MCHB EPI Atlanta Conference
 
December 5 - 7, 2006

MCH Epidemiology: Mapping the Future

WILLIAM SAPPENFIELD: Good afternoon. It’s indeed a pleasure to be with you this afternoon. We’re going to need to talk about some fairly basic epidemiology about MCH, and so I want to answer the basic questions of who and what, and I have approximately eight minutes to do that in because we want to save time to have rich discussion by you all. To help answer these questions, CSTE has been launching four major workforce initiatives. Two of which I want to talk about today because they help define some of the who and the what. For those who are not familiar with CSTE, that’s the Council of State and Territorial Epidemiologists. They’re a professional association of epidemiologists at the state, territorial, and local level. They were formed in 1951 as an ASTHO affiliate. Their funding is predominantly individual and state dues and CDC grants, and they actually have a national office here in Atlanta.

To talk about the first question of who, I want to talk about some of the results of the epidemiology capacity assessment. This is an instrument that’s mailed out periodically to state epidemiologists and those in territories to report on their capacity. They’re to include others in their agency who should be imminently involved and might be able to help within the assessment. They talk about the numbers, the training, the activities, the capability, the challenges; and this is going to be some of the earlier results. The 2006 report is expected to be released in the next month. This graph reports a number of epidemiologists working in states. It only reports for 37 to 40 states because when they tried to collect the information on the program areas, they don’t have consistent information all the way across all three periods. If you look at this you can clearly see that -- and these are organized by the highest number -- it’s organized by the highest number in 2001, and clearly the largest number of epidemiologists in state health departments are infectious diseases. Followed next in 2001 by environmental health, that’s had little change. Chronic disease had a large increase in 2004 with a little bit of recession. Bio-terrorism had a large increase with a little bit of flux in money, and then has been stable. But MCH has continued to increase slowly over time due to a lot of the partnership effort here within the state.

However, another way to look at this is not just simply the numbers of epidemiologists, but what is the perceived capacity within state health departments. This is a five-point rating scale. One is none, two is minimal, three is some, four is substantial, and five is full. When you look at this you can see from 2001 we had about 35 percent of states reporting substantial to full capacity to now over half reporting substantial to full capacity. However, at the time of growth and increase it’s very important to note that we’ve also had a very large increase in those who now report no to a minimal. It’s increased from about five percent up to about a little over 20 percent, so one in five states. Now, this is a perception question. So we don’t know if they perceived what they had was now not sufficient, or whether this absolutely represents a decrease in number or size. And it’s one of those questions that the current report is not able to answer, but one that they may want to address.

The second question is what; what is MCH Epidemiology? CSTE has been working on applied competencies to try and help define what it is. Hopefully you all have seen emails and had the opportunity to read and even provide input. This was a developmental process. They pulled an expert panel together over two years. I had the opportunity to participate as a CDC-MCH Epidemiology representative. We had three face-to-face meetings and several conference calls. Early in the process, as we tried to define these competencies, we had public meetings at the CSTE meeting in 2005 as well as APHA to get initial input as we were trying to develop these. We also used web-based technology to get input back from the expert panel, but also, when we tried to validate this from the field, we allow people to respond through this technology. We spent a lot of time focusing on crafting language that reflected the unique aspects of applied epidemiologic practice. It was (inaudible) process. We recognized the proficiency will depend really on the level experience and job expectations. We had some epidemiologists who said, “Maybe I’ll reach all these competencies by the time I retire.” We also spent a lot of time struggling about what is applied epidemiology because we came from fairly different backgrounds. And who is an epidemiologist and who’s not because who that is in infectious diseases is very different than MCH or chronic diseases or one of the other fields. But we worked very hard and used competencies that really stretched across program areas.

To develop a framework, we chose to use a framework that all of public health is defining itself around. It was the framework developed by the council of linkages between academic and public health practices. They use these eight categories of skill domains: analytic assessment, basic public health sciences, communication, community dimensions of practice. To give you an example of how this might look, we looked at the analytic assessment. For applied epidemiology, that would look like the following: identifying public health problems, conducting surveillance, investigating acute and chronic conditions, apply ethical and legal principles, manage data, analyze data, summarize results, recommend evidence-based interventions or control measures, and evaluate programs. This is fairly broad. So we would then drill down to the next level, which would be sub-competencies.

For example, in conducting surveillance, the sub-competencies would look like: designing surveillance for particular public health problems, identifying surveillance data needs, implementing new or revising existing surveillance systems, interpreting key findings, conducting evaluation of surveillance systems. And to go to further specificity, we actually had sub-sub-competencies under each of these. And the reason we did this is people need competencies at different levels, and so we wanted to try and provide a broad overview when programs would need it, but also provide specificity when further was needed.

We also attempted to divide this up into tiers of performance. The first tier being an entry or level position -- entry-level position, recent master’s graduates, bachelors with some degree of experience. A mid-level tier, tier two, that look at masters with experience, doctor of epidemiologist, non-epidemiologist professionals who’ve had epi training. And then on the third level we took two different tracks, one was a supervisory management track, and one was more of a senior scientist researcher track. And with each of these competencies, sub-competencies, and sub-sub-competencies, we got down to that level of decision of who would be functioning at what level.

This is up here just to show you that we did actually go back to the field to actually get input on each of the domains, both for an overall validation of whether they thought it was appropriate or not, and also for individual feedback. We took this information, really spent time trying to make sure the wording was correct, either clarified, added, or changed, and that we are now ready to put these out for the field to start to use; because in competencies, that’s really the next step, to put it out there and get some experience with it. To help do that, we see targeting on three predominant uses. For the practitioner, we’re really talking about addressing current skills, creating clear development plans, planning specific training plans that you might be needing. For employers we could see this helping develop career ladders, position descriptions, training plans, and even assessing the capacity within your own agency. And for educators this could be their use to create educational programs or to focus on content of particular degrees.

And to help on this, we actually have a very clear dissemination plan. Right now we’re doing oral presentations at national meetings, this being one of them, putting out the full information on the CSTE and CDC website, quick reference fact sheets to make it very transportable to tell people about what this is so they can dig in further. We’re working on a tool kit at this time and it not only includes this material but other materials that could help people in using it. And the latter is we’re calling it special issue for public health reports where we hope to collect articles and actually get this published into the literature for peer review process.

Both of these provide some very important points as we get ready to have our discussion that I thought we ought to put it on the table today. First, that we’re having a very remarkable increase in state capacity, but we need to be aware that not everybody is increasing, and some may in fact be having a decreasing capacity. Second, that we actually are having some applied competencies for the field of epidemiology that have been defined and will be applied as a whole, and that many of them are very applicable to us. The third thing is that CSTE is emerging as an applied epidemiology leader for the entire field, setting up processes to monitor the capacity, defining what competencies are, and with their new Fellows program actually equipping epidemiology departments out in the field. And fourth, CSTE has been including us as one of their program areas, but we’re sort of not (inaudible) CSTE, and we need to stay involved in this process as we start to define further what epidemiology is. Thank you.