Undergraduate public health education: past, present, and future.

The IOM's 2003 report Who Will Keep the Public Healthy? recommended that "...all undergraduates should have access to education in public health." They justified their recommendations stating that "public health is an essential part of the training of citizens." The IOM recommendations have catalyzed a movement linking undergraduate public health education with arts and sciences' Liberal Education and America's Promise (LEAP), an initiative designed to produce an educated citizenry. Schools and programs in public health rapidly adopted the IOM recommendations and efforts to reach the other 1900 4-year colleges and universities are now underway. A November 2006 Consensus Conference on Undergraduate Public Health Education brought together public health, arts and science, and clinical health professions educators. The recommendations of the Consensus Conference supported the development of core undergraduate public health curricula designed to fulfill general education requirement in institutions with and without graduate public health education. Minors built upon required core curricula, utilizing faculty and institution strengths, and providing opportunities for experiential learning such as service-learning were encouraged. A curriculum guide, faculty development program, and multiple presentations, websites, and publications have sought to implement these recommendations. The IOM has recently approved a multi-year Roundtable on Undergraduate Public Health Education to help develop the strategies and collaboration needed to bring these efforts to fruition. Enduring understandings for three core courses-Public Health 101, Epidemiology 101, and Global Health 101-are included to help guide the development of undergraduate public health education.

Evidence-based public health education as preparation for medical school.

The Institute of Medicine has recommended that all undergraduates have access to public health education. An evidence-based public health framework including curricula such as "Public Health 101" and "Epidemiology 101" was recommended for all colleges and universities by arts and sciences, public health, and clinical health professions educators as part of the Consensus Conference on Undergraduate Public Health Education. These courses should foster critical thinking whereby students learn to broadly frame options, critically analyze data, and understand the uncertainties that remain. College-level competencies or learning outcomes in research literature reading, determinants of health, basic understanding of health care systems, and the synergies between health care and public health can provide preparation for medical education. Formally tested competencies could substitute for a growing list of prerequisite courses. Grounded in principles similar to those of evidence-based medicine, evidence-based public health includes problem description, causation, evidence-based recommendations for intervention, and implementation considering key issues of when, who, and how to intervene. Curriculum frameworks for structuring "Public Health 101" and "Epidemiology 101" are provided by the Consensus Conference that lay the foundation for teaching evidence-based public health as well as evidence-based medicine. Medical school preparation based on this foundation should enable the Clinical Prevention and Population Health Curriculum Framework, including the evidence base for practice and health systems and health policy, to be fully integrated into the four years of medical school. A faculty development program, curriculum guide, interest group, and clear student interest are facilitating rapid acceptance of the need for these curricula.

An examination of the growing US undergraduate public health movement.

OBJECTIVES: With over 10,900 public health bachelor's degree graduates conferred in 2015, public health undergraduate education in the USA has become mainstream. However, with the recent establishment of a majority of the programs, the impact of the undergraduate programs remains largely unknown. This study examines a sample of undergraduate programs in public health to further elucidate the undergraduate landscape. METHODS: Semi-structured interviews and a review of program websites from a sample of 39 institutions across the USA with undergraduate majors labeled as public health were conducted in 2015 to examine program content and operations. RESULTS: Findings from the 39 programs reviewed demonstrated growing and diverse undergraduate public health programs rapidly evolving. While program enrollments, infrastructure, and curriculum varied among the individual programs, collectively, findings indicated increasing numbers of undergraduate students gaining knowledge and experience in matters related to the health of societies locally, nationally, and globally. CONCLUSIONS: Study findings suggest it is an opportune time for the field to offer guidance, support, and vision to these burgeoning undergraduate programs. Such engagement offers opportunities to advance the programs as well as increase the number of students attuned to societal health in whatever life roles they assume.

Commentary: Health systems and health policy: a curriculum for all medical students.

A companion article in this issue of Academic Medicine provides an example of a method for electively integrating health systems and health policy issues into medical education. However, a curriculum in health systems and health policy is crucial to the education of all future physicians and other health professionals. The Clinical Prevention and Population Health Curriculum Framework of the Healthy People Curriculum Task Force has recently recommended a health systems and health policy curriculum that includes the domains of organization of clinical and public health systems; health services financing; health workforce; and health policy process. The curriculum should commence prior to year three and continue in years three and four so that students have a framework for integrating and subsequently sharing their experiences. Current Liaison Committee on Medical Education data indicate that on average less than 70% of medical schools require any curriculum in these four domains and only 40% of medical schools include all four of these domains in their required curriculum. Incorporation all of these domains into well-defined, required curricula that are broad in scope has the potential to change the attitudes of future clinicians toward efforts to control costs, collaborate with other health professions, and influence health policies.

