Public Health Hotline

Summary

This Public Health Hotline article describes the current efforts of the Office of Public Health in the John A. Burns School of Medicine, University of Hawai‘i at Manoa, to research and develop a new doctorate in global and indigenous health leadership. It reviews the history of the Doctor of Public Health (DrPH) program, structural limitations, imperatives for content, and identifies an appropriate delivery model.

History of the DrPH Program

The formal organization of academic public health programs commenced shortly after the turn of the 20th Century with the DrPH being offered in the United States by the American Public Health Association (APHA).¹ The Harvard School of Medicine initiated their DrPH program in 1909 and produced the first DrPH graduates in 1911.² Medical graduates were required to spend a year producing a research thesis while those without a medical degree were required to study relevant classes for four years before completing a thesis in one year of research.³ In what was an important step for the DrPH, the General Education Board of the Rockefeller Foundation delineated a foundation for schools of public health and their degree programs.⁴ To this end, public health workers were classified as executives (commissioners and directors of boards of health), technical experts (eg, statisticians, bacteriologists, etc), and field workers (eg, nurses, food inspectors). Regardless of entry criteria, the DrPH was designated for executive administrative positions in public health. In 1921, the APHA voiced its concern over the quality of DrPH programs offered by no less than nine institutions, since some required only 36 hours of training while others required three years.⁵ A standard was set with the degree requiring a medical degree as a prerequisite and two years of academic work in residence, practical field work, and a thesis based on original investigation. In 1941, the Association of Schools of Public Health was created and within five years it had developed the Master of Public Health pathway into the DrPH for non-medical students.⁶ Eight schools of public health were accredited in 1946 and the School of Public Health at the University of Hawai‘i was the twelfth in 1965.⁷

The following Figure 1, generated by Google Ngrams, shows the number of times “Doctor of Public Health” (red), “Master of Public Health” (blue), and “DrPH” (green) were mentioned in the 15 million books that have been digitized thus far by Google. It shows how the DrPH was the original public health qualification which was replaced in popularity by the MPH after the 1950s. Despite the continued decline in the use of the phrase, “Doctor of Public Health”, use of the actual label of the degree (DrPH) in books rose sharply from the 1970s. Use of “MPH” also rose in a similar manner to the red line, but was an order of magnitude higher and thus cannot be displayed in Figure 1. Use of the alternative term, DrPH was almost non-existent and is not shown in this figure. Actual numbers of DrPH graduates in the United States rose from 80 in 1985 to 129 in 2006 indicating considerable growth and interest in the degree (ASPH annual data reports).

Figure 1.

Occurrences of the phrases “Doctor of Public Health” (red) and “Master of Public Health” (blue) and “DrPH” (green) by year in 15 million books digitized by Google (http://books.google.com/ngrams)

Doctoral Requirements for a School of Global and Community Health

The Office of Public Health Studies (OPHS) in the John A. Burns School of Medicine is an accredited public health program, and has aspirations to reacquire School status from the national Council on Education for Public Health accreditation body. One of the requirements for accreditation is that the “school shall offer at least three doctoral degree programs that are relevant to any of the five areas of basic public health knowledge.”⁸ To be accredited, a school of public health requires sufficient faculty (five full-time faculty per doctorate), adequate faculty expertise, and availability of advanced-level courses; in addition, faculty must be active in research. The doctoral programs may be professional, such as the DrPH, or academic, such as the PhD, and interdisciplinary programs that are based in the school of public health may also satisfy this expectation.

Currently, the OPHS has a PhD in the epidemiology (EPI) discipline and a DrPH in the social and behavioral health sciences (SBHS) discipline. Since current MPH students typically apply to EPI, SBHS and health policy and management (HPM), the need now exists for a DrPH in the HPM discipline. In addition to these three disciplines there are two other growth areas that are generating significant interest among public health students. They are global health and indigenous health. While these areas can be catered to in generic EPI, SBHS, or HPM doctorate programs, their recognition for marketing purposes and the need to promote research capacity building in indigenous populations is important and cannot be neglected. Thus the title of the DrPH needs to reflect their inclusion despite it being placed in the HPM discipline. The next sections reflect on the importance of global health and indigenous health. Furthermore, the Institute of Medicine made a well-accepted statement that the DrPH “is offered for advanced training in public health leadership.”⁹ Thus the title of the DrPH needs to reflect this and include the word ‘leadership’.

