The Changing Pattern of Doctoral Education in Public Health From 1985 to 2006 and the Challenge of Doctoral Training for Practice and Leadership
By Declercq, Eugene Caldwell, Karen; Hobbs, Suzanne Havala; Guyer, Bernard
We examined trends in doctoral education in public health and the challenges facing practice-oriented doctor of public health (DrPH) programs. We found a rapid rise in the numbers of doctoral programs and students. Most of the increase was in PhD students who in 2006 composed 73% of the total 5247 current public health doctoral students, compared with 53% in 1985. There has also been a substantial increase (40%) in students in DrPH programs since 2002. Challenges raised by the increased demand for DrPH practice- oriented education relate to admissions, curriculum, assessment processes, and faculty hiring and promotion. We describe approaches to practice-based doctoral education taken by three schools of public health. (Am J Public Health. 2008;98:1565-1569. doi:10. 2105/ AJPH.2007.117481)
THERE HAS LONG BEEN concern expressed in research and commentaries about how best to train experienced public health professionals for leadership positions.1 Several themes have emerged in the past two decades from this literature, including the need to incorporate new subject matter (e.g., informatics, genomics, ethics) into public health education2; the need to meet training3 and continuing education needs, including possible certification of the large proportion of the public health workforce without formal training in public health4; and the need to more thoroughly integrate practice skills into public health education, particularly in master of public health (MPH) programs.5 At the same time, there has been rapid growth in the number of and enrollments in schools of public health, with the total number of public health students more than doubling between 1985 (n=9494) and 2006 (n=20907).6
There has also been a substantial increase in the number of students seeking doctorates in public health. We examined trends in doctoral education in public health with particular attention to the doctor of public health (DrPH) degree and the challenges associated with developing doctoral-level, practiceoriented degree programs. Data for this commentary have been drawn from the annual reports of the Association of Schools of Public Health (ASPH).7 These reports contain a compilation of data supplied by every accredited school of public health on the characteristics of applicants, students, and graduates. Data are summarized by ASPH staff overseen by a data advisory committee comprising deans and staff at schools of public health.
THE GROWTH OF DOCTORAL EDUCATION IN PUBLIC HEALTH
Between 1985 and 1995, there was a slight increase in the number of ASPH-accredited schools of public health (from 24 to 27) and doctoral programs (from 21 to 25; Table 1). However, there was a 59% growth in the total number of doctoral students and a 33% increase in average program size. Between 1995 and 2006, the number of schools increased by 37%, whereas the number of doctoral students increased by 64%.
Virtually all of the increase in students from 1995 to 2006 was generated by the development of additional doctoral programs, with average program size staying the same between 2000 and 2006 (Table 1). Seven more DrPH programs and nine more PhD programs existed in 2006 compared with 1995. The overall addition of 12 schools with doctoral programs included 11 new schools, two new doctoral programs at existing schools-Emory University Rollins School of Public Health (PhD) and University of Puerto Rico Graduate School of Public Health (DrPH)-and the loss of the University of Hawaii School of Public Health. Of the 11 new schools, five offered only a DrPH program (University of Arkansas for Medical Sciences Fay W. Boozman College of Public Health, Drexel University School of Public Health, George Washington University School of Public Health and Health Services, New York Medical College, and University of North Texas Health Science Center School of Public Health), three had only a PhD program (University of Arizona Mel and Enid Zuckerman College of Public Health, University of Iowa College of Public Health, and Ohio State University College of Public Health), and three offered both (University of Kentucky College of Public Health, University of Medicine and Dentistry of New Jersey- School of Public Health, and Texas A&M Health Science Center School of Rural Public Health).
Rapid overall growth in the number of doctoral students since 1985 has come almost entirely from PhD programs (Figure 1). Although PhD students made up slightly more than half (53%) of all public health doctoral students in 1985, they accounted for almost three fourths (73%) of the total by 2006. The number of doctor of science (ScD) students reached an all-time high in 2001 (509 students) but has decreased since to only 369 students in 2006.