Interaction and intervention modeling: predicting and extrapolating the impact of multiple interventions.

PURPOSE: Methods called interaction and intervention modeling are presented. Interaction modeling examines the interactions between variables as the basis for predicting the impact of multiple variables on a target population and on populations with difference distributions of risk factors. Intervention modeling incorporates these interactions and aims to extrapolate the impact of multiple interventions to new populations. The aim is to develop methods that will be useful for modeling and comparing intervention strategies using existing data and standard statistical methods. METHODS: Traditional hypothesis testing methods used for randomized clinical trials and cohort studies and extrapolating the results to new populations are compared with interaction and intervention modeling methods. Interaction and intervention modeling utilizes the same data as the traditional approach but examines the impact of multiple simultaneous interactions and allows extrapolation of the results to populations with different prevalences and distributions of risk factors. An example using real data demonstrates the potential of interaction and intervention modeling to predict the impact of multiple interacting variables and to compare the impact of alternative interventions. RESULTS: The methods outlined take into account the impact of the magnitude of the relative risks, prevalence of risk factors, and interaction of risk variables when predicting the impact on a new population or extrapolating the results of one or more interventions on a new population. Traditional methods that do not take into account interactions are shown to produce different conclusions from the intervention modeling approach that incorporates interactions. The impact of the intervention modeling approach compared with the traditional approach will be quite variable depending on the prevalence of the risk factors and their extent of interaction. CONCLUSIONS: Studies designed to test a hypothesis treat most variables as potential confounding variables adjusting for their impact and their interactions as part of the analysis using traditional regression methods. Interaction and intervention modeling focuses on the interactions themselves and allows comparison of the effectiveness of alternative interventions.

Clinical prevention and population health: curriculum framework for health professions.

The Clinical Prevention and Population Health Curriculum Framework is the initial product of the Healthy People Curriculum Task Force convened by the Association of Teachers of Preventive Medicine and the Association of Academic Health Centers. The Task Force includes representatives of allopathic and osteopathic medicine, nursing and nurse practitioners, dentistry, pharmacy, and physician assistants. The Task Force aims to accomplish the Healthy People 2010 goal of increasing the prevention content of clinical health professional education. The Curriculum Framework provides a structure for organizing curriculum, monitoring curriculum, and communicating within and among professions. The Framework contains four components: evidence base for practice, clinical preventive services-health promotion, health systems and health policy, and community aspects of practice. The full Framework includes 19 domains. The title "Clinical Prevention and Population Health" has been carefully chosen to include both individual- and population-oriented prevention efforts. It is recommended that all participating clinical health professions use this title when referring to this area of curriculum. The Task Force recommends that each profession systematically determine whether appropriate items in the Curriculum Framework are included in its standardized examinations for licensure and certification and for program accreditation.

Reading the research literature. Putting randomized clinical trials into practice. 2.

Randomized clinical trials (RCT) are our best available method for determining whether a treatment works or has what we technically call efficacy. RCTs set out to demonstrate that a particular treatment regimen works better than a conventional standard treatment or placebo, for a particular type of patient, with a particular condition or indication. The results of an RCT are, generally, used by the Food and Drug Administration (FDA) as the basis for approving treatments--especially drug treatments. The approval of a drug generally indicates that at least two independently conducted, randomized clinical trials have demonstrated that the treatment has efficacy for at least one indication. Once a drug is FDA approved, a physician has the authority to prescribe it for the approved, as well as other, indications. However, if used for another indication, a physician may risk a greater liability, should the outcome not be as expected. Unfortunately, RCT conducted for one indication cannot be used to support either the efficacy or safety of the treatment for another indication. Even when used for an approved indication, it is difficult to know what to expect when a new treatment is put into practice. The most difficult part of reading medical literature is to apply or put it into practice--what we call extrapolation. Extrapolation differs from interpretation, which refers to results of patients included in the investigations, while extrapolation asks questions about those who receive the treatment in practice. This important distinction is called effectiveness--when a treatment works in practice, as opposed to efficacy, which indicates it works under the conditions of an RCT. Authors of a randomized clinical trial draw conclusions about effectiveness as well as efficacy, because they are eager to have their successful treatment used and, despite being tempered by the peer review process, are likely to encourage its widespread adoption. Even if the author is not biased toward adopting the treatment, it is important to recognize that you, as the practitioner, know your patients best. Your patients may be quite different from those included in the RCT. Therefore, we need a systematic approach in order to draw conclusions from an RCT and apply them in practice. This paper will take a look at two basic questions in order to apply the results of an RCT. It will ask how large an impact can we expect on average for patients who are different from those in the RCT, and what conclusions can we draw about safety from an RCT?

