Doctor of Public Health Education and Training

In 1919, the American Public Health Association Committee of Sixteen on the Standardization of Public Health Training first recognized the doctor of public health (DrPH) degree as advanced training for physicians in sanitary engineering.¹ This degree was generally considered a professional degree, as opposed to a doctor of philosophy (PhD) degree, which was considered an academic degree. Since then, the DrPH degree has increased in importance. In 1986, Roemer described the DrPH degree as an “extensive battery of courses based on professional public health knowledge and integrated with extensive supervised field experience as part of academic training linking theory with practice.”² Today, the Council on Education for Public Health (CEPH) requires that, to be accredited, schools and programs of public health must award the master of public health (MPH) degree and at least 1 doctoral degree relevant to 1 of 5 areas of basic public health knowledge: epidemiology, biostatistics, environmental health, social and behavioral sciences, and health policy and management. Accredited schools and programs of public health address the doctoral requirement by offering a PhD degree, a DrPH degree, or both (unpublished interim report, draft criteria, CEPH, February 1, 2016).

As the DrPH degree has increased in importance, it has evolved as a solution to a perceived gap between public health research and practice. The landmark Institute of Medicine report in 1988, The Future of Public Health, identified the chasm between schools/programs of public health and public health practice and promoted the need to integrate research science into public health practice. The report recommended that public health education emphasize practice and equip graduates with the knowledge and skills needed to confront the scope and breadth of public health.³ Armed with knowledge from evidence-based research combined with leadership skills, future graduates of DrPH programs should have the skills needed to implement interventions at the community level.

In the years after the 1988 report was published, the DrPH degree has stood as a way to fulfill the chasm between research and practice by emphasizing public health leadership. Indeed, in a follow-up to the 1988 report published by the Institute of Medicine in 2003, Who Will Keep the Public Healthy?, Gebbie et al referred to the MPH degree as a basic public health degree and the DrPH degree as advanced training in public health leadership.⁴

In line with this view, the prescribed competencies for DrPH graduates—developed in 2009 by the Association of Schools and Programs of Public Health (ASPPH)—are advocacy, communication, community and cultural orientation, critical analysis, leadership, management, professionalism and ethics, and policy analysis and development.⁵ In 2014, an expert panel appointed by ASPPH published Framing the Future: DrPH for the 21st Century, which presented a vision for the DrPH graduate as “a transformative leader with expertise in evidence-based public health practice and research who is able to convene diverse partners and communicate to effect change across a range of sectors and settings.”⁶

Various surveys of DrPH programs in the United States have tracked the evolution of the DrPH degree. The first was by Venezia in 1993, who discovered substantial diversity in curricular format, structure, and content.⁷ More recent studies also have examined changes in the DrPH degree. Declercq et al described changing sociodemographic trends in the education of DrPH students from 1985 to 2006 and identified rapid growth in enrollment.⁸ In 2009, a survey of associate deans in schools and programs of public health conducted by Lee et al identified issues related to defining the field and continued growth and proliferation of DrPH programs, nationally and internationally. The most prominent challenges identified were integration and acceptance of professional doctoral curricula within traditional research-oriented university environments and garnering commensurate respect.⁹

According to ASPPH data, the number of accredited schools and programs of public health with students in DrPH programs increased from 18 in 2000 to 38 in 2015, reflecting in part the increase in the number of schools and programs of public health. After remaining steady from 1985 to 2002, the number of students in DrPH programs has more than doubled, growing from 605 students in 2002 to 1526 students in 2015 (Figure). The number of students graduating with DrPH degrees reached a new high during 2014-2015, when 204 students graduated with a DrPH degree, the highest number to date (unpublished data, ASPPH annual reports).

Figure.

Number of DrPH students enrolled in CEPH-accredited schools and programs of public health in the United States, 1985-2014. Source: Association of Schools and Programs of Public Health annual data reports. Figure includes Tulane University’s 2004 data for 2005. Abbreviations: CEPH, Council on Education for Public Health; DrPH, doctor of public health.

We conducted a survey to further describe the evolution of DrPH programs by examining the range of curricula and teaching models that have emerged since the survey conducted by Lee et al in 2009. Our data provide the latest complete information on DrPH preparation and can help to lay the groundwork for future conversations about criteria and standards for DrPH education and training.