Over the course of the past two decades, the number of DrPH students has fluctuated, with an early peak of 755 students in 1992 and a low of 569 students in 1996, increasing to 702 in 2000, then declining again to 605 in 2002. The number of DrPH programs was relatively stable between 1985 and 2000, and causes of this pattern are unclear. From 2002 to 2006, however, the number of DrPH students increased by 40% to 846 DrPH students, and the growth in the number of DrPH programs suggests this increase is likely to continue. This growth also comes at a time when the number of DrPH graduates (72 in 2003; 129 in 2006) has increased rapidly.
The increase in DrPH students from 2002 to 2006 was the result of adding students in new programs at University of Kentucky College of Public Health (n=52), Drexel University School of Public Health (n=26), Boston University School of Public Health (n=24), University of Arkansas for Medical Sciences Fay W. Boozman College of Public Health (n=14), New York Medical College School of Public Health (n=8), and Texas A&M Health Science Center School of Rural Public Health (n=5), as well as increases in DrPH students in some existing programs, specifically Johns Hopkins Bloomberg School of Public Health (+34), Loma Linda University School of Public Health (+27), University of Alabama at Birmingham School of Public Health (+19), University of Pittsburgh Graduate School of Public Health (+18), and University of North Carolina at Chapel Hill School of Public Health (+18). These increases were somewhat offset by major declines in DrPH students at Harvard School of Public Health (-17) and Columbia University Mailman School of Public Health (-14).
The annual ASPH reports also present limited background data on doctoral students, and in 2006, DrPH and PhD students in public health differed markedly. The DrPH students were much more likely than were PhD students to attend classes on a part-time basis (52% vs 26%) and to be a race or ethnicity other than White (43% vs 29%). The PhD students were more likely to be foreign born (26% vs 18%). There were no differences by gender (68% women in each case).7
The programmatic distribution of public health doctoral students (Table 2) has changed in the past decade, although the extent to which the changes represent shifts in program interest or merely shifts in program names (e.g., from Health Services to Health Policy and Management) is unclear. Almost half of PhD students (44%) were registered in epidemiology or biostatistics programs during each period. In the case of DrPH students, the major change was in health education and behavioral sciences programs, which accounted for 16% of DrPH students in 1995 compared with 28% in 2005.
CHALLENGES OF PRACTICE-ORIENTED DRPH EDUCATION
Three interesting trends emerged from this brief examination of doctoral study in public health. The first was the rapid growth in public health doctoral students, with numbers increasing at a rate even faster than the substantial growth in MPH students during the same period. The second is the overall dominance of the PhD degree as the doctoral degree of choice in schools of public health, with 73% of all public health doctoral students now enrolled in PhD programs. The third is the recent (2002-2006) and rapid growth (40%) in the number of DrPH students. The increase in public health doctoral students is likely to continue as the number of those graduating with an MPH (4392 in 2006 compared with 2803 in 1995) grows.7
Although there is clearly demand for doctoral education in public health, schools of public health now must determine the content of their doctoral curriculum. 8 For those seeking a PhD in a research field (epidemiology, biostatistics, health services, and environmental sciences accounted for 71% of all PhD students), the development of highly skilled researchers is a difficult but fairly straightforward process. In a sense, this is what faculty do best- mentor students to become future public health faculty.
The DrPH programs that emphasize training in leadership and practice face a different challenge. Although a large proportion of DrPH students (44%) were in research skills areas (epidemiology, biostatistics, health services, and environmental sciences), most programs emphasize advanced, practice-oriented training. The Council on Education for Public Health requirements and the accreditation process make clear to schools the content requirements for master’s degree programs. However, the only requirement associated with doctoral programs is that schools must offer at least three doctoral degree programs related to any of the five core areas of graduate public health education.9 Several challenges arise for DrPH programs interested in emphasizing practice skills and leadership. First, who should be admitted to a practice-oriented doctoral program? At the MPH level, public health education has shifted from a concentration on clinicians and midcareer public health practitioners to significantly younger students, often including those directly out of undergraduate institutions.10 Evaluation of applicants at the MPH level resembles that of other professional schools, with an emphasis on grades, scores on standardized tests, essays, and letters of recommendation. The DrPH programs that emphasize practice use the same metrics, but they typically also consider a student’s experience in the field. How does one assess public health experience and potential for leadership and weigh that against intellectual ability and classroom skills?