Global Health

Health disparities are receiving progressively more attention from funding agencies and the media which is fueling a dynamic expansion in university and government engagement in global health.^10–12 Almost half a billion indigenous people across the Earth have a lower than average standard of health.¹³ Associated conditions range from poverty, malnutrition, overcrowding and poor hygiene to environmental contamination and infection. Often, a lack of health promotion, inadequate clinical care and poor disease prevention services exacerbate this situation. As indigenous people make the transition from traditional to transitional and modern lifestyles, they rapidly acquire related diseases, such as obesity, cardiovascular disease, and type 2 diabetes.¹⁴ The misuse of alcohol and drugs confounds these conditions leading to a plethora of physical, social, and mental disorders. Remedies for these serious and complex disparities, which are often caused by government denial and neglect, require increased awareness, recognition, and international political commitment.¹³

Many public health professionals have an interest in health challenges that originate from or perpetuate in low to middle income, developing nations. The Global Health and Population Studies division under the OPHS will leverage its position to attract doctoral researchers who are interested in these wide-ranging and critically urgent public health issues. After exposure to global health training, it is common to see students engaging in teaching, practice, administration, or research in international settings.

Indigenous Health

The dominant mode of health research on indigenous populations is the external, investigator-driven descriptive survey and epidemiological study. There are few examples of best-practice, collaborative health research that is strongly centered on indigenous communities, that harness external expertise while balancing key local power players, address strategic research priorities, deliver health gains through improved practice or policy, and enhance community capacity and leadership. Taking the participation of indigenous investigators beyond mere gate-keeping or junior partnership to full partnership or principal investigator status is fundamentally important to define appropriate and locally relevant research problems, identify solutions, and translate, implement and evaluate public health research. A key strategy is the provision of doctoral training to indigenous people so that they are empowered to drive their own agenda and become increasingly involved in overcoming these challenges. The new, interdisciplinary division of Indigenous Health under the OPHS will use the new DrPH program to develop capacity and promote research training on behalf of indigenous populations throughout the American territories in the Pacific.

Identifying the Target Student Population

The current PhD in EPI and DrPH in SBHS attract students that often come straight out of the MPH program. While most of them gain employment in health-related organizations at some point during their candidacy, they possess limited experience in public health, policy development, management and leadership. While this strategy provides advanced training for potential, aspiring public health leaders, it leaves existing managers and leaders underserved. To complement the existing approach, a new tactic is required to target the executive market. Thus the DrPH in Global and Indigenous Health Leadership is designed to prepare mid-career professionals for senior-level positions in organizations working to improve the public's health. Specifically, the degree seeks to attract diverse individuals from the United States and other countries who have managerial and leadership responsibilities in their communities, organizations and/or institutions. The program will be of most benefit to health directors, managers in government departments, health agencies or foundations, leaders within the nonprofit and non-governmental sector, program managers, and others working in nontraditional settings that have a significant impact on the health of the public.

Identifying an Appropriate DrPH Structure

In 1988, the Institute of Medicine published a report entitled, The Future of Public Health, which claimed that public health schools were becoming increasingly isolated from public health practice, and that the governmental public health infrastructure was in disarray.¹⁵ This disconnect resulted in fewer graduates being trained with the practical skills required to work in health agencies. The diminishing focus on the practice of public health and increasing focus on academic pursuit was said to have had the effect of rendering DrPH degrees more similar to PhD programs.¹⁶ Much has changed since this time and the Association of Schools of Public Health (ASPH) has worked tirelessly to improve standards. However, in what appears to be a reaction to the IOM report, many schools have adopted a prescriptive approach to curriculum design that devalues the ASPH's efforts to maintain a minimum standard of competencies for public health practitioners. For instance, most schools offer MPH degrees with five core courses, a major with a few more core courses and some offer minors requiring a couple more core courses. This leaves almost no room to add attractive electives and tailor the MPH to suit “interesting” jobs.

While the DrPH degree was the primary postgraduate public health degree for the first half of the 20th Century, times changed and in 2003 the IOM felt the need to clarify that the “basic public health degree is the master of public health (MPH), while the doctor of public health (DrPH) is offered for advanced training in public health leadership.” ⁹ The ASPH was in agreement that the DrPH should prepare graduates for evidence-based leadership and practice-based research roles.¹⁷ They stated that the DrPH curriculum should serve to integrate the five core areas of public health, emphasize work experience relevant to the degree, and address learning methods in the context of public health practice. “The DrPH should represent an advanced competency in public health practice and leadership skills, among others.” Figure 2 depicts the ASPH DrPH core competency model published in 2009. The model was offered as a resource and guide with the aim of improving the “quality and accountability of graduate public health education and training, not as a prescriptive model.” Since the ASPH does not prescribe how students achieve the competencies, the implementation of this model varies according to each school's mission and goals for their DrPH program.

Figure 2.

