Practicing Epidemiology at the Local Level: Conversations about Capacities, Priorities, and Gaps

Paul Etkind, DrPH, MPH

Senior Director of Infectious Diseases

National Association of County and City Health Officials

June 4, 2012

Thanks to the following co-investigators

Gretchen Weiss, MPH Analyst, NACCHO

Robert Kim-Farley, MD, MPH Director, Communicable Disease Control and Prevention, Los Angeles County Department of Public Health

Michael Coletta, MPH Lead Informatics Analyst, NACCHO

Presentation Outline

• Background

• Methods

• Results

• Limitations

• Discussion/Conclusions

Background

• Public health epidemiology capacities at the state level have been measured and characterized for more than a decade by CSTE.

• Assessments of public health epidemiology capacities at the local health level have not been undertaken, for reasons including:

o The absence of a registry for epidemiologists working at this level.o Difficulties identifying who is an epidemiologist due to the variety of job titles

used for those who perform epidemiological tasks.

Background

• In 2010, NACCHO received funding to help improve the capacity of local health departments (LHDs) to continuously and systematically collect, analyze, and interpret health-related data needed to plan, implement, and evaluate public health practice.

• As a first step, NACCHO conducted key informant interviews to develop a sense of the realities, challenges, and needs of practicing epidemiology at the local public health level.

Methods

• Two samples were selected.

1. Formally trained epidemiologists

2. Experientially trained epidemiologists

Methods

Sample Selection for Formally Trained Epidemiologists

• In 2011, NACCHO began assembling a registry of epidemiologists practicing at the LHD level.

o A brief questionnaire was administered through the NACCHO Annual registration process, which asked the person registering to identify their health department’s epidemiologist.

• Starting with New York State and then spreading to others via word of mouth, the questionnaire was also distributed to LHDs through their state’s SACCHO.

• By January 2012, the registry contained approximately 400 names, from which a sample of 20 was drawn to participate in the key informant interviews.

• The sample reflected the distribution of population sizes and the geography of the registry.

• Of the 20 epidemiologists selected, 17 completed the key informant interview.

Methods

Sample Selection for Experientially Trained Epidemiologists

• Using NACCHO’s database, a list of LHDs was created to mimic those represented in the registry of epidemiologists practicing at the local level, in terms of size and geography of jurisdiction served.

• NACCHO staff called the health departments and asked to speak with their epidemiologist.

o If connected to someone falling into the formally trained category, NACCHO staff asked permission to include their name in the local epidemiologist registry.

o If told that no one met that job description, NACCHO staff asked to speak to the Health Official and, using CTSE’s definition of an epidemiologist, asked if anyone working at the health department fit that description.

If yes, NACCHO staff asked to speak to that person and invited him/her to participate in a key informant interview, as well as to be part of the registry.

• Eighteen experientially trained epidemiologists completed the key informant interview.

Methods

Interview Guide Development and Interviewing

• An interview guide was created by NACCHO staff, in conjunction with the CDC Project Officer, and vetted by the Project Officer and NACCHO’s Epidemiology Workgroup.

• The interview guide contained four sections:

o Section 1: Interviewee and Health Department Characteristics

o Section 2: Interviewee Education/Training and Outlets for Technical Assistance

o Section 3: Priority Duties and Responsibilities

o Section 4: Role in Informatics and Meaningful Use

• Pilot interviews were conducted by the two NACCHO staff that would be conducting the key informant interviews.

• NACCHO staff shared their interview experience and pilot participant reactions to the questions in order to assure as much similarity in the interviews as possible.

• Interviews averaged 45 minutes each.

Results: Section 1

Formally Trained Epidemiologists

Experientially Trained Epidemiologists

Total 17 18

Jurisdiction Size <25,000 25,000-49,999 50,000-99,999 100,000-249,999 250,000-499,999 500,000-999,999 1,000,000+

1022552

6462000

Geographical Region Northeast South Midwest West

3536

7353

Interviewee and Health Department Characteristics- Key Observations

Results: Section 1

Interviewee and Health Department Characteristics- Key Observations

• 82% of the formally trained epidemiologists responded that there are not enough epidemiologists working at the health department.

• 44% of the experientially trained epidemiologists responded that there are not enough people performing epidemiological functions working at the health department.

o For those reporting that there are not enough, it was often noted that while there is time to do what is mandated, there is not enough time to go beyond that. As one interviewee explained, there is not enough time to “take the information and make it useful in terms of prevention.”

o This sentiment was also noted by some of the interviewees who responded that there are enough. As explained by one interviewee, “while there are enough to handle the workload, there are not enough to be proactive.”

• The reasons given to explain why there is not enough epidemiological staff support at the health department were very similar for both groups. The main reason reported was lack of funding to support additional positions.

Results: Section 2

Education/Training and Outlets for Technical Assistance- Key Observations

• 71% (12) of the formally trained epidemiologists have a Masters in Public Health and of those with an MPH, 67% (8) concentrated in epidemiology. (Note: Not all with masters degrees received that degree in public health; some of the participants with doctoral degrees also hold an MPH.)

• 82% of the experientially trained epidemiologists have a background in nursing.

Formally Trained Epidemiologists

Experientially Trained Epidemiologists

Bachelors 1 10

Masters 12 4

Doctorate 4 0

Other 0 4

Results: Section 2

Interviewee Education/Training and Outlets for Technical Assistance- Key Observations (cont’d)

• 100% of the participants responded that they use their state-level colleagues for technical assistance related to the epidemiological functions of their position.

