whose job requires use of epidemiologic methods—gain minimal competency in all of the defined skill domains. However, every applied epidemiologist is not expected to be equally competent in all areas. Different content areas of applied epidemiology (e.g., infectious disease, chronic disease, environmental health) might emphasize different competency areas. In addition, job descriptions among public health agencies vary by the agency's needs and resources, the setting (e.g., rural or urban), and the scope of the agency's responsibilities (i.e., local, state, or federal), and may not always uniformly comply with stated competencies.
Guiding careers in applied epidemiology
The competencies represent a continuum of applied epidemiologic practice, not a single point in time in a person's career. In other words, a person might not start with knowledge and skills in all areas but is expected to gain knowledge within each tier and potentially move through tiers over time. The AECs provide a tool that epidemiologists can use to plan careers and chart professional growth.
Disseminating the AECs
CDC and CSTE are disseminating the AEC report broadly throughout the epidemiology and public health communities. The final competency set has been presented at multiple state, regional, national, and international public health and epidemiology meetings with a focus on educating the target audiences about the development and use of the AECs. The complete competency set, along with tools and documentation to support their use, is available on the CDC (http://www.cdc.gov/od/owcd/cdd/aec) and CSTE (http://www.cste.org/competencies.asp) websites.
CONCLUSION
CDC and CSTE anticipate the AECs will be used as the basis of instructional competencies for training government epidemiologists, and as the framework for developing position descriptions, work expectations, and job announcements for epidemiologists practicing in public health agencies. After public health agencies have used them for a sufficient period, CDC and CSTE will evaluate their utility and effectiveness as part of an ongoing process to update and improve them.
Acknowledgments
The authors thank the members of the Applied Epidemiology Competencies Expert Panel: Kaye Bender, RN, PhD, University of Mississippi Medical Center School of Nursing; Roger Bernier, PhD, MPH, Centers for Disease Control and Prevention (CDC); Mike Crutcher, MD, MPH, Oklahoma State Department of Health; Richard Dicker, MD, MSc, CDC; James Gale, MD, MS, School of Public Health and Community Medicine, University of Washington; Kristine Gebbie, DrPH, RN, Columbia University School of Nursing; Gail Hansen, DVM, MPH, Kansas Department of Health and Environment; Richard Hopkins, MD, MSPH, Florida Department of Health (formerly with CDC); Sara L. Huston, PhD, University of North Carolina at Chapel Hill; Maureen Lichtveld, MD, MPH, Tulane University School of Public Health and Tropical Medicine; Miriam Link-Mullison, MS, RD, Jackson County Health Department; Kristine Moore, MD, University of Minnesota; Hal Morgenstern, PhD, University of Michigan School of Public Health; Lloyd Novick, MD, MPH, Brody School of Medicine; Len Paulozzi, MD, MPH, CDC; Arthur Reingold, MD, University of California at Berkeley; William M. Sappenfield, MD, MPH, Florida Department of Health (formerly with CDC); Gregory Steele, DrPH, MPH, Indiana University School of Medicine; Lou Turner, DrPH, MPH, North Carolina Division of Public Health; and Mark E. White, MD, CDC.
The authors thank Matthew Boulton, MD, MPH, University of Michigan School of Public Health, who was one of the original conveners of the Applied Epidemiology Competencies project. They also thank Pat McConnon, MPH, and LaKesha Robinson, MPH, of the Council of State and Territorial Epidemiologists (CSTE) for their expert support of the competencies development process. In addition, they thank Jacqueline Silvia-Fink for assistance in preparing the article.
Appendix
The complete CDC/CSTE Competencies for Applied Epidemiologists in Governmental Public Health Agencies document
I. Skill Domain—Assessment and Analysis
II. Skill Domain—Basic Public Health Sciences
III. Skill Domain—Communication
IV. Skill Domain—Community Dimensions of Practice
V. Skill Domain—Cultural Competency
VI. Skill Domain—Financial and Operational Planning and Management (Operational Planning, Financial Planning, and Management Skills)
VII. Skill Domain—Leadership and Systems Thinking
VIII. Skill Domain—Policy Development
CDC = Centers for Disease Control and Prevention
CSTE = Council of State and Territorial Epidemiologists
N/A = not applicable
Footnotes
This work was supported by cooperative agreement #U60/CCU07277 from CDC to CSTE.
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