Methods

We compiled a list of potential participants from contacts in accredited schools and programs of public health identified through ASPPH, representatives at annual DrPH directors meetings held at ASPPH meetings and American Public Health Association meetings, and an online review of existing DrPH programs. In August 2014, we emailed a link to an electronic survey to 103 recipients representing 38 accredited schools and programs of public health in North America, including 1 program in Mexico. We emailed the survey to >1 recipient for schools and programs that had DrPH programs housed within multiple departments. Recipients were asked to respond through SurveyMonkey.¹⁰ We sent follow-up emails every 3 weeks from August through October 2014.

If multiple people from the same program responded to the survey, we used responses from the respondent who provided the most complete information. We calculated frequency statistics for each survey question for each school or program of public health and based results on all respondents. Where the proportion of missing information was >20%, we excluded those questions from analysis. Whereas the 2009 and 2012 surveys defined the field and distinguished the DrPH and PhD degrees from each other, we focused on the breadth and depth in variation among DrPH programs in curricular structure and content.

After reviewing the previous survey by Lee et al, we added, removed, and/or reworded questions to fit the intent of our survey.⁹ The revised survey contained 129 closed-ended questions, grouped into multiple categories: respondent information, program background, admissions, curriculum, practicum requirements, comprehensive examination, program faculty, student support, dissertation, attrition, and information about graduates’ career tracks. Open-ended questions covered the following topics: how directors interpreted Graduate Record Examinations, requirements for field practicum experiences, and current positions of employment held by graduates. The study received a determination of exempt from the University at Albany Institutional Review Board.

Results

Respondent Information

Of the 103 people who received the survey, 40 deans and directors of DrPH programs responded, representing 28 of the 38 schools and programs of public health that offered a DrPH degree in 2014. Of the 40 respondents, 20 were aged 45 to 64 (age range for all respondents, 35 to >70). Twenty-one respondents were men, 37 were white, 35 were non-Hispanic, and 26 were born in the United States. Of those born outside the United States, 4 respondents reported their country of birth as the United Kingdom, and 1 respondent each came from various countries (Table 1). The most frequently reported academic backgrounds of DrPH program directors were behavioral and community health (n = 6), health policy and management (n = 6), and epidemiology (n = 4). Only 6 respondents held a DrPH degree.

Table 1.

Demographic characteristics of deans and directors who responded to a survey of CEPH-accredited DrPH programs in North America, 2014

Demographic Characteristics	Respondents, No. (%)
Totala	40 (100)
Age, y
35-44	5 (12)
45-54	9 (23)
55-64	11 (27)
≥65	7 (18)
Missing	8 (20)
Sex
Male	21 (53)
Female	18 (45)
Missing	1 (3)
Race
White	37 (93)
Missing	3 (7)
Ethnicity
Hispanic	2 (5)
Non-Hispanic	35 (88)
Missing	3 (8)
Country of birth
United States	26 (65)
United Kingdom	4 (10)
Canada	1 (3)
Cuba	1 (3)
Egypt	1 (3)
Ireland	1 (3)
Jordan	1 (3)
Mexico	1 (3)
Switzerland	1 (3)
Missing	3 (8)

Abbreviations: CEPH, Council on Education for Public Health; DrPH, doctor of public health.

^aA total of 103 people (representing 38 schools and programs of public health) were contacted, and 40 responded (representing 28 schools and programs of public health).

Program Background

Eighteen programs were launched between 2000 and 2010. Of the 28 respondent programs, 13 were department-based formats (ie, separate departments offered their own DrPH degree), and 13 were schoolwide formats (ie, offering a central DrPH degree; Table 2). When the program had a department-based format, the most frequently reported home departments were behavioral and community health (n = 6), health policy and management (n = 6), biostatistics (n = 5), and epidemiology (n = 5). Twenty-five programs offered PhD or other doctoral-level degrees in addition to the DrPH degree. Twenty-two programs offered on-campus instruction with full- and part-time options. The most frequently reported time to course completion in the on-campus format was 1 to 3 years for full-time students and 3 to 5 years for part-time students. The modal reported time to degree completion for full-time students in the on-campus format was 3 to 5 years and for part-time students, 4 to 7 years. Five schools offered DrPH curricula in an online distance learning format, 4 of which offered a part-time option.

Table 2.