• Other reported providers of technical assistance, as well as training opportunities, included the CDC, CSTE, APHA, APIC, ESRI, Emory University’s Epidemiology in Action course for public health professionals, University of North Carolina’s FOCUS on Field Epidemiology periodical, regional consortiums within states, long-time colleagues in other health departments, and classmates from graduate school.

Results: Section 2

Education/Training and Outlets for Technical Assistance- Key Observations

• 34/35 interviewees responded that they participate in continuing education or training events related to epidemiology.

o Both the formally and experientially trained epidemiologists reported that over time there seem to be fewer and fewer opportunities and that most opportunities are not directly related to epidemiology, rather they are disease-specific.

o Participants noted that it would be useful to have more training opportunities directly related to applied epidemiology.

o Similar challenges and facilitating factors were noted by both groups, in terms of ability to participate in training events.

Challenges: Funding, time, distance to travel, staffing for coverage in their absence from the health department, and relevance/applicability of the training opportunity.

Facilitating factors: Web-based and brief.

Results: Section 3

Importance of the following duties/ responsibilities in the participants’ position:

Formally Trained Epidemiologists

Experientially Trained Epidemiologists

Conduct surveillance 4.8 (5 – 3) 4.6 (5 – 2)

Conduct case investigations 4.1 (5 – 1) 4.7 (5 – 3)

Conduct outbreak investigations 4.8 (5 – 4) 4.5 (5 – 1)

Evaluate health services 3.0 (5 – 1) 2.7 (5 – 1)

Conduct research 2.6 (5 – 1) 2.2 (5 – 1)

Manage data/databases 4.4 (5 – 3) 4.1 (5 – 2)

Analyze data 4.4 (5 – 3) 3.5 (5 – 1)

Write reports 4.0 (5 – 2) 2.6 (5 – 1)

Develop policy 2.4 (4 – 1) 3.3 (5 – 1)

Design interventions 3.3 (5 – 1) 3.2 (5 – 1)

Publish in professional journals 1.8 (4 – 1) 1.4 (3 – 1)

Serve as a media spokesperson 2.1 (4 – 1) 1.8 (5 – 1)

Serve as a mentor/trainer to others 4.4 (5 – 3) 4.0 (5 – 1)

Results: Section 3

Priority Duties and Responsibilities- Key Observations

• The response ranges tended to be greater for the experientially trained epidemiologists, highlighting the wide variety of backgrounds and job responsibilities represented in this group.

• The two groups seemed to understand/interpret some of the duties and responsibilities differently. For example:

o Managing databases was a broader, more technically-demanding task for the formally trained epidemiologists, whereas the experientially trained epidemiologists related data management to having completed case and outbreak investigations.

o Formally trained epidemiologists seemed to serve in more of a supervisory role in regard to conducting case and outbreak investigations, whereas the experientially trained epidemiologists seemed to have a more of a hands-on role.

Results: Section 4

Role in Informatics and Meaningful Use- Key Observations

• In general, awareness and understanding of informatics and Meaningful Use was low.• Many of the formally trained epidemiologists and a few of the experientially trained epidemiologists

reported that the state is largely responsible for these activities, thus there is little discussion or action at the local level.

• A few formally trained epidemiologists reported that they see their role increasing with time, but that they will not be the person primarily responsible for these issues at the health department.

• Many experientially trained epidemiologists who noted some familiarity withinformatics focused on EMR case data elements in their comments.

Familiarity with Informatics and Meaningful Use

Formally Trained Epidemiologists

Experientially Trained Epidemiologists

Not familiar 6 (35%) 13 (72%)

Somewhat familiar 5 (29%) 5 (28%)

Familiar 6 (35%) 0 (0%)

Limitations

• Small sample size• Sample not nationally representative• Lack of a comprehensive registry of epidemiologists practicing at the local level• Incomplete definition for epidemiologists practicing at the local level• Complications stemming from the variety in job title used to describe positions that have

epidemiological duties and responsibilities

Discussion/Conclusions

The results of the key informant interviews indicate that:

• There are not enough people practicing epidemiology at the local level.• The people practicing epidemiology at the local level encompass a variety of educational, training,

and experiential backgrounds.• Finding time to attend or participate in training events is difficult. • Resources to pay for training events (including travel and lodging) are very limited.• Desired trainings would be focused on basic/fundamental epidemiology skills.

o Many interviewees noted that the majority of training opportunities are disease-specific and that it would be helpful to have more opportunities focused on epidemiological skills or techniques, such as interviewing, investigating, and analyzing data.

o It was also noted that there is no known place to send people to learn how to be a nurse epidemiologist or an applied field epidemiologist.

Discussion/Conclusions

Based on what we learned from the key informant interviews, next steps might include:

• Working with CSTE to collaboratively strengthen the epidemiologic capacity assessment (ECA) in order to attain a more complete and generalizable picture of local epidemiology capacity.

• Bringing local epidemiologists, including those performing epidemiologic functions without the title of epidemiologist, together to discuss how training should be structured and delivered.

• Promoting the enhancement of job descriptions to capture the epidemiologist role. • Working to enhance experientially trained epidemiologists’ identification with the epidemiology

profession.o One experientially trained epidemiologist stated, "I think that we, as nurses, have been doing

it [epidemiology] for a long, long time, but we just haven't been thinking about it in terms of epidemiology. We just think of it as our job to do."

• Reviewing environmental scans of available resources and training opportunities to identify and verify gaps for those practicing at the local level.

Thank you very much

Questions?

Paul Etkind

petkind@naccho.org

202-507-4260

Gretchen Weiss

gweiss@naccho.org

202-507-4276