Second, what do we mean by training for leadership in policy and management?11 Schools claim to address these issues in the master’s- level curriculum, but what higher-level training in these areas means is unclear. It is unlikely that leadership skills can be taught didactically. How much emphasis should be placed on research and statistical skills? Schools of public health are organized to provide research training, but does a public health commissioner or the director of a nongovernmental organization need to be a skilled SAS programmer? The challenge for schools of public health is to seriously address the question of how much of what we offer in a DrPH program is the result of the needs of the field and how much is a repackaging of our research training. Related to this question is the third challenge: What are the appropriate assessment tools for leadership and practice? What is the appropriate format for a comprehensive examination? What criteria define a doctoral-level practicum? What do we mean by an applied or “practice-relevant” dissertation?
Finally, schools face a fourth serious challenge as they implement practice-oriented DrPH programs: Who will teach in them? The problem was anticipated in the 2003 Institute of Medicine report, Who Will Keep the Public Healthy? 3 The report recommended major changes in the criteria used in hiring and promoting school of public health faculty, rewarding “experiential excellence in the classroom and practical training of practitioners.” 3(p127) Building a practiceoriented faculty involves a change in the current culture of schools of public health, where research is the primary source of revenue. Recruiting practitioners as public health faculty also raises challenges in identifying individuals who are truly committed to full-scope teaching in a contemporary graduate setting, as well as establishing criteria for their tenure and promotion.
THREE APPROACHES TO DOCTORAL-LEVEL, PRACTICE-ORIENTED EDUCATION
Starting a New DrPH Program at Boston University
The Boston University School of Public Health 1999 Strategic Plan included the objective, “Develop an interdisciplinary DrPH degree,” which would complement four existing, department- based, researchoriented doctoral programs. The program would involve three different departments: International Health, Maternal and Child Health, and Social and Behavioral Sciences. A faculty committee with representatives from all departments in the school developed the program over a four-year period, and the first nine students were admitted in the fall of 2004.
Several key decisions were made in implementing the program. To acquire experienced students, the program requires applicants to have a master’s degree and at least three years of practice experience. The school-wide program involves the three departments noted previously but is centrally administered. With regard to curriculum, although using existing courses would have decreased startup costs, it was felt that a new, integrated curriculum that emphasized management and leadership would be more appropriate (a summary of the curriculum is available at http:// sph.bu.edu/drph).
Also, rather than having students study how to develop a major research project, the program emphasizes public health practice and focuses on how to run organizations, necessitating the identification of practice-oriented faculty. To link assessment to practice, the comprehensive examination is a case study requiring students to develop a plan in response to a problem. The dissertation, although it involves rigorous research, has to be applicable to contemporary public health settings, and a practicum emphasizing leadership training is required, regardless of prior experience. The biggest challenges faced thus far have been finding financial support for students, because they are not eligible for most traineeships that emphasize research careers, and recruitment of appropriate faculty to teach high-level management courses.
Developing an Online DrPH at the University of North Carolina
The nation’s first executive doctoral program in health leadership was launched in August 2005 by the Department of Health Policy and Administration at the University of North Carolina, Chapel Hill, School of Public Health. The three-year, cohort-based distance program prepares midcareer professionals for top positions in organizations working to improve the public’s health. The program confers a DrPH in Health Administration. Students may be based in the United States or abroad, providing they have access to highspeed Internet services.
One new cohort is admitted annually and each comprises 10 to 12 diverse individuals from a wide range of academic backgrounds and experience in traditional and nontraditional settings. Coursework is completed in the first two years and the dissertation in year three. Students come to Chapel Hill three times per year, for three to four days each time, in years one and two. Between visits, learning occurs from students’ homes and offices off campus. Students communicate with their cohort, faculty, and guest discussants by using stateof- the-art computer technology that supports live video, audio, and data sharing.
The executive program replaced a freestanding, interdisciplinary, residential DrPH program that, for 12 years, admitted applicants via several departments in the school. An ongoing challenge of the residential program was finding midcareer professionals able and willing to leave their jobs to return to school. In late 2002, the administrative home of the program was transferred to the Department of Health Policy and Administration, because most students in the residential program matriculated through that department. The transition from residential to distance format was aided considerably by the department’s extensive experience in distance education dating back to the 1970s and by its close working relationship with the school’s information technology experts.