Findings from a survey of CEPH-accredited DrPH programs in North America, 2014

Variable	DrPH Programs, No. (%)
Total surveyed programs with responsea	28 (100)
DrPH program history
Year program launched
1970-1979	3 (11)
1980-1989	0 (0)
1990-1999	2 (7)
2000-2014	18 (64)
Missing	5 (18)
DrPH program department based or schoolwide
Department based	13 (46)
Schoolwide	13 (46)
Missing	2 (7)
DrPH program is offered in on-campus/face-to-face format
Yes	25 (89)
No	2 (7)
Missing	1 (4)
Program type for on-campus formatb
Full-time only	2 (8)
Part-time only	1 (4)
Both	22 (88)
DrPH degree available in distance-learning/online format
Yes	5 (18)
No	22 (79)
Missing	1 (4)
Admissions
Fall-only or rolling admissions
Fall only	24 (86)
Rolling	2 (7)
Other	1 (4)
Missing	1 (4)
Master of public health degree required
Yes	15 (54)
No	12 (43)
Missing	1 (4)
Graduate Record Examination required
Yes	21 (75)
No	4 (14)
Missing	3 (11)
Number of years of public health work experience required
0	12 (43)
1-2	7 (25)
≥3	6 (22)
Missing	3 (11)
Currently matriculated international students
Yes	24 (86)
No	1 (4)
Missing	3 (11)
Curriculum
Total semester credit hours of coursework required
<45	3 (11)
45-54	7 (25)
55-64	9 (32)
≥65	4 (15)
Missing	5 (18)
Allow transfer of previous degree credits
Yes	9 (32)
No	16 (57)
Missing	3 (11)
DrPH curriculum directly addresses ASPPH DrPH competencies
Yes	21 (75)
No	3 (11)
Missing	4 (14)
Practicum
Field practicum, internship, or residency required
Yes	22 (79)
No	4 (14)
Missing	2 (7)
Comprehensive examination
Comprehensive or qualifying examination required
Yes	24 (86)
No	2 (7)
Missing	2 (7)
Written or oral format
Written only	8 (29)
Oral only	0 (0)
Both	16 (57)
Missing	4 (14)
Dissertation
Dissertation committee required
Yes	24 (86)
No	4 (14)
Formal written or oral proposal for dissertation required
Yes	24 (86)
No	4 (14)
Formal written or oral defense of completed dissertation required
Yes	24 (86)
No	4 (14)

Abbreviations: ASPPH, Association of Schools and Programs of Public Health; CEPH, Council on Education for Public Health; DrPH, doctor of public health.

^aThirty-eight schools and programs of public health were surveyed, and 28 responded.

^bBased on 25 programs that indicated having an on-campus format.

Admissions

Twenty-two DrPH programs used the School of Public Health Application Service alone or in conjunction with a separate application procedure for admissions. In 21 institutions, the admissions process for acceptance into the DrPH program was separate from the admissions process for PhD candidates. Twenty-four institutions admitted students only in the fall. Fifteen institutions required an MPH degree as a prerequisite for admission. Those with non-MPH graduate or professional degrees were required to complete 5 MPH core courses as prerequisites. Twenty-one DrPH programs required the Graduate Record Examination (Table 2). Other required or accepted tests included the Medical College Admission Test (n = 4), Law School Admission Test (n = 2), and United States Medical Licensing Examination (n = 1).

Twenty-four institutions accepted international students, and evaluation of their previous academic work was identical, with the exception of also requiring the Test of English as a Foreign Language examination. In 22 responding institutions, an interview was required for either all applicants (n = 7) or selected applicants (n = 15). Twenty-six institutions required letters of reference for admission, usually from 3 or 4 academic or professional contacts. Twenty-five institutions required a statement of purpose and a writing sample, particularly from international students whose first language was not English.

Concerning priorities for admissions decisions, directors most frequently cited previous academic performance and grade point average, Graduate Record Examination scores, a statement of purpose, a writing sample, previous experience, references, and leadership potential. Fifteen institutions reported increases in the number of applications in the previous 5 years, and 24 institutions reported that applicant quality was either stable or improving.

Curriculum

The total number of semester credit hours of coursework beyond the master’s level varied widely (range, 36-70). Sixteen institutions did not allow transfer of credits toward the DrPH degree from previous MPH or master of science degrees. Twenty-one respondents said the DrPH curricula directly addressed the DrPH core competencies of ASPPH. The most frequently mentioned required courses for degree completion included epidemiology, biostatistics, research methods, DrPH seminar, leadership, and management. Twenty-one institutions offered at least 1 seminar for DrPH students only. The proportion of total credit hours dedicated to DrPH required courses (not electives) varied widely, from none to >80%.