The effect of birth month on the risk of respiratory syncytial virus hospitalization in the first year of life in the United States.

BACKGROUND: Respiratory syncytial virus (RSV) is the most common cause of severe respiratory illness in infants. To help direct targeted interventions and future RSV vaccine programs, we examined risk of RSV-related hospitalization by infant age and birth month. METHODS: We conducted Poisson regression analyses to evaluate birth month as a risk factor for RSV-related pediatric hospitalizations (identified by any mention of ICD-9-CM diagnosis codes: 466.11, 480.1 or 079.6) from State Inpatient Data in Arizona, Iowa, New York, Oregon and Wisconsin between July 1996 and June 2006. We used an age cohort approach to compute total relative risk of RSV during the first year of life. RESULTS: We identified 82,296 RSV-related infant hospital admissions, corresponding to 13.9 per 1000 person-years among infants <12 months of age. Of these, 42% of the patients were female and 73% were <6 months old. One-month-old infants born in January were ~10 times more at risk for RSV-related hospitalization than 1-month-old infants born in October [relative risk: 9.8 (7.8-12.4)]. Across the first year of life, infants born in December and January had a 2- and 3-fold higher risk, respectively, of an RSV-related hospitalization event than infants born in July. CONCLUSIONS: Birth month and age at admission impacted the risk of RSV-related hospitalization within the first year of life in 5 states we investigated. As RSV vaccine candidates are currently under investigation in clinical trials, our findings help identify ideal RSV vaccine schedules to prevent early and severe events while improving the use of expensive prophylactic drugs.

Undergraduate public health at 4-year institutions: it's here to stay.

Undergraduate public health education at 4-year institutions, those with and without graduate public health education, has grown rapidly during the first decade of the 21st century since the IOM recommended that "all undergraduates have access to education in public health." Much of this growth has been guided by the Educated Citizen and Public Health initiative, a collaboration of arts and sciences and public health educators that encourages introductory course work in public health, epidemiology, and global health plus undergraduate minors and majors in public health. The Educated Citizen and Public Health model, as opposed to existing professional models, envisions core public health education based on the Association of American Colleges and Universities' Liberal Education and America's Promise essential learning outcomes that encourage experiential learning, evidence-based thinking, a global and community focus, plus integration and synthesis. Public health education in this model provides solid generalist grounding for graduate education in public health as well as a range of graduate disciplines from the health professions to international affairs and from law to business. In addition, it helps ensure a broad range of college graduates who understand and support public health approaches. The Healthy People 2020 objective to increase the proportion of 4-year colleges and universities that offer minor or major in public health should help propel additional growth, especially in 4-year colleges without graduate public health education. Integrative curricula designed as part of the reform of undergraduate education provide opportunities to make evidence-based public health approaches available to a large number of undergraduates.

Healthy People 2020 and Education for Health: what are the objectives?

The Education for Health framework is designed as an educational roadmap for Healthy People 2020. It aims to connect the educational phases and suggests overall educational strategies needed to educate health professionals and the public to achieve a healthier America. The framework seeks to develop a seamless approach to prevention and population health education from Pre-K through graduate school. The framework is built on national movements in health literacy, undergraduate public health education and evidence-based thinking. It envisions a coordinated set of learning objectives divided into Pre-K through Grade 12, 2-year and 4-year colleges, and graduate education in the health professions as well as for health education for the community-at-large. The Healthy People Curriculum Task Force, a consortium of eight health professions education associations, has developed the framework and connected the framework with new and revised educational objectives of Healthy People 2020. The Task Force envisions a decade-long process to define and implement specific learning outcomes that can be integrated across the educational continuum. Interprofessional prevention education, in which health professionals learn and practice together, is seen by the Task Force as a key method for implementation. Understanding the roles played by a range of clinical health professions is also essential to communication and understanding. Healthy People 2020 and its new and revised educational objectives provide a vehicle for promoting the discussion and experimentation that will be needed to achieve an integrated and seamless approach to education for health for the American public as well as for health professionals.

Community colleges and public health: making the connections.

Community colleges, in collaboration with public health agencies, can advance public health education by reaching a diverse student body, integrating public health into general education, and providing specialized associate degrees that serve workforce needs. Career ladders that include transferability of coursework to 4-year institutions and continuing education, including certificate programs, are key to success of these efforts. Community, or 2-year, colleges are well positioned to connect components of the Healthy People Curriculum Task Force's Education for Health framework by providing general education core courses in public health, epidemiology, and global health compatible with the educated citizen and public health movement. To serve specific workforce needs, associate degree programs are proposed, including environmental health, public health preparedness, public health informatics, and pre-health education. A generalist option designed for transfer to public health and related majors at 4-year institutions is also recommended.