All aspects of the DrPH program were reworked, including the pedagogical approach, admissions policies, curriculum, course content, and dissertation design, and the residential program was dissolved in 2004. As of 2007, a total of 30 students have been admitted in three cohorts. The number of highly qualified applicants has exceeded the capacity to admit. Details about the executive program are available at: http://www.sph.unc.edu/hpaa/ executive_drph.
Revamping an Existing DrPH Program at Johns Hopkins
The DrPH program at Johns Hopkins Bloomberg School of Public Health evolved over a period of 10 years from a doctoral degree that was virtually indistinguishable from the research PhD to a doctorate focused on public health practice and leadership. That transition was codified in 2005 by the definition of educational objectives, eligibility, degree requirements, and the conditions for a part- time degree program.
The DrPH degree is unique in being a hybrid departmental and school-wide program. The departments that offer the degree (Environmental Health Sciences; Epidemiology; International Health; Health Policy and Management; Population, Family, and Reproductive Health) define all disciplinary requirements and provide the specialized course work in the field as well as supervision of dissertation research. The school-wide program defines common school- wide requirements, including those in leadership and other crosscutting areas.
The greatest challenge to the DrPH program has been clarifying the distinctions from the PhD program while maintaining the standards for rigor that ensure equality between the two doctoral degrees. The PhD is a fulltime degree that prepares students for independent careers as research scientists and teachers. To accomplish this, the program is entirely departmentally based and emphasizes disciplinary skills and knowledge. Table 3 shows the way the distinctions and similarities are presented to faculty and students.
The DrPH, in contrast, can be a full- or part-time program that applies analytic skills to the solution of real-world public health problems. The DrPH applicants are admitted with at least three years of public health experience as well as an MPH or equivalent master’s degree. They maintain their connections to the practice world through their faculty mentors; involvement of practitioners in their comprehensive, preliminary oral, and final defense exams; and participation in a year-long DrPH seminar that emphasizes leadership, the history and theory of public health practice, professional communication, and translation of research to practice and policy. The latter seminar is taught by the director of the DrPH program and guests from the practice world. The DrPH program continues to respond to requests for innovative part-time opportunities and for a distance-education version of the degree. The greatest challenge to developing these alternatives is convincing the full-time academic faculty that it is possible to maintain the high standards of analytic skills and disciplinary course work in such for- mats. In addition, the program is continually challenged to recruit practicebased faculty into an environment that is heavily research based and soft-money funded.
No one disputes the need for training the next generation of public health leaders,13 and demand for such training is high among potential doctoral students. A key component of such training must include preparation for leading in a fast-changing environment. The challenge to schools of public health is to practice what they preach and to adapt DrPH program admissions criteria, curriculum, and student assessment processes-as well as faculty promotion and tenure policies-to better support the preparation of future public health leaders.
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Eugene Declercq, PhD, Karen Caldwell, MPH, Suzanne Havala Hobbs, DrPH, RD, and Bernard Guyer MD, MPH
About the Authors
At the time of the study, Eugene Declercq was with the Maternal and Child Health Department of the Boston University School of Public Health, Boston, MA. Karen Caldwell was with Management Sciences for Health, Cambridge, MA. Suzanne Havala Hobbs was with the Department of Health Policy and Administration, University of North Carolina, Chapel Hill. Bernard Guyer was with Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Requests for reprints should be sent to Eugene Declercq, PhD, Professor, Maternal and Child Health Department, Assistant Dean for Doctoral Education, Boston University School of Public Health, 715 Albany St, Boston, MA 02118-2526 (e-mail: firstname.lastname@example.org).
This commentary was accepted October 24, 2007.
E. Declercq originated the commentary, analyzed the data, and wrote the first draft. K. Caldwell collected and organized the data. S. H. Hobbs wrote the profile of the Doctor of Public Health (DrPH) program at University of North Carolina at Chapel Hill. B. Guyer wrote the profile of the DrPH program at Johns Hopkins University. All authors reviewed and contributed to the final draft of the commentary.
The authors wish to acknowledge the help of staff at the Association of Schools of Public Health, particularly Kalpana Ramiah, Mah-Sere Keita Sow, Kristin Dolinski, and Elizabeth Weist for their help in accessing and checking the data. Ned Brooks at the University of North Carolina, Chapel Hill, also assisted with the preparation of that institution’s profile.
Copyright American Public Health Association Sep 2008
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