ASPH DrPH competencies.¹⁸

Nevertheless, the ASPH recommends that all DrPH programs contain two key structural elements to ensure minimum standards of professional experience and research capacity.¹⁸

1. Provide opportunities for students to collaborate with experienced public health practitioners through some form of practical attachment so that they can observe and develop advocacy and leadership skills

2. Require a written research thesis/dissertation that addresses, generates, and/or interprets and evaluates knowledge applicable to practice

The research training aspect is required to avoid esoteric and overly theoretical topics and focus specifically on practice-oriented research. This includes “not only the science implicit in academic public health practice, but its application through research, teaching, and service (the art of practice), that builds skill in adapting things in the natural world to improve human life.”¹⁹ In providing these guidelines, the ASPH does not stifle the wide variety of forms in which DrPH education is offered, but simply sets minimum standards. The competency developers intentionally created a non-discipline-specific model so that the competencies can be broadly applied across disciplines. This is a wonderful departure from Roemer's recommendation for a five year, course-based and field-based doctoral program in 1986 which focuses on producing administrators, but which fails to appreciate market needs.²⁰ Roemer's program is better suited for a bachelor-masters sequence with no intention of producing research-capable graduates or administrators that are capable of driving research agendas.

Bearing the target student population in mind, the most appropriate structure for the DrPH in Global and Indigenous Health Leadership is one that is more experiential and research focused rather than classroom focused. The competencies will be imparted in a series of courses that are designed to maximize exposure to external, expert public health practitioners while the research will consist of a significant study on a topic that is of importance to the practice of health policy and management. The duration of the program is also of considerable importance to the targeted student group. Mid-career health professionals are busy people with little additional time available for large pursuits, so the degree must be very flexible and as short as possible. The emerging international standard of three years for completion of the DrPH is required.

Identifying an Appropriate Delivery Model

Given that the students targeted by this DrPH will be, for the most part, working full-time and will have to complete their studies by allocating short blocks of time, a flexible, distance education approach is required to make the degree attractive and realistic. One case that has succeeded in catering to this particular population is notable. The Gillings School of Global Public Health at the University of North Carolina at Chapel Hill (UNC) has developed the world's first executive, three-year, cohort-based, online DrPH. Students remain where they are, working full-time as they complete their degrees, and are only required to make three brief residential visits. Technology and internet connections, even in many developing countries, are now advanced enough to enable live video, audio, and data sharing between instructors and participants. The success of this model has been documented by program evaluations during the past three years and via demonstrated progress of students in the program. Building upon this innovative model, UNC developed the International Network for Doctoral Training in Health Leadership (NETDOC) to accelerate the pace and reach of urgently needed doctoral-level leadership training for senior health professionals around the world by creating an international network of partner programs (http://www.sph.unc.edu/docglobal/).

NETDOC is a global, collaborative network of educational institutions that offer or intend to offer professional distance doctoral program in health leadership.²¹ Its members are committed to sharing objectives, substance and expertise to maximize access to and the quality of doctoral health leadership education worldwide. The urgent call by governments and health authorities worldwide for such an effort has been previously described.²¹ The OPHS at the University of Hawai‘i is a member of NETDOC and embraces its philosophy.

Based on a review of these and several other DrPH programs, including a particularly minimalist one offered by the London School of Hygiene and Tropical Medicine, and a particularly flexible one offered by James Cook University in Australia, the DrPH in Global and Indigenous Health Leadership will adopt a design that provides mid-career health professionals the opportunity to study externally while undertaking a number of experiential courses and completing a research dissertation. As a prerequisite, students are required to have the five core competencies required in accredited MPH programs (or equivalent). Core requirements include a two-year dissertation, two 3-credit, in-house summer seminars in block mode, two 3-credit seminars in distance mode, two 6-credit practica in distance mode (selected from several electives and tailored towards career interests), and a 2-credit methods course.

The process of formulating the new DrPH in Global and Indigenous Health Leadership involved scanning for best practices, focusing on specific market needs, aligning key players, assessing resources and inspiring those who will be expected to play a role in supporting the program. Since many other DrPH programs went through a similar developmental process that drew on approaches from other programs to match particular markets, the result is a lot of very distinct degrees. This is not a problem according to the ASPH DrPH guidelines, but will it be a problem for NETDOC. It is difficult to imagine how this international effort will progress towards its goal of having a shared curriculum structure and shared delivery platforms when so much variety exists.

Summary

The DrPH is a professional doctorate designed to offer specialized training for the rising number of graduates from health-related masters degrees who recognize their need for advanced knowledge and practical skills to succeed in the increasingly complex health policy and management environment. The DrPH in Global and Indigenous Health Leadership will provide a vehicle for this need and takes it to another level through the inclusion of global health and indigenous health perspectives.

Conflict of Interest

The author does not identify any conflict of interest.