Practicum

Only 4 programs did not require a field practicum, internship, or residency. Twenty-two programs did not waive the credit requirement based on previous experience. The total number of hours of on-site work participation required for practicum experiences varied widely, from 100 to >900 hours. Of the 22 programs that required practicum experiences, 14 stipulated that the practicum be separate from students’ current employment duties or roles.

Comprehensive Examination

Of the 28 DrPH programs, 24 required a comprehensive or qualifying examination. Half used a format that consisted of a common examination for all students. The most frequently reported content areas included the DrPH core competencies: biostatistics, epidemiology, health promotion and behavior, and community/cultural orientation. Sixteen institutions reported that the examination combined written and oral components, and 16 used a take-home format. The amount of time permitted to respond to the examination questions ranged from <24 hours to 1 month.

Dissertation/Culminating Experience

Twenty programs labeled their DrPH doctoral project a dissertation. The most frequent format was the traditional chapter-based dissertation and/or publishable manuscript. The most frequently reported content requirements were original data collection and/or secondary data analysis. Twenty-four institutions required a dissertation/culminating experience with a committee comprising 2 to 5 members. In most instances, core committee members were required to be university faculty. Twenty-four schools also required a formal oral and/or written presentation of the proposal and a formal oral and/or written defense of the completed dissertation. Only 4 programs had moved away from the traditional dissertation model in favor of culminating practical experiences and competencies. These programs replaced the traditional dissertation with a portfolio.

Discussion

This survey provides a snapshot of DrPH programs in 2014. Our study found that, by 2014, most programs had incorporated DrPH core competencies into curricula with specific learning objectives and had developed training that emphasized leadership. Admission criteria typically required an MPH or other master’s degree and at least 2 years of professional experience. Programs typically operated in an on-campus in-person format and included full- and part-time options. Field practicum experiences had to be independent of student employment, with written and oral comprehensive examinations being followed by a dissertation or portfolio. Most programs offered a DrPH seminar designed for DrPH students.

A noteworthy result was the degree of diversity of structure and content of curricula beyond the master’s and DrPH cores. In particular, the greatest range of responses pertained to (1) total credit hours required; (2) total practicum hours required; (3) format, content, and administration of comprehensive examinations; and (4) culminating written product. This finding once again identified the continuing challenge to clearly articulate the essence and purpose of the DrPH degree and which skills and competencies to recommend for cultivation going forward.

The revelation that so few DrPH program directors had DrPH degrees suggests that future generations of public health professors need to include DrPH graduate prodigies. Although the DrPH degree originated in North America, the number of institutions offering DrPH degrees has grown steadily in Europe as well.¹¹ CEPH-accredited and non-CEPH-accredited schools, programs, and universities offer the DrPH degree in the United States. Because professional degrees typically embrace more standardized curricula when compared with more traditional academic degrees, the patterns currently illustrated by established DrPH programs in CEPH-accredited schools and programs of public health offer a model to guide future development of new programs around the globe as well as to inform ongoing revision of CEPH criteria.

The major strength of this survey is that it describes current experiences in DrPH programs based on information collected from CEPH-accredited schools, programs, and universities granting DrPH degrees in North America. DrPH directors developed the survey by using questions about a broad range of topics related to the conferral of DrPH degrees. The diversity and range of responses from programs—small and large, full- and part-time, on- and off-campus—suggest that the survey, at a minimum, captured the full range of DrPH experiences in schools and programs of public health. There is a growing need to increase recognition and respect for the DrPH degree around the world as a moniker that evokes leadership, scholarship, and teaching. Our findings could not be more relevant or perfectly timed. The current undertaking by CEPH to develop new criteria for the DrPH degree can greatly benefit from information presented in our study. Future surveys of DrPH programs should continue to document the degree to which DrPH curricula have adopted and integrated core doctoral competencies and common learning objectives to determine if the curricula lead to greater standardization and improvement of the DrPH degree.

Conclusion

The recent rapid increase in the number of DrPH programs and students reflects a growing curiosity about public health doctoral education, to train not only academic researchers but also multiskilled practitioners for leadership around the world. As public health challenges become more global and complex, requiring comprehensive systems approaches to address entrenched problems, schools and programs of public health must prepare the next generation of leaders, which can lead only to an even greater need for DrPH graduates.